Over the past 50 years, the mental health system in New York City has evolved from a system of dependent care to a more person-centered system. But there is still much work to be done. Employment rates for people living with mental illness are still abysmally low….unemployment for people with mental illness is three to five times higher than those without mental illness and one third to one half live below the poverty level.
How do we make recovery more than just a word? The New York City Department of Health and Mental Hygiene (DOHMH) struggles with this every day. We’ve created committees, hosted trainings, built consumer advisory boards, and funded peer services, yet building a recovery-oriented system of care remains an enormous challenge. We are faced with deconstructing many norms and boundaries that have been built over decades. Funding streams have been created to support service silos rather than integrated care and we have major deficits to overcome in equal access to opportunity, integration and self-sufficiency in the forms of unemployment, homelessness, incarceration, poverty, and stigma.
SAMHSA’s definition of recovery is a “process of change whereby individuals work to improve their own health and wellness and to live a meaningful life in a community of their choice while striving to achieve their full potential.” Many of the programs we fund and oversee throughout the City ranging from supportive housing to Assertive Community Treatment (ACT) and psychosocial clubs are making dramatic improvements in becoming more recovery-oriented; but this requires, for many, a paradigm shift. DOHMH has begun including recovery language in every program that we fund requiring that programs “increase the individuals’ capacity to manage their health & wellness, live a self-directed life, and reach their fullest potential by providing consumer directed, recovery-oriented services.” Now we have to measure our progress through increased employment rates, increased income levels, housing stability and independence, community integration and improvements in health and wellness.
The Department has committed to achieving these outcomes by supporting programs through that paradigm shift. We are beginning to help programs assess their own recovery-orientation using an adapted tool by Dr. Mark Ragins. Our intent is to get a better picture of recovery “on the ground”… how programs are implementing recovery-oriented practices in concrete and measurable ways. This includes domains such as: A welcome and inclusive environment; Service treatment choice; Participation in program management; Focus on education and employment; Focus on housing; Involvement in the community; Growth orientation; and Quality of life.
This tool encourages the transformation of a program by focusing on relationships rather than traditional treatments. The tool is intended to be low burden, is interview based and completed over time. In selecting this tool, the Department conducted extensive research, consulted experts, and identified many instruments. We looked for those with sensitivity to change that would provide valid, reliable measures, longitudinally track improvements in recovery practices within agencies (e.g. at baseline and again in 5 years), identify areas where agencies need technical assistance, and compare scores across different program types or agencies. We’ve now piloted this tool at several programs and are hosting training in February conducted by Dr. Ragins. As a benefit of this research, DOHMH has a compendium of instruments that will support agencies, providers and individuals.
As a public health department, we seek out and identify best and promising practices worldwide. We engage experts from around the globe to better learn and understand what is working in other places and to import, adapt, implement and evaluate them here in New York City. We recently did so by identifying Intentional Peer Support (IPS) and the Need Adapted Treatment Model (NATM) to incorporate into Parachute NYC, a continuum of crisis services that DOHMH is building.
IPS was developed originally in New Hampshire through the work of Shery Mead and NATM began in Finland. Both models have expanded significantly since their inceptions. Parachute NYC will practice these models together for the first time and will use a mixed staffing pattern of clinicians and peers. Both models embrace recovery. “IPS is a way of thinking about and intentionally inviting powerfully transformative relationships among peers. Participants learn to use relationships to see things from new angles, develop greater awareness of personal and relational patterns, and to support and challenge each other as we try new things” (www.intentionalpeersupport.org/whatisips.htm).
NATM is a non-hierarchical approach to working with people experiencing psychosis that emphasizes communication, relationship, tolerance of uncertainty and reliance on an individual’s “family” network rather than service providers. Additionally, Dr. Peggy Swarbrick is designing a new curriculum to train peers as Health Navigators in order to help link Parachute participants with primary and preventive care and promote wellness. Parachute NYC will create a system of community-based services for individuals experiencing psychiatric crisis. These services include four enhanced mobile crisis teams that will respond within 24 hours to crisis calls and work with people for up to one year, four crisis respite centers that will offer people a safe, and home-like place to stay for up to fourteen days as an alternative to hospitalization for people experiencing or anticipating a psychiatric crisis, and a citywide peer operated support line for anyone to call for someone to talk to in times of distress. The first Need Adapted Mobile Crisis Team (NA-MCT) and Crisis Respite Center (CRC) opened in Manhattan on January 10, 2013 and can be accessed via 1-800-LIFENET. The Support Line will launch in February and the Brooklyn, Bronx and Queens NA-MCTs and CRCs will open over the next 14 months. Services in Brooklyn will focus exclusively on young adults (16-25) experiencing a first episode of psychosis (first-break).
This project is funded through a 3 year $17.6M grant from the Federal Centers for Medicaid and Medicare Services with the goal of improving care, improving health and reducing costs. It will create 185 new jobs, 165 of which are designated for people with a lived experience of mental illness.
In order to help people recover from mental illness, this recovery orientation must be pervasive throughout all our systems of care. We begin here, within the four walls of the New York City Department of Health and Mental Hygiene by educating ourselves, our colleagues, funders, oversights, and partners. The Department strives to view all of our work through a recovery lens—whether it involves developing new hospital diversion programs, creating alternatives to incarceration, or changing how we serve people with co-occurring mental health and substance use issues. In everything we do, we need to ask ourselves: is this helping people recover? Is this the service system I want to build for my friends, my family and myself? How do I know what we’re doing is working? How do we measure this change? We are challenging ourselves every day to approach our work – whether contracts and audits, training, oversight, new program development, funding decisions, data gathering, research and evaluation, policy development, and planning—with a recovery framework. Many of you are partnering with us in these efforts already and we look forward to hearing feedback from all of you in the future.