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
National Association of State Mental Health Program Directors (NASMHPD)
Recovery: Guiding Principle of a Transformed Mental Health System
Ames, IA
October 11, 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. It’s wonderful to be here in Iowa. From a Rhode Island perspective, which is the place I call home, Iowa is often depicted as a flat place in the middle of America that’s covered with sizeable hogs and high corn. In reality, Iowa is a hilly State of unique beauty and incredible accomplishments.
It’s fitting that we are meeting here, at Iowa State University, to discuss how we can create a recovery-focused system. Such a change represents a transformation of our current mental health system. This university, which is a land-grant university, represents a transformation in our education system. In 1862, Congress passed the Morrill Act, which authorized land grants to States that would build public universities. The purpose of the Act was to make higher education accessible to Americans who could not afford a private university.
The founding principle of a land grant university was this—to serve the public good by serving the underserved. Iowa was the first State in the Nation to embrace this concept of education. Iowa State University symbolizes an ideal—to benefit a Nation by ensuring that all individuals have equal access to services that educate, empower, and enable them to live a more productive life.
A mental health system focused on recovery embodies a similar ideal. A recovery-focused system will serve the public good by better serving individuals with mental illnesses and their families. It will educate consumers about treatment options, empower them to make decisions about their care, and enable them to achieve their full potential in life. Most important, a recovery-focused system will offer to consumers the greatest hope in themselves, their health, and their future.
A recovery-focused system is within our grasp. Never before have we known so much about mental health and how to enable individuals with mental illnesses to live, work, go to school, and participate fully in their communities. Never before has science given us such powerful evidence-based tools. Never before have consumers and their families rightfully been allowed to demonstrate the amazing healing power of self-direction and peer support. We stand now at the threshold of a system of care in which recovery—and not disability—is the expected outcome of services.
Recovery as expectation—this is the heart of a recovery-focused system. But how do we achieve this ideal? How do we create a system in which every policy, program, and person reflects a message of hope and recovery? How?―By making certain that everyone involved—from program administrators to providers to consumers and their families―fully understands, embraces, and integrates recovery as the fundamental principle of a transformed mental health system.
[SLIDE 2. Principle definition]
A principle, by definition, is a belief, law, or motivating force that guides all other actions. A principle shapes our vision of what should be. It is a framework for developing the goals and objectives needed to achieve our vision. It becomes the foundation for planning, delivering, financing, and evaluating the services we provide. In short, a principle is the organizational Velcro that binds a vision to its operation.
Recovery from mental illnesses or emotional disturbances is a real possibility! Am I talking about a complete cure, in the medical sense?―No. In a medical context, recovery is often an end state. The illness ends, the broken bone heals. The person returns to the same previous state of health.
Recovery in a mental health context is different. It is a life-affirming journey of personal growth. Its focus is on what a person can achieve as he or she gains control of a disorder and moves forward with life. Consumers in recovery are able to overcome the consequences of mental illness, such as discrimination and social isolation. As adults regain control over their own lives, or as children develop greater independence, they discover entirely new possibilities within themselves.
Our ability to embrace recovery as the fundamental principle of mental health has profound implications for the shape of our mental health system. Last December, my agency brought together consumers and other experts to develop an operational meaning of recovery. We examined such topics as recovery across the lifespan and recovery in different cultural contexts. We considered how recovery applied at individual, family and community, provider, organizational, and systems levels.
Our meeting led to this consensus definition of recovery for adults.
[SLIDE 3. 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.”
A few words based on a wealth of beliefs! The most unshakable premise is that every individual has a continuous capacity for growth. The process of recovery 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. It empowers consumers to make decisions that impact their lives. It recognizes the valued role of consumers in supporting and encouraging others as they continue on their own journey toward recovery.
Recovery is not an end point! Our definition implies a continuum of services…and a breadth of services that acknowledge the whole person and not just the disorder. The scope of this definition changes our entire perspective on how we should provide care.
Two years ago, the President’s New Freedom Commission on Mental Health issued its final report on the status of mental health care in America. (Executive copies of the report are available on the resource table in the back of the room.) The report reached this conclusion: our mental health system is not geared to the single most important goal of the people it serves—the goal of recovery! It called for a fundamental transformation in how our Nation views and provides mental health care.
The New Freedom Commission report did not tell us how to achieve this transformation. It did tell us what a recovery-focused system would look like.
[SLIDE 4. Goals of a transformed system]
In a transformed system, Americans will understand that mental health is essential to overall health, mental health care will be consumer and family driven, and disparities in mental health care will be eliminated. In a transformed system, early mental health screenings, assessments, and referrals will occur. Research will be accelerated and excellent care will be delivered. Technology will be used to access mental health care and information.
