Implementing EvidenceBased Practices EBPs for Consumers with Severe Mental Illness

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Implementing Evidence-Based Practices
(EBPs)for Consumers with Severe Mental Illness
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What is an evidence-based practice (EBP)?

• Intervention with a body of evidence
• - rigorous research studies
• - specified target population
• - specified client outcomes
• Specific implementation criteria (treatment
  manual/fidelity scale)
• A track record showing that the practice can be
  implemented in different settings

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Evidence-Based Practice (EBP)
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National Implementing EBP Project Some Background

• National group of leading mental health services
  researchers convened
• To identify EBPs
• To identify strategies to enhance implementation
  of EBPs
• Multiple funding sources
• (RWJ, SAMHSA, NASMHPD Research Institute)

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National EBP Project

• Implementing the EBPs using toolkits and
  consultation/training
• 8 states (IN, NH, VT, NY, MD, OH, KS, OR)
• Three-fold purpose
• Get EBPs up running in the field
• Evaluate efficacy of the implementation process
  (toolkits, training/consultation methods, etc.)
• Evaluate fidelity (or adherence to the EBP) as a
  major outcome

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• National EBP Project
• Implementing 6 EBPs

• Assertive Community Treatment (ACT)
• Integrated Dual Disorder Treatment (IDDT)
• Illness Management and Recovery (IMR)
• Supported Employment
• Family Psychoeducation (FPE)
• Medication Management Approaches

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Assertive Community Treatment (ACT)
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ACT

• Developed during 1970s (Stein Test)
• Revolving Door
• Hospital without Walls

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ACT

• Multidisciplinary staffing
• Team approach
• Integration of all services
• Low client-staff ratios
• Locus of contact in the community
• Assertive outreach
• Focus on symptom management and everyday problems
  in living
• Ready access in times of crisis
• Time-unlimited services

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Typical Admission Criteria

• Frequent psychiatric admissions
• Frequent use of emergency rooms
• Homeless or unstable housing
• Treatment nonadherence
• Dual diagnosis (SMI substance abuse)
• Legal problems
• Discharge from long-term hospital

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Primary Goals of 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 Outcomes

• 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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A New Approach to Treatment

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

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Critical Components of IDDT

• Integration of mental health and substance abuse
  treatment
• Stage-wise interventions
• Assertive outreach
• Motivational counseling
• Substance abuse counseling

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Principles of IDDT

• 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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Stagewise treatment

• Engagement
• Outreach, practical help, crisis intervention,
  develop alliance, assessment, education to reduce
  negative consequences of use
• Persuasion
• Education, set goals, build awareness of problem,
  family support, peer support
• Active Treatment
• Substance abuse counseling, medications, skills
  training, family, self help, groups
• Relapse prevention
• Relapse prevention plan, skills training, expand
  recovery to other areas of life

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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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Illness Management Recovery (IMR)
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IMR 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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IMR 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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IMR Content Areas

• Recovery strategies
• Facts about mental illness
• Stress-vulnerability model
• 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
• 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 urban areas
• Caseloads of about 25 clients

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Family Psychoeducation (FPE)
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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 Approaches
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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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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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National EBP Project Website

• Contact
• http//www.mentalhealthpractices.org/index.html