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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 10-11, 1998
Washington, D.C.
Closed Session
Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session for the purpose of reviewing CMHS grants and contracts on the morning of September 10, 1998, at the Omni Shoreham Hotel, Washington, D.C. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons convened the open meeting at 1:45 p.m. Council members in attendance included Dolores S. Bigfoot, Ph.D., Thomas Bornemann, Ed.D., Frank D. Burgmann, Marshall Forstein, M.D., Eric J. Getka, Ph.D., Daniel Gottlieb, Ph.D., Thomas B. Horvath, M.D., Larry Lehmann, M.D., Ruby J. Martinez, R.N., Ph.D., Donna Mayeux, Andres Pumariega, M.D., Ian Shaffer, M.D., David K. Yamakawa, Jr., J.D., and Daryl Regier, M.D., representing the National Institute of Mental Health (NIMH). Anne Mathews-Younes, Ed.D., Advisory Council Executive Secretary, also attended.
Approval of Minutes
Members unanimously approved the minutes of both the May 5, 1998, CMHS Council meeting and the May 4, 1998, SAMHSA Joint Council meeting.
CMHS Director's Report
Dr. Arons discussed the following highlights of the written CMHS Director's Report:
- CMHS, in conjunction with NIMH, is coordinating the forthcoming Surgeon General's Report on Mental Health. Several CMHS staff members are contributing articles; Captain Patricia Rye serves as managing editor and has hired Dr. Howard Goldman to serve as scientific editor.
- Efforts by SAMHSA experts to avoid computer-related problems in the year 2000 are expected to reach fruition by year-end, which will permit a year for testing; independent contractors will test critical systems. Many aspects of mental health may be affected by obsolete systems, and all are encouraged to attend to this issue.
- Dr. Arons and Judith Katz-Levy attended the Vice President's Family Reunion Conference on family-centered health care. CMHS Presidential Management intern Gina Tesauro helped to coordinate the effort and to ensure that mental health was integrated into the discussions. Mrs. Gore specifically addressed the importance of implementing community based systems of care, a concept that has been fostered within CMHS, and cited CMHS findings from the comprehensive community services program for children and their families.
- The final of three regional meetings designed to give consumers of mental health services a forum to define and set priorities for the issues that affect them was to be held shortly. Reports of the three meetings are to be available on the CMHS website, mentalhealth.samhsa.gov; information gathered from these meetings will be used internally to better align programs and services with consumer needs.
- Psychologists and mental health consumers met recently, and a paper on the dialogue was produced. A meeting with psychiatrists had been held previously, and future meetings will be convened with professionals from other disciplines.
- Michael English (Director, Division of Knowledge Development and Systems Change) received the Secretary's Award for Distinguished Service; Dr. Arons received a Lifetime Achievement Award from the International Association of Psychosocial Rehabilitation Services.
- Consumer Affairs Specialist Paolo del Vecchio attended a meeting of older consumers of mental health services, whose main priorities were public education, education of other consumers on civil rights and the importance of involvement, peer-operated resources, and the need to educate providers about the diagnosis and treatment of mental health problems in older adults.
- CMHS staff have presented papers, consulted, and collaborated with other agencies regarding leading-edge mental health issues, including effects of emergency events involving radiation exposure and the U.S. embassy bombings in Africa, and an interagency counter-terrorism plan under development. Future presentations will include the discussion of violence as a public health issue.
- Final findings of the HIV/AIDS Mental Health Services Demonstration Project, conducted collaboratively with NIH and HRSA, were released and dissemination was begun.
- CMHS will cosponsor the October conference of the Suicide Prevention Advocacy Network.
- CMHS' Technical Assistance Center at Georgetown University sponsored a standing room-only training institute on systems of care for children with serious emotional disturbances.
- "Circles of Care," a collaborative initiative cosponsored by the Indian Health Service and the Department of Justice, will establish three-year grants in nine sites by September 1998, with a focus on planning culturally appropriate mental health services models for children in American Indian and Alaskan Native communities.
- The July 1998 shootings at the U.S. Capitol by a man reported to have been diagnosed with paranoid schizophrenia presents an opportunity for public education and for the examination of ways to improve mental health services. Stigma also remains a significant problem in mental illness, which was evident in media coverage of the event.
- CMHS will spend its entire 1998 budget allocation by fiscal year-end. Congress has not yet passed the 1999 budget, but indications are that increased funding will be available for the PATH and certain other programs. A continuing resolution is expected to sustain CMHS programs prior to passage of a FY99 budget. CMHS is currently formulating programs for the year 2000 as part of the budgeting process.
