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APA Achievement Awards   |    
Silver and Bronze Achievement Awards
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.10.1398
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Tobacco use among individuals with a mental illness or addiction is a significant health problem, with numerous studies showing higher rates of smoking and lower rates of smoking cessation in these populations. These groups are estimated to consume nearly half of all cigarettes in the United States, and the consequences are considerable. Smokers with mental illnesses incur significant tobacco-caused medical illnesses and lose up to 25 years of life expectancy. Although public health interventions have led to lower smoking rates in the United States over the past 40 years, smokers with mental illness or addiction have benefited less. Efforts to promote smoking cessation in this population are in their infancy.

Despite evidence that tobacco dependence is a major health issue, the mental health system has been slow to develop counteractive strategies. There is evidence that the mentally ill population has less access to tobacco treatment services than the general population. One model for systems change is to target consumers directly to boost the demand for tobacco cessation services. One way of doing so is to involve persons with mental illness in talking with peers with mental illness who smoke and who may have low motivation to address their tobacco use. In the CHOICES program, patients are the peer providers. Peer-delivered services are in keeping with the recovery model's goal to provide services via people who have experienced the condition themselves. To those fearful of change, peers are less threatening than professionals. Mental health consumers also report high satisfaction with peer-delivered services.

The CHOICES program, based at the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey, takes a unique consumer-driven approach to addressing tobacco dependence among people with mental illness. The full name behind CHOICES—Consumers Helping Others Improve Their Condition by Ending Smoking—symbolizes empowerment and personal choice in recovery. CHOICES employs mental health peer counselors to deliver the message to smokers with mental illness in the community that addressing tobacco use is vital to their health and to motivate them to seek treatment. CHOICES mental health peer counselors, or consumer tobacco advocates (CTAs), serve as consultants to consumers to assist them with linkages to treatment, referrals, advocacy, and support and to provide educational materials. CTAs are paid positions filled by nonsmokers or former smokers who are moderately impaired or disabled by mental illness. Most CTAs work for the program part-time. The goal of the CTAs is not to provide tobacco treatment but to visit mental health centers, psychiatric hospitals, group homes, self-help centers, and health fairs and conferences to communicate with and educate consumers about their smoking. They also provide resources about places in New Jersey where smokers with mental illness can receive tobacco dependence treatment.

The CHOICES program exemplifies many aspects of a successful wellness and recovery initiative. For example, it targets a group with a vital health care need; seeks to reduce tobacco's harm in a vulnerable group; focuses its efforts in the community, which best accommodates the target population; employs peers to reduce educational and cultural barriers; and develops successful partnerships with key stakeholders for sustainability.

CHOICES is reaching people. Since its inception in 2005, the CHOICES team has conducted over 282 community visits, reaching more than 9,600 smokers with mental illness. CHOICES counselors have provided personalized feedback to over 1,200 individual consumers regarding their smoking. CHOICES has participated in or presented at 19 consumer conferences and 27 other events (health fairs, peer advocate training, and consumer forums). The CHOICES newsletter circulates to more than 900 consumers, and the Web site (www.njchoices.org) has had more than 235,000 hits, currently about 5,000 per month.

In recognition of its unique peer-to-peer approach to promoting tobacco cessation, CHOICES was selected to receive APA's 2009 Silver Achievement Award.

CTAs participate in 30 hours of intensive training to learn how to discuss tobacco issues with peers and to organize activities such as health fairs and smoke-outs. They also learn how to perform a 20-minute peer-to-peer feedback intervention. This straightforward intervention uses two concrete examples to deliver brief, personalized feedback about the impact of tobacco use. One example concerns expired carbon monoxide; the other focuses on the consumer's spending on tobacco.

The current CHOICES team includes three CTAs. Program Director Martha Dwyer supervises the daily operations. CHOICES cofounders Jill Williams, M.D., and Marie Verna are medical director and advocacy director, respectively.

In addition to community visits, the CHOICES program reaches its clients via a free quarterly newsletter. Consumers are encouraged to submit articles and artwork for publication in the newsletter, which also incorporates information on tobacco education and treatment options. The CHOICES newsletter also disseminates information about recovery initiatives in New Jersey and builds support for tobacco treatment. The CHOICES Web site is an additional tool to link consumers to tobacco education and resources.

