APA Journals Dialogue
August 2, 2017
Introducing the June 2017 Special Issue of Psychiatric Rehabilitation Journal
About the Guest
Dr. Crystal Blyler is a senior researcher at Mathematica Policy Research, where she directed the evaluation of the Medicaid Emergency Psychiatric Services Demonstration. In addition to her work at Mathematica, Dr. Blyler has experience as a researcher at various universities and in government at both the national and state level.
About the Journal
Visit the Psychiatric Rehabilitation Journal website.
Marla Bonner: Hello, I'm Marla Bonner. Welcome to APA Journals Dialogue, a podcast featuring research from the journals program of the American Psychological Association. In this episode, we take a look at a special issue from Psychiatric Rehabilitation Journal.
Psychiatric Rehabilitation Journal is published in partnership with the Psychiatric Rehabilitation Association and the Boston University Center for Psychiatric Rehabilitation. The journal presents studies on rehabilitation, treatment, and recovery of people with serious mental illnesses.
In this special issue, guest editor Dr. Crystal Blyler examined the research surrounding disability policy research and the ways psychiatric rehabilitation researchers and professionals can help to shape it.
Here with us to discuss the special issue is Dr. Blyler. Welcome. We're so happy to have you today.
Dr. Blyler: Thank you. It's great to be here.
Marla: So, the topic of this special issue is disability policy research. Could you share with our audience what exactly is disability policy research, as opposed to other types of research?
Dr. Blyler: Sure. So there actually isn't any real clear line and there is overlap with certain other types of research (in particular, health services research), but there are also some differences. I would say the main defining characteristic of policy research in general is both the audience and the motivation. So, who's driving the research? Why is the research being done?
In health services research, research is driven primarily by researchers and clinicians. So people are trying to figure out, what can we do at a clinical level, one-on-one, between the service provider and the patient? What can we do to improve services, and what's the effect of those services on clinical outcomes?
Policy research, on the other hand, is really driven by the needs and the interests of policy makers. Policy makers also often want to know about clinical issues, but in addition to that, they have other concerns. Rather than looking just at clinical interventions, they're also interested in broader policy-level changes and interventions.
Back in the 90s and the early 2000s, there was a lot of interest in disability policy reform, the Social Security administration program, because since the 2000s, there have been concerns about the disability trust funds that fund the Social Security disability programs running out.
There isn't enough money in them to sustain them. So there's been a lot of interest in Social Security disability policy reforms. And welfare reform was very popular when there was a change from the old way of doing welfare, to now. For the last twenty years, it's been about welfare to work, so helping people on welfare get jobs and move forward.
And now, of course, in this day and age, there's a lot of policy focus on health reform, which is also very important for people with disabilities and people with mental illness to make sure the services that you need are covered and that the policies are working to support those services and getting people what they need.
A lot of the interest in policy research is on availability of services to different populations, the access to different populations. Service utilization, which is, what do people actually get? The services may be theoretically available, but what do people actually use and how much of that do they use?
There's also interest at the policy level on assessing the quality of care, not just for an individual clinic, like in health services research, but across large swaths of people. So, the entire Medicaid population in the country — when you have the number of providers that bill Medicaid, how do you assess quality of care?
Also the organization of services and how the systems work together, because people, and particularly people with disabilities and serious mental illnesses, need an array of services that are provided by a bunch of different kinds of programs and different federal agencies and are affected by different policies.
In health services research, I find that people in mental health don't really like numbers. To some degree, they don't like evaluation at all, because it's all about numbers, but there are, of course, health services researchers that focus on that. But people in mental health don't like stuff about money.
A lot of clinician- and provider- and researcher-driven studies focus on clinical outcomes, but in the policy area, everything costs money, and the costs are really important to consider in policy research. You know, what does the program cost? What does the intervention cost? Is the cost of the intervention worth it for the outcomes you get, and how does that compare to other kinds of interventions that you might do that are cheaper but maybe not as effective? Are there savings somewhere else in the system?
If you do something for mental health, maybe that will decrease costs in the area of criminal justice or somewhere else. So the cost considerations are kind of a key feature of policy interventions.
Also, the generalizability to the full population is really important. So, policies are affecting everyone in an area, so you have to think about all the different subgroups, and how would the policy work for that particular subgroup or the program? How does it work for rural areas? How does it work for different racial and ethnic groups? There's a big concern in the policy arena about equity across all these different populations.
