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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
February 7–8, 2002
Rockville, Maryland
Minutes
February 7–8, 2002
Closed Session
The National Advisory Council of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) met in closed session at 8:30 a.m. on February 7, 2002, at the Doubletree Hotel in Rockville, MD, to review grant applications. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons convened the open session at 9:30 a.m. Council members present included CMHS Director Bernard S. Arons, M.D., William R. Beardslee, M.D., Col. Molly J. Hall, U.S.A.F., M.C. (ex-officio), Francis G. Lu, M.D., Ruby J. Martinez, R.N., Ph.D.; Donna Mayeux, Josie Torralba-Romero, M.S.W., Karina K. Uldall, M.D., William W. Van Stone, M.D. (ex-officio), and Cynthia A. Wainscott. Richard Nakamura, Ph.D., Acting Director, National Institute of Mental Health (NIMH) and David Shore, M.D., NIMH liaison member, were also present.
Administrator's Update. Joseph H. Autry, III, M.D., Deputy Administrator, SAMHSA, stated that the President's budget for fiscal year (FY) 2003 has been submitted to the Congress. He described the budget as a document reflecting input from the three SAMHSA centers, CMHS, the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT); the SAMHSA Office of the Administrator (OA); the Department of Health and Human Services (DHHS); the Office of Management and Budget (OMB); and the White House, with the end result being an appropriation from the Congress. He noted that both the budget and congressional justification are on the SAMHSA Web page.
The FY 2003 budget calls for a $57 million increase across the Agency; CMHS' Projects for Assistance in Transition from Homelessness (PATH) program is slated to gain $7 million and bioterrorism $10 million. It is proposed that CMHS and CSAT receive $6 million for co-occurring incentive grants to help states leverage other resources to focus on a given problem. The budget calls for SAMHSA to (1) phase back knowledge development and application (KDA) activities, seen as an overlap with the National Institutes of Health (NIH) and (2) provide services in the mental health and substance abuse area, leaving the provision of primary care (aside from offering technical assistance) to the Health Resources and Services Administration (HRSA).
Dr. Autry also mentioned the FY 2002 budget which increased SAMHSA funds by $175 million. Increases include $60 million for the Substance Abuse Prevention and Treatment Block Grant,
$13 million for the Mental Health Block Grant, $3 million for PATH, $2 million for Protection and Advocacy (P & A), and $5 million for the Children's Program.
He described the new SAMHSA administrator, Mr. Charles Curie's, vision for the Agency as one SAMHSA under one DHHS, with goals, objectives, and mission aligned within all of the DHHS operating divisions. He said that Mr. Curie has articulated a vision for SAMHSA to ensure positive outcomes for all individuals with mental or addictive disorders. Dr. Autry mentioned that there are important guiding principles for government established by the President; he went on to describe how these principles apply to SAMHSA. These principles are: citizen centered (positive outcomes for consumers/families); results oriented (most effective/cost-effective services possible, using the best science available); and market based (with cost-effectiveness and efficacy to meet the needs of the consumers/families SAMHSA serves).
Dr. Autry introduced an organizational schematic, i.e., a draft matrix of program priorities and principles. These priorities include co-occurring disorders; the substance abuse treatment gap; seclusion and restraint; prevention/early intervention; the children's agenda; the New Freedom Initiative (NFI) (viewing mental health and substance abuse issues vis-à-vis disability); terrorism/bioterrorism; homelessness; aging; HIV/AIDS; and criminal justice. Cross-cutting principles for every program include evidence-based outcomes; collaboration (including stakeholders); recovery/anti-stigma/discrimination; cultural competence; community-/faith-based; violence; financing and cost-effectiveness; private-sector partnerships; and others, including developmental principles. He invited the Council to provide input concerning this matrix and indicated that a management matrix is also being developed.
Dr. Autry also discussed SAMHSA's restructuring and delayering (R & D) process, which will collapse small offices into the Office of the Administrator, with some policy, planning, and budget formulation and execution staff formerly housed within the Centers now reporting to the OA. Communications will be centralized officially at the Department level, along with legislative and public affairs. Dr. Frank Sullivan is back in SAMHSA, following a long-term assignment with the Center for Medicare and Medicaid Services, to focus on workforce and strategic planning, R&D, and Medicaid/Medicare issues.
