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
A Public Health Approach to Mental Health: Taking Transformation to Scale
May 13, 2008
Kansas City, MO
PowerPoint Version (2.2 MB)
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[Slide 1: Title slide]
Thank you Ken (Ken Stark, Director of the Governor's Mental Health Transformation Project) for your kind introduction and for the energy, leadership, and political savvy that you bring to transformation initiatives in Washington State. The successes you've had in Washington represent the very best of what it means to work collaboratively, and they also show us how effective an inspirational leader can be. Ken, your reputation as a coalition builder and tenacious supporter for people with mental and substance use disorders has galvanized this State's progress toward development of a consumer-driven, recovery-focused, and evidence-based system of care for individuals of all ages with mental health needs.
[Slide 2: Global burden of disease]
And I'm here today to tell you that we haven't a moment to lose. We know that when measured across all age groups, mental illnesses are the leading causes of disability worldwide.
We also know that half of all diagnosable lifetime cases of mental illness begin by age 14, and three-fourths of all lifetime cases start by age 24. Suicide is the third leading cause of death for adolescents and young adults.
And sadly, we know that the life expectancy for individuals with serious mental illnesses is about 25 years less than that of the general population. Individuals with mental illnesses die from treatable medical conditions that are caused by modifiable risk factors, including smoking, obesity, substance abuse, and inadequate access to medical care.
Leadership consultant Anthony Robbins has said, "If you do what you've always done, you'll get what you've always gotten."
Clearly, we can no longer do what we've always done, because we can't afford the lost productivity, the lost hopes and dreams, and the lost lives that result when we ignore the fact that mental health is essential to overall health.
By virtue of the hard work you have done that has led to this summit today, you are the vanguard of a cultural shift which says that promoting health and preventing disease are the cornerstones of a transformed system of care.
[Slide 3: Mental health continuum]
To change not only our mindset about mental health but also the behaviors that flow from it, we must understand what we mean when we talk about "mental health." Nearly 10 years ago, the Surgeon General's Mental Health Report laid the foundation for a public health approach to mental health care when it offered important distinctions between mental health, mental health problems, and mental illnesses.
"Mental health," the Surgeon General said, "is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensible to personal well-being, family and interpersonal relationships, and contribution to community or society."
At the other end of the continuum is mental illness, a term that refers collectively to disorders that are characterized by "alterations in thinking, mood, or behavior…associated with distress and/or impaired functioning."
In between mental health and mental illness are mental health problems, marked by "signs and symptoms of insufficient intensity or duration to meet the criteria for any mental disorder." Nearly all of us have experienced mental health problems. Think about how we feel when a loved one dies. Bereavement symptoms that persist can become debilitating and lead to depression, particularly in older adults.
These definitions are the embodiment of what it means to take a public health approach to mental health care.
First, the Surgeon General makes clear the mental health is much more than the absence of mental illness! Mental health is that which makes live enjoyable, productive, and fulfilling. We can and we must help individuals, organizations, and communities understand that being healthy means having good mental health.
To promote mental health, we must dispel the popular notion that the mind and the body are separate. We didn't always think this way.
Hippocrates, a Greek physician of the 4th century B.C. who is widely credited as being the father of medicine, believed in a delicate interrelationship between the mind and the body. He maintained that an individual's physical symptoms were affected by his or her psychological state, spiritual leanings, and social connections. We need only think about the racing heart, dry mouth, and sweaty palms that accompany a nightmare to know that physical changes in the brain often trigger physical changes in other parts of the body, as well.
This integrated view of mind and body began to shift during the early part of the 17th century, however, when some prominent European philosophers—such as England's Francis Bacon and France's Rene Descartes—were beginning to develop the worldview that underlies today's Western medicine. Descartes, in particular, viewed the "mind" as completely separate from the "body." This partitioning ushered in a separation between so-called "mental" and "physical" health that persists to this day, despite scientific evidence to the contrary.
This Cartesian split is likely at the root of what is often called "stigma." That's the first and last time you'll hear me use that word today because I believe the word itself is stigmatizing. We simply do not need yet another label for people with mental health problems.
Let's talk instead about what individuals with mental health problems experience when people believe that they have a disorder of the mind. All too often, they encounter discrimination, prejudice, fear, isolation, and bias.
Inaccurate and hurtful perceptions lead others to avoid living, socializing or working with, renting to, or employing individuals with mental health problems.
These misperceptions lead to low self-esteem, learned helplessness, and hopelessness on the part of individuals and deter the public from wanting to pay for care.
Worst of all, the fear of discrimination often causes individuals, young people, and whole families with mental health problems to become so embarrassed or ashamed that they conceal symptoms—and avoid seeking the very treatment, services, and supports they need and deserve.
