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

State Mental Health System Transformation:
Technical Assistance Workshop (Eastern regional meeting)

May 3, 2007
Philadelphia, PA

PowerPoint Version

Good morning. Welcome to our technical assistance workshop for transforming State mental health systems. I’m going to begin the meeting by summarizing the two key messages that we want you to take away at the end. Let’s call them our Home Depot and Nike messages.

Our first take-away message is “You can do it, and we can help.” Transforming State mental health systems is very much like remodeling an old home. Old walls can be torn down to make way for innovative designs. New, state-of-science technologies can replace those that are out-of-date and inefficient. You may have to completely rewire the place to bring it up to code, with code representing the best in current knowledge and practice.

As your State-selected representatives, consider yourselves to be the primary contractors for your remodeling effort. And, like any remodeling project, your efforts will go smoother if you build from a solid foundation. While there is no “one way” to move toward system transformation, there are certain core areas that must underlie any recovery-oriented system. The technical assistance models we offer here address those core areas. Many thanks to the National Association of State Mental Health Program Directors for its contributions in helping to identify these areas and develop this workshop.

Our second message is “Just do it.” We’re borrowing this message from the Nike commercials. Nike’s tagline encourages individuals to take charge and take action…without delays or excuses. “Just do it” reflects the mindset of someone who willingly accepts the personal challenges involved in the pursuit…and the achievement…of the highest levels of performance. That kind of person is a transformational leader. We expect you to become transformational leaders and “just do it” to move your State mental health system forward.

Later on in my remarks, I’ll talk more about transformational leadership. I’ll also describe some possible blueprints for remodeling your State mental health system. For now, I’d like to discuss the basics of transformation.

In 2003, the President’s New Freedom Commission on Mental Health released its final report, entitled Achieving the Promise: Transforming Mental Health Care in America. This workshop is one outcome of the national call for action that followed the report’s release.

In the report, Commission members called for an unprecedented degree of change. They wrote, “The time has long passed for yet another piecemeal approach to mental health reform. Instead, the Commission recommends a fundamental transformation of the Nation’s approach to mental health care.” The Commission then went on to envision a transformed mental health care system that is consumer driven and focused on recovery.

Our very first challenge in working toward this vision was to understand the concept of transformation. What does it mean? How broad is its scope? How will we even know if it’s happening?

Some of the most informative lessons about systems transformation come from our defense department. For several years now, our military has been working to transform itself into a 21st century fighting force.

The late Vice Admiral Cebrowski served as the Special Assistant for Transformation for the Department of Defense. He studied the concept in depth by looking at corporations and systems that had been able to recreate themselves successfully. Cebrowski identified several common characteristics that define transformation.

• Transformation is a continuous process, without end. It is meant to create or anticipate the future.
• Transformation is accomplished through changes at the core of a system and not at its margins. These fundamental changes result in new behaviors and new competencies. Thus, in transformation, we look at what we are able to 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.

Transformation ultimately is about newness—about new values, new attitudes, and new beliefs that are expressed in the changed behaviors of people and institutions. Transformation is about creating the future rather than perfecting the past.

That brings us to the second challenge of mental health transformation—once we understand the inherent scope of transformation, how do we even begin to conceptualize the framework for change? What goals, objectives, and strategies will help us define and prioritize the actions we must take?

The Substance Abuse and Mental Health Services Administration (SAMHSA) adopted Achieving the Promise as our blueprint for action. Its six goals frame the changes that we want to see at the Federal level…and at the State level. We used these goals to develop our Federal action agenda. We asked the States to use the goals as a framework for their mental health block grant planning. We required States applying for a State Incentive Grants for Mental Health Transformation to crosswalk their proposed actions with the six goals from the report.

The New Freedom Commission’s approach to transformation was to develop an “overarching vision” that would guide the changes to follow. The Commission

• envisioned an ideal system;
• established broad goals for achieving that vision; and
• identified broad pathways to achieve the goals.

The slide on the screen gives an example of this process.

The Commission did not define the specific steps to be taken nor did it lay out priorities and timetables. Instead, the Commission’s report reflects the vision of consumer-driven care by calling upon the States to engage consumers in planning efforts.

