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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
September 6-7, 2001
Rockville, Maryland
MINUTES
Closed Session
The National Advisory Council of the Center for Mental Health Services (CMHS) met
in closed session at 8:30 a.m. on September 6, 2001, at the Doubletree Hotel in Rockville, Maryland, to review grant applications. CMHS Director Bernard S. Arons, M.D., and then CMHS Deputy Director Camille Barry, Ph.D., R.N., presided.
Open Session
Dr. Barry convened the open session at 1:30 p.m. Council members present included CMHS Director Bernard S. Arons, M.D.; CMHS Deputy Director Camille Barry, Ph.D.,R.N.; 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; Andres Julio Pumariega, M.D.; Josie Torralba- Romero, M.S.W.; William W. Van Stone, M.D.(ex-officio); and Cynthia A. Wainscott. Karina K. Uldall,
M.D., was on a speaker phone during the grant review portion of the meeting.
Welcome and Opening Remarks
Dr. Barry welcomed Col. Hall to the Council and announced the retirement in December 2001 of CMHS’ Admiral Brian Flynn, Director, Division of Program Development, Special Populations and Projects. Anne Mathews-Younes, Ed.D., Special Programs Development Branch Chief, introduced new CMHS publications on depression, low-income women, and school violence prevention. Dr. Beardslee announced that he will publish Out of the Darkened Room: Protecting the Child and
Strengthening the Family When a Parent is Depressed this spring.
Financing Trends and Public Mental Health Services
Jeffrey A. Buck, Ph.D., Associate Director for Organization and Financing, CMHS/SAMHSA, presented evidence on Medicaid’s increasing dominance of the public mental health service system at the State and local levels. He also described characteristics of mental health services
within Medicaid, the primary payer of State/local public mental health services. In 1997, Medicaid paid for 36 percent of public mental health services; Medicare, 22 percent; other Federal agencies (Departments of Defense and Veterans Affairs), 7 percent; and State/local funds, 35 percent. Public mental health spending in 1997 on programs solely Federally administered
(Medicare) amounted to 22 percent; on other Federal programs, 6 percent; and on State- and locally-administered programs, 72 percent. The Block Grant is a minor component of public funding for mental health services at the State and local levels. Over the next 10 to 20 years, Medicaid will pay for two-thirds of all spending administered by States and localities for public mental health services.
Discussion
Because Medicaid is an entitlement program, States are obligated to pay for services
regardless of unbudgeted increases in enrollment figures. Dr. Buck noted that when the economy does poorly, Medicaid expenditures increase. Dr. Beardslee observed that State spending in Medicaid is vulnerable to Federal vagaries, and that, if Federal support of Medicaid was to be diminished, the programs would be vulnerable. Dr. Buck noted that the proportion of Medicaid dollars spent by States for mental health is relatively consistent, but that the cost of medical
care, number of people in poverty, and optional services from which States can choose account for varying amounts spent by States. He explained that the Health Insurance Flexibility and Accountability (HIFA) waiver initiative is an Administration effort to respond to governors’ requests to enable Medicaid to cover groups otherwise ineligible. Mental health services are not required under the HIFA initiative.
Dr. Buck explained the changing role of Medicaid in the mental health service system, using integrated 1996 data from the Medicaid, substance abuse, and mental health agencies in Delaware, Oklahoma, and Washington (with data forthcoming for 1997 and 1998). This project has produced an analytic file based on 278,000 non-elderly persons with a primary mental health/substance
abuse diagnosis and/or receipt of mental health or substance abuse services. About 70 percent of the people in the file use mental health services. Between 40 and 70 percent received support for their mental health services either wholly or partially through Medicaid. Data maintained by State mental health agencies do not include 25 to 50 percent of people who receive mental health
services. For an additional 10 to 20 percent of people who receive mental health services (paid for by Medicaid and the mental health agency), mental health agency data miss at least part of the picture. Dr. Buck stated that 25 to 75 percent of children and adolescents who receive mental health services receive them only through Medicaid; no agency is aware of this group other than
the Medicaid agency. States’ approaches to services are idiosyncratic, as are their approaches to collecting, organizing, and coding data.
A separate analysis for people with severe mental illnesses showed that a majority in all three States receive at least some mental health services from Medicaid. From 20 to 25 percent receive all of their mental health services through Medicaid.
