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Evidence-Based Practicesand Recovery at Thresholds:Transformation of a CommunityPsychiatric RehabilitationCenterSANDRA WILKNISS a & ANTHONY ZIPPLE aa Thresholds Psychiatric Rehabilitation Centers ,Chicago, Illinois, USAPublished online: 13 May 2009.

To cite this article: SANDRA WILKNISS & ANTHONY ZIPPLE (2009) Evidence-BasedPractices and Recovery at Thresholds: Transformation of a Community PsychiatricRehabilitation Center, American Journal of Psychiatric Rehabilitation, 12:2, 161-171,DOI: 10.1080/15487760902813160

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Evidence-Based Practices andRecovery at Thresholds:Transformation of a CommunityPsychiatric Rehabilitation Center

Sandra Wilkniss and Anthony Zipple

Thresholds Psychiatric Rehabilitation Centers, Chicago,Illinois, USA

The following series of articles describes how a community psychiatric reha-bilitation agency serving individuals with severe mental illness has integratedrecovery-oriented services and evidence-based practices in its service deliverymodel. The lead article describes the rationale and organizational commit-ments required to implement the model, followed by several case studies ofindividual evidence-based practice implementation highlighting successesand challenges. The final article offers perspectives from three consumers ofthese services.

A confluence of events over the past half-century has led tothe current revolution in mental health care: from custodial anddiscipline-driven to recovery-focused and evidence-based services(Bellack, 2006; Silverstein, Spaulding & Menditto, 2006). Three fac-tors appear to be driving this fundamental transformation. First,research findings from the last several decades proved that recov-ery from severe mental illness in the strictest sense (prolongedremission of symptoms and restoration of functioning to adequatelevels) is not an unusual outcome (e.g., Harding, Brooks, Ashikaga,Strauss, & Breier, 1987; Harrow, Grossman, Jobe, & Herbener, 2005;see Liberman & Kopelowicz, 2005; and Davidson & McGlashan,

Address correspondence to Dr. Sandra Wilkniss, Thresholds Psychiatric RehabilitationCenters, 4101 N. Ravenswood Avenue, Chicago, IL 60613, USA. E-mail:swilkniss@thresholds.org

American Journal of Psychiatric Rehabilitation, 12: 161–171

Taylor & Francis Group, LLC # 2009

ISSN: 1548-7768 print=1548-7776 online

DOI: 10.1080/15487760902813160

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1997 for review). As many as two thirds of people with even themost severe illnesses achieve substantial recovery over the courseof their lives. Second, the consumer movement has championedrecovery in the broader, deeply personal sense. This movementhas hit full stride and serves as a rallying point for consumersand families (Frese, 1998). Third, on the provider side, the rehabili-tation approach became the organizing paradigm for serviceswith a focus on satisfaction, quality of life, and positive effects on‘‘real-world’’ outcomes, rather than mere symptom remission, asthe goal (Silverstein & Wilkniss, 2004). These simultaneous devel-opments propelled the concept of recovery from severe mentalillness into the national spotlight, transforming national mentalhealth priorities. Most recently, the President’s New Freedom Com-mission Report (2003) and Surgeon General’s Mental Health Report(U. S. Department of Health and Human Services [USDHHS], 1999)set the national agenda for mental health care which is taking rootin federal, state, and local level policy initiatives and practice guide-lines. Among the top priorities described in these documentsare recovery as the guiding vision and rapid dissemination,followed by routine adoption, of evidence-based practices (EBPs)in the service of recovery.

A whole host of conceptual papers on implementation of EBPsand consumer-influenced, recovery-oriented services followed;however, providers continue to struggle with routine adoption ofEBPs and comprehensive integration of recovery-oriented practices.This special issue of the American Journal of Psychiatric Rehabilitationspotlights one agency’s systematic incorporation of EBPs in the ser-vice of recovery. Thresholds, Illinois’ oldest and largest communitypsychiatric rehabilitation agency serving upwards of 6,000 personsin recovery annually, has a 48-year-old commitment to psychiatricrehabilitation and, four years ago, restated its mission with a focuson recovery and EBP. We have made great strides in achieving ourmission and are continuing to learn from challenges of this under-taking. The following articles detail Threshold’s planning, lessonslearned form our efforts, and future directions for implementationof EBPs in a recovery context. Perspectives from senior manage-ment, clinical supervisors, research and training staff, and members(the term for persons in recovery who are consumers of Thresholds’services) are offered. The articles include (1) an overview providingbackground and practical aspects of organizational change support-ing implementation of evidence-based and recovery-oriented