There are other, equally valid approaches to conceptualizing transformation. There is but one absolute: meaningful consumer involvement.

Scotland, for example, also is working to transform its mental health system. Last year, the Scottish Executive released a report entitled Delivering for Mental Health. Its report takes a functional approach to reform by focusing on key elements of service. For example, among these elements are

• improving the physical health of people with mental illnesses;
• better managing of long-term mental health conditions; and
• better managing of admissions and discharges from hospital care.

To quote the report, these are “services that need to be in place at each point in a journey of care so that clinicians, service users, and carers can be clear about what needs to be delivered.”

“Carers,” by the way, is the Scottish term for the individuals who look after family, partners, or friends in need of help because they are ill, frail, or have a disability. The care they provide is unpaid. I particularly like this term because it connotes an empathy between individuals that should be a hallmark of our response to the health challenges faced by others.

The Scottish blueprint for transformation

• identifies key service elements requiring change;
• characterizes the commitment to change; and, for most of the service elements,
• sets measurable performance targets.

Like the New Freedom Commission, the Scottish Executive does not provide explicit instructions about how to transform services. The executive explained the absence of direction by saying that “Rigid structures can often lead to a reduction in innovation and are not appropriate to the changing populations they serve.” We at the Federal level share this sentiment. It’s each State’s right—and responsibility—to work with its constituency in determining specific needs and changes.

The Commonwealth Fund offers a third blueprint for wrapping our minds around transformative actions. The fund is a private foundation that supports independent research on health care issues and makes grants to improve health care practice and policy. Its mission is to move the United States toward a system of care that offers better access, higher quality, and greater efficiency for everyone.

Karen Davis is the president of the fund. She recently wrote an article entitled “The Best Health System in the World” that compares U.S. health care against the highest performance measures. Davis writes, “…the United States scored just 66 out of 100 when comparing the nation's average performance on three dozen indicators against benchmarks set either within the U.S. or abroad. Given America's high standards—and high spending on health care—that is simply unacceptable.”

The fund takes a strategic approach to identify how we can make our health care system the best in the world. Among its strategies are to

• expand health insurance for all;
• implement proven quality and safety improvements; and
• expand the use of information technology.

Some of the fund’s proposed strategies require new policies at the Federal or State level. Other strategies, however, can be carried out by health care leaders who make decisions every day about the way health care is organized, delivered, and financed.

These are achievable strategies…just like the broad goals from Achieving the Promise or the key service areas from Scotland’s Delivering for Mental Health. The Commonwealth Fund goes so far as to follow each strategy with examples of how an organization or a State already is translating the strategy into action. As Davis points out, the task of overhauling our health system is enormous. But, she observes further, “…benchmark practices, organizations, or even nations offer useful and sometimes inspiring roadmaps for change.”

I’ve just given you three different ways to approach transformation at the State level: vision driven, functional, and strategic. There are other available blueprints for change, such as the Institute of Medicine’s reports on “crossing the quality chasm.”

The approach you take, while vital to your planning efforts, is not nearly as important as taking action. An ounce of action is worth a ton of process analysis. One of the lessons we’ve learned from evaluating our co-occurring disorder grant, or COSIG, programs is that States have spent too much time on planning for change and are not moving ahead fast enough with change management. We found “paralysis through analysis” when we wanted “traction through action.”

Transformation, by its very nature, requires simultaneous planning and action. In his book entitled Deep Change: Discovering the Leader Within, Robert Quinn asserts the continuous nature of transformation. Quinn writes, “Once we have our sense of direction, we need to get organized, pack our gear, get motivated, and move on out. This process introduces new information and allows us to make choices and progress and grow our way forward—to, in effect, build the bridge as we cross it.”

Transformation of our mental health system is an evolving process that moves forward as we “just do it!” The progress we make—or not—will inform our next steps. If we’re not making progress toward our vision of transformation, we should alter our actions rather than our vision.

Transformation also is not achieved through a single giant step forward, but rather by a combination of steps that vary in scope and effect.

