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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
Mental Health in an Era of Health Care Reform: Get Your Seat at the Table!
May 13, 2009
Mandan, ND
PowerPoint Version (3.17MB)
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, JoAnne (and/or Carol)1 for your kind introduction and for the invitation to join you today. This is my first visit to your beautiful State but I hope it won’t be my last. Renowned local author Louise Erdrich has called the North Dakota sky “shattering, spectacular, [and] inescapable…[It] stretches down on every side and quiets the mind…Sound travels as far as the ear allows. Vision stretches as far the eye can strain. Pure sky pulls you right out of yourself and yet bears down so close it seems crushing.”
The North Dakota sky is a wonderful metaphor for the important role that mental health plays in overall health and wellbeing. The potential to live a mentally healthy life is all around us. We hear it in children laughing joyfully on a school playground. We see it in the faces of our friends, family, and coworkers. Good mental health pulls us out of ourselves into the life of the community.
But mental health conditions—not properly recognized or addressed—can be crushing. Untreated or inappropriately treated mental health conditions leave individuals isolated, fearful, and often physically ill. Mental illness exacts a terrible toll on families, on communities, and on the Nation as a whole.
As the Nation increasingly turns its attention to health care reform, mental health must be at the table.
We must be there to acknowledge that there is no health without mental health. We can strengthen individuals by promoting resilience, recovery, and person-centered care.
We must be there to share the good news that we can promote mental health and prevent mental illnesses. We can strengthen communities that support healthy individuals.
Perhaps most important, we must be there to work in partnership with one another, not just for health care reform, but for health reform. We can strengthen the Nation by making prevention and healthy lifestyles as important as treatment. The time to begin is now!
[Slide 2—Global burden of disease]
Improving Individuals’ Health
The notion that mental health is essential for overall health represents a sea change in our thinking. In fact, I believe we have reached the “tipping point” where it is no longer appropriate to consider the mind and the body separately. We must “create the neck,” as Center for Mental Health Services Medical Director Dr. Ken Thompson is fond of saying.
Increasingly, the concept of integrated care for mental health and general health conditions is seen as both a financial and an ethical imperative. When asked about integrated care at her recent confirmation hearings, Health and Human Services Secretary Kathleen Sebelius indicated her strong desire to ensure that mental health is included in the health care reform debate by pointing to her work in Kansas to pass mental health parity legislation.
At the national level, the newly enacted Mental Health Parity and Addiction Equity Act requires insurance coverage for mental and substance use disorders to be equivalent to that offered for other medical conditions. This hard-won legislation is testament to the growing recognition of the need to integrate care for mental health and general health problems.
And at the Federal level, the Substance Abuse and Mental Health Services Administration is now accepting grant applications for the Primary and Behavioral Health Care Integration program. We hope to improve the physical health status of people with serious mental illnesses by supporting communities to coordinate and integrate primary care services into publicly funded community mental health agencies. We expect the services we fund will incorporate a prevention and wellness approach and show cooperation and collaboration across community mental health and primary care.
The concept of an integrated approach to health care is not new. Hippocrates, 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.
This integrated view of mind and body began to shift during the early part of the 17th century when some prominent European philosophers began to develop the worldview that underlies today’s Western medicine. France’s Rene 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 issue is about more than semantics, however. It is a matter of life and death. We know that the top three leading causes of disability worldwide are behavioral health disorders, as reported in the World Health Report of 2001.
We also know that people with serious mental illnesses die, on average, 25 years earlier than the general population. More important, we know they die from treatable medical conditions that are caused by modifiable risk factors, including smoking, obesity, substance abuse, and inadequate access to medical care. This is a public health crisis that must be addressed.
I’m pleased to hear that you have a session called “Leading Healthier Lives, Building Stronger Hearts.” The fact that this session is full indicates just how important it is to promote healthier lifestyles for people with mental health conditions. Eating right, exercising, and getting needed support can help enhance an individual’s ability to withstand the stressors of everyday life. Individuals who cope successfully with adversity are said to be “resilient.”
Resilient individuals are those that bend rather than break during stressful conditions. They are most likely to have a positive outlook and a sense of personal mastery and to find meaning even in difficult circumstances. We saw ample evidence of resilience as we watched you and your neighbors come together to fill thousands of sandbags to hold back the Red and Missouri rivers. Overcoming fear and exhaustion, you persevered with pride, hard work, and indomitable North Dakota spirit.
