"It's Stable but Not Stable": A Conceptual Framework of Subjective Housing Stability Definition Among Individuals with Co-occurring Mental Health and Substance Use Disorders.

Objective: Despite increasing efforts to improve housing stability, research has largely defined housing stability in a narrow sense and heavily relied on objective measures, such as housing types and housing duration. The present study constructed a conceptual framework for a subjective housing stability definition from the perspectives of individuals with co-occurring mental health and substance use disorders and their behavioral health service providers. Methods: Following the principles of grounded theory, we collected and analyzed qualitative data through semistructured interviews with 24 individuals with serious mental illness and substance use problems and three focus groups with 22 behavioral health service providers. Results: We developed a conceptual framework with two domains of subjective housing stability: functional stability and experiential stability. The functional stability domain includes four theoretical concepts: meeting basic needs, housing quality, housing affordability, and housing permanence. The experiential stability domain includes four theoretical concepts: autonomy and independence, connectedness, safety, and supportiveness. Conclusions: The conceptual framework can inform future research, practices, and policies to move beyond focusing on merely providing housing to consider the diverse and underlying needs in improving housing stability and well-being among those experiencing or at risk of housing instability.

Managing substance use for clients with serious mental illnesses: Knowledge, attitude, and training challenges among outpatient behavioral health providers in California, Ohio, and New York.

PURPOSE: Individuals with serious mental illness have high rates of substance use. The most commonly used substances among this population are alcohol and cannabis, and whether clinical providers delivering mental health services feel adequately prepared to address substance use is unclear. While information about the effects of alcohol are well established, the effects of cannabis are less well known and staff may feel less confident in their abilities to assess its use and may rely on more informal sources to learn about it. METHODS: Mental health agencies in three states (California, Ohio, and New York) surveyed their staff (n =717) to explore their knowledge, training, and expertise in assessment of substance use generally as well as cannabis and alcohol specifically. RESULTS: Overall, providers felt more prepared to address their clients' alcohol use than cannabis use. In between-state comparisons, California providers felt significantly less well prepared to assess, discuss, and refer their clients to treatment compared to Ohio and New York providers. Using a series of multi-categorical mediation models, we confirmed that deficits in training for these specific substances largely accounted for between-state differences in assessment, capacity, and treatment. CONCLUSIONS: Substance use training to address the service needs of individuals with co-occurring disorders is insufficient and a significant need exists for systemic changes to workforce training of community mental health providers.

Definitions of Community for Individuals with Serious Mental Illnesses: Implications for Community Integration and Recovery.

While recent work on community integration for individuals with serious mental illnesses (SMIs) has focused on the multi-dimensionality of community integration, it has not been fully rooted in how consumers define and experience communities for themselves. Guided by symbolic interactionism theory, the goal of the present study is to explore definitions of community as provided by individuals with SMIs, and to incorporate those definitions into a theoretical framework of community to inform community integration efforts in the context of mental health services and recovery. Semi-structured interviews were conducted between November 2017 and September 2018 with 90 racially/ethnically diverse participants who were 18 years and older with an SMI and receiving community mental health services. Interviews were audio-recorded, transcribed, and analyzed using ResearchTalk's "Sort and Sift, Think and Shift" methodology. Themes derived from participants' definitions of community included a structural aspect of people and places; a functional aspect of socializing, helping and receiving resources; and an experiential aspect of shared struggles and experiences, finding safety, and identifying with others. To this end, we propose a Structural, Functional and Experiential (SFE) model of community. The SFE model of community provides a conceptual framework and guidance for clinicians, researchers, policy makers and service stakeholders regarding the complexity and variability of community for their consumers, which is essential to their recovery. Application of the SFE framework for assessment and intervention is discussed.

Forty-five years later: the challenge of optimizing assertive community treatment.

PURPOSE OF REVIEW: Assertive Community Treatment is an established evidenced based practice that provides intensive community treatment for individuals with severe mental illness with recurrent hospitalizations and/or homelessness. Emerging evidence indicates limitations in its implementation in terms of to the original ACT model and its current relevance. RECENT FINDINGS: Findings from recent studies (2018-2020) reveals challenges with implementation centered around basic implementation activities, such as changes in the psychosocial context of individuals with SMI, clinicians' abilities to demonstrate competencies with new practices, and ongoing evolution of mental health systems of care worldwide. Intermediary and purveyor organizations (IPO) can provide the infrastructure to support the spread of EBPs while addressing challenges and opportunities. Thus, implementation of ACT can be accomplished when employing a rigorous framework and infrastructure that can synthesize and translate science relevant for practice. SUMMARY: The relevance of ACT depends on its implementation that is responsive to change. An implementation science-informed approach is key to providing ACT to individuals in the critical space between the hospital and community. With this approach, we can optimize ACT as a service delivery vehicle by careful analysis of how best to furnish and evaluate the latest, most effective and efficient treatments, rehabilitation and support services.

Giving Back to Families: Evidence and Predictors of Persons with Serious Mental Illness Contributing Help and Support to Families.

Persons with serious mental illness (SMI) often rely on family for significant assistance and support, but the contributions made by persons with SMI to their families have been overlooked. This study assessed the extent to which persons with SMI contribute help or support to their families and identified significant predictors of contribution using an analysis of 1 year of clinicians' electronic health record (EHR) notes. EHR notes with reference to families of 226 Veterans with SMI were extracted and classified as suggesting help being given to and/or received from families. Forty-one percent of the sample contributed to family in a variety of ways. More frequent contact with family and being female were significant predictors of contribution. This study underlines the potential for reciprocal relationships within families of individuals with SMI. Clinicians can help clients and families maximize the support they provide to one another and possibly improve outcomes.