Transformation represents a bold vision to change the very form and function of the mental health system. It means that we will be making changes at the very core of the system and not around its margins. It has profound implications for policy, funding, and practice as well as for our individual attitudes and beliefs.
The New Freedom Commission’s report has become a roadmap for change at the Federal, State, and local levels. Many States already have begun the vital work of creating recovery-focused systems. The Connecticut Department of Mental Health and Addiction Services, for example, has created a Recovery Education and Training Institute. This institute is just one element of a statewide effort to promote a “recovery model” for public mental health services.
The Substance Abuse and Mental Health Services Administration, or SAMHSA, is leading transformation at the national level. We now have engaged nine Federal departments and the Social Security Administration in an unprecedented effort to change the status quo of mental health. Together, we will be taking 70 specific steps that we believe can achieve immediate improvements in mental health care.
The steps are summarized in another document that is available to you here today. It’s called Transforming the Mental Health System: The Federal Action Agenda. I have brought along a copy for each of you. Look at what we are doing at the Federal level to promote a focus on recovery. The steps we are taking can guide similar steps at the State and local levels.
[SLIDE 5. Federal Partners Workgroup]
This slide lists the departments and agencies that make up our Federal Partners Workgroup for mental health transformation. The range of interests is broad—agriculture, transportation, defense, housing, and labor.
One of the most important outcomes of our transformation efforts so far is the precedent for cross-agency collaboration that now is taking place at the Federal level. The same level of broad-base collaboration is required, and should be demanded, at the State level. This is a key theme of a recovery-focused system: Any organization that serves children, families, and adults has a role to play in promoting the mental health of Americans.
At this point, I want to take a minute to reflect on the aftermath of Hurricanes Katrina and Rita. These disasters are teaching us a great deal about mental health and what we must do to protect it.
Americans are an incredibly resilient people. The majority of individuals already are moving forward with their lives. But what do they need to ease their grief and overcome their trauma? They need access to health care, of course, including mental health counseling. But they also need homes, schools, and jobs. They need to be reunited with their family and friends. They need their pets! What a powerful reminder of human complexity!—Our mental health is bound tightly to all the pieces that make up a full life in the community.
Promoting recovery and resilience among the survivors requires a collaboration of interests. Collaboration is essential both for the short term as well as for the long haul ahead. Research suggests that up to 30 percent of adults in the most severely affected areas will develop mental and substance abuse disorders. The percentages among children may be higher. These problems are going to surface in primary health care, business, and schools…in any system dealing with the survivors. All of these systems must help to promote recovery.
SAMHSA is providing widespread assistance to affected States. We have awarded emergency grants to Alabama, Louisiana, Mississippi, and Texas 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. I understand that Iowa may absorb thousands of displaced persons.
We also have mobilized the SAMHSA Emergency Response Center and put our Disaster Technical Assistance Center into overdrive. The States need enormous support in conducting needs assessments, providing services, supporting ongoing administrative operations, and accessing financial assistance. We are working with the States to help build resilience among those affected by these tragedies. We also are helping the States meet the recovery needs of adults and children who already experience mental health problems.
I thank Iowa and its citizens for all that you have done for individuals and families displaced by Hurricanes Katrina and Rita. Similar to other Americans, you have reached out with compassion and concern. As your own Senator Tom Harkin observed, “At times like this, we are reminded that we truly are one American family. And families look out for one another.” The compassion you have shown undoubtedly will help to prevent mental illnesses and promote recovery among the storm’s victims. I am extremely proud of the way that my agency and your State have responded to these tragedies.
Hurricanes Katrina and Rita are lessons in mental health planning. State mental health systems must be prepared for the aftershock of disasters. In Iowa, tornados and floods can cause widespread trauma. Is your State ready? A focus on recovery also means this: promoting recovery by preventing illnesses and relapse after trauma.
So how does a State create a recovery-focused system? As your conference agenda asks, how do you walk the talk of recovery? I’ve organized my suggestions into six steps. As I go through them, a slide for each step will pose a few questions. Ask yourself how close the Iowa system comes to an affirmative answer.
The source of these questions is a recovery-based program inventory developed by Dr. Mark Ragins of the Village Integrated Services Agency in California. He calls his inventory an attempt to translate the recovery vision into a practical program evaluation tool. Such an inventory is definitely a worthwhile exercise for any State or program struggling to translate the talk of recovery into the walk of recovery.
[SLIDE 6. Step 1―Engage]
The first step is to engage all stakeholders in creating a recovery focus. What does recovery mean to Iowans and how can it be achieved? What partnerships are necessary? We are talking about a whole new orientation—one in which an entire community plans and delivers services based on a belief that consumers can improve over time.
