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

Coming Together, Working Together, Staying Together to Transform Systems of Care

May 18, 2007
New Orleans, LA

PowerPoint Version

Good morning. Thank you, Mr. Conrad, for that generous introduction and thank you for inviting me to be part of this important conference. It is rare for me to have the opportunity to speak to people from both the substance abuse and mental health fields. All too often, these fields function independently of one another, despite the fact that our work is intimately connected.

You and AHHAP are doing a remarkable job bringing together people to promote the recovery, rehabilitation, and rights of the individuals we serve. You are among the people in the world who already get it - who already understand that serving individuals who struggle with addictions and mental illnesses is about caring for people, helping them to improve the quality of their lives, and move toward recovery. I commend you for the important work you do.

The title of your conference says it all, “Working Together to Reduce Addiction.” To quote Henry Ford, "Coming together is a beginning, staying together is progress, and working together is success."

The need to come together and collaborate across our fields is clear. Co-occurring disorders present a serious challenge to our country’s public health.

Nationwide, about 5.2 million Americans have a co-occurring disorder. This is a staggering number of individuals who need integrated treatment. This number, however, pales in comparison to the number of individuals who already have one disorder and may be at risk of developing another disorder. The presence of either substances use disorder or a diagnosed serious mental illness appears to leave persons at high risk of developing the other.

As evidence, consider the overlap between mental illnesses and substance use disorders. Up to half of those with a diagnosable mental illness will develop a substance use disorder at some time in their lives. From a different perspective, individuals with a substance use disorder are almost three times as likely to have a serious mental illness as those who do not have a substance use disorder.

These individuals are members of our families and our communities. We interact with them daily in every aspect of our lives--in our homes, our offices, and our schools. These illnesses can destroy families and wreak havoc on careers and educational aspirations. Ultimately, these illnesses will affect us all in some way.

Co-occurring disorders place a heavy burden on our communities. Consider the costs—financially, socially, and personally. Treatment of co-occurring disorders frequently is long term and complex. In addition, individuals with co-occurring disorders are at increased risk for other serious medical problems, such as HIV/AIDS, hepatitis B, and cardiac and pulmonary diseases. As a result, they often require high-cost services, such as inpatient and emergency room care.

Co-occurring disorders also can result in homelessness and incarceration. An estimated 50 percent of homeless adults with serious mental illnesses have a co-occurring substance use disorder. An estimated 16 percent of incarcerated individuals have severe mental and substance use disorders. Among detainees with mental disorders, 72 percent also have a co-occurring substance use disorder. These statistics represent a tremendous financial burden on our communities. The costs rise even higher as individuals with co-occurring disorders recycle through our health care and criminal justice systems again and again, as we know to happen.

These are just some of our communities’ more direct expenditures. What about the losses to communities when individuals fail to realize their full potential? What happens when an individual with a co-occurring disorder drops out of school, or becomes unemployed? The consequence is that we lose, in part or in whole, the contributions that they could have made to our communities.

Providing a quality life in the community for everyone is our primary vision at SAMHSA. It is what drives all of us who have chosen this as our life's work. It guides us on our mission to build resilience and facilitate recovery.

In most systems of care, treating co-occurring disorders presents a unique challenge. Nationally, only about half of individuals with co-occurring serious mental and substance use disorders receive treatment of any kind. Only an eighth of those receiving care receive integrated treatment! Why? Individuals with co-occurring disorders most often face two distinct systems of specialty care. They bounce between systems, receiving sequential treatment, at best, and with neither system being fully capable of diagnosing and treating a dual disorder. A behavioral health orientation opens doors between the two systems.

You—the people in this room—represent the change in orientation that needs to occur across the country. You are here because you have the power to begin to bridge services between the mental health and substance abuse systems, and provide persons with co-occurring disorders with the comprehensive, integrated treatment they need.

The implications of integrated treatment are far reaching. Integrated treatment requires changes at all levels, from administrative to clinical. Both mental health and substance abuse providers must be cross-trained to screen, address, and respond to co-occurring disorders. Any person seeking care for either or both disorders must be accepted and actively engaged no matter which door he or she walks through.

Every point of contact is an opportunity to give consumers hope in recovery. When they are ready to accept treatment, we must be ready to provide it. Coordinated workforce development is a necessary and pivotal change to ensure that any door becomes the right door to effective treatment.

