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.
III. 2 New
York/New York Housing
Background The New York/New York Agreement to provide housing for persons
with mental
disorders resulted in the placement of over 3,500 previously homeless
or at-risk individuals into newly
developed supportive housing. This study provides an analysis of
descriptive and housing tenure data that
had been collected by the New York City Human Resources Administration
on 3,114 persons housed as
part of the New York/ New York housing program from 1990 to 1995.
Accomplishment
Center researchers found supportive housing
is a viable program to
reduce residential instability for most persons
with severe mental disorders found in
the community.
Highlights
Researchers studied the length of tenure of persons with mental disorders
placed
in low-, moderate-, and highly structured models of supportive housing. Data
was
correlated
with demographics, psychiatric diagnosis, chemical abuse co-morbidities,
source
of referral, and the characteristics of specific housing models. Survival
analysis
was
used to generate the distribution of the length of time in housing for the
group as a
whole,
as well as the probability of residents leaving supportive housing over time.
•
Persons with mental disorders placed in
supportive housing remained in stable
residence
for extended periods of time: 75% for at least one year, 64% were still
housed
after two years, and at least 50% remained throughout the five year study
period.
The older the individual, the longer the stay in residential housing. Those
referred
from shelter programs to housing had better outcomes than those placed
from
hospitals.
•
Tenure in housing also varied by the degree
of structure to the residential setting.
o Persons in highly structured settings remained
in residence for the shortest
periods
of time. Those placed in this setting included individuals with
histories
of substance abuse and/or a diagnosis of schizophrenia.
o
Individuals in moderately structured settings
remained in housing longer.
They
were more than likely to be women, diagnosed with schizophrenia,
but
less likely to have a substance abuse history.
o
Residents in the least structured settings
remained in housing the longest.
They
had been long-term users of the shelter system, typically have a
bipolar
or other mood disorder diagnosis, and only a moderate level of
substance
abuse history.
Impact
•
The study points to the need for further
development of varied housing models.
•
Data obtained from this study can yield
criteria for matching individuals needing
housing
with the type of housing that would best meet their needs.
Researchers:
Carole Siegel, Ph.D, Judith Samuels, Ph.D, Frank Lipton, M.D.,
Anthony
Hannigan, MSW, Sherryl Baker, Ph.D.
Publication: Lipton F, Siegel
C, Hannigan A, Samuels J, Baker S. (2000). Tenure in
supportive
housing for homeless persons with severe mental illness. Psychiatric Services,
51(4):479-486.
27
III. 3 Housing
Alternatives for Persons with Severe Mental Disorders
Background The level of supports and autonomy required for tenants who
have mental illness is under
debate. Many advocate for a continuum of options and that persons
should graduate from most to least
autonomous arrangements. Supported housing as defined by SAMHSA provides
a residential placement
separately operated from support services, a high degree of community
integration and tenant autonomy.
Community residences provide housing and support services in one
setting, with services a requirement of
housing. Is it necessary to traverse the residential continuum from
least to most autonomous? The project
was a follow-up to the New York/New York Housing study and was conducted
in collaboration with the
New York City Office of Health and Mental Health Services of the
Human Resources Administration, the
Center for Urban Community Services, and Pathways to Housing.
Accomplishment: Researchers determined that even individuals
initially considered
least likely to benefit from supported housing
had favorable tenure in supported
housing. Consumers placed in supported housing
had greater satisfaction with their
housing than those placed in community residences.
Highlights Phase I of this study examined the operations and ecology of 11 housing
sites:
two that met the SAMHSA definition for Supported Housing and nine that
collectively
represent community residences. Fidelity assessments showed that the two
housing
model types were well differentiated. However, the two models of supported
housing
had distinctive differences in definition of the problem to be solved, target
clientele,
potential supporters, and neighborhood development strategy but
commonalities
in their approach to client independence. In Phase II, data were collected
to
test the hypothesis that there is no difference in outcomes among tenants
in supported
housing
in comparison to those in community residences. The analyzable sample was
138
individuals
with substantial histories of homelessness. The design was non-randomized
requiring
propensity scoring in statistical analysis. To overcome problems of not being
in
initial
placement housing at the time of interview, a true stayer analysis as well
as an
intent
to treat analysis was performed.
•
There were no significant differences
in residential stability for individuals in
supported
housing when compared to those in community residences.
•
Persons in supported housing compared
to those in community residences had
significantly
greater housing satisfaction overall and in particular on autonomy
and
economic scales.
•
Some persons in supported housing
at 18 months reported significantly greater
isolation
scores that did those in community residences.
•
Independent of housing model, baseline
depression/anxiety symptom scores
increased
the risk of poor outcomes.
Impact
•
Supported housing is a viable portal
of entry into community housing for persons
with
severe mental illness exiting homelessness.
•
Clinical attentiveness to depression
and anxiety is called for independent of
housing
model.
Researchers: Carole Siegel, Ph.D., Judith Samuels, Ph.D., Kim Hopper, Ph.D., Sue
Barrow,
Ph.D., Kristine Jones, Ph.D., Dei-In Tang, Ph.D., Ilyssa Berg, BS, Frank Lipton,
MD
(New York City Human Resources Administration), Anthony Hannigan, MSW
(Center
for Urban Community Services), Sam Tsemberis, Ph.D. (Pathways to Housing).
Publications:
Hopper
K, Barrow SM: Two genealogies of supported housing and their implications
for
outcome
assessment. Psychiatric Services, 54(1): 50-54, 2003
Siegel
C, Samuels J, Tang D, Jones K, Hopper K. (2005). Tenant Outcomes in
Supported
Housing and Community Residences in New York City Under revision for
Psychiatric
Services
29
III. 4 Critical
Time Intervention applied to Transitional Housing
Background The President’s New Freedom Commission on Mental Health was
formed in 2002 as part
of a Presidential initiative to expand opportunities for persons
with disabilities. The Commission conducted
a year-long in-depth examination of the nation’s system of public
and private sector care for individuals
with mental illness. Under the theme, Excellent
Mental Health Care is Delivered and Research is
Accelerated, the Commission made a number of recommendations that would
enable persons with mental
illness to participate fully in community living. The model in this
ongoing study was cited.
Accomplishment:
The President’s New Freedom Commission on Mental
Health cited
the housing model studied in the Center study
of homeless families who receive time limited
intensive case management along with transitional
housing.
Highlights Researchers are studying the social outcomes attained by both mothers
and
children
in homeless families when subsidized housing and Family Critical Time
Intervention
are provided. The supportive housing approach for homeless mothers with
mental
illness and substance abuse disorders caring for dependent children within
shelters
aims
to provide effective, time-limited, and intensive intervention strategies
to them in
lieu
of lengthy housing readiness programs provided prior to housing. The project
has
joint
SAMHSA and NIMH funding.
•
The study group consists of 228 families
being followed over a 15-month period.
Mothers
enrolled in the study tend to be poorly educated, have meager work
histories,
and face multiple medical, mental health and substance abuse problems.
Their
children’s lives have lacked stability.
•
The experimental study challenges the prevailing
assumption that homeless
mothers
require an extended stay in congregate shelter living before they are
ready
to manage households on their own.
