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

Giving A Voice To The Voiceless: Rural Mental Health Care In The 21st Century

August 9, 2007
Kansas City, MO

Thank you, Ann (Schumacher—pronounced Shoe-maker—conference chair), for your kind introduction and your willingness to host the NARMH conference in Kansas City. I’m so pleased to be joining you again this year, because I have some exciting developments to report about how the Substance Abuse and Mental Health Services Administration—or SAMHSA—is addressing rural mental health in collaboration with our Federal partners, States, communities, providers, and consumers.

I’m also honored to be sharing just a bit of the limelight with your distinguished honorees, Charlie Griffin and Senator Tom Harkin. As director of the Kansas Rural Family Helpline and coordinator of the State’s disaster behavioral health response, Charlie has made significant contributions to the rural mental health field. Senator Harkin has been a strong voice and advocate for the needs of all Americans with mental health needs, particularly those in rural areas. I congratulate both of them.

And I’m particularly happy to be here in Kansas City, home of the American Jazz Museum, where such legends as Charlie Parker, Count Basie, and Big Joe Turner—with his hit “Kansas City, Here I Come”—defined the sounds of the 1920s, 30s, and 40s at 18th and Vine.

Jazz has been called an original American art form. In a thoughtful essay on Jazz and Social Justice, Olivier Urbain, associate professor of Art and Peace Studies at Soka University in Japan, said

Jazz is about giving voice to the voiceless. It is based on individuality which can be found in the solos, but also on participation and togetherness, since the solos are within the framework of a specific song, which the musicians have agreed to play.

Individuality and togetherness are the hallmarks of life in rural America. Certainly when we think of the American frontier, we envision the rugged individualist striking out on his or her own to find a better life.

But close connections to community, and to the land, are also an important feature of life in rural America. Several years ago, the Pew Partnership for Civic Change commissioned a national survey of 1,830 adults in rural, urban, and suburban communities. They asked questions about community life and participation, key problems facing communities, and community problem solvers. Here’s some of what they found:

• Rual residents were more likely to feel connected to their communities than urban residents. This is in part because more than 80 percent of rural residents reported lending a helping hand to a neighbor in need, the highest percentage in the survey.
• When asked to rank potential problem solvers in their community, rural respondents ranked friends and neighbors first, followed by local religious organizations and the local police department. Guess who was farthest down the list? The Federal government!
• Certainly, problems identified by rural residents are similar to those that urban and suburban communities experience, as well. Illegal drugs and access to affordable health care were among the top five concerns of rural respondents, along with lack of living wage jobs, teenage pregnancies, and lack of activities for children and teens.
• In the end, the authors of the survey concluded that friends and neighbors are one of the biggest building blocks for rural communities. Rural residents are quick to lend a hand and most likely to take a hand when it comes to addressing tough issues. And despite some daunting problems, there are enough positives in their community to make them want to stay.

There’s No Place Like Home

We need to build on these strengths in rural America and the sense rural residents have that, “there’s no place like home.” Home is a powerful construct.

When Dorothy wants to return from the Land of Oz to the State of Kansas, she clicks her heels three times and says, “There’s no place like home.”

T.S. Eliot tells us that, “Home is where one starts from.”

And in the oft quoted line from Robert Frost, “Home is the place where when you have to go there, they have to take you in.”

What is it that’s so powerful about home? Many of you know that I work in Rockville, Maryland, but make my home in Rhode Island. Recently, Boston Globe writer Tina Cassidy mused about why her brother, despite having a well-paying job in Boston, would have chosen to live at home with his parents and his wife in Cranston, Rhode Island, until a few months shy of his 31st birthday.

“It was not about money,” Ms. Cassidy concluded. “It was about community. About my aunt and uncle and cousin across the street, another cousin and her family next door, my grandparents down the street, and friends from childhood all around. Cranston is a place that doesn’t let you leave.”

