NYAPRS' experience in training and technical assistance of the past decade has shown that even well-intentioned administrators and practitioners cannot change their practice and services without three essential ingredients: (1) an operational understanding of what "facilitating recovery" means and looks like on the ground; (2) a reliable way to assess program capacity across multiple program domains and measure progress over time; and (3) practical and effective tools to improve practitioners' competencies and overall program capacity.

In order to respond to the needs and opportunities created by New York State's current efforts to transform the mental health system, this project will develop a blueprint for improving program capacity and develop tools for programs to use in their transformation process.

On average, people with psychiatric disabilities die twenty five years younger than those without disabilities (Newcomer & Hennekens, 2007); over eighty percent are unemployed (OMH, 2009; Marrone, Gandolfo, Gold, & Hoff, 1998; Anthony, 1994); more than thirty percent live in poverty (Bjelland, Erickson, & Lee, 2008); and many more spend their lives in some form of semi-institutionalization in the mental health system. As a result, mental illness is the number one cause of disability in the country, accounting for more burden than that associated with all forms of cancer (McAlpine & Warner, 2002). Why is it that, despite the potential for full recovery, the quality of life of people with psychiatric disabilities in New York State continues to be much poorer than that of people without disabilities?

The two most comprehensive reports on mental health of the past decade, the Surgeon General's   Report on Mental Health (U.S. Department of Health and Human Services [DHHS], 1999) and the New Freedom Commission Report (DHHS, 2003), established that the single most important problem of the mental health system in the United States is the predominance of an illness-orientation, which aims to only manage symptoms and accepts long-term disability (DHHS, 2003).  These reports concluded that transforming services towards a recovery-orientation, that is, improving the capacity to support people with psychiatric disabilities to "live, work, learn and fully participate in their communities," is of paramount importance and urgency (DHHS, 2003; DHHS, 1999). Existing research supports the findings of these landmark reports. During the past two decades, research has provided evidence that services structured to support recovery are more effective at improving the quality of the life and community integration of people with psychiatric disabilities and it has also identified the most essential standards for the effective implementation of recovery-oriented services (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b; Davidson, et al., 2009; Ragins, 2009; Farkas et al, 2005; Onken et al., 2002; Ridgway, 2005). A now classic study comparing individuals with schizophrenia from Vermont and Maine, found strong evidence for the effectiveness of the recovery-orientation. Vermonters- who participated in a model psychiatric rehabilitation program with strong supports for community integration, and  meaningful residential, work and social opportunities - achieved better long-term outcomes across multiple domains, including fewer symptoms, higher employment rates, and increased social functioning and community adjustment (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b). Several studies have also identified the programmatic traits that are most likely to support individual recovery. In a study about the factors that help and hinder recovery, Onken et al (2002) found that several environmental factors are essential in supporting recovery, such as access to material resources (e.g., livable income, safe and decent housing), social relationships, meaningful activities that connect individuals to their communities (e.g., employment), and supportive services and staff who belief that recovery is possible. Most recently, a study by Davidson et al. (2009) identified a number of programmatic standards that promote and sustain recovery. These include conducting strengths-based assessments, offering individualized recovery planning, building communities, and supporting community-based continuity of care.

If recovery-oriented services can improve quality of life more effectively, why is it that an illness-orientation continues to predominate? To us, the answer lies in the failure of the mental health system to shift the illness-oriented paradigm that has predominated since the time of state mental hospitals. Almost a half-century ago, the process of deinstitutionalization held the promise of a "normal" life in the community (Joint Commission on Mental Illness and Health, 1961). Since then, multiple federal and state laws have promised community integration and better lives for people with disabilities, such as the Community Mental Health Center Act of 1963, the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990.  Indeed, today most people with psychiatric disabilities receive care in their communities. In the early fifties almost eighty percent of mental health care episodes in New York State took place in state psychiatric hospitals, while now less than one quarter of them occur in inpatient programs (Aneshensel & J. Phelan, 1999).  Nonetheless, despite the best intentions of the deinstitutionalization, this process seems to have mainly relocated people to community settings without effective supports to participate fully in their communities (Davidson, et al., 2009). The "deinstitutionalization" was in many respects a process of "trans-institutionalization" that landed people with psychiatric disabilities in new institutions with limited capacity to support their full mental health recovery, meaningful community integration, and overall quality of life. Program structures and funding changed faster than the approaches and methodologies guiding mental healthcare. The institutional care predominant in state mental hospitals transitioned from institutions to community-based services maintaining what has also been referred to as a "chronicity-orientation" (California Association of Social Rehabilitation Agencies, 2007).

Over the past three decades, multiple efforts to increase awareness and build practitioners' knowledge about recovery approaches do not seem to have improved the capacity of the mental health system to facilitate recovery, largely because this lack of capacity is a systemic failure, not a practitioner failure (Davidson, et al. 2009). Consequently, the transformation of the system cannot only rely on the retraining of practitioners, but must be aimed at improving the implementation capacity of programs. Retraining of practitioners is necessary but not sufficient. Most importantly, the system requires significant changes in the ways in which services are organized and delivered, that is, in the predominant paradigm of care. This can only be accomplished by providing administrators and practitioners with a framework for change, assessing their programmatic capacity with concrete tools, measuring their progress over time and offering technical assistance to transform their services. The mental health system has failed to not only improve programmatic capacity, but also to provide programs with concrete tools to transform their practice in order to facilitate meaningful recovery and quality of life.  Without such resources, the call for systems transformation and the promise of community integration will remain illusory.