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practices; (2) implementation case studies of four EBPs: SupportedEmployment, Integrated Dual Disorders Treatment, Illness Man-agement and Recovery, and Assertive Community Treatments;and (3) the members’ perspective on integration of EBPs and recov-ery at Thresholds. Through this series of articles, we hope toprovide insight into the practical, ‘‘real world’’ aspects facing acommunity-based mental health agency working to support thevision of the President’s New Freedom Commission on MentalHealth (2003): ‘‘a future when everyone with a mental illness willrecover . . . and a future when everyone with a mental illness atany stage of life has access to effective treatment and supports—essentials for living, working, learning and participating fully inthe community.’’

RECOVERY

The concept of recovery as applied to individuals with severe mentalillness does not have a single, widely accepted definition. Generallyspeaking, the multitude of recovery definitions can be capturedin two main categories: recovery as an outcome and recovery as aprocess (or guiding principle) (Silverstein, Spaulding, & Menditto,2006). The treatment research community traditionally has viewedrecovery as an outcome (Bellack, 2006). Defined in this way,recovery significantly overlaps with the concept of remission andis readily operationalized facilitating reliable and meaningfulmeasurement of clinical effectiveness, that is, a person who isrecovered is seen as a person whose symptoms and disabilitiesare either no longer present, or are reduced to the point of notinterfering significantly with daily living.

The second conceptualization of recovery is rooted in theconsumer=survivor movement initiated in the 1960s and 1970s.Simultaneous systematic deinstitutionalization of consumers andservices with the advent of relatively effective medications andthe thriving civil rights movement during this time encouragedformer patients to organize, protest their treatment in the mentalhealth systems, and champion self-determination and empower-ment for individuals with mental illness (Chamberlain, 1971; Frese,1998). This resulted in a number of widely-cited definitions ofrecovery all with the central theme of recovering hope about thefuture, purpose, and meaningful engagement with a community

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of one’s choosing despite dealing with mental illness and survivingcontemporary mental health treatments (USDHHS, 1999; Anthony,1993; Deegan, 1996). It has been argued that recovery defined in thisway is too individualized and intangible a process to adequatelymeasure for scientific or health care purposes (e.g., Bellack, 2006).The opposing argument is that the very essence of recovery as ahighly individualized, deeply personal journey of the heart is lostwith the introduction of scientific rigor.

This conundrum has led to confusion about recovery, controversyand, worse yet, apathy on the part of many providers about the roleof recovery in service systems. The risk of the latter is, as LarryDavidson (2006) put it, that it puts us in ‘‘. . . a situation in whichthe term recovery is now in danger of becoming the latest in a lineof shibboleths within mental health (Fink, 1988); that is, words thatare used frequently and connote insider status (being in sync withthe latest fad or fashion) without having any meaningful or sub-stantive content.’’ Developing a meaningful, measurable constructis more than a mere scientific exercise. Without one, recovery maylose credibility as a construct and be diluted by dissemination oftreatments and development of delivery systems with only super-ficial resemblance to a true recovery-orientation (Silverstein &Bellack, unpublished ms; Bellack, 2006; Davidson, 2006; Liberman& Kopelowicz, 2005; Jacobson & Greenly, 2001).

While conceptual struggles continue, conscientious providersand persons in recovery are acting now on their commitment to rea-lize environments that foster recovery and offer services supportingrecovery goals. To this end, Thresholds has opted to work with ana-logues of recovery (i.e., analogues of meaning, purpose, happinessin most anyone’s life) including home, work, friends, family, com-munity, independence, and empowerment in wellness manage-ment. We, along with others, argue that EBPs identified forpersons in recovery from SMI move us toward these analogue out-comes (e.g., Drake et al., 2001; Torrey et al., 2001); therefore, we areearly adopters of several evidence-based practices with these lifepursuits as the focus.

