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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

Transforming Mental Health Care in Texas
Texas Transformation Working Group Meeting

March 9, 2006
Austin, TX

PowerPoint version

Good afternoon. It’s a pleasure to be here in the great state of Texas and to have the opportunity to congratulate you once again on the award of your State Incentive Grant for Mental Health Transformation (Transformation SIGs). I’m particularly pleased to be sharing the podium with Dave Wanser, the Chairman of Texas’ Transformation Working Group, which is widely recognized as the most diverse in the country. I’d like to note that the Substance Abuse and Mental Health Services Administration (SAMHSA) recently recruited Dave for a think tank of national experts who could crosswalk the goals of mental health transformation with the Institute of Medicine’s (IOM’s) recommendations for improving behavioral health care in the United States. We could use a man of Dave’s abilities in every State in the Nation.

I’d also like to note that three members of the President’s New Freedom Commission on Mental Health were Texans. This is the commission that released the report that launched a national initiative for mental health transformation. The promise held out by that report for the future of mental health care is giving hope in recovery to millions of American adults, children, and families. The fact that Texans were so instrumental in the report’s development illustrates the visionary and innovative leadership that characterizes the Lone Star State.

President George W. Bush once said, “Some folks look at me and see a certain swagger, which in Texas is called ‘walking.’” I think that’s a great way to describe the reputation your State has earned so justifiably earned ―the proud “get it done” attitude, a willingness to tackle the big issues, and the solid belief that if a problem CAN be solved, Texans WILL solve d it. The Nation has come to expect boldness, creativity, excellence, and innovation from you. You have a history of extraordinary accomplishment,…and I’m certain that you will continue to be torchbearers for mental health transformation.

As you may know, there was strong competition for the Transformation SIGs as well as a high level of nationwide interest nationwide. That your State was one of the seven winning applicants reflects, in part, the commitment of the strong leadership team you have assembled, supported by the very impressive brain trust your State enjoys.

Governor Perry has pledged to “fight hard to protect Texas’ most vulnerable citizens.” That attitude is what it will take to continue the ongoing work of transformation. I am gratified to know that the finest experts in our Nation, many of whom hail from this State, are lending their efforts to the challenges before us.

System transformation of the magnitude we seek through the Transformation SIGs requires many things. It demands hard work―work that requires the very best from each of us. It requires strong and steady leadership. It requires innovation and the courage to move beyond prescribed limits and traditional thinking. It requires a kind of heroism…a measure of fortitude and an intrepid spirit. It requires the adoption of a new way of thinking. It requires boldness and perseverance.

It also requires the establishment of partnerships―partnerships that span many entities, both public and private. Successful transformation demands collaboration across agencies, across and between all levels of government, between the public and private sectors, and between providers and consumers and their families. Collaboration is the lifeblood of the transformation process.

At the Federal level, SAMHSA has been pushing forward aggressivel aggressively y with to build the broad-based collaboration necessary to move transformation forward. Nine Federal departments, the Equal Employment Opportunity Commission, and the Social Security Administration now are represented in the Federal Partners Workgroup for Transformation. The U.S. Departments of Agriculture, Transportation, and Defense, and the Equal Opportunity Employment Commission are the most recent members. They join the U.S. Departments of Health and Human Services, Education, Housing and Urban Development, Justice, Labor and Veterans Affairs, as well as the Social Security Administration.

There is a reason for such broad representation. Each of these departments and agencies plays its own distinctive role in promoting and protecting the mental health of consumers. Consider, for example, the U.S. Department of Defense (DoD). 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 very well. However, more than 1 million men and woman have served in war zones since the terrorist attacks of September 11. They are experiencing difficulties particular to the kind of warfare they are encountering.

An article in Newsweek magazine this past August warns of an emerging challenge to our ability to meet the mental health needs of these brave citizens. The magazine observed that, “The percentage of those wounded on the battlefield who have survived is the highest in the history of combat….The result is that there will be a group of Iraq-war vets with catastrophic injuries…. They may need medical intervention for the rest of their lives.” The magazine goes on to quote the Army’s surgeon general, who reports that 3 to 4 months after their return, 30 percent (of returning veterans) had problems ranging from depression to full-blown PTSD.

Along with regular combat troops, reservists have played a more central role in this conflict than in any since World War II. These individuals are not eligible for some benefits accorded enlisted soldiers. Many have lost their jobs and must be re-employed. These are broad-based challenges to returning veterans ’ to a full life in their community.

