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
Change Management in Mental Health Systems: Key for Implementing Eveidence-Based Practices
“Transformation in the Mental Health Systems”
Albuquerque, NM
June 23, 2005
PowerPoint version
[SLIDE 1. Title slide]
Good morning and welcome. Our conference is called “Change Management in Mental Health Systems: Key for Implementing Evidence-Based Systems.” As the name implies, the focus during the next 2 days will be on management strategies for implementing evidence-based practices. We also will be talking about the kind of leadership that can bring about effective change in mental health care. We really must discuss the two topics together. Attempting change without leadership is like putting a car in gear without a driver behind the wheel.
[SLIDE 2. Car photo]
The car is bound to go off course . . . . if it goes anywhere at all.
Peter Drucker is considered the founding father of the study of management. In his book, Management Challenges for the 21 st Century, he writes:
[SLIDE 3. Drucker quote]
"Everybody has accepted by now that change is unavoidable. But that still implies that change is like death and taxes—it should be postponed as long as possible and no change would be vastly preferable. But in a period of upheaval, such as the one we are living in, change is the norm." As a consequence, Mr. Drucker believes that every organization has to build into its very structure the management of change.
We, as program administrators, want to able to control change as best we can—to set a steady course for action, and to keep on track. The reality, however, is that not all change is within our control—only our response to it. Change management is the continuous balancing of internal change in response to external change. For example, the demographics of the people we serve are changing rapidly. Within the next half century, more than 50 percent of our Nation’s population will be people of color. Within the next quarter century, the number of older adults will double. Demographics is an external change outside of our control. Workforce development, cultural competence, and age-appropriate treatments, however, are internal responses—or changes—within our control.
[SLIDE 4. Cover scan]
All of us here are involved in a national initiative to transform our mental health system. The basis for this initiative is a report released 2 years ago by the President’s New Freedom Commission on Mental Health. This report, called Achieving the Promise: Transforming Mental Health Care in America, is a critical assessment of our mental health system. (Copies are available at this conference.) The report describes a system that has not kept pace with changes in mental health care. Services offered are fragmented, disconnected, and often inadequate. Treatments and services based on years of research languish for years before moving into common practice. Most important, our mental health system is not oriented to the single most important advance of the past several years—the very real possibility of recovery from mental illnesses.
Achieving the Promise calls for a fundamental transformation of America’s mental health care system. The report outlines 6 broad goals and 19 specific recommendations for a transformed system. These are the goals—
- [SLIDE 5. Goals]
- 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.
The ultimate goal of transformation is to create a system that is consumer and family driven, focuses on recovery, and builds resilience.
[SLIDE 6. Definitions]
Consumer and family driven means each adult or child will have access to the full spectrum of services needed to support recovery. It means they will have real and meaningful choices among providers, services, and treatment options. Recovery is a process, sometimes lifelong, through which a consumer achieves independence, self-esteem, and a meaningful life in the community. Resilience is a person’s ability to face life’s challenges.
Shortly after the New Freedom Commission released its report, this Administration charged SAMHSA with carrying out the Commission’s goals and recommendations. Since then, we have worked tirelessly and systematically to set the wheels of change in motion. I’m going to talk just briefly about our overall transformation efforts and then I’ll describe some of our activities related to evidence-based practices. Finally, I’ll discuss how we can apply the principles of change management to implementing evidence-based practices.
Our transformation efforts follow three key stages of change:
[SLIDE 7. Stages of change]
- Engaging and motivating for change (or why we do it),
- Developing skills and supports to implement change (or how we do it), and
- Sustaining the change (or how we maintain and extend the gain).
[SLIDE 8. Federal Partners Workgroup]
During stage one, SAMHSA created an executive team to drive change. Our Federal Partners Workgroup is composed of representatives from nine Federal departments and the Social Security Administration. We began with an exhaustive inventory of programs and funding that each agency already had in place. By organizing our inventories around the Commission’s six goals, we were able to clearly identify ongoing programs that already supported transformation. These are programs we are maintaining and enhancing. We also were able to determine where we could collaborate on new initiatives to support transformation.
This process led to the second outcome of our Federal Partner Workgroup: the Federal Action Agenda. Our agenda describes how SAMHSA and its partners will respond to each of the Commission’s 6 goals and 19 recommendations. It identifies specific steps we can take to motivate, facilitate, and compel change at the State, community, and individual levels. These steps correspond to the second stage of change, which is to develop skills and supports for implementing change.
