Special Report: Highlights of the 2008 Institute on Psychiatric Services

Studies in the early 1990s showed that people with severe mental illness often identified work as their top goal and more than 70% wanted to work. However, less than 10% actually worked, and no effective interventions were available to support this group's work-related goals. However, since the development of supported employment, an evidence-based practice, the model has been able to help persons with severe mental illness move toward their recovery goals.

In a lecture titled "The Future of Supported Employment," Robert Drake, M.D., Ph.D., Andrew Thomson Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School and director of the Dartmouth Psychiatric Research Center, detailed the creation, effectiveness, limitations, and future of supported employment programs. "The field has changed dramatically in the past 15 years," said Dr. Drake. "We were all taught that work might stress and destabilize people. And that turned out to be completely wrong."

With supported employment, the average client starts out working about five hours per week, and typically over six to 12 months clients will work up to about 22 hours per week. For those who want to work, this type of program places consumers directly in competitive jobs in integrated work settings and provides the support and training needed to ensure job success. As with most interventions that are successful, supported employment is direct and simple, showing improved work outcomes in almost every study.

"Every experiment we did seemed to say that the supported employment model was more effective than other models at that time," said Dr. Drake. "There are now four ten-year follow-up studies, and in every one of them you see that employment is improving over time, in terms of the amount of time working and the amount of time that clients stay in jobs…. When you follow people for ten years, the average person has been in their job about four years and really considers it a career; many have gotten more education and have been promoted over time. And the amazing thing is that most of consistent workers just aren't as involved in the mental health system anymore." The one-third of clients who become consistent workers have also shown benefits in improved self-esteem, symptom control, and quality of life.

Not only are results positive, but costs decrease dramatically for consistent workers. "It costs about $3,000 to provide supported employment for a year, but after the first year, costs go down dramatically; they move to close to zero, both for outpatient cost and inpatient cost," said Dr. Drake. "Over the course of ten years, for the average person who becomes a consistent worker, mental health services cost $110,000 less than for those who don't work. So it just absolutely amazes me when mental health systems say … we can't afford to provide vocational services to our patients. It's the most cost-effective thing that I've seen that we can do."

However, as effective as supportive employment is, there are still limitations and hopes of improving the model even further. Some ideas for improvement include providing benefits counseling and providing motivational interventions, such as counseling to clarify goals, resolve ambivalence, and enhance motivation.

For the workers who become consistent workers, but don't work full-time, Dr. Drake said, "I hear again and again that the clients would like to work more hours, that their boss would like them to work more hours, but it's just the disability benefits structure that keeps them from doing that." Such a problem, said Dr. Drake, calls out for restructuring of the benefits system, so people are not socialized into disability. Ideas include offering national health insurance, experiments with Social Security Administration regulations, and examining temporary assistance and extended benefits when clients return to work.

"Over the past 15 years I've gone from thinking that work is not such an important thing, not what we ought to be focused on in mental health, to thinking now that this is probably the most important mental health intervention that we have," said Dr. Drake. "We're all really remiss if we aren't providing this in our systems of care."

Jonathan Davidson, M.D., of Duke University Medical Center, gave a comprehensive presentation on the state of resilience research. Everyone has some level of resilience, or the ability to cope successfully with adversity. Dr. Davidson described the "ordinary magic" that 90% of trauma survivors do not develop posttraumatic stress disorder. Characteristics of resilience include a person's optimism, faith, humor, enthusiasm, curiosity, self-efficacy, confidence, resourcefulness, adaptability, tenacity, and general ability to bounce back. What are the mechanisms of resilience, and can it be maximized so that persons with low resilience can better cope with adversity?

Dr. Davidson listed several psychometrically valid instruments for measuring resilience, including the Connor-Davidson Resilience Scale (CD-RISC). A study of current psychiatric symptoms used the variables of early childhood trauma, personality factors, and resilience, as measured by the CD-RISC. Regardless of how much emotional neglect persons experienced, those with high resilience had the fewest psychiatric symptoms. Substituting a neuroticism measure for the CD-RISC did not show the same interaction, so although resilience and neuroticism are related constructs, resilience is unique.

