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

Partners For Recovery: Putting The Individuals We Serve First
Sponsored by Alcoholism and Substance Abuse Providers of New York State

June 14, 2007
Albany, NY

PowerPoint Version

[SLIDE 1. Title slide]

John Coppola [ka-POLE-a] invited me here to discuss Partners for Recovery (PFR), an initiative of the Substance Abuse and Mental Health Services Administration, or SAMHSA. Dr. Coppola is a highly valued member of the PFR steering committee, which provides the program with guidance and leadership. Many thanks to Dr. Coppola for his efforts. With his help, the PFR program is spreading the message that recovery is a realistic goal for individuals with a substance abuse disorder.

I’ll describe our PFR initiative in a few minutes, but first I’d like to tell you a story. This brief tale illustrates a key point I want to make today, which is the need for the mental health and substance abuse fields to be more strongly united in promoting recovery.

My story is about “Kate,” a participant in SAMHSA’s “Women, Co-Occurring Disorders, and Violence Study.” Her story, and many others like it, can be found in our newly released document entitled, “It’s My Time to Live: Journeys to Healing and Recovery.” Kate’s name is fictitious, but her experiences and her hopes of overcoming her disorders are real. This is how Kate describes her early life.

"When I was a kid, I couldn't control my mother mentally abusing me, I couldn't control my father physically abusing me, and I couldn't control my brother sexually abusing me, and it's like I couldn't control anything. It got to the point where it was either move out or check out. I couldn't move out as a little kid, so I just got high. You know, you just want to feel better. So I was high most of the time from age 11 'til age 37.”

Similar to many individuals who have a substance abuse problem, Kate also has a mental illness. And, like so many others, her undiagnosed and untreated mental illness complicated and undermined her attempts to overcome her addiction. In Kate’s words,

“My job supervisor got me to admit I had a problem. I went to the ER and then to an inpatient program where they put me on methadone. And when I got out, I wasn't addicted anymore physically, but mentally I wasn't capable of staying clean for 24 hours — I couldn't do it…I relapsed and went into detox….I got out; I relapsed again….The more you have the memories and the flashbacks of trauma, you just want to check out. I mean, I was self-medicating because of the trauma and being bi-polar… I was ODing constantly; in an out of the ER.”

Eventually, Kate was referred to Women Embracing Life and Living, or the WELL Project. The WELL Project delivers integrated care to women with co-occurring mental health and substance abuse disorders who also have been physically or sexually abused. The program saved Kate’s life, while helping her change her life. With proper diagnosis, medication and integrated care, Kate has hope for her recovery. She has begun to believe in her own potential and her own ability to deal with the challenges of life that lay ahead. She is able to say, “If [my providers] found something in me worth saving, then maybe I’d better try doing it myself. Maybe there is something worth saving.”

[SLIDE 2. Mental health/substance abuse overlap]

Kate is one of millions of Americans with or at risk of developing co-occurring disorders. According to SAMHSA’s National Survey on Drug Use and Health, more than 24 million American adults experienced serious psychological distress in 2005. More than 22 million were dependent on or abused substances. These substance abuse disorders also are mental illnesses, as defined by the Diagnostic and Statistical Manual of Mental Disorders.

The risk for co-occurring disorders among these two groups is extremely high. Up to half of those who have a serious mental illness will develop a substance abuse disorder at some time in their lives. Individuals who have a substance abuse disorder are almost three times as likely to have a serious mental illness as those who do not a have a substance abuse disorder.

We don’t know why so many individuals are vulnerable to both disorders. Scientists are searching for a common genetic cause, but have yet to identify one. Growing evidence, however, points to a disturbing relationship. Some serious mental illnesses appear to increase a person’s risk for substance abuse. Substance abuse appears to worsen or hasten psychiatric disorders in persons who are genetically predisposed to mental illnesses.

