Bridge House Presentation

The following is a presentation by James Pisciotta, CEO, Southwest CT Mental Health System, made at the Annual Employees Recognition Luncheon at Bridge House in Bridgeport, CT on October 16, 2002.

"It is an honor to be able to share thoughts and viewpoints with a gathering such as this.         

The reason is that the purpose of this event is to celebrate the success of an organization, and its supporters, which is totally oriented around the needs of its constituency.

As background, let us examine some trends in the healthcare industry in America during the last 15 years.  During the mid-to-late 1980’s, the average annual growth rate in overall healthcare costs was in double digits.  In behavioral healthcare alone, over a period of 10 years during the 1980’s, the annual growth rate jumped from 7% per year to nearly 14% annually by the late 80’s.  Healthcare costs were spiraling out of control.  A cost containment strategy was devised by large corporate interests, which led to an approach to managing costs.  While managing care was a related activity, the primary objective was to place significant limitations on expenditures.  The activity was successful.  For nearly 10 years annual cost increases dropped to single digits.  In behavioral healthcare, annual costs dropped to 6 – 7%.  Unfortunately, in our field it is continuing to drop to 3 – 4% and the trend continues to be downward.  If this keeps going, there will be actual “deflation” in our industry, if we are not already at that point in red dollar terms.

The function of consumer choice in this managed cost/managed care paradigm was virtually non-existent.  Rather, the phalanx of corporate interests, with a view to the “bottom line”, and the insurance interests, concerned with their “bottom line”, could, and did, decide what we, as healthcare consumers, would receive for benefits.  However, during the 1990’s, a new force emerged which complicated the earlier strategy.  This force has become known as the “educated healthcare consumer”.  With access to basic information about the necessary components of healthy living, and, while being mindful of the increasing necessity of sharing costs for our healthcare, we, as educated consumers, are demanding greater choices in our overall planning for healthy living.

While the parallels in behavioral healthcare are obvious, there are blatant problems, which prevent the full emergence of consumer choice and empowerment.  First, the problem of stigma of mental illness and substance misuse tinges the credibility of our field and of our consumers.  Second, the intellectual arrogance of some of us as providers gets in the way of accepting our consumers as capable of choice and self-direction.

Although we are all well meaning, the training modules in graduate education are significantly outdated.  They plead ignorance of the practice management imperatives operating in today’s behavioral healthcare industry, which are increasingly responsible for limiting access to and choice of services, particularly for the medically indigent. 

And, in our state, these limitations extend to persons on Medicaid and Medicare, due to low reimbursement rates.  

But, lest we get carried away by the fiscal theme again, let’s focus on the problem of our perception of consumers.  There is a failure to appreciate the stages of recovery that consumers experience.  There is a tendency to lump all persons with mental illness and substance misuse into the same category: acute and chronic illness.

That is the historical view of the illnesses.  However, over the past 20 years there is growing research that documents that many persons with major mental illness do recover higher levels of function and achieve much success in leading more “normal” lives.

This includes their functioning as “educated consumers” like many others.

I would now try to link this notion of the “educated consumer” to the Recovery Model now being discussed in Connecticut.  As a helpful reference, it’s useful to look at a work published in November 2001, in the journal Psychiatric Services.  The authors include Frese, Stanley, Kress and Vogel-Scibilia.  In this article entitled “Integrating Evidence-Based Practices and the Recovery Model” there is a direct reference from Munetz and Frese in an earlier work.  They acknowledge that in the acute stages of mental illness many individuals are so disabled that they do not have the capacity to understand how ill they are.  For these persons, externally initiated interventions are appropriate.

As individuals recover, they must gradually be afforded a larger role in the selection of treatments and services.  Throughout the recovery process, persons should be given every opportunity to regain control over their lives.  They should be given increasingly greater choice about evidence-based interventions and other available services.  This is the essence of recovery: to have substantially benefited from treatments so as to be afforded opportunity for greater autonomy.

As individuals progress along the road to recovery, their growing capacity for autonomy should be respected.  Indeed, as persons progress along the continuum from illness to health, they can be viewed as benefiting the most from the autonomy-centered Recovery Model.

To emphasize the point, Recovery is a process, a movement from illness to more autonomous functioning.  Recovery is not a constitutional right.  It is not a political platform statement.  It is, indeed, a process of improvement and increasing independence of choice.  On the face of it, this appears common-sensical.  However, too many of us have had the “chronic disease” label stamped on us, and are reluctant to recognize our consumers as capable of valid choices.

The growing recognition of a “Recovery Philosophy” is helping to change the historical insistence on the chronic disease model, yet some of us humans seem slow to accept change.  It is the job of some of us to promote and accelerate the rate of attitude change, and that process is under way.  Yet we must acknowledge that hundreds of behavioral healthcare organizations employing thousands of providers are still locked onto an earlier model. 

The term “Recovery” easily rolls off of the lips, but it is not so easy to change the philosophy, values, and practice patterns of so many well meaning people, most of whom have a personal and financial stake in the older model of intervention.  This is not a request for sympathy, but a suggestion that positive pressure is needed to accelerate the changeover.  Such pressures are changing the broader healthcare industry in America via “educated consumers”, and will lead to increasing decision-making by consumers of behavioral healthcare as well.

But, just as you thought, and probably hoped that I would sit down, there is one other point to be made today.  We’re going to ask your help in restoring the place of vocational activity in the lives of persons with mental illness. 

It is a fact that work is a central value and activity of all people worldwide, and persons with mental illness must be encouraged and allowed to join the workforce.  The ratio of productivity of the person is not so important.  What is important is that all consumers, not just those “job ready” or “abstinent” at the moment, be given every opportunity to be gainfully employed.  An essential aspect of recovery is to regain a sense of self-worth and self-esteem.  In America, that means work-related activity!  More of our state and federal dollars must be dedicated to vocational activity than at present!  For now, it is an afterthought. 

Speaking as a provider, we must reorient our services so that vocational training and job-choice opportunities are available to all persons with mental illness and substance misuse.

Although the laws of state budgeting in Connecticut make it difficult for us to reallocate general service dollars to support vocational activity, a way must be found to give more than lip service to the role of work in the recovery process.  We are committing ourselves to this process in the Southwest Connecticut Mental Health System, and we ask for your assistance in making this needed change. 

In our system today, only about 15% of our consumers are engaged in work-related activity.  In many other states in America, up to 40 - 50% of consumers are so involved.

The illnesses are the same, but our systems are designed quite differently.  And, so are the expectations of one another.  We have a lot of “catching up” to do! 

In practice, this means that as we reform “Treatment Plans” into “Recovery Plans”, that a central component of this represents the “Vocational Plan”.  If a consumer is not presently engaged in work-related activity that is satisfying, and, designed to lead to competitive employment, you are encouraged to ask for such a change in services, if you are interested in getting any type of job.  If you get an answer from a service provider that is not satisfactory, ask for a change in your service plan that will assist in getting a job.

When enough people apply this type of “positive pressure”, we must all pay more attention to the central value of work in our lives.  Changing a system does not happen overnight, yet systems do eventually respond to “educated consumers”.  We ask for your help in changing our system."

Thank you for listening.
James Pisciotta, CEO, Southwest CT Mental Health System