Project GREAT:
Bringing Consumerism to Mental
Health Education and Services
Department of Psychiatry and Health Behavior
Medical College of Georgia, Augusta, GA
Gareth Fenley, MSW
Certified Peer Specialist
Alex Mabe, PhD
Professor and Chief of Psychology
Joseph S. Ricci, PhD
Administrative Director
“…the mental health delivery system
is fragmented and in disarray.”
Source: New Freedom Commission on Mental Health (2003).
Achieving the promise: Transforming mental health care in
America. Final Report. DHHS Pub No. SMA-03-3832,
Rockville, MD.
Mental Illness Affects People in the
Prime of Their Lives
Half of the lifetime cases of mental illness
begin by age 15 and three-quarters by age 24
About half of
Americans
will meet
criteria for a
DSM-IV
Disorder in
their lifetime.
Kessler, et al., 2005
Use of Mental Health Services- Adults
Between 2001 and 2003,
60 percent of individuals with
a mental disorder got no
treatment
National Comorbidty Survey Replication Study- Wang et al., 2005
Use of Mental Health Services-
Serious Mental Illness
55 percent stated that they
had not received services
because they did not need it.
National Comorbidty Survey Study- Kessler et al., 2001
Use of Mental Health Services
Delays in making treatment contact
range from 6-8 years for mood disorders
and 6-23 years for anxiety disorders.
10% dropout by the 5th visit, 18% by the
10th visit, 20% by the 25th visit.
National Comorbidty Survey Replication Study- Wang et al., 2005
National Comorbidty Survey Study- Edlund et al., 2002
Medication Regimen Adherence
Noncompliance rates well over 50% for
most medication treatments of major
psychiatric disorders – often not detected
by the provider.
100
90
80
70
60
50
40
30
20
10
0
1980
Area
Line
Line
Line
Line
Line
1990
2000
2006
Access to High Quality Care
In the National Comorbidity Study:
78.2 % of mood disorders and 95.9%
among nonaffective psychoses did
not receive minimally adequate
mental health treatment
•Wang, Berglund, & Kessler, 2000
1
6
5
4
3
2
Have Psychiatrists Become Medication Managers?
From 1987 to 1997:
Percent of patients receiving
medications doubled.
Average number of visits declined
from 12.6 to 8.7.
•Olfson et al., 2002
Traditional Psychiatric Care
Case Vignette
Stigma
 Surgeon General’s Report on Mental
Health of 1999,
“…despite unprecedented knowledge
gained in just the past three decades
about brain and human behavior,
mental health is often an afterthought
and illnesses of the mind remain
shrouded in fear and
misunderstanding.”
Stigma
 National survey data indicate that 75 percent
of the public views individuals with mental
illness as dangerous.
This negative view has been influenced by
negative images of psychosis, poor social skills,
poor personal appearance.
Stigma is worse for schizophrenia versus
depression.
Stigma- Mental Health Care
 People with mental illness often
internalize negative attitudes toward
those with mental illness, resulting in
reluctance to seek and/or maintain
adequate mental health care.
Recovery and Project GREAT
“Houses” by an unnamed child from Vienna
Buzz Aldrin - Astronaut
The Recovery Model of mental
health care
…represents a convergence of data and
theory and a consumer-driven movement
that all clearly point to the enormous
benefits of giving individuals a sense of
self-determination in their own health and
well-being.
The Recovery Model
 Transcends the exclusive focus on symptom
reduction that marks the traditional medical
model.
 Instills hope while emphasizing a non-linear
process of recovery that includes setback
and challenges.
 Recognizes that people living with mental
illness have strengths, goals, and dreams to
be honored.
 Emphasizes holistic and individualized care.
 Defines recovery as what the patient does.
The Recovery Model
 Insists that health care is to be
collaborative.
It is a partnership, more like midwifery
than surgery, but perhaps characterized
best in the words of The Home Depot,
“You can do it. We can help.”
Used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation
at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
The Essence of the
Recovery Model of
Mental Health Care
 Self-Determination
 Self-Efficacy
 Support
Diane Arbus - Photographer
Project G.R.E.A.T.
(Georgia Recovery-Based
Educational Approach to
Treatment)
 System transformation to a Recovery model
of care through teaching and dissemination.
 Funded by the Georgia Department of
Human Resources, Division of Mental
Health, Developmental Disabilities, and
Addictive Diseases with special assistance
by the Carter Center in Atlanta.
Project G.R.E.A.T.
The Team
 Peter F. Buckley, MD
 Gareth Fenley, MSW
 P. Alex Mabe, PhD
 Scott A. Peebles, PhD
Project G.R.E.A.T.
The Goals
 To transform an academic
department into a Recovery Model
program.