Dr. Buck reported that roughly 10 percent of Medicaid enrollees use mental health services, and about 10 percent of total Medicaid funding pays for mental health services (exclusive
of drugs). Mental health service users are among the highest cost group within the total Medicaid population. States show relative consistency in the proportion of the care dollar for Medicaid mental health services. Medicaid expenditures for mental health/substance abuse vary
by age.
Important trends and issues include the following:
- Increasing dominance of Medicaid and Medicaid authorities in mental health systems
administered at State and local levels. Medicaid agency administrators have increasing
influence.
- Change from “grants” model to “insurance” model, where people have an insurance card with defined benefits and choice of providers. This trend has implications for services.
- Absorption of independent mental health agencies into umbrella health or health and human
service agencies at the State level.
- Elimination or transformation of “safety net” providers in terms of business
organization, what is paid for, and what is not. Credentialing standards are part of these changes.
Some policy issues require thought about their ramifications:
- How do we think about State mental health services and policies? The current system
is increasingly difficult to distinguish from the private sector system.
- Data and reporting on Medicaid mental health services are poor. No Federal
requirement exists for States to report how Medicaid mental health funds are spent.
- State mental health planning requirements exist, but no requirements exist that
include incorporation of Medicaid information to enable systematic review of service provision.
- No requirements exist for Medicaid accountability for mental health services.
Discussion
Ms. Wainscott and Dr. Buck noted the need for improved coordination between Medicaid and mental health agencies within States. Ms. Torralba-Romero noted that 10 percent of all mental
health service users are members of minority groups. Dr. Buck stated that the data reflect ethnicity in the States included in the project, but the fact that there are no national reporting requirements may leave data voids for other States.
Administrator’s Update
Joseph H. Autry, III, M.D., Acting Administrator, SAMHSA, announced that Mr. Charles Curie is the SAMHSA Administrator designee. Dr. Autry described the first-ever breakfast meeting for Recovery Month with the Secretary of Health and Human Services. Substance abuse and mental health are on the Department’s “radar screen.” Dr. Autry described Mr. Curie’s executive leadership style, whereby he and the Center directors will decide on SAMHSA’s
direction, in consensus, to the maximum extent possible.
Dr. Autry discussed the ongoing 2001 grant review process—a streamlined, small group model—that is undergoing evaluation and producing early positive results. He promised to
report to the Council on its outcomes.
Dr. Autry briefly discussed faith-based initiatives and noted that SAMHSA has a
history of working with many faith-based organizations and providers. Regulations regarding charitable choice provisions for substance abuse programs are expected within the year. Dr. Autry noted that the faith-based issues tie in with the New Freedom Initiative (based on the U.S. Supreme Court’s Olmstead decision to permit widest access to the least restrictive services) and also with the new National Mental Health Commission’s activities. At a listening session, both substance abuse and particularly mental illness advocates were well represented.
Dr. Autry noted that Mr. Curie’s interests include seclusion and restraint. CMHS and the Center for Medicare and Medicaid Services (formerly HCFA) have the lead in developing regulations on this issue. SAMHSA and CMHS are drafting preliminary regulations, with input from others, for nonmedical facilities such as residential and day facilities. Training needs will be addressed.
Dr. Autry also mentioned that the Performance Partnerships Report to Congress is due in October 2002 on plans for the mental health and substance abuse Block Grants to give States more flexibility in the use of funds and to work with States to develop outcome and process measures. NASMHPD and NASADAD have provided input, and dialogue will take place to formulate a requisite May 2002 draft.
In terms of fiscal resources, both the 2002 and 2003 budgets remain unknown, and the contracted economy may bode for a tight budget. Dr. Autry explained the Administration’s
restructuring and delayering plan to have fewer numbers of management and coordinating positions, and to bring decision makers closer to the citizenry and constituent groups.
