William C. Torrey

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis.

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

Implementing Evidence-Based Practices for People with Severe Mental Illness

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.

Rehabilitative day treatment vs. supported employment: I. Vocational outcomes

Day treatment remains a core component in many community mental health programs for persons with severe mental disorders throughout the United States. Many other mental health centers are moving away from day treatment toward psychosocial and vocational rehabilitation programs. Empirical research directly comparing these two systems of organizing outpatient services is needed. In this study the authors compared a rehabilitative day treatment program in one small city with a similar program in a nearby city that changed from day treatment to a supported employment model. Clients who were enrolled in community support services during a baseline year prior to the change and during a follow-up year after the change (71 in the program that changed and 112 in the other) were evaluated during both intervals. In the program that changed, competitive employment improved from 25.4% to 39.4% for all clients, and from 33.3% to 55.6% for those clients who had been regular attenders of day treatment during the baseline. Hours worked and wages earned similarly improved after the program change. For all work variables, clients who had not worked during the baseline year accounted for the improvements in outcome. Meanwhile, employment remained stable in the day treatment program. No negative outcomes were detected. These results indicate that eliminating day treatment and replacing it with a supported employment program can improve integration into competitive jobs in the community.

The Role of Staff Turnover in the Implementation of Evidence-Based Practices in Mental Health Care

OBJECTIVES This study examined turnover rates of teams implementing psychosocial evidence-based practices in public-sector mental health settings. It also explored the relationship between turnover and implementation outcomes in an effort to understand whether practitioner perspectives on turnover are related to implementation outcomes. METHODS Team turnover was measured for 42 implementing teams participating in a national demonstration project examining implementation of five evidence-based practices between 2002 and 2005. Regression techniques were used to analyze the effects of team turnover on penetration and fidelity. Qualitative data collected throughout the project were blended with the quantitative data to examine the significance of team turnover to those attempting to implement the practices. RESULTS High team turnover was common (M+/-SD=81%+/-46%) and did not vary by practice. The 24-month turnover rate was inversely related to fidelity scores at 24 months (N=40, beta=-.005, p=.01). A negative trend was observed for penetration. Further analysis indicated that 71% of teams noted that turnover was a relevant factor in implementation. CONCLUSIONS The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions.

Evidence-Based Practice Implementation in Community Mental Health Settings: The Relative Importance of Key Domains of Implementation Activity

Implementation research has examined practice prioritization, implementation leadership, workforce development, workflow re-engineering, and practice reinforcement, but not addressed their relative importance as implementation drivers. This study investigated domains of implementation activities and correlated them to implementation success during a large national evidence-based practice implementation project. Implementation success was correlated with active leadership strategically devoted to redesigning the flow of work and reinforcing implementation through measurement and feedback. Relative attention to workforce development was negatively correlated with implementation. Active leaders should focus on redesigning the flow of work to support the implementation and on reinforcing program improvements.

Recovery principles and evidence-based practice: essential ingredients of service improvement.

The two of the most commonly advocated service improvement proposals for adults with severe mental illnesses are to redesign services based on recovery principles and to increase the availability of services with strong research support. The two improvement strategies complement and inform each other much more than they conflict. To improve, the field needs the insights of people who have personally experienced severe mental illnesses and it needs the scientific process. Applied together, the two strategies can guide the development of an optimal service system: The kind of service system that most people would want for themselves or their family should they have the need.

The challenge of implementing and sustaining integrated dual disorders treatment programs.

Integrated dual disorders treatment programs for people with severe mental illness and co-occurring substance use disorder have been implemented in a variety of community mental health center sites across the U.S. and in several other countries over the past 15 years. Consumers who receive services from programs that offer integrated dual diagnosis treatments that are faithful to evidence-based principles achieve significant improvements in their outcomes. Unfortunately, not all programs that attempt implementation are successful, and the quality of high-fidelity programs sometimes erodes over time. This article outlines implementation strategies that have been used by successful programs. As a general rule, success is achieved by involving all major participants (consumers, family members, clinicians, program leaders, and state or county mental health authorities) in the process and attending to the three phases of change: motivating, enacting, and sustaining implementation.

Practicing Shared Decision Making in the Outpatient Psychiatric Care of Adults with Severe Mental Illnesses: Redesigning Care for the Future

Psychiatrist outpatient office visits have the potential to support the recovery of adults with severe mental illnesses by engaging them in a collaborative process of evaluating, selecting, and trying individually-tailored therapeutic options. Evidence-informed shared decision making is difficult for psychiatrists to offer within the framework of care as it is delivered today: it requires time, easy access to relevant scientific information, and extensive communication between patients and psychiatrists. In this paper, we describe the current structural obstacles to collaborative psychiatric care and envision a redesigned office visit process that facilitates active informed patient involvement.

Strategies for leading the implementation of evidence-based practices.

Many mental health authority and program administrators would like to implement behavioral health practices that have been demonstrated to be effective. Leading practice implementation involves promoting behavior change in health care providers. Reviews of the general medical literature on practice change conclude that education alone has little impact on practitioner behavior and that intensive, multifaceted interventions that attend to local circumstances have the greatest likelihood of affecting change. This article briefly reviews the literature on health care practice change and offers some strategy suggestions for administrators who are leading evidence-based practice implementation initiatives.

Strategies for implementing evidence-based practices in routine mental health settings

The term `evidence-based medicine‘ was coined in 1990. Since then, the systematic use of scientific evidence in clinical decision-making has expanded.1 The evidence-based medicine movement inspired parallel developments in mental health. Administrators, clinicians, advocates and researchers generally agree that they are obligated to provide the most effective mental health treatments. Implementing evidence-based practices in routine treatment settings is a crucial part of this.2–5 The key question is: how do we implement evidence-based practices? Routine mental health settings are generally deficient in evidence-based practices.2–5 To redress this, we must understand broad-scale implementation in diverse treatment systems. Working with state mental health systems and researchers throughout the United States, we have been engaged in a multi-state demonstration, the National Evidence-Based Practices Project.6–9 We used several sources to understand implementation: literature on changing healthcare practices; focus groups and interviews with stakeholders; the experience of advocacy groups, and the collective experiences of mental health researchers.9 This editorial summarises findings from these sources and describes the US National Evidence-Based Practices Project. ### PRACTICE IMPLEMENTATION LITERATURE The practice implementation literature agrees on several points. First, education alone is ineffective at changing health care practices.10 Changing complex programmes requires more extensive interventions than education or training. Among the strategies involved are enhancing motivation, providing adequate resources, increasing skill development and removing environmental constraints.11 Second, change occurs over …