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

Tracking Transformation:
Data Infrastructure Grantee Annual Meeting

February 14, 2007
Washington, DC

PowerPoint Version

Good afternoon, and welcome back to Washington, DC, for the third and final meeting of this round of data infrastructure grants (DIGs). Are you happy to be here? [PAUSE] How do you know if you’re happy? What measure are you using? Could you accurately compare your degree of happiness to the person next to you?

Harvard psychology professor Daniel Gilbert is the author of Stumbling on Happiness. In his book, Dr. Gilbert asserts that happiness is a subjective experience, for which there is no perfectly reliable measuring instrument. He uses Siamese twins as an example. We who are not Siamese twins probably believe that conjoined twins would be happier separated. Medical research, however, has found that twins exhibit an almost universal desire to remain together. Their happiness comes from the security of having a loved one always by their side, someone who knows them as well as they know themselves and who shares their hopes and worries. We who have not experienced that closeness cannot easily comprehend their feelings.

And yet, you could just tell me if you’re happy to be here. You can name events and experiences that make you happy and compare the intensity of your feelings. You can set goals and say, “When I achieve this, I will be happy.” Even though happiness has no tangible qualities, you can plan for it and establish benchmarks toward achieving it.

So, I’m asking this question of you, as State planners and data managers: How can the Substance Abuse and Mental Health Services Administration (SAMHSA) track mental health transformation? Transformation, like happiness, is an abstract concept. Our understanding of what it is and how to get there varies from State to State and from consumer to provider. And yet, mental health transformation is a national initiative…a driving force behind congressional budgeting, SAMSHA’s grant programming, and your State planning efforts.

As you may recall from our previous discussions, mental health transformation is a broad-based approach that SAMHSA has adopted to introduce fundamental change in the way mental health services are perceived, accessed, delivered, and financed across the Nation. The goal of transformation is to create a system that is consumer driven and focused on recovery. In a transformed system, recovery is defined by the consumer—that person whose daily life and future is affected by the services provided and the outcomes achieved.

Let’s take a moment to define transformation. Dr. Noel Mazade is the executive director of the National Association of State Mental Health Program Directors (NASMHPD) Research Institute, which supports State efforts to improve the quality and accountability of mental health services. He wrote a paper on the “Concepts of Transformation” to help mental health directors understand how this concept applies to State mental health systems. In his paper, Dr. Mazade included this analysis: “In some ways, transformation is a fancy word for change. But [transformation] does imply a certain type of change—one that makes a sharp break with past practices and that ushers in a new set of assumptions and values about the institution. It suggests a structural, procedural, and even cultural makeover of huge proportions with long-term consequences.”

That definition really sums up the challenge we face: Tracking transformation means being able to quantify our progress toward something that doesn’t exist yet. Instead, transformation is a vision, a process, and a goal.

And yet we must find a way to track our progress towards transformation, both nationally and by State. We serve the public. We are accountable for both the services we provide and the results we achieve. I’d like to take you back to a book written in 1992 by David Osborne and Ted Gaebler. Their book, entitled Reinventing Government, was a groundbreaking and influential look at the delivery of social and human services. According to the authors, how we manage programs from the very beginning should be driven by the results we want to achieve at the end. Consequently, the focus of program planning and implementation should be on purpose, with far less emphasis on process.

The authors also make this observation: A paradigm shift that takes us from focusing on process to purpose is possible only with good data—by identifying outcomes, measuring results, and using the results to make management decisions and program improvements. Their notions about the relationship between data and reinventing—or transforming—government programs can be summarized in these four points:

• What gets measured gets done;
• If you don’t measure results, you can’t tell success from failure;
• If you can’t see success, you can’t reward it; (and, I would add, you can’t replicate it elsewhere); and
• If you can’t reward success, you probably are rewarding failure.

Nearly 25 million Americans experience serious psychological distress. We need only look to them to understand why recognizing, rewarding, and replicating success is a monumental responsibility and a moral imperative.

In addition, Congress and the Office of Management and Budget (OMB) see SAMHSA as a business, and they increasingly are evaluating our success in business terms. Both are looking to us for stronger data measures and more positive indicators of program efficiency and effectiveness…which they will use to determine and justify continued funding. In this fiscal climate, strong programs will survive. Weak programs will be discarded as quickly as the Ford Edsel.

In almost every area of our government, we expect transparency and accountability for our tax dollars. And, like any other investment or enterprise, we need meaningful information to satisfy this expectation. Margaret Spelling, Secretary of the U.S. Department of Education, has a favorite quote that applies here. She likes to say, “In God we trust; everybody else has to show data!”

