National Council magazine 2009, Issue 2
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National Council magazine 2009, Issue 2



If we truly value an improved quality of life for all Americans, we can no longer afford to overlook prevention and early intervention in behavioral health. National Council Magazine profiles member ...

If we truly value an improved quality of life for all Americans, we can no longer afford to overlook prevention and early intervention in behavioral health. National Council Magazine profiles member programs in prevention–early intervention for mental and substance use disorders, examining a broad range of initiatives — public education, screening in primary care, school-based initiatives, suicide prevention, employee assistance programs, and more. The magazine also features the views of policy and clinical experts on why prevention-early intervention is critical as we attempt to piece the healthcare puzzle together.



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National Council magazine 2009, Issue 2 National Council magazine 2009, Issue 2 Document Transcript

  • A quarterly publication from the National Council for Community Behavioral Healthcare 2009, Issue 2 nationalCouncil magazine sharIng Best PractIces In Mental health & addIctIons treatMent Prevention and Early Intervention for Mental & Addiction Disorders the time is right, Page 2 Mental health First aid, Page 14 geoffrey canada on his harlem Miracle, Page 20 It takes a community, Page 24 From the Field, Page 30
  • INSPIRED SOLUTIONS NEW DIRECTIONS COOL CONNECTIONS 40th National Mental Health and Addictions Conference & Expo March 15-17, 2010 Disney’s Coronado Springs Resort Florida Register and reserve your hotel now! Call for Papers open through Sept 15, 2009. | 202.684.7457
  • PDF available at nationalCouncil M A G A Z I N E PolIcY PersPectIVes 2 Prevention and Early Intervention: The Time is Right Editorial by Linda Rosenberg National Council Magazine, 2009, Issue 2 4 Point/Counterpoint: Prevention — What Does It Really Save? Media Excerpts Prevention and early Intervention for 6 IOM Report on Prevention and Carl Bell Interview Mental & addiction disorders Meena Dayak, Chris Loftis 10 Saving Jobs, Saving Public Dollars Mental illnesses and addiction disorders remain an Vidhya Alakeson unsolved mystery to many. Against the backdrop of stigma, 12 Call to Include Prevention in Healthcare Reform lack of access to quality care, and funding constraints, SAMHSA Core Consensus Principles prevention-early intervention remains the missing piece of the puzzle. It’s the piece that completes the equation of total care for those we serve and commitment to improve the communities we live in. Many community-based healthcare organizations have been operating model programs in prevention–early intervention p.14 for mental and substance use disorders with impressive outcomes. These programs reach a range of populations — children, youth, older adults, veterans, and persons already eVIdence-Based earlY InterVentIons diagnosed with one form of mental illness or addictions who 14 Mental Health First Aid Educates and Transforms Communities may be at risk for other disorders. The programs comprise Lea Ann Browning McNee, Susan Partain a broad range of initiatives—public education, screening in 20 Geoffrey Canada on His Harlem Miracle primary care, school-based initiatives, suicide prevention, Meena Dayak, Chris Loftis employee assistance programs, and more. This issue of 22 Nurse-Family Partnership: Effective and Affordable National Council Magazine profiles some of these model Peggy Hill programs and features the views of policy and clinical 24 It Takes a Community experts on why prevention-early intervention is important as William R. McFarlane, Donna Downing, Anita Ruff we attempt to piece the healthcare puzzle together. 26 A Long-term Approach to Early Psychosis Intervention Tamara Sale, Ryan Melton 29 SBIRT: Effective Interventions for Alcohol-Related Health Problems Maureen Fitzgerald FroM the FIeld 30 Getting a Head Start on Mental Health: Children’s Programs National Council Magazine is published quarterly by the National Council for Community Behavioral Healthcare, 36 Saving Our Future: Youth Substance Use and Suicide Prevention 1701 K Street, Suite 400, Washington, DC 20006. 44 Across the Spectrum: Working with Special Needs Populations Editor-in-Chief: Meena Dayak targetIng hIgh-rIsK PoPulatIons Specialty Editor, Prevention and Early Intervention: Chris Loftis 50 HOPE for Homeless Youth and Families Editorial Associate: Nathan Sprenger Nisha Beharie, Mary McKay, Kosta Kalogerogiannis Editorial and advertising queries to 54 InSHAPE: Promoting Wellness, Saving Lives or Ken Jue interviewed by Laura Galbreath 202.684.7457, ext. 240.
  • Policy Perspectives ditorial Prevention and Early Intervention: The Time is Right linda rosenberg, MsW, President & CEO, National Council for Community Behavioral Healthcare E pic arguments are being waged regarding the pros and cons of disease prevention. However, few, if any, are offering serious insight as to how to address the host of mental health disorders estimated to affect 14 to 20 percent of America’s young people in any given year. A perfect storm is brewing, exacerbated by a troubled economy, rising unemployment, increasing bankruptcies and home foreclosures, and dwindling funds for programs. Dismal realities affect families and threaten the mental health of our nation’s youth. Saving money Passionate exchanges tout the medical benefits is important, however, and lives saved through the early detection of breast cancer, stroke, and heart disease, while the bottom line should include the stigma surrounding mental illness persists. safeguarding a quality of life. Workplace shootings, familicides, and the overdose live a “normal” life. deaths and suicides of notable celebrities prompt According to the March their wake. The Early Detection and Intervention for frequent news coverage, with discourse on preven- 2009 Institute of Medicine (IOM) report brief for the Prevention of Psychosis Program, a national ef- tion and early detection in an everyday setting tak- policymakers: Preventing Mental, Emotional, and fort launched by the Robert Wood Johnson Founda- ing a noticeable backseat. The public interprets the Behavioral Disorders Among Young People, Progress tion and spearheaded by program director, William message: the mentally ill aren’t safe to be around. and Possibilities, evidence-based approaches are R. McFarlane, MD, estimates the cost to society As a result, would-be-patients fly below the radar proving to prevent certain mental health disorders, to be higher than $10 million over the lifespan to avoid detection. Without the increased use of and limit risk factors, and are likely to be far more of a person who has schizophrenia. The National prevention strategies that are scientifically proven cost-effective at addressing mental, emotional, and Council supports early intervention, before costs to work, and a correspondingly swift uptick in early behavioral disorders (MEBs). escalate and the prospects of a happy, healthy life detection efforts and community awareness and Most MEB disorders erupt during childhood and disintegrate. The ensuing discussions beg the ques- education in national media, mental disorders con- adolescence. The IOM report suggests that the tion — just how much is an improved quality of life tinue to fester like an undetected cancer. “window of opportunity” when symptoms first ap- worth these days? The discussions regarding preventative healthcare pear, typically 2 to 4 years before the onset of the The National Council recognizes that the issue are more than politically fueled punditry about disorder, is the prime time when prevention strat- reaches beyond the bread and butter aspects of dollars and cents. Saving money is important, how- egies have the most impact. Persons with mental healthcare, and becomes muddled when editori- ever, the bottom line should include safeguarding health disorders have usually been identified only als sound the alarm of diagnosing millions with a quality of life. When it comes to mental health- after they dropped out of school, and shuffled a disease that requires treatment. An op-ed piece care, or lack thereof, individuals and their families through the criminal justice system, and multiple by David Harsanyi in The Denver Post insists that are hoping for anyone to throw them a lifeline, to hospitals, leaving extraordinary healthcare bills in expanding the definition of diseases such as dia- 4 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • betes, high cholesterol, and osteoporosis, has already tion of Psychosis Program uses evidence-based in- needs to move from laboratory settings to real world placed millions more Americans at the swelling terventions that help youths succeed, without stigma, settings, and must be responsive to community so- healthcare trough. The idea that patients shouldn’t before they experience the negative effects of a fully cioeconomic needs, diversities, values, and goals. The be identified for having a disease, or the potential to developed mental illness. IOM report also cautions that funding should not sup- develop one, is a precarious one, especially for men- Geoffrey Canada’s Harlem Children’s Zone, launched port programs that lack empirical evidence, despite tal health. Sweeping mentally ill patients under the in 1970 as a community-based truancy prevention their popularity within communities. carpet has been going on for years and has hindered program, has grown to include diverse programs and Identifying children with risk factors: Screenings even the most ardent efforts of dedicated mental serve more than 10,000 youth. The proven results — in can be a helpful tool if parents and communities are health professionals. Harsanyi is blunt — end of life 2008, nearly all students in third and eighth grade in aware of the purposes and methods of screenings, care is costly, and free will overrides the patient’s de- HCZ charter schools outperformed the average New and have the ability to decline if they do not want cision to follow the doctors’ advice anyway. Part of the York student in math. their children included. But all families can learn to stigma plaguing mental illness is the notion that one be aware of warning signals for teen depression, for College Dreams, an alcohol and drug prevention pro- can simply “snap out of” depression, or that persons example, and to distinguish between signs of impend- gram in Oregon, has saved thousands of youth from “choose” to be mentally ill. ing psychosis, and teenage angst that falls within the school dropout, substance abuse, and delinquency. Chicago Tribune reporter Carla Johnson acknowledges The program is based on scientific evidence regarding norm of behaviors prompted by the transition from in her article, Disease Prevention Often Costs More the risk factors for substance abuse and the protec- children to teens to young adults. than it Saves, that disease prevention won’t neces- tive factors that lead to long-term success for children Speak up: Programs that work need media attention sarily save money, but that some efforts to prevent who are beset by multiple and severe life adversities. to thrive. Seek out members of the media, distribute illness are necessary. Johnson quotes Robert Gould, press releases, and invite the media and the public to Based on recommendations in the March 2009 IOM president of the nonprofit Partnership for Preven- “community education nights” that highlight preven- report described in further detail in this issue, the tion, saying that “Many of the services that don’t save tion and early intervention efforts that build strong, National Council offers the following suggestions to money, improve people’s lives at relatively low cost.” healthy communities and improve the quality of life. increase public awareness and education efforts, and A “pro-prevention” piece, More Attacks on Prevention to fortify the case for evidence-based research and Society can no longer afford to ignore the risk factors and Its Role in Health Reform That Make No Sense, the use of proven practices regarding prevention and for and the onset of mental illnesses and substance by Kenneth Thorpe in The Huffington Post, cautions early detection: use disorders. Ignoring prevention and early interven- against using “imprecise language” when it comes to Taking charge on a national level: The IOM report tion is issuing a personal invitation to cut a young life policy-making, and strongly supports effective preven- recommends that “the White House create an entity drastically short. tion programs that work simply “because they reach the right people at the right places with the right in- to lead toward a broad implementation of evidence- terventions.” Precisely steering back to that “window based prevention approaches and to direct research With more than 30 years of distinguished service in mental health policy, services, and system reform, Rosenberg is a leading of opportunity” and the value of a healthy mind and a on interventions.” Public goals must be set for pre- mental health expert. Under Rosenberg’s leadership since 2004, sound quality of life. venting specific disorders and promoting mental the National Council for Community Behavioral Healthcare has grown to 1,600 member organizations, employing 250,000 staff health, and funding must be provided to launch and To further illustrate what research reveals, this issue and serving 6 million adults and children in communities across improve evidence-based programs. the country. Prior to joining the National Council, Rosenberg was of National Council Magazine focuses on stories of the senior deputy commissioner for the New York State Office of early intervention success. Dovetail efforts: Many mental disorders have common Mental Health. In addition to responsibility for New York’s state- developmental pathways. Resources must be aligned run adult, child, and forensic hospitals, she tripled New York’s The National Council has helped to bring the ev- assertive community treatment capacity, expanded children’s between the departments of Education, Justice, and idence-based public education program, Mental community-based services, developed an extensive array of Health and Human Services. The National Institutes housing options for people with mental illnesses and addictions, Health First Aid to the U.S. The program has trained of Health should develop a comprehensive 10-year implemented a network of jail diversion programs including New more than 3,000 persons in its first year. Studies show York’s first mental health court, and promoted the adoption of plan to research ways to promote mental health and evidence-based practices and consumer and family programs. A that persons trained in what to do when someone is prevent mental disorders in young people. State and certified social worker, as well as a trained family therapist and experiencing a mental health crisis have a greater psychiatric rehabilitation practitioner, Rosenberg has held faculty local agencies should coordinate efforts and foster a likelihood of actually helping the person, and show appointments at a number of schools of social work, serves on multi-agency approach to ensure a comprehensive numerous agency and editorial boards, and writes and presents a decrease in attitudes that encourage stigma and developmental perspective. extensively on mental health and addictions issues including the misperceptions. impact of organizational and financing strategies on consumer Equality in research funding: At present, a great outcomes. The Early Detection and Intervention for the Preven- deal of research leans toward treatment. Research NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 5
  • Policy Perspectives Perspectives from General Healthcare Point/Counterpoint Prevention: What Does It Really Save? The Myth of Prevention Excerpts from an essay by Abraham Verghese in the Wall Street Journal, June 20, 2009 A doctor explains why it doesn’t pay to stay well. Decoding what works, what falls short in Obama’s plans to reform healthcare. M y wife tried to tell me the other day that she had just “saved” us money by buying on sale a couple of things for which we have no earthly use. She then pro- more in women (since their heart-attack risk is lower)—I don’t see the savings there. plan: despite being an admirer, I just don’t see how the president can pull off the reform he has in mind without cost cutting. I recently came on a phrase in an article in Or take the coronary calcium scans or heart scan, which ceeded to tote up all our “savings” from said purchases most authorities suggest is not a test to be done on the journal “Annals of Internal Medicine” about an axi- and gave me a figure that represented the money we people who have no symptoms, and which I think of as om of medical economics: a dollar spent on medical had generated, which we could now spend... she had the equivalent of the miracle glow-in-the-dark minnow care is a dollar of income for someone. I have been me going for a minute. lure advertised on late night informercials. It’s a money reciting this as a mantra ever since. It may be the single I mention this because I have similar problems with the maker, without any doubt, and some institutions actually most important fact about health care in America that way President Obama hopes to pay for the huge and advertise on billboards or in newspapers, luring you in you or I need to know. It means that all of us—doctors, costly health reform package he has in mind that will for this “cheap” and “painless” way to get a look at your hospitals, pharmacists, drug companies, nurses, home cover all Americans; he is counting on the “savings” that coronary arteries. If you take the test and find you have health agencies, and so many others—are drinking at will come as a result of investing in preventive care and no calcium on your coronaries, you have learned that... the same trough, which happens to hold $2.1 trillion, investing in the electronic medical record among other you have no calcium on your coronaries. If they do find or 16% of our GDP. But reform cannot happen without things. It’s a dangerous and probably an incorrect pro- calcium on your coronaries, then my friend, you have cutting costs, without turning people away from the jection. just bought yourself some major worry. You will want to trough and having them eat less. Prevention of a disease, we all assume, should save us know, What does this mean? Are my coronary arteries We may not like it, but the only way a government can money, right? An ounce of prevention...? Alas, if only narrowed to a trickle? Am I about to die? Is it nothing? control costs is by wielding great purchasing power to such aphorisms were true we’d hand out apples each Asking such questions almost inevitably leads to more get concessions on the price of drugs, physician fees, day and our problems would be over. tests: a stress test, an echocardiogram, a stress echo, a and hospital services; the only way they can control ad- cardiac catheterization, stents and even cardiac bypass ministrative costs is by providing a simplified service, If the prevention strategies we are talking about are be- operations—all because you opted for a “cheap” and yes, the Medicare model (with a 3% overhead), and not havioral things—eat better, lose weight, exercise more, “painless” test—if only you’d never seen that billboard. allowing private insurance to cherry-pick patients. smoke less, wear a seat belt—then they cost very little and they do save money by keeping people healthy. Poor McAllen, Texas. It happens to be the focus of a re- Contrary to what we might think, comparative studies cent “New Yorker” piece by Atul Gawande, a piece that show us that the U.S. when compared to other advanced But if your preventive strategy is medical, if it involves President Obama referred to in his speech to the AMA, countries, does not have a sicker population: We actual- us, if it consists of screening, finding medical conditions because health care costs in McAllen are twice that of ly use fewer prescription drugs, and we have shorter hos- early, shaking the bushes for high cholesterols, abnor- comparable cities while health outcomes are no dif- pital stays (though we manage to do a lot more imaging mal EKGs, or markers for prostate cancer such as PSA, ferent. The reasons are complex but probably because in those short stays—got to feed the MRI machines). The then more often than not you don’t save anything and good physicians are ordering lots of tests, calling in lots bottom line is that our healthcare is costly because it is you might generate more medical costs. Prevention is a of consultants, making good use of the equipment they costly, not because we deliver more care, better care, or good thing to do, but why equate it with saving mon- own and the imaging centers they might have a stake special care. Alas, a solution that does not address the ey when it won’t? Think about this: Discovering high in (and yes, they think they can be objective in order- cost of care, and negotiate new prices for the services cholesterol in a person who is feeling well, is really just ing an MRI or CAT scan that sends the patient to their offered will not work; a solution that does not put caps discovering a risk factor and not a disease; it predicts own facility); it has to do with hospitals competing with on spending and that instead projects cost-savings here that you have a greater chance of having a heart attack each other for the kinds of patients with conditions that and there also won’t cut it. Leaders have to make tough than someone with a normal cholesterol. Now you can are reimbursed well, and wooing patients, wooing high- and unpopular decisions, and if he is to be the first reduce the probability of a heart attack by swallowing a volume physicians (some of whom are invited to invest president to successfully accomplish reform there does statin, and it will make good sense for you personally, in the hospital) to make full use of their PET scan, their not seem to be much choice: cut costs. especially if you have other risk factors (male sex, smok- gamma knife, their robotic-surgery facility, their cancer ing, etc.) But if you are treating a population, keep in center, their birthing center. That was Atul Gawande’s Abraham Verghese is professor and senior associate chair for mind that you may have to treat several hundred people conclusion, and I would concur. the Theory and Practice of Medicine at Stanford University. He to prevent one heart attack. Using a statin costs about is the author of the novel “Cutting for Stone.” $150,000 for every year of life it saves in men, and even Which brings me to my problem with the president’s 6 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • More Attacks on Prevention and Its Role in Health Reform That Make No Sense Excerpts from an article by Kenneth Thorpe and Lydia Ogden in The Huffington Post, June 26, 2009 wo recent newspaper pieces on prevention by Carla reduced absenteeism at work and school, and enhanced all of every Medicare dollar 96 cents of each and every one, T Johnson (Associated Press) and David Harsanyi (Denver quality of life. or more than $447 billion last year and 85 cents out of Post) repeat some long-standing misperceptions about Worksite health promotion programs, too, are effective at every dollar in Medicaid nearly $300 billion go to care for prevention. Because prevention is central to health reform, both primary and secondary prevention. A systematic re- chronic disease, most of which is preventable. In one year, it’s time to set the record straight. view of more than 50 studies meeting rigorous guidelines total, this amounts to approximately $1.7 trillion spent Both the articles suffer from baby-with-bathwater syn- for review by the U.S. Task Force on Community Preventive treating patients with one or more chronic diseases roughly drome, brought on by lumping all kinds of prevention into Services found strong evidence of WHP program effective- 75 percent of all U.S. health care spending. This is essen- one big pot. Imprecise language is dangerous, particularly ness in specific areas: reducing tobacco use, dietary fat tially a hidden tax on every taxpayer in America. Anyone who in the realm of policy-making. It leads to fuzzy thinking and consumption, high blood pressure, total serum cholesterol cares about long-term health spending, particularly govern- that produces bad policy. levels, and days absent from work due to illness or dis- ment health care spending, should support prevention. It’s ability, as well as improve other general measures of worker common sense. Research shows that scientifically sound prevention programs for both individuals and populations improve productivity. At Citibank, for example, a comprehensive Mr. Harsanyi’s argument that we should avoid prevention be- health and save money. Research also shows that ef- health management program showed a return on invest- cause “the longer people hang around, the longer they fective prevention programs are targeted. They work ment of $4.70 for every $1.00 in cost. A similar compre- utilize the healthcare system” and drive up costs is hardly because they reach the right people at the right time in the hensive program at Johnson & Johnson reduced health worth addressing. It’s a bizarre concept that a civilized so- right places with the right interventions. risks, including high cholesterol levels, cigarette smoking, ciety would let people die of preventable causes. And it’s and high blood pressure, and saved the company up to economically inaccurate. Obese and chronically ill Ameri- Prevention can be divided into three parts: Things we do $8.8 million annually. cans tend to live shorter lives, but chronic diseases and to avert disease (primary prevention), like vaccinations for obesity are linked to two-thirds of the growth in U.S. health children or the YMCA diabetes program mentioned in the As far as tertiary prevention goes, there’s evidence of effec- tiveness for that, too. Here’s one of the best: For nearly 25 spending since the mid-1980s. We’re not cutting any cor- article. Things we do to find and treat disease in its earliest ners in health care costs by allowing these people to meet stages (secondary prevention), like mammograms and co- years, senior researchers at the University of Pennsylvania have implemented a series of large, randomized controlled the Grim Reaper earlier. lon cancer screenings. And things we do to avoid complica- tions when people are already ill (tertiary prevention), like trials with high-risk elders. Their studies have demonstrated The other major point both Mr. Harsanyi and Ms. Johnson programs to help older people with multiple chronic condi- that comprehensive tertiary prevention focused particularly miss is the “how” of prevention. How are policymakers tions manage their care at home, like the PACE (Program on transitional care produces better health outcomes and proposing to increase effective prevention inside and out- of All-Inclusive Care for the Elderly) and similar initiatives. significant cost savings. Their most recent research showed side the health care system? Contrary to how their articles Dumping various interventions for various groups together a 56% reduction in readmissions and 65% fewer hospi- describe it, the idea isn’t to insert one-off prevention ef- and concluding prevention doesn’t save money is just plain tal days for patients in transitional care. At the 12-month forts into the existing system. Instead, Congress and the wrong. mark, average costs were $4,845 lower for these patients. president are proposing fundamental changes to the way If this model were scaled nationally with an investment of we deliver prevention, care, and treatment. That means Not all prevention programs work, many because they $25 billion over 10 years, savings could reach $100 billion improving community-based primary and secondary pre- aren’t grounded in science. Not all of them save money. over the same period. vention, strengthening primary care (primary and second- All medical interventions including secondary and tertiary ary prevention), and incentivizing providers and patients prevention cost money. Screening for common and costly The AP article’s Mrs. Jones is 55 years old, obese, and at risk for diabetes. Studies show that in 10 years, when she to better prevent and manage diseases (secondary and diseases, like diabetes, high blood pressure, and high tertiary prevention). In sum: A comprehensive prevention cholesterol, may actually raise spending in the short-term, turns 65 and enters Medicare, the government will spend $20,000-$40,000 more on Mrs. Jones’ health care than plan rather than scattershot, unconnected, and ineffective because people who need treatment will get it. But over the efforts. long-term, that treatment is likely to avert even more costly Mrs. Smith’s, who’s the same age but a normal weight. Over complications, and thereby avoid higher spending. 30% of the recent rise in Medicare spending in the last By preventing costly diseases or better managing them, we decade is associated with the persistent rise in obesity in can help contain our out-of-control health spending. We Many studies show well-designed prevention programs are the Medicare population. The increase in obesity-related can boost productivity. In our troubled economy, we need cost-saving. For example, a significant reduction in total chronic diseases among all Medicare beneficiaries and to do both. Even if it didn’t save money, preventing suffering health care spending is linked to community-based life- particularly among the most expensive 5% is a key factor when we can is the right thing to do. Research, common style interventions (primary prevention). Research shows driving growth in traditional fee-for-service (FFS) Medicare. sense, and ethics all tell us the same thing: An ounce of that savings range from a short-term return on investment Six medical conditions, all related to obesity — diabetes, (science-based) prevention is worth a pound of cure. of $1 for every $1 invested, rising to more than $6 over hypertension, hyperlipidemia, asthma, back problems, and the longer term. An investment of $10 per person per year co-morbid depression account for most of the recent rise Kenneth Thorpe, PhD, is the Robert W. Woodruff Professor and in community-based programs tackling physical inactivity, in spending in the Medicare population. Chair of the Department of Health Policy & Management in the poor nutrition, and smoking could yield more than $16 bil- Rollins School of Public Health of Emory University. He serves as lion in medical cost savings annually within 5 years. This is Chronic disease resulted in more than $987 billion in pri- the executive director of the Partnership to Fight Chronic Disease. a remarkable return of $5.60 for every dollar spent, with- vate spending most of it covered by private health insur- Lydia L. Ogden, MA, MPP, is the chief of staff for the Institute for out considering the additional gains in worker productivity, ance, which means higher premiums for everybody. Nearly Advanced Policy Solutions of the Center for Entitlement Reform at Emory University. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 7