What influences resilience? Dr. Davidson summarized studies concerning neurobiology and genetic factors. Among the findings: persons who are highly resilient can regulate fear conditioning and extinction at times of uncontrollable stress; can act effectively when afraid; show preservation of memory encoding, consolidation, and retrieval at times of hyperarousal; and can maintain effective bonding at times of severe loss.

Neuropeptide Y, which has a calming effect, is associated with enhanced performance during stress and positively correlates with cortisol and norepinephrine. Researchers looking to the serotonergic system for clues about resilience have found that persons with the short transporter allele may have increased risk of depression and perhaps less resilience. In a study of plasma cortisol levels of persons with major depressive disorder, those with higher resilience scores had a higher remission rate. Therefore, if resilience can be improved, then remission rates may improve among those predisposed for low resilience.

Resilience is strengthened through a person's social environment via social supports, connectedness, and altruism. A study showed that children growing up in an environment of parental alcoholism and chronic poverty were found to be stress resistant when they could elicit positive responses from their caregiving environment. In another study children who had a supportive relationship, who took on a socially desirable task, and who had interests and hobbies to turn to at difficult times all had stronger resilience. The 12th step in Alcoholics Anonymous calls for altruism in sponsoring fellow alcoholics. Sponsors typically have a higher rate of abstinence, and it is thought that the altruistic connectedness with others may also strengthen resilience.

Research shows that there may indeed be ways to strengthen resilience. Some medications, such as selective serotonin reuptake inhibitors and venlafaxine, have been associated with improved resilience. Other factors that may promote resiliency include having an active task-oriented coping style, doing physical exercise, having a positive outlook, having a sense of humor, having a moral compass, having social supports, and having cognitive flexibility. Mindfulness meditation has been shown to activate the left side of the prefrontal cortex, which is associated with positive affect. The magnitude of activation also predicted a rise in antibodies after the volunteers were administered influenza vaccine.

Do resilience-oriented psychotherapies exist, and if so, are they effective? Well-being therapy, which builds on cognitive-behavioral therapy, focuses on environmental mastery, personal growth, purposefulness, autonomy, self-acceptance, and cultivation of positive relationships. There is some evidence that well-being therapy is superior to cognitive-behavioral therapy in strengthening resilience. The goal is not only to bring the person out of negative functioning but also to facilitate progress toward positive functioning. Well-being therapy might be particularly useful as maintenance therapy for persons whose mood disorders are in remission.

Dr. Davidson summarized the evidence presented on resilience: "There is a growing body of literature—whether it's pharmacotherapy, whether it's well-being therapy, or whether it's out in the real world for people who are employed and doing mindfulness meditation—positive well-being or resilience-promoting treatments do actually help."

Do people who are homeless and mentally ill have more in common with each other because of their homelessness or because of their mental illness? Making that distinction is important in determining which type of intervention is most critical, said Sam Tsemberis, Ph.D., founder and executive director of Pathways to Housing, in a lecture titled "Pathways' Housing First."

Pathways to Housing believed that this population was more alike in their homelessness and sought to serve these consumers and help to end homelessness by providing immediate, independent permanent housing along with client-driven treatment and support. Most programs designed to serve this population focus first on providing treatment for psychiatric and substance abuse problems. Clients in these programs are then typically moved from a shelter to transitional housing, and then to permanent housing after they have "earned" it by maintaining a period of sobriety and complying with psychiatric treatment and other program rules.

"Housing providers set up services for homeless, mentally ill, and addicted persons, and they require them to not to be mentally ill, really, or to abuse substances when they show up for housing. This is the predominant system," said Dr. Tsemberis. "More programs are built that won't help people who can't or won't meet these criteria ever. If you're in shelter and you relapse, as most people with addictions do, you're back into homelessness. If you're in transitional housing and you're not compliant with medication or you break a curfew, you're back into homelessness."

The Housing First model developed by Pathways to Housing is based on the belief that housing is a basic right and that treatment should be separated from housing. Clients are housed in subsidized apartments in the community, and they pay 30% of their income (typically from Supplemental Security Income) toward the rent. The program began in New York City and is currently operating in approximately 30 cities.

