RESEARCH
ACCOMPLISHMENTS
A selection of the Center's most significant
findings
Center for
the Study of Issues in Public Mental Health
Period: July 1994- August 2005
P.I. and Director: Carole Siegel, Ph.D.
Current Research Co- Directors
Mary Jane Alexander, Ph.D.
Kim Hopper, Ph.D.
Current Core Directors
Mary Jane Alexander, Ph.D.
Kim Hopper, Ph.D.
Judith Samuels, Ph.D.
Colleen Gillespie, Ph.D.
Carole Siegel, Ph.D.
Administrative Director
Dixianne Penney, Ph.D
A Collaborative Center
Nathan Kline Institute for Psychiatric Research
New York State Office of Mental Health
New York University, Robert F. Wagner Graduate School
of Public Service
Nelson A. Rockefeller College of Public Affairs and
Policy, School of Social Welfare
University at Albany, State University of New York
November, 2005
Table of
Contents
1. Measurement tools
II.Co-occurring
Disorders
1. Participation in an Interagency Workgroup
2. Screening for Co-occuring Disorders
3. Treatment for Women with Co-occuring Disorders
III. Community
Living
1. Residential Instability
among Homeless Persons with
Mental Illness
2. New York/New York Housing
3. Housing Alternatives for Persons with Severe Mental
Disorders
4. Critical Time Intervention applied to Transitional
Housing
5. Pathways through Temporary
Assistance for Needy Families
(TANF)
6. Arraignment of Offenders with Severe Mental
Disorders
7. The Nathaniel Project
1. Conference on Work of Recovery: Implications for
Psychiatry and Research
2. An Instrument to Measure Recovery
3. Evaluation of the NYC Involuntary Commitment
Program
4. Psychiatric Advance Directives
5. Motherhood and Mental Illness Conference
6. Invisible Mothers: An Exploratory Study of the
Contact, Caretaking, and Custody
Arrangements Negotiated by Women with
Severe Psychiatric Disorders in the New York
City Shelter System
7. Creating a Stake in Working
8. Employment Profiles of Persons with Severe
Mental Illness in the Workforce
1. Potential for Cost Shifting under Parity Legislation
2. How to Estimate Capacity Requirements for Mental
Health Services Post-Disaster
3. Estimation of Additional Capacity of the Mental Health
Sector to meet Extended Service Demands
4. Working Clergy and Mental Health
1. Emergency Room Decision Making
2.
Risk Assessment
1. Mental Health Indices
2. Statistical Methods for Cost-Effectiveness Analyses
3. Sequential Decision Making in Cost-Effective Analyses
4. Statistical Cost-Effectiveness Analysis of Treatments
Based on Net Health Benefits
5. The Family-wise Error Rate of a Simultaneous
Confidence Band for the Net Health Benefit Function
6. Counting Methods for Multiple list problems
To view additional Center
projects click above.
I. Cultural
Competency
I. 1
Measurement tools
Background Reports of the disparate experiences of minority group members
in mental health settings abound in the literature. A number of studies have
noted higher rates of inpatient hospitalizations for minorities than for the
dominant population, misdiagnosis, language barriers, inappropriate planning,
early terminations from treatment, and restrictions imposed by managed care.
Cultural competency has been proposed as a remedy. Cultural competency has
been defined as "the set of behaviors, attitudes and skills, policies
and procedures that come together in a system, agency or individuals to enable
mental health caregivers to work effectively and efficiently in cross/ multicultural
situations."
Accomplishment Center researchers working directly with multi-cultural
groups developed a framework of cultural competency, and based on it, performance
measures and their benchmarks and an organizational level assessment scale.
Highlights Working with multi-cultural expert panels reflecting the major ethnic
groups in the United States and a broad range of mental health stakeholders,
a comprehensive set of indicators of cultural competency and performance measures
of their attainment within mental health programs were selected and reduced
to a workable list. Data sources for these indicators and the feasibility
of collecting information were specified. Selections made fell within the
domains of need assessment, information exchange, services, human resources,
policies and plans, and outcomes. The indicators and measures were applied
across administrative, service delivery, and individual caregiver levels.