Discussion
Ms. Wainscott suggested that SAMHSA articulate the prevention message in developing Performance Partnerships. Dr. Autry noted that although the substance abuse block grant has
a set-aside for prevention, mental health does not. The Targeted Capacity Expansion Program was created in recognition of the need for prevention, early intervention, and illnesses beyond serious mental illnesses and severe emotional disturbances. Ms. Torralba-Romero commented that primary prevention will increase the constituency and increase access to people who need services. Early intervention and prevention are essential for communities that do not
normally mainstream into mental health services, and prevention can reduce high Medicaid/Medicare costs later on. Observing that housing and stability reduce recidivism, she encouraged quantifying results and using them as a persuasive tool. In response to a question, Dr. Autry stated that the National Commission on Mental Health is likely to have family and consumer representation. Responding to Ms. Torralba-Romero’s concern about the need for more diversity
among SAMHSA staff, he said that staff has been informed that no one will lose his or her job or permanent grade as a result of the restructuring and delayering activity, and that the agency will continue recruiting to increase diversity.
Public Comment
Paul Seifert, Director of Government Affairs, International Association of Psychosocial Rehabilitation Services, noted the significance of the Block Grant in rural areas, where in some States the Block Grant accounts for 15 to 20 percent of the budget.
Remarks by SAMHSA Administrator Designee
Charles G. Curie, M.A., A.C.S.W., SAMHSA Administrator Designee, stated that
cultural competence is a major priority in ensuring that SAMHSA’s services are relevant to all persons. His vision focuses on what are we doing in and for the lives of people. He expressed his strong support for both consumer and family voices at the table.
Discussion
Ms. Wainscott urged Mr. Curie to focus on prevention and the health of the community, according to the public health model, and to include consumers and family members on the National Commission. Ms. Torralba-Romero concurred that the Commission should be representative of
America in terms of family, consumers, and diversity. Dr. Beardslee urged Mr. Curie to consider policies that treat and support families. Mr. Curie stated that the Surgeon General’s reports on mental health should be guidance for policy. A major continuing priority will be to address
discrimination/ prejudice/stigma related to mental illness.
New Freedom Initiative, Eileen Elias, M.Ed., Special Expert on Mental Health, Office of
Policy and Program Coordination (OPPC), SAMHSA; Daryl Kade, M.A. Associate Administrator, OPPC, SAMHSA; Carole Schauer, R.N., M.S., Consumer Affairs Specialist, Office of External Liaison, CMHS.
Ms.Elias described the New Freedom Initiative as promoting community living under the Americans with Disabilities Act, Title II, and the Olmstead decision. A Presidential Executive Order calls for the swift implementation of the Olmstead decision and aims to ensure that Americans with disabilities have the opportunity to learn and develop skills, engage in productive work, and choose where to live and participate in community life—including
people in institutions who have the right to live in communities. Ms. Kade stated that CMHS and OPPC have the lead in a cross-center Work Group. The Executive Order directs the Departments of Justice, HHS, Education, Labor, HUD, Transportation, and Veterans Affairs; the Social Security Administration; Small Business Administration; and Office of Personnel Management to provide
assistance and work cooperatively with the States to assist in implementation of the Olmstead decision. It also directs the Federal agencies to evaluate policies, programs, statutes, and regulations to determine whether any should be revised or modified to improve
the availability of community-based services for people with disabilities. States can establish compliance by establishing a comprehensive working plan for placing persons with disabilities
in less restrictive settings.
Discussion
Dr. Lu noted the need of people with serious mental illnesses for housing options, such as residential care facilities and halfway homes. Barriers to service provision exist in funding, zoning, and community-response issues. A cross-cutting issue is housing for people with serious mental illnesses and physical disabilities. Language access and cultural issues are also important. Although the Surgeon General’s report discusses multiple disabilities, it
is increasingly difficult to provide services needed to carry forth Olmstead
with overlapping requirements.
Dr. Martinez noted the need for sufficient family-support and case-management models to help people from falling through the cracks as they did during deinstitutionalization. Ms. Torralba- Romero noted that residential housing for persons with mental illness should be available to families, not just individuals, in order to keep families intact. Many Latinos lack access to
mental health services because of language or transportation barriers. Ms. Wainscott stated that an adequate delivery system must include medications, psychotherapy, psychosocial rehabilitation, and community supports. Funding silos created in the public and private sectors are barriers to treatment; if money were spent on people, not programs, progress would result. Dr. Beardslee
stated that services should be integrated and co-located in one place, and that physical and mental health care should be integrated with universal access. Col. Hall noted that the Air Force has had success with one-stop shopping, where all helping agencies are linked on a base, and Ms. Wainscott noted that many people with depression have had successful military careers because of the availability of early treatment. Ms. Schauer suggested accessing the http://www.hhs.gov/newfreedom/ website for more information on the New Freedom Initiative.
