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
Leading Transformation One Move at a Time
July 22, 2009
Honolulu, HI
PowerPoint Version (3.36MB)
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]
Aloha and thank you, Rupert (Goetz, MHT SIG Director) for your kind introduction and for the invitation to join you today. I’m struck by the beauty and deeper meaning of the word “aloha,” which speaks of unity, humility, patience, and perseverance. I am humbled to be among you at a time that I know is testing our ability to be patient and to persevere in the face of significant economic difficulties. It is in unity—of purpose, of spirit, and of action—that we will prevail.
Indeed, Winston Churchill once said, “Success is not final, failure is not fatal; it is the courage to continue that counts.” In Hawaii and in States around the country we are continuing our efforts to transform health and mental health care because the lives of the individuals we serve depend on it.
I know that the difficulties we face are all too real. We only have to pick up a morning newspaper or scan the Internet to know that these are difficult times for States, for providers, and for individuals of all ages with mental health conditions.
We know that nearly every State in the country is facing budget gaps this year and next. Together, States are projecting 105 billion dollars in shortfalls for 2010. Hawaii is no exception. In response to declining revenue, as many as 32 States are enacting mental health funding cuts. State Mental Health Authorities are responding to required budget cuts creatively and conscientiously, but sadly many have to lay off staff, cut services, and reduce the number of individuals being served.
At the same time in which States and providers struggle to do more with less, an increasing number of individuals are in need of services. According to the American Psychological Association’s recent Stress in America survey, almost half of Americans say they are increasingly stressed about their ability to provide for their family’s basic needs. They are turning to food, alcohol, and cigarettes to cope.
The National Suicide Prevention Lifeline has experienced a 30 percent increase in calls over the last year. Crisis centers are reporting a significant increase in the number of people who are calling because they have lost their job or their home or are afraid they will.
But far from this being a bad time to continue our efforts to transform the delivery of health care in this country, this is precisely the time when we must redouble our efforts.
Transformation is about the need to both anticipate and respond to change.
It helps us think about old problems in new ways and address new challenges with renewed hope.
It demands that we set aside that which divides us and harness the power of that which unites us.
In fact, the current economic crisis is a golden opportunity to reshape the mental health service system to be efficient, effective, and centered on the needs of the individuals it is designed to serve.
It is time to take a fearless inventory of those things that are barriers to achieving this vision and work to eliminate them.
Now, more than ever, we can’t afford to waste time, money, and human capital clinging to rigid and inefficient systems that waste money and drain our spirits.
You may have heard the story about the European chess grandmaster who played an exhibition match against an amateur and lost. The champion was renowned for his ability to plan a dozen or more moves ahead as a game developed. At the post-match press conference the amateur was asked how many moves ahead he had planned in defeating the master. “Only one,” he replied. “The right one.”
This story, according to author Carol Kinsey Goman, holds the key to success in a constantly changing world. The amateur player did have an overall game plan, but he tailored his moves to the immediate possibilities inherent in each position as it arose. We, too, must never lose sight of why we do the challenging and rewarding work of transformation. We are committed to ensuring that each and every individual in this country has access to the community opportunities and health and social supports that will help them excel in a complex and competitive society.
But having this as the long view, we also must adapt to the circumstances in which we find ourselves at any given moment. To do so, we must, as the President has urged us, be both pragmatic and progressive in how we respond to the challenges before us.
This morning, I’d like to suggest three critical things we have to do to continue to transform not only the delivery of mental health care in this country, but the very face of health care itself. We must:
- Promote new attitudes about mental health and mental illnesses;
- Change our approach to addressing mental health conditions; and
- Hold ourselves accountable for outcomes that matter.
[Slide 2—Mental health is essential]
New Attitudes
First and foremost, we must articulate a consistent and unified message that there is no health without mental health. The separation of the mind from the body that underlies today’s Western medicine is incompatible not only with many native cultures, but with also with recent research. Statistics on increased morbidity and mortality among individuals with mental health conditions make clear that we can’t treat the mind and not the body.
An important corollary to the importance of mental health to overall health is the fact that mental health is critical economic recovery. Just as we rebuild our Nation’s infrastructure, we must build the mental health, rehabilitation, and community services that act as a bridge for individuals with mental illnesses to recovery, employment, and productivity.
In fact, there is substantial evidence to demonstrate that providing adequate levels of mental health and addictions prevention and treatment, as well as integrating these services with those of general health care, can:
- Improve health outcomes;
- Lessen the rate, duration, and intensity of disability of many illnesses;
- Cut and/or control the growth of overall health care costs;
- Improve individuals’ productivity;
- And control the size and growth of other social costs.