Subsequently these
measures were benchmarked and used to develop a Cultural Competency Assessment
Scale. They synthesized a large number of performance measures and their benchmarks
into 11 critical areas of cultural competency. These areas are considered
high priority areas and activities that should begin an early on in a cultural
competency process. It is fully compatible with prior work of other groups
and in particular with the Federal Cultural and Linguistic Assessment Standards.
It measures:
o
Organizational commitment
to cultural competency, expressed in
dedicated
budgets, assigned person, comprehensiveness of plan.
o Assessment of service
needs.
o Input of cultural groups
into organizational activities incorporating
community,
consumer and family representatives.
o Integration of cultural
competency in organizational activities including
service
review, linkages to quality assessment programs, reporting to the
CEO.
o Attention to language
needs of target populations in terms of interpreters,
bilingual
staff, forms and educational materials.
The scale has been pilot tested. The project received additional funding from
SAMHSA
Impact
•
An NIMH grant has been received to establish
the reliability and validity of the
scale.
Reliability will ensure that different raters apply the scale consistently
and
accurately.
Validity will indicate whether there is correlation between cultural
competency
and a reduction in service disparities.
•
NIH monies are supporting an NYU subcontract
to adapt the scale to Asian
American
populations.
•
Dr. Robert Drake at Dartmouth will include
the scale in the Evidence-Based
Practice
(EBP) Toolkits to ensure that cultural competency is taken into account
when
disseminating and adapting EBPs.
•
Several grant submissions to SAMHSA on EBPs
have included the use of the
scale
in their assessment plans.
•
The scale has been disseminated to over
200 persons.
•
Use of the scale is expected to move and
promote organizations and their
personnel
toward culturally competent behaviors in the delivery of mental health
services.
Researchers:
Carole Siegel, Ph.D.,
Gary Haugland, MA, Ethel Davis Chambers, RN, MS., Lenora-Reid Rose, MBA
Publications:
Siegel
C, Chambers ED, Haugland G, Bank R, Aponte C. (1998). A Framework for the
Development of Performance Measures of Cultural Competency in Managed Care
and Other Mental Health Organizations. NYS Office of Mental Health.
Siegel C, Chambers E D, Haugland G,
Bank R, Aponte C, McCombs H (2000).
Performance measures of cultural competency
in mental health organizations.
Administration and Policy in Mental
Health 28(2): 91-106.
Siegel C, Haugland G, Chambers ED (2002).
Cultural Competency Methodological and Data Strategies to Assess the Quality
of Services in Mental Health Systems of Care. Orangeburg NY: CSIPMH; NKI;
NYSOMH (89 pp.)
Siegel C, Haugland G, Chambers ED (2003).
Performance measures and their
benchmarks for assessing organizational
cultural competency in behavioral health care service delivery. Administration
and Policy in Mental Health, 31(2): 141-170.
Siegel C, Haugland G, Schore R (2005).
The interface of cultural competency and
evidence-based practices. In: Drake
RE, Merrens MR, Lynde D, eds. Evidence-Based Mental Health Practice. New
York: W.W. Norton & Co, 273-299.
Top
of Page
II. Co-occurring
Disorders
II.1 Participation in an Interagency Workgroup
on Co-occuring Disorders
Background High rates and adverse consequences of co-occurring mental
illness and substance use
disorders make detection critical, but surveys of local providers
show that neither set of conditions are
adequately identified or addressed outside of their specialty sector
settings. Though research has
established that integrated services improve outcomes for co-occurring
disorders, there are few established
methods for localities to develop and sustain integrated networks
across providers and systems. An
Interagency Workgroup on Co-occurring Disorders (IWCD) works across
NYS OMH and NYS OASAS to
develop a policy and service infrastructure that will support a seamless
system of care - No Wrong Door -
for people with co-occurring mental health and substance abuse problems.