For many rural Americans, as well, home is a place that makes you want to stay. Those of us who serve people with mental and substance use disorders in rural areas must ensure that home is also a place that doesn’t let you suffer needlessly when effective, evidence-based treatment and services are available right now.

Too often in rural America, these services aren’t getting to the people who need them. Rural America makes up 90 percent of our Nation’s landmass and is home to more than 25 percent of our Nation’s people.

When it released its final report in 2003, the President’s New Freedom Commission on Mental Health concluded that, “Despite these proportions, rural issues are often misunderstood, minimized, and not considered in forming national health policy.” We must listen to what rural America is telling us about the great diversity of its people, its challenges, and its opportunities.

The Voice of Rural America

Certainly, if we are listening closely, we will hear about the many challenges that rural residents—especially those with mental and substance use disorders—face when they need care. A report that NARMH released last year on barriers and best practices in rural mental health noted that there has long been a tendency to think about the “ideal rural America” with its scenic mountain and desert vistas and postcard perfect farms. In reality, many rural communities grapple with issues of substantial ethnic and cultural diversity, deteriorating infrastructure, pervasive poverty, limited employment opportunities, and declining populations.

The myth of an idyllic rural existence becomes a barrier to creating an impetus for action to address rural mental health problems. We know that the prevalence of adults and children who suffer from mental illnesses is not significantly different in rural and urban areas. What appears to be different in rural America is the experience of individuals with mental illnesses and their families.

In particular, rural Americans face three main barriers to receiving adequate, appropriate, quality treatment. These barriers are accessibility, availability, and acceptability. Rural Americans must understand their need for care, have someone there to provide it, and be able to pay for it.

When services are not accessible, available, and acceptable, rural residents with mental health needs enter care later in the course of their disease than do their urban peers; they enter care with more serious, persistent, and disabling symptoms; and they require more expensive and intensive treatment responses.

The National Plan for Rural Mental Health

I’d like to share with you what SAMHSA and its Federal partners are doing to ensure that individuals of all ages in rural and frontier communities have accessible, available, and acceptable behavioral health care when and where they need it.

By way of background, in 2003, the President’s New Freedom Commission on Mental Health released its final report called, “Achieving the Promise: Transforming Mental Health Care in America.” The Commission found that the mental health system was not oriented toward promoting mental health, preventing or reducing the severity of mental and behavioral health challenges, and, most important, not oriented toward the single most important goal of the individuals it served—the goal of recovery.

Stigma and discrimination, fragmented and inadequate services, and limited opportunities for consumer involvement and self-determination were impassable barriers to hope for recovery and a life in the community.

The report concluded that the only way to keep our promise to all Americans is to transform our mental health system.

The word “transformation” was chosen carefully to reflect the belief that mere reforms to the existing mental health system are not enough. Transformation is a powerful word with implications for policy, funding, and practice, as well as for attitudes and beliefs.

Transformation is a deep, profound, and ongoing process along a continuum of innovation. It is a way of creating something possible from the perceived impossible. It implies profound change—not at the margins of the system, but at its very core. In transformation, new sources of power emerge and new competencies develop. Opportunities and challenges are looked at with a new perspective.

The needs of rural America were highlighted by the New Freedom Commission in several of its specific recommendations, including its call to “improve access to quality care in rural and geographically remote areas” and to “use health technology and telehealth to improve access and coordination of care, especially for Americans in remote areas or in underserved populations.”

In response to the Commission’s report, SAMHSA released the Federal Action Agenda. The result of an unprecedented, collaborative effort among more than 20 Federal agencies and offices, the Federal Action Agenda outlined specific, actionable items to make the Commission’s goal of transforming the mental health system a reality. These action steps include our charge to develop a plan for strengthening our national behavioral health workforce; to create a plan to reduce mental health disparities; to develop a strategy to implement innovative technology in the mental health field; and to develop a National Plan for Rural Mental Health.