An overarching goal of CHOICES is to increase the demand for tobacco treatment among mental health consumers through a process of education, advocacy, and culture change. Although it is based at the Robert Wood Johnson Medical School, CHOICES has had strong partnerships with the community (through work with the Mental Health Association of New Jersey [MHANJ]) and the New Jersey State Division of Mental Health Services (NJDMHS). These partnerships have contributed to the rapid growth and success of CHOICES. NJDMHS supports projects that employ mental health peer counselors, and it has been the primary funding source for the past two years.

MHANJ, a consumer-driven mental health advocacy organization, has been an especially effective community partner, linking CHOICES to an audience of consumers and sharing a commitment to address tobacco dependence through policy and other work. This grass-roots advocacy approach is leading to evidence of change in the mental health system in the state; clinicians are responding to their clients' demand for these services and seeking out training to acquire the skills needed to treat tobacco dependence.

CHOICES was awarded the 2007 Innovative Programming Award by Mental Health America. It was also selected to make an "innovative programs" presentation at the 2007 Institute on Psychiatric Services. The program is listed as a best-practices resource in several national provider toolkits for the treatment of tobacco use in mental health settings, including those published by the Smoking Cessation Leadership and the Behavioral Health and Wellness Program of the University of Colorado in 2009. The CHOICES model is expanding beyond New Jersey to reach a larger audience of smokers.

CHOICES faced numerous obstacles and barriers in its early work. Despite compelling and troubling health statistics, tobacco addiction receives insufficient attention in mental health care. Mental health professionals lack education in effective tobacco treatments. Professionals and families often incorrectly assume that consumers do not want to quit or cannot quit smoking. Combining academic research expertise with strong consumer network and advocacy experience was a critical step in advancing the development of CHOICES.

A telephone-based outcome study was conducted with outpatient smokers who received the peer-to-peer session. Most smokers surveyed were moderately to severely nicotine dependent. Few had access to tobacco counseling or treatment at their mental health program. There was a significant reduction in the amount of cigarettes smoked per day as reported by participants at the one- and six-month follow-up calls, and some had tried to quit smoking. Feedback from smokers about the program was positive. At both follow-ups, smokers reported that CTAs were extremely knowledgeable about tobacco and interested in their smoking. Seventy percent of those surveyed said that talking to a CTA about their smoking was much easier than talking to a mental health professional.

Additional evidence of CHOICES' success: CTAs report that the experience of working has improved their own recovery in mental illness. They speak strongly of the therapeutic experience of working that CHOICES has brought them personally. Each has gone on to achieve personal milestones, including participating in publications and in conferences on wellness and recovery; some have pursued additional formal education. Several have written about these recovery experiences in the CHOICES newsletter.

For more information contact Jill M. Williams, M.D., Division of Addiction Psychiatry, UMDNJ-Robert Wood Johnson Medical School, 317 George St., Suite 105, New Brunswick, NJ 08901 (e-mail: williajm@umdnj.edu).

In 2005 the South Bronx Mental Health Council's Children and Adolescent Services (C&AS) Program collaborated with five other outpatient mental health clinics in the Bronx (Bronx Behavioral Network) to find evidence-based practices that could be implemented in community clinic settings. The Community Parent Education Program (COPE), a school-based family-systems program, was chosen for implementation as a means to help parents of children who were coming to the attention of school officials or others, and in April 2006 the C&AS Program launched COPE.

COPE was originally developed to help youths with disruptive behavior disorders, but the C&AS Program wanted to expand the treatment model to include youths with attention-deficit hyperactivity disorder (ADHD). The C&AS Program also wanted to adapt COPE so it could better help the community served by the South Bronx Mental Health Council, a primarily economically disadvantaged urban community with high needs and a high proportion (95%) of African Americans and Latinos.

In recognition of successfully implementing COPE, an evidence-based treatment, and adapting it into a culturally and linguistically sensitive model that helps children with ADHD or disruptive behavior disorders, the C&AS Program was selected to receive APA's 2009 Bronze Achievement Award.