Consumers can choose which type of services they want, if any, and the intensity of services. One of the few requirements of participating in the program is that clients must agree to a weekly visit with a Housing First team member. "Where it gets difficult is where people make wrong choices…. Do you take over the situation or do you let the person continue to make that choice? And we continue to let that person make that choice, because we've learned over time that if you don't, the person is never going to learn from [the] mistakes," said Dr. Tsemberis. "It's the only way the person will benefit."

Housing and services are separated. Relapse is expected and does not result in housing loss. And even if a client leaves to receive long-term inpatient services, his or her home will be waiting when treatment is finished.

Results from this evidence-based program are impressive. Studies have consistently found a housing retention rate of approximately 85%. Another study showed that over a three-year follow-up, compared with clients in traditional housing programs, Housing First clients show reduced psychiatric symptoms, reduced literal homelessness, and improved residential stability. And when the Department of Housing and Urban Development performed its yearly count of persons on the street ("one-night count") during the winter, they found a 30% reduction in homelessness between 2005 and 2007, almost 50,000 persons, and they attributed the reduction to the Housing First approach.

Housing First is also one of the most cost-effective solutions to ending chronic homelessness. A bed in a New York City shelter costs between $27,000 and $35,000 per year, and a bed in a state psychiatric hospital costs $175,000 a year. However, the Pathways program costs $22,500 per client per year for both housing and treatment.

By believing that recovery from mental illness is possible, that consumers can make competent choices, and that housing is a fundamental human right, Housing First is able to serve chronically homeless individuals who are not engaged in treatment.

In a lively symposium chaired by Carl C. Bell, M.D., CEO and president of the Community Mental Health Council, Inc., in Chicago, panelists spoke of their experience as agents of change in public mental health care. Dr. Bell described an intervention model he has used in public health care and family services programs in Chicago and New Orleans. R. Dale Walker, M.D., with the Department of Psychiatry at Oregon Health Sciences University, spoke of his work with One Sky Center, which provides outreach to American Indian communities. Kenneth S. Thompson, M.D., with the University of Pittsburgh and on contract with Community Mental Health Services (CMHS) at SAMHSA, discussed the transformation agenda and the government's role as change agent. Altha J. Stewart, M.D., executive director of the National Leadership Council on African-American Behavioral Health, gave tips from her long career as a public administrator in several major cities.

Several common themes emerged from the presentations. One was striving for order in the often chaotic public health system. Dr. Bell illustrated the phenomenon with a chart that depicted the way that many public agencies interact with one another, with each working diligently but all moving in different directions. To achieve an integrated system, transformational leaders strive to find a common language, use evidence-based practices, maximize resources, and drive outcomes. Other common themes included being able to influence others, incorporating the "indigenous knowledge" of the community, openness to innovation and feedback, commitment to service, being a leader instead of an administrator, and remaining resolute even if others feel threatened.

Dr. Bell developed his own set of "protective factor field principles" to apply to community psychiatry, a model he has used in programs for violence prevention, dropout and truancy prevention, teenage sexual behavior prevention, and HIV prevention. The theme behind this model is "risk factors are not predictive factors because of protective factors." The model involves rebuilding the village and strengthening the social fabric within one's community, including ensuring access to modern medicine, developing connectedness and building trust, and minimizing the effects of trauma.

In 2007 Dr. Bell convened a forum of over 60 high-level leaders in health, education, and law enforcement systems to develop a program on disease prevention for Chicago. The meeting began a paradigm shift across the city and a commitment to carry the initiative forward. As a transformational leader, Dr. Bell tries to "infect" people with his vision. He noted that outstanding public mental health agencies have a strong pro-agency work culture, are open to innovation and feedback, have supervision that is appropriately supportive, and have highly cooperative case management teams.

Dr. Walker described the fragmentation of services between the Bureau of Indian Affairs and the Indian Health Service, noting that agency consultation, communication, and support are critical to providing appropriate services and helping individuals navigate the system. "Best practice includes evidence-based practice plus use of indigenous knowledge of the community to provide the best care," he said. The task of One Sky Center is to partner with communities to integrate the best of conventional and traditional medicine and to recognize the interaction between mind, body, spirit, and environment within the communities it serves. By looking additively at clinical and services research, traditional medicine and mainstream practice, models of service can be improved.

