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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
June 8, 1999
Rockville, Maryland
Closed Session
Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session to review grant applications and contracts on June 8, 1999, at the Parklawn Building, Rockville, Maryland. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons convened the open meeting at 9:30 a.m. Council members in attendance included Thomas Bornemann, Ed.D.; Frank D. Burgmann; Eric J. Getka, Ph.D.; Daniel Gottlieb, Ph.D.; Francais G. Lu, M.D.; Andres Pumariega, M.D.; Steven P. Shon, M.D.; Karina K. Uldall, M.D.; and Cynthia Wainscott.
Approval of Minutes
Members unanimously approved the minutes of the December 3-4, 1998 CMHS Council meeting.
CMHS Director's Report
Dr. Arons welcomed Drs. Lu and Uldall and Ms. Wainscott to the Council, and noted that former member Elizabeth Rukeyser has been named Commissioner of Tennessee's Department of Mental Health and Mental Retardation. He discussed the following highlights of the CMHS Director's Report.
- A SAMHSA reauthorization bill, S. 976, named the Youth Drug, and Mental Health Services Act, was introduced in the Senate in may 1999. This legislative initiative, while a positive move given its focus on children's services, is nevertheless expected to be highly political. Among the issues to be debated are co-occurring disorders and "charitable choice."
- Dr. Arons welcomed input from Council members on the agency's activities. CMHS' recent activities include:
- High-profile participation in two school violence prevention initiatives, plus the establishment of a technical assistance center and a public awareness campaign for school violence prevention and healthy development of students.
- Trauma management services in the wake of the Littleton, Colorado school shootings
- Project Serve, a Department of Education-sponsored program to facilitate school response to traumatic events.
- Emergency Services Branch's response to the trauma engendered by floods, hurricanes and tornadoes. The Vice President's National Performance Review conferred a Hammer Award on FEMA and CMHS' Emergency Services Branch for their effective and cost- efficient public services.
- Research studies to advance the nation's mental health, including the ACCESS program to integrate services to individuals who are homeless and have mental illnesses.
- A joint program with CSAP and CSAT to study women who have experienced physical or sexual violence.
- A project to evaluate consumer-provided mental health services.
- A second-generation study of the delivery of mental health services to people living with HIV/AIDS.
- Partnership and coalition building, particularly among Federal agencies.
- Pursuit of a Knowledge Development and Application (KDA) program in criminal justice diversion.
- Work on cultural competence. CMHS has focused on the cultural attitudes and approaches to mental health services in four populations-African American, Hispanic, Asian and Pacific Islander, and Native American-to enable better planning for services. Standards and guidelines for cultural competence in serving the four groups as well as related performance measures for managed behavioral health care programs have been devised. CMHS will work with the American Institutes for Research to reconcile the differing definitions of cultural competency across Federal agencies.
- Sponsorship in July 1999 of an Asian American and Pacific Islander Mental Health Summit designed to improve service delivery to the stated populations.
- Outstanding publications, including Mental Health United States 1998, a summary report on resilience, and article in Health Affairs entitled "Cost of Mental Health and Substance Abuse Treatment," and the monograph series "Promising Practices."
- Great amounts of information have been disseminated by the Information Center on its recently redesigned and upgraded web site mentalhealth.samhsa.gov and toll-free phone at 800-789-CMHS (2647).
- CMHS has broadened its global impact; senior staff members served as consultants to the governments of Mexico, Australia, and Kenya, and as keynote speakers at overseas and domestic conferences.
- Dr. Arons noted that the responsibilities Congress has recently added for CMHS and the work the agency has taken on have been accomplished with no additional staff allocations.
- Dr. Arons emphasized the importance of Mrs. Gore's role in putting the subject of mental health before the American people, announced that President Clinton has enabled the Federal Employees Health Benefit Plan (FEHBP) to cover mental health services in the same way it does other health services, and stated that a Federal anti-stigma plan will be launched.