In Hawaii, you have laid an important foundation for this work by building your T-SIG program from the ground up. You have planted the seeds for long-term change by stimulating grassroots involvement with the grant, particularly among consumers, families, and youth. This type of community outreach and education is vital.
It was Oliver Wendell Holmes who said, “A mind that is stretched by a new experience can never go back to its old dimensions.” The community support you have garnered is the basis on which to choose those projects that are most likely to ensure the ability of all Hawaiians to live full, healthy, and productive lives.
This is transformation made real!
[Slide 3—Mental health continuum]
New Approaches
The second thing we have to do to seize the opportunity to transform the delivery of health care in this country is to change our approach—from one that focuses on treating illness to one that centers on promoting health. We must adopt a public health approach as the foundation for everything we do. Public health is a community approach to preventing and treating illnesses. Its premise is that caring for the health of an individual protects the community, while, in turn, caring for the health of the community protects the individual. As such, health promotion and disease prevention are the cornerstones of a public health approach.
In March, the Institute of Medicine released a much anticipated report, Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities. CMHS was pleased to support this update to the seminal 1994 report, Reducing Risks for Mental Disorders.
I’m happy to be able to share with you two key findings from the new report. First, the 2009 update reveals concrete evidence that an increasing number of mental, emotional, and behavioral disorders are, in fact, preventable. Second, and equally important, this groundbreaking report goes beyond the 1994 report by recommending the inclusion of mental health promotion in the full spectrum of mental health interventions.
The authors conclude, “The nation is now well positioned to equip young people with the skills, interests, assets, and health habits… needed to live healthy, happy, and productive lives…in caring relationships that strengthen the social fabric.” What a wonderful vision for health care reform.
[Slide 4—Integration]
To promote health and prevent disease, we must embrace a whole health, person-centered approach to health care. In practice, this means that all of the factors that influence a person’s health status must be acknowledged and addressed across the continuum of health care services…with the full participation of the individual at all stages of care.
One important way to do this is to integrate and coordinate mental health with primary care. I know that integration of services, financing, data collection, and training is an important transformation strategy for Hawaii and the other T-SIG States.
To help support the development of integrated systems, SAMHSA announced the Primary and Behavioral Health Care Integration program. We sought applications from community-based behavioral health agencies to improve the physical health status of people with serious mental illnesses. We will help them do so by supporting coordination and integration of primary care services into publicly funded community mental health agencies.
The services we fund will incorporate a prevention and wellness approach and show cooperation and collaboration across community mental health and primary care. Clearly, we can’t improve the health of individuals, communities, and the Nation unless we transform the way we provide treatment and services.
[Slide 5—Social-ecological model]
A public health approach also takes into account the fact that health and wellness are products of the individual acting in concert with friends and families, their workplaces, the community, and the broader society. As our colleagues at the Mental Health Commission of Canada have so eloquently stated, “The context of people’s lives matters.”
This means that any attempts to improve the overall health of individuals and the communities in which they live must address the personal, social, economic, and environmental determinants of health. For people with serious mental illnesses, this means focusing on such issues as poverty, widespread unemployment, and inequitable distribution of health care resources.
Indeed, the new IOM report cites evidence that reducing exposure to poverty-related risks is at least as important for preventing mental, emotional, and behavioral disorders in young people as other preventive interventions. “We are persuaded that the future mental health of the Nation depends crucially on how… the costly legacy of poverty is dealt with,” the authors note.
We must remember that poverty can be more than lack of monetary resources. Even when individuals with mental health conditions are living in the community, they may not be of the community. Being of the community means having socially valued activity, adequate income, personal relationships, recognition and respect from others, and a political voice.
Unfortunately, we have excluded people with mental illnesses from the social fabric of our lives for far too long. We know that social exclusion increases the likelihood of significant psychological distress and illness, including substance abuse.
On the other hand, social inclusion means that we adopt policies and activities that are not necessarily planned as mental health interventions, but—because they improve access to a wide variety of resources—have important mental health effects. We include all members of a community when we have safe schools, stores that sell healthy foods, and places to gather together for recreation and relaxation.
Clearly, what we often refer to as “community services” are not enough for individuals to be full participants in their communities. Indeed, as John McKnight noted in a seminal piece titled “Redefining Community,” it is possible to be surrounded by community services and still be isolated from the community. “Community services,” Professor McKnight says, “involve people in community relationships.”