  • Policy Perspectives eatured interview dr. Carl Bell New IOM Report on Prevention Calls for Leadership, Collaboration, and Emphasis on Research Summary of the Institute of Medicine’s report “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” (2009) Based on report briefs and press release at T he federal government should make promotion of mental health in young people a national priority, says a new Institute of Medicine report, “Preventing Mental, Emotional, and Behavioral Dis- orders among Young People.” Mental, Emotional, and Behavioral (MEB) disorders which include depression, anxiety, conduct disorder, and substance abuse are about as likely as frac- tured limbs in children and adolescents; inevitable and not at all uncommon. Almost one in five young people have one or more MEB disorders. Many disorders have life-long effects that include high psychosocial and economic costs, not only for the young people, but also for their families, schools, and communities. Among adults, half of Preventing mental, emotional, and behavioral disorders all MEB disorders were first diagnosed by age 14 among young people may be one of the best investments a and three-fourths by age 24. The financial costs in society can make: The benefits include higher productivity, terms of treatment services and lost productivity lower treatment costs, less suffering and premature mortality, are estimated at $247 billion annually. MEB disor- and more cohesive families, as well as happier, better adjusted, ders also interfere with young people’s ability to ac- and more successful young people. complish developmental tasks, such as establishing healthy interpersonal relationships, succeeding in Early identification and intervention of MEB prob- billions of dollars by preventing or mitigating school, and making their way in the workforce. lems, before they warrant a formal diagnosis, of- disorders that would otherwise require expensive Clear windows of opportunity are available to fer the best opportunity to protect young people. treatment. prevent MEB disorders and related problems be- Such interventions can be integrated with routine Yet the nation’s approach has largely been to wait fore they occur. Risk factors are well established, healthcare and wellness promotion through policies to act until a disorder is well-established and has preventive interventions are available, and the and practices that target young people with specific already done considerable harm. All too often, op- first symptoms typically precede a disorder by 2 to risk factors; promote positive emotional develop- portunities are missed to use evidence-based ap- 4 years. And because mental health and physical ment; and build on family, school, and community proaches to prevent the occurrence of disorders, health problems are interwoven, improvements in resources. Making use of the evidence-based in- establish building blocks for healthy development, mental health also improve physical health. terventions already at hand could potentially save and limit the environmental exposures that increase 8 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • risk — approaches that are likely to be far more cost-effective in addressing MEB disorders in the an Interview with carl Bell long run. Because risk factors tend to come in Meena dayak, Director of Marketing and Communications and chris loftis, Phd, Director of clusters and to be associated with more than one Practice Improvement for the National Council for Community Behavioral Healthcare spoke to disorder, a focus on prevention and wellness can Dr. Carl C. Bell, member of the IOM Committee that authored the report on preventing mental, have far-reaching benefits that extend beyond a emotional, and behavioral disorders. specific disorder. Research has shown that a number of programs are can you tell us about your role on the IoM sexual affections so they have triple the rate of HIC effective at preventing these problems and promot- committee? infection. There is evidence we can prevent children ing mental health. Meta-analyses and numerous I was on that committee because I’ve been a cli- who experience trauma from participating in these nician for 30 years. I do business I’m a CEO of a behaviors as adults. This report could fix 1/3 of randomized trials have demonstrated the value of: comprehensive mental health center on the south healthcare problem. >> Strengthening families by targeting problems side of Chicago and that gives a very different per- Then there is the issue of braided funding. If we such as substance use or aggressive behavior, spective. I am a researcher, usually in high-risk set- could get CDC, NIH, NIDA, SAMHSA, and NIMH all teaching effective parenting skills, improving tings, community psychiatry settings, urban poor, working on prevention in concert, we would get communication, and helping families deal with African-American, HIV, violence prevention, children somewhere with this. disruptions (such as divorce) or adversities exposed to violence, and trauma. And I have expe- (such as parental mental illness or poverty). rience translating academic efficacy and research- the IoM had published a report on preven- based science into real world settings. tion in 1994. how is this new 2009 report >> Strengthening individuals by building resilience an improvement? and skills and improving cognitive processes Is the delay from research to implementa- Science, tons and tons of science! This new report and behaviors. tion a translation or funding issue? shows you how to implement this science for differ- Both. They’re prevented from doing research with the ent socio-economic groups. We’re closer than we’ve >> Screening to identify individuals at risk for process. NIMH is charged with research and SAMH- ever been. some specific disorders, such as anxiety or de- SA is charged with overseeing programs. It’s difficult pression, and making simple interventions such to do research in a culture that is prevention defi- The other issue that is crystal clear is that now is as cognitive training or social supports easily cient, illness-based, and overly focused on tertiary the time! There are so many other things coming accessible. issues. And the bulk of what they are talking about together that make this possible. There’s a tremen- is treatment prevention and not primary prevention. dous amount of synergy between the brain science >> Promoting mental health in schools by offer- and the psycho-social science. The problem is that ing support to children encountering serious Money is of course a problem, too! There is ample we haven’t put them together yet, but now is the stresses; modifying the school environment to evidence in the report that says it’s likely that vio- time do it as the science has exploded. promote prosocial behavior; developing stu- lence can be prevented, drug abuse can be pre- dents’ skills at decision making, self-awareness, vented, post partum depression can be prevented, Is there anything from the IoM report that is and conducting relationships; and targeting vio- and depression in children can be prevented. But getting traction in the healthcare debate? lence, aggressive behavior, and substance use. how is it all funded? Obama knows about the report. The problem is, Obama’s infrastructure hasn’t been in place yet. >> Promoting mental health through health- What three recommendations from the re- There has been a bit of pushback on some aspects care and community settings by supporting port are likely to have the most impact? of the report because some don’t want the govern- programs that teach coping skills, and target The first one would be to have the White House ment intrusion in their lives–a fear of big brother. modifiable lifestyle factors that can affect be- create a cabinet level group to put prevention into It really takes presidential leadership to remind place in the U.S. A great example is how prevention people of our interdependence! havior and emotional health, such as sleep, diet, of violence against women has worked with presi- activity and physical fitness, sunshine and light, dential support. What can leaders of community health cen- and television viewing. We’ve learned that children who are traumatized ters take away from this report? The key to most of these approaches is to identify have twice the rates of cancer, twice the rates of If they want to stay in business, they need to change risks — biological, psychological, and social fac- heart disease, four times the rate of lung cancer, their business. We’re in a different world. And if they tors — may increase a child’s risk of MEB disorders. and twice the rates of liver disease because trauma don’t keep up with the times, they’re being unethical Some of these risks reside in specific characteris- causes children to eat, drink, smoke, and trade because the science is there. tics of the individual or family environment (such NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 9
  • Policy Perspectives as parental mental illness or substance abuse or shown that the program significantly reduces ag- many young people and their families. serious family disruptions), but they also include so- gressive and disruptive behavior during first grade. National leadership is necessary to make sys- cial stresses such as poverty, violence, lack of safe The one-year intervention also has benefits over the tematic prevention efforts a high priority in the schools, and lack of access to healthcare. Most risk long term, lowering the students’ risk of alcohol and healthcare system as well as an integral aspect of factors tend to come in clusters and are associated drug abuse, as well as rates of suicidal thoughts and the network of local, state, and federal programs with more than one disorder. attempts. And it significantly reduces the likelihood and systems that serve young people and families. Early symptoms typically occur two to four years that highly aggressive boys will be diagnosed with The IOM report makes several recommendations, before the onset of a full-blown disorder, creating antisocial personality disorder as adults. Research including:: a window of opportunity when preventive programs has shown that programs that focus on enhancing social and emotional skills can also improve stu- >> A White House-created leadership body to devel- might make a difference. And some programs have op an inter-departmental strategy that identifies shown effectiveness at preventing specific disorders dents’ academic performance. specific prevention goals, directs multiple fed- in at-risk groups. For example, the Clarke Cognitive- Other programs improve children’s mental health eral agency resources toward these goals, and Behavioral Prevention Intervention, which focuses and behavior by enhancing parenting skills. The provides guidance to state and local partners on helping adolescents at risk for depression learn Positive Parenting Program, for example, uses a (however, the report cautions that federal and to cope with stress, has prevented episodes of ma- range of approaches, from a television series on state agencies should not support programs that jor depression in several controlled experiments. how to handle common child-rearing problems to lack empirical evidence, even if they have commu- Other programs have demonstrated broader pre- in-person skills training for parents struggling to nity endorsement). ventive effects in populations of young people. Pro- handle children’s aggressiveness or lack of coop- eration. These methods have been shown to lower >> Develop state and local systems that support grams that can be offered in family or educational partnerships among families, schools, courts, settings show particular promise in promoting men- kids’ disruptive behaviors, a positive change that persisted one year later. health care providers, and local programs to tal health and addressing major risk factors. One create coordinated approaches that support example of an effective school-based program is The IOM report emphasizes the value of promoting healthy development. the Good Behavior Game, which divides elementary mental health and considering mental health within school classes into teams and reinforces desirable a developmental framework. The mental health re- >> Invest in prevention and promotion, including behaviors with rewards such as extra free time and search spectrum should include not just the preven- setting aside resources for evidence-based pre- other privileges. Studies have tion of MEB disorders, but also a focus on wellness vention in mental health service programs and the promotion of mental health. Good prevention investment in proven prevention approaches by and mental wellness promotion interventions are school systems. grounded in research on the interrelationships >> Workforce training, including development of among the principal milestones of healthy devel- prevention training standards and training pro- opment and the family, school, and community fac- grams across disciplines including health, edu- tors that are associated with them. cation, and social work. PolIcY IMPlIcatIons >> Long-term tracking of the prevalence and fre- Officials at the local, state, and federal levels all quency of MEB disorders. play a role in mental health promotion and the pre- >> Implementation and evaluation of screening with vention of MEB disorders. Many providers and agen- community involvement, parental support, valid cies are responsible for the care, protection, or sup- tools, and interventions to address identified port of young people: the child welfare, education, needs. and juvenile justice systems, as well as medical and >> Continued research on both the efficacy of new mental health care providers and community orga- prevention models and real-world effectiveness of nizations. Yet resources within these agencies are proven prevention and wellness promotion inter- scattered, not coordinated, and often do not effec- ventions. tively support prevention programs or policies. The result is a patchwork that does not perform as an >> Adaptation of research-based programs to cul- integrated system and fails to serve the needs of tural, linguistic, and socioeconomic subgroups. 10 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • >> Public education, with mass media and the inter- evidence-based intervention is needed. net offering the opportunity to greatly expand the Economic analyses: Funding for prevention programs reach of specific messages about risk factors and is increasingly made in an environment of decreased available resources, to reduce stigma, and to de- resources. Evidence of the economic benefits of pre- liver some kinds of interventions. ventive interventions is a critical policy tool. Yet, many role oF research research designs do not include information about Research has exploded in recent decades on efforts the costs of an intervention against which a commu- to prevent MEB disorders. Findings include improved nity could weigh the benefits. Even fewer include cost- understanding of the origins of MEB disorders and effectiveness analyses. Guidelines for conducting this advances in methodological approaches that al- type of analysis, as well as incentives for researchers low causal inferences to be drawn from evaluations to conduct it, are necessary. of preventive interventions and to track effects over Copies of Preventing Mental, Emotional, and Behav- multiple years. Many interventions have been tested ioral Disorders Among Young People: Progress and in multiple randomized trials and show long-term Possibilities are available from the National Acad- reductions in MEB disorders and related problem be- emies Press; 202.334.3313 or 800.624.6242 or at haviors, such as aggression, high-risk sexual behavior, and substance use, as well as such positive outcomes as improved grades and higher self-esteem. to prevent mental and behavioral disorders and ways Carl C. Bell is president and CEO of the Community Mental Health to treat these problems, the report says; currently, the Council & Foundation, Inc. in Chicago. He is also the director Neuroscience research may lead to early identifica- balance is weighted toward research on treatment. of public and community psychiatry and a clinical professor of tion of specific young people at risk for MEB disorders psychiatry and public health, University of Illinois at Chicago. He and to the refinement of specific, targeted interven- coMMunItY releVance is a member and former chairman of the National Medical As- sociation’s Section on Psychiatry; a fellow of the American College tions. Related research has identified opportunities Interventions are unlikely to be implemented, or of Psychiatrists; a fellow of the American Psychiatric Association, to change environments in ways that might influence implemented with fidelity, if they are not respon- a founding member and past board chairman of the National Commission on Correctional Health Care. Dr. Bell has published the expression of specific genetic or biological pre- sive to community needs and priorities. Communi- more than 350 articles on mental health. dispositions, for both current generations and their ties often have substantial expertise and professional Meena Dayak has 15+ years of experience in marketing and offspring. wisdom but have developed approaches that are not public relations for nonprofit healthcare organizations. She leads supported by empirical evidence. Researchers and National Council efforts to help consumers and providers tell The report encourages more collaboration between a compelling story so that the world will recognize that mental communities need to develop partnerships to evalu- traditional prevention and wellness researchers with illnesses and addictions are treatable health conditions from ate interventions that have both a solid theoretical which people can recover and lead full lives. Prior to joining developmental neuroscientists in order to widen the the National Council, she managed marketing initiatives for grounding and are responsive to community needs. body of research focused on advancing health and healthcare standards and information programs at the United Increasing relevance to a community also calls for States Pharmacopeia. preventing disorders, rather than the more traditional consideration of such other issues. Chris Loftis offers practice improvement and legislative guidance emphasis of research focused on diagnosed disorders to the National Council’s more than 1,600 member organizations after they are well established and have done consid- Adaptation: The effectiveness of evidence-based in- that provide treatment and rehabilitation to individuals with men- erable harm. Greater collaboration between research terventions may be significantly facilitated or impeded tal illnesses and addiction disorders. Loftis has served as a policy analyst for the National Health Policy Forum in Washington, DC, a fields—specifically, the testing of hypotheses across by aspects of the ethnic, linguistic, and cultural envi- nonpartisan organization that provides health policy programming the disciplines—will yield both theoretical and practi- ronment in which they are implemented. Research is for senior staff in Congress and the executive agencies. He also cal advances in prevention. needed to identify the specific factors that influence has worked as a practitioner and researcher, and has completed advanced specialty training in pediatric neuropsychology. Loftis effectiveness and the adaptations that are needed to has a doctorate in clinical psychology with a specialization in neu- The IOM report also urges continued research to build serve different populations. ropsychology from the University of Florida and completed a clini- understanding of what interventions work for whom cal internship at the Kennedy Krieger Institute at Johns Hopkins and when, and how best to implement them. The Screening in conjunction with intervention: Screen- in Baltimore, MD, where he worked with children with traumatic ing can be done in a number of ways and for a variety injuries, developmental disabilities, and chronic illnesses. National Institutes of Health should develop a com- Nathan Sprenger, the National Council’s marketing and communi- prehensive 10-year plan to research ways to promote of risk and early symptoms. Community acceptance, cations associate, provided administrative and research support mental health and prevent MEB disorders in young parental endorsement, and the capacity to respond to for this article and interview. people. In addition, agencies and foundations should needs that are identified are critical to its value. Re- establish equality in research funding between ways search on the effectiveness of linking screening with NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 11
  • Policy Perspectives Saving Jobs, Saving Public Dollars: Intervening Before Disability Vidhya alakeson, Policy Analyst, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services This article represents the views of the author and not those of the U.S. Department of Health and Human Services. J uan was a delivery driver, but his health prob- lems were putting him at risk of losing his job. His diabetes was poorly controlled and had caused Security Insurance, for people who are no longer able to work. These programs, in turn, act as gate- ways to health insurance — Medicare in the case of can remain in their jobs and do not apply for public disability programs. Two of the demonstration sites, Texas and Minnesota, focus on people with serious foot ulcers that made it difficult for him to walk. He SSDI and Medicaid for those who quality for SSI. This mental illnesses and people with chronic physical also had bipolar disorder, which was not being con- safety net is vital for people who are too disabled to health problems who also have a mental health trolled. When he joined the Working Well program in work. Once people qualify for Social Security, how- condition. The ingredients that make up the service Harris County, Texas, Juan worked with a case man- ever, they rarely move off it, despite strong evidence packages in Minnesota and Texas are similar: com- ager to get orthopedic shoes, to receive support in that many people with mental health problems want prehensive health insurance, including dental and developing a diabetic diet and exercise plan, and to to and can work. People with mental illnesses now vision services as well as behavioral health benefits; make an appointment with a psychiatrist to bring constitute the largest and most rapidly growing employment supports; and a “broker” who works his mental health condition under control. As a re- The Demonstration to Maintain Independence and Employment, sult, Juan was able to continue working full time as a delivery driver and received a raise for exceptional funded by CMS, is evaluating the impact of actively supporting people performance (Bohman, Stoner, & Chimera, 2009). with mental illnesses who are at risk of becoming too disabled to Working Well is part of the Demonstration to Main- work, so that they can remain in their jobs. The intervention is proving tain Independence and Employment, which is funded to be effective in improving clients’ access to healthcare services, by the Centers for Medicare and Medicaid Services. health and functional status, job stability, and earnings. The DMIE is one of the federal initiatives currently evaluating the impact of earlier intervention for group of Social Security disability beneficiaries, and with participants to help them keep their jobs. The people with mental illnesses (earlier interventions every year only 1 percent of people who qualify for broker’s role is broad; it can range from helping a in the context of this article refer to interventions SSDI on the basis of a mental illness leave the rolls participant get an appointment with a psychiatrist prior to application for Social Security Benefits but and return to work. to finding him or her a place to live to organizing do not include first onset interventions). The DMIE represents a break with existing policy. child care (Gimm & Weathers, 2007). Current federal policy provides support, through So- Its purpose is to actively support people who are at Early results are promising. In Minnesota, the DMIE cial Security Disability Insurance and Supplemental risk of becoming too disabled to work, so that they intervention is proving to be effective in improving 12 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • clients’ access to healthcare services, health and Providing integrated behavioral healthcare and supported functional status, job stability, and earnings. It has employment to a third of Social Security applicants with also reduced the number of applications for SSDI mental health conditions to help them return to work and stay off (Linkins & Brya, 2009). Analysis indicates that earlier interventions, such as the DMIE, could make sound the disability rolls could save the government $48 million in financial sense for the federal government as well as providing all the necessary services. for clients. A new study by Drake, Skinner, Bond, and back into work, following the principle that economic on qualifying for disability benefits. Goldman (2009) concluded that providing integrated self-sufficiency is in the best interest of their families. behavioral healthcare and supported employment The Social Security Administration is currently working Vidhya Alakeson is a policy analyst in the Office of the Assistant to a third of Social Security applicants with mental Secretary for Planning and Evaluation at the Department of with the Administration for Children and Families to health conditions to help them return to work and Health and Human Services where she leads work on mental look in greater depth at the movement of beneficia- health and disabilities. Prior to taking up this position in 2008, stay off the disability rolls could save the government she was a Harkness Fellow in Healthcare Policy based at HHS ries between TANF and SSI. $48 million in providing all the necessary services. and supported by the Commonwealth Fund in New York. Prior Drake et al. (2009) concluded their analysis of the to working in the US, Vidhya worked for the UK Government and One of the challenges of adopting a more comprehen- in several leading UK think tanks conducting policy research in potential savings from earlier intervention with sev- the areas of health, human services, and education. She has a sive approach to earlier intervention is the absence eral policy proposals. First, they suggested that states first class degree from Oxford University and a masters from the of strong evidence as to how to effectively support London School of Economics. provide supported employment and mental health people before they become Social Security beneficia- services early in the course of mental illness. Initia- REfEREncES ries. DMIE is one federal effort to address this evi- Bohman, T., Stoner, D., & Chimera, D. (2009, April). Working Well: tives such as the DMIE and RAISE are testing that Preliminary findings. Paper presented at the Centers for Medicare dence gap; the Recovery After an Initial Schizophrenia approach. Second, they suggested that health insur- and Medicaid Services MIG/DMIE Employment Summit, San Episode program is another. RAISE is a major new Francisco. ance be delinked from disability status. The two rec- initiative from the National Institute for Mental Health Drake, R. E., Skinner, J. S., Bond, G. R., & Goldman, H. H. (2009). ommendations are intimately connected. For people Social Security and mental illness: Reducing disability with sup- that will be launched this summer. For most people, with any kind of chronic condition, including a men- ported employment. Health Affairs,28, 761−770. the first onset of schizophrenia occurs in adolescence tal illness, access to healthcare is vital. The only way Gimm, G., & Weathers, B. (2007). What is the Demonstration or early adulthood. Emerging evidence suggests that to Maintain Independence and Employment (DMIE) and who is some people can access healthcare is to qualify for participating? Princeton, NJ: Mathematica Policy Research. intervening at this point can reduce the likelihood disability benefits. Fear of losing healthcare then be- Linkins, K., & Brya, J. (2009, April). MN DMIE: The role of that a patient will develop full-blown schizophrenia, comes a major barrier to moving off benefits. In this personal navigation and employment supports in client outcomes. but researchers have not reached a consensus as to Paper presented at the CMS MIG/DMIE Employment Summit, San respect, current discussions around extending health Francisco. which early interventions work best. RAISE will test insurance to the uninsured are particularly important. Loprest, P., & Maag, E. (2009). Disabilities among TANF recipi- two sets of interventions to assess whether they can Earlier intervention will only take hold if patients have 6/5/09 4:40 NHIS, Washington, DC:1 Institute. 10706 VVA.mech2:magazine ad ents: Evidence from the PM Page Urban effectively prevent the development of the condition a route to accessing healthcare that does not depend and reduce long-term disability as a result of mental illness. Research has indicated other opportunities for earlier Veterans & Their Families: Health Care intervention to prevent long-term dependence on dis- ability programs. A recent study by the Urban Institute WHAT YOUR Provider SHOULD KNOW… showed that close to 14 percent of recipients of Tem- porary Assistance for Needy Families have an emotion- al or mental health problem (Loprest & Maag, 2009). States have to meet strict work participation criteria for the TANF population, and participation in mental health treatment does not qualify as work participa- tion. As a result, it is often in the state’s interest to try to move women with mental health problems and other disabilities onto SSI. A focus on earlier interven- tion, by contrast, would seek to address the mental A program of Vietnam Veterans of America health needs of women on TANF and support them NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 13
  • Policy Perspectives Call to Include Prevention in Healthcare Reform Excerpts from SAMHSA’s “A Framework for Discussion: Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Use Disorders: Core Consensus Principles for Reform from the Mental Health and Substance Abuse Community” at T he Substance Abuse and Mental Health Ser- vices Administration reached out to hundreds of stakeholder and consumer groups and dozens of than waiting until they become acute or chronic. The national plan should utilize a public health Our nation is crying out for a health system that makes prevention and model for prevention that organizes multiple com- treatment for mental and substance use nationally and internationally recognized experts in munity sectors to plan, implement, and evaluate the fields of mental health and addictions to solicit disorders a priority rather than an after- appropriate strategies and programs designed to insight and recommendations on the most critical thought, that considers the whole person change community norms and environments to issues related to mental and substance use dis- rather than physical symptoms alone, and promote healthy choices and behaviors. Universal orders facing the American population today, with screening tools should be used to detect medical that seeks to eliminate the stigma and an emphasis on identifying opportunities to ensure conditions including mental and substance use dis- fragmented systems that interfere with that imminent health reform efforts include preven- orders early and treat them at a low level of acuity. Americans’ ability to access necessary tion and treatment for these disorders. These approaches will slash billions of dollars from preventive and treatment services funda- With consistency and solidarity, mental health and annual healthcare costs and dramatically improve mental to achieving recovery and enabling substance abuse professionals, consumers, and the overall health of Americans. them to lead healthy and productive lives.” family members from every part of the country, every cultural and socioeconomic group, and every diag- nosis and condition spoke with a single voice: “Our 2 legislate universal coverage of health Insurance with Full Parity nation is crying out for a health system that makes prevention and treatment for mental and substance Equal treatment for people with serious mental illness and substance use disorders must mean 3 achieve Improved health and long-term Fiscal sustainability use disorders a priority rather than an afterthought, access to effective services and high-quality care. There is a substantial body of evidence to demon- that considers the whole person rather than physi- Children and adults with mental and substance use strate that providing adequate levels of mental and cal symptoms alone, and that seeks to eliminate disorders are medically vulnerable populations. substance use disorders prevention and treatment the stigma and fragmented systems that interfere Many will not access needed primary health care services as well as integrating these services with with Americans’ ability to access necessary preven- or comply with medical treatment without signifi- primary healthcare can improve outcomes; cut tive and treatment services fundamental to achiev- cant support. Mechanisms developed under health and/or control the growth of overall healthcare ing recovery and enabling them to lead healthy and reform to expand coverage for currently uninsured costs; lessen the rate, duration, and intensity of dis- productive lives.” populations must require compliance with the new ability of many illnesses; improve productivity; and parity law. Similarly, the discriminatory IMD exclu- control the size and growth of other social costs. Based on stakeholder input, SAMHSA has developed sion under Medicaid must be modified. By including information about preventing as well a set of NINE CORE CONSENSUS PRINCIPLES: as detecting mental and substance use disorders Achieving universal coverage will also help to pro- in primary healthcare, institutional, and community 1 articulate a national health and Wellness Plan for all americans Our nation needs a national health and wellness mote health equity and increase access by requiring that priority attention be given to populations dis- proportionately affected by chronic disease. Such settings, we create an environment that enables early, low-cost treatment, thereby avoiding escala- plan that provides for comprehensive, community- populations include racial and ethnic minorities, tion to expensive, urgent-care facilities; minimizing wide prevention, screening, health, and wellness groups with low socioeconomic status, residents impact to family members, workmates, and others; services from infancy through old age. The plan of rural areas, chronically unemployed populations, and reducing the likelihood of lasting adverse ef- should provide for public education, prevention, women, children, older adults, persons with multiple fects to the consumer. Further, this cultivates a early intervention, treatment, and recovery services, chronic conditions, persons with disabilities, and whole-health, person-centered approach that fos- and must be a holistic, standardized system that criminal and juvenile justice–involved populations. ters not only recovery but also resilience. 4 emphasizes promoting wellness and resilience, pre- Health reform must recognize the need for special- eradicate Fragmentation by requiring venting risky and unhealthy behaviors before they ized mental and substance use disorders services coordination and Integration of care for occur to avoid the onset of illness or drug use, and to enable these populations to benefit from health- Physical, Mental, and substance use conditions addressing symptoms when they first emerge rather care coverage. 14 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Complicating the challenges faced by the current treatment system for mental and substance use disor- ders is the frequent co-occurrence of these disorders, disease, needs to be a key consideration if health reform is to succeed with achieving improved health outcomes. Accordingly, we must invest in research and 9 ensure a safety net for People with the Most serious and disabling Mental and substance use disorders often together with other chronic health conditions. accelerate the transfer of new science and anecdotal Our current system promotes disconnection among reports into evidence-based practices that take into Locating and dedicating the funds needed to bring interrelated diseases and conditions leading to frag- account diverse populations. about health reform will, by necessity, result in in- mentation and frustration among providers and con- creased pressures to shift funding away from exist- sumers. The presence of multiple concurrent health conditions makes it increasingly difficult to engage 7 adopt and Fully utilize health Information technology ing strategies and services and instead to repurpose these resources toward new healthcare reform pri- consumers successfully in treatment and sustained Our reformed health system must build on the in- orities. Prevention has historically been underutilized recovery. creasing availability of HIT to provide a system of and under-resourced in relation to its potential to cut electronic health records that is universally available, healthcare costs. In addition, far too many Americans 5 Provide for a Full range of Prevention, early Intervention, treatment, and recovery ser- vices that embodies a Whole-health approach affordable, and accessible to large and small provid- ers nationwide and is one that provides for captur- ing overall health information including both physical with diagnosable mental and substance use disorders already do not have access to treatments and ser- vices that are known to be effective. We can ill afford Provide for a Full Range of Prevention, Early Interven- health and mental health and substance use. EHRs to dismantle the current safety net of block grants tion, Treatment, and Recovery Services that Embodies allow the sharing of information across providers to states and other resources that in many states a Whole-Health Approach and facilitate care coordination, while also enabling and communities are the only blockade between national and regional data collection to monitor and even higher rates of risky behaviors, illness, disability, Addressing physical health including mental and sub- measure access to and cost effectiveness of care. To death, healthcare costs, and lost productivity. Assum- stance use disorders through effective prevention ef- maximize the value of these tools, a uniform language ing expanded access to private and public insurance forts that promote healthy environments, norms, and and format are required, and consumers must retain (Medicaid) for people with mental and substance behaviors rather than waiting for the development control and ownership of their health data. use disorders will require a reexamination of the role of full-blown acute or chronic diseases is the most of the public system at the local, state, and federal cost-effective approach. It is essential that any health reform regard mental and substance use disorders as 8 Invest in the Prevention, treatment, and recovery support Workforce levels. Absent clear evidence that newly substituted health reform programs, systems, and processes are chronic diseases that are preventable, treatable, and Lack of adequate healthcare for mental and sub- fully implemented and effective, it is imperative that often co-occurring with other physical illnesses. As stance use conditions is a constant cycle exacerbated our nation’s current safety net that finances health with other chronic ailments such as asthma or diabe- by a system that has failed to grow with the needs services, including school and community-based pre- tes, they may require lifelong management; but those of a quickly expanding society and has not equipped vention programs and treatment programs for mental who experience these disorders can achieve recovery its workforce with the right tools and experience to and substance use disorders, not be dismantled pre- and lead full, healthy, and productive lives in the com- provide sorely needed care. Because there are simply maturely. munity with the proper supports. Managing chronic too few specialists in mental and substance use dis- disease has also been shown to be essential to long- orders available, large numbers of Americans who re- Healthcare reform is indeed a moral imperative — but term fiscal sustainability of any health reform plan. quire services for serious mental or substance abuse it will be meaningless if it does not incorporate men- disorders receive them from general health care tal and substance use disorders prevention and treat- 6 Implement national standards for clinical and Quality outcomes tied to reimburse- ment and accountability practitioners, who largely lack training in mental and substance use disorders prevention, treatment, and ment as central to national wellness. Screening and early intervention, access to and funding of compre- hensive services, and lifelong care mean lower health recovery services. It must become a national priority to increase the mental and substance use disorders costs for individuals, communities, and the nation. We Reimbursement guidelines and benefits should be workforce and provide appropriate compensation and can no longer dismiss the connection between men- tied to need and severity regardless of payer. These professional support for these key members of the tal health, addiction, and medical health and before guidelines must link quality improvement with reim- U.S. health system. Such incentives as loan forgive- us now is an unprecedented opportunity to build and bursement and both encourage and reward the use ness may attract professionals to train in the mental traverse the bridge between the two. of evidence-based practices without restricting cover- age for those consumers who may not achieve desired health and addictions fields, and increased funding By making prevention, early intervention, and treat- outcomes with the least-costly alternative. Compara- for graduate medical education will expand the avail- ment of mental and substance use disorders a health tive effectiveness may be one consideration in making ability of psychiatric training programs. We must also priority, we will not only reduce costs and strain on our treatment decisions, but not be the wholesale substi- develop a national, centralized credentialing and systems, but will also create stronger families, stron- tute for the many factors that should be considered privileging system across all payers, and a national ger communities, and a stronger nation. for coverage. Promoting health equity, especially for system for clinician licensing and the licensing and populations disproportionately affected by chronic regulation of care delivery systems. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 15