Discussion
Dr. Arons described the focus and process of the forthcoming Surgeon General's Report on Mental Health, in preparation jointly by the National Institute of Mental Health and CMHS. The report, which summarizes the science rather than makes recommendations, will take a developmental approach, discuss mental health issues across the life span, aim to dispel stigma, emphasize mental health as part of public health, take a preventive/response-to-illness approach, and be disseminated in both traditional and innovative ways. Ms. Wainscott suggested training a cadre of individuals nationwide to respond proactively t local media upon release of the report.
Dr. Lu suggested that Council members may have valuable insights for SAMHSA on whether substance abuse and mental health services should be mainstreamed into primary health care, and on the advisability of earmarking state block grant funds for specific subpopulations. Ms. Wainscott acknowledged the desirability of accountability for use of the funds, but recognized the reality that resistance to mandates sometimes is expressed in less-than-complete reporting. Dr. Shon stated that the emphasis ought to be on better, more inclusive planning processes at the local, state, and Federal levels that focus on meeting local needs in priority order.
Members also discussed whether SAMHSA's reauthorization should require special attention to delivery of mental health and substance abuse services within the primary care context. Dr. Lu pointed out that for many minority communities, primary health care is often the place where psychiatric disorders are first observed, acknowledged, and treated; it is therefore important that increased collaboration occur between the primary and mental health care arenas.
Ms. Wainscott stated that the specific of proposed legislation must be considered in their evaluation. Dr. Pumariega cautioned against redirection of dollars from other priorities and needs; primary care receives its own stream of dollars, which that segment should also put on the table. He suggested that a bill that addresses collaboration issues would be more appropriate than a bill that redirected either CMHS' or other agencies' missions. Dr. Shon noted that primary care medicine typically underdiagnoses and undertreats mental illness and substance abuse. Dr. Arons explained that although dollar considerations are determined in appropriations bills, language in an authorization bill sets up the infrastructure for allocation of dollars. Mr. Burgmann noted that unfunded mandates are usually poorly executed. Ms. Wainscott suggested that parity within the FEHBP creates an opportunity to demonstrate that parity works. Dr. Martinez noted that inadequate training in medical and nursing schools for mental health care exacerbates the problem of shorter time slots for treatment in the managed care environment.
Strategy Session
Council members suggested areas of focus for CMHS over the next 10 years. Dr. Gottlieb observes that there appears to be a pervasive subclinical anxiety disorder; people are feeling more mistrustful. Ms. Wainscott noted that Americans are increasingly viewing mental health as life span issue, a perspective on which CMHS can build through the transmission of scientific information about mental wellness and mental illness; this recognition can be the basis for stigma reduction and policy change.
Dr. Pumariega pointed to the gap between knowledge and understanding in the field, and among policy makers and funding sources; increased efforts must be made to convince policy makers that services are effective in permitting people to lead productive lives and save dollars. Dr. Lu urged better dissemination to policy makers of cost-effectiveness data of mental health care.
Dr. Shon urged CMHS to provide leadership in improving the quality-improvement processes used in the public and private arenas, and in how the outcomes are demonstrated. He also urged CMHS to examine how to narrow the gap between best practices in the field and standards of care currently taught by many teaching institutions.
Dr. Getka suggested that CMHS look into developing psychological prevention programs to increase communities' resilience to terrorism, taking into consideration the reality that preparation raises anxiety. Dr. Gottlieb added that trauma actually helps communities act like communities; perhaps, if communities are helped to function better as communities, that will help them be more resilient in the face of trauma.
Ms. Wainscott urged greater focus on the mental health needs of children, including better screening, and urged that CMHS continue to monitor the issue of reimbursement for services. Dr. Arons stated that CMHS will consider funding a study of the effects of parity on Federal employees.
International Mental Health Initiatives, Professor Marten W. deVries, President, World Federation for Mental Health (WFMH)
Professor deVries described the activities of his organization, and international nongovernmental organization accredited as a consultant in mental health to all relevant United Nations agencies, including the World Health Organization. He noted that one in five people will experience a mental disorder in their lifetime, meaning that every social network in the world will be in contact with a mental disorder at some point, and that the stigmatization and marginalization of people that occurred in the past is going to be almost impossible in the future.
