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yale
program
for
recovery
and
community
health
On Defining Appropriate
Consumer-Centered
Mental Health Care
Larry Davidson, Ph.D.
Program for Recovery and Community Health
Yale University
What I hope to cover in 20 minutes:
• Why mental health care needs
to be made both “appropriate”
and “consumer-centered”
-- (i.e., why it isn’t already).
• How systems can be transformed to make
mental health care both appropriate and
consumer-centered.
• What appropriate and consumer-centered
mental health care looks like in practice.
Isn’t Mental Health Care Already
Appropriate and Consumer-Centered?
This is the “what’s broken . . .” problem. Are things
(really) so bad that they need to be transformed?
To this question, there are at least two answers:
1) Objectively speaking, yes, things are so bad that
they need to be substantively transformed; however
2) The degree of awareness of these issues, and the
amount of support for making transformative change,
vary considerably from state to state and will
determine how much change will be possible
(i.e., elected and appointed officials alone will not be able to effect such
change without the broad-scale investment of their constituents)
How is mental health care not
appropriate or consumer-centered?
• According to the President’s New Freedom Commission
on Mental Health (DHHS, 2003), mental health services
are “fragmented and in disarray [leading to] unnecessary
and costly disability, homelessness ... and incarceration.”
• Current care “simply manages symptoms and accepts
long-term disability” (DHHS, 2003).
• The rights of people with mental illnesses to live, work,
learn, and participate fully in their communities have
been “derailed by outdated science, outmoded financing,
and unspoken discrimination” (DHHS, 2005).
What are the costs of this to your state?
Causes of Disability in the United States, Canada,
and Western Europe
Mental Illnesses
Alcohol and Drug Use Disorders
Alzheimer's Disease and Dementias
Musculoskeletal Diseases
Respiratory Diseases
Cardiovascular Diseases
Sense Organ Diseases
Injuries
Digestive Diseases
Communicable Diseases
Cancer
Diabetes
Migraine
0
5
10
15
Percent of Total Disability
20
25
Employment as one example
• In the U.S., mental illnesses are (by far) the single
greatest cause of disability and lost productivity
• While 70% of adults with serious mental illnesses
express a desire for competitive employment, only
15% are employed at any given time
• Currently less than ½ of 1% (.005) of adults on
SSDI ever get off of disability, with more money
being spent on keeping people disabled than on
offering them treatment, rehabilitation, or supports
But isn’t that because people with mental
illnesses simply cannot work?
No. When provided with adequate supports, up to 65%
of people with serious mental illnesses have been able
to work in competitive jobs (a full half of the
population more than are currently employed).
A remaining segment of the population could be
employed in affirmative/social cooperative business
models, peer or consumer-run businesses, or other
subsidized settings, working and occupying valued
social roles as the route to securing a livable wage (e.g.,
The Village; Trieste, Italy; Canadian and Swiss models).
But is this “realistic”?
While well-meaning practitioners and
family members express concerns
that work may, in fact, be stressful for
some people with some mental
illnesses some of the time,
they overlook the equally important fact that:
most
time
Being out of work and poor is
sure to be stressful for
people with most mental
illnesses most of the
The shift is subtle but profound and far-reaching
According to:
• Surgeon General’s Report on Mental Health (1999) and Supplement
on Culture, Race & Ethnicity (2001)
• New Freedom Commission on Mental Health Final Report:
Transforming Mental Health Care in America (2003)
• SAMHSA Federal Action Agenda: First Steps (2005)
It requires dramatic, substantive change:
“Transformation . . . is nothing short of revolutionary. . . It
implies profound change—not at the margins of a system, but
at its very core. In transformation, new sources of power
emerge and new competencies develop” (DHHS, 2005).
What “new sources of power” emerge in transformation?
The power of people with mental illnesses reclaiming
their lives.
In a transformed system, people with mental illnesses
are no longer viewed as a burden on taxpayers or as a
problem the state mental health system has to address.
Instead, they become the most valuable, yet relatively
untapped, resource available to a system of care.
When offered effective treatments and adequate
supports, they become contributing citizens.
What new competencies need to be developed
in order for this power to be maximized?