  • Evidence-Based Early Interventions Healthy Minds, Strong communities Mental health First aid usa Educates and Transforms Communities, 3,000 Trained in One Year lea ann Browning Mcnee, Outreach and Development Officer and susan Partain, Outreach Associate — National Council for Community Behavioral Healthcare L aunching a new program is a bit like eating an elephant. Even though you’ve got a great vision and a huge goal, you still have to tackle it one bite at a time. That’s the approach the National Council has taken with launching Mental Health First Aid in the United States. We envision Mental Health First Aid becoming as commonplace as CPR and First Aid within the next fifteen years. Some may call that an elephant, but the results of our first program year demonstrate that the challenge is immensely doable especially with a few extra-large bites. Since it’s launch last year, more than 300 instructors have been certified in Mental Health First Aid, a program that builds mental health literacy and teaches non-clinicians basic skills in how to Mental Health First Aid USA help someone experiencing a mental health problem or crisis. by the Numbers A Mental Health First Aider learns to provide assistance until 300 instructors certified the problem resolves or until other appropriate help is engaged. 33 states running the program “It’s evident that Mental Health First Aid is the right program coming 180+ community trainings at the right time,” says Linda Rosenberg, president and CEO of the 3,000 individuals trained National Council. “When we began this initiative, we were hoping to 1,000,000 media impressions 16 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • certify about twenty organizations to introduce Mental Health First Aid in their communities. As of this summer — the end of our official pilot year we have nearly one hundred fifty organizations offering the program.” “Mental Health First Aid — with it’s new The growth of the program has not surprised many of the National Council’s board leaders, who were among emphasis on recovery — has the power the first to adopt Mental Health First Aid. “The multiple wins of the program were obvious from the start,” says to transform communities, the power to Dr. Carl Clark, first vice chair of the National Council Board and CEO of the Mental Health Center of Denver, one change beliefs, and the ability to con- of the initial pilot sites. “We can enhance community resilience, offer potential partners an easy-to-understand nect people in ways they never would service, broaden our focus beyond serious mental illness, and further secure our role as community problem- have connected otherwise.” solvers.” Larry Fricks Don Miskowiec of North Central Behavioral Health Systems agrees. “Even though we’re dealing with devastating National Consumer Leader and demanding budget cuts here in Illinois, we are committed to Mental Health First Aid. If anything, it’s even more necessary in our current environment.” After participating in the initial training, Miskowiec’s center added six additional instructors to his team for 2009. “What struck me most about Mental The program focuses on three key elements: recognizing warning signs, increasing skills to help individuals Health First Aid is the interest it gener- reach out to those with mental health challenges, and understanding how professional and self-help supports ates among people who don’t have a can help. direct connection to the mental health From hospitals and the workplace to college campuses and the general public, Mental Health First Aid address- field,” says David Johnson, CEO of the es not only stigma, but also the real desire to help someone who is struggling. “ Mental Health First Aid makes it Bert Nash Center. “It’s obvious that this okay to reach out,” explains Rosenberg. “So often people want to help, but we’re not sure what to do and don’t is a program than can move us beyond usual constituencies to truly build a healthy community.” Mental health First aid: history and evidence Base Mental Health First Aid was created in 2000 by Profes- To date, Mental Health First Aid has been replicated One trial of 301 randomized participants, 5-6 months sor Anthony Jorm, a respected mental health literacy in Cambodia, Canada, England, Finland, Hong Kong, after they received Mental Health First Aid training, professor, and Betty Kitchener, a nurse specializing in Japan, New Zealand, Northern Ireland, Scotland, Sin- found that those who trained have greater confidence health education, to improve the mental health lit- gapore, South Africa, Thailand, USA, and Wales. in providing help to others, greater likelihood of advis- eracy of members of the Australian community. The The National Council for Community Behavioral ing people to seek professional help, improved con- program is auspiced at the ORYGEN Research Center Healthcare, the Maryland Department of Health and cordance with health professionals about treatments, at the University of Melbourne, Australia. Mental Hygiene, and the Missouri Department of and decreased stigmatizing attitudes. Studies also Mental Health First Aid includes a 5-day instructor Mental Health chose to help bring Mental Health First found that Mental Health First Aid improved the men- training course to certify suitable candidates to be- Aid to the USA due to the strong evidence supporting tal health of the participants themselves. come MHFA instructors who deliver the 12-hour MHFA the program. In summary, Mental Health First Aid has been proven course to their communities. This 12-hour course is Five published studies, based on effectiveness trials to improve designed to give members of the public some skills and qualitative surveys in Australia, show that Men- KNOWLEDGE: Improved agreement with health to help someone developing a mental health problem tal Health First Aid saves lives, improves the mental professionals about treatments. or in a mental health crisis situation. The philosophy health of the individual administering care and the BEHAVIOR: Improved helping behavior behind the course is that mental health crises, such one receiving it, expands knowledge of mental ill- as suicidal and self-harming actions, may be avoided INTENTIONS: Greater confidence in providing help nesses and their treatments, increases the services through early intervention with people developing to others provided, and reduces overall stigma by improving, mental disorders. If crises do arise, then members of mental health literacy. ATTITUDES: Decreased social distance from people the public can take action to reduce the harm that with mental disorders. could result. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 17
  • Evidence-Based Early Interventions want to risk doing the ‘wrong’ thing. Mental Health First Aid teaches participants that it’s okay not to have all the answers and increases their comfort level.” To date, the National Council has partnered with the Australian founders as well as the state governments in Maryland and Missouri to ensure that we have a clear, evidence-based and unified Mental Health First Aid curriculum in the United States. In addition, the National Council has created and refined the instructor training program, tracked community engagement, and partnered with the University of Maryland and SAMHSA to evaluate the fidelity of the U.S. program to that of the Australian original. And, the National Council provides ongoing support to MHFA program sites and instructors through individual consultation, a technical assistance website and an instructors listserve. This spring, the national MHFA E-News monthly newsletter was launched to provide updates, share successes, and keep the momentum going. “It’s important that we continue our relationship with the instructors,” Rosenberg con- tinues. “We’re identifying new ways to share learnings and outcomes from across the an effective early Intervention Most of us assume mental illness is something that tal health problems and those only affects others and believe it won’t affect our who are developing mental family or friends. The truth is that mental health disorders. They aim to prevent problems are more common than heart disease, problems from becoming more lung disease, and cancer combined. Mental health serious and reduce the likeli- also presented at a mental health unit as an in- issues affect all of society in some way, shape, or hood of secondary effects such as job loss, dropping patient for a few days but has since discontinued form. It’s estimated that one in four Americans will out of school, relationship breakup, and drug and regular counselling. have a diagnosable mental disorder at some point alcohol problems. Many people have a long delay How relations changed: I now have a little more in their lives. between developing a mental disorder and receiv- understanding but I feel there is still an underlying It is extremely likely you will encounter someone in ing appropriate treatment and support. The longer serious problem and I find it difficult to know how to your family, workplace, school, church, or commu- the delay in getting help, the more difficult recov- best handle potentially explosive situations. nity who lives with a diagnosed mental disorder. In ery can be. It is important that people get support Longer term effects on the person: There was a addition, you will encounter others who are experi- from family, friends, and work colleagues during this temporary effect for the good. He may also be more encing distress or facing a mental health challenge time. People are more likely to seek help if some- willing to seek help in the future if needed now he that may require support and assistance, but not one close to them suggests it. It is during this early has experienced what the mental health unit can medical intervention. intervention phase that Mental Health First Aid can offer. play an important role. Just as in the case of a physical illness, a person How the [MHFA] course has changed you: I am may move from being well to developing mental A study in Australia asked trained Mental Health somewhat more understanding and make more al- health problems, which may progress to a diagnos- First Aiders if they had experienced a post-training lowance for irrational behavior, etc, but it is still not able mental disorder, and then on to recovery. Differ- situation where someone appeared to have a men- always easy. ent types of interventions are appropriate for these tal health problem and how they had been able to help. Here’s a sample story that a respondent Anything else: I am very pleased I did the course states of mental health. For the person who is well shared. and it has made me aware not only of the problems or with mild symptoms, prevention programs are people have due to mental health, but of the help appropriate. For the person who is moving toward “The situation: The man concerned was experienc- that is available if only the person will seek it.” a mental disorder, early intervention approaches ing severe depression and anxiety due to marriage/ can be used. For a person who is very unwell with a family break-up and child custody problems. mental disorder, a range of treatment and support What you did: I persuaded him to seek counselling. REfEREncES Experiences in applying skills learned in a mental health first approaches are available to assist the person in the I tried to listen and advise and I also gave essential aid training course: a qualitative study of participants’ stories. recovery process. financial assistance. Jorm, Kitchener, Mugford. 09 November 2005. BMC Psychiatry 2005, 5:43 doi:10.1186/1471-244X-5-43. Early intervention programs target people with men- Effects on that person: He did seek counselling and 18 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • country and connecting to common needs, such as supplemental programs and standardized evaluation tools.” Recognizing that the popularity of Mental Health First Aid also increases the need for significant support, capacity Who Can Be A Mental Health and branding, Rosenberg emphasizes that the National Council is in this for the long haul. She calls the pilot’s First Aider success “both fulfilling and a little intimidating.” Perhaps a bit like eating an elephant. From policymakers to the general public, a broad array of audiences is BRING IT TO YOUR COMMUNITY interested in Mental Health First Aid. Learn more about Mental Health First Aid at To date, the following groups have To find out about bringing the program to your community, please contact Susan Partain received training in the USA at or 202.684.7457 ext. 232. >> Educators/School administrators >> Employers >> Faith communities >> Homeless shelters >> Hospitals and primary care Mental health First aid certification & 12-hour Program health centers >> Law enforcement/other first Mental Health First Aid USA runs a 5-day instructor public how to respond in a mental health emergency, responders training program to certify trainers from community- and offer support to someone who appears to be in >> Mental health authorities based organizations that then offer the public 12-hour emotional distress. >> Nursing homes Mental Health First Aid program to target audiences Mental Health First Aid offers education on signs and >> Policymakers in their local area. Each Mental Health First Aid site symptoms of a variety of diagnosable mental disor- >> Substance abuse professionals develops individualized plans to reach their commu- ders. It describes, in detail, how a “Mental Health First >> Families and caring citizens nities, but all deliver the core 12-hour program and Aider” can assume a helpful role when encountering each participating site undergoes tight credentialing a distressed individual, the program is not used to to guarantee fidelity to the original, tested model, diagnose or to replace a therapist. Mental Health >> An understanding of the prevalence of various while also maintaining the flexibility necessary to First Aid recognizes that just as with physical health, mental health disorders in the U.S. and the need reach its unique citizens’ needs and demographics. people may use many effective alternative and com- for reduced stigma in their communities Sites receive significant support from the National plementary strategies to recover from mental health Council for ongoing implementation of Mental Health >> A 5-step action plan encompassing the skills, re- challenges. First Aid through individual consulting, national track- sources and knowledge to assess the situation, to Specifically, Mental Health First Aid participants select and implement appropriate interventions, ing and monitoring, continuous networking with other learn: and to help the individual in crisis connect with sites and instructors, teaching materials, tips and re- sources for funding and marketing, and more. >> The potential risk factors and warning signs for a appropriate professional care range of mental health problems, including: de- >> The evidence-based professional, peer, social, and The interactive 12-hour program can be conducted as pression, anxiety/trauma, psychosis and psychotic self-help resources available to help someone with one 2-day seminar, two 1-day events, or four 3-hour disorders, eating disorders, substance use disor- a mental health problem. sessions. Mental Health First Aid certification must ders, and self-injury be renewed every three years, and introduces par- ticipants to risk factors and warning signs of mental health problems, builds understanding of their impact and overviews common treatments. Knowledge and skills serve us well in navigating an emergency, and can potentially prevent a medical emergency through early intervention. Mental Health First Aid aims to do both — teach members of the NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 19
  • Evidence-Based Early Interventions coMMunItY outREAcH sites trained in Mental health First aid by The National Council has certified instructors from more than 180 organizations in the USA. Here’s a snapshot of where some of our pilot sites are with rolling the program the national council out in their communities. through July 15, 2009 BERT NASH CENTER Partnering with the Chamber of Commerce was just the first step in launching Mental Health alasKa First Aid in Lawerence, Kansas. The group had the program added to the curriculum of the Center for Rural Health Chamber’s Leadership Lawrence program, reaching diverse community leaders from the Denali Family Services fields of business, academics, and finance. The Center also launched a comprehensive pub- DHSS Behavioral Health/Prevention Early lic outreach program, certified additional MHFA instructors and their efforts were recently Identification Services Office featured on Kansas Public Radio. State of Alaska Division of Behavioral Health arIZona COMMUNITY COUNSELING CENTERS OF CHICAGO (C4) Community Partnership of Southern Arizona Since certifying two instructors in February 2008, C4 has trained more than 100 community NAMI Phoenix members throughout Chicago in Mental Health First Aid, focusing their efforts on training a calIFornIa variety of community members including employees, volunteers at homeless shelters, and Asian Americans for Community Involvement substance abuse and addictions groups. Partnering with fellow pilot site North Central (Catholic Charities) Behavioral Health, C4 certified six additional instructors in December 2008 to expand their Bill Wilson Center (Catholic Charities) MHFA offerings in the Chicago area in 2009. Mental Health America of San Diego County GATEWAY HEALTHCARE colorado From partnering with law enforcement to reaching employers, Gateway has made tremen- Arapahoe/Douglas Mental Health Network dous headway in certifying a large number of key groups throughout Rhode Island as Mental Aurora Mental Health Center Health First Aiders. Since last April, their partnership with the Rhode Island Municipal Police Centennial Mental Health Center Academy has certified more than 100 officers from all over the state, including members Colorado West Regional Mental Health Center of security forces from colleges and universities. Gateway also secured support of their Community Reach Center community programs through Blue Cross Blue Shield of Rhode Island. Blue Cross recently Connections featured the program in their quarterly magazine to all of their members and stakeholders Jefferson Center for Mental Health across the state. Larimer Center for Mental Health Mental Health Center of Denver NORTH CENTRAL BEHAVIORAL HEALTH SYSTEMS Mental Health Center Serving Boulder and In their first six months, NCBHS made incredible headway in improving understanding of Broomfield Counties mental health among Illinois residents, certifying more than 130 Mental Health First Aiders, NCMC Foundation, Inc including hospital personnel, educators, and members of the general public. In December North Range Behavioral Health 2008, NCBHS certified six additional instructors to enable expansion of their program even Pikes Peak Mental Health further in 2009. Red Cross IOWA DEPARTMENT OF HUMAN SERVICES, DIVISION OF MENTAL HEALTH WICHE Mental Health Program Iowa holds the distinction of the only state to have its mental health commissioner certified connectIcut as a MHFA instructor. After that initiation, Iowa formed a strategic plan to reach 7,500 state Ability Beyond Disability residents with MHFA in a single year. So far, they are well on their way, hosting two statewide Bridges Milford instructor training programs that included the National Guard, emergency services, higher United Services, Inc. education, and nursing in addition to mental health and addictions professionals. Yale Department of Psychiatry FlorIda SEMINOLE American Foundation for Suicide Prevention Not content to merely serve their own community, Seminole took the lead in creating a Circles of Care comprehensive Mental Health First Aid initiative across the state of Florida. Last fall, the Department of Children and Families agency hosted an instructor training of 24 additional instructors to expand efforts. Florida Council for Community Mental Health Florida Department of Children and Families 20 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Florida Partners in Crisis Behavioral Health Professionals, Inc./CareLink/ ohIo Lakeside Behavioral Health ConsumerLink Ohio Association of Occupational Health Nurses Meridian Behavioral Healthcare, Inc. Washtenaw Community Health Organization oKlahoMa NAMI Central Florida MInnesota Long Term Care Authority of Tulsa Seminole Community Mental Health Center African American Adoption Agency Oklahoma Community Mental Health Services georgIa Belgrade Ave. United Methodist Church oregon Pastoral Institute East Metro Womens Council DBT Wallowa Center for Wellness Idaho Family and Childrens Service PennsYlVanIa DHW/Children’s Mental Health Family Life Mental Health Center Adams Hanover Counseling Services, Inc. Project ACCESS H.C. Child Crisis Services Community Services Group NAMI Minnesota IllInoIs Mental Health Association of the Captial Region Normandale College Ben Gordon Center rhode Island Northern Pines Mental Health Center Community Counseling Centers of Chicago Gateway Healthcare Northwestern Mental Health center North Central Behavioral Health Systems Kent Center People Inc. Rush University Public Health Solutions south daKota IndIana South Dakota Division of Mental Health RangeMental Health Center Behavior Services & Therapy RSI is Residential Services, Inc. tennessee IoWa Snyder Health Care ValueOptions Backbone Area Counseling/Community Circle of Care Upper Mississippi Mental Health Center teXas Black Hawk Grundy RSN Woodland Centers Austin Travis County MHMR Decatur County Community Services MIssIssIPPI El Paso MHMR Department of Human Services, Mental Health/ Community Counseling Services MHMRA of Harris County Disability Services MHA of the Capital Area Sunwest Behavioral Health Organization DHS Case Management MIssourI The Burke Center Humboldt County Mental Health Coalition Mental Health, Independence Tropical Texas Behavioral Health Iowa Department of Public Health State of Missouri VIrgInIa Iowa State Deptartment of Health neBrasKa AMERIGROUP Community Care Iowa State Patrol Behavioral Health Specialists ValueOptions Magellan Health MECCA Region 3 Behavioral Health WashIngton National Guard neW JerseY Behavioral Health Resources Orchard Place Child Guidance Center Care Plus NJ Cascade Mental Health Care Plains Area Community Mental Health Center Greater Trenton Behavioral Healthcare Catholic Family & Child Service Polk County Health Services Central Washington Comprehensive Mental Health north carolIna Pottawattamie County Community Services Community Psychiatric Clinic Centerpoint SE Polk Community Schools Compass Health Cherokee County Safe Schools Healthy Students St. Luke’s Hospital Kitsap Mental Health Crossroads Urbandale Community Schools Lower Columbia Mental Health Center Cumberland County Mental Health Vera French Community Mental Health Center NAVOS Eastpointe Winneshiek County CPC (Luther College) Quality Behavioral Health Five County Mental Health Association Youth and Shelter Services, Ames Spokane Mental Health Mental Health Partners Valley Cities Counseling & Consultation Kansas NAMI Iredell Washington Community Mental Health Council COMCARE of Sedgwick County North Carolina Council of Community Programs Youth & Family Link High Plains Mental Health Center Piedmont Behavioral Health The Bert Nash Center Southeastern Regional Mental Health Center WYoMIng Wake Center for Families and Children Cloud Peak Counseling Services KentucKY Western Highlands Network Fremont Counseling Services Kentucky River Foothills Community Action Agency UPLIFT MIchIgan north daKota Department of Health and Human Services NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 21
  • Evidence-Based Early Interventions Geoffrey Canada on His Harlem Miracle Meena dayak, Director of Marketing and Communications and chris loftis, Phd, Director of Practice Improvement National Council for Community Behavioral Healthcare I n 2008, nearly all students in third and eighth grade in Harlem Children’s The comprehensive system of programs extends to nearly 100 blocks of Central Zone charter schools outperformed the average New York student in math. Harlem. HCZ also works to reweave the social fabric of Harlem, which has been “The math thing is just so far above anything I’ve ever seen,” says Roland Fryer, torn apart by crime, drugs, and decades of poverty. a Harvard economist, in the Wall Street The founder of HCZ, Geoffrey Canada, Journal. “The real hard work is to figure out settled on a career in social work when he why it’s working and whether that kind of thing can be exported so we can help more What has been your best moment was about nine, living in a rodent-infested kids.” with HCZ? When President Obama apartment with his mother and three broth- said he wants to replicate our model. ers in the South Bronx during the 1960s. His What’s working is the “conveyor belt” con- His budget allocates $10 million father left when he was four years old. He cept of the Harlem Children’s Zone® (HCZ) to create ‘Promise Neighborhoods’ says he spent most of his childhood fighting project, started in 1997 to give children in gangs. He also says he stared down guns. across the nation. And we are eager an intensive experience in a succession of Despite brushes with violence, Mr. Canada to be helpful. We don’t want to run programs until they graduate from college. was a bookworm who did well in school. a ‘Promise Neighborhood’ anywhere Described as “One of the most ambitious He got a scholarship to Bowdoin College in social-service experiments of our time,” by else but we can share what we’ve Maine and then earned a master’s in educa- the New York Times, HCZ is a unique, holis- learned and what works. tion from Harvard. tic approach to rebuilding a community so In an interview with the Wall Street Journal, that its children can stay on track through Canada shared that one of the saddest mo- college and go on to the job market. ments in his life was when his mother told HCZ creates a “tipping point” in the neigh- him Superman didn’t exist. “I really believed borhood so that children are surrounded in Superman,” Canada said, recalling he by an enriching environment of college thought it would take a superhero to clean oriented peers and supportive adults, a up his neighborhood. “And then I suddenly counterweight to “the street” and a toxic popular culture that glorifies misogyny realized ... there’s no one coming to rescue us.” He says he vowed then to help and antisocial behavior. The fundamental principles are simple: (1) Help kids as poor children one day. early in their lives as possible, and (2) create a critical mass of adults around The National Council interviewed Geoffrey Canada about the them who understand what it takes to help children succeed. highlights of HCZ and his advice for others wanting to travel down The HCZ pipeline begins with The Baby College®, a series of workshops for par- the road of early intervention through community building. ents of children ages 0-3. Meanwhile, their kids attend “Harlem Gems,” HCZ’s Is there some aspect of the Harlem children’s Zone model that is pre-kindergarten. After that, they move on to charter schools. A bevy of other often missed or not fully appreciated? programs psychological and financial counseling for parents, health clinics and Yes, our work in rebuilding communities is often glossed over. We not only sup- after-school arts, computer, and karate classes supports their path. The pipeline port physical rebuilding of communities, but we also work with the adults in our goes on to include best practice programs for children of every age through program to help them reclaim their communities as their own, to drive change. college. The network includes in school, after school, social service, health, and We believe that for children to do well, their families have to do well. And for community building programs. “The objective is to create a safety net woven so families, to do well, their community must do well. tightly that children in the neighborhood just can’t slip through,” says the New York Times Magazine. Community Pride is the community organizing and housing stabilization arm of the Harlem Children’s Zone. In the 11 years since it was founded, HCZ’s 22 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Community Pride has made remarkable strides towards achieving its goal: revital- The Wall Street Journal reports that Wall Street’s meltdown and money manager izing the structure and spirit of central Harlem. Community Pride has worked with Bernard Madoff’s alleged financial fraud threaten the donor base that bankrolls thousands of community residents to help tenants purchase the homes they live Geoffrey Canada’s work. His Wall Street support had reached upwards of $15 in, establish low-income rental programs, plant community gardens, paint public million annually. His budget has grown at least 15% annually in eight of the past hallways, and beautify neighborhood streets. Hand in hand with community resi- nine years, to $68 million from just under $12 million. His charity’s endowment dents, Community Pride works to establish and accrue social capital in Harlem. stands at around $94 million. Revenue in the last fiscal year ending June 2009, The work is accomplished holistically, through HCZ programs linked to provide probably fell 7%, or $5 million. The board, with Mr. Canada’s support, unanimously residents with comprehensive services, from prenatal care to family development, approved cutting about 140 employees, or 10% of the staff. In addition, Canada from employment counseling to assistance in receiving Social Security benefits. had to shelve plans to add another 1,000 children to HCZ in the months ahead. All programs were protected, but many with reduced staff. The outlook for the current What is HcZ’s approach to addressing mental health and addictions fiscal year is uncertain. challenges? We believe in an approach where we help people heal themselves. And we have What is the secret of the massive donor support you’ve gotten? four outreach workers in our program who provide mental health and addictions People give because they realize communities must be accountable. services through individual counseling and motivation. We also have two of the President Clinton noted that “If you volunteer or give money to the Harlem Chil- largest Narcotics Anonymous meetings on site. We have a strong prevention focus dren’s Zone, you know you will get a high rate of return.” When Geoffrey Canada — we work with high-risk families, say where a parent has an addiction disorder, launched HCZ, he emphasized a long-term plan with measurable results to show and we educate youth on the consequences of alcohol, tobacco, and drug use. We potential donors. His central argument was “Spending $3,500 annually to keep hold health fairs where we encourage youth themselves to take a lead role. Our a poor child out of jail trumps the $50,000 Americans would spend each year to prevention efforts are supplemented by intensive support; we believe that support keep the same kid behind bars. He says, “We need a movement in America... We’re and care should be seamless, no matter how someone comes in the door. saying let’s intervene early, pay the money upfront and not have to pay the money What has been your best moment with HcZ? on the back end. We think there’s a positive net benefit for society.” When President Obama said he wants to replicate our model. His budget allocates from your recent and past fundraising efforts, in good and bad times, $10 million to create “Promise Neighborhoods” across the nation. And we are what is your advice for other communities interested in replicating eager to be helpful. We don’t want to run a ‘Promise Neighborhood’ anywhere else, aspects of your work? but we can share what we’ve learned and what works. Don’t go in for a project of this scale if you don’t have the infrastructure. You have President Obama’s fiscal 2010 budget proposal calls for neighborhoods to im- to be able to count on support from foundations, corporations, wealthy individuals, prove the lives of children living in poverty through programs modeled after the and public sources. Harlem Children’s Zone. As a presidential candidate, Obama said “If we know it If you do embark on a project like HCZ, start with your strength. Community build- works, there’s no reason this program should stop at the end of those blocks in ing requires managing and delivering multiple programs and relationships that Harlem. It’s time to change the odds for neighborhoods all across America. And address different developmental stages. But you can’t do everything at once. We that’s why when I’m president, the first part of my plan to combat urban poverty started with education and kids, as that was our strength. will be to replicate the Harlem Children’s Zone in 20 cities across the country.” Most important, you must have a passion to help those you are helping to succeed. Has your model already been replicated elsewhere? If so, what are And the focus on integrity and ethics is key. the lessons learned? In the HcZ model, do you run all your programs or collaborate with Boston, Philadelphia, San Francisco, and most major cities have been replicating others? What works better? the Harlem Children’s Zone model, but not on the same scale. The biggest lesson We run 75% of our own programs and for the services where we do contract with learned is that you need massive infusion of financial resources to do something on others, we manage relationships. For instance, Children’s Health Fund runs our an effective scale. Public dollars are best to support a venture of this magnitude. health clinics, and we have a terrific relationship with them. We’ve learned that you We hear you lost millions in donor support with the Wall Street col- need partners who deliver quality and share your accountability and values. It must lapse. How are you surviving and how do you plan to make good? be a win-win to work well. Yes, we have been hurt but our board has been wonderful and has really stepped What are you reading? up. We’ve had to cut back but we tried to cut back through layoffs rather than Outliers by Malcolm Gladwell. It’s an amazing book, emphasizing that there are service cuts. We’ve tried to put together a 2-year survival plan if the economy really opportunities for ALL children. worsens. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 23