As you recognize, all of this requires a major mind shift in how our Nation currently addresses co-occurring disorders. It calls for dramatic changes in policies, practices, and funding schemes. It demands better coordination of services across systems that traditionally have held different philosophies of treatment. It requires greater collaboration. It demands transformation.

Now, transformation is an enormous concept. It connotes a complete upheaval and reorganization of what we know, what we do, and how we are used to doing it. Ultimately, transformation is about newness—about new values, new attitudes, and new beliefs. . . about what we can accomplish now that we were unable to do before.

Transformation is not simply a fancy word for reform. It is far more encompassing than that. Transformation calls for fundamental change at the very core of the system, and not on the margin. Transformation is meant to identify, leverage, and even create new underlying principles for the way things are done. New sources of power emerge. Once transformation begins, a profoundly different system materializes—a system changed in structure, culture, policy, and programs.

Why is a transformed system necessary? Let me share a story with you that explains it well… My friend and the former SAMHSA Administrator Charley Curie was a new graduate, working as a therapist helping consumers make the transition from in-patient care in State hospitals back into the community. When he asked his aftercare group what they needed most to make a successful transition, they didn't say they needed a psychiatrist…or psychologist…or a social worker. One consumer said it very clearly, when he commented, "I need a job, a home, and a set of relationships."

This is the goal of the transformed, consumer-centered, recovery-focused health system—a life, a quality life, with all of its rewards. Achieving this goal is not a step-by-step process, but one based on continual growth, occasional setbacks and learning from experience. Recovery should be strengths-based, focusing on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of the individual. With help and support, individuals with co-occurring disorders can, in fact, lead stable, fulfilling lives.

The treatment of mental illnesses and substance use disorders has a host of challenges—separate delivery systems, administrative structures, eligibility criteria, and funding streams as well as limited resources for both mental health services and substance abuse treatment.

Treating people with co-occurring disorders also includes addressing physical health problems. Research tells us that people who have been diagnosed with co-occurring disorders often have physical health problems or are at high risk of developing them. These health problems are going to complicate treatment of and recovery from co-occurring disorders. By the same token, co-occurring disorders are going to complicate treatment of and recovery from physical health problems.

Treating co-occurring disorders with integrated treatment can improve patients’ interest and ability to care for themselves. This can engage them in following their primary care provider’s directions and advice, particularly about taking medications. It can transform their hope in recovery or bolster their ability to cope with illnesses from which there is little chance of recovery.

This treatment approach is part of the transformation of the mental health system. It is a broad-based approach that SAMHSA has adopted to introduce fundamental change in the way mental health services are perceived, accessed, delivered, and financed. This action agenda identifies the first steps that SAMHSA, in partnership with agencies from nine Federal departments, will take to guide mental health transformation.

Our agenda is built around the goals laid out in the final report by the President’s New Freedom Commission on Mental Health. In a transformed system:

• Americans understand that mental health is essential to overall health.
• Mental health care is consumer and family driven.
• Disparities in mental health services are eliminated.
• Early mental health screening, assessment, and referral to services are common practice.
• Excellent mental health care is delivered and research is accelerated. And
• Technology is used to access mental health care and information.

These are lofty goals that require comprehensive and collaborative strategies to achieve. But they are necessary. When the New Freedom Commission began examining our current system, they discovered that services were so fragmented, disconnected, and often inadequate that piecemeal reform would not be enough. The only way that our Nation could address this public health crisis was through a fundamental transformation to our mental health system.

This transformation is what we’ve been working towards. Last year, SAMSHA unveiled a consensus statement outlining the principle components of mental health recovery. The statement was developed through the deliberations of more than 110 expert panelists representing mental health consumers, families, providers, advocates, researchers, managed care organizations, State and local public officials, and others. We examined topics like recovery across the lifespan and recovery in different cultural contexts. We considered how recovery applied at individual, family and community, provider, organizational, and systems levels.

Our meeting led to this consensus definition of recovery for adults. “Mental health recovery is a journey of healing and transformation for a person with a mental health problem to be able to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential.”

