Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Mental Health System Transformation: Solving The Mental Health Maze
Mental Health Community Forum Meeting
Kansas City, MO
January 13, 2006
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Slide 1/Cover
Good morning…and thank you, Dorn ( Dorn Schuffman, Director- Missouri Department of Mental Health) for that warm introduction. It’s good to be here in Kansas City for this important first—the first-ever regional community discussion on the state of mental health care in Missouri and Kansas. I am impressed with your willingness to have these candid discussions about the way you develop, deliver, and finance mental health services here in this region. I salute you for recognizing and confronting the need for fundamental change…here, in a part of the country where change hasn’t always come easily…here, where people really do demand to be shown before they embrace new ideas.
I am equally impressed with the theme you have chosen for today’s meeting. “The Mental Health Maze” is a fitting description of the state of the mental health system across the nation.
I’ve often heard “maze” and “labyrinth” used interchangeably to describe a confusing network of pathways. But, when I did a little research on the subject, I discovered that a “labyrinth,” in its true and original sense, has only one path that leads to the final destination. The explorer is not confronted with choices or problems of orientation. In a labyrinth, success is a natural consequence of the path’s design…there’s no chance of going astray.
A “maze,” on the other hand, is a convoluted structure that offers the traveler many paths—some of which lead to dead ends, or blind alleys. The path to the “reward” is determined by the choices the individual makes at each intersection. The way out can only be found if he or she takes the initiative…by constantly working to orient and redirect him or herself toward the goal.
Slide 2/Mental Health Maze: Challenges
We are, indeed, operating in a mental health maze. As we go about our day-to-day work—as clinicians, policymakers, advocates, consumers, family members—it can be difficult to make our way through the jumble of confusing pathways that make up our mental health system. Too often, we can only see barriers and obstacles in front, behind, and to either side of us. From this vantage point, the solution to improving mental health care for all Americans seems out of reach…if not impossible!
But, I am here this morning to say emphatically: we can make our way out of the mental health maze. We can. And we must.
Slide 3/Public Health Priority
We must make improving the mental health of our nation a public health priority. An estimated 23 percent of the U.S. population experiences a mental disorder in any given year. That’s one in five Americans—or, some 44 million adults and 14 million children—who are living with mental disorders. Even more disturbing: less than half of these individuals seek treatment.
The costs to the nation are staggering. A 2003 Journal of Clinical Psychiatry estimates the economic cost of depression, alone, at more than $83 billion a year in the U.S. The total economic cost of mental illness to the Nation exceeds $148 billion—2.5% of the U.S. GNP.
And the challenges are mounting. By 2020, disability from mental illness will increase by 50% globally—a larger proportionate increase than that for cardiovascular disease.
We must address these urgent issues and create a mental health system that offers people of all ages, with or at risk for mental or substance use disorders, the opportunity for a fulfilling life in the community.
We must make our way out of the mental health maze. But to do so will require a profound change in perspective. It is always easier to solve a maze when you can see it from above. Likewise, to achieve our goal, we must step back, and take a top-down view of our mental health care system.
Slide 4/Mental Health Maze: Opportunities
We must re-orient and redirect ourselves, and the nation, toward a shared goal…the goal of recovery for all Americans. When we change the way we think about…and go about…providing care, we will find the solution. When we change our expectations of what is possible, and act on those expectations, we will achieve the success we seek!
Two years ago, the President’s New Freedom Commission on Mental Health issued a report on the status of mental health care in America entitled Achieving the Promise: Transforming Mental Health Care in America. This landmark report provided a catalyst for the kind of fundamental, whole scale systems change that will be required to solve the mental health maze.
Slide 5/Achieving the Promise
Achieving the Promise called for a complete transformation in how our Nation views and provides mental health care. The report outlined six goals describing an idealized end state…a transformed, recovery-focused, consumer- and family-centered mental health care system that educates consumers about treatment options, empowers them to make decisions about their care, and offers them the greatest hope in themselves, their health, and their future.
I have copies of the report here for you today. If you have not read it, I urge you to do so…because system transformation is the solution to the mental health maze. And, I am happy to report, we are on the threshold of achieving the promise of a transformed mental health care system in America.
I’d like to take a moment here to look at what we mean by “transformation.” As we move forward, it is imperative that we all understand the meaning of our shared goal. In fact, I believe one of my most important roles is to make sure that everyone with a stake in system transformation has exposure to what transformation means.
Slide 6/Defining Transformation
Transformation is an extremely powerful concept. It suggests an upheaval and reorganization of what we know, what we do, and how we go about doing it. It has many implications for policy, funding, and practice, as well as for attitudes and beliefs.
