Evidence Based Practices for People With Severe Mental Illness

1. Evidence Based Practices for People With Severe Mental Illness Why You Should Ask For Them By Name & Settle For Nothing Less Tony Zipple, Sc.D, MBA CEO, Thresholds 773-572-5220 tzipple@thresholds.org www.thresholds.org

2. What Are Our First Thoughts When We Hear... Schizophrenia Disabled Chronically mentally ill Severe & persistent mental illness Mentally ill/substance abusing Etc?

3. Generally We Think • Sick • Disturbed • Helpless • Hopeless • Out of control • Damaged or broken • Substance abusing • Unemployable • Criminal • Homeless • Frightening • Unhappy • And other generally negative things!

4. Do You Know People With Severe Mental Illnesses? Friends? Family? Clients? Neighbors? Are most hopeless, helpless, scary, & broken?

5. What We Know About The Course Of Mental Illness • As many as 2/3 of people with serious mental illness get much better over the long term • Level of illness severity today does not predict long-term outcome • Access to rehabilitation services improves long term outcome • The course of the illness varies greatly from person to person • Medications & hospital time are important in managing symptoms but not strongly related to long term outcome • People can have significant levels of control over their levels of happiness and recovery

6. In Short • People can and most do get better • We can not predict who will do better so we need to do our best for everyone • Everyone’s story and recovery is unique • People have significant control of their lives and recovery • The work that we do can support recovery • There is real hope for recovery for everyone

7. Recovery is… “ … a process of reclaiming one’s life after the catastrophe of mental illness” William Anthony

8. When We Recover From Tragedy (and all of us have experienced tragedy) We go back to work We start seeing friends & family We pick up our hobbies We start doing household chores We go back to church We stop or modify therapy/counseling We have fun and enjoy life We Reclaim Our Lives & Start Living Again!!!

9. Recovery is A Journey Of The Heart “It is only with the heart that one can see rightly; what is essential is invisible to the eye. “ -Antoine De Saint-Exupery-

10. But Matters Of The Heart Have No Clear Definition…Like Jazz “ Anyone who understands jazz knows that you can't understand it. It's too complicated. That's what’s so simple about it…. That's why I can explain it. If I understood it, I wouldn’t know anything about it. “ -Yogi Berra-

11. Recovery, As A “Heart” Matter, Is… Heartfelt & hopeful Passionate Warm & fuzzy Internal & personal Spiritual And almost impossible to define So how do we build a recovery services?

12. Consider The Program & Policy Challenges of Recovery How do we operationalize a journey of the heart without killing it? How do we develop policy for things that are essential but invisible to the eye? How do we accredit things that you know are essential but can not define? How do you teach something that disappears in the explanation?

13. SAMHSA Evidence Based Practices As The Toolkit For Recovery

14. A Question • You have been diagnosed with a life threatening cancer. Without a crystal ball you can not be sure what treatment will be best. Do you bet on… • Individual clinical judgment of a single oncologist? • An informed synthesis of the best available research & practice?

15. How Have We Known What Works? • Historically psychiatric rehab has focused on anecdotal & values oriented evidence. This is valuable but limited by: • Variations in the intervention, population, system variables, and implementation issues • Biases of observers • Charisma of proponents (the family therapy school effect) • Limited interest in and/or ability to replicate the work • Reliance in poorly defined “models” to guide us • Limited ability to systematically teach others how to do the work

16. “Employing clinical interventions that research has shown to be effective in helping consumers to recover and achieve their goals” Susan Azrin & Howard Goldman, 2005 EBP is simply the accumulated and tested wisdom of our growing experience, organized in a way that it can be shared and used by other providers Tony Zipple, 2006 Evidence Based Practice

17. Summary Of Experience with Medical EBPs “Physicians trained in evidence based techniques are better informed that their peers, even 15 years after graduating from medical school. Studies also show conclusively that patients receiving the care indicated by evidence based medicine experience better outcomes.” J. Pfeffer & R.Sutton, Harvard Business Journal (Jan. 2006)

18. Evidence-Based Practice Is A Way To Give The Best That We Have • Intervention with a body of evidence: - Expert consensus - rigorous research studies & specified populations - specified client outcomes • Well defined intervention construct (treatment manual/fidelity scale) • Replication in many different settings • Evolution of the intervention and research as we learn

19. National EBP Project • National group of leading mental health services researchers convened • To identify interventions that qualify as EBPs • To identify strategies to enhance implementation of EBPs • Multiple funding sources • (Johnson Foundation, SAMHSA, NASMHPD Research Institute)

20. Integrated Dual Disorder Treatment • Illness Management and Recovery • Supported Employment • Family Psychoeducation • Assertive Community Treatment • Medication Management Approaches in Psychiatry National EBP Project: Implementing 6 EBPs

21. And All Of These EBPs Are Designed To Support Recovery Focused on surrogate outcomes like good jobs, staying stable and in your life, etc. Minimize iatrogenic effects Embrace consumer choice Require ethical practitioner behavior Built on values of hope, respect, partnership They are the “head” that supports the “heart” of recovery

22. Caution! Some Good Practices Are Not Yet Evidence Based Practices • Clubhouse • Supported Education • Supported Housing • Peer Support & Education • Forensic ACT • Aging services • Case management

