When I first became involved in community mental health more than twenty years ago, I had a rather paternalistic view of mental health services. I saw the providers and their programs that took care of individuals at the center of the system of care. I have come to understand over these years that the real center is the individual struggling with mental illness and not the system

itself. I learned this by listening to peers (current or former recipients of services) who have come to play a significant role in the planning and implementation of services in Erie County. Peers, consumers, and family members now participate in every one of the County planning committees. Their contribution has been invaluable. It was a consumer (Ritchie Freelock) who first suggested the need of a drop-in center. Now Harbor House serves more than forty of the most vulnerable individuals every night. It was a consumer (Marcie Kelley) who said that individuals wish to live as independently as possible As I shall address shortly, there are presently more than four hundred supported housing units that allow individuals that possibility. It was a consumer (Michael DiPirro) who first said that vocational programming must be a priority, and there are literally hundreds of individuals enrolled in vocational programming each year.

However, the role of peers and consumers goes beyond merely advising and planning. Dozens of peers presently work side by side with professionals, delivering services as equals. As those who have been there, consumers seem more able to engage certain clients and thus make a unique contribution. In Erie County, peers offer supportive services to individuals transitioning from the hospitals and the jails back into the community. They help these people maintain stability and live independently in our housing programs. They work in vocational programs, in the social clubs and drop-in center. Peers provide education to consumers in agencies throughout the county, and they have instituted their own phone-line. Much of this has resulted from the work of what is known in Erie County as "the Partnership," which consists of representatives of peers and traditional agencies who have been meeting together for almost four years now. It is something to behold: the executive directors of traditional agencies, planning, and then implementing joint projects along with peers --- as equals. This process, perhaps more than anything else, demonstrates how far the system has come from its paternalistic past to the present.

Developments in Erie County with respect to housing and accompaninging supports also merit comment. As a sign of the importance of this area, Michael Weiner, Erie County Commissioner of Mental Health, has recently established a task force to address housing and supports as one of the highest priorities. This task force will build on the work of the housing needs assessment committee that has been working for about six or seven years now. It is noteworthy that the task force is being asked to approach planning for housing and related from as comprehensive, integrated, and coordinated a manner as possible. Until recently, the tendency has been to look at housing issues as a separate piece within the mental health system. This new initiative will approach housing and supports in a more comprehensive manner that is coordinated with other aspects of the system such as outpatient and outreach. To some extent, this more comprehensive approach to housing and supports is a result of the real successes during the past several years with the development of more than four hundred individual scattered-site apartments for individuals with a mental illness, most of whom have also been homeless. Also, transitional housing units have been established for adolescents aging out of the child system, as well as for adult individuals who not yet ready for more permanent housing. This has been accomplished using State Reinvestment and HUD Shelter Plus Care dollars. (Acknowledgment must be extended to Deborah Goldman of the Erie County Department of Mental Health for supplying the leadership during four years for these housing initiatives). Beside those initiatives, funds are presently being sought for individuals with a mental illness who are generally excluded from housing programs for several reasons, and Erie County has recently received resources to develop a seventy-five unit Single Room Occupancy (SRO) project. All these initiatives during the past several years have been in response to the request and need for individuals to be able to live in the community as independently as possible. These initiatives represent the belief that recovery, while different for each individual, is a real possibility, and that the goal of our system is not to keep and take care of individuals, but to support and assist them to live their lives in as healthy a manner as possible.

The significance of the newly established task force is that it will look at housing and supports as a whole, taking into account all levels of care. A recent assessment has already indicated that there is a great need for more supported housing units as well as for emergency housing units. Furthermore, there is growing evidence that we need to develop housing that incorporates even higher levels of care than we have been addressing. There are a significant number of individuals with a mental illness who need levels of care with respect to housing and supports that are simply not adequately available in our community. The housing task force is coming at an opportune time and may provide the next significant step to address this issue in a comprehensive manner.

