Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
American Psychological Association Symposium on Evidence-Based
Practices for Individuals With Serious Mental Illnesses: Evidence-Based
Practices: Learning from the Numbers
August 12, 2006
New Orleans, LA
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1. Title slide]
Lord Kelvin was a Scottish mathematician and physicist during the
late 1800s. In his mind, numbers equaled knowledge. As he expressed
it, "When you can measure what you are speaking about…and express
it in numbers, then you know something about it; but when you cannot
measure it, when you cannot express it in numbers, your knowledge
is of a meagre and unsatisfactory kind." We may deal with incredibly
complex mental illnesses, but we still can learn from the numbers,
particularly as they apply to evidence-based practices (EBPs) for
individuals with serious mental illnesses (SMI).
More than 15 million American adults have a diagnosable SMI. Up
to 9 percent of our children have a serious emotional or behavioral
problem. These numbers alone tell us that we need to make available
the best treatments possible to improve the lives and futures of
those who are affected. Psychology, of course, offers many best practices.
Your field is one of four core disciplines for promoting sound behavioral
health, together with psychiatric nursing, psychiatry, and social
work.
Other numbers speak of the amazing capacity of individuals to recover.
I’ll summarize just one study, which also highlights the value of
psychological practices to aid recovery. During the 1950s, George
Brooks—a hospital director—treated residents with schizophrenia with
a new drug called thorazine. He found that the drug alone could not
enable many patients to leave the hospital successfully. Brooks helped
design a psychosocial rehabilitation program to help them develop
social and work skills, cope with daily living, and gain confidence.
Many patients who had not responded well to the drug became well
enough to return to their community. Thirty years later, researchers
conducted a followup study. What did they find?—Almost 70 percent
of the individuals had significantly improved. A full 45 percent
no longer had any signs or symptoms of a mental illness.
People can recover from serious mental illnesses and they do recover!
But their recovery often hinges on their access to services that
best meet their needs; in other words, EBPs, or practices that have
been proven effective in producing positive outcomes. We, as providers
and decisionmakers, have to look to the numbers to identify which
practices qualify as EBPs…to measure the extent of their effectiveness
across different groups…to identify gaps in treatment and application…and
to guide future research efforts.
The Substance Abuse and Mental Health Services Administration (SAMHSA)
is engaged in a long-term initiative to accomplish each of these
objectives. Together with the National Institute of Mental Health,
we are working to develop, distribute, and increase the use of EBPs.
In a few minutes, Kevin Hennessey, SAMHSA’s science-to-service coordinator
will describe some of our key activities. I’ll be discussing some
related activities conducted by the Center for Mental Health Services
(CMHS), which is one of three centers within SAMSHA.
My center contributes to SAMHSA’s overall science-to-service initiative
and we also support more targeted efforts. We do not conduct basic
research. Instead, we identify evidence-based practices and move
these practices into the field. We use an array of strategies to
promote evidence-based methods of engagement, outreach, assessment,
treatment, and prevention. I will briefly describe some of these
strategies today.
[SLIDE 2. Resource kits available]
A few years ago, CMHS began developing resource implementation kits
for several EBPs. This slide shows the first set of kits. We then
awarded grants to various States across the Nation to field test
the kits in different settings and for different populations. We
currently are using feedback from the field to refine the kits. You
can download any of the kits for free from the SAMHSA Web site. Each
kit contains all of the resource materials you should need to replicate
the intervention with fidelity.
[SLIDE 3. Resource kits being developed]
We now are working on several more kits. Our first set of kits
targeted a specific EBP for treating individuals with SMI in public
mental health clinics. Our second set of kits will address broader
populations and offer treatment options for different service settings.
For example, our kit for older adults is focused on late-life depression.
Older adults often experience depression in conjunction with other
issues, such as chronic physical health problems. They also tend
to seek treatment for their depression from their primary care physician.
Our kit will describe EBPs for treating late-life depression in relation
to other health issues.
Our new kits also will describe practices of use to providers outside
of mental health settings. The rationale is in the numbers. Older
adults are represented disproportionately in suicide numbers. Up
to 75 percent of those who commit suicide visited a primary care
physician within the preceding month. This is a reality of mental
health care: we need to better engage several service systems, and
particularly primary health care, in recognizing, assessing, and
responding effectively to serious mental illnesses.
Our second set of kits is in the development stage. We’re doing
our best to learn from the field about what information is needed
and how we can best present it. There are many wonderful EBPs available,
but the field isn’t taking advantage of them and using the full protocols.
