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CMHS National Advisory Council
Meeting Minutes
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council
September 5-6, 2002
Rockville, Maryland
Minutes
Closed Session
The National Advisory Council of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) met at 8:30 a.m. on September 5, 2002, at the DoubleTree Hotel, Rockville, Maryland, to review grant applications.
Open Session
The Council met in open session at 11:15 a.m. CMHS Director Bernard S. Arons, M.D., presided over the first part of the meeting, and CMHS Acting Deputy Director Edward "Ted" Searle, M.B.A., presided over the latter part. Council members present over the course of the meeting included William R. Beardslee, M.D., Francis G. Lu, M.D., Art Martinez, Ph.D., Donna Mayeux, Sally Satel, M.D., Josie Torralba-Romero, M.S.W., Karina K. Uldall, M.D., Cynthia A. Wainscott, William Van Stone, M.D. (ex officio), Richard Nakamura, Ph.D. (Acting Director, National Institute of Mental Health (NIMH), and David Shore, M.D., (NIMH liaison). CMHS Acting Director designee Gail Hutchings, M.P.A., and Eileen "Teddi" Pensinger, M.Ed., also were present.
Welcome and Opening Remarks. Dr. Arons, in announcing his departure from CMHS, reflected on his opportunity to help CMHS develop practical, effective solutions for persons with severe mental illnesses (SMI) and severe emotional disturbances (SED), and others whose lives have been touched by CMHS' work. He acknowledged the contributions of his colleagues and introduced new CMHS publications. Dr. Arons welcomed Dr. Sally Satel to the Council and recognized the contributions of Dr. Francis Lu, Dr. Karina Uldall, and Cynthia Wainscott, whose terms officially end in November.
Approval of Minutes. The Council unanimously approved the minutes of the June 20-21, 2002, CMHS Advisory Council meeting.
CMHS Director's Report. Bernard S. Arons, M.D., presented highlights of the Director's Report, referring to the written report at http://mentalhealth.samhsa.gov. Recent projects and programs include responses to the September 11, 2001, attacks. CMHS staff has offered on-the-scene support to survivors and first responders, funding for crisis counseling, risk communications guidance for public officials, and ongoing national recovery activities. He mentioned the National Child Traumatic Stress Initiative, designed to improve treatment and services for children exposed to traumatic events, including terrorism.
Dr. Arons discussed co-occurring mental health and substance abuse disorders in the context of SAMHSA's programs and principles matrix-driven activities. SAMHSA has compiled a report to Congress on addressing co-occurring disorders within a strategic planning process that will provide training and education for providers and consumers and their families. Capacity building for State and local providers will include training and cross training of staff to establish an integrated treatment system. The Joint Task Force on Co-occurring Disorders has developed a conceptual framework and is developing case studies of how States and localities have resolved and improved issues of financing and payment for services for a variety of co-occurring disorders.
A regional consumer meeting in Denver provided feedback from representatives of six Western states. CMHS staff are developing a consumer education card and training video for consumers/ survivors and providers about the Health Insurance Portability and Accountability Act (HIPAA) and its privacy regulations. A new web site will address discrimination and stigma associated with mental illness. To support the President's New Freedom Initiative, CMHS will convene a dialogue between consumers and members of faith- and community-based organizations.
An important theme of the future will be to translate research into practice by adopting evidence-based practices to guide program implementation. Dr. Arons acknowledged the controversy linked to the concept of evidence-based services, but he asserted the importance of bringing into clinical care "what we know and agree works." Dr. Arons acknowledged the importance of CMHS staff and its work. Council members expressed their appreciation for Dr. Arons' broad and important contributions to CMHS and the field of mental health.
