CMHS National Advisory Council
Meeting Minutes
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council Meeting Minutes
January 20-21, 2000
Rockville, Maryland
Washington, DC
Minutes
Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in open session on January 20, 2000, at the DoubleTree Hotel in Rockville, Maryland, and on January 21, 2000, at the Washington Hilton in Washington, D.C. CMHS Director Bernard S. Arons, M.D., convened the meeting at 9:05 a.m. on January 20. Council members in attendance included Frank D. Burgmann, Francis G. Lu, M.D., Ruby J. Martinez, R.N., Ph.D., Donna Mayeux, Andres Julio Pumariega, M.D., Steven P. Shon, M.D., and Cynthia Wainscott. Dr. Arons welcomed participants and introduced Eileen S. (Teddi) Pensinger, M.Ed., new Executive Secretary to the National Advisory Council meetings, and Deputy Director Thomas Bornemann, Ed.D., who presided over the meeting later in the day.
CMHS Director's Report
Dr. Arons referred committee members to the written Director's Report for details of CMHS's activities since the last meeting, and to the "CMHS Year-end Report for Fiscal 1999." He suggested that members consider ways to use the "CMHS Year-end Report" to further the aims of the mental health field. Dr. Arons discussed the following highlights of recent CMHS initiatives:
- Following CMHS's July 1999 Asian American and Pacific Islander (AAPI) Mental Health Summit, CMHS responded to the Summit's recommendations and published a report. The report was widely distributed in the AAPI community and presented to officials from the U.S. Department of Health and Human Services (DHHS) and the White House Initiative on Asian Americans and Pacific Islanders. CMHS will continue to support the White House Initiative and will host a follow-up meeting on children's mental health issues in the AAPI community.
- On Capitol Hill, the SAMHSA reauthorization bill unanimously passed the Senate; the House will address the issue in the current session of Congress. Language similar to the welfare reform legislation relating to hiring of staff and their religious practices remains in the bill. CMHS's Fiscal Year 2000 allocation includes a $67 million increase for the mental health block grant, the first major increase in that program since it became a mental health services block grant. Funding for the School Violence Prevention Initiative doubled to $80 million. Funding for children's programming increased by $5 million, and increases were also added for the Protection and Advocacy (P&A) Program and for PATH programs for homeless individuals.
- The World Health Organization will focus its 2001 annual report on the state of the world's mental health, building on the momentum initiated by the recently published
Mental Health:A Report of the Surgeon General.
- An anti-stigma campaign media will debut in the spring, a result of the June 1999 White House Conference on Mental Health.
A Visit Down Under: The Mental Health Systems of Australia and New Zealand
Dr. Arons presented a slide talk on his two-week trip to Australia and New Zealand with Dr. Satcher to see first hand those countries' mental health systems. Among the highlights of his presentation were the following:
- Although significant sensitivity and responsiveness is shown to the needs of the Maori people in New Zealand, differences exist in mental health service delivery and outcomes that officials are attempting to address.
- Both New Zealand and Australia demonstrated willingness to convert an "imperfect science" into action, taking a "best-bets" approach and evaluating it, specifically with their national suicide prevention programs.
- The two Pacific countries emphasize mental health promotion and early intervention.
- There is generally better access to health care in Australia and New Zealand than in the United States since health care is a national societal obligation in both of the countries.
- Visits to an Australian health delivery center in the desert revealed that the life expectancy of the aborigine population, representing about 1 percent of the general population, is 20 years below that of the caucasian population in the same area. Work is scarce, and government efforts to promote the arts, such as batik and bead work, are aimed to improve the economic situation.
- In the populated East Coast of Australia, the investigative party learned about a comprehensive educational effort focusing on mental health issues including stigma reduction. The "Mind Matters" program for school-age youth was particularly impressive.
- Dr. Arons shared a variety of informational materials relating to mental health issues including official governmental Australian and New Zealand documents and the free post cards with a stigma reduction message which are placed in restaurants and other public places.
Discussion. Dr. Arons noted that Australia is beginning to study the impact of its stigma reduction campaign. It was also noted that Australia has a well-developed system of care at the community level, which includes housing and other support programs.