Discussion. Ms. Mayeux suggested surveying States to see if mental health dollars are spent appropriately (e.g., not for criminal justice) and if States' legal definitions of disability exclude mental illness. She also noted the importance of discussing mental health and care for mental illness as primary care. Ms. Torralba-Romero urged the importance of collaboration with HRSA to bring a mental health focus to primary care and of advocating and collaborating with the Department of Housing and Urban Development (HUD) for supportive housing for consumers and their families. Dr. Autry stated that a work group has been established at the Department level to address issues with HUD. Dr. Van Stone noted that a joint Department of Veterans Affairs and SAMHSA grant focuses on integrating mental health into primary care. Ms. Wainscott lauded the inclusion of prevention/early intervention as a primary focus of SAMHSA; urged substituting, or at least adding, "discrimination" for stigma" in SAMHSA's vocabulary; urged the New Freedom Commission on Mental Health to focus on mental health rather than mental illness; and urged that the cuts in the FY 2003 budget for technical assistance centers and the Community Action Grant program be rescinded. Dr. Lu echoed remarks on funding for the technical assistance centers and urged adding, as a cross-cutting principle, disparity reduction among ethnic groups. Dr. Autry stated that the NFI and Commission are expected to address funding of community- and home-based services and that SAMHSA leadership is committed to grassroots consumerism and families.
Approval of Minutes. The Council unanimously approved the minutes of both the September 6-7, 2001, CMHS Advisory Council Meeting and the 2001 SAMHSA Joint Council meeting.
CMHS Director's Report. Dr. Arons reported on CMHS' activities and noted that additional information was available in the written report. On the legislative front, he reported that the FY 2002 budget exceeded funding expectations. The budget raised CMHS' discretionary fund to $230 million for Programs of Regional and National Significance, which include best practices, targeted capacity expansion, and youth violence prevention activities. There will be a new program to provide mental health services to first responders to emergencies and one which will support programs for children and youth with post-traumatic stress disorder (PTSD). Suicide prevention activities were augmented, and both a credentialing process for hotlines and a resource center for technical assistance for suicide prevention programs were funded. Two major new programmatic areas were also funded in 2002, one for an aging program and the other for a jail diversion program. He also mentioned the President's FY 2003 budget, noting that funding for most programs is straight-lined, although some new activities are indicated that reflect the Administration's new priorities, including the New Freedom Commission on Mental Health and a bioterrorism initiative.
He reported that CMHS is involved in SAMHSA's strategic planning efforts and is planning how to tell its story to its constituents for maximum benefit. On the staffing front, Dr. Arons announced that Dr. Anne Mathews-Younes is serving as acting director of the Division of Program Development, Special Populations and Projects, following Dr. Brian Flynn's retirement.
Dr. Arons also highlighted several of the Center's programmatic activities. CMHS' consumer activities have included plans to launch an anti-stigma/anti-discrimination resource center to offer technical assistance to communities and States and develop models for addressing stigma and discrimination issues. Efforts are under way to test best practices, develop training standards, produce a manual for de-escalating situations to avoid or greatly reduce need for seclusion and restraint, and plan regulations required by legislation. CMHS is planning an African American Mental Health Policy Forum and a dialogue between consumers and faith-based and community organizations. Another consumer-related activity was the National Employment Summit held by CMHS to convince employers that it is worth the investment to hire persons with psychiatric disabilities. More than 200 leaders shared insights on hiring and retention and on cost-effective insurance packages. In all of the consumer activities, a common
theme is to increase consumers' voice in mental health research, legislation, and service delivery.
Dr. Arons went on to describe some other recent initiatives. Homeless program activities included a national training conference on housing, treatment, and support needs for mental health and substance abuse consumers who are also homeless; more than 10 percent of the 800 attendees were consumers, of whom about half served as faculty. He next mentioned that a communications initiative, "Listening Dads are Champs," a public education dissemination activity of 15+, was launched: The Baltimore Ravens and other community organizations will encourage fathers/male caregivers to use positive parenting methods and materials. This pilot program will be evaluated and possibly replicated elsewhere.