Community relationships are those that are reciprocal, notes Robert Putnam, author of the book Bowling Alone. Reciprocal relationships don’t involve one person—the professional—telling another person—the consumer—what to do. I know that reciprocity is at the heart of Hawaiian culture and is epitomized by the proverb that translates to “No kind deed has ever lacked its reward.”
When we ensure that every individual we serve has access to housing, health care, meaningful activities, social support, and community relationships—we are helping provide all that it means to be healthy in today’s society.
[Slide 6—Workforce screenshot]
The final aspect of a transformed approach to health care for individuals with mental health conditions involves the need to train, educate, and support the workforce that delivers care—not only in behavioral health care, but across the health care professions. “The people who deliver care are the health system’s most important resource,” the IOM noted in its report, A New Health System for the 21st Century.
We know that insufficient workforce capacity in the mental health field is a significant problem, but service capacity isn’t only about individuals; it’s about new ways to practice. Indeed, the ultimate goal in building capacity is to create communities that support prevention, promotion, and healthy living for all Americans.
This summer, SAMHSA will launch a Behavioral Health Workforce Development Resource Center. This will serve as a comprehensive Web portal for mental health and substance abuse treatment providers and the programs that employ them. The site will contain a wealth of information on such cutting-edge issues as licensing, credentialing, education, and employment, as well as recruitment, retention, supervision, and leadership training.
Behavioral health providers will be able to search for a job and build a resume. They will also have access to state-of-the-art education and training resources. Employers will find information on how to recruit qualified, well-trained staff. Information on the site will be updated daily.
As part of this project, we are also developing core competencies for behavioral health care providers who work with a full range of individuals—from adults and older adults to women, children and families, and various ethnic and cultural minority groups.
In addition, SAMHSA recently released a Request for Proposals to create a standardized training manual on recovery-oriented care. We recognize the urgent need to transform the concepts of recovery from a set of beliefs into action at the service provider level. This project will support the expansion and integration of recovery-oriented care delivered by mental health providers. This is transformation made real!
[Slide 7—Transformation Tracker Explorer screenshot]
The final thing we have to do if we are going to succeed in transforming systems, services, and individuals’ lives is to hold ourselves accountable for producing outcomes that matter. This means we must collect data that allows us to be certain we are providing the most effective health care to the right individual at the right time and in the right way.
We should be very proud of the fact that the mental health community has been at the forefront of efforts to develop, adopt, and adapt evidence-based practices. A decade ago, then Surgeon General David Satcher pointed out that most mental health conditions are as treatable as most general health conditions.
In the intervening years, we have shown the comparative effectiveness of a number of practices, including supportive housing, supported employment, and integrated treatment for co-occurring disorders. In Hawaii as in the other T-SIG States, you are beginning to adopt and adapt many of these practices to meet the unique cultural, social, and political context in which your grant operates.
In order to know whether or not we are succeeding, we have to collect the data to show whether infrastructure changes are leading to service changes and whether service changes are leading to changes in the lives of the individuals we serve. Each of the T-SIG States is participating in a cross-site evaluation to determine the specific types of infrastructure changes they are making and the impact those changes are having on consumer outcomes, including recovery.
The data we have collected thus far reveal that the 9 T-SIG States have:
- Made over 238 significant policy changes, including 88 in the financing arena;
- Trained almost 50,000 providers;
- Made 150 significant organizational changes;
- Expanded data accountability systems across 139 organizations; and
- Implemented over 1,600 state-of-the-art mental health programs.
To make information about T-SIG infrastructure changes easily available to you, we have created the online Transformation Tracker Explorer. You can find it by entering “Transformation Tracker Explorer” as an Internet search term.
Once there, you can explore in detail what activities States are implementing to bring about transformation. You can examine activities by State, keyword, New Freedom Commission goal, GPRA measure, and/ or fiscal year. You can use broad search terms such as “cultural competence” or more narrow search terms such as “traditional healing.” You can also post feedback on how States are transforming their mental health systems through the T-SIG program.
Because the Transformation Tracker Explorer is available not only to T-SIG States but also to the general public, this is a wonderful way to share exemplary practices with a broader group interested in transforming health and mental health care. I’m reminded that leadership expert Margaret Wheatley has said that “even great and famous change initiatives begin…with the actions of just a few people.” Much like a single stone causes ripples throughout a pond, when we share our good ideas with even one other person, we can start a whole wave of change.
This truly is transformation made real!