Members of the National Advisory Council, individually and collectively, expressed appreciation for the exceptional effort the CMHS staff has put forth, especially in recent months, to meet the challenges of all the new programs they have been establishing and running. Ms. Wainscott urged formal efforts to create and foster existing collaborative relationships with other agencies. She suggested sending a copy of the Surgeon General's report to the governor and head of each legislative body of all the states.
Dr. Pumariega urged reforming IDEA on the California model, which is to superimpose the state law that mandates that, when a youngster's special need is identified, the burden to address the special needs falls not on the school district, but rather on an interagency child-serving team. He noted the promise of pilot mental health courts that direct people with mental illnesses to treatment rather than jail. Dr. Shon echoed Dr. Pumariega's view of IDEA reform. Dr. Shon emphasized that the evidence base for many mental health programs is established.
Dr. Bornemann described companion reports to the Surgeon General's report on mental health released in December 1999. CMHS has the lead for the Surgeon General's Report on Mental Health: Culture, Race and Ethnicity, which will focus on reducing barriers to access to services, and will collaborate with NIMH and the Centers for Disease Control (CDC) on another Surgeon General's report on youth violence prevention. Other papers under consideration include family needs in treatment of elders and substance abuse. Ms. Wainscott urged family/consumer involvement in the reports under development. Dr. Pumariega suggested that the Surgeon General's warning against tobacco use as a public health hazard could serve as a paradigm to promote anti-stigma initiatives concerning mental illness — the message should convey that mental illness is not something that only happens to someone else. Dr. Gottlieb cautioned against inciting anxiety about this subject. Ms. Wainscott stated that instead of the word "stigma," she now uses "discrimination" and "prejudice." Ms. Mayeux pointed out that in successful media campaigns, the "shocker" message comes first, and the educational message follows.
Consumer Affairs Update. Paolo del Vecchio, M.S.W., CMHS Senior Policy Analyst, updated Council members on consumer/survivor-related activities. He described the nomination process for the Consumer/Survivor Subcommittee, noting that 100 applications were received for the nine slots on the new subcommittee. At the Houston Alternatives '99 conference, CMHS sponsored a multicultural training institute and the second People of Color Consumer Survivor Summit. CMHS also sponsored a delegation of consumer leaders to the World Congress for Mental Health in Santiago, Chile, in September 1999. Consumers have been involved in the formulation of mental health objectives for Healthy People 2010. A series of anti-stigma events are continuing. In the wake of the Institute of Medicine's December 1999 report, CMHS, as a member of the federal government's interagency Quality Improvement Council, will examine the government's response to medical errors. CMHS continues its involvement in bioethics, promoting the Patient's Bill of Rights, and updating the Consumer Report Card. CMHS is planning regional meetings in New York and San Francisco. Long-awaited departmental clearance is about to be conferred on a series of written materials.
CMHS encouraged and facilitated consumer participation throughout the formulation, review, and kickoff of Mental Health: A Report of the Surgeon General. Several messages in the document reflect this perspective, notably the emergence of the consumer movement and its importance as an agents of change; a recovery perspective supported by science-based research on rehabilitation, treatment, and involvement in the communities of choice; the role of severe trauma in jeopardizing mental health; the importance of self-help and a broad array of support services; the criticality of cultural competence and consumer involvement in care and treatment; the importance of respecting people's rights; the importance of addressing stigma; and the incompatibility of coercion with effective care.
Mr. del Vecchio described CMHS's work in the area of restraint and seclusion, an issue of national importance highlighted by a U.S. General Accounting Office report, subsequent Congressional legislative activity, and a report published by DHHS's Inspector General that examined hospital quality and called for more effective reporting of medical errors. The Inspector General is preparing two additional reports, one that examines psychiatric hospital quality and the other an audit of restraint and seclusion incidence.
The Centers for Medicare and Medicare Services issued in July 1999 an interim final rule for conditions of participation by hospitals that outlined a series of standards dealing with restraint and seclusion within behavioral and acute health care settings. CMHS has been collaborating in the comments review process. Two controversial issues have emerged: a standard for a physician assessment within one hour of people placed in restraint and seclusion, and a standard regarding reporting deaths and sharing that information with P&A agencies. CMHS is working with the Centers for Medicare and Medicare Services in developing an interim final rule dealing with children's programs. In the past six months, the Centers for Medicare and Medicare Services has taken action against two providers over restraint and seclusion issues. CMHS has promoted staff training on the subject and is looking at selected specific models to demonstrate and evaluate. The Joint Commission on Accreditation of Healthcare Organizations has set in place new practices to address restraint and seclusion, and has undertaken to revise standards on restraint and seclusion within behavioral health care settings. The residential health care provider Charter has pledged to become restraint-free; the company reported that incidence of restraint has declined by 50 percent over a four-month period.
