Apparently, some people do have an idea, and their name may surprise you: the City of Philadelphia.
The city has been making sweeping changes in how it deals with behavioral health, embracing grassroots recovery movements on a scale that outside experts say no other city has attempted.
The shift introduces a wellness model that has been absent from care for addiction: After an episode of treatment, a network of support will, in theory, help sustain recovery in the community. And for mentally ill people, the new approach encourages real-life goals - riding a bus alone, getting a job - that go beyond managing symptoms.
Saturday will be a coming out of sorts for the city's "recovery transformation": Philadelphia's Recovery Walk is the focus of more than 1,000 September rallies nationwide, and organizers predict 10,000 people here.
"I've been very impressed with what I've seen" in Philadelphia, said Gil Kerlikowske, director of the White House Office of National Drug Control Policy, who will be at the Penn's Landing kickoff. "I think there is a lot to learn from them." The drug czar said the new health law would support similar efforts nationally.
There are challenges in the transition. Reimbursement nationwide is still based on acute care, and providers worry about how they will get paid for recovery services - and whether lawmakers will use the self-help model as a reason to cut treatment funding. More peer specialists raises questions about their training and ethical boundaries.
"Evolution happens very imperfectly," said Mike Flaherty, executive director of the Pittsburgh-based Institute for Research, Education and Training in Addiction. But "this is not a fad. This is a change in the entire way we approach addiction in this country."
Said William White, a national leader of the recovery movement who has consulted for the city for five years: "If somebody at the beginning of that would have said there will be 10,000 people marching in Philadelphia, I would have thought they were delusional."
The medical response to addiction has long resembled emergency-room care: crisis, rehab, release. Adding to the stigma of addiction was the derision of relapse.
"My mother had cancer three times. Every time she had cancer, we got her into treatment, and no one ever said, 'I can't believe you can't get rid of this thing,' " said Libby O'Connell, an executive with the A&E television network who got involved when the reality show Intervention triggered an avalanche of calls for help from families. That led the network to do outreach that includes sponsoring the recovery walk.
And unlike cancer patients, people with behavioral-health problems often are surrounded by obstacles - drug dealers, mentally ill relatives - to recovery.
"It would be like me performing surgery and letting you recover in an alley," said Roland Lamb, the city's director of addiction services. "You are going to get infected, and you are going to die."
The alternative: "It is the empowering of the person in recovery - if they can do it, we are here to help."
The city provides addiction treatment and mental-health services to 100,000 people a year, most of them poor. But its influence reaches into private and suburban centers.
"Things have been changing by the example set by Philadelphia," said Debbie Plotnick, advocacy director for the Mental Health Association of Southeastern Pennsylvania. Now they are looking "not at what people can't do but what they can do."
NorthEast Treatment Centers, which provides services at various locations, made changes even before the city asked.
Wanda Hudson was 53 when she entered intensive outpatient treatment after a life of "cocaine, marijuana, and everything else" that began at age 9. It was 2006, right at the transition, and NET was starting a Consumer Council to give clients - now called persons in recovery - more power in the direction of the agency as well as their own treatment. Hudson was a founding member.
"I needed to know a better way of life," Hudson said. "That voice didn't always come from a clinic staff member. We actually became a voice for each other."
Their first project: Making it more likely that people who walked into the center actually stayed for treatment.
"When you came in the door, they [used to] say: 'Fill out these papers.' It changed," she said, "to 'Hi, my name is Wanda. I'm an addict. How can I help you?' "
When the city launched a pilot program for day programs that work with mentally ill people, the Wedge Medical Center applied. These programs, often called "partial hospitalization," proliferated when the deinstitutionalization movement of the late 20th century succeeded in getting the mentally ill out of state hospitals but failed at returning them to communities. People spend all day at the program - in group therapy at good places, watching TV at bad ones - and return, often to boardinghouses, by van at night.
To do what the city wanted required "a mind-set change," particularly about power and hierarchy, said Jason McLaughlin, who oversees day programs at the Wedge.
Doctors and counselors used to be the experts. Now they are the expert "consultants," he said. Clients "are the experts in their recovery."
The staff had to give up its protective impulses. "Psychiatrists would tell people they could not work," McLaughlin said. Now a counselor might say, "Let's look in the paper, try to put together a resumé," he said, and if feelings of panic come up, "then we will talk about it."
Cornelius Jones, 51, went into a major depression after his wife died and spent two years at the Wedge, graduating from the day program in June. He had been in treatment before, he said, but was never taught about his disorders by staff who had experienced similar problems.