Transformation calls for a different set of values…an entirely new way of thinking…and a better way of providing services to consumers and families. Transformation calls for fundamental change at the very core of a system…not on the margins. It leads to new behaviors and new competencies. Thus, in transformation, we are able to do things we were unable to do before.
Transformation is meant to identify, leverage, and even create new underlying principles for the way things are done. New sources of power emerge. And once the process of transformation begins, a profoundly different system materializes…a system changed in structure, culture, policy, and programs.
Guided by the vision outlined in Achieving the Promise, last year, SAMHSA and its federal partners, took a critical step toward moving the transformation vision to reality.
Slide 7/Federal Partners
Nine Federal Departments and the Social Security Administration, with SAMHSA at the lead, have joined in an unprecedented effort to solve the mental health maze. We recently released the Federal Mental Health Action Agenda—the roadmap that will guide our steps as a Nation toward this fundamental transformation.
Slide 8/Federal Action Agenda
This first Action Agenda identifies 70 specific steps that can result in immediate improvements in mental health care. These steps can guide similar steps at the State and local levels. This document is our pledge to take action. With it, Congress, the Nation and the people we serve can hold us accountable for achieving the goals we have set. There are copies of the Agenda available to you (HOLD UP COPY). Please read it, and share it with your colleagues as you develop your transformation agendas here in Missouri and Kansas.
Just a few weeks ago, the Institute of Medicine’s 2006 report on Improving the Quality of Health Care for Mental and Substance Use Conditions confirmed that we are on the right path. The new report concludes that improving the nation’s general health and resolving quality problems of the overall health care system will require attending equally to the quality problems of care for mental health and substance use conditions. The report offers two overarching recommendations that dovetail nicely with the recommendations outlined in Achieving the Promise and in the action steps proposed in the Federal Action Agenda.
Slide 9/IOM Recommendations
First, the IOM report recommends that health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body.
Secondly, the report found that the IOM’s earlier recommendations for the redesign of health care—including care based on healing relationships…individualized, patient-centered care…evidence-based decision making… cooperation and collaboration—are as applicable to care for mental health and substance use disorders as to general health care. You can read more about these recommendations at www.iom.edu.
The bottom line: We know what we must do to successfully navigate our way around the mental health maze and through it to the other side. We have a roadmap. But, to achieve the promise, we must walk the path. Phil Lane, Jr.—an internationally recognized leader in human and community development, and member of the Yankton Dakota and Chickasaw tribes—says it well: “We must seek to be living examples of the change we wish to see in the world. By walking the path, we make the path visible."
This morning, I urge each of you to take action…to walk the path…to make the path through the mental health maze visible for those you serve.
A recovery-focused system is within our grasp. Never before have we known so much about mental health and how to enable individuals with mental illnesses to live, work, go to school, and participate fully in their communities. Never before has science given us such powerful evidence-based tools. Never before have consumers and their families rightfully been allowed to demonstrate the amazing healing power of self-direction and peer support. We stand now at the threshold of a system of care in which recovery…not disability…is the expected outcome of services.
Recovery as expectation…this is the heart of a recovery-focused system. But how do we achieve this ideal? How do we create a system in which every policy, program, and person reflects a message of hope and recovery? By making certain that everyone involved—from program administrators to providers to consumers and their families— fully understands, embraces, and integrates recovery as the fundamental principle of a transformed mental health system.
Recovery from mental illnesses or emotional disturbances is a real possibility! Am I talking about a complete cure, in the medical sense? No. In a medical context, recovery is often an end state. The illness ends, the broken bone heals. The person returns to the same previous state of health.
Slide 10/ Recovery
Recovery in a mental health context is different. It is a life-affirming journey of personal growth. Its focus is on what a person can achieve as he or she gains control of a disorder and moves forward with life. Consumers in recovery are able to overcome the consequences of mental illness, such as discrimination and social isolation. As adults regain control over their own lives, or as children develop greater independence, they discover entirely new possibilities within themselves.
Our ability to embrace recovery as the fundamental principle of mental health has profound implications for the shape of our mental health system. Last December, SAMHSA brought together consumers and other experts to develop an operational meaning of recovery. We examined such topics as recovery across the lifespan and recovery in different cultural contexts. We considered how recovery applied at individual, family and community, provider, organizational, and systems levels. Our meeting led to this consensus definition of recovery for adults—
Slide 11/Consensus Definition
Mental health recovery is an individual’s journey of healing and transformation to live a meaningful life in a community of his or her choice, while striving to achieve maximum human potential.