One Sky has had success with taking evidence-based interventions and culturally adapting them—doing motivational enhancement therapy or cognitive-behavioral therapy "Indian style," for example, and developing a suicide prevention manual that incorporates native interventions.

Dr. Thompson described CMHS as an agency charged with transforming services into recovery-oriented services. The federal government is acting as the change agent for some parts of the system that are not ready for change. Psychiatry has vested interests in not changing, Thompson noted, and he outlined ways that psychiatry can rethink itself. For example, psychiatry needs to bring service back to science. Practitioners working in community settings must communicate what they're finding in their practices. Thompson noted that problems with weight gain and diabetes from second-generation medications may have been acted on sooner if there had been better communication. Although the scientific literature's hype of the new drugs was overwhelming, he said, practitioners need to be active participants in the process, not just receivers of information.

All practitioners have a responsibility to serve as agents of change in mental health. Public health involves surveillance of what is happening in the surrounding community, and Dr. Thompson challenged the audience to identify an epidemiology study in their own communities and to be proactive about supporting and improving public health.

Dr. Thompson also noted the need to break down the barriers between psychiatry and the consumer movement and to address health equity issues, noting that the life expectancy of persons with severe psychiatric disorders is now 25 years shorter than the general population and that psychiatry needs to advocate for better primary care.

Finally, Dr. Thompson noted that psychiatry needs to examine its relationship to the country. He pointed out that although the Institute on Psychiatric Services is for those concerned about public health, the meeting is constantly under threat. He challenged the audience to bring someone with them next year and to think about the aspirational effort to bring psychiatry into public service: "Psychiatry started with a public charge; what is our relationship to public service now?"

Dr. Stewart mentioned typical challenges that public administrators face: working within the fiscal constraints, adhering to sometimes nonsensical regulations, and recruiting and retaining a dedicated workforce. These challenges are balanced by the opportunities of collaborating to improve access to care and treatment outcomes and create culturally appropriate service delivery.

Dr. Stewart emphasized that successful psychiatrist-administrators embrace the system and lead from a point of values and feelings for the system and the people they serve: "Exemplary leaders take actions that get extraordinary things done." What is exemplary leadership? Drawing from leadership training she has completed, Dr. Stewart advised that a leader must challenge the process, inspire a shared vision, enable others to act, model the way, and encourage the heart. This means learning to take risks, being mentally tough to fight for what you believe in even if it upsets the status quo, being ambitious, developing the social skills to engage others and be persuasive, and taking responsibility.

The National Alliance on Mental Illness (NAMI) is scheduled to release in early 2009 its latest Grading the States report on the status of mental health care for serious mental illness. Anand Pandya, M.D., president of NAMI, reviewed the history of these reports and highlighted features of the new report.

NAMI began reporting on the status of mental health care in 1986 under the title Care of the Seriously Mentally Ill: A Rating of State Programs . Published until 1990, the reports offer historical snapshots of the deinstitutionalization process, and the narrative reflects an impassioned, at times inflammatory, advocacy group. The reports resumed in 2006 and reflect NAMI's evolution to the more politically astute advocacy organization it is today. The new Grading the States title signaled NAMI's efforts to take a more evidence-based approach and make its findings more transparent to support comparisons.

The goals of the report are to increase accountability of public agencies to consumers, to educate the public and support mental health literacy, to move the transformation agenda from rhetoric to reality, to support state-specific action agendas, to create a baseline for future performance measures, and to put mental health care consumers and their families at the heart of reform efforts.

The report aims to identify each state's successes and help mental health systems improve and transform. Using the best practices for mental health care set forth by the Substance Abuse and Mental Health Services Administration, NAMI surveys the state commissioners about whether their states offer integrated substance abuse and mental health care, supported employment, family psychoeducation, and so on. Commissioners are told what they are being graded on, and NAMI invites them to send supporting documentation.

The 2006 results were disappointing overall. States on average received a D. No states received an A. Only five states received a B. The findings often showed that improvements over the 1990 report were concentrated in a state's major cities. States reported budget cuts or flat funding of mental health care; changes to Medicaid that restrict eligibility and cost-sharing; inpatient bed shortages, especially in acute care; cost shifting to criminal justice, emergency care, and homelessness services; and long waiting lists for vital community services. Also, despite movement toward best practices—assertive community treatment, for example—states often had no follow-up to ensure model fidelity.

