An Overview of the Illness Management and Recovery Program
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The Illness Management and Recovery Program consists of a series of weekly sessions where mental health practitioners help people who have experienced psychiatric symptoms to develop personalized strategies for managing their mental illness and moving forward in their lives. The program can be provided in an individual or group format, and generally lasts between three and six months. In the sessions, practitioners work collaboratively with people, offering a variety of information, strategies, and skills that people can use to further their own recovery. There is a strong emphasis on helping people set and pursue personal goals and helping them put strategies into action in their everyday lives.
Materials for Providing the Illness Management and Recovery Program
In the Practitioners’ Workbook (this document) there are two sets of materials for Illness Management and Recovery: the Practitioners’ Guide (Chapters 1-10) and Educational Handouts. The educational handouts contain practical information and strategies that people can use in the recovery process. The handouts are not meant to stand alone. Practitioners are expected to help people select and put into practice the knowledge and strategies that are most helpful to themselves as individuals. The following topics are covered in nine educational handouts:
Recovery Strategies
Practical Facts about Schizophrenia/Bipolar Disorder/ Depression
The Stress-Vulnerability Model and Strategies for Treatment
Building Social Support
Using Medication Effectively
Reducing Relapses
Coping with Stress
Coping with Problems and Symptoms
Getting Your Needs Met in the Mental Health System
Chapter 1 of the Practitioners’ Guide contains overall strategies for conducting the program, and Chapters 2-10 contain practitioner guidelines for using each of the educational handouts to conduct sessions. The guidelines contain specific suggestions for using motivational, educational, and cognitive behavioral techniques to help people use strategies from the handouts in their daily lives. They also provide tips for developing homework assignments and for dealing with problems that might arise during sessions.
Getting started
First, practitioners are advised to familiarize themselves with the format, content and tone of the program. This can be accomplished by first reading the following:
Chapter 1 of the Practitioners’ Guide
Educational Handout #1 (“Recovery Strategies”)
Practitioner Guidelines for Educational Handout #1 (“Recovery Strategies”)
It is optimal for practitioners to read the remaining educational handouts and accompanying practitioners’ guidelines before beginning to work with people. Practitioners are advised to review specific handouts and guidelines prior to addressing these particular topic areas with people.
Preparing For Sessions
The first session is usually spent on orientation, using the “Orientation Sheet” (see Appendix 1) as a guide. The second (and sometimes third) session is spent on getting to know the person better, using the ”Knowledge and Skills Inventory” (see Appendix 2) as a guide. This inventory is focused on the person’s positive attributes rather than their problems or “deficits.” It is important to gather information in a friendly, low- key manner, using a conversational tone. The remaining sessions are focused on helping people to learn and practice the information and strategies in the educational handouts and to set and pursue their personal goals. Each session should be documented, using the “Progress Note for Illness Management and Recovery” (Appendix 3). The format of the progress note helps practitioners to keep track of the person’s personal goals, the kinds of interventions provided (motivational, educational, cognitive-behavioral), the specific evidence-based skill(s) that are taught (coping skills, relapse prevention skills and behavioral tailoring skills) and the homework that is agreed upon.
Before beginning each educational handout, the practitioner is encouraged to review the contents of the handout and the practitioner guidelines of the same title in the Practitioners’ Guide. Most educational handouts will require two to four sessions to put the important principles into practice. Preparation for sessions is most effective when practitioners review the educational handout and the corresponding practitioners’ guidelines side-by-side, noting the goals of the handout, the specific topic headings, the probe questions, the checklists, etc. As noted above, sessions should be recorded on the form “Progress Note for Illness Management and Recovery” (Appendix 3). Although for many people it is most helpful to go through the handouts in the order they are listed, it is important to tailor the program to respond to individual needs. For example, when a person is very distressed by the symptoms he or she is experiencing, it would be preferable to address this problem early in the program using Educational Handout #8, “Coping with Problems and Symptoms. ” Practitioners need to be responsive to people’s concerns and use their clinical judgment regarding the order and pacing of handouts.
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Importance of Recovery
There is widespread acceptance of the importance of recovery as a guiding vision for helping people who experience psychiatric symptoms to achieve personal success in their lives. The term recovery means different things to different individuals. Each person is free to define it in his or her terms. For some individuals, recovery means no longer having any symptoms or signs of a mental illness. For others, recovery means taking on challenges, enjoying the pleasures life has to offer, pursuing personal dreams and goals, and learning how to cope with or grow past one’s mental illness despite symptoms or setbacks.
Regardless of the personal understanding each individual develops about recovery, the overriding message is one of hope and optimism. The recovery vision is at the heart of the Illness Management and Recovery Toolkit. Through learning information about mental illness and its treatment, developing skills for reducing relapses, dealing with stress, and coping with symptoms, people can become empowered to manage their own illness, to find their own goals for recovery, and to assume responsibility for directing their own treatment. People who experience psychiatric symptoms are not passive recipients of treatment, and the goal is not to make them “comply” with treatment recommendations. Rather, the focus of Illness Management and Recovery is providing people with the information and skills they need in order to make informed decisions about their own treatment.
Broadly speaking, the goals of Illness Management and Recovery are to:
Instill hope that change is possible
Develop a collaborative relationship with a treatment team
Help people establish personally meaningful goals to strive towards
Teach information about mental illness and treatment options
Develop skills for reducing relapses, dealing with stress, and coping with symptoms
Provide information about where to obtain needed resources
Help people develop or enhance their natural supports for managing their illness and pursuing goals
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Importance of Helping People Set and Pursue Personal Goals
Being able to set and pursue personal goals is an essential part of recovery. At the same time that information and skills are being taught in the Illness Management and Recovery Program, people are also helped to define what recovery means to them and to identify what goals and dreams are important to them. The first educational handout, “Recovery Strategies,” contains specific information about setting goals. However, throughout the entire program, practitioners help people set meaningful personal goals and follow up regularly on those goals. As people gain more mastery over their psychiatric symptoms, they gain more control over their lives and become better able to realize their vision of recovery. In each session of the program, practitioners should follow up on the participants’ progress towards their goals. “Goals Set in the Illness Management and Recovery Program” (Appendix 5) helps practitioners to keep track of a person’s goals. Another form, “Step-By-Step Problem-Solving and Goal Achievement” (Appendix 6) is useful for helping a person plan the steps for achieving a goal (or solving a problem).
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Logistics
The content and teaching methods used in the Illness Management and Recovery Program are derived from multiple studies of professionally based illness management training programs for people who have experienced psychiatric symptoms. Information is taught using a combination of motivational, educational, and cognitive-behavioral teaching principles. Critical information is summarized in educational handouts that are written for people who experience psychiatric symptoms but are also suitable for distribution to anyone with a professional or caring relationship with a person who experiences psychiatric symptoms (such as a case manager or a family member).