Discussion of the Application Process and Grant Review Update, Cynthia Wainscott, CMHS National Advisory Council; Judith B. Braslow, Deputy Associate Administrator, OPPC, SAMHSA.
Ms. Braslow reported progress in improving the peer review process. Work is continuing on the electronic transmission of summary statements. The evaluation of the 2000 grant review process found that the small group process provides a sound basis upon which the agency can frame immediate improvements, and that the review staff were professionally competent—despite an imperfect process, too great a work load, and too much variability among groups. Preliminary observations show that reviewers in the small group process were better prepared than in the
standard process; the use of PowerPoint presentations enhanced communication during the review; and IRG deliberations were more rigorous and faster.
Ms. Braslow described process changes for the summer 2001 GFAs. Almost all were written in plain English; all reviews were completed using the small group process; reviewers were sent applications for which they would have responsibility; time was allotted during meetings to review additional applications; a standardized orientation was developed and used by all review
administrators; standing committees were used where possible; and a reviewer database was developed to identify reviewers. Upon completion of the review session, the entire IRG reviewed written summary statements for each application.
The action plan for the future includes the following: complete the study, refine GFAs,
review funding criteria for improvements, increase electronic processing, issue GFAs throughout the year, present technical assistance (TA) workshops earlier in the process, use reviewer feedback, and offer improved instructions on participant protection. Other longer-term considerations include upgrading reviewer compensation, reassessing agency resource requirements, and standardizing orientation.
Discussion
Ms. Wainscott invited comment on how to make the GFA process more user friendly.
Dr. Martinez noted the improved accuracy, reduced stress, and improved cost-effectiveness. An unresolved issue is input from consumers at several critical points in the process, including advice on what might be critical elements in the GFA. It was noted that, in some cases, consumers are not consulted because of a potential conflict of interest. It was further stated that a minimum of two consumer reviewers serve on each IRG panel. CMHS staff also solicit input from consumers on ideas to incorporate into GFAs and is contemplating convening focus groups of unfunded and successful applicants.
Ms. Wainscott and Ms. Braslow discussed some decisions inherent in improving GFAs:
length, amount of critical information, and limitations on application length. Ms. Elizabeth Sweet stated that unfunded applicants’ meetings provide two-way communication—feedback on the GFA process and TA to the applicants, particularly in understanding the targeted population. Dr. Teresa Chapa noted that time constraints may impact GFA writing and that the existence of efficient structures and positive relationships may improve the process. Ms. Braslow stated that a template development process is in place to make GFA writing easier. Ms. Wainscott suggested that internal staffing be examined, that reviewer compensation be upgraded, and that geographical distribution of applications be examined to reveal patterns of underrepresentation.
Dr. Barry recessed the meeting at 5:15 pm. Dr. Arons reconvened the meeting the
following day at 8:40 am.
CMHS Update
Bernard S. Arons, M.D., Director, CMHS, saluted retiring members Ruby Martinez, Donna Mayeux, and Andres Julio Pumariega for their outstanding service to the CMHS Council. Members unanimously approved the minutes of the January 2001 CMHS Advisory Council meeting. Next, Dr. Arons gave a number of updates. He reported that CMHS has linked with the SAMHSA Council’s Subcommittee on Co-occurring Disorders; Dr. Ruby Martinez and Ms. Wainscott serve as representatives with Dr. White-Perry as an alternate. CMHS staff has compiled fact sheets on homeless programs. Staff liaisons have been identified for health disparities (Teresa
Chapa) and faith-based issues (John Tuscan).
Resolution on the Support of National Parity Legislation
Dr. Arons then turned to Ms. Wainscott for another Council business item. She introduced resolution to support national parity legislation which was passed unanimously. The text of the resolution follows:
Although one in five Americans will have a mental illness each year and, in the year 2000, an estimated 14 million Americans were current illicit drug users, and approximately 12.6 million
people were heavy drinkers, discriminatory practices in health plan coverage unfairly limit access to mental health and substance abuse treatment services through lower day and visit limits, higher co-payments and deductibles, and lower annual and lifetime spending caps compared to general health care. These practices create barriers to needed services and result in unnecessary suffering. They impose serious financial hardships on families and shift costs
to government systems. Accordingly, the Center for Mental Health Services National Advisory Council 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.