Reducing Racial and Ethnic Disparities Through Workforce Training. Kana Enomoto, M.A., Public Health Advisor, Office of the Director, Division of Service and Systems Improvement, described new workforce training grants to reduce racial and ethnic disparities in mental health services. Ms. Enomoto referred to an epidemiological study of Mexican Americans that found disparate rates of mental disorders between immigrant and U.S.-born subgroups. The National Comorbidity Study also found that racial and ethnic minorities were less likely than White Americans to seek mental health services and were more likely to seek primary versus specialty care. Barriers to receiving services include differential access to insurance, quality of care, availability of services, linguistically inaccessible services, and stigma or mistrust. Racial and ethnic minorities were underrepresented in the clinical trials on which guideline-based treatments have been developed, and the Surgeon General's Supplement on Mental Health: Culture, Race, and Ethnicity revealed that no ethnic-specific analyses have been conducted to show if any guideline-based treatments have differential effectiveness for racial or ethnic minorities (DHHS, 2001). Cultural competence standards and training and multicultural programs are widespread, but there are few data to tell us which models are more effective or create superior outcomes for consumers. CMHS has allocated $1.6 million in FY2002 for four 3-year grants. The goals of the grants are: (1) to develop, implement, and document promising training programs to increase the capacity of the mental health workforce to serve racial and ethnic minority communities in a culturally competent manner; and (2) to evaluate the effectiveness of the training in improving provider knowledge, skills, or abilities to work with racial/ethnic minority populations. Ms. Enomoto noted that 63 applicants from 33 different States responded to the complex RFA, including 21 local organizations, 19 universities, nine State governments, five tribal colleges/governments, four national organizations, and four counties or cities. Target trainee populations included a broad spectrum of general and mental health professionals, paraprofessionals, administrators, family members, consumer providers, and nonclinical staff.
Discussion. Ms. Torralba-Romero noted the importance of realizing that one size does not fit all and that culturally competent workforce development is an emerging field that requires further attention and funding. She emphasized the need to change the infrastructure to ensure that clinicians change how they function; clinicians do not provide services that Medicaid/Medicare does not pay for, even though consumers may need those services. Ms. Enomoto described the model proposed by one strong applicant: training providers who speak Spanish to provide mental health care services in Spanish. The goal would be to better communicate and convey information, which would hopefully lead to better treatment adherence. Ms. Hutchings acknowledged SAMHSA's priority to tweak the science-to-services cycle, in an effort to determine what is "good practice." Ms. Enomoto emphasized that funding represents training and evaluation dollars, not clinical trials. Ms. Torralba-Romero explained that cultural competence first involves the values, beliefs, stereotypes, and attitudes of the practitioners and how they apply themselves in the intervention. Then skills can be taught. Dr. Satel observed that sometimes the issue is less one of cultural competence than competence. Ms. Enomoto noted that some ethnic match and ethnic service outcome studies have shown improved outcomes, but it is unknown whether the differences relate to good or bad services, or to cultural differences. Dr. Satel stated the importance of investigating that issue. Dr. Beardslee stated that if one assumes that people render high-quality, evidence-based services, an added layer of cultural competence might take a long time to influence practitioners' behaviors. He noted that standards have had great influence on awareness and have urged creative thinking about areas beyond mental health that can inform the mental health field. Ms. Enomoto stated that the Surgeon General's supplement represents an intensive synthesis of the reliable literature, of which there is little. In the general health domain, people who have interpreters are more likely to return for treatment or adhere to services. Dr. Van Stone suggested that diversity training might have implications for this discussion of culture. Ms. Mayeux recommended that grantees work with State departments of labor, which can retrain private mental health providers and State public systems staff. Training funds are available, administered through governors' offices. Dr. Van Stone pointed to the benefit of the applicants' focus on cultural competence in applying for the grant, whether or not they receive funds. Ms. Enomoto commented, "GFA as intervention," and explained that the applications have brought higher-level local government officials together to form coalitions. Ms. Torralba-Romero discussed the low access rates for individuals with limited English-language abilities and the costs of not doing what is necessary to provide mental health services to all who need them. Dr. Satel applauded the empirical approach of the program.
Council Discussion. Dr. Satel asserted that CMHS' real focus should be to get people with SMI out of jails and off the streets. She pointed out that since mental health dollars are largely from the states and the federal contribution is practically on the margin, funds should go to those who need it the most. Practitioners might have to develop special skills to help those who have special needs. She stated that the approach of "looking at the group" is not the way to go, although it was very much valued in the last SAMHSA administration and a whole culture surrounds it.
