Strategies for disseminating evidence-based practices to staff who treat people with serious mental illness.

Evidence-based practices have not been widely implemented in real-world treatment settings for several reasons, including existing state laws, administrative policies, funding priorities, advocates' concerns, and program staffing. Dissemination strategies focus largely on program staffing and the question of why treatment teams that are responsible for assisting people with serious mental illness fail to use evidence-based practices. In a review of the research literature, two barriers to staff dissemination emerge: individual service providers lack the necessary knowledge and skills to assimilate these practices, and certain organizational dynamics undermine the treatment teams' ability to implement and maintain innovative approaches. Three sets of strategies are useful for overcoming these barriers and fostering dissemination: packaging evidence-based practices so that specific interventions are more accessible and user-friendly to service providers; educating providers about relevant knowledge and skills; and addressing the organizational dynamics of the team to facilitate the implementation of innovations. Research on dissemination is relatively new and is less well developed than the clinical and services research enterprise that has led to evidence-based practices. Implications for future studies are discussed.

Motivational interviews as goal assessment for persons with psychiatric disability.

A necessary first step in the psychosocial treatment of persons with severe mental illness is helping them identify their goals. Unfortunately, goal assessment is often viewed as a categorical process in which individuals list needs for which they require services. Motivational interviews provide a more sophisticated approach in which persons specify the costs and benefits to each of the needs in the list. Benefits define the reasons why a person should pursue a goal; costs define barriers to achieving that goal. The basic mechanisms for understanding and implementing motivational interviews are summarized. Ways to circumvent barriers to motivational interviews are also discussed.

Staff attitudes that impede the implementation of behavioral treatment programs.

Staff who have negative attitudes about behavioral treatments are less likely to implement them. Previous research suggests that negative attitudes are associated with staff burnout and perceived collegial support. A path analysis is conducted in this study to determine the direction of these effects. Ninety staff members who work in treatment programs for severely mentally ill adults completed measures of attitudes about behavior therapy, experience with behavior therapy, burnout, and collegial support. Results of the path analysis yielded a model with good fit that confirmed our hypotheses; namely, burnout leads to negative attitudes and experience with behavior therapy yields positive attitudes. Insufficient collegial support leads to negative attitudes through burnout. Implications of these findings for improving the use of behavior treatments in real-world programs are discussed.

An interactive approach to training teams and developing programs.

A combination of educational and organizational strategies help rehabilitation teams develop programs that effectively address the needs of their consumers.

Staff training to improve implementation and impact of behavioral rehabilitation programs.

Staff who provide services for persons with severe mental illness often have pessimistic attitudes about adopting behavioral innovations for their programs. Thirty-five staff members in psychiatric residential programs participated in eight months of interactive staff training, an organizational development strategy that helps the rehabilitation team develop behavioral approaches to changing clients' behavior. After the training, staff members reported significant improvement in their attitudes about behavioral interventions and increased perceptions of collegial support. Direct care staff reported significantly less emotional exhaustion. Interactive staff training may facilitate implementation of behavioral strategies by improving attitudes toward these interventions.

How mental health and developmental disabilities staff prioritize training and development needs.

This paper contrasts a staff training needs assessment distributed to three groups: staff serving persons with mental health needs in the community, staff serving persons with mental health needs in state hospitals, and staff serving persons with developmental disabilities in the community. Analyses revealed that all three groups rated team-related training as the area in greatest need of development. Further analyses suggested that community staff serving persons with developmental disabilities reported significantly less need for training on direct client care compared to community and inpatient staff who serve persons with mental health needs. The community staff serving persons with mental health needs did not differ significantly from the inpatient staff on any of the surveyed training areas. Results suggest that future development efforts should begin with team building skills.

Refocusing the training of psychiatric rehabilitation staff.

The authors describe an approach to training staff in psychiatric rehabilitation programs that is based on principles of organizational psychology. The approach promotes two shifts in the focus of training. First, training efforts should not only educate individual staff members about state-of-the-art rehabilitation skills but also organize the treatment team into a system that will consistently carry out these skills. Second, training should help the team develop user-friendly programs rather than insisting on faithful implementation of state-of-the-art interventions. A four-phase, eight-step training method called interactive staff training that can help programs achieve these goals is presented. The first phase involves obtaining administrative support for change, assessing staff needs, and forming a program committee. In the second phase, staff participate in decision making about program components, and a facilitator conducts sessions to reach consensus on a draft program. A pilot program is implemented and evaluated in the third phase. In the final phase, a user-friendly program is maintained through continuous quality improvement.

Preference for diazepam in anxious adults.

This study investigated whether anxious adults desiring treatment for their anxiety would choose to take 10 mg of diazepam (Valium) or placebo after sampling both substances under double-blind conditions. Subjective effects of the drugs were also assessed, and the relationship between self-reported subjective effects and the number of times subjects chose diazepam or placebo was examined. Fourteen male and female volunteers meeting criteria for generalized anxiety disorder were recruited. They participated in a nine-session choice experiment in which they sampled diazepam 10 mg and a placebo on the first four sessions and chose whichever they preferred on the next five sessions. Only three subjects chose diazepam on all five choice occasions, no subjects chose diazepam on three or four occasions, and 11 subjects chose diazepam on two or fewer occasions. Overall, diazepam produced typical, tranquilizer-like subjective effects. However, subjective responses to diazepam differed in the 0-2-time choosers compared with the 5-time choosers: the 0-2-time choosers showed an increase on the measure of confusion, while the 5-time choosers showed decreases on measures of anxiety and confusion and increases on measures of stimulation.

Ethanol self-administration in males with and without an alcoholic first-degree relative.

The reinforcing and subjective effects of a low dose of ethanol (ETH; 0.5 g/kg) were investigated in normal males with or without an alcoholic first-degree relative. Reinforcing effects were measured using a double-blind preference procedure comparing ETH to placebo (PLC), and subjective effects were assessed using standardized self-report questionnaires. Subjects with a positive family history of alcoholism (FHP) did not differ from subjects without alcoholic relatives (FHN) either in frequency of choice of ETH over PLC (about 60% of occasions) or in the total dose self-administered (about 0.9 g/kg per session). The two groups also did not differ on most measures of acute ETH effects (e.g., mood-altering effects, liking ratings, behavioral changes, or blood ETH levels). The FHP subjects reported a slightly faster onset of "feeling any drug effects" and "high" after ETH than the FHN group. The FHP group also scored higher than the FHN group on several scales indicative of dysphoric mood, regardless of drug administration. Thus, under these conditions male social drinkers with or without a family history of alcoholism did not differ either in preference for ETH or in their subjective responses to the drug.

Lack of preference for diazepam in anxious volunteers.

Using a choice procedure, these experiments tested whether diazepam is more highly preferred by anxious subjects than by normal control subjects. Subjects first sampled and then chose between two capsules containing diazepam (5 or 10 mg) and placebo, or amphetamine (5 mg) and placebo. The number of times each drug was chosen over placebo and the subjective effects of the drugs were measured. Anxious subjects did not differ from controls in their drug choices. Most subjects chose diazepam less often than placebo, especially at the higher dose, whereas they chose amphetamine more often than placebo. The subjective drug effects (including anxiety reduction after diazepam) were similar for anxious and nonanxious subjects, despite predrug differences in anxiety. The results suggest that individuals with high anxiety are not at greater risk for dependence on antianxiety drugs.