CMHS sponsored a dialogue meeting in November 1999 between representatives of the social work field and consumer leaders. Issues discussed included the social work code of ethics, particularly on self-determination versus coercion; importance of support systems and benefits of self-help; disrespect and lack of status of social workers; cultural and geographical differences, and the importance of cultural competence; and how stigma affects the work of social workers. Next steps include establishment of an e-mail discussion group and planning for a panel presentation at the upcoming National Association of Social Workers conference.
Discussion. Mr. del Vecchio requested input from the Council on the following issues:
- How best to use the findings in Mental Health: A Report of the Surgeon General; how best to communicate and leverage the messages within the report; the role of the consumer community
- Suggestions for additional CMHS activities on the restraint and seclusion issue
- Future plans for dialogue meetings
Dr. Martinez suggested components of an educational initiative on restraint and seclusion: training of hospital staff on handling aggressive behavior, especially low-level interventions and verbal techniques to induce a de-escalation; comprehensive patient evaluation, including an assessment of "when you are out of control, what makes a difference for you?" and facilitating bringing in family members or changing the environment; and the importance of having sufficient staff to initiate creative programs. She urged education about when respectful restraint and seclusion are appropriate. Dr. Pumariega echoed Dr. Martinez's views and added his own assessment of how managed care has significantly adversely affected quality of care. He asserted that reductions in staff of all types available to care for people with serious mental illness have come at a cost of increased human suffering; the robust economy has produced wage increases that are not generally enjoyed by the individual who cares for very ill people; and insufficient physical space exists in inpatient units to avoid escalation of behavior because of claustrophobic responses. He emphasized training and retraining of all staff in prevention and management of aggressive behavior, and approaching seclusion and restraint from a TQM systems perspective that involves the patient and family, and avoids ascribing blame. Dr. Pumariega pointed to seclusion and restraint in community homes, unlicensed facilities contracted by the child welfare and not the mental health system. He suggested establishing links with the Office of Juvenile Justice and Delinquency Programs (OJJDP) and the federal welfare agency to develop standards.
Ms. Wainscott asserted that one effective way to leverage the messages in
Mental Health: A Report of the Surgeon General is for many people to take the same message to key individuals. Another would be to host a dialogue with media representatives, perhaps on a local or regional basis, and perhaps in conjunction with the mental health journalism program at the Carter Center.
Dr. Shon suggested working with the National Association of State Mental Health Program Directors' (NASMHPD) medical directors group on seclusion and restraint issues; their work sets the tone throughout the states and locally. He also suggested initiating discussions with the National Institute of Mental Health (NIMH,) which is seeking input to their new agenda, and forging links between hospital chaplains and local faith communities to minimize stigma in the community.
Mr. Burgmann urged that training be continuous, not sporadic, and that patient assessments be interactive, not merely a nurse's checklist. Using these tactics, his facility has experienced dramatic successes in reducing the incidence of restraint and seclusion. Dr. Shon stated his concern that in a private company's zeal to reduce its incidence of restraint and seclusion, it may either refuse entry to or discharge certain individuals, who would then end up in the public system. Dr. Pumariega asserted that the issues of cost shifting and cost cutting must be addressed to reflect the imminent, if not actual, crossing the line where care cannot be delivered for the dollars allotted.
Ms. Mayeux discussed the message of mental illness, the alacrity with which people respond to warnings about the health of their body, and the ease with which people deny that mental illness could affect them; she suggested examining the terminology. Dr. Bornemann noted that Mental Health: A Report of the Surgeon General addresses the mind/body distinction, and that focus groups were held in New York and Los Angeles on terminology. Dr. Gottlieb questioned the meaning and use of the word "consumer" in light of the them/us dichotomy.