Certainly, the two disorders share risk factors, such as childhood abuse and trauma. Like Kate, many individuals report that they first started using drugs to escape mentally from traumatic situations and memories. Some — whose mental illness has been identified — abuse substances to lessen the loneliness, discrimination and loss of self-worth too often associated with their diagnosis.

Whatever the cause, a relationship between mental illnesses and substance abuse is clear…and strong…and urgently underscores our need to coordinate prevention and treatment efforts. Fifty to 75 percent of patients in substance abuse treatment programs have co-occurring mental illnesses. Twenty to 50 percent of those treated in mental health settings have co-occurring substance abuse disorders. Co-occurring disorders are so common that they should be considered the norm and not the exception in persons seeking treatment in behavioral health settings.

[SLIDE 3. Treatment of Disorders]

But…while millions of Americans have co-occurring disorders, more than half receive no treatment for either disorder. Only a tiny fraction of them — about eight percent — receive integrated treatment, which offers the best hope for recovery.

Why? Although the reasons are complex, the common theme is systemic barriers to integrated treatment and support services. What are these barriers? — Separate administrative structures, treatment philosophies, eligibility criteria, and funding streams…compounded by limited resources for both mental health services and substance abuse treatment.

For the sake of the people we serve, the mental health and substance abuse fields must become true partners in recovery. Vision, collaboration and leadership are needed to bring about this transformation.

I’m using the word “transformation” rather than “reform” deliberately. Transformation implies a profound change at the core of our behavioral health system rather than piecemeal improvements around its margins. Transformation ultimately is about newness — about new values, new attitudes, and new beliefs that are expressed in the changed behaviors of people and institutions. As partners for recovery, we won’t be trying to perfect the status quo. Instead, we will be creating a vastly different reality — one that puts the individuals we jointly serve first!

When consumers come first, who or what will come last? The answer is “a host of outdated values, attitudes, and beliefs.” Banished to the back will be bureaucratic boundaries, professional competition, exclusionary treatment protocols, silo-delivered services, and care that does not have the consumer at its heart.

[SLIDE 4. Transformed approach]

Transformation of the behavioral health system, however, goes far beyond a partnership between mental health and substance abuse professionals. A transformed approach to behavioral health care will involve a broad-based coalition of service systems. This coalition also will include criminal justice, education, and labor, and other systems that serve children, adults, and families. It will be based upon a unified approach to treatment, with an emphasis on integrated, trauma-informed care. There will be “no wrong door” for entry into care. Early intervention and prevention across systems will reduce the incidence and severity of illnesses, including behavioral disorders.

I’m going to add one note to this last point. Individuals with serious mental illnesses have a life expectancy that is 25 years less than individuals without an illness. The causes are many, but poor health — and particularly cardiovascular problems — are the primary reasons. Poor health complicates recovery from both mental and substance abuse disorders. Primary care absolutely must be our partner for recovery. Michael Hogan, your commissioner of the Office of Mental Health, summed up the relationship in these words: “We know that mental health is critical to overall health, but also that mental health recovery requires overall wellness.”

[SLIDE 5. PFR Initiative]

PFR — SAMHSA’s initiative to transform behavioral health services and systems — addresses all of these concerns. PFR was launched in 2003 by SAMHSA’s Center for Substance Abuse Treatment. The center first conceived PFR as a way to engage a variety of organizations and systems in efforts to improve addiction treatment and to support individuals in recovery. In 2005, PFR was broadened from a focus on addiction treatment to be a SAMHSA-wide initiative.

This shift reflects SAMHSA’s emphasis on co-occurring disorders…which is one of our four highest priority programs, and on cross-system collaboration…which is our model for service improvement at the state and community levels. Our PFR steering committee now includes representation from all three disciplines: substance abuse treatment, substance abuse prevention and mental health.

