Hello! My Name is: Andrew L. Cherry, DSW, ACSW

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Teaching Best Practices in an Evolving Science
Treating People with Co-Occurring Disorders

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PRESENTERS Andrew L. Cherry, DSW, ACSWOklahoma
Endowed Professor of Mental Health,University
of Oklahoma, School of Social Work, Tulsa
Campus. Mary E. Dillon, MSW, Ed.DOK-COSIG
Associate EvaluatorTulsa, OK. L. D. Barney,
LADCSt. Anthony's Hospital, Oklahoma City, OK
MSW Student, University of Oklahoma, Norman
Campus.

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Presentation Overview

• The presentation addresses issues relevant to
  social work practice and social work education
  raised by the President's New Freedom Commission
  report, which calls for a transformation in
  mental health and substance abuse care in the
  United States (Farkas, Anthony, 2006).
• The President's New Freedom Commission report can
  be found at http//www.mentalhealthcommission.gov
  /

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Primary Issues

• The primary issues for social work educators
  cluster around preparing students to participate
  and contribute to the transformation taking place
  in health care.
• How do we determine what to teach?
• What services and modalities meet the criteria of
  best-practices?
• More critical is the task of equipping students
  with skills to identify best practices as the
  science evolves throughout their professional
  career.

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Best Practices State-of-the-Art

• The concept of using "best practices" carries the
  connotation of being state-of-the-art treatment
  (Bushy, 2006).
• This presentation highlights research conducted
  over four years by the authors in the
  development, implementation, and evaluation of a
  state initiative to develop best practice
  services for people with co-occurring disorders.
  
• The development of best practice interventions
  that evolved from the mid 1990s and in particular
  since 2003as a result of the SAMHSA Co-Occurring
  State Incentive Grant (COSIG)provides a set of
  principals and approaches for identifying best
  practices.

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Promising Practice Evidence-Based Practice

• In the mental health and substance abuse
  literature, Best Practices tends to fall into
  two general categories promising practice
  (empirically supported, consensus-based, direct
  practice techniques) and evidence-based
  practice.
• Promising practices are typically based on
  practice wisdom and studies that suggest such
  practices are safe and possibly effective.

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Evidence-Based Practices

• Evidence-based practices are derived from
  research and meta-analyses. The procedures used
  in evidence-based practice are standardized and
  can be replicated.
• Evidence-based practices are characterized by the
  use of empirical research techniques (randomized
  controlled trials similar to those used to test
  medical interventions) to demonstrate that the
  evidence-based practice produces a positive
  outcome. And, there is ongoing objective
  evaluation of clinical cases to monitor the
  effectiveness of the evidence-based practice
  (Lakeman, 2008 Stuart, Lilienfeld, 2007).

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There is a Disconnect

• The primary issues for social work educators is
  related to preparing students to participate and
  contribute to the current transformation and
  future innovations.
• In part, this disconnect between Social Work
  education and the training needs of our students
  is responsible for the science to service lag
  reiterated by the Annapolis Coalition on the
  Behavioral Health Workforce in 2007. Their point
  was that it takes well over a decade for proven
  interventions to make their way into practice,
  since prevention and treatment services are
  driven more by tradition than by science
  (Glisson, 2007 Hoge, et al., 2007).

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Bridging the Gap

• Social work educators are well positioned to
  bridge the gap between the training provided in
  schools of social work and workforce needs in the
  treatment community to provide best practice
  services, for example, for people with a
  co-occurring disorder. Teaching best practices,
  however, must include teaching students how to
  identify best practices as the science evolves
  (Mendel, et al., 2008).
• For most Social Work Faculty this means retooling
  our curricula.

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Retooling Our Curricula

• First, Social Work curricula has not kept pace
  with the dramatic changes wrought by managed
  care, health care reforms, and presented here as
  and example, the ongoing transformation in the
  treatment for people with a co-occurring
  disorder.
• This lag of teaching current best practices has
  left our students unprepared for contemporary
  practice environments.
• It takes more than telling our students that best
  practices are out there.

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Retooling Our Curricula (contd)

• Second, too many programs persist in using
  passive, didactic models of instructions that
  have been proven ineffective in changing practice
  patterns or improving healthcare outcomes.
• Third, consumers and their families, who play an
  enormous care-giving role, typically receive no
  educational support, nor is their considerable
  expertise about the lived experience of illness
  and recovery tapped by engaging them as educators
  of our students (Hoge Morris, 2004).

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Best Practices in Behavioral Health Education
Training

• Six recommendations for the how, what, where,
  and who of Social Work Education and Training
• Best Practice 1 Professional social work
  training needs to instill an understanding of the
  competing paradigms of service delivery and the
  diverse scientific, economic, and social forces
  that shape healthcare and social services.