Public Comment Judi Chamberlin, National Empowerment Center, a CMHS-funded consumer/survivor-run technical assistance center, discussed the ongoing need to bring the consumer/survivor voice into CMHS and to recognize the wide diversity of the movement and of consumers and survivors. She noted that consumers/survivors are the people the Council is discussing and urged "nothing about us without us." She urged the Council to ensure that consumers/survivors are consulted with and regarded as serious participants, not as passive subjects. Independent consultant Laura Van Tosh thanked Dr. Arons for his leadership and for his support of giving consumers and families a role in their own treatment and design of services and a voice at the local, State, and national levels. Sharon Yokote, mental health consumer, stated that efforts to find a bridge to cultural competence standards for consumers and families are critical to helping keep people healthy.
Council Discussion. Dr. Satel stated that certain new CMHS publications are not evidence-based, that they have errors and are misleading in part, and that their tone is inappropriate. She acknowledged that some individuals might find the books helpful, but urged that the series be re-examined. Ms. Hutchings stated her willingness to engage in dialogue on the issue and the target audience, noting that the series will not be recalled. Ms. Mayeux urged the inclusion of consumers, the intended audience for the series of publications, in any dialogue about refinement and improvement. She stated that consumers who use the publications to teach recovery and self-help courses report great success with them and are approached by mental health providers desiring copies of the publications. Ms. Torralba-Romero acknowledged the importance of correcting factual errors, but also of issuing understandable materials. Ms. Wainscott responded to Dr. Satel's earlier assertion about CMHS' primary focus, stating that unless a Federal agency provides leadership in finding children early, before they show the first symptoms of mental illness, the citizenry is failed. She noted that CMHS has taken those steps and that this approach need not detract from attention to people with SMI. She suggested adding the issue to the Council's agenda.
Subcommittee on Consumer/Survivor Issues: Update. Sharon Yokote, Subcommittee Acting Chair, reported on the September 3-4, 2002, Subcommittee meeting. Speakers discussed cross-disabilities—physical and mental health—and SAMHSA/CMHS staff described its matrix-driven activities to serve children and families, and to address terrorism/bioterrorism and co-occurring mental illness and substance abuse. Ms. Hutchings stated that CMHS will continue to seek input from consumers and families and that consumer/family involvement in treatment will be supported.
The Council passed the following recommendation: The CMHS National Advisory Council accepts the Subcommittee's Briefing Paper [on models, practices, and principles that underlie the self-care movement] and will forward the document to the President's New Freedom Commission on Mental Health. Ms. Yokote expressed the Subcommittee's disappointment that Dan Fisher is the sole consumer/survivor on the New Freedom Commission.
The Council passed the following Subcommittee recommendation, as amended: The CMHS Subcommittee on Consumer/Survivor Issues recommends that the CMHS National Advisory Council recommends the inclusion of consumer/survivor involvement in the selection of the new CMHS director and includes a consumer/survivor representative and a representative of the National Advisory Council in the selection process. Ms. Hutchings urged members to submit to SAMHSA names of qualified candidates for CMHS director (and CSAP director), noting that the selection process has not been formalized. Dr. Beardslee suggested including a staff member on the selection committee, and Ms. Mayeux suggested that the Council submits a set of questions for candidates.
In response to a Subcommittee recommendation, the Council passed a recommendation for the Council to write to the President's personnel office, strongly recommending that a mental health consumer/survivor be chosen to fill an upcoming vacancy on the Ticket to Work and Work Incentives Improvement Act Advisory Panel. Ms. Wainscott asked that the Subcommittee's tribute to Dr. Arons be included in the record of the meeting (see attachment). Ms. Mayeux suggested that CMHS sponsor a dialogue between consumers/survivors and small business employers with a perspective on hiring people with mental illness, in order to discuss nontraditional solutions to employment problems.
Council Discussion. Ms. Wainscott led a discussion on Council recommendations to the New Freedom Commission. Mr. Curie is an ex officio member of the Commission.