  • Evidence-Based Early Interventions Nurse-Family Partnership: Effective and Affordable Peggy hill, Director of Program Development, Nurse-Family Partnership National Service Office Investments in nurse-Family B ehavioral health practitioners and managers will at some point find themselves contemplating a life lived in what I call the “life preserver paradox.” >> Reductions in child abuse and neglect, early childhood injuries, mental health problems, to- bacco use, and crime Partnership lead to significant returns to society and government; estimates of economic return can You are intervening with an ever-growing number of >> Improvements in prenatal health; birth out- easily reach $34,000 per family children and families who are diagnostically com- comes (including greater intervals between plex, on what appears to be an ever-shrinking bud- served in net benefit to public births); child development, school readiness, get, and you wonder if you can ever stop saving the funding when the program and academic achievement; and maternal em- drowning long enough to figure out how to keep kids ployment. is appropriately targeted to and families out of the whitewater rapids of evolving higher-risk families. dysfunction to begin with. Three independent studies have found that invest- ments in Nurse-Family Partnership lead to signifi- That’s where Nurse-Family Partnership® can help visits during the course of the program. cant returns to society and government; depending the program puts young families on a physically, on which outcomes are monetized for the evalua- Nurse-Family Partnership is typically administered socially, psychologically, and economically healthy tion, estimates of economic return can easily reach by state and local public health agencies, commu- trajectory from the very beginning of their lives as a $34,000 per family served in net benefit to public nity-service oriented hospitals, or health-focused family. Nurse-Family Partnership engages first-time funding (over program cost) when the program is community-based organizations. Women may be re- parents living in poverty in home visits by nurses appropriately targeted to higher-risk families. Since ferred to Nurse-Family Partnership by a wide variety beginning early in the mother’s pregnancy through the problems Nurse-Family Partnership successfully of people each agency’s referral system should be their child’s second birthday. Home visits are prevents touch so many domains of individual and built to engage anyone and any agency that is likely structured to help parents focus on goals related family functioning, the sources of those savings ac- to be a woman’s first contact when she learns she to improved pregnancy health, infant and toddler crue to many systems: health (including Medicaid), is pregnant for the first time. That usually includes social-emotional attachment and healthy develop- child welfare, education, employment, juvenile jus- pregnancy testing centers or family planning clinics, ment, and economic self-sufficiency. Nurse-Family tice and corrections. school nurses, counselors, WIC clinics, obstetrics Partnership nurses are trained to think ecologically practices, and informal support systems or leaders about human development, looking at the individual Nurse-Family Partnership costs approximately who are imbedded within many minority communi- and family as part of a larger social and economic $5,000/family/year. A minimum start-up program ties. system where stress and support comes from many in a given community serves 100 families, with ap- proximately a $500,000 budget. Planning budgets Programs are supported by a range of public and points in that system, and individual and family cul- are available from the NFP National Office. Nurses’ private funding sources, including Medicaid, Mater- ture, values, and beliefs significantly impact devel- salaries are the primary factor affecting the total nal and Child Health Block Grant (Title V), tobacco opmental pathways. budget, and salaries vary by geographic region, with settlement funds, Temporary Assistance for Needy David Olds, PhD, a developmental psychologist cur- highest costs typically found in urban centers on ei- Families, Child Care Development and Social Ser- rently on faculty at the University of Colorado at ther coast and in hospital-based programs. Due to vices Block Grants, child development and school Denver Health Sciences Center, designed and test- variations in the type of staff employed, caseloads, readiness initiatives, mental health services and ed this preventive intervention in randomized, con- training, supervision, and worker turnover costs, prevention funds, and state and local general funds. trolled research trials in Elmira, New York (1977); there may or may not be a cost differential between If approved by Congress, a newly-proposed federal Memphis, Tennessee (1987); and Denver, Colorado Nurse-Family Partnership and other home visitation initiative sponsored by President Obama will make (1993). Families in both control and experimental programs. $8.6 billion available over the next 10 years in groups were followed longitudinally to determine A nursing team serves a minimum of 100–200 fami- matching grants to states to implement evidence- whether or not effects were sustained beyond the lies and comprises four to eight nurses (each carrying based home visitation programs with a goal of pro- two year nursing intervention. Findings from the a caseload of no greater than 25 families), one full- viding service to all eligible families: Nurse-Family three trials serving diverse populations living in ur- time nurse supervisor, and administrative support. Partnership is one of the programs that will read- ban and rural settings over the past three decades Nurse-Family Partnership nurses visit families every ily qualify if Congress approves this new initiative. demonstrate that the Nurse-Family Partnership reli- one to two weeks from early in pregnancy through President Obama cited Nurse-Family Partnership in ably produces the following outcomes: the child’s second year of life, making about 65 several of his campaign speeches and in his White 24 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • House governing platform as an example of a “pro- of the women in the program need mental or behav- quality over time and ensure that early indicators of gram that works” and warrants federal investment. ioral healthcare and/or substance abuse treatment, desired outcomes are strong. When program size is Nurse-Family Partnership currently is serving approxi- and it is recommended that an experienced mental adequate, reports may be used to describe the im- mately 18,000 families a day in 28 states across the health provider be part of each nursing team’s in- pact the program is making among participating nation. Demand for Nurse-Family Partnership services terdisciplinary counsel for continuing education and families. These data prove extremely useful in con- is growing, and the program is being widely and suc- case conferencing. tinuously monitoring and improving program quality cessfully replicated in urban, rural, and suburban com- Implementation plans must be approved by the and performance; and in documenting the impact the munities across nearly all racial/ethnic populations. Nurse-Family Partnership National Service Office program is having locally. It typically takes 12–18 months to develop a solid (headquarters) prior to each local agency hiring their The Nurse-Family Partnership National Office wel- plan for program implementation and fiscal sustain- nursing staffs who subsequently receive required comes contacts from state and local officials and oth- ability within a community. Statewide or large urban, training from Nurse-Family Partnership expert nurse ers interested in establishing and expanding Nurse- multi-site implementations may take longer, depend- consultants. Learning to conduct this unique prac- Family Partnership where local needs exist. For more ing on the number of nursing teams and families tice with diverse families takes time and coaching. information, visit served, what the administrative sponsor envisions, Experienced nursing teams say it takes at least 12–18 and the sponsors’ usual processes for developing months before practitioners feel confident utilizing all Peggy Hill is director of program development for the Nurse- of the program’s resources flexibly and competently Family Partnership National Service Office. She has 20 years and managing request for proposal processes. Expe- of experience establishing and replicating community-based rienced Nurse-Family Partnership program develop- and can manage a full caseload efficiently. programs to improve family and child health and prevent child abuse. She was instrumental in laying the groundwork for early ment staff work closely with state and local leaders Data about family characteristics, program imple- community implementation of the Nurse-Family Partnership, to engineer these initiatives, including development mentation, and outcomes are entered locally into assuring that new program sites had the resources and support needed to achieve outcomes comparable to those achieved in the of local agency implementation plans. We urge those Nurse-Family Partnership’s Web-based national data randomized trials. She earned a masters degree in counseling who are building implementation plans to include collection and reporting system. Reports enable local and community organization from Purdue University with a focus on social change and community systems of care. their local mental health centers and providers many program managers to monitor and enhance program Today’s environment demands accountability: from clinical Executive Dashboard Providing outcomes to demonstrated, proven cost-effectiveness. NOT JUST Key Indicator Measurement David Lloyd and the SPQM Consultants will work closely with your management team ANOTHER to help identify strategic quality service process outcomes/variances, compliance levels and SOFTWARE performance measurement. PROGRAM Take the SPQM test drive and unleash your company’s potential Take a free SPQM test drive: Schedule a complimentary Internet-based consultation and SPQM report set today. ...AN ESSENTIAL 919-387-9892 or MANAGEMENT CONSULTATION TOOL! (Click on Resources and Services, then on SPQM Dashboards) NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 25
  • Evidence-Based Early Interventions It Takes a Community: Stopping Progression of Severe Mental Illness in Youth William r. McFarlane, Md, Director; donna downing, Ms, otr/l, Director of Training; and anita ruff, MPh, ches, Director of Administration—Early Detection and Intervention for the Prevention of Psychosis Program R ecognizing the tremendous anguish that severe mental illness inflicts on young people, their families, and entire communities, the Robert Wood Portland, Maine (this site also serves as the na- tional program office for EDIPPP) esteem, increased dependency, repeated need for hospitalizations, inability to maintain friendships, and difficulty attaining life goals, such as complet- >> Early Diagnosis and Preventative Treatment of Johnson Foundation launched a national effort, the Psychosis Illness Program at the University of ing school and working. It has been estimated that Early Detection and Intervention for the Prevention California, Davis, Medical Center in Sacramento, the cost to society can be higher than $10 million of Psychosis Program, that builds on the pioneering California over the course of an individual’s lifetime, espe- work of the Portland Identification and Early Refer- cially if they have schizophrenia. When we con- ral (PIER, see sidebar) Program in Portland, Maine. >> Early Assessment and Support Team Program at sider that psychosis can derail a young person’s life This work holds the promise of redefining mental Mid-Valley Behavioral Care Network in Salem, permanently, it is hopeful to think that offsetting an health services and redirecting the course of treat- Oregon illness process early in its development is possible. ment to stop the progression of severe mental ill- >> Michigan Prevents Prodromal Progression Pro- EDIPPP works with young people ages 12 to 25 and ness in adolescents and young adults. With $16.9 gram at Washtenaw Community Health Organi- their families in a defined geographic area. The million in funding from RWJF and with six participat- zation in Ypsilanti, Michigan program uses evidence-based interventions that ing sites across the nation, EDIPPP is the founda- >> Recognition and Prevention Program at Zucker can help youths achieve their full potential, without tion’s largest investment in mental health to date. Hillside Hospital in Glen Oaks, New York stigma, before they exhibit the negative effects of a The program is focused on gathering the evidence fully developed mental illness. practitioners need to better meet the mental health >> Early Assessment and Resource Linkage for needs of adolescents and young adults at risk for Youth Program at the University of New Mexico The evidence-based treatment tools used in EDIP- severe mental illness before the illness develops. and Mind Research Network in Albuquerque, PP are as follows: The six sites that are part of this national endeavor New Mexico >> Family psychoeducation, which helps families use a combination of evidence-based practices to Psychotic illnesses, such as schizophrenia, are understand the illness process and how to treat the early warning signs of serious mental ill- known to be disabling and expensive in multiple help their loved one. ness (schizophrenia, bipolar disorder with psycho- ways. There is a tremendous cost to individuals with >> Education and employment support to ensure sis, and major depression with psychosis): these illnesses, as well as to their families and com- success in life skill areas. >> PIER Program at the Maine Medical Center in munities, e.g., lost productivity, increased family stress, increased physical illnesses, diminished self- >> Family-aided assertive community treatment, which provides rapid access to a multidisci- EDIPPP Community Outreach and Education Activities by Site plinary team to assess and treat young people. April 2007–April 2009 >> Medication, as needed, to minimize the most # of community extreme symptoms. EDIPPP site outreach and # of participants Community outreach and education are a major education events component of EDIPPP; they serve as a mechanism Early Assessment and Resource Linkage for referrals and allow program professionals to for Youth Program 64 1,442 convey specific information about early signs of Early Assessment and Support Team Program 91 1,276 psychosis, to connect with community members Early Diagnosis and Preventative Treatment 123 2,513 outside the mental health system, and to demystify of Psychosis Illness Program and destigmatize mental illness. EDIPPP’s leaders Michigan Prevents Prodromal 149 3,552 hope that if specific community stakeholders are Progression Program offered information and support, they will develop Portland Identification and Early Referral Program 98 3,315 collaborative relationships with EDIPPP staff, which Recognition and Prevention Program 40 916 will lead to early referrals of at-risk youths. Stake- 26 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • holders are defined as people in a unique position to identify young people who demonstrate the early mental changes predictive of a developing psy- More About PIER chosis, and they include staff at medical practices, educational institutions, and community organizations. Excerpts from an article on the PIER program from National Council Because community outreach and education are critical to the successful Magazine, 2007, Volume 3 identification of young people experiencing early warning signs of mental ill- ness, all EDIPPP sites have devoted a significant amount of time and energy to community outreach and education. Between April 2007 and April 2009, T he mission of the Portland Identification and Early Referral Program is to identify young people between the ages of 12 and 25 who might be at risk for psychosis in the Greater Portland area, and then offer appropriate treatment. 565 community outreach and education events took place and reached 13,014 people in the EDIPPP communities. Starting in December of 2000, the multidisciplinary PIER team began educating As a result of the community outreach and education efforts, more than community stakeholders about the early signs of psychosis. 725 people have been referred to the respective EDIPPP programs across PIER’s outreach effort to educate community members was based on initiatives the country. As EDIPPP continues, the program’s professionals are trying to developed in Australia, Norway, and Denmark, where the focus was to interrupt evaluate the effectiveness of the community outreach and education activi- the progression of schizophrenia and other severe psychotic disorders. PIER’s ties, examining whether outreach and education participants have increased goal was to improve outcomes and prevent the onset of the psychotic phase of knowledge, intend to refer youths to the program, understand the referral those illnesses. The Australian and Norwegian initiatives identified stakeholders process, and, eventually, make a referral. Led by staff of the University of Southern Maine’s Muskie School of Public Service, this evaluation will pro- outside of the mental health system who could participate in early detection and vide important information on the role of community outreach and education show commitment to the effort. in increasing the public’s awareness of EDIPPP, understanding and use of its It was reasoned that if specific community professionals were offered information referral process, and identification of young people at risk. and support, collaborative relationships between them and the PIER staff would develop and lead to early referrals of “at risk” youth. The community education EARLY SIGNS OF PSYCHOSIS presentations and outreach activities were designed to give specific information about early signs of psychosis, to network with community members outside the A combination of at least two of the following: mental health system, and to demystify and destigmatize mental illness. These > Being fearful for no good reason trainings offered important information about the biology of the brain, which > Jumbled thoughts and confusion raised awareness about brain disorders versus personality disorders. They also > Feeling “something’s not quite right” offered resource and referral suggestions for stakeholders. > Declining interest in people, activities, and self-care The result of PIER’s outreach was that school professionals, teachers, health pro- fessionals, parents, and mental health practitioners became familiar with PIER’s > Hearing sounds or voices that are not there message, knowledgeable about the importance of making early referrals as a > Trouble speaking clearly, not understanding others deterrent to disability, and learned how to make referrals. PIER has been de- > Declining mental acuity, memory, or attention signed to respond quickly to referrals and to partner with young persons and their families from the start through the intake assessment process and then Don’t ignore the early symptoms! through various client-centered psychosocial interventions, such as family psy- choeducation, counseling, supported education, and supported employment. When appropriate, clients have also had occupational therapy assessments to William R. McFarlane, MD, is the director of the Early Detection and Intervention for the better understand cognitive and functional difficulties results and recommenda- Prevention of Psychosis Program and the director of the Center for Psychiatric Research at tions are then shared with the family and treatment team. Maine Medical Center. He has received numerous awards and honors for his work in the field of psychiatry. Most participants have been on low-dose medications, but overall, their symp- Donna Downing, MS, OTR/L, is the director of training for the Early Detection and Intervention toms have subsided as they and their families have learned to keep stress low for the Prevention of Psychosis Program and oversees the clinical functions of each replication and identify early signals of symptom recurrence. Research has been an impor- site. She served as the first team leader of the Portland Identification and Early Referral Program, from 2000 to 2006. She has worked in various psychiatric inpatient and community tant component of the program because much still needs to be learned about settings throughout her career and has taught at the university level. Her area of expertise is the early phases of illness, what works in terms of interventions, and what indi- family psychoeducation. viduals and their families need. The result is that the majority of young people Anita Ruff, MPH, CHES, is director of administration for the Early Detection and Intervention who have participated in the program have stayed in school, graduated, held for the Prevention of Psychosis Program. She has worked in federal, state, and local public jobs, maintained relationships, participated in extra-curricular activities, and set health organizations throughout her career and has expertise in community health education, social marketing, and program evaluation. goals for the future. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 27
  • Evidence-Based Early Interventions A Long-term Approach to Early Psychosis Intervention tamara sale, Ma, EAST Program Coordinator and Ryan Melton, LPC NCC, Clinical Coordinator—Mid-Valley Behavioral Care Network I n 2001, the Mid-Valley Behavioral Care Network, based in Salem, Oregon, launched the first sys- tematic effort to implement early intervention for schizophrenia, given that the observed outcomes of people dealing with this illness were particularly poor. Mrazek introduced MVBCN to the work of the public health, secondary and postsecondary educa- tion, the medical community, vocational rehabilita- tion, and business. Local and national foundations schizophreniform and bipolar spectrum psychosis Early Psychosis Prevention and Intervention Center contributed significant funding to allow EAST to in a U.S. public managed care system through a (now called Orygen) in Melbourne, Australia. serve all clients regardless of insurance coverage program called the Early Assessment and Support After a yearlong review and planning process, MVBCN and to document its results to create the needed Team. In 2007, the Oregon legislature funded dis- launched EAST in January 2001. EAST based its ser- momentum. From EAST’s inception, the MVBCN semination of the EAST approach through the Early vices on Australian guidelines and consultation. As partners viewed the program as a community-based Assessment and Support Alliance. The goal was to EAST evolved, it incorporated the multifamily group public health strategy and system reform effort. make the services available across Oregon. These process and integrated practice elements from best As a result of the Oregon legislature’s investment in efforts are part of a statewide effort to maximize practice methods developed in the United States, 2007, more than 60 percent of Oregon’s population recovery through services that are based on current such as the family-aided assertive community treat- has access to early psychosis (first-episode) inter- research. ment model developed by the Portland Identifica- vention based on EAST’s approach. Core elements MVBCN is an intergovernmental managed mental tion and Early Referral program (see page 24-25). of the program model are as follows: healthcare organization that has succeeded in bring- Initially, seven of MVBCN’s 16 provider agencies and >> Ongoing community education focused on ing evidence-based and preventive approaches to several separate subprograms were included in the schools, doctors, parents, and other potential re- its local communities. In 1999, MVBCN hired Patri- clinical implementation team. Each agency con- ferral sources to increase identification of early cia Mrazek, a mental health prevention researcher, tributed clinical staff, and MVBCN provided direct symptoms. to identify and recommend evidence-based preven- funding for the clinical services in addition to a full- >> Attempts to eliminate financial, regulatory, cul- tion programs that could be implemented across time coordinator and training expenses. EAST also its network. MVBCN specifically requested models tural, and logistical barriers to care. brought in partners from allied systems, including associated with early intervention or prevention of >> Emphasis on voluntary, empowering approaches 28 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • that assume a hopeful long-term prognosis. ily burden, job loss, homelessness, accidental death, ning to lay the groundwork for the system that is ulti- >> Active efforts to reach out to, welcome, and be- suicide, or entry into lifelong dependency on the dis- mately needed. Much remains to be done: friend each client, use his or her explanatory lan- ability system. >> Expanding early psychosis intervention alternatives guage, and emphasize his or her strengths and The lifetime course of one person’s illness can easily to the rest of Oregon. goals. cost in the millions of dollars, including acute care, >> Ensuring continuity of quality care beyond the ini- >> The perspective that clients and families are full legal expenses, disability and medical costs, housing, tial couple of years of early intervention. partners and, accordingly, a transparent decision- food stamps, and both the client’s and the family’s lost wages and increased illness. Research compiled >> Restructuring disability support and insurance making process; the ultimate goal is to prepare alternatives to encourage clients’ maximal partici- clients and their families for their role as “owners” by Orygen has documented that the cost of the first 5 to 7 years of treatment alone for people who receive pation in the workforce without endangering their of the treatment and support process. access to healthcare. early intervention is one-third the cost of treatment >> Provision of service to clients within the same for people who do not receive such intervention. >> Participating in research and dissemination that team regardless of their youth or adult status. will create a system of early psychosis services na- Evidence-based care at the early stages of illness >> Encouragement of multifamily group psychoeduca- requires leadership and system redesign. For ex- tionwide. tion as a core service. ample, systems must be able to accept diverse fund- >> Systematically incorporating emerging research >> Support of vocational, educational, and other de- ing sources and to serve clients during both teen and into practice, including developing program mod- velopmental goals. adult years. If efforts are to be successfully sustained els that provide support for early symptoms with- >> Careful use of medications at low doses as appro- in spite of funding and political changes, consistent out making inappropriate assumptions about the priate, with an emphasis on patient education and commitment and prioritization of efforts are critical. ultimate diagnosis or prognosis. side-effect monitoring. During the EASA dissemination process, multiple ses- sions for senior administrators included in-depth dis- >> Inclusion of occupational therapy, with an empha- cussions of the unique and challenging requirements Without continued support, sis on identifying and addressing the sensory and the benefits of short-term of supporting this program development. Communi- cognitive issues that often underlie functional dif- intervention can be lost within the cation and strategizing with senior staff are ongoing. ficulties. first 5 years. To support long-term The support of senior management champions is Oregon’s experience offers important insights. recovery, the larger system of necessary to sustain the effort required. In addition, The benefits of early intervention for psychosis are leadership at the state level has been critical. ongoing care must have adequate easily established compared with the tremendous resources, an orientation toward To support long-term recovery, the larger system of costs of acute and extended illness. EAST and, now, recovery, evidence-based care, ongoing care must have adequate resources, an ori- the EASA programs have followed the pattern of other and easy access for clients who entation toward recovery, evidence-based care, and international programs in showing an immediate and experience psychotic illness. easy access for clients who experience psychotic dramatic decrease in hospitalizations among the cli- illness. International data are clear that without con- ents served. Approximately 50 percent of the people tinued support, the benefits of short-term intervention who entered EAST and EASA programs were hospital- can be lost within the first 5 years. The ability to tran- ized in the 3 months before intake. After intake, the sition clients into long-term supports that are based hospitalization rate dropped to 10 percent or less per on a philosophy consistent with the early intervention quarter, with a further decline over time. A similar de- program is important to sustain the benefits. Thus, cline was seen in the number of arrests. programs that applied to be part of EASA’s dissemina- Where early psychosis services are not easily avail- tion process were required to demonstrate how EASA able, people often experience repeated acute invol- would fit into the mission and direction of their orga- untary hospitalizations and legal involvement rather nization. Likewise, at the state level, the features of than a more positive and effective entry into servic- early psychosis intervention parallel other efforts to es. This approach not only is far more expensive but move the system toward recovery-oriented, evidence- also can result in a host of negative consequences, based care. such as trauma, future treatment resistance, fam- EAST, EASA, and other national efforts are only begin- NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 29
