Transcript Why You Should Ask For Them By Name & Settle For Nothing Less Tony Zipple, Sc.D, MBA CEO, Thresholds 773-572-5220 [email protected] www.thresholds.org.

Why You Should Ask For Them
By Name & Settle For Nothing
Less
Tony Zipple, Sc.D, MBA
CEO, Thresholds
773-572-5220
[email protected]
www.thresholds.org
 Schizophrenia
 Disabled
 Chronically
mentally ill
 Severe & persistent mental illness
 Mentally ill/substance abusing
 Etc?
 Sick
 Disturbed
 Helpless
 Hopeless
 Out
of control
 Damaged or broken
 Substance
abusing
 Unemployable
 Criminal
 Homeless
 Frightening
 Unhappy
 And
other generally
negative things!
 Friends?
 Family?
 Clients?
 Neighbors?
 Are
most hopeless, helpless, scary, &
broken?

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 longterm 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
 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
“ … a process of reclaiming one’s life after
the catastrophe of mental illness”
William Anthony
 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!!!
“It is only with the heart that one
can see rightly; what is essential
is invisible to the eye. “
-Antoine De Saint-Exupery-
“ 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-
 Heartfelt
& hopeful
 Passionate
 Warm & fuzzy
 Internal & personal
 Spiritual
 And almost impossible to define
 So how do we build a recovery services?
 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?
 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?
 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
“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
“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)

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
 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)
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
 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
 Clubhouse
 Supported
Education
 Supported Housing
 Peer Support & Education
 Forensic ACT
 Aging services
 Case management
EBPs are not the only useful
interventions, but using non-EBPs
requires really good justification if
an EBP exists for that area
 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

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
 Stable
housing
 Sober support network/family
 Regular meaningful activity
 Trusting clinical relationship
Alverson et al, Com MHJ, 2000
 Abstinence
comes after supports in place
 Relapse comes after loss of supports
 Alverson et al, Com MHJ, 2000
 Access
to comprehensive services (e.g.,
employment, psychiatry, etc.)
 Social and family support interventions
 Long term perspective
 Cultural Sensitivity and competence
 Program fidelity
 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
 Learn
about mental illness and strategies
for treatment
 Decrease symptoms
 Reduce relapses and hospitalizations
 Make progress toward consumer’s goals
and recovery
 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
 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
 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
 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
 Partnership/collaboration
Consumers
Family or other support system
Practitioners
 Building
between
relationships/alliance
 Education: structured sessions
 CBT: Problem-solving, Skill-building
 Uses variety of formats (individual, group,
home visits)
 Variety of materials (written, video, etc.)
 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
 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
 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
 If
 If
someone is working…. (SE)
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?
 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
EBPs help us to more
effectively help consumers
to achieve recovery!
 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
 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
 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?