why you should ask for them by name & settle for nothing less tony zipple, sc.d, mba ceo,...
TRANSCRIPT
Why You Should Ask For Them By Name & Settle For
Nothing Less
Tony Zipple, Sc.D, MBACEO, Thresholds
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 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
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 betweenConsumersFamily or other support systemPractitioners
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.)
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 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?
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?