To shift from people with mental illnesses
being viewed as problems to their occupying the
role of citizens who contribute to the common
good, mental health services and systems need to
be reoriented:
from containing and reducing illness
to promoting resilience, recovery, and the
pursuit of a safe, dignified, and gratifying
life in the community for everyone
New Competencies to be Developed
• For people with mental illness, this requires shifting
from getting rid of or being cured of the illness to
learning how to live with, manage, and have a
whole life despite the illness.
• For practitioners, this requires shifting from taking
care of people to enhancing their access to
opportunities to “live, work, learn, and participate
fully in the community” and offering the supports
needed for them to take advantage of these
opportunities.
How Systems can be Transformed
• Distinguish between recovery and recovery-oriented care:
• Recovery is what the person with a mental illness does to manage
his or her illness while in pursuit of his or her own life goals.
• Recovery-oriented care is what health care practitioners offer in
support of the person’s own efforts toward his or her recovery.
• Acknowledge the crucial first step of restoring civil rights.
“A
respect
keystone of the transformation process will be the protection and
of the rights of adults with serious mental illnesses” (DHHS, 2005). In
particular, the fundamental rights to:
• Self-Determination and
• Social Inclusion
Social Inclusion
People with mental illness are entitled to a
life in the community first, as the foundation
for recovery—not as its reward.
For example,
It is very hard to recover if you don’t
have a place to live (a home). Housing
cannot be contingent on compliance
or improvement in one’s condition.
Self-Determination
People with mental illness retain the right to make
their own decisions—both in life and in treatment—
unless, until, and only for as long as there are
compelling reasons for society to interfere with their
sovereignty. That means that . . .
. . . Psychiatry is a form of health care.
As in all (non-emergency) health care, people reserve
the right to be free from coercion, and to have all
care provided only with their informed consent . . .
even when they still have symptoms or deficits, just
like in other forms of health care.
What does recovery-oriented care
look like in practice?
-- Not a pilot program
-- Not an add-on to existing care
-- Not a new provider-driven practice
-- Not what happens after care, treatment, or cure
-- Not a new term for compliance or adherence
-- Not limited to self-help, peer support, or quality of life
-- Not ancillary or supportive of ‘real’ treatment
-- Not a fad, fashion, or flavor of the month
Connecticut’s Systemic Approach
Rather than developing several pilot recovery-oriented
programs, DMHAS Commissioner Thomas Kirk, Jr.
viewed recovery and evidence of healthcare
disparities as calling for major systemic changes.
This called for a multi-level and multi-dimensional
approach to transforming all aspects of the system of
care, from basic policy and funding decisions, to
program development, to the delivery of care at the
level of the individual person/family.
And people in recovery led the way . . .
Vision of Recovery-Oriented System of Care
Direction
Equal
opportunity for wellness
Recovery encompasses all phases of care
Entire system to support recovery
Input at every level
Recovery-based outcome measures
New nomenclature of recovery
System-wide training for culturally diverse,
relevant, and competent services
Consumers review funding
Commitment to Peer Support and to
Consumer-Operated services
Participation on Boards, Committees, and
other decision-making bodies
Financial support for consumer involvement
Participation
No
wrong door
Entry at any time
Choice is respected
Right to participate
Person defines goals
Programming
Individually
tailored care
Culturally competent care
Staff know resources
Funding
No
outcomes, no income
Person selects provider
Protection from undue influence
Providers don't oversee themselves
Providers compete for business
“Recovery” Defined
Recovery involves a process of restoring or
developing a meaningful sense of belonging
and positive sense of identity apart from one’s
condition while rebuilding a life in the broader
community despite or within the limitations
imposed by that condition.
Recovery-Oriented Care Defined
Recovery-oriented care identifies and builds upon each
person’s assets, strengths, and areas of health and
competence to support the person’s efforts in managing
his or her condition
while regaining a
faith
meaningful,
work or
treatment &
constructive
school
rehabilitation
sense of
Self-help
membership
housing
in the broader
social
community.
family
support
belonging
*The Home Depot
“You can do it.
