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
Fifth Annual Judge Aubrey E. Robinson, Jr., Memorial Mental Heath Conference—
"Toward Resiliency and Recovery: Transitions in Mental Health"
Washington, DC
September 16, 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 morning.
Whenever I speak to an audience of consumers and their families, I feel like I should be sharing the podium. There’s an old Chinese proverb that says, “No one knows better where the shoe pinches than the one who wears it.” What can I possibly tell you about mental illnesses, recovery, and resilience…or about how they differ across a person’s lifespan or from culture to culture? By virtue of your experiences, each of you has something true, meaningful, and instructive to share with me and with others. I am going to leave time for discussion at the end of my remarks. I hope that you will take this opportunity to add your comments.
What I can tell you is this: Each of you is unique, and yet all of us are the same. Achieving and maintaining mental wellness is a journey that every person takes, from the light of birth until the dark of death. It may be a bumpier trip for some, but we all continuously strive to reach the same destination. Different ages and stages of our lives are simply milestones that we pass by on our lifelong journey.
[SLIDE 2. Newsweek cover scan]
Just last month, Newsweek magazine featured an article about the mental development of infants. New research suggests that even very young babies are learning to deal with complex emotions, such as jealousy, empathy, and frustration. Babies also are far more sophisticated intellectually than we once thought.
But what’s most amazing about the new research? It’s not just the growing evidence that babies have superior emotional and deductive abilities. Instead, the most amazing aspect is the potential of new research to help prevent mental disorders among children. Doctors are using emerging information to identify key emotional milestones in babies. They are discovering ways to tell whether a baby as young as 3 months of age is showing early signs of possible disorders, such as depression, anxiety, learning disabilities, and perhaps autism.
Just imagine what this scientific advancement could mean to children and their families! We already know that a child’s social and emotional development tremendously affects his or her success in school and in life. If doctors can identify at-risk children at a very young age, parents can begin interventions years earlier than now is possible. We may be able to reduce significantly…and possibly eliminate…the severity and potential long-term consequences of childhood disorders.
[SLIDE 3. Elderly man]
At the other end of the age spectrum are elderly adults. Here, too, research is forcing us to abandon old ideas about mental health. One saying about senior citizens is this: “Snow on the roof doesn’t mean there isn’t a fire inside.” There’s truth in that expression. Our brain continues to renew itself as long as we keep fueling it with new ideas. Declining mental health is not a foregone conclusion of the aging process.
There are lifestyle choices we can make to help protect our brain from age-related diseases. High cholesterol, high blood pressure, and smoking—the same factors that raise our risk of heart disease also appear to raise our risk of developing Alzheimer’s disease.
Our minds and our bodies are closely linked. We must think holistically about our health at every stage of life. Promoting and protecting our mental health also will help to promote and protect our physical health.
I’ve been asked to speak today about Federal mental health services that support transitions in the lives of mental health consumers. As groundwork for my remarks, I’d like to clarify some of the concepts involved.
The first concept is transitions. Usually, we define transitions in mental health in terms of age—a young adult moving from the juvenile to the adult system of care or an elderly adult aging into assisted living. This definition, however, is far too limited. Our lives are measured not just by time but by the events that shape our psyche.
[SLIDE 4. Collage of transition events]
Motherhood and immigration are life-altering transitions in our lives. So is re-entry into the community after military service, incarceration, or institutionalization. Trauma can be a watershed event. Think of the unfortunate individuals who lost homes, family, and friends to Hurricane Katrina. Their lives now are divided into two—before and after the storm. How will their profound loss affect their mental health status?
My agency—the Substance Abuse and Mental Health Services Administration, or SAMHSA—is providing widespread assistance to survivors. We have awarded emergency grants to the four most affected States to help them provide clinical services, including medications, to individuals in need. We will extend additional help to States absorbing large numbers of people who were left homeless. In addition, we have mobilized our Emergency Response Center and our Disaster Technical Assistance Center. The States need enormous support in conducting needs assessments, providing services, supporting ongoing administrative operations, and accessing financial assistance. Our goal is to help our fellow citizens build resilience in dealing with this tragedy and plan for their long-term recovery.