Professor deVries described the WFMH and presented a brief overview of a multistage methodology for entering communities worldwide, for getting adequate information, and for developing clinically relevant statements for policy at the epidemiology level. He discussed several WFMH activities, including technical assistance to institutions worldwide and developing partnerships in mental health. One such partnership is producing Global Mental Health Videos, a series of soap operas and ethnographic videos on such topics as sexual abuse that are hoped to become training films for practitioners. Other activities involve promoting prevention and developing an electronic mental health network.
Consumer Affairs Update, Paolo del Vecchio, Senior Policy Analyst, CMHS
Mr. del Vecchio updated the Council members on CMHS's consumer affairs activities:
- CMHS will provide scholarships to consumer/survivors to attend the upcoming World Conference Mental Health.
- The planning group for the Subcommittee on Consumer Issues is accepting and reviewing applications for membership; Council members will review selection, probably in December.
- Plans are underway for a dialogue between consumers and psychiatric nurses this summer, with hopes to conduct another dialogue between consumers and social workers in the fall; it is hoped that partnerships will be forged between these groups. An earlier dialogue between consumers and psychiatrists has resulted in a video (in production) of first-person experiences, to be used in training psychiatric residents. Following a psychologist/consumer dialogue, the American Psychological Association plans to include a consumer track at its upcoming summer convention.
- Plans for regional consumer meetings are on track to develop input to CMHS on high-priority needs and concerns.
- Several anti-stigma activities are underway.
- CMHS has trained all SAMHSA staff on the impacts of the Consumer Bill of Rights, has sought input on it at grant meetings, and has drafted language for grant announcements encouraging adherence to it.
- An informal study of restraint and seclusion has revealed, among other findings: (1) a general lack of available data on prevalence; and (2) great varialblitiy among states and facilities in the use of restriants and seclusion.
Dr. Aarons invited suggestions for helping CMHS to coordinate efforts in the emerging Federal campaign against stigma; he suggested that CMHS sponsor a kick-off meeting.
CMHS School Violence Prevention Program, Michael English, J.D., Director, Division of Knowledge Development and Systems Change, and CAPT. Brian W. Flynn, Director, Program Development, Special Popualtions and Projects Division
The two division directors presented an update on the CMHS School Violence Prevention Program. CAPT. Flynn highlighted the exceptional amount of interdivisional and interagency collaboration that has taken place among CMHS, SAMHS, and NIMH. As background, CAPT. Flynn presented statistics on violence in American schools, both actual and perceived. CMHS and the Departments of Education and Justice fashioned an initiative designed to:
- Marry security with healthy childhood development;
- Take a school-based, public health approach that would facilitate a focus on prevention;
- Offer comprehensive, coordinated services along the entire developmental path of childhood;
- Forge school, law enforcement, and mental health partnerships; and
- Pay for services that have been shown to work.
The goals of the program are to:
- Improve/increase services to "at-risk" children and their families;
- Link child-serving agencies in a consistent and complementary strategy;
- Decrease violence, drug abuse, and school disciplinary activity; and
- Measurably increase healthy development of all children.
The initiative is composed of two grant programs: Safe Schools/Healthy Students (SS/HS) (in collaboration with the Departments of Justice, including Community Oriented Police Services [COPS], and Education) and CMHS' School Action Grant program. The SS/HS program will award about $180 million to a total of 500 rural, suburban, and urban grantees, ranging from $1 million to $3 million each. Awards will be made to school districts partnered with law enforcement and public mental health agencies to fund projects incorporating the following activities: school security issues; school policy; educational reform; alcohol, other drug, and violence prevention and early intervention activities; school and community mental health preventive and treatment intervention services; and early childhood psychosocial and emotional development. Agencies involved in the provision of services must have been involved in the project planning. A notional evaluation will coordinate local process evaluations, and will also conduct specific studies to determine the effectiveness of particular interventions and of the overall strategy.
The School Action Grant program received 97 applications, and approximately 33 awards will be made in the range of $150,00. The interdepartmental SS/HS program received 443 applications.