We can take continuous small steps to improve what our mental health system already is doing. We can take exploratory medium jumps to push the boundaries of our core competencies or to create something new within the existing paradigm. Occasionally, we will be able to move transformation forward in a few big jumps. These jumps occur when we can create new rule sets that leverage new ideas.

It’s helpful to think about the dimensions, or extent, of transformation in considering the actions to take. We recently have begun to use these lessons learned from the military to examine State transformation efforts objectively. All of these dimensions must be aligned as part of our efforts to make fundamental changes at the core of a system rather than at its margins. The dimensions are

• Culture—the understandings, beliefs, and practices that define and shape our reaction to change;
• Concepts—structured approaches to expressing how a course of action might be accomplished;
• Capabilities—techniques, tools, and systems that may be required to execute specified actions;
• Processes—the changes in steps, tasks, and procedures that may be required to implement concepts or apply capabilities;
• Authorities—the changes in public laws or regulations that may be necessary to implement transformation; and
• Organizational design—the change in an organization’s division of labor that will facilitate a desired course of action to bring about desired results.

The first dimension of transformation is culture. Culture provides the environment in which change can thrive…or wither over time, depending on the attitudes and values of those involved.

The transformation called for in Achieving the Promise demands a complete upheaval in the culture of mental health service delivery. In the transformed system, recovery, and not disability, will be the expectation of care. Consumers will take charge of their own wellness and engage in meaningful decisionmaking about the services to be provided.

Consumer-driven care and recovery represent two fairly recent and radical concepts in mental health care. We no longer define recovery from a mental illness in the traditional medical sense of a “cure.” Instead, recovery is a process enabling individuals with mental illnesses to participate as fully as possible in their community.

Placing consumers at center of care upsets another traditional view of consumers in which they are seen as the passive recipients of care. Many consumers and their families told the New Freedom Commission that having hope and the opportunity to regain control of their lives were vital to their recovery.

Control is extremely important to the human mind. Daniel Gilbert is the author of a book entitled Stumbling on Happiness. Gilbert maintains that our brains, with their large frontal lobes, are naturally endowed with a fundamental need for control over our lives and well-being. According to Gilbert “…human beings come into this world with a passion for control, they go out of it the same way, and research suggests that if they lose their ability to control things at any point between their entrance and their exit, they become unhappy, helpless, hopeless, and depressed.”

Gilbert describes an experiment in a nursing facility in which some elderly residents were given greater control over their environment. The residents’ newly acquired control ended when the experiment did. Several months later, the researchers were appalled to learn that a disproportionate number of residents who had been in the group with the new degree of control had died. Apparently, gaining control had affected the health and well-being of the participants positively, while losing control produced tragic results.

If you look at your workshop agenda, you will see that nearly one-third of the presentations directly address consumer involvement. This is a recovery strategy as well as a moral issue.

A culture of consumer-driven care focused on recovery must permeate our transformation efforts. How your State understands, believes in, acts upon, and reflects this culture will shape your approach to all of the other dimensions of transformation.

I’ll use one other dimension—authorities—as an example. Many States still do not have full parity for mental health care, which is a barrier to recovery. And yet, the majority of Americans understand the importance of their mental health. In a survey conducted by the Charlton Research Company, nearly 90 percent of respondents thought that their mental and physical health were equally important to their own health.

More than 70 percent strongly agreed that mental health services should be part of any basic health care plan.

These numbers represent a cultural shift in how Americans view mental health, mental illness, and recovery. As a result, legislative authorities are changing, with most States ahead of the Federal Government. A nonpartisan bill that would require parity in insurance coverage for mental health and substance abuse care currently is making its way through Congress. I’m delighted that the Democratic House sponsor of the bill—Patrick Kennedy—represents my home State of Rhode Island. The bill’s Republican cosponsor is Jim Ramstad from Minnesota.

Kennedy has been open about his struggles with mental illness and his entry last year into recovery for alcoholism and substance abuse. Ramstad, a recovering alcoholic, is Kennedy's recovery sponsor. Their bill illustrates an important element of transformation. When we change the culture, we open the way for changes in laws, regulations, and policies.