Each major transition in our lives can make us more vulnerable to a mental disorder. A mother can find the joy of birth darkened by post-partum depression. A consumer released into the community without adequate social supports can experience relapse. Each transition, however, also presents us with opportunities to develop greater resilience. We gain strength, courage, and confidence every time we confront our personal challenges. We can say to ourselves, “I overcame this hurdle. I can handle the next thing that comes along.”
The term “resilience” has its origins in physics and architecture. To be “resilient” means that a building material, such as tempered steel, has the ability to withstand stress. We have adapted this same term to describe a person’s ability to face the challenges of life.
Resilience often is defined as “ the ability of a person to spring back from and successfully adapt to adversity.” Just like tempered steel, it means that a person can withstand stress. Resilience is the reason why one abused child grows into a mature and successful adult while another abused child develops chronic depression. It’s the reason why one combat veteran develops debilitating post-traumatic stress disorder while another veteran goes on to become President.
The most intriguing aspect of resilience is that it can be developed. We can teach these skills to our children; we can learn them as adults.
[SLIDE 5. Social and emotional learning definition]
Children develop resilience by learning how to manage their emotions, develop caring and concern for others, make responsible decisions, establish positive relationships, and handle challenging situations effectively. These skills are milestones in a child’s social and emotional learning. They enable children to succeed as members of their schools, families, and communities.
The District of Columbia school system piloted a form of social and emotional learning called character education. Character education is similar to social and emotional learning in that it encourages children to develop personal and social responsibility. For the past decade, the district has received grants from the U.S. Department of Education to conduct character education programs in select elementary, middle, and high schools. The school system currently is seeking to renew and expand its program.
The District’s public and charter school systems also have received multiyear grants through our Safe Schools/Healthy Students program. Just this month, we awarded a new grant to the District’s Mary McLeod Bethune Day Academy Public Charter School. In this program, the schools work with local mental health and juvenile justice agencies. The goal is to create safe and mentally healthy environments in which children can learn and develop.
Efforts such as these are successfully promoting the mental health of children. How do we measure success? We measure it in terms of positive outcomes for children—the kinds of outcomes that help prepare children for healthy, productive futures. We are seeing improved attendance and academic performance among students as well as less violence, racial teasing, and substance abuse. These programs demonstrate that we can decrease risk factors for mental illnesses and that we can increase protective factors. We can build resilience in our children. Based on the recent surge in gang violence, we absolutely must build greater resilience among our children. Violence is a threat to the mental health of those who suffer it, witness it, or perpetrate it.
What about the term “recovery?” What does recovery mean and what expectations do we hold for it? The notion that individuals with serious mental illnesses and children with serious emotional disturbances can recover and lead productive lives is fairly new and almost revolutionary. Only a short decade ago, our public mental health system was dominated by State mental hospitals and institutionalization. Mental health treatment revolved around symptom management.
Science has tossed outmoded ideas right out of the window! Never before have we known so much about mental health and how to enable people with mental illnesses to live, work, learn, and participate fully in their communities. Recovery from mental illnesses is now a realistic possibility!
Last December, my agency brought together consumers and other experts to develop an operational meaning of recovery. We wanted a definition that would reflect a better, broader, and more enlightened view of recovery as the expectation of treatment. We examined such topics as recovery across the lifespan and recovery in cultural contexts. We considered how recovery applied at individual, family and community, provider, organizational, and system levels. Our meeting led to this consensus definition of recovery for adults.
[SLIDE 6. Recovery definition]
Mental health recovery is a journey of healing and transformation for a person with mental health problems to achieve full human potential or “personhood” in leading a meaningful life in communities of his or her choice.
[SLIDE 7. Principles of recovery]
This definition is based on several fundamental principles. Recovery is a process that builds on the strengths of each individual. It is nonlinear and self-directed. It is holistic and person-centered, and it involves personal and community respect, responsibility, and hope. The process of recovery empowers consumers to make decisions that impact their lives. It recognizes the valued role of consumers in supporting and encouraging others as they continue their own journey toward recovery.
