Transcript of Talking Heads with Dr. Noosha Niv – Episode 8
Announcer: This is talking heads. Explore the latest in research and policy about serious mental health disorders with Dr. Naan.
Dr. Niv: Today’s guest is Dr. Sandra Resnik. She is a licensed clinical psychologist, a professor in the department of psychiatry at Yale University School of Medicine, deputy director of the Department of Veterans Affairs Northeast Program Evaluation Center, and director of the Veterans Health Administration National measurement based care and mental health initiative. She is also a valued colleague and I’m so glad she’s here today. Um, welcome Sandy. Thank you so much for joining me.
Dr. Resnik: It’s great to be here. Thanks.
Dr. Niv: Let’s start off with you. What led you to psychology and then more specifically the focus on psychosis.
Dr. Resnik: Oh, so that’s interesting. I’m I don’t actually know, but I found something I wrote in elementary school which was a Hey, what do you want to be when you grow up? And it was literally like third grade and I wrote that I wanted to be a psychologist. What? I didn’t even spell it right. Like I couldn’t even spell it. And I wanted to be a psychologist. I think maybe somebody’s textbooks. Like there was a cognitive psychology textbook in the room where I played and I was like reading cognitive psychology textbooks and elementary school or something bizarre. I don’t know how much I understood. And then I think I read a biography in again in elementary school of Doraththa Dicks. And somehow I just always wanted to be a psychologist. And it’s interesting because I was also a trained musician. I was a classically trained pianist and sang later in life. So I was always pursuing music. And there was always a part of me that was thinking about music professionally but also wanting to be a psychologist. But at the same time, and in fact, when I chose an undergraduate school, I chose one that also had an associated affiliated conservatory in case I changed my mind yet again and decided to go to music. But at some point, so first it was going to be more like cognitive developmental, then I switched to clinical in undergrad and briefly thought about psychiatry, but went back to clinical. But at the time I was thinking, you know, maybe because I was a musician And I would become a psychologist who worked with artists either around performance anxiety or an injured dancer who was struggling. And I would live in Manhattan and I would just have this very specialized practice. And then in undergrad, I had a year-long practicum working in basically a drop-in center for people with mental illness. And I Turned out that when I wanted to take a few years off before grad school that when I was looking for a job, that was like my biggest qualification is that I now had a year of experience working and got a job as a case manager for a case management team. It wasn’t really an assertive community treatment team, but it was sort of like that. And it was an intensive case management team and doing community work and all of that. And about halfway into that experience, I was like, I think this is what I want to do. Huh? How about that?
Dr. Niv: Cuz were there a lot of people with psychosis, I imagine, in that program.
Dr. Resnik: Exactly. Exactly.
Dr. Niv: And then you went to grad school, studied
Dr. Resnik: and then I went to grad school and specifically went to a program with a focus in psych rehab.
Dr. Niv: Well, you know, we’ve talked about you, you and I have talked about psych rehab, and I think a lot of people mistake psych rehab for treatment,
Dr. Resnik: like like regular mental health treatment. And what is the difference? How are they the same? And what’s What is the difference?
Dr. Resnik: You know, one of the fascinating things to me in this field is a lack of consensus around definitions. And so
Dr. Niv: always
Dr. Resnik: it’s not like there’s truth here. So I can tell you how I think about it, but somebody else who’s as equally exposed and knowledgeable might have a completely different approach to how they think about it. So to me, psych rehab tends to be predominantly pragmatic and strength-based, whereas I think about treatment as fixing deficits. Like we’ve talked about cognitive remediation, which I think about more as remediating deficits. And to me, it’s not as pragmatic. It’s sort of a technique. It more of a treatment than it is a rehabilitation. But I know lots of people think about it as like rehab. And I’m not going to tell them they’re wrong. It’s just that’s just not my personal framework. And if you were to go into the literature and try to find good definitions, I defy you to find a consensus definition about what they are.