SAMHSA Administrator's Update. Charles G. Curie, M.A., A.C.S.W., announced the release of the Household Survey on Drug Abuse and the kickoff for Recovery Month. The survey now includes data on people with SMI and with co-occurring mental illness and substance abuse disorders. Mr. Curie acknowledged Dr. Arons' departure and commended his commitment to people with mental illness and to ensuring that people have a good life in the community. Mr. Curie introduced Gail Hutchings and welcomed advice and suggestions from Council members in the search for a permanent director, who will implement recommendations of the New Freedom Commission. The President anticipates receiving a plan for Federal and State actions, recognizing that frontline providers, communities, consumers, and families need to take ownership of these actions.
Public mental health has evolved dramatically from practices in colonial days. Mr. Curie described the desired focus, in today's "era of recovery," that people with SMI have access to treatment and community supports and are able to help chart their own course of action. This approach reduces recidivism and improves opportunities for an avocation, a safe place to live, a job, and connectedness. The system must look at the evidence base in funding decisions.
The substance abuse field can inform the mental health field on recovery. Also, Household Survey findings can provide information on the prevalence of SMI, help shape recovery in the mental health field, and provide valid information on prevalence and treatment of co-occurring mental illness and substance abuse disorders. The survey found a strong relationship between substance abuse and mental health problems among both youth and adults. Treatment systems must include appropriate assessment of either or both disorders at the door when the person arrives and then have the capacity to treat the person in an integrated way. The new data will help the New Freedom Commission to guide assessment and treatment services.
CMS and SAMHSA will co-chair a meeting on seclusion and restraint regulations that reflect the reality that seclusion and restraint are not treatment interventions, but rather safety measures of the last resort. The issue has resisted resolution, but more States are looking at models that have worked.
Discussion. Ms. Wainscott suggested that someone who has experienced restraint be present at the CMS/SAMHSA meeting. Mr. Curie suggested that stakeholders might speak at the town hall-style meeting. He stated that he is seeking informal advice in the selection of the CMHS director. Dr. Satel acknowledged the valid literacy issue in connection with the series of CMHS publications to which she had referred earlier. Mr. Curie asserted the importance of ensuring that language is understandable to a wide range of people. Dr. Beardslee pointed out that most mental health models are developed with adults with SMI, and many do not work well with kids. He urged an emphasis on care of people within families; people with mental illnesses can be good parents. Mr. Curie concurred that family-centered care, such as CASSP and Systems of Care, is consistent with recovery. Dr. Beardslee stated that, in a Boston Public Health Commission survey of Boston public school students, 8 percent reported they had thought seriously about suicide; suicide prevention is an important concern. Mr. Curie reported on progress in developing SAMHSA's principles and priorities matrix. SAMHSA used the matrix as a foundation for its budget development. The centers identified several million dollars from programs that did not align with SAMHSA's priorities, and the funds were transferred into priority issues. SAMHSA also established staff leads in all priority areas, and workgroups function around the areas to ensure that centers collaborate with each other and with other agencies within and outside HHS.
Ms. Torralba-Romero stated that barriers often beset life in the community for people with SMI who have families. Medications and supportive treatment in communities have permitted people with SMI to enjoy relationships and have families, but then they often become ineligible for housing supports; these policies must be addressed. She also emphasized the importance of working with both small and large businesses to bring people with mental illnesses back into the work force. Mr. Curie stated that the Commission includes representatives from labor, housing, education, veterans' affairs, and NIH/NIMH. Ms. Mayeux noted that certain regulations and laws must be changed to make elements of the action plan work.
Ms. Van Tosh stated that many people in Maryland's State hospitals cannot be released solely because of a lack of affordable housing. Mr. Curie noted that, although States are responsible for State mental hospitals and their closings, CMHS and SAMHSA can educate and offer incentives with NASHMPD to emphasize models that work, such as using funding from closed hospitals to support community hospitals and ongoing services, instead of expecting people to return to the community without sufficient infrastructure and outreach. Ms. Van Tosh stated that The Washington Post supports expansion of involuntary outpatient commitment laws. Mr. Curie acknowledged the need to examine whether laws are working as they were intended to make the public safer, and whether laws have had unintended consequences. Ms. Chamberlin stated that data show that, although a large percentage of people in New York's public mental health system are White, an overwhelming percentage of people locked up under Kendra's Law are minorities. Dr. Beardslee noted that the movement in the 1970s to close hospitals and move people into the community failed because of insufficient community supports.