Accomplishment
Dr. Alexander is a member of the IWCD, and
two of its members
are Center faculty. Work with the IWCD resulted
in Center development of screens for
detecting mental illness and for substance
abuse. Consensus panels were organized
by Center researchers better to understand
the activities and successes of Dual
Recovery Coordinators hired to build and sustain
locally integrated networks.
-
The
IWCD asked the Center to develop evidence based, decision support tools
for
intake staff to identify people with co occurring disorders across the NYS
service
ecology
as the first step toward a “No Wrong Door” system (See project II.2).
-
The
IWCD developed an OMH-OASAS, braided funding initiative, the Dual
Recovery
Coordinator (DRC), to accomplish local integration of services for co occurring
disorders
within and across specialty sectors, housing, income support and criminal
justice
systems.
-
Consensus
panels were conducted with cross system stakeholders in 5 counties
and
semi structured interviews with county behavioral health directors in 12
counties to
understand
how DRCs build and sustain locally integrated networks.
-
A
process evaluation was funded by CMHC/CSAT to evaluate the impact of
the
use of DRCs
.
Impact
OMH,
OASAS and the localities used results to better support DRCs in
introducing
innovations, such as the screens, to integrate services.
Researchers Mary Jane Alexander, Ph.D., Gary Haugland, M.S.
Publications Alexander, M.
J. & Haugland, G. (2004). The New York State Dual
Recovery Coordinator Initiative: A process evaluation (CSAT State Systems Technical
Assistance
Project No. 270-99-7070). Rockville, MD: SAMHSA.
21
II.2 Screening
for co-occurring disorders
Background
A major barrier in providing effective services for persons
with co-occurring mental illness and
substance abuse disorders has been the lack of systematic tools and
procedures to identify these disorders. Persons
with dual disorders follow multiple pathways to care: some through
a mental health agency, others a substance
abuse program. Many are not engaged in either system. Historically,
the two systems have been unsuccessful at
coordinating the services offered, resulting in fragmented care.
In New York State, Center researchers collaborated
with an inter-agency work group of NYS Office of Substance Abuse
and Alcohol Services [OASAS] and the Office
of Mental Health [OMH]), the IWCD, to conceptualize the issues surrounding
treatment of persons with Co-occuring
disorders, and to design local screening, training and integration
initiatives.
Accomplishment:
Screening instruments were selected, computerized
and validated to detect
mental health and substance abuse disorders.
These instruments proved to be accurate in
naturalistic settings and can provide- useful
tools in service systems developing a “No Wrong
Door” policy for persons with co-occurring
mental health and substance abuse problems.
Highlights
Items from the DSM-IV-TR, the SCID and the MINI International Neuropsychiatric
Interview
(MMS) and the Dartmouth Assessment of Lifestyle Inventory (DALI-14) were
validated
for use in identifying mental health disorders and substance abuse problems
respectively
with culturally heterogeneous, high-risk clients in primary care, specialty
sector, and
non-traditional
service settings. Screens were validated using the SCID (Structured Clinical
Interview
for Diagnosis) as well as clinician ratings and record reviews. The instruments
are
used
to establish the presence of current and lifetime Mood, Anxiety, Psychosis
and
Psychoactive
Substance Use Disorders.
• The study was conducted in 37 rural, urban
and suburban settings, including primary care
clinics,
outpatient and residential chemical dependency settings, mental health crisis
clinics,
psychiatric emergency rooms, local jails and shelters.
•
The MMS and DALI-14 were delivered to and
validated with consumers in settings that
span
the systems delineated in the SAMHSA 4 Quadrant Model of Loci of Care for
persons
with co-occurring disorders.
•
The MMS at cut points of 6-9 (range : 0-22),
had sensitivities ranging from .70 - .82,
specificities
ranging from .61 - .78, and an overall accuracy of 70 - 74% for detecting
patients
with high risk for current mental illness.
•
The DALI-14 at cut points of 3-4 (range:0-18)
had sensitivities ranging from .77 - .86,
specificities
ranging from .57 - .75, and overall accuracy ranging from 66 - 81% for
detecting
patients with high risk for lifetime alcohol and/or drug abuse.