In particular, research tells us that only about one-quarter of young adults believe that a person with a mental illness can eventually recover.
When you think about it, this may not be that surprising. I'm old enough to remember when "cancer" was a word you whispered, or you avoided the word altogether and just said "the big C." But in light of improved treatment and the educational efforts of such groups as the American Cancer Society and patient advocates around the country, cancer is no longer automatically considered a death sentence and individuals with cancer are embraced rather than shunned.
In much the same way, it wasn't that long ago when mental disorders were believed to be debilitating, lifelong conditions; when people were given no hope for recovery; when they spent years confined to life in an institution.
Today, we know that—given the right combination of effective treatment and support and a voice in decisions concerning their care—people with serious mental illnesses can and do recover.
[Slide 4: Campaign for Mental Health Recovery]
But we must spread this good news beyond the confines of this room.
SAMHSA's Campaign for Mental Health Recovery is designed specifically to encourage, educate, and inspire young people ages 18 to 25 to step up and support friends they know are experiencing a mental health problem. Our theme is "What a difference a friend makes." You can view radio and TV ads at www.whatadifference.samhsa.gov.
Thus far, we have distributed more than half a million copies of the Campaign brochure and have begun a concerted effort to get materials into the hands of students and peer educators at colleges and universities nationwide. In addition, we are developing multicultural campaign materials for 18 to 25 year olds who are African American, Asian American, Native American, and Hispanic American. We know that minorities have less access to mental health services and often receive poorer quality mental health care.
The Campaign for Mental Health Recovery is a perfect segue to my next point, which is the second half of the public health equation. When we embrace the fact that mental health and mental illness are points along a continuum, we see clearly that we have not only an opportunity but also an obligation to intervene early to help prevent mental health problems from becoming full blown mental illnesses.
Further, when we remove the false dichotomy between mental and physical health, we can more easily understand the fact that mental illnesses can be prevented.
Think about Type 2 diabetes. We now know that diet, physical activity, and even modest weight loss can forestall or prevent the onset of Type 2 diabetes in at-risk individuals.
In the same vein, we are learning that if we intervene early, we may be able to prevent the onset of some mental disorders, lessen their impact, or preclude both co-morbid conditions and long-term disability.
At SAMHSA, we take a broad view of prevention. We believe, as does the Institute of Medicine, that it is important to prevent the onset of a disorder. However, we also understand, as the National Institute of Mental Health has noted, that prevention can apply to interventions that prevent comorbidity, relapse, disability, and the consequences of serious mental illnesses for individuals and families.
Much of our thinking about prevention in mental health has been guided by a seminal 1994 report on this topic by the Institute of Medicine, and I'm pleased to let you know that SAMHSA has commissioned an update of this report, which will be released later this year.
I'm also pleased to note that Washington State has become a laboratory for successful prevention activities. With a SAMHSA Prevention and Early Intervention Targeted Capacity Expansion Grant, Children's Village in Yakima implemented the evidence-based Nurse-Family Partnership, developed by Dr. David Olds. In close collaboration with Dr. Olds, they modified this intervention—which features nurse home visits to low-income, first-time parents—by adding an infant mental health practitioner to the team.
The amazing thing about the Nurse-Family Partnership is not only the changes we see in the short-term—such as improved prenatal health and fewer childhood injuries—but also such outcomes as fewer maternal arrests and a reduction in child abuse and neglect 15 years after the intervention.
Prevention activities in King and Yakima counties caught the attention of the Bill and Melinda Gates Foundation, which, together with Thrive by Five Washington, is supporting the development of early learning opportunities for children birth to age 5. A total of $11.7 million will fund partnerships between the community, public agencies, and private caregivers to meet the unique needs of families with young children in King and Yakima counties. This is transformation in action!
Prevention is not only humane; it may be cost-effective, as well. In a 2002 update on the public health of our Nation, the Institute of Medicine notes, "the vast majority of health care spending, as much as 95 percent by some estimates, is directed toward medical care and biomedical research. However, there is strong evidence that behavior and environment are responsible for over 70 percent of avoidable mortality."
Closer to home, in 2004, the Washington State Institute for Public Policy set out to answer the question, "Does prevention pay?"
The researchers concluded that "there is credible evidence that certain well-implemented [prevention and early intervention programs for youth] can achieve significantly more benefits than costs." They tempered their findings with the caveat that while the State should invest in these proven "blue-chip" programs, it should avoid spending money on programs where there is little evidence of proven effectiveness and should keep abreast of the best science in the field.