Why?— Because much of the material is technical and providers aren’t
sure how to access or apply it. They haven’t the time to sort out
what is relevant to the populations they serve. It often isn’t clear
whether a practice fits within their real-world constraints. Many
interventions are tested in controlled settings and they often are
developed without consideration for how providers and complex systems
will implement them.
The information available about EBPs can be overwhelming! In fact,
there are more than 550 named therapies already! Our new kits will
provide a shorthand approach to determining if the EBPs presented
in our kits are right for you. They will tell you about levels of
evidence and what you need to adopt a practice. We will give you
a framework for deciding if a practice fits your population, resources,
and training capacity. You will be able to reach decisions with these
real-world factors in mind.
Our next stage will be to package the information in ways that encourage
examination and application. To accomplish this, we’re transforming
our approach.
[SLIDE 4. Innovations]
Our new set of kits will be presented in an interactive CD-ROM
format. We’ve researched adult learning theory to identify how best
to organize and present information. We’re asking social marketing
experts to help us create a useful, engaging, and usable product.
I’m excited about our potential to design kits that will be practical
and powerful tools for implementation.
I want you to think of the word "kit" as an acronym for what we
are striving to achieve through EBPs. For CMHS, K-I-T stands for
[SLIDE 5. K-I-T]
Knowledge Informing Transformation. Our kits cover a variety of
services. Their broad scope reflects an ongoing transformation of
mental health services, as called for by the President’s New Freedom
Commission on Mental Health. Through transformation, we are creating
a service delivery system that is consumer driven. Through transformation,
individuals with SMI will have access to all of the comprehensive
services that can help to achieve and sustain recovery.
The word "health" derives from the Greek word meaning "whole." Only
by seeing the "whole" individual can we truly promote the mental
health of individuals with SMI. This "holistic" approach goes beyond
symptom management to consider other aspects. In the Brooks study
I mentioned previously, pathways to recovery included having a home,
a job, social relationships, and reintegration into their communities.
These supports contributed to the consumers’ self-sufficiency, relearned
optimism, and a sense of hope. According to consumers, hope—and the
opportunity to regain control of their own lives and futures—is essential
to recovery.
The centrality of consumers to everything we try to achieve through
EBPs is paramount. This includes our efforts to measure the effectiveness
of EBPs. Consumer outcomes are the bottom-line for mental health
services, just like profit is the bottom line in businesses. We,
however, measure gains and losses in very human terms. And, yet,
we must find ways to quantify these sometimes subjective terms. To
repeat Lord Kelvin, "when you cannot measure it, when you cannot
express it in numbers, your knowledge is of a meagre and unsatisfactory
kind."
The ongoing move toward consumer-driven care significantly affects
the kind of data we should collect. Most important, the outcomes
we measure should incorporate the consumer’s perspective so that
we can better understand the benefits and risks of each intervention
for them.
Last year, SAMHSA introduced a set of national outcomes measures,
or NOMs, for measuring the effectiveness of mental and substance
abuse programs. Fifty years ago, when we first began to develop performance
measures for mental health, we focused on population data and service
input measures, such as the number of hospital beds. Our NOMs take
a different approach. They reflect a transformed view of effective
mental health care because they focus on positive outcome measures
for consumers.
[SLIDE 6. Selected NOMs]
Our NOMs include such outcomes as improved functioning, greater
stability in living conditions, increased employment or education,
social connectedness, and better access to services. While each individual
with a serious mental illness will have a unique goal for treatment,
the core outcomes they seek reflect very basic desires. Our NOMs
represent the outcomes that consumers tell us are most important
to them. They want to be able to live a life in their community.
They want to live independently in a place called home, to hold a
paying and meaningful job, to have friends, and to avoid the spirit-breaking
experiences of hospitalization, incarceration, or substance abuse.
One of our NOMs is the use of EBPs. EBPs represent the consumers’
greatest hope of achieving any and all of the other outcomes. We’ve
embedded the NOMs in State mental health block grants. The States
now must report annually on their progress related to the NOMs.
We also use our service grants to leverage the use of EBPs. By making
the use of EBPs a grant requirement, we promote their use and we
gain valuable insight into the challenges and successes of implementation.
SAMHSA and CMHS are committed to promoting the use of EBPs, but
the greatest challenges—and opportunities—for their implementation
rest with you. We can make the information available, but only you
can apply it effectively.
A major challenge you face with EBP implementation is adaptation:
a lot of it often is needed, yet there are no rules to guide it.