EBPs

There are a number of practices considered evidence-based for indi-viduals with severe mental illness. The precise list varies by source

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(e.g., the National Project on Evidence-Based Practices, 2001; theSchizophrenia Patient Outcomes Research Team project, 1998)and criteria used to define evidence-based (Drake et al., 2001).According to findings of the National Evidence Based Practices Pro-ject (Drake et al., 2001), the core set of EBPs meeting the strictestcriteria (i.e., significantly better treatment outcomes in several ran-domized controlled trials) include pharmacotherapy with specificparameters, illness self-management training, assertive communitytreatment, family psychoeducation, supported employment, andintegrated treatment for co-occurring substance use disorders.Those with greatest penetration at Thresholds to date (anddescribed in this issue) are Supported Employment, IntegratedDual Disorders Treatment, Illness Management and Recovery,and Assertive Community Treatment. Historically, these fit bestwith Threshold’s mission. Rationale for selection of these EBPs isprovided in the articles that follow.

EBPs, by definition, are scientifically proven practices—practicesthat work. The mechanism of therapeutic action remains to beexplored, but common elements may explain their effectivenessand amenability to recovery objectives. For example, when usedwith recovery principles in mind, they are individually focused,involve person-centered planning, focus on increasing indepen-dence and self-determination, but also allow for nonlinear progress.They require a collaborative effort between clinician and consumerwith both bringing their own expertise and experience to the endea-vor. Moreover, the toolkits accompanying the EBPs described herewere written and evaluated by five stakeholder groups: consumersof mental health services, families, providers, and mental healthauthorities (Drake, Torrey, & McHugo, 2003) lending credibilityto the collaborative, community-based nature of the practices.

An additional advantage of EBPs is that they lend themselves tosystematic implementation and straightforward evaluation. They aremanualized, standardized approaches with tools to assess organiza-tional readiness for implementation and fidelity to the EBP. So, imple-mentation status can be readily evaluated and progress can be easilymonitored. Feedback is quantifiable and easy to understand allowingfor rapid modification and improvement of practices offered. In addi-tion, clinicians benefit from the discipline of EBPs. They provide asolid foundation for good clinical practice with cues to guide one backto providing the practice as originally intended. This is critical giventhe reality of ‘‘therapist drift’’ (or deviation from prescribed practice)

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so common to routine use of effective services. The result is, on bal-ance, stronger more reliable interventions leading to better outcomes;however, providing EPS successfully requires not only individualclinician commitment but organizational commitment.

Organizational ChangeWhile it is clear that EBPs provide both tools for supportingthe recovery of individuals with serious mental illness and aframework for services evaluation and evolution, incorporatingEBPs in the day-to-day operations of mental health organizationspractices is a significant challenge. There are many references inthe clinical literature to the difficulty that people with major mentalillness have making changes; however, anyone who has ever triedto make major organizational changes understands that mentalhealth staff have just as much difficulty making changes in theirown behavior! Over the last six years Thresholds has learned agreat deal about EBPs and their value. Just as important, we havelearned a great deal about what it takes to succeed in implementingevidence based practices in mental health organizations. Thelessons from the Thresholds’ experience can be summarized asthe following ten strategies:

1. Start with a Single EBP: The mental health field is fortunate to have agrowing number of established EBPs in its toolkit. When scanning therange of opportunities to incorporate EBPs in organizations, organiza-tions may be tempted to try to launch several of them simultaneously.Thresholds has learned that it usually works best to work with onenew EBP at a time. This gives the organization the opportunity to getfamiliar with and incorporate significant staff and organizational changesassociatedwith one EBP before embarking on another new set of staff andorganizational changes associatedwith an additional EBP. In short, orga-nizations should become proficient with these complex practice changesin a sequential fashion, beginning with the EBP that is most relevant andhas the best chance of succeeding.Doing so allows the organization to cre-ate an ever-deepening base of clinical wisdom, change managementexpertise, and strong organizational systems that will continue to expandthe range of EBPs available within the organization.