The information and skills taught in Illness management and Recovery are organized into nine topic areas: recovery strategies, practical facts about mental illness, the stress-vulnerability model, building social support, using medication effectively, reducing relapses, coping with stress, coping with problems and symptoms, and getting your needs met in the mental health system. There are educational handouts and practitioners’ guidelines for each topic area.
Each topic is taught using a combination of motivational, educational, and cognitive behavioral methods. Also, in order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the practitioner and the person collaborate to develop homework assignments at the end of each session. These homework assignments are tailored to the individual, to help him or her practice strategies in “the real world.” Because developing and enhancing natural supports is a goal of Illness Management and Recovery, people are encouraged to identify significant others with whom they can share the handout materials and who may support them in applying newly acquired skills or completing homework.
The amount of time required to teach Illness Management and Recovery depends on a variety of factors, including people’s prior knowledge and level of skills, the problem areas that they would like to work on, and the presence of either cognitive difficulties or severe symptoms that may slow the learning process. In general, between three and six months of weekly sessions of 45 to 60 minutes may be required to teach Illness Management and Recovery. Following the completion of the nine topic areas, people may also benefit from either booster sessions or participation in support groups aimed at using and expanding skills.
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March 28, 2010
A guide to mental health concerns for victims of violent crime
A guide to mental health concerns for victims of violent crime
As a survivor of violent crime, you may face a wide range of emotional and physical struggles, along with some difficult questions that often surface: Why did this happen to me? How will I ever heal from this? Why can’t I connect with others the way I did before? When will I start to feel “normal” again? While the answers may be different for each individual, there are some striking similarities in how trauma affects nearly all victims. Understanding the nature and impact of violent trauma can be essential to the healing process. This brochure is intended as a guide to help you along the path to healing and to avoid some of the common pitfalls along the way.
What is Post Traumatic Stress Disorder (PTSD)?
PTSD is a mental health condition that can be caused by experiencing or observing virtually any kind of deep emotional trauma, especially one that is unexpected. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life. PTSD is a potentially serious condition that should not be taken lightly.
Why is substance abuse common following a traumatic event?
Since violent trauma can bring about so many changes, questions, and uncertainties, many survivors turn to alcohol and illicit drugs in an attempt to get some relief from their almost round-the-clock emotional turmoil and suffering. Substance abuse and mental health problems often accompany violent trauma. All survivors of trauma manage their experiences in different ways. Substance abuse, however, is not only an ineffective tool in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.
What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?
According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.
PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.
What can I do to begin the healing process?
There are some positive steps that you can take right away to begin healing. Here are some suggestions:
Recognize your loss.
Establish safety for yourself.
Respect the way you feel and your right to feel that way.
Talk about your feelings with those you trust.
Connect with other survivors of violence, many of whom experience similar difficulties.
Do not be afraid to seek professional help.
Try to recognize triggers that may take you back to the memory and fear of your trauma.
Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there.
Take care of yourself—exercise, eat right, and take a deep breath when you feel tense.
Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions.
Do not abandon hope—believe that healing can and will take place.
Where can I go for help?
The healing process takes time, and many questions, hurdles and frustrations may surface along the way.
Contact Information
SAMHSA’s Mental Health Services Locator
www.mentalhealth.samhsa.gov/databases
SAMHSA’s National Mental Health
Information Center
1-800-789-2647
1-866-889-2647 (tdd)
As a survivor of violent crime, you may face a wide range of emotional and physical struggles, along with some difficult questions that often surface: Why did this happen to me? How will I ever heal from this? Why can’t I connect with others the way I did before? When will I start to feel “normal” again? While the answers may be different for each individual, there are some striking similarities in how trauma affects nearly all victims. Understanding the nature and impact of violent trauma can be essential to the healing process. This brochure is intended as a guide to help you along the path to healing and to avoid some of the common pitfalls along the way.
What is Post Traumatic Stress Disorder (PTSD)?
PTSD is a mental health condition that can be caused by experiencing or observing virtually any kind of deep emotional trauma, especially one that is unexpected. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life. PTSD is a potentially serious condition that should not be taken lightly.
Why is substance abuse common following a traumatic event?
Since violent trauma can bring about so many changes, questions, and uncertainties, many survivors turn to alcohol and illicit drugs in an attempt to get some relief from their almost round-the-clock emotional turmoil and suffering. Substance abuse and mental health problems often accompany violent trauma. All survivors of trauma manage their experiences in different ways. Substance abuse, however, is not only an ineffective tool in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.
What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?
According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.
PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.
What can I do to begin the healing process?
There are some positive steps that you can take right away to begin healing. Here are some suggestions:
Recognize your loss.
Establish safety for yourself.
Respect the way you feel and your right to feel that way.
Talk about your feelings with those you trust.
Connect with other survivors of violence, many of whom experience similar difficulties.
Do not be afraid to seek professional help.
Try to recognize triggers that may take you back to the memory and fear of your trauma.
Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there.
Take care of yourself—exercise, eat right, and take a deep breath when you feel tense.
Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions.
Do not abandon hope—believe that healing can and will take place.
Where can I go for help?
The healing process takes time, and many questions, hurdles and frustrations may surface along the way.
Contact Information
SAMHSA’s Mental Health Services Locator
www.mentalhealth.samhsa.gov/databases
SAMHSA’s National Mental Health
Information Center
1-800-789-2647
1-866-889-2647 (tdd)
March 22, 2010
Health Service Disparities: Access, Quality, and Diversity
Online CEUs
Health Service Disparities: Access, Quality, and Diversity
CHAIR: Spero M. Manson, Ph.D., University of Colorado.
ACCESS, BARRIERS, and QUALITY
Pathways into, through, and out of service systems are issues of critical importance when addressing access to care, adequacy or appropriateness of care, as well as quality. This panel addressed these issues examining the impact of race, ethnicity, and cultural attitudes.
David T. Takeuchi, Ph.D.,
Indiana University
Dr. Takeuchi discussed the importance of race as a separate and independent factor in children's mental health status, as well as access to and quality of care. Over the past two decades, it has been common to advocate for a more universal approach to resolving the disparities found among racial groups. Despite one's position regarding whether race has or has not declined in significance in American society, an advocacy for policies that attempt to reduce socio-economic status (SES) differentials is seen as a more effective public policy strategy to gain acceptance among all racial groups and, equally important, policy makers.
While this approach is popular and well meaning, it tends to ignore an evolving body of research that finds race to have a strong effect on mental health variables, independent of SES. For example, a recent study assessing health outcomes for 50 states found a strong association between racial composition and health. The greater the minority composition, the poorer the child health profiles. When race was included in analytical models, income and equality did not have a significant association with child health outcomes. Another significant variable linked to improved child health outcomes was the willingness of states to fund social welfare programs. These analyses suggest that simply focusing on income inequality will not resolve racism and its consequences. Racism is a continuous problem and creates a social environment characterized by alienation, frustration, powerlessness, stress and demoralization, all of which can have pernicious consequences on mental health. There are programs that are trying to make health systems more equitable through education, and attempting to reduce stereotypes and prejudice by providing information about different racial groups. Research indicates, however, that individuals who have preexisting racist beliefs may actually have these beliefs reinforced through such educational programs.