In the C&AS Program, parents and children in COPE meet separately for eight to 16 group training sessions. The model also involves coordination with the children's teachers to monitor target behaviors at home and school. The model is short term and time limited, and it is adaptable to environments where service needs exceed resources. Groups are run by bilingual social workers: two therapists to each children's group and one therapist to each parenting skills group. Two full-time psychiatrists also spend a proportion of their time working with COPE.

For parents, the group sessions focus on parenting skills and strategies to address disruptive behavior. The curriculum for parents includes balancing family relationships or sibling dynamics, reinforcement of positive behaviors, attending to siblings, and managing transitions. The model attempts to encourage positive behavior and reduce caregiver strain and negative family dynamics. Group sessions for children complement the ones for parents. Children's sessions focus on identifying and exploring social skills. Children are oriented to, verbally process, and then rehearse or role-play certain social skills, such as cooperation and communication.

Participating children are assessed upon admission, complete measures, and are then evaluated by a psychiatrist. Psychiatrists diagnose, evaluate for medication, and help to assess whether participants should remain in treatment or whether they can benefit from additional interventions. Group facilitators meet weekly and rely upon recommendations by psychiatrists. The team of psychiatrists has recommended that medication be offered at onset of treatment and that clients be assessed upon graduation from COPE in order to determine the behavioral outcomes of group treatment. Beyond medication treatment, staff members incorporate the needs and interests of the parents. By using COPE, psychiatrists are able to use lower doses of medication for a shorter period of time in a more targeted fashion.

The needs of the community served by the C&AS Program are great, so participants welcomed the program, but there was doubt initially that such a simple, non-medication-based approach would be efficacious. The C&AS Program also had to modify the material somewhat to reach the targeted population, such as translating COPE material and making it more culturally sensitive. In addition, because it was unusual for two parents to be available, either because of work schedules or because of a single-parent household, the C&AS Program needed to make accommodations for parents' schedules. Babysitting services were also offered for participating parents, which were then turned into a social skills training intervention.

Since the introduction of COPE in 2006, the C&AS Program has offered ten COPE cycles to parents and children, with more than 200 participants. Outcomes of the first cycle, when compared with outcomes of COPE clients of other agencies in the Bronx Behavioral Network, indicated that the C&AS Program is quite successful. The C&AS Program sustained the most positive behavioral outcomes for participants. Another formal outcomes assessment performed in 2006 found significantly reduced reported problem behaviors and reduced symptoms of ADHD. Long-term outcomes indicated continued gains, and the program has been effective in decreasing anxiety as well as disruptive behaviors. In 2007 the New York State Office of Mental Health and the City of New York sought to mandate that mental health programs use the COPE model and endeavored to train agencies on a citywide level.

The success of COPE has also been evidenced by positive responses from parents. In each COPE cycle, parents reported that the model and its recommendations or strategies were very helpful. Parents have also noted that they found the psychoeducational model to be culturally and linguistically sensitive. They appear to appreciate that they can identify with the parents presented in visual materials, role plays, and video materials that are used in the model and report that the goals of the model are within their grasp. They also seem to appreciate the model's content as less focused on emotion and dynamic processing, serving to facilitate the more pragmatic goals of problem solving and parenting skill development.

In the past, efforts to offer other parenting models to this population were met with resistance because parents found most models to be alienating, in that they presented clients in more suburban or rural settings who spoke English. They found most of the older models to have little to no validation of cultural nuances, values, or family roles and relationships. Parents had difficulty identifying with and communicating about issues that faced other populations and found other models to be invalidating of their own struggles.

COPE, an early intervention program that assists both the child and the parent, has been shown to be effective in one of the most challenged areas in the New York metropolitan area, the South Bronx. By demonstrating that the model can be applied in the South Bronx, with accommodations to the cultural needs of clients, the C&AS Program has helped to show that the model can be successfully adapted and adopted by other agencies.

For more information, contact Vicky Gatell, Children and Adolescent Services Program, South Bronx Mental Health Council, Inc., 781 E. 142nd St., Bronx, NY 10454 (e-mail: sbmhci@aol.com).

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