Dr. Lu endorsed Ms. Wainscott's comments regarding dialogues with the media and dovetailing the effort with a focus on the anti-stigma campaign with media leaders. He offered his guidance on suicide prevention and the media, in his role as media chairperson of the American Psychiatric Association's Scientific Program Committee. He urged CMHS to continue its efforts to seat representatives of ethnic minority groups at their dialogue tables. Dr. Bornemann noted that the Carter Center had convened focus groups with media experts and journalists to focus on public perceptions of mental illness.
Ms. Wainscott urged integration of the mental health and general health payment systems; the fact of two systems broadcasts the message that they are two different things. Dr. Bornemann noted that this is not just an issue of parity, it is one of discrimination. Ms. Wainscott also suggested that public relations/media experts be enlisted to help devise an effective message for the public. Ms. Mayeux counseled from her experience that insiders should take the experts' advice and not tinker with their professional guidance.
Consideration of Minutes. Members unanimously approved the minutes of the September 1999 CMHS Council meeting.
Public Comment. Irene Lynch, Aleppos Foundation, suggested a dialogue between consumer survivors and managed health care organizational staff who handle mental health. She noted that she is disseminating relevant portions of Mental Health: A Report of the Surgeon General via e-mail for consumers to study.
School Violence Prevention Initiative
Michael J. English, J.D., Director, Division of Knowledge Development and Systems Change, updated the Council on the Safe Schools/Health Students (SS/HS) initiative undertaken jointly with the Departments of Education and Justice. Approximately $105 million in grant funds was awarded to 54 applicants in 40 separate states, with 27 awards to projects in large and medium-size cities, 16 to suburban projects, 13 to rural sites, and 2 to tribes. He also summarized the School Action Grant program, which made 40 awards to a broader variety of applicants who sponsored effective practices for violence prevention in their communities. An annual $2.8 million technical assistance grant for school violence protection was awarded to a coalition led by the National Mental Health Association and the National Association of School Psychologists; the enterprise has completed its staffing, which includes consultant/brokers dispersed geographically across the country. A contract has been awarded to a group led by Gallup and the international public relations firm Porter-Novelli to develop a communications plan that takes into account current technological capabilities to communicate with children and their parents and teachers. Research Triangle Institute will conduct a national evaluation of the SS/HS program; the design is currently under discussion.
Mr. English noted that the School Action Grants are modeled on the highly successful Community Action Grant program. He announced an upcoming standing announcement for Community Action Grants. Applications will be accepted year round and reviewed several times during the year. Mr. English asked Council members to help publicize this new format and invited feedback on the program.
Congress has appropriated additional funds for school violence prevention in Fiscal 2000 to support continuation and new activity. CMHS proposes to invest the majority of the new funds in 16 to 20 new SS/HS grants to outstanding, but unfunded, applicants in the earlier review, and also to invest in additional School Action Grants.
Acknowledging the time-limited nature of federal funding for such initiatives, Mr. English described an additional grant program under consideration, possibly to be called Community Partnership Development Grants, which would go to states and/or their political subdivisions and be structured like Children's Services Grants. These grants would promote partnerships that would drive local programs for the foreseeable future.
Several new initiatives related to violence prevention also are in the pipeline. Technical assistance to the evaluation community will be supplied by CMHS and the Center for Substance Abuse Prevention (CSAP) in a grant program to collect, synthesize, and disseminate best practices around parenting skills. CMHS is exploring another partnership with the Office of Juvenile and Delinquency Prevention (OJJDP) to examine methods of sharing information among agencies that ensure confidentiality and other protections, and facilitate information sharing. The Program would support technical assistance and training opportunities for communities. Suicide prevention is another major focus, as is a program related to four Florida juvenile assessment centers and their exemplary work.
Discussion. Ms. Wainscott suggested that CMHS link with SPAN to provide funding for states to develop plans to create and implement suicide prevention models. She also noted that at some point in the future, preventing school failure, which involves the same set of skills, resiliencies, and protective factors that work in school violence prevention, would be an appropriate focus.
Mr. English explained that the Community Action Grant program requires only that the practice sponsored by a community has an evidence base; the sponsor may be any type of entity. The two phases of this program are: (1) consensus building, creating support for the adoption of an exemplary practice, and community agreement, and (2) funding to eliminate implementation barriers and to develop a permanent financing plan for the program. CMHS has undertaken outreach to appropriate programs and urged them to apply for funds. Mr. English solicited input from the Council on ways to market the grant program to the field.