[SLIDE 6. PFR goals]

PFR has five major goals. These are to

1. Define recovery and provide strategies and tools to support a recovery-oriented system,
2. Foster collaboration among the various systems that affect those with substance abuse disorders,
3. Reduce the stigma associated with addiction,
4. Maintain workforce competency to ensure quality care and to support recruitment and retention strategies to ensure a viable workforce, and
5. Develop leadership within the treatment field.

All three of SAMHSA’s centers — the Center for Substance Abuse Treatment, the Center for Substance Abuse Prevention, and my center, the Center for Mental Health Services — collaborate on programs to achieve the goals of the PFR initiative. I’m going to highlight a few of the PFR programs. My focus is on programs related to the three essential ingredients of transformation that I just mentioned: vision, collaboration and leadership.

[SLIDE 7. Defining the Vision]

Robert Collier, the author and publisher, wrote that “Vision reaches beyond the thing that is, into the conception of what can be.” I believe that true vision reaches even farther, until it conceives of how things should be. In transformation…in conceiving of a behavioral health system that is consumer driven and focused on recovery…we have the vision that guides the PFR.

Crucial to achieving this vision is a universal understanding of what is meant by “recovery.” The language we use to discuss recovery, or to define a “recovery-oriented system,” is important. Language conveys ideas. As SAMHSA moves forward with transforming the behavioral health care system, we have found that old language cannot convey new ideas. We are creating a new way to think and speak about recovery — one that incorporates such radical new concepts as consumer-driven and person-centered care.

In September 2005, PFR convened more than 100 stakeholders at a national summit on recovery. These were the goals we set for the participants.

[SLIDE 8. National recovery summit goals]

• To develop new ideas for policies, services, and systems that can help create a recovery-oriented system;
• To articulate guiding principles and measures of recovery that can be used across programs and services so that we can make it easier to share data, capture improvements, and enhance program coordination; and
• To generate ideas for advancing recovery-oriented systems of care in various settings and systems, such as criminal justice, and for specific populations, such as individuals with co-occurring disorders.

The outcome of our summit was a broad-based consensus on a definition of recovery, its guiding principles, and the elements of a recovery-oriented system.

[SLIDE 9. Recovery definition]

This is the working definition of recovery that evolved from the summit:

“Recovery from an alcohol and drug problem is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.”

[SLIDE 10. Guiding principles] [PAUSE briefly for reading]

The guiding principles of recovery are broad and overarching. They give a general direction for a recovery-oriented system of care and for developing core measures and evidence-based practices.

[SLIDE 11. PFR Web site]

The full report from the national summit on recovery is available on the PFR Web site. Take time to read it. The report discusses in more detail the guiding principles of recovery as well as the elements that define a recovery-oriented system.

This is a brief summary of the elements arrived at by the summit participants. Recovery-oriented systems of care are as complex and dynamic as the process of recovery itself. Such systems are designed to support individuals across the lifespan who seek to overcome substance abuse disorders. They are comprehensive, flexible, outcome-driven and uniquely individualized. They offer a fully coordinated menu of services and supports to maximize choice at every point in a person’s recovery process.

[SLIDE 12. Collaboration]

The elements of a recovery-oriented system do more than define it: they also emphasize the broad-based collaboration that will be essential to system-wide transformation. In a truly collaborative system, all stakeholders will come to recognize the interdependence of their goals. This recognition can lead to an effectively coordinated continuum of care, with greater efficiencies in services and improved consumer outcomes. Through collaboration, your state can “manage” care while still ensuring that the people you serve can receive an appropriate level and duration of care.

Collaboration will enable New York and other states to achieve the goals of a recovery-oriented system of care. Such a system will:

[SLIDE 13. Recovery-oriented systems of care]

• Provide and encourage greater access to a variety of services and supports,
• Intervene early with individuals with or at risk of mental and substance abuse disorders,
• Improve prevention and treatment outcomes, and
• Support long-term recovery for those with mental and substance abuse disorders.

