Manual II: Implementation Coordinated Specialty Care for First

Manual II:

Implementation

Coordinated Specialty Care

for First Episode Psychosis

This manual was prepared under contract number HHSN271200900020C between the National

Institute of Mental Health and the Research Foundation for Mental Hygiene. This project has

been funded in whole or in part with Federal funds from the American Recovery and

Reinvestment Act of 2009 and the National Institute of Mental Health, National Institutes of

Health, Department of Health and Human Services. Amy Goldstein, PhD., served as the

Government Project Officer.

Disclaimer:

The views, opinions, and content of this publication are those of the author and do not

necessarily reflect the views, opinions, or policies of HHS.

Contributors:

Melanie Bennett, Ph.D., University of Maryland School of Medicine, Baltimore, MD

Sarah Piscitelli, M.A., M.H.C., Research Foundation for Mental Hygiene, New York, NY

Howard Goldman, M.D., Ph.D., University of Maryland School of Medicine, Baltimore, MD

Susan Essock, Ph.D., New York State Psychiatric Institute, New York, NY: Department of

Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY

Lisa Dixon, M.D., M.P.H., New York State Psychiatric Institute, New York, NY; Columbia

University Medical Center, NY

Table of Contents

I. Introduction ....................................................................................................................1

II. Administrative Issues in Implementation ........................................................................2

A. Program Structure and Services .............................................................................2

B. Geographic Boundaries ..........................................................................................2

C. Types of Clients Who Will Receive Services ........................................................3

D. Connection with State and Surrounding Partners ..................................................3

E. Determine Funding / Operating Budget .................................................................4

F. Establish a Referral Network ..................................................................................4

G. Application of Clinic Procedures to the Team .......................................................4

H. Staffing Requirements............................................................................................6

I. Team Features .........................................................................................................7

III. Training ........................................................................................................................11

A. Training Overview ...............................................................................................11

B. Team Training (Training the Team as a Whole) ..................................................12

C. Ongoing Training for the Team ...........................................................................14

D. Specialty Training (Training Components of the Team) .....................................14

E. Training for Team Members ................................................................................15

IV. Supervision ..................................................................................................................16

A. Types of Supervision ...........................................................................................16

B. Ways to Deliver Supervision................................................................................18

C. Supervision How-To’s .........................................................................................19

V. Fidelity ..........................................................................................................................21

Appendix List.....................................................................................................................23

Appendix 1. Getting Started Checklist ........................................................................24

Appendix 2. Inclusion and Exclusion Criteria Used in the RAISE

Connection Program ..............................................................................25

Appendix 3. Sample Job Descriptions for Team Hires ................................................29

Appendix 4. Background Readings and Resources - Team .........................................30

Appendix 5. Background Readings and Resources - Recovery Coach

Training .................................................................................................34

Appendix 6. Background Readings and Resources - Supported Employment

and Education ........................................................................................37

Appendix 7. Vignettes to Use in Team Training .........................................................38

Appendix 8. Scripts for Training Role Plays ...............................................................44

Appendix 9. Forms to Use for Team Training Topics .................................................59

Appendix 10. Sample Forms for Supervision Notes ...................................................67

Appendix 11. Resources for Supervision .....................................................................68

Appendix 12. Resources for Fidelity ...........................................................................72

I. Introduction

This manual is designed to guide implementation of a team-based program to serve individuals

who are experiencing emerging psychosis within an existing mental health clinic (MHC). It

provides information on administrative issues that must be discussed and resolved between the

team and the clinic, such as hiring team members, managing team caseloads, providing services

outside of the clinic setting, using the clinic’s support staff for smooth team functioning, and

sharing space and resources. Other critical implementation issues involve training and ongoing

supervision of team members, ways to measure fidelity to the team model, and how to build

supervision and fidelity assessment into ongoing practice within the clinic.

The recommendations and resources provided in this manual are derived from the experiences of

the Recovery After an Initial Schizophrenia Episode Implementation and Evaluation Study

(RAISE-IES). RAISE-IES was funded by the National Institute of Mental Health (NIMH) to

develop tools that would support the implementation of Coordinated Specialty Care (CSC)

programs designed to provide early intervention services for people with non-affective

psychoses. The Connection Program represents an example of a CSC program recommended for

first episode psychosis (FEP), and was the clinical intervention developed and evaluated in

RAISE-IES. This manual is based on the experience of creating and implementing CSC

programs in New York, New York and Baltimore, Maryland. Two Connection Teams were

formed, one in each city. Per the CSC treatment model, and as will be further discussed

throughout this manual, teams were comprised of a Team Leader, a Team Psychiatrist, an

Individualized Placement and Support (IPS) Specialist, and a Recovery Coach. Throughout this

document, we may refer to these team members in our examples of implementation. Keep in

mind that teams in other locations, under different circumstances, may have different staffing

configurations. These particular titles and associated training plans may not apply. They can,

however, serve as useful guides for how to construct new programs.

Experience with creating and implementing these two Connection Teams illustrates the many

opportunities that arise from embedding such a team within a larger MHC in terms of

administration, resource sharing, and collaborations among staff members. The manual is

intended to convey general concepts, providing examples from two program implementations:

The RAISE Connection Program and OnTrackNY. OnTrackNY represents an extension and

adaptation of RAISE Connection and is also a CSC model currently being implemented in four

locations throughout New York.

II. Administrative Issues in Implementation

Section Tools

 Appendix 1: Getting Started Checklist

 Appendix 2: RAISE Connection Program Eligibility Criteria

 Appendix 3: Sample Job Descriptions for Team Hires

This section describes a number of issues that need to be considered when implementing a team-

based CSC program that serves individuals who are experiencing emerging psychosis. A

checklist of these issues is provided in Appendix 1.

A. Program Structure and Services

An early consideration is the operational location of the team—will the team-based program

operate and reside within an existing and established MHC, or will it be established as a separate

organization and/or in a separate location? Advantages of the former include the opportunity for

efficiencies within a shared infrastructure. Advantages of the latter include the possible

opportunity to be more flexible and less stigmatizing for individuals who might avoid

community mental health programs entirely. A related question is whether there will be a single

team that functions on its own or a collection of teams that network to provide services to a

broader area. In the case of related or collaborating teams, some efforts (e.g., training,

developing an outreach and referral network, and performing outreach and recruitment) may be

performed centrally to share costs. The single vs. multiple team issue will also influence the

development of a referral network. Establishing a network for a single team will generally

require efforts targeted to a specific area and/or set of referral sources, whereas creating a

network of referral sources for a linked set of teams would require strategies to blanket outreach

across large areas.

B. Geographic Boundaries

Two important issues related to geographic boundaries are population density and service

boundaries. A population base of about 550,000 will have enough incident FEP cases to keep

one FEP team filled at capacity given the team size and service durations proposed here, even

with fairly conservative estimates about the number of such individuals who are identified and

agree to be served.

The report by Humensky et al.

includes an interactive spreadsheet tool to

estimate the number of teams that a given area can support and the associated cost given user-

specified values for relevant variables (e.g., fraction of incident cases approached). When

deciding whether the population density is sufficient to support one or more teams, the service

boundaries need to be determined for each team operating in the area. Since part of the team’s

mission is to provide at least some services in the field, it is important to consider setting service

boundaries that are reachable and will not require excessive time for travel when team members

provide services in the community. Availability of public transportation is an important

Humensky JL, Dixon LB, Essock SE. An interactive tool to estimate costs and resources for a first episode

psychosis initiative in New York State. Psychiatric Services, 2013; 64 (9):832–834.

consideration, as is how accustomed to travel the potential population is. If the program will

provide supported education or employment, the Individual Placement and Support (IPS)

Specialist will make visits to community locations that need to be within reach of the young

people and families served. As a rule of thumb, new teams should consider accepting clients

living one-half hour from the clinic if education and employment services are offered. Without

education and employment services, consider accepting clients no more than 45 minutes away

from the team location.

C. Types of Clients Who Will Receive Services

Each program should establish its eligibility criteria. The first critical decision around eligibility

is determining a definition of early psychosis. This includes not only how long an individual can

have had psychotic symptoms, but what constitutes psychotic symptoms. Each team also needs

to determine whether they will include individuals with diagnoses associated with psychosis,

such as psychosis due to a medical condition, substance-induced psychosis, or mood disorders

with psychotic features. Finally, the team needs to decide if there are any diagnoses that would

exclude an individual from admission, such as developmental delays, pervasive developmental

disorders, oppositional defiant disorder, or substance abuse and/or dependence disorders.

Other domains to consider when determining eligibility for team services include:

• Age range

• Comorbid medication conditions

• Comorbid trauma

• Housing instability

• Legal problems or prisoner status

• Cultural diversity and need for culturally sensitive services

• Primary language other than English

• Insurance status

The eligibility criteria used for the Connection Program are listed in Appendix 2, along with the

rationale for each. Service eligibility was determined prior to admission. If, after admission, the

team obtained new information that indicated that the individual was not eligible for the CSC

program, the team continued providing services.

D. Connection with State and Surrounding Partners

It is important for a first-episode specialty care program to link with other programs in the

community that may be needed in the course of a young person’s care. For example, emergency

care services, inpatient substance abuse treatment programs, and other services are not provided

by the CSC but may need to be accessed by clients. It is critical that CSC programs and their

clinicians connect and develop relationships with these other services during the set-up phase, so

that these services may be easily accessed in a crisis situation. To ensure smooth transitions, the

partnerships need to be in place and ready for use.

E. Determine Funding/Operating Budget

Funding for FEP services will vary by locality and insurance source. In some states, FEP

services may be state supported via Medicaid waivers or other categorical funding. For a detailed

discussion of approaches to financing interventions for FEP, see:

http://aspe.hhs.gov/daltcp/reports/2012/EarlyInt.pdf . Budget issues that need consideration for

FEP programs are similar to those of any other clinic-based program: identification of payment

sources, billing, budget management, expense tracking, supply ordering, and laboratory and

pharmacy tracking and reimbursement.

F. Establish a Referral Network

A referral network is key for the success of the CSC program. Establishing a referral network has

many components that are summarized in Coordinated Specialty Care for First Episode

Psychosis Manual I: Outreach and Recruitment. Once established, the referral network needs

ongoing management – referral sources contacted regularly, contact information updated, etc.

The team or mental health center will also need to track referrals and outreach activities.

Strategies for this are provided in detail in the Outreach and Recruitment Manual.

G. Application of Clinic Procedures to the Team

There are a range of procedural issues that are relevant to setting up a CSC team within an

existing MHC.

1. Human Resources and Hiring. Administrators are responsible for hiring staff. Sample job

descriptions are provided in Appendix 3. All agency rules regarding evaluation and

credentialing should be followed. If possible, hire the Team Leader first so that the Team

Leader can be involved in the hiring of the other team members.

2. Resources. Resources needed include space, computers, office equipment, and other

transportation funds.

• Setting. Issues pertaining to the setting and space for services (including the capacity to

provide services outside of the clinic) need to be addressed between the team and the

clinic administrators at the start. Early psychosis intervention teams serve a young

population. The setting in which the team is located needs to appeal to young clients.

The setting should be pleasant, inviting, and recovery-oriented. Integrating the service

into community or general health services would be preferred. The team needs

sufficient space to hold groups and team meetings as well as some space for private

individual meetings. The space should, if possible, be in an area that is easily

accessible, either via public transportation and/or with parking. There also needs to be

the option of providing services outside of the clinic.

• Computer Access. It is important for all team members to have computer access in a

large enough space to also accommodate clients and their families. During sessions or

meetings, team members may use computers to access resources, direct clients and

families to services, assist with job searches, and watch videos or view other treatment-

consistent content. Ideally, team members would have access to a laptop computer that

could be used in different locations and shared among team members.

• Medical Equipment. Basic medical equipment needed to dispense and monitor

medication should be available so that clients can work with the Team Psychiatrist on

site at regular appointments. This equipment includes a scale and blood pressure cuff,

as well as a way of obtaining labs, either on site or off site. Working out the logistics of

labs and injections is critical and must be addressed at the start of program

implementation.

• Additional Resources. Programs should also have access to money for petty cash.

These funds would be used to make small purchases such as refreshments, snacks,

reading material, or cab fare. The team also needs access to transportation for

community visits and to provide access to community services. This could include a car

depending on the community. Telephones, cell phones, and computers should be

provided according to agency policy.

3. Programmatic Oversight and Management. These tasks include supervision, consultation,

back-up coverage, and other administrative management duties. All of these issues must be

addressed collaboratively and constructively between the team and the MHC.

• Supervision. Access to supervision for each of the team members is a critical

consideration. Supervision for the Team Leader within the reporting structure is also

necessary to facilitate integrating the program into the overall agency structure.

Ideally, the Team Leader should have administrative supervision with the clinic

coordinator at least every 2 weeks, and monthly supervision with the clinic’s program

director. Optimal there would be an Individual Placement and Support Supervisor in the

agency or available to the program.

• Consultation. Access to expert consultation and/or peer supervision, especially for the

Team Psychiatrist, is also important. At the beginning of the program, it would be

optimal for the physician to have access to consultative expertise to assist with unique

problems that arise for FEP patients.

• Back-up Coverage. The clinic administration needs to have back-up plans for coverage

for the Team Leader and the Team Psychiatrist in the event that either is out for a

scheduled absence. Emergency back-up coverage is also necessary if the physician is

not available.

• Management Duties. Other personnel and management tasks can include annual

evaluations for the Team Leader and time tracking for all team members. The Team

Leader presumably evaluates all team members. Psychiatrist evaluation should be done

according to program policy.

4. Adherence to/Compliance with clinic regulations. The Clinic Administration must ensure

that FEP program elements are compatible with existing agency requirements. Suggested

FEP forms should be compared and matched to required agency forms so that redundancy

can be eliminated.

5. Clinical oversight and management tasks. These include medical records management,

patient registration and tracking, evaluation of clients’ insurance to confirm coverage, and

census and visit tracking reports.

H. Staffing Requirements

First episode specialty teams are comprised of a group of professionals who have different but

overlapping roles. At minimum, teams should have a main leader or coordinator who is

responsible for the client’s overall treatment plan and programming. In addition, each client

should have a team member who provides in-depth individual and family support, suicide

prevention planning and crisis management, and assistance with access to community resources

and supports. This can be the Team Leader or primary clinician. Case management can also be

provided, if needed, by the designated primary clinician or by another team member. Each team

should have a psychiatrist or prescriber who works with clients on issues of medication,

management, wellness, and side effects. Teams should also have a Supported Employment

Specialist to work with clients on re-entry to school or work, as well as team members who can

work with clients on goals that require social or coping skills training and attention to substance

use. Each team must have someone dedicated to establishing and maintaining a referral network

and evaluating potential clients as described in the Coordinated Specialty Care for First Episode

Psychosis Manual I: Outreach and Recruitment.

Team members should have dedicated time for their team-related work. This is especially

important for team members who are not 100% full-time equivalent (FTE). If someone’s time is

divided between the CSC team and other responsibilities, steps should be taken to ensure that

their team time is preserved and differentiated from their other clinic-related responsibilities.

RAISE Connection Program Teams were comprised of a Team Leader, a Team Psychiatrist, an

Individualized Placement and Support (IPS) Specialist, and a Recovery Coach. The Team Leader

and IPS specialist were full-time clinicians, whereas the Recovery Coach and the Psychiatrist

were part-time at 50% and 20% effort, respectively. Teams in other locations and under different

circumstances may have alternate staffing configurations, so these particular titles may not apply.

