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

Meeting of the IIMHL
Leading Transformation: Lessons Learned in the United States


Edinburgh, Scotland
June 8, 2006

PowerPoint version

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]

Good afternoon. I’ve been asked to present the Federal perspective on managing behavioral health care transformation in the United States. This would be an easier topic if the United States could be described as one culture…one country…or even as one political framework.

Transformation management in the United States presents all of the challenges faced by other countries, only magnified. Our population is nearly 300 million individuals. More than 15 million have a serious substance abuse disorder; more than 15 million have a serious psychological disorder. The number of individuals with serious dual-diagnosis disorders is more than 4 million. In contrast, the entire population of Scotland is a little more than 5 million.

[SLIDE 2. Map/faces of diversity]

We have 50 States as well as territories and protectorates. Each one has its own identity as well as its own challenges in providing appropriate services. These challenges may be demographic, such as an ethnically diverse population. Our citizens are incredibly diverse, wi th growing percentages of African Americans, Hispanics, Asians, and other racial and ethnic groups. Within the next half century, more than half of the U.S. population will be people of color. The fastest percentage growth is among our Hispanic population, with its own unique culture and language. Several of our States already are what we term “majority-minority,” which means that most of the population is made up of racial and ethnic groups.

The challenges to service delivery can be geographic, such as when a State is largely rural or urban. In some of our more rural States, such as Alaska, behavioral health services can be located hundreds of miles away from the individuals who need them. How does a State respond adequately to the needs of individuals with behavioral health challenges when treatment is a day’s drive away? Conversely, how does a State provide sufficient services when the sheer number of individuals who may need services is overwhelming? New York City, for example, has more than 26,000 people per square mile.

The service demands on a State’s resources may be known, but the State may be scrambling to find adequate funding. California is our most populous State, with 36 million residents—12 million of whom are Hispanic. Last year, California took the unprecedented step of levying a new tax on the very wealthy specifically to pay for more comprehensive mental health services.

Some service demands are unprecedented, and therefore can’t be anticipated. New York is still dealing with the aftermath of the terrorist attack on 9/11. A recently released study by our American Red Cross found that two-thirds of people who received therapy following the attack are still grief stricken. Half the children of families in treatment are still psychologically scarred, participants said. This is 5 years after the terrorist attacks!

We all are well aware of the potential long-term impact of trauma on survivors. What does this say about the difficulty of allocating discretionary funding among the States? There is a continuous need for additional behavioral health care resources in New York…and in New Orleans, Louisiana. After Hurricane Katrina, hundreds of thousands of individuals lost families, friends, and communities—everything that represented their home and security. Thousands of other States absorbed survivors of the storm. Houston, Texas, alone, took in more than 150,000 evacuees. The behavioral health needs of the survivors are staggering.

Adding to the challenge of leading behavioral health care transformation is our political structure. In many ways, achieving consensus among States is similar to reaching an agreement within the European Union. Each of our States is governed by its own legislative body, with its own priorities and constituency to please. Even though the Federal government awards a mental health block grant to each State each year, the States have wide latitude in how the funding is spent. Decisions about what services will be provided and who will have access to them are State decisions. As a result, we at the Federal level have to be extraordinarily sensitive to the differences between States. Our opinion matters most when we can provide informed guidance.

The challenges faced in managing behavioral health care transformation in the United States are enormous! My role as director of the Center for Mental Health Services is to inspire, facilitate, or compel change at the State level. But how do I ensure that changes being pursued by the individual States reflect national values and leadership efforts? How do I ensure that the States, territories, or protectorates embrace the concept of recovery? How do I inspire them to make greater use of the tools of recovery: that is, evidence-based practices, individualized plans of care, and social inclusion?

The answers lie in leadership…and in learning from each of you how to lead change effectively. A primary purpose of the International Initiative for Mental Health Leadership (IIMHL) is to identify strategies that can work across continents and cultures. We can share as many solutions as challenges. I believe absolutely in the promise of the IIMHL to guide universal change. My belief is so strong that I have used my Federal dollars to commission a comparative study of policies, frameworks, and strategies used to support behavioral health care transformation in different countries. The study, which remains a work in progress, is called “International Pathways to Behavioral Health Systems Transformations: Strategies and Challenges.”