In order to address ethnic and racial inequities in children's mental healthcare, racism must be viewed in a broader context, focusing on institutional racism and the racial hierarchy of society and its systems, including healthcare. It is unclear how to do this, but two examples to consider would be Native Americans' building casinos to address economic inequity; and Native Hawaiians' current effort to achieve sovereignty. These are two natural situations in which it can be seen how health outcomes will be influenced.
Margarita Alegría, Ph.D.,
University of Puerto Rico
Dr. Alegría discussed challenges in advancing equity in mental healthcare for children of color. She presented three arguments for increased focus on racial and ethnic differences. First, race, ethnicity and culture of children play a major role in shaping the care provided to them by health institutions. Racial, ethnic and cultural differences influence the expression and identification of the need for services. Studies have shown ethnic and racial differences in youths' self-reports of problem behaviors, caregivers' value judgments of what is normative behavior, and caregiver expectations of the child. Ethnic and racial bias in who gets identified, referred and treated within certain institutions has also been documented. For example, African American youth are more frequently referred for conduct problems to corrections rather than psychiatric hospitals, even with lower or equal measures of aggressive behavior. Quality of care is also impacted. For example, ADHD is less often treated by medications in minority groups than in white populations. There is also increased probability of misdiagnoses among minority individuals, affecting subsequent care.
Second, there are challenges in identifying the mechanisms by which ethnicity, race, and culture account for disparities in behavioral and emotional problems and service delivery. Understanding these mechanisms has important implications for how to intervene correctly. Factors that mediate such challenges may be related to lack of early detection by providers and parents; untrained and culturally insensitive providers; and lack of parent and provider knowledge of efficacious treatments. For example, Latino youths have the highest rate of suicide, yet they are less likely to be identified by their caregivers as having problems. Disparities in services may be due to different barriers such as insurance status and settings where mental healthcare is delivered. Minority children tend to receive mental health services through the juvenile justice and welfare systems more often than through schools or special settings.
Third, efforts to address racial and ethnic disparities in mental health and service delivery are constrained by profound socio-environmental, institutional, and market forces. For example, managed care, by targeting medical necessity, may be constrained in obtaining the complexity of funding streams that are necessary to service minority children in the schools, juvenile justice settings or welfare agencies. Expansion of Medicaid eligibility for near poor families may not prove sufficient to increase mental health service usage, if it is not tied to increased provider availability and provider payment incentives to treat minority populations within depressed inner-city communities. Thus, a critical analysis of how residential, institutional, and market policies may create disparities is needed, and more importantly, how these policies are implemented in ways that result in disparities. There is a need to address these disparities by moving beyond the healthcare sector, examining neighborhoods where minority children live (areas of economic disadvantage, concentration of violence in certain areas), addressing the institutions with which minority children interact (i.e., the referral bias in the various systems), and addressing the role of managed care and the lack of culturally competent providers in the various systems.
Suggestions to address these disparities include: (1) Ensure that efforts focus not only on equalizing access to treatment, but also on equalizing outcomes of care; (2) Aggressively monitor institutional progress towards an equitable and compassionate system of mental healthcare for children of color; and (3) Move beyond policy interventions in the healthcare system to more socio-educational approaches, where government agencies are not agents of control but agents of support.
Kenneth B. Wells, M.D., M.P.H.,
UCLA/RAND
Dr. Wells presented new preliminary data from three national surveys on access to specialty mental healthcare. The findings demonstrated high levels of unmet need for specialty care for children and adolescents and substantial ethnic disparities in access to such care. Detailed findings will be presented in a forthcoming article. Dr. Wells also drew attention to key issues in formulating public policy to address unmet need for child services. One set of issues relates to children in the public sector, where differences within and across states in implementation of policies to cover uninsured children result in children with varying degrees of vulnerability to unmet need for mental healthcare. Policies that guarantee coverage for uninsured children across diverse populations and geographic areas are needed to address this problem. Another set of issues applies to the private sector, where there has been much debate about the feasibility of implementing parity for mental health and physical health services for both children and adults; yet prior studies suggest that children have more to gain from parity, as they tend to be high utilizers if they use services and more quickly reach plan limits on coverage (Sturm, 1997). Thus achieving parity of coverage in the private sector may be especially important for addressing the unmet need for child mental health services. Yet, Dr. Wells indicated that the meaning of parity is changing under managed care, as the defined benefit does not necessarily directly correspond to the level of care provided under management policies (Burnam and Escarce,1999). Finally, Dr. Wells provided an example of the promise of quality improvement for mental disorders for adults, Partners in Care; in that study, depressed primary care patients from clinics using quality improvement programs had better one-year clinical outcomes and retention in employment than similar patients in clinics without quality improvement programs (Wells, et. al., 2000). These kinds of studies should be developed for children and adolescents with major mental disorders, as we develop practice-based solutions across public and private sectors to address unmet mental healthcare needs of diverse child and adolescent populations.
Suggestions for future research include: (1) Develop access and mental health quality of care indicators for children and adolescents; (2) Profile unmet need for under- and uninsured subgroups in particular areas, in light of disparity in coverage and implementation across federal and state programs; and (3) Monitor access and quality of care for children and adolescents nationally. Suggestions for policy changes include: (1) For the uninsured, replace existing programs or fill the diverse gaps in federal and state policies; (2) For the privately insured, start with parity of mental health coverage with medical conditions, and enforce tougher mandates for implementation. In addition, the management and quality under parity needs to be evaluated; and (3) For the publicly insured, implement quality improvement, and reduce delays and the financial barriers to mental healthcare.
REACHING OUT TO AND ENGAGING FAMILIES
This panel discussed the challenges affecting access to and coordination of mental healthcare for children and families, including the lack of availability of non-traditional services. One critical question addressed how to better engage families in evidence-based services and treatments.
Barbara J. Friesen, Ph.D.,
Portland State University
Dr. Friesen argued that effective mental health services require cultural competence, full family participation and appropriate services and supports. Family support and participation can provide benefits, including reduced need for inpatient treatment, shorter length of inpatient stay, better service coordination, increased likelihood that a child will return home following out-of-home placement, and increased caregiver satisfaction. When families were involved in the child welfare system, they were more likely to follow through with treatment and the caseworkers were more likely to provide appropriate care.
There are several significant barriers to family participation and effective treatment for children's psychiatric disorders. First, stigma attached to mental disorders results in families feeling at fault for their child's mental illness. Low-income families are most likely to receive disrespect from healthcare providers. Second, family and service providers lack information. Third, gaps in services are a major problem. Even when a family is armed with information about exactly what they are looking for, very often they cannot find it. Other practical, tangible barriers include cost; many families have gone bankrupt trying to care for their children. The most damaging policy is one in which parents need to give up custody in order to get services for their children. Distance can also be a barrier to care. Sometimes families must travel long distances to receive appropriate care for their child.