For example, OnTrackNY Teams have two full time equivalent staff covering the Team Leader,

Primary Clinician, Recovery Coach and Outreach Coordinator roles. A full-time IPS specialist,

0.3 FTE prescriber, and 0.2 FTE nurse round out the team.

I. Team Features

There are specific aspects of CSC team functioning that are recommended in order to ensure

program success:

1. Small Caseloads. The team should have small caseloads, consisting of 25–30 clients or less,

to ensure that team members have sufficient time to fully address all areas of intervention.

The small caseload will also enable team members to develop and nurture a trusting

relationship with the client and allow the team member time to perform activities outside of

the clinic setting, such as home visits and community outreach, as needed. This flexibility is

particularly important during the earlier phases of intervention and engagement.

2. Frequent Team Meetings. The whole team should plan to meet once per week. At these

meetings, the team will review the status of each client, discuss each team member's role in

the client’s care, and review progress towards treatment goals. Team meetings should model

respect, recovery, and shared decision-making. These meetings give team members the

opportunity to inform and be informed by one another. They also provide time for the Team

Leader to “check in” with each team member regarding the activities and goals of each

respective specialty. During team meetings, the principles and practices of CSC care are

reinforced through review of current cases and ongoing training to improve clinical

knowledge and skills. For instance, after a case is presented, the team may provide feedback

on such issues as making the transition to the next phase of care, negotiating with

community providers, and taking a harm-reduction approach to resolving problems.

The team should save the hour following the weekly team meeting for treatment planning or

updating with clients. When an initial treatment plan or an update is discussed with clients,

the goal is to have all team members present. Scheduling time for treatment planning

meetings following the weekly team meeting is an easy way of ensuring that all team

members will be present.

Section IV: Supervision provides a detailed discussion of team meetings for the purpose of

supervision.

3. Central Point of Referral. As discussed in Coordinated Specialty Care for First Episode

Psychosis Manual I: Outreach and Recruitment, referrals to the team should come to a staff

member dedicated to outreach and referral activities. This may be a staff member on the

team (Outreach and Referral Specialist), or a group of staff members on an outreach and

referral team. All advertising about the FEP program should list appropriate contact

information. A central referral process that involves a dedicated referral line staff makes

calling and contacting the team an easy process for clients, families, community providers,

and other potential referral sources.

4. Coordinating Entry to the Program. The person receiving referrals should work with the

team to coordinate the initial team activities, including intake assessment and preliminary

treatment planning. Based on the assessment, the team will engage in shared decision

making with the client to plot an overall treatment plan to meet the individual’s expressed

recovery goals; treatment planning is conducted in full consultation with the client. Clients’

capacity and interest in formal goal setting and making decisions can fluctuate throughout

the course of treatment; preference and comfort with the decision-making role should be

regularly explored. For the RAISE Connection Program Teams in Maryland and New York,

the Team Leader coordinated a young person’s entry to the program after the Outreach and

Referral Specialist identified them as eligible.

5. Working as a Team in a Shared Decision Making Framework. Although the CSC team

works collaboratively in the treatment of a client, a client may only be working with one or

two clinicians at any point in time. At a minimum, all clients should work with the Team

Leader (or assigned primary clinician for programs with others serving in the primary role)

and the Team Psychiatrist. Even clients who are not interested in taking medication should

meet with the psychiatrist to learn about medication options, set goals regarding when a

medication trial may be warranted, and establish a relationship with the psychiatrist in case

his/her feelings about medication change. Working with other members of the team is not

mandatory but strongly encouraged, and it is expected that these working relationships may

change over time.

Case Narrative 1: Introduction to Team Members and Gradual Engagement with Different Team

Components

The Connection Program Team uses treatment planning to help new clients learn about the different

aspects of the program and decide, within a framework of Shared Decision Making, which components

they wanted to use and when. For example, at program entry, one new client may be most interested in a

trial of medication, and not be ready to work on skills training or employment. Another new client may be

very interested in getting back to work or school, but less interested in medication or family work. A third

might be willing to work on decreasing his/her substance use in order to benefit most from medication

and prepare for an eventual job search. Getting started with the team is flexible such that what is most

important to the client and his/her family can be addressed first, and components can be added later as

clients feel better, revise their goals, and look to the future.

Although team members may cover for each other occasionally (e.g., the Team Leader may

see a client and work on employment related goals if the employment specialist is not

available one day), each team member specializes in his/her component of the intervention.

If a team wants to be structured to be able to accommodate overlapping roles, it is important

to hire people with common skill sets so that tasks can be shared across team members. As

discussed in Section III: Training, role flexibility is also the reason why cross-team training

is important; the team members should be trained in all components they will be expected to

cover clinically. For example, Maryland and New York Connection Teams were comprised

of a Team Leader, a Team Psychiatrist, an Individualized Placement and Support (IPS)

Specialist, and a Recovery Coach; these staff members largely focused on their individual

areas of expertise and there was little overlapping of roles.

While the RAISE Connection Program had little overlap in roles, new teams in other

locations with different circumstances, may have alternate staffing configurations and be

structured to have more flexibility in sharing roles. OnTrackNY, is now being implemented

in four locations in New York. OnTrackNY teams will be made up of a Team Leader, a

Primary Clinician, a Team Psychiatrist, an IPS Specialist, a Recovery Coach, a Team

Nurse, and an Outreach and Referral Specialist. In this structure, the individuals serving as

the Recovery Coach or Outreach and Referral Specialist can also serve in the Primary

Clinician role.

6. Connecting with Community Partners. The team helps the client create or re-establish a

social network within and beyond the family. School and work provide other opportunities

to establish and grow natural supports. Some clients need help connecting with resources to

avoid housing loss or other adverse social outcomes. The team works with the client and

family to develop advocacy skills.

Use of community resources is directly linked to goals in the treatment plan. The role of the

team members is to not only identify resources and make referrals, but actively assist the

client and family in linking to and using these resources. This can include the Team Leader

following up with a referral source to check on a client's progress, the Recovery Coach

accompanying the client to meetings or appointments in the community, or other active

assistance as needed. Identifying community resources will be actively encouraged and

assisted by the team.

There are several areas in which resources in the community may be sought:

• Mental Health or Clinical Services Not Provided by the Team: examples include

cognitive behavioral treatment for depression, anxiety disorders, or PTSD; inpatient

substance abuse treatment; dialectical behavior therapy

• Non-Psychiatric Medical Services: examples include primary care services, lab

services, or other medical appointments; substance use detoxification

• Peer or Community Support Resources: examples include National Alliance on

Mental Illness (NAMI), Alcoholics Anonymous/ Narcotics Anonymous (AA/NA,

Double Trouble, and the Depression and Bipolar Support Alliance. Consumer

organizations, such as On Our Own Wellness and Recovery Centers, are also

important resources for clients and families.

It is also important to assist clients in re-connecting with their communities around activities

that are social and pleasurable. These may be activities that consumers do with their

families, friends, or alone.

Case Narrative 2: Ways to Re-Engage with the Community.

It is important to remember that clients with early psychosis are young people and an important

component of their recovery is doing things they enjoy with other young people. The Team helped clients

access social supports and engage or re-engage with their communities in line with their treatment goals.

Clients looking to make new friends might participate in the team’s social skills group, meet with the RC

in the community to practice these skills, and then plan a community activity to do on his/her own in

order to put these skills into practice. Clients were encouraged by team members to engage in community

activities they found enjoyable or that would allow them to try out new skills gradually and prior to

having to use them in an important situation. For example, one client had, before his hospitalization,

enjoyed playing basketball at college with his friends. The team worked with him to identify places he

could play basketball now that he was living at home, people he could ask to play ball with him, and

times during the week when he could get a game together. Another client was distressed by the weight

gain she experienced due to her medication and told the team that she wanted to start exercising. The

team helped her talk to her brother about taking her to a gym; assisted her in signing up for a gym

membership; and provided support, encouragement, and praise as she began to swim at the gym several

times per week. The team helped another client who wrote poetry to find locations in the community

where he could listen to poetry; he eventually presented some of his own work. In all of these examples,

the team helped consumers engage with people, activities, and community settings in ways that were

positive and in line with their recovery goals.

III. Training

Section Tools:

 Appendix 4: Background Readings and Resources – Team

 Appendix 5:Background Readings and Resources – Recovery Coach Training

 Appendix 6: Background Readings and Resources – Supported Employment and

Education

 Appendix 7. Vignettes to Use in Team Training

 Appendix 8. Scripts for Training Role Plays

 Appendix 9: Slides and Forms to Use for Team Training Topics

A. Training Overview

As has been emphasized throughout this manual, developing a CSC program to serve individuals

with emerging psychosis will be influenced by the clinic in which the team is going to function

and by the needs and resources of that clinic. This means that not all teams will be exactly the

same, though all will be implementing the same underlying principles of CSC care. Training

should be tailored to the specific needs of the clinic and team staff. This section provides an

overview of training approaches for the team members in clinical roles. Training considerations

for those responsible for outreach and recruitment can be found in the Coordinated Specialty

Care for First Episode Psychosis Manual I: Outreach and Recruitment.

Team member training encompasses two domains: Team Training and Specialty Training. Team

Training focuses on information and skills needed by all team members, including the overall

program philosophy and principles of the CSC program and the procedures that structure the

team and guide the ways that team members work together and assign tasks within the team.

Specialty Trainings are targeted to the responsibilities of each team member; these trainings

focus on the skills and interventions required by particular team members to effectively deliver

their assigned component(s). A program should decide up front how much flexibility there will

be in role assignments. If there is greater flexibility, team members should be ‘cross-trained’ to

competency in the various specialized areas in which they will be expected to serve.

Background readings and discussions are useful for all team members. More intensive in-person

or in some cases on-line training is also needed. The amount of time devoted to training is

influenced by the background and previous training/experience of team members. In training the

RAISE Connection Program Teams in Maryland and New York, initial in-person training lasted

for 2 days and included presentations on the model supporting the work of the team, didactic

presentations on the different components of the team, and exercises designed to illustrate

clinical activities and ways for the team to work together to understand clients, their needs, and

how these impact treatment planning.

An important consideration is who should provide training as outlined in this section. New FEP

teams need to identify the experts and resources in their communities and within the larger

community of FEP treatment development. This manual includes a range of written and online

resources. New teams should plan to reach out to national experts, local community

organizations and providers, and existing teams for assistance in accomplishing the training.

Information can be found on the NIMH RAISE website (http://www.nimh.nih.gov/raise) or from

the RAISE intervention program developers.

B. Team Training (Training the Team as a Whole)

1. Background Readings and Discussions

a) Readings. All team clinicians should be provided with background readings on FEP and

the lived experience of psychosis, and topics that are important across program elements.

The cross-cutting topics include: shared decision making, trauma-informed care, the

recovery model, and suicide/safety planning. A list of background readings and resources

is provided in Appendices 4–6. An experienced trainer or facilitator should lead

discussions of the readings so that team members learn about and understand the unique

challenges experienced by individuals experiencing an FEP and their families. In

addition, readings should emphasize the importance of incorporating client and family

input into treatment and goals and the strategies for how to interact with and include

families in decision making while respecting the preferences of the young adult.

b) Online resources. In addition to readings, many online resources provide valuable

information in different formats and allow team members to practice or learn new content

and skills (See Appendices 4–6). The Voices of Recovery video series, developed for the

RAISE project, can be found at the following link:

http://practiceinnovations.org/ConsumersandFamilies/ViewAllContent/tabid/232/Default.

aspx. A manual that provides guidance as to how the videos may be used for staff

training, as well a discussion for how to use with clients and families is available at

http://practiceinnovations.org/OnTrackUSA/tabid/253/Default.aspx.

c) Additional Perspectives in Training.

 Peers. Including peers or a consumer-professional who understand both receiving

and providing services can provide an invaluable perspective to training.

Peer/consumer knowledge of the subjective experience of psychosis and treatment

is a critical perspective to represent in training. Existing resources on peer

experience, such as those provided online or newly created materials to address this

topic, can be key adjuncts to care.

 Family. The importance of understanding the perspective of family members who

are often central in the lives of individuals experiencing psychosis cannot be

overstated. Trainings should include family members or a family–professional who

can communicate to staff how the family might be experiencing the situation and

who understands the impact of accepting the changes and challenges taking place

with their loved one. NAMI presentations and trainings might also be helpful for

staff training.

2. Intensive, In-Person Activities

The purpose of the in-person, whole-team training activities is to present a thorough review of

information that is key to understanding the team approach and to introduce and practice the

concept of “team-ness” to the team members. In-person training sessions allow for presentation

of material that is relevant to the team as a whole, and then for breakout sessions to present

material by component.

The informational and didactic components of training should include:

• Topics relevant to the CSC conceptual model:

 first episode psychosis

 critical time intervention

 mental health recovery

 working with youth

 shared decision making

 trauma informed care

 safety planning

 person-centered treatment planning

• Topics relevant to the components of the team:

 psychopharmacology

 supported employment and education

 working with families

 social skills training and substance abuse treatment

 relapse prevention planning

• A review of functional procedures of the team:

 team member roles

 small caseloads

 frequent team meetings

 progress notes and documentation of team activities

 after hours roles and responsibilities

• A thorough review of the timing of team activities:

 initial referral and treatment planning

 a history and needs assessment done collaboratively by the Team Leader and the

Team Psychiatrist

 development and implementation of the initial treatment plan

 Team Leader activities at the start of treatment (e.g., set up a family meeting;

complete safety planning, develop a relapse prevention and crisis plan)

 activities for other team members at the start of treatment (e.g., IPS Specialist and

the Skills Trainer must introduce themselves to the client, meet with the client to

describe what services they provide, and assess the client’s needs and goals in their

respective areas)

 ongoing treatment

 issues around missed appointments/potential dropout/assertive outreach

 transition

 linking with community and peer resources

Forms to use for many of these topics are available in Appendix 9.

The experiential/practice components of the training should include:

•

Clinical Vignettes (see samples in Appendix 7) can be used to stimulate discussion

among the team members, asking them to identify the important administrative and

personal aspects of the needs assessment process and determine how to address the

relevant needs and issues.

•

Role Playing Situations (see samples in Appendix 8) can illustrate key clinical concepts

and activities relevant for new team members.

•

Mock Team Meetings are also useful to practice/discuss how to coordinate, sequence,

and prioritize the various treatments and services and engage a client and family in

developing a full and integrated treatment plan. Materials including clinical vignettes

and scripts for role plays are provided in Appendix 9.

C. Ongoing Training for the Team

Ongoing training is essential. Training key intervention components such as shared decision

making, motivational enhancement, critical time intervention, and safety planning should be

repeated regularly to make sure knowledge and skills stay fresh. Ongoing training can take the

form of in-person expert training, reviewing and role-playing situations to get continued practice,

or finding relevant (training experiences in the team’s geographic area. Hospitals, colleges,

universities, and other research institutions are excellent resources – the team should explore

these settings, meet people doing related work, and get on listservs and mailing lists so that they

will be aware of any training opportunities. The team will be faced with new experiences and

situations each day; making ongoing training a priority will help prepare team members for new

treatment issues when they arise. Team members should keep a list of areas they feel additional

training is needed and work with MHC staff to link with training opportunities in these areas.

D. Specialty Training (Training Components of the Team)

Specialty training focuses on specific team roles. The in-person or intensive component is

enhanced and more efficient when more than one team is being trained.

1. Background Readings and Discussion.

All team members should be provided with background readings on topics related to their

specialty area. A list of background readings and resources relevant to different team members

is provided in Appendices 4–6. Team members should share what they learn with each other—

this both reinforces new learning and also helps team members inform each other about their

areas of expertise.

