Evidence-Based Practices in Mental Health: Ready or Not, Here They Come

1. Evidence-Based Practices in Mental Health: Ready or Not, Here They Come Session VII: “Illness Management and Recovery” Michael Flaum Iowa Consortium for Mental Health Michelle P. Salyers, Ph.D. ACT Center of Indiana October 7, 2004

2. National EBP Project:6 Selected Practices • Family Psycho-education • Supported Employment • Medication Management Approaches in Psychiatry (MedMAP) • Assertive Community Treatment • Integrated Treatment of Co-occurring Disorders • Illness Management and Recovery

3. Stated Objectives • Core components of model • Evidence base for effectiveness • Extent of implementation • Barriers to implementation and strategies to overcome them

4. Is “recovery” a part of any one model? • Family Psycho-education and Recovery • Supported Employment and Recovery • Medication Management Approaches in Psychiatry (MedMAP) and Recovery • Assertive Community Treatment and Recovery • Integrated Treatment of Co-occurring Disorders and Recovery • Illness Management and Recovery

5. Clarification of termsWhat do we mean by… • Illness Management? • Recovery? • Illness management and Recovery (IMR) • Wellness management and Recovery (WMR)

6. Illness Management – Definition used in the IMR model • “Illness management is a broad set of strategies designed to help individuals with serious mental illness… • collaborate with professionals • reduce their susceptibility to the illness • cope effectively with their symptoms” Source: Mueser et al, Illness Management andRecovery: A Review of the Research Psychiatric Services 53: 1272-1284, 2002

7. Professional vs. Peer-Based Illness Management • Complementary? • Hierarchical vs. non-hierarchical • Responsibility for care vs. sharing of personal experience

8. Recovery – Definition used in this model • “Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness” Source: Mueser et al, Illness Management andRecovery: A Review of the Research Psychiatric Services 53: 1272-1284, 2002

9. Recovery – Other Perspectives • “Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” Anthony, WA: Recovery from mental illness: the guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal 16: 11-23, 1993

10. Recovery – Other Perspectives • “Recovery” is a process, a way of life, an attitude and a way of approaching the day’s challenges. It is not a perfectly linear process. At times our course is erratic and we falter, slide back, regroup, and start again…” • “…The need is to re-establish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the inspiration to live, work, and love in a community in which one makes a significant contribution.” Patricia Deegan, 1998

11. Key Recovery Concepts • Hope • Personal Responsibility • Self Advocacy • Education • Support Mary Ellen Copeland, MA, MS

12. Characteristics of Recovery • Defined and accomplished by the one who is living with a mental illness • Viewed as a process and outcome • Involves personal and social success • Universal human experience • Includes themes of hope, self-confidence, enjoyment, well-being, & optimism

13. Development of the IMR program • National evidence-based practices project • Reviewed 40 randomized controlled studies • Identified four effective components of illness management • Committee developed toolkit

14. Evidence for Effectiveness of “Illness Management” for Adults with SMI Summary of Results from Review of 40 Randomized Controlled Trials Mueser et al, Psychiatric Services 53: 1272-1284, 2002

15. Illness Management and Recovery (a la National EBP Project) Michelle Salyers, Ph.D. ACT Center of Indiana

16. What is Illness Management and Recovery? • A structured program that helps people • seek meaningful goals for themselves • acquire information and skills to develop more control over their psychiatric illness • make progress towards their own personal recovery

17. Overarching Goals of IMR • Inspire people to become hopeful about their recovery • Prepare people to be informed decision-makers about their own treatment • Help people gain more sense of control over their mental illness • Free people up to spend less time dealing with their illness and more time enjoying life

18. Specific Goals • Help people set and make progress towards personal recovery goals • Teach people about psychiatric illness and its treatment • Teach people how to use medication effectively • Help people develop relapse prevention plans • Teach people strategies for coping with and reducing persistent symptoms and other problems

19. Core Values of IMR model • Hope is the key ingredient • The person is the expert • Personal choice is a must • Practitioners of IMR are partners • Practitioners demonstrate not dictate • Respect is always present

20. Components of IMR Program • Structured curriculum of 9 modules • Individual or small group format • 4 to 8 months of weekly sessions with trained practitioner • People set personal goals and pursue them

21. Components of IMR Program, cont’d • People practice strategies and skills in sessions • People have home assignments to practice strategies and skills in the real world • Significant others are invited to participate in sessions and homework • EVERYTHING IS TAILORED TO THE INDIVIDUAL

22. Topics of Modules 1. Recovery Strategies 2. Practical Facts about Mental Illness 3. The Stress-Vulnerability Model 4. Building Social Support 5. Using Medication Effectively

23. Topics of Modules 6. Reducing Relapses 7. Coping with Stress 8. Coping with Problems and Symptoms 9. Getting Your Needs Met in the Mental Health System

24. For Each Module • Educational handout for consumer • Practitioners’ guidelines for clinician

25. Teaching Strategies • Motivational • Educational • Cognitive-Behavioral

26. Structure of IMR Sessions • Review previous session • Review home assignment • Follow up on personal goals • Set agenda for current session • Teach and practice new material • Agree on home assignment • Summarize progress made in session