Discussion. In response to a question, Dr. Arons explained that approved but not yet funded applicants for the original child trauma grant program probably will receive awards with the new infusion of funds into the program, without having to issue another Guidance for Applicants (GFA). Another question concerned workforce training and Dr. Arons reported that a grant announcement focused on exemplary programs addressing elimination of racial and ethnic disparities is underway. He also remarked that funding for minority fellowships will be maintained. Next followed some discussion concerning the relationship between CMHS and NIMH and the respective administrative boundaries of their activities. Dr. Arons stressed the importance of continuing to build and reinforce the relationship between the two agencies. Ms. Torralba-Romero asserted that disparities in funding for mental health must be addressed. Ms. Wainscott commended NIMH on its strategic planning to reduce depression in America.
Old Business. Dr. Arons recognized outgoing Council member Ms. Mayeux for her service to the CMHS National Advisory Council.
SAMHSA's Strategic Planning Process. Dr. Arons described the strategic planning process as it applies to CMHS. He briefed the Council on the proposed mission statement ("caring for the Nation's mental health by promoting effective mental health services"), goals (capacity, effectiveness, and accountability), and strategic objectives.
Discussion. Council members stated that "caring" seems both not measurable and passive ("improving" may be better); consumers and families should be referenced in the capacity section. Dr. Arons stated that adding measurable outcomes to the objectives is the next step in this process, and members recommended that measuring outcomes should be an objective under effectiveness. Members also stated that "special populations" is not sufficiently descriptive; additional capacity objectives should be added concerning development of a professional workforce targeted toward reducing disparities and on capacity development in consumer and family leadership; a focus on cultural competence should be articulated vis-à-vis access; the diagram should show that effectiveness objectives for capacity and access interact with each other; a philosophy of consumerism should be articulated; and attention should be paid in accountability to cost-effectiveness.
Administrator's Priorities and Alignment with SAMHSA's Strategic Planning Process. Dr. Arons and the Council discussed SAMHSA's programs and principles matrix. As had occurred in the previous earlier discussion on this topic, members suggested adding disparity reduction and the consumer focus as cross-cutting principles. They also want to ensure that key objectives are addressed in applications for funding, that strategic plan components must drive the language of GFAs, and that every piece of the strategic plan is evident in some number of programs and issues that are identified. In the access component in the strategic plan, eliminating barriers should be added; measurable outcomes and a public health focus should be added to the cross-cutting principles. Dr. Autry noted that the Secretary is emphasizing improved quality of services, capitalizing on NIH's research findings. Dr. Arons explained that staff discussions from all centers will be shared; a status report will be presented at the SAMHSA level; the process will move toward language stabilization; and outcomes and action steps will be developed for each objective. It was also noted that SAMHSA is defining its own mission statement.
Products from the Homeless Programs Branch. Phyllis Wolfe, M.A., M.S.W., Special Expert, Homeless Programs Branch, Division of Knowledge Development and Systems Change, CMHS, SAMHSA; Mary Anne Myers, Ph.D.; and Cynthia Robins, Ph.D., WESTAT
Ms. Wolfe described the activities of the Homeless Programs Branch. She reported that the national training conference on homelessness was successful and also that a policy academy will be held for State teams to focus on accessing mainstream services for people who are chronically homeless and are consumers of mental health and substance abuse services.
WESTAT is helping CMHS to develop effective ways to disseminate information on providing quality services to homeless persons living with mental illness. Drs. Myers and Robins solicited feedback from Council members on print materials under development to disseminate knowledge on homeless programs. These materials may serve as templates for CMHS-wide knowledge dissemination. Comments may be sent to Dr. Myers at maryannemyers@westat.com. Council members praised the use of graphics and suggested the addition of specific language; inclusion of more organizations; use of a design that permits legible, rapid photocopying; presentation of all data on the Information Center Web site with a note on the print materials "downloadable at [address]"; and comprehensive documentation of the evidence base on the Web site.
Concerning the overall communications strategy, an analysis of media coverage of homelessness in 10 newspapers nationwide revealed that a shift occurred between 1990 and 2000/1 from a sympathetic attitude toward blaming the individual. Ms. Wolfe noted the need to enlist local community leaders who sit on mental health boards and other stakeholders to change the public perception.