2. Intensive, In-Person Activities.

As noted above, in-person trainings allow for in-depth presentation of material. As part of a

team-wide, in-person training, time should be allocated to breakout sessions to present material

that is relevant and specific to each team member. These breakout sessions allow all Team

Leaders, Psychiatrists, IPS Specialists, Recovery Coaches, and other team members to learn

and practice topics and interventions that are specifically relevant to their areas of focus. Below

is a brief listing of the topic areas to cover for each clinical role. These breakdowns reflect the

division of roles and responsibilities used in the RAISE Connection Program.

• Team Leaders

 How to be a Team Leader

 Critical time intervention

 Working with families

 Safety planning

 Relapse prevention planning

• Team Prescriber

 Antipsychotic treatment schedules

 Side effect monitoring

 Linkage to primary care

 Smoking cessation

• Supported Employment/Education Specialists

 Background and implementation of supported employment and education

• Recovery Coaches (see Appendix 5 for resources and readings)

 Treatment interventions and strategies – e.g., social skills training, substance abuse

treatment

 Coping skills

 Helping clients become more active and master the skills needed to engage in

different activities

 Strategies for support and engagement activities

E. Training for Team Members

Ongoing training for team members in their areas of specialty is important. Team members

should connect with community and state sources of support such as learning collaboratives,

listservs, and interest groups, and should link with other FEP teams both locally and nationally. It

is relatively easy to reach out to others doing FEP treatment, supported employment and

education, family psycho-education, and behavioral family interventions, etc. Each team member

should keep a list of areas in which they feel they need additional training and work with MHC

staff to locate training opportunities in these areas.

IV. Supervision

Section Tools:

 Appendix 10. Sample Forms for Supervision Notes

 Appendix 11. Resources for Supervision

A. Types of Supervision

CSC programs require several types of supervision. How supervision is handled may be

contingent on where the program is located and the rules of the clinic in which the CSC program

may be embedded. The following supervision is recommended:

1. Administrative Supervision involves oversight to ensure that the FEP team is following the

rules and procedures of the clinic in which it is embedded. The format, frequency, and

emphasis of this supervision will need to be worked out on a team-by-team basis as clinic

needs vary. Generally, the individual who is leading the team will receive administrative

supervision from someone within the clinic administration and then pass along information

and monitor the rest of the team regarding issues such as changes in clinic policy or larger

programmatic issues that impact the CSC team. In the NIMH RAISE Connection Program,

the Team Leader met weekly with the Clinic Coordinator and monthly with the clinic

Program Director.

2. Clinical Supervision involves reviewing clients’ status to ensure sound and competent

clinical care. The amount of clinical supervision will also vary by team depending on clinic

rules and regulations. Supervision is distinct from team meetings, in which all members of

the team meet, report on their work with an individual, and plan continued work towards

goals; team meetings may often include the client and/or family member/s. In contrast,

clinical supervision includes discussion of the specific activities and techniques the

clinician is providing, periodic review of session tapes or notes, and identification of ways

to improve or enhance clinical interactions. In the RAISE Connection Program, the Team

Leader conducted clinical supervision every other week with both the Recovery Coach and

the Supported Employment Specialist.

3. Clinical Consultation involves discussion of individual clients with someone outside of the

team to maintain good clinical decision-making. The Team Leader and the psychiatrist

each should identify an individual with similar credentials within the clinic but outside of

the team to provide this consultation in monthly meetings.

4. “Component” Supervision can bring together team members across multiple teams. If

there are multiple teams in a region or state, a creative addition to supervision would be to

have a regular meeting of all the team members (e.g., a meeting of all of the Recovery

Coaches, or supported employment/education providers). These meetings can provide a

forum in which those with similar roles on teams would be able to share materials,

resources, and successes, as well as help in problem solving and creative thinking. This

mode of supervision is especially well-suited to issues related to family involvement as

team members can discuss ways to engage families in care and give each other new ideas

in this area. For example, in the RAISE Connection Programs in New York and Maryland,

Team Leaders from the two states met via conference call for component supervision, as

did the Psychiatrists, Recovery Coaches, and IPS Specialists. These conferences occurred

about once a month and were facilitated initially by national experts and then by local

training teams.

The experience of the RAISE Connection Program generated suggested topics for

component supervision meetings:

• Team Leader Component Supervision:

 Case discussion

 Integrating clinic requirements into care (e.g., clinic specific forms and assessments)

 Integrating the model throughout all of the Team Leader roles and responsibilities,

including the family component.

• Psychiatrist Component Supervision:

 Case discussion

 Problems encountered with the implementation of preferred medications

 Strategies /approaches that have been found useful to help participants manage their

illness and psychotropic medications.

• IPS Specialist Component Supervision:

 Review of work and employment status of each client

 Successes and challenges in job development

 Applying the model to supported education

 Creative ways to engage clients in job searches

 How to coordinate and organize meetings with job sites, schools, etc.

• Recovery Coach Component Supervision:

 Review areas being addressed (social skills training or substance abuse)

 Challenges in teaching skills and supporting implementation outside the clinic

 Ways to build rapport and engagement,

 Educating clients about the role of the Recovery Coach

 How to use motivational enhancement strategies and shared decision making when

approaching clinical problems with clients

 Discussions regarding strategies for talking with young clients about planning for

goals and using new skills in their lives.

• Family Work Component Supervision:

 implementation of monthly family education groups and other family program

components

 Engaging families

 Educating family members about psychosis

 Family work/issues not addressed during the regular supervision meetings.

5. Supervision in the Team-based Model: In the same way that training has team- and role-

based components, supervision also requires both perspectives. Supervision in the team-

based model involves all team members and focuses on whether the team is working

together in accordance with the model. Model supervision involves client reviews or

reviews of specific topics to ensure that the team is adhering to the underlying principles

of mental health recovery, shared decision making, and critical time intervention. All

members of the team participate in this monthly meeting. It can take the form of a team

meeting in which a theme that runs across the care of different clients is discussed. This

is also a good place to discuss issues that are common to many clients, such as how to

address trauma or how to work with families within the team.

If all types of supervision are needed, decisions must be made about who will provide them and

how to manage the amount of supervision so that there is not an excess of meetings. It will be up

to the team and the clinic to decide how best to use supervision time to cover the needs of the

team.

B. Ways to Deliver Supervision

Supervision can be done in person or on the phone. It is recommended that administrative and

clinical supervision be done in person, and that the medical records for the clients being

discussed be available during the meeting. This allows for review of records to make sure that

forms are properly completed in a timely manner. Clinical consultation and model supervision

can be done in person or on the phone. A plan for each should be developed and provided to

attendees prior to the meeting. For clinical consultation, the Team Leader or the Team

Psychiatrist should list one to two clients to discuss with the consultant, provide a brief write-up

on the background of the case and the issues for which consultation is sought. For model

supervision, each team member should be assigned a date to prepare a clinical case or several

cases that illustrate an issue. A write-up of the case(s) should be provided to all attendees prior

to the meeting.

While supervision can be done by telephone or in person, experience suggests that some in-

person time is necessary and beneficial. The team and the clinic can decide the exact ratio of

phone to in-person meetings. Some types of supervision—especially if it is component

supervision shared among multiple teams—may be suited to the telephone. For example,

“model” supervision could be shared among multiple teams, done over the phone or via video

conference. The discussion could involve teams sharing common patterns or themes they see

among clients and share how to address these while adhering to the model.

C. Supervision How-To’s

Supervision is an important part of clinical care. Supervision should be on a regular day and time

that is good for all attendees and should be identified as an important part of the service of the

team.

Good supervision takes planning. As noted above, each supervision meeting should have a leader

who is responsible for planning the content of the meeting, creating an agenda, distributing the

agenda to attendees, writing the supervision note, and recording attendance and what was

discussed. A sample form for supervision notes is provided in Appendix 10. For some types of

supervision (e.g., clinical), the leader of the meeting is generally the more senior person (e.g.,

Team Leader). In other cases, the leader of the supervision meeting can be alternated so that all

members of the meeting are the leader at some point.

The following are some sample structures for supervision meetings:

Clinical Supervision, Team Leader/Recovery Coach

1. Review list of clients who are working with the Recovery Coach. Note clients who are

nearing the end of their work with the Recovery Coach and provide a status summary to

the Team Leader. Assign new cases to Recovery Coach; Team Leader can provide a

summary of the case and a reason for the referral to the Recovery Coach.

2. Identify one or two clients to discuss in-depth. These could be cases that are progressing

well and the Recovery Coach has ideas about additional work to be done, or cases that

are challenging (e.g., poor engagement with Recovery Coach, lack of progress, feeling

stuck). The Recovery Coach should be prepared to provide a summary of these cases and

identify the issue or challenge to discuss with the Team Leader.

3. Check in regarding groups (e.g., social skills, substance abuse treatment, family) that are

led by the Recovery Coach and update on attendance, topics covered, and how these

topics can be integrated into individual work.

4. Other issues/action plan to work on between supervision meetings.

Administrative Supervision, Team Leader and Clinic Administrator

1. Review all clients receiving services from the Team. Make sure all forms are complete

for all clients or identify what’s needed for whom and when it’s due.

2. Discuss any administrative challenges that have taken place since the last meeting.

3. Check in regarding new cases or cases that will soon be discharged/transitioned to

community care.

4. Other issues/action plan to work on between supervision meetings.

Model Supervision, All Team Members Present

1. One team member is the leader of the meeting. This can rotate among team members.

2. The leader identifies an issue or client whose care is challenging for discussion and

provides a care summary. These challenges are discussed and possible responses are

identified according to the treatment model.

3. Discuss how each team member can contribute to this case in ways that are in line with

the model.

4. Other issues/action plan to work on between supervision meetings.

A list of resources for supervision is provided in Appendix 11.

V. Fidelity

Section Tools:

 Appendix 12: Resources for Fidelity

Fidelity measures are important because they provide valuable information to three stakeholder

groups:

• Payers want to know if they are getting what they are paying for

• Trainers/supervisors want to know whether clinical staff are implementing the

interventions as intended over time

• Clients/families want to know if the services they are investing their time/effort/finances

in are up to par and can reasonably be expected to promote the outcomes they care about

(school/work/friends/health)

A practical approach to fidelity is recommended, with measures drawn from information that is

typically readily available in routine practice settings implementing the CSC program as

described. Fidelity measures should support and draw from routine clinical operations.

Optimal fidelity measures are those that are good proxies for the components of the intervention

that they are measuring. For example, a core expectation for the intervention is that antipsychotic

medications are a central part of treatment for almost everyone. Hence, associated fidelity

measures would examine the proportion of clients prescribed an antipsychotic and the proportion

who had had an adequate trial on an antipsychotic, where “adequate” was specified clearly

enough to be measured objectively. Routine service logs will support many fidelity measures so

long as they note for each contact the client, staff involved, whether family was present, and the

location of the service (office versus community). The presence of routine clinical forms such as

those included in this manual to support the intervention can be used to document that those

components of the intervention occurred. For example, if a program expectation is that safety is

assessed at intake, then the presence of such a completed safety-assessment form at intake

signifies that such an assessment was completed. Routine medication records and associated

laboratory orders provide information necessary to assess fidelity to the psychopharmacology

components of the intervention. Appendix 12 provides, for each intervention component, core

expectations and how they may be operationalized.

Most clinics or hospitals housing an FEP team will have staff record service contacts via an

electronic record. All will have electronic claims records. Many also will have electronic health

records for each client that will contain information such as weight, medications prescribed, and

various symptom check lists. Whenever possible, fidelity data should be obtained from claims

data and other electronic sources to minimize the data collection/compilation burden on clinical

and administrative staff. As a fallback, payers can specify the data an FEP program is required to

submit, and those submissions can be verified via site visits. The RAISE Connection Program

Teams in Maryland and New York were part of a research project operating in two very different

sites and relied on abstracting information from specified locations in the project’s required

clinical forms maintained in clients’ charts and entry of that data into a centralized database

built for this study. Designing, building, debugging, and implementing such a chart abstraction

system is cumbersome for short-term use, but is a feasible approach when abstraction from

electronic claims is not an option.

Appendix List

Appendix 1: Getting Started Checklist

Appendix 2: Inclusion and Exclusion Criteria Used in the RAISE Connection Program

Appendix 3: Sample Job Descriptions for Team Hires

Appendix 4: Background Readings and Resources - Team

Appendix 5: Background Readings and Resources - Recovery Coach Training

Appendix 6: Background Readings and Resources - Supported Employment and Education

Appendix 7: Vignettes to Use in Team Training

Appendix 8: Scripts for Training Role Plays

Appendix 9: Forms to Use for Team Training Topics

Appendix 10: Sample Forms for Supervision Notes

Appendix 11: Resources for Supervision

Appendix 12: Resources for Fidelity

Appendix 1: Getting Started Checklist

Getting Started Checklist:

Activity



Identify program structure and services



Determine geographic boundaries



Define clinic population and eligibility criteria



Connect with state and surrounding partners



Establish funding / operating budget



Establish a referral network



Apply clinic procedures to the team



Establish programmatic oversight rules



Assess staffing requirements



Develop standards for team functioning



Develop training plan

Appendix 2: Inclusion and Exclusion Criteria Used in the RAISE Connection Program

Inclusion Criteria: All Should Be Met

1. Age range: 15–35 years (Maryland 15–35; New York 16–35)

2. Diagnosis: schizophrenia, schizoaffective and schizophreniform disorders, delusional

disorder, psychosis not otherwise specified (NOS)

3. Duration of psychotic symptoms > 1 week and < 2 years

4. Ability to speak and understand English

5. Anticipated availability to attend the clinic for 1 year

Exclusion Criteria: None Should Be Met

1. Other diagnoses associated with psychosis:

o Substance-induced psychotic disorder

o Psychotic affective disorder (e.g., major depressive or manic episode with psychotic

features)

o Psychotic disorder due to a general medical condition

2. Medical conditions that impair function independent of psychosis

3. Intellectual disability

Inclusion Criteria 1: Age range 15–35 years (Maryland 15–35; New York 16–35). Treatment

at each specialty clinic will be informed by the developmental stage of its clients. Each clinic

will need to select the age range for services, and then ensure that the team is appropriately

trained to meet the psychosocial treatment needs of that population. This is particularly true for

IPS services, because educational and vocation needs can vary widely for different age groups.

Recovery groups could also be targeted for developmental stages or goals, such as transitional

aged youth or college groups.

Inclusion Criteria 2: Diagnosis of schizophrenia, schizoaffective disorder, schizophreniform

disorder, delusional disorder, psychosis not otherwise specified (NOS), or brief psychotic

disorder. In the case of the Connection Program, the clinic served individuals who were in the

early stages of a primary psychotic disorder. The interventions were selected and staff trained

specifically for individuals experiencing these symptoms. Other clinics may consider expanding

to include individuals experiencing mood-or substance-induced psychosis.

Inclusion Criteria 3: Duration of psychotic symptoms > 1 week and < 2 years. A wide

variety of methods exist for defining the start of psychotic symptoms. For the Connection

Program, the ORS evaluated the date of each of the earliest symptoms. Many individuals

experience transient, attenuated symptoms of psychosis without ever developing psychosis. For

an individual to be eligible for the Connection Program, the potential clients’ symptoms were

evaluated for

o the level of their symptom intensity (frequency),

o the impact on their behavior, and

o whether the individual experiences a reduced awareness that their unusual

perceptual experiences and/or unusual beliefs are symptoms.

Date of onset should be determined for each symptom. In the Connection Program, the earliest

date of onset was used to calculate the duration of psychotic symptoms. Psychotic symptoms

include:

• Delusions of reference—belief that others are taking special notice of them,

talking about them, references on TV, reading material, etc.

