What works for mental health system change: evolution or revolution?

The mental health system has realized significant metamorphoses in the standards and practices of quality care for people with psychiatric disability during the past decade. Now change agents are wrestling with effective strategies that help real-world systems to adopt programs reflecting these metamorphoses. Two fundamental approaches to systems change are compared and contrasted here: evolution and revolution. First, the authors compare the different ways in which evolution and revolution might approach change in the mental health system. They do this by showing how they might influence the transformation of day treatment into supported employment programs. Then, the authors present the two approaches as naturally occurring change processes that work in tandem to affect real-world adaptations. Finally, they summarize practical strategies that change agents might adopt to realize evolution and revolution. Clearly, all stakeholder groups need to become strategic about system change so that real-world practices keep up with the ideals emerging in practice guidelines and evidence-based practice reviews.