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
NIMH Alliance for Research Progress
Transforming America's Mental Health Care
Washington, DC
July 25, 2005
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’m delighted to be here, surrounded by fellow advocates for better mental health care. I’m particularly pleased to participate in a meeting focused on research. For me, research represents our conviction that we ultimately will triumph over mental illnesses through prevention, recovery, and a cure.
We all know that improvements in mental health care are needed—critically and immediately—and that we need to work together to achieve them. Each new report on mental health care highlights the gaps in our knowledge, our services, and our capacity to prevent and treat illnesses. Just last month, the National Institute of Mental Health (NIMH) released its National Comorbidity Survey Replication. This survey is an extremely important and eye-opening study with respect to the incredible prevalence of mental illnesses, the early age of onset, and the tragically long delay before most individuals seek treatment.
The National Comorbidity Survey Replication reaffirms the findings of the Final Report of the New Freedom Commission on Mental Health.
[SLIDE 2. Cover scan]
This report, called Achieving the Promise: Transforming Mental Health Care in America, is a national call to action. It recommends nothing less than a fundamental transformation of our Nation’s public mental health system. Profound changes are called for in how Americans view mental health and how we plan, finance, deliver, and evaluate services. The ultimate goal of this transformation is to create a system that is consumer driven and focused on recovery.
The power of this report lies in its underlying message. The message is one of “hope”! Hope that we can achieve a future in which mental illnesses can be prevented or cured—hope that we can achieve a future in which recovery is the expected outcome of treatment for anyone at any stage of life. The promise to be fulfilled is that everyone with a mental illness will have access to treatments and supports enabling them to live, work, learn, and participate fully in the community.
Is this a realistic view of the future? I say an emphatic “Yes!” Both research and practice are shedding new light on the complex workings of the human brain. We are learning exponentially more about the integrated functioning of the mind and body and the relationships between biology, environment, and behavior. Advances in pharmacology and psychotherapy are easing the burden of mental illnesses for individuals, their families, and our communities. Consumers are using their lived experiences to inform us about what services are effective in helping them achieve their recovery goals. Individuals with mental illnesses are finding greater hope in recovery and in their own futures.
This Administration has embraced the vision of mental health care that is presented in Achieving the Promise. President Bush has charged the U.S. Department of Health and Human Services (HHS), through the Substance Abuse and Mental Health Services Administration (SAMHSA), to carry out the report’s recommendations. This report is not a dusty document on some bureaucrat’s bookcase—instead, it has become a national and growing catalyst for change.
Transformation of the mental health system is one of SAMHSA’s four highest priority programs. We believe in our mandate for change, and we are committed to making progress! I’m going to give you a brief status report on our efforts. Then, I’ll address more directly how transformation applies to the central theme of this meeting, which is to develop a research agenda focused on the needs of persons with mental illnesses.
[SLIDE 3. Federal Partners Workgroup]
Shortly after the release of Achieving the Promise, SAMHSA convened a Federal Partners Workgroup to identify opportunities to transform mental health care. Our workgroup now consists of nine Federal departments and the Social Security Administration. The U.S. Departments of Transportation, Agriculture, and Defense are the most recent additions. Their membership highlights a crucial element of transformation: every organization—every person—with the power to shape our communities and our daily lives has a role in promoting the mental health of Americans. We all are responsible: we all are accountable.
Our Federal Partners Workgroup has been meeting regularly to identify priorities for change and to set realistic, time-limited strategies to achieve them. We have documented planned strategies in a workplan called our Federal Mental Health Action Agenda.
[SLIDE 4. Cover scan/Web address]
I’m delighted to report that on July 22 we presented our first action agenda to Congress and to a broad group of mental health constituents. Our action agenda represents an unprecedented commitment by SAMHSA and our Federal Partners to transform the status quo of mental health service delivery. Our framework is the principles that guided the work and vision of the New Freedom Commission. Within this framework, we have identified those first steps that can yield immediate results.
[SLIDE 5. Five principles—PAUSE for reading]
Our action agenda is an evolving document. We will develop new priorities and new strategies as we move forward with transformation. A Federal executive steering committee will oversee the progress we make. The steering committee is composed of senior administrators from each of the organizations represented in our workgroup. Committee members will be responsible for making certain that their agencies commit the resources needed to keep transformation moving forward.
Collaboration is the bedrock of our Federal efforts, including our efforts to encourage transformation at State and local levels. Consumers and families living with mental illnesses have complex and multiple issues that cut across departments, agencies, and systems. Consequently, transformation hinges on how well we work together to transform the current maze of services, treatments, and supports. Our common objective must be to create a delivery system that is seamless and that is accountable to Congress, . . . to taxpayers, . . . and—most important—to consumers seeking recovery.