In another item of business, the Council unanimously elected Ms. Wainscott Council
Secretary.
After concluding these business matters, Dr. Arons returned to the delivery of the
Director’s Report. He highlighted several developments in the legislative arena and indicated that the Patient’s Bill of Rights is headed for conference committee. A Senate committee
unanimously passed the Mental Health Equitable Treatment Act to replace and expand the existing parity law. The Foundations for Learning Act seeks to address emotional and behavioral problems and their causes that may impede learning by having early childcare and preschool providers identify children in need of services.
He went on to acknowledge CMHS leadership in publishing the Surgeon General’s Mental
Health: Culture, Race, and Ethnicity, an important step in eliminating disparities in mental health care. He also stated that the written Director’s Report describes a rich array of CMHS activities, including the new $14 million Targeted Capacity Expansion grant program for mental health services in nonspecialty locations, with a focus on homeless individuals, individuals with co-occurring disorders, and individuals in the criminal and juvenile justice
systems—plus the elimination of racial and ethnic disparities. Dr. Arons noted that the
National Child Traumatic Stress Initiative will develop a service network for children and adolescents. He announced that the 15+ program has received prestigious awards and that the Baltimore Ravens will participate in the fall, targeting the involvement of fathers with their children.
Discussion
Dr. Arons stated that under the reorganization, CMHS will move Consumer Affairs activities to the Office of the Director. In response to a question, Dr. Arons stated that discussions will take place before resolution on parity legislation is achieved. Dr. Mathews-Younes stated that all 15+ materials have been translated into Spanish, and it is hoped that the fathers project also will be translated into other languages.
Comprehensive Community Mental Health Services Program for Children and Their Families: A Mid-course Review, Michael J. English, J.D., Director, Division of Knowledge Development and Systems Change, CMHS; Gary De Carolis, M.Ed., Chief, Child, Adolescent and Family Services Branch, Division of Knowledge Development and Systems Change, CMHS.
Mr. English introduced this decade-old grant program that has provided mental health services to 65,000 children and adolescents with serious emotional disturbances and their families nationwide. The program is undergoing a formal mid-course review, particularly on the issues of cultural competence, family involvement, implementation of evidence-based clinical practices, and the appropriate role for conducting evaluation and research activities within the grant program. Basic tenets of the program are to build leadership and service-provision capacity within communities, look at children’s strengths versus failings, provide individualized care, and be accountable both for finances and for outcomes of children. A new grant announcement is expected
this winter for new communities. CMHS has funded 67 grants since 1993; 45 are currently funded with 22 graduated. A requirement for increasing nonfederal matching funds over the duration of the grant has raised more than $200 million to date. Native American communities have embraced the program, but CMHS feels that it may be possible to do more to help cities. CMHS is seeking ways to enhance the program’s analysis work. The development of a valid systems-of-care assessment instrument is a major accomplishment. The essential element in systems of care is that the partners work together to serve children. Future emphasis will be placed on recruiting primary health care providers into the partnership mix.
Much data has been collected that shows positive outcomes for children, including reducing changes in a number of residential placements. A requirement of the program is care coordination, and its intensity varies with the needs of the child. Caregiver satisfaction scales for validity are in question, and youth scales show less satisfaction than their parents. This can be a learning opportunity.
A comparison study of outcomes shows that grantee communities have greater consistency across performance indexes than nongrantee communities. For instance, this is the case in terms of
infrastructure and services delivered. Participants who are in the systems-of-care program have had less involvement with the juvenile justice system than those who are not. Mr. De Carolis explained that children not receiving services are not included in the statistical analysis. Another positive outcome is reduced costs due to reduced involvement in the juvenile justice system. Communities may spend more money on coordination in the beginning, but over time the costs shrink. In non-systems of care, communities spend less at first, but costs rise. Where
communities have implemented evidence-based treatment programs, early evidence shows great gains.
