Recovery

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Recovery Evidence Based Practices

• Advocating For The Future Of Psychiatric
  Rehabilitation
• 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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Think Of Know People With Mental Illness Whom You
Personally Know?

• Friends?
• Family?
• Clients?
• Neighbors?
• People here today in this room?
• Are most of them hopeless, helpless, scary,
  broken most of the time?

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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
• We do not know how to predict who gets better and
  who does not
• Access to rehabilitation services improves long
  term outcome

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More On What We Know

• The course of the illness varies greatly from
  person to person
• Medications hospital time are important in
  symptom management, but not strongly related to
  long-term outcome
• People have significant levels of control over
  their own levels of happiness and recovery

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In Short

• People can, and most do, get better
• We can not predict who will get 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

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There is hope for recovery for every person with
a mental illness!

• (And I mean EVERY person)

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Recovery Is Recognized By New Freedom Commission

• We envision a future when everyone with a mental
  illness will recover
• But success is not guaranteed
• What do we mean by recover?
• Are we willing to spend the time and money to
  support recovery?
• What resources tools do we need to realize this
  vision?

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What Is Recovery

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

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Recovery, Like Tragedy, Happens In Everyones Life

• Consider a time when something really bad
  happened in your life
• What happened
• What were you like in the weeks/months after the
  event
• How did you know when you were recovering from
  it?
• Did doing some things help?
• Did some things hurt?
• How did you survive the events?

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People Are Resilient

• Recovery is a natural process seen following all
  traumatic events. And bad things happen to us all
• Over time, most people recover from the most
  tragic events even if their lives are different
  in the aftermath
• physical disabilities
• death of loved one
• war related losses
• loss of home
• etc.

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Recovery is What Happens When We Bounce Back.
It Is

• Our own place in the world
• Peace of mind
• Friends family
• Opportunities to grow and to be who we are
• Activities that provide genuine pleasure
• Authentic happiness
• A good life (though perhaps a different life)

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Recovery Is Not

• A cure
• Freedom from symptoms
• An end to problems
• Elimination of relapses
• A life like you originally planned
• But it can be a good, if different life

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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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Important Journeys, Like Recovery, Start With The
Heart

• Heartfelt passion compassion motivate us,
  inspires us, makes life worth living
• The heart leads us to places where we want to be
• The heart keeps us going during bad times

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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

• Emotional 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 public policy for things that
  are essential but invisible to the eye?
• How do we review accredit things that we know
  are essential but can not define?
• How do we teach something that disappears in the
  explanation?

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Evidence Based Practices

• A Toolkit For Making Recovery Real For Our Loved
  Ones

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The Question

• You have been diagnosed with a life threatening
  cancer. You want your life back. 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 Do We Know What Works?

• Historically PSR has focused on best clinical
  judgment. This is valuable but limited by
• Variations in the intervention, population,
  system variables, and implementation issues
• Biases of observers
• Charisma of proponents
• 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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The Result Psychiatric Rehabilitation Is

• Built on values and good intentions
• Based on political positioning
• Passed on through apprenticeship
• Generally, based on anecdotal experiences not
  well evaluated
• Not easily taught or disseminated
• Of very uneven quality or effectiveness for
  consumers
• It has not been based on standard interventions
  or systematic evaluation!

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Fifty Years Ago, Clinical Judgment Was The Best
We Had

• New mission
• New interventions
• Limited experience
• Little research
• Limited resources
• Little national infrastructure

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Today We Have More Experience

• 20 years of supported housing
• 30 years of family psychoeducation
• 30 years of PACT replications
• 40 years of community employment
• 50 years of clubhouse replications
• 50 years of medication
• 60 years of peer support
• And far stronger national infrastructure
• We know a lot about what works well and what
  does not work so well!

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What Is 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, 2007

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Extensive Data EBP Superior To General Clinical
Judgment

• Cognitive therapy for depression
• Systematic desensitization for phobias
• Dialectical Behavior Therapy
• Coronary bypass surgery
• Anesthesia malpractice rates
• Psychiatric medication algorithms
• Diabetes treatment algorithms
• Response to stroke
• Response to myocardial infarction
• Over 15,000 medical EBP articles have been
  published!

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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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So Why Dont We Use EPBs More Often In PSR?

• There is too much sometimes conflicting evidence
• There is not enough good evidence
• Our situation is always unique
• We like stories more than data
• Mostly, we like to think that our clinical
  judgment is better than research based
  interventions

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Generally, People Are Not Fast Learners

• If all we have is a hammer, every problem looks
  like a nail
• Sometimes called the Simon Garfunkel Principle
  A man hears what he wants to hear and disregards
  the rest
• The Lake Wobegon Effect Where all the children
  are above average

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Evidence-Based Practice Is Simply 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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All Of The SAMHSA EBPs Are Designed To Support
Recovery

• Focused on surrogate outcomes like good jobs,
  staying stable and in your life, etc.
• Embrace consumer choice
• Requires ethical practitioner behavior
• Built on values of hope, respect, partnership
• They are the head that supports the heart of
  recovery

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Summarizing The Last Half Hour

• All of us have a natural inclination to recover
• All of us recover as we do things that help us to
  feel better to recover
• Defining recovery is difficult
• Some interventions may work better that others at
  supporting recovery
• How do we help consumers do things that promote
  their recovery and avoid things that interfere
  with their recovery?

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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

• Integrated Dual Disorder Treatment
• Illness Management and Recovery
• Supported Employment
• Family Psychoeducation
• Assertive Community Treatment
• Medication Management Approaches in Psychiatry

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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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However, EBPs Are The 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
• 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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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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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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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
• Beginning to add peer specialist component

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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 Individualized Placement
Support
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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
• Vocational generalists

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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
• 60-80 success rates
• Long term, broad impact

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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 or dual disorders

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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 Evidence Based Practice

• 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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What Can Families Do To Support EBPs?

• Get smart and stay current about the best
  interventions
• Help your loved one to ask for EBPs by name
• Ask about fidelity scores
• Demand that payers support EBPs
• Support provider use of EBPs
• Advocate for funding for EBPs

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Evidence Based Practices Increase The Odds Of
Recovery

• And Your Loved One Deserves The Best Chance To
  Recover!

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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!