I’m going to describe some of the issues related to mental health and some of what our Federal partners are doing about these issues. Many more collaborative activities are identified in our action agenda.
[SLIDE 6. Medicaid and MH financing]
Let’s begin with the financing of public mental health services, because financing significantly affects the kind and quality of services provided and who can access them. Medicaid is the largest single payer of mental health services in the United States. In fact, Medicaid figures so prominently that transformation will not happen without Medicaid’s involvement.
The Centers for Medicare and Medicaid Services, or CMS, fully comprehends its essential role in transforming mental health services. As an example of its commitment, CMS has joined with SAMHSA to conduct a series of strategy meetings between State mental health program directors and State Medicaid directors. For some States, these meetings represent the first time the directors of these programs have sat down to explore common problems and opportunities to resolve them.
In addition, CMS has launched an innovative grant program called Real Choice Systems Change. This program encourages States to develop new ways of funding and delivering effective, community-based care. The emphasis is on empowering consumers to direct their own journeys toward recovery.
The Social Security Administration is another essential partner in transformation. This agency manages the Supplemental Security Income (SSI) program, which provides an income to individuals with disabilities. Eligibility for SSI is a gateway to Medicare and Medicaid, as well as a route to stable housing, . . . to employability, . . . and to recovery!
[SLIDE 7. Homelessness and MI]
SSI eligibility is of utmost value to the thousands of individuals with serious mental illnesses who also are homeless. In one groundbreaking new effort, SAMHSA is partnering with the Department of Housing and Urban Development and the Social Security Administration to develop training materials related to SSI. Local providers are receiving the tools and information they need to assist persons with mental illnesses and who are homeless to gain SSI eligibility.
[SLIDE 8. Employment and MI]
Employment is another critical issue. For many individuals with a serious mental illness, a job is a gateway to recovery and to a full, independent, and productive life in the communities. To address this issue on the Federal level, the Department of Labor is leading a collaborative effort to increase employment opportunities for individuals with mental illnesses. Partners in this effort are the Small Business Administration, Rehabilitation Services Administration, Social Security Administration, and HHS.
In addition, the Department of Labor has created an internal workgroup to promote transformation across its agencies. Included in these initiatives are two diverse examples of consumer-driven services: integrating ex-offenders with mental disorders into the workforce and helping young adults with serious emotional disturbances make a successful transition from education to employment. These programs are transformation in action because they are tailored to the unique needs of individuals with mental illnesses who are oft different ages and at different stages of life.
The preceding examples describe a few Federal efforts to decrease homelessness and increase employment. If we can accomplish those two goals, we also will be helping to prevent the needless incarceration of persons with mental illnesses. The role of criminal justice in transforming mental health care is huge!
[SLIDE 9. Justice and MI]
Each year, our jails and prisons admit about 800,000 persons with serious mental illnesses. Their mental health needs are seldom met because our justice facilities were never designed to be treatment facilities. Well- monitored and proven diversion programs, however, do offer the possibility for recovery. SAMHSA and the Department of Justice are partnering to expand court-based diversion programs. Our focus is mental health courts and reintegration practices for adults as well as for youth.
The prevalence of behavioral disorders among youth in justice facilities is staggering! Of teens in juvenile detention centers, two-thirds of boys and three-quarters of girls have at least one psychiatric disorder. Working with parents to ensure that their children receive early screening and assessment of behavioral disorders can help prevent youth from landing in our juvenile justice system. One Federal initiative that addresses this problem is the Safe Schools/Healthy Students Interdepartmental Grant Program, which is a collaborative effort by the Departments of Education, Justice, and HHS. Together, we are promoting partnerships between local education systems and the mental health and law enforcement systems. The goals of the grant program are to promote the healthy development of children and youth and to reduce school violence. At present, we have grant programs in 124 communities. We plan to award grants to another 45 to 50 communities in October.
Collectively and individually, agencies within our Federal Partners Workgroup are engaged in new or expanded activities that respond to the principles of mental health transformation. Each activity is another step forward. One of the most important outcomes of our Federal Partners Workgroup, however, is not a program or a partnership. Instead, it is a precedent. The cross-agency collaboration that is occurring at the Federal level provides a model for what should be expected and demanded at every level of the system—especially at the State level.
We at the Federal level can provide leadership. We can facilitate, promote, and compel shared responsibility for change. We can provide resources and use our convening power to raise issues to the national level. States, however, are the centers of gravity for transformation. This is the level where transformation comes to life. This is level where the greatest opportunity exists to make real differences in the mental health of millions of American adults and children.