"Learning to live with my illness vs. suffering from my illness," said Jones, now a peer specialist at another center, is like "day and night."
Sixteen agencies run day programs in the city, and 11 have been revamped so far, with two more in process.
To assess the impact of the changes, the city tried to measure whether the day programs' clients were experiencing more or fewer crises that sent them to inpatient units. An analysis of billing data for 190 people who were in the programs for one year before the transition and one year after found a 43 percent drop in inpatient charges, from $982,895 to $561,011.
Although there have been no randomized studies, parts of what the city is trying to do have been found to be effective in academic research, said psychiatrist Larry Davidson, director of the Yale Program for Recovery and Community Health who has consulted with the city.
"I would say Philadelphia is leading the country at this point at what the feds are calling a recovery-oriented system of care," said Davidson, who had just returned from a Washington summit on recovery last week. The city's practice guidelines, due out in a few weeks, "will be the cutting edge of where the [federal] government is trying to go."
The recovery orientation has roots in mental-health and addiction consumer movements that began in the 1930s with Alcoholics Anonymous and other 12-step programs. Then, over the last decade or so, the medical community began to view addiction as a chronic disease. And it recognized that many people with substance-abuse issues had mental illness and vice versa.
Philadelphia, whose reputation in both fields dates to colonial times, started changing its system in the 1990s. Estelle Richman, as city health commissioner and later managing director, worked to create a city-owned managed-care agency to allow more flexibility with Medicaid payments. And she fought to merge historically separate bureaucracies for addiction and mental illness.
These moves set the stage for Arthur C. Evans Jr., who became the first director of the new Department of Behavioral Health and Mental Retardation Services in 2004. The former psychologist, researcher, and community-health advocate had led the transformation of behavioral health in Connecticut, still the most comprehensive statewide change.
Philadelphia is home to 116,000 people in need of substance-abuse treatment, according to federal estimates, and no more than 30,000 receive it from the city; the ratio is similar nationwide. About 165,000 residents need mental-health services; the city covers 94,000. Any attempt to close the gap would require radical rethinking.
Evans began by transforming the $1.1 billion behavioral health department using the same principles that he wanted to guide providers' treatment of individual clients.
Top administrators talk openly about their recovery. People with mental illness are not rejected for jobs; they work with their disabilities.
"In fact, we have people who work here and still hear voices," Evans said.
Although the city pays for treatment that is supported by research, it does not reject different approaches, such as AA and church programs, that work for different people.
Evans' staff members taught clergy how to spot people needing help. They held hundreds of community training sessions in high-risk areas. They revamped the department's website. And they commissioned art.
Artist James Burns spent the last year leading 1,200 people, many on methadone maintenance for heroin addiction, in designing and painting a recovery mural five stories high at Fourth and Berks Streets in Kensington. It was dedicated Wednesday.
The mural, reminiscent in richness, density, and theme of Diego Rivera's work, loosely depicts stages of addiction - hitting rock bottom, deciding to move toward the light, return to normalcy.
In a nondescript office building at 17th and Lehigh Streets in North Philadelphia, peer specialist George Ruiz is showing two newcomers around the Philadelphia Recovery Community Center. He points at a banner across one wall: How can we help you with your recovery? "That's what we do," he said.
The center is run by PRO-ACT, an addiction-recovery group based in Bucks County, on contract for the city. It's like other community centers, shaping services for its constituents: help with education and jobs, sober social events, one-on-one coaching.
Sue Jenkins, who is coordinating the recovery transformation for Maryland's Alcohol and Drug Abuse Administration, visited the center two weeks ago. Hers was the latest in a series of delegations touring the city to learn how it's done: Texas, England, Hong Kong. And next month, Iraq.
"What I was surprised by in Philly was how much [the recovery orientation] makes a difference in how people feel, both clients and counselors and program directors," Jenkins said. "How much better people get, and how much happier they are."
Bits of an emerging community have appeared with no city help. A small, independent recovery high school is looking for a location to start next year. At 24th and Lehigh, a restaurant affiliated with the faith-based treatment organization Stop and Surrender serves eggs, waffles, and conversations about recovery.
The Rebirth to Recovery Barber & Hair Salon opened across the street five months ago. It is owned by Everything Must Change, another faith-based outfit, and offers cuts on a sliding scale, often free, to people in recovery.
"This [area] is a center of people in recovery," said Tony Day, 35, drawn here from Baltimore in 2008, when he was ready to end 16 years of drug use.
"Once you get clean," he said, waiting outside the shop, "you want to look good and feel good about yourself."
Contact staff writer Don Sapatkin at 215-854-2617 or firstname.lastname@example.org.