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
National Alliance on Mental Illness North Carolina Spring Conference 2006
Mental Health Care: What Lies Ahead for North Carolina?
April 29, 2006
Raleigh, NC
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Good morning. Thank you for that generous introduction, Mr. Staples. It’s a great pleasure to be here with all of you. NAMI members are, without a doubt, some of the most important players in the transformation of our nation’s mental health care system. NAMI’s influence and institutional knowledge and experience are peerless. Consumers and families look to you for information, education and, most important, hope in their future. It’s a privilege to join you today.
I am especially pleased to be here in North Carolina, where some very important developments are taking place in terms of transformation…developments that mirror the work being led by the Substance Abuse and Mental Health Services Administration (SAMHSA) on the Federal level…work that is geared toward ensuring that consumers and families are at the heart of the mental health care system and that recovery is the expectation of treatment. Our vision is that consumer-driven, community-based, state-of- the- art treatment will be available to everyone who needs and deserves it. This is the vision that focuses and informs all of our efforts. With your help, it is a vision that can be brought to reality.
Mental health reform is the key topic of discussion at this conference. It is also the guiding mission for most of the major work taking place in the mental health system across the country. Never in the history of America have we known so much about mental health and how to enable people with mental illness to live, work, learn, and participate fully in the community. Recovery from mental illness is now a realistic possibility.
However, much of what we know about effective treatment of mental illness is not always accessible to the people who need it most. So, we’re here today to talk about how to ensure that each individual who needs help receives it. We’re here to ask ourselves, what lies ahead for North Carolina, and for our Nation as a whole? We’re here to determine how we can develop a mental health care system for the future that will provide all of the services necessary for a full and productive life in the community. We’re looking for guideposts: markers along the road to mental health transformation that let us know that we’re moving steadily forward…and in the right direction.
We can’t expect to walk into a forest for 20 years, and walk back out in 5. There’s a lot of work ahead. So, it won’t be a quick trip. Let me begin with that cautionary note. One of SAMHSA’s most basic challenges in leading transformation is to help all of the stakeholders involved understand that we are not engaged in a short-term, piecemeal effort. What we are trying to accomplish through transformation is nothing less than a revolution! We really are undertaking a revolution in how Americans need to think about mental health, mental illnesses, and recovery.
We want to upend traditional notions of which agencies or individuals should be held accountable for preventing and treating mental illnesses. We want to restructure decisionmaking so that consumers have a leading role in making choices that affect their lives. The policies, procedures, and financing that shape service delivery….the attitudes, values, and behaviors of those who deliver and receive services—all of these must change dramatically if we are to achieve real transformation.
SLIDE 3 – DEFINING TRANSFORMATION
Transformation, by its very nature, implies fundamental change at the core of a system…not on its margins. It is a continuous process, without end. And that’s a good thing…we want to keep expanding our knowledge base, we want to keep putting more effective practices into place, and we want to imbed the idea of continuous quality improvement into our mental health system. Recovery is rooted in the endless human capacity for change—we have to build a service system that will accommodate each person’s individual growth.
Here in North Carolina, you have been experiencing a huge transition in terms of mental health reform—in moving from community mental health to a more privatized system. Your legislature took a major step forward in 2000. It signaled its intention to begin addressing the major issues that affect the State’s mental health care system. Your State’s problems—fragmentation, the lack of access to care, and the lack of funding—are mirrored in every single State in the country. You also have experienced a lack of crisis services, poor accountability, and hospitals that were not meeting consumer needs for recovery. Your legislature said, as so many other State Legislatures are saying, “We must deal with these things. Our people deserve better. We have to face these problems head on and forge ahead with solutions.”
Your State is modeling a specific kind of transformation. We know that the massive shifts taking place in the public mental health care delivery system have been very difficult for many North Carolinians who have relied on it for treatment for many years. You have proven that you are deeply committed to ensuring that, with the continuing shifts to come, services will continue to be available, and that when services are shifted from one arena to another, those services will be equal or superior.
So, a large part of your work is to help your State establish guideposts for moving forward in areas that promote recovery, such as housing, employment, the criminal justice system, and access to care. You must put in place all of the supports that are necessary for recovery and address all of the needs of those relying on the mental health care system.