This definition emphasizes that recovery is a process rather than an end point. It changes our entire perspective on how we provide care because it implies a continuum of services. I’m talking about more than medication and psychotherapy. I’m also talking about employment, housing, and transportation. Recovery-focused treatment will include the full spectrum of services and supports that each individual may need to face life’s emerging challenges successfully.
[SLIDE 8. Trapeze shot]
During the 1970s, an author named Marilyn Ferguson wrote about personal and societal transformation. She described transitions in our lives like this: “It’s not so much that we’re afraid of change or so in love with the old ways, but it’s that place in between that we fear...It’s like being between trapezes. It’s Linus when his blanket is in the dryer. There’s nothing to hold on to.”
Transitions are “like being between trapezes”—that’s a pretty vivid description…and probably an accurate one for individuals who have a serious mental disorder and their families. Consumers in transition sometimes feel like their future is hanging in mid-air. They may feel as if they could fall through the safety net of the public mental health system. A young woman may worry about her placement when she ages out of the juvenile care system. A man who has been in jail and is re-entering the community may wonder how he can continue with treatment and recovery. Will he be able to find employment? Can he find a place to live that will give him access to services? What about a recently arrived immigrant? What expectation of adequate care can he or she hold onto? Will a local provider speak the same language or understand his or her culture?
My agency is working to create nets of care that stretch across service gaps. I have made available for each of you a document called Transforming Mental Health Care in America: The Federal Action Agenda. This document describes actions being taken by the Federal Government to create a seamless system of mental health care for all Americans.
Our action agenda is the Federal response to the final report by President Bush’s New Freedom Commission on Mental Health. The report describes a mental health system that is fragmented, disconnected, and often inadequate…a system that is driven more by bureaucratic constraints than by the needs of the individuals it serves. The solution proposed by the report is staggering! Reform is not enough to create a system that is consumer driven and focused on recovery. Instead, we must fundamentally transform our mental health system.
The New Freedom Commission’s report outlined several opportunities to transform mental health care. These are to:
[SLIDE 9. Opportunities]
- Close the 15- to 20-year gap between the development of new research and its use in day-to-day services for individuals with mental illnesses;
- Harness the power of health information technology to improve the quality of care;
- Identify ways for Federal, State, and local agencies to leverage human and economic resources better;
- Expand access to quality mental health care that serves the needs of racial and ethnic minorities and individuals living in underserved areas;
and
- Promote quality employment opportunities for people with mental illnesses.
These changes require major shifts in policies, funding, and practice. They call for new attitudes and beliefs. Consumers and their families have complex and multiple issues. These issues cut across departments, agencies, and systems. The time has come for agencies and individuals to step out of a silo mentality and into a working relationship that crosses traditional policy, practice, and funding boundaries.
[SLIDE 10. Federal Partners Workgroup]
SAMHSA is leading collaboration at the Federal level. Nine U.S. Departments and the Social Security Administration are members of our Federal Partners Workgroup for mental health transformation. Our most recent members are the Departments of Agriculture, Transportation, and Defense. They, too, have a role in promoting and protecting the mental health of American adults and children.
What does this Federal collaboration mean in real terms? It means that these agencies—all of which serve individuals with mental disorders and their families—are combining their resources to provide comprehensive services that build resilience and facilitate recovery.
[SLIDE 11. Housing/jobs]
Consider the importance of housing and employment to recovery from a mental illness. The transition from a life on the streets to stable housing substantially increases a person’s opportunities to access treatment and services. A job can be both a goal for recovery and a tool for achieving it. The Department of Labor and the Department of Housing and Urban Development will jointly fund five grant programs aimed at improving employment opportunities for individuals experiencing chronic homelessness. These grants will be linked with SAMHSA’s initiatives to end homelessness among those who have mental disorders.
[SLIDE 12. Transportation picture]
Transportation is another basic service that can help an individual achieve and sustain recovery. Transportation is essential to accessing treatment and a job. Transportation may serve a need as basic as a consumer’s ability to establish and maintain social relationships. The Departments of Health and Human Services, Education, and Labor are working with the Federal Transportation Administration to address transportation barriers. These agencies will work with the States to ensure that consumers have access to transportation as a means to full community integration.
