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
Joint DoD/VA Conference on Post-Deployment Mental Health
Transforming Mental Health for All Americans
Alexandria, VA
March 8, 2005
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. Title slide]
Good afternoon. I’ve been invited here as the director for the Center for Mental Health Services, an agency within our U.S. Department of Health and Human Services.
[SLIDE 2.
SAMHSA organizational chart]
I also hold another professional position, as a captain in the U.S. Naval Reserve. I have proudly served as a member of our Armed Forces for 24 years. My dual professional roles give me fairly broad insight into the challenges of post-deployment mental health care.
[SLIDE 3.
MacArthur quote]
General Douglas MacArthur, in his farewell address at West Point, spoke very emotionally about military service. He remarked that “…the soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war. But always in our ears ring the ominous words of Plato, that wisest of philosophers: “Only the dead have seen the end of war.”
Listen to these words again: “Only the dead have seen the end of war.” General MacArthur’s words obviously referred to our steadfast need to defend our country and its values against those who would destroy them. But his words also convey a deeper, more symbolic meaning—that the memories of military service, and especially combat, remain in a veteran’s mind for life. Only a paragraph later in the same speech, and after alluding to his own death, General MacArthur confided that “In my dreams I hear again the crash of guns, the rattle of musketry, the strange, mournful mutter of the battlefield.”
Combat, no matter how necessary, is brutal. It is mentally as well as physically demanding. Sometimes, it is mentally overwhelming. Service members can and do develop combat-related disorders, such as post-traumatic stress disorder, or PTSD. How does this disorder manifest itself? For many individuals, PTSD is the repeated re-experiencing of their ordeal through flashbacks, memories, nightmares, or frightening thoughts—in their dreams, both day and night.
Most service members have sound mental health and an inner resilience that enable them to deal successfully with combat-related stressors and trauma. We select and train our military personnel well. A recent study published in the New England Journal of Medicine confirms this. Fewer than 20 percent of U.S. troops returning from Iraq and Afghanistan experience serious symptoms of depression, anxiety, or PTSD.
This percentage represents a significant decline in mental health disorders when compared with prior engagements, such as Vietnam. About 30 percent of Vietnam veterans developed PTSD at some point after the war. I credit the military’s growing appreciation of mental health status and its focus on mental health care for this decline. The Department of Defense (DoD) now requires that every service member be briefed on mental health before, during, and after deployment. DoD’s policy embraces the full spectrum of necessary mental health care, from prevention of mental illnesses through treatment and recovery.
I am extremely gratified by the Armed Services’ continuing efforts to improve the mental health care it offers. This meeting is part of those efforts. The number of people here and the variety of interests represented demonstrate the high value the military places on maintaining the mental health and well-being of the men and women who serve. Thank you for asking me to join you. As the director of the Center for Mental Health Services, I have a mission. I want to do whatever I can to ensure that all Americans with or at risk of developing a mental disorder will have access to the best mental health care services and supports available.
I’ve been asked to present an overview of mental health transformation, which is a charge handed down by President Bush to my agency. His directive stems from a report released by the President’s New Freedom Commission on Mental Health. The name of this report is Achieving the Promise: Transforming Mental Health Care in America.
[SLIDE 4.
Achieving the Promise]
Achieving the Promise is a critical assessment of our national mental health system . This system is really a combination of systems, which includes State mental health, substance abuse, and other authorities that ultimately are responsible for the mental health care of our citizens.
Achieving the Promise describes a system in disarray. Services and supports are fragmented, disconnected, and often inadequate. Instead of ready access to quality care, the system presents barriers to recovery. The report’s final conclusion is staggering. It declares that the time is long past for piecemeal reform. Instead, the report recommends that we fundamentally transform our Nation’s approach to mental health care. The overarching goal of this transformation?—To create a mental health system that facilitates recovery and builds resilience in the children and adults it serves.
Now, transformation is an enormous concept. Achieving the Promise does not define transformation, nor does the report discuss the theory, characteristics, technologies, and processes involved. Without this knowledge, my agency faced a huge theoretical challenge. We couldn’t even begin to develop transformational steps without a better understanding of what transformation meant.
[SLIDE 5.
Cover of Military Transformation]
For our education, we looked first to DoD, which is undergoing its own systemwide transformation. We found our theoretical framework in the writings of Retired Vice Admiral Arthur Cebrowski, the former director of the Office of Force Transformation within the Office of the Secretary of Defense. There is a great deal of similarity between the steps DoD is taking to transform the military system and what we need to do to transform the mental health system.