•
The Freedom Commission noted that the model
provides for a focused team
approach
to service delivery aimed at reducing homelessness, and brokering and
monitoring
appropriate support arrangements to ensure continuity of care.
•
These aims can be addressed by buying into
services from collaborators and
involved
agencies, acquiring needed housing resources, evaluating the project
with
respect to model fidelity, and attaining ongoing involvement of practice
innovators.
•
Caseworkers have been given reduced caseloads
in order to focus intensively on
these
families.
•
Data collection and analysis is ongoing.
•
A manual to guide program replication will
be available at the conclusion of the
study.
Researchers: Judith Samuels, Ph.D., Marybeth Shinn, Ph.D., Nancy Travers, Dan
Herman,
Ph.D., Alan Felix, Ph.D.
Consultants: Carole Siegel, Ph.D., Kim Hopper,
Ph.D.
III. 5. Pathways through Temporary Assistance
for Needy Families-TANF)
Background Welfare reform set limits on the length of time recipients
may receive public assistance.
This project aimed to understand whether undiagnosed mental health
problems and exposure to violence
affect women's ability to meet the requirements of the welfare system
and to move from welfare to work.
The study was conducted in collaboration with the NYC Human Resources
Administration and New York
University.
Accomplishment In a screening of 568 women at four NYC job
centers, mental
health problems were found to be far greater
than anticipated.
Highlights
•
Screening instruments used included
the MINI diagnostic interview and the CESD
inventory
of depressive symptoms. A Center developed computer-assisted
interview
program was also utilized.
•
43% of the women screened were found
with symptoms of depression warranting
referral
for further examination. A high proportion also reported symptoms of
agoraphobia.
67% of these women accepted the referrals made. Respondents who
completed
the interview in Spanish (196) were more likely to be eligible for
referrals
(51%) than those who completed the interview in English (40%).
•
Rates of co-morbidity were high.
The majority of women who were eligible for a
referral
either had a high CES-D score, were diagnosed with depression or
generalized
anxiety disorder. A small number of women (10) received a referral
from
a single diagnosis of agoraphobia. All other diagnoses (including
Obsessive-Compulsive
Disorder, PTSD, Mania, Dysthymia, Panic Disorder and
Social
Phobia) were co-morbid with at least one of these four diagnoses
(depression,
anxiety, agoraphobia or high distress on CES-D).
•
Experiences of violence were prevalent.
36% reported having been robbed
without
the use of force, 27% reported with the use of force. 20% experienced
forced
sex. Other stressful events included seeing others injured (49%), having
heard
a gun fired from their home (33%), having lived in an unsafe place (33%),
having
had a partner or child die (18%) and knowing someone who committed
suicide
(22%). Domestic violence was a serious problem: 35% had been granted
an
order of protection at some point and 9% reported currently having an order
of
protection
against someone. Preliminary analyses suggest that reports of violence
are
highly related to mental health symptoms.
Impact
•
Determining whether interview responses
are related to problems with welfare
and
work will provide further evidence about the linkage of interview reports
with
functional
impairment in important life domains.
Researchers: Mary Beth Shinn, Ph.D., Mary Jane Alexander, Ph.D., Frank Lipton,
M.D.
31
C. Criminal
Justice System
III.6 Arraignment
of offenders with severe mental disorders
Background This project aimed to determine the roles of mental health
resources and interventions in
the criminal justice system, and to use that information to better
understand how and why criminal justice
system personnel make particular decisions involving the processing
during arraignment of offenders with
severe mental disorders committing low-level offenses.
Accomplishment
Semi-structured interviews with key criminal
justice personnel
revealed that persons with mental illness who
enter the criminal justice system for low level,
non-violent offenses are unlikely to receive
referrals to the mental health system
and have their underlying problems addressed.
Highlights
•
Opportunities for intervention,
assignment to treatment or release to mental
health
programs are bypassed in the “arrest-to-arraignment” phase of the
criminal
justice system.
•
Lawyers, judges, court and correctional
personnel tend to lack understanding of
mental
illness and either do not know that treatment programs are available or
how
to access them.
•
Mental health evaluations are not
conducted until detained individuals actually
enter
the jail system, up to 48 hours after arrest, leaving the mentally ill person
confused
and frightened.
•
The criminal justice system in New
York City has only 736 beds for about 1,800
persons
with severe mental illness.
•
Behavior in detention based on psychiatric
symptoms is likely to be perceived as
willful
and defiant and may lead to an escalation of charges and punishment.
•
In the “sentencing and release”
phase, judges and prosecutors express distrust of
the
mental health system’s ability to supervise individuals suspected of a
propensity
for violence.
•
When alternatives to detention are
considered, they often prove difficult to
arrange.
Impact
•
Court and correctional personnel
should receive training that provides an
adequate
understanding of mental illness and of the capacity of the mental health
system
to manage individuals involved in low-level offenses.
•
The criminal justice system needs
to be equipped to conduct early screening and
to
make available appropriate services in prison.
•
Mechanisms need to be developed
to improve communication between the
mental
health and criminal justice systems.
Principal Investigator: Colleen Gillespie, Ph.D
III. 7 The
Nathaniel Project
Background Estimates suggest that between 10 and 20% of people in jails
and prisons have a serious
mental illness. Many are in the criminal justice system for reasons
indirectly or directly related to their
mental illness. This group would include homeless people whose psychotic
episodes occur in the public
arena and who may commit low-level “survival” crimes to make it on
the street, individuals whose
behavior led family members to call the police for help, and dually
diagnosed people whose addiction has
repeatedly resulted in arrests and incarcerations for buying and
sell drugs. Recent attention has focused on
ways of minimizing the “criminalization” of those with mental illness.
Accomplishment
The Nathaniel Project, an award-winning NYC
program offering
an alternative to incarceration for people
with serious mental illness charged with
felony offenses, brokers arrangements between
the criminal justice system and
community providers in line with goals of participants.
Preliminary indications are that
it has been successful in keeping people stably
housed and out of trouble. Its
replication requires an understanding of what
makes it work. The study identified the
philosophical underpinnings, operating principles,
informing values and actual
practices of the Nathaniel Project.
Highlights Participants included program enrollees, court personnel (judges,
defense
attorneys,
and prosecutors), and community-based providers (supportive and other
housing
providers, mental health and substance abuse treatment providers). Data were
collected
over a year in a field-based process: interviews (n=32 interviewees) and focus
groups
(n=5) with program staff and participants, targeted field observations (n=16
activities),
and shadowing of four different staff members (in court and during staff-client
interactions
and interactions with providers). Fieldnotes and transcripts were analyzed
by
identifying
and coding the essential elements of the program, determining the values and
principles
reflected in each element, and then organizing the emergent values and
principles
into a conceptual schema.
Core
operating principles identified included:
•
Building and maintaining relationships
by extending respect and
engendering
trust among its participants and partners.
•
Serving bridging and buffering functions
as well as helping clients reframe
and
contextualize behaviors.