A recovery focus means that the services provided will help adults and children develop the skills they need for a life in the community. We’re talking about jobs, and about greater access to safe and affordable housing within a community, and not on its fringes. We’re talking about transportation so that consumers can keep their clinical appointments and build a full life. We’re talking about independence, and about helping adults and children develop meaningful relationships with others.
Your first challenge is to engage stakeholders in creating a focus that acknowledges their roles in recovery. Consumers and families living with mental illnesses have complex and multiple issues. These issues cut across departments, agencies, and systems. A focus on recovery means collaboration. Organizations must come together in ways that make it easier for consumers and their families to access appropriate services.
Consider ongoing collaboration in the State of New Mexico. Just this past July, New Mexico enacted a systemwide change that combines all behavioral health funding, including funds from Medicaid and other State agencies. Public mental health and substance abuse services provided and funded by 15 separate State agencies now are managed through a single statewide entity. A change of this magnitude involved the Governor, the State secretary of health, and the heads of the 15 agencies, as well as other stakeholders.
New Mexico is well along the path to a recovery-focused system. The coherent vision that drives its actions also led to its selection by SAMHSA for a new grant. New Mexico is one of the first seven States to receive one of our State incentive grants for mental health transformation. The State will use the grant to further integrate behavioral health services across agencies, to create new partnerships, and to expand behavioral health coverage to the State’s most isolated corners.
[SLIDE 7. Step 2―Empower]
Step 2 in creating a recovery-focused system is to empower consumers and their families to take the lead. Consumers and families should be key members of advisory boards, planning and quality management committees, and research planning groups. Ask them to share their vision of what this system would look like, what services it would offer, and what the expected outcomes should be. Because of their lived experiences, consumers and families lend unique insight into mental illness and what makes recovery possible.
I’m delighted that consumers and families are attaining their rightful places in designing a system that is meant to serve them. This week, the American Psychiatric Association is holding its 5th Institute on Psychiatric Services. For the first time ever, the institute has a workshop on the consumers’ perspective on recovery.
We also can look to ongoing changes in some States. SAMHSA, for example, is helping to fund Georgia’s Peer Specialist Certification Project. In Georgia, certified peer specialists conduct Medicaid-reimbursable support services and serve on assertive community treatment teams and on community support teams. Georgia is transforming its mental health system from one that focuses on an individual’s illness to one that focuses on the individual’s strength. Consumers are valued—and valuable—assets to the service system. Through peer specialists, recovery has become part of what consumers do for themselves and for each other.
[SLIDE 8. Step 3―Enlighten]
The next step is to bring in evidence-based practices. As it now stands, it may take up to 20 years before an effective practice becomes a standard procedure. You could lose a whole generation of Iowans in that length of time. A recovery-focused system will develop methods to accelerate this process. It will find ways to reward providers who continue to educate themselves and others in new and promising practices.
SAMHSA will support your efforts. We currently fund more than 50 technical assistance efforts in such critical areas as integrated treatment for co-occurring disorders and making mental health care more trauma informed. Our efforts are designed to make state-of-the-science information more accessible to providers and consumers.
In addition, we have available resource implementation kits for the six practices shown on this slide. Each kit contains manuals and fidelity measures for implementing the practice.
[SLIDE 9. Step 4 ― Expand]
A focus on recovery also means expanding our view so that we see each consumer as an individual and not just as a person with a categorical disability. A recovery-focused system pays attention to wellness and health promotion and not simply to symptom suppression or clinical concerns. A recovery-focused system respects the fundamental rights of consumers. These rights include the right to choose care through advance directives and the elimination of seclusion and restraints.
A recovery-focused system also gives consumers information on and access to a range of meaningful choices, such as choices in housing, providers, and treatment. These kinds of choices give consumers control over their own lives and the quality of their lives. The focus shifts from a treatment plan to a recovery plan.
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 relationship between self-directed care and the personal process of recovery. Ms. Fudge wrote,
“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.”
A little later today is a session called “Out of the Shadows.” I hope that you will have, or that you will find, an opportunity to view the documentary of a similar name. “Out of the Shadow” is the story of one woman’s travels through the public mental health system, as told by her daughter. The mother’s journey has taken her through 17 psychiatric wards and 47 housing units. At one point, her daughter observes,
“[My mother] has been dumped in this nursing home because it is the only place with a bed. Unfortunately, she has been assigned an absentee doctor. She will be treated by another in a long line of nameless, faceless physicians.”
The mother’s story is important, but not as an indictment of a frequently overworked and under-funded mental health system. The story is important because it is about hope…and about recovery! At its conclusion, the mother has found a spot in a group home. She has a job. She has reunited with her family. She has regained valued social roles in her community and is moving forward with her life.