Time in Assertive Community Treatment: A Statewide Quality Improvement Initiative to Reduce Length of Participation.

The investigators describe a New York State initiative to increase flow through assertive community treatment (ACT) while encouraging transition to less intensive services. This initiative began as ACT approached full capacity and as evidence emerged that participants can sustain recovery post-ACT. Comparison of performance indicators over time showed that time in ACT decreased, turnover rate increased, and the percentage of ACT participants who met treatment objectives rose. Also, post-ACT rates of ambulatory behavioral health follow-up increased while rates of psychiatric inpatient hospitalization decreased. Monitoring utilization of services while demonstrating positive outcomes has become increasingly critical as states shift to managed health care.

Adoption of a Blended Training Curriculum for ACT in New York State.

Scant evidence exists in the literature for best practices in training assertive community treatment (ACT) teams to deliver highly effective services to consumers. This column describes a blended training curriculum, which includes both face-to-face and distance learning strategies, developed by the ACT Training Institute in New York State to meet the ongoing training needs of teams across New York State. Data on training uptake, which has steadily increased over time, are reported. The role of the state is crucial in driving adoption of training activities. The column also describes how the ACT Training Institute uses fidelity and outcome data to identify training needs.

Using incentives for training participation.

TOPIC: This column describes how public partners can help incentivize participation in training. Specifically, a state mental health agency and its implementation center applied financial and nonfinancial incentives to encourage participation in training and implementation supports. PURPOSE: Although training is not sufficient to change practice, it is a necessary first step in implementing evidence-based treatments. Finding ways to incentivize participation, particularly strategies with minimal resource involvement, is important for the psychiatric rehabilitation workforce and cash-strapped public systems. SOURCES USED: This description draws from published material and experiences from New York State. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Engaging public partners to incentivize training can significantly increase participation in training. Incentive programs exist that do not require additional funding-an important consideration, given the fiscal climate for most public payers.

Moving toward integrated health: an opportunity for social work.

With the passage of the Patient Protection and Affordable Care Act (PPACA) and ongoing health care reform efforts, this is a critical time for the social work profession. The approaches and values embedded in health care reform are congruent with social work. One strategy is to improve care for people with co-morbid and chronic illnesses by integrating primary care and behavioral health services. This paper defines integrated health and how the PPACA promotes integrated health care through system redesign and payment reform. We consider how social workers can prepare for health care reform and discuss the implications of these changes for the future of the profession.

Scaling up evidence-based behavioral health care practices in New York state.

This column describes the Center for Practice Innovations (CPI), which was created in 2007 by the New York State Office of Mental Health and the Department of Psychiatry at Columbia University. CPI uses innovative approaches to build stakeholder collaborations, develop and maintain practitioners' expertise, and build agency infrastructures that support implementing and sustaining evidence-based practices. CPI's five core initiatives provide training in co-occurring mental and substance use disorders, assertive community treatment, supported employment and education, wellness self-management, and treatment of first-episode psychosis. Central to CPI's activities are award-winning training modules, statewide learning collaboratives, and use of a learning management system.

Economic expenditures associated with instrumental caregiving roles of adult siblings of persons with severe mental illness.

Siblings of persons with mental illness who assume primary caregiving roles experience substantial and tangible economic impacts associated with this responsibility. This study investigated mailed survey responses collected from 156 adult siblings of persons with mental illness from New York State to examine instrumental costs associated with providing support to siblings with illness. Genders of both siblings, severity of the relatives' mental illness, and number of surviving parents in the family distinguished those occupying primary caregiving responsibility from those not in primary roles. Current caregivers incurred greater instrumental costs in the form of financial expenses, time spent in care activities, and crisis involvement than did those who were not primary care providers. Additional demographic and behavioral factors related to siblings with and without illness were associated with specific dimensions of instrumental expenditure. As siblings become increasingly engaged in caregiving, social service professionals must assume leadership in promoting programs and policies that meaningfully support family involvement for relatives with mental illness.

Sibling perspectives on severe mental illness: reflections on self and family.

Through focus group interviews, participants were asked to describe the impact over time of having a sibling with severe mental illness. Transcript content was then organized into categories and overarching themes using grounded-theory analysis. Respondents' personal and interpersonal experiences are presented, along with suggestions for professional outreach and further research.

How siblings of those with severe mental illness perceive services and support.

This study examines the complex and varied effects associated with having a brother or sister with a severe and persistent mental illness (SPMI) on the lives of adult siblings without chronic disability. Through five focus group interviews, 19 participants were asked to describe the impact that having a brother or sister with mental illness had on their lives. Codes and categories derived from the text of the transcribed interviews were grouped into broad themes. The respondents described the manifestations and challenges of contending with the SPMI of an adult sibling. They focused on gaps in services and communication with mental health providers, particularly with regard to timing of interventions and identifying readiness for treatment, as well as their own mental health needs. The article concludes with a discussion of the increased need for exchange of information and clarity of communication among family members and providers, following best practice guidelines that are well documented but not well implemented.

Evaluating awareness of New York's Assisted Outpatient Treatment Law among adult siblings of persons with mental illness.

This study examined knowledge of New York's Assisted Outpatient Treatment law, enacted November 1999, among adult siblings of persons with mental illness. Mailed survey responses collected between April, 2000 and September, 2001 from 100 siblings residing in New York State were reviewed. Only 48% acknowledged familiarity with the law. Possessing higher education, reading about mental illness more often, planning to occupy future caregiving roles, maintaining membership in a support group, and reporting that their siblings experienced more difficulties with treatment compliance were associated with a familiarity with the law. Among those aware of the law, two thirds incorrectly believed eligibility for a court order was contingent on a history of violent behavior. Low rates of general awareness and knowledge of the law highlight the need for further community education.