For psychologist Arthur C. Evans Jr., PhD, the word "maintenance" exemplifies everything that's wrong with many programs for people with serious mental illness: People who would once have been institutionalized in state hospitals now spend their lives being "maintained" in day programs instead. "We can do better," says Evans, commissioner of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services.
What's needed instead, he says, is a recovery orientation — an approach that tries to help every person with a mental health or substance use condition achieve his or her highest level of functioning and integration into the community.
That has been one of Evans's top priorities since he became commissioner in 2004. And he isn't limiting his efforts to Philadelphia's $1 billion public sector behavioral health system and the 120,000 city residents it serves each year. By working with APA's Recovery to Practice initiative and speaking around the country, he is also helping to ensure that other behavioral health systems and the next generation of psychologists embrace the recovery orientation.
Transforming city services …
Recovery isn't a new idea, of course. The 2003 report of President George W. Bush's New Freedom Commission on Mental Health, for example, recommended strategies for moving the nation's mental health system toward a recovery orientation. What is unusual about Philadelphia, says Evans, is the community's embrace of a wide range of strategies designed to promote recovery.
Evans first began putting his ideas about recovery into practice as deputy commissioner of Connecticut's Department of Mental Health and Addiction Services, when Commissioner Thomas Kirk, PhD — also a psychologist — signed the nation's first policy directing a state service system to adopt a recovery framework.
In Connecticut, Evans and his colleagues initiated the transformation of the state's behavioral health system by developing core values and principles based on input from people in recovery. With that feedback they retrained the state's behavioral health workforce and revamped programs and policies. The state defined recovery as the "process of restoring a meaningful sense of belonging to one's community and positive sense of identity apart from one's condition while rebuilding a life despite or within the limitations imposed by that condition."
One way the state put that philosophy into practice was to create a program in hospital emergency rooms that deployed peer advocates to crisis intervention units to offer support and practical assistance to others with mental health or substance use conditions.
At a broader level, the state shifted from an acute care model within the arena of substance use disorders to a longitudinal recovery management model. That paradigm shift represented a movement from models of care that have focused primarily on brief, episodic treatment modalities that help people to achieve abstinence or get "clean" to services that go far beyond stabilization.
With mental health conditions, a recovery-oriented approach to treatment similarly expanded the focus beyond symptom reduction. Providers now work collaboratively with people to assist them in learning how to manage their conditions and how to draw on support beyond the formal health-care system to establish the quality of life they desire in their communities.
Now Evans is taking the same approach to "re-engineer" Philadelphia's service system.
Take the day programs where many city residents with serious mental illness spent their time in the past, for example. One of the first things Evans and his colleagues did was to help people in those programs become more engaged in their communities. "We want to help people be a part of the community versus just being in the community," he says. As a result, those programs' focus now is to help people live full lives just like everyone else, not simply to occupy people's time during the day, he says.
One easy but effective change has been to teach participants how to use public transportation rather than relying on Medicaid-funded vans to get to the programs. "It opens up a whole new world beyond treatment," says Evans. "People can use the library, even go back to school."
In addition to re-orienting the system toward recovery, Evans takes seriously his commitment as a psychologist to "ground what we're doing in what science tells us works." That means providers now receive training not just in the recovery orientation but in such under-used but evidence-based techniques as cognitive therapy and trauma-informed care. Over the last six years or so, for example, the system has trained hundreds of providers to use cognitive therapy and its principles in inpatient and outpatient settings, with children and adults and for mental health and substance use conditions.
In addition, Philadelphia now has what Evans says is one of the nation's largest initiatives related to peer specialists, people who have firsthand experience with mental health and substance use conditions.
"Peers with lived experience are very effective at engaging people, keeping them connected to services and helping them maneuver their own personal recoveries," says Evans.
Allowing peers to work alongside professionals aligns with Evans's philosophy of engaging the people he serves in the decision-making that affects them. In fact, his department never makes a major policy or funding decision without involving people with lived experience.