Let’s spend a moment on the first point: greater access to service and supports other than clinical treatment. Putting the people we serve first implies a holistic view of each individual’s unique recovery needs. Ideally, the services we offer will include the many facets of a person’s health and wellness, such as their physical, social, emotional, spiritual and intellectual needs. All of these facets help to define a person’s sense of self-worth and place within the community.

A holistic view of recovery differs from the traditional medical model, with its focus on illness rather than wellness. A focus on illness is reactive, with treatment responding only to a person’s immediate health problem. A focus on wellness, on the other hand, actively addresses the broader dimensions of an individual’s behavioral health problems, which can be long term. Illnesses, whether mental, behavioral or physical, often are a sign that some other aspect of the person’s life needs attention.

[SLIDE 14. Supports]

This slide shows the kinds of supports that promote and sustain recovery from behavioral health disorders. At the same time, these supports enable individuals to remain or to become valued and contributing members of their community. To promote recovery, consumers should have access to these supports across the recovery continuum, from pretreatment to primary service and during treatment and post-treatment.

Let’s consider two supports from this list. One is housing. On any given night, up to 600,000 individuals are homeless. A substantial percentage of them have serious mental health and substance abuse disorders or both. How can we improve their hopes for recovery? — Give them a home! Having a stable home can be their critical first step to accepting and benefiting from treatment. With housing and appropriate supports, persons with the most chronic, most severe mental illnesses and those with extensive histories of substance abuse can leave the streets and lead stable lives. The value of housing to treatment speaks directly to the need for the housing system to be our partner in recovery.

Another support is spiritual. This factor speaks strongly to having faith-based organizations as a partner in recovery. Alcoholics Anonymous and other 12-step programs ask participants to turn their lives over to a higher spiritual power. Through belief comes strength. Thomas Kathan, who contributed his recovery story to SAMHSA’s “Voices of Recovery” credits God with saving his life and ending his alcoholism. In his words, “One does not go from drinking a fifth of liquor a day for over five years to absolute abstinence with no compulsion to drink without divine intervention. I am a miracle, one day at a time.”

[SLIDE 15. Meeting goals]

SAMHSA, through the PFR, is offering a new service to help New York and other states develop and strengthen a recovery-oriented system of care…one that can meet the diverse needs of consumers. We are inviting each state to send a small team to one of five regional planning meetings. During these meetings, we will

• Inform attendees about the national summit on recovery and its outcome,
• Provide resources for developing recovery-oriented systems of care,
• Provide a venue for individual state team planning, and
• Create a forum in which states and organizations can share lessons learned.

Resources to help your state design a recovery-oriented system of care, such as case studies and research findings, are available on the PFR Web site.

[SLIDE 16. COCE Screen Grab]

We are offering additional resources through our Center for Co-occurring Excellence, or COCE [co-see], SAMHSA’s program for advancing integrated treatment of co-occurring disorders. COCE is co-funded by the Centers for Substance Abuse Treatment and the Center for Mental Health Services. The program provides current information about co-occurring disorders, evidence-based practices for their treatment and training and technical assistance to the states. No recovery-oriented system of care is possible without integrated services.

[SLIDE 17. Developing leadership]

Let’s now move on to the third essential element of transformation: leadership. The field of addiction treatment is facing a transition as many current leaders retire. Those who take their place must be able to whole-heartedly embrace and advance a partnership between the substance abuse and mental health fields.

PFR, in collaboration with the national network of Addiction Technology Transfer Centers, is sponsoring 13 regional Leadership Institutes across the country. These institutes are part of the PFR strategy to identify, train and mentor a cadre of individuals who can inspire and lead change in behavioral health care.

[SLIDE 18. Leadership Institute Goals]

We intend for the leaders we train to:

• Enhance cultural appropriateness in service delivery,
• Develop and disseminate tools,
• Build a better workforce,
• Advance knowledge adoption,
• Provide ongoing assessment and improvement, and
• Forge partnerships across systems.