As an example, SAMHSA recently launched State Incentive Grants for Mental Health Transformation. This new grant program is designed to accelerate transformation by focusing on State infrastructure. Grant funding will support State efforts to link together all of the agencies needed to provide comprehensive mental health services.
The third stage of change is sustainability. Our agenda is not a universal, all-encompassing document. SAMHSA and our Federal partners made a conscious effort to set time-limited, realistic priorities to be accomplished within a year. We will develop new annual agendas, addressing new issues, as we make progress.
A Federal Executive Steering Committee on Mental Health will move our agenda forward, government-wide. SAMHSA’s internal Matrix Workgroup on Transformation will spearhead and keep track of our overall progress. Our management objective is to sustain continuous quality improvement.
Several action agenda items involve evidence-based practices. Evidence-based practices operationalize transformation! They offer consumers their greatest hope in recovery because they have proven to be effective in producing positive outcomes. They are individualized and consumer centered and they respect and integrate cultural strengths and diversity. In other words, evidence-based practices epitomize the ultimate goal of transformation—consumer drive care focused on recovery.
In addition, at the heart of mental health transformation is accountability—that is, the need to ensure that the services we provide respond to the needs of those we serve. We also are accountable to Americans at large for the results we achieve. Evidence-based practices are the best method to make certain our services are data driven and outcome oriented.
One of the external changes confronting the mental health system is decreasing resources paired with increasing need. We are facing tremendous pressure to—
- Find out what really works, and to
- Leverage our limited resources to move proven practices into treatment.
In this respect, implementation of evidence-based practices, with their focus on recovery, is one of the most important steps we can take. To quote Linda Rosenberg, spokeswoman for the Campaign for Mental Health Reform and President and CEO of the National Council for Community Behavioral Healthcare
"In the long run, increasing the number of Americans who recover from mental illness and increasing their opportunities to lead successful lives in the community is the best way to save money in Medicaid and other Federal programs that serve people with mental illnesses."
[SLIDE 9. Goal 5 recommendation]
SAMHSA’s response to shrinking budgets at the Federal, State, and local levels is to accelerate the development and implementation of evidence-based practices. We are responding directly to a recommendation from Achieving the Promise, which is to use dissemination and demonstration projects to advance their use.
Our process for managing evidence-based practice implementation again reflects the three stages of change.
[SLIDE 10. First-stage activities]
During the past 15 years, researchers in mental health service systems have gathered extensive data to support the effectiveness of several psychosocial and pharmacological treatments. In 1998, the Robert Wood Johnson Foundation convened a consensus panel to determine which practices currently demonstrated a strong evidence base. The panel consisted of researchers, clinicians, administrators, consumers, and family advocates. Research shows that providing practice guidelines to practitioners alone does not change practice. Change is most likely to occur and be sustained if all of the major stakeholders in the mental health system are engaged and involved in the process of change.
[SLIDE 11. Three phases]
As an offshoot of these efforts, SAMHSA launched a program to implement six of the strongest practices. This is a three-phase program involving the development and testing of pilot kits followed by widespread distribution of a refined kit. In addition, we also are using numerous grant programs to engage the States in the use of evidence-based practices throughout our grant programs.
Our efforts to promote the use of evidence-based practices rest on two philosophical tenets that underlie transformation.
- First, mental health services for individuals with severe mental illnesses should have the goal of helping individuals develop high-quality, satisfying, and functional lives. Consumers want services that are proven effective in helping them manage their illnesses and move ahead with their lives.
- Second, consumers and their families have a right to information about, and access to, effective services. Evidence-based practices are not intended to be exclusive, mandatory, or rigid. Rather, they imply self-knowledge, self-determination, choice, individualization, and recovery.
[SLIDE 12. Second-stage activities]
SAMHSA, together with the Dartmouth-led consortium, developed six evidence-based practice toolkits. Many of you are testing one or more of these kits in your State. For everyone’s benefit, I’ll summarize them briefly:
[NOTE: PAUSE FOR READING. SLIDES CONTAIN ADDITIONAL DETAIL]
[SLIDE 13. Illness Management and Recovery]
Illness management and recovery strongly emphasizes how we must support consumer efforts to set and pursue personal goals and to develop coping strategies for their everyday lives.
[SLIDE 14. Medication Management]
Medication management in psychiatry focuses on using medication in a systematic and effective way as part of the overall treatment for severe mental illness. The goal is to ensure that medications are prescribed in a way that supports a person’s recovery efforts.
