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

Advocating for Action
Keynote Address

March 20, 2007
Nashville, TN

Thank you, Dr. Stewart, for that introduction. I take to heart the praise of someone I admire as a fellow advocate for better behavioral health care. The American Psychiatric Foundation is doing great work. I particularly applaud your Depression Is Real campaign and your Typical or Troubled?™ School Mental Health Education program. These programs can reach millions of Americans with the facts about behavioral health disorders: What are the facts? — These disorders are common…they are treatable…and recovery is a real possibility. Thank you for sharing this message of hope with America.

[Turn to audience]

Good morning. For most events, it’s customary for speakers to begin by recognizing the VIPs in the room…and so I will. Everyone in the audience — consumers and families, providers and consumer advocates — is a Very Important Person. VIPs are individuals with the power to attract attention…to influence decisions…and to make waves. VIPs, in the words of Aretha Franklin, a Memphis girl by birth, are those who deserve R-E-S-P-E-C-T…respect! And more than just a little bit!

Today, I’m going to talk about the power of advocacy. I’ll also talk about your role in guiding the future of behavioral health care in Tennessee. Similar to other states, Tennessee faces some serious challenges. Among these challenges are a tight budget, limited workforce, and uneven access to care in rural areas. But, as Henry Ford observed, “What's right about America is that although we have a mess of problems, we have great capacity — in intellect and resources — to do something about them.” The greatest resource, of course, is advocates such as you — people who respond to problems with solutions.

Advocates believe passionately in a particular course of action and argue strongly on behalf of those affected. One of the best examples is Dorthea Dix. She has been described as the most effective advocate for mental health care during the 19th century. This is her story.

Back in 1941, Ms. Dix had an experience that changed her life and, eventually, the lives of millions of others. Ms. Dix had volunteered to teach a Sunday school class to women inmates at the local jail. This was a time when individuals with mental illnesses were kept in jails or poorhouses. When she entered the jail, her eyes were filled with terrible images of women with mental illnesses being kept in filthy, foul-smelling and unfurnished cells.

Ms. Dix was appalled, and felt driven to take immediate action. She began to travel across Massachusetts, visiting jails and poorhouses where individuals with mental illnesses were housed. She talked with jailers and caretakers. She made careful notes, which she eventually presented to the Massachusetts legislators. [Her report may have been the first briefing sheet on mental health care in history.] Her evidence engaged their minds… enraged their consciences…and moved their hearts. The legislators set aside funds for better housing and care of individuals with mental illnesses.

Did Dorthea Dix stop at her state border? No, she didn’t. Just like you, she was an advocate for action. She traveled to other states and took the same steps. She visited places where people with mental illnesses were being kept, took careful notes, and then presented the indisputable evidence to the legislature. Although her own health was poor, Ms. Dix covered every state east of the Mississippi. In all, she helped to create 32 mental hospitals in the United States. She “rested up” by traveling around Europe, changing the way Europeans viewed mental health treatment.

Ms. Dix held a radical view of mental health care for her day. The popular belief was that individuals couldn’t recover from mental illnesses. Ms. Dix helped demonstrate how wrong this belief is. The mental health status of individuals began to improve as soon as the conditions in which they lived improved! Ms. Dix kept records of recovery, such as this one about a woman was had been chained in an institution for years. “She was helped by a husband and wife who agreed to take care of her in their home, and slowly she recovered her senses.” Fact triumphs over myth! — Recovery is possible! Recovery is made more possible when treatment is provided in the community.

The substance abuse field has its own champions, such as Bill Wilson and Dr. Bob Smith, the cofounders of Alcoholics Anonymous. More than 2 million individuals now belong to AA, which became the model for Narcotics Anonymous and similar groups. These groups are successful, in large part, because they value the hard-won wisdom of the individuals they serve. AA and similar self-help groups are built on a foundation of peer support. And why not? No one can speak with more knowledge, passion, and conviction about recovery than those who have traveled successfully down that same rough road.

Tennessee has its own advocates for behavioral health reform. Several share this stage with me; hundreds sit in front of me. With your help, Tennessee has an opportunity to live up to its state motto of “America at its best.”