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Recommendations (contd 2)

• Best Practice 2 Curricula are routinely updated
  to address the values, knowledge, and skills
  essential for practice in contemporary health and
  social service systems
• Best Practice 3 Best practice guidelines need
  to be used as teaching tools

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Recommendations (contd 3)

• Best Practice 4 Teaching methods need to be
  evidence-based
• Best Practice 5 Social Work educators need to
  be knowledgeable and experienced in providing
  best practices in the delivery of healthcare and
  social services
• Best Practice 6 To deal with the evolving
  science, students need to learn the importance of
  engaging in lifelong learning (Hoge, Huey,
  OConnell, 2004).

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Underprepared from the Moment They Complete
Their Training

• While the incidence of co-occurring mental and
  addictive disorders among individuals has
  increased dramatically, most of the workforce
  lacks the array of skills needed to assess and
  treat persons with these co-occurring conditions.
  Training and education programs largely have
  ignored the need to alter their curricula to
  address this problem, and, thus, the nation
  continues to prepare new members of the workforce
  who simply are underprepared from the moment they
  complete their training (SAMHSA, 2007).

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Impact of a Best Practice

• What is the outcome of a best practice that is
  taught to a community of clinicians?
• The results of the Oklahoma-COSIG evaluation is a
  case example.
• This is a comparative study of the outcome of
  19,241 people who were treated in 15 co-occurring
  model programs that identified and implemented
  best practices and 5 control programs that used
  typical treatment.

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Description of those Treated

• Age Differences As a group people with an
  indication of a co-occurring disorder who enter
  treatment tended to be younger.
• Education There was no significant difference
  in education among males however, women with an
  indication of a co-occurring disorder had
  slightly less education than women without an
  indication of a co-occurring disorder.
• Income The average yearly reported income for
  men admitted to treatment was 11,636, slightly
  higher than for women admitted for treatment
  (10,648). The per capita income in Oklahoma in
  2006 was 32,391.

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Description of those Treated (contd 2)

• Homelessness Both men and women with an
  indication of a co-occurring disorder were likely
  to be homeless. Among homeless people in this
  study sample approximately 50 were identified as
  having a co-occurring disorder.
• Admission Status You can expect both men and
  women with a co-occurring disorder to be admitted
  as a result of a legal intervention.
• Arrests Men and women with an indication of a
  co-occurring disorder will have had more arrests
  when entering treatment.
• Serious Mental Illness People with a
  co-occurring disorder were less likely to be
  identified as having a serious mental disorder
  (men 25, women 15).

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Outcomes

• Preliminary Findings Differences between Model
  programs and Control programs on identifying
  people with a co-occurring disorder (N 19,241).

Model and Control Programs MEN No COD MEN COD Women No COD Women COD
Model 54.5 45.5 66.3 33.7
Control 75.5 24.5 82.2 17.8
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Outcomes (contd 2)

• Preliminary Findings Differences between Model
  programs and Control programs on Treatment
  Completion (N 19,241).

Model and Control Programs MEN No COD MEN COD Women No COD Women COD
Model 57.5 70.4 45 65.5
Control 25.5 29 15 17
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Outcomes (contd 3)

• Preliminary Findings Differences between
  Mental Health Model programs and Control programs
  on Days in Treatment (N 19,241).

Model and Control Programs MEN No COD MEN COD Women No COD Women COD
Model 86 41 109 54
Control 192 190 212 222
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Outcomes (contd 4)

• Preliminary Findings Differences between
  Substance Abuse TX Model programs and Control
  programs on Days in Treatment (N 19,241).

Model and Control Programs MEN No COD MEN COD Women No COD Women COD
Model 79 70 76 66
Control 55 50 71 54
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Identifying Best Practices

• Teaching best practices, however, must include
  learning how to identify best practices and
  teaching students how to identify best practices
  in their careers as the science evolves (Mendel,
  et al., 2008).
• Our study and the literature suggests that there
  are three basic principals for identifying best
  practice interventions, services, and modalities
  in an evolving science.

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Three Principals

• The first principal is Do no harm. There are
  evidence-based practices that are of low and high
  risk. Interventions that depend on cohesive
  techniques are more risky than collaborative
  techniques.
• The second principal is that evidence-based
  practices meet the value-based principals of
  social work practice. For instance, a best
  practice intervention must also be culturally
  appropriate.
• The third principal is that the intervention
  increases optimal outcomes for participants
  (Bushy, 2006 Petr Walter, 2005).

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Conclusion

• We teach to prepare our students for the world of
  social work practice. Like the world, however,
  the profession and our students are facing a
  rapidly changing practice landscape.
• This is problematic because
• Social Work curricula has not kept pace with the
  dramatic changes in health care reforms,
• This lag of teaching current best practices has
  left our students unprepared for contemporary
  practice,

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Conclusion (contd )

• There are specific steps we need to take
• We need to engage the expertise of consumers and
  families as educators of our students,
• Evidence-based practices must meet the
  value-based principals of social work practice,
• Best practice guidelines need to be used as
  teaching tools,
• To deal with the evolving science, faculty and
  students need to learn the importance of engaging
  in lifelong learning.

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• The End