I’m very excited about the potential of this study to identify common themes in transformational leadership. We hope to be able to answer these questions: What are the absolute active ingredients for change in Scotland, or England, or the United States? What is common to all countries in terms of the leadership needed to ensure the basic elements of recovery? I’m speaking here about ensuring the basic rights of consumers. These rights include the right to direct their own care…to remain and be socially included in their communities…and to be respected as valued and contributing members of society.

We have a recognized need for leaders who can operationalize transformation. Our job is see that the right policies are in place so that the best services are provided. However, we face a curious dichotomy in trying to carry out this responsibility. We are government officials. As such, we function in an environment that values stability and maintaining the status quo. This, in and of itself, can be good. There is strength in stability, and the public rightfully places its faith in institutions that hold fast to their mission. But what if the mission remains the same, but the right policy becomes radically different? We saw such a reversal in policies and practices when we began moving from mental institutions to community-based services.

What does this dichotomy imply about our ability to be innovative? I’d like to read a passage from The Art of Possibilities: Transforming Professional and Personal Life, by Rosamund and Benjamin Zander. The authors’ assessment of business practices applies equally well to government policy. The authors wrote, “Standard social and business practices are built on certain assumptions—shared understandings that have evolved from older beliefs and conditions. While these conditions may have changed since the start of these practices, their continued use tends to reconfirm the old beliefs. For this reason, our daily practices feel right and true to us, regardless of whether they have kept up with the pace of change.” This passage sums up where most behavioral health institutions are now—trying valiantly to realign aging policies with evolving reality.

Consider the concept of recovery. Many of our current policies and practices are based on an old—and erroneous—assumption. What is the assumption?—that individuals can not recover from serious mental illnesses. The evolving reality?—People can recover; people do recover. We simply must transform our policies and practices to reflect this new reality.

I’d now like to share with you some of what we are learning in the United States about the role of leadership in transformation.

[SLIDE 3. Transformation wheel]

Dr. Noel Mazade is the executive director of the National Association of State Mental Health Program Directors Research Institute. This institute supports the efforts by our States to improve the quality and accountability of their behavioral health service delivery. At SAMHSA’s request, Dr. Mazade identified the most tangible competencies of transformational leadership.

[SLIDE 4. Personal development]

I’d like to highlight continuous personal development as a core competency of a transformational leader. Dr. Mazade’s assessment of desired traits includes this one: the ability to demonstrate personal values, vision, and goals. Leadership is character. It’s not a superficial role that we can take on and off. It has to do with who we are and the forces that have shaped us. Our actions as well as our words send daily messages about our personal commitment to visions, goals, and priorities. If we only talk the talk and don’t walk the walk, the people we manage…or hope to inspire…will stop listening, and quit following.

Dr. Mazade also noted that transformation leaders must be courageous enough to take risks and be resilient and resolute in pursuing their vision. Transformation management implies that we, as leaders, develop these same traits in others and at every level of our organization. True change…continuous and sustainable change…occurs when many become dedicated to achieving the transformational vision…whether or not we ourselves continue in our current positions. Charlie Curie will soon step down as SAMHSA’s administrator, but his vision of a life in the community for everyone will be carried on by myself and others that he has inspired. The responsibility of leaders is to create other leaders, at all levels of the system.

[SLIDE 5. Eight steps of change]

Transformation management, like transformation itself, is a continuous process. In his book entitled Leading Change, John Kotter describes eight steps in leading positive change.

[SLIDE 6. First phase]

First, he says, leaders must create a climate for change that drives people out of their comfort zones. We do this by increasing the sense of urgency about the challenges we face so that people are compelled to contribute the extra effort that is essential to creating something new. The next step is to build a guiding team to begin work on possible solutions. The right vision is crucial to the process as well.

[SLIDE 7. Federal partners workgroup]

In terms of America’s mental health care transformation efforts, SAMHSA has been working to create a climate for change by broadening the number of departments and agencies directly involved in transformation. Nine Federal departments, the Social Security Administration, and the Equal Employment Opportunity Commission now are members of our Federal Partners Workgroup for Transformation.

Each of these departments and agencies plays its own distinctive role in promoting and protecting the mental health of consumers. Each is essential for providing the variety of services that help people to achieve and sustain recovery…including a home, a job, and other reflections of social inclusion.

We are finding that change of the magnitude we seek demands an entirely new kind of leadership within each partnering organization. We need leadership capable of changing the very language used to speak about behavioral health. Old language cannot convey new ideas. This tenet is behind many of the actions that SAMHSA has taken recently, such as developing a consensus statement on the meaning of consumer-driven recovery and launching a multimedia anti-stigma campaign. Copies of our recovery consensus statement are available to you at this meeting.