Each year, NAMI rates the mental health services provided by our states. According to NAMI, Tennessee has the foundation for a good mental health care system, and the potential to set the pace for national mental health transformation. Your state is a leader in supportive housing. Your highly successful “Creating Housing Initiative” has spurred a similar” Creating Jobs Initiative.” Your Memphis Police Crisis Intervention Team program is recognized nationally as a model. Your use of evidence-based practices is increasing steadily. Commissioner of Mental Health Virginia Betts deserves special recognition for her efforts to improve behavioral health care through a systems-wide approach.

That’s the silver lining…now for the cloud: funding. How can Tennessee, or any other state facing stormy economic conditions, get out from under it? This is where you become particularly valuable as advocates for action.

Behavioral health care is a business. There are customers…there are services…and there is an expected return from services, which we know is recovery! Businesses have a board of directors. For any business, the main responsibility of the board is to determine the organization’s mission and vision…define its long-term goals…and keep the organization moving in the right direction. You — as consumers and advocates – sit on the board for Tennessee’s behavioral health care.

Think of Governor Phil Bredesen [pronounced BREAD-a-zen] as the CEO of your business. Last month, Governor Bredesen spoke at the annual conference held by the Healthcare Information and Management Systems Society. I share his sentiments so exactly that I’m borrowing his words for my remarks here. Take this message from the Governor to your legislators later today.

Governor Bredesen stated, “Our [national health] system is first class in terms of convenience, but very middle of the road in results. Our health indicators are, in many cases, worse than those in economies that spend far less. This is America, the land of efficiency and ingenuity—why should we put up with this? We clearly have to do at least two things: First, we have to alter the economics of health care….And second, we have to forge a system that is much more centered on the individual.”

Wise and foresighted words from your Governor! Let’s look at his two calls for action. The first is to alter the economics of health care. My agency — the Substance Abuse and Mental Health Services Administration (SAMHSA) — is leading a national initiative to transform behavioral health care across America. Transformation is the name we have given to a broad-based approach to introduce fundamental change in the way behavioral health services are perceived, accessed, delivered, and financed in this country. Here are two options that we believe can transform behavioral health care financing:

• One is to reduce funding silos, so that a state has more flexibility in combining money streams and maximizing resources.
• Another is to spread the cost of prevention and treatment across all child- and family-serving systems.

Consider the facts presented in your briefing paper on funding for substance abuse treatment. Out of every dollar Tennessee spends on substance abuse, only one penny goes for research, prevention, and treatment. The other 99 cents are spent on public programs negatively affected by substance abuse. These include the criminal justice system, health care services, and child and family assistance.

What if we turned those figures around, even slightly? What if greater amounts of funding were directed to prevention and early intervention, before serious disorders begin or before the consequences start to accumulate? The payback to the state would be tremendous! Look at the results your State achieved by providing individuals with substance abuse treatment! Employment rates tripled; domestic violence, either as an abuser or a victim, nearly disappeared. Behavioral health care is a pay-now or pay-later proposition, with the costs and the consequences adding up for every year of delay.

A third finance option is to reduce costs by improving services. By using a little ingenuity, we can do more with less. The proof is right here in Tennessee.

Telehealth, for example, can help solve two of your pressing problems: delivering behavioral health care to people in remote areas and expanding the available workforce. These are critical and overlapping concerns because one-third of your population lives in rural areas. Folks in rural Tennessee sometimes live hours away from treatment facilities. Often, there isn’t a behavioral health care provider who can diagnose or treat a person’s needs locally.

Bob Denning, the president and CEO of Ridgeview Psychiatric Hospital and Center, believes in the power of telehealth to transform care. According to Mr. Denning, it could take the Ridgeview Mobile Crisis Team 90 minutes to get from the Ridgeview facilities in Oak Ridge to the Scott County Hospital in Oneida…and that’s on a good day. Ninety minutes or more is a looong time for someone experiencing psychiatric distress.

Through a long-standing partnership with the University of Tennessee’s telehealth department, Ridgeview has linked its Oak Ridge facilities to the emergency room in Oneida. Now, a behavioral health care professional in Oak Ridge can begin to assess a person in Oneida within minutes. Psychiatric care isn’t 90 minutes away; it’s in the next room.

You might ask how consumers feel about long-distance diagnosis and care. Bottom line: Does it meet their needs? The answer appears to be “yes.” The number of consumers who do not consent or who cannot be treated appropriately by telehealth is extremely small: the rate of consumer satisfaction is extremely high.