SAMHSA has created a Federal Executive Steering Committee to guide the collaborative work of transformation. Our committee is made up of senior-level members from each of the departments and agencies in the Federal Partners Workgroup. I’ll give you some idea of the stature of committee members. The committee includes Charles Curie, the administrator of SAMHSA; Thomas Insel, the director of the National Institute of Mental Health; and Mark McClellan, administrator of the Centers for Medicare and Medicaid Services. Members of our steering committee are the movers and shakers in their own organizations. They can make certain that their organizations commit the resources needed to carry out proposed actions and to keep transformation moving forward.
Our action agenda addresses the needs of individuals across the lifespan. It covers the continuum of mental health care from promotion and prevention through treatment and recovery. The Federal action agenda lists 70 specific steps that we will take to achieve immediate results. I’m going to highlight a few of our ongoing programs that are specifically related to consumer transitions in life.
Our agenda includes several initiatives designed to address the special mental health needs of children and adolescents with or at risk of severe emotional disturbances. We are going to help parents avoid giving up custody of their children as a means to get them mental health services. We’re encouraging the use of Medicaid home- and community-based waivers for children and adolescents. We also are enhancing existing Federal grant programs that serve children and adolescents.
[SLIDE 13. Motherhood picture]
SAMHSA’s Prevention and Early Intervention grant program seeks to reduce a child’s risk of developing a disorder and to reduce the long-term consequences of disorders. A project in Baltimore called “TAMAR’s Children” is an example of a grant-funded activity aimed at prevention. “Tamar” is a Biblical reference, but it also is an acronym for Trauma, Addiction, Mental Health, and Recovery. TAMAR’s Children is a jail diversion program for pregnant women in the criminal justice system who have histories of trauma, substance abuse, and mental illness. It incorporates an evidence-based program called “Circles of Security.”
Traditionally, if a woman gives birth while incarcerated, the baby is placed in foster or kinship care, and the mother remains in jail. She has no opportunity to bond with her child. There is no attempt to help the mother with her own life issues or to teach her how to be a good parent. The baby, then, has a poor social and emotional foundation in life. He or she is at risk of experiencing the same trauma, poor mental health, substance abuse, and criminal history as the mother.
TAMAR’s Children turns all of this around. The program provides prenatal care for the mothers. It helps them to deal with their trauma and other problems, and it teaches them how to nurture their babies. Our hope is that the babies will develop a solid foundation for a secure life and a bright future.
[SLIDE 14. Teen pictures]
We also fund Youth Transition Program grants in five pilot States. We have both child and adult systems of care, but the needs of youth between the ages of 14 and 25 create challenges for both systems. Often, coordination is needed among children’s mental health, child welfare, education, adult mental health, substance abuse treatment, and housing and rehabilitative systems. These systems all touch the lives of youth and their families, and they need to work together!
Better coordination across systems is a goal of our Youth Transition Program. We want the States to develop collaborative programs that help adolescents move into adulthood and into the adult system of care. We currently fund five demonstration sites. We intend to fund more of these programs at the State level in the years to come. The cross-agency linkages needed to support transition programs for adolescents can only serve to improve the quality of care for all age groups.
I’m extremely pleased that the District of Columbia is one of the nine attendees selected for our National Center on Mental Health and Juvenile Justice Academy. Of teens in juvenile detention centers, two-thirds of boys and three-quarters of girls have at least one psychiatric disorder. The District has begun the critical work of engaging the juvenile justice system in promoting recovery among these youth. Jail diversion and community-based re-entry strategies are evidence-based alternatives to long-term incarceration. Greater attention to the mental health needs of youth in the justice system will reduce recidivism and protect our communities. We also will be giving these youth greater hope in themselves and in their future.
SAMHSA also is working with the Departments of Labor and Education and with the Social Security Administration to help young adults move into post-secondary education and employment. The transition into the workforce is a significant event in a young person’s life, primarily because it is a marker of his or her ability to be a mature, independent, and self-supporting adult. Too many young adults with emotional and behavioral disorders are ill-prepared for this transition. In fact, 50 percent of students with disorders drop out of high school, with severely limited prospects for employment. We are working to change that statistic.