Discussion. Ms. Torralba-Romero suggested enlisting ethnic-specific and faith-based organizations. Ms. Wolfe stated that op-ed pieces and letters to the editor will be prepared to increase access to the media. Members discussed messages targeted toward policymakers and service providers. Dr. Beardslee noted the relationship between abuse and homelessness. Col. Hall discussed homelessness and the military, noting the necessity for the military to address adequate compensation. Ms. Wolfe stated that CMHS is working on a small youth-in-transition-to-adulthood program and is seeking funding partners. CMHS also will mount an anti-stigma media campaign targeting African American youth. Dr. Myers noted that efforts are underway to analyze qualitative data to understand the positive outcomes of the ACCESS Program. The issue brief on the ACCESS Program will be updated as understanding increases. As dissemination points, members suggested public libraries, high school and college libraries, professional associations of college and high school social studies teachers, national associations of county commissioners and of mayors, schools of social work, and the National Association of Social Workers.
Resolution on the Support of National Parity Legislation. The final item of business for the day was the finalization of a resolution in support of national parity legislation, which was passed unanimously.
Whereas the Center for Mental Health Services (CMHS) National Advisory Council believes that the passage of national parity legislation warrants support because of the following:
- Although one in five Americans will have a mental illness each year, and an estimated 14.0 million Americans were current illicit drug users, and approximately 12.6 million people were heavy drinkers in the year 2000, discriminatory practices in health plan coverage unfairly limit access to mental health and substance abuse treatment services.
- These discriminatory practices in health plan coverage include lower day and visit limits, higher co-payments and deductibles, and lower annual and lifetime spending caps compared to general health care. They create barriers to needed services, result in unnecessary suffering, impose financial hardships on families, and shift costs to government systems.
Therefore, be it resolved that the Center for Mental Health Services National Advisory Council specifically supports broad-based mental health and substance abuse parity in private, individual employer-based, and publicly supported Medicare, Medicaid, SCHIP, and other government-sponsored health plans.
The meeting adjourned at 3:55 p.m. and reconvened the following day at 9:00 a.m.
Subcommittee on Consumer/Survivor Issues Update. Sylvia Caras, Ph.D., Coordinator of "People Who Net," reported on the February 5-6, 2002, meeting of the Subcommittee. Members expressed concern about the implications of the President's budget and the proposed defunded activities. The Subcommittee welcomed new member Paula Stockdale and made decisions concerning Subcommittee operations. Filling the ninth seat on the Subcommittee is in process. Subcommittee members will provide input to the CMHS strategic planning process, emphasizing language of wholeness, including "enriching, developing, underpinning, supporting." People with disabilities find the "Delivering on the Promise" report inadequate, and the Subcommittee would like to see more valuing of volunteerism.
The Subcommittee put forth the following recommendation to the CMHS National Advisory Council, which was unanimously approved, as amended:
- CMHS supports programs that promote recovery by involving consumer/survivors in the design, delivery, and evaluation of services; the availability of resources for national training of consumers; and the existence of vehicles for community initiatives that promote consumer involvement in services.
Next, Ms. Wainscott made a motion to reaffirm the Subcommittee recommendations originally voted on at the September 2001 meeting. The Council unanimously reiterated their support for the following:
- Continue grant support at current funding levels or higher for a minimum of five national consumer technical assistance centers, of which at least three are consumer operated.
Endorse knowledge development and application efforts in the area of mental health consumer-directed self-determination models such as personal care attendants, voucher programs (e.g., cash and counseling), individualized budgeting, etc., that have been demonstrated successfully with persons with physical disabilities, older adults, and people with developmental disabilities.
Discussion. In a response to a question, Dr. Arons noted that there are typically several family members on the Council itself, while the Subcommittee was specifically established to address consumer/survivor issues. With regard to the nature of parity, Dr. Beardslee questioned how to give youth a voice. He explained that because children and adolescents are treated by assent, not consent, "voluntary" is an issue; parity for children and adolescents is equally important. Dr. Arons indicated that there are a number of interesting studies underway in the parity area. Ms. Wainscott urged naming a consumer/survivor member to the SAMHSA Council.