[SLIDE 15. Assertive Community Treatment]
Assertive community treatment is an individualized, 24-hour community-based approach for helping consumers to develop skills for living in the community to stay out of the hospital. Its goal is to help people stay out of the hospital and to develop skills for living in the community. Their mental illnesses should not be the driving force in their lives.
[SLIDE 16. Family Psychoeducation]
Family psychoeducation involves a partnership among consumers, families and supporters, and practitioners. Through relationship building, education, and collaborative problem solving, families come together in cooperation and hope for the future.
[SLIDE 17. Supported Employment]
Supported employment is a well-defined approach to helping people with mental illnesses find and keep competitive employment within their communities.
[SLIDE 18. Co-Occurring Disorders]
Co-Occurring Disorders: Integrated Dual Diagnosis Treatment helps people recover by offering both mental health and substance abuse services at the same time and in one setting.
Our National EBP Center facilitates State and community implementation of these and other evidence-based practices. The Center is being operated by the National Association of State Mental Health Program Directors Research Institute, which also is a co-sponsor of this conference.
[SLIDE 19. Sustaining the Change]
SAMHSA currently is evaluating our six toolkits through real-world application, which is Phase II of our National Demonstration Project. More than 50 community mental health programs in 18 pilot States currently are helping to evaluate their use in practice. We have asked the pilot States to give us feedback on how effectively the treatments work for different populations in different community settings. Other States are testing the toolkits through our Evidence-Based Practice Training and Evaluation Grants. The feedback from your test sites will enable us to refine the kits, leading to their greater distribution and effectiveness.
All of us here today are working to sustain the gains made by implementing evidence-based practices. Thanks to your hard work, we will be able to refine our six toolkits so that they will be equally effective for different populations and different settings. Obtaining widespread adoption of these and similar effective practice interventions is at the center of SAMHSA’s transformation efforts.
In addition, we see broad-based adoption of evidence-based practices as essential to achieving our strategic goals. These goals are to increase accountability, service capacity, and effectiveness in preventing and treating mental disorders.
We are making tremendous progress in advancing the use of evidence-based practices for adults and for children. Our success rests with a joint commitment to implementation and a systematic approach to effective change management. The transformation highway is a long and winding road. We must all contribute to the journey.
To speed us along the way, we must learn from others who have traveled a similar road. Transformation, because it demands a new way of doing business, suggests that we should approach this problem from a business perspective. Our business is to supply consumers and their families with the tools necessary to build hope in recovery. Our business goal is a full and meaningful life in the community for everyone. Our bottom line is positive outcomes for consumers.
As a professional field, change management is like mental health services. There is a body of knowledge, with theories and models, practices, techniques, and tools. There is a body of practitioners, people who provide change management services, often as consultants and teachers. Change management software has been developed, along with professional associations and journals, dozens upon dozens of books, and even more seminars and workshops. During the next 2 days, you will become familiar with both the science and the practice of change management.
We at SAMHSA are becoming avid students of change management techniques. One book that I recommend is Improving Organizational Effectiveness Through Transformational Leadership by Bernard Bass and Bruce Avolio. This book presents organizational transformation as a process in which “regular and significant change is a natural, continual response to changing environmental and internal conditions.”
A chapter on strategies for change and improvement describes the principle objectives for change management. These are:
[SLIDE 20. Three principles]
- To change attitudes or values,
- To modify behavior, and
- To bring about change in structure, policy, and culture.
Let’s briefly review these principles as they apply to implementing evidence-based practices.
The first principle of change management is to change attitudes or values. Surveys still are telling us that States are not using the most recent science. The reason is this: our whole mental health system is pretty much set up to reward and report service utilization instead of consumer outcomes. Not too long ago, recovery was a radical concept for treatment. The standard operating procedure was to remove persons with an illness from their families and communities and to commit them into institutions. Then, we delivered mental health care focused on managing symptoms. . . because a lifetime of illness and dependency was the expected outcome.
Today, we have a far different outlook. We know that with access to effective treatment and supports, individuals with mental illnesses can enjoy full, productive, and rewarding lives in the community. We know that treatment works! We know that recovery is possible. In fact, we now look to recovery as the expected outcome of treatment.
Evidence-based practices are one of the best tools we can use to move consumers toward recovery. Their implementation will require an entirely new view of consumers and the treatment and supports that providers must offer to ensure a full life in the community for everyone. Before we can achieve this new view, however, we must address the attitudes and beliefs that can impede implementation. Some providers express:
- A concern about reducing people’s choices for treatment and a
- Fear of being limited to “cookie cutter” approaches, which may limit their ability to provide individualized care.