• Being
accountable –staff felt that they must always be there for all
participants,
which in turn, showcased the degree of commitment required
by
staff. Such commitment
was accompanied by the following themes: shouldering responsibility,
burn-out, work/life imbalance, high thresholds for
tolerating frustration and ambiguity,
autonomy, and the rewards that result from making the systems work
for felony offenders
with serious mental illness.
•
Having shared views on problems
that the Nathaniel Project solves and the
strategies
that can be used to solve these problems most effectively
•
Having shared values, philosophies,
principles and goals that inform
everyday
practice.
•
Viewing reentry into the community
as a brand new effort at
independence
and stability outside of institutional realms. For the vast
majority,
life in institutions was much more normative than life in the
community
– from foster care to psychiatric hospitalization to
incarceration,
their lives were marked by infrequent, short-lived, and
chaotic
community tenures.
Impact
•
Boundary spanners need to do a little
work of both systems in order to create a
seamless
integration.
•
Substantial time, effort, and funding
resources are necessary to do boundary
spanning
work.
•
Reframing the concept of “reentry”
to creating a life in the community.
•
Help to inform applied anthropology
paper, “Redistribution and its Discontents”,
forthcoming
in Human Organization
Researchers
Colleen
Gillespie, PhD, Kim Hopper, PhD, John Jost, PhD, Megan McDonald, MA,
34
IV. Recovery
and Enhancing Consumer Capabilities
IV.1 Conference
on Work of Recovery: Implications for Psychiatry and Research
Background In 1994, there was little focused activity on the concept of
recovery from the consumer
focus.
Accomplishment
In collaboration with multiple stakeholders,
the Center formulated
a research agenda on the process of recovery,
which it pursued during subsequent
years.
Highlights Early in the Center’s history (October, 1994), a conference was held
that
brought together more than 80 mental health service recipients, practitioners,
and
researchers
in a collective effort to rethink the meaning of recovery and formulate a
research
agenda. Co-sponsored by the Center and the New York State Office of Mental
Health's
Community Support Programs, with funding from the Center for Mental Health
Services,
speakers included psychiatric survivors, individuals active in the
consumer/recipient
movement who presented personal reflections on recovery, and
professionals
in the field. Among these were: Richard Warner, MD, a psychiatrist and
anthropologist
well known for his epidemiological work on the differential rates of
recovery
and interventions to facilitate the recovery process, Dan Fisher, MD, Ph.D.,
Executive
Director of the Mental Health Empowerment Project who now serves on the
President’s
Freedom Commission on Mental Health, consumer survivor advocates Sally
Clay
and Amy Long, and Ed Knight, Ph.D., now a vice-president at Value Options
and
member
of the Center’s Executive Committee, Julian Rappaport, Ph.D., a researcher
who
has
worked with mutual help organizations for individuals in recovery, and Anne
Krause,
a
peer advocate at the Mental Patients Liberation Alliance.
Over
the course of the two-day meeting, participants had the opportunity to:
•
Review research findings and hear
personal narratives that illuminated aspects
of
the work of recovery; learn more about how the process of recovery
unfolds
and what facilitates it; and examine how individual practice or
research
might relate to recovery.
•
Explore what the experience of and
reflections upon recovery might mean for
the
development of a mental health services research agenda and the research
process
of formulating questions, designing methods, pursuing answers,
sharing
results, and contesting the interpretations.
•
Begin to build a foundation for
future collaborations among recipients,
practitioners,
policymakers, and researchers.
According
to conference coordinators, "The conference was generally seen as a
good
first step in rethinking our long range research agenda and research process,
introducing
the concept of widespread consumer involvement in the Center, the Nathan
Kline
Institute, and academic settings, and identifying a number of potential research
areas
relevant to the experience of recovery."
Impact Out of this early conference, a research agenda ultimately emerged
that
has
remained with the Center for 10 years and brought to fruition many of the
projects
found
in this summary.
IV.2 An
Instrument to Measure Recovery
Background Agreement on the construct of recovery from mental illness
or understanding how
recovery takes place is lacking. Instruments measuring recovery cited
in the literature are few in number,
generally fail to provide information about how change occurs over
time and have not been attuned to
regional variations.
Accomplishment:
An instrument measuring the recovery process
was developed in
conjunction with consumer groups.
Highlights A recovery model developed by a consumer group became the basis for
selecting
items and scales for inclusion in a proposed instrument to monitor the recovery
process.
Cultural sensitivity, language, literacy and reading levels were considered
in
constructing
items for the instrument. Consumer groups played a major role in the final
product
developed.
•
Consumer/survivors defined the stages
of recovery that they had personally
experienced.
Recovery was seen as a process that begins with feelings of anguish
and
leads to problem awareness, insight, action, and an acquired determination
to
be
well and attain a sense of well-being. The order these stages are acquired
varies
among individuals. While internalized dimensions of recovery are
cognitive,
emotional, spiritual and physical, external dimensions include
interpersonal
and situational reactions to outside influences. Activity, social
support,
social relations and independence in taking care of one’s self abets the
recovery
process.
•
About 100 items based on these stages
were selected for inclusion in an
instrument
measuring the process.
•
The developed instruments were pilot
tested and validated with a population of
more
than 100 consumer/survivors.
•
The consumer-validated instrument
holds promise in planning cost-effective
approaches
leading to positive outcomes.
•
Further study is needed to provide
construct and criterion validity for these
measures.
Researcher: Ruth O. Ralph, Ph.D. (Edmund S. Muskie School of Public Service,
University
of Southern Maine)
Publications:
Ralph
RO, Kidder K (2000). What is recovery? A compendium of recovery and recovery
related instruments. Cambridge, MA. Human Services Research Institute.
Ralph,
RO (2000). Review of recovery literature: A synthesis of a sample of recovery
literature. Alexandria, VA: National Technical Assistance Center. generally fail
to
provide
information about how change occurs over time; and are not attuned to regional
patterns.
IV.3 Evaluation
of the NYC Involuntary Commitment Program
Background In the 1990s, the New York State Legislature enacted a pilot
program to test involuntary
outpatient commitment orders. The program targeted persons with mental
disorders who had two
involuntary admissions to mental health facilities within an 18-month
period and were clinically judged to
be incapable of surviving safely in the community without supervision.
New York City designated
Bellevue Hospital as a test site. The enabling legislation provided
for an evaluation of the pilot program. A
patient group court-committed to out-patient treatment was compared
with a control group attending
treatment voluntarily. Participants in both groups received intensive,
enhanced services.
Accomplishment Study of involuntary commitment orders for
outpatient treatment
found no significant statistical differences
on outcome measures between individuals
court-committed and those receiving services
voluntarily. Court orders were useful in
gaining the participation of a limited number
of subjects. When assertive, enhanced
services are offered, both groups benefited.
Highlights The evaluation design included interviews with consumers at baseline
and
three
follow-up points; interviews with community providers; descriptions of program
characteristics
and the service system; ethnographic follow-up of subjects to assess their
functioning
in the community; and focus groups to examine the perspectives of family
members
and consumers affected. The evaluation component was integrated directly into
the
treatment services (pre- and post-discharge) and the court proceedings. Subjects
were
enrolled
and randomly assigned to either an experimental group (receiving court-ordered
commitments
to enhanced treatment services) or to a control group (enhanced services
provided
on a voluntary basis).