In addition, the DoD is aware of the growing need for mental health care for the spouses and children of service members. It is looking at how deployment affects families and how resulting changes in family structure impact the mental health of its members. This is yet another indicator that mental illnesses are a “family issue.” Just like substance abuse and other diseases, every member of a family often is impacted in some way.

SAMHSA has launched a Returning Veterans Initiative in collaboration with the DoDs. We believe that, despite the best of intentions, no one agency―not even one with an unlimited budget―can meet the needs of these veterans. ” DoD is working with us to explo re ring collaborat ive e opportunities to provide ALL of the services necessary to support returning troops. Together, we are looking for a more holistic approach to providing the mental health care of our nation’s veterans and their families.

Just as in the case of DoD, each Federal and State organization that affects the lives of children, families and adults is responsible for ensuring that all Americans are able to lead full and productive lives in their communities. For those individuals who have a mental illness, each organization has a role in making available the variety of services that will help them achieve and sustain recovery…including a home, a job, or something as basic as transportation so that they can access services.

Our Federal Partners Workgroup reflects a genuine government-wide commitment to achieving real progress in mental health care service delivery. The workgroup also is a perfect example of the critical collaboration called for to develop and drive the systemic change needed for transformation. You can get some idea of the depth and breadth of needed change by reviewing the document that outlines the steps being taken by the Federal Partners Workgroup. I have brought along copies of that document, entitled Transforming Mental Health Care in America: The Federal Action Agenda, for each of you.

As Alexander Graham Bell once said, “ Concentrate all your thoughts upon the work at hand. The sun's rays do not burn until brought to a focus.”Our action agenda identifies 70 different activities that we believe have the greatest potential to make an immediate impact. We have organized our activities within priority areas, and established a workgroup for each to ensure that we maintain a focus on achievement.

We also have created a Federal Executive Steering Committee to help us maintain our focus. The committee includes individuals at the highest level of their agencies. These senior-level personnel have assumed the responsibility of ensuring that resources will be available so that transformation activities promised by their agencies will take place. The first meeting of the Steering Committee was held in January. It is scheduled to meet twice a year to review the progress of workgroups and to issue a summary of each partner’s accomplishments. As SAMHSA Director Charles Curie has stated, our action agenda is meant to be a “living agenda,” one that evolves as we make progress and as new priorities emerge.

Our five highest priority areas are:

• Suicide prevention
• Integration of primary and mental health care
• Financing
• Employment and transition
• Disaster and emergency response

We also have established workgroups for

• Access and early intervention
• Child and youth service systems
• Consumer and family driven services
• Youth-guided care
• Criminal and juvenile justice
• Homelessness and housing
• Information technology
• Public education
• Research activities
• State system transformation issues
• Workforce issues, and
• Emerging issues.

Texas is playing a vital role in one priority focus area through your suicide prevention efforts. Last year alone, approximately 900,000 youth across our country made plans to commit suicide during their worst or most recent episode of major depression. About 712,000 attempted suicide during such an episode.

Your youth-focused grant activities, funded through SAMHSA’s Garrett Lee Smith Memorial Act grant program, are being watched with great interest. We look forward to learning from the work of the Texas Suicide Prevention Council, which will convene this month. Your Council is an outstanding example of the public/private partnerships that are so important to transformation. I know that suicide prevention training for youth gatekeepers has been taking place across your State, with a training in Houston in January, a session in Austin last month, and more sessions scheduled to take place in the months ahead. I am grateful that Texans have turned their considerable talents, abilities, and knowledge to helping us find solutions to this terrible problem.

In another area of major importance, your State’s Transformation SIG focuses on information technology (IT). The importance of IT cannot be overstated, especially in States with large rural areas such as Texas. Your grant application stressed your need to rely on IT to identify shared clients, track outcomes, and facilitate collaborative planning across service systems. A transformed mental health system will increase service access, direct resources where they’re needed, improve the cultural competency and privacy needs of consumers and their families, and reduce fragmentation. IT is the perfect tool for accomplishing these goals. In a transformed system, the technology infrastructure will function as a systems integrator, bridging organizational and geographic boundaries.

Texas ’ vision of its transformed system mirrors the one formulated by the President’s New Freedom Commission. With your strategies to utilize information technology to support a transformed system, you are providing a roadmap for other states who are working to integrate IT into their transformation efforts. I am duly impressed with the ambitious agenda you have outlined. You have vowed to use IT to increase efficiency and improve work processes at three levels of the system: state and local use of timely and accurate information and service delivery to underserved areas and to underserved minorities. You are already using electronic and web tools in your behavioral health system to accomplish training goals in preparing the workforce. The planned expansion of this practice will provide an immense benefit to Texans who are dealing with mental illnesses.