Her daughter confides,
“Along the way, I’ve gained great admiration for [my mother], for her resilient spirit. And instead of being afraid of where I come from, I’m finding ways to honor it.”
“Out of the Shadow” demonstrates the power of healing that grows from a holistic view of a person. A recovery-focused system will embrace this concept. It will make certain that consumers have access to services, such as housing, employment, education, and community-based care, that promote recovery and build resilience. This is how we honor the potential and “personhood” within each individual.
[SLIDE 10. Step 5―Embrace]
Step 5 to a recovery-focused system is to embrace transformation as a continuous process and to commit to achieving the goals of transformation over time. A system must continue to evolve as we learn from new research, as service informs science, and as we respond to the changing needs of consumers and their families.
The idea is to build a process of change into the system—to have continuous quality improvement as your primary constant. Think of transformation as a strategy involving small, medium, and large steps.
[SLIDE 11. Steps]
We can take continuous small steps to improve what the mental health system already is doing. We can take exploratory medium jumps to push the boundaries of our core competencies or to create something new within the existing paradigm. Occasionally, we will be able to move transformation forward in a few big jumps. These jumps occur when we can create new rule sets that leverage new ideas.
In reality, changing the form and function of a mental health system will be a long-term process. Even though our vision should be idealistic, our plans of action should be realistic. We, however, should find reasons to celebrate as we proceed. A celebration of progress is important, not just for providers and consumers, who might get discouraged by the pace of change, but for others as well. The more often we can point to recovery, the more apparent it will become to funding legislatures and the general public that mental illnesses are just that—illnesses that can be treated. More important, the message that mental illnesses are treatable reinforces the hopefulness of recovery. It helps to maintain our commitment to the people we serve.
[SLIDE 12. Step 6―Experience―Learn From It!]
The last step is to learn from experience by monitoring outcomes. Outcome data establish accountability. They answer questions such as “Do our programs achieve positive outcomes for consumers?” and “Which services work best in promoting recovery?”
Last year, SAMHSA incorporated National Outcome Measures, or NOMs, for mental health into State mental health block grant reporting requirements. The NOMs reflect a transformed view of effective mental health care because they focus on positive outcomes for consumers. The NOMs, for example, consider employment status and the stability of family and living conditions. The NOMs are a test bed for measuring our basic concepts of what recovery means to consumers.
We have asked Iowa and other 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 a State most needs to transform the services it offers. Use of the NOMs will help a State to ensure that consumers will have access to the comprehensive treatments and supports they need to achieve and sustain recovery.
Up to this point, I’ve talked primarily about changing a system to focus on recovery. However, the most important change is not systemic—it is personal. We are the system! Our attitudes and our beliefs guide the actions we take. And change does not just happen—someone makes it happen. First and foremost, implementation of a recovery-focused system calls for leaders—those exemplary individuals whose actions inspire others to follow.
Each of you in the audience can show others how to walk the talk by acting on the principle of recovery. In his book, Deep Change: Discovering the Leader Within, Robert Quinn made this observation:
“We are all potential change agents. As we discipline our talents, we deepen our perceptions of what is possible…. We become empowered and empowering to our context. Having experienced deep change within ourselves, we are able to bring deep change to the systems around us.”
Is this an easy process?―No. As Quinn notes, many of the rules and procedures that govern our programs are aging solutions to yesterday’s problems. The old rules may bind a system together, but they also can be barriers to change. As a result, a system can evolve only when a few individuals—a few leaders―are willing to take risks. They leave their comfort zone and step outside their normal roles.
System change always begins with personal change. Quinn contends that achieving deep personal change means developing a new paradigm―a new self. We explore new areas, try new methodologies, and strive for new goals. We follow a path that is paved with unfamiliar procedures.
Transformational leaders become credible through action. Their courage and integrity in taking risks makes it possible for others to change. Providers, for example, can educate, empower, and enable consumers to make more informed decisions. Consumers can take more responsibility for their own recovery, such as through self-management and learned coping skills. Administrators can actively engage consumers to co-lead or conduct programs. Leaders exist at any level. We are leaders when our principles guide our actions and when our attitudes speak louder than our words.
[SLIDE 13. Adams quote]
Former President John Quincy Adams may have developed the best definition of leadership. He declared, “If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”
I’m going to leave you with President Adams’s words because they echo the essence of recovery as a guiding principle. Recovery is the opportunity for a consumer to conceive of a life full of possibilities and to move hopefully toward that future—to dream, to learn, to do, to become. This opportunity for growth must be made possible by each of us—administrator, provider, advocate, and consumer—in our own way. We will have a system focused on recovery when we, ourselves, become focused on recovery. Thank you.
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