•
Court-ordered subjects were slightly
more likely to be re-hospitalized, but
stayed
for briefer periods and were less likely to be transferred to a state
facility.
Those with co-occurring mental illness and substance abuse disorders
were
the ones most likely to be re-hospitalized.
•
Both groups -- court-ordered and
voluntary -- were hospitalized less often
while
receiving enhanced services, as compared with the prior year when they
were
not receiving enhanced services.
•
There were no documented incidents
of violence by either court-committed or
voluntary
individuals during the follow-up study period.
•
Court-ordered subjects were more
likely to drop out of treatment than those
attending
voluntarily. .
•
Clinicians viewed court orders as
useful leverage for only a limited number of
participants.
Impact
•
Findings complemented those obtained
as part of the parallel Duke Outpatient
Commitment
study by another research team.
•
Researchers concluded legal coercion
may not play a significant role in
keeping
individuals in treatment, and enhanced meaningful treatment made
the
difference in obtaining consumer involvement in their programs. The need
is
for continued availability of enhanced, assertive community treatment
programs,
and the use of court orders in only limited circumstances.
Researchers: Kim Hopper, Ph.D., Jeanne Dumont, Ph.D., David L. She rn, Ph.D.,
Henry
J.
Steadman, Ph.D. (Policy Research Associates), Marvin Swartz, M.D. (Duke University
Dept.
of Psychiatry).
Publication: Policy Research
Associates (1998). Research Study of the New York
City
Involuntary Outpatient Commitment Pilot Program.
39
IV.4 Psychiatric Advance Directives
Background Psychiatric Advance Directives (PADs) are legal instruments
that allow competent
individuals to appoint proxies and specify how treatment decisions
should be made in the event they
become incompetent. Established legal mandates and expectations for
PADs are not matched by empirical
evidence documenting their actual implementation. The aim of this
study was to explore the interests,
concerns and planning activities of mental health consumers contemplating
such directives.
Accomplishment:
Mental health service users found PADs to be
especially meaningful
by providing them with the expectation of being
treated as responsible individuals in
their future interactions with the mental health
system.
Highlights Standard qualitative research techniques were used: field observations,
interviews,
focus groups, archival research and key informant interviews. A sample of
33
individuals
participated in the consumer interviews and focus groups. Interviewees
included
those who decided to prepare PADs as well as those who declined. Transcripts
were
coded and analyzed for thematic content.
•
NYS-wide formal training sessions
helped nearly 6000 participants
conceptualize
how PADs work in one’s life, mobilize resources, review past
experiences
and assess risks.
•
PADs are best thought of as complex
planning tools for psychiatric case
management,
rather than as a means to enforce compliance with treatment
decisions.
.
•
Drawing up a PAD is demanding and
consequential: It allows individuals to
accept
responsibility for managing their illness, anticipate future planning to
forestall
harmful interventions and ensure treatment of proven benefit, hold on
to
one’s self-identity, and provide a new form of cooperation between
consumers
and the system.
•
PADs afford the means that allow
a consumer to take seriously the
orchestration
of one’s treatment, rather than passively being its object.
•
Among individuals declining to construct
a PAD, there was little trust in the
mental
health system.
•
PADs require intense training and
follow-up.
Impact
•
Further study is needed to assess
the system’s response to PADs.
Researchers: Michaela Amering, MD, Peter Stastny MD, Kim Hopper, Ph.D.
Publication: Amering M, Stastny
P, Hopper K (2005). Psychiatric advance directives:
qualitative
study of informed deliberations by mental health service users. British Journal
of Psychiatry, 186:247-252.
IV. 5.
Motherhood and Mental Illness Conference
Background In order to both call attention to this paucity of research on
mothers
with mental illness in the mental health system and to begin formulating
a
research agenda to redress it, the Center convened the Motherhood
and Mental
Illness Conference: How Systems Create Barriers
to Parenting in April 2003.
This
conference brought together multiple stakeholders from diverse sectors of
the
mental health sphere to discuss the ways in which public systems influence
parenting
among those with mental illness and to develop strategies for improving
and
integrating systems of care for mothers with mental illness and their families.
Accomplishment
Conference participants identified fundamental
barriers to
successful motherhood posed by the constellation
of systems that confront
families headed by mothers with mental illness.
Highlights
•
Mothers with mental illness have
been neglected within the very
systems
designed to serve them.
•
Most programs look at and work with
mothers as individuals,
excluding
their partners and children in the recovery process.
•
Lack of childcare makes mothers'
participation in program activities
and
gainful employment difficult to impossible.
•
The absence of insurance coverage
for mental health counseling
creates
a barrier to the access of preventative services.
•
Many barriers to help and innovation
exist within the legal framework
that
surrounds mothers with mental illness when they become
involved
in the multiple public systems.
•
Social and relational barriers also
exist, in the now-familiar form of
stigma
and as part of the trend in disintegrating family and social ties.
•
The need to do things differently,
to overcome the aforementioned
barriers
is critical to improving the outcomes of mothers and their
children.
•
Researchers, advocates, practitioners,
policy makers, consumers, and
others
who have a vested interest in the field need to ensure that the
various
factions of the social service system work collaboratively in
delivering
services to mothers and their children and overcome the
barriers
that impede success.
•
Participants in all of the workshops
agreed that too much energy is put
into
identifying what we do not have rather than what can we do
differently.
•
Proposals made included the creation
of multi-system interventions --
a
“continuity of care.” To do so will require the utilization of creative
grass
roots solutions like combining funding sources, waivers of
regulations,
inter-agency collaborations at local levels, and multidisciplinary
staff
training.
•
The parenting role needs to be addressed
within the recovery
paradigm.
Impact
•
Several attendees of this conference
meet on a regular basis to
discuss
and plan for future collaborative projects.
Conference Planning
Group:
Judith
Samuels, Nathan
Kline Institute: Chair
Andrea
Ault, Nathan
Kline Institute: Logistics Coordinator
Mary
Jane Alexander, Nathan Kline Institute
Susan
Barrow, NY
State Psychiatric Institute
Susan
Davidson, Gains Center, Policy Research Associates
Colleen
Gillespie, New York University
Denise
Juliano-Boult, National Institute of Mental Health
Terese
Lawinski, Nathan Kline Institute
Susan
Salasin, Substance
Abuse and Mental Health Service Administration
Beth
Shinn, New
York University
Lynn
Videka-Sherman, State University of New York, Albany
Beth
Weitzman, New York University
Publications
Blanch
AK, Nicholson J, Purcell J (1994). Parents with severe mental illness and
their
children: The need for human services integration. Journal of Mental Health
Administration, 21.4: 388-9
Hopper, K. et al. (1997). Homelessness, severe mental
illness, and the institutional circuit. Psychiatr.Serv, 48(5):59-65.
Nicholson J, Blanch, A (1994). Rehabilitation For Parenting Roles For People
With
Serious Mental Illness. Psychosocial Rehabilitation Journal 18:109-11.