[SLIDE 6.
Transformation is . .]
According to Vice Admiral Cebrowski,
- Transformation is a continuous process, without end. It is meant to create or anticipate the future.
- Transformation is not accomplished through change on the margin but, instead, through profound changes in kind and in degree.
- These changes result in new behaviors and new competencies. Thus, in transformation, we look at what we can do now that 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.
- Once the process of transformation begins, a profoundly different organization materializes—changed in structure, culture, policy, and programs.
As Vice Admiral Cebrowski made clear, transformation ultimately is about newness—about new values, new attitudes, and new beliefs that are expressed in the changed behaviors of people and institutions. And how can we achieve these changes? The answer is the same for both the military and the mental health systems. It is our readiness to change and our willingness to risk that will determine the scope and speed of the progress we make.
DoD has distilled its transformation strategy into six operational goals. The mental health system also has goals to guide its efforts. Achieving the Promise presents us with 6 broad goals, as well as 19 specific recommendations, for mental health transformation. These are the goals.
[SLIDE 7.
Six goals]
I’m going to review just briefly the goals and recommendations as they relate to post-deployment mental health. I urge you, however, to read the full report, which I have made available to you. The report discusses the goals and recommendations in terms of mental health care for all Americans. It stresses a public health approach to mental health, which recognizes the relationship between the health of individuals and the health of their communities. The military community is not isolated. The mental health of its members affects and is affected by the mental health of the larger social communities around it. As you evaluate your continuum of post-deployment services and necessary collaborations, look beyond the military community. There is a full spectrum of organizations that have a stake in the sound mental health care of service members.
[SLIDE 8.
Goal 1 and recommendations]
Goal 1 and its recommendations focus on mental health and its relationship to overall health. The mind and the body are inseparable. We cannot treat one effectively without treating the other. Consider, for example, the physical ailments commonly experienced by individuals with PTSD. These include headaches, gastrointestinal distress, immune system problems, dizziness, and chest pains. Primary care doctors often treat these ailments unsuccessfully because they do not realize that they are symptoms of an underlying anxiety disorder.
How does this relationship between mental and physical health affect post-deployment mental health care? The most obvious response is that primary care doctors should be cross-trained in techniques for recognizing and assessing symptoms related to mental disorders. Any door should be the right door for mental health care.
Goal 1 also addresses ignorance, bias, stigma, and discrimination. Fear itself may be the greatest barrier to treatment among service members. The study reported in the New England Journal of Medicine revealed this disturbing statistic: Of those service members afflicted by PTSD, less than 40 percent sought help. The reason?―Many service members fear that admitting to a mental disorder will hamper or damage their military careers.
Individuals with mental illnesses need a healing environment in which they can seek care—willingly, openly, and with hope in their recovery—and in their future. We must turn around the message received by our troops. As Major Paul Morrissey, chief of mental health services at Fort Drum in New York, stated to a CNN reporter: “Soldiers are concerned that coming to us might harm their careers. I can say to them sincerely and honestly that not coming to get some assistance will harm their careers.” That is the message our service members need to hear!
[SLIDE 9.
Goal 2 and three recommendations]
Goal 2 has five recommendations—these three are most relevant to post-deployment mental health. Goal 2 places the individual and family at the center of mental health care. A mental disorder affects more than an individual. In particular, it can affect family members and close friends profoundly.
A Navy SEAL, recently returned from Baghdad, observed that his biggest challenge in returning stateside was reuniting with his fiancée. He said, “My life in Iraq was so bizarrely different from my life in San Diego. In a world turned upside down, you pick up new behaviors and habits, both good and bad. Either way, you come home different from the way people knew you before, and you end up fighting with them because you can’t meet their expectations. It’s really hard trying to make them understand—to fit back in. I thought I’d be getting away from stress when I came home. Instead, I just returned to a different kind.”
At least half of all service members are married, many also have children. In fact, the number of active duty dependents, at 1.9 million spouses and children, exceeds the number of active duty personnel. I’m gratified that the military is taking steps to address the post-deployment needs of families as well as individuals.
[SLIDE 10.
Care: Becoming a Couple Again]
I commend, for example, the Uniformed Services University Health Services for its health promotion campaign called “Courage To Care.” This program is a valuable tool for reducing the stress of re-entry for service members.