  • Evidence-Based Early Interventions EAST is currently one of six sites across the nation participating in a study funded by the Ryan Melton is the EAST clinical coordinator. Ryan has been a clinician with EAST since 2001. He has a masters degree in counseling psychology from Pacific Robert Wood Johnson Foundation Early Detection and Intervention for the Prevention of University, and is currently a PhD candidate in counselor education at Oregon Psychosis Program, which replicates PIER’s FACT model for people who have less severe psy- State University and a psychology instructor at Chemeketa Community College. chotic symptoms or who have had acute symptoms for less than 1 month. Because extensive REfEREncES evidence shows that the disability associated with schizophrenia often begins during the American Psychiatric Association. (2007). Silver and bronze achievement awards. Psychiatric Services, 58, 1372−1373. prodrome, or preacute, stage of illness and because acute psychosis is highly disruptive and Bertolote, J., & McGorry, P. (2005). Early intervention and recovery for young potentially life threatening, earlier identification holds the potential to significantly improve people with early psychosis: Consensus statement. British Journal of Psychiatry, outcomes (more about EDIPPP and PIER on page 24). 187(Suppl. 48), S116−S119. Birchwood, M., & Macmillan, F. (1993). Early intervention in schizophrenia. In a community behavioral health system driven all too often by crisis and rigid funding Australian and New Zealand Journal of Psychiatry, 27, 374−378. requirements, EAST and EASA are helping to demonstrate that it is possible to move out of a Edwards, J., & McGorry, P. (2002). Implementing early intervention in psychosis. London: Martin Dunitz. reactive mode and reorient services in a way that is most beneficial for the people who use Egnew, R. C. (1993). Supported education and employment: An integrated ap- them. The clients served by EAST and EASA will help shape and direct the next generation of proach. Psychosocial Rehabilitation Journal, 17(1). mental health system development. Ehman, T., & Hanson, L. (2002). Early psychosis: A care guide. Vancouver: Department of Psychiatry, University of British Columbia. Given Oregon’s early experiences and the work of mental health advocates across the United Ehman, T., Yager, J., & Hanson, L. (2004). Early psychosis: A review of the treat- States, we anticipate that recovery from psychosis will begin to be viewed as commonplace, ment literature. Vancouver: University of British Columbia. in the same fashion as other chronic illnesses. International Early Psychosis Association Writing Group. (2005). International clinical practice guidelines for early psychosis. British Journal of Psychiatry, 187(Suppl. 48), s120−s124. Tamara Sale has been program coordinator for EAST since its inception in 2001. Tamara has 20 years of experi- Johannesen, J. O. (2001). Early recognition and intervention: The key to success ence focused on mental health service system development. Tamara has a masters degree in management of in the treatment of schizophrenia? Disease Management & Health Outcomes, public and nonprofit organizations with a concentration in fiscal policy. Her experience includes eight years as a 9(6). state leader in the National Alliance on Mental Illness in Oregon. Killackey, E., & Yung, A. (2007). Effectiveness of early intervention in psychosis. Current Opinion in Psychiatry, 20, 121−125. McFarlane, W. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford Press. McFarlane, W. R., Dushay, R. A., Stastny, P., Deakins, S. M., & Link, B. (1996). A comparison of two levels of family-aided assertive community treatment. Psychiatric Services, 47, 744−750. McGorry, P. D., Edwards, J., Mihalopoulos, C., & Harrigan, S. M. (1996). EPPIC: An evolving system of early detection and optimal management. Schizophrenia Bulletin, 22, 305−326. McGorry, P., & Jackson, H. (Eds.). (1999). The recognition and management of early psychosis: A preventative approach. Cambridge, England: Cambridge University Press. McGorry, P., Killackey, E., Elkins, K., Lambert, M., & Lambert, T. (2003). Summary Australian and New Zealand clinical practice guideline for the treatment of schizophrenia. Australasian Psychiatry, 11(2), 136−147. Mikalopoulos, C., McGorry, P. D., & Carter, R. (1999). Is phase-specific, communi- ty-oriented treatment of early psychosis an economically viable alternative? Acta Psychiatrica Scandinavica, 100, 47−55. Mrazek, P. J., & Haggerty, R. J. (Eds.). (1994). Reducing risks for mental disor- ders: Frontiers for preventive intervention research. Washington DC: National Academies Press. National Early Psychosis Project Working Party. (1998). The Australian clinical guidelines for early psychosis. Melbourne, Australia: University of Melbourne. National Institute for Mental Health in England, Department of Health Policy Research Program. (2003). Early intervention for people with psychosis. Leeds, England: Author. Power, P., Elkins, K., Adlard, S., Curry, C., McGorry, P., & Harrigan, S. (1998). Analysis of the initial treatment phase of first-episode psychosis. British Journal of Psychiatry, 172(Suppl. 33), 71−76. Rupp, A., & Keith, S. J. (1993). The costs of schizophrenia: Assessing the burden. Psychiatric Clinics of North America, 16, 413−423. 30 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • SBIRT: Effective Interventions for Alcohol-Related Health Problems Maureen Fitzgerald, Editor, NIATx National Program Office their levels of risk or problems. Most patients receive over or under the influence pose substantial costs to an intervention of about 20 minutes and, perhaps, a an employer, given that such workers are at high risk for follow-up visit or phone contact. Interventions are low productivity, workplace injuries, worker’s compen- based on motivational interviewing techniques and are sation claims, and potentially lifelong payouts. conducted on site by trained WIPHL health educators. A recent study by researchers Andrew Quanbeck, Katha- Studies have shown SBIRT to be one of the most effec- rine Lang, and Kohei Enami at the University of Wiscon- “We’re seeing that simple screening can tive interventions for alcohol-related health problems. sin–Madison showed that employers have a lot to gain reduce healthcare costs and build hap- According to the National Commission on Prevention by making sure that their insurance companies and pier families and healthier communities,” Priorities, alcohol SBIRT services are ranked fourth healthcare providers offer SBIRT. The analysis quanti- says Rich Brown, who directs the Wisconsin Initiative to among clinical preventive services for cost-effective- fied how employers benefit by requiring insurers to Promote Healthy Lifestyles, a screening and assistance ness and clinically preventable burden, which is de- adopt the SBIRT program. The researchers calculated program for alcohol and drug abuse coordinated by fined as “the disease, injury and premature death that the likely costs of problem drinking for a representative the Department of Family Medicine at the University would be prevented if the service were delivered to all Wisconsin firm that does not currently provide SBIRT of Wisconsin–Madison. The 5-year project is funded people in the target population”. services. They then constructed a cost−benefit model by a $12.6 million grant from the federal Substance “Evaluations are showing that SBIRT is making an in which the firm would fund SBIRT for its employees Abuse and Mental Health Services Administration and impact on patient drinking,” says Brown. For many pa- through a group health insurance plan. The authors administered by the Wisconsin Department of Health tients, this early and brief intervention, which includes estimated the net present value of SBIRT adoption by Services. one to three follow-up consultations, is enough to help comparing costs due to problem drinking both with and them significantly decrease or stop their alcohol and without SBIRT. This innovative program aims to address problem drinking, which the state has identified as a major drug use. When absenteeism, presenteeism, and healthcare public health issue. Between 2002 and 2006, alcohol Primary care providers at the Wisconsin SBIRT sites costs were explicitly considered from the employer’s abuse rates among Wisconsin residents ages 12 and are also pleased with the project. Adds Brown, “They’re perspective, the net present value for the representa- older ranged from 9% to 11%, compared with the na- already challenged to address three clinical problems tive firm was $1,464 per employee. Benefits of the re- tional rate of 8%. In addition, Wisconsin’s per capita in the 15 minutes they spend with a patient, and the duction in motor vehicle accidents are shared between driving-under-the-influence arrests are 1.5 times those response to having a trained health educator on site to society and employers. Societal net present value, with of the United States as a whole, and the state’s rate of conduct the screening has been very positive.” the exclusion of quality of life values, was estimated to drinking and driving is the highest in the nation. Accord- be $3,405 per employee. “While absenteeism and pre- To date, WIPHL clinics have screened 60,000 patients senteeism costs are difficult to estimate empirically, we ing to a 2008 needs assessment project report by the and conducted 10,000 brief interventions. More clinics used the best estimates available from the literature,” Wisconsin Department of Health and Family Services will be added in coming years, and the effort includes a noted Quanbeck et al. “Notably, SBIRT is cost-benefi- (now the Wisconsin Department of Health Services), focus on changing public policy and standards of care cial from the employer’s perspective if healthcare costs the state’s healthcare, social services, and criminal jus- so that services continue to be delivered on a perma- alone are considered. There appears to be a business tice systems incur more than $2.6 billion in costs each nent basis. case for employers to fund SBIRT services, since the year from alcohol-related injuries, hospitalizations, ar- rests, treatments, and deaths. SBIRT both improves people’s lives and helps lower so- costs are minimal and many of the benefits accrue di- cietal costs. A 2002 Wisconsin study showed that the rectly to the employer,” the researchers said. Since March 2007, WIPHL has administered screening, state saves nearly $1,000 in healthcare and criminal “This study helps show that SBIRT is cost-beneficial brief intervention, and referral to treatment (SBIRT) justice costs for every patient who receives screen- from both societal and employer perspectives,” says through 21 participating primary care settings across ing and brief intervention services. This study counted Brown. “It makes economic sense for employers to the state. The brief screening consists of four questions reductions in motor vehicle accident and injury, and make sure that SBIRT is a benefit covered in the group asked of each patient once a year during a routine medical, and legal event costs as benefits of the pro- health insurance plans they offer,” he concludes. healthcare visit. People who score positive and are at gram. risk for alcohol abuse see an on-site health educator who has received WIPHL training. Patients’ responses Less widely recognized but just as significant is the toll Maureen Fitzgerald is an editor for NIATx, based at the national that substance abuse problems take in the workplace. program office on the University of Wisconsin-Madison campus. to a lengthier set of questions the Alcohol, Smoking She writes frequently on the NIATx model of process improvement and Substance Involvement Screening Test indicate Absenteeism and “presenteeism”coming to work hung and its successful application in behavioral health settings. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 31
  • From The Field GettinG a Head Start on Mental HealtH Prevention and Early Intervention Programs for Children Community mental health organizations across the country share examples of infant and child mental health promotion through successful prevention programs. Focus on Relationships: Parent-Infant Psychotherapy at Navos christy Kimpo, Phd, MHP, Infant Mental Health Specialist and Victor Place, LMFT, Program Director, Child & Family—Navos, Seattle, WA I n June 2008, we interviewed 254 clients at seven BHS outpatient and residential treatment sites about their access to general medical services and emotional development provides the foundation for all later experiences in life, including the ability to self-regulate, the capacity to relate to others, flex- associated with insecure attachment relationships (Ainsworth & Marvin, 1995). In the juvenile justice system, a large percentage of juveniles with violent medical need. 66% of clients interviewed were in res- ibility in adaptive problem solving, and all academic offenses have a history of conduct disorders and idential treatment, 33% were women, and 37% were achievements (Committee on Integrating the Science disrupted social and emotional development in early Latino; 44% had less than a high school education, of Early Childhood Development, Youth and Families childhood (Evans, Gonnella, Marcynyszyn, Gentile, & and half had been released from jail or prison within Board on Children, 2000). All of these aspects of early Salpekar, 2004). 6 months of starting treatment. life growth and development occur in the context of Many cost–benefit studies support investing in high- The Diagnostic Classification of Mental Health and the infant’s relationships with significant caregivers quality early intervention. Relationship-based dyadic Developmental Disorders of Infancy and Early Child- during the first 3 years of life. therapy with a primary caregiver and an infant or hood (Zero to Three, 2005) was introduced in 1994 Much research shows that young children who have young child can be seen as promoting healthy de- and revised in 2005 as a way to evaluate and under- difficulty regulating their emotions and relating to velopment in young children and preventing later stand how very young children display developmental others are more likely to have persistent and serious disorders. In a perfect world, every family would have differences and emotional difficulties. mental disorders later in life (Keenan, Shaw, & Del- this kind of comprehensive support during the first 75 percent of brain growth and development occurs liquadri, 1998). Poor outcomes in social and emo- year of a child’s life to promote an enduring, strong during the first three years of life. Early social and tional development and academic achievement are foundation. 32 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Parent−infant psychotherapy a relationship-based, dy- collaboration with other systems throughout the course dlers. By working with the dyad together, therapists can adic form of intervention that focuses on the interac- of treatment to ensure comprehensive care for the family. help very young children and their primary caregivers tions between caregivers and their children is currently Home visits, a key part of this type of work, often cen- form close attachment relationships. viewed as a promising practice (Zero to Three, 2007) ter on developmentally appropriate play between the for promoting early social and emotional development caregiver and the child. Caregivers and infants play REfEREncES and preventing later mental illness. Early evaluation Ainsworth, M., & Marvin, R (1995). On the shaping of attach- together while the therapist observes and “notices” ment theory and research: An interview with Mary Ainsworth. studies analyzing the efficacy of dyadic relationship– each dyad member’s emotional responses. The goals Monographs of the Society for Research in Child Development, based therapy suggest that parent−infant psychothera- of these play sessions include identifying capacities of 60(2−3), 3–21. py may be quite effective in helping families cope with the dyad, helping the caregiver read and understand Committee on Integrating the Science of Early Childhood Develop- traumatic events (Lieberman, Weston, & Pawl, 1991). In ment, Youth and Families Board on Children. (2000). In J. P. the nonverbal cues of his or her child, interpreting the Shonkoff & D. A. Phillips (Eds.), From neurons to neighborhoods: addition, dyadic therapy is highly effective in reducing child’s response to the caregiver’s efforts, and helping The science of early childhood development. Washington, DC: relationship problems between caregivers and young both partners be attuned (emotionally “in synch” with National Academy Press. children (Sameroff, McDonough, & Rosenthal, 2004). each other) in the context of a nonthreatening activity Evans, G., Gonnella, C., Marcynyszyn, L., Gentile, L., & Salpekar, N. (2004). The role of chaos in poverty and children’s socioemo- Navos is a comprehensive mental health center whose — play. The therapist may also focus on helping caregiv- tional adjustment. Psychological Science, 16, 560−565. Mindful Beginnings program, run by five full-time staff, ers match their play’s content, intensity, and pacing to Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the serves Medicaid-eligible, low-income, high-risk in- that of the child. This, in turn, allows the young child to nursery: A psychoanalytical approach to the problems of impaired fants, toddlers, and preschoolers and their caregivers begin to regulate his or her emotions and arousal and mother-infant relationships. Journal of the American Academy of Child Psychiatry, 14, 387−421. together through weekly visits in the home, office, or gives the child a beginning sense that he or she has Keenan, K., Shaw, D., & Delliquadri, E. (1998). Evidence for community. Parent−infant psychotherapy is a key com- some control over the environment. the continuity of early problem behaviors: Application of a ponent of this work. Sessions focus on a variety of ar- Caregiver−child interactions are imbued with a set of developmental model. Journal of Abnormal Child Psychology, 26, eas, including meeting the concrete needs of families, 441−452. meanings, including the caregiver’s own experience Lieberman, A., Weston, D., & Pawl, J. (1991). Preventive interven- providing information on typical development in early as a very young child. Many families in our program tion and outcome with anxiously attached dyads. Child Develop- childhood, offering emotional support, and promoting have an intergenerational history of trauma, abuse, and ment, 62, 199–209. healthy social and emotional development by working neglect. Fraiberg, Adelson, and Shapiro (1975) called Sameroff, A., McDonough, S., & Rosenthal, K. (2004). Treating to create strong attachment relationships. Families are these intrusions from the past “ghosts” and introduced parent-infant relationship problems: Strategies for intervention. New York: Guilford Press. referred for services by primary care physicians, public the model of parent−infant psychotherapy as a means Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out. health nursing staff, child protective and child welfare of helping families exorcise the “ghosts in the nursery.” New York: Tarcher/Putnam. services, the dependency court system, child care cen- Dyadic therapy helps troubled caregivers deal with Zero to Three. (2005). DC0−3 R: Diagnostic classification of ters, early childhood educational settings, substance emotional issues from their past by exploring how those mental health and developmental disorders of infancy and early abuse treatment centers, detention centers and jails, childhood, revised. Washington, DC: Zero to Three Press. experiences may interfere with the caregivers’ ability to and other clients. In addition to therapy, infant mental Zero to Three. (2007, November). Keynote address, National be present in the moment with their own infants or tod- Training Institute, Orlando, Florida. health work involves rigorous case management and From Home to School: A Multi-Pronged Approach at Eastern Shore Kathryn seifert, Phd, CEO/Owner, Eastern Shore Psychological Services, Salisbury, MD / R ecognizing that there are cost-effective ways to sup- port youths and families for better outcomes and to reduce the negative effects of violence, crime, sub- and the family’s successes every day and throughout the year. Fathers are encouraged to participate. Well- trained paraprofessionals bring developmentally ap- county to help in early identification of children who are experiencing mental and behavioral problems and pro- vide services to help these children. Six years of data stance abuse, and mental illness, Eastern Shore Psy- propriate activities, toys, and resources to the home show reduced behavior and mental health problems chological Services in Maryland operates three preven- and teach family bonding and child development. The and increased attendance and self-esteem for youths tion programs — Healthy Families, School Based Mental program is based on the Olds home visiting program, who participate in the program. Parents are included in Health, and the Psychiatric Rehabilitation Program. which has been proven to prevent child abuse and de- the program when possible, to ensure better results. The Healthy Families program, now in its 10th year, is linquency. Many children with mental health and behavioral a home visiting program open to any pregnant wom- Eastern Shore delivers individual and group therapy, problems also have delays in social and personal skill an and her family unit. The family can remain in the teacher and staff education, consultation, and resourc- development, such as communication, interpersonal, program until the youngest child is 5 years old. This es in its School-Based Mental Health program. Social task, self-management, and adaptive skills. The Psychi- strengths-based program celebrates the children’s workers are placed in every school in a particular rural atric Rehabilitation staff at Eastern Shore are trained NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 33
  • From The Field to provide skill-building activities that are fun, engaging, and based on the skill level of the child. The staff also reinforce values such as respect and kindness to others. Eastern Shore’s strengths-based programs have flourished and help support many families emotionally, educationally, and de- velopmentally. All three programs are based on wellness research program models. In combination, they foster success in children, families, and communities. Screening and Problem-Solving: Preschool Interventions at Child Access Program sally sweitzer, Ma, Program Coordinator, The Child Access Program, Framingham, MA / E arly childhood educators are seeing a rapid rise in disruptive and aggressive behaviors in preschool children. Studies at the Devereux Institute indicate term, billable, and evidence-based. This aspect of the program is easily measured in dollars per hour per service type. the classroom. The specialists develop and imple- ment positive (behavior) plans for individual children to increase protective factors and respond to con- that the increase in these behaviors corresponds to The second tier of the model is prevention-based cerns or challenges identified as a result of the DECA a decrease in the protective factors (LeBuffe & Na- and founded on core principals of the Devereux screening. Weekly meetings with each teacher in and glieri, 1999) of attachment, self-control, and initia- Early Childhood Assessment program. This aspect of outside of the classroom provide ongoing profes- tive. Prevention and early intervention research indi- the program uses a strengths-based approach to sional development. cates that raising the protective factors associated analyzing and problem solving. It offers teachers an The program’s outcomes are excellent. Each year with resilience at an early age has a direct impact opportunity to reflect on and explore changes in their since the program began, we have seen an increase on the number of children who commit crimes and teaching practices and to increase their competency in one or more protective factors for all children. have serious emotional and mental health issues as in the program’s core training areas: resiliency, ob- Teachers and parents report increased confidence teenagers and young adults. jective observation, and management of challenging and competency as well as a reduction in challeng- The Child Access Program is a grant-funded project behaviors. ing behaviors. that currently serves 160 children in three preschools A workshop series for parents offers them new skills TCAP is in its third year, and we have just received in Framingham, Massachusetts. The model is facili- for raising a resilient child and coping with behavior- word that the grant will be funded by the MetroWest tated by a team of three mental health clinicians we al challenges. In addition, each child receives three Community Health Care Foundation for another cycle. call “child specialists” and a program coordinator to DECA social and emotional competency screenings In these difficult economic times, receiving such oversee daily operations. during the course of the school year. The goal for funding is no small feat. The grant approval is also The program has two tiers. The first tier, the inter- these assessments over a 10-month period is to see an affirmation that early intervention and prevention vention tier, is basic and involves responding to the an increase in protective factors and a reduction in provide long-term, sustainable outcomes and raise significant behavioral problems and mental health problem behaviors for all children. Child specialists confident and resilient children who are poised to needs of identified children by assembling a team create universal classroom profiles based on DECA contribute positively to their world. of parents and professionals to provide the children results to look for patterns that may indicate a need with appropriate services. The services are short for changes in the environment or daily practices in Intensive Behavioral Therapy Groups Foster Wellness at Samaritan John d. Kinsel, Ms, lPcc-s, YCATS Clinical Supervisor, Samaritan Behavioral Health, Inc., Dayton, OH / T he Young Children’s Assessment and Treatment Services program of Samaritan Behavioral Health in Dayton, Ohio, is dedicated to meeting the mental YCATS provides intensive behavioral therapy groups for behavior-disordered children ages 3 to 5. Two spe- cially trained early childhood mental health thera- operates eight intensive behavioral therapy groups: three at Samaritan’s main facility and five co-located in the community in YCATS’ partner early childhood health needs of children from birth through age 5. pists guide each group of 8 to 10 preschoolers. YCATS education settings. 34 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Intensive group interventions are strengths-based and occupational therapy if such a need is assessed. By promoting emotional wellness in young children, focus on the three resiliency factors of attachment, YCATS also sends early childhood mental health consul- YCATS helps to prevent future emotional and behav- self-control, and initiative, as identified in compre- tants into the community to consult on site with a wide ioral problems. hensive studies of trauma-exposed children (Werner & array of early childhood education programs. Services, Smith, 1982). The intervention’s intent is to ameliorate REfEREncES which are based on the Georgetown model (Substance LeBuffe, P. A., & Naglieri, J. (2003). The Devereux Early Childhood problem behavior by promoting prosocial functioning. Abuse and Mental Health Services Administration, Assessment—Clinical form. Lewisville, NC: Kaplan Press. Progress is tracked with the Devereux Early Childhood 2001), include early childhood education staff training, Shonkoff, J. P., & Phillips, D. A. (2000). From neurons to neighbor- Assessment–Clinical Form (LeBuffe & Naglieri, 2003). center- and classroom-based consultation, and indi- hoods: The science of early childhood development. Washington, DC: National Academies Press. Children are eligible for intensive group therapy if they vidual child- and family-focused consultation. Substance Abuse and Mental Health Services Administration. have been or are at risk of being suspended or expelled Infant mental health needs are addressed through (2001). Early childhood mental health consultation. Washington, from their early childhood education program. Other partnership with local organizations that serve children DC: Author. young children with home-centered or trauma-based from birth to age 3. The infant mental health specialist Werner, E. E., & Smith, R. S. (1982). Vulnerable but invincible: issues are assigned to individual treatment with thera- A longitudinal study of resilient children and youth. New York: meets with the parent−child dyad in their home to ad- McGraw-Hill. pists who work with them and their families in play and dress issues of attachment, behavior management, and Zero to Three. (2005). Diagnostic classification 0–3: Diagnostic dyadic therapies. YCATS clients may also access on-site specific disorders of infancy (Zero to Three, 2005). classification of mental health and developmental disorders of psychiatric consultation and sensory integration–based infancy and early childhood. Washington, DC: Author. Providence Center Focuses on Understanding Behaviors Kristle l. gagne, Marketing Communication Specialist, The Providence Center, Providence, RI / S ome children are labeled as problem children because their behavior is unacceptable they act out, cannot sit still for circle time, do not make friends easily, and an ECI clinical therapist goes to the child’s day care to observe the child and identify his or her developmental, emotional, or behavioral needs. The clinical therapist with their child is vital to good behavior.” Some children also attend the ECI Day Treatment Center for several consecutive weeks to hone their emotional do not do well in day care settings. The experts at the then works with the adults in the child’s life to make the management skills, their communication skills, and their Providence Center’s Early Childhood Institute, in Provi- child’s environment more supportive and to teach him ability to take turns, wait, and make choices. Designed dence, Rhode Island, believe that behavior has meaning or her better social and emotional management skills. to look like a traditional day care, the ECI Day Treatment and that understanding that meaning is the first step in Sometimes therapists discover that the challenging Center implements a developmentally appropriate cur- making the early years a positive experience for children, “problem” behaviors are the result of a developmental riculum that promotes social−emotional development their families, and their early childhood care providers. delay. while engaging children in typical play centers that For children from birth to nearly 6 years old who have “After an ECI clinical therapist observed my son, she encourage interaction as the children explore dramatic behavioral, social, or emotional difficulties or delays, it thought that he might have difficulty in processing lan- play, art, and basic reading and math concepts. can be difficult to succeed in a day care or Head Start guage,” said an ECI parent. “A speech and language test Early childhood specialists also provide consultation and program or to enter kindergarten ready to learn. The confirmed this, and it all made sense he didn’t under- training for childcare providers in the community on how staff at the ECI works with children and their families stand what we were telling him, so that’s why he was to promote healthy social and emotional development to explain inappropriate behavior and teaches families, misbehaving.” in their students. During interactive trainings, teachers early childhood educators, and the children strategies After the observation, the ECI staff work to develop a learn the power of positive relationships and high-quality that help children succeed both at home and in early positive relationship between the child and his or her supportive environments as well as how to observe be- childhood settings. family. They teach the family the importance of emotion- havior. “When children are referred to us, we believe they are al regulation, about typical development and the ways in “Kids talk to us through their behaviors,” says Bryna simply ‘misunderstood,’” says Simmy Carter, LICSW, RN, which young children are very different than adults, and Hebert, MEd, the ECI clinical therapist who conducts clinical supervisor of the ECI. “Our goal is to understand the power of strong relationships. Families learn strate- the trainings for early childhood educators. “We help the family’s goals for the child and the causes of their gies that will help them manage their child’s challenging teachers learn the function of the child’s behavior and behavior and teach strategies that help not only the behavior with understanding and control, including giv- how to create a plan to replace inappropriate behaviors children but also their families and early childhood pro- ing clear instructions, maintaining consistent routines, with more acceptable behaviors.” Training units include viders.” calming down, and having fun as a family. Building Positive Relationships, High-Quality Supportive Referrals to the ECI include children who are exhibiting “If a child is having bedtime hassles, we work with the Environments, Supporting Social and Emotional Devel- disruptive behaviors and are in danger of being asked to family to develop an evening routine that makes bedtime opment, Behavior Has Meaning, and Parenting Survival leave their day care. At the request of a parent, pediatri- special instead of a fight,” explains Carter. “Most impor- Skills. cian, day care provider, school district, or state agency, tantly, we remind parents that a positive relationship NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 35
