(10-16-18) Last week’s news that Paolo del Vecchio is being reassigned inside the Substance Abuse and Mental Health Services Administration sparked a flurry of reactions.
Del Vecchio has served as director of SAMHSA’s Center for Mental Health Services (CMHS) for six years and is viewed as a powerful advocate for persons with lived experience. His transfer by Dr. Elinore F. McCance-Katz, Assistant Secretary for Mental Health and Substance Abuse, is being seen by some of del Vecchio’s supporters as a sign that the agency is moving away from supporting peer services and the recovery model of treatment in favor of the traditional medical model and paternalism.
Dr. McCance-Katz’s supporters insist del Vecchio’s transfer simply reflects her desire to build her own leadership team.
Appointed last August, Dr. McCance-Katz could have fired del Vecchio after her first 120 days in office or demoted him if she wanted to undermine peers and del Vecchio’s recovery work as CMHS director. She kept him as one of her top mental health and substance abuse advisors until last week when she asked him to direct SAMHSA’s Office of Management, Technology, and Operations, a top post at SAMHSA, but one with less direct oversight of mental health and substance abuse policy.
Said one insider: they simply didn’t gel and she has the right to pick her own managers who support her. Said another: she bent over backwards giving him chances but it didn’t work.
A third point of view expressed to me is that speculation about del Vecchio’s reassignment is resulting in both Dr. McCance-Katz and del Vecchio being wrongly branded. Her as being anti-peer. Him as not carrying about the serious mentally ill.
This blog is based on interviews with those familiar with del Vecchio’s transfer. Several officials agreed to speak only after being promised confidentiality.
Angst among peers and del Vecchio’s supporters is partly rooted in the past.
After resigning as SAMHSA’s Chief Medical Officer – a position Dr. McCance-Katz held for two years – she published a 2016 essay in the Psychiatric Times that was highly critical of SAMHSA. She wrote that SAMHSA’s leadership (which included del Vecchio although he was not specifically named in the essay) was openly hostile toward the use of psychiatric medicine, didn’t focus on helping the serious mentally ill, and questioned whether bipolar disorder and schizophrenia were even real, arguing that psychosis is just a “different way of thinking for someone experiencing stress.”
Those criticisms echoed comments raised at congressional hearings held by former Rep. Tim Murphy (R.-Pa.) when he was drafting his Helping Families In Mental Health Crisis legislation. SAMSHA critics Dr. E. Fuller Torrey, Dr. Sally Satel, Mary Zdanowitz, and D. J. Jaffe all complained that SAMHSA was ignoring serious mental illnesses in favor of feel good remedies that had little scientific basis but were popular with persons with mental illnesses who were not as ill as the most sick.
Because of del Vecchio’s support of the recovery model and wellness, he became a target.“Paolo del Vecchio is a big part of the problem,” Jaffe wrote in an email to me. “He has done virtually nothing to focus CMHS on the seriously mentally ill…”
Del Vecchio’s supporters strongly disagree that SAMHSA has ignored serious mental illness during his tenure. Under his leadership, SAMHSA launched a First Episode Psychosis initiative and established programs promoting Assisted Outpatient Treatment, criminal justice reform and integrated care. More than 75% of the budget was focused on SMI, according to a blog that he authored. His supporters further insist that del Vecchio was not anti-medication as evidenced by another blog that he posted explaining how SAMHSA was helping individuals obtain medication.
“Paolo del Vecchio gave us hope,” said a supporter. “He is a hero. Under his leadership, recovery and wellness became a central focuses of SAMHSA, not simply forcing individuals to shut up and take medications.”
Paolo del Vecchio’s past and rise through SAMHSA
Del Vecchio was first hired by SAMHSA in 1995 to work in what then was a newly created office of consumer affairs. At the time, he was identified as the first SAMHSA employee who openly acknowledged that he had a mental illness. At one point, he contemplated ending his life. His support of the recovery movement is deeply rooted in his childhood, according to one newspaper account about him.
School officials pulled an 8-year-old boy who was having mental health issues out of class, so he could see a psychiatrist. On the bus ride home, other students taunted him. “Psycho! Crazy!” Once home, he “cried his eyes out to his parents.” For 20 years he avoided mental health services. Not if it led to that kind of rejection and contempt. “Of course, I was that 8-year-old boy,” said Paolo del Vecchio,
His emergence as an advocate in the early 1990s dovetailed with the national recovery movement that stressed empowerment, hope and self-determination and a rise in advocacy by peers. (Full disclosure: my son Kevin is a peer specialist who works in Arlington County.)
The ongoing argument about recovery/self determination – peers/parents
The tension between peers and their families, as well as the recovery model versus the medical model has been building for years. The recovery model emerged after deinstitutionalization, with the rise of consumer empowerment and enforcement of civil rights laws intended to protect individuals who became ill. With those changes have come complaints from parents that the pendulum has swung too far – allowing persons who have no “insight” about their illnesses to die in the streets “with their rights on.”
Questions have been raised about what is recovery? SAMHSA spent 16 months writing a 1,100-word definition of recovery that del Vecchio described in a 2012 blog.