Tremendous change is taking place in overcoming the problems affecting North Carolina’s mental health care system. The same proactive, positive attitude and actions are found in every State in the country. Mental health is experiencing more attention than it has in a very long time. As advocates, it’s up to us to continue to be vocal, active, and fierce in our determination to keep mental health care issues at the forefront of the political debate. It’s critical that we remind the public and our elected officials about the importance of mental health. It’s also very important that we keep talking about mental health, mental illness, and recovery to everyone who will listen. Talking to one another is the very best way to demystify and destigmatize mental illness and to educate the public and others about mental illness, recovery, and prevention. It’s the exchange of ideas and experiences that will move us forward at the most rapid rate possible.
I’d like to share with you some success stories from other States. NAMI recently rated the mental health systems of each State. In its “report card,” it noted that many States already are moving forward with transformation. All across the country, smart, dedicated, innovative people are focusing their considerable talents on fixing what’s wrong with the mental health delivery system. And all across the country, action is taking place that is changing both the face of mental health care and the lives of thousands of people. There is a lot being done right…as well as right now.
It’s important that we talk about those things, that we focus on the solutions to the problems we are dealing with, rather than focusing too much on the problems. I’m very encouraged by the developments I see and hear about every day and I’m excited to share them with you. States such as North Carolina can build upon these successes. Where other States have developed proven pathways for change, North Carolina can follow…and shorten its trip to similar success in the future.
Let’s look now at some of your brass-tacks issues, starting with jobs and housing. Successful transformation efforts involve linkages and collaboration. A number of States have launched highly effective programs that link employment and housing services with mental health and other services. California’s Integrated Services for Homeless Adults with Serious Mental Illness program was recognized as an exemplary program by the President’s New Freedom Commission. Services in the program include outreach, supported housing and employment, mental health and medical treatment, substance abuse treatment, benefits assistance, and other services. There is close collaboration at the local level among service providers, including mental health, law enforcement, veterans’ services agencies, and other community agencies.
California’s program is one that your legislators should learn about. Funding for mental health is not a line-item expenditure—it’s an investment! And, similar to other sound investments, it pays large dividends. These are some of the dividends from the California program:
- Participants reduced their homeless days by 67 percent
- Reduced psychiatric hospital days by 56 percent
- Reduced days of incarceration by 72 percent, and
- Increased the number of individuals who are employed by 13 percent.
The State of Tennessee also has made tremendous progress—its housing level for individuals with mental illnesses now is among our Nation’s best. Illinois has also been very innovative: it is using a real estate transaction fee to promote rental housing assistance. The Minnesota State mental health authority has launched a cooperative program with the housing finance agency to finance housing subsidies for people with serious mental illnesses. New Jersey is raising $200 million over the next 10 years to create 10,000 units of new supported housing. So, we’re getting there. People are beginning to better understand the needs and the urgency of the challenges we’re facing and they are looking for creative ways to address those needs.
NAMI recognized five States for their work in employment. Connecticut, for example, is providing a very focused recovery model of care, which includes excellent programs specific to supported employment and vocational rehabilitation. Half of North Carolina’s population lives in rural areas. You might find strategic guidance in programs being conducted by South Dakota, which also has a large portion of its citizens living in rural areas. South Dakota has focused a lot of its transformation efforts on employment opportunities. The results are a 41 percent employment rate for consumers.
Jobs provide consumers with an important role in their communities. It’s evident that work is a critical element in a successful life. A therapist once said to me that, in her opinion, a paycheck can be the equivalent of a year of therapy. The benefits of working are clear: autonomy, independence, accomplishment, work relationships, financial security. But what about housing? Housing is the most basic tie to a community and provides the gateway to local services. Examples of States that have developed exemplary housing programs include Oregon’s Affordable Housing program. The program’s purpose is to develop and preserve integrated housing resources for people with serious mental illnesses. Those efforts are now being expanded by a new community mental health housing fund that was established by the sale of a former State hospital property. So far, Oregon has made more than 200 new community placements. The State also increased its housing and homeless services staff and is implementing a program that has allowed about 500 individuals to eliminate financial barriers to acquiring more integrated community housing.