  • From The Field Addressing Maternal Depression Fosters Child Development at Institute for Family Health nikki Pison, lMhc, Program Director, Institute for Family Health, New York, NY/ R esearch on postpartum depression makes it abun- dantly clear that maternal depression not only affects the women who suffer from it but also has that depressed mothers are at increased risk for ne- glecting their infants, create less consistent and less stimulating parenting environments, and may tend depression symptoms for mothers and improve de- velopmental scores for infants to generate long-term protective benefits. long-term deleterious effects on their children. The to use more punitive parenting behaviors. Currently, A unique aspect of this project is its reliance on home literature shows a great consensus that maternal de- mothers who are identified as depressed are given ap- visitors who are not formally trained clinicians. The pression is related to cognitive and language delays propriate referrals to mental health treatment. cognitive−behavioral strategies endorsed in the new during infancy that often persist into adolescence. As a further intervention, the Institute for Family Health curriculum are easy to master and communicate to Maternal depression is also associated with childhood is developing a cognitive−behavioral curriculum that families and do not require an academic background depression, early conduct disorders, sleep disorders, home visitors can implement in addition to their regu- in psychology or social work. The Institute for Family childhood injuries, and lack of involvement in school lar parenting curriculum. This intervention is designed Health will provide the home visitors with specialized activities and is linked to physical health problems to specifically target dysfunctional mother−child training in administering the activities to ensure that such as asthma. interactions, which are typical when mothers have they are prepared to use the techniques. Many of these difficulties can persist into adulthood postpartum depression. This 12-week curriculum will Home visitors will give the new mothers colorful, user- and may predict later pathologies, such as physical, be used with all new mothers who are recognized as friendly handouts that focus on creative ways to ad- mental health, and substance abuse issues. Fortu- having significant symptoms of depression, defined as dress lack of contact and emotional bonding with their nately, outcomes for children of mothers who receive mothers who score 10 or greater on the Patient Health infants. For example, one activity will promote eye treatment are much more favorable. Efforts to identify Questionnaire Nine-Symptom Checklist, a validated contact and co-smiling (i.e., shared smiling between and treat postpartum depression are therefore critical tool for identifying depression. mother and infant) and will provide psychoeducation to the prevention of childhood illnesses and mental The Institute for Family Health is currently in the initial to mothers about the importance of these gestures for health issues that can affect lifelong health and pro- phases of the project and has begun screening all par- infant brain and social development. The home visi- ductivity. ticipants in the home-visiting programs. The interven- tor will guide mothers through the activities and leave Ulster County Healthy Start and Dutchess County tion that uses the new cognitive−behavioral curriculum them with homework to practice with their babies until Healthy Families are home-visiting programs of the is expected to be launched in January 2010. After this the next visit. Although these techniques are specifical- Institute for Family Health, in New York, New York, that point, comparisons will be made between depressed ly designed to help improve infant outcomes, they are provide prenatal and parenting education and support participants who received the existing curriculum and also expected to help reduce maternal depression. to at-risk families. Program goals include supporting those who receive the newly developed intervention Because this project will be administered by noncli- child development and parent−child bonding and curriculum. The intervention is expected to improve nicians, it is economically feasible and applicable preventing child abuse and neglect by conducting depression for mothers with postpartum symptoms. to many other programs and organizations that work home visits that use an evidence-based parenting cur- The increased positive parent−child interactions that with at-risk families. Therefore, other home-visiting riculum. Professional home visitors hold sessions that the curriculum will encourage are known to influence programs could easily adopt the model. If success- focus on strengthening the parent−child relationship, development; therefore, the intervention is also ex- ful, this model will provide an effective intervention to assisting families in meeting self-sufficiency goals, and pected to improve cognitive and other developmental decrease depression in mothers at risk of developing helping children reach developmental milestones. scores for infants. a major depressive episode and will increase positive The programs recently implemented depression By implementing this cognitive−behavioral interven- child health outcomes. screening for all participants to address the evidence tion, the Institute for Family Health expects to improve Youth and Family Link Obtains Results through Engagement for Early Intervention stephen Watters, Ma, Executive Director, Youth and Family Link, Longview, WA / M any professionals have examined engagement to illuminate the need for increased enrollment and retention of clients in mental health treatment (McKay, part of the therapeutic process. Engagement is important for two reasons. First, treat- of treatment starts and stops. Engagement is even more pertinent as it relates to prevention and early intervention. ment and other services may be available, but if 2004; Spooner, 1996). The New York State Office of they are not accessed, then people do not benefit. If Care providers interested in prevention and early Mental Health Workgroup (2008) studied and reported people use available treatment, then the use of more intervention use engagement efforts to reach out to on the importance of family and child engagement as costly services is avoided. Second, people experience clients in their real-life environments rather than an early intervention and prevention strategy. Engage- more stability when they take advantage of available wait for them to walk through the door. Engagement ment is increasingly being recognized as an important services rather than go through the revolving door is most effective when it is on the client’s terms, 36 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • nonthreatening, and provided in a progressive manner (a) to engage the child and family early in life or (b) to Early intervention engagement helps the child and family that takes small steps. Engagement recognizes clients’ engage the child early in the intervention process. Either through the barriers that either deter them from enrolling lack of involvement not as resistance to treatment but approach encourages the child and family to access and in services or keep them from returning after they have as the result of system barriers that deter them from use available services and thus avoids adding further begun treatment. Clients who access and use treatment participation. complexity and difficulty to the family’s already stress- are involved in proactive mental healthcare; problems Youth and Family Link, a licensed mental health agency ful life. therefore do not deteriorate to the point that they re- in Cowlitz County, Washington, specializes in engagement By working closely with other mental health providers, quire more costly services (e.g., hospitalization, emer- with children and families. Youth and Family Link’s par- Youth and Family Link staff reach out at the earliest stage gency room treatment, and crisis services). ent agency, Toutle River Ranch, which has served youths of involvement to engage the child and family. The initial Whether it takes place early in a child’s life or early in since 1960, developed the program in 1997 to engage contact might occur in the hospital, emergency room, the intervention process, engagement helps the child youths and families to enroll in mental health treatment home, school, or other setting. Referrals come from a and family through the barriers that deter them from and to remain in treatment. The agency’s hope was that variety of professionals as well as from family members beginning or continuing treatment. Early intervention the program would help youths avoid unnecessary hospi- and self-referrals. engagement in mental health services provides greater talizations, decrease their frequent use of crisis services, Youth and Family Link staff, who are trained in engage- opportunity and benefit so the client may succeed in and decrease their visits to the hospital emergency room. ment approach and techniques, respond to referrals by accomplishing his or her treatment goals. If early inter- Outcome data have shown a significant reduction in use initiating contact within days or even hours. They try to vention engagement is a primary part of the therapeutic of these costly services and an increase in prosocial behav- respond during the critical window of opportunity when process, more clients could become involved in treat- ior, such as family involvement and school attendance. the child and family may be receptive to services but will ment, remain in treatment, live more comfortably, and Early intervention engagement has a double definition: not follow through if left to take the initiative. be less costly to the system. COMHAR Addresses Fetal Alcohol Spectrum Disorders linda s. Bamberger, lsW, Director of Children’s Services and Jaimee Arndt MBA, Program Director, COMHAR, Inc., Philadelphia, PA / F etal alcohol spectrum disorders is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. Until recently, screening, diagnostic, and intervention ser- vices specifically designed to meet the unique needs of children with an FASD were not available in Philadelphia, the diagnosis. Our priority target population is children birth through seven years of age presently receiving ser- vices in COMHAR’s Early Intervention or Behavioral Health These effects include physical, mental, behavioral, and/ PA. COMHAR, Inc., a private, not-for-profit community- programs. This initiative fosters medical homes (central- or learning disabilities. FASD is believed to be underre- based human services agency in Philadelphia, PA was ized bases for all medical treatment) and coordination of ported and obtaining an exact estimate of prevalence is one of eight providers nationwide awarded a subcontract care resources for children with FASD and their families. difficult. In 2001, it was estimated that about 1 percent in 2008 for FASD Screening, Diagnosis and Treatment/ The project includes screening, assessing, diagnosing a of children have an FASD. Intervention with Northrop Grumman Corporation, a child with an FASD, providing needed interventions/sup- FASDs are the leading preventable cause of develop- contractor for SAMHSA’s FASD Center for Excellence. ports (SDT), and case management (follow up). mental disabilities and birth defects. All FASDs are 100% This initiative boasts a partnership with two diagnostic Integration of the FASD-SDT initiative into COMHAR’s preventable if a woman does not drink alcohol while entities: St. Christopher’s Hospital for Children – Center existing system of care expands the range of services she is pregnant or could become pregnant. Presently, for Children with Special Health Care Needs in North available to our children. Because participation in this there is no known “safe” amount of alcohol that can be Philadelphia, representing a site-specific diagnostic initiative is voluntary and mothers often have difficulty consumed during pregnancy. Fathers can also play an model during which children are evaluated by a team admitting to behavior that may have contributed to their important role in helping mothers abstain from drinking in one day, and Center City Pediatrics in South Philadel- children’s disabilities, education and advocacy are very alcohol during pregnancy by encouraging avoidance of phia, representing a networking diagnostic model, where important. Having met specific criteria for risk of an social situations that involve drinking and by not drink- children are evaluated over a period of time by various FASD, children are eligible to receive a screening. Follow- ing alcohol themselves. Communities and health and independent professionals, completing the process with ing positive screening results, families are referred for social service organizations can help prevent FASDs the developmental pediatrician. Both models offer diag- a multidisciplinary diagnostic evaluation to confirm or through education and intervention. nostic teams that may include a pediatrician or develop- rule out an FASD. With this additional information, we mental pediatrician, nurse/nurse practitioner, medical are better able to assist the family with specific interven- Children with an FASD who receive special education are specialists in dysmorphology, occupational therapist, more likely to achieve their developmental and educa- tions and tailored strategies to meet the needs of the child psychologist, social worker, parent advocate, and child and family. tional potential. These children need a loving, nurturing, when necessary a physical therapist and speech lan- and stable home life to avoid disruptions, transient life- The information in this article about FASD has been printed guage pathologist. styles, or harmful relationships. Children with an FASD with permission from the Department of Health and Hu- who live in abusive or unstable homes or who become in- The goal of The Philadelphia FASD Screening, Diagnosis man Services – Centers for Disease Control and Preven- volved in youth violence are much more likely than those and Treatment Initiative is to improve the functioning and tion. Content source: National Center on Birth Defects and quality of life of children and their families by diagnosing Developmental Disabilities. For more information, go to who do not have such negative experiences to develop those with an FASD and providing interventions based on secondary conditions. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 37
  • From The Field Saving our future substance use and suicide Prevention Programs for Youth Recognizing their critical role in saving and improving communities, many behavioral health organizations reach out to prevent substance abuse and suicide among youth through education and promotion programs. College Dreams Begin in Middle School tom and Judie drummond, Codirectors, College Dreams, Grants Pass, OR / C ollege Dreams was founded in 1998 as an al- cohol and drug prevention program for 33 sixth graders at two middle schools in Josephine County, set by multiple and severe life adversities. College Dreams has interagency agreements with both local school districts and provides regularly scheduled earn college scholarship awards, barrier removal funds, and special outings through good atten- dance, good grades, healthy youth activities, and Oregon. Josephine County is a rural timber county outreach services to 428 “Dreamers,” who attend community service. Our prevention specialists de- in southwest Oregon with a population of 81,618, all nine local secondary schools. Long-term services velop powerful long-term relationships with Dream- including 16,508 children from infancy to age 18. begin during middle school, continue throughout ers as role models, skill trainers, counselors, crisis Oregon’s preliminary March 2009 unemployment high school, and are still being provided for 280 intervention specialists, and life success coaches. rate of 12.1% is the second highest nationally, and alumni who are in postsecondary education, train- An external program evaluation conducted by RMC Josephine County’s 16.8% rate is 38% above the ing, or vocational settings. Descriptions of core Col- Research (Portland, Oregon) found that the Col- Oregon average. During 2008, College Dreams pro- lege Dreams programs follow. lege Incentive Program produced large effect sizes vided prevention services for approximately 1,238 The College Incentive Program, a program for re- for Dreamers (vs. a matched comparison group) in children, youths, and family members. siliency development, serves students with three terms of reduced dropouts and delinquency arrests College Dreams promotes healthy development or more risk factors for school dropout, substance as well as increased rates of acceptance into the for children and youths, especially those who have abuse, and delinquency. Our longitudinal studies National Honor Society and preparation for college. multiple risk factors for school dropout, substance show that without help, 58% of students with such Fostering Success was developed to provide spe- abuse, and delinquency. Our framework is based risk factors drop out of high school and 44% have cialized resiliency development opportunities (e.g., on scientific evidence regarding the risk factors for been arrested by 10th grade. Their odds of delin- summer day camps, recreational outings, service substance abuse and the protective factors that quency and substance abuse are 10 to 15 times projects) for children and youths who are in foster lead to long-term success for children who are be- higher than those of low-risk students. Dreamers care. Research on foster care has clearly document- 38 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • ed that foster children are at exceptionally high risk versity’s Regional Research Unit indicate significant cluding infants, toddlers, children, teens, and adults). for academic failure, substance abuse, mental health improvement in academic grades and attendance for Approximately 86% of the families “graduated” from issues, homelessness, and lifelong problems. Through mentored participants in contrast to random com- the program. Most of the participating families were a contract with our child welfare branch office, we are parison students. referred by local treatment programs, schools, and serving 32 children in Fostering Success. Dream$avers: Sixty-one low-income students current- the child welfare office because of serious issues with The Guiding Lights Mentoring Program is a school- ly participate in our Oregon Individual Development substance abuse, youth behavior problems, or crimi- based mentoring program that has 132 adult and stu- Account Program, which provides each Dream$aver nal justice issues. dent mentors who volunteer to meet weekly with 137 with financial education, individualized planning, College Dreams has received numerous awards for “most in need” fourth-grade to ninth-grade students and a $6,000 college scholarship match when he academic excellence from Oregon foundations and at five middle schools, four high schools, the YMCA, or she saves $2,000 in a special trust fund account. organizations. Our program has been recognized as and the Boys and Girls Club. The middle school stu- Dream$avers serves as a powerful incentive for high- a National Prevention Network “promising practices” dents selected for Guiding Lights had a mean grade risk students to excel in school and to avoid alcohol program for promoting academic excellence and pre- point average of 1.61 and a 9.2% absence rate when and drug problems that interfere with academic success. venting substance abuse, has completed a nation- they entered the program. Mentored students receive Strengthening Families is an evidence-based family ally competitive Substance Abuse and Mental Health academic motivational enhancement services, in- camp program run by College Dreams. In the three Services Administration Service-to-Science contract, cluding special outings, recognition ceremonies, and family camps held so far, Strengthening Families has and was selected for two national SAMHSA workshop earned incentives for academic improvement. Initial served 49 families (totaling 137 family members, in- panels. program evaluation results from Portland State Uni- Five Town Sees Results from Skill Building and Recognition dalene dutton, Executive Director, Five Town Communities That Care, Rockport, ME / S kills Training And Recognition is a primary preven- tion program that is based on the Participate and Learn Skills program tested by physicians Marshall newly mastered skills. For the past 2 years, an analy- sis of grade cohorts has shown that more than 50% of the current grade 5 through 8 population had at- accomplishments. The program is offered 3 times a year — in the fall immediately after the start of the school year, in the winter, and in the spring before Jones and David Offord (1989). STAR was implement- tended STAR at least once during middle school. Many school summer vacation. ed by Five Town Communities That Care in midcoastal students attend multiple cycles. STAR uses the original Participate and Learn Skills Maine in the fall of 2004 to increase levels of three Students attend STAR 3 days per week in 6-week cy- program model, which included a focus on “chunk- protective factors: community recognition for proso- cles. Two days each week are spent with skill instruc- ing” skills into levels that can be mastered in approxi- cial involvement, rewards for prosocial involvement, tors and are focused on learning new skills. The third mately 8 hours of focused practice and instruction. and prosocial involvement. In 2008, the Substance day is a “Fun Friday,” when all students in the program Dividing the skills into such chunks provides enough Abuse and Mental Health Services Administration gather for loosely structured activities designed to challenge to be motivational but not so much that awarded Five Town CTC its Science and Service Award help them get to know one another before they come students get discouraged and give up. for substance abuse prevention, one of only seven together as part of the same student body at the local such awards given nationally. An integral part of STAR’s adaptation of the Partici- high school. pate and Learn Skills program is the infusion of social The service area for STAR is a rural community with STAR offers training in skills that run the gamut from development theory into staff training. Staff learn how a population of 13,000 in which local rates of youth the arts to athletics. Past classes have included ani- to offer young people opportunities to learn new skills substance abuse, suicide, delinquency, and violence mal husbandry, yoga, tennis, rock climbing, painting, and to provide recognition as students progress in or- are elevated and have been the focus of much effort cooking, knitting, and snowshoeing. Any skill set that der to increase the likelihood that they will internalize since 2004. STAR was chosen as a good match for the can be used in the local community in a prosocial the standards and beliefs staff express. Skill-specific community’s risk and protective profile. way is a candidate for a STAR class. The program is feedback is important both for skill mastery and for STAR is offered as an after-school program to all local supported entirely by grants and local contributions. the bonding that takes place. Rather than saying, students in grades 5 through 8. It provides opportuni- There is no cost to participants or their families. “Good job,” for example, the tennis instructor learns ties for children to learn new skills, recognizes them At the end of each cycle, participants, their families, to say, “Lisa, your follow-through on that swing was as they master those skills, and connects them with program staff, and the general public gather for a excellent.” Not only does Lisa get reinforcement for places in the community where they can use these community celebration to recognize each student’s her follow-through, she knows that the instructor was NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 39
  • From The Field paying attention to her to see that swing. Five Town CTC is engaged in ongoing evaluation of by 42% and lifetime alcohol use has dropped by Staff do not ignore comments about substance the STAR program. Results are encouraging com- 28%. To date, rates of the targeted protective factors use, violence, bullying, or suicide but address and parison of community youth survey data from 2004 have been steadily increasing, and rates of problem discuss them. Healthy choices and behaviors are and 2008 revealed that grade 8 rates of community behaviors are trending downward. consistently emphasized. recognition for prosocial behavior have increased Computerized Screening Assesses Risk of Suicide in Youth lawrence epp, edd, Director of School Mental Health Services, GUIDE Program, Inc., Laurel, MD / S uicidal ideation is common among youth who live in impoverished urban communities. These young people may see gun battles between warring drug what they feel inside. The adult−adolescent thera- peutic alliance is a cross-cultural encounter riddled with as much distrust and anxiety as any clash of TeenScreen-installed computer to complete the in- terview, out of the clinician’s view. Soon, a child in the care of two perceptive and traffickers every night. They may live with adults who two very different human beings. The cultural rift is seasoned school mental health professionals was are addicted to drugs or who periodically sexually or one of vast generational difference. referred to me and revealed suicidal thoughts to physically abuse them. Some years later, I learned that Columbia Univer- TeenScreen that he had not disclosed to the clini- Early in my career, I worked with a truly extraordinary sity was experimenting with a computerized mental cians working so closely with him. pediatrician, Michelle Horlein, who was completing health screening tool, TeenScreen, and had discov- The interface between an adolescent and a com- her developmental pediatrics residency at Johns ered the same phenomenon adolescents would puter screen creates an anonymity that allows more Hopkins Hospital. She administered to adolescents disclose to TeenScreen suicidal thoughts and be- honest disclosure by the adolescent. The comput- a computerized risk assessment tool and found haviors that they would not discuss with the adults erized screening process removes the shame of that they were willing to reveal to the computer closest to them, including, at times, their guidance disclosing socially unacceptable thoughts or symp- program what they would not tell an adult. Some of counselor or therapist. toms. the adolescents were my clients with whom I felt I Two years ago, I initiated TeenScreen at the GUIDE had formed an open and close relationship but they Clearly, today’s youth see the computer as a re- Program in Laurel, Maryland, in one of our middle source for connection with others and not as a disclosed to the computerized assessment program school mental health programs. On a spare com- high-risk behaviors that they would not dare to cold, impersonal technology, as my generation of puter, I set up the TeenScreen computerized as- therapists have. Computerized assessment may be share with me. sessment software. It essentially works as a talking the next advancement in mental health screening, When I learned of Dr. Horlein’s findings, I discovered psychiatric interview that produces a summary of and I think TeenScreen is leading the way with this a dangerous assumption of my own: I believed that the child’s risk factors for suicide and other men- potentially life-saving new technology. adolescents tell their therapists everything, whereas tal illnesses. After appropriate parental consent is the truth may be that they tell us only a fraction of obtained, the adolescent is placed in front of the You Gotta Know: Spectrum’s Peer Educators Spread the Word on Prevention rhonda Bohs, Phd, Vice President of Research Development and Emy Lou Pesantes, MSW, Research Coordinator — Spectrum Programs, Miami, FL / S pectrum Programs started the You Gotta Know Campaign at a large university in South Florida. First, we assessed the students’ alcohol use, the were an average of 21.6 years old. They were 10.1% White, 17.9% Black, 56.9% Hispanic, 5.1% Asian, 0.1% American Indian, and 7.3% other ethnicities. alcohol in the past month, whereas only 53.2% of women had done so. Most believed that the typical student usually has between five and six drinks in consequences they experienced, and their knowl- The survey showed that 59.7% of students had con- one sitting. edge of drinking. A total of 1,229 students were sur- sumed alcohol in the past 30 days and that 30.8% Students reported several alcohol-related con- veyed during three time periods in 2008 and 2009. had engaged in binge drinking. Some gender differ- sequences: driving under the influence (17.7%), Students were 45% male and 53.7% female and ences were found — 67.4% of men had consumed having unprotected sex (15.0%), physically injuring 40 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • to empower students to develop and implement peer education models, the You gotta Know campaign held a con- test soliciting proposals from student organizations and their “ambassadors,” who took leadership roles in educating college students on substance use and abuse risk behaviors. themselves (13.4%), being involved in a fight (12.2%), binge drinking and driving (8.5%), physically injuring someone else (6.7%), and being forced to have sex (3.9%). These results are alarming compared with those from a national sample; students from the Florida university ranked higher on all but one of the alcoholrelated consequences. The survey data are consistent with other descriptive studies indicating that college students commonly misperceive their friends and peers as drinking more in quantity and frequency than themselves. Students may not perceive drinking as an impediment to academic achievement because they see it as a normal part of the college experience, or they might expect benefits from drinking that outweigh the risks. A good strategy to discourage on-campus drinking is to educate students about the discrepancy between drinking norms and alcohol expectancies, because most college students have incorrect per- ceptions of their peers’ use. This strategy became the focus of the You Gotta Know campaign. Group processes including actual and perceived norms for a behavior in a group, modeling of behaviors, and peer support for the behavior influence people’s adoption and maintenance of a behavior. To empower students to develop and implement peer education models, the You Gotta Know cam- paign held a contest soliciting proposals from student organizations and their “ambassadors,” who took leadership roles in educating college students on substance use and abuse risk behaviors. Selected organization ambas- sadors received education on the risks of HIV/AIDS and substance use and abuse among college students, prevention and treatment resources in the community, and how to measure the effectiveness of their activities. Each or- ganization was provided with informational booklets that featured the results of the university survey on substance use. Along with this information, the student organizations were given a budget of $2,000 to plan, implement, and evaluate their activities. The organiza- tions brought guest speakers to campus to discuss responsible alcohol use and HIV risk behaviors, arranged experiential activities that simulated the effects of alcohol on motor functioning, and held carnivals that provided prizes for increased knowledge concerning alcohol consequences and HIV risk behaviors. Evaluation results indicated that students’ knowledge of peer drinking norms and alcohol expectancies were improved through this peer educator model. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 41