Dr. Niv: Yeah. It’s like 20some years into this field. I could not define it. I like this definition of focusing on strengths rather than like trying to get rid of symptoms. Are you talking about like improving socializing, improving work skills? What What do you say strength? What is that? Yeah, exactly. And really practical life domains. And I think that’s what drew me to it is because I get lost in long theories and conceptualizations and like fancy techniques. Like somebody’s got a job or they don’t. Like that’s pretty concrete. And helping them get a job while it might be a nuanced thing that requires expertise is inherently explainable to most people. Like it just feels more tangible to me than again going to cognitive remediation, like talking about executive function and you’re going to do this and that and the other and and honestly like my attention span’s just not that long. So like you’ve lost me already. So let’s just talk about getting somebody a job.
Dr. Niv: And and so these are really important things to talk about in psychosis, right? Because of these functional problems that people have. So Can you talk about some of the functional issues? I mean, we spend so much time talking about symptoms, but let’s talk about other types of functioning, you know,
Dr. Resnik: exactly. And and it’s obviously it’s individualized. It’s complicated. It depends on the supports that people have. And increasingly, as we all talk about, we know how much is really driven by poverty, by the social environment, by the communities in which people live. I mean, I think we’ve had some evidence that where somebody lives has more to do with their quality of life and how they live than pretty much anything else. And so I think that’s really important to to note, especially because many people who have psychotic disorders are under-resourced and are impoverished in so many ways. And so it’s a double whammy if you’re having issues around your daily life and then you’re in an environment which is also defeating. So I just increasing awareness of that. But I would say that for many people it’s relationships, it’s work. And in our society, work is so central. I mean, some of that shifted, I imagine, in the last couple of years with increasing awareness of societal emphasis on work may not be as healthy as people might have thought, but it is still such an important part of how this Society judges people and reinforces people whether it’s income, health insurance, all of that. So, relationships, work, just being able to take care of yourself, to be able to be planful, money management is such a big thing,
Dr. Niv: huge,
Dr. Resnik: such a big thing. And you know, they’ve done studies that show that the less money you have, the poor decisions often people make because because it becomes overwhelming and so what’s the point you know how many folks have you worked with or have I worked with who have very little money and buy lots of lottery tickets for example or invest in poor investments like beat up cars
Dr. Niv: the financial literacy isn’t there right
Dr. Resnik: and again creating that cycle that makes it even harder for people to to dig out of
Dr. Resnik: but we’ve thankfully seen a big shift with the recovery move in some ways, not in other ways. I think we’ve seen at the VA, we’ve seen a bigger shift than I think out in the general public. You know, it’s an interesting thing. So, Kim Hopper wrote a great paper on recovery and sort of a historical look and the thesis, I haven’t read it in a while and my memory is not so hot, but the thesis was basically more or less we say that we’ve seen these changes, but in fact, nothing’s new and nothing’s really changed all that much. That a lot of what we talk about now was already present years and years and years ago. And I really do wonder sometimes how much is jargon and well-intentioned attempts to infuse recovery. But well, and and I’ve written about this with my friend and colleague Marcy Hunt. This sort of professionalization of recovery which is almost defeating the whole purpose, right? That recovery is a movement by people with lived experience to reclaim their treatment, to reclaim their lives, and that a bunch of well-intentioned but perhaps misdirected professionals have decided that they’re going to make recovery oriented systems, but we’re still professionals. And like You see that in the adoption of peer support to me. Peer support which originally was all about mutual support. When you hire somebody to be a peer support specialist and then they’re in a professional setting and they take on aspects of professional mental health and does it change the nature of what that is? Maybe probably a little. C
Dr. Niv: can you just to back up a little bit? Can you explain what peer support is
Dr. Resnik: sure. So pure support is when someone with a history of lived experience presumably a shared lived experience with the person that they’re supporting is providing some sort of well support whether that’s you know if you hire somebody in more traditional mental health settings but there are other models of peer support in which it’s done outside of a of a professional mental health setting.
Dr. Niv: And it really some of the things we’re talking about in terms of recovery are things that don’t need a professional, right? Like you you don’t necessarily need a licensed psychologist to teach someone to write a resume or
Dr. Resnik: Exactly.
