“Progress Only Occurs when People Make Demands”: Paolo del Vecchio Reflects on a Life of Federal Service, and His Fears and Hopes for the Future

Paulo del Vecchio is a person in long-term recovery from mental health and addictions, who has been a leader in the peer recovery movement for 40 years. He recently completed a 30-year career at the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, where he served in multiple roles including the director of the Center for Mental Health Services and the founding director of the Office of Recovery.

Paolo is now an independent advocate, working to advance recovery-oriented policies and practices on national and international levels.

In this interview, he speaks with Mad in America’s Leah Harris about his roots as a housing justice activist to his decades of public service at SAMHSA, what worries him most about mental health in today’s America, and where he sees hope in the recovery movement that he helped create.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Leah Harris: I’m wondering if you can start off by talking to us about how you got involved in the field of mental health, your early activism and lived experiences?

Paolo del Vecchio: I’ll start with a little bit about my story; stories are the basis of what the peer recovery movement is all about. Like many of us, I grew up in a family that knew mental health and addictions intimately. My mom, who I consider the heroine in my life, was someone who was state- hospitalized multiple times during her life. She was someone who was subject to the evidence-based practices of the day, including forced insulin shock treatment. She went on to raise four kids by herself, got a graduate degree in philosophy, taught for many years in the local community college, and became a nationally published poet. My number one champion. 

My dad was a Korean War vet. He didn’t talk much about his battlefield experiences, but dealt with it through the bottle. Some of my earliest memories were the smashing of whiskey bottles and the domestic violence in my household. That early childhood trauma is what I believe led to my own mental health and addiction issues. As a child experiencing these things at home, blaming myself, I became wary, withdrawn, depressed, anxious, fearful. The teachers at my school in the third grade noticed this. They decided to ask me to see a school psychologist. That was my first experience in receiving mental health care. It wasn’t necessarily bad, talking to that school psychologist. What was bad was that she pulled me out of the classroom in front of my peers. What I remember most from that day was the ride home on the school bus: “What are you crazy, psycho? What’s wrong with you?” Going home to my parents and saying, “There must be something wrong with me.” 

Frankly, that turned me away from seeking care for 20 years. Why would I want to have anything to do with seeking treatment, if social exclusion–what we term stigma, was associated with these conditions? Instead, like many young people, I turned to drugs and alcohol to deal with the pain, depression, and anxiety I was feeling. Anything to dull with the pain during that time, [when I was] bullied almost on a daily basis, from elementary through high school. 

Trauma compounding trauma is one of the things that we know has a serious impact on our wellbeing. That was certainly the case for me. Like many people, young adulthood was the hardest time: Not being able to get out of bed for days at a time, finding myself feeling that my life wasn’t worth living. 

My plan was to end my life in front of a subway train in North Philadelphia where I was living. Down on that subway platform, I was ready to take that step as the train was coming down into the station, with the light approaching. As I was getting ready to take that step, the thought of my mom pulled me back from that ledge. I say that because family really is important; there are a lot of differences between peers and families, but family support for me has been really critical. 

I decided to try to get some help. I went to a local counseling center, and told them that I was in crisis. They said, “Come back in 30 days. We have an opening then.” How many times do we turn away people seeking help? But what I found there changed my life. It was literally a sign on the door for a job at a local community mental health agency, the Mental Health Association of Southeastern Pennsylvania. I went to work on an information referral line–what we call a warmline today. That was my first introduction to peer support. 

I found three things through that job: One, is that I wasn’t alone with these conditions. The second thing I found was that recovery was possible–in fact, we could overcome these issues. The third thing I found was that by helping others, we also help ourselves. That gave me a sense of purpose, a sense of value for my own life. And so that really began my life’s work in terms of peer and recovery work.

Harris: I’m curious if you could share a little bit more about some of your earlier experiences with peer support and with exposure to the movement, and how those experiences shifted your life trajectory?

del Vecchio: I went back to finish my college degree, got a Master’s in social work and graduated summa cum laude, and I went back to work at the Mental Health Association of Southeastern Pennsylvania. That was in 1987. I have to give Joe Rogers lots of credit, because he introduced me to the national peer movement. I had opportunity to meet with some of our really founding members–Judi Chamberlin, Howie the Harp, Sally Zinman–these incredible leaders in the peer movement. 

At that time in Philadelphia, we were going through a process of closing a local state hospital–Philadelphia State Hospital, also known as Byberry–which was notorious for abuse and neglect. The state, in their wisdom, decided to close that hospital and to develop a range of community services, including peer-operated services. We found ourselves developing community peer programming, including drop-in centers and vocational programs. I had opportunity to work with Laura Van Tosh on Project OATS, one of the first programs nationally to hire peers to do street outreach to folks experiencing homelessness in the city of Philadelphia. We developed housing programs. With the help of Jacki McKinney, another one of my mentors and leaders, we created a consumer case management program that was also on the forefront of the peer workforce that we have today. 

