Working for the Underdog

Center for Psychiatric Rehabilitation director Kim Mueser is pursuing opportunities for curriculum development programs to ensure future mental health practitioners are being taught the latest, most effective treatment methods. Photo by Cydney Scott

This is not what ’70s disco cool should look like. A community dance. With your mom. In a New Jersey state psychiatric hospital. But for the teenage Kim Mueser, it was still pretty neat.

His mother was a clinical psychologist at the hospital and tagging along to work with her afforded an insider’s view of a fledgling progressive era: deinstitutionalization.

“There was a lot of energy, a lot of optimism that these people who’d lived in the hospital for 20 years could get out and lead valuable lives,” says Mueser, newly appointed director of Sargent College’s Center for Psychiatric Rehabilitation and a professor of occupational therapy.

He decided early on that he could play a part in that. “I’ve always liked to root for the underdog and to try to help people who had the greatest need,” he says, “so I focused on schizophrenia.”

But while Mueser now champions the underdog cause as American editor of the Journal of Mental Health and a frequent National Institute of Mental Health review committee member, he says the nation’s approach to treating people with psychiatric disorders, especially severe ones, is still wedged in the past. It’s not that advances haven’t been made, he says, but that they’ve remained stuck at a local level—an effective program at an individual clinic, a lone researcher trying something different with 20 test patients.

Familiar culprits can take some of the blame for the lack of universal access to the best treatments: limited funding, undertrained practitioners, enduring stigma. But the field also seems to be hampered by limited vision; great ideas largely remain just that, failing to evolve into usable national guidelines that enable clinicians and empower patients.

This is where that changes.

America’s D grade on care

The National Alliance on Mental Illness gives America a grade of D on its care of people with psychiatric disorders. In its last Grading the States report, not one state was given an A, only 6 mustered a B, and 27 were chided with a D or an F. For people with a mental illness, those grades translate into inadequate provision of many services essential to recovery: illness self-management programs, supported housing and employment, family education programs, and wellness promotion, to name a few (the report lists a total of 65).

One of the keys to improving care across the country, according to Mueser, is evidence-based practice. It sounds so fundamental that it’s hard to believe it’s not already commonplace. He contends that recent rehabilitation and treatment breakthroughs have had a limited impact in an environment of undertrained practitioners and high caseloads. “Much more work is needed in terms of developing models that can support the implementation of these practices in real-world treatment settings,” he says.

He’s positioning the Center for Psychiatric Rehabilitation to lead that charge. Funded by the National Institute on Disability and Rehabilitation Research, the center is an on-campus hub for mental health care research, training, and clinical programs. A pioneer in shifting the field’s focus from symptom control to recovery, it’s long been a globally recognized advocate of “the importance of self-determination in terms of treatment and goals.” According to Mueser, a center task now is to use “that recovery vision in implementing specific evidence-based practices.”

Susan McGurk, a SAR associate professor of occupational therapy and the center’s director of cognitive remediation initiatives, notes that with more than 20 research projects and clinical programs under way there, a lot of the groundwork has already been laid. “More of the services developed here will be tested in randomized-controlled trials to further increase their impact on the field,” she says.

Close to half of people with a severe mental illness suffer from post-traumatic stress disorder (PTSD); emblematically, little work has been done to develop tailored treatments. In research funded by the National Institute of Mental Health, Mueser and his team are conducting a series of randomized-controlled trials—the evidence-based approach—to evaluate a new treatment and clinician training program. The treatment uses a cognitive-behavioral approach that teaches clients to recognize and change inaccurate thoughts and beliefs, often related to traumatic experiences. As people with PTSD learn to challenge incorrect or unhelpful trauma-related beliefs, they gain better control over their emotions and their lives. While clients’ levels of depression and PTSD symptoms are tracked during treatment, clinicians-in-training are given weekly feedback on their implementation of the program.

After evaluating the intervention “in a controlled study across several states with very well-trained, PhD-level clinicians,” Mueser says, the researchers had good results, but they still didn’t know “whether the program would work with less academically trained graduate-level clinicians.” A second study was needed. “We’re now testing the program at five different sites, including urban ones, in New Jersey. All of the clinicians providing the intervention are frontline, people who are simply working with this population on a daily basis.” Those aren’t grant-funded positions—“all the services they provide are billable,” Mueser says—but by expanding the reach of its study, the team has been able to probe additional questions: will the program work in more urban settings, with greater numbers of minority clients? Are the effects of the program long-lasting? What are the effects on other areas of functioning, such as overall functioning, quality of life, and so forth?

A workforce problem

That Mueser included a training element in the PTSD study is revealing.

His blunt assessment of mental health care provision in the United States: “We have a workforce problem.” It stretches from generalists—physicians, for instance, have been shown to provide poorer physical care to people with schizophrenia than to those who don’t have schizophrenia—to specialists: psychology students, who should be well placed to help, don’t want to; they’re worried patients won’t be motivated to change, according to a 2010 study.

Why is this happening? Some of it, as in the attitudes of psychology students, is stigma, according to Mueser. The education system is also at fault. “You can get a PhD in clinical psychology,” he says, “and never meet or work with somebody with schizophrenia or bipolar disorder, which are two of the most common severe mental illnesses.”

One of his aims is to take advantage of Boston University’s closely intertwined health-related colleges—including Sargent and BU’s School of Medicine and School of Social Work—and departments, particularly psychology, to model new curriculum and training opportunities across a broad range of disciplines. He’s also hoping to establish relationships with more public mental health service providers in Boston.

“The single most powerful way of overcoming stigma is having contact with somebody who’s had a mental illness,” Mueser says, pointing to his teenage trips to the New Jersey state hospital. “Even if you don’t want to make it a specialty, when you work with very challenging, difficult people, it expands your skills, it expands your understanding of the range of different challenges that people face.” He believes that working with people with schizophrenia as they overcome symptoms such as auditory hallucinations or disordered speech, only to find barriers to work or social activities, is “good experientially and facilitates the development of clinical skills.”

He’s pursuing opportunities for “curriculum development and training of people in professional programs—occupational therapy, social work, psychology”—to ensure future practitioners are being taught the latest, most effective treatment methods.

And for the one in 17 Americans with a severe mental illness, not to mention the one in 4 with some form of psychiatric disorder, it should mean they finally get A-grade-care. A worthy victory for all underdogs—and their longtime champion.

Andrew Thurston can be reached at thurston@bu.edu.

A version of this article was published in the fall 2012 issue of Inside Sargent.