Discussion
Mr. English described the target population: 50 percent minority and broad geographical distribution (but light in cities). Dr. Pumariega discussed the need to move beyond model demonstrations to replication in communities. He also noted that cultural competence is shown to be a predictor of outcome in highly statistically significant findings. He urged CMHS to provide incentives to motivate culturally competent practices in the field. Dr. Lu suggested the
value of ethnic analysis of the data and a determination of whether systems of care are culturally competent, in part in response to the Surgeon General’s call for more research and data on cultural competence. Language access for some populations is an issue; the question of whether language competency makes a difference must be raised. The issues of religion and spirituality and resilience are also important in this context. Mr. English suggested that
prevention and mental health promotion could be added into the program design. Mr. De Carolis noted that work has been done to define cultural competence, but difficulties arise in operationalization of policy and practice by agencies. Future technical assistance will focus on this issue.
To promote city involvement, Ms. Torralba-Romero recommended enlisting the cooperation of leaders in parks and recreation divisions, which often have better connections with CBOs than mental health systems. To operationalize cultural competence, she recommended incorporating it into every principle and programming aspect and deleting cultural competence as a program area. Dr. Pumariega urged using the cultural competence standards in TA efforts. Ms. Wainscott questioned continuing to use the term “serious emotional disturbances” vis-à-vis stigma and funding and replication issues. It may be easier to sell a program using the term “disturbed” or “sick” child. She also questioned the advisability of merging the two separate tracks of serious emotional disturbances for children and serious mental illnesses for adults. The Surgeon General’s report calls for the public health view of mental health and mental illness,
which involves talking about the entire spectrum (including prevention)—even when working on only one end of it. Ms. Torralba-Romero urged discussion of cultural competence standards in Leadership Academy training, particularly the issues of cross-cultural supervision and recruitment and retention of staff. Dr. Beardslee urged studying how to translate cultural competence standards into practice behaviors.
Dr. Beardslee discussed the need for devising an experimental study design of the features that permit systems of care to work best before taking the program to scale. He noted that some providers follow customary practice in the community, rather than evidence-based standards, and suggested conducting an efficacy rather than an effectiveness study. Dr. Richard Nakamura of NIMH suggested using data to generate a factor analysis for feedback about what correlates with good outcomes and then to structure serious research projects around them to help (with NIMH support) identify principles that generate good outcomes. Dr. Pumariega suggested issuing special GFAs for systems of care that focus on a specific evidence base, train people to reliability, conduct field intervention with random assignment, train people on protocol within systems of care, and then evaluate outcomes.
Ms. Torralba-Romero stated requirements for successful family involvement:
education and information up front about the benefits of staying in the system
and investment in family advocate mentoring with a language match. Ms.
Wainscott discouraged GFAs from asking for development of a family organization
and encouraged asking for a “significant role,” not
indicating a percentage, for families in planning, governance, training, and
service delivery. TA is critical in this regard. Dr. Beardslee suggested asking
family partners how they define families and what they want included in family
systems of care settings. It is important to configure resources to support
what family partners believe will support the preservation and integrity of the
family. Dr. Lu commented on the role of faith communities as nontraditional
support agencies.
Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General, Michael J. English, J.D., Director, Division of Knowledge Development and Systems Change, CMHS; Nancy J. Davis, Ed.D., Public Health Advisor, Special Programs Development Branch, CMHS, and Managing Editor; Kana Enomoto, M.A., Public Health Advisor, Division of Knowledge Development and Systems Change, and Associate Managing Editor.
Mr. English and Dr. Davis recognized the contributions of multitudes of individuals, including Teresa Chapa, Ph.D., and reported on the complexities of bringing the report from concept to roll-out. Mr. English presented the themes of the original Surgeon General’s Report on Mental Health: the focus is on a public health approach; mental disorders are disabling and are points on a continuum; mind and body are inseparable; stigma is a major obstacle to seeking help; mental health is fundamental to health; mental illnesses are health conditions; efficacy of mental health treatments are well documented; and a range of treatments exists for most disorders.
To underscore the importance of the current Supplement, Ms. Enomoto noted that the 2000 Census found three out of 10 Americans to be people of color; by 2025, the numbers will rise to four out of 10. The four racial/ethnic groups featured in the report are African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic
Americans.