Kennedy and Ramstad developed a vision of care that is, inspired by their own personal experiences with illness and recovery. They also acted on their vision by taking the lead in proposing legislation that can offer the same hope of recovery to others. Their action brings to mind a quote from Joel Barker, who introduced the concept of paradigm shifts to the corporate world.

Barker observed, “Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world.” To that, I’d like to add, “Action without leadership is like putting a car in gear without a driver behind the wheel. If the car goes anywhere at all, it will likely go off course before slowing to a complete halt.”

Transformation requires special leaders…individuals who are deeply committed to the transformation vision and the risks and challenges of achieving it. In Deep Change: Discovering the Leader Within, Quinn discusses how every individual can undergo a process of change that enables him or her to become a transformational leader. Quinn’s definition of deep personal change is very much like our definition of system transformation. According to Quinn, “Deep change differs from incremental change in that it requires new ways of thinking and behaving. It is change that is major in scope, discontinuous with the past and generally irreversible. The deep change effort distorts existing patterns of action and involves taking risks.”

Quinn’s chapter on “The Internally Driven Leader” uses three paradigms of organizational life to illustrate the differences between garden-variety managers and exceptional leaders.

Managers engage in a transactional paradigm, which suggests that a system is a coalition of political interests. Every coalition has an agenda and a set of needs and engages in a variety of transactions through which resources are exchanged. In this system, a manager gains power by making the most effective transactions among competing groups. Basically, managers work within the system, act conventionally, and resolve conflicts through compromise as they protect their own position.

Leaders, on the other hand, engage in a transformational paradigm. Vision realization is more personally motivating to them than personal survival within the organization. They view an organization as a moral system, with core values and principles transcending the political interests and agenda of any coalition within the system. “A transformational leader,” according to Quinn, “will develop a plan of action, mobilize the workforce, and unleash power by vocalizing the core values of the system.”

Transformational leaders establish their source of credibility in their own behavioral integrity. They both talk the talk and walk the walk, and their actions speak louder than their words. Every action they take will align with the organization’s vision. In Quinn’s estimation, “To fail on this dimension is to reduce the vision to an exercise in hypocrisy.” Those within a system, and particularly those who oppose, fear, or simply are slow to embrace change, will be alert to hollow rhetoric by the person in charge. Their response may be to ignore the vision or wait until it dies out or the person moves on.

Transformational leaders are self-authorizing. Their authority to pursue a course of action comes from the organization’s core values. They are able to step outside of traditional boundaries and processes and away from political motivation. As a result, when a conflict arises, transformational leaders often engage in a series of very complex strategies that are filled with risk and surprise. Instead of working within a system like managers, transformational leaders will work outside of or on the system.

ransformational leaders are not constrained by a rational planning process. Deep change, like transformation, is about newness—exploring new areas, trying new methodologies, and reaching new goals. As a result, transformational leaders cannot specify every means to a desired end. They identify these means only as part of a risky action-learning process. Learning—and progress—come from “doing.”

If the transactional paradigm comes from internalizing the organization, the transformational paradigm comes from transcending the organization. As Quinn puts it, “The transformational process [of becoming a leader] involves a rebirth—a deep personal change—a hero’s journey from which the leader emerges empowered and empowering.”

Transformation of our mental health system will not follow a pathway paved with familiar processes and procedures. Consequently, each of us must be open to personal change before we change the world around us. Your State will need a transformational leader—become that person.

We are all are potential change agents in making transformation happen. As we discipline our talents, we deepen our perceptions about what is possible. In turn, we bring a discipline to our vision, and our work becomes more meaningful.

During the next 2 days, you will hear 10 presentations by expert consultants on training and technical assistance models that your States will be able to request through the National Technical Assistance Center. We hope that these sessions will help you open up to new possibilities within transformation. By taking advantage of our technical assistance models, your State can ou can do it, and we can help.

You may have to leave your comfort zone and step outside of your normal roles to implement a model within your State. But, as Quinn observed,

“Though we often prefer to believe that nothing can be done about the…problems we face, there comes a time when we have to take on the system because the system needs to change. There comes a time when we must ‘just do it.’”

This is the time, and you are the people picked by your States to do it. Enjoy the workshop. Thank you.

Questions? Comments?