Those who adapt practices must be able to justify why. They have
to ensure the practice remains science driven and research guided.
How can they measure success?
Let’s consider some of the issues around adaptation. We’re meeting
in a city that has experienced tremendous and continuing trauma in
the wake of Hurricane Katrina. One practice for treating severe trauma
requires 18 to 20 sessions of psychotherapy. In the real world, In
the real world the average number of sessions a consumer might be
willing to attend may range from seven to five or even less. So how
can you adapt this practice to a group of elder consumers in rural
settings? Can you reframe the practice to better fit the way that
people seek help, yet still meet their needs? Can some of the information
be provided through different channels than outpatient visits? Many
individuals will not have the time or resources to commit to 18 sessions.
Look around you at the incredibly diverse population of New Orleans.
Can you shape this practice so it is equally effective across cultures
and socioeconomic divisions? Can you take it out of the city into
rural areas? Evidence-based practices are dynamic and evolving. Our
lessons from the field indicate that practices often must be adapted
to be appropriate for specific populations, settings, and funding
mechanisms.
Look to and learn from evaluation data. Each attempted implementation
of an EPB is an opportunity to learn more about it…to explore the
conditions under which it can be used with fidelity and to good effect.
Each attempt presents opportunities to add to the knowledge base.
Changes that reduce its effectiveness will be a threat to fidelity.
On the other hand, changes that improve outcomes will be innovations
that should be included as core components.
Implementation is not an event: it’s a process. You implement some
core practices, evaluate outcomes, get some feedback, and use the
results to make incremental quality improvements—each step of the
process is a move towards better treatment and more positive outcomes
for consumers.
You are the vanguard in improving mental health services. Consequently,
I’m asking you today to think about your role in promoting the use
of EBPs. SAMHSA and CMHS have been put in the position of making
many of the front-end decisions about EPBs, such as which ones work
best for which populations. Do you want to give up that role? I’d
rather we shared the role.
SAMHSA has developed a National Registry of Evidence-Based Programs
and Practices for substance abuse and mental health. We need developers
to submit practices for review. You can encourage developers with
good practices to apply…and you can help them through the process.
We are looking for scientific evidence that a practice is effective
and utility measures that show it can be implemented effectively.
To meet our requirements, developers should be collaborating with
providers who are using their models. You can use your experience
with a practice to ensure the model reflects real-world situations…clearly
identifies core components…and offers explicit manuals and other
tools for successful implementation.
In addition, your field can continue working to expand the knowledge
base. Emerging practices that remain to be studied through research
and service include peer support, consumer-run programs, and consumer
engagement in planning and decisionmaking.
You also can acknowledge those who are expanding the knowledge base
around implementation. I’ve been told there I have been told that
tenure-track positions for academic psychologists involved in the
work of implementation are rare. Implementation science is not the
hot discipline in academic psychology. Why? For policymakers, State
planners, program administrators, and researchers, information about
implementation is as important as information about the intervention.
Without this information, how can we determine if the practice or
the practitioner needs improvement? Implementation is a substantive
and critical area, with a growing science base. Implementation has
many commonalities with change management. In business schools, change
management is a highly respected and rewarded area. Implementation
should be valued equally by those engaged in the business of recovery.
You can identify and develop leaders among you—individuals whom
the National Implementation Research Network calls "purveyors." In
its just-completed monograph on implementation research, the Network
defines purveyors as an individual or group of individuals who actively
work to implement a practice or program with good effect and fidelity."
These are individuals who push, pull, and promote EBPs through those
challenging months, and often years, before full implementation.
David Fisher is a former clinical director of the New Mexico State
Hospital. He explored the difficulties of initial implementation
in his article entitled "The going gets tough when we descend from
the ivory tower." He made this observation about the real-world environment
of applied psychology. "It is full of personnel rules, social stressors,
union stewards, anxious administrators, political pressures, interprofessional
rivalry, staff turnover, and diamond-hard inertia." He failed to
emphasize that it also is filled with dedicated individuals capable
of meeting these challenges head-on to improve services for individuals
with SMI. You are here at this meeting because you have faith in
your profession to heal.
EBPs present our greatest opportunity to help consumers toward recovery
and a better and more hopeful future. We know this from research
and practice: Good outcomes for consumers occur when effective practices
are implemented effectively.
[SLIDE 7. If we can...]
If we measure how well a practice works…and we measure how well
we work at putting it into practice—and we learn from these data—we
can change lives. This is knowledge of a very satisfactory kind.
Thank you.
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