Dr. Arons described the difficulty in packaging some grants so Congress understands the importance of maintaining the integrity and continuity of their funding stream. Dr. Shon urged improved "reader friendliness" of grant applications, marketing grant programs by offering examples of funded programs under the individual umbrellas. Ms. Wainscott suggested that CMHS examine an eight-page application devised by OJJDP as an example. A one-page summary cover sheet will accompany the next grant announcement.
Mr. English noted that the School Action Grant is a two-year grant with an explicit provision for piloting, and that other programs do not have a pilot program capability. Dr. Pumariega suggested that pilot programs of exemplary practices be conducted on a smaller scale to give the community hands-on operational experience and to examine outcomes. The School Action Grant program will produce knowledge about piloting programs.
Dr. Lu raised the issue of ensuring that cultural competence occurs in the technical assistance center. Dr. Anne Mathews-Younes pointed out that diversity has been achieved in the technical assistance advisory committee, research evaluation work group, and staff.
Dr. Arons noted that despite a current lack of funding for the project, CMHS is proceeding with the Department of Education in developing Project SERV, an immediate crisis counseling response to help schools respond to violence. Ms. Wainscott pointed out that school failure is an issue attractive to businesses, and that corporate funds may be available for partnership funding. In the area of suicide prevention, the educational community is a natural partner. Dr. Mathews-Younes commented that the SS/HS communications program will target the grantees' business communities for engagement in the process.
Dr. Arons stated that the 2001 budget proposal will include a provision for targeted treatment capacity expansion within the mental health area and solicited the Council's views. Dr. Bornemann explained that the goals are to minimize infrastructure resources, to maximize direct services delivery, not to compete with the block grant, and to add components that recognize the importance of prevention and early intervention beyond school violence. Because of the maturity of the prevention approach, CMHS wants to increase the number of evidence-based practices that are ready for wider dissemination and to examine them for cultural competence. With NIMH support, a literature review has been undertaken on the evidence for prevention practices to be disseminated. CMHS also is sponsoring development of a curriculum of life-span prevention issues for mental health practitioners that would be disseminated as a continuing education tape. CMHS has also worked with New York State to train prevention professionals in order determine how best to promote the prevention approach in state systems.
Funding patterns for some programs are to be determined and may include a shifting match requirement from state and local components. Among the integration strategies in communities under consideration are the no-wrong-door approach (i.e., service delivery at nontraditional sites), service delivery across systems by the public mental health system under contract, specific interventions implemented for specific populations (e.g., treatment foster care, multisystemic therapy) through specific systems (e.g., juvenile justice), and possibly home-oriented services that target, for example, parents of adults with mental illnesses. Ms. Mayeux encouraged CMHS to consider five-year programs, particularly with states, because of the length of time typically needed to achieve workable relationships within and among bureaucracies. Dr. Shon suggested three years as sufficient time. He urged targeting one or two populations/programs, such as in-home capacity for youth in out-of-home placement or disaster response, rather than a fragmented approach, in order to be able to describe and study what the funds will address. He also urged ensuring that the taped professional training program will be sufficiently specific to promote fidelity and effectiveness. Dr. Pumariega concurred, urging involvement of the academic system in evaluation and quality assessment in order to avoid vendors altering the program. Dr. Shon stated the need for a strong oversight and training component by knowledgeable trainers, and Dr. Pumariega noted the importance of community input to accommodate cultural and ethnic diversity. Dr. Bornemann summarized the emerging CMHS approach— to look at systems already legitimized in certain communities and populations which need mental health services. He also urged Council members to contact CMHS staff with additional ideas.
SAMHSA Administrator's Update
Nelba Chavez, Ph.D., described the shootings at Columbine High School as a clear call for action. She acknowledged the efforts of the CMHS staff with the SS/HS initiative, but noted that more remains to be done. She pointed to increased Congressional funding and unprecedented interagency collaboration as very positive moves, but went on to say that even with the budget increase, there still remains a large unmet need throughout the country of unserved and underserved populations. She described Mental Health: A Report of the Surgeon General as an imperfect but powerful tool to examine those needs. She mentioned the existence of special needs related to burgeoning cultural diversity and regional differences, particularly increased suicide rates and alcohol use. SAMHSA is involved in such issues as stigma, access to services, misdiagnosis, affordability of medication, and parity.
