Evidence-Based Practices in Mental Health: Ready or Not

Report
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
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
Stated Objectives

Core components of model

Evidence base for effectiveness

Extent of implementation

Barriers to implementation and
strategies to overcome them
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
Clarification of terms
What do we mean by…

Illness Management?

Recovery?

Illness management and Recovery
(IMR)

Wellness management and Recovery
(WMR)
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 and Recovery:
A Review of the Research
Psychiatric Services 53: 1272-1284, 2002
Professional vs. Peer-Based Illness
Management

Complementary?

Hierarchical vs. non-hierarchical

Responsibility for care vs. sharing of
personal experience
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 and Recovery:
A Review of the Research
Psychiatric Services 53: 1272-1284, 2002
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
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
Key Recovery Concepts

Hope

Personal Responsibility

Self Advocacy

Education

Support
Mary Ellen Copeland, MA, MS
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, selfconfidence, enjoyment, well-being, &
optimism
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
Evidence for Effectiveness of “Illness
Management” for Adults with SMI
Summary of Results from Review of 40
Randomized Controlled Trials
Components
Outcome(s)
Psycho-education
Improves knowledge of mental
illness
Behavioral Tailoring
Helps people take medication as
prescribed
Relapse Prevention
Programs
Reduce symptom relapses and rehospitalizations
Coping Skills Training
Reduces the severity and distress
(Cognitive - Behavioral) of persistent symptoms
Mueser et al, Psychiatric Services 53: 1272-1284, 2002
Illness Management and Recovery
(a la National EBP Project)
Michelle Salyers, Ph.D.
ACT Center of Indiana
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
Overarching Goals of IMR

Inspire people to become hopeful about their
recovery

Prepare people to be informed decisionmakers 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
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
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
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
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
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
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
For Each Module

Educational handout for consumer

Practitioners’ guidelines for clinician
Teaching Strategies

Motivational

Educational

Cognitive-Behavioral
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
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
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 evidencebased interventions
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
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
Preliminary results

Pre-post sample too small to examine
yet (6 complete so far)

Interviews were very positive about
IMR experiences
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.”
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?”
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
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
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
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
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.
Iowa Recovery Initiatives
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
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
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
WRAP
Wellness Recovery Action Plans


WRAP training

Level I

Level II

Level III
Goal in year 1: expose 100
individuals statewide
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
Support and Education Component

Ongoing organization, coordination,
education, and support of consumer
educators

Curriculum development and
refinement

Quality Assurance methods

Dissemination to stakeholders
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
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
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

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