American Psychological Association Recovery to Practice Initiative Curriculum: Reframing Psychology for the Emerging Health Care Environment 9. Interventions III: Promising or Emerging Practices and Supporting Services NOTE: There are three Interventions modules. They are designed to be used together and are not intended to be used separately or as stand alone modules August 2014 1 Contents Overview .............................................................................................................................................. 3 Learning Objectives ............................................................................................................................ 4 Resources .............................................................................................................................................. 4 Required Readings .............................................................................................................................. 4 Activities ............................................................................................................................................... 5 Lecture Notes ....................................................................................................................................... 6 Introduction ..................................................................................................................................... 6 Promising or Emerging Practices .................................................................................................. 7 Medication Management or Medication Adherence, also known as Illness Management and Recovery ............................................................................................................................... 7 Cognitive Enhancement: Cognitive Remediation and Social Cognition Training ............ 9 Psychosocial Treatments for Recent Onset Schizophrenia ................................................. 10 Peer Support and Peer Delivered Services ............................................................................ 12 Supporting Services ...................................................................................................................... 13 Motivational Interviewing ....................................................................................................... 13 Supported Housing .................................................................................................................. 14 Supported Education ................................................................................................................ 15 Interventions to Provide Trauma Informed Care ................................................................. 16 Smoking Cessation .................................................................................................................... 21 Health Education ...................................................................................................................... 22 Clubhouses, Drop-in Centers, and Recovery Education Centers ...................................... 23 Leisure Services ......................................................................................................................... 24 Personal Life/Daily Living Skills ............................................................................................ 25 Challenges ...................................................................................................................................... 25 Summary ........................................................................................................................................ 26 Sample Learning Activity ................................................................................................................ 27 Sample Evaluation Questions ......................................................................................................... 28 Lecture Notes Citations .................................................................................................................... 30 Additional Resources ....................................................................................................................... 42 Citing the Curriculum ...................................................................................................................... 43 2 Overview This is the third of three modules on Interventions. The three modules are designed to be used together; they cannot stand alone as the content of any one is not sufficient to understand or provide Psychosocial Rehabilitation (PSR) interventions. In Interventions I, the guiding principles that underlie the provision of all PSR services are discussed along with an integrative framework model that can be used to coordinate PSR services. The guiding principles are essential for the successful implementation of the interventions discussed in Interventions II and Interventions III. In Interventions II, interventions that have been proven through empirical research to achieve specific outcomes are presented; these are known as evidence based practices (EBPs). In Interventions III, interventions that have shown promise of achieving specified outcomes are presented; these are known as promising or emerging practices. Interventions III also presents supporting services that are widely acknowledged to be essential services for helping people recover from the effects of serious mental illness. Importantly, research evidence has been accumulating that an integrated approach that combines multiple interventions within a recovery oriented context may be the most effective approach (Lyman, Kurtz, Farkas, George, Dougherty, et al., 2014; Spaulding & Deogun, 2011) and scholars are increasingly calling for such an integrated, recovery oriented system (Davidson & Chan, 2014). Such an approach must be