Our Leadership Institute involves several components conducted over six months, with one five-day onsite session. Participants complete independent pre-course assignments, assess their personal strengths, and complete a project based on their leadership goals. At the end of the course, they reconvene, present their projects and formally graduate from the Leadership Institute. SAMHSA currently is considering a national conference for the graduates of the 2006 Leadership Institutes.

I’ve just described some of the activities being conducted at the Federal level, through the PFR. I’d now like to address how these activities apply to your state. With a new Governor, new heads of state agencies and a growing emphasis on containing Medicaid costs and managing care, how will you ensure that the people you serve receive the services they need?

The answer is “vision, collaboration, and leadership.” Governor Eliot Spitzer has created a starting point to help define a vision for your state. In April, when Governor Spitzer announced the “People First” Coordinated Care Listening Forums, he made this statement:

“Our agenda is based on a single premise: patients, not institutions, must be at the center of our health care system. That means that every decision, every initiative, and every investment we make must be designed to suit the needs of patients first. The result will be a high-quality health care system at a price we can all afford.”

This agenda — as it is refined by consumers — will be a blueprint for action. It may not provide all of the answers, but it will certainly help you frame the right questions: “What needs changing?”…“Who’s involved?”...and — especially important — “How can we begin?”

[SLIDE 19. Quinn quote]

Robert Quinn is the author of Deep Change: Discovering the Leader Within. In describing transformational leadership, he wrote, “Once we have our sense of direction, we need to get organized, pack our gear, get motivated, and move on out. This process introduces new information and allows us to make choices and progress and grow our way forward —to, in effect, build the bridge as we cross it.

I particularly like this quote because of its emphasis on action as a learning process. We can’t wait until we have all of the solutions to all of our challenges before we begin. The need for immediate change is too urgent. As President John F. Kennedy pointed out, “Actions deferred are all too often opportunities lost.” We must act on what we believe and, as Quinn wrote, “grow our way forward.”

I also like Quinn’s reference to building bridges as we move forward with change. Many bridges are necessary to put people and their recovery needs first: bridges between the substance abuse and mental health fields…between the multiple services that support and sustain recovery…and between different treatment philosophies and practices. Collaboration is the spirit of transformation.

As you grow forward, look to other states for their lessons learned. Different states are leading the transformation of different services. One example is jail diversion for non-violent individuals with mental and substance abuse disorders. According to the National Alliance for the Mentally Ill, more people with serious mental illnesses are incarcerated in New York City's Riker's Island jail than in any other psychiatric hospital in the country. Research suggests that the majority of these individuals also have a substance abuse disorder.

Several states are developing model programs that divert individuals into treatment programs. Connecticut has extensive post-booking jail diversion programs in its arraignment courts. Texas has mandatory jail diversion strategies for every county, as authorized by legislation. Ohio has a culture of jail diversion that permeates almost the entire state. Michael Hogan, no doubt, is working to develop a similar culture across New York. There is a saying that “a rising tide lifts all boats.” By looking to success stories in other states…by sharing your own lessons learned, New York can help raise behavioral health services both within and outside of its borders.

Leadership in achieving your vision is vital. Twelve addictions treatment and mental health professionals from New York graduated from the PFR Leadership Institute during the past year. Encourage them to use their developing skills to help you arrive at a consensus for the best model to meet the needs of your consumers and their families.

New York has the inspirational state motto of “Excelsior” — ever upward. Accept the challenge. Work together to identify ways to raise the bar for behavioral health care. Increase the number of organizations providing services to support recovery.

Look also to consumers for guidance. They are your partners for recovery. Their participation in transforming the behavioral health system is not just a critical piece of the puzzle, it is the reason for the difficult but necessary work ahead. We put the people we serve first when first we listen to and learn from their experiences. Thank you.

I’d now like to open the floor for discussion. Are there significant differences in how the mental health and substance abuse fields define recovery? [About 20 minutes of session time will remain.]