Suggestions for engaging families include: (1) Develop anti-stigma campaigns to educate the public and healthcare providers; (2) Train services providers in effective, family-centered treatment approaches; (3) Support family members and family organizations who can improve access to services through a variety of outreach and support roles; and (4) Evaluate these practices.
C. Veree’ Jenkins,
Family Involvement Coordinator, Family HOPE, West Palm Beach, Florida
Ms. Jenkins described her family's experience overcoming the ravages of the mental illness of her son, Joel. She called it the story of "J.O.E.L.: Joy Overcoming Everything Logical." She emphasized the importance of faith in dealing with a child's mental illness. Joel had a journey through mental illness, substance abuse, the juvenile justice system and early fatherhood. All along the way, no one ever asked the family their faith and what they believed in, said Ms. Jenkins. In a substance abuse treatment program, Joel had his bible taken from him, told it was a crutch preventing him from overcoming his substance abuse problems. But, Ms. Jenkins said, you need faith in God to make it through these systems; you put faith in the hands of the therapist managing your care and sometimes are let down. Finally, Joel went to the church where he found ‘wrap-around faith’ where they provided mentoring, counseling services 24 hours a day, seven days a week, helped him get a job, and get rid of his guns and provided other assistance. Ms. Jenkins encouraged consideration of faith-based organizations, which can provide safe havens, camps, music, art, and all sorts of activities that can be very helpful to a family in need. Joel is now drug, alcohol and cigarette free. He is a law-abiding citizen, married, a good parent, employed and owns his home. A recent graduate of the McCollough Seminary, he is Assistant Youth Pastor of his church. As a family, Joel, Ms. Jenkins and her husband work together to share their faith and hope with others.
Lynn Pedraza, Ed.S.,
Family Member
Ms. Pedraza described how her family, which includes biological, foster and adoptive children, encountered many challenges trying to navigate the multiple systems often involved in the care and treatment of children with mental disorders. So much of the mental health world operates from a deficit perspective requiring families to prove their needs, rather than strengths, to get services. Workers have coerced parents and threatened to take children away when families try to fight for appropriate services. Suggestions to engage families include: (1) Put mental health at the forefront of health policy decisions and research efforts; (2) Research should focus on the human side of mental health, the connections to others, trust, pleasure, joy and respect. In other words, examine what caring looks like and what happens when this caring is incorporated into mental health services; and (3) Researchers need to become involved with families and their children long enough and deeply enough to really understand the multiple factors that affect children and their families. Researchers need to listen to families.
DISCUSSANTS
Brenda Souto,
National Alliance for the Mentally Ill
Ms. Souto described her experiences as a parent of a child with several disorders. She has been her son's case manager for 20 years and has had good experiences with psychiatrists and psychologists in Maryland, a parity-enforced state. Trying to find good services was another problem. She cited a report, Families on the Brink, that NAMI released a year ago, summarizing the stigmatization of families who often are blamed for no-fault brain disorders. She said the most unfortunate result of the lack of access to mental healthcare is when the family is forced to relinquish custody of their ill child to the state in order to get needed mental health services.
Carl Bell, M.D.,
Community Mental Health Council, Chicago
Dr. Bell described the insufficient infrastructure in the community health system. Back in 1980, President Jimmy Carter pushed for a plan to increase the infrastructure. But the plan never came into being because Carter lost the presidency. Dr. Bell encouraged conference participants to make sure they take action to ensure the agenda moves forward. He is particularly interested in African Americans. In order to fix the problems of African Americans within these various systems, African Americans must be involved in the conversations. The black community trusts the community centers but not the universities. Black people are concerned about who is testing their children and why. Partnerships between community-based organizations and the universities is one way to make technical expertise available to train community-based staff. Such efforts are underway at Dr. Bell's agency and the University of Illinois in Chicago, but they are costly. Few community agencies have the resources needed to train their staff in evidence-based interventions. Community-based organizations need to receive funding to assist them in training their staff and such support is necessary to help infuse evidence-based interventions into community-based services.
Michael M. Faenza, MSSW,
National Mental Health Association
Mr. Faenza noted that this session's presentations demonstrate children's mental health as a social justice issue. The disparities in access and treatment highlight the social injustice issues that come into play in children's services. He highlighted challenges in diagnosing mental disorders in children, and a need for more research in diagnosis and treatment. Because so much negative public attention is focused on overprescription of psychotropic medications and overdiagnosis in young children, particular sensitivity around such issues is needed to prevent the damage that such publicity could do. The prevalence of mental disorders and substance abuse disorders in the juvenile justice system suggests a starting point for change in operative services systems for children.
Phillipa Hambrick,
Family Member
Ms. Hambrick described her experiences as a grandmother and mother, providing family care to four grandchildren in need of mental health services for ADHD and major depression. She had difficulty getting services for these children, due to distance or because the children were put on a waiting list for services. The children eventually received services through the school system and through youth and family services. But such services must be expanded and made more comprehensive, she said. If she were to move, her children would lose the services because they would be in a different jurisdiction.
Health Service Disparities: Access, Quality, and Diversity
CHAIR: Spero M. Manson, Ph.D., University of Colorado.
ACCESS, BARRIERS, and QUALITY
Pathways into, through, and out of service systems are issues of critical importance when addressing access to care, adequacy or appropriateness of care, as well as quality. This panel addressed these issues examining the impact of race, ethnicity, and cultural attitudes.
David T. Takeuchi, Ph.D.,
Indiana University
Dr. Takeuchi discussed the importance of race as a separate and independent factor in children's mental health status, as well as access to and quality of care. Over the past two decades, it has been common to advocate for a more universal approach to resolving the disparities found among racial groups. Despite one's position regarding whether race has or has not declined in significance in American society, an advocacy for policies that attempt to reduce socio-economic status (SES) differentials is seen as a more effective public policy strategy to gain acceptance among all racial groups and, equally important, policy makers.
While this approach is popular and well meaning, it tends to ignore an evolving body of research that finds race to have a strong effect on mental health variables, independent of SES. For example, a recent study assessing health outcomes for 50 states found a strong association between racial composition and health. The greater the minority composition, the poorer the child health profiles. When race was included in analytical models, income and equality did not have a significant association with child health outcomes. Another significant variable linked to improved child health outcomes was the willingness of states to fund social welfare programs. These analyses suggest that simply focusing on income inequality will not resolve racism and its consequences. Racism is a continuous problem and creates a social environment characterized by alienation, frustration, powerlessness, stress and demoralization, all of which can have pernicious consequences on mental health. There are programs that are trying to make health systems more equitable through education, and attempting to reduce stereotypes and prejudice by providing information about different racial groups. Research indicates, however, that individuals who have preexisting racist beliefs may actually have these beliefs reinforced through such educational programs.
In order to address ethnic and racial inequities in children's mental healthcare, racism must be viewed in a broader context, focusing on institutional racism and the racial hierarchy of society and its systems, including healthcare. It is unclear how to do this, but two examples to consider would be Native Americans' building casinos to address economic inequity; and Native Hawaiians' current effort to achieve sovereignty. These are two natural situations in which it can be seen how health outcomes will be influenced.
