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

Fourth Annual Psychology Summer Institute:
A Life in the Community for Everyone: Transforming America's Mental Health Care

July 25, 2006
Washington, DC

PowerPoint version

[SLIDE 1. Title slide]

Good morning, and thank you for inviting me to address the Minority Fellowship Program (MFP) of the American Psychological Association (APA).

During the 7 seconds it just took me to say “hello,” another child was born in the United States. The baby was very likely to be African American, or Hispanic, or a member of another ethnic minority group. Four out of every 10 babies born in this country are minorities. In addition, every 31 seconds our country gains one international migrant, many of whom also are members of minority populations.

[SLIDE 2. Population estimates]

The face of our Nation is changing rapidly…and significantly. According to current U.S. Census Bureau estimates, minority groups will account for nearly 90 percent of the total growth in our population between 1995 and 2050. Within the next half century, more than half of our population will be people of color. What does this demographic change imply for the future of behavioral health care in our country…and for you?

The most obvious answer is this: The need for a culturally competent workforce is expanding dramatically as our population becomes more ethnically, racially, and culturally diverse. We had better be ready to meet the need.

As our country’s demographics change, so must our behavioral health care workforce. In my remarks, I’ll be discussing some of the ways in which the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services (CMHS) are working to promote a more diverse and culturally competent workforce.

[SLIDE 3. SAMHSA organization chart]

Let’s begin with this program. All three centers within SAMHSA—CMHS, the Center for Substance Abuse Prevention, and the Center for Substance Abuse Treatment—provide funding to support this mission. My center—CMHS—is pleased to be a co-sponsor of the APA’s Minority Fellowship Program. We share a similar objective: to reduce disparities in mental health and substance abuse care by developing a workforce that better reflects the individuals we serve and that is capable of providing high-quality, evidence-based care to underserved populations.

My center holds primary responsibility for the MFP’s service training component. We took over this responsibility from the National Institute of Mental Health (NIMH) in 1992, when Congress first established SAMHSA and its centers. Training fits better with the mandate of CMHS. NIMH is the Nation’s leading agency for research about behavioral health disorders. CMHS is the Nation’s leading agency for guiding the application of new knowledge through practice.

We view the MFP as critical to our efforts to help our country meet the staggering need for culturally competent mental health care, both now and in the future. Let’s take a moment to define the term “culturally competent.” In grant applications, SAMHSA asks applicants to demonstrate their ability to provide culturally competent care. We often define cultural competence in these words: First, it is the knowledge, skills, and attitudes that enable administrators and practitioners to care and provide for diverse populations. Second, it is an understanding of the language, beliefs, norms, values, and socioeconomic and political factors that have a significant impact on well-being, assessment, and treatment.

The term “race” is not used. I suspect that all of you have seen the special issue of American Psychologist on genes, race, and psychology in the genome era. Dr. Nickerson, the director of the MFP, and Dr. Norman Anderson of the APA’s executive office coauthored the introduction to the issue.

As their introduction points out, mapping of the human genome offers unprecedented opportunities to examine why some populations live longer and in better health. Many researchers, however, reject the notion of a genetic basis for any observed racial or ethnic group differences in health. Such a notion implies that particular groups might differ genetically in some fundamental way that could influence outcome.

Some authors in the special issue maintain that, for psychologists, “race” may not exist. They argue that the hallmark of the best psychological research is conceptual clarity, which is lacking in any definition of race. Ambiguities abound when it comes to race and research. For example, how do we classify people into racial categories and how do they classify themselves? How should we use these categories in research? What are the larger implications of research into genes, race, and psychology for public policy and practice, and what are some of the ethical, legal, and social issues that might result from such research?

The issues surrounding race as a research construct are not easily resolved. Consider hypertension in African Americans. The disease is more prevalent among African Americans than among Whites. African Americans experience more rapid progression of end-organ damage. African-American males are particularly at risk because they often are unaware of the disease, do not receive treatment, or fail to follow their treatment regimen. Environmental and cultural factors appear to lead to more serious consequences of disease for African Americans. The greater prevalence of the disease, however, may have a genetic basis.

