Last year, I blogged about Bill White’s interview with Roland Lamb, one of the key players in helping transform the behavioural healhcare system in Philadelphia to a system based on recovery. This system is concerned with both mental health and addiction, and is a $1 billion system caring for over 100,000 people.
I’ve combined my four blogs into one, which highlights key parts of this very interesting interview. There is a lot we can learn from the Philadelphia in transforming our own behavioural health are systems.
1. Why the need to transform the addiction treatment system?
Bill White: “Given the distinguished work that was already underway, the obvious question is, ‘Why was there a need to transform addiction treatment in the City of Philadelphia?’
Roland Lamb: “I’m thinking of the words of Maya Angelou: ‘You did then what you knew how to do. When you knew better, you did better.’
With all of our resources we found ourselves with a system that responded well to a crisis, able to deliver a diverse array of service episodes, graduate/complete folks from a treatment episode and send them home.
But what we had become was provider-focused and constricted by diagnostic codes that led to deficit-based labeling of those seeking care. We had become a system of acute care lacking an understanding of and support for long-term recovery.
As a result, we found that despite the tremendous efforts of those in recovery and the providers serving them, there was far too much recycling through serial detoxification and readmission to brief residential and outpatient treatment that was disconnected from recovery maintenance supports in the community.
Most of all, we had become a system so preoccupied with deficits, we had difficulty seeing the value in those seeking and in care, those providing care, and even the care itself.
We decried the inability of people to get into treatment, stay in treatment, and sustain recovery after treatment. We expected one program to treat the whole person and then release them into the community able to sustain recovery on their own.
We were like a drawbridge built with the bridge up and no consistent access to the assets that existed on either side. The community was not closely connected to treatment programs, and treatment programs often lacked strong connections to recovery support resources in the community.”
Bill White: “Could you elaborate on this drawbridge metaphor?”
Roland Lamb: “With respect to those seeking recovery from addiction and the many challenges that come with it, we have done a great job addressing acute/crisis needs of those seeking care. We are managing care in our emergency rooms, crisis centers, and residential facilities.
At our best within this model, we screen, assess, engage, retain, treat, and discharge/ graduate, but we lack connection to the experience of living a life of recovery in the community and the struggles that come with such an effort.
We lack the continuity of care that extends recovery initiation in the treatment setting to recovery maintenance in one’s natural environment in the community.
We really are like a drawbridge built with the bridge up. For too long, we have existed with professional treatment estranged from the rich inventory of supports in the community. They have been divided by rivers of funding, diagnostic categories, regulations, and disagreements over particular treatment philosophies.
What we are trying to do is bring the community into treatment and bring treatment into the community. To do that, we have had to lower the drawbridge and break down the isolation of these two worlds.
One of the ways we have done this is to train and employ recovery specialists who have knowledge of both worlds and serve as a link between these worlds.
By investing in the community and in coalitions between grassroots community organizations and treatment providers, we can bring added value to treatment to extend our presence into the community via recovery support services for those in care who need continued supports. Each mutually enhances the other.
Acute care, deficit-based systems contribute to recidivism, a narrow focus on crisis care, disconnected serial episodes of care, and the intergenerational transmission of addiction and related problems.
We could have certainly been satisfied with that status quo, but we would not have been able to sustain it. The approach had to change, and the first people who asserted that were individuals and families in recovery.”
2. First steps in system transformation
Bill White: “When you look back today, what were the most important first steps in the systems transformation process in Philadelphia?”
Roland Lamb: “The first step was to acknowledge that our most important resource was people in recovery. It was their message of the lived experience of long-term recovery that helped us move beyond just talking about addiction and addiction treatment. They were the ones who convinced us we needed to focus on more than just surviving addiction.
We – the Department of Behavioral Health and Intellectual disAbility Services and our provider network – had to build credibility through relationships with those in recovery, their families, and indigenous recovery support organizations within the community.
We had to bring them into the process of defining what we meant by recovery, creating a vision of a recovery-transformed system, and including people at all levels of the discussion and decision making.
There is nothing like seeing people empowered in their recovery take ownership through this process, both for their own recoveries and for the larger systems of recovery support.
To achieve this required several things. First, we had to bring together people in recovery from different cultures of recovery in ways that they could transcend the differences that had historically separated them.
Second, we had to help everyone in the system – Medical Directors, CEOs, board members, support staff, clinicians, security guards, and each of our own DBH/IDS staff – redefine their roles within this recovery-transformed system.
At every level of the system, we needed and began to find recovery champions.”
3. The importance of trust
Bill White: “What new structures had to be put in place to reflect that vision and those values?”
Roland Lamb: “When organizations embark on the system transformation process, the first challenge is to establish trust – trust in what you say and that what you are doing is consistent with the vision and values that are being elevated.
And you ask them to trust even when you don’t yet have organizational and/or system fidelity across all functions.