Discussion:
- Members discussed the consumer/professional meetings. Continued participation across meetings and representation of a broad range of experiences (private and public sector, academics, caregivers-in-training) among the professionals were stressed, in addition to diversity and geographical distribution.
- The future of mental health and ways to foster it, including the provider-consumer relationship, will be explored indirectly from a number of angles in the Surgeon General's Report. CMHS will continue its work in the areas of individuals with severe mental illness and children with serious emotional disturbances and will continue to develop its new initiative in the area of resilience and recovery.
Update on Consumer Affairs Activities
Mr. del Vecchio identified the recent U.S. Capitol shootings as an opportunity to address stigma issues and to focus on public education. He reported that progress on the Consumer Subcommittee has included development of a concept paper, responses to which have been positive. Some individuals have expressed concern that the Subcommittee not be a substitute for meaningful membership on the Council, that different age groups be represented and forensic experience be included, and that the Subcommittee be assured a meaningful voice and adequate budget. A three-phased process will be used to constitute the panel: (1) Subcommittee planning group will develop a nomination package and possible review criteria. Participation on the planning group has been solicited widely. (2) Nominations will be solicited in a broad fashion. (3) Nominations will be reviewed, and final selections will be made by the CMHS Director and SAMHSA Administrator.
Mr. del Vecchio reported the priority needs identified at two regional consumer meetings: employment, housing, peer-run services, and access to new medications (Southeast conference); self-help/consumer-operated services, employment/loss of benefits, housing, medication issues, and external grievance procedures (Midwest conference).
Recommendations that emerged from the psychologist/consumer dialogue meetings included the following: (1) establish ongoing forums for collaboration, (2) publish journal articles, (3) replicate similar dialogues, and (4) improve psychologist training. Resolutions were passed on alternatives to involuntary treatment and on the practices of restraint and seclusion.
Consumer networking and communication activities have included an older adult consumer meeting, people of color meeting, consumer-operated services network (to form a trade organization of consumer-operated programs), Internet training of trainers and curricula newsletter, and electronic list updates. Mr. Del Vecchio listed ongoing consumer focus grants and activities in the areas of managed care, rights protection, stigma, the Surgeon General's Report, and interagency collaboration.
Mr. del Vecchio described the Walk for Mental Health held in May 1998, and Dr. Arons stated that CMHS might be able to help cosponsors stage another major event in the future. Dr. Horvath described ways in which the VA is supporting veterans with serious, chronic mental illness.
Dr. Arons noted that the methodology for states to identify and estimate numbers of children with a serious emotional disturbance has been printed in the Federal Register. Input was requested from Council members on the Healthy People 2010 objectives that appear on the Web site http://www.health.gov/healthypeople/.
Service System Research: The Employment Intervention Demonstration Program
Drs. Martha Ann Carey (Community Support Program, Division of Knowledge Development and Systems Change, CMHS) and Judith Cook (Director, National Research and Training Center on Psychiatric Disability) described the purpose, process, and preliminary findings of the Employment Intervention Demonstration Program, a CMHS services research project to "discover new ways of enhancing employment opportunities and quality of life for mental health consumers." Dr. Carey stated that the goal of this rigorous evaluation project is to examine the effectiveness of different vocational models to determine what works best for different types of mental health consumers under different conditions, with the objective of putting the results into practice. This multi-site study is characterized by rigorous inter-reliability, a sample of more than 1,500 subjects, consumer input, and a qualitative element.
Dr. Judith Cook emphasized that, at this early stage, it is not yet possible to know which model works best. She described the structure of the study and the demographics of the participants. She also presented preliminary findings, which indicate that (1) the study population is composed of highly impaired individuals; (2) the potential of people with psychiatric disabilities to contribute productively to the labor force is great; (3) initial employment rates are positive; (4) initial jobs are largely low- skilled and part-time, yet socially integrated and at or above minimum wage; and (5) a relationship exists between SSI/SSDI benefits and willingness to work; Dr. Cook stated that the relationship is likely linked to a third variable, severity of disability.
Discussion:
- Dr. Pumariega noted that another factor to be considered in quality of employment is level of education and that early implementation of long-term rehabilitation of individuals whose schooling was interrupted because of mental illness must be examined. Dr. Gottlieb posed a question as another way of looking at the issue: Are children who leave school early at greater risk for developing severe mental illness? Ms. Mayeux emphasized literacy level as an important factor and suggested that this presentation would be valuable at conferences of state business or industry groups in sessions dealing with the Americans with Disabilities Act.