A few words based on a wealth of beliefs! The most unshakable premise is that every individual has a continuous capacity for growth. The process of recovery builds on the strengths of each individual. It is nonlinear and self-directed. It is holistic and person-centered, and it involves personal and community respect, responsibility, and hope. It empowers consumers to make decisions that impact their lives. It recognizes the valued role of consumers in supporting and encouraging others as they continue on their own journey toward recovery.
Recovery is not an end point! Our definition implies a continuum of services…and a breadth of services…that acknowledge the whole person and not just the disorder. The scope of this definition changes our entire perspective on how we should provide care.
Certainly recovery is not a new concept. We’ve talked about it on the community level…and on the State level. But here’s the difference: We are, for the first time, working to reorient the Nation’s entire mental health system toward recovery… shattering decades of the status quo.
This vision puts consumers at the center of a transformed system of care. It is a vision that moves the role of consumers and families far beyond simply participating in the system. In a transformed system, consumers will direct their own futures. It is a powerful idea. And, a critical one.
You can see that transformation of this magnitude will require nothing short of a social movement…a movement to build a national system…State by State…community by community…that facilitates recovery and empowers people with mental illnesses to develop and reach their uniquely individual life goals.
In Kansas and Missouri you have already demonstrated a deep and true commitment to transforming your systems into ones that are consumer- and family-driven...accountable to those you serve...and focused on the goal of recovery. You are making excellent use of funding provided by the SAMHSA Block Grant and other resources to make transformation real in your communities!
For example, in Kansas, the New Freedom Commission summits that your Governor’s Mental Health Services Planning Council has held throughout the State during the past year are truly transformation in action! The Transformation Subcommittee that you recently formed is another productive next step forward as you advance transformation across the State.
I know that Kansas has a number of transformative consumer-focused initiatives underway—more than 325 consumers and 150 providers have been trained in Wellness Recovery Action Planning (WRAP) in the last three years and many consumers have gone on to start their own WRAP support groups locally.
19 local State-funded Consumer-Run Organizations (CROs) in Kansas are offering peer support and self-help—playing a key role in the recovery of many consumers throughout the State.
The Leadership Empowerment Advocacy Project (LEAP), funded by the Kansas Department of Social and Rehabilitation Services provides three college courses designed for persons with severe and persistent mental illness. LEAP emphasizes student strengths and recovery as well as the student’s development as a learner.
The mental health and aging services systems in Kansas have also made progress toward transformation. I applaud you for including workshops on older adult mental health at the Association of Community Mental Health Centers’ annual conference. Likewise, your current work to implement the supported employment tool kits and the co-occurring mental health and substance abuse tool kits…and your future plans to replicate the tool kits throughout the State…are admirable.
I know that transformation is a top priority here in Missouri, as well.
Recent passage of State Legislation, SB 103, establishes the groundwork for a comprehensive children’s mental health services system in Missouri. The new system will build upon current successful services systems in the State and offer a full array of services. By tying together the best practices developed in Missouri over the past 15 years—in the areas of service delivery, funding, policy, and accountability—the new law will create a coordinated and compassionate system of community-based mental health care for all of Missouri’s children…so that no parent will have to relinquish custody of their child to ensure appropriate care. Another excellent example of transformation in action!
I salute you for making involvement and inclusion of consumers, providers, and advocates in the planning, monitoring, and evaluation of programs a high priority in Missouri. I am impressed by so many of your efforts to move forward with a recovery-based care model—including your commitment to training consumers to be more effective advocates in the legislative process and the range of consumer-run services you are developing.
I also salute the progress you are making with administrative restructuring. I know that decentralization of supported community living programs is under way, enabling community programs to provide direct services to consumers, with DMH providing the training, support and oversight. Your hospital systems are developing the infrastructure to support their consolidation as well as the processes for coordinating with community providers on administrative, planning, and services matters.
I am excited to learn that you are using Kathleen Crowley’s empowering paradigm—PROCOVERY, which brings together consumers, family members, and staff—as the service model that will move your transformed system forward.
This is what transformation is all about! You, here in Missouri and Kansas, have a lot to be proud of. Your mental health programs exemplify many of the values that are the very foundation of transformation—including the importance of community to recovery…and the necessity of leadership by consumers. We want to see these kinds of programs take hold in States across the nation.
Slide 12/Momentum toward Transformation
As it is here in Missouri and Kansas, momentum toward transformation is building steadily across America. From California to the Carolinas, I am seeing a readiness and a willingness to change. Each of the States and Territories is answering the call...in its own way.
For example, Georgia has launched an historic partnership between its Department of Human Resources and the Medical College of Georgia that will train psychiatrists in Georgia’s strengths-based peer supported recovery model. This collaboration has the potential to transform how future generations of psychiatrists and mental health professionals will serve those will mental illnesses.