The most important thing to know about resilience is the fact that it is not a static trait. Rather, resilience in an individual is dynamic and varies across time and life domains, including relationships, academic and professional life, and health. Individuals do not develop resilience by “pulling themselves up by their bootstraps” when faced with life’s challenges.
Instead, resilient adaptation to adversity comes about as a result of characteristics of an individual interacting with resources in the environment. This means that we can, in fact, help build resilience in the individuals we serve. There are a number of ways to do so.
[Slide 3—Consensus definition of recovery]
- First, we build resilience when we honor and promote the principles and practices of person-centered care. Person-centered care is respectful and responsive to the needs and values of individuals and honors and supports recovery and wellness. It means that consumers of mental health services have full access to and make informed use of such tools as shared decision-making, self-directed care, and advance directives. They design, deliver, and evaluate services. They are empowered to take charge of their recovery and their lives.
I’ve heard that you also have a “sold out” session called “It’s My Life: The Person in Person-Centered Care.” We cannot underestimate the power of offering hope and dignity—two powerful components of both person-centered care and mental health recovery.
If, like me, you have been in the mental health field for many years, you remember a time not all that long ago when mental illnesses were believed to be lifelong, debilitating conditions that required ongoing, custodial care. Today, we know that given the right combination of treatment and support and a voice in decisions concerning their care, people with mental health conditions can and do recover.
[Slide 4—Campaign for Mental Health Recovery]
- Second, we build resilience when we address the discrimination, fear, and bias that too often leave individuals with mental health conditions at the margins of society. At SAMHSA, our National Campaign for Mental Health Recovery teaches young adults how to reach out to their friends who may be having a mental health crisis. We are currently developing multicultural materials based on the “What a Difference a Friend Makes” theme targeting 18 to 25 year olds who are African American, Asian American, Native American, and Hispanic American. You can learn more about this campaign at www.samhsa.gov.
Another promising effort called Mental Health First Aid teaches community members how to assess a situation and help an individual in a mental health crisis to connect with appropriate care. It was developed and tested extensively in Australia, where a study in a large rural area of the country found that the training produces positive changes in knowledge, attitudes, and behavior toward people with mental health conditions.
With SAMHSA’s support, the National Council for Community Behavioral Healthcare has trained instructors throughout the United States who are now certified to teach Mental Health First Aid to consumers, advocates, and interested community members. Training is also being offered in the western States by the WICHE Mental Health Program. When we reach a hand across the prejudices and stereotypes that divide us, this truly is mental health transformation in action!
[Slide 5—Suicide Prevention Lifeline]
- Finally, we promote resilience when we make easily accessible the kinds of resources that can help those who are struggling with fear, uncertainty, and loss. This might be a veteran who is having trouble readjusting to civilian life, a widow who is overcome with grief and loss, a victim of a natural disaster who is trying to pick up the pieces, or a recent immigrant who is having trouble adjusting to a new way of life.
At these critical life junctures, vulnerable individuals without appropriate support may be at increased risk for suicide. In 2005, the most recent year for which we have national data, suicide resulted in more than 32,000 deaths, according to the Centers for Disease Control and Prevention (CDC). Sadly, suicide is the third leading cause of death among young people aged 15 to 24. Suicide also is a significant problem among older adults and increasingly among veterans and active duty military.
SAMHSA’s National Suicide Prevention Lifeline, at 1-800-273-TALK, averages 1,500 calls every day. Over the past year, the Lifeline has experienced a 30 percent increase in calls, with crisis centers reporting a significant number of people who are calling because of economic fears. Many individuals have lost their job or their home or are afraid they will.
To help our Nation’s veterans, SAMHSA and the Department of Veterans Affairs created a special feature that allows Lifeline callers who are veterans to be connected to VA Suicide Prevention Coordinators. In its first year of operation, calls from veterans led to more than 6,000 referrals to VA Suicide Prevention Coordinators. These calls also resulted in more than 1,700 rescues—calls to police or emergency medical personnel for immediate responses for individuals judged to be at imminent risk. This is mental health transformation in action!
[Slide 6—Mental health continuum]
Healthier Communities
Individuals are not resilient in isolation. Just as we strengthen individuals, so too must we strengthen the communities that support them.