targeted to the unique needs of each individual including those in forensic and criminal justice systems (Epperson, Wolff, Morgan, Fisher, Frueh & Huening, 2011; Strauss, 2014). In addition, it has become apparent that cognitive impairment is likely at the heart of the functional skill deficits so commonly experienced by people with serious mental illnesses (Harvey, & Penn, 2010) leading to the conclusion that integrated approaches should include cognitive enhancement approaches as a fundamental component (Pfammatter, Brenner, Junghan & Tschacher, 2011; Roder, Mueller & Schmidt, 2011) and underscores the importance of social cognition for improving community functioning. Indeed, some have stated that including cognitive remediation “may result in a magnitude of change that exceeds that which can be achieved by targeted treatments alone” (Pinkham & Harvey, 2013, p. 499). Notwithstanding the above, each of the EBPs, promising practices, and supporting services are discussed separately in the interventions modules (Interventions II and Interventions III) because as of the publication date of this curriculum, no definitive combination of approaches has been determined to be most effective, although some combination of cognitive therapies (cognitive remediation, social cognition training, cognitive behavioral therapy), supported employment, psychoeducation (client/family approaches, illness management approaches), and social and communication skills training, seems to be most promising. As the research literature evolves, additional interventions, especially those that contain a cognitive or learning component, may be identified as critically important. Furthermore, identification of which interventions work best for whom, under which 3 conditions, at which stage of illness, and potentially at which age of each individual, may lead to the development of personalized approaches tailored for each individual. Learning Objectives At the end of this module you will be able to:  Define promising / emerging practices and identify at least three promising or emerging practices identified in the PORT study  Define Supporting services and identify at least three supporting services described in this module  State at least two reasons why supporting services are important adjuncts to the EBPS and promising/emerging practices  Identify at least three challenges faced by psychologists and other practitioners who advocate for provision of the promising practices and supporting services Resources  Lecture Notes  Required Readings  Lecture Notes Citations  Sample Learning Activity  Sample Evaluation Questions  Additional Resources Required Readings Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., et al. (2010). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin, 36, 1, 48-70. Miller, W. R. & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 6, 527-537. Mueser, K. T., Lu, W., Rosenberg, S. D. & Wolfe, R. (2010). The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis. Schizophrenia Research, 116, 217-227. Yung, A. R., 2012). Early intervention in psychosis: Evidence, evidence gaps, criticism, and confusion. Australian & New Zealand Journal of Psychiatry, 46, 1, 7–9. 4 Activities Complete the following activities:  Read the lecture notes  Read the required readings  Engage in a learning activity related to this module  Evaluate students’ understanding of this module. 5 Lecture Notes People with lived experience of serious mental illness are strongly encouraged to be part of the delivery of the curriculum including being active participants in the delivery of the lecture. Refer to the curriculum Instruction module for additional information. Introduction As described in previous modules, studies over the past several decades have shown that many people with serious mental illnesses can and do recover when they are provided with supports and services that assist them to gain the skills needed to live a satisfying and productive life. Users of mental health services have consistently said that they want the same things for themselves that every citizen wants: a family, a safe place to live, meaningful activities, adequate income, job satisfaction, and an enjoyable social life. Where children and youth are concerned, the same is true: families seeking services for children with mental health concerns want services that promote the development of competencies, and functional lifetime outcomes (Bellonci, Jordan, Massey, Lieberman, Zubritsky & Edwall, 2012). For people with serious mental illnesses, attainment of life goals often requires substantial assistance in the form of specially designed psychosocial rehabilitation (PSR) services. While some people with serious mental illness may recover without assistance, many are unable to recover sufficiently to achieve the quality of life that they desire without these specialized services (Silverstein, 2000). Several of these specialized services have been shown in multiple randomized clinical trials to be highly effective; these are known as evidence based practices (EBPs). In addition to the EBPs that have been proven to help people learn the skills they need to live satisfying lives, there are services that have an emerging evidence base. These are known are promising practices. There are also services that people with lived experience of mental illness cite as important and helpful. These are known as supporting services. Both of these categories of services, promising and supporting, are reviewed in this third Interventions module. It is important to keep in mind that none of the interventions are suggested as a “cure” for serious mental illness. Rather these interventions are a means to inform individuals and their families about the illness and to help individuals achieve the life goals they have for themselves. It is also important to keep in mind that all interventions must be provided within a recovery oriented framework and perspective that is person centered, draws on the strengths and capabilities of the individual, and is oriented to the goals of the person served (Davidson, 2010; Mueser, 2012). 