SAMHSA is looking to gather evidence of such programs with a brand new initiative called Linking Actions for Unmet Needs in Children's Health or Project LAUNCH. The purpose of Project LAUNCH is to promote the wellness of young children, birth to age 8. Project LAUNCH defines wellness as a state of positive physical, emotional, social, and behavioral health. The goal is to create thriving, safe, and supportive environments for children, allowing them to enter school ready to learn and succeed.
One of the most exciting parts of this initiative is the fact that Project LAUNCH will support partnership at the Federal, State, territorial, tribal, and local levels.
- At the Federal level, we are convening an advisory committee to guide the future direction of this initiative. This committee will build on an interagency group that informed the design of Project LAUNCH and includes representatives from the Health Resources and Services Administration (HRSA), the Administration for Children and Families (ACF), and the Centers for Disease Control and Prevention.
- There is also significant Federal interagency cooperation at the program level. Project LAUNCH will build on HRSA's Early Childhood Comprehensive Systems Grant Program, and we are partnering with ACF to manage a national cross-site evaluation of the initiative.
- At the State, territorial, and tribal level, grantees will be required to convene a council with representation from health, mental health, child welfare, substance abuse, early childhood, and education systems. This council will work to build infrastructure and reform policy.
- At the local level, grantees will be required to convene a parallel council with representation across service systems to build a coordinated local service system.
Partnerships in support of mental health promotion and mental illness prevention truly are transformation in action!
[Slide 5: Essential public health services]
Partnerships are critical to a public health approach to mental health. In a few minutes, I'll expand on the notion of partnerships to include "networks" and "communities of practice." But now I want to emphasize the fact that, as the Institute of Medicine has said, public health is "what society does collectively to assure the conditions for people to be healthy." Public health engages both private and public organizations and individuals in accomplishing this mission. No one agency or individual can do this work alone.
In its report, the Institute of Medicine defined the three core functions of public health as:
- The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities;
- The formulation of public policies designed to solve identified local and national health problems and priorities; and
- The assurance that all populations have access to appropriate and cost-effective care and evaluation of the effectiveness of that care.
Each of these components builds on the other. If we are to develop effective public policies designed to promote mental health and prevent mental illness, we must assess the health of our communities and the individuals we serve and we must provide our assurance that they will have the care they need, designed by them and with them, when and where they need it. This must be our solemn promise to individuals with mental health problems, and it must become the way we do business.
[Slide 6: Social-ecological approach to public health]
Ultimately, the public health model recognizes that mental health does not reside solely in the individual but also within the web of interactions among the individual, the family, the school, the neighborhood, and the community in which he or she lives. In particular:
- Recognizing that mental health and substance use problems can lead to other health and social problems, a public health approach is holistic, taking into consideration all aspects of the individual's wellbeing.
- Public health seeks long-term solutions that are best achieved by high-quality care before symptoms and co-occurring conditions become severe. Accordingly, prevention is as important as treatment.
- Public health employs evidence-based practices and always measures outcomes.
- Finally, a public health model focuses treatment and care on the needs of the individual, but also develops interventions for the entire population.
In essence, public health is mental health transformation in action!
[Slide 7: Lifecycle of emergence]
Taking Innovations to Scale
We have not always thought about mental health as a public health discipline, and we too often view mental health solely as the absence of mental illness. Changing long-held attitudes and beliefs and longstanding ways of doing business are not easy. But I've reviewed the work you've done that has led to this day, and I know you are up to the task.
You embrace the public health approach.
You acknowledge the importance of prevention and the need to reduce risk factors and enhance protective factors.
And you understand that in order to support individual change, you must also support change in the family, the community, and in the broader society.
But I want to acknowledge that perhaps the most difficult part of your task in transforming the mental health system in Washington State is one with which all innovators struggle; namely, how do you sustain your progress and bring your innovations to scale?
Certainly, change of this magnitude does not come without risk—to individuals promoting new ideas; to systems that must embrace them; and to the ingrained attitudes, beliefs, and behaviors that must be jettisoned to make room for innovating thinking.
I recently came across a wonderful article by Margaret Wheatley that speaks to issue of taking social innovations to scale.
Ms. Wheatley is the author of Leadership and the New Science: Discovering Order in a Chaotic World and is founder of the Berkana Institute, a research foundation working on the design of new organizations.
Since its inception in 1992, the Berkana Institute has been experimenting with what it calls the lifecycle of "emergence," which is a term that describes how living systems begin as networks, shift to intentional communities of practice, and evolve into powerful systems capable of widespread influence. Emergence, Ms. Wheatley says, is "how life creates radical change and takes things to scale."