We’ve made great progress on developing a National Plan for Rural Mental Health. An Intradepartmental Rural Behavioral Health Workgroup that includes representatives of SAMHSA and the Health Resources and Services Administration or HRSA is leading this work. Its members met with key stakeholders in November 2005 and January 2006 to assess the current situation, prioritize issues, and develop a logic model for rural behavioral health. Additional discussions since then have engaged families, youth, Federal and State representatives, SAMHSA’s Children’s Grantee programs, rural research centers, and technical assistance resources to inform implementation of this work.

The clear consensus for action continues to focus our first steps on activities designed to improve, expand, and sustain the rural mental health workforce. Individuals who live in rural and frontier areas express their desire for communities where they can fully live, work, play, and learn. Narrowing the focus of our efforts was challenging, but we have identified seven areas that seem to be critical, and workforce issues cut across all of them. Taken together, these seven action areas provide a framework for transformation in rural and frontier communities.

I’d like to highlight each of them briefly.

1. Action Area 1 calls for public health approaches to behavioral health to be implemented in rural and frontier areas. This means that rural and frontier communities need to have access to practices and services that promote mental health, prevent mental illnesses, and treat those with mental health problems and disorders. We’ve begun to explore what needs to exist to develop and sustain such a system of care for rural communities by linking the resources of our technical assistance providers to facilitate communication, collaboration, and cross-grantee linkages.

   You can see one result of this work at the new rural Web portal at www.promoteprevent.
   org/rural. This portal is a “living” document that brings together grantees from our Safe Schools/Healthy Students, Systems of Care, National Child Traumatic Stress Initiative, and Youth Suicide Prevention and Early Intervention to help communities enhance social and emotional outcomes for children and families in rural and frontier areas.

   The site recently hosted its first “webinar” on Creating Systems Change in Rural and Frontier Areas for Children’s Mental Health, which attracted more than 75 participants. This program was a collaborative effort of the American Institutes for Research, Georgetown’s National Technical Assistance Center for Children’s Mental Health, and the National Center for Mental Health Promotion and Youth Violence Prevention, assisted by HRSA’s Office of Rural Health Policy. I’d like to recognize several of the faculty for the call who are attending this conference, including Nancy Speck and Mimi McFaul (of WICHE). Thank you for your contributions.

   I also want to acknowledge Jenifer Kitson from the National Center for Mental Health Promotion and Youth Violence Prevention, who is presenting at this conference, and Kristi Martinsen from HRSA for their hard work in helping launch this wonderful online resource. Watch this site for additional education and training opportunities and be certain to sign up for the discussion boards.

2. Action Area 2 calls for research to inform practice and policy regarding rural behavioral health services and supports. Research to practice is a two-way street—practitioners need the best evidence-based practices and researchers need the best practice-based evidence. SAMHSA is working with HRSA, the National Institute of Mental Health, and other partners to access and prioritize existing knowledge and data on rural and frontier approaches, expand research efforts, and achieve an effective rural research agenda.

3. Action Area 3 call for disparities in financing behavioral health services and supports to be reduced or eliminated in rural and frontier areas. Financial incentives must be in place to support efforts to build a quality workforce for rural and frontier areas, and we must identify and reduce or eliminate financial and regulatory barriers that put the rural community at a disadvantage. Adjusting reimbursement policies to support the increased growth of telemedicine is one important strategy.

   We know that telemedicine has been instrumental in helping Americans living in rural or frontier areas gain access to quality healthcare. Telemedicine, or telehealth as it is sometimes called, can be used for long-distance clinical treatment, patient and professional education, and consultation—including support to primary care providers, as well as specialty and peer-to-peer consultations—just to name a few of its many applications.

   In Georgia, a 20-year-old telemedicine network now connects more than 60 sites, including rural community hospitals, an ambulatory center, a public health facility, and correctional institutions. Along with interactive patient consultation, the system enables rural physicians to acquire continuing medical education. Originally financed through telephone company rate overcharges, the system has been expanded and maintained through the joint efforts of the phone companies, a medical college, and the Governor’s office. ¹ This is a perfect example of the fact that mental health transformation is being led by States in collaboration with the public and private sectors.