Race also seems to affect treatment protocols. I’ll use racial variations in psychopharmacology as examples. When compared with Whites, Asian consumers require lower doses of antipsychotic drugs. They also appear to have higher incidences of toxicity and side effects. Hispanics may require lower doses of antidepressants than other groups.

So where does race fit into culturally competent behavioral health care? Racial distinctions both shape and complicate our efforts to provide appropriate care. I appreciate the position taken by anthropologist Audred Smedley and psychologist Brian Smedley in their article for American Psychologist. The authors argue that race is a poor construct for science, but a very relevant construct for social policy. They maintain that “race remains a significant predictor of which groups will have greater access to societal goods and resources and which groups will face barriers.” As numerous studies point out, racial minorities tend to have less access and face greater barriers when it comes to high-quality health care. We need to eliminate these disparities of care, but in ways that respond to the amazing complexity of each individual.

Our challenge in creating a culturally competent workforce is to recognize the impact race or ethnicity may have on an individual’s culture while we also recognize individual differences. The word “health” derives from the Greek word meaning “whole.” Only by seeing the “whole” individual can we truly help consumers with mental health problems to achieve and sustain behavioral health. This “holistic” approach considers all aspects of the individual, including gender, age, and sexual orientation. Any defining characteristic of a person has a “culture” of its own that affects treatment and recovery.

Let’s return to the definition of cultural competence. Cultural competence includes an understanding of the language, beliefs, norms, values, and socioeconomic and political factors that have a significant impact on well-being, assessment, and treatment. Are we referring only to how these factors affect consumers and their expectations of treatment? Not entirely—we also must be sensitive to how our own beliefs, norms, values, and other factors may affect our view of a consumer. This anecdote helps to illustrate what I mean.

In Arizona, CMHS funds Tiempo de Oro, a behavioral health care project targeting older Latino adults with depression, anxiety, and suicidal ideation. This can be a challenging group to treat because m any Latinos fail to recognize or accept the symptoms of mental illness or the need to seek treatment.

On the other hand, many Latinos would welcome treatment, if only it fit within their cultural framework. One of our Teimpo de Oro grantees was having a difficult time setting up an appointment time with an older Latina. The specialist thought the woman was resisting treatment because she kept delaying a home visit. Fortunately, the specialist overcame his own preconceived ideas and persevered. As it turned out, the Latinadid want the services being offered. Although her resistance was rooted in her culture, her reason was not a cultural stigma attached to mental illness, as the specialist believed. The reason? The Latina didn’t want the specialist to visit her home until she had food befitting a visitor.

CMHS, similar to the MFP, is expanding its efforts to promote culturally competent care as our knowledge of this complex area evolves. Our current efforts fit within a larger initiative, which we call “mental health transformation.” This is the name we have given to a broad-based approach to introduce fundamental change in the way mental health services are perceived, accessed, delivered, and financed in this country.

[SLIDE 4. Achieving the Promise]

Three years ago, President Bush charged CMHS, through the U.S. Department of Health and Human Services and SAMHSA, to implement the goals and recommendations of a groundbreaking report by the New Freedom Commission on Mental Health. The title of this report is Achieving the Promise: Transforming Mental Health Care in America.

The first part of the title—Achieving the Promise―refers to promises that our government has made to all Americans through legislative and judicial actions. Laws such as the Americans With Disabilities Act have consistently affirmed our social and moral obligation to prevent discrimination against persons with disabilities, including mental disabilities. Our Supreme Court’s ruling in the Olmstead decision interpreted this particular law to mean that persons with mental disorders are entitled to live in the least restrictive settings possible. This, then, is the ultimate promise: a life in the community for everyone. SAMHSA has since adopted that promise as the vision that guides all of our programs and policies. This vision certainly applies to our continuing partnership with the APA and the MFP.

The second part of the report’s title―Transforming Mental Health Care in America—is the briefest summary of how we can achieve the promise of a life in the community for everyone.