As I mentioned earlier, age is just one kind of transition in life. Another transition highlighted by this conference is cultural transitions. Individuals who immigrate to this country can face severe mental health challenges. They have left their homes and their communities for a strange new land. They may find languages, customs, and values that are dramatically different. Their own children may adopt behaviors that drive their generations apart. These are added stressors to already challenging lives. If an immigrant has or develops a mental illness, his or her cultural values can affect diagnosis, treatment, and recovery.
In June of this year, the Washington Post ran a series of articles about culture and mental health. Studies cited in the articles confirm that minorities are more likely than White individuals to be misdiagnosed with serious psychiatric problems. The presumed reason is lack of cultural competence among providers. As one panel of academic experts observed, “ Inattention to the role that social standards and cultural factors play in diagnosis has caused patients to be stereotyped, with obvious negative consequences for diagnosis and treatment.”
[SLIDE 15. Pictures of diversity]
SAMHSA is taking a two-pronged approach to improve mental health care for all Americans. We have appointed a Task Force of the Federal Executive Steering Committee on Mental Health to look at this issue. The task force will spearhead efforts to create a National Strategic Workforce Development Plan to Reduce Mental Health Disparities. The mental health service delivery system can only be as good as the providers who staff it. Therefore, our goal is to expand and improve the capacity of the mental health workforce to meet the needs of all racial and ethnic minorities and others who are underserved.
Our second approach is to examine the cultural competence of behavioral health care education and training programs that receive Federal funding. We will study their efforts to develop a multiracial and multilingual workforce and we will examine how they are training providers in the effects of culture, race, ethnicity, and geography on mental health and mental illnesses.
There is another transition of growing importance to our Nation. This transition is the re-entry of military veterans into our communities.
[SLIDE 16. Picture of military members]
A record number of veterans are expected to return from overseas with potentially disabling post-traumatic stress disorders and other serious mental illnesses. We can serve them best by ensuring their access to the services and supports they need.
Our action agenda primarily addresses the needs of veterans in the broader context of mental health transformation. Veterans are of all races and ethnicities, so whatever we do to improve cultural competence will affect their care. Veterans deserve the best care available, so whatever we do to promote the use of evidence-based practices will affect their care.
Our efforts to end homelessness will affect veterans. Veterans account for nearly one-third of all homeless men in America. About half of our homeless veterans have some form of mental illness, and nearly 70 percent struggle with alcohol and drug abuse.
One of our agenda actions is an interdepartmental initiative to end chronic homelessness among people with co-occurring disorders. The U.S. Department of Veterans Affairs has been instrumental in planning and coordinating this initiative. SAMHSA also is involved, as well as the Department of Housing and Urban Development, the Federal Interagency Council on Homelessness, and the Health Resources and Services Administration.
Throughout our action agenda, we emphasize the need to accelerate and broaden the use of evidence-based practices. An evidence-based practice is one that has been proven effective in creating positive outcomes for consumers. SAMHSA is working to develop these practices and to get them into the hands of providers and consumers as soon as possible.
We are expanding the National Registry of Effective Programs and Practices, or NREPP. SAMHSA created NREPP in 1998 to review and evaluate substance abuse prevention programs. Those designated as model, effective, or promising are included in an online national registry. For each program listed, we describe the population for which it is most effective. We now propose to expand NREPP to include programs for treating mental illnesses and co-occurring disorders and to promote mental health. We intend to launch the new NREPP Web site next year.
[SLIDE 17. Toolkits]
We also are pilot-testing six evidence-based practice resource kits nationwide. Each kit includes the materials providers need to put the evidence-based practice into use. More than 50 community mental health programs in 18 States currently are helping to evaluate how well these practices work for different populations and in different community settings.
All of our efforts are aimed at making care more consumer and family driven. Mental health care never can be one-size-fits-all. Our biology, our life experiences, and our resilience in facing life’s challenges are as unique as our fingerprints. Consequently, we need you, as consumers, to help us create a mental health system that will meet your changing needs.