Ridgeview now hopes to expand its telehealth services to other emergency rooms more than 50 miles from it main facilities. Telehealth can be a win-win situation for everyone. The consumer won’t have to wait to be assessed. Medical staff members won’t have to travel long distances, making them immediately available to take other crisis calls. This is transformation in action: bringing better behavioral health care to the consumer! I’m delighted that both Governor Bredesen and Commissioner Betts are passionate advocates of telehealth.

Let’s move on to Governor Bredesen’s second call for action: to create a behavioral health system centered on the individual.

SAMHSA has many initiatives underway to promote consumer-driven care. We expect our actions to inform and be a model for the states. We hope that you work with your legislators to take similar steps in Tennessee.

Last year, we declared 2006 as the “Year of the Consumer.” We began to develop prototypes for individualized plans of care. We started evaluating shared decisionmaking. This is a process through which consumers and providers work together to make informed choices among treatment options. We see shared decisionmaking as a concrete tool to promote individualized plans of care and recovery.

We launched a national public education campaign to reduce the stigma associated with mental illnesses. Twenty-eight thousand TV and radio stations now have copies of our new public service announcements, ready to roll out. We’re now working with local representatives to design state campaigns. Two fantastic people are working with us here in Tennessee: Joe Swinford, of the National Association of Consumer/Survivor Mental Health Administrators, and Angie McKinney Jones, of the Department of Mental Health and Disabilities. The theme of our campaign is “What a Difference a Friend Makes.” In taking an anti-stigma message to Americans, what a difference good people on the ground make.

Another piece of SAMHSA’s national anti-stigma campaign is our “Voice Awards.” We held our second annual awards ceremony in Hollywood last August, with Mariel Hemingway as our host. Similar to the Emmys, our Voice Awards recognize excellence in television programming. We pay tribute to the writers and actors who use their talents to give a face and voice to people with mental illnesses…and to bring the message of recovery into homes across America.

We continued to promote peer support services by funding five technical assistance centers and 19 statewide consumer networks. We are nearly done with a step-by-step guide to train former or current consumers to be certified peer specialists underway. When it’s completed, we will send it out to constituency groups in all of the states. We’re excited about the guide because many services provided through certified specialists are Medicaid-reimbursable.

We also published a consensus statement on recovery. Our consensus statement identifies 10 fundamental principles of recovery, including consumer self-direction, individualized and person-centered care, peer support, respect, and responsibility.

At SAMHSA, we believe recovery is possible for anyone with a behavioral disorder. Research continues to substantiate this view. Many longitudinal studies document recovery from schizophrenia, alcoholism, and other serious illnesses. More effective treatments are being developed. The concept of “wellness” is taking hold, with the medical community giving greater attention to the physical health of individuals with behavioral health disorders. We stand now at the threshold of a system of care in which recovery — and not disability — will be the expected outcome of services.

Equally important, research and practice consistently confirm the value of the hope of recovery, regardless of a person’s disorder. Many consumers report that hope, and the opportunity to regain control of their own lives, was vital to their recovery. When you read our recovery consensus statement, you will see “hope” as the 10th principle of recovery — the foundation on which every other principle is built.

These principles reflect one fundamental truth: Consumers are at the heart of care. It is their life, future, and hope for recovery at stake. Therefore, it is their needs, wants, and goals for recovery that should drive the decisionmaking process. Tennessee has been a leader in adopting these principles as its own. I commend Tennessee for using our consensus statement to introduce your managed care standards for behavioral health.

A companion action to our consensus statement is a pilot program recently launched by a critical partner in SAMHSA’s efforts to transform behavioral health services. That partner is the Centers for Medicaid and Medicare Services (CMS). Medicaid is the largest single payer of mental health care services in this country. Its dominant role in funding services has serious implications for behavioral health care reform. How Medicaid policies are designed and how payment rates are determined significantly affects the services provided and who is able to access them.

The new program by CMS is called “Money Follows the Person.” Under this program, states will not have to apply for waivers to fund home- and community-based services. Consumers will have greater control over how and where they get the Medicaid services they need. This is a “payment by results” system because consumers are going to direct funds to the most effective providers and programs. As such, it marks a radical shift to a more business-minded model.

If we are going to finish the business of recovery and resilience, than we must follow good business practices. A business succeeds when its products meet the needs of its customers. The best way for a business…or a government…to achieve success is to be guided by the people it serves. John Abrams is the author of The Company We Keep: Reinventing Small Business for People, Community and Place. He observed that better decisions will result when the people who make the decisions are the same as the people who bear the consequences of those decisions.