 To disseminate the Recovery Model
to mental health agencies and
medical schools throughout Georgia
and beyond.
Project G.R.E.A.T.
The Challenges
 “If it ain’t broke, don’t fix it” attitude.
 Fears that the Recovery Model would
infringe on the best practices in
traditional care.
 Time constraints.
 Stigmatizing attitudes.
 No administrative precedent for a
Certified Peer Specialist.
 No consumer presence on
hospital/clinic advisory boards.
Tom Harrell - Jazz Musician
Project Great:
Defining and Refining as we go.
Phase I: Bringing on a Certified
Peer Specialist.
A “Peer Specialist”
or “Peer Support Specialist”:
 Manages his or her
own life with mental
illness
 Provides mental health
services to others with
mental illness (peers)
Winning against
Ongoing Challenges
 The peer specialist
May have been disabled by the most
severe diagnoses (schizophrenia, PTSD,
etc.)
May also be in recovery from co-occurring
substance abuse
May experience continuing symptoms of
mental illness
The Peer Specialist’s Role
 Part of a multidisciplinary team
 Does not treat symptoms
 Offers role modeling and teaching
about Recovery
The Georgia Certified
Peer Specialist (CPS)
Program
 High school diploma or
GED required
 Competitive
admissions process
 Two-week training
 Certification exam
 Continuing education
Peer Support in Georgia
 First ever rewarded with Medicaid
reimbursement
 Has trained residents of 13 US states
and Canada
 300+ Georgians certified
 The leading curriculum for peer
specialist training internationally
Project GREAT
and the CPS Project
 Intimately linked from the beginning
 Hiring a CPS to join the MCG staff was
planned from the outset
 Several CPSs collaborated to advise
MCG on a Steering Committee and in
focus groups during the creation of the
plan
Institutional Barriers
 Obtaining administrative clearance to hire
the CPS took a year after grant funding
began
 CPS credential is not recognized by MCG
hospital administration
 CPS is unable to view medical records or
access scheduling system
 CPS has hospital privileges similar to a
volunteer but is full-time paid staff expected
to collaborate with clinical treatment teams
Opportunities and Challenges
 Faculty, staff, and residents at all levels have
welcomed the CPS
 Expressed attitudes toward CPS on team
have been positive
 A handful of MDs have made most of the
referrals (mostly inpatients who may be
difficult to follow up with as outpatients)
 Many providers have expressed willingness
to refer to CPS services, but puzzlement over
how the process works
Dr. Kay Redfield Jamison- Psychologist, Scientist
and Author
Project Great:
Defining and Refining as we go.
Phase II: Developing a Behavioral
Health Advisory Council
Lunatics Running
The Asylum?
(Is there a place for
PFCC in Mental
Health?)
 Psychiatric patients are traditionally seen
as unable to collaborate in their own care
due to mental impairment
 Many family members have been
encouraged to surrender care decisions
entirely to professionals and even to
consider some loved ones “dead”
Patient and Family Advisors in Mental
Health: Unique Challenges
 Physical logistics (locked units, unmarked
locations)
 Procedural logistics (heightened
confidentiality, separate and often lesser
insurance benefits)
 Funding
 STIGMA
Affecting patients
Affecting families
Affecting care providers
MCG’s
Commitment
 Vision: To be a national leader in patient and family




centered teaching, research and care
PFCC inaugurated in children’s medical center
MCG featured in PBS series “Remaking American
Medicine”
Under leadership of VP Patricia Sodomka, FACHE,
expanding PFCC to entire MCG enterprise
Top Level Departmental Leadership has attended
meeting and supported the enterprise.
MCG’s
Behavioral Health Advisory Council
 Patient and family members referred by
clinicians
 Active participation by psychiatry faculty,
staff, and administrators
 CPS – Serves as the Facilitator
 Meets monthly.
 Minutes and policy recommendations
distributed to all members of the council and
targeted faculty, staff, and administrators.
Topics Tackled by the Council
 Billing procedures
 Reminder calls and letters
 Interior decoration/renovation
 Involving kids in policy making
 Transition to tobacco free campus
 Inpatient programming/volunteering
 Patient and family info leaflet
 Feedback on patient and family
experiences
Sigmund Freud – Psychiatrist,
Scientist
Project Great:
Defining and Refining as we go.
Phase III: Developing workshops to
immerse psychology and psychiatry
faculty and students in the Recovery
Model of Mental Health Care.
Workshop I:
Knowledge, Attitudes, and Behavior
 Active learning is more effective.
 Expose the learner to individuals with
mental illness that promote a more
positive sense of what patients can do
for themselves.
 Build “the case” from relevant and
empirically supported data.
 Provide useable tools.