- Dr. Shaffer pointed out the value of the study's focus on ability to work, as contrasted with private practitioners who see no role in facilitating employment and see their role ending when the acute episode is over.
- Dr. Cook noted that this study is unique in its emphasis on educational levels, family constellation, and child-care issues.
SAMHSA Administrator's Report
SAMHSA Administrator Nelba Chavez enumerated significant personnel actions, including the selection of Westley Clark, M.D., as the new Director, Center for Substance Abuse Treatment (CSAT); the return of Camille Barry, Ph.D., to her post as Deputy Director, CSAT; and the selection of Dr. Jim Sayers as Deputy Director for the Center for Substance Abuse Prevention. Dr. Mary Knipmeyer has been appointed Associate Administrator for the Office of Policy and Program Coordination, and Ulonda Shamwell is the new Associate Administrator for the Office of Women's Services.
In detailing SAMHSA's budget status, Dr. Chavez stated her expectation for a continuing resolution for FY 1999 and noted that she planned to continue working with Congress to enhance the CMHS budget. This will be the first year that budget requests will be linked to performance measures under GPRA.
Dr. Chavez also (1) discussed mental health and substance abuse block grants vis-a-vis GPRA long-range objectives currently under development; (2) noted Dr. Satcher's priority emphasis on mental health during his term of office; (3) highlighted progress on the child mental health public education campaign and the Children's Health Insurance Program (CHIP); (4) described SAMHSA's intra-agency collaborations and its cooperative efforts with the Centers for Medicare and Medicare Services on the CHIP program in providing technical assistance to the states and in joint training efforts on contracting for managing substance abuse and mental health services; and (5) urged Council members to be advocates for mental health at all levels.
Public Comment
- In the segment allotted for public comment, participants discussed the potential role for CMHS as part of a task force to be established in response to the July Capitol Hill shootings.
- Dan Fisher of the National Empowerment Center advocated CMHS discussions with the Social Security Administration (SSA) on disincentives to work, continued support for Frank Sullivan's work with the Centers for Medicare and Medicare Services, and the education of both consumers and professionals conducting rehabilitative work.
- Dr. Bornemann responded that six federal agencies are collaborating on the HIV/AIDS education project; half the GFAs have significant federal partners; and educational regional meetings and teleconferences for the Centers for Medicare and Medicare Services staff have been conducted. Also in response to Mr. Fisher, Mr. English described collaboration on a grant project with SSA that focuses on persons with serious mental illness. Dr. Bornemann added that CMHS is also collaborating with the Department of Labor to examine mental health disability issues in the labor force.
- David Nelson of the National Mental Health Association urged CMHS to expand the networking grant program into the future and to all states.
- Irene Lynch of the Allepos Foundation urged CMHS to address the lack of education among persons with severe mental illness.
Resolutions
The Council unanimously approved two resolutions for the purpose of ensuring adequate time for Council involvement in the review of CMHS grants, cooperative agreements, and contracts. The first resolution:
Council recommends that SAMHSA immediately convene a working group of representative past grantees, Center program staff, review staff, and Center Advisory Council members to assess the current GFA application and review process and to delineate steps to enhance the process. Recommendations shall focus on, but are not limited to, ways to:
- Expand the time available to develop and submit applications.
- Enhance the technical assistance available.
- Ensure timely, high-quality reviews and summary statement preparation.
- Assure that Council members have no less than two weeks to conduct their review of summary statements.
The second resolution:
Council recommends the establishment of a working group of all Council members and selected program staff of CMHS to develop:
- A better definition of the role of Council in the secondary review process.
- Clarification of information to be made available to Council members about each grant program.
The meeting was recessed at 4:50 p.m. and reconvened Friday morning, September 11, 1998, at 9:00 a.m.
Report from the Project on the Future of Mental Health Services
Dr. Joyce Berry (Director, Division of State and Community Systems Development), Dr. Michael Hogan (Director, Ohio Department of Mental Health), and Mr. Bruce Emery (Director, Office of Technical Assistance) discussed a preliminary report of the Project on the Future of Mental Health Services, an ongoing effort to help state and community mental health agencies understand and plan for the trends that will affect their future.
The panelists described the key issues, trends, and challenges expected to affect public and private mental health services delivery over the next 10 to 20 years, according to the participants of a spring 1998 national meeting of experts. Dr. Berry itemized the initial topics examined: psychiatric diagnosis, mental health treatments, mental health service systems, impact of law and government on mental health, mental health care factors, social and cultural factors likely to affect mental health, and economics and the future of state mental health policy.
