The federal government has called for a massive transformation of America's mental healthcare system—a change to “recovery.” Indeed, recovery is the current politically correct buzzword. We are reading about this change across the country—such as the development of a recovery framework and shared leadership system in Ohio to the creation of a Recovery Institute in Connecticut. While these new models are promising, we still have a long way to go if we are going to realize widespread recovery at the consumer level.
The two operative words here are recovery and transformation. The recovery model is based on the tenet that individuals suffering from a mental illness are able to manage their illness to the degree that they can live an independent life and achieve their personal goals. In this context, transformation is the innovations in system design that will allow consumers to move to this new role. In this futuristic, transformed system, consumers use available services to achieve their personal goals. With this shift, consumer preference drives financial resources and shapes the available services. And because consumers’ involvement in the system is a means to an end—and not the end—consumers are not defined by their illness and receipt of services.
There is lots of talk about transformation. It's on the agenda of most conferences addressing public mental health issues. Even the Institute of Medicine weighed in on the transformative activities needed to address problems in the mental health system. The IOM's landmark 2005 report listed six strategies that should be the focus for improving the system: assure the system is patient centered, enhance measurements and quality-improvement infrastructures, improve linkages across systems of care, actively participate in the national health information infrastructure, assure the competency and capability of the workforce, and adapt to the unique marketplace for the care of mental health and substance-use conditions.
But while there's lots of talk about system transformation, little will happen until a wide array of stakeholders in the public mental health system are willing to cede some of their power in the system to consumers to permit recovery to occur. For we can change all the infrastructure and systems that we want, but if we don't change the system's control and incentives, little will actually occur.
That being said, I would like to point out some of the control points in need of change. Starting at the top, someone at the federal level needs to step out of the 19th century and enforce benefit parity for mental illness. We know as much about the causes of mental illness as other chronic health conditions. Denying parity has resulted in the financial oppression of families and people suffering from mental illness and has resulted in half of Americans with severe mental illnesses residing in correctional facilities. That's hardly recovery. System transformation isn't going to happen until parity is addressed.
While the federal government sets the trademark for the mental health system, state governments control most of the spending. State systems will continue to impede recovery until two shifts happen. First, of course, is the integration of all mental health funding into models directed by consumers (rather than departments, limits of government, or treatment locations). Second is performance transparency: Make public the performance (outcomes, consumer satisfaction, costs, and more) of professionals and programs so consumers can make informed choices.
Then we have the professional community and provider organizations. Their “transformation” is moving to a role of providing consultation and services for consumers in pursuit of their personal goals. This change will occur as rapidly as spending is directed by consumers and system performance measures are made transparent.
The last necessary element in system transformation applies to all stakeholders. Recovery requires the acceptance of consumers with mental illness as independent adults with the right to make their own choices—regardless of our value judgments about these choices. The Constitution guarantees each of us the right to pursue happiness, not the assurance that we will achieve it. My understanding of recovery is that individuals have a right to pursue their personal goals—and to succeed or fail. Obviously, we want to protect vulnerable citizens. But an end to financial discrimination and the right to direct treatment funding would do much to eliminate the more destructive elements of the current mental health system.
I think we have the means to move mental health treatment to a recovery model and allow consumers suffering from mental illness the same rights as Americans suffering from other illnesses. But I believe the success of system transformation to accomplish this is less about procedures and processes than it is about control.
Monica E. Oss, Editor Emeritus of
Behavioral Healthcare, is CEO of
OPEN MINDS, a research and management consulting firm for the behavioral health and social services field.