Margarita Alegría, Ph.D.,
University of Puerto Rico
Dr. Alegría discussed challenges in advancing equity in mental healthcare for children of color. She presented three arguments for increased focus on racial and ethnic differences. First, race, ethnicity and culture of children play a major role in shaping the care provided to them by health institutions. Racial, ethnic and cultural differences influence the expression and identification of the need for services. Studies have shown ethnic and racial differences in youths' self-reports of problem behaviors, caregivers' value judgments of what is normative behavior, and caregiver expectations of the child. Ethnic and racial bias in who gets identified, referred and treated within certain institutions has also been documented. For example, African American youth are more frequently referred for conduct problems to corrections rather than psychiatric hospitals, even with lower or equal measures of aggressive behavior. Quality of care is also impacted. For example, ADHD is less often treated by medications in minority groups than in white populations. There is also increased probability of misdiagnoses among minority individuals, affecting subsequent care.
Second, there are challenges in identifying the mechanisms by which ethnicity, race, and culture account for disparities in behavioral and emotional problems and service delivery. Understanding these mechanisms has important implications for how to intervene correctly. Factors that mediate such challenges may be related to lack of early detection by providers and parents; untrained and culturally insensitive providers; and lack of parent and provider knowledge of efficacious treatments. For example, Latino youths have the highest rate of suicide, yet they are less likely to be identified by their caregivers as having problems. Disparities in services may be due to different barriers such as insurance status and settings where mental healthcare is delivered. Minority children tend to receive mental health services through the juvenile justice and welfare systems more often than through schools or special settings.
Third, efforts to address racial and ethnic disparities in mental health and service delivery are constrained by profound socio-environmental, institutional, and market forces. For example, managed care, by targeting medical necessity, may be constrained in obtaining the complexity of funding streams that are necessary to service minority children in the schools, juvenile justice settings or welfare agencies. Expansion of Medicaid eligibility for near poor families may not prove sufficient to increase mental health service usage, if it is not tied to increased provider availability and provider payment incentives to treat minority populations within depressed inner-city communities. Thus, a critical analysis of how residential, institutional, and market policies may create disparities is needed, and more importantly, how these policies are implemented in ways that result in disparities. There is a need to address these disparities by moving beyond the healthcare sector, examining neighborhoods where minority children live (areas of economic disadvantage, concentration of violence in certain areas), addressing the institutions with which minority children interact (i.e., the referral bias in the various systems), and addressing the role of managed care and the lack of culturally competent providers in the various systems.
Suggestions to address these disparities include: (1) Ensure that efforts focus not only on equalizing access to treatment, but also on equalizing outcomes of care; (2) Aggressively monitor institutional progress towards an equitable and compassionate system of mental healthcare for children of color; and (3) Move beyond policy interventions in the healthcare system to more socio-educational approaches, where government agencies are not agents of control but agents of support.
Kenneth B. Wells, M.D., M.P.H.,
UCLA/RAND
Dr. Wells presented new preliminary data from three national surveys on access to specialty mental healthcare. The findings demonstrated high levels of unmet need for specialty care for children and adolescents and substantial ethnic disparities in access to such care. Detailed findings will be presented in a forthcoming article. Dr. Wells also drew attention to key issues in formulating public policy to address unmet need for child services. One set of issues relates to children in the public sector, where differences within and across states in implementation of policies to cover uninsured children result in children with varying degrees of vulnerability to unmet need for mental healthcare. Policies that guarantee coverage for uninsured children across diverse populations and geographic areas are needed to address this problem. Another set of issues applies to the private sector, where there has been much debate about the feasibility of implementing parity for mental health and physical health services for both children and adults; yet prior studies suggest that children have more to gain from parity, as they tend to be high utilizers if they use services and more quickly reach plan limits on coverage (Sturm, 1997). Thus achieving parity of coverage in the private sector may be especially important for addressing the unmet need for child mental health services. Yet, Dr. Wells indicated that the meaning of parity is changing under managed care, as the defined benefit does not necessarily directly correspond to the level of care provided under management policies (Burnam and Escarce,1999). Finally, Dr. Wells provided an example of the promise of quality improvement for mental disorders for adults, Partners in Care; in that study, depressed primary care patients from clinics using quality improvement programs had better one-year clinical outcomes and retention in employment than similar patients in clinics without quality improvement programs (Wells, et. al., 2000). These kinds of studies should be developed for children and adolescents with major mental disorders, as we develop practice-based solutions across public and private sectors to address unmet mental healthcare needs of diverse child and adolescent populations.
Suggestions for future research include: (1) Develop access and mental health quality of care indicators for children and adolescents; (2) Profile unmet need for under- and uninsured subgroups in particular areas, in light of disparity in coverage and implementation across federal and state programs; and (3) Monitor access and quality of care for children and adolescents nationally. Suggestions for policy changes include: (1) For the uninsured, replace existing programs or fill the diverse gaps in federal and state policies; (2) For the privately insured, start with parity of mental health coverage with medical conditions, and enforce tougher mandates for implementation. In addition, the management and quality under parity needs to be evaluated; and (3) For the publicly insured, implement quality improvement, and reduce delays and the financial barriers to mental healthcare.
REACHING OUT TO AND ENGAGING FAMILIES
This panel discussed the challenges affecting access to and coordination of mental healthcare for children and families, including the lack of availability of non-traditional services. One critical question addressed how to better engage families in evidence-based services and treatments.
Barbara J. Friesen, Ph.D.,
Portland State University
Dr. Friesen argued that effective mental health services require cultural competence, full family participation and appropriate services and supports. Family support and participation can provide benefits, including reduced need for inpatient treatment, shorter length of inpatient stay, better service coordination, increased likelihood that a child will return home following out-of-home placement, and increased caregiver satisfaction. When families were involved in the child welfare system, they were more likely to follow through with treatment and the caseworkers were more likely to provide appropriate care.
There are several significant barriers to family participation and effective treatment for children's psychiatric disorders. First, stigma attached to mental disorders results in families feeling at fault for their child's mental illness. Low-income families are most likely to receive disrespect from healthcare providers. Second, family and service providers lack information. Third, gaps in services are a major problem. Even when a family is armed with information about exactly what they are looking for, very often they cannot find it. Other practical, tangible barriers include cost; many families have gone bankrupt trying to care for their children. The most damaging policy is one in which parents need to give up custody in order to get services for their children. Distance can also be a barrier to care. Sometimes families must travel long distances to receive appropriate care for their child.
Suggestions for engaging families include: (1) Develop anti-stigma campaigns to educate the public and healthcare providers; (2) Train services providers in effective, family-centered treatment approaches; (3) Support family members and family organizations who can improve access to services through a variety of outreach and support roles; and (4) Evaluate these practices.