The 2006 survey also asked a group of consumers and family members to "test drive" access to mental health care in each state. Participants contacted state offices by telephone or via the Web and asked how to get an appointment for treatment of schizophrenia. Many Web sites had no such information, and phone calls often reached persons who did not know how to help.

In response to an open "bonus question" about any creative successes, NAMI found pockets of innovation in every state, including creative partnerships with law enforcement and emergency physicians. Findings also showed that consumers and families were becoming more involved in service design and delivery. An analysis of the 2006 results found only a weak correlation between state median income and NAMI ranking; states' "rational planning" was the key to providing good services.

The 2008 report refines the methodology used with the 2006 report and provides continuity to facilitate comparisons between reports. Slight adjustments have been made to strengthen the information gathered. For example, whereas the 2006 survey asked whether states had an Olmstead plan that ensures community residential placement when an inpatient is ready for discharge, the 2008 survey requests a copy of the plan, which will be rated for quality. The test drive will be repeated, and a brief Web-based survey of consumers and family members has been added.

NAMI's survey is primarily an advocacy tool for defining critical state issues and serving as a catalyst for change. By asking states to participate in the survey, NAMI is hoping that states will gather their own data and then determine ways to improve their systems. NAMI's mission is to create a better mental health care system and to ensure that consumers and families have input in states' development of future mental health plans

Private residential treatment programs for troubled teens offer a range of services, such as drug and alcohol treatment and psychological counseling for addiction, behavioral, and emotional problems. However, these behavioral health programs are not regulated by the federal government, and many are not subject to state licensing or monitoring.

In a lecture titled "The Trouble With Tough Love: How Boot Camps and Other Tough Residential Programs Hurt Families," Maia Szalavitz, a journalist and author of the book Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids, spoke about how these programs can be harmful and how psychiatrists can identify abusive practices.

A report by the Government Accountability Office found thousands of allegations of abuse, some involving death, at residential treatment programs across the country and in American-owned and -operated facilities abroad between 1990 and 2007. Many of these complaints stemmed from programs using a tough love approach.

Ms. Szalavitz said that the tough love approach stems from Synanon, the first tough love residential community, which was founded in the 1950s. Synanon declared that it was able to cure heroin addiction by forcing addicts to surrender to the 12-step program used by Alcoholics Anonymous. "Surrendering" in this case was not voluntary; it involved attack therapy, humiliation, peer pressure, and physical coercion.

An outcome study in New Jersey replicated this program and found that a tough love approach did not fare any better than no treatment in treating addiction, but this program's reported success still caught the attention of the media and the government and was rapidly replicated in programs such as the Seed, Straight, Inc., and WWASP (World Wide Association of Specialty Programs), where it is now a billion-dollar industry.

Aside from many complaints about attack therapy and humiliation, other complaints have involved being deprived of food and sleep, being physically and sexually abused, being placed in locked rooms at night (regardless of fire safety hazards), being forced to spend ten to 12 hours a day on hard-backed chairs while confessing "sins" to the group, not receiving needed medical attention (sometimes resulting in death), and being placed in seclusion and restraint for punitive reasons (for example, being forced to sleep in dog cages, a practice that was recorded on video by Mexican police when they were investigating a WWASP facility).

Such facilities often "demonize kids by telling parents to expect bizarre reports from children … that it's just your child trying to manipulate you," said Ms. Szalavitz. "The shocking fact is that in America today, you can send your child to what is essentially a private jail run by people with no qualifications at all," said Ms. Szalavitz. No diagnosis or conviction is required before taking a child. "And that child has no right to appeal his confinement. He has no physical way of doing so since phone calls and letters are monitored, Internet access is usually banned, and he will be locked down or restrained if he tries to flee…. There is no way for a child who is perfectly normal to flee from the program, as long as the parents are able to pay for it."

Because of the underregulation, and sometimes complete lack of regulation, Ms. Szalavitz urged meeting attendees to help parents and teens find compassionate evidence-based care and to help educate the public about what this type of care involves. She said, "Humiliating and brutalizing little children is known as child abuse, not treatment, and there's no reason to think that it's any healthier for adolescents or adults."

