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Evidence Based Practices for People With Severe Mental Illness. 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. What Are Our First Thoughts When We Hear. Schizophrenia Disabled

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evidence based practices for people with severe mental illness

Evidence Based Practices for People With Severe Mental Illness

Why You Should Ask For Them By Name & Settle For Nothing Less

Tony Zipple, Sc.D, MBA

CEO, Thresholds


[email protected]


what are our first thoughts when we hear
What Are Our First Thoughts When We Hear...



Chronically mentally ill

Severe & persistent mental illness

Mentally ill/substance abusing


generally we think
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!
do you know people with severe mental illnesses
Do You Know People With Severe Mental Illnesses?





Are most hopeless, helpless, scary, & broken?

what we know about the course of mental illness
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
  • 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
in short
In Short
  • 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
recovery is
Recovery is…

“ … a process of reclaiming one’s life after the catastrophe of mental illness”

William Anthony

when we recover from tragedy and all of us have experienced tragedy
When We Recover From Tragedy (and all of us have experienced tragedy)

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!!!

recovery is a journey of the heart

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-

but matters of the heart have no clear definition like jazz
But Matters Of The Heart Have No Clear Definition…Like Jazz

“ 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-

recovery as a heart matter is
Recovery, As A “Heart” Matter, Is…

Heartfelt & hopeful


Warm & fuzzy

Internal & personal


And almost impossible to define

So how do we build a recovery services?

consider the program policy challenges of recovery
Consider The Program & Policy Challenges of Recovery

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?

a question
A Question
  • 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?
how have we known what works
How Have We Known What Works?
  • 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
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, 2006

Evidence Based Practice
summary of experience with medical ebps
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)

evidence based practice is a way to give the best that we have
Evidence-Based Practice Is 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
national ebp project
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)
Integrated Dual Disorder Treatment
  • Illness Management and Recovery
  • Supported Employment
  • Family Psychoeducation
  • Assertive Community Treatment
  • Medication Management Approaches in Psychiatry

National EBP Project:

Implementing 6 EBPs

and all of these ebps are designed to support recovery
And All Of These EBPs Are Designed To Support Recovery

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

caution some good practices are not yet evidence based practices
Caution! Some Good Practices Are Not Yet Evidence Based Practices
  • Clubhouse
  • Supported Education
  • Supported Housing
  • Peer Support & Education
  • Forensic ACT
  • Aging services
  • Case management

Caution! Some Good Practices Are Not Yet Evidence Based Practices However…EBPs Are 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

primary goals of act treatment
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 (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

act works much of the time
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
how do people obtain remission from dual disorders
How do people obtain remission from dual disorders?
  • Stable housing
  • Sober support network/family
  • Regular meaningful activity
  • Trustingclinical relationship

Alverson et al, Com MHJ, 2000

built on non traditional lessons
Built On Non-Traditional Lessons
  • Abstinence comes after supports in place
  • Relapse comes after loss of supports
          • Alverson et al, Com MHJ, 2000
other important iddt elements
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

principles of integrated dual disorder treatment
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
wmr goals
WMR Goals

Learn about mental illness and strategies for treatment

Decrease symptoms

Reduce relapses and hospitalizations

Make progress toward consumer’s goals and recovery

wmr format
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

In Indiana, adding peer specialist component in both training and site personnel

wmr content areas
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
supported employment1
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

Employment is a priority

supported employment2
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

family psychoeducation1
Family Psychoeducation
  • Partnership/collaboration between


Family or other support system


  • 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.)
families and consumers learn
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

medication management1
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

Consumer’s needs and concerns are critical

medication management some specific examples
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

and ebps seem to support recovery
And 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?
importance of ebp
Importance Of EBP
  • 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
and the bottom line
And The Bottom Line

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

thresholds formal use of ebps
Thresholds Formal Use Of 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
the central issue
The Central Issue
  • 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?
Don’t Agonize… Organize!It’s not about waiting for the storm to pass, but about learning to dance in the rainThank You!