Dr. Niv: or do an interview or
Dr. Resnik: That’s exactly right. So, it’s interesting. So, the one of the things that I work on, I know we’re sort of going all over the place, but I’m involved in this effort to help train postdoctoral psychologists to specialize in SMI psychology and and helping to get postdoctoral programs. It’s a pretty new, we’ve just recently passed all of the rules that we need to and are now recruiting postdoctoral programs to become accredited in SMI psychology. And I believe so strongly in that because there are so many advanced things that we can do and yet there are so many things that you don’t need advanced education to do. But it it it brings me back to that first job that I had. had that I was talking about when I was right out of college and I was working as a a case manager and I was 22 years old. I made next to nothing. I made so little money that when my deferral for my student loans came due. I had to take a second job because otherwise I wouldn’t be able to pay my bills. That’s how little money I made. And I was actually one of the most experienced case managers because I had done a year of specialized training. And I was responsible for these people’s lives. Like we were doing, we had their money. I was in their houses. I was helping them with everything with laundry, with shopping, with, you know, helping them get to the doctor, with trying to get them engaged in treatment. I mean, I was doing everything.
Dr. Niv: Wow. That’s such amazing hands-on treatment, by the way. Like, or experience on treatment, but experience. That’s wonderful.
Dr. Resnik: Yeah, it was. And yet, I was exhausted. I was 22 years old and every Friday, I would go home and I would lie in bed and I wouldn’t get up until noon the next day cuz I was so tired. I was like, “How does anybody do this? I’m 22 years old. How are my colleagues who are older than I am managing, who have families, who have more responsibilities than I do, like
Dr. Niv: it’s exhausting.”
Dr. Resnik: Exhausting. And I got paid nothing. And yet we were the workforce. And I I don’t think things have changed all that much. I Think about community mental health and how hard people work and how little they get paid and how many needs people have and sometimes it’s just overwhelming to think about. And so anyway, that’s part of this idea that trying to promote that this is a special population where people can have specialized skills that might help to elevate this as a profession to attract more people, to help more people get engaged. and maybe elevate the workforce in a little bit
Dr. Niv: where you can actually make a living doing it. Right.
Dr. Resnik: That’s right. Yeah.
Dr. Niv: Um it’s a total change in topic, but you and I’ve emailed about this a couple times and I haven’t gotten an explanation. So, I want to talk about the term SMI.
Dr. Resnik: Yes.
Dr. Niv: So, back in back in the day when we were younger, it’s it stood for severe mental illness and then at some point it kind of shifted to serious mental illness and basically what it referred to were mental health challenges. that had resulted in like serious functional impairment that interfered with day-to-day life. You have feelings about this term.
Dr. Resnik: I have feelings. I do.
Dr. Niv: Tell me. Tell me what you think.
Dr. Resnik: I have big feelings.
Dr. Niv: Why should it be discontinued?
Dr. Resnik: Well, I think it should be discontinued and I don’t both. So, let me explain.
Dr. Niv: Okay.
Dr. Resnik: So, this gets back to the definitions, right? Like we can’t define psych rehab. God knows we can’t define recovery. Like how many many things can’t we define? Well, it turns out you can’t define SMI either. So, if you ask 10 people what SMI means, you’re going to get 10 different answers. And there’s some papers recently, some really nice papers that quantify that, who actually pull out definitions and show that there is no consensus. And so, when you use that term, we don’t know what it means. It’s it doesn’t mean anything. So, you and I because of our training think about it as people with schizophrenia. and bipolar disorder and maybe really severe depression with psychotic features. Like to me that’s what it is.
Dr. Niv: I throw schizoaffective disorder in there. But that
Dr. Resnik: schizo effect, right? Schizoprum. Exactly.
Dr. Niv: But that’s how I would also define it. But a lot of people also include like PTSD.
Dr. Resnik: That’s right. So if you look at the like federal register definitions, it could probably be any diagnosis. And then how do you define functioning? And then think about eating disorders. Eating disorders h have the highest mortality is my understanding of mental disorders, but most of us don’t think about eating disorders as an SMI.