There are examples of excellence in other areas of transformation in States all across the country. The Program of Assertive Community Treatment (PACT) programs in Oklahoma have demonstrated not only huge cost savings to the State, but are also firmly rooted at the client level. Oregon passed a budget note requiring its children’s public mental health system to fully integrate Medicaid-covered services into its Managed Care Organizations.
In terms of consumer-specific programs, New Mexico’s Office of Consumer Affairs has been recognized for its accomplishments. The Office’s goals are to offer consumers and communities the opportunities to develop skills that will allow them to successfully integrate. Regional teams are consumer-led and made up of representatives from statewide consumer groups and a service provider representative. Regions employ recovery empowerment specialists who guide citizen organizers and coordinators to develop and implement community-level education, outreach, empowerment activities, organization, and support for people with serious mental illness.
New Mexico also provides us with a good example of legislation that can support transformation. In its 2004 session, the New Mexico Legislature passed a law that created an Interagency Behavioral Health Purchasing Collaborative (the Collaborative), with the goal of replacing its multiple, fragmented behavioral health care systems with a single delivery system. This work is well under way, and similar collaborative efforts are being seen in many other States.
Court systems and law enforcement are also contributing to transformation with the move toward diversion and allowing other options for persons with mental illnesses who find themselves involved with the justice system. Oregon’s Office of Mental Health and Addiction Services collaborates with the Oregon Judicial Department to implement integrated Treatment Courts for juveniles and their families. Its pilot program, designed to help juvenile offenders with co-occurring disorders, shows preliminary outcomes of decreased recidivism and greater access to services among participants.
Nebraska has a jail diversion program in Lancaster County that sets an example for similar programs throughout the nation. Clients are provided with help in finding jobs, treatment, housing, food and transportation, and navigating the court system, among other things. Data indicates that participants had less recidivism, a decreased use of costly emergency services, and an increased use of less-costly ongoing services. Participants also show improvement in their attitudes and symptoms, and report a greater ability to control their lives, and to deal with crisis. They also report less depression and loneliness.
There are hundreds of examples of innovative initiatives and programs that are working, and working well, all across this country. That’s the good news. However, we still have a very long way to go, and there’s enough work ahead to keep all of us fully engaged in it for a long time to come. The people who make up NAMI will continue to be powerful agents of change. In this group lies the deepest and purest well of knowledge about mental illnesses and how to best address them.
SAMHSA is relying on NAMI and its State affiliates to help us transform the mental health care system. Every single idea, proposal, initiative, program—all of our efforts must remain focused on pushing change forward, on ensuring that people with mental illnesses have access to excellent, world-class, evidence-based, effective, cutting-edge care. In a society as blessed as ours, in terms of both resources and brain trust, we are capable of anything. I have no doubt that we will bring about transformation—that one day, we will look back on these years and marvel at how far we’ve come. The programs I’ve highlighted today as extraordinary will simply be the norm in years to come.
So how can we achieve the promise of a transformed system? What is the next milestone along the way? At SAMHSA, we are finding that change of the magnitude we seek demands an entirely new kind of leadership: the kind that can change the very language of behavioral health. Old language cannot convey new ideas. This tenet is behind many of the actions that SAMHSA has taken recently, such as developing a consensus statement on the meaning of consumer-driven recovery and launching a multimedia anti-stigma campaign.
We have been exploring different leadership models to identify which ones will effectively guide transformation. One of the most promising is this one, which appeared in the Harvard Business Review.
This model identifies eight steps of change for organizational transformation. You’ll notice that the steps are broken up into three phases: Creating a climate for change; engaging and enabling the whole organization; and implementing and sustaining change.
On the Federal level, SAMHSA has been working to create a climate for change by broadening the number of departments and agencies directly involved in transformation.
Nine Federal departments, the Social Security Administration, and the Equal Employment Opportunity Commission now are members of our Federal Partners Workgroup for Transformation. There’s a reason for such a broad representation. Each of these department and agencies plays its own distinctive role in promoting and protecting the mental health of consumers. Each organization plays its part in making available the variety of services that will help people to achieve and sustain recovery…including a home, a job, transportation, and social support. Together, we have developed the first Federal Action Agenda for change. This document outlines 70 steps we are going to take immediately to move transformation forward.
