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Promoting Recovery With Proven Solutions

By Steve Herndon

SAMHSA's Center for Mental Health Services (CMHS) is currently sponsoring a national project to promote the widespread adoption of six evidence-based practices (EBPs)—treatments that have consistently proven to generate positive outcomes for adults with serious mental illness. Specifically, project teams are working to develop, test, revise, and disseminate comprehensive resource toolkits that will enable practitioners to replicate EBPs successfully and reap the benefits in community settings.

In 1998, during a consensus panel convened by the Robert Wood Johnson Foundation, representatives from all major stakeholder groups first identified these six EBPs as the most effective:

Assertive community treatment
Illness management and recovery skills
Standardized pharmacological treatment
Family psychoeducation
Supported employment
Integrated treatment for co-occurring mental illnesses and substance use disorders.

Illness Management and Recovery Resource Kit

Two years later, researchers at the New Hampshire-Dartmouth Psychiatric Research Center requested funding to create toolkits for each practice, and CMHS gladly obliged. With additional support from a broad coalition of organizations (see "Widespread Support"), the proposal has evolved into the National Evidence-Based Practices Project.

This initiative—and EBPs in general—are especially vital for mental health professionals who work in an era defined by increased accountability, constrained budgets, and a growing demand for more effective services.

Developing Toolkits

"The Dartmouth proposal was attractive to us for several reasons," said CMHS Acting Director Gail Hutchings, M.P.A. "They were giving us a chance to put in manual form the exact components of the six most effective interventions. And, they demonstrated a commitment to reaching all stakeholders. This is critical to what we're trying to achieve—the widespread adoption and use of evidence-based practices."

For 2 years, representatives from major stakeholder groups were heavily involved in Phase I of the project. They produced and revised instructive guides, manuals, videos, presentations, scales for measuring fidelity to the models, and several other pieces that offered guidance to practitioners, consumers of mental health services and their families, administrators, and other audiences.

Paul Gorman, Ed.D., Director of the West Institute at New Hampshire-Dartmouth, managed the process of collecting stakeholder input and gathering information for the toolkits. "Consumers [of mental health services] and family advocates changed the way we talk about the six interventions," he said. "They brought a set of life experiences and perspectives to the table that many of us simply don't have."

"For our [co-occurring disorders] kit, we encouraged consumers and family members to do as much writing as possible for materials targeting their respective groups," said Robert Drake, M.D., Professor of Psychiatry and Community and Family Medicine at Dartmouth and coordinator of the Psychiatric Research Center team. "Our researchers mainly provided guidance and polished text for accuracy."

The toolkits are without question the heart and soul of the EBP project. Right now, they're being put to the test.

Gauging Effectiveness

Phase II—started in September 2002—is a 3-year evaluation process to measure the effectiveness of the toolkits. Eight pilot states will evaluate at least one of five toolkits in more than 50 community mental health programs. The medication management toolkit is not included in the state evaluations.

Specifically, states will determine how well the toolkit materials accomplish their intended goals of training clinicians, educating consumers and their families, and helping administrators adopt the practices in their mental health systems. Where possible, states will also record barriers and solutions they discover.

Medication Management Approaches in Psychology Resource Kit

Each pilot state will create a mechanism to coordinate training and support the chosen communities. As the main Coordinating Center, Dartmouth's Psychiatric Research Center will train individuals chosen to help states during implementation and evaluation. The Psychiatric Research Center will also provide each state with identical evaluation design and data collection instruments to enhance the accuracy of multi-site analyses.

Targeting Challenges

Team members for the project fully expect to encounter some difficulties in gaining nationwide acceptance of their evidence-based publications. "The simple inertia of existing systems can be a major barrier," said Crystal Blyler, Ph.D., social science analyst, CMHS Division of Service and Systems Improvement. "A lot of systems have been delivering treatment the same way for so long that it will take a lot of effort, money, and training to change direction."

Reimbursement is another key issue. "It is imperative that we generate a willingness among insurers like Medicaid to pay for and encourage the statewide use of evidence-based practices," said Ms. Hutchings. She believes the toolkits will be a valuable, tangible blueprint that helps insurers see the benefits of supporting EBPs within the care delivery system.

Shaping the Future

Phase III of the National EBP Project—slated to begin in 2005—will make refined versions of the toolkits widely available to all states. In the meantime, stakeholders will explore the addition of other promising treatments and services as potential EBP candidates. Many researchers and administrators are hopeful that treatments for children and adolescents will be next.

Several initiatives are also now underway to augment the efforts of the National Project and usher EBPs into the mainstream. For instance, SAMHSA's longstanding Community Action Grants continue to help communities build consensus, use toolkits, and explore other exemplary practices. SAMHSA and the National Institute of Mental Health are spearheading a joint project that gives states funding to plan for the implementation of EBPs. In addition, SAMHSA will award 3-year grants to up to nine states beginning in September for training and evaluation efforts.

Assertive Community Treatment Resource Kit

The National Association for State Mental Health Program Directors Research Institute established a Center for Mental Health Quality and Accountability, funded in part by CMHS, to serve as a resource for states and to coordinate the state-level evaluation of the national EBP Project. In addition, the Center is supporting a consortium of other states working on their own EBP initiatives in parallel with the eight pilot states.

"We want to develop and support models so that the mental health field can shift to a new way of doing business—even in an era of budget constraints," said the Center's Director, Vijay Ganju, Ph.D. "We want to determine what must happen within our current system to make evidence-based practices part of the norm."

The continuing shift to evidence-based practices exemplifies the Science-to-Services philosophy championed by SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "EBPs respond to demands from stakeholders for proven, cost-effective treatments," he said. "They provide clear, step-by-step direction for delivering treatments in community settings. And they help give consumers genuine hope for optimal recovery and fulfilling lives beyond mental illness."

For more information, contact SAMHSA's National Clearinghouse for Mental Health Information, P.O. Box 42490, Washington, DC 20015. Telephone: 1 (800) 789-2647 or 1 (866) 889-2647 (TTY). Or, visit www.mentalhealth.samhsa.gov.

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