• Persecutory delusions—belief that he or she is being attacked, harassed,

persecuted, or conspired against

• Grandiose delusions—belief that he or she possesses special powers, exaggerated

importance (rich or famous), or relationship to a deity

• Somatic delusions—belief that his or her body is grossly distorted; change or

disturbance in appearance or functioning

• Other (religious, guilt, jealousy)—unusual religious experiences, belief that he or

she must be punished for something (guilt), belief that partner was being

unfaithful, or belief that he or she is in a relationship with someone famous

• Mind control (insertion/withdrawal)—belief that thoughts and/or actions are

under the control of an external force. Individual may experience thoughts being

placed into head and/or thoughts being taken out of his or her head.

• Thought broadcasting—belief that others can hear their thoughts or read his or her

mind

• Hallucinations: auditory, visual, tactile, olfactory, and/or gustatory

A reduced awareness that a person’s unusual perceptual experiences and/or unusual beliefs are

symptoms must be present (e.g., a belief held with conviction despite evidence to the contrary).

Additionally, either impact on behavior and/or intensity (symptoms occur at least intermittently

or a preoccupation with belief) must be evident.

Other specialty clinics may use different criteria to determine the duration of psychotic

symptoms. Examples include date of first antipsychotic medications prescribed for psychosis, or

date of first psychiatric hospitalization due to psychosis. A date of onset can also be determined

by subjective terms through a discussion between the ORS and the Senior Clinician.

Inclusion Criteria 4: Ability to speak and understand English. Language inclusion criteria

should be determined based on the available services at each specialty clinic site. The

Connection Program staff did not have bilingual staff members or available interpreters. For

specialty clinics serving clients speaking other languages, this criteria item should be revised

accordingly. If the service-seeker was a minor, the Connection Program required that at least one

parent/guardian could discuss and approve participation in English. Specialty clinics will need to

communicate with parents/guardians about treatment and provide psycho-education to families.

Consider carefully the languages and fluency levels that your clinic will require for

parents/guardian attending the program to ensure that collaborative decision making can occur

with parents/guardians as well as with the minor service-seekers.

Exclusion Criteria: None Should Be Met

Like the inclusion criteria, the Connection Program exclusion criteria were created based on the

types of individuals that the clinic intended to serve and the available services at the program.

Some individuals were experiencing symptoms and illnesses beyond the scope of the teams’

specialized training. Other individuals were experiencing psychotic symptoms caused by

illnesses other than a primary psychotic illness.

Substance-Induced Psychosis.

• Type of substance and usual pattern of use

• Focus on alcohol, sedatives, hypnotics, and/or anxiolytics

• Focus on periods of significant increase or decrease in relation to onset of psychotic

symptoms

• Qualifying psychotic symptoms must be present in the absence of substance

intoxication and/or withdrawal

Affective Psychosis. Individuals experiencing affective psychosis were not included. This

included individuals experiencing either a major depressive episode or a manic episode with

psychotic features. Individuals with mood symptoms and substance abuse were accepted;

however, these individuals experienced prominent psychosis, in the absence of any mood

symptoms. Services for primary mood, substance use, or medical illnesses are substantively

different from those with primary psychotic disorders. Other specialty clinics include individuals

with mood- or substance-induced psychosis, and each clinic will need to choose parameters for

psychosis substance and mood.

a) Presence of Mood Symptoms (Based on DSM-IV) (Focus on temporal relationship

between mood symptoms and onset of psychotic symptoms)

• Major Depressive Episode: Five or more of the following symptoms with impact

on functioning for a period of 2 weeks or greater (1 or 2 must be present)

1) Depressed mood most of the day or nearly every day

2) Markedly diminished loss of interest in activities previously enjoyed

3) Significant weight change (loss or gain)

4) Insomnia nearly every day

5) Psychomotor agitation or retardation nearly every day

6) Fatigue or loss of energy

7) Feelings of worthlessness or excessive guilt

8) Diminished ability to concentrate or indecisiveness

9) Suicidal ideation and/or suicidal attempt

• Mania: Persistently expansive or irritable mood, plus three or more of the

following symptoms within a distinct period (at least 1 week)

1) Inflated self-esteem or grandiosity

2) Decreased need for sleep

3) Pressured speech

4) Flight of ideas/racing thoughts

5) Distractibility

6) Increase in goal-directed activity or psychomotor agitation

7) Excessive engagement in pleasurable risk-taking behaviors

• Qualifying psychotic symptoms must be present and primary with an absence of

mood symptoms for at least 2 weeks.

Psychosis Due to a General Medical Condition

• Prominent psychotic symptoms due to the direct physiological effects of a general

medical condition

• General Medical Conditions include: neurological conditions (including traumatic

brain injuries), endocrine conditions, metabolic conditions, autoimmune disorders

with central nervous system involvement

Medical Conditions that Impair Function Independent of Psychosis

As defined by disability necessitating the person to be on or to apply for Supplemental Security

Income [SSI], Social Security Disability Insurance [SSDI], workers compensation, veterans

disability, or similar benefits.

Intellectual Disability

Operationalized as an IQ below 70 for the intervention, but we recommend raising this to

exclude borderline intellectual functioning (IQ below 85).

Appendix 3: Sample Job Descriptions for Team Hires

At full capacity, the team’s caseload would be 30 clients. Clients will receive services for 2

years. Training will be provided to all staff members working with individuals experiencing their

first episode of psychosis and in the specific treatments that will be provided.

1. Team Leader, 1.0 FTE

An experienced Master’s level clinician who is trained in working with individuals

experiencing FEP. He or she will be the primary contact person for clients and families

and will spearhead efforts to engage clients in treatment. The Team Leader’s primary

goals are to build a positive relationship with participants and assist them in developing

their abilities for illness self-management. The Team Leader will work with participants

using a shared decision-making process to develop and modify treatment plans. The

Team Leader will provide support, education, consultation, and basic services to

participants and their families. With younger individuals, work with families will be more

prominent since they play a pivotal role in the individuals’ lives during adolescence and

the first years of adulthood. The Team Leader will monitor, oversee, and supervise the

team-based process.

2. Supported Education and Employment Specialist, 1.0 FTE

A Bachelor’s level position; someone in this position should ideally have prior

experience as a supported education or employment specialist. He or she will focus on

assisting participants to continue, resume, or adapt their academic or vocational activities

successfully, using the IPS (individual placement and support) model.

3. Recovery Coach, 0.5 FTE

An experienced Master’s level clinician who will help clients clarify goals, cope with

stressful situations, interact more effectively with other people, and in general, overcome

barriers to their recovery. This is done within a framework that is empowering and

cultivates peer support through the use of structured behavioral interventions aimed at

learning new skills and supporting behavior change, including social skills training,

substance abuse treatment, behavioral activation, coping skills training, and psycho-

education.

4. Outreach and Referral Specialist, 0.5 FTE

The designated individual(s) should be a Master’s level clinician (or possess a higher

clinical degree) and the ability to identify primary psychosis and perform differential

diagnoses for symptom profiles related to psychosis. A program may choose to identify

persons within the clinical team to lead outreach and recruitment activities, or establish a

separate team of individuals who will only be responsible for such activities.

5. Psychiatrist, 0.2 FTE

He or she will be responsible for diagnosis, medical care needs, medication management,

and acute management of suicidality and safety concerns. Medication management will

be guided by a medication algorithm that provides information about evolving best

practices. A shared decision-making framework will be used.

Appendix 4: Background Readings and Resources - Team

National Alliance on Mental Illness (NAMI)

Information on First Episode of Psychosis

http://www.nami.org/template.cfm?section=First_Episode

Substance Abuse and Mental Health Services Administration (SAMHSA)

Recovery to Practice

http://www.samhsa.gov/recoverytopractice/

Choices in Recovery

http://www.choicesinrecovery.com/

Shared Decision Making

http://patients.dartmouth-hitchcock.org/shared_decision_making.html

Lived Experience:

Addington J, Coldham E, Jones B, et al. (2003). The first episode of psychosis: the experience of

relatives. Acta PsychiatrScand, 108, 285–289.

Compton MT and Broussard B. (2009). The First Episode of Psychosis: A Guide for Patients

and their Families. NY: Oxford University Press.

Deegan, PE (2007). The lived experience of using psychiatric medication in the recovery process

and a shared decision-making program to support it. Psychiatr Rehabil J, 31(1), 62–69.

Deegan, P. (1988). Recovery: the lived experience of rehabilitation. Psychosoc Rehabil J, 9(4),

11–19.

Leete, E. (1989). How I perceive and manage my illness. Schizophr Bull, 15(2), 197–200.

Saks, ER (2007). The Center Cannot Hold: My Journal Through Madness. New York: Hyperion.

Schiller L, and Bennett A. (1994). The Quiet Room: A Journey Out of the Torment of Madness.

NY: Warner Books.

Peers/Community:

The Temple University Collaborative on Community Inclusion of Individuals with Psychiatric

Disabilities

http://tucollaborative.org/index.html

The Institute for Recovery and Community Integration

http://www.mhrecovery.org/

Recovery Model and Implications for Treatment:

Bellack AS. (2006). Scientific and client models of recovery in schizophrenia: Concordance,

contrasts, and implications. Schizophr Bull, 32: 432–442.

Davidson L, Drake RE, Schmutte T, et al.(2009). Oil and water or oil and vinegar? Evidence-

based medicine meets recovery. Community Ment Health J, 45:323-332.

Davidson L, Harding C, Spaniol L, eds. (2005). Recovery from Severe Mental Illnesses:

Research Evidence and Implications for Practice. Volume 1. Center for Psychiatric

Rehabilitation Sargent College of Health and Rehabilitation Sciences Boston University.

Harding CM, and Zahniser JH. (1994). Empirical correction of seven myths about schizophrenia

with implications for treatment. Acta Psychiatr Scand Suppl, 384, 140–146.

Kreyenbuhl J, Nossel IR, and Dixon LB. (2009). Disengagement from mental health treatment

among individuals with schizophrenia and strategies for facilitating connections to care: A

review of the literature. SchizophrBull35(4), 696–703.

Melle I, Johannesen JO, Friis S, et al. (2006). Early detection of the first episode of

schizophrenia and suicidal behavior. Am J Psychiatry, 163(5), 800–804.

Trauma-Informed Care:

Morrison AP, Frame L, and Larkin W. (2003). Relationships between trauma and psychosis: A

review and integration. Br J Clin Psychol, 42 (Pt 4), 331–353.

Neria Y, Bromet EJ, Sievers S, et al. (2002). Trauma exposure and posttraumatic stress disorder

in psychosis: Findings from a first-admission cohort. J ConsultClinPsychol, 70(1), 246–251.

ShevlinM, DorahyMJ, and Adamson G. (2007). Trauma and psychosis: An analysis of the

National Comorbidity Survey. Am J Psychiatry, 164(1), 166–169.

Voices of Recovery videos

http://practiceinnovations.org/ConsumersandFamilies/ViewAllContent/tabid/232/Default.aspx

http://www.theannainstitute.org/TSA-ADULTS.htm

http://www.ptsd.va.gov/index.asp

Shared Decision Making:

Adams J R, and Drake R E. (2006). Shared decision-making and evidence-based practice. Comm

Ment Health J, 42(1), 87–105.

Deegan PE, and Drake RE. (2006). Shared decision making and medication management in the

recovery process. Psychiatr Serv, 57, 16361639.

Examples of decision aids in the public domain can be found at the following sites:

• http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-

and-reports/?pageaction=displayproduct&productID=10 – decision aid on

antidepressants

• http://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOC

HWID=za1120 - decision aid on whether to use medicine to help sleep

• http://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOC

HWID=zw1124&SECHWID=zw1124-Intro - decision aid on whether to use

medicine to quit smoking

• http://www.healthwise.net/cochranedecisionaid/Content/StdDocument.aspx?DOC

HWID=aa45364&SECHWID=aa45364-Intro - decision aid for using medicine to

treat PMS

• http://mentalhealth.samhsa.gov/clientsurvivor/shared.asp - includes SAMHSA

“Cool Tools”

Suicide / Safety Planning:

CaldwellCB, and Gottesman JI. (1990). Schizophrenics kill themselves too: A review of risk

factors for suicide. SchizophrBull16(4): 571–589.

Drake R E, Gates C, Cotton PG, et al. (1984). Suicide among schizophrenics: who is at risk? J

Nerv MentDis, 172, 613–617.

Harkavy-FriedmanJM and NelsonEA (1997). Assessment and intervention for the suicidal

patient with schizophrenia. Psychiatr Q, 68(4): 361–375.

Harkavy-Friedman JM, Restifo K, Malaspina D, et al. (1999). Suicidal behavior in

schizophrenia: characteristics of individuals who had and had not attempted suicide. Am J

Psychiatry, 156(8): 1276–1278.

Harkavy-Friedman, JM,Kimhy D, Nelson, EA, et al. . (2003). Suicide attempts in schizophrenia:

the role of command auditory hallucinations. J Clin Psychiatry, 64(8): 871–874.

Harkavy-Friedman JM, Nelson EA, Vernarde DF, et al. (2004). Suicidal behavior in

schizophrenia and schizoaffective disorder: examining the role of depression. Suicide Life-

ThreatBehav, 34(1): 66–76.

Mamo DC. (2007). Managing suicidality in schizophrenia. Can J Psychiatry, 52: 59–70.

Melle I, Johannesen JO, Friis S, et al. (2006). Early detection of the first episode of

schizophrenia and suicidal behavior. Am J Psychiatry, 163: 800–804.

Stanley B andBrown GK. (2008). Safety planning: An intervention to mitigate suicide risk.

Washington, D.C: Veterans Health Administration Publication.

Stanley B, Brown F, Brent D, et al. (2009). Cognitive behavior therapy for suicide prevention

(CBT-SP): treatment model, feasibility and acceptability. JAmn AcadChild AdolescPsychiatry,

48(10): 1005–1013.

Appendix 5: Background Readings and Resources - Recovery Coach Training

VA VISN5 MIRECC Social Skills Training Program

http://www.mirecc.va.gov/visn5/training/social_skills.asp

The Institute for Recovery and Community Integration

http://www.mhrecovery.org/

Motivational Interviewing

http://www.motivationalinterview.org/

SAMHSA – Co-occurring Disorders

http://www.samhsa.gov/co-occurring/

Person Centered Planning / Strengths Based Care

http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/pcp-instructionmanual2-3-10.pdf

Stages of Change

http://www.aafp.org/afp/2000/0301/p1409.html

Substance Abuse Treatment Resources

http://casaa.unm.edu/

Addington J, Penn D, Woods SW, et al.(2008). Social functioning in individuals at clinical high

risk for psychosis. Schizophr Res, 99(1-3), 119–124.

Ballon JS, Kaur T, Marks .I, et al.(2007). Social functioning in young people at risk for

schizophrenia. Psychiatry Res, 151(1-2), 29–35.

Bellack AS. (2004). Skills training for people with severe mental illness. Psychiatr RehabJ, 27,

375–391.

Bellack AS, Bennett ME, and Gearon JS. (2007). Behavioral Treatment for Substance Abuse in

People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals.

NY: Taylor and Francis.

Bellack AS, and DiClemente CC. (1999). Treating substance abuse among clients with

schizophrenia. PsychiatrServ, 50(1), 75–80.

Bellack AS, and Gearon JS. (1998). Substance abuse treatment for people with schizophrenia.

Addictive Behaviors, 23(6), 749–766.

Bertrand MC, Sutton H, Achim AM, et al. (2007). Social cognitive impairments in first episode

psychosis. SchizophrRes, 95(1-3), 124–133.

Bradizza CM, Maisto SA, Vincent PC, et al.(2009). Predicting post-treatment-initiation alcohol

use among clients with severe mental illness and alcohol use disorders. J Consult Clin Psychol,

77(96), 1147–1158.