North Carolina certainly finds itself faced with the need to develop a climate for change. There is an urgency related to the upcoming changes that will accompany the closing of your State hospitals. The good news is that you are perfectly situated now to restructure mental health care delivery in North Carolina. So, urgency can be a great impetus for creating a climate for change.
SAMHSA also is working to enable each of the organizations represented by our Federal Partners to move forward with mental health reform. We have convened a Federal Executive Steering Committee to guide and monitor the Federal Government’s process of transforming mental health care. Twenty-one a ssistant secretaries and deputy commissioners are on this committee. Their charge is to promote consumer access to effective services by identifying and eliminating regulatory and funding barriers erected by their own organization’s policies or procedures. Just think of what can be accomplished by all of these departments and agencies moving forward together!
Collaboration and partnership are the lifeblood of transformation. I know that powerful collaboratives are supporting transformation here in North Carolina. As a great example of reform and progress, your State has expanded the range of services available in the community under Medicaid.
Funding is obviously of paramount importance in transformation. Working with all agencies and all organizations that are impacted by mental health—and that would be every one of them, if the truth were told—will be the way we draw in all of the resources necessary for success.
Implementing and sustaining change is the third phase. Again, I’d like to point to the opportunities provided by the closing of North Carolina’s State hospitals. Now is the time to develop and structure your mental health care system so that it’s good for the long haul…so that in 40 years, it has continued to embrace new research, new practices, and new goals for treatment.
SAMHSA is moving to implement and sustain change on several fronts. One of our most recent efforts is our State Incentive Grants for Mental Health Transformation. Just recently, we awarded grants to seven States to support their efforts to create the infrastructure necessary to support comprehensive mental health care. We will share the lessons learned by these States to help all of the other States. Our goal at SAMHSA is to create a gigantic learning community within mental health stakeholders so that positive strategies for change are made available to everyone. We are building bridges across and between levels of government; we are creating new partnerships with private-sector industries and with advocacy groups. We are asking consumers and their families to inform us at every turn.
As I mentioned earlier, transformation is a continuous process. Long-term planning…seeing the big picture…is necessary for successful transformation. No more quick fixes. This time, we’re going to deal with the substance of mental health care, the services and supports that really help a person with a mental illness live a full life in the community. This time, we’re going to do the heavy lifting and the innovative thinking and the risk-taking that transformation requires. There is such great energy, determination, wisdom, knowledge, skills, and spirit going into this work that we can’t help but succeed.
I love the quotes on your Web site that remind us that the future is not something we enter, but something we create. As Eleanor Roosevelt said, “The future belongs to those who believe in the beauty of their dreams”. I certainly agree.
Another wise and important American that we can look to for inspiration is Dr. Seuss. Has anyone read his book, “Oh, the Thinks You Can Think?” It’s a book about possibilities. The book opens with the lines “Look left and look right, look low and look high, oh, the ‘thinks’ you can think up if only you try.” A little later on is this bit of wisdom: “Oh, the things you can find, if you don’t stay behind.”
Dr. Seuss reminds us that we may have to break out of our traditional mindset to discover amazing new ideas. He reminds us that we must look at what is working and what isn’t, and not “stay behind” in terms of changing what needs to be changed.
When we see that something is not working in mental health care, we must be willing to take chances, be innovative, and be bold. We have to try new things, and maybe even make some mistakes.
There’s a saying that, aerodynamically, the bumble bee shouldn’t be able to fly, but since it doesn’t know that, it just keeps flying anyway. We all know the immense challenges ahead of us. We know the size of the problems we’re facing. But, we keep flying because we also know the power of collaboration, insight, plain hard work…and hope. And because we know how high the stakes are.
Our Nation is moving forward and so is North Carolina: sometimes quickly, sometimes slowly, but always steadily. We’re like that bee: we’re going to achieve the impossible because we can.
It’s been great to be here with you today. Thank you.
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