The process of recovery builds on the strengths of each individual. It is nonlinear and self-directed. It is holistic and person-centered, and it involves personal and community respect, responsibility and hope. It empowers consumers to make decisions that impact their lives. It recognizes the valued role of consumers in supporting and encouraging others as they continue on their own journey toward recovery.

Recovery is not an end point. Our definition implies a continuum of support...and a breadth of services that acknowledge the whole person and not just the disorder. The scope of this definition changes our entire perspective on how we should provide care.

The Consensus Statement offers 10 fundamental components of consumer-driven recovery. The first is self-direction— recovery that is self-directed by the individual, who defines his or her own life goals, and designs a unique path towards them. Second...is recovery that is individualized and centered on the person. With multiple pathways to recovery, each individual’s unique strengths and resiliencies, as well as his or her needs, preferences, experiences, and cultural background play a role in determining his or her particular path.

Consumers must also be empowered. They must have the authority to choose from a range of options and to participate in all decisions affecting their recovery, including the allocation of resources. Care should be holistic. Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Housing, employment, education, mental health care treatment and services, addictions treatment, spirituality, creativity, social networks, community participation, family supports—all of these elements are part of the recovery process.

Recovery is non-linear. It is not a step-by-step process, but one based on continual growth, occasional setbacks and learning from experience. Recovery should be strengths-based, focusing on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of the individual.

Peer support is critical... including the sharing of experiential knowledge and skills and social learning, and providing encouragement and a sense of belonging.

Respect is at the heart of the recovery process, both self-respect and the respect of the community. Self-acceptance and regaining belief in one’s self are vital. Consumers have a personal responsibility for their own care and their own journeys of recovery. It may take great courage to take the steps necessary. Consumers must strive to understand and give meaning to their experiences, as well as to identify their coping strategies and healing processes.

And finally, there’s hope...the catalyst of the recovery process. Recovery provides the essential and motivating message of a better future—that people can and do overcome the barriers and obstacles that confront them. Each of you, through your contact with persons who have addictions to substances and mental illnesses, can deliver hope. You have the power to help consumers understand and truly believe that they can recover.

Research and practice consistently confirm the value of the hope of recovery, regardless of a person’s condition. In his book, The Anatomy of Hope, Dr. Jerome Groopman describes the essential relationship between hope and healing. “Hope” he wrote, “is a search for freedom, both a freedom of the body shackled by disease and a freedom of the spirit to assert its dignity, of having some level of control over one’s life….To hope under the most extreme circumstances is an act of defiance that permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.”

I am here today to issue a call to action. To ask you for your help in transforming our nation’s mental health care system so that we can better serve people with co-occurring disorders and help them to believe that recover is achievable. We must ensure that patients have access to integrated treatment no matter where they enter the system—substance abuse treatment center or mental health facility.

What can you do to help in this transformation? Let me give you three ideas…

First, learn more about co-occurring disorders. SAMHSA supports the Co-occurring Center for Excellence, or COCE. COCE provides technical, informational, and training resources needed to promote the adoption of evidence-based practices in systems and programs that serve persons with co-occurring disorders. Their Web site is a valuable resource with a wealth of information and downloadable materials.

Second, seek out resources that can help you to better screen and assess patients for co-occurring disorders, and, most importantly provide appropriate treatment for these disorders. We have prepared several resources at the Federal level to help you.

We have been producing and disseminating evidence-based practices for treating co-occurring disorders. “TIP 42” is a treatment improvement protocol for persons with co-occurring disorders. It addresses treatment of co-occurring disorders from the substance abuse treatment perspective.

The Center for Mental Health Services also has produced an evidence-based practice “toolkit” to address treatment of co-occurring disorders from the community-based mental health side. Our toolkit is called Co-occurring Disorders: Integrated Dual Diagnosis Treatment. It includes the resource materials needed by providers to replicate the evidence-based practice, including implementation guidelines and fidelity measures. The kit is still being refined, but portions of it are available now on our Web site.

For the record, we have received more requests for the integrated treatment kit than for any other kit. States and communities clearly are seeking guidance on how best to serve consumers with co-occurring disorders. I’m elated that more providers are recognizing integrated treatment as the best practice available

We have additional evidence-based toolkits that are valuable for treating persons with co-occurring disorders. For example, most of these individuals will require medication for their mental illness, so medication management is important. Some will have employment as a goal for recovery, so supported employment is important. Families play a central role in sustaining an individual on his or her journey toward recovery, so family supports are important. Toolkits are available online at the Center for Mental Health Services Web site: www.mentalhealth.samhsa.gov.