Recovery from Mental Disorders and/or Substance Use Disorders: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
William Anthony, Director of the Boston Center for Psychiatric Rehabilitation, described the recovery movement as:
“A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”
Critics of the recovery movement argue that it is used to justify spending badly needed mental health funds on anything people believe will help them reach “their full potential” and is based on the belief that everyone can recover, ignoring a high percentage of individuals with schizophrenia and bipolar disorder who do not get better. The idea that everyone recovers is especially offensive to parents whose children have ended their own lives or are incarcerated because of crimes that could have been prevented with treatment. In an email, D. J. Jaffe, author of Insane Consequences, and one of the drafters of Murphy’s bill, commented:
Dr. E. Fuller Torrey wrote that “Under the ‘Recovery Model,’ John Hinckley was defining his own life goal—the attention of Jodie Foster—when he shot President Reagan.” Dr. Sally Satel of the American Enterprise Institute and Mary Zdanowicz, former executive director of the Treatment Advocacy Center, wrote an op-ed astutely observing, The Recovery Model ” is a dangerously partial vision. It sets up unrealistic expectations for those who will never fully ‘recover,’ no matter how hard they try, because their illness is so severe. What’s more, exclusive emphasis on recovery as a goal steers policymakers away from making changes vital to the needs of the most severely disabled. Dr. Satel was a former member of the Center for Mental Health Services (CMHS) National Advisory Council. She believes if a psychiatrist followed the principles of recovery, “he would be at risk of committing malpractice.”
Not surprisingly, those who support the recovery movement think differently. Said one:
In my view recovery is the middle ground. It recognizes that you need medical along with other supports including peer and family support. While I recognize the incredible distress that families go through, shouldn’t we hold out hope for all including those with the most serious of conditions? Would we say the same thing about a person with advanced cancer? This is not to say that all will achieve full remission or that all will be completely independent but that all can improve and all can live full lives to the best of their abilities. Recovery provides a unifying message and vision to consumers, families and providers that we can pursue a better life. It says we do not have to live in “back wards” but “back home.” Frankly, the Supreme Court endorsed this through the Olmstead decision.
Dr. Satel’s statements about malpractice don’t coincide with the fact that the American Psychiatric Association is officially on record endorsing recovery and developed training to foster such among their members. The American Psychological Association, the American Psychiatric Nurses Association and the Council of Social Work Education have all endorsed recovery. I doubt they would have done so if this was anywhere near malpractice. Recovery is now mainstream.
It is into this debate that Dr. McCance-Katz now finds herself.
When it comes to peers, Dr. McCance-Katz is on record stating that she supports peer involvement and wants to strengthen it. She also has said that she wants to elevate the voices of family members. Lived experience does not only apply to those with diagnoses but also family members. She has spoken about the importance of SAMHSA focusing more on science and evidence that programs produce intended results. She also has spoken about the need to focus on the most sick.
What I find frustrating about this ongoing argument is the automatic assumption that there are only two sides and only one of them can be correct. This pits those with mental disorders against family members and family members against their loved ones, when both sides should be working together to improve our system. It is the extremes that set us apart yet those extremes matter. Where can there be compromise?
The speculation and mistrust swirling around Paolo del Vecchio’s transfer reflects how difficult it is to get all sides to agree.
Dr. McCance-Katz has two years to reshape SAMHSA. I have personally always found her to be earnest, thoughtful, and frank in her conversations with me. I believe she values peers. I believe she wants to give a greater voice to family members. I believe peers and family members both need to be heard.
The trick will be pulling that off. I wish her luck.
Addendum:
In doing research for this blog, I came across this speech that Paolo del Vecchio delivered during a Mental Health America conference. His comments begin at 22 minutes, 50 seconds. It sums up his views.
For those of you who don’t have time to watch, here’s an excerpt that explains why del Vecchio has been such a strong supporter of peer voices and the recovery model.
Some 20 years ago, as SAMHSA was getting underway, a group of advocates, consumers and family leaders staged a sit-in in the office of then SAMHSA Director Bernie Arons. Bernie issued a letter – and I have that letter outside my office today – in which he promised that he would hire a person with lived experience to work in consumer affairs. I ended up applying and getting that position.
Let me share a little story about that. As I began that job, one of the workers – actually she was the special assistant to the director – said it was going to be her job to take care of this ‘consumer’ coming into work at the center. She expected – and she is a nurse and she was certainly very well meaning – she expected someone was going to come into work shuffling and drooling at the mouth. She was going to take care of this ‘consumer.’
Long story short.
Three years later, we were married and 16 years later, we have three beautiful children, a home and a mortgage, two cars and two dogs and we take care of each other.
What changed my life, what helped me move forward?
It wasn’t any specific treatment that I received though I found treatment very helpful. What changed me is what I found in the community – certainly the support of peers. I found peers with the courage and humility to share their stories. I found peers who weren’t sitting on the sidelines and I joined them. We took action both individually and collectively to change the way society thinks about mental illness and how society responds to the people who experience them.
Most importantly, I found peers who believed in the hope and the promise of recovery…
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