4. Action Area 4 calls on us to integrate behavioral health and primary health care services in rural and frontier areas. We know that primary care providers are on the front lines in rural communities and often are the early identifiers of behavioral health problems. In fact, more than 65 percent of rural Americans get their mental health care from primary health care providers. Primary health care systems must strengthen their capacity to identify, refer, or provide treatment for mental disorders and must, especially, be able to identify those at risk for suicide. Sadly, rural teens and older adults have a much higher rate of suicide than their urban peers. The use of mid-level practitioners in rural areas is part of the solution.

   We are working to better identify the barriers to integration of behavioral health and primary care services. Specifically, in partnership with HRSA, the Indian Health Service, and the Centers for Medicare & Medicaid Services, we are looking at payment barriers for mental health services in primary care settings.

   In addition, our Suicide Prevention Resource Center is developing a training curriculum for rural primary care physicians and others in order to identify patients at risk for suicide, and the National Child Traumatic Stress Initiative is convening an ongoing workshop focusing on traumatic stress in rural and frontier areas.

5. Action Area 5 is where the rubber meets the road. Recruitment, retention, and the provision of a quality professional work environment will result in a stable, highly qualified, culturally and linguistically competent behavioral health workforce in rural and frontier areas. This is a tall order to be certain, but one that we simply must address. Did you know that the average time to recruit psychiatrists to rural practice is 32 months? The time increases for those in private practice. We need to change the workforce dynamic immediately.

   The Rural Intradepartmental Workgroup is using recommendations from the Annapolis Coalition’s Action Plan on Behavioral Health Workforce Development, supported by SAMHSA. Rural mental health is a specific focus in this document. In addition, SAMHSA is working with NARMH’s Journal of Rural Mental Health to develop a special issue focusing on innovations in workforce development for children’s behavioral health. We will continue to use the new rural Web portal to help educate our grantees and other members of the workforce about the best evidence-based practices specific to the needs of rural Americans with mental and substance use disorders.

6. Action Area 6 expands our workforce efforts to ensure that consumers, families, and youth are employed as part of the behavioral health workforce in rural and frontier communities. We know that consumers, families, and youth bring a special perspective to their role as mental health providers that helps close the gap with clients and reduces the stigma of receiving services. This is particularly true in rural and frontier areas where the closeness of the community can both serve as a barrier for individuals seeking treatment and a source of support.

   Look at the success of trained paraprofessionals who conduct outreach in their own communities. The use of “Promotoras de Salud,” literally “promoters of health,” has become an established practice in many rural, Hispanic communities. We need to facilitate the hiring of consumers, youth, and families as part of the mental health workforce and offer them the support they need to be successful.

7. Action Area 7 is, in one sense, the logical outcome of steps 1-6. When we are successful in transforming the delivery of behavioral health services in rural and frontier communities, children, youth, and their families and consumers across the lifespan will have access to a full continuum of quality behavioral health services and supports within the community that are culturally and linguistically acceptable. We know that quality and acceptability demand a consumer-centered, evidence-based, recovery-focused system of care. One way to achieve such a system is to be certain that adult consumers and family members of children participate in decisions concerning their own care or the care of their family members.

Shared decision-making is a way to put the consumer at the center of care. This is an interactive, collaborative process in which consumers and providers partner to make health care decisions. It combines the provider’s medical expertise with the consumer’s knowledge of what gives his or her life meaning and value.

Shared decision-making is not a new concept in health care. However, it is not widely practiced or accepted in mental health care, in part because many providers mistakenly believe—despite evidence to the contrary—that people with psychiatric disabilities are not competent to participate in treatment decisions or don’t wish to do so.

But shared decision-making is entirely consistent with recovery, self-determination, and consumer-driven care and can help reduce barriers to treatment. Wouldn’t someone be more likely to participate in treatment if they knew they had a say in the type of care they would receive?