The OMB focus on accountability is reflected in the PART measures, with PART being an acronym for Performance Assessment Rating Tool. For your State’s mental health block grant, OMB has stipulated four PART measures:

• Utilization, which can measure both treatment capacity and consumer access;
• Readmission to State hospital systems;
• Client perception of service outcomes; and
• Use of evidence-based practices.

Later today, you’ll hear about the progress you have made in reporting on your block grant PART measures.

The PART measures are pulled from the same data you are collecting through the Uniform Reporting System (URS) and for the National Outcome Measures (NOMs). One purpose of the URS tables is to allow each State to track its individual performance over time. For the past 6 years, the DIG program has helped the States develop the capacity to record and report on the URS measures across multiple agencies. In a few minutes, we’ll give you an update on the continuing progress being made in this area. Tomorrow, you’ll get to explore the challenges of reporting on the use of evidence-based practices. Just like transformation, data collection is an evolving process. Please use this meeting as an opportunity to share your ideas about how we can improve the process.

A second purpose of the URS data is to enable SAMHSA to aggregate State information in a way that paints a national picture of the public mental health system. In 2005, we expanded the DIG program to include testing and reporting on the newly created NOMs, which we designed to reflect a transformed view of mental health care. We intend for the NOMs to be SAMHSA’s premier measures for reporting to Congress.

Unlike past measures, which focused on services provided, the NOMs focus on positive outcomes for consumers. In fact, the NOMs are a test bed for measuring our basic concepts of what recovery means to a consumer. A measure such as client perceptions of care outcomes, which you pilot-tested through your DIG this year, is groundbreaking in its recognition of consumers as the center of care.

Measuring client perceptions also asserts a key point about self-determination and recovery. Many consumers have reported that having or regaining control over their lives was essential to their recovery. Dr. Gilbert, in Stumbling on Happiness, notes that humans are born with a passion to control. Our brains appear to be naturally endowed with a fundamental need to be able to influence our environment. As research suggests, if we lose this ability at any time during our lives, we become unhappy, helpless, hopeless, and depressed. By acknowledging that consumers have a rightful place in our planning and evaluation, we are supporting their hope of recovery.

All of the measures—PART, URS, and NOMs—are contributing useful information about mental health service delivery within your States and across the Nation. Transformation of mental health care in America, however, is larger than just the public mental health system. In a transformed system, promoting and protecting the mental health of our citizens is the responsibility of every child- and adult-serving system.

Last year, I gave you an update on the Federal Partners Workgroup for Mental Health Transformation. As I pointed out then, SAMHSA has engaged nine Federal departments, the Social Security Administration, and the Equal Employment Opportunity Commission in this effort. We also are working to involve the primary health care system and business leaders. Just as an example, Fortune 500 companies now are teaming with the public sector to develop more effective ways to deliver mental health services through business settings. Our cross-agency and cross-system efforts are a model for similar collaborations that need to occur at the State level.

I am a captain in the Naval Reserve. Last August, I attended a military executive training course on transformational leadership. Our defense department is working to transform itself into a 21st century fighting force, just as we are working to create a 21st century mental health system capable of combating mental illnesses. Consequently, the lessons I am learning about military transformation have direct application to mental health transformation.

[SLIDE]

The focus of my course was the six dimensions of transformation. All of these dimensions must be aligned as part of our efforts to make fundamental changes at the core of a system rather than at its margins. These dimensions are:

• Culture—the understandings, beliefs, and practices that define and shape our reaction to change;
• Concepts—structured approaches to expressing how a course of action might be accomplished;
• Capabilities—techniques, tools, and systems that may be required to execute specified actions;
• Processes—the changes in steps, tasks, or procedures that may be required to implement concepts or apply capabilities;
• Authorities—the changes in public laws or regulations that may be necessary to implement transformation; and
• Organizational design—the change in an organization’s division of labor that will facilitate a desired course of action to bring about desired results.

These six dimensions can be our framework for tracking transformation…for really assessing how well we are achieving our ultimate vision of a transformed mental health system. For example, the first dimension of transformation is culture. Culture provides the environment in which change can thrive…or wither over time, depending on the attitudes and values of those involved. We can’t say that we have achieved transformation just through the greater use of evidence-based practices or even through greater numbers of individuals served. We also have to be able to point to a transformed culture that encourages individuals to seek treatment willingly…and without any fear of losing their jobs, homes, and friends. We have to see that cultural shift reflected in legislation and policies that place mental health care on a par with physical health care.