I’d also like to applaud your plan to expand your Jail Diversion Instant Messaging (JDIM) system. With its proven success in using data federation, instant messaging, and online awareness, it provides a successful template from which to work. As you know, the National Grains TAPA Center for jail diversion found the JDIM solution to expediting and compressing its timeframes to be unprecedented in national efforts. Again, Texas is ahead of the curve and richly deserving of national recognition.

Texas shares some features in common with the other the other six successful SIG applicants. At SAMHSA, we noticed that all the States that received Transformation SIGs demonstrate the following characteristics : .

• A very active and invested Governor, such as your Governor Perry, and dynamic leaders in pertinent government agencies
• Collaboration across agencies, with the private sector, and within communities
• A strategy for sustainability and the expansion of services
• Activities built on existing strengths and the leveraging of other grant monies to enhance SIG funds, and
• Consumers and families who are very active in and central to the process.

As your grant application so accurately states, “…real transformation will not occur nor be sustained unless a specific focus on cultural change within each organization exists.” Texas is a shining example of this truth. Texas has developed programs and services that bring to bear the strengths of every organization necessary to support and sustain recovery and to provide a life in the community. Many of your State’s grant-supported programs exemplify the broad approach that must be taken in order to provide persons with mental illnesses with ALL of the services and supports they need and deserve.

A look at your behavioral health programs shows the breadth of services and programs that offer hope and help for recovery to Texans. Texas received more than $223 million in Federal funds for Fiscal Year 2004 to 2005. Of this amount, $46 million was earmarked for mental health discretionary spending, $32 million for a community mental health services block grant, and almost $6 million in homelessness and protection and advocacy grants. Texas also received more than $1 million from SAMHSA’s Center for Substance Abuse Treatment for the treatment and prevention of co-occurring disorders, and nearly $3 million in grants for infrastructure development, strategic prevention, and jail diversion.

The current programs taking place in Texas reflect the extent to which they complement mental health system transformation and work in conjunction with one another. For example, your Data Infrastructure Grant will continue Texas’ efforts to build the infrastructure necessary for collecting and reporting data for the Uniform Reporting System (URS). Your program again addresses the goal of using technology to access mental health care and information.

Another example is a grant to Fort Worth’s Public Health Department. This grant is helping to create an accessible, culturally competent and seamless child and family-driven system of care for families impacted by severe emotional disturbance.

I also want to commend you for addressing some of the issues that are most pressing in terms of the prevention and treatment of substance abuse in the Ecstasy and Other Club Drug Prevention Services and Methamphetamine prevention programs. We know the linkage that often exists between substance abuse and mental illnesses. Your work on co-occurring disorders is exemplary and sets a very high standard for other States to meet. Texas is particularly important in modeling the importance and development of integrated services, as your State Incentive Cooperative Agreement programs reflect.

These are only a few of the programs underway in Texas. They are examples of the inventive, forward-thinking, and evidence-based services necessary for recovery. They illustrate how Texas is moving toward transformation…not just in theory, but in practice.

In addition to these ongoing transformation efforts, Texas has provided invaluable, life-saving services to survivors of Hurricane Katrina. Your State has absorbed thousands of evacuees. You continue to provide services to help reduce the mental health problems that often follow such horrible disasters.

The Nation has watched Texas’ outpouring of resources and extended assistance with admiration and gratitude. This terrible disaster impacted tens of thousands of our citizens, causing serious mental health and substance abuse consequences. I cannot overstate the importance of the help we received from the Texas State disaster coordinators in administering the FEMA Crisis Counseling and Assistance and Training Program. The assistance offered by Texas is truly impressive: it is yet another example of that Texan intrepidness I mentioned earlier. Thousands of individuals have been able to rebuild their lives and their hope for the future through your work.

I could talk for a very long time about all of the advances Texas has made in terms of transformation, but let me turn your attention now to one of the most challenging issues before us―the “quality chasm” in health care delivery. A recent report by the IOM identified a deep gap that exists between the care that is known to be effective and the care that Americans receive.

About a year ago, SAMHSA asked the IOM to conduct a similar assessment of behavioral health care. The IOM’s new report identifies the strong link between our mental health and our overall health. This link is so strong that the IOM reached this conclusion: We cannot improve our physical health care system without paying equal attention to the issues surrounding behavioral health care.