Today, you are the decisionmaker. Your day on Capitol Hill is your annual meeting of the board. Let your legislators know which behavioral health care programs Tennessee should keep and expand, which to toss, and where to invest in research.

But let’s make note of the greatest value of this day — the opportunity for you to share your stories of recovery. No one knows better than you about needed services…or about barriers to effective care. No one but you can speak from experience about the unfinished business of recovery and resilience.

Your experiences speak of vision, determination, and—most important—hope for those who have behavioral health disorders. I’m always humbled when I encounter the life-changing, life-affirming triumph of the human spirit over behavioral health disorders. Larry Fricks is a consumer and the former director of the Office of Consumer Relations and Recovery for the neighboring state of Georgia. As he has so eloquently stated, “Our greatest potential for improvement does not lie in our mental health system. It lies within the individual who has faith that she or he can recover, does recover, and then shares that good news with others.”

Very soon, you will leave for Capitol Hill. As inspiration, I’m going to take you back 40 years in history to an event that illustrates the value, necessity, and power of advocacy.

This week marks the anniversary of a turning point in our nation’s struggle for civil rights. The struggle for better behavioral health care often is compared to the struggle for civil rights. Let’s consider some of the parallels.

• Both efforts span decades past and will continue for decades to come, as we continue to move forward in understanding and tolerance.
• African Americans and other minorities, similar to individuals with behavioral health disorders, still strive for a future that is not limited by a legacy of poverty, discrimination, and a lack of opportunity. By opportunity, I mean equal access to jobs, education, housing, and health care.
• And both efforts share a common belief, which is this: Every person deserves a full and valued life in his or her community.

On this day in 1965, President Lyndon Johnson sent federal troops into Alabama. Their job was to guard marchers going from Selma to the capital of Montgomery. President Johnson took this action because then-Governor Wallace of Alabama refused to use the local National Guard to keep the marchers safe. The issue was voting. Intimidation and discrimination against African Americans had prevented Selma’s black population—over half of the city—from voting.

Fifty thousand marchers made the trip from Selma to Montgomery…far more than the 600 people who had been turned back two weeks earlier. Led by Martin Luther King, Jr., they asked their legislators for an end to discrimination and the beginning of an equal voice in their communities. Our entire nation watched…and five months later, Congress passed the Voting Rights Act.

The marchers’ goal may have been the right for African Americans to vote in Selma, but their efforts led to their right to vote across America. Advocacy of a just cause is like a candle flame, casting out darkness and drawing others to its light.

This is your sixth annual Day on the Hill. It, too, has grown and produced profound effects. Anita Betrand, of your Mental Health Association, remembers that first year like this: “We didn’t know what the impact would be, but we knew it was something that we should do. We may have had 40 people show up, and that’s a stretch.”

Now, look around you. There may be 1,000 people here this year. And, for the first time, your Lieutenant Governor has joined you.

Each year, more and more advocates for behavioral health care have walked the same halls as your elected officials…and talked about ways to improve care. Many have been empowered to return home and participate in local meetings with local representatives. Mental health and substance abuse advocates have found common ground and now join forces on the same Day on the Hill.

Your advocacy day, like that long-ago march in Alabama, also has produced some unanticipated benefits. During the second or third year of this event, organizers began a voter registration drive and to educate consumers about the right to vote. That effort spread. Soon, many mental health community and peer support centers were involved in voter education. I’m told that many of you take your voter registration card with you to Capitol Hill.

Voting is a right, a privilege, and a time-honored method of bringing about change. It’s another way to make your voice heard. As you continue to advocate for better behavioral health care, don’t be discouraged by the pace of change. The Mississippi River used to be Tennessee's western boundary. But, over time, the river has changed course in several spots, moving parts of Tennessee to the west side of the river and parts of Arkansas to the east side. In the battle between the river and the rock, the river always will win out…not by strength, but by perseverance.

Tennessee has the foundation for a good behavioral health care system. By listening to consumers and responding to their needs for recovery, your legislators can create a system that is “America at its best.” I wish you a very successful day on Capitol Hill. Persevere…and change the course of thousands of lives in Tennessee. Thank you.

And now, I’d like to hear from you.