The meeting adjourned at 5:50 p.m. and reconvened on September 6, 2002, at 9:12 a.m.
Select Matrix Reports
Aging. Neal Brown, M.P.A., Chief, Community Support Programs Branch, Division of Service and Systems Improvement, stated that, by 2020, more than 20 percent of the population will be over age 65. Currently, 26 percent of older adults suffer from a mental disorder, a growing problem among this population. CMHS activities for older adults include a multisite study involving SAMHSA, VA, HRSA, and CMS that focuses on integrated versus referral services for older adults with mental health and substance abuse issues. Mr. Brown noted that an older adult consumer organization has been formed, which is expected to be helpful in policy formulation. The new Targeted Capacity Expansion Program focuses on older adults and awards grants to communities to help them organize and implement services for this population.
A major focus has been the older adult action plan, as part of SAMHSA's strategic planning process. Its major goals are to develop and collect data on aging adults and to ensure that older adults are identified as part of the agency's target population. SAMHSA will begin to take a multigenerational approach and examine programs that blend the generations. Language focusing on aging will be added to all GFAs and RFAs in FY2003; staff will be trained to enhance SAMHSA's lifespan approach; and planning has begun on a policy academy to address State and community service enhancements. Another major goal is to identify and disseminate information on evidence-based practices, including a pamphlet on best practices in outreach programs to older adults that has been helpful in developing grant applications in the aging area. CMHS will develop an inventory of evidence-based practices.
Discussion. Ms. Torralba-Romero questioned whether HRSA is moving the agenda on older adults into educational institutions for curriculum development. She urged integrating the issue of housing and/or supportive housing with other support systems to help maintain independence. Ms. Wainscott commended the presence of advocates and consumers on the stakeholder list, noting that educating the public from outside the system is essential. Dr. Lu identified related crosscutting principles, including reducing stigma and barriers to service, and the integration of primary care, geriatric care, and mental health services. He urged attention to gender, sexual orientation, and religious and spiritual approaches, suggesting that some strategies might work better with one group than another. He also urged targeting workforce development in this area to avoid a future workforce crisis. Dr. Beardslee suggested seeking input on program design from informal caregivers and from Carter Center resources. Ms. Torralba-Romero noted that she co-directed a study on caregivers, focused on Latino and Northern European White populations, which produced interesting outcomes.
Children and Families. Judith Katz-Leavy, M.Ed., Senior Policy Analyst, Office of Program Analysis and Coordination, described SAMHSA's children's workgroup activities to strengthen the capacity and effectiveness of both treatment and prevention for mental health and substance abuse problems in children and adolescents, promote partnerships with the public, and improve outcomes. The Children's Workgroup has identified the need to increase infrastructure development and service capacity within States and communities, and to collaborate with NIMH to bring science to services. CMS has proposed the Alternatives to Residential Treatment for Children and Adolescents demonstration program, in partnership with SAMHSA. CMS would fund the sites for the services, and SAMHSA would provide technical assistance and evaluation.
A bill has been introduced in Congress to address the critical lack of qualified, competent caregivers for children. The bill would provide funding to academic institutions and provider agencies to upgrade training and provide additional post-graduate training opportunities to specialize in child mental health.
Funding has been requested in the FY2004 budget to enhance current prevention, early intervention, and treatment programs, and to collaborate with CMS. CMHS plans to focus on providing family-centered care within the context of culture, family, and community. The workgroup plans to work collaboratively with relevant Federal and State partners to develop an action agenda and coordinated approach.