You can promote the values of person-led care, but you have to support that in your operational tactics, such as in what you fund and how you authorize care. So there has to be alignment, coordination, and ultimately integration of the transformation vision and values in everything you do. Not everyone in the transformation immediately gets it.
You are going to have early adopters at one end of the stakeholder spectrum and those dependent on the security of the status quo at the other end and in between the majority moving in one direction or the other.
It is this middle group that will be most influenced by the consistency of the message and the consistency of our behaviors while the transformation is underway. As some have said, ‘Behavior doesn’t lie; people do.’
You have to engage in creating a learning environment that at its core encourages the exploration of how concepts become strategy and how strategy becomes tactics, or as Arthur puts it: Concept, Practice, Context.
Everyone and every group has to share in living the vision and reinforcing the values. That can only come with the creation of high performing collaborations and partnerships.”
Bill White: “What obstacles stand in the way of such trust-grounded partnerships?”
Roland Lamb: One obstacle to transformation is what is perceived as an implied accusation that we have been doing something wrong. This is true whether you are the one seeking treatment and/or in recovery, the provider of care, or one of the various stakeholders involved in the provision of social services, regulating and/or paying for services.
Potential defensiveness must be addressed by emphasizing system strengths and the development of new understandings and new technologies that allow us to elevate service practices and their outcomes. This is the foundation the mutual trust, respect, and safety that successful systems transformation requires.
That means we have to provide permission to make mistakes and learn from them. If we need for those in recovery to feel its OK to come back even if they have used or made a mistake, don’t we also want our providers to feel it’s OK if they make a mistake implementing recovery-focused service practices?
We are asking providers in the transformation to buy into person-directed care, adopt a holistic wellness approach, validate hope, guarantee choice, provide empowerment, support peer culture and support, encourage leadership, promote community integration, recognize spirituality, and wherever possible, facilitate family inclusion for those they serve. That’s a lot for providers to take on.”
Bill White: “To what extent must the ‘us versus them’ mentality be changed through this process?”
Roland Lamb: “The field is splintered by multiple divisions: drug-free versus medication-assisted treatments, recovery community versus treatment community, prevention vs. treatment, AA/NA vs. WFS and SOS, and on and on. Those we serve, their, families, and communities are not well-served by such divisions.
As we looked at such splits, we began to talk about the fact that we as a community and system of care had been wounded and needed a process of recovery – a process that could restore faith in ourselves and each other and help us (in the words of Rabbi Twersky) recover our humanity.
Starting to rise above the ‘us versus them’ has been an important step in the transformation process in Philadelphia.”
4. Implementing our trust philosophy
Bill White: “Could you give examples of how this trust philosophy was implemented at multiple levels?”
Roland Lamb: “I have always been impressed by Arthur’s use of the ‘You can do it; we can help’ slogan, primarily because it lays the foundation for a continuum of trust. This began for us by just listening as we created forums, workgroups, committees, task forces, and coalitions where people in recovery with lived experience, their families, and neighbors could be heard.
We invited them to move beyond their experience of the problem to become part of the solution by helping us transform an entire system of care. We began this with a collaboration with Pennsylvania’s Recovery Organization – Achieving Community Together (PRO-ACT) to develop Philadelphia’s first Recovery Community Center.
We took a road trip together to Connecticut to visit Phil Valentine and Connecticut’s recovery centers. We came back and put together a visionary team of recovering persons and in a couple of months, got the recovery center up and running. This could not have happened without the kind of trust we are talking about.
We created working forums that included providers and when we found ourselves in conflict around philosophy, practice, and/or performance, we dialogued. We worked together to correct the problem.
This is not to say we don’t have problems anymore. On the contrary, in some ways, our problems are more intense because we are at a tipping point in our transformation…
Early on, we in the Office of Addiction Services formed working groups to address inconsistencies in what we were saying about care in recovery and how we practiced authorizing and applying diagnostic and placement criteria and managed care.
Our early working groups evolved into what is now the Office of Addiction Services Advisory Board that is made up of people in recovery, recovery advocates, a diverse mix of providers, Department staff, stakeholders from the community, academia, and the research community.
The board, co-chaired by a provider and recovery advocate, has been an important forum for planning and project implementation…
… But Bill, more than anything, we have taken every opportunity to celebrate recovery and those who have gone from surviving in their addiction to thriving in their recovery. At every venue, we seek to have people in recovery tell their stories.
We also have continued to improve medication-assisted treatment services within the transformation process. We convened the Methadone Maintenance Treatment providers workgroup (a collaboration with our providers both inpatient/residential and Outpatient, DBH/IDS staff, the State Licensing authority, and the DEA).
Under Arthur’s leadership, we have included members of each program’s consumer groups in our decision making process.
With the guidance of this group, we have been able to expand the scope of services, reduce caseloads, increase co-occurring services via more available psychiatry time, and provide case management.”
Why not check out the full interview?