Carey KB, Leontieva L, Dimmock J, et al. (2007). Adapting motivational interviewing for

comorbid schizophrenia and alcohol use disorders. Clinical Psychology: Science and Practice,

14, 39–57.

Compton MT, Kelley ME, Ramsay CE, et al. (2007). Association of pre-onset cannabis, alcohol,

and tobacco use with age of onset of prodrome and age ot onset of psychosis in first-episode

clients. Am J Psychiatry, 166(11), 1251–1257.

Dixon LB, Dickerson FB, Bellack AS, et al. (2010). The 2009 schizophrenia PORT psychosocial

treatment recommendations and summary statements. Schizophr Bull, 36(1), 48–70.

Drake RE, O’Neal EL, and Wallach MA. (2008). A systematic review of psychosocial research

on psychosocial interventions for people with co-occurring severe mental illness and substance

use disorders. Journal of Substance Abuse Treatment, 34(1), 123–138.

Gearon JS, Kaltman SI, Brown C, et al.2003). Traumatic life events and PTSD among women

with substance use disorders and schizphrenia. PsychiatrServ, 54(4), 523528.

Kurtz MM and Mueser KT. (2008). Meta-analysis of controlled research on social skills training

for schizophrenia. J Consult Clin Psychol, 76, 491–504.

Miller WR, and Rollnick S. (1991). Motivational Interviewing: Preparing People to Change

Addictive Behaviors. New York: Guilford Press.

Miller WR, and Rollnick S. (2002). Motivational Interviewing: Preparing People for Change

(2nd ed.). New York: Guilford Press.

Mueser KT, and Bellack AS (1998). Social skills and social functioning. In K.T. Mueser and N.

Tarrier (Eds.), Handbook of Social Functioning in Schizophrenia. Needham Heights, MA: Allyn

& Bacon (pp. 79-96).

Mueser KT, Yarnold PR, Levinson DF, et al.(1990). Prevalence of substance abuse in

schizophrenia: Demographic and clinical correlates. SchizophrBull, 16, 31–56.

Mueser K T, Bennett M, and Kushner MG. (1995). Epidemiology of substance use disorders

among persons with chronic mental illnesses. In A. F. Lehman and L. B. Dixon (Eds.), Double

Jeopardy: Chronic Mental Illness and Substance Use Disorders, Vol. 3, (pp. 9–25). Longhorne,

Pa: Harwood Academic Publishers.

Mueser KT, Noordsy D L, Drake R E, and Fox L. (2003). Integrated Treatment for Dual

Disorders: A Guide to Effective Practice. New York: The Guilford Press.

Pilling S, Bebbington P, Kuipers E, et al (2002). Psychological treatments in schizophrenia: II.

Meta-analyses of randomized controlled trials and social skills training and cognitive

remediation. Psychol Med, 32(5), 783–791.

Reiger DA, Farmer ME, Rae DS, et al. (1990). Comorbidity of mental disorders with alcohol and

other drug abuse results for the epidemiologic catchment area (ECA) study. JAMA, 264, 2511–

2518.

Sullivan WP, and Rapp CA. (1994). Breaking away: The potential and promise of a strengths-

based approach to social work practice. In R.G. Meinert, J.T. Pardeck, & W.P. Sullivan (Eds.),

Issues in social work: A critical analysis (pp. 83–104). Westport, CT: Auburn House.

Tenhula WN and Bellack AS. (2008) Social Skills Training. In K. Mueser & D. Jeste (Eds.)

Clinical Handbook of Schizophrenia. Guilford Press, New York.

Weick A, Rapp C, Sullivan WP, et al. (1989). A strengths perspective for social work practice.

Social Work, 34, 350–354.

Whelan G. (2007). Impact of severity of substance use disorder on symptomatic and functional

outcome in young individuals with first-episode psychosis. J Clinl Psychiatry, 68(5), 767–774.

Appendix 6: Background Readings and Resources - Supported Employment and

Education

Supported Employment

Dartmouth IPS Supported Employment Center

http://www.dartmouth.edu/~ips/

SAMHSA

http://store.samhsa.gov/product/Supported-Employment-Evidence-Based-

Practices-EBP-KIT/SMA08-4365

Becker D, and Drake R. (2003). A Working Life for People with Severe Mental Illness.

NewYork: Oxford Press.

Drake R E, McHugo GJ, Becker D R, et al. (1996). The New Hampshire study of supported

employment for people with severe mental illness. J Consult Clin Psychol, 64, 391–399.

Killackey E J, Jackson H J, and McGorry P D. (2008). Vocational intervention in first-episode

psychosis: Individual Placement and Support.versus treatment as usual. BrJ Psychiatry, 193,

114–120.

Nuechterlein H, Subotnik K L, TurnerL R, et al. (2008). Individual placement and support for

individuals with recent-onset schizophrenia: integrating supported education and supported

employment. Psychiatr Rehabil J, 31(4), 340–349.

Appendix 7: Vignettes to Use in Team Training

Note: The goal in using vignettes is to demonstrate correct and incorrect ways of completing a

needs assessment with a young adult client and his or her family member. Discussion of the

vignette included all team members as a way to identify the important administrative and

personal aspects of the needs assessment process.

Vignette 1: Addressing Various Treatment Foci

Context/Details:

1) Review the summary of the needs assessment. The team as a whole can address relevant

considerations and issues relevant to their work as a team, as well as how they would

engage the client in moving forward with treatment planning and delivery of related

supports and services.

2) Next each break-out team can meet separately to discuss how they would address the

relevant needs and issues summarized in the assessment summary.

First group: Psychiatry and Medication Specialists

Second group: IPS team

Third group: RCs

Fourth group: Team Leaders (with consideration of range of treatment foci

including family, trauma, safety planning, housing/income,

wellness self-management, etc.)

3) Next the full group will re-assemble for a “mock” team meeting. Participants will be

charged with discussing how to coordinate/sequence/prioritize the various treatments and

services and engage the client in the development of a full and integrated treatment plan.

We also use this as a learning opportunity to discuss the challenges of working as a team.

Summary of Needs Assessment:

A 23-year-old woman was referred to the RAISE Connection Team at discharge from a 2-week

hospitalization for treatment of her first psychotic episode. She completed her first round of

meetings with various team members and the following information was collected as part of her

initial needs assessment. Consideration of this “report” should be discussed from the perspective

of each team so that each team can focus on and explore what services it has to offer and how

they might be presented to the client and his/her family.

Medication: The client had a favorable therapeutic response to oral risperidone and received an

injection of risperidone micorspheres (Risperdal CONSTA) 25 mg IM just before discharge. At

her first team meeting, the client reported that she has been sleeping well, that the voices are

greatly diminished and no longer intrusive, and that she feels safe again. However, she reported

concern about weight gain and stated that she was distressed by this. She also expressed concern

that she is pregnant because her menstrual period has not occurred this month; she denies recent

sexual activity.

Wellness Management: The client is concerned about recent weight can and also expressed

interest in getting fit and learning how to eat better. She also noted that she would like to learn

more about stress management.

Education and Employment: The client has a GED. She reported an interest in considering going

to a local community college. She also noted that she is tired of not having much money and

expressed interest in getting a job. She has only had a few part-time jobs and expressed anxiety

about the prospect of entering the job market.

Family Support: Client lives with her mom and step-dad. She has no siblings and reports having

no friends. She sees her biological father only about once or twice a year.

Housing and Income: Client lives with her mom and step-dad but reports that she is not happy

there and that her step-dad “creeps her out.” She has no health insurance and no source of

income. Her biological father, who lives out of state, provides her with intermittent financial

support.

Substance Abuse: Client smokes 2 packs of cigarettes a day. She reports feeling ambivalent

about quitting. She knows she “should” but is not sure she’s ready or able to.

Trauma: Client has hinted she may have been sexually abused as a child. She is unwilling to

discuss this but has referenced “bad” experiences that leave her feeling freaked out about getting

involved with anyone sexually. She also witnessed a stabbing in her neighborhood when she was

13 and says that she prefers to hang at home because it’s safer than dealing with her

neighborhood.

Safety: Client was actively suicidal at the time of her hospitalization. She currently notes that she

no longer is pre-occupied with wanting to end her life and that she only intermittently has

thoughts about hurting herself. She says that she has no current plans to hurt herself.

Vignette 2: How to Engage the Full Team and Client in

Coordinated Treatment Planning

Context/Details:

1) Review the summary of the needs assessment. The team as a whole can address

considerations and issues relevant to their work as a team, as well as how they would

engage the client in moving forward with coordinated treatment planning and delivery of

related supports and services.

2) Next each break-out team can meet separately to discuss how they would address the

relevant needs and issues summarized in the assessment summary.

First group: Psychiatry and Medication Specialists

Second group: IPS team

Third group: RCs

Fourth group: Team Leaders (with consideration of range of treatment foci

including family, trauma, safety planning, housing/income,

wellness self-management, etc.)

3) Next the full group will re-assemble for a “mock” team meeting. Participants will be

charged with discussing how to coordinate/sequence/prioritize the various treatments and

services and engage the client in the development of a full and integrated treatment plan.

We also use this as a learning opportunity to discuss the challenges of working as a team.

Summary of Needs Assessment

An 18-year-old male was referred to the Connection Team by the psychologist embedded in his

inner-city public high school, where he was struggling to complete his junior year. He lives with

his grandmother and two half-siblings. He and his grandmother have already met with the Team

Leader and Team Psychiatrist but both have been reluctant to meet with the other team members.

Medication: After 4 4-week trials each of perphenazine (up to 16 mg. daily at which coarse

EPSE were apparent) and risperidone (up to 6 mg daily at which he appeared slightly akinetic

and complained of sexual dysfunction), this young man continues to be preoccupied with voices

that were a central feature of his first psychotic break 2 months ago without any abatement in

frequency and intensity. Of note, his biological mother (who is currently incarcerated) and his

grandmother both have Type II diabetes mellitus.

Wellness Management: The client is overweight, has a very poor diet, and is generally inactive.

He reports significant difficulties with sleep. Although he huffed glue regularly for several years

and reported a history of poly-substance use, he reports that he has not used any substances for

the past 6 months. He also has moderate to severe asthma.

Education and Employment: The client repeated the third grade and has a long history of

learning disabilities. His current IEP provides access to a school counselor and additional

educational services. He has been having difficulty in school this current year and has missed

several days. He reports that he hates school and would like to drop-out. He has never held a

paying job.

Family Support: Client lives with his grandmother and two half siblings (ages 16 and 11). His

grandmother works full time as nurses’ aide with a rotating day-evening work schedule. The

client’s mother is currently in jail.

Substance Abuse: As noted, the client acknowledged that he huffed glue regularly for several

years and reported a history of poly-substance use. He reports that he has not used any

substances (other than cigarettes) for the past 6 months. The client smokes about a pack of

cigarettes a day.

Trauma: Client was removed from his mother’s care by Child Protective Services at age 4

secondary to investigated reports of neglect and physical abuse. He lived in one or two foster

care placements until moving in with grandmother where he has remained for the past 10 years.

Safety: Client reports hearing command hallucinations to hurt himself. Although he says he is

able to ignore these demands and that he is not suicidal, he reports feeling concerned that the

voices will get stronger and more powerful as he gets older.

Vignettes Related to Psychopharmacology for Team Psychiatrist Training

Psychopharm Vignette 1: A 23-year-old woman is referred to the Connection Team at

discharge from a two week hospitalization for treatment of her first psychotic episode. She had a

favorable therapeutic response to oral risperidone and received an injection of risperidone

microspheres (Risperdal CONSTA) 25 mg IM just before discharge. When you first meet her in

clinic, she and her family report that she has been sleeping well, that voices are rare and not

intrusive, and that she feels safe again. However, she reports that she has gained weight and that

her clothes have become too tight. She also expresses concern that she is pregnant because her

menstrual period has not occurred this month; she denies sexual activity.

Issues to discuss: Prolactin, long-acting injected med, birth control, convincing

patient/family to consider a switch in medications

Psychopharm Vignette 2: After 4 week trials each of perphenazine (up to 16 mg daily at which

coarse EPSE were apparent) and risperidone (up to 6 mg daily at which he appeared slightly

akinetic and complained of sexual dysfunction), this 18-year-old man continues to be

preoccupied with voices that were a central feature of his first psychotic break 2 months ago. He

has been unable to engage with vocational and social programming. You consider trials of

olanzapine, and later clozapine, if the olanzapine fails. His mother has Type II diabetes mellitus.

Issues to discuss: Metformin (preemptive or reactive), fish oil, exercise

Psychopharm Vignette 3: A 22-year-old man with first episode psychosis and ongoing abuse of

marijuana and alcohol remains unable to engage in programming despite being assured

antipsychotic treatment with a long-acting injected medication. He repeatedly fights with his

step-father and has made two suicide attempts. He has not engaged in substance use treatment

despite numerous attempts

Issues to discuss: Hospitalization, clozapine

Psychopharm Vignette 4: A 19-year-old woman responded favorably to oral fluphenazine

during a hospitalization for her first psychotic episode. At discharge, she was given an injection

of fluphenazine decanoate 25 mg IM. At her first visit, she is akinetic and has clear cog-

wheeling. Her family report she sleeps 18 hours per day. They want her taken off this “poison.”

Issues to discuss: sensible dosing, rapid interventions—aripiprazole, family: all meds can

be toxic if dosed incorrectly

Appendix 8: Scripts for Training Role Plays

Note: Role plays contain scripts for encounters done “well” and done “poorly.” It is

recommended that the poor example be done first, with the discussion focused on what made it

poor. This should be followed by the done “well” example and discussion of what was improved

and how the interaction was more consistent with the principles of the recovery model, shared

decision making, and compassionate interacting with young people with FEP.

Role Play 1: Young Adult, First Meeting with Team Leader for Initial Needs Assessment

Context/Details: John is a 22-year-old single man who was working full time as a front desk

clerk for a hotel until 4 months ago, when he started showing increasing signs of psychosis. He

had never been a very outgoing person, but he was able to interact appropriately with hotel

guests until about a year ago. His job involved answering the phones, taking reservations,

greeting and checking in guests, fielding customer service complaints, and assisting with

luggage. He sometimes had difficulty dealing with guests complaints, especially when the guest

was angry. His supervisor had to step in on occasion to help, but she was happy with his work

until about a year ago.

About a year ago, John became more sensitive about customer complaints at the hotel and

sometimes felt that the customers were blaming him personally for problems they were having

with their rooms. He thought that perhaps he was not concentrating as well as he had in the past,

and felt this might be contributing to mistakes he sometimes made in assigning rooms and

working on billing for hotel charges. However, John increasingly felt that customers were being

unreasonable in their complaints. He started trying to avoid those customers who he thought

were troublemakers. This caused additional trouble when these customers complained to his

supervisor. She tried to work with John to help him improve his interactions with customers.

About 4 months ago, John started believing that some hotel customers were deliberately trying to

trick him into making mistakes on their hotel bills, which they would then blame on him and ask

him to correct. John started hearing an accusatory voice talking to him while he worked at the

hotel, which he attributed to hotel customers who were trying to influence his mind and get him

fired. Then the voices started occurring when John was at home as well, so John got increasingly

upset. John called the police to report that some guests at the hotel were working together to

force him to make errors on the job and get him fired. John was then hospitalized for his

paranoid delusions and auditory hallucinations.

John was referred to the Connection Team for eligibility screening. He still thinks that customers

at the hotel were the main cause of his problems. He is aware, however, that his concentration

has been poor and that he has been very upset with the things that have been happening to him.