 Teach skills, not just knowledge.
Natalie Cole - Singer
Jack Dreyfus – Business Leader
Eleanor Roosevelt – Political Leader
The Primacy of Choice and
Personal Responsibility:
Example of Data Provided
 Langer and Rodin (1976) – a field study of
nursing home residents.
For one group it is stressed that their care and
well-being is the responsibility of the staff.
For the other group it is stressed that they are
responsible for themselves.
Langer & Rodin (1976) The effect of choice and enhanced
personal responsibility for the aged: A field experiment in an
institutional setting. J of Personality and Social Psychology,
34, 191-198.
The Effects of Choice and Enhanced
Responsibility
 Good care by the staff on behalf of the residents
resulted in 71% becoming more debilitated.
 93% of the residents given choice and
responsibility increased in their functioning.
Langer & Rodin (1976) The effect of choice and enhanced
personal responsibility for the aged: A field experiment in an
institutional setting. J of Personality and Social Psychology,
34, 191-198.
Follow-Up
Rodin and Langer - 1977
 18 months later:
 Those given choice and responsibility had a
15% mortality rate.
Those given care had a 30% mortality rate.
Rodin & Langer (1977) Long-term effects of a
control-relevant intervention with the
institutionalized aged. J of Personality and Social
Psychology, 35, 897-902.
Georgia Recovery Assessment Form
I. Individualized and Person-Centered Treatment Plan (Goals and Objectives)
Goal 1:
_______________________________________________________________________________________
_______________________________________________________________________________________
New Patient/Family Tasks ____________________________________________________
___________________________________________________________________________
New Provider Tasks/Responsibility____________________________________________
___________________________________________________________________________
Goal 2:
_______________________________________________________________________________________
_______________________________________________________________________________________
New Patient/Family Tasks ____________________________________________________
___________________________________________________________________________
New Provider Tasks/Responsibility____________________________________________
___________________________________________________________________________
Goal 3:
_______________________________________________________________________________________
_______________________________________________________________________________________
New Patient/Family Tasks ____________________________________________________
___________________________________________________________________________
New Provider Tasks/Responsibility____________________________________________
___________________________________________________________________________
Georgia Recovery Assessment Form - continued
II. List Personal Strengths for Patient related to personal goals:
1.
2.
3.
III. Systems-based Treatment Plan
Is this individual/family appropriate for referral for Peer Support Services? (e.g.,
Peer Support Specialist, Friendship Community Center, AA, NA, NAMI, Parent-toParent, Bereaved Parents of America, Health Grandparents Project of Augusta)
YES
NO
Would the patient like to participate in Peer Support Services here at MCG?
YES
NO
Would any of the following community support areas be appropriate for
consideration in your treatment planning (Please circle appropriate services):
Activities/Hobbies
Child Care
Financial support
Health Care
Housing
Physical fitness
Occupational/job support
School/Educational Support
Spiritual/religious support
Substance Abuse Program
Transportation
Monica Seles – Tennis Champion
Workshop II:
All about Attitudes
 Focused on reversing negative stereotypes
regarding those individual living with mental illness.
 Provided “real examples” of individuals “in
recovery.”
 Emphasized the stories and less so the principles.
 Hearing first hand from providers who have
transformed their practice to the Recovery Model.
Workshop II clips
Ray Charles - Musician
Project Great:
Defining and Refining as we go.
Phase IV: Putting the Recovery
Model into Practice.
Follow-Up Implementation of the
Georgia Recovery Assessment Form
 Working with PowerNote technical
support to make sure that all psychiatry
clinical notes have prompts to
complete the three key Recovery-Based
questions.
Putting into Practice - More
 Putting the Certified Peer Specialist into the
game.
 Keeping the fire under the Behavioral Health
Advisory Council.
 Data Collection.
 Relaunching the GREAT Steering Committee.
Preliminary Findings
 Workshop I – Knowledge of Recovery
significantly improved.
 Workshop II – Attitudes regarding the
capabilities of those with mental illness
to actively participate in their care
significantly improved.
“Lot Easier Said than Done”
 Where are the referrals for the Certified Peer
Specialist?
 Logistics of incorporating a Certified Peer
Specialist into a traditional academic
department.
 Getting administration to listen to the
Behavioral Health Advisory Council
recommendations.
 Changing practice habits is hard!
Next Steps
 More data collection, including comparison
academic site.
 Do a consumer needs assessment. Specific
data need to move beyond contemplation of
change.
 Identify Recovery Champions among our
faculty and residents.
 Establish participative decision-making:
Establish faculty and resident focus groups.
Dr. Patricia Deegan and AssociatesClinical Psychologist, Author, and Co-Founder
of the National Empowerment Center Inc.