Stigma and discrimination are the last vestiges of wrongful, harmful, and outdated fears and prejudices about mental illnesses. Because they stand as the most pervasive barriers to treatment and recovery, SAMHSA and its partners are working hard to determine how we best can eliminate them. In a transformed system, Americans will think and act differently in regard to their mental illnesses—they will take their problems out of the closet and into the clinic!

In December, SAMHSA launched a new national anti-stigma campaign aimed at young adults. Although this age group has the highest incidence of serious psychological distress, it has the lowest rate of help-seeking behavior. Only about a quarter of 18- to 24-years olds believe that someone with a mental illness can eventually recover. Only about half think that treatment can help a person lead a normal life! Through our campaign, we hope to create a generation of young people who support their friends with a mental health problem. The opportunities for recovery are far more likely within a culture of acceptance and understanding.

SAMHSA also is working with the Centers for Disease Control and Prevention (CDC) to identify the extent of stigma across all age groups. Through a special appropriation from Congress, CDC has integrated a mental health and stigma module into the 2007 Behavioral Risk Factor Surveillance System. Thirty-five States will be using this module. Last year, through a similar appropriation, CDC developed a module to help us determine the prevalence of anxiety, depression, and serious mental illness. Forty States integrated that module into their survey.

Tomorrow morning, you’ll be able to hear more about these modules from Dr. Ali Mokdad and Dr. Ruth Jiles of the CDC. Dr. Mokdad, Dr. Jiles—thank you for joining us. I’m delighted that you are attending this meeting. Our combined data collection efforts are a very positive example of how we all can work together to identify common problems and devise common solutions.

In a transformed system, stigma will not be the barrier to recovery than it now is. As it stands, only about half of those who have a serious mental illness receive treatment. Only a third of them will be employed, even though most could hold a competitive job with appropriate supports. Millions of consumers lack decent, safe, affordable housing within their communities. These are abysmal statistics, and a clarion call for change. Each statistic is reflected in the NOMs…and each one illustrates how other systems, such as employment and housing, must be part of transformation.

SAMHSA’s challenge, and the one I’m presenting to you, is to help us determine how we can use the URS and NOMs, which measure individual elements of transformation, to capture shifts in culture, concepts, capabilities, and other dimensions of transformation. It is these overarching measures that will tell us if the changes we are making are temporary…or if we successfully have embedded transformation across multiple systems and administrations. New approaches are fragile and vulnerable to regression. They become a standard way of doing business only after the values they represent are institutionalized within an organization’s culture.

We will have to mine deeply within our current data measures to track transformation in full. We must identify those outcomes that represent—in Noel Mazade’s words—“a sharp break with past practices and a new set of assumptions and values about mental illnesses and recovery.” Can we do this without adding to data collection? Can we tweak the data or phrase a question in a slightly different way to get the information we seek? I look to you and your expertise for answers.

As we bring this round of grants to a close, I thank you wholeheartedly for all of the work you already have done. Developing a better reporting system has been a demanding process. I personally commend the planning and data specialists who have worked with SAMHSA to improve their States’ data infrastructure and their reporting capacity. You consistently have increased the number of measures reported and have worked collaboratively to report these measures in the most feasible and meaningful way. Thanks to your efforts, SAMHSA will be able to report on most of the NOMs and URS measures by this December. This level of detail will demonstrate a higher standard of accountability to Congress and to the individuals we serve.

In closing, I offer the wisdom and words of Arnold Toynbee, a British historian and author of a 12-volume analysis of the rise and fall of civilizations. For Toynbee, civilizations were not intangible or unalterable machines, but a network of social relationships within a cultural boundary. Toynbee believed that a civilization rose in response to significant challenges…when “creative minorities” devised solutions that reoriented their entire society. You can find many parallels between Toynbee’s views and the potential of our national mental health system to rise in response to the challenge of transformation.

Toynbee observed, “It is a paradoxical but profoundly true and important principle of life that the most likely way to reach a goal is to aim not at that goal itself but at some more ambitious goal beyond it.” In your efforts to plan and evaluate State mental health services, aim higher than the basic reporting requirements. Instead, be a creative minority. Use the data you are collecting to help envision, create, and instigate solutions that will reorient our Nation toward transformation and better mental health for all Americans. There is no more ambitious goal.

Thank you…and Happy Valentine’s Day. If you left a significant other at home, call and say “I love you.” It will be good for his or her happiness and mental health. Enjoy your conference.

Question-and-answer session suggested, if time is available.