NYAPRS Note: Below, Harvey Rosenthal describes the need for a varied and systemic approach to effective outreach and engagement from both a policy and person-centered service perspective. Our need to answer critical questions about how to engage people in the community has never been greater; policy makers and new payers are seeking reasonable and easily defined solutions to the complex and often lengthy process of getting somebody engaged in their own process of recovery. At this year’s NYAPRS Annual Conference, we offer several workshops devoted to these questions, and allow opportunities for community members to contribute to the solutions we use to inform strategic policy at the state and national level. These workshops include one about the possibilities for engagement in the changing healthcare system, which will include Andrew Cleek and Kara M. Dean-Assael from the McSilver Institute for Poverty Policy and Research at NYU. Register for the conference today and share your voice to the recovery movement!
All Roads Lead to Better Outreach and Engagement
SAMHSA Recovery to Practice Newsletter; Harvey Rosenthal, 31 July, 2014
Across the nation, we’ve seen an intensified focus on expecting and incentivizing measurable outcomes like enhanced stability, health, and wellness and reductions in avoidable relapses, inpatient and detox readmissions, incarcerations, homelessness, and suicides.
There is an ever-growing call for system and service reform to achieve these outcomes from consumers, families, legislators, managed care groups, and states seeking more from scarce or diminishing funds.
But improved and more accountable system designs will not work if people don’t participate, and there is a whole spectrum of individuals who don’t respond because of insufficient or ineffective outreach and engagement.
This was the focus of a 2-day forum recently convened by SAMHSA. Representatives from families, consumers, providers, criminal justice, and faith-based communities all looked at a broad array of engagement strategies that ranged from more assertive peer and family outreach to outpatient commitment.
While the group reached consensus on a number of issues, my own beliefs and findings are based on 18 years as a mental health provider and 21 years as an advocate for systems and services reform. I believe the type of helping relationships we make at the start with people we want to support is critical to our success in engaging and supporting them. We must have the ability to make positive alliances with even the most distressed individuals.
For many, this starting point does not typically entail getting people to accept an agenda that offers assistance predicated on their willingness to identify as “mentally ill,” take medication, and go to treatment. This is not a great way to start a relationship!
In our efforts at the New York Association of Psychiatric Rehabilitation Services (NYAPRS) delivering Peer Bridger services to thousands of “high needs” Medicaid beneficiaries, we’ve learned outreach involves a feet on the street willingness to go where people are and respond in real time rather than wait in our offices and label people as noncompliant.
We have witnessed the great difficulties people face in keeping the hope and ability to wait for, remember, and get transportation to appointments that are often days or weeks away. And we’ve seen over and again that engagement often starts with meeting more basic needs—housing, safety, food, caring relationships, and advocacy—and the willingness to keep coming back to earn the trust that is fundamental to our work’s success.
We have also seen the understandably negative associations people make with accepting mental health treatment, from increased discrimination and shame, loss of hope and value, and the idleness, isolation, unemployment, poverty, and loss of choices and rights that come from being a “mental patient,” to the loss of sexuality and increased weight gain that often result from taking medications. I’m personally very grateful I found a medication without these side effects.
Even when people exhibit major symptoms and difficulties, it is possible to determine what they want and what they will respond to. But it often takes great patience, persistence, and time—to demonstrate empathy and caring, to offer hope, and to establish trust. It requires a willingness to be right there with people’s greatest suffering and incomprehensibility, even when it is disturbing or frightening to us personally. And it frequently requires us to work very closely with families and share information when health and safety are at risk.
Engagement cannot succeed from a one-style-fits-all approach. We must tailor our practices to work with vastly different people and needs and have the capacity and team diversity to address those with trauma; varied racial, ethnic, linguistic, and other cultural backgrounds and spiritual beliefs; and different gender identifications and age-specific needs across the spectrum of life. This typically requires much more specialized recovery-focused training and supervision.
We know a lot more now about how to help people in severe distress, but these approaches are generally not offered or sufficiently available. They include the following:
- Transitional supports that present critical opportunities to engage people leaving inpatient and detox facilities, prisons, and jails
- Individualized care managers and/or health navigators who can help organize care across multiple health and social systems to offer a well-coordinated, real-time response
- Housing First, crisis respite, and other harm and homelessness reduction models that offer many people what they need most to be safe—even if they’re not willing to take medications or stop using drugs and/or alcohol
- Person-centered wellness promotion and relapse prevention and management tools like Wellness Recovery Action Plans and Advance Directives
- Criminal justice diversion and reentry services that include court-based mental health workers, crisis intervention teams, and better prison discharge and follow-up
- Peer and family supports like peer crisis lines, respite houses, and peers in emergency rooms, on police calls, and during and following inpatient admissions, as well as greatly increased family-to-family support services
- Individualized evidence-based medicine consistent with the latest research
- Collaborative services in appealing settings like houses of workshop, malls, schools, libraries, and shelters, and co-located services within primary care clinics
- Community health workers who offer specialized services that are sensitive and responsive to cultural and neighborhood-specific backgrounds
Reimbursement reform is also essential. The government can tie provider reimbursements and financial incentives to successful outreach and engagement efforts, and must pay for what is often 3 to 6 months of engagement activity before treatment is even possible.
Just as 12-step meetings typically end with the exhortation for attendees to “keep coming back,” our providers need to keep coming back until they have achieved successful engagement. Just as we seek to respect a person’s dignity of risk, we must assume the duty to care and act when someone’s health and safety are at serious risk.
Once, I was asked by a director of a large New York City mental health agency what to do when an individual had consistently rejected the care offered by his community worker. I replied, “Send someone else, and offer something better.”
Harvey is the executive director of NYAPRS, a peer-led coalition of peers and providers that promotes recovery, rights, and community inclusion. Write him at HarveyR@nyaprs.org.