2. Budget Sufficient Time and Money: There is a principal in changemanagement suggesting that even small changes require a focusedcommitment of resources such as time, energy, and money, and thatbig changes require big resource commitments. This is certainly truein the case of EBPs. Mental health organizations often run on very thin

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margins and have limited capital resources. This makes it difficult forthem to invest sufficient resources in the implementation of new tech-nologies such as EBPs. At Thresholds, we have discovered that it is agreat error to assume that you can implement an EBP ‘‘on the cheap.’’EBPs require staff training, significant changes in quality managementand evaluation systems, clinical records systems, and in managerial=supervisory attention. All of these changes take staff time and energy,and staff time and energy cost money. It is important to budgetfor dedicated clinical manager time to train, consult, and supportprograms in the implementation of EBPs as well as for sufficient stafftime for training and retraining in EBPs. A wide range of departmentbudgets may be affected as a result of the need to modify existing qual-ity, fiscal, human resource, and information technology systems insupport of EBPs. While the process of implementing something likeintegrated dual disorders treatment is far less expensive than theprocess of implementing a new electronic medical record, the costassociated with the implementation of EBPs are not inconsequentialand should be specific items in budget planning.

3. Use ‘‘No Fault’’ Fidelity Assessment Visits: The correlation betweenEBP fidelity and positive client outcomes is well documented. Thismakes attention to fidelity a particularly important feature of anyimplementation process. The best way to tell if an EBP is being incor-porated in the program is through the use of fidelity reviews. Thresh-olds makes extensive use of the fidelity measures included in each ofthe SAMSHA toolkits. Each program using an EBP is evaluated forfidelity on a quarterly basis. This fidelity visit results in a set of recom-mendations and plans for improving fidelity to the EBP. One impor-tant feature of these fidelity visits is our effort to make them ‘‘no-fault’’ visits. Although there is great importance placed on improve-ments in fidelity, Thresholds recognizes that improvement often tracksalong an uneven course. There may be good reasons why a programdoes not improve from visit to visit; however, while we do not blame,we do emphasize the need to make changes. Management staff areheld accountable not for the fidelity score itself, but for a genuine effortto implement changes and recommendations of each fidelity visit.

4. Make Evidence Based Practices Part of the Job: Behaviorally-orientedclinicians understand that the simple act of monitoring a behaviorchanges the behavior. This is certainly true in EBP change and Thresh-olds looks for opportunities to incorporate and monitor EBPs in itsday-to-day activities. For example, staff performance evaluations havebeen modified to reflect staff performance on EBPs. Fidelity scores aretracked as part of annual program improvement plans. EBPs are asignificant focus of training. Thresholds’ Strategic Plan incorporatesexpansion of EBPs. Thresholds marketing activities maintain a focus

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on EBP. The Thresholds Members Council (a group of primary consu-mers who are paid by Thresholds to advise management) reviews andprovides suggestions for the use and deepening of EBPs. ThresholdsClinical Practice Director oversees steering committees (made up ofclinical, quality improvement, research and admin staff, and a consu-mer representative) dedicated to each EBP implemented. In short,Thresholds uses every opportunity that it can to make EBPs a day-to-day part of the job and to focus staff attention on this part of thejob through use of evaluation and accountability mechanisms.

5. Brag About Your Successes, Learn From Your Problems: As notedearlier, the implementation of EBPs is hard work and a significantinvestment on the part of many staff across the organization. It isimportant to look for opportunities to recognize and celebratesuccesses associated with the use of EBPs. ‘‘Bragging’’ about thesesuccesses reinforces staff behavior and focuses attention on EBPs.This seems to increase fidelity scores. Successes can be celebratedin many ways. Giving awards at Staff Recognition Day for perfor-mance associated EBPs, writing articles and giving professional work-shops on EBPs, providing updates to payers, advocates and otherimportant constituents about progress with EBPs, discussing theimportance of EBPs with the National Alliance for the Mentally IllChapters, and so on are all ways that organizations can brag aboutthe work they are doing and to feel good about their successes. Justas important, organizations need to examine carefully the placeswhere EBPs are not working well and understand the reasons fortheir shortcomings. The use of data-based monitoring, fidelity assess-ments, and common quality-management tools such as fishbone dia-grams are a good way to do this. Attention to failures as well assuccesses allows the organization to learn from its experiences andincorporate those lessons in both the evolution of the existing EPBsand the implementation of new EBPs.