1987 was also the first time that I attended the Alternatives Conference. That was a seminal activity for me: To be in a room with five other 500 other peers with a sense of homecoming, acceptance, and welcoming like I’ve never experienced before. 

We were also very much involved in direct action advocacy under Joe’s leadership. I found myself one day chained to the doors of a Federal office building in downtown Philadelphia, where we were protesting around homelessness and the need for housing. I spent a day in jail because of that action, and ended up with $6 million in state new funding around housing. Sometimes you need to do those kinds of actions to get the change that’s necessary. 

At that time, I decided to make a change from working outside of the system, to try to work within to affect change, so I went to work for the Philadelphia Office of Mental Health.

Around the time that SAMHSA was established, in 1993, they used to do an annual conference for the Community Support Program, and there was a track for peers and families. One year, because of politics, they decided not to hold that track. Folks weren’t happy about that. The conference was just a few blocks from where SAMHSA headquarters was, and they’re still in that building. People walked over to SAMHSA headquarters; it was before the tragic bombing in Oklahoma City, where you could walk into any Federal building. They staged a sit-in, at the office of Bernie Arons, the then-director of the Center for Mental Health Services. Bernie met with them, and he issued a letter to Sylvia Caras, one of the leaders of that action, a California leader who has since passed on, where he pledged to hire a person with lived experience to work on recovery. 

I ultimately ended up applying for that job, and was the first self-identified person with lived experience working at the agency because of those people took that action. The 30 years that I had working at SAMHSA, was because of the actions of those people. 

Harris: Thank you, Paolo. I’m wondering if you can share your perspective and reflections on SAMHSA’s accomplishments under your leadership over the past 30 years.

del Vecchio: There’s a lot I’m really proud of. I think SAMHSA’s definition of recovery that we published at the early part of the century continues to hold up over time. Key elements of that definition being that recovery is all about helping people improve three things: One, their health and behavioral health. The second, is to improve their independence, to live a self-defined life. And the third is to pursue their full potential. I think those key aspects continue to resonate with communities, states, and individuals across the country. 

Second, I would say the peer workforce. From that work that we started 40 years ago to now, today, the estimates are that a hundred thousand certified peer specialists are working in all kinds of settings across the United States. That shows real progress, and obviously, there’s a lot of ongoing challenges with the need for livable wages for people, the need to have career advancement, the need for people to have recovery-friendly workplaces. 

The third is the involvement of people with lived experience overall. When I was appointed the director of the Center for Mental Health Services for me, and for many of us, that was a landmark event in a way of “breaking the Prozac ceiling,” I call it. That really demonstrated that peers can do anything. People with lived experience can in fact achieve all kinds of jobs and activities, given the opportunity.

I’m really proud of work that we did to reduce the use of seclusion and restraint in settings across the country, developing guidance, training, regulation, and legislation. On my last day at SAMHSA, I had another colleague, a young man, come to my office and say, “Your work really impacted my life. I was in a residential treatment center as an adolescent, and the director came in with a piece of paper from SAMHSA. They ended the use of seclusion on that day.” Having that kind of impact is really meaningful. But the use of seclusion and restraint continues to happen far too often around the country—in residential treatment centers, hospitals, many other places. There is still much more work to be done. 

Finally, my last two and a half years as the director of the Office of Recovery was also a capstone to my Federal career, doing work to advance peer crisis respites, which have been such an exciting development to see coming up all over the nation. And doing work like last year’s technical expert panel on LGBTQ+ plus recovery. Those are a few of the things that I’m really proud of from my federal career.

We did a survey last year that identified that about 20% of SAMHSA’s staff are now people who identify as having lived experience, either as people in recovery or family members. So from myself, as one person 30 years ago, to almost 200 staff now at the Federal level, that shows progress in terms of what we’ve been able to accomplish collectively.