IV. 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
Background. A virtually unknown domain of unmet need is the circumstances
of motherhood among
homeless women with severe mental illness residing apart from their
children in shelters for “single”
adults. Though early homeless studies had documented that a majority
of sheltered homeless women were
mothers and that many attached great significance to their parenting
roles, their needs as mothers were
largely invisible to both homeless service systems and to mental
health providers.
Accomplishment
The project confirmed the importance of parenting
issues for
homeless mothers with severe mental illness,
identified factors that fostered ongoing
contact, and documented the virtual absence
of service support for parenting by
separated homeless mothers. It also identified
the multiple systems that are involved in
lives of homeless women as a source of significant
barriers to parenting.
Highlights This project (1) analyzed existing data on sheltered women to examine
parenting
goals and service needs, mother-child contact, care-giving arrangements, and
reunification;
and (2) for a sample of currently homeless mothers, examined in greater
depth
the circumstances of separation, the children’s living arrangements, and the
parenting
process and goals from the multiple perspectives of the mothers, the caregivers
of
their children, the homeless service providers working with them on housing
and
mental
health issues, and providers of family and foster care services.
•
Among 80 separated mothers diagnosed
with severe mental disorders, a
majority
desired services to address contact and custody issues, hoped to
reunite
with their children, and maintained contact with at least one child.
•
Mothers who had been in drug treatment,
those receiving financial
entitlements,
and those whose own relatives were caring for their children
were
more likely than others to maintain contact with their children.
•
Two years after being referred to
a mental health case management
program,
slightly under half were housed in supportive or independent
housing,
but only 8% were living with any of their children.
•
While mothers were in contact with
a variety of service agencies, they
received
virtually no support for parenting from service providers;
moreover.
•
Conflicting demands of homeless
services, mental health providers,
substance
abuse treatment programs, child welfare agencies and family
courts
consistently impeded their efforts to remain involved with their
children.
Impact:
•
There is a need for providers of
homeless and mental health services to focus
attention
on parenting needs of mothers separated from their children.
•
A larger examination of conditions
and contexts of separations in homeless
families
with maternal mental illness or substance abuse is being conducted as a
site-specific
component of the Westchester site in SAMHSA’s Homeless Families
Program.
•
The development of a new line of
work on parenting capabilities as a central
domain
in recovery-focused approaches to mental health services is being
undertaken
as a result of this study.
Researcher Susan M. Barrow, Ph.D.
Publications
Barrow, Susan
M. (2004). Family separations and reunifications. In: D. Levinson (Ed.),
Encyclopedia of Homelessness. Thousand Oaks, CA: Sage, pp. 156-161.
Barrow, Susan M. & Lawinski, Terese (submitted). Conditions and
contexts of mother-child
separations in homeless families. Under review.
IV. 7 Creating
a Stake in Working
Background This study examines factors that increase the likelihood
of employment among persons with
mental illness who reside in supportive housing. This was part of
a nation wide study examining
employment initiatives at three supportive housing sites.
Accomplishment
Researchers found that providing employment
opportunities for
persons with severe mental illness enhances
their self-esteem, and may promote
recovery.
Highlights
•
During a two-year period at two
of the sites, residents – some with long-standing
problems
of substance use and/or psychiatric disorder – worked 7 to 8 months
longer
than they had in the two years before the initiative.
•
When employment opportunities were
offered, persons with mental illness
consistently
expressed their willingness to work.
•
In creating a stake in working,
several factors seemed to make a difference to
various
residents: the necessity to earn income in order to sustain a rent subsidy;
the
desire to renew family ties; the wish to undo the status of “second-class”
citizenship
that comes with not working; and the need to test one’s own progress
in
recovery and move toward a more normal life.
•
Success in the workplace was more
likely when business made affirmative efforts
to
accommodate persons with severe mental illness.
Impact
•
Both supported employment and affirmative
enterprises (businesses established to
employ
persons with disabilities) should be encouraged in order to boost working
rates
among persons with severe psychiatric disorders.
•
The distinction between disability-related
difficulties and “social skill” deficits
can
be a tricky one. Employers may need ongoing assistance (perhaps through
designated
“brokers”) to ensure skill development and job retention.
Researcher: Kim Hopper, Ph.D.
Publication:
Hopper
K, Rog DJ, Holupka CS, Davidson C, Lester R, Roy K (1997, 1998).
Documenting
and evaluating. Next step: Jobs. Interim and final reports to the Corporation
for
Supportive Housing, New York.
IV.8 Employment
Profiles of Persons with Severe Mental Illness in the Workforce
Background It is important to document that people with mental illness
can work. Findings from national
surveys of employed persons with mental illness conducted between
1984 and 1991 were analyzed to
answer questions of who is working, and what factors increase the
likelihood of employment.*
Accomplishment:
Analysts found sizeable proportions of persons
with mental illness
hold gainful employment; some have substantial
earnings.
Highlights Data were used from the Institute for Social Research, Survey Research
Center
(1992),National comorbidity survey; National Center for Health Statistics
(1991,
1996),
the public use data files for the mental health supplements to the 1989 and
1994
National
Health Interview Surveys. Hyattsville MD: Division of Health Interview
Statistic.;
National Institute of Mental Health (1992)and the ECA study public use data
tape
NTIO #PB 92-503481. Employment and earning rates for persons with severe
mental
illness vary by DSM diagnostic criteria. Variables that especially increased
the
probability
of employment and greater earning capacity were participation in outpatient
therapy,
abatement of symptoms, and the number of years that had elapsed since
symptom
relief. However, whether or not a person received psychotropic medication
did
not
significantly correlate to employment.
•
High rates of employment were noted
for individuals diagnosed with major
depression
(64%), and bipolar disorder (64%).
•
Earned annual wages for those with
bipolar disorder ($20,315) by standards for
the
period analyzed were greater than for the general population.
•
Individuals with substance and alcohol
abuse disorders also had employment rates
at
the high end of the scale.
•
Individuals diagnosed with schizophrenia
had the lowest employment rate (43%),
and
least earnings ($10,761).
•
Persons with anxiety and affective
disorder also had relatively low employment
rates.
Impact
To
aid in destigmatizing campaigns, it is important to document that people with
disabilities
can work.
Researchers: David O’Neill, Ph.D., David N.Bertollo, BA.
Publications: O’Neill D, Bertollo
D (1998). Work and mental illness: Perspectives from
three
national surveys. Administration and Policy in Mental Health, 25:3.
V.1 Potential
for Cost Shifting under Parity Legislation
Background A feared negative consequence of parity legislation to equalize
mental health benefits with
those provided for other illness is that private insurers may find
ways to exclude enrollees or their
dependents with severe mental illness, effectively shifting costs
from the private to the public sector. This
is based on their belief that under parity legislation their costs
for mental health benefits would increase as
individuals make greater use of their private insurance for mental
health benefits.
Accomplishment:
The scene before the enactment of parity legislation
finds that there
is a pattern of movement from the private to
the public sector. Response to parity
legislation needs to take into account this
“baseline” movement.
Highlights Researchers analyzed the cost interface between the private and public
sectors
for two periods preceding the implementation of parity. Focus was on privately
insured
specialty mental health users that included a high percentage of persons
diagnosed
with severe mental illness, within two counties – urban and rural – in New
York
State. Data analyzed were on services received and paid for through indemnity
insurance,
HMO, public, or self- pay arrangements. Findings were submitted to NIMH
and
were included in their report to Congress on parity.