•
The screens performed equally well for men
and women, and for African Americans and
Caucasians,
and are comparable to the performance of other screens in less compromised
populations.
Impact
•
The screens and a manual for both screens
and are available from the authors.
•
A computer-assisted interview with visual
and audio prompts developed for the study
may
provide an approach for screening interviews. The program is available on
the
Center
web site.
•
Following successful pilot testing, OASAS
recommends and actively supports the MMS
statewide
in chemical dependency agencies. Implementation materials are available on
the
OASAS web site ( www.oasas.state.ny.us/hps/research)
•
New York City DOHMH is actively conducting
a 2 year Quality Improvement Project
using
the MMS and its decision support materials in 24 chemical dependency agencies.
•
Use of these screens will improve case finding
by identifying high-risk individuals and
improving
access to services through a more coordinated treatment planning process.
Researchers: PI: Mary Jane Alexander, Ph.D. Co-PIs: Gary Haugland, MA, Isaac Koilpillai,
M.D.,
Frank McCorry, Ph.D.
Publications:
Alexander
MJ (1998). Women with co-occurring addictive and mental disorders: An emerging
profile
of vulnerability. In:Drake RE Mercer-McFadden C, McHugo GF, Mueser KT,
Rosenberg
SD, Clark RE, Brunette MF, eds. Readings in dual diagnosis. Columbia, MD:.
International
Association of Psychosocial Rehabilitation Services.
Alexander
MJ et al.
(2005). Screening for
Co-Occurring Mental Illness and Substance Abuse
Disorders
in Diverse Settings: A Validation Study, in preparation.
II.3 Treatment
for Women with Co-occurring Disorders
Background Little information
existed on whether women with a dual diagnosis of mental illness and
substance abuse disorders require treatment approaches that differ
from treatment for men, or from women
who only have a diagnosis of mental illness. To respond, this study
aimed to develop prevalence rates,
including setting and gender specific rates, of coexisting severe
mental illness and substance abuse
problems among individuals receiving mental health services; to compare
characteristics of individuals
with and without substance abuse co-morbidity; and to examine gender-specific
risk factors and contextual
variables that affect outcomes and/or use of services.
Accomplishment Researchers found significant differences in
risk factors and service
use in women diagnosed with co-occurring mental
illness and substance abuse
disorders when compared with men, or with other
women with mental illness who did
not abuse alcohol or drugs.
Highlights Forty-nine New York State urban and rural treatment sites (excluding
New
York
City) were studied stratified by agency ownership (public or private), types
of
clinical
service (inpatient, ambulatory clinic, case management, social/ vocational
rehabilitation),
and agency complexity (multiple service provider; single service). 671
records
were reviewed for gender, age, ethnicity, psychiatric diagnoses of record
and
substance
use diagnoses as well as the presence of an alcohol or substance use problem
or
diagnosis.
546 persons were interviewed covering: Alcohol and substance use problems
and
history, housing, family relations, social relations, leisure, safety, finances,
health,
job,
school, mental health service utilization; optimism, coping and advocacy dimensions
of
empowerment.
•
Half of all women receiving mental
health services have co-occurring mental
illness
and substance abuse disorders.
•
Women with dual diagnoses were 1.6x
more likely than men to report childhood
experiences
of sexual trauma and 2x more likely to report emotional abuse and
adult
victimization.
•
They were more likely than men,
and more likely than women without dual
diagnoses,
to have been homeless or doubled up in living arrangements during the
past
year.
•
They were more likely than non-dually
diagnosed women to be married and living
with
their spouse and children, but had higher rates of dissatisfaction in their
family
relationships dealing with family crises through verbal and physical
aggression.
•
They made greater use of hospital
emergency rooms for psychiatric crises than
women
not dually diagnosed.
•
Persons with dual disorders (especially
women) were found at risk to overdose
and
for HIV infection by virtue of injection behavior.
•
Dually diagnosed women were more
likely to have been arrested during the prior
year
and imprisoned at some time in their lives with only a small percent
receiving
needed services while incarcerated. This finding also held true for men
with
dual diagnoses.
