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
Psychiatric Nurses Conference
Leadership Role of Psychiatric Nurses in
Transforming the Mental Health System
April 24, 2007
Philadelphia, PA
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Good morning, and welcome. I am Kathryn Power, Director of the Center for Mental Health Services, part of the Substance Abuse and Mental Health Services Administration. I am pleased to be here to help set the stage for the work that you all will do over the next 3 days.
Pennsylvania was nicknamed the Quaker State in honor of Quaker William Penn who is considered to be its founder and the author of its first constitution called, the First Frame of Government. This document incorporated a wealth of progressive ideas for its time period—especially religious tolerance and freedom.
Freedom is—and always has been— at the heart of great change. I’d like to begin today by telling you about another Quaker, a man named John Woolman, whose life was separated by William Penn’s by only two years. Change management expert, Robert Quinn, tells Woolman’s story in the book, Deep Change: Discovering the Leader Within, to illustrate how each of us can harness our individual talents to bring about fundamental change in the systems around us. It is a story not only of powerful leadership, but of the pursuit of freedom and profound change.
In the 1700s, many Quakers were wealthy, conservative, slave owners. Woolman dedicated his adult life to eliminating the practice of slavery among his brethren. Woolman pursued this effort by using the art of gentle persuasion. He spent more than 20 years visiting Quakers along the east coast. He did not criticize people, nor did he make them angry. He merely asked questions such as, “What does it mean to be a moral person? What does it mean to own a slave?” Driven by his vision, he persisted, visiting farm after farm. By 1770, a century before the Civil War, not one Quaker owned a slave. The Quakers were the first religious group to renounce slavery, the first organized people of faith who took a stand for freedom of all people.
In his book, Quinn ends the Woolman story with a question: “…what would have been the result if there had been 50 John Woolmans or even five, traveling the length and breadth of the colonies in the 18th century… persuading people, one by one…that a wrong should be righted by individual voluntary action? Perhaps we would not have had the war with its 600,000 casualties… We know now, in the perspective of history, that just a slight alleviation of the tension in the 1850s might have avoided the war. A few John Woolmans, just a few, might have made the difference.”
Quinn uses the Woolman story to make a simple, and yet profound, statement about how change happens: A single individual “has the ability to become a leader who induces change. The leader can transform separate individuals into cohesive teams. So linked, these individuals…can capture the imagination of larger communities, enticing them to dream new dreams. In the end,” Quinn declares, “excellence is infectious.”
One of those infected is transformation agent Tom Merrick from the Maryland Department of Disabilities. Tom shared with me his personal reflections on the book Deep Change. He observed,
“Transformative leaders are expected to experience and model deep personal change as they take necessary risks, putting vision attainment ahead of achieving political advantage, to create their desired results. This process is not reserved for the upper echelon alone, but is applicable and available to anyone at any level of an organization….”
As I look out into this audience, I see dozens of potential “John Woolmans.” As psychiatric nurses whose decisions and actions directly touch patients and their families, each of you has within you the power of one…the power of transformation. You can transform mental health care in your communities, your States…and across this country. We, at the Federal level, can facilitate, promote, and compel shared responsibility for the change that needs to happen. We can provide resources and use our convening power to raise issues to the national level. However, you are the ones who have the greatest, the most immediate, and the most personal opportunity to make a real difference in the mental health care provided to American adults and children.
You are the ones who provide front-line care to people with mental illnesses—we call them “consumers”— and their families. You assess mental health needs, develop a nursing diagnosis and a plan of nursing care. Many of you supervise, train, and evaluate other nurses. You have much to do with determining the manner in which consumers are afforded respect for their rights, personal values and choices. You influence the extent to which people with mental illnesses are empowered to set their own goals and determine what services they want and will receive. In providing care, you can also be the conveyors of hope in helping consumers to understand they can recover.
Research and practice consistently confirm the value of the hope of recovery, regardless of a person’s condition. In his book, The Anatomy of Hope, Dr. Jerome Groopman describes the essential relationship between hope and healing. “Hope” he wrote, “is a search for freedom, both a freedom of the body shackled by disease and a freedom of the spirit to assert its dignity, of having some level of control over one’s life….To hope under the most extreme circumstances is an act of defiance that permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.”
As people who often have more contact with consumers than doctors and other care-providers, you are in a pivotal position to impact the recovery process. Through your daily interactions, you are given an opportunity to care for the whole person, not just the patient. You are natural change agents of mental health transformation. It is a matter of will…and, of leadership.
Why is the transformation of our systems so critical?—Because the life expectancy for individuals with serious mental illnesses is 25 years fewer than the general population. The primary reason for this difference?— poor physical health. People with mental illnesses are dying at a higher rate mostly because of chronic, untreated, physical diseases. They are dying from high blood pressure, stroke, diabetes, heart disease, and the consequences of smoking and substance use.
The state of mental health in the United States is a public health crisis requiring a public health solution. Diagnoses of mental illnesses are almost as common as cancer, diabetes, and heart disease combined. Fifteen million people will have a serious mental illness such as schizophrenia, bipolar disorder, or a major depressive disorder. Almost one-fourth of all adult stays in U.S. community hospitals involve depressive, bipolar, schizophrenia and other mental health disorders or substance use related disorders. More than 30,000 persons will commit suicide. Surely, the critical state of our Nation’s mental health is reflected in other epidemics that now confront us, such as obesity and hypertension.
Let me speak just a moment to this idea of disease burden. The World Health Organization identified mental illnesses as the leading cause of disability worldwide, accounting for nearly 25 percent of all disability across major industrialized countries. In the United States, mental illnesses are on a par with cancer and heart disease as a cause of disability.