To promote the use of shared decision-making in mental health care, SAMHSA invited national experts to a meeting on shared decision-making July 10-11. We asked them to examine what shared decision-making is, how the process is being used in general health care, and how SAMHSA can promote its applicability to mental health care.

We will distribute a report on this meeting, and we plan to award a contract to develop and pilot test some innovative shared decision-making tools specific to mental health. These tools will help give rural consumers a voice in the care they receive.

A Rural Community System of Care

These seven action areas lead to the next logical step in our efforts to transform rural and frontier behavioral health systems—development of a rural community system of care. What should such a system look like?

In their well-known publication A System of Care for Children and Youth with Severe Emotional Disturbances, authors Beth Stroul and Robert Friedman highlight three core values of such a system that we can adapt to rural and frontier communities:

• First, a system of care should be consumer- and family- centered, with the needs of adults or children receiving services dictating the types and mix of services provided.
• Second, a system of care should be community-based, with the locus of services at the community level and decision-making responsibility resting with consumers and families.
• And third, a system of care should be culturally competent, with agencies, programs, and services that are responsive to the cultural, racial, and ethnic differences of the populations they serve, including the culture of rural and frontier life.

Treatment and services in a rural community system of care should proceed along a continuum from formal services at one end—including inpatient treatment, partial hospitalization, and crisis and assessment services—to natural supports and care at the other. As an individual moves along this continuum, he or she takes advantage of such recovery-focused services as psychosocial rehabilitation and informal community supports, including self-help groups and consumer-operated programs.

The centerpiece of a rural community system of care are the community-based treatment services that sustain an individual in his or her home, family, school, and neighborhood. Case managers help individuals negotiate these services, including those available in primary care and specialty behavioral health care.

Clearly, this is an ideal system, and one that requires thought and planning to implement in rural and frontier communities. If we address fully the action areas in our National Plan for Rural Mental Health, we will have providers trained to deliver culturally appropriate community-based services and consumers and family members who can offer peer support.

We will have primary care systems able to identify and treat or refer their patients with mental disorders.

We will finance those services, such as telemedicine, that promote a system of care approach in areas that are geographically isolated.

And children and adults with mental disorders in rural and frontier communities will have access to a full continuum of quality behavioral health services and supports that promote mental health, prevent mental illnesses, and treat mental health problems and disorders.

Conclusion

Clearly, we’ve made a start in addressing the needs of individuals who live in rural and frontier communities for accessible, available, and acceptable health care. But in no way can we rest on our laurels.

Full-scale transformation of the mental health system demands that each of us play a part. You may have heard the comment attributed to American officer and pilot Betty Reese, “If you think you are too small to be effective, you have never been in bed with a mosquito.”

Each and every one of you has the potential to be a leader in your community, driving the incremental changes that add up to a system of care that is better designed to meet the needs of the people it is intended to serve. In fact, Joan Holmes, President of the Hunger Project, has said, “Ordinary people—daring to be heroes—are the greatest expression of human potential.”

Thank you for coming here today to learn and to share and to return home to lead change in your communities. Thank you for embodying the mission of the National Association for Rural Mental Health, “Linking Voices to Promote Rural Mental Health.” If jazz gives voice to the voiceless, your work to promote mental health and prevent and treat mental and substance use disorders in rural and frontier communities—even against some very difficult odds—gives voice to the people you serve.

It was Robert F. Kennedy who said

Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope…and crossing each other from a million different centers of energy and daring those ripples build a current that can sweep down the mightiest walls of oppression and resistance.

Thank you for sending forth tiny ripples of hope as you strive to ensure that in rural and frontier America, there truly is no place like home. I’m happy to take your questions.

¹ Matthews, L., & Woodwell, W.H., Jr. (2005). A portrait of rural America—Challenges and opportunities. Research Brief on America’s Cities. Washington, DC: National League of Cities.