C. Veree’ Jenkins,
Family Involvement Coordinator, Family HOPE, West Palm Beach, Florida
Ms. Jenkins described her family's experience overcoming the ravages of the mental illness of her son, Joel. She called it the story of "J.O.E.L.: Joy Overcoming Everything Logical." She emphasized the importance of faith in dealing with a child's mental illness. Joel had a journey through mental illness, substance abuse, the juvenile justice system and early fatherhood. All along the way, no one ever asked the family their faith and what they believed in, said Ms. Jenkins. In a substance abuse treatment program, Joel had his bible taken from him, told it was a crutch preventing him from overcoming his substance abuse problems. But, Ms. Jenkins said, you need faith in God to make it through these systems; you put faith in the hands of the therapist managing your care and sometimes are let down. Finally, Joel went to the church where he found ‘wrap-around faith’ where they provided mentoring, counseling services 24 hours a day, seven days a week, helped him get a job, and get rid of his guns and provided other assistance. Ms. Jenkins encouraged consideration of faith-based organizations, which can provide safe havens, camps, music, art, and all sorts of activities that can be very helpful to a family in need. Joel is now drug, alcohol and cigarette free. He is a law-abiding citizen, married, a good parent, employed and owns his home. A recent graduate of the McCollough Seminary, he is Assistant Youth Pastor of his church. As a family, Joel, Ms. Jenkins and her husband work together to share their faith and hope with others.
Lynn Pedraza, Ed.S.,
Family Member
Ms. Pedraza described how her family, which includes biological, foster and adoptive children, encountered many challenges trying to navigate the multiple systems often involved in the care and treatment of children with mental disorders. So much of the mental health world operates from a deficit perspective requiring families to prove their needs, rather than strengths, to get services. Workers have coerced parents and threatened to take children away when families try to fight for appropriate services. Suggestions to engage families include: (1) Put mental health at the forefront of health policy decisions and research efforts; (2) Research should focus on the human side of mental health, the connections to others, trust, pleasure, joy and respect. In other words, examine what caring looks like and what happens when this caring is incorporated into mental health services; and (3) Researchers need to become involved with families and their children long enough and deeply enough to really understand the multiple factors that affect children and their families. Researchers need to listen to families.
DISCUSSANTS
Brenda Souto,
National Alliance for the Mentally Ill
Ms. Souto described her experiences as a parent of a child with several disorders. She has been her son's case manager for 20 years and has had good experiences with psychiatrists and psychologists in Maryland, a parity-enforced state. Trying to find good services was another problem. She cited a report, Families on the Brink, that NAMI released a year ago, summarizing the stigmatization of families who often are blamed for no-fault brain disorders. She said the most unfortunate result of the lack of access to mental healthcare is when the family is forced to relinquish custody of their ill child to the state in order to get needed mental health services.
Carl Bell, M.D.,
Community Mental Health Council, Chicago
Dr. Bell described the insufficient infrastructure in the community health system. Back in 1980, President Jimmy Carter pushed for a plan to increase the infrastructure. But the plan never came into being because Carter lost the presidency. Dr. Bell encouraged conference participants to make sure they take action to ensure the agenda moves forward. He is particularly interested in African Americans. In order to fix the problems of African Americans within these various systems, African Americans must be involved in the conversations. The black community trusts the community centers but not the universities. Black people are concerned about who is testing their children and why. Partnerships between community-based organizations and the universities is one way to make technical expertise available to train community-based staff. Such efforts are underway at Dr. Bell's agency and the University of Illinois in Chicago, but they are costly. Few community agencies have the resources needed to train their staff in evidence-based interventions. Community-based organizations need to receive funding to assist them in training their staff and such support is necessary to help infuse evidence-based interventions into community-based services.
Michael M. Faenza, MSSW,
National Mental Health Association
Mr. Faenza noted that this session's presentations demonstrate children's mental health as a social justice issue. The disparities in access and treatment highlight the social injustice issues that come into play in children's services. He highlighted challenges in diagnosing mental disorders in children, and a need for more research in diagnosis and treatment. Because so much negative public attention is focused on overprescription of psychotropic medications and overdiagnosis in young children, particular sensitivity around such issues is needed to prevent the damage that such publicity could do. The prevalence of mental disorders and substance abuse disorders in the juvenile justice system suggests a starting point for change in operative services systems for children.
Phillipa Hambrick,
Family Member
Ms. Hambrick described her experiences as a grandmother and mother, providing family care to four grandchildren in need of mental health services for ADHD and major depression. She had difficulty getting services for these children, due to distance or because the children were put on a waiting list for services. The children eventually received services through the school system and through youth and family services. But such services must be expanded and made more comprehensive, she said. If she were to move, her children would lose the services because they would be in a different jurisdiction.
March 18, 2010
GIRL POWER! Is Good Mental Health
GIRL POWER!
Is Good Mental Health
GIRL POWER! is paving the way for girls to build confidence, competence, and pride in themselves, in other words, enhancing girls' mental wellness. Girl Power! is also providing messages and materials to girls about the risks and consequences associated with substance abuse and with potential mental health concerns. For instance, did you know:
Girls are seven times more likely than boys to be depressed and twice as likely to attempt suicide.*
Girls are three times more likely than boys to have a negative body image (often reflected in eating disorders such as anorexia and bulimia).*
One in five girls in the U.S. between the ages of 12 and 17 drink alcohol and smoke cigarettes.*
Girls who develop positive interpersonal and social skills decrease their risk of substance abuse.*
Girls who have an interest and ability in areas such as academics, the arts, sports, and community activities are more likely to develop confidence and may be less likely to use drugs.*
On the other hand, this also is a time when girls may make decisions to try risky behaviors, including drinking, smoking, and using drugs.*
The Girl Power! Campaign, under the leadership of the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA) is collaborating with the Center for Mental Health Services (CMHS) to provide this valuable mental health information.
* Girl Power! Hometown Media Kit, Center for Substance Abuse Prevention, 1997.
Substance Abuse and Mental Health
Results from a study of nearly 6,000 people aged 15 to 24 show that among young people with a history of both a mental disorder and an addictive disorder, the mental disorder is usually reported to have occurred first. The onset of mental health problems may occur about 5 to 10 years before the substance abuse disorders.**
This provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services.
** "National Comorbidity Survey," Ronald C. Kessler, Ph.D., et al., American Journal of Orthopsychiatry, June 1996.
What Is Mental Health?
Mental health is how we think, feel, and act in order to face life's situations. It is how we look at ourselves, our lives, and the people we know and care about. It also helps determine how we handle stress, relate to others, evaluate our options, and make choices. Everyone has mental health.
A young girl's mental health affects her daily life and future. Schoolwork, relationships, and physical health can be affected by mental health. Like physical health, mental health is important at every stage of life. Caring for and protecting a child's mental health is a major part of helping that child grow to become the best she can be.
