Information Center Bulletin
Volume 3, No. 1 Spring 1999

The Community Support Program

Sets the Stage for Change

Two decades ago, policy makers and providers had sole say in what constituted the public mental health system. Today, people receiving mental health care and their families play an increasingly visible and influential role: they are involved in everything from advising States on managed care contracts to deciding what kinds of research (such as understanding the underpinnings of recovery) should be conducted.

The balance of power has tipped as a result of direct—yet behind-the-scenes—work by the Center for Mental Health Services (CMHS) Community Support Program (CSP). "CSP has been a catalyst for positive systematic change by recognizing the need for nontraditional behavioral health service provisions designed and implemented by consumers for consumers," says Larry Belcher, director of the West Virginia Consumer Organization and Networking Technical Assistance Center.

This approach is based on well-defined CSP principles:

• Work together with States and communities to help them move in a direction that is most effective for them.
• Help dependent people achieve maximum independence.
• Value and rely on the wisdom and priorities of people closest to the problem.
• Involve all stakeholders, both within and outside "the system," to change the system over time.

Managed Care: Making Systems Effective and Accountable

The mental health system is rapidly changing as State and county mental health administrators sign contracts with managed care organizations to curb spiraling health care costs. These contracts determine the mental health and substance abuse services people receive from the public health system. However, many mental health administrators lack the experience to negotiate contracts that will ensure high-quality care within a managed care environment.

CSP principles can be a powerful tool for making certain that health care systems go beyond managing symptoms, providing medications, and furnishing oversight. They can provide a contractual blueprint to create and regulate managed care systems that are effective and accountable. Managed behavioral health care systems that incorporate CSP principles can help move people away from a patient role toward independence. Using these principles can promote recovery by providing linkages to services such as vocational rehabilitation, housing, socialization, and self-help.

"Since its onset, CSP has provided support, encouragement, and resources to consumers, survivors, and former recipients of mental health services," Belcher says. "As a result, many voices have been heard that otherwise would have been lost to an unresponsive system."

Dual Disorders: Pushing the Mental Health Field Forward

But real care—providing services the person needs rather than services the system dictates—is often lacking for people who have both mental and substance abuse disorders. The CSP has responded to this problem by funding 13 demonstration projects across the country. Traditional programs for providing services to people with dual disorders were abandoned and replaced with innovative, consumer-oriented services (see sidebar on page 4). These projects show for the first time that it is possible to integrate services and that culturally sensitive, integrated programs can attract and retain people from different high-risk groups.

"Most [demonstration] projects that collected such data found they were able to retain between 75 percent to 80 percent of their participants for a year or longer," says Robert Drake, M.D., Ph.D., director of the New Hampshire-Dartmouth Psychiatric Research Center. "They also found that participants fared better than in traditional programs: they used the hospital less, encountered fewer legal problems, and engaged in some kind of substance abuse treatment."

Further, these demonstration projects have helped to define the clinical models for integrating substance abuse and mental health service systems that are used today. In traditional programs for substance abuse disorders, participants are expected to be motivated to pursue abstinence; however, mental disorders complicate and interfere with a person's ability to meet this expectation. To assist people with dual disorders, several of the CSP demonstration projects have developed components that elicit, cultivate, and help sustain motivation for substance abuse treatment. Recognizing that many participants were not yet ready for active treatment, several other projects have built on these components and designed a stage approach for dual disorders treatment:

• Becoming engaged in services.
• Developing the motivation to pursue substance abuse treatment.
• Participating actively in substance abuse treatment.
• Learning to prevent and deal with relapse.

In addition, researchers realized that the standard assessment measures for substance abuse simply did not work for people who also had a severe mental illness. The CSP demonstration projects sparked the development of new assessment tools that effectively describe and measure substance abuse among people with dual disorders.

"The groundwork of designing clinical models, working directly with people who have dual disorders to really respond to what they need and want, and developing innovative services and measures was critical," says Drake. "Only now is the dual disorders field ready to do classic controlled clinical trials that determine cost-effectiveness. CSP's accomplishments set the stage for the field to advance."

CSP's dual disorders demonstration projects are described in the report, "Review and Summaries: National Demonstration of Services for Young Adults With Severe Mental Illness and Substance Use Disorders." The report is available through the Information Center by calling toll free (1-800-789-2647) or visiting the Web site (mentalhealth.samhsa.gov).

Recovery: Uncovering Common Themes

CSP is also setting the stage for change in the area of recovery from mental illness. Recovery, long dismissed as attainable only for people with substance abuse disorders, is finally receiving significant attention.

To tease apart its essential components, the National Empowerment Center, a CMHS technical assistance center, has conducted in-depth interviews with 30 consumers in various stages of recovery. "It's the first study of how people recover from mental illness," says Daniel Fisher, M.D., Ph.D., the technical assistance center's director and principal investigator of the study.

An analysis of the interviews reveals a number of themes common to those who have recovered or have shown significant progress in recovery from mental illness:

• Believing in one’s recovery.
• Having one's thoughts validated by others, especially by peers through support groups.
• Being with people one can trust.
• Having a voice in important events in one’s community.
• Taking care of oneself.
• Transferring anguish into suffering that can have meaning.
• Having hope and wondering what can be achieved.
• Taking responsibility for one’s own life.
• Getting in touch with one’s emotional and spiritual side.

"Understanding the elemental themes involved in this process may lead to a new model of recovery," Fisher says. "When people know there can be an endpoint to their illness and that they can become well again, they have hope and are much more likely to continue to work toward recovery."

Results from the study on recovery should be available sometime later this year through the Empowerment Center (call toll free at 1-800-769-3728) and the Information Center (call toll free at 1-800-789-2647 or visit the Web site at mentalhealth.samhsa.gov).

For more information, contact Larry Belcher, M.A., West Virginia Consumer Organization and Networking Technical Assistance Center, 304-345-7312; Robert Drake, M.D., Ph.D., New Hampshire-Dartmouth Psychiatric Research Center, 603-448-0126; or Daniel Fisher, M.D., Ph.D., the National Empowerment Center, 800-769-3728.

Intergrated Services Gain Ground But Are Still The Exception

• Sequential Treatment
  Most people receive sequential treatment: that is, they receive treatment for one disorder and then treatment for the other disorder later. People call this "ping-pong treatment," and it requires navigating through a bewildering number of Government agencies.
  
  
• Parallel Treatment
  Some people receive parallel treatment: that is, they receive treatment for both disorders simultaneously but from different agencies, and therapists and case managers do not coordinate treatment.
  
• Linked Treatment
  Still others receive linked treatment, which is similar to parallel treatment. With linked treatment, therapists and case managers may talk with one another about the treatment plan, although this does not necessarily ensure coordinated services.
  
  
• Integrated Treatment
  When people receive integrated treatment, however, attention is paid to both disorders simultaneously, either through treatment from dual disorder specialists or through treatment for both disorders in one setting. Integrated treatment often includes such extras as access to other areas of support, including help with developing psychosocial skills, housing, employment, and physical health care.

Information Center Bulletin
Volume 3, No. 1, Spring 1999