Dr. Niv: When you know you’re training people in SMI interventions, we’re not thinking about eating disorders. That’s a whole other specialization. So, there’s been a lot of advocacy from the eating disorders organizations in the United States to try to help elevate this as like well this is an SMI it should be included and so once you start getting there then it becomes an issue of well how do you measure functioning and so back in the day we might have used a GAF score a global assessment of functioning but if you’ve ever given a GAF score you know how hard it is to get good interrator reliability on that and validity and it’s not used anymore as a measure because of the problems with rating So what do you use? We don’t have a common measure, an easily defined measure. So then where does it leave you? Who are the people with SMI then?
Dr. Niv: Well, and I I never really thought about this perspective of it diminishes other disorders that aren’t in this category but are equally harmful. Right.
Dr. Resnik: That’s right. And in fact, so even the terms like if you call something a serious mental illness, does it mean that other illnesses aren’t serious? ious and and what does severe mean? So, for all of these reasons, I think it’s just a bad term just because it’s imprecise and I prefer to have terms that are meaningful that actually communicate something instead of when I say SMI, I have something in my mind and you probably have something different in your mind, but we’re still having a conversation and our conversation could turn out to be completely meaningless because we’re talking about two different things.
Dr. Niv: Different things. any term that you think of when you think about this constellation like the disorders that we talked about schizophrenia, bipolar, what comes to your mind?
Dr. Resnik: Well, so that’s the flip side. That’s why I said I think we should get rid of it but we shouldn’t is because I don’t know what else to use. There’s just such there’s no shorthand here. So if if I’m writing a report for example, a quantitative report, I can spell out this includes people with these diagnosis, right? And so I don’t need to use the term at all. I can just literally spell out it includes these people. But there’s so much heterogeneity among people with a certain diagnosis. So
Dr. Niv: Right. Even among schizophrenia, there’s huge heterogeneity.
Dr. Resnik: Exactly. So it’s just on the on a very very basic level that I think we do a really lousy job of identifying people with the most severe needs or the most intensive needs. And I think that’s really what we want to get at when we talk about people with SMI is what we’re really talking about is who are the people that need the most help? How do we help the people who need the most help who either have the most deficits or the most challenges or whatever? But then how do you describe that? It’s not just the term that we’re using. It’s actually deeper than that. It’s it is definitional because I think if we had a better definition and a way of identifying people then perhaps the term would come along because we’d know what we were talking about and and that way of identifying people can be done through measurement through assessment which is what you’re doing these days. Talk to me about measurement based care. What is it? Let’s start with what is measurement-based care.
Dr. Resnik: Yeah. And so measurement-based care as we define it is a process of using patient reported outcome measures. So measures that pretty much anybody you could Google them and and find them. They’re not fancy protected psychological tests. They’re things like symptom measures uh for common disorders or quality of life measures where people self-report. PHQ9 is the most common which is for depression, but people generally know that because if you go for a primary care visit, you might be getting a PHQ9. In fact, I think most people now are getting PHQ9’s when they go for primary care visits. And so that’s what we’re talking about when we’re talking about a patient reported outcome measure. And we use those measures for people who are engaged in mental health treatment. And we follow them over time with these measures and use a process of what we call um in shorthand the model we use is collect, share, act where you collect a measure, you share it back with the client, with the person and have a meaningful discussion about Does this fit with your experience? What does this mean to you? Helping to identify perhaps things that might not have been discussed otherwise and then act where you use that data and that data over time in treatment in order to make collaborative decisions about treatment plans. And so the idea is it’s a very empowering transparent process where both the provider and the client can track how things are going in treatment.
Dr. Niv: So it that initially allows you to even identify what kind of treatment would be needed, right? In theory,
Dr. Resnik: no. I would say no. I would make a distinction between initial assessment, initial diagnostic assessment and measurement based care.
Dr. Niv: Okay.
Dr. Resnik: So, initial diagnostic assessment, you know, somebody’s new, maybe you’ll use measures, hopefully you’ll use standardized measures in order to figure out what’s going on, but those might be clinician administered. In addition, and Many patient reported outcome measures aren’t so great at diagnosis, even though people use them that way. But that’s not how you confirm a diagnosis. You might screen for something using a measure, but then you’d want to confirm that diagnosis with a more rigorous process
Dr. Niv: and and that would be through an interview. We don’t have like blood tests or x-rays or anything like that.