A second focus of goal 2 is to provide individuals and their families with real and meaningful choices about mental health care. Just as each person differs, the treatment and supports he or she will need to support recovery will differ. Individuals need choices so that they can select the ones that best support their own personal journeys toward recovery. This goal and its recommendation for an individualized plan of care simply reflect what research and experience tell us about the way people recover from a mental illness. Having hope and being able to regain control of their own lives are vital to their recovery.
I think, at this point, that I should clarify what we in the mental health community mean when we speak of “recovery.”
[SLIDE 11.
Defining recovery]
Recovery does not necessarily mean a cure. Recovery is a process, sometimes lifelong, through which a person achieves independence, self-esteem, and a meaningful life in the community. For some individuals, recovery implies the reduction or complete remission of symptoms. For others, recovery is the ability to live a fulfilling and productive life despite a disability.
Although this isn’t a precise analogy, compare our definition of mental health recovery to the recovery of a soldier who has lost his lower leg to a roadside bomb. The soldier will recover from his injury. However, he never will be able to live his life exactly as he did before. For him, recovery will be a process through which he develops a new sense of independence and self-esteem. With proper treatment and supports, he will succeed, and he will go on to lead a complete and fulfilling life.
Similarly, individuals can and do recover from mental illnesses such that they can be contributing members of their communities. Their personal triumph reflects the vision held by the Substance Abuse and Mental Health Services Administration as well as our President: a life in the community for everyone.
I now ask you two questions related to post-deployment mental health care. The first is, “How does the military define recovery from mental illnesses?” The second question is, “Do the treatment and services offered to individuals support a broad definition of recovery, or is disability the expected outcome?” How you define recovery will affect significantly the services you include in your comprehensive clinical and educational plans.
[SLIDE 12.
Goal 3 and recommendations]
Recommendations for goal 3 emphasize how we must eliminate disparities of care, particularly among ethnic and racial minorities and for those living in rural areas. In light of this goal, the military must consider how well it responds to the mental health needs of its minority service members. This includes the needs of women, who are their own minority within the military. Servicewomen currently represent about 15 percent of the enlisted ranks. Questions to be asked include these: “Are you meeting the needs of all groups equally?” and “How can you design your clinical and educational plans to recognize racial and gender differences ?” Here is another crucial question: Are you sufficiently protecting minority groups from stressors within the military community itself―stressors such as harassment, hostility, abuse, intolerance, and isolation?”
[SLIDE 13. 4 and recommendations]
Goal 4 addresses mental health needs across the lifespan. I’d like to focus on recommendation 4.4, which deals with the relationship between mental illnesses and substance use disorders.
Individuals who have a serious mental illness are more than twice as likely to use illegal drugs as those without a mental illness. In fact, research suggests that up to half of persons with a serious mental illness will develop a substance use disorder at some point in their lives. PTSD symptoms are a common trigger for substance use. Consequently, service members with PTSD are at high risk for developing a co-occurring disorder.
[SLIDE 14. 4
Scan of COD TIP cover]
Our growing awareness of the significant relationship between mental illnesses and substance use is transforming the way we treat what we refer to as co-occurring disorders. We now know that if only one disorder is treated, both tend to get worse. Both disorders must be addressed through treatment, and a person’s greatest hope in recovery is through integrated treatment.
Just last month, SAMHSA released state-of-the-science treatment guidelines for counselors and others working in the field of co-occurring substance use and mental disorders. I urge you to obtain copies of our Treatment Improvement Protocol 42: Substance Abuse Treatment for Persons With Co-occurring Disorders. Share this comprehensive document among your primary, substance use, and mental health care personnel. Copies are available through SAMHSA.
[SLIDE 15. Goal 5 and recommendations]
Goal 5 and its recommendations address improved mental health care through better research, better treatment, and a better-trained workforce.
Note the emphasis on evidence-based practices. Individuals with or at risk for mental illnesses deserve the best mental health care available. Widespread adoption of new and emerging practices, however, may demand a cultural shift among practitioners, consumers, and administrators who oversee mental health programs. This shift will be particularly necessary when a practice diverges significantly from the traditional way of providing care.
For example, think back to goal 2―that mental health care will be consumer and family driven. This goal envisions that consumers will be educated, empowered, and enabled to be equal partners in determining their own care. An individual’s ability to exercise independent decisionmaking can be a radical departure from standard medical practice and standard military procedure. This goes back to a point I made earlier: Readiness to change and willingness to risk will determine the scope and speed of the progress made to transform mental health care. Ask yourselves, as leaders in post-deployment mental health, “How ready and willing am I to change?”