Every policy has winners and losers, so which stakeholders win with this policy, and which lose? Sometimes the losing's just in terms of cost, and maybe the cost is worth it, so it's not necessarily a loss in that sense, but some people gain and some people lose and you want to have a clear understanding of that before you implement a policy.
So really, policy research, there's a big difference in who is the audience for the result, and what is that audience interested in? So what are the policy makers interested in, as opposed to the clinicians? And that can determine what questions you actually ask, and then also the language you use to describe the results and the research afterwards, and who you present the results to and how.
Marla: Well thank you for that. That's really important for our audience to be able to understand. As you know, every scientific discipline has its own set of scientific methods and standards. What types of methods are used to study disability policy?
Dr. Blyler: Well, the golden standard of health services research is the randomized controlled trial, or, as an alternative to that, a really well-done quasi-experimental design where you compare an intervention to something else that's either a different kind of intervention, or services as usual, or no services.
And then along with the randomized controlled trial is often a qualitative analysis of implementation factors. So what does it take to implement this practice.
Policy research also uses randomized controlled trials, and it typically includes a detailed implementation analysis, but when they do controlled trials and implementation analyses, it's on a much larger scale than your typical health research project. A typical health services research project focuses on one clinic, whereas, in policy research, it's of a multi-site nature, so there are many clinics involved, or it's just on a much larger scale to represent the country.
But there are other methods besides randomized controlled trials and implementation analyses that are of interest for policy.
The policy research field is multi-disciplinary, so they're drawing on different methods to answer different types of questions across academic and scientific disciplines. So it includes psychologists and psychiatrists certainly, but also people in all sorts of areas of public health, and epidemiology, economics, and each one of these disciplines has its own culture and standards of evidence and uses different methods, and policy research draws on all of them.
One of the distinguishing features of policy research is that it often uses secondary analysis of very large data sets. There are large recurring surveys — either epidemiological surveys to try to get the lay of the land regarding a particular topic across the country or an area, or surveys of national program participants or other stakeholders to see what's happening in the program as a whole.
So the state vocational rehabilitation agencies, whose funding comes from the national Department of Education, they do national surveys or local state surveys of the people who are receiving VR services. So these large data sets are used.
In addition to surveys, there's also large program administrative data sets. Social Security has certain data sets that they use in administering the program to track what their beneficiaries are getting and doing, and those large administrative data sets can also be used in conducting policy research. Medicaid claims are a big one.
In addition to the large data sets, policy research can also be doing smaller pilot projects and demonstrations, because if you're going to change a policy, you want to test it first before you take it nationwide.
Also, knowledge synthesis is really important. In the policy arena, you don't want to take the word of one study; you want to look across all of the studies. The first step of coming up with a new policy or figuring out what to change about a policy is often to find out what we know from all available sources. That would include the research literature, but not just that.
Also environmental scans of programs and approaches that people across the nation are trying that might not have made it into the research literature, but working with federal agencies and other sources to try to identify what's going that's not in the research literature.
And then, also, qualitative approaches — interviewing diverse stakeholders that have been involved in the issues. Pulling all of that information together and knowledge as synthesis is also very important.
Marla: So this journal specifically focuses on psychiatric rehabilitation, which is how to help people with mental illnesses recover. So, what is the importance of disability policy research to mental health?
Dr. Blyler: Let me give you an example from my own career. I started my career as an experimental psychopathologist, and I was trying to understand the root causes and symptoms of schizophrenia.
At one point, when I was doing experimental psychopathology, I was asked to analyze some data about the effect of cognitive deficits in schizophrenia on vocational outcomes. In the field of basic schizophrenia research, pretty much everything about people with schizophrenia is seen through the lens of their illness. Poor employment outcomes were seen as a natural result of the disease.
Later, though, I worked for the federal Substance Abuse and Mental Health Services Administration (SAMHSA), where I oversaw a multi-site randomized trial of employment support services for people with serious mental illness, and I was also, at SAMHSA, a liaison to a number of federal work groups with other agencies tackling how employment rates of people with all types of disabilities, not just mental health, could be improved.
So what I learned from my work at SAMHSA is that there are a lot of factors affecting employment rates among people with schizophrenia beyond just the illness itself. For example, the stigma of mental illness among employers can and does affect hiring and firing decisions, and access to supported employment programs can help people work despite their illnesses.