Dr. Resnik: Exly. That’s right. It would still be an interview. So the question getting back to we use assessment, the idea is how you identify who who needs the most care. Right. Right.
Dr. Resnik: One of the challenges we have right now with measurement based care is a lack of measures that have been validated for people with psychosis. And certainly for symptom measures, no self-report measures have really been validated because one of the unfortunate things with many psychotic disorders is a lack of insight about the illness which would make it very hard to self-report on certain things. And so it’s real gap in the measurement based care literature is that we really don’t have symptom measures for those diagnosis that could be patient reported. They really are clinician administered. But what we hope is that we can validate some quality of life measures, recovery measures. There’s a a really nice measure called the recall which is being used in the UK that might be able to help with all the other things. So there just literally isn’t research on measurement based care with this population. So, and my area of expertise isn’t so much the initial assessment, but I do know that there are assessment tools that can be used for that initial diagnosis. And some nice tools that I’ve seen, you know, in passing that I couldn’t speak to in in any depth, but that might help understand what somebody’s needs are in terms of housing or employment or social. There are measures for pretty much everything. Yeah.
Dr. Niv: So, in terms of how it would apply to this population, that we’re talking about. There’s nothing really for symptoms, but they could measure more general functioning in these specific areas
Dr. Resnik: for self-report. I mean, there are clinician administered measures as as I know you are well aware that that you can use whether they’re semi-structured or structured interviews for diagnostic assessment and severity assessment that you can certainly do, but nothing that we would consider for self-report for measuring progress over time. So why is that important to us? Why is patient self-report guiding measurement based care?
Dr. Resnik: This is one of those, you know, we don’t have the evidence to say why it’s important. It’s value based care, if you will. It’s not evidence based care, it’s value based care.
Dr. Niv: Yeah.
Dr. Resnik: We as providers, as clinicians, as professionals have a lot of power and influence a lot of judgment. And it’s really important that we have some pieces of information that are independent. from the filter of us. So, every assessment has bias. Every single assessment, no matter who does it, there’s going to be bias. But hopefully, you can have different sources of bias and get closer to maybe what a truth is. And we also think it’s really important from an engagement standpoint so that the client is actively giving their voice and has a time and it’s easier, I think, to fill out a standardized questionnaire independently and then hand it to somebody than it is to answer a question with somebody. So, you’ve built rapport and you like your therapist or your provider or your case manager, whoever it is. You want to be doing better because you know how hard they’re working to help you get better, but things aren’t great and it might be hard to tell them that. But if you’ve got a measure that you’re filling out that’s seemingly objective and I’m having trouble with this or I’m ating this because four days out of five I’m having trouble with this. It might be easier to be able to talk about the things that aren’t going well.
Dr. Niv: Right. When they’re sitting in the room with someone, they may want to please the therapist. So, there’s lots of issues.
Dr. Resnik: That’s right. It’s hard to tell people when things aren’t going well.
Dr. Niv: Yes. Yes. Or the opposite, right? Where you over-exaggerate the bad because you’re not maybe remembering what’s been going well.
Dr. Resnik: That’s right. That’s right.
Dr. Niv: Um, yeah. One of the things that really appeals to me about measurement-based care is that you get the clinician working in collaboration, right? It’s really different than the traditional model of like I’m the doctor, I’m the therapist, I know best, let me tell you what you’re going to do. It really is a share, you know, we talk about shared decision making. Um, what is shared decision- making? Like it’s such a buzz psychology, right?
Dr. Resnik: Well, there are a lot of different definitions about that.
Dr. Niv: Surprise.
Dr. Resnik: Yes. But I mean, I think I think the term speaks for itself. It’s a decision that you make in collaboration where you have two experts in the room who have different expertise and you come together. And I hadn’t actually really thought of it in this way before personally like my own doctor’s appointments. And I’ve had providers doctors well across the range from very expert driven to very very collaborative. And the truth of the matter is I struggle with the really collaborative providers because there’s a part of me that’s just like you’re the expert. Tell me what to do. This is too much. I can’t make this decision.