This sounds like a tall order, but the good news, according to Ms. Wheatley, is that "we don't need to convince large numbers of people to change; instead, we need to connect with kindred spirits. Through these relationships, we will develop the new knowledge, practices, courage and commitment that lead to broad-based change."
In the time I have left this morning, I'd like to walk you through the three steps of emergence that Ms. Wheatley outlines, because I think you'll see you are well along the road to both creating and institutionalizing transformative change in Washington State.
- Stage 1 in the lifecycle of emergence is discovering shared meaning and purpose through the development of networks. Networks make it possible for people to find others engaged in similar work.
Your ability to create and use networks in Washington State is exemplary. The Transformation Work Group at the epicenter of your systems change initiative is a network of representatives from all of the State's human services agencies and related support agencies, the Governor's office, consumers, consumer and family organizations, local government, providers, and regional support network representatives. One outgrowth of this group's work will be development of the State's Comprehensive Mental Health Plan.
- The second stage in the lifecycle of emergence is creating communities of practice. Members of communities of practice support one another, share what they know, and intentionally create new knowledge for their field of practice. They make their resources and knowledge available to those doing related work.
I applaud your efforts in Washington State to create numerous communities of practice. They include:
- The Community Transformation Partnership, the first and only statewide coalition bringing together as one voice the different mental health consumer, family, and youth advocacy organizations.
- A Research Workgroup, bringing together more than 40 researchers from universities and agencies.
- A Mental Health Council, including members from corrections, law enforcement, and mental health to advise the Department of Corrections on issues related to offenders with mental health problems.
- And of course the Prevention Advisory Group, with more than 85 participants tasked with defining and describing mental health promotion and mental illness prevention across the lifespan.
- Finally, I have every confidence that Washington State will arrive at Stage 3 of emergence, which Ms. Wheatley calls systems of influence. Listen to how she describes this stage:
"The third stage in emergence can never be predicted," Ms. Wheatley says. "It is the sudden appearance of a system that has real power and influence.
"Pioneering efforts that hovered at the periphery suddenly become the norm.
"The practices developed by courageous communities become the accepted standard.
"People no longer hesitate about adopting these approaches and methods, and they learn them easily.
"Policy and funding debates now include the perspectives and experiences of these pioneers...
"And critics who said it could never be done suddenly become chief supporters (often saying they knew it all along)."
This is such a wonderful vision, and I know this is where you are headed.
In fact, it strikes me that this final stage of emergence is analogous to what renowned author Malcolm Gladwell calls a "tipping point," that moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire. He relates a tipping point to an epidemic and says that what underlies a successful epidemic, in the end, "is a bedrock belief that change is possible [and that] people can radically transform their behavior or beliefs in the face of the right kind of impetus."
According to Ms. Wheatley, that impetus is exactly what you have been doing since you received your T-SIG award and what you are doing here today.
"Change begins as local actions spring up simultaneously in many different areas," she says. "If these changes remain disconnected, nothing happens beyond each locale. However, when they become connected, local actions can emerge as a powerful system with influence at a more global or comprehensive level. And the system that emerges," she adds, "always possesses greater power and influence than is possible through planned, incremental change."
In Washington State, you are making the necessary connections.
You are developing communities of practice to learn together and share what you know.
You are creating a system with greater power and influence than the sum of its individual parts—a system focused on promoting mental health, preventing mental illness, and intervening to prevent further disease and disability.
This truly is transformation in action!
[Slide 8: Henry Ford quote]
Wrap-up and Conclusion
In closing this morning I want to recognize the challenging work that lies ahead of you today. You've been given 14 themes, each of which and all of which could advance creation of a public health approach to mental health care across the lifespan. From marketing mental wellness to supporting transitions across the lifespan to creating trauma-informed systems, each of these actions is important to promote mental health and prevent mental illness in Washington State.
Unfortunately, you can only choose 5 of these actions to move forward to the Governor and the legislature as your most pressing priorities. But you have not shied away from making the difficult choices.
You have fully embraced the concept of a public health approach to transformation when others might think these are only the latest buzzwords in mental health care or government-speak.
You have involved all voices in the discussion and given them equal weight.
You have made small but significant changes that by themselves would not be considered transformative, but taken together have created a tipping point for change.
And you have never lost sight of the fact that we are not doing this work merely to transform systems—we are doing this work to transform people's lives.
I have no doubt that you will rise to the task before you today and choose those 5 actions you feel most represent your belief that transformation of the mental health system is a public health imperative that literally saves lives.
Industrialist Henry Ford once said, "Coming together is a beginning; keeping together is progress; working together is success."
As you continue to work together with much success, you do so with my gratitude and my full support.
Thank you. If we have time, I'd be happy to take your questions.
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