In a transformed mental health system, consumers will be educated, empowered, and enabled to take charge of their own lives, their own wellness, and their own case management. We know from research and practice that consumers who have the highest possible degree of control over their own care have the greatest hope in recovery.
Nancy Fudge is the consumer-director of FloridaSDC, a recovery program based on self-directed care. In a letter to us, she wrote about the importance of self-directed care to the personal process of recovery.
Ms. Fudge wrote,
“I know there are many concerns over the capacity or competency of an individual and whether or not they are capable of directing their own care. The real issue isn’t about whether a person needs assistance or not, but that they have a voice…and choice…and access to services based on their individual needs at all levels of care. Every opportunity of choice is a seed that will grow into a healthy, empowered, self-directed life. It’s about eliminating dependency in individuals who are capable of moving forward with their lives.”
[SLIDE 18. Free To Choose cover scan]
SAMHSA believes in the power of consumer self-direction to promote resilience and recovery. I have brought along copies of a new booklet called Free To Choose: Transforming Behavioral Health Care to Self Direction. The booklet is an outcome of our Consumer Direction Initiative Summit. Free To Choose discusses the values and principles of self-directed care, and it provides several examples of self-directed care programs and other resources.
Self-direction applies to mental health care across the lifespan, including for youth. We also are taking steps to make mental health care more youth guided, which means that youth will have an expanding role in decisionmaking. For older youth, their role may be to direct their own care. Children grow toward adulthood by practicing independence. This is what we want for their future—this is the future our children want for themselves.
Our action agenda is not a “quick fix” for the problems that have ailed the mental health care system for decades. Instead, it is a living document that begins to chart the course for the long term. In reality, transforming the form and function of our mental health system will be a multiyear effort across all levels of government. We only can meet the mental needs of all Americans, at any age and stage of life, by fully engaging all of the systems that serve adults and children. Change will take time and it often will be difficult. I say that as someone who has experienced many personal and professional transitions in my lifetime. Those who expect change to be easy, or comfortable, or free of conflict have not learned their history!
[SLIDE 19. Churchill quote]
But, as Winston Churchill once said, “A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.” I, for one, am extremely optimistic about the future. We have tremendous opportunities for change and every reason to believe that we can transform the mental health system. Transformation already is happening. Our Federal Partners Workgroup is a phenomenal demonstration of a Government-wide commitment to change. Similar efforts are underway at the State and local levels.
The District of Columbia, for example, recently received one of our State Incentive Grants for Co-occurring Disorders. Through this grant, the District will be building new bridges between mental health and substance abuse treatment. Individuals with co-occurring disorders will have greater access to integrated treatment. Integrated treatment is an evidence-based approach that provides individuals with the greatest hope in recovery from both disorders. This is a phenomenal change!—two disorders, but only one system of care to navigate.
Federal and State, public and private, providers and consumers—together, we can achieve the most valuable transition of all—from our current mental health system to one that is consumer driven and focused on recovery. When we accomplish this goal, we will have transformed more than service delivery. We will have transformed the lives of generations to come, from birth through old age and through all of life’s many changes. Thank you.
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And, now, I would like to hear about your mental health experiences.
I see that there are some children in the audience. I’d like to hear from you, too, because children deserve a voice in matters that affect their lives. You certainly deserve respect—and thanks—for trying to develop a better understanding of why your parent or another family member sometimes behaves differently. A mental illness is just as real as a physical illness, only it doesn’t show on the outside like some other diseases. But you can feel it in your own mind. And sometimes you may feel guilty or angry or helpless and confused, particularly when you are dealing with your own personal changes in life. These feelings are normal. They often are shared by the person who has the illness.
Believe in the future. Have hope. Enjoy the good times. You haven’t caused your parent’s illness and you can’t “fix” your parent. You can, however, take steps to help you cope during the difficult times, such as finding an adult you can talk with or who can help your parent. Protect your own mental health. Developing healthy ways to cope with stress is an important lifelong pursuit for anyone. Learning how to deal successfully with stress is one of those inner strengths that can carry us through the many transitions of life, whether these are changes in our own lives or in the lives of someone we love.
Now, who would like to start our discussion? How can we work together to build resilience and facilitate recovery at different ages and stages of life?
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