Dr. Resnik: But one of the nice things that measurement based care helps with is when you have that objective data that’s still from your perspective, but then you’re looking at it. It’s not as overwhelming because you have data in front of you. You have information and you can talk about the information to lead to a decision as opposed to just feeling like I don’t know this is too much. It helps to narrow the conversation a little bit.
Dr. Niv: And I think it’s helpful for people to know they don’t have to be the expert in everything. Right. Like they what I always tell my clients is I I’m the expert in the clinical world. You’re the expert in you.
Dr. Resnik: Right.
Dr. Niv: Right. And we got to get the two to work together. Yes. Because I can tell you to do X, Y, and Z, but if you can’t do it, if it doesn’t work for you, if you don’t want to do it, how’s that going to help?
Dr. Resnik: That’s right.
Dr. Niv: So I have some questions from Facebook groups.
Dr. Resnik: Okay,
Dr. Niv: so these are consumer and family questions. Um, some of them you already kind of answered a little bit, but maybe we could add Tim. So the first one, I have a doctor, a psychologist, and a case manager. Who should be measuring what?
Dr. Resnik: Oo, interesting. So the first question I would ask is, are they part of a team? Do they all work together in the same agency or are they in different places? Because
Dr. Resnik: if they are all working together as a as a team and they’re sharing a medical record, then only one person needs to measure anything and everybody can use the results. That’s also another definition of share. When we talk about collect, share, act, you’re sharing with everybody on the team and there’s no reason to keep giving the same measure over and over again to a million different providers. What a waste of everyone’s time, right?
Dr. Niv: And and the patient gets frustrated with it.
Dr. Resnik: Absolutely. Okay. So once is fine and then everybody can use the data in order to you know inform their treatment. Okay. The difference would be is if maybe the a therapist a psychologist maybe they’re doing let’s just go back to the sleep idea. Maybe there’s some insomnia going on and somebody’s doing CBT for insomnia. Well that person would clearly be administering the sleep measure and maybe that’s not something somebody else is all that interested. in and so that might be separate because you always want to make sure you’re measuring something that your treatment is targeting. But ideally it should be shared and at least because it’s just that’s just a waste of time and if it’s not it’s going to it’s a little hard to answer this question because we don’t know what the case manager is doing what the psychologist is doing right minimally I would say the psychiatrist symptoms
Dr. Resnik: psychiatrist would be measuring symptoms you know one of the things We don’t talk about um idiographic or um individualized measures all that much, but one of the things that I’ve been thinking about recently idiographic measures where you ask somebody initially, you know, what are your biggest challenges? What are the things you want to work on with me? And then you put them in a sort of a spreadsheet like maybe a the top two or three that you’re working on. And then every session you rate on a scale of 0 to 10 where zero is this is a problem and 10 is this is a terrible problem, how they’re doing with that problem. And so a case manager might benefit from that kind of measurement where it’s something really really concrete, but you’re still using that systematic objective quantitative ranking so that you can follow how progress is going.
Dr. Niv: And that’s really specific to the goals of the individual, right? What is bothering them the most, not again what we as professionals think should be the goal of treatment. Um, okay. Second question. My son’s doctor does not collect data about his symptoms. If I want to track symptoms at home, what should I use?
Dr. Resnik: Well, again, that would depend on what the disorder is and whether or not there is something that’s a self-report measure.
Dr. Niv: Just to clarify, this is a group for people with families of people with schizophrenia and or not and or or bipolar disorder. Okay. So, I’m not sure that there’s a good self-report for symptoms. And in fact, because there isn’t, I can’t even tell you off the top of my head a recommendation because I don’t pay that close attention to the clinician administered measures these days and and they’re probably not in the public domain in the sense that you can just Google the measure and come up with something. So, if that’s the case, something like the top problems idea where you identify for yourself as together what are the things that are the most challenging and then how do we keep track of them at some interval whatever makes sense is it a weekly rating you know every Monday we’re let’s just get together and talk about how these things are going so that you can track them over time something as informal as that might be helpful that’s it’s a tough one because there just really aren’t great measures to track things um And it really depends on where the problems are.