We at SAMHSA are doing all that is within our reach and resources to help States move toward transformation. Last year, we incorporated National Outcome Measures, or NOMs, for mental health into our State mental health block grant reporting requirements. We now are looking at how we can build the NOMs into all of our discretionary grant programs. The NOMs reflect a transformed view of effective mental health care because they focus on positive outcomes for consumers. They are, in fact, a test bed for measuring our basic concepts of what recovery means to a consumer.
These are the NOMs for mental health. As we read through them, consider how they point toward recovery and resilience as the expected goals of treatment. In particular, note how they reflect a life in the community for everyone—a life that includes a job or an education, a home, and meaningful relationships with others.
[SLIDES 10-12. NOMs—ALLOW TIME FOR READING OR READ ALOUD—CLICK for SLIDE 10]
- Decreased symptomatology and improved functioning,
- Increased or retained employment for adults and a return to or retention in school for children,
- Decreased criminal justice involvement,
[CLICK for SLIDE 11]
- Increased stability in family and living conditions,
- Increased access to services,
- Reduced utilization of psychiatric inpatient beds,
[CLICK for SLIDE 12]
- Increased social supports andsocial connectedness,
- Client perception of care outcomes, and
- Use of evidence-based practices (which doubles as our measure of cost-effectiveness)
We are asking the States to use NOMs data to identify the gaps between service needs and service delivery, to set outcome goals, and to identify priorities for action. This is a process focused on recovery. It pinpoints where changes are needed the most to ensure that consumers will have access to the treatments and supports they need to achieve and sustain recovery.
[SLIDE 13. SIGs]
SAMHSA’s newest action agenda step is our State Incentive Grants for Mental Health Transformation Program. This grant program is truly unique because it takes an overarching approach to improving service delivery. The grants are designed to support a State’s efforts to move forward with its own vision of a transformed system. The focus is on State infrastructure—what a State needs to put into place to weave together mental health planning, financing, services, and evaluations conducted by the multiple systems involved with adults and children.
Applications for the first round of grants currently are under review. We will be awarding 19 million dollars in grant funding by the end of September. Increased funding for a second round of grants is included in the President’s proposed budget for the next fiscal year.
[SLIDE 14. Regional meetings]
SAMHSA is taking an additional step to accelerate transformation at the State level. We are partnering with the National Governors Association’s Center for Best Practices to conduct four regional meetings called “ Transforming State Mental Health Systems.” These meetings are designed to bring together teams of individuals capable of leading transformation efforts in their States, such as cabinet-level members of the State government.
We want the teams to develop a transformation vision for their State and to reach a consensus about priorities and strategies for achieving it. We held the first meeting to transform State mental health systems in June and will hold the remaining three within a year.
We soon will launch our “Transformation Action Initiative” to promote State efforts to transform the services they offer. SAMHSA’s Center for Mental Health Services currently supports technical assistance efforts aimed at improving services in more than 50 critical and overlapping areas, such as eliminating stigma, preventing suicide, and ending chronic homelessness. Our Transformation Action Initiative will make it easier for the States and other stakeholders to navigate among these efforts. As part of this initiative, we are considering service brokers who can tailor a technical assistance plan in response to a State’s priorities for transformation. We also are exploring opportunities to use technology in broader and more innovative ways so that States and others will have greater access to support services.
Many States already have begun the critical work of transformation. The Research Institute of the National Association of State Mental Health Program Directors is tracking State efforts.
[SLIDE 15. NRI Survey]
According to its ongoing survey, the majority of States are—
- Collaborating with Medicaid and State health departments to better integrate mental and primary health care,
- Working to reduce fragmentation of services across agencies,
- Adopting recovery mission statements and developing recovery-oriented services,
- Providing prevention and early intervention services,
- Implementing at least one evidence-based practice service, and
- Investing heavily in technology to enhance quality and accountability.
What is the most exciting finding?—It’s the initiative being taken by the States to make care more consumer centered. Nearly every State is working to ensure that consumers receive individualized treatment plans. These are plans to identify the services and supports that support each individual’s unique goals for recovery.
This brings me to the second topic I want to address, which is how transformation applies to a mental health research agenda. The New Freedom Commission had a specific principle to guide the development of research recommendations. This principle is to “consider how mental health research findings can be used most effectively to influence the delivery of services.
[SLIDE 16. Principle D/Goal 5 recommendations]
The commission recommended that we—
- Accelerate research,
- Advance the use of evidence-based practices,
- Improve and expand a workforce capable of providing evidenced-based care, and
- Increase our knowledge in four understudied areas. These areas are disparities of care, long-term effects of medication, trauma, and acute care. I’m proud to say that the Federal Partners, including NIMH, the Agency for Healthcare Research and Quality, and SAMHSA are supporting efforts to improve knowledge and practice in each of these areas.