Girls' independence is usually encouraged in childhood, and their strengths nurtured. Most girls become emotionally, mentally, and physically healthy young adults. But sometimes, during the transition from childhood to adolescence, extra care is necessary, so that a girl's self-esteem and coping skills are not diminished. For more information on teen mental health, call 1-800-789-2647 and ask for the brochure: "You and Mental Health: What's the Deal?" (Order # CA-0002)
Nurturing Your Child's Mental Health
Parents and other caregivers are responsible for children’s physical safety and emotional well-being. Parenting styles vary; there is no one right way to raise a child. Clear and consistent expectations for each child, by all caregivers, are important. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills. The following suggestions are not meant to be complete.
Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.
Be aware of stages in child development so you don’t expect too much or too little from your child.
Encourage your child to express her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety.
Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.
Promote mutual respect and trust. Keep your voice level down—even when you don’t agree. Keep communication channels open.
Listen to your child. Use words and examples your child can understand. Encourage questions.
Provide comfort and assurance. Be honest. Focus on the positives. Express your willingness to talk about any subject.
Look at your own problem-solving and coping skills. Do you turn to alcohol or drugs? Are you setting a good example? Seek help if you are overwhelmed by your child’s feelings or behaviors or if you are unable to control your own frustration or anger.
Encourage your child’s talents and accept limitations.
Set goals based on the child’s abilities and interests—not someone else’s expectations. Celebrate accomplishments. Don’t compare your child’s abilities to those of other children; appreciate the uniqueness of your child. Spend time regularly with your child.
Foster your child’s independence and self-worth.
Help your child deal with life’s ups and downs. Show confidence in your child’s ability to handle problems and tackle new experiences.
Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from her mistakes.
Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others. Do not expect to be perfect; parenting is a difficult job. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills.
Mental Health Problems
Many children experience mental health problems that are real and painful and can be severe.
Mental health problems affect at least one in every five young people, at any given time. At least 1 in 10 children may have a serious emotional disturbance that severely disrupts his or her ability to function.
Tragically an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide.
Is Good Mental Health
GIRL POWER! is paving the way for girls to build confidence, competence, and pride in themselves, in other words, enhancing girls' mental wellness. Girl Power! is also providing messages and materials to girls about the risks and consequences associated with substance abuse and with potential mental health concerns. For instance, did you know:
Girls are seven times more likely than boys to be depressed and twice as likely to attempt suicide.*
Girls are three times more likely than boys to have a negative body image (often reflected in eating disorders such as anorexia and bulimia).*
One in five girls in the U.S. between the ages of 12 and 17 drink alcohol and smoke cigarettes.*
Girls who develop positive interpersonal and social skills decrease their risk of substance abuse.*
Girls who have an interest and ability in areas such as academics, the arts, sports, and community activities are more likely to develop confidence and may be less likely to use drugs.*
On the other hand, this also is a time when girls may make decisions to try risky behaviors, including drinking, smoking, and using drugs.*
The Girl Power! Campaign, under the leadership of the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA) is collaborating with the Center for Mental Health Services (CMHS) to provide this valuable mental health information.
* Girl Power! Hometown Media Kit, Center for Substance Abuse Prevention, 1997.
Substance Abuse and Mental Health
Results from a study of nearly 6,000 people aged 15 to 24 show that among young people with a history of both a mental disorder and an addictive disorder, the mental disorder is usually reported to have occurred first. The onset of mental health problems may occur about 5 to 10 years before the substance abuse disorders.**
This provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services.
** "National Comorbidity Survey," Ronald C. Kessler, Ph.D., et al., American Journal of Orthopsychiatry, June 1996.
What Is Mental Health?
Mental health is how we think, feel, and act in order to face life's situations. It is how we look at ourselves, our lives, and the people we know and care about. It also helps determine how we handle stress, relate to others, evaluate our options, and make choices. Everyone has mental health.
A young girl's mental health affects her daily life and future. Schoolwork, relationships, and physical health can be affected by mental health. Like physical health, mental health is important at every stage of life. Caring for and protecting a child's mental health is a major part of helping that child grow to become the best she can be.
Girls' independence is usually encouraged in childhood, and their strengths nurtured. Most girls become emotionally, mentally, and physically healthy young adults. But sometimes, during the transition from childhood to adolescence, extra care is necessary, so that a girl's self-esteem and coping skills are not diminished. For more information on teen mental health, call 1-800-789-2647 and ask for the brochure: "You and Mental Health: What's the Deal?" (Order # CA-0002)
Nurturing Your Child's Mental Health
Parents and other caregivers are responsible for children’s physical safety and emotional well-being. Parenting styles vary; there is no one right way to raise a child. Clear and consistent expectations for each child, by all caregivers, are important. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills. The following suggestions are not meant to be complete.
Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.
Be aware of stages in child development so you don’t expect too much or too little from your child.
Encourage your child to express her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety.
Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.
Promote mutual respect and trust. Keep your voice level down—even when you don’t agree. Keep communication channels open.
Listen to your child. Use words and examples your child can understand. Encourage questions.
Provide comfort and assurance. Be honest. Focus on the positives. Express your willingness to talk about any subject.
Look at your own problem-solving and coping skills. Do you turn to alcohol or drugs? Are you setting a good example? Seek help if you are overwhelmed by your child’s feelings or behaviors or if you are unable to control your own frustration or anger.
Encourage your child’s talents and accept limitations.
Set goals based on the child’s abilities and interests—not someone else’s expectations. Celebrate accomplishments. Don’t compare your child’s abilities to those of other children; appreciate the uniqueness of your child. Spend time regularly with your child.
Foster your child’s independence and self-worth.
Help your child deal with life’s ups and downs. Show confidence in your child’s ability to handle problems and tackle new experiences.
Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from her mistakes.
Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others. Do not expect to be perfect; parenting is a difficult job. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills.
Mental Health Problems
Many children experience mental health problems that are real and painful and can be severe.
Mental health problems affect at least one in every five young people, at any given time. At least 1 in 10 children may have a serious emotional disturbance that severely disrupts his or her ability to function.
Tragically an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide.
March 07, 2010
Models of Preventive Services
Models of Preventive Services
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
February 27, 2010
Questions to Help Children Talk About a Disaster
Emergency Mental Health and Traumatic Stress
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.
As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:
Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.
Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.
February 21, 2010
What is the difference between an Online Interactive CE Course and a Homestudy Course?
What is the difference between an Online Interactive CE Course and a Homestudy Course?
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.
February 14, 2010
Building Self-Esteem in Children
Building Self-Esteem in Children
Most parents have heard that "an ounce of prevention is worth a pound of cure" and it's especially true with self-esteem in children. All children need love and appreciation and thrive on positive attention. Yet, how often do parents forget to use words of encouragement such as, "that's right," "wonderful," or "good job"? No matter the age of children or adolescents, good parent-child communication is essential for raising children with self-esteem and confidence.
Self-esteem is an indicator of good mental health. It is how we feel about ourselves. Poor self-esteem is nothing to be blamed for, ashamed of, or embarrassed about. Some self-doubt, particularly during adolescence, is normal—even healthy-but poor self—esteem should not be ignored. In some instances, it can be a symptom of a mental health disorder or emotional disturbance.