Discussion. Dr. Beardslee lauded the focus on coordination and integration. He further stated that one answer to the caregiving crisis is to increase support for high-quality training and that care for parents enhances care for children. He suggested consulting with NIMH on the Blueprint for Change on research on children over the next 10 years. Ms. Mayeux stated that the National Governors Association and the National Council of State Legislators should be engaged to educate State governments on how to leverage their funds. She noted that extended family members who care for children should be included in the primary caregiving team. Ms. Katz-Leavy stated SAMHSA's intent to take a broad definition of family. Dr. Van Stone suggested involving the foster care area. Ms. Katz-Leavy noted that SAMHSA is entering a partnership with the Child League of America.
Homelessness. Phyllis Wolfe, Homeless Programs Branch, Division of Service and Systems Improvement, described the SAMHSA-wide workgroup's action plan. The process of science to services includes such steps as NIH putting forth an RFP on homeless research. The workgroup is identifying SAMHSA programs with model practices for dissemination. CMHS provides leadership in using block grants to address issues of homelessness, including the development of a document that draws on the experiences of States with block grants. In addition, 15 states have attended two policy academies on homeless families, and at least three more academies/conferences are planned. The National Resource Center for Homelessness conducts technical assistance, including disseminating model and promising practices. Collaboration with other stakeholders, including VA and HUD, is being undertaken in designing policy and programs. SAMHSA staff was involved in the design and implementation of the joint program with HUD and VA. CMHS is exploring connections with CSAP related to identifying links to homelessness prevention. Under a contract with CMHS, a national advocacy organization is developing a manual on SSI. Only 15 to 17 GBHI grants will be funded out of 238 applications received. Collaborative efforts with HUD are underway on data collection strategies.
Discussion. Ms. Wainscott applauded the collaboration and outreach within SAMHSA and with other departments, stating that change at the State level will be accomplished only by crossing over systems. Dr. Van Stone noted that the VA is interested in homelessness. About 25 percent of homeless people are veterans, and research has shown good outcomes for ending homelessness among them. Ms. Wolfe noted that a HRSA/SAMHSA initiative is underway to incorporate mental health into health care for the homeless.
Terrorism/Bioterrorism. Robert DeMartino, M.D., Associate Director, Program in Trauma and Terrorism, Division of Prevention, Traumatic Stress and Special Programs, explained that the new CMHS division has been chronicling its activities, identifying commonalities among the centers, and moving the agenda forward. Scant research exists on the effects of terrorism on mental health beyond the trauma literature on veterans. CMHS' approach will incorporate science to services; templates for response, recovery, and resilience; efforts to inform individuals at the State and local levels, where plans must be implemented; and infrastructure development to support State mental health programs involved in the emergency planning system. SAMHSA and NIMH are sponsoring an Institute of Medicine report, to be published in August 2003, to synthesize what is known about the field.
CMHS is helping to fund and develop the infrastructure for all-hazards planning to include templates for State mental health disaster plans. A primer on risk communication guidelines has been compiled to help public officials frame comments on perceived risks in emergencies and educate them on the connection between words and the behaviors of people. In the Bioterrorism Education Project, designed to mitigate the aftereffects of terrorist events, student art portrays themes of hope, support, and recovery after bioterror incidents.
Plans have been developed to support recovery, including short-term interventions in perceived-risk events. The ongoing crisis counseling program typically has responded to natural disasters, and it remains to be investigated what kinds of interventions might be available and implemented. Project Liberty has served the New York metropolitan area well in response to the events of September 11, 2001, and it may be adapted to fit new demands.