6 Promising or Emerging Practices In addition to the EBPs reviewed in the second Interventions module, the PORT study also indicated that reviews of treatments focused on medication management or adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services do not yet have enough evidence to merit a recommendation as an EBP. However, each of these is an emerging area of interest and each is currently undergoing considerable research and shows promise as an emerging promising practice. These PSR practices are reviewed below. Medication Management or Medication Adherence, also known as Illness Management and Recovery Medication is used by many individuals with serious mental illness to help decrease symptoms of the illness. Management of the dosage and side effects is a critically important aspect of a person’s decision to continue to use prescribed medications. Medication is a potentially important and yet often difficult component of most treatment regimens. Taking medications, for a variety of reasons (side effects, weight gain, health concerns, etc.) can be difficult and for some individuals, non-adherence to prescribed medications may result in relapse. As a result, identifying ways to assist those prescribed medication to adhere to the treatment can be important. However, to date, there are not sufficient data to support any of the interventions designed to maintain adherence. Approaches tailored to the needs of the individual and that involve the person, his or her family, and clinicians, offer the best success to date. The consumer’s concerns and preferences must be an integral part of the overall process. Use of medication should be driven by the evidence base for psychotropic medications, taking into account knowledge from the most recent research literature (Buchanan, Kreyenbuhl, Kelly, Noel, et al., 2010) and the emerging literature showing initial results related to long term use of these medications (Harrow & Jobe, 2007; Harrow & Jobe, 2013; Harrow, Jobe & Faull, 2012; McGorry, Alvarez-Jiminez & Killackey, 2013; Wunderlink, Nieboer, Wiersma, Sytema & Nienhuis, 2013). A widely used approach consists of teaching illness management skills and usually involves a series of sessions where mental health providers help individuals with serious mental illness learn a broad range of coping strategies for living with their mental illness. Illness Management and Recovery (IMR) (Gingerich & Mueser 2011) consists of combining a set of specific EBPs for teaching people with serious mental illness how to manage their disorder in collaboration with professional staff and family members in order to achieve their own recovery goals. The coping strategies taught in most illness management programs are a subset of those utilized in other EBPs and are designed to help individuals build healthy, wellness oriented lifestyles. Programs usually run for three to six months and consist of educational and skills building sessions. Programs are designed so that family members can also attend, with permission of the individual. 7 Several programs have been developed to help individuals learn the skills they need to take charge of their illness including its symptoms and its management. In addition to IMR, a peer led approach is the Wellness Recovery Action Plan (WRAP) (Copeland, 2002). WRAP and other programs that teach illness management and wellness skills have been found to help individuals feel more empowered to take charge of their illness, feel more hopeful and experience enhanced quality of life (Cook, Copeland, Jonikas, Hamilton, Razzano, et al., 2012). WRAP has also recently been found to reduce individuals’ perceived need for, and use of, mental health services (Cook, Jonikas, Hamilton, Goldrick, Steigman, et al., 2013), confirming the importance of peer led illness management groups in combination with other EBPs. Research on illness management programs indicates that provision of several key components, especially when utilizing a peer co-facilitator, can help those with serious mental illness reduce the severity of symptoms and cope better with the symptoms they have (Merinder, 2000; Mueser, Bond & Drake, 2001; Mueser, Corrigan, Hilton, Tanzman, et al., 2002). These components include:  Psychoeducation  Behavioral skills to learn how to take medication as prescribed and follow the medication regimen  Cognitive behavioral strategies to assist with symptom management. Topics covered in an illness management program include:  Recovery strategies  Practical facts about mental illness  The stress-vulnerability model and coping strategies  Building social support  Reducing relapses  Using medication effectively  Coping with stress  Coping with problems and symptoms  Getting one’s needs met in the mental health system (Mueser, Deavers, Penn & Cassisi, 2013) Because of the breadth of the topics covered, and the short duration of most programs (3 - 6 months), in-depth training in any one of them, is not possible. As a result, most individuals will also benefit from other EBPs that provide greater coverage of given topics. 