We can help.”*
Essential Elements of Appropriate
Consumer-Centered Care
• Promotes resilience, recovery, and community inclusion
• Identifies and builds on each individual’s interests,
assets, strengths, and areas of health and competence
• Supports the person’s efforts to manage his or her own
condition while pursuing or regaining a meaningful,
constructive sense of membership in the community
• Is based on person-centered care planning and practice
principles that orient care to the person’s own goals
• Allows for maximum choice and is culturally responsive
• Holds providers accountable for positive outcomes
Domains of Practice Guidelines
•
Primacy of Participation
•
[Prevention and Early Intervention]
•
•
•
•
•
Promoting Access and Engagement
Ensuing Continuity of Care
Employing Strengths-Based Assessment
Offering Individualized Recovery Planning
Functioning as a Recovery Guide
•
•
Community Mapping, Development, and Inclusion
Identifying and Addressing Barriers to Recovery
•
[Assessing and Monitoring Outcomes]
[still under development]
Sample Standards
Domain
Degree to which practices . . .
Sample standards
Primacy of
participation
place emphasis on the participation
of people in recovery and their
loved ones in all aspects and phases
of the care delivery process.

Promoting
Access and
Engagement
facilitate swift and uncomplicated
entry into care and identify and
remove barriers to receiving care;
address basis needs.

Ensuing
Continuity
of Care
ensure continuity of the person’s
most significant healing
relationships and supports over
time and across episodes and
agencies.

Employing
StrengthsBased
Assessment
balance critical needs that must be
met with the resources and
strengths that people possess to
assist them in the process.





People in recovery comprise a significant proportion of
an agency’s board of directors
Administration enforces ethical practice through
supervision and proactive human resource oversight
People can access a wide range of services from many
different points.
Staff examine organizational barriers or other obstacles to
care before concluding that a client is noncompliant with
treatment.
Motivation is no longer viewed as a pre-condition for
treatment but as one outcome of interventions oriented
to address pre-action stages of change.
People have a flexible array of options from which to
choose which allow for a high degree of individualization.
An individual’s needs are not captured by a label or
diagnosis, but by an accurate description of his or her
functional strengths and limitations.
Strengths-based assessment is conducted as a
collaborative process and all assessments in written form
are shared with the individual.
Sample Standards, continued
Offering
Individualized
Recovery
Planning
are based on an individualized, multidisciplinary recovery plan developed in
collaboration with the person and any
others that s/he identifies as supportive.
•
Functioning as a
Recovery Guide
remove personal and environmental
obstacles to recovery, link the person to
the community, and, where not available
naturally, serve as a mentor in processes
of recovery.
•
Identifying and
Addressing
Barriers to
Recovery
identify and address characteristics in the
service system and the community, as well
as factors intrinsic to the person’s
behavioral health condition(s), that
unwittingly contribute to the creation and
perpetuation of chronicity and disability.
•
Community
Mapping,
Development,
and Inclusion
involve a participatory process of
mapping the resources and capacities of a
community as a means of identifying
existing, but untapped or overlooked,
resources and potentially hospitable
places in which contributions of a person
with a disability will be valued.
•
•
•
•
•
The planning process solicits the individual’s unique goals and
these are documented in the plan in the individual’s own words.
The person’s cultural background, identity, and other social
affiliations are incorporated and addressed in all aspects of
recovery planning.
Providers offer practical assistance in the community contexts in
which their clients live, work, and play.
Efforts are made to identify sources of incongruence between the
person and his or her environment and to increase personenvironment fit.
Providers are aware of the importance of discrimination in the
lives of people with behavioral health disorders
A person’s symptoms are explored not only in terms of the
difficulties they pose, but also in terms of their potentially
adaptive function in his or her efforts to cope with the illness and
other life stressors. Delusions, for example, may be understood as
one component of a person’s efforts to understand his or her
experiences of hallucinations and disordered thought processes.
People in recovery are viewed primarily as citizens rather than as
clients and recognized for the gifts, strengths, skills, and resources
they have to contribute to community life.
Institutions do not duplicate services that are widely available in
the community through individuals and associations.
yale
program
for
recovery
and
community
health
Take Home Messages?
• Current systems are fragmented, outdated, ineffective,
and only manage symptoms while accepting disability
• An equally significant barrier to recovery is the stigma/
discrimination people with mental illnesses face within
the mental health system
• Transformation begins with restoring rights (i.e., selfdetermination & social inclusion) and dignity to people
with mental illnesses and their taking the wheel in
steering 1) their own care and 2) the system as a whole
• Transformation then requires choice and accountability,
with services and supports identifying and building on
strengths and interests to enable people to have safe
and meaningful lives in the community despite disability