23. Caution! Some Good Practices Are Not Yet Evidence Based Practices However…EBPs Are Preferred Interventions Where They Exist EBPs are not the only useful interventions, but using non-EBPs requires really good justification if an EBP exists for that area

24. Assertive Community Treatment (ACT)

25. Primary Goals of ACT Treatment Reduce symptoms of mental illness Minimize or prevent relapse of the illness Satisfy basic needs and enhance quality of life Improve functioning in normal adult roles (family, social, employment, etc.) Increase individual control and support recovery To lessen the family’s worry, concern and total responsibility for providing care - promote restoration of normal family relationships

26. ACT Works … Much Of The Time • Large impact on: • Hospital use • Housing • Retention in treatment • Moderate impact on: • Symptoms & quality of life • Weaker impact on: • Employment • Substance use • Jail and legal problems • Social adjustment

27. Integrated Dual Disorders Treatment (IDDT)

28. How do people obtain remission from dual disorders? • Stable housing • Sober support network/family • Regular meaningful activity • Trustingclinical relationship Alverson et al, Com MHJ, 2000

29. Built On Non-Traditional Lessons • Abstinence comes after supports in place • Relapse comes after loss of supports • Alverson et al, Com MHJ, 2000

30. Other Important IDDT Elements Access to comprehensive services (e.g., employment, psychiatry, etc.) Social and family support interventions Long term perspective Cultural Sensitivity and competence Program fidelity

31. Principles of Integrated Dual Disorder Treatment • Integration of mental health and substance abuse treatment • Same team of dually trained people • Same location of services • Both disorders treated at the same time • Stage-wise treatment • Different services are effective at different stages of treatment

32. Wellness (a.k.a. Illness) Management & Recovery

33. WMR Goals Learn about mental illness and strategies for treatment Decrease symptoms Reduce relapses and hospitalizations Make progress toward consumer’s goals and recovery

34. WMR Format Manualized, but tailored to needs of client CBT and motivational enhancement clinical techniques Weekly sessions About an hour but can be broken down for shorter/more frequent sessions Individual, group, or both Usually lasts 3 – 6 months In Indiana, adding peer specialist component in both training and site personnel

35. WMR Content Areas • Recovery strategies • Facts about mental illness • Stress-vulnerability model and strategies for treatment • Building social support • Using medications effectively • Reducing relapses • Coping with stress • Coping with symptoms and other problems • Getting your needs met in the mental health system

36. Supported Employment

37. Supported Employment Goal of competitive employment Rapid job search Integrating vocational and mental health services Consumer job preferences emphasized On-going, comprehensive assessment Time-unlimited support Employment is a priority

38. Supported Employment Place - train approach Jobs are transitions, keep trying until you find the right fit Developed for mental health centers Adopted in both rural and urban areas Caseloads of about 25 clients

39. Family Psychoeducation

40. Family Psychoeducation • Partnership/collaboration between Consumers Family or other support system Practitioners • Building relationships/alliance • Education: structured sessions • CBT: Problem-solving, Skill-building • Uses variety of formats (individual, group, home visits) • Variety of materials (written, video, etc.)

41. Families and consumers learn… Practical facts about mental illness New ways to manage illness To reduce tension and stress in families To provide social support and encouragement to consumer/each other To focus on future (not past) To find ways to help consumers in their recovery

42. Medication Management

43. Medication Management Systematic and effective use of medications Involve consumers, family/support system, practitioners, supervisors, MHA in the decision-making process (not just prescriber) Strategies for medication adherence Guidelines and steps for decisions on medications Monitor results (and document) for future medication decisions Consumer’s needs and concerns are critical

44. Medication Management: Some specific examples Treat all symptoms with specific plan Monitor outcomes and adjust as necessary Use simplest regimen possible Documentation of side effects and treatments for side effects Clients seen every 3 months or more often during medication adjustments Clozapine offered to consumers with refractory psychosis

45. And EBPs Seem To Support Recovery!!! • If someone is working…. (SE) • If someone is managing their illness better… (WMR, Med Mgt) • If someone has better family support…(Fam) • If someone has good, flexible supports… (ACT) • If someone is staying straight & sober… (IDDT) • What are the odds that they are experiencing recovery?

46. Importance Of EBP • Basis for public policy & funding decisions • Basis for dissemination of useful practices • Standardization makes teaching new staff easier • Improves assessment of program quality • Lets us know who it works with & who it does not work with • Standardization allows for careful learning and evolution of practices

47. And The Bottom Line EBPs help us to more effectively help consumers to achieve recovery!

48. Thresholds Founded 1959 Comprehensive, recovery focused “Present at the Creation” of psychiatric rehabilitation Long history of innovation 900 staff, 100 locations, 4 counties Many special services, serving many special populations 30 year old research department, now focused on recovery and EBPs

49. Thresholds Formal Use Of EBPs • Integrated Dual Disorders Treatment (1998) • Assertive Community Treatment (1979) • Supported Employment (2000) • Wellness Management & Recovery (2005) • Evolving Practices… • Cognitive Rehab, DBT, & CBT • Integrated Health Care • Forensic ACT • Transition to Independence Program • Supported Education

50. The Central Issue • This is not easy stuff • The challenge of change • The challenge of resources • The challenge of focus • But our clients deserve our best • A job • Friends & family • A good life on their terms • How Do We Bridge This Gap?