New York City has a long and proud history of providing a wide range of recovery-oriented programs for individuals with serious and persistent mental illness. Following in the activist path of Clifford Beers who started the modern mental health movement in 1909, six former psychiatric patients and two volunteers formed Fountain House, a clubhouse program, in 1948 to combat the loneliness and stigma of experienced by people living with mental illness. With the introduction of psychotropic medication in the mid-1950s, the achievement of the dream for people with serious mental illness to have a productive and integrated life in the community came within closer reach.
As a result of these advances in psychiatric care, the tireless efforts of mental health advocates, and advances in the evidence base of support and care in the community, the care of people with mental illness has undergone a series of transformations over the past 50 years. We have seen the growth of clubhouses alongside of the growth of community mental health centers as well as a variety of employment related programs.
As national views coalesced around the principles of recovery, federal, state and local government funding priorities followed suit. In New York State, the conversion from traditional clubhouse, employment programs and other psychiatric rehabilitation programs to Personalized Recovery Oriented Services (PROS) programs began in 2003, with implementation delayed in NYC until 2010.
The Mental Health Association of New York City (MHA-NYC) converted its Harlem Bay Clubhouse and Fast Track to Employment Programs to a Medicaid funded and licensed PROS program in 2011. MHA-NYC is an organization that prides itself on being an innovator in mental health and is at the forefront of developing or adopting best practices. Yet, staff members were, initially, somewhat reluctant to embrace the conversion. The Fast Track to Employment programs that they staffed produced good outcomes and the consumers who frequented the Harlem Bay Clubhouse found a place where they had their own community. The leap from a grant funded program where the funding was predictable to a program whose survival and growth would depend on billable visits was also challenging for staff. They feared that these new demands, particularly regarding the increase in additional documentation needed for Medicaid, would divert attention from serving program participants. Although peer support, strength based work and an empowerment model were already integrated into their program models, movement to a more goal oriented and classroom based approach to services required staff to make a paradigm shift from thinking about the Clubhouse as a “clubhouse for life” to a program that helps its participants reach life goals and build a life in the community.
Looking back over the first year of Harlem Bay PROS’s operation, we can say with confidence that the experience of working with consumers in PROS has put most of these concerns to rest. Key elements to our successful start include:
Preparation of staff and consumers: Our staff, received additional intensive training on best practice techniques such as motivational interviewing, Wellness Recovery Action Planning (WRAP), assessment, documentation standards for Medicaid reimbursement and concurrent Documentation which gives consumers input into every aspect of their programming. In keeping with principles of recovery, consumer involvement was also an integral part of the program development and transition process. This involvement in the identification and planning of courses was instrumental in getting the buy-in of consumers who were not familiar with the program model.
Consumer Choice and Voice: Maximizing ongoing consumer choice and voice has been a critical part of matching consumer needs and interests with program offerings that keep them coming. Harlem Bay PROS staff have risen to the challenge of keeping consumers engaged by translating consumer input into the development of classes like “What’s Your Story” and “Finding My Mojo” that catch and keep their interest. Consumers are also involved in the entire process from assessment to goal setting to what is written into the charts. In a program that depends on utilization for reimbursement this level of engagement is crucial.
Staff Flexibility: Because the participants’ needs change as they progress through the program, staff must continually assess the classes that are offered and make changes regularly. Classes are offered in 12-week sessions, and as the interests and needs of the participants change, new classes must be developed, and older classes put on the shelf until the need for them arises again.
Connection to Community: The ultimate goal of the program is to help people become so connected to life outside of the program that they no longer need the intensive supports that the program provides. Although consumers may need ongoing psychiatric services, when it is possible to connect participants to ongoing support from a family or others in the community, participants become less dependent on the “program” for a sense of belonging and support. The availability of psychoeducation and support for family members and members of the participant’s support system also helps to pave the way. The progression from dependence on a program to more independence is often seamless and through a “graduation” acknowledgement from the program, others still working on their goals are left with a sense of hope.
In the process of converting our clubhouse and employment programs to PROS, it appears that MHA-NYC’s staff have themselves become converts—one only needs to walk into the program space to see why.
Harlem Bay PROS is a place that is alive and buzzing with excitement. If you catch the program at a moment between classes, the hallways are full of people, talking, laughing, or hurrying to catch up with their counselor before the next class. There is a sense of hopefulness in the air. When you stop to chat with somebody conversations often turn quickly to their primary life goal in the community and you learn how close they are to getting housing or how it felt to reconnect with a child.
During class, group participation is high and discussion flows freely, with participants and staff working together to help people move forward in their lives. Moments of insight and connection occur as one person’s story helps another understand something about his symptoms or why a job interview didn’t go so well and how it can be done differently the next time. Conversations now reflect a desire to be a part of the community outside the program. As one participant, Della C, said so clearly, “They make you feel like you are somebody here, that you can do something with your life.”