6. Grab Opportunities for Small, Concrete Successes: As noted earlier,there is no universally accepted definition of recovery. Recovery isoften considered to be an intensely personal, quasispiritual processthat is unique to each individual. Clearly, this approach fails to giveadequate guidance to providers who are trying to integrate recoveryprinciples into their daily work. Where do you start? Our suggestionis to actively search for many small and specific program innovationsthat move the organization closer to the recovery ‘‘ideal.’’ For example,starting a ‘‘client council’’ which reviews program policies to makesure that they respond to client needs is an easy thing to do and itspeaks volumes to staff and clients about client roles and recovery.Committing to hiring at least one consumer in each program isanother small, specific step that any organization can make towards

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implementing a recovery philosophy. Transformations are processesmade up of many discrete decisions and the effects of these decisions.As Thresholds launched its transformation in 2003, we committed tomaking ‘‘100 specific recovery changes in a year.’’ We did not quitehit our goal, but we did make many very concrete changes that indivi-dually and collectively created ripples and then waves throughout theorganization. It is more important to make small, manageable, and fre-quent steps toward the goal of a recovery organization than to wait forthe right moment to try something big.

7. Avoid Over-Reliance On Staff Training: Mental health organiza-tions often have an unwarranted confidence in the effect of trainingon staff behavior. We often believe that training people in a newpractice will result in practice changes. Our own life experience tellsus that training is usually not enough. If training was a sufficientcondition for staff change, all of our staff would get their paperworkdone on time; inform human resources immediately of any addresschange; and respond appropriately to encouragement to lower healthinsurance costs by exercise, diet, and not smoking! Clearly, staff train-ing is a necessary condition for staff to change practice, but it is notsufficient. Just as important as staff training, organizations need topay attention to management and supervisory training and teachmanagers and supervisors to support staff in EBP performance andhold them accountable for the quality of that performance. Organiza-tions also need to change systems and reinforcements throughout theorganization to support EBP. For example, if an organization operat-ing in a fee-for-service environment is trying to get staff to spend moretime meeting with and educating families as a part of the Family Psy-choeducation EBP, but does not allow staff to count that family contactas billable time, staff will be very slow to adopt the practice. Theimplementation of EBPs requires a comprehensive technical assis-tance plan that addresses training as well as a wide range of incentivesand reinforcers in the organization that support the adoption andexpansion of EBPs.

8. Be Patient: Staff behavior and organizational performance do notchange overnight. Few organizations can successfully incorporate acomplex EBP throughout the organization in less than 24 months.For more complex and larger organizations it may take three to fiveyears before an EBP is fully and routinely embedded in organizationalbehavior. Clearly, this kind of horizon requires that managers adopt apatient stance towards change. It is more important to be sure the focusremains on the EBP and that the organization is moving ahead with theimplementation with the EBP than it is to have the EBP occur by a par-ticular deadline. Thresholds has also fount that implementing its firstEBP took the most time. Learning to do the first EBP well taught us

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many valuable lessons that allowed us to implement successive EBPmuch more rapidly.

9. EBPs Require That We Give Up Current Practices: One of the biggestchallenges of adopting an EBP is the need to give up existing practicesthat are incompatible with the EPB. For example, it is difficult to adoptin the evidence-based supported employment in one part of the orga-nization and allow transitional employment to be the primary strategyused in other parts of the organizations. Given the focus and commit-ment required of organizations to incorporate EBPs, it is criticalthat staff not be allowed to distract the effort by continuing to dothings incompatible with the EBP. Clearly, this does not mean thatorganizations give up all other practices immediately; however, it isclear that organizations need to replace current practices rather thansimply try to lay an EBP on top of them.

10. Market Evidence Based Practice Inside The Organization: In mostorganizations, staff will tend to gravitate towards behavior which isvalued by the organization. If the organization values EBP, it is impor-tant that the organization takes every opportunity to highlight EBP andmarket this to its staff. Organizations should take every opportunity toincorporate discussion on EBP in newsletters, staff meetings, organiza-tional celebrations, Board meetings, and other venues that allowcommunication to staff about the importance of focusing on EBPs.