Dr. Hogan noted that one of the major themes emerging from the meeting was that leaders in the field currently lack consensus in their vision of the future. Council members illustrated the point by suggesting widely diverging aspects of the mental health field that they expect to change in 20 years. Dr. Hogan recognized that Council members expressed the same the dualism as the national experts, who found that they hoped for one thing, but expected and/or feared another.
Mr. Emery identified the content of the first of five white papers to be developed: future trends and issues and their expected impact on future health systems. He identified trends in four broad areas of mental health: (1) social and cultural; (2) law and government; (3) treatment, services, and research; and (4) organization and financing. He described global social and economic trends (e.g., economic interdependence, the information and bioscience revolution, changing demographics, and political conservatism), and their relationship to mental health issues, such as the economic inequality generally experienced by individuals with severe mental illness, the perception of the failure of people with mental illness to take personal responsibility for their situation, the focus of more local jurisdictions on the problems of mental illness, and the inability to acquire adequate data on the cultural competency of programs for persons with mental illness. Dr. Bigfoot pointed out the failure to learn lessons in health care from the Indian Health Service.
Mr. Emery enumerated additional expectations for the future, including continued limited benefits available for persons with psychiatric disabilities, benefits tied largely to services that are demonstrably effective, litigation that continues to shape mental health policy, integration of mental health into larger health agencies or merged with substance abuse and mental retardation, enhanced opportunities and threats in terms of new medications and genetic engineering related to completion of the Human Genome Project, new medications, medications administered subcutaneously or by pump, and widening (geographical and/or cultural) gaps between research and practice. Mr. Emery introduced several possible scenarios for positive change in treatment and services: better use of treatment guidelines and better co-management of issues between people and professionals, more use of clinical management tools and less of growth rationing, and increased attention to co-occurring disorders.
Reform has occurred in the public sector, Mr. Emery asserted, but it has been uneven; community support exists in some places, but not in others. Meeting participants noted dramatic gaps in the mental health care delivery system: haves and have-nots, good plans and bad plans, good states and bad states, and public sector and private sector. Participants recognized, Dr. Hogan stated, that the health care system has been "so focused on management and control that we risk losing sight of the value of leadership with change."
Discussion:
- Ms. Mayeux suggested that technological advances and early diagnosis and treatment will result in a diminished need for broad supports for those with mental illness. She recommended a combined focus on immediate needs with a strong push for research, and, recognizing that change begins with the individual, empowerment of local communities.
- Dr. Gottlieb suggested that the mentality of blaming the victim must be addressed.
- Dr. Martinez suggested that a paradigm shift is necessary in considering the future of mental health services, similar to the concept of restorative justice in the criminal justice field. Dr. Bigfoot cautioned that economic motives must be examined in the process. Dr. Getka observed that educating political and media leaders about current views of mental illness and treatment is critical in view of the "medieval" attitudes some obviously hold today.
Update from the American Psychological Association
American Psychological Association President Martin Seligman, M.D., stressed the significance of integrating the work of scientists and practitioners interested in the strength model of mental illness with the work of those interested in the disease model. He described both positive psychology and a strength model known as learned optimism and their potential roles in the future mission of CMHS. In his talk, he also described the epidemic of unipolar depression in the United States and offered a model for its prevention. Highlights of his presentation include the following:
- According to Dr. Seligman's theory of learned optimism, people who identify transient, changeable causes for their failure(s) are resilient and typically recover rapidly when bad events occur to them; people who believe the causes of failure are long-term suffer more from depression and helplessness. People who use narrow, situational explanations for their failures put walls around their problems and recover more quickly than people who make global attributions. Individuals who habitually blame themselves for failures find that their self-esteem and self-worth decline when bad things happen; this approach contrasts with people who blame others or blame circumstances and get angry, but keep their self-esteem intact. Pessimists are those who "chronically say, when they fail, `It's going to last forever, it's going to undermine everything I do, and it's my fault'."
- Pessimists are more at risk for unipolar depression than optimists.
- The main skill of cognitive therapy is "disputing," a self-reinforcing technique that teaches the consumer/patient to "recognize the catastrophic things they say to themselves" and then to "regard these things as if they were said by an external person whose mission in life was to make them miserable, and then to dispute them."