Many of the IOM recommendations focus on better coordination of care, not only between mental health and substance abuse treatment providers but also between these providers and primary care. The report describes “a continuum of evidence-based coordination models” that primary care providers and specialty mental health and substance abuse treatment providers can move along to achieve more effective collaboration. That continuum begins with formal agreements among the providers, followed by three models of increasing coordination: case management, co-location of services, and the delivery of mental health, substance abuse, and primary care through clinically integrated practices of the three types of providers.

The IOM report underscores what those of us who have been working in the mental health care field have experienced: that mental illnesses are not treated with the same level and quality of services as physical illnesses, and that care this is available is often times limited or difficult to access. It’s our hope that, with the help of progressive States such as Texas, we will begin to close the “quality chasm” quickly and effectively.

Let’s turn now to yet another piece of the transformation puzzle: the irreplaceable, crucial role of consumers. The IOM made note that the obstacles faced by consumers of mental health care exceed those encountered by consumers of general health care. The report identifies stigma, the limited insurance coverage for mental health care, and the coercion into treatment that individuals with mental illnesses can face as sometimes significant barriers to receiving the care they need. The report offers several steps to address these issues, chief among them that “all parties involved in health care for mental or substance use conditions should support the decision-making abilities and preferences for treatment and recovery” of consumers.

You may be aware that on February 16, SAMHSA unveiled a consensus statement outlining the principles necessary to achieve mental health recovery. The statement was developed through the deliberations of more than 110 expert panelists representing mental health consumers, families, providers, advocates, researchers, managed care organizations, State and local public officials, and others. Upon the release of the statement, SAMHSA Administrator Curie said,

“Recovery must be the common, recognized outcome of the services we support. This consensus statement on mental health recovery provides essential guidance that helps us move towards operationalizing recovery from a public policy and public financing standpoint. Individuals, families, communities, providers, organizations, and systems can use these principles to build resilience and facilitate recovery.”

The consensus statement offers 10 fundamental components of consumer-driven recovery. The first is self direction, recovery that is self-directed by the individual, who defines his or her own life goals and designs a unique path towards them. Second, is recovery that is individualized and person-centered. With multiple pathways to recovery, each individual’s unique strengths and resiliencies, as well as his or her needs, preferences, experiences, and cultural background play a role in determining his or her particular path. Consumers must be empowered. They must have the authority to choose from a range of options and to participate in all decisions affecting their recovery, including the allocation of resources.

Care should be holistic. Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Housing, employment, education, mental health care treatment and services, addictions treatment, spirituality, creativity, social networks, community participation, family supports―all of these elements are part of the recovery process.

Recovery is non-linear. It is not a step-by-step process, but one based on continual growth, occasional setbacks and learning from experience. Recovery should be strengths-based, focusing on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of the individual.

Peer support is critical to recovery―including the sharing of experiential knowledge and skills and social learning, and providing encouragement and a sense of belonging. Respect is at the heart of the recovery process, both self-respect and the respect of the community. Self-acceptance and regaining belief in one’s self are vital.

Consumers have a personal responsibility for their own care and their own journeys of recovery. It may take great courage to take the steps necessary. Consumers must strive to understand and give meaning to their experiences, as well as to identify their coping strategies and healing processes. And finally, hope― the catalyst of the recovery process. Recovery provides the essential and motivating message of a better future―that people can and do overcome the barriers and obstacles that confront them.

The consensus statement is another major move toward transformation. It provides the cornerstone for the structure we are building. Along with the other important major steps we are taking, we are moving steadily toward a consumer-driven, recovery-focused system that is the basis of the transformation vision. As described in the President’s New Freedom Commission Report,

“We envision a future when everyone with a mental illness will recovery, 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.”

That’s our goal: That’s the mission we have undertaken.

In his State of the State address, Governor Perry said, “Our work is before us. It cannot be passed to future legislatures and must not be passed to future generations. May we boldly seize the moment with singular unity.” That’s a perfect statement for our purposes, too, in terms of mental health care transformation. We also must work together to provide solutions to the challenges confronting our Nation’s mental health care system. SAMHSA will be Texas’ working partner throughout the 5 years of the Transformation SIG.

We must be bold, innovative, and creative as we move forward. Just as Governor Perry stated, our responsibility cannot be passed to others. O ur work cannot be delayed. We must provide to our friends, family members, and neighbors the care and support they need and deserve to recover from mental illness… and we must do it now.