Added Ms. Szalavitz, "As psychiatrists you know that best practices in residential treatment involve the family and often increase family contact if the child is not doing well, rather than reducing it. You know that relationships with family are healing and encouraged if at all possible. You know that relationships and community are critical to recovery, particularly with trauma, and that these are best sustained in a home and in as close to a homelike setting as possible. You know that having powerless patients under the control of underpaid staff, an unaccountable administration, and an ideology that cruelty is good for its victims sets up a situation where abuses of power are simply inevitable…. You know that good treatment is based on empathy and respect."

What can ancient cultures and current research tell us about the therapeutic benefits of mind-altering substances? In a provocative lecture, Jerry Dincin, Ph.D., retired founder and director of Thresholds, Inc., reviewed practical applications of various natural and chemical substances as well as the government's stance toward their use and further research.

Although most mental health work deals with the awake state, Dr. Dincin noted that healing abilities may be found in nonordinary states of consciousness, elicited by such activities as hypnosis, Sufi dancing, "runner's high," meditation, and drumming. So too, several natural substances that achieve similar states include alcohol derived from various crops, marijuana, ayahausca, iboga, mushrooms, coca, poppies, peyote, cactus, chat, and even frog skin.

In the 1950s and 1960s applied research studies on hallucinogens were beginning to indicate that they had some value in psychotherapy, addiction treatment, and enhancement of creativity and mystical-spiritual experiences. The federal government's legacy of puritanism—"if it feels good, it must be bad"—led to fears that persons seeking nonordinary states of mind would undermine moral and power structures in society, Dr. Dincin noted. Although there were real dangers of addiction to some drugs, the subsequent "war on drugs" lumped all psychoactive substances as illegal and dangerous and thwarted research efforts.

Yet, long before this puritan view took hold, ancient societies had used these substances in their rituals and their medicine. For example, marijuana has a 4,000-year history of medical use, including for pain relief, countering insomnia, and serving as an antiemetic, antiepileptic, and anti-inflammatory. Dr. Dincin cited three independent studies of marijuana that confirmed improved cognitive ability for persons with schizophrenia and beneficial uses with glaucoma, eating disorders, pain management, anxiety, and even as a possible antibacterial agent.

The potential value of some psychoactive substances is emerging in several carefully constructed, scientifically sound studies, mostly done outside the United States. Dr. Dincin outlined recent research on the potential benefits of several substances.

MDMA, commonly known as Ecstasy, has shown some promise in treating autism, because the drug can produce feelings of closeness to others, a sense of well-being, feelings of empathy, and emotional recall, all of which are lacking with the disorder. The drug may also help in assisted psychotherapy for posttraumatic stress disorder. Studies in Switzerland and Israel are working with victims of sexual assault, soldiers, and civilian survivors of suicide bombers. In a rare U.S. study funded by the Food and Drug Administration, MDMA is being used in assisted psychotherapy for terminally ill cancer patients with treatment-resistant anxiety.

Psilocybin (found in psychedelic mushrooms) shows promise for relieving and preventing cluster headaches. Although the specific mechanism that provides relief is unknown, psilocybin is similar in structure to serotonin and may bind to some of the same receptors. Psilocybin has also been effective in treating body dysmorphic disorder. It and LSD have provided relief to patients with obsessive-compulsive disorder, with some patients achieving complete remission of symptoms.

Addiction research has found impressive results with several substances. Ibogaine, a plant derivative used for hundreds of years in West Africa, significantly reduces withdrawal, physiological cravings, and drug-seeking behavior among users of cocaine and heroin. LSD, ketamine, peyote, and San Pedro cactus have all been effective in treating alcoholism, with abstinence rates of 53% to 65%.

LSD has provided relief to terminally ill patients, who became less depressed, less anxious, and had less need for pain medications. When used in combination with MDMA, patients reported less fear of death than before the study.

Despite the untapped potential of entheogens, government approval and funding of further research are scarce. Possession and use of these substances remain illegal. Dr. Dincin advocated strongly for converting marijuana, MDMA, LSD, and psilocybin to prescription medications and for allowing legitimate research to develop experimental data on their usefulness.