[SLIDE 5. Goals—PAUSE for reading]

Achieving the Promise outlines 6 broad goals and 19 more specific recommendations for a transformed system. Two goals are particularly relevant to the mission of the MFP. Goal 3 is that disparities in mental health services are eliminated. The first recommendation under goal 3 is to improve access to quality care that is culturally competent. Goal 5 is that excellent mental health care is delivered and research is accelerated. Recommendations under goal 5 include an improved and expanded workforce capable of providing evidence-based mental health services and supports.

As you read through all of the goals, envision their potential to improve behavioral health care in this country. For example, how would our system change if all Americans understand that mental health is essential to overall health? One possibility is that individuals would seek out psychologists as readily as they seek out physical health care specialists. Another possibility is that mental health care would receive the same attention, funding, and financing as physical health care.

[SLIDE 6. Federal action agenda]

I have provided each of you with a copy of Transforming Mental Health Care in America: The Federal Action Agenda. This agenda is our roadmap for implementing the goals and recommendations of Achieving the Promise. It outlines the first steps that the Federal Government will take to transform our national mental health system. SAMHSA and all three of its centers are joined in this effort by nine U.S. departments, the Social Security Administration, and the Equal Employment Opportunity Commission. We expect that the collaboration we are achieving at the Federal level will be a role model for collaboration at the State and community levels.

[SLIDE 7. Goal 3 actions: PAUSE briefly for reading].

This slide shows ways in which we are working to eliminate disparities of care. The first item—to create a national strategic workforce development plan—also will help to ensure that excellent mental health care is delivered.

CMHS is the lead agency for these efforts. We are challenging ourselves and our national workforce to establish standards of care that are culturally competent and population-specific. We intend to create a system that is consumer- and family-driven, with policies and practices reflecting the unique and special qualities of the individuals we serve.

[SLIDE 8. Annapolis Coalition]

For the past few years, we have been working with the Annapolis Coalition on Behavioral Workforce Education. The coalition was formed by the American College of Mental Health Administration and the Academic Behavioral Health Consortium. Its mission is to promote major reforms in the quality and relevance of education and training for behavioral health care.

Last year, we asked the Annapolis Coalition, with the help of others in the field, to develop a national strategic plan on workforce development. Issues to be addressed include how we can recruit, train, educate, retain, and enhance an ethnically, culturally, and linguistically competent workforce. Expert panels are examining the needs of multiple underserved groups, such as children and adolescents, older adults, and people living in rural areas. Dr. Deborah DiGilio, of the APA’s Office on Aging, is a member of the expert group on older adults. Dr. Paul Nelson, APA’s deputy director of education, is a member of the educators advisory group.

Cultural competence is an overarching issue affecting all workforce development. According to the coalition’s preliminary analysis, developing a culturally competent workforce involves changing who we train as well as what and how we train. Let’s briefly talk about “who.”

One objective of the MFP is “to increase the number of ethnic minority psychologists delivering mental health and substance abuse services to ethnic minority populations.” The number of professionally trained minority mental health providers and service researchers is not increasing at the same pace as our minority populations.

[SLIDE 9. Comparative graphics]

While the U.S. population is 25 percent minority, only 8 percent of providers are from minority groups. This is a breakout by profession: 94 percent of psychologists, 88 percent of social workers, and 93 percent of marriage and family therapists are White. Ninety-five percent of school psychologists are White.

The lack of minority providers is compounded by a shortage of highly educated minority providers. Relatively few minority students pursue higher professional degrees. We consider this shortage a significant factor in why minority communities lack appropriate mental health services and why they fail to access available services. I’m delighted that the MFP is helping us to increase minority representation in the workforce. More than 600 trainees have earned their doctoral degrees through the MFP. Their entry into the workforce is a positive step forward.

Obviously, we need more highly trained and outstanding professionals such as you to enter the workforce. We view psychology as one of the four core behavioral health disciplines, together with psychiatric nursing, psychiatry, and social work.

Research consistently affirms the value of psychology in promoting recovery from mental illnesses. For example, the most effective treatment for chronic major depression may be a combination of cognitive behavioral therapy, or CBT, and medication. Some studies suggest that CBT is a valid alternative to antidepressants for individuals with mild to moderate depression. We know CBT works! ...and we know that therapy is a component of treatment that depends on the knowledge and skills of trained psychologists.

