. . .creating the change

Everybody's talking about recovery, but no two people, agencies, or state bureaucracies are talking about it the same way. When you come down to it, said psychiatrist Mark Ragins, despite lip service, not a lot has changed in the last decade. "The vast number of professionals are not doing anything different than they were ten years ago. . . no different skills, no different roles, no different anything," Ragins said.

Ragins is a co-founder and director of clinical services at The Village, in Long Beach, Cal., where he has been refining recovery services since the early 1990s. More recently he has been working with SAMHSA to develop curricula about recovery, a process complicated because psychiatrists, psychologists, social workers, bureaucrats and directors each have their own understanding of what recovery is all about. This extends to consumers, as well. SAMHSA recently announced its consensus statement on recovery.

Changing the culture requires changing many cultures. That, plus the gaps between policy and practice were discussed by people coming from California to Maine in Albany last week at a conference sponsored by NYAPRS.

The mandates in the President's New Freedom Commission are credited with he oft-quoted goal, "to live life fully in the community." Yet a gap exists between the avowed policy goals, and publicly funded services to actually do this, said New York's Commissioner of Mental Health, Mike Hogan. And with the number of stakeholders involved, building consensus has not been easy.

Here are a few of the questions needing to be resolved, or at least discussed, to move toward the goal of a consumer/family driven system: Is recovery a process, an end point, and what are the component parts? The definition changes according to who is discussing it. Using a medical model of illness, psychiatrists aim to "fix" something, mostly symptoms; psychologists are more likely to embrace a rehab model promoting skills to achieve independence. Others see it as nothing short of a civil right: how to affirm the entitlements of citizenship rather than restrict choice.

Another obstacle is the gulf between rhetoric and practice. While some embrace the idea of recovery, they continue to employ traditional methods. Too often the default, Ragins said, is to deliver services they have in their repertoire rather than to ask, "what works."

Changing practice and curriculum
The expectations of recovery, affirmed in the President's New Freedom Commission, were informed by the evidence summarized in the 1999 Surgeon General's Report on Mental Health. The evidence has been mounting for three decades, and service providers often know the names of giants in the field, but have not read the studies. When Ragins asked the 75 people in the audience how many in had actually read the Vermont longitudinal landmark study of Courtney Harding showing about two-thirds of people averaging 35 years in the hospital recovered, about half raised their hands. More than usual, he quipped. Often only two people had.

Ragins finds even those who agree with what must be done, bump into decades of power relationships and a hierarchical work force arguing about who knows best. The challenge for bureaucracies and agencies dependent on old models documenting time and services is how to engage in unconventional partnerships allowing the client to set the outcome goals and participate in achieving them.

Mandate is clear
The slow speed with which the field has met this challenge should not dim what has been done successfully. The authors of a new book,The Roots of the Recovery Movement in Psychiatry, point to "agency as the basis for transformation." Much of this has taken place organically, under the direction of consumers who are challenging existing notions of staffing organizations and going into places they never did before. Part II (coming soon) will discuss some of these innovations, created by people who have lived the experience and gained the knowledge to help others at different points of the cycle: for respite care during a crisis, in the emergency room, in the process of reintegration in the community.

Read Mark Ragins' review of Social Inclusion of People with Mental Illness.