As described in our action agenda, SAMHSA and NIMH are collaborating on a science-to-service initiative to achieve these recommendations. One step is our ongoing efforts to expand the number and distribution of evidence-based practices available through the National Registry of Evidence-Based Programs and Practices. Another step we already are taking is to ensure that States and providers can implement and sustain more widespread use of the practices.
Last year, in cooperation with the Dartmouth-led consortium, SAMHSA produced six resource implementation kits, better known as our “toolkits.”
[SLIDE 17. Toolkits]
Each toolkit contains the resource materials needed by providers to replicate the practice, including implementation guidelines and fidelity measures.
More than 50 community mental health programs in 18 pilot States currently are evaluating 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. We will use this information to refine the toolkits and to guide us in creating additional kits. In this way, we will be engaged in a science-to-service cycle that results in continuous learning, application, and improvement.
[SLIDE 18. Science-to-service cycle]
But what is the ultimate goal of transformation?—It’s to create a system that is consumer driven and focused on recovery. Thus, recovery—as defined by consumers and their families, and as reflected in their goals for treatment—should be the driving force behind future research.
[SLIDE 19. Recovery definition]
Achieving the Promise interprets recovery as “the process through which people are able to live, work, learn, and participate fully in their communities.” Recovery for a consumer does not necessarily mean a cure. Instead, recovery may be a consumer’s ability to lead a full and productive life even though a disorder persists.
During the past 25 years, science has made significant strides in helping to develop effective practices for reducing and eliminating symptoms, for helping consumers live in the community rather than be isolated in hospital wards, and for helping consumers work in mainstream competitive jobs and live independently.
We have a long way to go, however, before evidence-based care becomes the standard of treatment and supports. As it stands now, it may take up to 20 years before an effective treatment moves from research to routine practice. Twenty years—roughly the same time it takes to raise a child from birth to college graduation. We cannot lose a generation of children, or two decades of a better life for an adult, simply because it takes too long to move from science to service. This is not acceptable. Consumers have a right to state-of-the-art, evidence-based mental health services to the same degree that they expect such service from their physical health care providers. We have a responsibility to ensure that they do, through both research and practice.
Developing a research agenda for individuals with mental illnesses carries another responsibility. This responsibility is to engage in research that reflects the diversity of the people we serve, including their age, gender, race or ethnicity, sexual orientation, and culture. As I mentioned earlier, developing treatments that respond to—and respect—each person’s individuality is the foundation of consumer-driven care, . . . of recovery, . . . and of transformation.
[SLIDE 20. Washington Post headlines]
A few weeks ago, the Washington Post ran a three-part series on mental health. The articles cited several instances in which race and culture may affect significantly the development and treatment of mental disorders. For example, people of Mexican descent born in the United States have twice the risk of disorders such as depression and anxiety when compared with recent immigrants from Mexico. White women in the United States are three times as likely to commit suicide as black and Hispanic women. Individuals with schizophrenia who live in poorer countries such as India become symptom-free at rates far higher than in the United States. Some experts believe differences such as these can be attributed in part to the relative protective and healing factors provided by different cultural networks.
The articles questioned the future direction of mental health research. Should research focus primarily on biology and brain chemistry or should it give greater weight to racial, ethnic, and cultural factors? The debate should never be between biology and environment because the two interact. We can no more separate the mind from its environment anymore than we can separate the mind from the body. The real question is “How can we better incorporate racial, cultural, and ethnic factors into the research that we conduct?”
As I mentioned at the beginning of my remarks, research is making great strides forward in mental health care. Furthermore, the goals of research are continuing to evolve as we develop a greater understanding of what recovery means to consumers. The concept of recovery as a process rather than an end point primarily has come about during the past several years. For all of us in the mental health field, this concept of recovery has been transformational. It has awakened us to new directions in mental health research and practice.
We have come together at this meeting because we believe in the potential of research to help us triumph over mental illnesses—to prevent or cure them and to increase the opportunities for recovery.
[SLIDE 21. Quote]
Our collaboration is grounded in hope, which research has found to be essential to recovery. Our feelings are those expressed by Franklin Delano Roosevelt, who—in promoting programs for economic recovery—declared “ We have always held to the hope, the belief, the conviction, that there is a better life, a better world, beyond the horizon.” With consumers as our guides, research can help us achieve a better life, a better world, for those who have or are at risk for mental illnesses.
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With that, I'd be happy to answer any questions you might have and hear your thoughts.
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