Discussion. Dr. DeMartino noted that CMHS would consider engaging consultants from Israel to help collect data to inform the work of the National Child Traumatic Stress Initiative. Existing data focus on the aftermath of single events, including SCUD missile attacks, and show that the side effect of fear may be the most damaging consequence. The current focus is on the effects on people on alert for months or years at a time; nothing on this subject has been published or peer reviewed. Dr. Satel commented on the importance of separating out psychological reactions to these events from psychiatric syndromes. Dr. DeMartino pointed out that no one knows the long-term implications of a bioterror event. Studies on Chernobyl and Three Mile Island show that the long-lasting effect is anxiety, rather than physical symptoms. Ms. Wainscott urged avoidance of the term "worried well." Ms. Torralba-Romero, a pioneer of FEMA's crisis counseling programs, concurred that crisis counseling relates to normal reactions of individuals to abnormal situations. Ms. Mayeux reported that chemical companies often conduct mock disasters and suggested that companies may be sources of information on employee training and ways to engage government entities. Dr. Satel stated that utilization rates in New York City after September 11 showed that people are resilient. Dr. DeMartino stated that NIH has issued a report on a consensus conference related to crisis intervention post-mass casualty events. Ms. Wainscott observed that people are less apt to walk into a clinic and ask for mental health care than they might for help with a general medical problem following a terror incident. Dr. DeMartino stated that the risk communications product, a CD-ROM on CDC's training, will be disseminated to every State public information officer. Ms. Torralba-Romero noted that it is a myth that crisis-counseling facilities will be critically overwhelmed. Dr. Van Stone suggested including the media in catastrophe planning groups.
Election of Council Secretary. Torralba-Romero was elected secretary of the Council.
Potential Future Agenda Items. Council members suggested the following future agenda items: discussion of the Congressional mandate of the National Advisory Council, SAMHSA's priorities and principles matrix, ways to be valuable advisors to CMHS, data showing the broad impact of CMHS grants, discussions of key dilemmas facing CMHS (e.g., virtually the entire evidence base comes from White, middle-class individuals and families), identification of model programs with a strong evidence base, activity reports organized along the matrix, the Co-occurring Disorders Report to Congress, and the extent of consumer input.
Ms. Hutchings thanked the members who are leaving the Council for their contributions. She suggested that future meetings be structured to allow for more time for Council discussion and interaction. Dr. Beardslee agreed, but also stated the need to support CMHS staff. Dr. Lu suggested that dialogue be structured and that background information be provided to Council members in advance. Ms. Mayeux suggested sending out printed background materials well in advance of Council meetings. If specific questions are posed, open discussion and advice from the field might be more efficient.
Dr. Satel observed that the person who spoke the longest at the 2-day meeting was a consumer/patient. Members discussed the composition and attendance of Council members. Ms. Hutchings suggested that attendance might be a criterion in filling future vacancies; explained CMHS' need to update Council, facilitate direct staff interaction, and invite public comment; and acknowledged the need for balanced presentations. Ms. Wainscott concurred with the need for balance but disagreed that the Council has heard too much from consumers, an important voice that traditionally is not heard.
Update on Activities: President's New Freedom Commission on Mental Health. H. Stanley Eichenauer, M.S.W., Deputy Executive Director, New Freedom Commission on Mental Health, described the background and work plan of the Commission and also acknowledged the work of CMHS staff. On April 29, 2002, an Executive Order established the Commission to conduct a study of both the public and private sectors of the U.S. mental health service delivery system and then advise the President on methods for improving the system. The goal is to enable adults with SMI and children with SED to live, work, learn, and participate fully in the community. The Commission currently is learning and listening, along with framing and making decisions about the content of the Commission's report. Full communication with stakeholders and the general public is an essential component of identifying problems and recommending solutions. Each Commission subcommittee identifies issues to be explored, and consultants are helping to formulate issue papers and write the interim report, due in October. A final report, due in April 2003, will present an action plan to the President.
Learning and listening has been fueled by input from nearly 500 people who have sent comments to the Commission's web site to date. All comments are directly available to all commissioners, and a contractor also is conducting content analysis. At monthly Commission meetings, approximately 15 to 20 people testify during time set aside for public comment. The Commission also hears invited testimony from national organizations of stakeholders and experts. Content areas include the Surgeon General's report, consumer perspectives on SMI, evidence-based practices, children's mental health issues, the IOM report "Crossing the Quality Chasm," employment and income support, cultural competence, stigma, trauma, youth perspectives in dealing with mental illness, comprehensive community-based service systems for children, and school-based models. The Commission also plans to travel to program sites.