Parents can play important roles in helping their children feel better about themselves and developing greater confidence. Doing this is important because children with good self-esteem:
Act independently
Assume responsibility
Take pride in their accomplishments
Tolerate frustration
Handle peer pressure appropriately
Attempt new tasks and challenges
Handle positive and negative emotions
Offer assistance to others
Words and actions have great impact on the confidence of children, and children, including adolescents, remember the positive statements parents and caregivers say to them. Phrases such as "I like the way you…" or "You are improving at…" or "I appreciate the way you…" should be used on a daily basis. Parents also can smile, nod, wink, pat on the back, or hug a child to show attention and appreciation.
What else can parents do?
Be generous with praise. Parents must develop the habit of looking for situations in which children are doing good jobs, displaying talents, or demonstrating positive character traits. Remember to praise children for jobs well done and for effort.
Teach positive self-statements. It is important for parents to redirect children's inaccurate or negative beliefs about themselves and to teach them how to think in positive ways.
Avoid criticism that takes the form of ridicule or shame. Blame and negative judgments are at the core of poor self-esteem and can lead to emotional disorders.
Teach children about decisionmaking and to recognize when they have made good decisions. Let them "own" their problems. If they solve them, they gain confidence in themselves. If you solve them, they'll remain dependent on you. Take the time to answer questions. Help children think of alternative options.
Show children that you can laugh at yourself. Show them that life doesn't need to be serious all the time and that some teasing is all in fun. Your sense of humor is important for their well-being.
The Caring for Every Child's Mental Health Campaign Campaign is part of The Comprehensive Community Mental Health Services Program for Children and Their Families of the Federal Center for Mental Health Services. Parents and caregivers who wish to learn more about mental well-being in children should call 1-800-789-2647 (toll-free) or visit mentalhealth.samhsa.gov/child/ to download a free publications catalog (Order No. CA-0000). The Federal Center for Mental Health Services is an agency of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
Most parents have heard that "an ounce of prevention is worth a pound of cure" and it's especially true with self-esteem in children. All children need love and appreciation and thrive on positive attention. Yet, how often do parents forget to use words of encouragement such as, "that's right," "wonderful," or "good job"? No matter the age of children or adolescents, good parent-child communication is essential for raising children with self-esteem and confidence.
Self-esteem is an indicator of good mental health. It is how we feel about ourselves. Poor self-esteem is nothing to be blamed for, ashamed of, or embarrassed about. Some self-doubt, particularly during adolescence, is normal—even healthy-but poor self—esteem should not be ignored. In some instances, it can be a symptom of a mental health disorder or emotional disturbance.
Parents can play important roles in helping their children feel better about themselves and developing greater confidence. Doing this is important because children with good self-esteem:
Act independently
Assume responsibility
Take pride in their accomplishments
Tolerate frustration
Handle peer pressure appropriately
Attempt new tasks and challenges
Handle positive and negative emotions
Offer assistance to others
Words and actions have great impact on the confidence of children, and children, including adolescents, remember the positive statements parents and caregivers say to them. Phrases such as "I like the way you…" or "You are improving at…" or "I appreciate the way you…" should be used on a daily basis. Parents also can smile, nod, wink, pat on the back, or hug a child to show attention and appreciation.
What else can parents do?
Be generous with praise. Parents must develop the habit of looking for situations in which children are doing good jobs, displaying talents, or demonstrating positive character traits. Remember to praise children for jobs well done and for effort.
Teach positive self-statements. It is important for parents to redirect children's inaccurate or negative beliefs about themselves and to teach them how to think in positive ways.
Avoid criticism that takes the form of ridicule or shame. Blame and negative judgments are at the core of poor self-esteem and can lead to emotional disorders.
Teach children about decisionmaking and to recognize when they have made good decisions. Let them "own" their problems. If they solve them, they gain confidence in themselves. If you solve them, they'll remain dependent on you. Take the time to answer questions. Help children think of alternative options.
Show children that you can laugh at yourself. Show them that life doesn't need to be serious all the time and that some teasing is all in fun. Your sense of humor is important for their well-being.
The Caring for Every Child's Mental Health Campaign Campaign is part of The Comprehensive Community Mental Health Services Program for Children and Their Families of the Federal Center for Mental Health Services. Parents and caregivers who wish to learn more about mental well-being in children should call 1-800-789-2647 (toll-free) or visit mentalhealth.samhsa.gov/child/ to download a free publications catalog (Order No. CA-0000). The Federal Center for Mental Health Services is an agency of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
February 13, 2010
CEU Training Video for MFTs, LCSWs, LPCs, Social Workers and Counselors
Click link below for ceus video training
Continuing Education CEU Training Video for MFTs, LCSWs, LPCs, Social Workers and Counselors
Approved in many states including California BBS, Florida, New Jersey, New York, Texas, Hawaii, Nevada and Ohio.
Continuing Education CEU Training Video for MFTs, LCSWs, LPCs, Social Workers and Counselors
Approved in many states including California BBS, Florida, New Jersey, New York, Texas, Hawaii, Nevada and Ohio.
February 02, 2010
bbs approved ceus online
bbs approved ceus online
For mental health professionals
Aspira Continuing Education’s courses are focused strictly on mental health CEU requirements. Our founders and course writers include practicing clinical mental health professionals, making our courses relevant to today’s continuing education requirements. Our courses satisfy CEU requirements for the following professions in the following states:
Marriage and Family Therapists (MFT/LMFT/MFTI)
California, Colorado, Florida, Kentucky, Louisiana, Massachusetts, Nevada, Ohio, Oregon, Texas
Clinical Social Worker (CSW/LCSW/ASW)
Arkansas, California, Colorado, Florida, Hawaii, Michigan, Missouri, New York, Oregon
Alcohol and Drug Counselors (CADC I/CADC II)
California
Prevention Specialists (CPS)
California
Clinical Supervisors (CCS)
California
Professional Counselors (LPC/CPC)
Colorado, Hawaii, Kentucky, Louisiana, Missouri, Oregon, Texas
Mental Health Counselor (MHC)
Florida
For mental health professionals
Aspira Continuing Education’s courses are focused strictly on mental health CEU requirements. Our founders and course writers include practicing clinical mental health professionals, making our courses relevant to today’s continuing education requirements. Our courses satisfy CEU requirements for the following professions in the following states:
Marriage and Family Therapists (MFT/LMFT/MFTI)
California, Colorado, Florida, Kentucky, Louisiana, Massachusetts, Nevada, Ohio, Oregon, Texas
Clinical Social Worker (CSW/LCSW/ASW)
Arkansas, California, Colorado, Florida, Hawaii, Michigan, Missouri, New York, Oregon
Alcohol and Drug Counselors (CADC I/CADC II)
California
Prevention Specialists (CPS)
California
Clinical Supervisors (CCS)
California
Professional Counselors (LPC/CPC)
Colorado, Hawaii, Kentucky, Louisiana, Missouri, Oregon, Texas
Mental Health Counselor (MHC)
Florida
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