Minority psychologists, as well as minority providers in other behavioral health fields, are crucial to a more diverse and competent workforce. There are, however, other opportunities to end disparities of care that we must pursue. Cultural competence must be developed throughout the workforce. Underserved populations deserve proper care, regardless of who delivers the service. This fact highlights one of your future roles. You have been selected to participate in the APA’s minority fellowship program or to receive a health disparities grant for a reason—because your experiences suggest that you can contribute significantly to the mental health needs of ethnic and racial minorities.

We expect you to become leaders in your community as well as in your field. We expect you to use your education and training to inspire your colleagues to set higher standards for care. We expect you to help consumers and providers alike to value and respect diversity…to recognize cultural strengths that help to promote recovery…and to expand the knowledge of evidence-based practices for minority populations.

A key aspect of your leadership must be to create other leaders. This is how we will move forward—by expanding the number of individuals who embrace and promote the vision of recovery for individuals of every gender, race, ethnicity, age, and sexual orientation. No one should be denied the hope of recovery and a life in their community.

Look to consumers for leaders. Several decades ago, the eminent psychologist Carl Rogers created what became known as client-centered therapy. He believed consumers should be in control of the therapeutic process. In his book entitled On Becoming a Person, he wrote, “It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried.”

We see reflections of his philosophy in the ongoing consumer movement and our efforts to make care more consumer and family driven. A consumer-driven system of care recognizes their potential to guide service delivery for others as well as for themselves. Training, educating, and empowering consumers to provide self-help, or to operate consumer-run programs, does more than expand the workforce. This effort also—and perhaps most important—helps to improve the quality of care by drawing on the experience of those who are most directly affected.

I’d now like to briefly address the what and how of workforce training. I’ll begin by quoting Dr. Nickerson’s message on the MFP Web site homepage.

Dr. Nickerson observes that the MFP is taking on a larger training role. He says, “W hat is becoming increasingly clear is that simply obtaining the doctoral degree is not enough. Our clinical grant [which is funded by SAMHSA], now focuses on assisting our trainees to have significant experiences with both mental health and substance abuse.”

SAMHSA requires MFP fellows to receive cross-training in both areas. Why? The reason is because mental health and substance abuse disorders overlap significantly. 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. We see high incidences of co-occurring disorders among adults who are homeless and those who are incarcerated. We see very high incidences among adolescents in juvenile justice facilities. Minority populations are represented disproportionately in all of these settings.

Co-occurring disorders are so common that they should be considered the norm and not the exception of persons seeking mental health or substance abuse treatment. Given this reality, we need to alter dramatically our traditionally separate approaches to these disorders. What we need is a fully capable and cross-trained workforce so that any door becomes the right door to the services and treatment each consumer requires.

We encourage you to expand your knowledge about co-occurring disorders and treatment options after you complete your fellowship or as you work on your grants. As psychologist Carl Rogers observed,

[SLIDE 10. Rogers quote]

“The only person who is educated is the one who has learned how to learn and change.”

We are looking to the MFP…and to you…to help us achieve SAMHSA’s vision of a life in the community for everyone. Our vision is based on the very real possibility for recovery when consumers have access to the providers and services that fully support their unique treatment needs. The MFP’s success in expanding the number of minority psychologists who serve minority populations supports this vision. Your growing knowledge about evidence-based practices for specific populations promotes this vision. Psychology, and its proven methods for preventing and treating behavioral health disorders, is a critical element in attaining this vision.

As highly trained professionals, you are responsible for what you have achieved as well as what you still can accomplish. So, bef ore I close, I have one more challenge to offer you. Consider a career in the public sector. Our government needs the best among you to help develop national behavioral health care policies and programs. In this capacity, you will have the opportunity to help improve the lives and futures of millions of Americans with or at risk of developing behavioral health disorders. Is there a better way to fulfill your promise and commitment to a career that addresses the needs of minorities?