[Slide 8—Wangari/trees picture]
Moving Forward
I began my remarks this morning by talking about the difficult economic circumstances we face. You might wonder how we can implement some of the strategies I’ve outlined when resources are scarce. But how can we not when the need is so great? The individuals we serve are counting on us more than ever.
I’d like to share with you a wonderful story that Margaret Wheatley recounts in her article called “What Is Our Role in Creating Change?” She tells the story of Wangari Maathai (wan-GAH-ree mah-DHEYE), who was awarded the 2004 Nobel Peace Prize for her work in organizing The Greenbelt Movement, which has planted more than 30 million trees in Kenya and East Africa.
Wangari was a biology professor at the University of Nairobi in Kenya when she learned that the land of her youth had been devastated. All the trees had been cut down for coffee and tea plantations. Local women now had to walk miles for firewood, and the water had become polluted with chemicals and runoffs from the plantations.
She knew that the solution to the plight of these women was to plant trees and reforest the land. So she and a few women decided to begin immediately. They went to a large park in Nairobi and planted seven trees. However, five of these trees died. Their initial success rate was barely 29 percent, discouraging by anyone’s standards.
But they didn’t give up. The women carried what they had learned from their initial failure back to their villages, and gradually they became skilled at planting trees.
Other villages saw what they were doing and, over time, a large network of villages became engaged in tree planting. In less than 30 years, 30 million trees were flourishing in 600 communities across 20 nations. Villages now have clean water, shade and local firewood, improved health, and community vitality.
In Hawaiian culture, you might describe this as a Hui (hooey), which is created when people pull together, through their own initiative, to solve a shared problem.
But as Ms. Wheatley asks, “What if the African villagers had given up when the first five trees died? What if they had walked away and left it to the government or the U.N. to plant trees?”
I think the lessons for our work are clear.
- First, we have seen a need and we know how to address it. We know that fragmented health, mental health, and social services leave individuals at risk for poor outcomes—including poverty, homelessness, ill health, and suicide. We understand that a whole health, person-centered approach to health care…delivered using public health tools that take into account the broad determinants of health…can help individuals reclaim their rightful place in their families, schools, neighborhoods, and communities. We are planting the seeds of hope and health.
- Second, we must empower others to be responsible for their own health and recovery. This is the basis for the Healthiest Nation Alliance, created by the Centers for Disease Control and Prevention, together with the Association of State and Territorial Health Officials and the National Association of County and City Health Officials.
The group’s mission is to change the debate from a focus on “health care”—with its emphasis on access and cost—to a more proactive, prevention-focused national discussion on “health.” They hope to empower individuals and organizations to take responsibility for creating change within their own piece of the system, whether that be the “healthiest me,” the “healthiest family,” the “healthiest business,” or the “healthiest community.”
We know that healthy individuals are resilient. In recent months we have seen evidence of this fact in cities and towns across America, where individuals who have lost their jobs have swelled the ranks of volunteers. They are working with children, feeding individuals who are hungry, and reaching out to men and women living on the streets. The have turned challenge into opportunity. This is the face of resilience.
Resilient individuals are those that bend rather than break during stressful conditions. They are most likely to have a positive outlook and a sense of personal mastery and to find meaning even in difficult circumstances. We must nurture a resilient spirit not only in the individuals we serve but also in ourselves.
- Third and perhaps most important, we can’t look to others to make change happen. As President Obama has said, “Change will not come if we wait for some other person or some other time.” We are the ones we’ve been waiting for.” At the Federal level, we are pleased to be able to stimulate and support change. But here in Hawaii, and in States and communities around the country, change happens on the ground.
It happens when an individual who never thought he could finish school graduates with honors.
It happens when a family realizes they won’t have to give up custody of their child to get her the care she needs and deserves.
And it happens when an individual who might have been arrested is diverted into treatment and services instead.
These are truly transformative changes, and they are happening every day in Hawaii and around the country.
- Finally, we know that change takes patience and perseverance. It takes Aloha spirit. The women in Kenya planted their trees one at a time, year after year.
So, too, must we continue to plant the seeds of change, year after year, even if a few of our ideas die. Most will take hold and create a forest of change, one that shelters, nourishes, and promotes health and well-being for all of our citizens.
It was Henry Ford who said, “Coming together is a beginning. Keeping together is progress. Working together is success.” Now is the time to consolidate the gains you have made and go forward, one day at a time, one tree at a time, one move at a time.
Thank you for working together on behalf of the men, women, and children in Hawaii with or at risk for mental health conditions. They are counting on you to transform the systems and services they depend on and they deserve nothing less than your best.
Thank you. I’d be happy to take your questions.
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