  • From The Field Rushford Leads Community Action to Prevent Underage Drinking amy hickey, Vice President of Business Development and Community Relations, Rushford, Meriden, CT / “I drank when I was a kid; what’s the big deal?” “It amazes me that so many parents and community members are unaware of the serious consequences of underage drinking,” says Sprague. “What many “We let our son and his friends drink in our home because we know they’ll be people view as a rite of passage is actually life-threatening behavior.” safe.” Underage drinking is the leading cause of death among teens and is a contrib- “A few drinks won’t hurt them.” uting factor to many serious problems, including traumatic injury, burns, violent crime, high-risk sex, and alcohol abuse and dependence. Sheryl Sprague has heard many remarks like these from parents and community members in the 12 years she has worked as a certified prevention professional In 2006, Rushford received two Strategic Prevention Framework grants from in Connecticut, which has an underage drinking rate that is 28% higher than the Connecticut Department of Mental Health and Addiction Services to de- the national average. velop task forces aimed at helping three large communities prevent underage drinking. The task forces focus on major risk factors associated with underage Sprague currently leads the prevention division of Rushford, one of Connecticut’s drinking, including retail availability of alcohol, low enforcement of alcohol laws largest not-for-profit behavioral health prevention and treatment providers. and policies, and family norms and media messages that accept or encourage alcohol use. To address retail availability of alcohol to minors, Rushford has purchased hun- dreds of graphic decoders that help retailers easily spot fake identifications and is helping police departments conduct merchant education. The grant has also funded overtime pay for local law enforcement to target underage drinking parties. “Police will arrest a homeowner who allows minors to drink at his or her home,” said Jeffry Cossette, chief of police for Meriden, Conn. “That’s what this grant is trying to get across, that it’s not OK to let minors drink.” In 2006, Connecticut passed a law that made it illegal to host (or to be aware that one’s home will be used to host) a party at which alcohol is provided to minors. The penalty for breaking the law can range from a fine to one year in prison. Rushford also developed an aggressive social marketing campaign to combat media messages that encourage alcohol use. Billboards that illustrate the fatal consequences of underage drinking are featured in two high-traffic areas of the state, and a radio campaign spotlights the need for parents to help their chil- underage drinking is the leading cause dren make healthy choices. Rushford has also collaborated with schools and of death among teens and is a contributing factor civic groups to sponsor underage drinking forums, which have been attended by to many serious problems, including traumatic hundreds in the community. injury, burns, violent crime, high-risk sex, and “When you consider the thousands of teens who die senselessly each year as a alcohol abuse and dependence. result of underage drinking, as well as the staggering cost of underage drinking to our country [estimated at more than $53 billion annually], investing in pre- vention activities that help communities build and improve capacity to address the problem is really a no-brainer,” says Sprague. Research has shown that for every dollar spent on drug and alcohol preven- tion initiatives, communities save between $4 and $5 in treatment and other related costs. 42 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Seeking Help for Adolescents through Sharing the Truth: Ben Gordon Employee Assistance Programs Corrects False Perceptions About Peer Use of ATOD Marty laska, lPcc, lIcdc, nccgcII, Director of Employee Assistance Programs, The Source One Group, Wooster, OH Kris Povlsen, Director of Prevention, Ben Gordon Center, DeKalb, IL / What do parents do when they recognize behavior changes in their teenagers? What A s I hung antismoking posters at DeKalb High School in DeKalb, Ill., a action can parents take when their 12-year-old expresses feelings of depression 15-year-old student approached me and said, “I didn’t realize I was normal. or anxiety? What should parents do when contacted by the school and advised of I really thought that everyone smoked. Now I realize that everyone doesn’t. changes in the behavior of their 16-year-old? What is an adjustment issue, and what is a more serious disorder? Thank you.” Often, parents are advised to seek counseling for themselves or their adolescent chil- Often, adolescents assume that most of their peers are smoking, drinking, and dren as a method of intervention. Even if parents are comfortable with this choice, using drugs, and so they want to experiment with these substances, too. Sur- they face the very real obstacle of paying for the services. Working parents do not veys among youths in most communities, however, consistently suggest that a usually qualify for publicly supported services. Even if a family has health insurance, majority of youths do not use such substances. Using social norms prevention treatment can be expensive: many health insurance companies now offer only high- to send a positive message that lets adolescents know how their friends and deductible insurance plans (sometimes as high as $5,000 or more for a family). classmates really view these issues gives the community, especially parents, a Counseling, even for a child who is struggling, may be seen as a luxury by parents powerful tool for keeping youth on the right track. This positive social norming who can hardly afford regular healthcare. Moreover, wait times for public psychiatric strategy seeks to change false perceptions of drug use, and statistics show that services are often long. it is effective. An often overlooked and underused resource for families is the employee assistance The DeKalb County Partnership for a Safe, Active and Family Environment’s ini- program offered by many companies. Most EAP programs offer a set number of coun- tial survey of DeKalb and Sycamore high school students in 1999 revealed that seling sessions a anywhere from 3 to as many as 10 which are paid for by the em- 75% of the teens surveyed chose not to smoke and that 57% said they had not ployer. No copay or deductible applies, as with health insurance. This benefit is usually drunk alcohol in the past month. 81% of the teens surveyed reported that they extended to an employee’s dependents as well. The EAP service providers are licensed therapists and counselors with at least a masters degree. did not smoke at parties, and 65% said that they chose to drink beverages other than alcohol. These statistics support the premise that teens overper- EAPs offer significant benefits, the first of which is not obvious to many and lies in ceive their peers’ use of alcohol, tobacco, and other drugs (ATOD). Using these the perceptions of the adolescent and the parent. Working with an EAP counselor is baseline data, DCP/SAFE launched its campaign, and in the past 10 years it has often seen as less intimidating than finding a counselor through traditional methods. significantly decreased teens’ use of these substances. Families often cite limited finances as a reason intervention was delayed, and most children today are aware of their family’s financial situation. When families use an Inspired by the normative statistics from the 1999 survey, DeKalb County’s EAP, the cost factor is removed as a roadblock to the resistant adolescent. In addition, social norms prevention projects are based on a model of identifying and rein- EAP professionals are equipped to address emergency situations and frequently offer forcing existing protective norms concerning ATOD issues and correcting misin- same-day appointments as a normal part of their services. Many professionals book terpretations about the extent of ATOD use. The main method of this approach evening or Saturday appointments, which makes scheduling far easier for parents is social marketing, primarily through media and other appropriate methods. and teens alike. These two factors can help avoid delay and missed opportunities to After analyzing survey results, each month DCP/SAFE designs posters with a new engage the teen. message and displays them throughout schools. It also mails more than 8,000 EAP professionals often understand the work pressures that may be bearing down on postcards and letters each month to the families of all participating high school the employee and translated to the home. This knowledge can help them facilitate and middle school students. In addition, coalition volunteers display posters interactions with family members, save time, build trust, and moves the counseling in locations adults frequent throughout the community, including banks, dry process forward. cleaners, bookstores, churches, police departments, day care facilities, libraries, EAPs can easily encourage families to make use of the services by distributing bro- and various workplaces. Messages encouraging people to “share the truth” that chures and handouts to emphasize availability of the EAP to families before serious most students don’t smoke or drink alcohol saturate the community through problems manifest. Employers can hold orientations on the benefits of the EAP at billboards, radio announcements, and television advertisements. times families can attend. A “family-friendly” message may encourage employees to share demographic information at health fairs. With these figures at its disposal, the community is empowered to confidently embark on a mission of spreading positive messages to reduce adolescent Learn more at NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 43
  • From The Field alcohol and tobacco use. Follow-up surveys indicate to my children. I got them to talk about whether this >> 11.6% reduction in alcohol use by Hinckley−Big that students, parents, and teachers are changing was the normal experience at their school, and it Rock High School students between 2006 and their perceptions and are successfully communicat- enabled me to have a dialogue about drug use with 2008 ing with teens. During the first year that DCP/SAFE them.” This refreshing strategy is an important part >> 31.2% reduction in alcohol use by Genoa− used social norms prevention as a strategy, parents of a healthy community response to addressing the Kingston High School students between 2006 reported a 15% increase in the positive messages substance abuse issue among teens. and 2008 they conveyed to their kids about abstaining from Ten years after the project was started, the 2008 >> 18% drop below the national average in 30-day alcohol and marijuana usage, and teachers said DCP/SAFE Annual Student Survey shows: alcohol use by 10th graders at the four high they increased their messages by 9%. >> 28.4% reduction in alcohol use by DeKalb and schools in DeKalb County (DeKalb, Sycamore, “Driving home from work, I heard a radio ad ex- Sycamore High School 10th graders between Genoa−Kingston, and Hinckley−Big Rock High plaining that it is normal for kids to avoid and not 1999 and 2008 Schools) in 2008 drink alcohol. I thought, ‘What a novel, refreshing, >> 17.2% reduction in alcohol use by DeKalb and >> 5.6% decrease in 30-day marijuana use at and positive approach to the issue,’” says Kathy Sycamore High School 9th through 12th graders DeKalb High School between 2003 and 2008. Hicks, the mother of three children. “That evening between 2002 and 2008 at home, I repeated the message that I had heard Seacoast Focuses on Improving Quality of Life rob levey, Ma, Development and Communications Associate, Seacoast Mental Health Center, Portsmouth, NH / R ecognizing the need for prevention/early inter- vention services in New Hampshire, which ranks 46th in per capita spending on treatment and pre- ing a kid with more one-on-one mentoring time to experiential-learning activities designed to address specific needs, everything we do is designed to tar- “A teen whose problems stem from trauma needs something different from a youth who gets into trouble at school due to learning difficulties,” she vention, Seacoast Mental Health Center on New get and promote protective factors.” added, although she acknowledged the importance Hampshire’s Seacoast has implemented several Founded in 2006, Seacoast’s Adolescent Substance of providing basic rewards as motivators for absti- successful programs with significant potential for Abuse Program (ASAP) provides critically needed nence to all participants. replication. services and support to youth in grades 7 through In addition to its prevention-based youth programs, New Heights, an out-of-school program offered 12 who demonstrate early and mid level substance Seacoast offers the statewide Referral Education As- since 1987, recently developed and implemented abuse, but do not yet require inpatient/residential sistance & Prevention (REAP) Program, which is New an innovative Mentor Program that utilizes evi- treatment. Hampshire’s only free prevention program helping dence-based approaches to increase the resiliency Following an evidence-based motivational enhance- all elders with alcohol, drugs, mental health prob- of all Seacoast youth, ages 11 to 18, particularly ment therapy/cognitive behavioral therapy model, lems, or life changes. low-income participants and those with multiple ASAP incorporates a comprehensive ‘three-phase’ Citing the complex nature of these disorders, which risk factors. New Heights provides a safe haven out- approach over a 12-week period that include: indi- often co-occur, Lucille Karatzas, REAP’s statewide side the home where kids can engage in activities vidualized assessment and intervention/treatment director, said they broadened REAP’s initial focus to build skills and confidence and connect to caring planning, weekly counseling/education groups, in- from solely addressing substance abuse to include and supportive adults who can mentor them when dividual/family counseling sessions, and case man- various quality of life issues. She noted REAP also their parents may not be able to. agement and ongoing support. educates caregivers of “at-risk” elders on how to According to Tracey Tucker, New Heights’ director, According to Julie Golkowski, child, adolescent and intervene if an elder becomes unable or unwilling the key to the program is its formal Resiliency As- family services director at Seacoast, ASAP’s strength to accept help. sessment, developed by Seacoast’s Dr. Vance, which lies in its collaborative approach. “We actively work “Our program has been designed to lessen the stig- allows the staff to track and measure each partici- with judges, probation officers, area schools and we ma many elders feel when reaching out for help,” pant’s progress through the academic school year. have to because of the complexity of the issues,” said Karatzas. “A big piece of what we do is edu- “Data generated from each assessment enables us said Golkowski, who noted she rarely sees an ado- cation in order to prevent many of these problems to completely customize each participant’s experi- lescent with a serious substance abuse problem before they begin.” ence at New Heights,” said Tucker. “From provid- who doesn’t also have mental health issues. 44 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Project Sticker Shock Involves the Community in Sharing a Message Jason Blanchette, Community Prevention Coordinator, Chestnut Health Systems-Lighthouse Institute, Normal, IL / C hestnut Health Systems is battling the growing problem of adults providing minors with alcohol, particularly in Mason County, a rural county where which reminded buyers that it is illegal to provide al- cohol to minors. Project Sticker Shock was covered in newspapers, radio, and television. The message approached in Mason County participated, and many of the liquor retailers in Mason County thanked the youth and adult volunteers. When asked about los- we provide prevention services. Many Mason County was supported by youth, liquor retailers, police, com- ing business from purchases for minors, Jason Hunter citizens who strongly disapprove of underage drink- munity coalitions, schools, parents, and others who from Country General in Manito, IL said, “I want to ing and of providing alcohol to minors, feel a need to participated in Project Sticker Shock. lose that business. Kids are our future, and no sale speak out in a way the entire community will notice. Project Sticker Shock isn’t new, but it is growing. Teen- is worth it.” Communities across the state have similar issues. agers in Erie, Pennsylvania started the first Sticker Community complacency about underage drinking The Illinois Liquor Control Commission decided that Shock program 13 years ago, plastering stickers in can be deadly and damaging. But with the belief that a united message needed to be sent across Illinois participating beer stores in three areas of the state. something can be done, followed by action, the com- and coordinated the statewide Project Sticker Shock Since then, several states have established their own munity’s acceptance of underage drinking can begin campaign on April 2, 2009. Sticker Shock programs, including Maine, Michigan, to change. Youth and adult volunteers from 50 counties went Virginia, New Hampshire, Virginia, and now Illinois. For more information about bringing Sticker Shock to into participating liquor stores to place hundreds of In Mason County, we got support from many groups your community, visit thousands of stickers on liquor packages, posters on in the communities, including the alcohol retailers. /stickershock/sticker_shock.html walls, and window clings on refrigerator doors, all of Ten out of the 11 liquor establishments that were Follow the leader Negley Associates, founded in 1960, is the leading underwriting management firm serving the insurance needs of BEHAVIORAL HEALTHCARE and SOCIAL SERVICE agencies. We are proud of our role in the development of innovative insurance policies designed to meet emerging coverage needs. We are committed to providing outstanding service to our insured clients, and to the nationwide network of insurance professionals who market our products. We are proud to announce the launch of our new website and on-line applications. To take advantage of this time saving convenient option, please visit us at 1-800-845-1209 • Fax: 973-239-6241 • NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 45
  • From The Field aCroSS tHe SpeCtruM Prevention and Early Intervention Programs for Special-Needs Populations Community mental health organizations share examples of prevention and early intervention efforts among senior citizens, the incarcerated, persons with serious mental illness, and other high-needs groups. Jefferson’s Senior Reach Educates the Entire Community Vicki K. rodgers, Ms, lPc, Deputy Chief Operating Officer, Jefferson Center for Mental Health, Wheat Ridge, CO / S enior Reach is an award-winning, innovative part- nership that provides preventive education, out- reach, and mental health treatment to adults ages Three agencies (Seniors’ Resource Center, The Men- tal Health Center Serving Boulder and Broomfield Counties, and Jefferson Center for Mental Health) Two key strategies for the Senior Reach program are education provided to the community and preven- tion services offered to older adults. 60 and older in five counties in the Denver, Colorado partnered to develop an elder-friendly infrastructure The community-based education is provided in a metro area. The program’s mission is to support the to meet the needs of seniors. The result of the part- variety of settings to people who may not know when well-being and independence of seniors by educat- nership is reduced duplication of effort, expanded a referral to mental health would be appropriate. ing the community about how to identify and refer mental healthcare, creation of a “one-stop-shop” Education is tailored to the needs of the audience elders who may benefit from mental health treat- call center, and collaboration rather than fragmen- and covers such topics as ment, care management, information and referrals, tation across five counties. or wellness programming. >> Why Senior Reach is needed. 46 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • >> Signs that could indicate that an older adult next steps. Our work and previous research indicate 1,000 prevention services have been provided in the needs help. that 50% to 75% of the older adults referred will need past year, indicating that seniors are interested in liv- >> How to approach and refer a senior in need. mental health services. ing full, healthy lives and are focusing on nutrition, Prevention services include wellness-based classes, safety, mental wellness, and life review. >> Realities of aging well, including suicide preven- tion and facts. safety and prevention assessments, and screening for Senior Reach was designed to bring hope, relieve depression and anxiety. Our goal is to address con- depression, and increase socialization. The program Organizations (e.g., businesses, clubs, healthcare cerns before more serious problems develop. Senior outcomes are statistically significant, but even more providers, and agencies) have invited Senior Reach Reach has staff in Wellness Now!, a Jefferson Center important are the dramatic and positive effects seen clinicians to train their staff. In 3 years, more than for Mental Health team providing myriad wellness in the lives of the older adults served. The program is 6,000 people have become the “eyes and ears” of classes and services that focus on integrated health. becoming widely recognized as a promising practice the community and potential referral sources. Once Because of programming designed for elders, more to serve seniors and receives high customer satisfac- a referral is made, Senior Reach staff reach out to older adults now self-refer and are aware of how a tion scores. that senior to develop a solution-focused plan for program like Senior Reach can enrich their life. Almost Missouri’s Diabetes Prevention Efforts Improve Consumer Wellness Joe Parks, Md, Director of Comprehensive Psychiatric Services, Missouri Department of Mental Health, Jefferson City, MO; george oestreich, Pharmd, MPa, MoHealthNet, Jefferson City, MO; tim swinfard, Chief Executive Officer and President, Missouri Coalition of Community Mental Health Centers, Jefferson City, MO; rachelle glavin, Disease Management Coordinator, Missouri Coalition of Community Mental Health Centers, Jefferson City, MO; Kellie shuck, Health Liaison, MHNP, Comprehensive Neuroscience, Inc. (CNS), Morrisville, NC; sandra Ballentine, Diabetes Director, CNS, Morrisville, NC / T he Missouri Department of Mental Health and the Coalition of Community Mental Health Centers have come together in a preventative health initia- nity mental health centers and to improve the coordi- nation of care for consumers diagnosed with diabetes. CMT serves as the clinical data analytics partner for have received some type of care by a Federally Quali- fied Health Center or CMHC. After the identification analysis, the Missouri De- tive to identify people with serious mental illness who the Missouri Coalition of Community Mental Health partment of Mental Health strengthened the annual are at risk for diabetes. Targeting people with mental Centers in this project. Eli Lilly and Company serves as screening requirements for CMHCs and state psychi- illness for screening and identification of prediabetic the funding source for the initiative. atric hospitals to include screening for prediabetes. markers is especially important given that the preva- The program assists Missouri with the following: A screening and documentation tool that follows the lence of diabetes is 2 to 4 times higher in people with ADA−American Psychiatric Association guidelines for SMI than in the general American population (16 to >> Identification of prediabetes in patients who are receiving mental healthcare. follow-up of identified patients was designed and 25% vs. 7%, respectively; Dixon et al., 2004). Addition- distributed to the CMHC nurse liaisons and state hos- ally, many people with SMI who have diabetes are not >> Identification of CMHC consumers who have fully pitals. An online collection tool is being designed to receiving treatment (Nasrallah et al., 2006). developed diabetes and might not have received record collected data and improve continuity of care. People who have both schizophrenia and diabetes are the diabetes self-management education and The Missouri DMH is providing funding for each CMHC among the most vulnerable and costly consumers in management support recommended by the Ameri- to purchase screening equipment for lipid panels and state Medicaid systems. In a 2005 study of 19,733 can Diabetes Association. blood glucose and to purchase scales that calculate Missouri Medicaid consumers diagnosed with schizo- >> Dissemination of consumer-focused self-manage- body mass index, which will assist with ongoing risk phrenia conducted by Care Management Technolo- ment education tools. evaluation. gies (a subsidiary of Comprehensive Neuroscience), During the analysis phase, an additional 6,717 clients >> Distribution of appropriate case manager educa- the CMT risk predictive model found the concurrence served by the Missouri CMHCs were identified as hav- tional materials and referral information. of schizophrenia and diabetes to be one of the most ing Type 1 or Type 2 diabetes. The CMHC nurse liaisons significant variables predicting high Medicaid costs The program uses Medicaid claims data to iden- assisted with follow-up and referral of the consum- and adverse consumer outcomes (Byrd et al., 2005). tify consumers according to CMT-developed clinical ers to local diabetes self management education or The goals of the preventive initiative are to help Mis- markers for the full spectrum of diabetes disease medical nutrition therapy services, as appropriate. souri identify people with prediabetic conditions who states treated at CMHCs. Of the 50,097 consumers CMHC nurses are also working on a common self- are receiving mental healthcare services in commu- statewide with markers for prediabetes, about 26,918 NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 47
  • From The Field management curriculum that is based on estab- from schizophrenia or other mental illnesses. REfEREncES Byrd, J., Parks, J., Oestreich, G., Surles, R., Docherty, J., lished guidelines to use with consumers who cannot According to Dr. Joe Parks, “We anticipate that by & Simpson, K. (2005). The identification of schizophrenic receive locally available DSME or medical nutrition increasing early-stage disease identification and consumers at risk for high future healthcare costs. Poster therapy services. providing the necessary education for successful presented at the 57th meeting of the American Psychiatric Association Institute on Psychiatric Services. Because diabetes is a common condition among self-management through the CMHCs, this program Dixon, L. B., Kreyenbuhl, J. A., Dickerson, F. B., Donner, T. W., people with serious mental illness, a central pro- will ultimately improve the quality of life for those Brown, C. H., Wolheiter, K., et al. (2004). A comparison of Type gram goal is to facilitate coordination of care. CMT with SMI while simultaneously conserving health- 2 diabetes outcomes among persons with and without severe provides primary care case managers and mental care dollars through prevention-focused interven- mental illness. Psychiatric Services, 55, 892−900. Nasrallah, H. A., Meyer, J. M., Goff, D. C., McEvoy, J. P., Davis, health case managers who have educational cross- tions. Supporting wellness in Missouri consumers is S. M., Stroup, T. S., et al. (2006). Low rates of treatment for training on the unique characteristics and problems necessary if they are to achieve recovery from their hypertension, dyslipidemia and diabetes in schizophrenia: encountered by diabetic consumers who also suffer mental illness.” Data from the CATIE schizophrenia trial sample at baseline. Schizophrenia Research, 86, 15−22. Second Mile Offers Peer Support to Prevent Rehospitalization lisa Bonnett, Ms, Executive Director of Recovery f BS, Recovery Educator and Trainer — East Carolina Behavioral Health Local Management Entity, New Bern, NC / N outh Carolina’s reform of its mental health, de- velopmental disabilities, and substance abuse system began in 2001. Since then, concern has trauma reducing alternative crisis services, such as mobile crisis services, crisis respite centers, and transitional apartments. The project has also pur- During a typical month, peer support specialists fa- cilitate WRAP classes weekly in the treatment mall. The goal is for patients to have completed WRAP grown about psychiatric systems of care and the in- chased local hospital psychiatric beds in its nine classes by the time they are discharged from the creased use of state-operated psychiatric hospitals. counties to provide an alternative to state psychiat- hospital and have formed an in-depth crisis plan to In 2008, the state requested an improvement in the ric hospitalization. maintain wellness and avoid rehospitalization. Once connection for discharge between local manage- The implementation of Second Mile at Cherry Hospi- a client has completed WRAP and leaves the hos- ment entities and state-operated psychiatric facili- tal begins when clients are introduced to hope and pital, he or she is able to select a provider from a ties. LMEs are agencies of local government that are recovery through the Wellness Recovery Action Plan list that includes those who are trained in recovery. responsible for managing, coordinating, facilitating, classes. These classes are led by ECBH LME’s cer- WRAP can then be incorporated into the client’s in- and monitoring the provision of mental health, de- tified peer support specialists, who are also certi- dividual recovery plan. velopmental disabilities, and substance abuse ser- fied WRAP facilitators. WRAP classes promote client ECBH LME has developed surveys to measure re- vices in the catchment area served. awareness that mental health recovery is possible covery variables such as hope, support, education, The East Carolina Behavioral Health LME has re- and give people hope that they can take personal employment, and stable housing before and after sponded to the state’s request with the Second Mile responsibility, educate themselves, learn to be self- participants take a WRAP class. Follow-up surveys project. ECBH LME serves a nine-county catchment advocates, and get connected with support systems. will be conducted after discharge, and readmission area surrounding its headquarters in New Bern, Participants develop an individualized plan for stay- rates after hospitalization will also be tracked. ECBH North Carolina. The agency has chosen to do more ing well, a crisis plan, and a postcrisis plan. WRAP LME hopes to find an aggregate reduction in the use than the system has asked or requires, which is how was developed by researcher Mary Ellen Copeland of state hospital bed days, increased use of trauma- the project earned the name Second Mile. The proj- as the result of her own personal search for well- reducing alternative crisis services, and successful ect was developed by Cindy Ehlers, director of clini- ness. discharge planning. Prevention and early interven- cal operations at ECBH LME. Its goal is to prevent A considerable body of evidence suggests that peer tion are seen as successful when a discharged per- people from being rehospitalized in state-operated support and WRAP are effective when included at son is not readmitted within 90 days and lives in the psychiatric facilities and to support them in transi- various stages of a comprehensive service system. community with links to effective community-based tioning successfully back to the community after a These interventions can, for example, reduce the services and natural supports. hospitalization. length of inpatient hospital stays, readmission rates, ECBH LME will continuously evaluate the effective- The Second Mile project is off to a great start at and trauma. Peer support specialists can facilitate ness of the Second Mile project through the data Cherry Hospital, a state psychiatric hospital in access to other necessary mental health and sub- that are being generated. The goal is to replicate Goldsboro, thanks in part to the support of LME stance abuse services and natural and community this model in other state-operated psychiatric facili- hospital liaisons and Cherry Hospital employees. support systems. ties in North Carolina. Second Mile provides early intervention through 48 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Kansas Brings Incarcerated Back into the Community tina Waldron, Ma, Program Consultant II Community Corrections Services, Kansas Department of Corrections, Topeka, KS O n January 16, 2009, the incarcerated population in Kansas was 8,483 the lowest it had been since 2001. At the same time, 5,902 offenders were under post incarceration supervision into local intensive supervised probation agencies, with the goals of in- creased public safety, reduced risk level of probation- Community corrections program design is specific to local probationers’ needs and court procedures; therefore, strategies to address the needs of proba- parole supervision almost 2,000 more than in 2001. ers who are on community corrections supervision, tioners who are mentally ill or substance abusing vary To date, revocation to prison from parole supervision and increased successful completion of supervision. widely. For example, Northwest Kansas Community has declined by 51% since FY 2003. The number of Four million dollars was appropriated for commu- Corrections, a rural agency that serves 17 counties, felony convictions for crimes committed by offenders nity corrections agencies to implement or enhance contracts with a psychologist to provide mental health while under parole supervision saw a 35% decline evidence-based risk reduction efforts to work toward evaluations, individual treatment, close monitoring of from 1990 to 2007. these goals. treatment and interventions, and anger management The success reflected by these statistics is the result The results of this effort are already being realized. groups to probationers. This arrangement is effective of the Kansas Department of Corrections’ shift to a Between FY 2006 and 2008, revocations of offenders for the agency in part because the provider travels philosophy of reentry and risk reduction within the from community corrections supervision to incarcera- to meet the needs of clients across 16,194 square agency and the department’s active collaboration tion decreased by 21.9%, and the percentage of suc- miles. with state and local partners to effect system wide cessful completions increased by 26.2%. The Fifth Judicial District Community Corrections change and enhance public safety. Agencies funded under this initiative have committed agency, which serves two counties and 1,627 square The vision statement of the Kansas Department of to building a system to promote probationer success miles, has a full-time substance abuse counselor from Corrections is “a safer Kansas through effective cor- by targeting the evidence-based factors (e.g., mental the Mental Health Center of East Central Kansas. The rectional services.” The Statewide Risk Reduction Ini- health and substance use difficulties) that research counselor (who has offices in both the agency and the tiative has provided community corrections agencies shows, increase the risk that offenders will engage in mental health center) works primarily with juvenile of- with the additional resources and knowledge they criminal behavior. fenders but provides interim crisis intervention servic- need to better meet the mental health and substance es, substance abuse evaluations, and some individual Community stakeholder participation and appropri- substance abuse counseling for adult offenders. abuse needs of probationers. ate targeting of resources to individual client needs The work done in Kansas with offenders who were are critical to the ambitious goals of this initiative. The Risk Reduction Initiative provides targeted train- released from incarceration to community supervi- Mental health and substance abuse professionals ing for officers on topics such as collaborative case sion paved the way for the passage, in 2007, of State are key collaborative partners in building a system planning and client advocacy. Training and technical Senate Bill 14, which kicked off the Community Cor- to address the needs of clients involved with both the assistance are ongoing at the agency, stakeholder, rections Statewide Risk Reduction Initiative. This leg- correctional system and mental health or substance and system levels in the design of collaborative risk islation expanded reentry and risk reduction beyond abuse treatment. reduction initiatives. Cass County Provides Alternatives to Incarceration sheree spear, Grant Manager, Cass County Justice and Mental Health Collaboration Project, Cass County Sheriff’s Office, Fargo, ND J ust booked into the Cass County Jail in North Dako- ta, the detainee began licking the floor and exhibit- ing other odd behaviors. Corrections officers see it all, ing area to conduct an assessment. Tests showed no alcohol or substance use to account for the psychosis the detainee was suffering. A representative of South- the treatment he clearly needed. Charges against him were dropped. The young man’s family reported that they had taken it seems, and they suspected this prisoner was more east Human Service Center arrived in 15 minutes to him to an emergency room three times in the month than a typical DUI case. The in-house clinical mental facilitate the detainee’s admission to the state hospi- before his arrest, but the hospital refused to admit health coordinator, whose position is funded by a U.S. tal, and within half a day, the young man was trans- him. Sometimes, early intervention for a serious men- Department of Justice grant, was called to the book- ported from the jail to a facility equipped to provide tal illness falls on the shoulders of law enforcement, NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 49