•
While the number of persons shifting
from private to public payers was minimal,
the
two year period, the rate increased.
•
A greater number of persons, often
those incurring high service costs, shifted
from
private to shared private/public payers and the rate increased over time.
Persons
in this group more often included the dependents of insured persons,
younger
individuals, members of cultural minorities, and those with substance
abuse
problems.
Impact
•
Public payers will be able to make
use of this information to refine estimates of
desirable
capacities and expected mental health costs for publicly funded services.
This
information will be helpful in negotiating rates for contracted services with
for-profit
and not for-profit providers and behavioral health care entities.
•
Legislators need to be aware of
the potential for private insurers to exclude
dependents
with mental illness from their plans.
Researchers: Carole Siegel, Ph.D., Judy Samuels, Ph.D., Joseph Wanderling, MS
Publication: Siegel, C, Samuels
J, Wanderling J (2001). Cost-shifting from private to
public
payers: The scene before parity legislation. Journal of Mental Health Policy and
Economics, 4:17-23.
V.2 How
to Estimate Capacity Requirements for Mental Health Services Post-
Disaster
Background In the chaotic aftermath of a disaster, authorities are faced
with the need to provide an
extensive array of services to the affected population, as occurred
following the 9/11 WTC crisis in New
York when mental health and other related support systems mobilized
to deliver services to persons
impacted by the event.
Accomplishment
A mathematical algorithm to estimate the extended
mental health
needs and service capacities required in the
event of unforeseen disasters was specified.
Highlights Planning efforts require estimates of both anticipated mental health
needs
and
the mental health system’s capacity to respond to this need. While many formal
systems
can describe their current capacities, sparse data exist on current services
and
supports
used by people with mental health problems outside of these. Also, no
systematically
collected data are available on mental health needs and services offered
following
disasters impeding planning for the future.
•
Extended capacity requirements is
a function of the number of persons affected
and
the number of anticipated services that will need.
•
Systematic data collection efforts
on persons affected and services offered
following
disasters on the national, regional and local levels are needed to
enhance
effective planning.
•
Surveys are needed to determine
resources where people turn for help outside of
the
formal mental health system. The extent of assistance by the non-mental
health
sector in offering helping services needs to be understood and included in
planning
efforts. Clergy, native healers and other non-traditional service providers
need
to be consulted and included in planning for anticipated mental health needs.
Impact
•
This project led to the two projects
described below.
Researchers: Carole Siegel, Ph.D., Eugene Laska, Ph.D., Morris Meisner, Ph.D.
Publications:
Siegel
C, Laska E, Meisner M (2004). Estimated capacity requirements for mental health
services
after a disaster has occurred: A call for new data. American Journal of Public
Health, 94(4) 582-5.
V.3 Estimation
of Additional Capacity of the Mental Health Sector to meet
Extended
Service Demands
Background Budgets appropriated either nationally or locally to respond
to the mental health needs of
populations following disasters should be based on a reasonable model
to provide data estimates.
Accomplishments
An estimate of the ability of the NYC specialty
mental health system
to respond to mental health needs in the wake
of 9/11 in terms of deployment of “first responder”
existing staff was simulated and indicated
that considerable shortfalls
would occur if only existing OMH resources
were deployed.
Highlight Unexplainable variation in clinical service delivery rates suggested
that
clinical
production rates could be increased. But even with increased production,
substantial
shortfalls remain.
•
Percent increase in services that could
be produced was conservatively estimated
at
12% resulting in a simulated 6-month shortfall of 77%. This was based on a
population
estimate of need of 3%.
Impact
•
The estimates suggest that additional funding
and personnel are needed to provide
mental
health services in the event of a major disaster
•
A disaster plan is needed to coordinate
the use of current and additional personnel
including
mental health resources from other sources and sectors
Publication Siegel C, Wanderling
J, Laksa E (2004). Coping with disasters: Estimation
of
additional capacity of the mental health sector to meet extended service demands.
Journal Mental Health Policy and Economics, 7(1):29-35.
49
V.4 Working
Clergy and Mental Health
Background The long – and long-troubled – relationships between working
clergy and formal mental
health providers has received little attention from the mental health
side. Concerns about inventorying
informal resources as part of public disaster preparedness may be
changing that. This project was
undertaken under contract to the New York City Department of Health
and Mental Hygiene (DOHMH) to
provide information from front-line faith-based sources of care to
assist them in developing the mental
health components of a disaster preparedness plan for the City of
New York. Interviews were geared
toward assessing self-perceived need for, and interest in, psychiatric
expertise as it bears upon pastoral care
under both ordinary and crisis circumstances. Two intertwined projects
resulted: the first sought a
provisional assessment of the mental health-related training and
consultation needs of everyday working
clergy; the second was a targeted assessment of the clergy’s prospective
role in the mental health aspects of
disaster preparedness.
Accomplishment
These paired studies sought to identify and
provisionally assess the
strengths of working clergy as mental health
service providers and referral sources –
and their potential in disaster preparedness
especially – and the likely sources of
difficulty in seeking to enhance these strengths
and develop that potential.
Highlights In the first phase, prospective interviewees were identified in snowball
fashion,
beginning with critically-placed key informants, who held responsible positions
in
teaching institutions or faith-based “trade organizations.” Most were in community
congregations;
a few were hospital-based. Some had parallel therapeutic practices, in
additional
to the congregational responsibilities. And a few were clergy specializing
in
disaster-related
trauma relief. Using a semi-structured interview guide, we interviewed 26
clergy
members, from Islamic, Episcopalian, Baptist, Lutheran, Buddhist, Jewish,
Roman
Catholic
and Presbyterian associations. Interviews were almost all in person (a few
were
conducted
by telephone), lasted roughly an hour, and were typically done in teams of
two.
Structured summaries were prepared for each interview, which were then read
and
coded
independently by 3 team members, who then met to discuss readings and reach
consensus
on a common coding protocol.
Five themes emerged:
•
Everyday practice deals with practical
survival issues and (non-stigmatizing) help
for
emotional/family problems as much as spiritual crises.
•
Self perceived mental health training
and competency range widely, and affect
ease
with which need for appropriate referrals was assessed.
•
Great variation in referral resources/practice
reflects prior training and networking
–
but little affirmative outreach seems expected from the mental health system.
Informal
referral advice from congregation members raises confidentiality issues.
•
Prospects to enhance experience
and training were received favorably, not only to
improve
pastoral role but self-care as well.
•
Prospective role of mental health
system.
Phase 2 focused on disaster preparedness and was conducted through a year
of field
study,
conference work, and interviews. Interviewees were identified in snowball
fashion;
we
were looking for experienced key informants who have a bird’s eye view of
the
relationship
between disaster mental health and clergy. Some of the ensuing
conversations
took the form of formal interview, during which we took notes and
peppered
sources with questions (as with 10 organizational leaders in NYC). Many more
took
the form of conversations, over the electronic transom, over lunch, or at
the three
conferences
at which the clergy’s role in disaster preparedness was explicitly addressed.