•
Women were more likely than men
to have been victims of either violent or nonviolent
crimes.
•
Thirty per cent of those with lifetime
problems have never received treatment for
their
substance use problems, despite the fact that alcohol or drugs are implicated
in
the use of roughly half of reported inpatient and outpatient psychiatric
episodes.
•
There were differences in the types
of services used recently: Dual diagnosed
women
were 4x as likely as women not dually diagnosed to have used emergency
room
services. Both dually diagnosed men and women were 1.5x more likely to
use
psychiatric outpatient services, and 1.7x as likely as to use psychiatric
inpatient
services. Many relied on self help and outpatient counseling services for
help
with their alcohol and drug problems.
•
In related projects the Center field
tested the utility of screening instruments for
mental
illness and substance abuse.
Impact
•
Treatment programs for dually diagnosed
women need to be tailored to their
special
needs, and include services in forensic settings.
•
Women should be offered special
residential options to accommodate their role as
mothers.
Researchers: Mary Jane Alexander, Ph.D., Gary Haugland, MA
Publications:
Alexander
MJ (1996). Women with co occurring addictive and mental disorders: An emerging
profile
of vulnerability. American Journal of Orthopsychiatry, 66:61-70.
Alexander
MJ. (1998). Women with co-occurring addictive and mental disorders: An
emerging
profile of vulnerability, In: Drake RE. Mercer-McFadden C, McHugo GF,
Mueser
KT, Rosenberg SD, Clark RE, Brunette MF (eds.), Readings in dual diagnosis.
Columbia
MD: Inter Assn of Psychosocial Rehabilitation Services.
Alexander,
MJ, Haugland G (1998). Gender specific rates of dual diagnoses among
individuals using mental health services. Report to the National Institute of Mental
Health.
III. Community Living
A. Housing
III. 1
Residential Instability among Homeless Persons with Mental Illness
Background Homelessness appears to be a persistent problem for many individuals
with severe mental
illness. Understanding their residential pathways could provide some
insight into its causes.
Accomplishment
Researchers determined that substantial numbers
of homeless
persons with mental illness or substance abuse
disorders cycle through an
“institutional circuit” that takes them through
stays in shelters, hospitals, prisons,
detoxification and rehabilitation facilities,
as well as time on the street.
Highlights In a quasi-ethnographic study conducted in Westchester County, 36
individuals
with severe psychiatric disability were interviewed in depth, and followed
for
six
months. There was sufficient data to chart the course of homelessness for
25 of them.
Researchers
found that intensive, targeted re-housing efforts are needed to break the
institutional
circuit.
•
Only a small percentage ever attained successful
housing placements. Far more
common
were essentially uninterrupted shelter stays or a pattern of cycling
through
a variety of short-term institutional placements.
•
For 56% of the subjects, shelters had become
an enduring pattern of life lived on
the
“institutional circuit.”
•
Shelters functioned in four ways: as a temporary
source of transitional housing; as
a
surrogate for kin support, as part of an extended institutional circuit; and
as a
haphazard
resource to turn to in essentially nomadic lives.
•
For a group of high-use service recipients,
suitable supported housing was not
available.
Their residential instability was re-enforced by the absence of
institutional
services follow-through.
Impact
•
Gaps in the Westchester County homeless
service system were identified with
specifications
for the reasons for these gaps.
Researchers: Kim Hopper, Ph.D., Gary Haugland, MA, Terry Hay, BA, John Jost MS
Publications:
Haugland
G, Siegel C, Hopper K, et al. (1997).
Mental illness among single homeless
adults
in a suburban county. Psychiatric Services 48: 504-509.
Hopper
K, Jost J, Hay T, Welber S, Haugland G (1997). Homelessness, severe mental
illness
and the institutional circuit. Psychiatric Services 48: 659-665
.
Shinn
M, Weitzman B, Hopper K. (1998). Homelessness, in Encyclopedia of Mental
Health. San Diego: Academic Press.