In the framing and decision-making phase, more than 17 subcommittees are focusing on, for example, children and families, consumers (consumer-provided/operated services), co-occurring disorders (mental health and substance abuse), interface with criminal justice, homelessness and housing, evidence-based practices, rights and engagement, cultural competence, Medicaid and Medicare, medication issues, interface with general medicine, rural issues, older adults, and suicide prevention. Subcommittees are identifying expert consultants to prepare 20- to 25-page issue papers that define the issues and the extent to which people are impacted. These drafts will be submitted to reviewers to bring balance to biases. Reviewer comments and original drafts will be considered in integrating and making decisions for policy and recommendations in the Commission's final action plan. Although the action plan is expected to be succinct, it will be bolstered by appendixes that provide guidance to the field.
Discussion. Ms. Mayeux urged that the Commission's report convey the philosophy of recovery and the importance of noncoercive treatment; appropriate, adequate community-based services tied to incentives to States to move in that direction; and the inclusion of informal caregivers by treatment professionals as essential components of treatment teams.
Ms. Wainscott urged the Commission to recommend that payment for services be tied to outcomes, noting that the capacity to do so exists. She added that cost shifting must be ended, fiscal incentives tied to outcomes across systems must be undertaken, and funding must be coordinated across fields. She urged that parity be a priority. Mr. Eichenauer stated that several subcommittees are concerned about dismantling disincentives to "do what we know works." He noted that parity, however, is being addressed on a separate track from the Commission. The Commission's report will discuss the impact of parity but will not make a recommendation.
Dr. Satel urged the Commission to focus on coercive treatment for individuals with SMI who cannot live in the community, outpatient commitment, and mental health courts. Mr. Eichenauer responded that the subcommittee on rights and engagement is addressing those issues.
Dr. Lu urged that attention be given to the need for training, in response to the crisis in the human resources field, especially for those who work with racial and ethnic groups. He commended the Commission's attention to integrating mental health and primary care, a major recommendation of the Surgeon General's report, and urged a focus on primary care physicians as providers of psychotropic medications. Mr. Eichenauer stated that subcommittees are considering workforce issues.
Dr. Beardslee described several perspectives on children's services and the dramatically expanding knowledge base. A way to support empirically based practices and delivery systems now and as they evolve must be developed. The lack of integration of services across systems must be addressed to conserve resources and share costs. The integration of medical and psychiatric care, and of prevention practices, is essential. Since the occurrence of a major mental illness in a child is catastrophic to a family, it is important to focus on family-centered care. Dr. Beardslee asked the Commission to recommend that it reconvene annually to measure progress. Mr. Eichenauer suggested that Council members attend meetings or provide written comments to commissioners and the consultants who are writing the papers.
Ms. Torralba-Romero discussed language and mental health care access issues for minorities. Many minority children and youth are highly represented in the criminal justice system, which becomes the portal to mental health care. She echoed the need to focus on family-centered care. She also urged an investment in education to reduce the stigma of mental illness in communities, especially minority communities. Mr. Eichenauer stated that no Spanish hearings are planned but that soon the Commission's web site will be translated and set up to take public comments in Spanish. The cultural competence subcommittee is studying these issues. He stated that consideration will be given to providing translation services at Commission meetings. Dr. Van Stone urged a focus on the mental health problems of the elderly. Mr. Eichenauer noted that the subcommittee on services for older persons will meet for the first time in the near future. People representing the elderly population have submitted public comments.
Dr. Satel stated that people must be protected against abuses, and some must be protected from the way they act when they are very sick, while still ensuring their rights. Ms. Wainscott concurred, observing that, because rights have often been denied, putting rights first (as in the subcommittee on rights and engagement) is often important to people whose rights have been denied. Dr. Satel explained that laws that prohibit protecting people who are really in trouble often have frustrated her capacity as a physician. Mr. Eichenauer commented that a variety of perspectives will be heard in the subcommittee, and a balanced view will be achieved.
Ms. Wainscott observed that the designated consumer seat on the Council has been vacant for a year.
The meeting was adjourned at 12:10 p.m.
Future CMHS National Advisory Council Meetings:
Conference Call, September 23, 2002
February 20-21, June 19-20, and September 4-5, 2003
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