In addition, people who could work may choose not to work because they want to be able to qualify for or keep their benefits that are based on having a low income, benefits that they need to help them live with their illness. So all of these things can affect people's employment rate beyond just their illness.
Policies can have just as much of an effect on the lives and well-being of people with mental illness as the illness itself.
Marla: So we're excited about the special issue, and again we want to congratulate you on completing that process and we certainly encourage our audience to pick up that issue of the June Psychiatric Rehabilitation Journal.
And so, the special issue is divided into three sections, the first of which focuses on Employment, Education, and Disability Policy. Could you tell us a bit about what issues were studied in the research presented, and what the results mean for disability policy?
Dr. Blyler: Sure. I'm excited about the issue, too, because it covers a lot of really interesting topics.
The first paper is actually an evidence review, and it's looking at the types of interventions that can help prevent unemployment and disability due to mental illness.
In the world of mental health, there is one gold standard program model for helping people with mental illness work, and that is the individual placement and support model. That model has been almost exclusively tested for people who have been out of the labor force and people who have been on the disability roles for a long time.
But some of the work on supported employment has suggested that younger people benefit more from a supported employment or are more likely to be able to work than people who have been out of the labor force for a long time.
Multiple agencies in the federal government for the last ten or fifteen years have had the idea that maybe it would be more helpful to look at ways to prevent people from entering the disability rolls in the first place.
This particular evidence review in the special issue specifically focused on, what do we know about preventing people from getting on the disability rolls in the first place?
Social Security is actually now doing a large, multi-site trial of the individual placement and support model at the point of application, because a lot of people who have been rejected the first time will reapply or appeal the decision and end up on benefits later. The thought is, if you can give them supported employment services at that point, maybe they will end up more on a work path than on the disability path.
There are also in this section three papers that are comparing people with psychiatric conditions to those with other types of disabilities in programs designed to help people with all types of disabilities to work. Namely, the Social Security administration has a program called the Ticket to Work, which provides disability beneficiaries with a voucher to receive employment services from the provider of their choice. In addition to that, there is the state vocational rehabilitation program that I talked about earlier.
Together, what these three papers show is that there are important differences in both of these programs — in the outcomes, services received, and barriers to employment between people with mental illnesses versus other types of disabilities.
In some ways, people with mental illnesses are better prepared to work than people with other disabilities. They have better work histories from before they became ill. They're more interested in work oftentimes and motivated to work, but they also face some unique challenges, such as certain types of stigma and the episodic nature of the illness that can disrupt positive work advancements.
The important policy point is that programs designed to serve people with all types of disabilities may not work the same way for people with mental illnesses. So, specific approaches and effects for mental illness need to be considered in formulating equitable policies.
Another couple of papers in this section talk about supported education. Mental illness often emerges in people's youth, just as you're making that transition from childhood to adulthood, and during that period is often when people finish high school and go on to higher education, and higher education is associated with better employment outcomes.
We also know from the supported employment literature, although it has been shown to help more people get jobs, the jobs that people get still, in supported employment, tend to be entry level, low pay, part time, no healthcare benefits, and people need those benefits for mental health.
So the federal government has been quite interested in models for helping people to get more advanced education. There have been various attempts at this at state and local levels, but there's no real standardized model, and the evidence about the effectiveness is kind of limited at this time.
So in this case, the policy message is that this is a really important area of investigation, and it's a promising approach in general, but we need to support more rigorous program development and research before we should commit to funding any particular model on a widespread basis.
The final group of papers in the employment and education section are two papers that focus on what we call the demand side of the employment equation. An employment relationship includes not only the employee but also the employer. These are studies about how the hiring environment and work environment interact with mental health.
Different types of policy interventions are needed on the demand side — that is, the demand for workers. We need to figure out how to incentivize employer behavior and change the work environment, rather than only changing what people with the mental illnesses do as individuals.
Marla: And so, the second of the three sections in the special issue focuses on Medicaid Policy and Health Reform, a subject that obviously is getting a fair amount of attention from Congress as well as in the media. What types of information does the research presented provide that might be important to consider in the national discussion of health reform?
Dr. Blyler: Well, one of the biggest areas that's been a topic regarding mental health and health reform is about integrated care. Integrated care means people are not divided into people with mental health problems and people with physical health problems, but you have to see it as the whole person.
To address both simultaneously, which is important because they interact with one another and the treatments for them can interact with each other, we're looking for integrated models of care that address both mental health and physical health challenges at the same time.