  • From The Field and communities like Cass County have launched The group the Cass County Jail Intervention Coordi- programs to ensure that people with undiagnosed nating Committee researched programs, collected mental illness are identified and linked to treat- data, and decided to focus first on developing a ment, housing, case management, and medication jail-based post-booking strategy. monitoring. The JICC defined the target population to include The concept of providing an alternative to incar- people with psychotic or mood disorders who met ceration isn’t new. In the 1700s, Governor Fauquier specific offense criteria. Legal alternatives would of Williamsburg, Virginia, gained financial support be maximized, and services would be provided to from the colonial legislature for the first state hospi- qualified people who volunteered for the program. sometimes, early intervention for a tal specifically for people with mental illness, believ- The committee identified gaps in services and de- serious mental illness falls on the ing that treatment should be provided rather than veloped a programmatic strategy to address risk shoulders of law enforcement, and incarceration in the public jail. Recent advances factors and quality-of-life issues for the target popu- communities like cass county have in medicine and policy reforms have reshaped the lation. In particular, capacity expansion was needed launched programs to ensure that landscape and call for programs designed to fit the in two key areas: a full-time clinical mental health people with undiagnosed mental new definition of alternative a life in the community coordinator at the jail, and a case manager. illness are identified and linked to and opportunities for employment. Yet, the alterna- The JICC collected data on how many detainees re- treatment, housing, case manage- tives are still inaccessible to many people who cycle ceived a mental health assessment. Data revealed ment, and medication monitoring. in and out of county jails. Fortunately, today the field that in 2005, jail staff referred 191 detainees for has evidence-based practices, a wealth of research, a psychiatric assessment, but only 92 actually re- and even an instruction manual to guideg the de- ceived one because of limited resources. JICC made although many clients are well served, others are velopment of programs such as the Cass County it a goal to close the gap at this critical point. From placed on waiting lists because of treatment profes- Justice and Mental Health Collaboration Project. January through May of 2009, 550 clients received sionals’ heavy caseloads. Grant funding has been In 2004, following recommendations put forth by an assessment by the new clinical mental health dedicated to hiring an additional case manager to the Criminal Justice/Mental Health Consensus Proj- coordinator. Of those people, 373 were referred for help clients establish personal goals and remain ect Report and the Center for Mental Health Servic- treatment and services, and 10 were transported for engaged with treatment while on the waiting list. es’ National GAINS Center, the Cass County sheriff’s inpatient hospitalization or evaluation. Cass County’s interventions are helping to provide office brought together 26 people from community A case manager is the critical link between a per- alternatives to incarceration through early identifica- and state agencies to discuss the question, “How son with serious mental illness and the community- tion. can we respond differently to reduce recidivism and based services he or she needs. In Cass County, improve outcomes for those with mental illness?” Re:solve Markets Crisis Preparation eleanor Medved, rn, Msn, Vice President of Ambulatory and Crisis Operations; Frank ghinassi, Phd, Vice President of Quality and Performance Improvement; and Jewel denne, Med, lPc, Clinical Administrator — re:solve Crisis Network; rodney Williams, Md, Medical Director, re:solve Crisis Network and Western Psychiatric Institute and Clinic of UPMC, Pittsburgh, PA; Jill trainor, Communications Manager in Clinical Marketing, UPMC, Pittsburgh, PA; Mary Jo dickson, Administrator, Bureau of Adult Mental Health Services, Allegheny County Office of Behavioral Health, Pittsburgh, PA; debbie duch, MPh, Program Manager, Allegheny HealthChoices, Community Care Behavioral Health, Pittsburgh, PA / T he Allegheny County Department of Human Ser- vices’ Office of Behavioral Health, Community Care Behavioral Health, and Western Psychiatric In- county to a coordinated crisis continuum under one provider. Informed by consumer and community in- put, the project’s goal was to unify services, enhance counseling, referral, and linkages. This continuum is intended to preserve community tenure through in- creased access and service utilization for all county stitute and Clinic of UPMC, all based in Pittsburgh, continuity of care, streamline access to services, residents (including people who have not previously PA., partnered to create the re:solve Crisis Network. and clarify performance expectations. engaged in behavioral health services) and focuses The inception of this network marked a shift from Programming includes telephone, mobile, walk-in, on prevention and early intervention. Existing litera- dispersed crisis services that operated across the and residential services; as well as assessment, ture supports the effectiveness of crisis intervention 50 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • in prevention and early intervention in terms of im- ion to a diverse, all-county demographic. Although the service and support professionals, advocates, law proved user outcomes and as a cost-effective alter- following list summarizes people’s general identifica- enforcement officials, hotline operators, peer service native to hospitalization for many clients (Jackson, tion with specific graphics, individual interpretations providers, hospital and emergency room profession- 2005; Ontario Ministry of Health and Long-Term Care, of and responses to the “meaning” of the graphics als, school employees, providers of services to the 2005; Robin, Bronchard, & Kannas, 2008; Rosen, have been highly variable: homeless, spiritual and religious communities, disas- 1997; Scott, 2000). ter response professionals, youth and aging profes- >> Broken plate (represents loss, distress, emotion) Marketing and outreach efforts were incorporated sionals, emergency medical service providers, and >> Torn family photo (represents relationship or family physicians. Many of these sessions have resulted in into the development of a program that transformed the continuum from a multiprovider to a single- conflict) standing collaborative meetings that provide ongoing provider entity while supporting its person-centered >> Overflowing laundry (represents an overwhelming performance feedback to re:solve Crisis Network. mission and vision. Critical input was collected from home life) Recently, an older gentleman contacted the crisis line consumers, families, and other stakeholders through because of significant personal and health losses and >> Poor test results (represents performance or meetings, surveys, and focus groups. said that he had received the re:solve Crisis Network school issues) postcard but had not previously used behavioral The program’s name (re:solve Crisis Network) and phone number (1.888.7.YOU.CAN) were chosen to >> Overflowing “in−out basket” (represents work health services. He engaged in dialogue and ultimately work in tandem to instill confidence and hope and to problems). accepted community linkages and services that he communicate that problem resolution can be driven was not aware were available to him. The program uses a variety of marketing campaign by the person in crisis (“You can resolve a crisis”). tactics to reach the diverse target audience, such as Efforts since the program opening in July 2008 have Early intervention is supported by the advertising direct mailers (sent to every household in the area yielded dramatic improvements in the community’s message, which begins with the headline “Call before served); outdoor advertising (e.g., billboards); transit perception of the service. Prevention and early inter- a crisis becomes a crisis” and subsequent tagline advertising; ads on radio, newspapers, and in the vention are now seen as the hallmarks of the new crisis “We’re here for you any time, any day, for any reason,” yellow pages; Internet presence ( continuum. Two indicators have been used to measure which communicates that the program is accessible solvecrisis); collateral advertising (e.g., displays, mag- the desired outcomes: frequency of telephone calls 24 hours a day, 365 days a year. nets, pocket cards, key chains), and public relations. and frequency of mobile crisis visits. Since the imple- re:solve Crisis Network’s branding includes consistent mentation of re:solve Crisis Network and marketing Concurrent with the marketing launch, a comprehen- use of logo, color treatment, and graphic illustrations and outreach efforts, community engagement in sive face-to-face outreach initiative was implemented. to support the program’s message. Color is used to crisis services has significantly increased. Telephone Scores of meetings and informational sessions have acknowledge the tension of crisis, and common sce- calls have increased by 2,761 per month (34%), and been held with stakeholder groups, including con- narios are used to depict distress (as a precursor to or mobile crisis visits have increased by 362 per month sumers, families, community members, government proxy for crisis) in a nonthreatening, accessible fash- (140%). officials, behavioral health professionals, social REfEREncES Jackson, E. (2005). A community-based comprehensive psychi- atric crisis response service: An informational and instructional monograph. Boston: Technical Assistance Collaborative. The inception of the Ontario Ministry of Health and Long-Term Care. (2005). Crisis re:solve Crisis Network response service standards for mental health services and sup- ports. Retrieved from marked a shift from ministry_reports/mentalhealth/cris_resp.pdf dispersed crisis services Robin, M., Bronchard, M., & Kannas, S. (2008). Ambulatory care provision versus first admission to psychiatric hospital: Five years that operated across the follow up. Social Psychiatry and Psychiatric Epidemiology, 43, county to a coordinated 498−506. crisis continuum under Rosen, A. (1997). Crisis management in the community. Medical Journal of Australia, 167, 633−638. one provider. Scott, R. L. (2000). Evaluation of a mobile crisis program: Effectiveness, efficiency, and consumer satisfaction. Psychiatric Services, 51, 1153−1156. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 51
  • Targeting High-Risk Populations hoPe for homeless Youth and Families nisha Beharie, MPh, Program Coordinator, Mary McKay, Phd., Professor of Psychiatry & Community Medicine, Kosta Kalogerogiannis, lMsW, Community Collaborative Board — Mount Sinai School of Medicine, Department of Psychiatry I t has been estimated that as many as 12 to 26 million adults have experienced at least one pe- riod of homelessness over their lifetime, with up to opportunities and welfare benefits, particularly for single women and their children, and lack of afford- able housing. Yet, homeless families often simulta- school placement. Adolescence covers a large age range, beginning as young as 9 or 10 and lasting to 18 to 24 years of age. Throughout this period, youth 6 million adults being homeless annually. Homeless neously experience an expanded range of difficul- are moving between the worlds of childhood and families constitute a significant proportion of the ties that increases their vulnerability to losing their adulthood, experiencing multiple new and stressful homeless population nationally. In 1995, the U.S. housing and being less able to compete for scarce challenges. As children move through adolescence Department of Education estimated that 744,000 housing resources and employment. These factors toward adulthood, they have basic developmental school age children and adolescents were home- include parental alcohol or other drug-related prob- and psychosocial needs, including being valued less during the course of one school year. This esti- lems, mental illness, serious histories of childhood as a member of a group, receiving family support, mate had increased to one million youth in 2002. abuse and domestic violence, unemployment and participating in caring relationships, acquiring skills Approximately 87% of homeless youth are enrolled poor health. The same set of factors that place to cope adaptively with everyday life, and believing in school, but only 77% attend school regularly. families at risk for losing their housing also serve to in a future with real opportunities. Youth who enter The rates of homelessness in New York are equally disrupt parenting and family relationships, thereby this period under adverse circumstances are often staggering. Most recently, due to the current reces- placing youth at substantial risk for engaging in a ill-prepared to effectively cope with these normative sion, the number of families entering New York City range of problematic behaviors, including early and challenges, making this period particularly prob- homeless shelters increased by 40% from 2007 to risky sexual behavior and drug abuse. lematic and potentially associated with high rates 2008 alone. of school dropout, early and risky sexual behavior, Furthermore, adolescent youth may be more im- pregnancy, drug abuse, and suicide. In particular, While the current economic situation has made pacted by homelessness in comparison to younger the experience of homelessness, compounded by homelessness among families a more pressing issue, children as a result of their cognitive capacities that residential flux, disruption in schooling, and the the factors that contribute to a family experiencing allow for increased awareness of family circum- stigma associated with homelessness provides a homelessness are myriad and complex. At the most stances, experiences of stigma related to homeless- highly stressful context for youth development. In basic level, homelessness has been described as ness, and the effects of disruptions that moving into fact, there is a growing body of research that docu- a direct result of poverty, inadequate employment the shelter system creates on peer relations and ments the negative impact of homelessness on chil- 52 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Drug abuse and HIV-focused prevention programs targeting home- the participants came together and were provided with activities for the family discussion to facilitate less youth must address the needs of the youth for information communication between the parents and youth and and skills development. Family-based programs must reduce adult engage them in the session topic. During these activi- ties and discussions the caregivers and youth could caregivers’ risk behaviors and support protective family processes, identify and develop strategies to deal with the core particularly in a shelter environment that can decrease parental topic of the session together. The family discussion control and increase contact between youth and peers and other also served as a wrap-up of the session and a means for the facilitators to introduce the next week’s topic. adults using drugs and engaging in risky behaviors. The goals and content for each session are described dren’s health, mental health and overall development, HOPE was created by key stakeholders in an urban below. which in turn places them at higher risk for engaging community to address the prevention needs of youth in early, high risk sexual activity and drug abuse. and families experiencing disruptions in housing. The sessIon I — Introduction and Family development, delivery, and testing of the program communication Thus, drug abuse and HIV- focused prevention pro- were funded by the National Institute on Drug Abuse. This session served to introduce families to the HOPE grams targeting homeless youth must be multi-level Family Program staff and to each other while discuss- and address the needs of the youth for information The curriculum for HOPE consists of eight family ing why the HOPE Family Program is in their com- and skills development. In addition, family-based pro- workshop sessions that focus on HIV/AIDS, sexually munity. This session also focused on one of the main grams must reduce adult caregivers’ risk behaviors transmitted infections, and drug abuse while taking themes of the HOPE Family Program: family communi- and support and bolster protective family processes into account the context of youth and families ex- cation. Families discussed the importance of commu- particularly in a shelter environment that can decrease periencing disruptions in housing. Concepts such as nication between youth and caregivers and practiced parental control and increase contact between youth self-efficacy and comfort surrounding health protec- some methods of effective communication. and peers and other adults using drugs and engaging tive sexual communication were also integrated into in risky behaviors. each workshop. The content of these sessions came sessIon II — Monitoring and supervision from three evidence-based curriculums (CHAMP, This session focused on the importance of monitoring The Social Learning Theory is very helpful in inform- Strengthening Families, and SISTA Partnership for the and supervising youth as a means to preventing risky ing programming to change sexual risk behavior and Homeless) and were adapted to meet the needs of behavior. Families discussed rules that currently exist drug use. Furthermore, recognizing the construct of the specific population being served. in their home and how these rules change as youth self-efficacy within the premise of the Social Learning get older. Youth were asked to discuss rules that are Theory is crucial to understanding human and collec- This program was targeted to adolescent ages 11 to “hard to follow” and to also discuss their friendships tive functioning as defined by Albert Bandura. Specific 14 and their care givers and was delivered in com- and how some may help or not help with following to “learning” protective factors to minimize risk of HIV, munity-based sites. Each session was divided into rules. Families were also asked to role play scenarios research findings have documented the wide-ranging three parts: 1) group welcome (the caregivers and with risky situations and develop alternatives to en- effects of efficacy perceptions on learning and moti- youth were together), 2) parents and youth groups gaging in the high risk behavior. vation. Self-efficacy theory predicts that highly effica- (the caregivers and youth were separate), and 3) cious individuals will choose to participate in groups the family discussion (the caregivers and youth were sessIon III — self respect and Peer Pressure more often. They will also expend more effort on chal- together again). Sessions began with a warm-up pe- In this session, families discussed the effects of peer lenging learning tasks and persist longer in the face of riod, which provided an opportunity for the families to pressure on youth and its relation to self-esteem. The difficulty. HIV-risk reduction self-efficacy can be dem- connect with each other and to share updates about discussion focused on the connection between man- onstrated through reinforcement of change efforts, the previous topics and issues that had come up in aging peer pressure and preventing risky behavior. providing opportunities to practice and successfully their families since the previous group meeting. Each Families discussed assertive, aggressive, and non- rehearse skills needed to implement behavior change, parent and youth group allowed the participants to assertive communication when confronted with risky and real-life success in risk avoidance. discuss issues openly among their peers to increase situations. The anticipated outcome was an increase the comfort level of the participants during this por- in skills among youth to be able to discuss with their An example of use of this theoretical model is within tion of the session. peers their decision to not partake in risky behaviors. urban communities is the HOPE (Homeless Outreach Role-plays based on peer pressure scenarios were for Parents and Early Adolescents) Family Program. Following the separate youth and caregiver groups, practiced. NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 53
  • Targeting High-Risk Populations sessIon IV — Puberty HOPE (Homeless Outreach for In this session, families discussed puberty and its Parents and Early Adolescents) effects on youth and their families. Caregivers dis- cussed and practiced communicating with their Family Program was created by key youth about puberty. Youth discussed their knowl- edge of puberty while also receiving factual infor- stakeholders in an urban community mation. Parents and youth were given an opportu- to address the prevention needs of nity to discuss puberty together and were provided with materials that would aid them in discussing youth and families experiencing puberty at home. disruptions in housing. sessIon V — hIV/aIds/stIs The development, delivery, and This session focused on increasing knowledge sur- rounding HIV/AIDS and STIs. Parents and youth were testing of the program were provided with facts surrounding HIV/AIDS, including funded by the National transmission; myths surrounding transmission were discussed. Other major STIs were discussed with an Institute on Drug Abuse. emphasis on transmission and symptoms as well as reducing risk in high-risk situations. Male and female condom demonstrations were performed, sessIon VIII — hope Family game has worked with underserved populations both internationally and domestically, in various capacities. At Mount Sinai School and families had an opportunity to practice using This session served as a review of the topics and of Medicine, she has co-directed a NIDA funded grant entitled a male condom. information discussed in the previous HOPE Fam- HIV/AIDS Outreach Program for Parents and Early Adolescents ily Program sessions. Families participated in an (HOPE) providing HIV/AIDS and alcohol abuse prevention sessIon VI — substance use education to families living in NYC family shelters. interactive game in which they competed with one This session focused on increasing knowledge Mary McKay is a professor of psychiatry and community another while assessing their knowledge of the in- medicine. Her interests include identifying the specific mental around the negative effects of substance abuse. formation. Families also received certificates for health and prevention needs of urban youth and their families, Facts on illicit substances were presented. Families as well as testing family and community-based, collaboratively their completion of the HOPE Family Program. developed interventions. learn about addiction and its relation to HIV/AIDS, and STI risk. Thus far, HOPE has involved 223 parents and youth. Kosta Kalogerogiannis is a doctoral student at the Columbia University School of Social Work and an NIMH research fellow High attendance in groups suggested that the com- with the Council on Social Work Education Underrepresented sessIon VII — domestic Violence and munity educators were successful in engaging this Mental Health Research Fellowship Program. She has worked in Intimate Partner Violence NYC’s inner-city communities for the past decade and has been high risk population. The need was highlighted for involved in a range of clinical and research interventions aimed This session focused on discussing domestic vio- additional prevention programs that are sufficiently at reducing adolescent and adult risk in the areas of sexual lence. The signs and manifestations of domestic vio- health and mental health. flexible to achieve high rates of participation and lence and intimate partner violence were reviewed. Acknowledgments: HOPE is supported by National Institute that can incorporate changes in residence and cir- Families discussed different ways of recognizing if of Drug Abuse (RO1 DA018574). We thank the entire HOPE cumstances of these families. Family Committee for their tireless efforts. Ervin Torres, Angela one is in a domestic violence or IPV situation, as Paulino, Ana Miranda, Aida Ortiz, Anita Rivera-Rodríguez, Rhina well as ways of leaving a domestic violence situa- Paulino, Jason Patrick, Kerby Jean, and Jovan Jones as well as Nisha Beharie received her masters degree in Public Health others who worked on the program, Rita Lawrence, Indamora tion. Facts on domestic violence and IPV were also from the Mailman School of Public Health at Columbia Castro, Natalie Parker, Greg Mudd, Mary Savva, and Nealdow presented. University. Ms. Beharie is a former Peace Corps volunteer who Chambers. Compliance Watch > Quality & compliance best practices > Regulatory changes A b e h Av i o r A l h e A lt h e x c l u s i v e > Enforcement & oversight updates QuArterly Newsletter subscribe at 54 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
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  • Targeting High-Risk Populations InSHAPE: Promoting Wellness, Saving Lives Ken Jue, MsW, CEO, Monadnock Family Services in an interview with InSHAPE won the National laura galbreath, Director of Policy and Advocacy, National Council for Community Behavioral Healthcare Council’s 2008 Award for Excellence in Innovation P eople with severe and relentless mental illness such as schizophrenia and bipolar disorder also bear a greater physical burden; they are at increased time in their lives. Jue started researching information about comorbid medical illnesses among people with SMI and also interviewed Monadnock staff about pa- not receive formal mental health training so that they would not be influenced to think about and treat the participants as “ill” or “sick” patients.5 risk for obesity and chronic diseases including diabe- tients’ medical conditions. Staff members confirmed Participants were not only given the chance to be edu- tes, hypertension, cardiovascular disease, and nicotine that many of their patients had died prematurely or cated on leading a healthy lifestyle, but they were also While InshaPe does not promote exercise as a replacement for pharmaco- given the opportunity to meet other people with similar therapy, preliminary results suggest that the exercise and increased health challenges and to feel included in the community. Fit- ness assessments were repeated every three months awareness help patients better cope with their mental illness. to track progress, and there were regular celebrations dependence. Serious mental illness is an important had a number of other chronic health conditions exac- during which participants received recognition for their risk factor for morbidity and morality; these patients erbated by their lifestyle choices and their mental ill- efforts and incentive prizes. die an average of 25 years earlier than the average ness.4 Jue knew something had to be done to help this A pilot study was launched with the commencement of individual due to higher rates of medical illness than unique population, and so he outlined key program the In SHAPE program to gauge participants’ progress in can lead to premature mortality.1 elements that he would want to see in a program that improving their overall health. While Jue only expected These gloomy statistics inspired Ken Jue, MSW, CEO of helped people with SMI improve their physical health. 40 people to enroll in the program, he was surprised to Monadnock Family Services in Keene, New Hampshire Instead of relying on formal referrals from mental see that 65 people had signed up, and more wanted to to start the In SHAPE program. “What we’re trying to health providers, Monadnock encouraged voluntary join but couldn’t due to limited funding. Three months do is prevent premature death of persons with serious participation and began to form partnerships with after beginning the program, participants exhibited mental illness,” says Jue. hospitals and organizations that would provide exer- increased exercise capacity and flexibility, enhanced Research shows that people with schizophrenia and cise, nutrition, and general health services. These part- readiness to change, and improved mental well-being; other psychotic and mood disorders who exercise nerships were critical to In SHAPE’s success. The local weight loss was variable across participants. Anecdotal three times a week for approximately 4 months lose hospital provided smoking cessation programs, while evidence suggests that participants seemed to have weight, gain cardiovascular fitness, and experience a large non-profit medical clinic provided primary care greater confidence in social situations, reduction in less depression and fewer psychiatric symptoms.2 But services to participants without a medical home at their waist circumference and blood pressure, and an few programs exist to help people with SMI maintain no charge to the patient. The local YMCA and a dance overall reduction in their depressive symptoms.6 While healthier lifestyles; for example, fewer than 20% of peo- and fitness center also offered up their services to en- In SHAPE does not promote exercise as a replacement ple with schizophrenia engage in regular exercise, and courage creative forms of physical activity. Graduates for pharmacotherapy, preliminary results suggest that approximately 40% are completely inactive.3 In SHAPE from Keene State College Department of Health and the exercise and increased health awareness help pa- is one of the few wellness and prevention program for Fitness were hired to serve as health mentors. They did tients better cope with their mental illness. individuals with SMI that seeks to fill this void. In SHAPE seeks to improve physical health and quality of life, reduce the risk of preventable diseases, and 27 -year-old “ Matt” described himself as “A heart attack waiting to happen.” He weighed more than 300 pounds and smoked two packs a day. Diagnosed with bipolar disorder in his senior year in high school, Matt had been hospitalized twice. During one six week stay, he gained 25 pounds. Matt’s enhance life expectancy of individuals with SMI. Each participant is teamed up with a trained health mentor weight had wildly fluctuated before. As a college freshman suffering from depression, he lost 119 pounds to create a Self Health Action Plan for Empowerment on only cigarettes and diet soft drinks. (SHAPE) that includes physical activity, healthy eating Matt joined Monadnock’s InSHAPE program, which offered him the services of a personal trainer to focus goals, and attention to medical needs. The program on health and nutrition. A year after joining the program, Matt looks at diet and exercise differently, and enrolls adults in community wellness activities such excels in the cooking class. He has learned how to judge the nutritional values of foods by reading the as exercise, dance classes, weight loss programs, and information on the packaging. smoking cessation activities. Until 2002, Jue continued to attend a number of funer- He’s also gained self-esteem through his athletic success, particularly in tennis, and gained perspective als of his patients that seemed far too young to be dy- on his mental illness. “Now I don’t view myself as Matt with this major mental illness. It’s a component ing. He often looked at his patients’ photographs and of me but not me. I try not to make it forefront of my entire being.” noticed that they all looked youthful and active at one A true story from Monadnock Family Services, Keene, New Hampshire 56 / NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2
  • Currently, the In SHAPE program is active in New Hamp- mately improve their quality of life and reduce local under the state’s Medicaid program. shire, Massachusetts, and Maine. Jue and his team at stigma. Monadnock have strengthened In SHAPE by developing >> Seek community partnerships: Programs don’t need REfEREncES new programs that help address challenges that come 1. Shiner B, Whitley R, Van Citters AD, et al. Learning what to have their own exercise centers or nutrition staff; matters for patients: qualitative evaluation of a health promotion with varying populations with SMI. For example, Parents they should leverage use of community resources by program for those with serious mental illness. Health Promotion as Teachers is a new initiative developed for mothers Int. 2008 Sep; 23(3): 275-82. creating mutually beneficial partnerships. with mental illness on Medicaid. Through home visits, 2. Exercise and Nutrition Program Helps Individuals with Serious >> Employ a patient centered approach: Encouraging Mental Illness Develop Healthier Lifestyles, Improves Fitness, and mothers are taught on how to grow and develop rela- participants to set their own goals will increase the Mental Well-Being Retrieved July 21, 2009, from http://www. tionships with their children with greater continuity and likelihood that goals will be achieved. Participants less disruption as a result of their mental illness. While 3. ibid 4. ibid 5. ibid 6. ibid 7. ibid should understand that they have responsibility for the program presents its own challenges for the mothers As CEO of Monadnock Family Services Ken Jue has instituted and control of their health. involved, most participants are deeply committed to the many new and innovative programs and services, including New one-year program and strive to make significant changes >> Do not “medicalize” the program: Orient the pro- Hampshire’s only organized mental health court, a consumer- gram as an activity to promote the participant’s directed housing cooperative, a consumer and family directed for themselves and their families. fund to support consumer initiatives toward independence, and health and wellness, not as a response to his or her an interagency supported dental practice for consumers. Jue has Jue encourages other associations to support wellness mental illness or medical comorbidities. consulted with international government agencies and nonprofits and build partnerships with their local healthcare clinics on public mental health and welfare services and has presented and organizations with a few caveats7: Funding for the In SHAPE program initially came from the at national and international conferences. He is active in New Hampshire Endowment for Health. The Robert Wood community volunteer activities and has held elected office. >> Do not underestimate the insight of people with Johnson Foundation also provided monies for program Laura Galbreath supports the National Council’s state and federal mental illness: Patients with SMI are likely to readily policy initiatives and focuses on expanding opportunities for expansion and a pilot study to test the effectiveness of acknowledge the need to make lifestyle changes to 1,600 member community mental health and addictions services the program. Enrolled patients also pay a $5 monthly organizations to meet the primary health needs of the people improve their health. they serve. Galbreath has extensive experience in health policy membership fee to access exercise facilities and classes >> Emphasize local inclusion: Involving people with SMI analysis, community organizing, and project management. Before offered by In SHAPE partners. Recently, the state of New coming to the National Council, she served as the senior director in community activities and exercise centers will ulti- Hampshire agreed to reimburse the In SHAPE program of healthcare reform at Mental Health America. The Benefits of Ownership… As an insured of MHRRG you actually: • Own your insurance company . Mental Health • Receive the financial benefit of a dividend opportunity. Risk Retention Group, Inc. • Your board of directors is comprised of your peers, giving you direct access to decision making. Negley Associates • P.O. Box 206 • Cedar Grove, NJ 07009 (800) 845-1209 • Fax: (973) 239-6241 You can relax, we’ve got you covered. Email: • NATIONAL COUNCIL MAGAZINE • 2009, ISSUE 2 / 57
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