Harris: I’m curious if, looking back over your time at SAMHSA, were there any things that you wished that SAMHSA had approached or done differently?

del Vecchio: The big thing in my view is the allocation of resources and funding for recovery and recovery supports. Congress has a lot to do with that; SAMHSA basically administers the dollars. When I started the Office of Recovery, I did an analysis of the funding levels, and the vast majority of the agency’s funding, probably 95 percent, goes to treatment and service delivery. About five, six percent goes to prevention activities. And recovery supports are less than one percent of the funding that gets forward. If we talk about rebalancing care in the country and moving towards home and community-based services, ways to keep people living healthy in communities, then we need recovery supports like health, home, purpose, and community. Having access to quality and affordable healthcare. Having safe, affordable housing: That’s probably number one. The data is really clear on this: If we give people a safe place to lay their head down at night, that’s probably the most important thing for people to be able to recover in long term. Third thing, purpose: jobs, education, we know those are critical. Finally, community–having peer support and family, these are the things that sustain us in terms of our recovery. And yet, less than one percent of funding goes to these things.

Harris: Thinking forward, what are your thoughts on SAMHSA’s future direction? Where do you see things headed at the agency?

del Vecchio: A lot of concerns. At my closing remarks at my retirement event, I talked about what I termed the “Three Cs:” the carceral, corporate, complacent state. In terms of carceral, the ongoing criminalization and increased use of involuntary interventions and coercion that we’re seeing across the country. This is bipartisan, right? We’re seeing this in red and blue states — blue states, in particular — the increased use of outpatient and inpatient commitment. When we see our president calling for increased institutionalization and long-term institutionalization, if that’s “making America great again,” that’s a real problem. So that worries me, hugely. 

In the coming years, we’re going to see an increased push for more Federal financing of long-term institutional care through lifting of the Institutions for Mental Diseases Medicaid financing. That’s right on the horizon and coming quick. That’s very worrisome. All the focus we’ve had, both at SAMHSA and across the nation, on crisis care–there need to be crisis supports, but not hospitals. That is not the answer to what we need to have happen, which is preventing crises from occurring in the first place. And then, alternatives to hospitals and emergency rooms, like crisis respites, are really key. 

The second C is corporate: What we’re seeing now are private equity firms buying up community behavioral health providers across the nation, and what this means in terms of the corporatization of care, the quality of care, and the potential for abuse and neglect. We know that private psychiatric hospitals have a sordid history when it comes to quality of care, abuse, and neglect issues, and frankly, fraud as well, in terms of Medicaid fraud. And so, again, the combination of the privatization of care, along with corporatization of care, along with the carceral, and you can see a really concerning match in terms of the push for increased hospital care and involuntary hospital care, along with private interests that perhaps are pushing this as well for their own profit margins. 

And finally, the third C is complacent. The worry here is, with the peer workforce, has the peer recovery movement become more complacent? Are we satisfied with these low-paying jobs, in fact that many of us are receiving? And the need to speak out, to have advocacy–not just peers, but frankly well-meaning providers and policy makers and others, particularly during these times where our very rights are being threatened. All these things are major concerns. 

In addition to these three Cs, the concerns about the attacks on diversity, equity, and inclusion and accessibility. I talked earlier about the LGBTQI+ work that we did in the Office of Recovery. The guidance that we developed out of those expert panels were removed from SAMHSA’s websites. That’s just one example, of course; across government, all efforts focused on diversity, equity, and inclusion are being removed. That’s not about “making America great again,” but putting us back decades and decades. 

When we look at SAMHSA’s future, we also have to question what SAMHSA itself will even have a future when we’ve seen major layoffs and firings occur across government. Just before I left SAMHSA, in fact, half of my staff at the Office of Recovery were terminated. Most of these were individuals that were hired through Schedule A disability hiring authorities, and had a longer probationary period. They were terminated without cause. This included veterans on my team, who were terminated this way. 

With the push from across the Trump administration to look at shrinking government, will SAMHSA be combined with another agency? There’s been lots of rumors about that in the past. Folks can criticize SAMHSA, but the agency has been a central point around advancing peer voice and recovery concepts. Not having that central Federal voice anymore will be also a way to push us back decades. So those are a few my concerns about the future of SAMHSA, and the direction of mental health and addictions overall.

Harris: Thank you so much, Paulo. It’s really helpful to kind of think through that framework of the three Cs, as well as the equity and access pieces to really understand the sort of intersecting nature of this beast that we are collectively confronting at this time. 

I’d be interested in hearing more of your thoughts on the current state of mental health. You’ve already touched on the rise of outpatient commitment. There’s the increasing diagnosis of children and young people, among many other issues. In your opinion, where do you see the United States heading in terms of these kinds of challenges?

del Vecchio: We talked earlier about homelessness. That’s a huge challenge, when we have record numbers of people living in our streets and shelters–last count from HUD, 770,000 individuals on any given day. As we spoke to before, there’s an affordable housing crisis in every community across the nation. And yet, people who are unhoused are too often blamed for these conditions, and then subject to things like being swept off the street, subject to involuntary treatment. The proposals for things like wellness farms from the current administration are really concerning, about forced labor in these settings and, are these going to be voluntary? 