Third, get additional training in the assessment and treatment of co-occurring disorders. The Addiction Technology Transfer Centers (ATTCs) are a nationwide, multidisciplinary resource. They transmit the latest knowledge, skills, and attitudes of professional addiction treatment practice. Launched by CSAT in 1993, the ATTC network comprises 14 regional centers and a national office that help treatment systems adopt or adapt evidence-based practices for people with substance use disorders, including those with co-occurring mental illnesses.

These three action steps are part of the cycle of science and service. Evidence-based practices represent excellence in treatment. Excellence, however, is not an end state. Instead, excellence is an ongoing process of improvement, refinement, and adjustment to a changing world. Just think about recent advances in the mental health field—better medications, more effective psychotherapies, the absolutely transformational notion that the goal of treatment is not symptom management but recovery! Each advance has changed our perspective on what is the best care available.

The behavioral health field has a rich investment in research to draw upon when providing evidence-based practices. SAMHSA is working to enrich this knowledge base by offering Co-Occurring State Incentive Grants (COSIGs). We’ve awarded 17 grants, totaling more than $35 million over the last 4 years. These grants not only increase services to persons with co-occurring disorders and their families, but they also help teach us what works when it comes to treating co-occurring disorders through collaborative, consultative, and integrated models of care.

Louisiana was part of our first round of grantees back in 2003. This State has been doing incredible work. They have a training curriculum to provide an 8-hour overview of treatment of co-occurring disorders to mental health and substance abuse staff. They have conducted 35 sessions with more than 1900 participants! Louisiana also has developed a shared data warehouse between substance abuse and mental health divisions that allows them to make the best use of common resources. I understand that their next steps include a central client registry that will improve integrated treatment options. All of these advances increase the quality and effectiveness of services.

We all must continue to increase the dividends for consumers by using service to inform the sciences we provide. We must reinvest what is learned through clinical practice to further develop the science and to fill in voids in the knowledge base.

Those voids are most effectively filled when we come together to share ideas, challenges, and lessons learned. Sometimes we work together voluntarily, other times, circumstances thrust us into collaboration.

Twenty months ago, this wonderful city was hit by Hurricane Katrina. In the aftermath of great tragedy, people found ways to pull together. SAMHSA was no different. Katrina challenged us to collaborate more effectively…to make greater use of active community outreach and other proven case management models…and to quickly increase capacity to respond to mounting demands for services. Katrina prompted us to strategize about how to meet the need for immediate assistance while assessing how to rebuild the mental health system in the affected areas in the right way. Katrina challenged us to carefully consider how to invest dollars in evidence-based practices that we know are going to work, and to put the incentives in the right place as these systems are being rebuilt.

We cannot wait for tragedy to bring about transformation. An unprecedented window of opportunity is opening…right now. We’re moving steadily forward along the road to mental health system transformation. Transformation is happening. It is real. From California to Connecticut, promising models of transformation in behavioral health are being developed and piloted. Together with our Federal Partners, SAMHSA and CMHS are taking realistic action steps to motivate, facilitate, and compel change at the Federal, State, community, and individual levels.

But we cannot do it alone. All of us…at the local, State, and national level…must advocate for the transformed mental health system that will give people with co-occurring disorders access to the full range of services they need to recover. We must make sure that whether they enter the door of a substance abuse treatment center or a mental health clinic, that any door becomes the right door for individuals seeking treatment.

A recovery-focused system is within our grasp. Never before have we known so much about co-occurring disorders and how to enable individuals with addictions and mental illnesses to live, work, go to school, and participate fully in their communities. Never before has science given us such powerful evidence-based tools. Never before have consumers and their families rightfully been allowed to demonstrate the amazing healing power of self-direction and peer-support. We stand now at the threshold of a system of care in which recovery—not disability—is the expected outcome. That is truly great progress.

You’ll recall that I began today by quoting Henry Ford, "Coming together is a beginning, staying together is progress, and working together is success." We’ve come together. We’re making progress. It’s time to work together so that success—the success of recovery—comes to those we serve.