Disaster and Crisis Mental Health: Federal Perspective for Community Response. Mary Elizabeth Nelson, M.S.W., Chief, Emergency Services and Disaster Relief Branch, Division of Program Development, Special Populations and Projects, CMHS, SAMHSA.
Ms. Nelson acknowledged CMHS' Federal partners in crisis mental health: the Federal Emergency Management Agency (FEMA), the Department of Justice's Office for Victims of Crime, the Department of Veterans Affairs' National Center for Post-Traumatic Stress Disorder; the National Transportation Safety Board's (NTSB) Family Assistance Office, the Department of Education's Project School Emergency Response to Violence, and NIMH, plus others. Ms. Nelson described the core functions of the CMHS Emergency Services and Disaster Relief Branch, including disaster mental health services, victims-of-crime mental health, training and education, emergency preparedness and planning, stress management consultation, and interagency collaboration. CMHS is analyzing a needs assessment from nine States.
She stated the factors that influence recovery from a disaster are natural versus human caused, degrees of personal impact, size and scope, and probability of recurrence. Survivor risk and resiliency factors include psychological, capacity to tolerate stress, prior trauma history, socioeconomic and education level, family stability, social support, and female gender.
She also gave an overview of program constructs. Subtle marketing to avoid stigma is necessary to reach people who need crisis counseling. For example, "Project Liberty" in New York has no mental health overtones. Overarching concepts include a focus on normalcy, flexibility/improvisation, strengths based, nontraditional settings, and understanding the culture and community. Interventions used are rapid assessment and triage, supportive listening, problem-solving concerning immediate issues, education on disaster stress, debriefing and community meetings, and information and referral. Strategies include community outreach, establishing a mental health Lifenet hotline, initiating contact at gathering sites, outreach to survivors through the media and the Internet, education of providers, and having bilingual/bicultural workers. Building on individual and family strengths is critical, as are supporting existing community services and developing expertise and experience.
A culturally competent approach is also critical, using empowerment-based approaches, and understanding the cultural definitions of mental health, well-being, coping, and recovery. Another key to success is developing mutual aid agreements-linking emergency services with adjacent jurisdictions, such as collaborative planning, coordinated training, collaboration with voluntary agencies, gathering contact information (phone tree), and administrative coordination to create a "seamless system." Helpful web sites are http://mentalhealth.samhsa.gov/cmhs/EmergencyServices/default.asp services and http://www.ojp.usdoj.gov/ovc/.
Community-Based Disaster Mental Health Services in New York City for Cultural Groups: Challenges and Opportunities. Teresa Chapa, Ph.D., M.P.A., Special Expert, Special Programs Development Branch, Division of Program Development, Special Populations and Projects, CMHS, SAMHSA; Josie Torralba_Romero, M.S.W., CMHS National Advisory Council Member and President, National Latino Behavioral Health Association; Zena Itani, M.P.H., Presidential Management Intern, Community Support Programs Branch, Division of Knowledge Development and Systems Change, CMHS, SAMHSA.
Members of this panel described the cultural challenges and opportunities of the mental health response to the events of September 11. The September 11 disasters impacted people around the Nation, and Ms. Torralba-Romero predicted that additional phases of recovery not yet in the literature will be articulated. She presented a new model of the phases of disaster: heroic, activity focused on immediate rescue of survivors (for 9/11, much longer than earthquake or hurricane recoveries); honeymoon, activities formalized to facilitate individual, family, and community recovery; uncertainty, continuous state of limbo due to ongoing threats and the multidimensional societal impact of terrorism; socioeconomic adjustment, unemployment, and stress on family and livelihood; disillusionment, long-term individual and community efforts to recover to former stability and rebuild community are delayed, and actual and/or perceived promises are not kept due to bureaucratic or other reasons; reconstruction, individual and community adaptation and integration of new changes.
The panel noted that, earlier, CMHS had established a Cultural Competence Leadership Work Group, which had established communications with minority, political, faith-based, and consumer leaders nationwide. CMHS volunteered help to those contacts, both locally and in New York, and also established communication links with CMHS grantees. CMHS identified issues such as communities that already experience a large disparity of access and receipt of services, an insufficient infrastructure of culturally competent providers, undocumented taxpaying workers, some immigrants with few (or no) family supports, and people with previous mental health experiences or earlier traumas.