- In addition, some providers are concerned about the need to learn new skills and fear their current skills are becoming obsolete.
In the journey ahead, we must work to change the values, attitudes, and beliefs that are roadblocks to evidence-based care. We must take steps to ensure that individuals and organizations embrace evidence-based practices by infusing their use into plans, policies, and daily operations. We must learn how to create working environments that recognize and reward their use.
The second principle of change management is to modify the behavior of those involved. This aspect of change certainly is evident in the implementation of integrated treatment for co-occurring disorders. Integrated treatment requires different ways of thinking and practicing for persons trained in either mental health or substance abuse treatment. Traditional addiction programs tend to be confrontational; an approach that may not be well-suited to individuals with serious mental illnesses. Standard addiction programs also require abstinence from all chemicals, including medications. Persons with mental disorders, however, often need medication to stabilize or improve their condition. As a result, separate treatment of disorders can present incompatible and sometimes conflicting approaches. The power and potential of integrated treatment is that it resolves these conflicts, guiding both providers and consumers to new ways of being.
Consumer-driven care represents another major behavioral shift by professionals. Consumers and their families are too seldom educated, empowered, or encouraged about their essential role in making health care decisions. This situation completely defies logic. There are serious life choices to be made about care—choices in providers, and necessary services, and medications. . . choices in living in a community . . . choices about required supports. Who should make these choices? The consumers and families whose lives and futures are directly affected by the decisions made.
Youth as well as adults deserve a role in deciding their care. For older youth, their role may be to direct their own care. Children grow toward adulthood by practicing independence. Every opportunity of choice is an opportunity for them to grow toward a healthy, self-directed adult life.
The third principle of change management is to change an organization’s structure, policy, and culture. These changes are the very essence of transformation as well as implementation of evidence-based practices.
[SLIDE 21. Systemwide change]
Both require changes throughout the mental health system. They require changes in planning, financing, infrastructure, and systems integration. They require a long-term investment in more positive outcomes for consumers.
One of the most powerful lessons we’ve learned in the dissemination and sustainability of evidence-based practices is the absolute necessity for buy-in at the administrative level. Just as you can’t jump a 20-foot chasm in two 10-foot jumps, a State can’t make a half-hearted leap toward implementing evidence-based practices. The commitment has to be there at the outset! This commitment has to be followed with a mighty push for workforce development, program alignment, consumer and family involvement, and broad-based community collaboration.
The transformation journey is getting exciting and we are on the right road with evidence-based practices. It’s the road to recovery for the millions of Americans who have mental illnesses.
As leaders in your State agencies, you have to be in the driver’s seat. It’s up to you to help make evidence-based practices a fundamental piece of your State’s transformation efforts. You have been investigating what works, what doesn’t work, what still must be done, who must be persuaded, how and when to make changes, and more. Keep working to bring other senior administrators on board.
Continue your transformation journey by learning to manage all the changes needed in policies, financing, reporting mechanisms, and all of the other aspects of change management. Change occurs whether we are ready for it or not. Change management is how we control our response to our evolving environment. We need tools and techniques that work and can be replicated everywhere. Only if organizations and individuals learn and improve their skills can recovery for all consumers be realized.
[SLIDE 22. Transformation highway]
Transformation is a long and winding road. We will need skilled drivers who can navigate its twists and turns and avoid its potholes and dead ends. As we know from change management literature, mistakes can be expected. We move forward by learning from those mistakes.
I firmly believe, however, that change management, led by leaders such as yourselves, can take us to our destination. In the words of Steven Covey, author of the 7 Habits of Highly Effective People, “ I am personally convinced that one person can be a change catalyst, a ‘transformer’ in any situation, any organization. Such an individual is yeast that can leaven an entire loaf. It requires vision, initiative, patience, respect, persistence, courage, and faith to be a transforming leader.”
Take full advantage of the information presented at this conference. Leave with two key messages in mind. The first message is that transformation requires a logical, systematic approach. Unplanned change is ineffective at best and counterproductive at worst. The second is message is this: Just like we should base the services we provide to consumers on the science and evidence of effective practices, we should base our transformation efforts on the science and evidence of change management. T he outcomes are the same.
[SLIDE 23. End Quote]
As observed in this month’s issue of the Harvard Management Update, “The more cutting-edge ideas, concepts, guiding principles, and best practices you have in your leadership tool box, the greater the rewards you will reap.” Our reward is to make the promise of transformation happen for the people we serve. Thank you.
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