27. Who is IMR For? Anyone can benefit • When people learn more about their symptoms and develop skills for coping with problems, they often feel more confident and can be more effective at resolving some of their life stresses • Clients can benefit regardless of how long they have had their mental illness or where they are in their recovery process

28. IMR is good clinical practice • Gives practitioners tools • Creates a partnership between consumer and practitioner • Is consumer-directed, with their goals the focus of every session • Brings together recovery and evidence-based interventions

29. Indiana’s initial experiences with IMR • Pilot study integrating ACT and IMR • Consumer peer specialist hired for this role • Part-time, but full team member • Primarily does IMR • Individual sessions • Developed support group to pursue common interests • Randomized study of ACT- IMR underway

30. Pilot feedback • 14 consumers had started IMR prior to April 2004 • Pre-post recovery and knowledge • Qualitative interviews in April 2004 • Consumers (14) and Staff (16) • Change as a result of IMR • Most helpful/least helpful • Impact of peer specialist

31. Preliminary results • Pre-post sample too small to examine yet (6 complete so far) • Interviews were very positive about IMR experiences

32. Staff views • Consumer benefits: • more confidence, trying new things • more involved in meaningful activity • managing their own illness better • Staff benefits: • better understanding of consumer goals/needs • less “protective,” more recovery focused “In 15 years, this is the first new thing that's made a huge impact.”

33. Consumer views • Feel more hopeful, confident • Doing more meaningful activities • Increased vocational activity “She's gone through the same thing. I can relate to her better. If she can do it, why can't I do it?”

34. IMR in other settings • Working with 3 agencies to implement IMR • Clubhouse, case management services, partial hospitalization program • Clubhouse trying IMR in groups and individually • Groups more difficult to implement, needs to be small to focus on personal goals, takes longer, peers get more ideas and support from each other

35. Implementing IMR • Program leader and practitioners identified • Training (2-day intensive) • Follow-up consultation (monthly visits) • Ongoing technical support as needed • Program evaluation (fidelity and outcomes) • Administrative supports

36. Important for IMR practitioners to: • Have IMR as part of their job description • Receive PROTECTED time for training, preparing for sessions, and completing necessary documentation • Receive weekly supervision • Have accountability for providing IMR

37. IMR coordinator/program leader is critical • IMR coordination is part of job description • A specific portion of their time is designated to devote to IMR coordination • Receives training in IMR & works with some consumers • Supervises IMR practitioners • Establishes and monitors methods for referring consumers to IMR • Monitors program quality

38. Closing Thoughts “Having strategies for coping with mental illness is extremely important. It’s hard to enjoy your life if you are constantly sick with mental illness…” “…however, believing in yourself, having hope that things will continue to get better and looking forward to your future are also vital in overcoming mental illness. Our hopes and dreams are not delusions. Our hopes and dreams are what make us human.” David Kime, artist, writer, floral designer, person in recovery from bipolar disorder.

39. Iowa Recovery Initiatives

40. Iowa “Recovery”- oriented initiatives • IAPSRS / USPRA • International Association of Psychosocial Rehabilitation Services, recently renamed U.S. Psychiatric Rehabilitation Association • Wellness Recovery Action Plan (WRAP) trainings • NAMI’s “Peer to Peer” program • IPR - Intensive Psych Rehab Consumer • Resource and Outreach Project • Iowa PEERS • Recovery, Inc. • Many others

41. WMR Technical Assistance Center • Supported by MBC – Community Reinvestment • Collaboration between ICMH and North East Iowa CMHC • Steering Committee • ICMH, Patrick Smith, Brenda Burke, Virginia Liedel • Mary Hughes

42. Recasting Terms and Goals • Initial intent was to pilot IMR model • Renamed IMR to WMR: Wellness Management and Recovery • Recast goals • Provide a forum for recovery initiatives • Speaking with a more unified voice • WRAP trainings

43. WRAPWellness Recovery Action Plans • WRAP training • Level I • Level II • Level III • Goal in year 1: expose 100 individuals statewide

44. Year 2 goals and activities • Continue to support Statewide Advisory Board • Morph into an Alliance for Recovery in Iowa? • Expand executive steering committee • Develop “Support and Education” Component • White paper • More “level 1” WRAP trainings

45. Support and Education Component • Ongoing organization, coordination, education, and support of consumer educators • Curriculum development and refinement • Quality Assurance methods • Dissemination to stakeholders

46. Recovery initiatives as “bottom up” evidence-based practices • Specify target population • Specify target outcomes • Methods to assess achievement of outcomes • Manualization • Replicability across sites • Fidelity Assessments

47. Why move towards an evidence-based culture? • Optimize outcomes • Optimize Value (Outcomes / Cost) • Not waste scarce resources on ineffective practices • Put relatively more of available resources into more effective practices • Advance the practice • Continually translate experience into knowledge • Allow for sharing of experience and knowledge • Have a system that learns

48. Sponsors and Partners • Community Mental Health Block Grant • Feds – SAMHSA, CMHS • Iowa – DHS, Mental Health Planning Council • University of Iowa College of Medicine • Department of Psychiatry • Telemedicine Resource Center • Magellan Behavior Care of Iowa • State Public Policy Group • ACT Center of Indiana