- In the battle against unipolar depression and in the domains of achievement and physical wellness, optimism/pessimism has been shown to be a protective/risk factor either statistically or robustly. Studies of achievement at work and play show that optimists do better than predicted and pessimists do worse. Studies of the relationship between optimism/pessimism and physical illness have shown that pessimistic college students have twice as many infectious illnesses and use twice as much of the nation's health dollar as optimistic students. In studies of immune function in elderly people, the function of T-lymphocytes and natural killer cells work well in optimistic women and not so well in pessimistic women. Pessimism/optimism has also been linked to the prediction of second heart attacks in men.
- The incidence of serious mental illness in the industrialized world is ten times higher than it was two generations ago, and it appears earlier, particularly in teenagers. Although Dr. Seligman acknowledges that the reasons are speculative, he suggests three main causes: (1) The I/we balance has shifted. The "I" has become more important; the "we," characterized by spiritual relationship with God, the nation, and an extended family, has become very small; (2) The misguided self-esteem movement, which is not based on accomplishment or doing well in the world, as it was before the 1960s, has undermined the normal coping mechanisms for much of depression; and (3) Seeing oneself as a victim is a formula for helplessness and giving up, and for depression.
- In order to prevent depression, workshops in which the techniques of cognitive therapy are presented to pessimistic college students have shown success in diminishing the expected incidence of depression. School-based programs also have shown successes with children at risk for depression.
- To combat what he sees as an epidemic of unipolar depression, Dr. Seligman suggests that medication is not the answer; what is needed instead is a public health movement of prevention.
- In a brief historical overview, Dr. Seligman identified the major successes of the "government underwriting the practice and science of mental illness" in the 1940s: 14 mental illnesses are now treatable or curable, an experimental methodology has been developed, and interventions have been developed and tested for efficacy. He also identified the negatives: psychology has dropped its prior goals of helping individuals develop more fulfilling lives and of nurturing genius.
- Psychologists and psychiatrists have adopted the disease model in which the focus is on repairing damage in this "science of human weakness." In the area of medications, palliative remedies have been developed, but there is no push for a cure of schizophrenia, manic-depression, or unipolar depression.
- To be able to focus successfully on prevention and cure, human strengths must be the focus. Cures will come not from the treatment or palliation of severe mental disorders, but from the study of human strengths: "future-mindedness, optimism, work ethic, honesty, interpersonal skills, hope, courage. We need a science of those things. Those are going to be our preventives," asserted Dr. Seligman.
- The result of CMHS, or NIMH, or Congress integrating the disease model with the strength model, according to Dr. Seligman, will be to "learn how to prevent the major mental illnesses." "By renewing our commitment to working on what is best in life, in making the lives of all people better and more productive and more fulfilling," the main effect is that "we will create from this change in mission the scientific study and the practice of individual strength and of civic virtue."
Public Comment
In the segment allotted for public comment, several individuals spoke to the Council:
- Irene Lynch of the Allepos Foundation urged the Council to recognize the individuality of consumers and to acknowledge the toxicity of the drugs taken by individuals with mental illness.
- Marie Verna, Program Director, National Mental Health Consumer Self-Help Clearinghouse, discussed her concerns about the future of the Clearinghouse and about the process by which it may remain an organization.
- Bob Reeg, health policy analyst with the National Coalition for the Homeless, described a high-level SAMHSA meeting on homelessness and mental illness; urged the Council to request additional Congressional funding for the PATH program and to conduct an evaluation of PATH (including its impact on changing mainstream programs and the relative responsiveness of community mental health systems to the needs of homeless people); and urged the Council to encourage states to make more grants to organizations prepared to provide a combination of primary care, addiction, and mental health services. He also encouraged the Council to ensure that best practices developed in research are implemented and to consider the addition of a homeless advocate to Council membership. Mr. Reeg deplored the trend to criminalize poverty and urged consideration of the continuum of care and specific needs for discharge planning.
- Cynthia Focarelli, Director of State Health Care Reform, National Mental Health Association (NMHA), expressed support for the National Mental Health Consumer Self-Help Clearinghouse and described NMHA's Justice for Juveniles project vis-a-vis the criminalization of poverty issue. She noted that through its nationwide training efforts, NMHA has learned that consumers and families are finding it difficult to access the services they need from the states. NMHA has developed a set of standards for consumer center-managed care programs in mental health and substance abuse.
Adjournment
Dr. Arons announced the dates of future CMHS National Advisory Council meetings (December 3-4, 1998, and April 15-16, 1999), and adjourned the meeting at 12:45 p.m.
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