Mr. English and Ms. Enomoto presented the findings of the Supplement, which
were that mental illnesses are real and affect all groups, regardless of race or ethnicity (about 21 percent of adults and children in the U.S.). Disparities in mental health care are found
for racial and ethnic minorities, particularly in areas such as access and availability of mental health services. Disparities impose a greater disability burden on minorities, because, although the prevalence of mental disorders is roughly equal across groups, ethnic and racial minorities are much less likely to access mental health services, and when they do, to receive evidence-based treatments. There are many barriers to effective treatment that disproportionately affect racial and ethnic minorities, including refugee or immigrant status, poverty, stigma, discrimination, and misdiagnosis.
The report notes that a relationship exists between sociocultural factors such as racism or discrimination and mental health, but the science base is limited. Socioeconomic status, access to care, and appropriateness/quality of care are addressed. The report notes that culture relates to what all people bring to the clinical setting. Culture counts, both for consumers and providers.
The Surgeon General identified several promising directions to reduce mental health
disparities: include minorities in mental health research endeavors as investigators and participants; develop ways to improve access; reduce social, geographical, and financial barriers to care; tailor services and understand cultural competence; and build on intrinsic strengths by engaging consumers, families, and communities.
Discussion
Dr. Pumariega urged all SAMHSA entities and NIMH to become major consumers of the report in GFA development and TA. He noted the need for a CMHS strategic plan, including use at every level of pre-service education; incentives for professional organizations to influence their constituents, including the science base and training on cultural competence at annual meetings; and use in State-level policy to operationalize cultural competence. California requires
counties to create plans, so data from the plans might be evaluated to see which standards make a difference. This work and work in New York, Texas, and Florida can inform other states. Ms.
Torralba-Romero noted the potential role of accrediting bodies in making providers accountable for cultural competence and the need for information and education among the report’s constituencies. Dr. Martinez suggested that CMHS help practitioners by translating cultural competence into actual practice. Financial incentives for including diverse populations in the
research is another motivational method. Ms. Wainscott noted unmet needs for cultural competence vis-à-vis the gay, lesbian, transgender, and bisexual populations. As part of the response to the report, she urged public education, the creation of new alliances, and an increased focus on prevention of mental illness and promotion of mental health. Dr. Beardslee called for CMHS
leadership in implementing the report internally and in tracking progress. Dr. Lu suggested that CMHS prepare fact sheets based on the report, create an ongoing dialogue with the professional associations, and arrange for training opportunities with the associations. Dr. Van Stone suggested working with professional and accrediting organizations such as JCAHO to devise specific incentives. Col. Hall suggested creating educational opportunities for county
leaders. Mr. Joseph Rogers urged further dialogue on the impact of racism and denial of rights.
CMHS Consumer Technical Assistance Centers: Update and Discussion
Mr. English identified consumer-related achievements, including the Alternatives Conference,
Leadership Academies for consumers, and grassroots organizations. He noted the CMHS study on self-help and consumer-operated services.
Facilitator Risa Fox, M.S., A.C.S.W., Public Health Advisor, Community Support Programs Branch, Division of Knowledge Development and Systems Change, CMHS, noted that CMHS has funded consumer TA centers since 1992. Consumer-related achievements include a first-ever meeting of the three TA centers with the president of The National Alliance on Mental Illness and
implementation of the consumer evaluation.
Kentucky Center for Mental Health Studies
Paul Weaver, Ed.D., President/CEO, noted that a
consumer-governed and -financed organization conducted the evaluation. Of
individual requests for TA, 59 percent were from consumers and 29 percent from
family members. More than 800 organizations requested TA. The consumer
community has organized around the TA centers and the Alternatives Conference.
Many consumers are among the Medicaid population. Inquirers request information
on specific mental illnesses, professional referrals, the Olmstead decision,
PACT, the cemetery project, and self-help. The evaluation addressed
satisfaction with the TA Center’s services, organizational tracking
information, and portfolios of work products. Suggestions for the future
include day-long site visits and focus groups at the Alternatives Conference.
The study found that the Centers surpass their goals and objectives.