[SLIDE 8. Second phase]

The second phase Kotter identifies is engaging and enabling the whole organization. He suggests that the following steps must take place to achieve this goal: Leaders must communicate so that all of those involved will buy into the process…they must empower action on the part of those around them…and they must create short-term wins to keep people motivated and spur them on.

[SLIDE 9. Third phase]

The last phase is implementing and sustaining change. These are huge considerations for mental health care transformation. How do we engage a sufficiently broad-based coalition to deliver coordinated, comprehensive services? How do we build an infrastructure that will support and sustain collaborative decisionmaking over time? Kotter puts it very succinctly: He says, don’t let up and make it stick.

[SLIDE 10. Federal action agenda]

We’re working hard in the United States to embed transformation across the many systems involved in behavioral health care. At the Federal level, we have established accountability for change through our Federal action agenda. This document outlines the steps we will take to achieve the transformation goals of the President’s New Freedom Commission on Mental Health. We have created a Federal Executive Steering Committee of senior administrators from each of the departments and agencies involved. This committee is charged with seeing that we don’t let up in moving our agenda forward.

Several months ago, the Center for Mental Health Services launched a new mental health transformation grant program. We awarded 5-year grants to seven States. The program is aimed at radically transforming the State infrastructure to better support treatment and services for people with, or at risk for, mental illnesses. The process through which the States are going about transforming their systems is itself transformative.

We did not award the grants to the State mental health authorities. Instead, we awarded the grants to the Offices of the Governor to emphasize that mental health concerns cut across all agencies responsible for human services. Each Governor appointed executive leaders of all relevant State agencies to a Transformation Working Group that will lead the process of transforming the State systems. These steps mirror Kotter’s model for change, particularly in building a guiding team that can shape and promote the right vision.

So, is transformation occurring in these States? The answer is a resounding “Yes!” Let me share a few examples.

[SLIDE 11. State location/example]

Washington State is reducing disparities of care. A major challenge in Washington State is the wide disparity in the availability of mental health services between urban and rural areas. Washington is developing a telehealth program to provide quality mental health services in areas where they are not available.

[CLICK for second State]

Connecticut is creating a network for more comprehensive services. Connecticut is responding to the need to integrate the efforts of several service systems to eliminate duplication or gaps in services. When Connecticut applied for a Mental Health Transformation grant, it brought together 14 State agencies, such as mental health, housing, justice, labor, aging, and education. These agencies signed a memorandum of understanding that they would work together to find better ways to collectively address the comprehensive needs of individuals with mental health problems.

[CLICK for third State]

Ohio is making services more consumer and family driven. Pending legislation in Ohio will require an advocate for the families of children and youth with behavioral health challenges. The advocate will assist the families during treatment planning meetings by helping to educate and inform them about treatment options. The ultimate purpose of the advocate will be to empower the family and youth in choosing the best possible treatment approaches.    

These are just a few examples of ongoing transformation in the United States. Each State is taking a different approach to transformation, based on its resources and the needs and desires of its constituents. This diversity is its own challenge to leading transformation in the United States. The seven States that received transformation grants will be role models for other States to follow—even though their circumstances may differ significantly. As a leader, I must be able to inspire the States to celebrate the differences…to help them understand that their vision of transformation and the steps they take to achieve it can be…in fact, must be…as diverse as the needs of the individuals they serve.

Of course, the differences must fit within the recovery vision. There are certain commonalities of the transformation vision that transcend all geographic boundaries. In every State…or country…there is a need for care that is holistic, culturally competent, and respectful of the individual. Ultimately, we should be able to extend this vision beyond our boundaries to leaders in the developing world. The language of recovery must become universal.

[PAUSE]

I’m delighted to have had this opportunity to share some of my observations about transformation management in the United States. I look forward with great anticipation to hearing your ideas throughout this conference. We in the IIMHL can gain strength and inspiration from each other as we celebrate the progress we each make. We can encourage each other to do more, for we must continue to change as our knowledge expands.

[SLIDE 12. Churchill quote]

Our need to guide continuous improvement will never change. But, as Winston Churchill observed, there is a particular joy in the endless pursuit of excellence. Churchill remarked, “Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever-lengthening, ever-ascending, ever- improving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb.” In closing, I can only add that I am grateful for the support and company of the IIMHL as I lead the United States up the ever-improving path to better behavioral health care.

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