One of the most interesting things about service transformation is that it can happen anywhere. It can creep into some of the most rigid, highly regulated settings and shift the foundation of what we believe to be unchangeable.
Take the concept of recovery, for instance. Themental health system has not been designed to facilitate recovery because recovery from serious mental illness was/nt discussed until recently. Today, conversations about recovery can be overheard in the hallways of nearly any behavioral health organization. Program directors are scrambling to understand and incorporate recovery concepts; researchers are testing recovery practices; accreditation bodies are including recovery principles and practices in their protocols; and program evaluators are measuring recovery outcomes. Now that's transformation!
Conventional wisdom implies that recovery is here to stay. The tipping point has been reached. Recovery is an idea whose time has come, and it requires a fundamental shift in the way we talk, therapeutic relationships' power base and, in general, the way we conduct our daily business.
So how much do existing projects and programs need to change to incorporate recovery-based principles and practices? Noted recovery researcher William A. Anthony, PhD, offers some perspective: “People do not feel in charge of their recovery if they are not choosing what they want to try to do. This sounds like common sense, but common sense has not always been that common in the mental health field.”
Some places are struggling against incredible odds to use recovery practices. Take Arizona State Hospital. Superintendent John Cooper is committed to developing recovery opportunities and environments, but he faces daunting challenges. For starters, the hospital is highly regulated by agencies such as the Centers for Medicare and Medicaid Services, state licensing bodies, and accreditation bodies—many of these organizations have yet to develop a recovery focus.
Also keep in mind that most, if not all, state hospitals have many referrals from the judicial system, adding another set of forensic and civil restrictions and requirements (including involuntary treatments). In many cases the courts, guardians, or security review boards make key decisions. Perhaps in many circumstances, administrators don't have any more decision-making power than the people they are trying to serve.
To help make recovery a reality, Cooper decided to partner with META Services, Inc., a local nonprofit behavioral health company nationally known for its recovery work. Cooper asked META to train a few of his forensic “guests” in using the Wellness Recovery Action Plan (WRAP). WRAP, developed by Mary Ellen Copeland, MS, MA, is a process that:
guides people through identifying who they are when well, what their triggers and early warning signs are, and what works best for them in crisis situations; and
prompts and offers suggestions for people to make plans for each of their issues to diminish the difficulties they are having managing symptoms and troubling situations.
When the WRAP training was completed, the hospital and META were impressed by the trainees' enthusiasm and their motivation to teach others in the hospital how to use it. The partnership decided to have the trainees formally teach WRAP to other hospital guests. As Cooper's staff started to look for a way to make this happen, META suggested hiring the trainees as long as they completed META's 70-hour Peer Employment Training.
Unfortunately, the forensic patients were not allowed to leave the hospital grounds to participate in the training. While this seemed incredulous to META staff, it seemed like business as usual to the hospital personnel. This could have been a point at which the partnership unraveled, since each party had its own way of looking at the circumstances, but they dug in and began to look for a way around the obstacles.
After several weeks of looking at alternatives, a potential solution came to mind: Was there a place on the hospital's grounds where META could deliver the Peer Employment class? Cooper's staff didn't think so, but eventually they found a space for a classroom.
While this was a real breakthrough, the joy was dampened by the next problem. Tuition for META's Peer Employment Training classes was routinely covered through a partnership META had with the state Rehabilitation Services Administration (RSA). RSA was a great partner, and it was through its financial and moral support that peer training became a reality in Arizona. RSA was solidly behind the plan to extend the peer training to the state hospital guests, but RSA was not able to fund some students' tuition for a variety of reasons. Without RSA's financial support, the plan seemed dead in the water.
Then META considered another solution: What if students from the community could take the class on hospital grounds? This would allow enough reimbursable students to cover most of the class's cost.
When the community students heard about our dilemma, they jumped to the rescue. They were willing to venture behind the hospital's two locked gates, even though as one of them put it, “This freaks me out!” Some had been in state hospitals before, without the opportunity to leave at the end of the day. They were concerned that painful memories might be triggered. But they were willing to take the chance to allow students from the state hospital to participate.
The class began with 17 students, 5 being from the hospital. Thirteen graduated from the 70-hour class five weeks later ready to go to work. (Four of the hospital trainees graduated; one decided to not continue after the first session.) Cooper and his staff were amazed and elated that their students completed the training. Cooper was the speaker at the graduation ceremony, and he assured the students that they were the greatest hope the hospital had for creating a transformation.
At the graduation, one student noted, “Working as a team with my class was pure joy—a remembrance of things past made whole.” Another said, “I had to relearn study habits. I also had to relearn using a rather highly medicated brain. I think that alternate pathways were formed.” And yet another commented, “I learned great skills for work and for everyday life. I truly learned a more complete way to be with people.”
Janice Brewer, Arizona's secretary of state, attended the graduation. Brewer has been a strong advocate for behavioral health services for many years, and she was so moved by hearing the graduates that she stood and spoke:
I have been involved in behavioral health services for most of my career, but it's only been in the last five or six years that we've heard talk about recovery. I was skeptical at first, but am now a believer that recovery can happen, and this day is the evidence. The program is unbelievable and gives hope to the families and people receiving services. What progress!
META hired two of the four students from the hospital as peer facilitators to train other hospital guests. (One hospital student was discharged shortly after the training was finished, and we helped her find employment as a peer in a local behavioral health company. META would have hired the remaining peer, but he didn't have a GED, so we couldn't proceed.) They teach WRAP classes and receive paychecks from META. The hospital's staff are so amazed with the personal growth of the peer facilitators that they are rotating through the class themselves because just being there is so transformational.
When properly trained, peers can have an incredible impact on an organization's ability to move into recovery-based services. Their very presence allows staff to see that recovery is possible. The hope derived from “if I can do it, so can you” gives those interested in recovery the strength to keep up the work necessary to succeed. Peers are living evidence that recovery is possible.
Organizations use many reasons to justify why they can't include peers in their workforce, but none is insurmountable with a little tenacity. If a highly regulated state hospital can take these brave and necessary steps, others can do it too!Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
Michael Zeeb, BA, is a Peer Training Instructor at the Recovery Education Center at META Services.