John has been given antipsychotic medication, but he is not sure that it is doing him any good

and wonders whether he needs to continue taking it. He would just like to put the whole period

behind him and get back to work as soon as possible.

Role play that models the encounter “done poorly”:

Team Leader: Thanks for coming in today to meet with me. I want to use our time today

to complete a needs assessment so that I can put your treatment plan together. I apologize

in advance for the number of questions I’m going to ask, but we’ve got to get through this

full assessment today (hold up papers). Ok let’s get started. I see from your intake form

that you were hospitalized 4 months ago. Can you tell me why you were hospitalized.

John: I was having concerns about my job. I was only in the hospital for a few days,

though.

Team Leader: That’s good. Do you remember what medications you were taking when

you left the hospital?

John: Yes. They started me on something called Respira something

Team Leader: Riperidone?

John: Yeah, that’s it.

Team Leader: Are you still taking that medicine.

John: Yes…well sort of. I mean, I’m not sure if I really need it.

Team Leader: Sounds like medication compliance is something that we should put on

your treatment plan. I will let your psychiatrist know so you can talk to her about why

taking medicine is so important. I can also work with you to helpwith your medication

compliance.

John: Uh, ok. I really don’t think I want to take the medicine though. I don’t think I need

it. Do you think I can stop taking it?

Team Leader: Well…. I can’t really answer that question. Again, I know that you will be

meeting your psychiatrist soon, so I suggest you discuss that issue with her. OK. Great.

Now back to your last hospitalization. What symptoms were you experiencing at that

time.

John: Well, I was really having trouble at work.

Team Leader: That’s right you mentioned that. Were you having any specific symptoms

that were making it difficult for you at work? For example, was your mood a problem, or

were you having any unusual thoughts or concerns, or feeling very distracted, things like

that.

John: I was having a hard time dealing with difficult guests at the hotel where I work.

Still a lot of stuff going on there but I’m hoping that it will get better soon.

Team Leader: OK. Since you are going to be meeting with the psychiatrist too, so you

can talk more about specific symptoms when you meet with her. Ok. Great, now the next

set of questions is about substance abuse. Are you using drugs or alcohol?

John: I smoke marijuana sometimes.

Team Leader: How often?

John: A couple of times a week. Usually just at night before I go to bed.

Team Leader: Any other substances?

John: No.

Team Leader: Do you smoke cigarettes?

John: Yes.

Team Leader: How much do you smoke?

John: About a pack a day.

Team Leader: Ok. We don’t have time today, but it sounds like we may want to focus on

helping you with your smoking both cigarettes and marijuana. I know that these

substances can interfere with one’s life and of course as you know they both present

significant health risks too.

I can also tell you about various resources and treatments to help with smoking cessation

next time we meet. OK. Let’s see (while turning pages) Let’s move on. Next, I’d like to

ask about your educational background. How far did you get in school?

John: I graduated from high school. I also took some classes at Washington County

Community College.

Team Leader: That’s great. What are your goals regarding your education?

John: Well, I don’t know.

Team Leader: That’s OK. Next time we meet we can talk more about this and get a feel

for your ideas about this. OK…regarding employment, you mentioned that you work the

front desk at the Marriott Courtyard in Washingtonville.

John: That’s right.

Team Leader: Great. How long have you been working there?

John: About a year now.

Team Leader: That’s great. I do know, however, that you said things have been difficult

at work for you lately. I’m sure we will talk more about this as we get to know each

other. Part of learning how to live with mental illness is learning how it will challenge

you at work and in your relationships, etc. As you learn more about living with your

illness we can work together to help you make sure that you’re prepared to deal with

these challenges.

(NOTE FROM FACILITATOR)….”Alright, we’re now going to fast forward and re-join this

meeting right before it wraps up.”

Team Leader: Terrific. I apologize again for moving across so many topics but I wanted

to make sure that we completed the assessment. You were very helpful. I feel I learned

about you and look forward to working with you!

Facilitated Discussion re: what was missing/done poorly:

This should include review/application of intervention principles/clinical concepts etc.

(SDM, recovery-oriented, active/focused Stance, use of open-ended explorations,

flexibility and consistency, autonomy/availability).

Role play that models the encounter done “well”:

Team Leader: Hello (reach out to shake client’s hand). Very nice to meet you in person.

OK, as I mentioned what I hope to do today is learn more about how things are going for

you and how we can be of help to you.

John: OK.

Team Leader: Great. OK. You talked a lot about your job when we spoke briefly on the

phone. Sounds like work is a big and important part of your life right now.

John: I guess so. Although it’s stressing me out and really hoping I don’t get fired.

Team Leader: OK let’s start there. Help me understand how the stress has interfered with

things at work.

John: Well. I’ve been having trouble with hotel guests. I get angry all the time cause

they’re deliberately trying to make my job harder and get me fired.

Team Leader: Tell me more about feeling angry and how that affects your job.

John: I get so angry that I get confused and have trouble concentrating and my thoughts

start racing and I get all pre-occupied.

Team Leader: Those sound like they would make any job difficult. I guess step one is to

decide if those are problems you want to address right now.

John: Well I don’t want to lose my job.

Team Leader: I hear that. That sounds like a clear goal. Let’s talk about what things

might be helpful in working on this goal.

John: OK. How do we do that.

Team Leader: Well, we can start by talking about options and then review what the pros

and cons are for those options. For example, medication is one option. We can also figure

out together who else you’d like to have involved in making decisions and what your

preferences are so that you can identify how you’d like to proceed.

John: I’m not sure I want to take medication at all. I’m currently taking those pills they

started me on when I was in the hospital and I’m gaining all this weight and not sure I

even really need ‘em, let alone what I’m taking them for.

Team Leader: You don’t need to make any decisions today. Does sound like you want to

explore this further, though. Also sounds like you may have some questions, concerns or

want more information. I know that you are going to be meeting with the psychiatrist

soon so we can talk more at our next meeting about how to prepare for that meeting and

what to expect so that you can be fully involved in making decisions about medication.

John: OK.

Team Leader: Great. I also want to make sure we spend some time talking about what

you’ve been doing or used to do to help deal with the stress you’ve been talking about.

John: You’re not gonna wanna hear this, but smoking a joint before going to bed helps

and smoking cigarettes also helps me chill out.

Team Leader: That’s helpful to know, thanks. Any down sides or concerns you have

about smoking a joint or smoking cigarettes.

John: Well, in addition to the money, the pot does sometimes make me kinda paranoid.

Team Leader: Ok. So just like with all things there are going to be pros and cons to

discuss for this too. Are you OK keeping this on our agenda as something to check in on?

John: Well. I guess. Although I am not feeling ready to quit.

Team Leader: OK. I hear that. Thanks for permission to check back in with you though.

John: Whatever.

Team Leader: OK in addition to identifying things you want to work on, I want to make

sure we also make time to talk about what your life goals are and how you can best work

toward reaching those goals.

John: Well, if I don’t shape up, I’m gonna lose my job. I’m also scared that things are

going to get worse. I don’t even understand why this is getting worse.

Team Leader: I hear that you’re stressed about that. I also hear that you have a lot of

questions. That’s very normal. Part of our journey is making sense of how our lives

unfold. I look forward to exploring those questions with you and offer assistance to help

you move forward with you goals and achieve the full and rich life that you deserve. I

know we need to end for today, but thanks for getting started with me. As we move

forward know that I and others on the team will be available to meet with you to help you

stay connected to your goals and the services we have available here. We are also

available to help you identify and choose what you’d like to work on, and get the

supports you need to. Again, thanks for coming today.

Facilitated Discussion re: what was done well: This should include review/application of

intervention principles/clinical concepts etc. (e.g., Shared Decision Making , recovery-oriented,

active/focused stance, use of open-ended explorations, flexibility and consistency,

autonomy/availability).

Role Play 2: Follow-up Meeting with a Teenager and Team Leader to

Formulate/Develop Treatment Foci/Goals

Context/Details: Max is a 16-year-old 10

grade boy who was recently discharged from the

hospital where he had been admitted for suicidal ideation and substance abuse after a 3 week

hospitalization. Although he stated that he was abusing multiple substances, his urine tox screen

was negative and also had been negative when he was hospitalized 2 months previously for

similar complaints. His parents noted that he has become increasingly withdrawn over the past

two years and now only interacts with a few friends. He has always been hard to motivate to do

schoolwork, but his grades slipped from mostly B’s to C’s and D’s over the past year. Last

summer he worked as an assistant at a drama camp for elementary age kids and enjoyed it, but he

did not apply this year. He did not run track this year, but thinks he might continue cross country

in the fall.

During his evaluation, he admitted to almost constantly feeling like his mind was arguing with

itself, hearing an old woman talking to him saying what a bad person he is, feeling someone

standing behind him, and seeing odd light trails that others do not see. He notes that he is

concerned that people in the government and in his neighborhood are monitoring him and want

to put him in jail. He feels that if he stays in the house with the curtains closed and lights off it

will be harder for them to catch him. He also changes his email frequently and avoids talking on

the phone to make it harder to catch him. He sometimes gets messages from the TV. He reports

recent suicidal thoughts but has no current plan. He denies homicidality but does not know what

he would need to do if the neighbors or government entered his house. He reports that it has been

hard to pay attention in school with his head arguing and that he is not sure that he will pass

some of his classes.

At the time of his recent discharge, he was not able to identify any activities that he was sure he

would enjoy. He was open to the idea of trying the drama class again. He continued to hear the

woman especially late at night or when he was alone for an extended period of time, but knew

others thought she was not real. He knew others thought the government was not interested in

him but was not sure they would really know and continued to be concerned about this. He still

preferred to be alone and continued to maintain that he had been abusing drugs.

Client and his mother return after 3 weeks for another team meeting. In the meantime, they

have met with the Team Leader three times once in the family home, with the psychiatrist once

and with the supported education worker once. The supported education worker has observed the

client at school and obtained additional information from school staff. Skills specialist has not

had any separate meetings with client or his family.

The Team Leader notes that the client seems to get upset when his mother, father, or brother

express concern about him by clenching his fists or looking down at the floor. He does seem to

be relaxed when the family dog sits by him or he is listening to music. He also seems more

agitated when news shows or talk shows are on TV. She has gone over the shared decision

making card with him and his parents. His parents have told the Team Leader that he can be very

irritable if they ask about his homework or try to get him to sit with them after dinner. They also

note that he is eating a lot and his clothes are getting tight. At times he seems very anxious and

preoccupied, and occasionally, he will talk quietly to himself but they are unsure what he is

saying. Max’s brother notes that Max is being teased at school, and Max reports that other

students comment on his weight gain and untidy appearance. Other kids accuse him of using

drugs, and most kids who are in classes with him seem to be afraid of him.

The supported education worker notes that the client currently is failing one class and has C’s

and D’s in the others. His first period teacher (English) said he frequently puts his head down on

the desk and appears to be asleep. He is not contributing to discussions in that class or in world

history. If pushed in class, he begins muttering to himself or clenching his fists. He is also having

trouble turning in homework and has particular trouble in geometry with understanding what to

do or what formulas to use. He eats by himself in an isolated hallway. He will sometimes go

watch people on the track after school. He reports difficulty paying attention in school, with his

arguing head and that he is not sure that he will pass some of his classes.

He notes that he continues to hear the woman especially late at night or when he is alone for an

extended period of time, but knows she is not real. He knows others think the government is not

interested in him but is not sure how they would really know and continues to be concerned

about this. He still prefers to be alone and continues to maintain that he had been abusing drugs.

He has been taking his risperidone, but has noted some sleepiness that makes school harder. He

is worried about his weight.

Role play that models the encounter “done poorly”:

Team Leader: Welcome to the meeting. You are really lucky that everyone could come.

We wanted to see how things were going and what else needs to be done. You know

everyone here don’t you?

Max: Uh, I guess so?

Mother: I don’t remember everyone’s names and I don’t think I know the person on your

left.

Team Leader: Oh don’t worry about remembering everyone’s names. We know this is a

stressful time for you. This is Sue, the skill trainer. Now let’s see how things are going.

Max, do you have any things that you especially want to work on?

Max: Not really.

Team Leader: Ok, Max are you having any thoughts about hurting yourself or someone

else now?

Max: Not really.

Mother: But his brother did tell me that some of the kids were afraid of him.

Team Leader: Are you afraid of him and have you had any complaints from school

staff?

Mom: No, but he does ball his fists up sometimes.

Team Leader: Max, would you tell someone if you were really feeling like hurting

someone.

Max: Probably.

Team Leader: Good. Then it probably isn’t a concern. Probably just their lack of

awareness about schizophrenia. How are your symptoms Max?

Max: They seem a little bit better but I’m still having problems at school.

Psychiatrist: That is great. Are you having any stiffness, any restlessness?

Max: No.

Mother: He is eating a lot.

Psychiatrist: Don’t worry. We can add a side effect medicine called metformin that I’ll

call in. And you should encourage him to eat more fruits. Any other concerns?

Max: Uhh, nah.

Team Leader: OK, are you doing things with friends or doing any things you enjoy.

Max: I talked to some guys on the track team the other day and that was ok. I like to play

my games.

Team Leader: Great. Keep working on that. Ok. Now let’s hear what the education

specialist has to say about school.

IPS: Well, I’ve observed Max at school and talked to his teachers. They all seem very

willing to help him but feel like he has to do his part. Max, they are concerned that you

aren’t turning in a lot of your work. Can you try to do better with that? I think it would

really help you to use a planner to keep track of your assignments. Will you try that?

Max: I am trying. I already use a planner, but I keep losing it. It is really hard for me to

pay attention sometimes because of the arguments and the noise.

IPS: We can have you sit in the front of the class so you won’t get so distracted. We’ll

have to set up an IEP meeting. I know you are failing geometry, so I’ll get you a tutor for

that. The other thing the teachers brought up was your muttering under your breath and

being more fidgety at times. I know that it is hard to do what adults ask you to do, but

you really have to or you’ll be suspended. Can you try to be more respectful?

Max: I guess so, mumbles, “I am respectful, it’s the other people who aren’t.”

Team Leader: Let’s see what’s left. No issues with family support, money, trauma or

substance use so I guess we’re done. Does anyone want to add anything or have any

comments? OK, well see you in 2-3 weeks. We’ll call to set something up. Thanks. Bye.

Facilitated Discussion re: What was Missing/Done Poorly:

This should include review/application of intervention principles/clinical concepts etc.

(e.g., SDM, recovery-oriented, active/focused stance, use of open-ended explorations,

flexibility and consistency, autonomy/availability).

Consideration of intervention components reviewed during previous session (including

supported employment/education, social skills training/substance abuse, medication

adherence, family support, etc.)

Role Play that Models the Encounter Done “Well”:

Team Leader: Welcome to the meeting. Thank you all for coming. Helping Max get

back to his usual self is going to take all of us working together as a team. We especially

need your input Max and Mrs. Brown. The rest of us are here to help you understand

what has happened with Max’s thoughts and feelings and to help you figure out ways to

make things work out better for him. We each have different experiences and skills that

can be helpful to young people in situations like Max’s, but everyone is unique and we

need the two of you to tell us what is important to you and what you want to do. I know

you have met most of the people here, but I wanted to have us all go around and

introduce ourselves again and tell you a little bit about what we can help you figure out.

Team goes around and introduce themselves and briefly describes the kinds of services

they can provide and the kinds of problems they can help with.

Team Leader: This meeting is really to make sure we are going in the right directions

and that you two don’t have any other things that you want to work on right now or that

other people on the team haven’t noticed things that it might be helpful to consider. Max,

how do you think things have been going the last few weeks?

Max: Uh, I don’t know. It has been hard going back to school and everybody gets on my

case all the time. But my brain isn’t arguing with itself as much and I’m not hearing that

mean lady as much.