I’m struck by the mission of North Dakota’s Three Affiliated Tribes2, which is to provide quality services by being “responsible, accountable, respectful, [and] caring” and by incorporating “the traditional values of our elders and ancestors.” These individual and community values are closely linked, and they form the basis for a public health approach to health care.
Public health is a community approach to preventing and treating illnesses. Its premise is that caring for the health of the individual protects the community, while—in turn—caring for the health of a community protects the individual. As such, health promotion is a primary focus of a public health approach.
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 co-morbid conditions and long-term disability.
In March, the Institute of Medicine and the National Research Council released the much anticipated report, Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities. CMHS was pleased to support this update to the seminal 1994 report, Reducing Risks for Mental Disorders. That report provided the basis for understanding the science of prevention, examined early research in the field, and proposed areas for further study.
This new report focuses on our Nation’s young people. We 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. We also know that first symptoms occur 2 to 4 years prior to the development of a diagnosable disorder, which means we have an important window of opportunity in which to respond. Unfortunately, data show a significant lack of access to services for both mental health and substance use problems for our Nation’s youth.
I’m pleased to be able to share with you two key findings from the new report. First, the 2009 update reveals concrete evidence that an increasing number of mental, emotional, and behavioral disorders are, in fact, preventable. Second, and equally important, this groundbreaking report goes beyond the 1994 report by recommending the inclusion of mental health promotion in the full spectrum of mental health interventions.
The authors conclude, “The nation is now well positioned to equip young people with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships that strengthen the social fabric.” This should be the vision for health care reform.
A Healthier Nation
Resilient individuals living in healthy communities are two key components of what it means to be a healthy Nation.
The CDC has embarked on a “Healthiest Nation” initiative. The key values that guide their work include the following public health concepts:
- First, health is valued as a personal, community, national, and international asset.
- Second, health protection is understood as a strategic economic imperative by nations and businesses.
- Third, people have the information they need to make decisions when, where, and how they need it.
- And fourth, people are confident that the health system will protect them and provide effective and affordable care when they need it.
Just as a public health approach supports health promotion and disease prevention; it also recognizes the importance of the personal, social, economic, and environmental determinants of health. Indeed, The World Health Organization defines health as “a complete state of physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”
Unfortunately, for too long, we have excluded people with mental illnesses from the social fabric of our lives. We know that social exclusion increases the likelihood of significant psychological distress and psychiatric illness, including substance abuse.
On the other hand, social inclusion means that we adopt policies and activities that are not necessarily planned as mental health interventions, but—because they improve access to a wide variety of resources—have important mental health effects.
I was interested to learn that in contrast to nomadic tribes in the Great Plains region, the Mandan established permanent villages. These villages were usually oriented around a central plaza that was used for games and ceremonial purposes. This central plaza was a gathering place that drew individual members into the life of their community.
We must create a similar sense of community and belonging for individuals of all ages in this country. To do so, we must confront the poverty that cripples opportunities and worsens health outcomes for many individuals with mental health conditions. As the authors of the new IOM report point out, “the future mental health of the Nation depends crucially on how…the costly legacy of poverty is dealt with.”
We must promote employment, volunteerism, social connection, and other meaningful activities for individuals with mental illnesses, who have the highest unemployment rates in the Nation.
We must address the inequitable distribution of health care resources.
And, most important, we must remove attitudinal barriers and establish appropriate supports that make it possible for people with mental health conditions not just to be IN the community, but to be OF the community. They should be able to flourish not merely function in their communities, as Dr. Daniel Fisher of the National Empowerment Center has said.
Ultimately, without access to housing, health care, meaningful activities, social support, and community relationships, individuals of all ages are excluded from all that it means to be healthy in today’s society.
[Slide 7—North Dakota mental health shortage area]
Workforce
Healthy individuals, healthy communities, and a healthy Nation depend on the ability of those of you gathered here today to provide and promote evidence-based, person-centered, recovery-focused services. Together, we must help train, educate, and support a workforce—not only in behavioral health care, but across the health care professions—that is capable of practicing 21st century health care. “The people who deliver care are the health system’s most important resource,” noted the Institute of Medicine.
In rural communities, workforce needs are particularly acute. We know, for example, that:
- In North Dakota, 94 percent of the State’s counties are designated mental health professional shortage areas.