Consumer Organization and Networking Technical Assistance Center (CONTAC)
Larry Belcher, M.A., Chief Executive Officer, noted that CONTAC often works collaboratively with the other two consumer TA organizations and with community leaders. CONTAC trains trainers, offers turn-key assistance, and places resources in communities where people live. Its expertise is in nonprofit governance and management, leadership training academies, web site hosting and design, enhanced peer support, listserv (“cybrary”), WRAP training, customized TA, and information sharing and collaboration with many partners and other organizations on many dimensions. The Center’s approach to diversity is to contract to translate materials contextually for a Latino audience, then to train the trainers, and then to enter Latino communities within the next few years.
National Empowerment Center (NEC)
Daniel B. Fisher, M.D., Ph.D., Co-director, noted that CMHS funds State networking grants and research by consumers themselves. NEC’s major activities include general TA, historical projects (such as graveyard restoration), leadership development, collaboration with Offices of Consumer Relations on historical projects; presentations of the Politics of Memory
Multimedia Slide Show at State and national conferences, cross-disability collaboration, NEC West, and recovery research and education. He stated the importance of attending the Alternatives Conference to network and to become energized. The Center is studying recovery and taking control of one’s life, but it is often difficult to find people willing to participate. The empowerment model for recovery has been published in the Journal of Psychosocial Nursing. NEC has developed PACE (Personal Assistance in Community Existence) education/training resources, many of which have been translated into Spanish.
National Mental Health Consumers Self-Help Clearinghouse
Joseph Rogers, Executive Director, described the clearinghouse’s activities, including the Alternatives Conference, facilitation of the National Summit of Mental Health Consumers and Survivors 2000, dissemination of self-published and other resources, links to information providers via the web site, self-advocacy skills training, network and coalition building,
information and referrals, and promotion of grassroots organizing.
Discussion
Dr. Pumariega supported consumers taking the lead in cultural competence issues,
specifically in crisis response and in linguistic competency. Ms. Torralba-Romero described ways to increase outreach to Latino consumers and their families—work with professionals in grassroots organizations, such as the National Latino Behavioral Health Association, that advocate for
and share a voice with consumers and families. The aim is to provide education, information, and mentoring; use contextual cultural translation where appropriate; and use appropriate languages in personal contacts. Mr. Rogers added that it is essential to be in the community, with entrée
through the church, professionals, or families, and then consumers. Dr. Fisher noted that the issue often is complicated by different cultures and traditional oppression. Dr. Lu noted the existence of the National Asian American Pacific Islander Mental Health Association, suggested the approach of helping consumers deal with stigma at the clinical level, and observed the emergence of a new movement of positive psychology that focuses on such qualities as forgiveness,
gratitude, and hope. Mr. Rogers noted the increased challenges to be addressed by the “sectionalization” of the consumer movement by multiple ethnicities and by gender.
Subcommittee on Consumer/Survivor Issues: Update
Sylvia Caras, Ph.D., Coordinator, People Who Net, reported
that Subcommittee members made presentations at and attended the National
Mental Health Statistics, Alternatives, and other CMHS-sponsored conferences.
Paula Stockdale has filled one vacancy, and the Subcommittee is seeking
applications by Latino persons to fill another. She also reported that the
Subcommittee heard presentations on program models of self-determination,
evidence-based practices, technical assistance centers, and a model treatment
law. Finally, Dr. Caras urged consumer and survivor representation on the
National Mental Health Commission.
The Council unanimously approved the Subcommittee’s recommendations that the National Advisory
Council:
- Endorse the continuation of grant support, at current funding levels or higher, for a
minimum of five national consumer technical assistance centers, at least three
of which are consumer-operated; and
- 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), and individualized budgeting, etc., that have been demonstrated successfully with persons with physical disabilities, older adults, and people with developmental disabilities.
Dr. Pumariega recommended that all five TA Centers focus on outreach to diverse
populations. Dr. Barry suggested that the centers might help disseminate the
Surgeon General’s report.
Dr. Barry asked that suggestions for the next meeting’s agenda be communicated to Ms. Wainscott. She noted that a freeze exists on Council nominations, but that suggestions and
resumes are welcomed. Dr. Barry adjourned the meeting at 3:45 p.m.
Tentative Meeting Schedule
The next CMHS National Advisory Council meeting will be held January 16-17, 2002.
The SAMHSA Joint Council and CMHS Council meeting is tentatively scheduled for three days during the week of May 20, 2002 (since changed to the week of June 17, 2002). The following CMHS Council meeting will be held September 5-6, 2002.
[ Advisory Council ]
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