Dr. Chavez noted that the Surgeon General will issue a report on youth violence prevention published late in the year, a collaborative project of CMS, CDC, and NIMH. To illustrate some problematic areas, she mentioned a recent study supported by SAMHSA and the National Alliance of State and Territorial AIDS Directors which found that 80 percent of AIDS directors reported that mental health agencies did not seek input from them when they were developing their programs, and there is no coordination between their offices. In that same study, 53 percent of the AIDS Directors reported that individuals with a positive test result were not able to get access to substance abuse services.
She also discussed the problem of the imminent loss of significant resources as large numbers of valued federal employees retire and because of the lack of skilled behavioral health workers at all levels with experience in working with the changing U.S. population.
Discussion. Ms. Wainscott described briefly how the Surgeon General's companion reports will help her state advocacy program work more effectively with the state government. Dr. Chavez described the criminalization and stigmatization of mental illness and substance abuse: "It's not my child who is involved." Ms. Wainscott reiterated the Council's earlier discussion on devising a public health message for mental health to parallel the Surgeon General's warning against smoking; Dr. Chavez agreed that need exists.
Dr. Pumariega discussed the withdrawal of the federal government from the mental health training arena and, in light of diminishing numbers of professionals being trained and the number of professional training programs shutting down, suggested that SAMHSA revisit this area. Dr. Arons mentioned the Minority Fellowship Program and agreed to examine the issue. Dr. Chavez suggested that the impetus for this program will be driven by grassroots forces, particularly, as Dr. Bornemann pointed out, because 1996 Congressional appropriations language stipulated government withdrawal from the training arena..
Dr. Gottlieb related youth and parental stress to increased suicidal thoughts, and suggested helping parents as a way also to help the youth. Dr. Chavez described the prevention program "Hablemos en Confianza," "Let's Talk," developed "by the people for the people" and launched with a celebration, not a press conference. She added that Latinos' calls to the Clearinghouse have increased dramatically to request information about mental health and about treatment.
Update from the Field
Jane Ryan, R.N., M.N., C.N.A.A., President, American Psychiatric Nurses Association (APNA), described the field of psychiatric nursing. Psychiatric nurses are in an increasingly short supply. Although the designation of "psychiatric nurse" is conferred by certification, it is likely that many nurses work in the field without certification. About 8,000 individuals are certified as advanced practice nurses, with 1,000 certified in child and adolescent practice. The APNA spun off from the American Nurses Association in 1986.
Ms. Ryan noted that NIMH funding stopped in the mid-1980s for convening directors of graduate schools of nursing, an outcome that resulted in fewer people enrolling in the clinical nurse specialist program. She urged convening a group to examine the educational curriculum of psychiatric nursing in the United States. The APNA has initiated establishing relationships with industry to move into the long-term care arena and has established treatment best-practices award programs.
Seclusion and restraint are primary interests of APNA, which has taken a number of strong positions and actions. She asserted that the APNA supports assessment within an hour of a candidate for restraint or seclusion, and is currently devising prescriptive standards as guidance for their implementation. She stated that advanced practice nurses are qualified to be licensed independent practitioners and should not be denied that opportunity.
To reflect changing demographics in America, APNA has added a day to its October 2000 conference (in Washington, D.C.) on the care of the African American patient, with a focus to follow on the Hispanic population shortly thereafter.
Ms. Ryan noted the ANA's collaborative relationship with The National Alliance on Mental Illness and the National Mental Health Association. APNA seeks funding for research in some psychiatric nursing interventions to determine their efficacy.
Discussion. Ms. Bayeux recognized the success of APNA's government relations arm with its work in Louisiana, and noted that psychiatric nurses might play a significant role in service delivery in nontraditional settings. Dr. Bornemann suggested discussing workforce issues at an upcoming Council meeting. Mr. Burgmann will compose a resolution from the National Advisory Council on restraint and seclusion for future consideration.
Adjournment. Dr. Bornemann adjourned the meeting at 4:15 p.m. The meeting reconvened the following day, as members of the CMHS National Advisory Council joined the SAMHSA National Advisory Council at the Washington Hilton in Washington, D.C.
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