Impact
With
respect to everyday work:
•
Despite a wide range of training
and experience, all working clergy evinced keen
interest
in enhancing mental health literacy and skills – if only referral.
•
Religious clergy are positioned
(and perceived) to offer non-stigmatized help for
problems
for which some people would only reluctantly seek help for otherwise.
•
Despite recognizing a need for greater
collaboration, clergy remain skeptical of
the
formal mental health, suspecting that it sees clerical counterparts as second
class
providers.
•
Working collaboratively with indigenous
experts – clergy trained in pastoral
counseling
and/or psychotherapy as well as those with extensive teaching
experience
– could bridge that breach and offer regular training, upgrading of
relevant
skills, and referral assistance.
•
A singular challenge (identified
but unmet during our interview process) is
reaching
the more marginalized (or less affiliated) “storefront” churches,
ministers
and congregations, especially in communities of recent immigrants.
With
respect to disaster preparedness:
•
Specific tools, developed collaboratively
with members of the religious
community
– curricula, information sheets, resource directories, and guidelines in
dealing
with mental health, disaster and terrorism – would be helpful.
•
Again, great collaboration between
religious groups and formal mental health
system
is needed well in advance of the heightened needs of disaster response.
•
Preparedness should build on existing
networks of community based
organizations
(CBO) and religious groups.
•
Providing pragmatic training resources
for clergy that helps to educate them about
the
wider network of service resources would be important first step to meeting
service
gaps
Researchers Kim Hopper, PhD, Joshua Moses, M.A., Alix Teleki, M.A., Rachel Jones
V1.1 Emergency
Room Decision Making
Background Emergency rooms are one of the primary portals of care into
inpatient care of persons with
mental illness. The way in which emergency room makes decisions regarding
admission were not that well
understood. This study was undertaken to examine whether clinical
decisions to admit persons with
persistent and severe mental disorder into inpatient care are based
on systematic criteria.
Accomplishment
Generally acceptable criteria were delineated.
Decision models
based on these were developed and shown to
accurately predict clinical determinations
about which persons seen in psychiatric emergency
rooms need to be admitted to
inpatient care.
Highlights
•
Based on assessments of more than
400 patients seen in four psychiatric
emergency
rooms, Center investigators developed a model to predict an
emergency
room physician’s decision to admit a person with severe mental
disorder
to inpatient care.
•
When tested, the model accurately
predicted 85% of actual decisions (87.5%
when
adjusted for variations among facilities).
•
Predictor variables include danger
to self, psychosis, ability to care for self,
impulse
control, psychopathology, depression, collateral contacts (family/ police/
community),
substance abuse, social support and client’s dispositional factors.
•
Predictor variables with high reliability
included those that measured: psychosis
(68.4%),
substance abuse (64.9%), and social support (55.2%).
•
Predictor variables with less reliability
included: measures of impulse control
(30.6%),
psychopathology (31.1%), and danger to self (32.9%).
Impact
•
Decision models -- based on statistical
models and expert consensus validation –
should
be used to contribute to the education and training of clinicians.
•
Decision making tools based on these
models should be used to improve the
quality
of decision making for individuals who are in psychiatric crisis.
Investigators: Bruce B. Way, Ph.D., Jeryl Mumpower, Ph.D., Thomas Stewart, Ph.D.
Publication:
Way
BB, Allen MH, Mumpower JL, et al. (1998). Inter-rater agreement among
psychiatrists
in psychiatric emergency assessments. American Journal of Psychiatry
155(10):1423-1428.
VI. 2 Risk
Assessment
Background In the United Kingdom, an increase in violence and homicides
within the mental health
services has been noted. Risk assessment has gained in importance
as a tool for determining entry to mental
health services. Inquiries by multi-disciplinary panels have focused
on appraisal of predictability and risk.
The recommendations of such inquiry reports have been central to
installing risk assessment at the centre of
UK mental health practice. Question is raised about its implication
for mental health practice in the United
States.
Accomplishment
A visiting Fulbright scholar at the Center
analyzed the implications
of using risk assessment as the de-facto gateway
to mental health services in the
United Kingdom. Questions are raised about
its implications elsewhere.
Highlights Since the early 1990s, the UK has seen a remarkable growth in specialist
mental
health services for offenders with mental disorders. While community treatment
and
a recovery perspective dominate the published agenda for service development,
in
practice
resources have followed people assessed as presenting a high risk to others.
The
centrality
of risk management has extended to mental health services generally. This
study
aimed to locate clinical ideas of risk in mental health within the theoretical
context
of
sociological Risk Society theory, describe how of ideas of risk influence
entry to
mental
health services, clinical practice and the service implications both for people
assessed
as high risk and those assessed as outside the high risk domain, and provide
a
critique
of the service focus on individual risk from a public health perspective.
•
Within the United Kingdom, risk
assessment is evolving to become the gateway
to
accessing mental health services.
•
Risk assessment in mental health
is assuming the role once occupied by diagnosis,
placing
under surveillance every aspect of service users’ lives. Theories of risk
culture
are altering the clientele and social function of psychiatry.
•
It is likely that at a later stage
the day-to-day clinical dimensions of risk will be
explored
in structured interviews. This may include also an exploration of the
clinical
dimensions of trust, on the hypothesis that at the level of individual
interaction,
trust strategies present an alternative or complement to risk strategies.
•
Comparative analyses of UK and US
approaches in mental health should yield
lessons
for both systems.
Researcher: John Wilkinson, Asst. Director for Mental Health, Northeast London
Strategic
Health Authority, UK, was on a Fulbright fellowship at this Center in 2003-4.
Publication: Wilkerson J (2004).
Health – the politics of risk and trust in mental health.
Critical Quarterly, 46(3):133-50.
VII.1 Mental
Health Indices
Background While indicators of mental health conditions abound, an index
that aggregates
multiple indicators might be of help in trending the course of service
development , use and
outcomes.
Accomplishment Two interrelated indices were designed for
New York City: A Mental
Health Index to measure the status of persons
with mental illness; and a Social and
Mental Well Being Index to measure the status
of residents of the community at large
While the project was conducted for NYC, the
methodology can be adapted for other
communities.
Highlights A conceptual model was developed to describe the relationship between
community
mental health and well being outcomes and the domains of influence on these
outcomes.
The model is based on two premises: (i) the socio-economic environment of
a
community
impacts the social and mental well being of its constituents and their risk
for
mental
illness; and (ii) the provision of social and economic support systems and
behavioral
services improves a community's well being and the outcomes of mental
illness.
For each index, a set of factors was selected to characterize the domains
and
indicators
to characterize each factor. The domains included were socio-economic, needs
(represented
by the prevalence of mental illness and the size of the community
population),
supports available, and outcome represented by the quality of life for the
community
at large and for those with mental illness. The project was funded through
the
New
York City Department of Mental Health, Mental Retardation and Alcoholism
Services
(DMHMRAS).
An application of the indices showed:
•
For the period from 1991 to 1996,
the Mental Health Index increased by 11%
over
its base year, reflecting a major increase in the availability of community
supports
and programs for persons with mental illness, and a moderate growth in
attaining
desirable social outcomes.