Dr. Niv: Uh we got a couple more here. One more from our group. Is there some sort of feedback or data we should be collecting from our loved one as a supportive family member and give it to the doctors or is this feedback we should be getting from the doctors? Probably a little bit of both, huh?
Dr. Resnik: Yeah. You know, it’s interesting. It’s not that different from the question that you just asked. And yet the way you asked it had me thinking in a really different way. So, family members are family members. They’re not providers. Now, I know many family members are in the role of caregiver, and I know that that’s just a reality, but I wonder if this sort of rating process among family members might create an uncomfortable dynamic that is emphasizing that caregiver way. I’m not articulating this well.
Dr. Niv: So, putting more burden on the caregiver to collect the data.
Dr. Resnik: Not so much burden, but that dynamic, I’m raiding you.
Dr. Niv: You’re my son, you’re my daughter.
Dr. Resnik: So, then you feel like you’re being observed all the time.
Dr. Niv: That’s right. And if that’s really the role of of a doctor or a case manager or a professional, now there are apps So the VA for example has apps where people can practice skills and rate themselves. There’s wellness apps and insomnia coach and covid coach and like those things would be great but there isn’t something like schizophrenia coach or bipolar coach that would be ideal if that was a more independent process. So I mean we do have quality of life scales and other scales that are in the public domain but unless the provider is willing to actually do something about the items that are being graded, it would just be frustrating. So, you come in and you say, I’m here are the challenges. It’s relationships and employment, but for whatever reason, the people that you’re working with don’t have employment resources, for example, there there’s no way to refer to a supported employment program or they don’t have the capacity to manage that. Then that’s just a setup for everybody to feel disappointed, right? So, ideally, the measures would be coming from a collaborative effort with the treatment providers. So, you’re not putting the caregiver in the role of treatment provider and the treatment provider is in a position to do something about what’s being rated.
Dr. Niv: So, so even though family, we don’t necessarily want them in that sort of observation rating role, there is still a role for family to give healthcare providers feedback of what they’re seeing.
Dr. Resnik: That’s right. And even if the individual doesn’t want information to be shared with the family member, the family member can always share information, right? And so if they want to share that information or if they want to do independent ratings and it helps them feel like the information that they’re providing is going to help enrich the provider’s ability to fully understand what’s going on, then go for it. I think that’s fine. But I think there’s always that relationship to be aware of and to, you know, if you’re doing that without the consent of the individual and understand that there is a risk there that it could feel like somebody going behind their back, a betrayal of some sort. And on the other hand, if it’s collaborative, hey, let’s sit down together, that’s a really different feel than like rating someone who could potentially be delusional and suspicious, rating them behind their back.
Dr. Niv: That’s exactly right. And ideally, you know, one of the things that we talked about when we started implementing measurement based care is when do we start educating the clients to expect it? And in the beginning, you can’t because there just wasn’t enough going on in order to like want a client to walk in and say to their provider, “Hey, where’s my measures?” Right? At some point, like it’s becoming the standard of care. And so, why couldn’t somebody just walk in to their doctor and say, “Hey, where are my measures? I heard about this thing called measurement based care and I heard that it improves treatment outcomes. Why aren’t we doing that?”
Dr. Niv: So, we should set expectations for people to advocate for themselves in that that way.
Dr. Resnik: Exactly.
Dr. Niv: Okay.
Dr. Resnik: I think so. Why not?
Dr. Niv: I you know, if we want the best care possible, we need to ask for it.
Dr. Resnik: That’s right. The catch again here is that there’s no research evidence in
Dr. Niv: specific to this
Dr. Resnik: specific to schizophrenia and bipolar disorder. So
Dr. Niv: we should change that.
Dr. Resnik: So we need to change that so that we can then advocate for that.
Dr. Niv: And um last question.
Dr. Resnik: I love your questions by the way. Tell your Facebook group that these are great questions.
Dr. Niv: I will do that. Last question. What are you most excited about in the field of schizophrenia? Like what are you seeing right now that really has a potential to impact people’s lives in a positive way?