Ms. Itani described CMHS' response to the needs of the Arab American and American Muslim communities. Fifteen health and mental health providers nationwide who deal directly with those populations, including religious leaders, both Muslim and Christian, and legal experts, held a day-long fact-finding session on the status of mental health and services in both communities. The agenda focused on ethnicity and culture, immigration status, role of religion in delivery and perception of mental health services, stigma and discrimination, and mental health services post-September 11. Current and future needs of those communities were addressed, and a series of recommendations came out of the meeting. The recommendations covered two broad areas: community and interfaith outreach and culturally sensitive services.
Community and Interfaith Outreach
- Mosques and Muslim community centers should invite representatives from the police, fire, and public health departments as well as churches, synagogues, and temples to attend events and prayer services.
- Educational programs about Arabs and Muslims should be offered to schools to help foster understanding among children, teachers, and other school personnel.
Culturally Sensitive Services
- Training in cultural sensitivity should be provided to mental health professionals, who should work closely with Muslim religious leaders. Collaborating with imams and providing them with additional education about mental health would enable the mental health and religious communities to reach and assist people more effectively.
- More research needs to be funded on culturally grounded therapeutic approaches for Arab Americans and Muslims, for the development of manuals detailing best treatment practices, and for the compilations of a directory of Muslim resources and services in America.
- More work needs to be done with the media and entertainment industries to combat negative stereotyping.
Dr. Chapa noted that several CMHS staff have met with several minority communities and helped them to link to leadership and funding sources for mental health services. Needs remain to develop capacity for service providers to serve minority communities.
Ms. Torralba-Romero noted the important role of Council members to advocate for and support CMHS to ensure that services are provided to the community when most needed. She described her disaster work, as president of the National Latino Behavioral Health Association, with the City University of New York's Borough of Manhattan Community College, just two blocks from the World Trade Center, most of whose students must work to pay their tuition; most are members of minority groups and most are relatively recent immigrants. In the first 2 weeks after the University reopened, 35 percent of the students dropped out, reflecting the personal burden on the students and an ensuing economic burden on the college. Ms. Torralba-Romero's team provided the university with a response plan. The academic counseling division, unprepared for the psychiatric responses and volume of need, took the team's recommendation to supplement the office with professional expertise and develop a mental health crisis-response policy. Services are now provided.
In summary, it is important in disaster recovery to offer education, normalization, and infrastructure supports. With these resources, people can begin to prepare psychologically for integrating the loss and identifying gains in insight and/or feelings. Anniversaries will be important milestones.
Public Comment. Dan Dodgen, American Psychological Association, (APA), described that organization's Disaster Response Network, which mobilizes local psychologists to respond to disasters. Their work was effective in the New York and DC areas. The way this works is that there is a disaster coordinator in every State who can be called on by the Red Cross and can mobilize licensed psychologists immediately to respond to a disaster. He described a number of activities and stated that APA is working with many Federal Agency partners to show how social scientists help in the mental health arena. A task force is looking at resilience factors around disaster response. APA is helping Senate and House Employee Assistance Programs with their anthrax response, and is organizing a meeting of first responders to consider the mental health needs of the metropolitan Washington, DC, community in the event of a disaster.
Council Discussion. Members suggested agenda items for Joint Council. These include disparity reduction efforts by the three SAMHSA Centers; the difference between clinical and services research and clarification of the relationships between SAMHSA and the NIH Institutes, i.e., NIMH, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism; and an update on the New Freedom Commission on Mental Health and its activities. Other future topics for discussion include parity language and current studies which might illuminate the parity issue and its implications. To derive maximum Council benefit from the Consumer/Survivor Subcommittee, CMHS will inform the Subcommittee of the Council's agenda so the Subcommittee can inform it. Ms. Wainscott urged e-mail contact among Council members between meetings.
The meeting adjourned at 11:50 a.m.
FUTURE NATIONAL ADVISORY COUNCIL MEETINGS
SAMHSA Joint Council Meeting: June 19 and 20, 2002
CMHS National Advisory Council Meeting: June 20 and 21, 2002
CMHS National Advisory Council Meeting: September 5 and 6, 2002
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