Liberty to change

Philadelphia is aiming to live up to its ‘city of brotherly love’ motto by fully integrating its substance and mental health services to provide seamless support for vulnerable people. David Gilliver talks to its director of addiction services, Roland Lamb

Roland Lamb, who was one of the speakers at the second national Recovery in the Community conference in Sheffield last month (DDN, September, page 5), has used his five years as director of the Office of Addiction Services at the Philadelphia Department of Behavioural Health to help to oversee the introduction of ‘recovery-orientated systems of care’ across the board.

The City of Philadelphia’s drug and alcohol treatment and mental health services are integrated into one comprehensive system, working via a network of agencies and collaborating closely with criminal justice, education and child welfare departments. The city’s philosophy is that the ‘central role of individuals and families in responding to, managing, and overcoming’ substance and mental health problems should be ‘an organising point for the entire system’. Its vision is one of ‘recovery, resilience, and self-determination’ with professional treatment viewed as one aspect among many to support people in managing their own conditions while ‘building their own recovery resources’.

Although it had always been proficient at dealing with immediate crises, transformation was needed to shift the department’s focus to the long-term, says Lamb. ‘We had a very good acute care system, a very good crisis-oriented system. We did a very good job of taking people in, treating them and sending them home, but then you have a person who finds themselves coming out of a treatment programme and going back into the very community in which they struggled and survived their initial addiction.’

As a result, that acute care level had become characterised by the ‘recycling’ of people, he states, and it was this – coupled with wider issues – that convinced the department that something needed to change. ‘They’d go into our detoxes and our residential treatment programmes and in less than six months they’d be back. And then there were the collateral issues, like increases in the prison population because of our preoccupation with the drug war. One out of every 100 Americans is incarcerated – we’re filling up our prisons, we have broken families and we have the disconnect between professional help and community support, families and therapists. A lot of fragmentation all over the place.’

It’s this disconnect that the city aims to address, and his vision is one of aligning and integrating departments throughout the local government structure to ensure that professionals ‘coordinate our dollars’ to provide ongoing support. Everyone wins as a result, he maintains. ‘It’s to the prisons’ benefit to keep folks in the community and functioning well and it’s to the child welfare department’s benefit to keep families intact and functioning well.’

On a wider level, the aim is for far more ‘functional involvement’ with the clinical healthcare system, something that’s being partly facilitated by the Affordable Healthcare Act, which is pushing both sides to work more closely, he explains. ‘So ideally we’d have a system where no matter where I presented, if I had these other issues on board those services could be brought to me in one place. We’re talking about the creation of managed care hubs and healthcare navigators – people who can help others navigate the system, an excellent role for how we use peers.’

Fully achieving this vision won’t be easy, he acknowledges, not least because of the economic situation. ‘These last few years of really having a recovery focus have positioned us well, but we’ve received a number of cuts in our drug and alcohol area – we just got hit this July with a $1m cut.’ And while greater integration does allow the city to manage its money better, some of the biggest obstacles to change have come from within both the departmental structure and the recovery community itself. 

‘The resistance comes from all directions. It comes from people in recovery who’ve been used to a system where people tell them what to do and what they are and what they’re not. We’re a stigma-driven society, so you have people who don’t have a high opinion of their worthiness for care and, for that reason, in many cases don’t even access it. Then you have the treatment providers, who are used to one particular way of doing things, and then you have the administrators and the recovery advocates. When you propose a system transformation you propose that all those folks are going to have to change their position and be something different.’ 

He compares the system’s previous incarnation to ‘rich parents’, throwing resources at a problem unaware of how little long-term effect it has, and says the department is ‘still not over the hump’ in getting everyone on board. ‘Like any other transformational model you have your early adopters, your late adopters, and you spend a lot of energy trying to convince everybody in the middle. People want to be in control, and I often tell people that the most insidious of all addictions is the addiction to power, and it’s also the greatest illusion. People think that they’re going to lose something that they never really had – “I’m not going to have the power do decide how these dollars get spent”.’ 

Although he’s been at the helm in Philadelphia for five years, he’s spent the whole of his 37-year working life in the addictions field, with his interest stemming partly from personal experience. ‘As a young man I got into drugs and enjoyed it maybe to the point where it was a problem. It didn’t keep me from going through school and graduating from college, but it kept me from doing a lot of other things. Then I became interested in wanting to work with young people, mainly in the area of addiction, and I’ve been doing that ever since.’

There’s no shortage of need for that work, as Philadelphia continues to struggle with challenging social problems, particularly around drug-related violence, although crime rates have fallen from their high five years ago. ‘We also have a homeless issue and we were bringing down our incarceration numbers but because of the cutbacks and so on those things are going back up again. But we need to maintain activity in our city system as far as continuing to move folks towards recovery – the longer people stay in the community in their recovery they are outside of that recycling and we’re just dealing with new faces in that cycle. We need to continue to keep people in the community.’

Recovery-orientated systems of care are more developed in the US than the UK – is there anything that people here might find surprising in the way Philadelphia is doing things? ‘For us, everything begins with the people who are in recovery,’ he says. ‘Solutions, collaborations and partnerships begin in the community, and there’s no exclusion. We’re all accountable for recovery and we are all citizens of a larger community of recovery, and for that reason we began in the community – we had meetings in churches and different community venues, forming boards and inviting input from all over the place. 

‘We’re still looking for new ways to connect to groups who hold anonymity as their calling card, for example – you can remain anonymous but we want to support you too,’ he continues. ‘We need to create a free flow of traffic so you have your professional side – the licensed treatment programmes – but then you have all the riches of the community with people creating all kinds of activities. They need to be a part of professional care, and professional care needs to be accessible to those folks in the community.’

Definitions of recovery can be a tricky issue in the UK, but Philadelphia has come up with ‘an evolving definition’ of their approach, seeing recovery as ‘the process of pursuing a fulfilling and contributing life regardless of the difficulties one has faced’ and involving the ‘continued enhancement of a positive identity and personally meaningful connections and roles in one’s community’.  

Is Philadelphia fairly unique or is this becoming a more common model? ‘It’s a struggle,’ he says. ‘When I travel around the country, I see it mostly being done on a state level. We have an advantage, being a city of 1.4m people having access to the dollars that we do for behavioural health, and we’re still sort of an anomaly. A lot of the efforts that you see around recovery are state efforts and they’re a lot slower because you’re talking about trying to move this concept across geographically separated counties, whereas we’re all in one place.’

Ultimately, it all comes back to that focus on the long-term, he says. ‘It’s a lot like the soldiers coming back from overseas to a community – they don’t know where they are, don’t know their place, don’t know how to function, and we’re seeing suicides. In some ways a post-traumatic reaction to an addictive career is not too much unlike that. It’s very much about long-term support.’