Terry Krupa, Queens University & Tim Aubry, University of Ottawa

Developing an Evidence-base for Psychosocial Rehabilitation in Canada: Ideals, Challenges and Opportunities Terry Krupa, Queens University & Tim Aubry, University of Ottawa Presentation at PSR Canada Conference September 21, 2010

PSR and Evidence-Based Practice Increasing pressure within all areas of health care to engage in “evidence-based practice” Evidence- based practice refers to the use of systematic processes of research and inquiry to determine good practices in a field

PSR and Evidence-based Practice Refers to both the “production” of good evidence (evaluation and research) and the dissemination of the evidence-base (dissemination to practice) Despite consistency in ideals (accountability, quality care and positive outcomes in real world) in general uptake of evidence-based approach has been slow in PSR

Overview of Today’s Address • Begin a dialogue among participants about evidence-based practice in psr by: • Discussing 6 challenges to evidence-based practice along with promising initiatives to address these challenges • Offering several recommendations for advancing evidence-based practice in the field • Opening the floor to questions and discussion

Advancing Evidenced-Based Practice In PSR 6 Challenges Many Promising Opportunities

Challenge 1 “Concern that evidence-base practice is not consistent with the strong values base of PSR”

Consistency with the Value Base of PSR Evidence-based practice emerged from a medical paradigm that focuses on illness, symptoms, impairment and reducing hospitalization and a cost-containment paradigm that focuses on reducing hospitalization Question compatibility with psr values of consumer voice, choice, empowerment, social participation, citizenship, quality of life in the community etc.

Promising Opportunities A growing interest in evaluating a broader range of personal and social changes resulting from health-related practice, perhaps in response to development of recovery as a guiding vision Ongoing consideration of evidence-based practices in mental health to ensure that positive changes include changes consistent with psr values (for example, revisiting Assertive Community Treatment)

Promising Opportunities Advancing values-based practice may be one of the greatest contributions that PSR can make Our values are “ideals” that need to be operationalized For example, describing and evaluating practices that engage people with serious mental illness who are highly marginalized in making choices, and reconnecting to meaningful activities

Challenge 2 “Concerns that favoured research methods and designs are not suitable for PSR practice”

Suitability of Research Designs • “Levels” of evidence favour randomized controlled trials (RCT) • Not easily designed in the “real”, “messy” world of psr service delivery • Not recognizing importance of designs that enable the “voice” of people who receive psr services

Promising Opportunities • Several examples of use of RCT in PSR practice • Witnessing development and recognition of a range of research methods and designs suitable to PSR practice • PSR practice stands to make an important contribution to the development of research designs that • Are participatory • Account for variations in individual choice and preferences • Borrow from outside of the mental health field

Promising Opportunities • Increasing call from funders of programs of research to develop designs that • use a mixture of methods • Demonstrate meaningful participation of range of stakeholders including people receiving services • Depend on stakeholder involvement for interpretation of findings For example: Systems Enhancement Evaluation Initiative (http://www.ontario.cmha.ca/seei.asp)

Challenge 3 “PSR programs and services lack the infrastructure required to conduct quality evaluation and research”

Limited Infrastructure Evaluation/research not routinely built into the resource and organizational structure of psr programs PSR providers practicing in the midst on an information and knowledge “explosion” but not always having mechanisms in place to gain access to this information

Promising Opportunities • Examples of novel structures that can enhance the capacity of even very small psr services to engage in evidence-based practice • For example, Ontario Federation of Community Mental Health and Addictions Programs • Providing “infrastructure support” around learning about research and evaluation, dissemination measures that might be used in evaluation and research, dissemination of information etc.

Promising Opportunities Novel structures: • Development of position on program “Board of Directors” dedicated to evidence-based practice • Newsletters focusing on evidence-based practices developed by knowledge-exchange initiatives (eg. CMHA, Ontario Mental Health Knowledge Exchange Network) • Conferences, like the PSR conference, that can provide opportunity to learn and dialogue about evidence-based practice

Challenge 4 “PSR programs have limited research capacity”

Limited Research Capacity Limited capacity among PSR practitioners to conduct research Little training in PSR devoted to conducting research in mental health service settings

Promising Opportunities Growing interest in Canadian universities to engage with the community Increased opportunities for collaboration with university researchers Targeted funding by research granting councils for community mental health research Development of training programs in program evaluation

Challenge 5 “Evidence-based PSR practices shows only limited uptake in Canada”

Limited Uptake of Evidence-Based Practices • Slowness in Canadian mental health systems in initiating EBP • Apparent in such areas as ACT & ICM, Housing First, & Supported Work • Favouring of home-made programs • Explosion of research information

Promising Opportunities Dissemination of evidence-based practices as a goal of MHCC Development of research dissemination tools for practitioners – e.g., SAMSHA, Cochrane Collaboration, Campbell Collaboration

Challenge 6 Paucity of “effectiveness research” in PSR Practice

Paucity of Effectiveness Research Universal tension in service settings to combine services and data collection Very few examples of successful performance measurement systems Frequent collection of data without utility in service delivery or program improvement

Promising Opportunities Developments in the field of psychotherapy in the area of effectiveness research Creation of simple data collection tools in community mental health that can have clinical utility (e.g., PSR toolkit, MCAS)

Recommendations Encourage the active involvement of PSR practitioners in the development of research questions that are most relevant to capture the processes and outcomes of services Take a lead in creating research and evaluation strategies that meaningfully include consumers so that research activities can make difference in the lives of people

Recommendations Proactively seek out relationships with universities and other research organizations to establish partnerships and collaborations. Support PSR personnel to develop research abilities through participation in conferences, workshops, and academic training programs

Recommendations Recognize and disseminate research achievements that reflect the philosophy, mission and values of PSR. Let these become shining examples of what is possible. Use PSR friendly organizations to demonstrate novel research capacity and infrastructure possibilities Look for opportunities to have PSR represented in contexts where research is conceptualized, prioritized and funded.

Thank You! Any Comments or Questions?

Terry Krupa, Queens University & Tim Aubry, University of Ottawa