I do think there’s some things that we’ve learned over the years. We’ve certainly seen a lot of progress in trauma-informed care. But a lot of it is in words only. How can we assure that we look at how trauma impacts the development of our conditions? How do we look at preventing trauma in the first place? 

When we think about child abuse and sexual abuse in particular, so prevalent in our communities but often un-talked about, if we really want to look at preventing mental illness and addictions, then we need to get in front of these issues. So those prevention issues are critical. 

Related to that is that I’ve really come to believe that inflammation is, in fact, at the heart of many of the conditions that we experience. Inflammation is often triggered because of traumatic stress. And so you can connect the dots here that the traumatic stress impacting inflammation that is clearly connected now. The science is really clear: The connection from inflammation and things like our gut microbiome, in fact impacting the development of mental health and addictions, including psychosis. 

I also think we’re seeing a greater recognition of the limitations of psychiatric medications and the efficacy of medications, that certainly this audience knows well, are limited: 30% efficacy, on average. The development of things like psychedelics hold lots of promise, but again, the corporatization of psychedelics is also a concern. But there is a growing recognition that there needs to be much more of a whole-health holistic care for people really to achieve wellness in long term.

When it comes to children, we’re seeing, particularly among youth and girls, high rates of reported depression and anxiety. Suicide is still the second leading cause of death among our nation’s youth. And it’s not too surprising–with the anxiety, the trauma, that youth experience growing up in this world today — everything from climate change to the politics that we’re experiencing, to gun violence, their experience in our schools. It’s not a surprise that our youth are in crisis. And so again, I think we ultimately must help solve these issues, rather than reverting to things like more medications or residential treatment centers.

Harris: What are your views on the current state and opportunities for the peer support and recovery movements?

del Vecchio: We talked about the peer workforce earlier and my hope — I think many of our hopes — was that the peer workforce would be the Trojan horse to get within mental health systems and affect change from within and promote recovery, trauma-informed care, and rights protections in particular. The fear has always been: We don’t want to create an oppressive mental health system, using people with lived experience as the workforce. And so it’s really incumbent on us to look at ways of avoiding “peer drift” as we’ve called it, to keep the values and principles of what the peer movement has been about — self-determination, about choice and voice, about rights protections front and center as the peer workforce continues to grow. I think there are continued opportunities there. 

I think there’s also opportunities to take a bigger tent approach with our work. In the Office of Recovery, we were very much working towards that. So not just mental health, but bringing people in recovery from addictions and substance use, working as colleagues with mental health peers. Really, they’re all similar issues that we’re facing. I also think working with broader disability communities holds a lot of promise around community living, around self-direction, determination, independence.

I shared earlier about how there’s been differences between peers and families, but joining with families around things that are common ground–like peer support, home and community-based services–these are all things that families and peers agree on. Working alongside supportive families also presents a lot of opportunities. 

I think there’s opportunities with crisis care, with the focus on peer respites. We’re seeing incredible growth in peer respites, which were really Judi Chamberlin’s vision in On Our Own, her seminal work. Seeing that come to life has been awesome. 

I also think getting back to the roots of mutual support — we’re going to face a lot of tough times in the years ahead — getting back to people at local community level supporting one another, through mutual support groups. We don’t need the government to convene a support group. 

The final thing–I talked about complacency earlier. One thing I certainly have learned in my career in government and that history tells us is that progress only occurs when people make demands, to paraphrase Frederick Douglass. And that you know, we need to speak out, we need to be vigilant, we need to continue to advocate around rights protections because particularly during these times, and yeah, there might be some risks involved and, you know, but the long-term benefits of speaking out of using our voices not only for ourselves, but for our peers, we’ll make all the difference in the long run.

Harris: I have one last question for you: What is next for you personally? After this 30-year career at SAMHSA, what are you excited about being involved in next?

del Vecchio: I may have retired from federal service, but this has been my life’s work and I’m going to continue. There’s a saying in the disability community: “I’m not dead yet.” I’m going to continue to be active and involved. I’m going to continue to use my voice after 30 years of being a Federal leader, through LinkedIn and through other ways to get the word out as well. My dear friend and colleague Gilberto Romero taught me the adage of ‘each one teach one,’ early in my life. The more that we can continue to share knowledge and use our voices, that will help ultimately to empower us and empower new voices in the next generation to come up, to continue to speak out and speak truth to power.

Harris. I think that is a perfect note to end on. I want to thank you so much once again, Paulo del Vecchio, for joining us today on the podcast.

del Vecchio: Thank you, Leah.

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