Team Leader: It’s great to hear that your symptoms are a bit better, but sounds like you

wish things were better with school and people getting on your case. Would you rather

talk about school or people getting on your case first.

Max: I don’t know. I guess school. There isn’t a lot of time left in the semester and I am

afraid I’m going to flunk out.

Team Leader: Can you help us understand more about what has been hard at school?

Max: I feel like people are looking at me and talking about me and I just want them to

shut up.

Team Leader: That can be a really uncomfortable feeling. When does that happen?

Max: It happens a lot in class and there are these three guys who keep bothering me

during lunch. They keep calling me a druggie and a zombie.

Team Leader: Do you have any ideas why those guys are saying that?

Max: No.

Mom: Your brother had mentioned that you often talk about using drugs at school. I

know that you still talk about it at home sometimes. Do you think that has anything to do

with it?

Max: I don’t know.

IPS: I noticed that you often put your head down in class and don’t very often talk unless

you are upset and talking under your breath.

Max: It’s when I am upset that people start looking at me and talking about me in class.

They act like I am going to hurt them.

IPS: You can look a bit scary then because you also often make your hands into fists.

Maybe we could help you figure out a different way to deal with being upset. Would you

like that?

Max: Yeah. But it would be even better if people quit upsetting me by getting on my

case. I try to stay awake but in the morning it is really hard. Sometimes it is just too much

with my head arguing with itself and the teacher talking or asking why I don’t say

something or didn’t turn in my work. When that happens I just try to tune everything out,

if I try to keep up with the teacher I think my head will explode.

IPS: It sounds like there are lots of things going on at school. Let me see if I understand

what you have said so far. You are worried about your grades. There is a problem with

being sleepy in the morning. There are still problems with your head arguing that make it

hard to pay attention. There are problems with people pushing you to hard. There are

problems with people looking at you and talking with you that might have something to

do with talking about using drugs or looking scary when you are upset. Is there anything I

misunderstood or anything else going on at school that you want to tell us about.

Max: I guess that’s it. I just don’t feel like there is anyone there who cares or

understands.

IPS: I think there are several things that might help. Do you want us to tell you the things

that we can think of first and then you can choose how you want to approach it or do you

want to tell us what’s most important to try to fix right now?

Max: Ugh. I don’t know.

Psychiatrist: I think it sounds like we need to do some fine-tuning with your medicine so

you aren’t so sleepy in the morning and so you have more relief from the arguing. There

might be other things that are bugging you about your medicine too.

Mother: I’m worried about his weight and Max keeps saying he’s getting fat.

Psychiatrist: That is a very real concern, thanks for letting me know about it. Let’s talk

more about the medicine in a bit. Right now let’s hear from the rest of the team and see

what ideas they have for improving things at school.

RC: You mentioned you didn’t feel like there was anyone you could talk to at school?

Are you having a hard time reconnecting with your friends or were you thinking more of

a teacher or counselor?

Max: Both I guess. I tried saying hi to a few guys from the track team, but didn’t know

what to say next . . . I was afraid they’d think I was weird too . . . guess I’m just more

comfortable being by myself.

RC: We could probably work together on some strategies for reconnecting if you’d like.

I could also help you see if there are things that you are doing that you might not even be

aware of that make you look different or put people off. Kind of like the mumbling.

Max: Maybe.

RC: I could also help with the drug use issues. I’m not real clear what you are thinking

about that – it sounds like you really don’t want people calling you a druggie. Just let me

or Team Leader know when you want to deal with that.

IPS: Sometimes we can set up systems at school to try to help with hard classes or

getting too much information at once or even things like homework or somebody to talk

to when you’re upset. We usually start with you and me and your Mom brainstorming

about things that might help, then have a meeting at school with your principal and

teachers to help them understand what’s going on and get their ideas for helpful things.

Would you be open to working together like that?

Max: Yeah.

Team Leader: Great we’ll set up a time to do that. I was wondering if there are any

times when you are feeling stressed that you have any thoughts about hurting yourself or

hurting someone else?

Max: Not really.

Mother: But his brother did tell me that some of the kids were afraid of him and

sometimes at home it is a little bit scary when he balls up his fists and is talking to

himself.

Team Leader: Max, can you help us understand what you are thinking and feeling at

those times?

Max: I just want to be left alone. I don’t want to hurt anyone although sometimes I think

people are trying to set me off so the government has an excuse to come get me. I don’t

want people to be afraid and I definitely don’t want the government involved.

Team Leader: It sounds like you really want to find a way to get some space but don’t

want people to be afraid. Is that something that we could help you work on – finding a

way to get space when you need it so you don’t feel like people are pressuring you?

Sounds like we’ll need a system at home and at school.

Max: Yeah, that would be good.

Team Leader: So we’ve agreed to work on adjusting your medicine so you aren’t so

sleepy or hungry and so it works better, to work on some ways for you to get space when

you need it and to not get so upset or look scary, and ways to work on helping you

succeed in your classes and have people, both kids and grownups, who you can talk to at

school. We can make some decisions about the medicine right after this meeting, and set

up a time with the education specialist and later with your school in the next few days.

You and I can work on ways for you to get space so you don’t feel under so much

pressure from people. Maybe we can also identify some things that will help you know

when you are starting to feel pressured before it gets too bad or things that almost always

lead to feeling pressured. The skills trainer can also work with you on reconnecting to

people. Are there other things that you are concerned about right now Max? Or any

things you have questions about?

Max: No, this seems like a lot for now.

Team Leader: Mrs. Brown, are there any other concerns that you have that we should

address now, before we stop today?

Mother: No, I think we have set out the most urgent things. Can we set up the

appointments with you and education specialist now?

Team Leader: Why don’t you, I, and education specialist do that now while Max talks to

the psychiatrist by himself for a few minutes. We’ll also plan to get back together as a

whole team in 3-4 weeks to see how things are going. Thank you everybody for coming. I

think we’ve made a good start to helping Max get to where he wants to be. Max thanks

so much for helping us all figure out the things we can help you with. You did a great

job.

Facilitated Discussion re: What was done well:

This should include review/application of intervention principles/clinical concepts etc. (Shared

Decision Making, Recovery-oriented, Active/Focused Stance, use of open-ended explorations,

Flexibility and Consistency, Autonomy/Availability).

Appendix 9: Forms to Use for Team Training Topics

 Client Shared Decision Making Card

 General Educational Handouts for Clients and Families:

 What is the Connection Team

 What is Psychosis

 Role of the Family

 Recovery from Psychosis

Client Shared Decision Making Card

The text below may be used to produce a laminated card for clients to have in order to prompt

them to engage in shared decision making during meetings with the team.

Side 1:

Tips for Talking About Important Decisions with Your Treatment Provider

 PREPARE before you see your provider. Write down your questions and concerns so you

don’t forget.

 TELL providers what is most important to you. Answer their questions honestly. This helps

them understand and respect what is important to you.

 ASK for explanations or more information. When a provider offers a recommendation, ask

them to explain WHY they think it is right for you. What are the benefits? What are the costs?

What are the pros and cons?

 SPEAK UP about your concerns and ask for options. For instance, if sexual side effects are

of concern, it’s okay to speak up and say you would like to find a medicine that does not have

these side effects.

 REMEMBER what was said. Write down what you and the provider agreed to.

 FOLLOW THROUGH with the decision you and the provider made. If you were not able to

follow-through, be honest about that. At the next appointment, report the good and the not-so-

good results of your decision.

Side 2:

For all major decisions regarding your medications, treatment, school, work, family, and so on,

ask yourself these questions:

 When your provider gave you a recommendation, did they offer you onechoice, or options to

choose from?

 Did your provider tell you about the pros and cons of each option?

 Did you have a chance to ask your questions?

 Did you have a chance to talk with important people like family before making your decision?

 Did the provider listen to your opinion and what was important to you?

 Did you have a say in what decision was right for you?

The Connection Team

Helping People Live Their Best Lives

What Is the Connection Team?

The Connection Team is a program to help young people who are experiencing psychosis get

effective treatment so they can successfully reach their goals in life such as completing school,

getting a good job, living independently, and having rewarding relationships with friends.

What Does the Connection Team Offer?

The goal of the Connection Team is to provide hope and effective treatment so that young adults

with psychosis can achieve their goals in life. Rather than working with just one mental health

professional, we offer a collaborative team approach that relies on everyone’s strengths and

energy. The young adult with psychosis is a member of the team, along with the family when

possible and other mental health professionals. A Team Leader helps to keep everyone on the

team working together toward the young adult’s recovery. We use a “shared decision making”

approach. That means that the young adult and the Team work together to decide on the best

treatment options. The treatment offered includes:

1. Comprehensive assessment of the young adult’s personal recovery goals to inform and guide

treatment.

2. Treatment and support from team members, including a doctor, mental health professionals,

and vocational specialists who have worked with people recovering from psychosis.

3. Counseling and educational support for family members focused on providing information

about psychosis and teaching family members how to assist young people in their recovery.

4. Coaching from a vocational specialist with expertise in helping young people identify and

reach their school and work goals.

5. Assistance with strategies for building healthy relationships and coping with problems in

positive ways.

6. Treatment and support for drug or alcohol problems.

The RAISE Connection Program:

Helping people live their best lives

What Is Psychosis?

Psychosis occurs when a person loses contact with reality. The word “psychosis” scares some

people, but it actually describes an experience that many people have. Three out of every 100

people experience psychosis at some time in their lives, and most of them recover.

What Are the Symptoms of Psychosis?

Psychosis can affect the way a person thinks, feels, and acts. Some common symptoms of

psychosis are:

• Hallucinations can affect any of the five senses. People experiencing psychosis might

see, hear, taste, smell, or feel things that are not there, and they have difficulty believing

that their senses are tricking them.

• Delusions are false beliefs that people hold strongly, despite all evidence that their beliefs

are not true. For example, a person experiencing a delusion might believe she is being

watched or followed.

• Confused thinking occurs when a person’s thoughts don’t make sense. His or her

thoughts can be jumbled together, or they can be too fast or too slow. A person with

confused thinking can have a hard time concentrating or remembering anything.

• Changes in feelings can include quick changes in mood. A person might also feel cut off

from the rest of the world, or feel strange in some other way.

• Behavior changes often result in a person not bathing, dressing, or otherwise caring for

him- or herself as usual. Other behavior changes might involve behaviors that don’t make

sense, such as laughing while someone else is talking about something sad.

What Causes Psychosis?

Psychosis could have a number of different causes, and many researchers are working to

understand why psychosis occurs. Some popular ideas are:

• Biological: Some people are more likely to develop psychosis because of their biology or

their heredity. Many cases of psychosis have been linked to problems with

neurotransmitters, the chemical messengers that transmit impulses throughout a person’s

brain and central nervous system. In addition, the relatives of people who experience

psychosis are more likely to experience psychosis themselves.

• Other factors: A person’s first episode of psychosis can be triggered by stressful events or

by drug use (especially use of marijuana, speed, or LSD).

What Are the Phases of Psychosis?

Psychosis occurs in three predictable phases, but the length of each phase varies from person to

person. These phases are:

1. The prodromal phase is the early warning phase of psychosis, when a person experiences

some mild symptoms and vague signs that something is not quite right.

2. During the acute phase, a person clearly experiences one or more of the symptoms of

psychosis.

3. A person reaching the recovery phase, he begins to feel like him- or herself again.

Different people experience the recovery phase differently. With effective treatment,

many people who reach the recovery phase may never experience psychosis again.

How Is Psychosis Treated?

Most people recover from psychosis, and many do so with the help of treatment. This treatment

usually includes several parts:

• Learning treatment options and working with professionals to determine which options are

right for you.

• Working with a mental health professional to practice ways to cope when things feel bad.

• Working with a doctor to determine how medications can help.

• Working with professionals who specialize in helping individuals learn to manage everything

from relationships to jobs and school.

The RAISE Connection Program:

Helping people live their best lives

What Is Psychosis?

Psychosis occurs when a person loses contact with reality. The word “psychosis” scares some

people, but it actually describes an experience that many people have. Three out of every 100

people experience psychosis at some time in their lives, and most of them recover.

What Causes Psychosis?

Psychosis could have a number of different causes, and many researchers are working to

understand why psychosis occurs. Some popular ideas are:

• Biological: Some people are more likely to develop psychosis because of their biology or

their heredity. Many cases of psychosis have been linked to problems with

neurotransmitters, the chemical messengers that transmit impulses throughout a person’s

brain and central nervous system. In addition, the relatives of people who experience

psychosis are more likely to experience psychosis themselves.

• Other factors: A person’s first episode of psychosis can be triggered by stressful events or

by drug use (especially use of marijuana, speed, or LSD).

What Is the Role of the Family in Recovery From Psychosis?

Family members can be extremely important in the recovery process. The person may have

difficulty in the early period with many things which used to be easy for them. When a person is

recovering from their psychotic episode you can provide love, stability, understanding and reas-

surance, as well as help with practical issues. There are many ways that family members can help

a person in recovery from psychosis. Family members can:

• Help the person with psychosis get to treatment appointments and work with their

treatment team.

• Stay in regular contact with the treatment team.

• Advocate for the person with psychosis to get the support he/she needs.

• Learn about psychosis so you know what is happening.

• Assist with remembering and initiating appointments and activities.

• Observe and report symptoms the person with psychosis may not be aware of.

• Include the person with psychosis in family and social activities.

• Maintain a safe, positive, supportive atmosphere at home.

• Help with finances.

• Take care of yourself and get your questions answered.

• Understand the goals that your loved one has for recovery.

• Be patient.

• Attend family support groups in your area to learn how other families cope and support

the recovery of loved ones.

The RAISE Connection Program:

Helping people live their best lives

Recovery From Psychosis

Three out of every 100 people experience psychosis at some time in their lives, and most of them

recover. Recovery from psychosis results in some important life changes, and there are several

things people can do to help themselves .

What Is It Like to Recover From Psychosis?

Different people have different stories to tell about their recovery from psychosis. For example,

some recover very quickly, while others feel better after several months. With treatment, support,

and hard work, people in recovery from psychosis can look forward to their lives improving in

some important ways:

• Symptom reduction: People recovering from psychosis have fewer symptoms of

psychosis, and the symptoms they do experience are less intense. That means these

individuals are less likely to hallucinate (i.e., see, hear, taste, smell, or feel things that are

not there), and they are less likely to have delusions (i.e., beliefs in things that are not

true). These individuals also begin to think, feel, and act more like they did before they

had psychosis.

• Improved relationships: People experiencing psychosis usually cannot relate to friends,

family, and other significant people in their lives as they did before psychosis. Once the

psychosis begins to subside, though, they can begin to rebuild those relationships.

• More connections with outside world: Perhaps because they have fewer symptoms to

deal with – and more support from other people—people recovering from psychosis often

can focus more time and energy on important personal goals like completing school,

getting a good job, enjoying friends and family, and other things that make life fun and

meaningful.

What Helps People Recover From Psychosis?

The most important thing that helps people recover from psychosis is getting active. It may

sound strange, but passively sitting around waiting for medicine and the professionals to cure

you is usually not the way recovery happens! Most people who recover get active by:

• Participating in treatment: Active treatment participants partner with their treatment

providers to learn all they can about their treatment options, such as medications and

therapy. They keep their appointments with these providers, and give the providers

honest feedback about how treatment is working or not working for them.

• Focus on personal goals: Personal goals in work, school, or other areas of life can be

strong motivators for people recovering from psychosis. If they are not immediately

ready to resume all their previous activities, people recovering from psychosis can set

smaller, more realistic goals that will help them make progress.