Mr. English and CAPT. Flynn described the effort's public health approach, which focuses on risk and protective factors, and the emphasis on evidence-based research on which to base local programs. In addition to a strong evaluation component, the program will incorporate national education campaign and technical assistance elements. Following July/August reviews, awards are expected to be made in September. Dr. Arons asked the panel members to reserve August 13 to participate in a second-level, conference-call review of the interdepartmental SS/HS grants.
Mr. English assured the members that most of the exemplary practices the initiative aims to fund have a strong focus on family-based services. He acknowledged that family members did not sign off an the SS/HS grant applications, but noted that was a motivation for the CMHS School Action Grants targeted at families and community-based organizations.
Dr. Ruby N. Martinez described her experiences as a first-line counselor to school-age children communities neighboring Littleton, Colorado, following the school shootings there. Middle-school students told her: (1) They had no avenue to pursue effective conflict resolution among themselves and among various school groups, and (2) police posted at the doors made the adults feel better, but raised the level of anxiety among the students. Dr. Martinez felt it important that students be helped to deal better with conflict. She observed that students feel it is not safe to be different.
CMHS is involved with the EchoStar Education Initiative that will provide satellite-fed programming on safer schools. CAPT. Flynn pointed out that teacher stress reduction must be addressed, and noted CMHS' collaboration with the National Education Association; a serious school-personnel attrition problem may result from the increased incidence of violence in U.S. schools. Dr. Gottlieb urged that adults listen better to children in traumatic situations.
Dr. Pumariega expressed concern about violations of IDEA by schools that exclude students from school for disruptive behavior. He cautioned that expulsion may lead to replication of the Littleton school shootings and emphasized that in-school suspension is the best approach.
Mental Health United States, 1998, Ron Manderscheid, Ph.D., Chief, Survey and Analysis Branch, CMHS
Dr. Manderscheid described the subject matter of Mental Health United States, 1998, the CMHS- produced compendium of mental health statistics. Major discussions include key issues of concern that are related to the emergence of managed behavioral health care, including assessment of outcomes, assessment of performance, key factors in managed care, work force initiative, rural mental health, population-based analyses, and national statistics.
Dr. Manderscheid invited members of the Council to contribute their expertise to upcoming technical assistance documents on managed behavioral health care. New papers are to be published on risk adjustment and the role of employee assistance programs.
He pointed to the dilemma of how to incorporate psychosocial rehabilitation into the integrated delivery systems of managed health care without destroying the cultures that exist in the separate components that are under pressure from shrinking dollars. An information system project is underway that focuses on local area needs, on defining how practitioners will know if they are following system or clinical guidelines, and on report cards for services.
Dr. Manderscheid stated that technology (including the Internet) is expected to play new roles in an increased focus on mental health screening, prevention and early intervention, monitoring and peer support. He described features of Australia's mental health system, which now has in place practice guidelines for depression in schools and several state-of-the-art prevention interventions.
Discussion
Dr. Manderscheid noted that CMHS is addressing encryption and using the Internet for data collection, and stated he expects it will be used for dynamic analysis over time. The department is currently considering the issue of unique identifiers, a concept that has not been popular in the field. CMHS favors an electronic medical record system in which the information stays where it originated and the consumer decides who has access to the information.
Ms. Wainscott raised the question of how CMHS can assist states to focus on prevention and early intervention services, at a time when states feel they have all they can do, with their limited resources, to take care of their most seriously disturbed individuals. Dr. Manderscheid responded that, first, best practices must be agreed upon, and second, funding ultimately will drive the move to earlier intervention, in part because of dollar savings. He pointed again to the example of the Australian system. He noted that the development of quality tools is essential to improving the ratio of health care benefits allocated to mental health.
Report from the SAMHSA Administrator, Nelba Chavez, Ph.D.
In her report on SAMHSA activities, Dr. Chavez highlighted the staff work in support of the recent White House Conference on Mental Health. Other high-profile activities have included work on the Surgeon General's Report on Mental Health and work in the area of violence. She stated that the agency has begun to focus on activities to be conducted in the next century to combat mental illness and substance abuse from a public health perspective, and she invited members to offer suggestions concerning budget items and programs for the 2001 budget and beyond.