8 Cognitive Enhancement: Cognitive Remediation and Social Cognition Training Neuropsychological functioning is often negatively affected in people with serious mental illnesses, resulting in impaired thinking ability and inability to function well in social, educational, and work settings. The phrase “social cognition” encompasses several components of neuropsychological functioning most notably those associated with one’s ability to perceive cues related to social interaction such as perception of another’s affect and to empathize with another person, and an ability to pick up on social cues. As noted in the Overview of this module, “…it has become apparent that cognitive impairment is likely at the heart of the functional skill deficits so commonly experienced by people with serious mental illnesses (Harvey, & Penn, 2010) leading to the conclusion that integrated approaches should include cognitive enhancement approaches as a fundamental component (Pfammatter, Brenner, Junghan & Tschacher, 2011; Roder, Mueller & Schmidt, 2011) and underscores the importance of social cognition for improving community functioning. Indeed, some have stated that including cognitive remediation “may result in a magnitude of change that exceeds that which can be achieved by targeted treatments alone” (Pinkham & Harvey, 2013, p. 499).” Cognitive remediation has been shown to improve neuropsychological functioning and life skills outcomes in social, educational, and employment settings by improving cognitive functioning. Recent studies have led to the conclusion that cognitive remediation holds the greatest promise when delivered in conjunction with other rehabilitation interventions such as supported employment. Importantly, in order to impact on aspects of social cognition (also important in a variety of settings such as work, education, social interactions, etc.), cognitive remediation has been found especially effective when combined with social cognition training which includes emotional processing skills and affect recognition, illness management skills, attributional bias and mentalizing exercises (Horan, Kern, Tripp, Hellemann, et al., 2011; Kurtz & Richardson, 2012; Lindenmayer, McGurk, Khan, Kaushik, Thanju, et al., 2013; Roder, Mueller & Schmidt, 2011). Cognitive remediation programs generally provide computer assisted training exercises designed to help clients re-learn cognitive skills aimed at improving learning, memory, attention, concentration, and executive functions that control and regulate adaptive abilities and behaviors, such as initiating, monitoring and changing behavior as needed. Several studies have found increased cognitive functioning after remediation efforts (Anaya, Martinez, Ayuso-Mateos, Wykes, Vieta, & Scott, 2012; Fisher, Holland, Subramaniam & Vinogradov, 2009; McGurk, Twamley, Sitzer, McHugo, et al., 2007; Pfammatter, Junghan & Brenner, 2006; Wykes, Reeder, Landau, Everitt, et al., 2007) and some studies have found enhanced employment outcomes when cognitive remediation is paired with supported employment (Lindenmayer, McGurk, Mueser, Kahn, et al., 2008; McGurk, Mueser & Pascaris, 2005), although one recently published study found these effects mainly for those with lower community functioning capability (Bell, Choi, Dyer & Wexler, 2014). Recently evidence has begun to accumulate which indicates that emotional distress and negative 9 symptoms may also be positively impacted (Sanchez, Pena, Bengoetxea, Ojeda, Elizagarate, et al., 2014). Other studies have found only small effects of cognitive remediation efforts on neuropsychological or functional outcomes (Dickinson, Tenhula, Morris, Brown, et al., 2010). Because of the importance of the range of neuropsychological processes for attainment of one’s life goals, this is an important area where more research is needed to identify the conditions under which maximum benefit can be obtained from these interventions. Psychosocial Treatments for Recent Onset Schizophrenia Although serious mental illnesses can strike adults in the prime of their lives, these illnesses most frequently strike young people between the ages of 15 and 26 (Dickinson, Tenhula, Morris, Brown, et al., 2010), with a median age at which symptoms first appear of 14 (National Health Policy Forum, 2009). Often, people with serious mental health and substance use disorders become ill early in their lives when the skills needed for success in life are just developing. When this happens, thinking ability is often severely compromised because of the negative effects these disorders have on cognitive processing capabilities. Education and work are disrupted, and often stopped completely along with the ability to form meaningful relationships with family and friends. Frequently, there is a period of symptomatology that occurs before full blown psychosis develops. This period has been called the “prodromal period”, and those in this state have been said to be at “ultra high-risk”, or to be experiencing an “attenuated psychosis syndrome” (Yung, Woods, Ruhrman, Addington, Schultze-Lutter, et al., 2012); the rate of onset of a psychotic disorder has been shown to be thirty six percent within three years (Fusar-Poli, Bonoldi, Yung, Borgwardt, Kempton, et al., 2012). Recently, clinical staging models have been applied to those with mental health disorders in an effort to help clinicians identify the best course of action for those who may not have progressed to full blown psychosis and to help prevent progression (Cross, Hermens, Scott, Ottavio, McGorry & Hickie, 2014; Hickie, Scott, Hermens, Naismith, Guastella et al., 2013). Previous models have focused on symptoms usually seen in early stages of illness such as anxiety and depression but do not account for the symptoms that may indicate signs of more serious illness. Innovatively, the model described by the authors above incorporates a range of symptoms and syndromes within a single staging model, thus allowing for attention to potential developing psychosis. Although there are many factors that influence functional outcomes, there is growing evidence that early intervention with pharmacologic and psychosocial interventions during the first episode of psychosis may lead to improved outcomes (Baksheev, Allott, Jackson, McGorry & Killackey, 2012; Bertelsen, Jeppesen, Petersen, Thorup, et al., 2008; Bird, Premkumar, Kendall, Whittington, et al., 2010; Ehmann, Yager & Hanson, 2008; Marshall & Rathbone, 2011; Tandon, Keshavan & Nasrallah, 2008) and may prevent or delay relapse (Álvarez-Jiménez, Parker, Hetrick, McGorry, et al., 2011). Early intervention programs 10