Evidence Based Practices for People With Severe Mental Illness

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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_at_thresholds.org
• www.thresholds.org

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What Are Our First Thoughts When We Hear...

• Schizophrenia
• Disabled
• Chronically mentally ill
• Severe persistent mental illness
• Mentally ill/substance abusing
• Etc?

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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!

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Do You Know People With Severe Mental Illnesses?

• Friends?
• Family?
• Clients?
• Neighbors?
• Are most hopeless, helpless, scary, broken?

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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

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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
• Everyones 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

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Recovery is

• a process of reclaiming ones life after the
  catastrophe of mental illness
• William Anthony

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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!!!

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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-

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But Matters Of The Heart Have No Clear
DefinitionLike Jazz

• Anyone who understands jazz knows that you
  can't understand it. It's too complicated. That's
  whats so simple about it. That's why I can
  explain it. If I understood it, I wouldnt know
  anything about it.
• -Yogi Berra-

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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?

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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?

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SAMHSA Evidence Based Practices As The Toolkit
For Recovery
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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?

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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

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Evidence Based Practice

• 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

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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)

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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

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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)

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• National EBP Project
• Implementing 6 EBPs

1. Integrated Dual Disorder Treatment
2. Illness Management and Recovery
3. Supported Employment
4. Family Psychoeducation
5. Assertive Community Treatment
6. Medication Management Approaches in Psychiatry

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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

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Caution! Some Good Practices Are Not Yet
Evidence Based Practices

• Clubhouse
• Supported Education
• Supported Housing
• Peer Support Education
• Forensic ACT
• Aging services
• Case management

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Caution! Some Good Practices Are Not Yet
Evidence Based Practices HoweverEBPs 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

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Assertive Community Treatment (ACT)
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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 familys worry, concern and total
  responsibility for providing care - promote
  restoration of normal family relationships

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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

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Integrated Dual Disorders Treatment (IDDT)
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How do people obtain remission from dual
disorders?

• Stable housing
• Sober support network/family
• Regular meaningful activity
• Trusting clinical relationship
• Alverson et al, Com MHJ, 2000

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Built On Non-Traditional Lessons

• Abstinence comes after supports in place
• Relapse comes after loss of supports
• Alverson et al, Com MHJ, 2000

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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

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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

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Wellness (a.k.a. Illness) Management Recovery
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WMR Goals

• Learn about mental illness and strategies for
  treatment
• Decrease symptoms
• Reduce relapses and hospitalizations
• Make progress toward consumers goals and recovery

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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

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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

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Supported Employment
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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

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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

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Family Psychoeducation
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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.)

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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

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Medication Management
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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
• Consumers needs and concerns are critical

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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

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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?

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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

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And The Bottom Line

• EBPs help us to more effectively help consumers
  to achieve recovery!

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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

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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

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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?

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Dont Agonize Organize!Its not about waiting
for the storm to pass, but about learning to
dance in the rainThank You!