At Dr. Chavez's request, Dr. Arons summarized the Council's earlier strategic discussion, noting the need to promote prevention and early intervention, the important role of taking a community perspective to ease what may amount to a subclinical anxiety disorder, taking the life span approach, and using some funding to influence policy makers.
Dr. Gottlieb identified the increasing isolation and alienation in communities and in families characterized by less trust, less faith, and less generosity of spirit. Ms. Wainscott discussed the current opportunity to build bridges and reduce stigma. Mr. Burgmann urged CMHS and SAMHSA to plan for a new mental health regime that serves the needs of individuals across the entire mental health spectrum of severity.
Dr. Pumariega noted that managing diversity and cultural competence must be a major agenda item in discussions of service provision and prevention. Dr. Lu urged a look at how to implement best practices and policy regarding cultural competency in the communities to a greater degree, including achieving buy-in by communities.
Several members discussed the difficulty of implementing practice guidelines broadly in the field once they are promulgated. Ms. Wainscott urged CMHS to mobilize the grassroots mental health movement, state by state, to help disseminate the information in the upcoming Surgeon General's Report on Mental Health. The president's executive order for parity for government employees is an opportunity to build on the life span concept of mental health and to assure that all mental health services are covered under a public health model. Dr. Gottlieb suggested that dissemination guidelines be published along with the Surgeon General's Report. Dr. Lu emphasized that opportunities for cultural competence to be addressed in the roll-out of the report and for the Federal government to serve as a model of cultural competence. Mr. Burgmann and Ms. Wainscott emphasized the role in this effort of grassroots organizations with media contacts.
Dr. Chavez identified several components of a rare opportunity to think about and promote mental health, and to devise ways to fix the broken system: the upcoming issuance of the Surgeon General's Report, the White House Conference on Mental Health, and the school violence incidents. She also pointed out a number of challenges to be overcome: 60 percent of children with mental health needs do not receive services; 10 million children in the United States have a family member affected by alcohol or substance abuse or mental illness; providers resist implementing "products;" and fewer and fewer providers are trained.
Dr. Chavez announced the upcoming SAMHSA Women's Conference, June 27-30,1999, in Los Angeles, in which 14 Federal agencies will participate. Participants are expected to communicate their visions for the next century related to all issues that impact women concerning health-particularly mental health, substance abuse, prevention, and violence.
Public Comment
In the segment allotted for public comment, four individuals spoke to the Council:
- Joe Rogers, the Executive Director of the Mental Health Association for Southeastern Pennsylvania, expressed concern that the grant programs do not include advocacy for children identified as having emotional problems and who therefore may be stigmatized. He said participation of consumers, advocates, and family groups is essential in addressing this issue. Rogers said that the organized movement of consumer/survivors has a growing voice that should be heard. HE urged CMHS to support financially or morally a national summit of consumers to be held in Oregon to discuss an organizing platform and to organize energy for various national networking efforts.
- Larry Belcher described the activities of the CONTAC Center, an onsite technical assistance project of the West Virginia Mental Health Consumers Association. The group helps establish grassroots organizations and helps to enhance the activities of existing organizations. CONTAC was instrumental in helping the Maine consumer self-advocacy network to form; the next effort will be in Fort Lauderdale, Florida. CONTAC offers free web sites to consumer organizations and has established a prototype outcome system for the center.
- Daniel Fisher, M.D., executive director, National Empowerment Center, described the center's work: consumer/survivors spreading the message that people can recover from mental illness. He noted that recovery cannot be complete unless consumers can exit the mental health system. The center has developed a model called PACE (Personal Assistance in Community Existence) founded on consumer-based values of recovery, self help, and peer support, and a system of care based on the principles that people can recover, regain control of their lives, make decisions, and learn to self-manage care. Projects are underway in several states to document and clean up unmarked graves of patients who died in mental hospitals.
- Laura Van Tosh described the Mental Health Policy Roundtable, which provides a mechanism for seasoned mental health policy veterans to interact with younger policy makers. She also reminded the Council members that only people with insurance can gain parity; millions of Americans have no insurance.
Adjournment
Dr. Arons adjourned the meeting at 5:08 p.m.
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