Ohio ’s behavioral health leaders have created the Adult Recovery Network, which provides a framework for local and statewide leadership on recovery practices. Through this effort, the State is fostering shared leadership and building capacity for change at every level.
Florida has formulated a State Action Plan promoting a system of care aimed at recovery and resilience. The New Mexico Interagency Behavioral Health Purchasing Collaborative will replace that State’s fragmented system with a single behavioral health delivery system, thus minimizing confusion for providers, consumers and families. With the passage of the Mental Health Services Act, planning is underway in every county in California toward the development of comprehensive plans to address the needs of adults and children with mental health problems.
Slide 13/SIGs
The States are the very center of gravity for transformation. That’s why SAMHSA is making a strategic investment in transformation at the State level. Last month, we awarded the first Mental Health Transformation State Incentive Grants to seven States ─ Connecticut, Ohio, Oklahoma, Washington, Maryland, New Mexico and Texas. With this $92.5 million investment, over the next five years, these States will begin to make the systemic changes needed to meet multiple consumer needs and foster recovery. We are asking these States to do something truly revolutionary—to unite all of their State agencies involved with adults and children behind a common vision of mental health care as it should be! These States have an unprecedented opportunity to be lead by example . What they learn can help speed the pace and extent of transformation by others.
As part of the Transformation SIG program, we are piloting a new initiative we call our “Transformation Action Initiative” or TAI. Through the TAI, technical assistance brokers will tailor a technical assistance plan in response to a given State’s specific priorities for transformation. All of the many TA resources that currently exist across the Agency will be centralized through the TAI, making it easier for States and others to find the assistance they require. Through the TAI, we will be able to build better connections between those involved in transformation. Importantly, we will also be able to measure the impact of the technical assistance we provide…an important part of our cross-agency effort to tie resources to performance.
At the same time, we are working with the National Association of State Mental Health Program Directors (NASMHPD) to develop templates for model Comprehensive State Mental Health Plans. These plans will assist the SIG states…and every State…in addressing the full range of treatment and support services consumers need to live in their communities. We are also developing prototype Individualized Plans of Care that consider the specific needs and concerns of every adult, child, or family coping with a mental illness.
(pause)
At this point, you may be asking yourself…where is all of this leading? What will a transformed system actually look like when we achieve it? How will we know when we’ve found our way out of the maze and achieved the promise?”
Slide 14/Transformation/Solving the Mental Health Maze
We will have achieved the promise when mental illnesses are seen for what they are…not personal weaknesses, but treatable illnesses from which recovery is possible.
We will have achieved the promise when the discrimination and stigma that make it so difficult for people with mental illnesses to find jobs or homes, to obtain health insurance or to find appropriate care, will be greatly reduced, if not eliminated entirely.
We will have achieved the promise when the disparities in mental health services for individuals in rural and frontier areas, for cultural and ethnic minorities, for children and youth, will no longer exist.
We will not realize this ideal of a transformed mental health system overnight. It is not an “event”…but a continuing process.
I am not naïve about the complexity of the mental health maze. I understand that it is not solely within any of our individual abilities to enable a whole scale system transformation. This is about entire sectors changing. It is about each one of us knowing where we fit in the big picture.
But, it is difficult to see that picture when you’re trapped inside the frame. I urge each of you to step outside of the frame. We have to be able to see the maze from above to gain the necessary perspective. We have to change minds before we can change the system. We must educate people about mental illnesses to eliminate the stigma of having and getting treatment for these conditions. We must change how health care is legislated. We must integrate the fiscal care of the whole person, rather than perpetuating the concept of the “piecemeal” consumer who has, too often, been created in our policies, funding, and service strategies. And, we must do it now!
James Baldwin, American essayist, playwright and novelist, said: “The challenge is in the moment; the time is always now.” Each of us must apply our particular and rare gifts to realize the possibilities of this moment.
You, here in Missouri and Kansas, have made a good start on focusing your strategy for change. How can you move forward from here to make the changes needed to realize the full possibility of this historic moment? I urge each of you to change your expectations of what is possible…and then, act on these expectations.
The “mental health maze” can be formidable. We are challenged at each twist and turn to take action…to choose the right direction…to discover the path of heart. The information you will gain in your sessions today will help you begin to find your way through the maze. When this meeting adjourns, I am confident you will be better equipped to walk the path…to lead the way…with clarity of vision, understanding, and new energy.
Through transformation, we will triumph over the mental health maze. Together, we will achieve the promise of a life in the community for everyone…in Kansas and Missouri…and across America. Thank you.
Kern, Hermann. Through the Labyrinth: Designs and Meanings Over 5,000 Years. New York: Prestel Verlag. 2000
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