Dr. Resnik: I’m struggling with answering that question because I don’t know that there is anything.
Dr. Niv: It doesn’t feel like much has changed and last like 10 15 years I would say
Dr. Resnik: that’s exactly how I feel and I’m not sure why that is. We had so many advancements for so long. I’ve been in this field a long time and I feel like there was lots that was new like evidence for assertive community treatment was really really hopping you know in the 80s and then by the ‘9s you know I was on a team that was basically doing that. We were learning so much about early peer support efforts supported employment being defined in the early studies in the 80s and you know and then randomized control trials through the ‘9s and beyond. And back then I felt like I was part of this underdog group, right? Doing these sort of things that weren’t mainstream. They’re mainstream now. Like that’s amazing. So much of what was was niche and underdogy is now mainstream and that’s amazing. But where are the new ones? And I don’t know where.
Dr. Niv: It seems like the emphasis has definitely been toward first episode psychosis,
Dr. Resnik: right? Which is really important. And I think the evidence is suggesting when you intervene earlier with really good coordinated care that you can prevent disability from happening, which is great. But when you look at what coordinated specialty care is, it’s all those things. things that we’ve been doing
Dr. Resnik: in a package that we’ve been doing which is super and we should be doing them in a package for everybody right oh and family like we didn’t talk about family services which we know have the highest effect size of pretty much like anything right
Dr. Niv: you can’t find it anywhere
Dr. Resnik: you can’t find it anywhere so that’s why I can’t answer the question is because I’m not excited by anything new I’m a little frustrated actually And so we need to improve our implementation of the things that we know work. And I mean, I’m an incrementalist by nature. That’s just how my brain works. I’m never going to be the person who just comes up with a whole new thing. That’s not who I am. I have a lot of respect for those. I am the person who’s going to slowly improve something. And I think that’s happening. There are lots of studies that are trying to improve supported employment or improve that. You know, you’re adding on, you’re modifying. And I think those are really important, but they’re Not the big breakthroughs of the new thing,
Dr. Niv: right? Like the new medication or the new way to improve cognition or
Dr. Resnik: Exactly.
Dr. Niv: There’s, you know, tons of studies going on, but as we all know, research actual implementation of treatment is a serious challenge.
Dr. Resnik: That’s right.
Dr. Niv: And even all of the psycho-social rehab and treatments that we’re talking about, like families for example, they’re not offered in so many places. It is hard to get a lot of these treatments
Dr. Resnik: and when they are offered they’re often not offered to fidelity. They’re not following the models. They’re
Dr. Niv: right. So for for people who may not know what fidelity means, can can you explain what that means a little bit?
Dr. Resnik: So fidelity is when the core components of a model that have been defined um are implemented as described. So when we say you’re doing cognitive behavioral therapy that you’re actually doing cognitive behavioral therapy and you’re not just chatting talking about how your day was. So you could say you’re doing cognitive behavioral therapy and you’re actually not. And the same thing is true for any of our evidence-based practices whether that be supported employment or housing first or any of the thing you know sort of community treatment that you can say you’re doing them but you might not actually be doing them the way that they were intended to and the way that the research would support.
Dr. Niv: Well, on that positive note, Sandy.
Dr. Resnik: Yes. Sorry.
Dr. Niv: Um, you know, I think one of the things that does excite me is these interventions we’re talking about, there’s increasingly more research and implementation and what does it take to actually get those in the hands of the people who need them. Um, and that is slow, slow work,
Dr. Resnik: but I think that’s worth stating that implementation science as a discipline in mental health and in academic medicine is really growing and growing and so many more people are interested in implementation science and I do think that even if we don’t have new exciting interventions that hopefully those advances will help us to figure out how to get more of these existing practices into the hands of people that that need them. So I think that’s a fair statement.
Dr. Niv: I love that. I love Ed on that note instead.
Dr. Resnik: How about that?
Dr. Niv: Thank you so much, Dr. Resnik. I really appreciate you joining us. It was really great to have you.
Dr. Resnik: It was a pleasure. You asked amazing questions. It was a lot of fun. So, thank you.
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