• Finding support: Friends, family, and other important people can provide important

encouragement as people recover from psychosis. In addition, support groups for people

who are recovering from psychosis can be important. In a support group you can find

hope, friends, pride and proven strategies for getting well.

• Taking care of yourself: Recovering from psychosis is hard work, so people recovering

from psychosis must make sure they take good care of themselves. This means they need

good diets, plenty of exercise and sleep, and regular medical check-ups.

• Taking an honest look at drug and alcohol use: For some people, drug and alcohol use

can trigger psychosis or make it worse. It can really help to take an honest look at one’s

drug or alcohol use and ask , “has it contributed to my psychosis?”

• Keeping your time structured: Many people find that being bored is stressful. Just

hanging around doing nothing is typically not helpful. Get busy and structure your day

with activities such as school, work, volunteering, friends and exercise. Try to find the

right balance between time alone and time with people.

Appendix 10: Sample Forms for Supervision Notes

Supervision Note

Date: _________________________________________________________________________

Type of meeting: Administrative supervision

Clinical supervision

Clinical consultation

Component supervision

Model supervision

Team members present: Team Leader

Psychiatrist

Recovery Coach

IPS Specialist

Clinic Administrator

Program Director

Other: ________________________________________________

Meeting Leader: ________________________________________________________________

Attendance (please check):

Name Name

Issues Discussed:

Plans/actions for next meeting:

Appendix 11: Resources for Supervision

Association of Psychology Postdoctoral and Internship Centers

http://www.appic.org/Training-Resources/Resources#Supervision

Mental Health Evidence Based Practice Project

http://www.socialwork.buffalo.edu/ebp/supervision/index.htm

SAMHSA

http://toolkit.ahpnet.com/Dealing-with-Stress-in-the-Workplace/Impact-of-Stress-on-

Retention/Want-to-Reduce-Stress-and-Burnout-in-Behavioral-He/Mentoring-and-Clinical-

Supervision-Programs.aspx

Slide sets and other resources for Clinical Supervision: A Competency-based Approach by

Carol Falender, Ph.D.

http://www.cfalender.com/

Azar S A. (2000). Preventing burnout in professionals and paraprofessionals who work with

child abuse and neglect cases: A cognitive behavioral approach to supervision. J Clin Psychol,

56(5), 643–663.

Edwards D, Burnard P, Hannigan B, et al. (2005). Clinical supervision and burnout: The

influences of clinical supervision for community mental health nurses. J ClinNurs, 15(8), 1007–

1015.

Torrey WC, Drake, RE, Dixon L, et al. (2001). Implementing evidence-based practices for

persons with severe mental illness. Psychiatr Serv, 52(1), 45–50.

Triantafillou N. (1997). A solution-focused approach to mental health supervision. J Syst Ther,

16(4), 305–328.

Mental Health Self Help (and other) Resources

FINDING RESOURCES LOCALLY

The three agencies / projects below are resource centers in our area to help people connect to a wide variety of

health, human services, self-help and other resources. Useful for clinicians, clients, families etc.

Maryland Community Services Locator:www.mdcsl.org

Searchable directory of health, human services, self help and other community resources across the state.

Available to anyone who can access the website. See handout flier

Dial 2-1-1:www.211metrodc.org

Anyone can literally dial 2-1-1 any day on any phone (like dialing 311 for city services or 911 for emergency) to get

connected to operators who can help them find social services in DC, Northern VA and parts of MD.

The website also has a searchable directory like MDCSL

See the bottom of the site’s front page for additional regional resource centers to call for help as well.

Baltimore Crisis Response, Inc (BCRI): www.bcresponse.org

Hotline: 410-433-5175 or 410-752-2272

Office: 410-433-5255

NATIONAL SELF-HELP RESOURCE WEBSITES

American Self Help Group Clearing House:http://www.mentalhelp.net/selfhelp/

Self-Help Group Sourcebook Online – look up groups on many topics, US and international. Very good links to

related resources

National Self Help Clearing House:http://www.selfhelpweb.org/index.html

(???) or 212-817-1822

“to facilitate access to self-help groups and increase the awareness of the importance of mutual support”

National Mental Health Consumers Self Help Clearing House:http://www.mhselfhelp.org/

Info source and technical assistance for mental health consumer self-help organizations and individuals

Center for Community Support and Research, WSU:http://www.ccsr.wichita.edu

Broad center re strengthening community organizations with a long history and deep relationship with self help

groups. Many good resources re self help research and capacity-building.

MH SELF HELP LOCALLY

Also see National Resources, below

On Our Own of Maryland, Inc:www.onourownmd.org

Wide array of self help and advocacy programs and support groups across the state for people with mental illnesses

List of affiliates across Maryland: http://www.onourownmd.org/affiliates.html

State office: 410-646-0262 or 800-704-0262

Depression and Bipolar Support Alliance www.dbsalliance.org

National contacts to find local groups: 800-826-3632 or chapters@dbsalliance.org

To find local chapters and support groups:

http://www.dbsalliance.org/site/PageServer?pagename=support_findsupport

Recovery International, Inc.:http://www.lowselfhelpsystems.org/index.asp

“self-help mental health organization founded in 1937, sponsors weekly group peer-led meetings in nearly 600

communities around the world, as well as telephone and Internet-based meetings..” (312) 337-5661 or

inquiries@recovery-inc.org

To find a Maryland meeting: http://www.lowselfhelpsystems.org/meetings/meetings-per-city.asp

Alcoholics Anonymous, Baltimore area:http://baltimoreaa.org

or 410 663-1922

Provides contacts for local meetings and 24hr phone support

Narcotics Anonymous, MD:http://www.freestatena.org

or 1-800-317-3222

Provides contacts for local meetings and 24hr phone support

MD Coalition of Families for Children’s Mental Health:http://www.mdcoalition.org/

“dedicated to improving services for children with mental health needs and their families, and building a network of

information and support for families across Maryland”

Statewide office: 410.730.8267 or 1.888.607.3637

Baltimore office: 410.235.6340 or 1.888.607.3637

Parents Place of Maryland:http://www.ppmd.org/

410-768-9100 or info@ppmd.org “peer support for parents of children with all disabilities”

Jewish Coalition Against Sexual Abuse and Assault: http://www.theawarenesscenter.org/networkinggroups.html

[email protected] or 443-857-5560 support groups and information

Autism Society of America – Baltimore Chesapeake Chapter:

http://www.bcc-asa.org/BCCASAMeeting.htm or questions@bcc-asa.org

or 410-655-7933

support groups and information for parents of children with autism spectrum, for siblings, and for adults with autism

spectrum

NAMI Maryland:http://md.nami.org/

410-863-0470 or helpline:800-467-0075 or namimd@nami.org

Information, support, skill classes, education programs and other resources for family members of people with

mental illnesses and clients themselves. Local chapters in every county:

http://md.nami.org/aboutus/aboutus_affiliates.htm

MH SELF HELP NATIONAL RESOURCES

National Empowerment Center:www.power2u.org

800-769-3728 or info4@power2u.org

wide array of high quality consumer-created resources, trainings, self-help packages, strategies and links

Emotions Anonymous:http://www.emotionsanonymous.org/

“a twelve-step organization… composed of people who come together in weekly meetings for the purpose of

working toward recovery from emotional difficulties…the only requirement for membership is a desire to become

well emotionally.” Many meetings online, but also in person. To find local meetings: (651) 647-9712 or

infodf3498fjsd@emotionsanonymous.org

GROW, Inc:www.growinamerica.org

“an international mental health movement with a network of member-run support groups in the USA, Australia,

New Zealand and Ireland. GROW in America is fully developed in Illinois and New Jersey. It also has a small core

of groups in Rhode Island. GROW is organized, friendly help. It is based on mutual-help groups, friendship,

leadership and mutual education. People come to GROW with diverse problems in living, such as mental health

issues, emotional troubles, or difficulty coping with grief, loneliness, anxiety or stress…”

OTHER

Example of in print self help resources (domestic violence):

http://resources.baltimorecountymd.gov/Documents/Women/selfhelp2005.pdf

Suicide Hotlines, (various organizations centralized service):

http://www.suicide.org/suicide-hotlines.htm

Appendix 12: Resources for Fidelity

Recommended Performance Measures/Fidelity Requirements for

First Episode Psychosis Programs

Based on Experience with the RAISE Connection Program’s Standards and Practices

(January 29, 2013)

Performance Expectations for the Team’s Structure and Functioning

Program Component and Associated Expectations

Operationalization of Expectations

Staffing. Teams hire and maintain the required staff.

1.0 FTE Team Leader who is a licensed clinician

1.0 FTE IPS Specialist

0.5 FTE Skills Trainer who is a licensed clinician

0.2 FTE Psychiatrist

Vacancies are filled within 30 days

Caseload size. Teams maintain a caseload that is small enough to allow for

intensive and highly individualized services while, at the same time, serving as

many clients as possible within these service demands.

Caseload does not exceed 30

Staff meet as a team. These meetings are for strategic clinical thinking and

reviewing the status and “next steps toward goals” for each person on the team’s

caseload.

Full team meets at least weekly.

Intake occurs promptly.

Intake occurs within 1 week of referral.

At least one member of the team is available 24/7.

Team has on-call system for after-hours availability and service logs show

that any given month includes services on nights and weekends.

Outreach. Teams see clients in the field as needed.

At least 10% of participants have at least one visit in the community with

the Team Leader, psychiatrist, and/or recovery coach.

Program Component and Associated Expectations

Operationalization of Expectations

Safety assessment. All clients assessed for suicide risk and safety plans are

formulated and implemented for those determined to be at risk.

The HASS Demo or equivalent screening tool is completed with every

participant at intake and whenever concerns about possible suicide are

raised.

For those who meet or exceed the specified threshold indicating a risk of

suicide, a safety plan developed the same day of the screening is included

in the chart. Is this given to the individual and the family so they will be

able to act according to the plan?

Discharge.

The team provides a critical time intervention rather than a source of services

for people well along in their recovery. Clients transition from the team to

routine services as soon as clinically appropriate. The team follows up with

discharged clients and with post-

discharge providers as appropriate to help

assure a smooth transition to routine community services.

Median and average length of stay with Connection Team of all

participants to be calculated at the end of each quarter.

Mean length of stay for discharged clients will not exceed 30 months.

Individual length of stay for any participant will not exceed 36 months.

At least 90% of participants plan for discharge with Team (as opposed to

leaving precipitously).

Discharge planning begins at least XXX months

prior to the discharge date.

At least 90% percent of discha

rged participants attend their first

appointment with a mental health service provider within 30 days of

discharge.

Performance Expectations for the Psychopharmacology Intervention

Domain and Expectation

Operationalization of Expectations

Psychotropic Medications.

Pharmacotherapy is a core component of treatment. Because many clients with

FEP are reluctant to try medication, teams work to develop trusting

relationships and provide education about medication options and best practices

for medication treatment for FEP so that clients are willing to try antipsychotic

medications.

Antipsychotic medication is prescribed for at least 60% of patients on the

team at any given time.

At least 75% of patients have had at least one trial of an antipsychotic

medication prescribed for at least 4 weeks within the recommended

dosage range.

Assessment of medication effects. Psychiatrist and client regularly review

medication effectiveness and side effects.

At least quarterly, psychiatrist and client review medications.

Psychiatrist records symptoms and side effects using standardized

assessment scales in a manner that facilitates monitoring changes over

time.

Domain and Expectation

Operationalization of Expectations

Weight gain of over 1 BMI prompts consideration of a change (in

medication, dosage, or behavioral intervention).

Assessment of weight.

Weight is assessed monthly.

Assessment of fasting glucose/HbA1c and lipids.

Assessment of fasting glucose/HbA1c and lipids conducted at intake, 2

months after, and then annually. Schedule repeated if new antipsychotic

started.

Performance Expectations for Services by the Recovery Coach or Equivalent Clinician

Domain and Expectation

Operationalization of Expectations

Recovery Coach provides flexible, motivational interventions. Recovery

Coach works with clients and families, supporting resiliency and skill building

in illness management and recovery treatment and treatment for substance use.

Recovery Coach’s service logs indicate the provision of both group and

individual sessions in illness management and recovery.

At least 75% of patients participate in at least one session provided by the

Recovery Coach.

At least 25% of clients have one or more family members participate

(whether or not client is present) in at least one session provided by the

Recovery Coach.

Recovery Coach’s service logs indicate the provision of substance abuse

treatment to at least 25% of clients.

Performance Expectations for the Family Intervention

Domain and Expectation

Operationalization of Expectations

Working with families.

Team discusses with each client ways family might be involved in the client’s

treatment and determines each client’s preferences and reassesses these

preferences periodically. Team documents family’s participation in treatment

over time.

Team has conversation with all participants regarding their preferences for

family involvement as part of intake and at least quarterly thereafter.

Service logs note when family member is present.

Service logs indicate that, in any given quarter, at least 50% of clients

have one or more family members meeting with a member of the team at

least once.

Performance Expectations for the Individual Placement and Support (IPS) Specialist

Domain and Expectation

Operationalization of Expectations

IPS specialist focuses exclusively on supported employment and supported

education.

IPS specialists provide only employment and education services. Service

logs indicate that less than 10% of the IPS specialist’s time is devoted to

case management and crisis services, administrative duties, or other duties

not directly related to employment or education.

Team Leader provides intensive, outcome-based supervision

Team Leader conducts biweekly IPS supervision to review client

situations and identify new strategies and ideas to help clients in their

work lives. IPS records document at least 2 such meetings per month.

Team L

eader reviews employer contact logs with IPS specialist at least

twice per month and helps IPS specialist think of plans to follow up with

employers and teachers/instructors. IPS records document at least 2 such

meetings per month.

Team Leader reviews current client outcomes with IPS specialist and sets

goals to improve program performance at least quarterly, with a monthly

review.

Team maintains a list of performance goals and associated

performance over time.

Zero exclusion criteria.

All clients interested have access to IPS regardless of readiness factors,

substance abuse, symptoms, history of violent behavior, cognition impairments,

treatment non-adherence, and personal presentation.

IPS specialist has met with at least 90% of clients at least once. Current

case load of IPS specialist includes individuals actively using substances

(unless the very unlikely situation exists wherein no clients on the team

are abusing drugs/alcohol).

Competitive jobs and mainstream education promptly pursued.

IPS specialists help clients pursue permanent competitive jobs and academic

opportunities in mainstream, integrated educational settings.

Acceptable jobs

include seasonal jobs and temporary jobs that are part of the community's

regular labor market.

Team monitors rates of being in school or employed and at least 50% of

clients are either in school pursuing a degree or competitively employed.

Individualized follow-along supports. IPS specialist helps client problem

solve work/school iss

ues, based on a job/education support plan. The IPS

specialist assists the client to seek out and benefit from natural supports (e.g.,

tutoring services, coworkers, family, etc.).

Support is based on client

preferences, work history, needs, and demands of the work/school environment.

At client's request, IPS specialist provides employer supports or intervenes at an

academic institution (e.g., educational information, job accommodations). The

At least 80% of the time, there is at least one visit with the IPS specialist

between the job/academic start and end dates. If there exists at least one

face-to-face meeting by the IPS worker during the client's job tenure/time

in school, then the standard of follow along supports has been met. If there

is no such service, then the standard hasn't been met.

If the job/school lasted only one day, omit from the computing of this

measure.

Domain and Expectation

Operationalization of Expectations

IPS specialist promotes career development, assisting clients in the pursuit of

education and training, more desirable jobs and more preferred job duties. Most

contact is face-to-face.

At least 50% of IPS specialist's time is in community settings (outside the

mental health center), devoted to engagement, employer and educational

institution contacts, providing follow-along support, etc.