Physical illnesses frequently accompany mental illnesses, and vice versa, thereby compounding the disease burden. For example, we know that patients who experience a major depressive episode following a heart attack have an increased risk of early cardiac death. We know that emotions such as fear, anxiety, and depression can worsen the pain of cancer and other severe illnesses.
As each of you knows so well, we must look at the whole person, rather than just focusing on the disease. Because of your knowledge of physical health, you are in a pivotal place to promote care that encompasses an individual’s whole life, including mind, body, spirit and community. We must take that holistic approach to wellness because it considers an individual’s psychiatric illness in context with other aspects of his well-being.
Treating the mental health of patients who face both physical and mental illnesses can improve their interest and ability to care for themselves. This can engage them in following their primary care provider’s directions and advice, particularly about taking medications. It can transform their hope in recovery or bolster their ability to cope with illnesses from which there is little chance of recovery.
This holistic treatment approach is part of the transformation of the mental health system. It 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. This action agenda identifies the first steps that SAMHSA, in partnership with agencies from nine Federal departments, will take to guide mental health transformation.
Our agenda is built around the goals laid out in the final report by the President’s New Freedom Commission on Mental Health. These are the goals. In a transformed system:
• Americans understand that mental health is essential to overall health.
• Mental health care is consumer and family driven.
• Disparities in mental health services are eliminated.
• Early mental health screening, assessment, and referral to services are common practice.
• Excellent mental health care is delivered and research is accelerated, and
• Technology is used to access mental health care and information.
These are lofty goals that require comprehensive and collaborative strategies to achieve. But they are necessary. When the New Freedom Commission began examining our current system, they discovered that services were so fragmented, disconnected, and often inadequate that piecemeal reform would not be enough. The only way that our Nation could address this public health crisis was through a fundamental transformation to our mental health system.
Now, transformation is an enormous concept. It connotes a complete upheaval and reorganization of what we know, what we do, and how we are used to doing it. Ultimately, transformation is about newness—about new values, new attitudes, and new beliefs. . . about what we can accomplish now that we were unable to do before.
Transformation is not simply a fancy word for reform. It is far more encompassing than that. Transformation calls for fundamental change at the very core of the system, and not on the margin. Transformation is meant to identify, leverage, and even create new underlying principles for the way things are done. New sources of power emerge. Once transformation begins, a profoundly different system materializes—a system changed in structure, culture, policy, and programs.
Yes, transformation will require radical shifts in attitudes and actions. But, the end state…the transformed mental health care system…will be well worth our deliberate and courageous action. In this system, recovery is the single most important goal.
Earlier this year, SAMSHA unveiled a consensus statement outlining the principle components of 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. We examined topics like 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. “Mental health recovery is a journey of healing and transformation for a person with a mental health problem to be able to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential.”
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 support...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.
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 centered on the person. 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 also 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... 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, there’s 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. Each of you, through your contact with persons who have mental illnesses, can deliver hope. You have the power to help consumers understand and truly believe that they can recover.
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. That is truly great progress.
With this progress, comes a shift in the way that we provide care. Our roles will change. The work of nurses and other care-providers will be different. Psychiatric nurses will need to critically evaluate and reassess their own practice. We will rely on you to be a central part in developing and implementing policies and practices that provide a safe, respectful, and healing setting for recovery. This is the real foundation of transformation.
The discussion about how we care for people with mental illnesses will shift to how can we facilitate consumers’ freedom to live in the community …enable authority over the funds needed for one’s own care…offer support for choices that are best for them…foster responsibility for choosing services and handling the tasks of daily living…and provide opportunities for consumers to participate in decision-making about their care delivery systems.
A transformed system will encompass both prevention and treatment to remove barriers in lives, and begin a chain reaction for future success. In a transformed system, we will work to prevent the onset of disorders. We will also provide prevention-minded treatment— treatment that goes beyond symptom management to consider what else a person needs to achieve and to sustain recovery.
Transformation really is a matter of personal action—of believing in a vision so deeply, so intensely, that a person is driven to make that vision a reality. As nurses, each of you possesses the potential to induce change…one consumer, one family, one community at a time. You have the ability to impact your fellow nurses, administrators, medical practitioners, and other staff. Your leadership will be critical to our ability to advance the transformation agenda across this country.
I am here to send out an urgent call to action to each of you. An unprecedented window of opportunity is opening…right now. We’re moving steadily forward along the road to mental health system transformation. Transformation is happening. It is real. From California to Connecticut, promising models of transformation in behavioral health are being developed and piloted. Together with our Federal Partners, SAMHSA and CMHS are taking realistic action steps to motivate, facilitate, and compel change at the Federal, State, community, and individual levels.
But we cannot do it alone. All of us…at the local, State, and national level…must advocate for the transformed mental health system that will give American men, women, and children access to the full range of services they need to recover. It is time to deliver on our advocacy with personal action. It is time for each of us to step forward and accept our personal responsibility to lead this crusade for change.
The time to transform is now. John Woolman did it more than 200 years ago. Many of you are already doing it in your current work. I encourage those of you in the midst of transformational change to increase your efforts, leverage your resources, and move forward in a spirit of hope. For those of you who have yet to embark upon this journey of transformation, I urge you to start today. You have the opportunity…right here, right now…to begin changing the world for the better. At this conference, take the important first steps toward transforming mental health care in the course of your daily work. Use your power of one to help achieve the promise of transformation for many. Thank you.
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