11. Practice Humility: Dr. Leroy Spaniol, who recently retired from theBoston University Center for Psychiatric Rehabilitation, likes todescribe humility as ‘‘the openness to being taught.’’ Succeeding atEBPs require this kind of humility. If organizations are going to suc-ceed with EBPs they must learn from their experiences with theEBPs. Listening to staff that are expected to perform the EBPs, man-agers who supervise the staff, consumers in the organization whoreceive evidence based services, family members who observe theimpact of EBPs on their loved ones, payers who monitor the costeffectiveness of services that they fund, and so on all can teach usabout the importance, impact, and success of EBPs. It is critical thatwe are open to learning about our experience using and evolvingEBPs in organizations.

The following five articles will describe, in more detail, the wayin which we acquired these practical strategies. Each article willdiscuss a particular EBP, implementation efforts with this practiceat Thresholds, the integration with our recovery-orientated philoso-phy, the current status and future directions for these efforts. Weend with an article from a consumer perspective on the integrationof Evidence Based Practice and recovery.

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REFERENCES

Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of themental health service system in the 1990s. Psychosocial Rehabilitation Journal,16(4), 11–23.

Bellack, A. S. (2006). Scientific and consumer models of recovery in schizophrenia:concordance, contrasts, and implications. Schizophrenia Bulletin, 32(3), 432–442.

Davidson, L., & McGlashan, H. (1997). The varied outcomes of schizophrenia.Canadian Journal of Psychiatry, 42, 34–43.

Davidson, L., O’Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006). The topten concerns about recovery encountered in mental health system transformation.Psychiatric Services, 57, 640–645.

Deegan, P. (1996). Recovery as a journey of the heart. Retrieved on January 1, 2008from http://www.patdeegan.com.

Drake, R. E., Goldman, H. H., Leff, H. S., Lehman, F., Dixon, L., Mueser, K. T., &Torrey, W. C. (2001). Implementing evidence-based practices in routine medicalhealth service settings. Psychiatric Services, 52, 179–182.

Drake, R. E., Torrey, W. C., & McHugo, G. J. (2003). Strategies for implementingevidence-based practices in routine mental health settings. Evidence-Based MentalHealth, 6, 6–7.

Frese, F. J. (1998). Advocacy, recovery, and the challenges of consumerism for schizo-phrenia. Psychiatric Clinics of North America, 21, 233–249.

Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987). TheVermont longitudinal study of persons with severe mental illness, II: Long-termoutcome of subjects who retrospectively met DSM-III criteria for schizophrenia.American Journal of Psychiatry, 144, 727–735.

Harrow, M., Grossman, L., Jobe, T. H., Herbener, E. S. (2005). Do patients withschizophrenia ever show periods of recovery? A 15-year multi-follow-up study.Schizophrenia Bulletin, 31, 723–734.

Liberman, R. P., & Kopelowicz, A. (2005). Recovery from schizophrenia: A concept insearch of research. Psychiatric Services, 56(6), 735–742.

The President’s New Freedom Commission on Mental Health. (2003). Achieving thepromise: Transforming mental health care in america: Final report.

Silverstein, S. M., & Bellack, A. S. (2008). A scientific agenda for the concept ofrecovery. Clinical Psychology Review, 28(7), 1108–1124.

Silverstein, S. M., Spaulding, W. D., & Menditto, A. (2006). Advances in psychotherapy:Evidence-based practices, Volume 5: Schizophrenia. Cambridge, MA: Hogrefe & Huber.

Silverstein, S. M., & Wilkniss, S. M. (2004). The future of cognitive rehabilitation ofschizophrenia: What should we be rehabilitating and how should we be doingit? Schizophrenia Bulletin, 30(4), 679–692.

Torrey, W. C., Drake, R. E., Dixon, L., et al. (2001). Implementing evidence-basedpractices for persons with severe mental illnesses. Psychiatric Services, 52, 45–50.

U.S. Department of Health and Human Services (USDHHS). (1999). Mental health: Areport of the surgeon general. Rockville, MD: U. S. Department of Health and HumanServices, Substance Abuse and Mental Health Services Administration, Center forMental Health Services.

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