Certainly, one of the biggest improvements of recent years has been the decision within the county to find ways to engage individuals who have too often been deemed as too difficult to serve. As a result, there is an increased attempt within the system of care to think "outside the box" of the traditional package of services. Those responsible for providing services can no longer be content simply to terminate individuals who do not strictly comply with program demands leaving them to fend for themselves. That approach tended to leave many individuals outside the system of care who were most vulnerable and at risk, most in need of intervention. Several initiatives are presently underway in the county to address the needs of these individuals. No doubt, some of this is being done as part of the Assisted Outpatient Treatment initiative for which the new state law was the catalyst. Nevertheless, county planners listened carefully to the recommendations of consumers and family members and implemented an approach that seeks to make available to individuals an array of service options they might find more friendly and amenable to their individual needs.

The hope is that individuals who have generally not accessed services will opt to engage these more mobile, community-based, outreach, and individualized services. Four new teams of care coordination (all including peers) have been developed to engage individuals where they are rather than demanding compliance with programming they find alien. Besides these teams, which include two Assertive Treatment programs, there are the homeless outreach programs, and also Alternatives to Incarceration initiatives. No fewer than one hundred individuals in Erie County have opted to participate in this service approach. Although it is much too early to adequately evaluate these initiatives, the preliminary indicators are very encouraging. Indeed, these recent initiatives are a good example of a responsiveness that takes the needs of individuals with mental illness as having priority over the needs of the system itself. It is a sign of looking for ways to accommodate the system in a manner that individuals needing help will see as friendlier and more acceptable. Indeed, what I expect is that the work presently going on in this direction may well help us understand other areas in the system of care which call for needed improvement, such as a better approach to the transitioning process from hospital to community.

I suspect that the implementation of the Special Needs Plan (SNP) has the possibility of moving things even further in this direction. Actually, it is a tribute to many years of planning and the concerted efforts of the networks in the county that Erie County has been selected for the SNP. And while many individuals have worked very hard for many years on this project, I cannot but make special note of the efforts of Peter Curtis, the Deputy Commissioner of the Erie County Department of Mental Health and Jeanne Figurel, the executive director of Spectrum Human Services. Although it is certainly unclear yet just how the SNP will develop, and there are many pitfalls to encounter, nevertheless, I am hopeful that it can allow us to move even further in the directions that have been underway. The SNP can help focus the system even more on the individual whose needs the package of services can be better tailored to serve. This will not happen automatically, and a great deal of attention needs to be given to developing the SNP properly. Unfortunately, the manner in which managed care has developed does seem to have placed more obstacles in our way than were necessary. I continue to hear from too many individuals, both providers and recipients, that there are simply too many restrictions placed on the delivery of services. I have no doubt that under our present managed care approach, there are people not receiving the adequate array of needed services. Also, the burden of the bureaucracies and paper work involved are becoming overwhelming. Hopefully, the SNP will not develop in such a direction.

I cannot reflect on where we are without commenting on what I see as our failure to break through the prevailing image so many within our community still have with respect to those who do struggle with a mental illness. Unfortunately, the stigmatizing and stereotyping of individuals with a mental illness remain. We see this time and again in forums where applications have been made for Siting and Special Use Permits for programs and services. We are encountering barriers and obstacles to locating community-based services where they are most needed. We simply have not done enough by way of adequate community education. We have not done enough to bring political figures to understand the significant contribution mental health services make not just to those individuals they serve, but to the larger community as well. Indeed, our very successes over the years may well have brought these stereotypes and stigmas to the surface.

Apparently, many in the community were content when mental illness was hidden away, locked away, kept from sight. More individuals who have a mental illness are living in the community, and this seems to be fueling the underlying fears, ignorance, and bias. Thus, in spite of what I see to be a lot of positive developments over the years, there is no cause for complacency. The work remains in process and on the way.

I have said nothing about the children’s system, though there have been significant developments over the years with such things as the enhancement programs, the Coordinated Children’s Service Improvements program, the Respite programs, the Waiver programs, and others. The more recent children’s needs assessment study also has the potential for bringing about very positive developments with children’s services during the next several years. However, this must be left to another time. The strength of our system is that there are so many individuals participating in it in one way or another who do care and who will not stop looking for better ways to respond to needs. The strength of our system is that there are so many who are willing to keep at it, refusing to give up. The strength of your system is that it remains in process.