- Nationwide, more than 90 percent of all psychologists and psychiatrists and 80 percent of all MSWs work exclusively in metropolitan areas.
- More than 65 percent of rural Americans get their mental health care from their primary care provider.
- And, sadly, the mental health crisis responder for many rural Americans is a law enforcement officer.
In North Dakota, participants in the Health Care Workforce Summit recommended strategies designed to increase, recruit, and retain qualified workers at every stage of the “workforce pipeline.” I applaud your efforts and hope that we can learn from you because rural America is not alone in needing to address these issues.
We know that current education and training in behavioral health care often are not consistent with evidence-based practice, and there are no national core competency standards to ensure that minimum requirements are met. SAMHSA has undertaken a major Behavioral Health Workforce Development Initiative to meet this challenge.
[Slide 8—Workforce screenshot]
The centerpiece of our efforts is a Behavioral Health Workforce Development Resource Center to serve as a comprehensive Web portal for mental health and substance abuse treatment providers and the programs that employ them. When we launch the site later this year, it will contain a wealth of information on such cutting-edge issues as licensing, credentialing, education, employment, recruitment, retention, supervision, and leadership training.
If you are a behavioral health provider, you will be able to search for a job and build a resume. You will also have access to state-of-the-art education and training resources on such topics as recovery, consumer-directed care, and integration with general health care.
If you employ a behavioral health provider, you will find information on how to recruit the best and the brightest and help them succeed both in serving their clients and in meeting their own personal and professional goals.
We will use the Resource Center Web portal to host webinars on topics in behavioral health workforce development, and we’ll have an “ask the expert” feature. Information on the site will be updated daily.
As part of this project, we will also develop core competencies for behavioral health care providers who work with a full range of clients—from adults and older adults to women, children and families, and various ethnic and cultural minority groups. The Resource Center Web portal allows us to extend SAMHSA’s resources for workforce development to the most people, with the most current information, and in the most readily accessible manner. Watch the SAMHSA Web site at www.samhsa.gov for announcement of the portal’s launch later this year.
Collaboration
None of the activities I’ve outlined this morning can be accomplished by any one group, or agency, or Federal department working alone. I’ve read that “Dakota” is a Sioux term meaning “allies.” Today, we are all allies, joined together for the common purpose of promoting policies that will lead to healthy individuals, healthy communities, and a healthy Nation.
You may have heard the saying that collaboration is an “unnatural act between non-consenting adults.” In Washington, we’ve begun to turn this saying on its head. Since 2003, SAMHSA has led an unprecedented group of more than 20 Federal agencies and offices that have come together to help implement the goals and recommendations in the final report of the New Freedom Commission on Mental Health.
This alliance of Federal Partners created a Federal Executive Steering Committee, comprised of Assistant Secretary-level staff who can commit the resources and expertise of their agencies to the goals of mental health transformation.
Our efforts are not codified in law and they receive no special funding. We meet together willingly as concerned citizens, mental health and social service professionals, and stewards of public resources to transform the delivery of health care in this country. This is mental health transformation in action and it is happening here in North Dakota, as well.
[Slide 9—North Dakota sky photo]
Wrap-up and Conclusion
I’d like to leave you this morning where I began, with the North Dakota sky. More than any other place I’ve been, the sky in North Dakota appears limitless and full of possibilities.
Albert Einstein once said, “To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.”
With the work you are doing in North Dakota, you are advancing the science of what it means to be healthy in today’s society. You know that we must address the root causes of illness morbidity and mortality, including poverty, inadequate access to medical care, and racial and ethnic disparities.
You are using creative imagination to consider old problems in new ways. You know that we must design services to reflect individuals’ values and needs. These services must be of the highest quality, based on current evidence and practiced with fidelity to accepted models.
Most important, you see the real possibilities for people with mental health conditions and their families. You know that we must empower individuals to take charge of their recovery and their lives. And we must empower communities to provide the full range of services and supports that individuals need to live meaningful and productive lives. They deserve nothing less.
Thank you. If we have time, I’d be happy to take your questions.
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1Joanne Hoesel is Director of the Division of Mental Health and Substance Abuse Services in the North Dakota Department of Human Services (DHS); Carol Olson is the DHS Executive Director.
2The Mandan, Hidatsa, and Arikara Nation, also known as the Three Affiliated Tribes.
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