Although Evans says the transformation of the city's behavioral health system is still a work in progress, he's getting results. The re-orientation of the day program from maintenance to recovery, for instance, has resulted in fewer visits to crisis centers, fewer inpatient admissions and cost savings that the city can then re-invest in other community-based services, Evans reports.
But persuading the city's more traditional mental health professionals to embrace the recovery orientation hasn't always been easy, says Evans.
"It challenges fundamentally the way clinicians view themselves, their role and people with behavioral health conditions and their potential," he says.
Because a recovery orientation encourages individuals to drive the process of their own recovery, it can be threatening to professionals accustomed to being in charge, he says. People may resist certain treatments or reject professionals' advice about their relationships — forms of pushback that are good for individuals but may trouble providers.
"What we tell providers is that their professional role is enhanced in a recovery-oriented system because they have to have a much broader set of skills and much broader way of working with people," says Evans. "It's relatively easy to help people manage symptoms; it's much more complex to help people figure out a pathway in life."
Now the wider world is paying attention. Earlier this year, Evans won the American Medical Association's Dr. Nathan Davis Award for Outstanding Government Service, the association's top government service award in health care. The award honored Evans for his leadership in transforming Philadelphia's behavioral health system and strengthening its ability to take a public health approach.
Evans also received an America Honors Recovery Award in 2013. Sponsored by Faces & Voices of Recovery with the Caron Treatment Centers, the award recognized Evans's leadership and its role in inspiring others to value change, listen and learn from people in recovery and work toward recovery-oriented institutions and communities.
... and beyond
Evans isn't the only one emphasizing a recovery orientation.
This way of working is the wave of the future as health-care reform continues, according to Evans. "If you look at health-care reform, what does it emphasize? Outcomes." Reform is also encouraging person-driven care that focuses on treating the whole person rather than just his or her symptoms and on integrating physical and behavioral health care — all emphasized in Philadelphia's transforming system as well.
The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) has also embraced recovery. Along with four other mental health organizations, APA has a grant from SAMHSA to support a Recovery to Practice initiative designed to encourage the adoption of a recovery orientation. (See "Yes, recovery is possible" in the January 2012 Monitor.)
During the five-year initiative, APA and other grantees will contribute to an online repository of recovery-related resources and develop recovery-focused training materials for their constituencies. APA has developed 15 training modules on such topics as recovery-based psychological practice, assessment, intervention, peer-delivered services, health disparities and scientific foundations and is pilot-testing them in 20 doctoral, internship and postdoctoral training sites around the country. Once that round of testing ends, APA will fine-tune the modules and make them available to psychology training programs.
That's good news for clinicians and people with behavioral health conditions alike, says Evans, who serves on the Recovery Advisory Committee that guides APA's Recovery to Practice work. That's because the recovery orientation doesn't just help individuals in recovery. It also helps clinicians like their jobs better.
"Most people come into this field because they want to help people," says Evans. "In a recovery-oriented system, people are much more likely to see that kind of progress."
For more information about APA's Recovery to Practice initiative, visit Recovery to Practice.
Rebecca A. Clay is a writer in Washington, D.C.
- Achara-Abrahams, I., Evans, A.C., & Kenerson King, J. (2011). Recovery-focused behavioral health system transformation: A framework for change and lessons learned from Philadelphia. In J.F. Kelly & W.L. White (Eds.), Addiction recovery management: Theory, research and practice. Totowa, NJ: Humana Press.
- Davidson, L., Tondora, J., O'Connell, M.J., Kirk, T., Rockholz, P., & Evans, A.C. (2007). Creating a recovery-oriented system of behavioral health care: Moving from concept to reality. Psychiatric Rehabilitation Journal, 31(1), 23–31.
- Evans, A., et al. (2012). Converting partial hospitals to community integrated recovery centers. Community Mental Health Journal, 48(5), 557–563.
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