[SLIDE 16. Goal 6 and recommendations]
Goal 6 and its recommendations focus on technology. Technology offers incredible opportunities to improve mental health services. What are some of these opportunities?—to educate and inform consumers, to offer online training and information in evidence-based practices, and to provide more comprehensive care to individuals in remote or underserved locations.
DoD is a leader in strategic technological applications. In fact, the field of operations research originated with the study of military operations. The military also is a leader in applying technology to better health care. Achieving the Promise singled out the Department of Veterans Affairs (VA) as a frontrunner in developing an electronic health record system that benefits patients and providers. All 1,300 VA medical sites already use a fully integrated medical record system.
Additional improvements related to health technology will no doubt follow as part of DoD’s transformational efforts to leverage technological information. I have equal faith in this workgroup’s ability to harness the power of technology to improve post-deployment mental health. Imagine the potential of technology to accelerate research, collaboration, and innovation among you.
That concludes my overview of the goals and recommendations for transforming mental health. I’m pleased that your agenda reflect many of these key concepts. I’m particularly gratified that you have included veterans. As the old Chinese proverb advises, “No one knows better how the shoe pinches than the one who wears it.”
The collaborative process this workgroup is using to improve post-deployment mental health is quite similar to the process my agency is using to promote mental health transformation. We, too, have brought together a broad-based group of stakeholders to identify gaps in service and to determine the next steps for progress.
[SLIDE 17.
Federal Partners Workgroup]
During the past several months, SAMHSA has met with 20 other Federal agencies to determine how we can respond to the goals and recommendations from Achieving the Promise. Workgroup members are those agencies that have a significant stake in the mental health of the people they serve, such as the VA. As you can see, this broad spectrum of groups represents the kinds of services that support a person’s recovery from mental illnesses. A home, a job, an education—in other words, the means to live a full life in the community.
Our workgroup, similar to this one, began its efforts by taking an inventory of programs each agency already had in place. We organized our inventories around the Commission’s six goals. This enabled us to identify clearly our ongoing programs that already support transformation. These are programs we will maintain and enhance. We also were able to determine where we could collaborate on new initiatives to support transformation.
This process led to the second outcome of our Federal Partner Workgroup: The Federal Action Agenda. Our agenda describes how SAMHSA and its partners will respond to each of the Commission’s 6 goals and 19 recommendations. It identifies specific, measurable steps that we can take during the next year to motivate, facilitate, and compel change. Our action agenda is an evolving document. We will develop new agendas and identify new priorities as we make progress.
One of our transformation actions is an interdepartmental initiative to end chronic homelessness among people with co-occurring disorders. The VA has been instrumental in planning and coordinating this initiative, which involves SAMHSA as well as the Department of Housing and Urban Development, the Federal Interagency Council on Homelessness, and the Health Resources and Services Administration. Veterans account for nearly one-third of all homeless men in America. About half of our homeless veterans have some form of mental illness, and nearly 70 percent struggle with alcohol and drugs.
These statistics illustrate why we must work together for mental health transformation. Through transformation, we can change our mental health system and other systems of support and service. Our objective must be to help veterans and other Americans with serious mental illnesses avoid the most serious consequences of illness. How can we do this? By designing a system that detects illnesses early and provides individuals with the kinds of treatment and services they need, when and where they need them. When we do this—and we can—the outcome will be recovery─not homelessness, or substance use, or family disintegration, or suicide.
[SLIDE 18.
NFC vision]
Ultimately, we should be able to transform our system to fulfill the vision that underlies the goals and recommendations of Achieving the Promise. This vision is a future “when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports—essentials for living, working, learning, and participating fully in the community.”
It falls to us to make this vision a reality. Together, we share a collective responsibility to ensure that military members, as well as other Americans, receive the treatments and supports they need to protect, maintain, or regain sound mental health.
Those who serve our country do so bravely. If, in the course of their service, they develop a mental illness, it is not a sign of weakness or of cowardice. It is a sign of their humanity. It is our sign to step forward to take care of them. If we do our job well enough, service members with or at risk for mental illnesses will be brave enough to seek our help. If they have an illness, we can help them recover; if they are at risk, we can help them build resilience to face the challenges that lie ahead. As General MacArthur emphasized, military service should instill in its members “a sense of wonder, the unfailing hope of “what next,” and the joy and inspiration of life.” Let’s make that our goal. Thank you.
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