The health services research has focused on kind of a clinical level of integration, where you try to integrate physical health primary care services into a behavioral health service provider organization, or, conversely, you try to introduce better behavioral health treatment into a primary care setting, because a lot of people only see a primary care physician, but they still have mental health issues that need to be addressed within the primary care setting.
At the policy level, there's interest in those models, how we can support them, but there's also another level that's important and addressed in this special issue, which is the level of managed care plans.
Managed care often divides mental health and physical health. So there will be, within the same state or area, a managed care plan that addresses all your physical healthcare aspects, and then carved out of that plan is anything about mental health. So it's a separate plan that covers the mental health benefit.
This can create some conflicts or challenges in terms of integrating care at the clinical level. We have an article that's talking about strategies for integrating managed care, behavioral health and physical health managed care plans, at the state level.
Another aspect of integrated care at the clinical level is regarding disparities among different subgroups. For example, not everybody in the country uses primary care in the same way. Women are more likely to use more primary care; people with more severe mental illness are less likely to get their behavioral health services through primary care; there are some racial and ethnic differences in how primary care versus behavioral health specialty care are used. We have a paper in the special issue about those disparities and what it means for integrated care.
Another thing about the integrated care is that, as we focus more and more on blending primary and behavioral healthcare, there is some danger that something might be lost. People with serious mental illness or psychiatric disabilities need not only medications or direct treatment, but they also have a lot of life challenges related to their illness.
The field of psychiatric rehabilitation addresses those additional life challenges and quality of life. If you integrate care into a primary care setting, primary care physicians have limited time with each patient, and they can't do all of the kinds of things that psychiatric rehabilitation professionals provide.
The paper in this special issue talks about the added value of psychiatric rehabilitation within the Medicaid system. One of the added values is that psychiatric rehabilitation has additional effects on hope and goal setting, which have both been shown to be very important in recovery from mental illness, and goals particularly regarding things like housing and employment and self-care that will help people become more independent in the long run and help their overall mental health improve.
Another issue along the same lines is integrating Medicaid with housing support. So there is an evidence-based model called supported housing for people with psychiatric disabilities, which provides a combination of something like housing vouchers or supplements, because people with these illnesses in a long-term chronic way are often very poor, but then on top of that you need other kinds of supports to help you stay in the housing.
Education about how you manage your budget to pay your rent, how you interact with your landlord, how you handle what happens with your housing when you have a crisis that lands you in the hospital — things like that.
Case managers and psychiatric rehabilitation people help people work with both sides of that equation on an individual basis, so they'll help them negotiate with the housing authority, they'll help them to get their Medicaid benefits to cover the other supports, but that's not all that efficient and can be very frustrating for the case managers and the consumers alike.
We have a paper in this issue that talks about how you integrate Medicaid and housing at a systems level to get the two types of agencies working together to address these issues in a more efficient way for a large group of people.
Marla: And the final of the three sections in this special issue is on Supporting the Workforce. What workforce does this refer to, and what is the policy concern about it? What does the research suggest?
Dr. Blyler: In this case, the work force we're talking about is the people who provide the mental health and related services.
For many years now, we have known that there is a shortage of behavioral health workers, and it's just getting worse and worse over the years. And this is particularly true in rural areas, it's particularly true regarding psychiatrists, although other related services, such as supported employment, are also all too few. There are also particularly severe shortages in child psychiatrists, but overall the shortage is, at this point, covering most of the country.
The paper in this special issue that addresses this looks at the extent to which behavioral health providers work overtime and the effect of working overtime on worker morale and, importantly, quality of care. What they found was that more than half of the behavioral health professionals at both urban and rural clinics worked overtime in a typical week.
This working overtime led to increased burnout and lower job satisfaction as well as lower quality of care. This type of thing does not make working in community behavioral health attractive to young people at the start of their careers, and may also lead to existing providers leaving the field, such as through retiring early.
So, identifying these kinds of factors that affect the behavioral health work force can identify potential areas for intervention to try to improve the availability of mental health services across the nation.
Marla: Well, really important stuff, and again, we really appreciate you stopping by and speaking with us and sharing with our audience what to expect in this awesome, exciting special issue. Thank you so much today.
Dr. Blyler: Thank you.
Marla: To read this issue and others from Psychiatric Rehabilitation Journal, please visit our website at psycnet.apa.org/journals/prj.
Thank you for joining us. I'm Marla Bonner with APA Journals Dialogue.
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