•
For the same period, the Social
and Mental Well Being Index increased 12% over
its
base year, reflecting an expansion of social programs for the community at
large
and a high degree of positive social outcomes.
•
For the years studied, the indexes
correlated well with the historical record of the
time:
an improved quality of life for New York City residents marked by reduced
crime,
homicides, suicides, deaths from unnatural causes, and improved housing
and
employment conditions.
Researchers: Carole Siegel, Ph.D., David O'Neill, Ph.D., Kristine Jones, Ph.D.,
Eugene
Laska,
Ph.D., Morris Meisner, Ph.D., Judith Samuels, Ph.D., Gary Haugland, M.A
Publications: Siegel, C., et
al. (1998), The Development and Construction of Two
Community Indices of Mental Health and Social and Mental Well Being.
Final Contract
Report
to the New York City Department of Mental Health, Mental Retardation and
Alcoholism
Services.
Siegel,
C., Laska, E., Haugland, G., O’Neill, D., Cohen, N., Lesser, M (2000). The
construction
of community indexes of mental health and social and mental well being and
their
application to New York City, Evaluation and Program Planning 23:315-327.
VII.2 –
VII.5. Cost Effectiveness Research
Background Intervention studies in health services research are greatly
enhanced when they contain a
cost-effectiveness component. These series of projects focused on
expanding the statistical methodologies
for conducting cost effectiveness analyses.
Accomplishment
Methodologies were developed for analyzing
cost and effectiveness
data in intervention trials in health services
research studies. Statistical programs were
Highlights
• VII.2. Statistical Methods for Cost-Effectiveness
Analyses
o
A statistical framework for examining
cost and effect data on competing
interventions
obtained either from a randomized clinical trial (RCT) or an
observational
study to define cost-effectiveness (c-e) measures was
described.
Several new c-e measures are proposed that utilize the linkage
between
costs and effects on the patient level.
o
The cost-effectiveness of interventions
are assessed statistically in a two
stage
procedure that (1) eliminates clearly inferior interventions, and (2)
then
rank orders according to a c-e preference measure.
o
These techniques provide methods
for obtaining confidence intervals, for
testing
the hypothesis of admissibility and for the equality of
interventions,
and for ranking interventions.
o
A procedure has been programmed
in both SAS and Mathematica.
• VII.3 Sequential Decision
Making in Cost-Effective Analyses
o
For resource allocation under a
constrained budget, optimal decision rules
have
been given for independent, mutually exclusive, and independent
clusters
of mutually exclusive programs. Each program has associated
with
it a cost and effectiveness. We treat an arbitrary complex structure
that
describes hierarchical interrelationships among mutually exclusive
and
independent programs.
o
A procedure for obtaining an optimal
resource allocation for complex
structures
has been programmed in Mathematica (version 3.0).
• VII.4 Statistical Cost-Effectiveness
Analysis of Treatments Based on Net
Health Benefits
o
Statistical methods are given for
producing a cost-effectiveness frontier
for
an arbitrary number of programs. In the deterministic case, the net
health
benefit (NHB) decision rule is optimal; the rule funds the program
with
the largest
positive NHB
at each l, the amount a decision-maker is
willing
to pay (WTP) for an additional unit of effectiveness.
o
A Mathematica program has been developed
for this procedure.
56
• VII.5 The Family-wise Error
Rate of a Simultaneous Confidence Band for
the Net Health Benefit Function
o
There is considerable interest in
the use of net health benefit (NHB) for
decision
making in cost-effectiveness analysis. The method developed
derives
a pointwise error rate (PWER) and a family wise error rate
(FWER).
o
Procedures have been programmed
in Mathematica.
Researchers: Eugene Laska, Ph.D., Carole Siegel, Ph.D., Morris Meisner, Ph.D.,
Joseph
Wanderling, MA.
Publications:
Brent
RJ (2004). The role of public and private transfers in the cost-benefit analysis
of
mental health programs. Health Economics, 13(11): 1125-1136.
Siegel
C, et al.
(1996). Statistical
Methods for Cost-Effectiveness Analyses.
Controlled Clinical Trials, 17:387-406.
Laska
E, Meisner M, Siegel C, Wanderling, J (2001). Statistical Cost-Effectiveness
Analysis
of Two Treatments Based on Net Health Benefits. Statistics in Medicine,
20:1279-1302.
Laska
E, Meisner M, Siegel C, Wanderling, J (2001). Statistical
Determination
of a Cost-Effectiveness Frontier Based on Net Health Benefits.
Health Economics, 11(3):249-264.
Meisner
M, Laska E, Siegel C, Wanderling, J. (2001). The familywise error rate of
a
simultaneous
confidence band for the net health benefit function. Health Economics,
11(3):275-280.
Laska
E, Meisner M, Siegel C. Statistics and experimental design. In: Sadock BJ,
Sadock
VA eds., (2005). Kaplan & Sadock's Comprehensive Textbook of Psychiatry,
8th edition. Lippincott Willias & Wilkins, pp. 672-686.
57
VII. 6 Counting
Methods for Multiple list problems
Background Population size counts are necessary for administering and
planning cost-effective mental
health programs. Methods for statistically estimating the size of
a population are required when no simple
way exists for full enumeration or when only limited information
is available.
Accomplishment
The method applies to obtaining unduplicated
counts of persons
on more than one list. The multiple list method
has been applied to count persons
served by multiple systems. It also has been
formulated to apply to those who appear
on a capture and recapture list and has been
used to count homeless persons.
Highlights
•
Considered was a common situation
in mental health in which confidentiality
constraints
limit the information available to the date of birth of each individual
on
each list. A method was developed to estimate the number of individuals on
both
lists. The method was based on the number of individuals on one list whose
birth-dates
coincide with a birth date of an individual on the other list. This
statistic
enables calculation of an estimate of the number in common to both lists.
Using
the sample distributions of observed birth dates and conditioning on the
size
of each list we write the likelihood of the observations. From this, the
maximum
likelihood estimates of the size of the population, the probabilities of
appearing
on each list and the asymptotic variances of these estimators can be
obtained
numerically.
Impact
•
The need for protection of the privacy
of individuals may prevent sharing
identifying
information, yet it is important for the payers and managers of mental
health
systems to be aware of the number of individuals who use multiple
resources,
as well as the number in their catchment area who are mentally ill.
Without
compromising their confidentiality obligations, limited information such
as
gender, county of residence and date of birth of each individual served by
their
respective
system may be provided enabling the application of the above methods.
•
The methodology developed has found
practical application in a comparison
study
of veterans receiving services from the Dept. of Veterans’ Affairs and/or
the
NYS
Office of Mental Health.
•
Plant/capture methods were used
to count NYC homeless in the NYC 2005 count
of
the homeless.
Researchers: Eugene Laska, Ph.D., Morris Meisner, Ph.D, Carole Siegel, Ph.D.,
Joseph
Wanderling,
MA
Publication: Laska EM, Meisner
M, Wanderling J., Siegel C. (2003). Estimating
duplication
rate and population size based only on birth dates. Statistics in Medicine,
