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
Innovations and Best Practices: Transformation in Action
October 19, 2007
San Diego, CA
[Opening slide]
Thank you, Cheryl [Cheryl Beversdorf is President and CEO of the National Coalition for Homeless Veterans] for your kind introduction. Advocacy on the part of the National Coalition for Homeless Veterans has strengthened and increased funding for virtually every Federal homeless veterans assistance program in existence today. I extend my thanks to you and your organization for your tireless dedication to supporting the men and women who have served our country well.
I am especially pleased to be with you today because this is an exciting time to do the work we do. There is a great deal of both synergy and energy evident in the way that we—as a country and as individuals—are rising to the challenge of working with our Nation’s war veterans, both those who have become homeless and those who are at risk of homelessness. The Department of Veterans Affairs (VA), together with its key Federal partners—including the Department of Defense (DoD) and the Department of Health and Human Services (HHS)—and with community and faith-based providers, veterans service organizations, families, and individuals are working tirelessly and effectively to ensure that the men and women who serve their country with honor can live with dignity when they return home. This is transformation in action!
What do I mean by “transformation in action?” Let me give you an example.
Susan Storti is a registered nurse and Director of the Addiction Technology Transfer Center of New England. The ATTCs are funded by Center for Substance Abuse Treatment in the Substance Abuse and Mental Health Services Administration (SAMHSA).
When Susan’s fiancé was deployed with the Rhode Island National Guard, she realized that service members and their families needed support. She assessed the needs of soldiers, veterans, and their families; identified available resources; and helped create a “Rhode Island Blueprint” to fill the gaps.
Now the entire community is involved in welcoming veterans home and supporting families while they’re gone. Experts train community providers in such areas as traumatic brain injury. Support groups give families tips on stress management and opportunities to vent. Researchers are studying ways of enhancing resilience in children. Even the local theater company has gotten into the act, with a play drawing on the words of soldiers, journalists, and others who have been to Iraq.
As a woman, I’m proud of Susan because when she saw a need, she jumped into action.
As a Captain in the Naval Reserves and a Rhode Island resident, I’m proud of Susan because she is helping service members and their families in my home State.
And as Director of SAMHSA’s Center for Mental Health Services, I’m proud of Susan because is a shining example of transformation in action.
I want to share three key messages with you today.
- First, I’d like to talk about the importance of addressing psychological problems and substance abuse among America’s veterans.
- Second, I want to share with you the incredible synergy that I see happening as we transform mental health services in this country to better serve individuals of all ages and in all walks of life, including this country’s brave men and women in the Armed Services, the reserves, and the National Guard.
- Third, and most important, I bring you the good news that we know what works to help people with mental and substance use disorders recover from their illnesses and become stable, productive members of their communities.
Veterans Are a Vulnerable Group
I know that it’s not news to you that our veterans, particularly those returning from the conflicts in Iraq and Afghanistan, are an especially vulnerable group. A former colleague of mine once said, “The duties of today’s soldiers can leave footprints on their psyches. We owe veterans more than our gratitude.”
Indeed, we owe them our full support to help heal the wounds of war, including those that are not easy to see. Clearly, most service members have sound mental health and an inner resilience that enable them to deal successfully with combat-related stressors and trauma. We select and train our military personnel very well. However, more than 1 million men and women have served in war zones since the terrorist attacks of September 11, 2001. They are experiencing difficulties particular to the kind of warfare they are encountering.
In Iraq and Afghanistan, for example, the lack of a front line means that soldiers can face danger anywhere—even in supposedly “safe” zones. And medical advances now allow soldiers to survive catastrophic brain injuries, spinal cord injuries, and wounds that once would have been fatal.
Those fighting in Iraq and Afghanistan also differ from those who fought previous wars. Women now constitute 16 percent of the members of the Armed Forces and are assigned to 90 percent of all military occupations. I recently learned that women make up 17 percent of the Class of 2011 at West Point, the highest proportion for any class.
Further, roughly half of the 150,000 troops in combat are National Guard members and reservists. These “citizen soldiers” are not eligible for some benefits accorded to enlisted soldiers, and some may lose their jobs and have to be re-employed. These are broad-based challenges to a successful life in the community.
Indeed, the DoD Task Force on Mental Health found that 38 percent of soldiers and 31 percent of Marines report psychological concerns such as traumatic brain injury and posttraumatic stress disorder (PTSD) after returning from deployment.
Among members of the National Guard, the figure is much higher—49 percent—with numbers expected to grow because of repeated deployments. In fact, veterans with PTSD increased by 42 percent from 1998 to 2003.
[War zone trauma slide]
We know that exposure to war zone trauma is a risk factor for PTSD. However, we must also confront the realization that sexual trauma in the military is also a growing concern. Our silence on this issue will only make the problem worse.
It should come as no surprise, therefore, that mental disorders are one of the top three conditions that lead veterans to seek care from the VA. But what is more troubling is that many veterans don’t reach out for help when they need it. This is not unique to veterans.
Despite the availability of effective treatments, fewer than half of all people who require mental health services get the help they need. But stigma may be an especially significant barrier for men and women who are taught to “be all they can be.”
A study that assessed beliefs about mental health treatment in a small group of National Guard soldiers who recently returned from the war in Iraq found that pride, not being able to ask for help, and not being able to admit having a problem were major impediments to seeking help. Clearly, we have our work cut out for us to dispel the stigma that keeps people from getting the care that will help them recover and lead productive lives.
We must do so because we know that when veterans don’t receive the treatment and services they need, they are at risk for a host of negative outcomes, including arrest and incarceration, homelessness, and suicide. Mental health officials in the Veterans Health Administration estimate 1,000 suicides per year among veterans receiving care with VHA and as many as 5,000 per year among all living veterans. This is unacceptable.
Thankfully, the military’s attitude toward suicide prevention has changed dramatically. In the recent past, leaders often wouldn’t tolerate any sign of weakness among the troops. In contrast, today’s leaders make it widely known that they want people to take care of themselves. In fact, in its 2003 Final Report, the President’s New Freedom Commission on Mental Health named the Air Force Initiative to Prevent Suicide a model program.
[Suicide Prevention Lifeline slide]
More recently, SAMHSA and the VA collaborated to add a special feature for veterans to the National Suicide Prevention Lifeline. Callers who identify themselves as veterans are connected to VA suicide prevention and mental health professionals. The Suicide Prevention Lifeline is even on the popular networking site MySpace, which is expected to increase word-of-mouth referrals to this free telephone resource.
Here’s another set of sobering statistics that I’m certain you know all too well. About one-third of the adult homeless population has served their country in the Armed Services. Current population estimates suggest that about 195,000 veterans, both men and women, are homeless on any given night and perhaps twice as many experience homelessness at some point during the course of a year. Many other veterans are considered near homeless or at risk.
Right now—and this is a fact that I find both amazing and sad—the number of homeless male and female Vietnam era veterans is greater than the number of service persons who died during that war. We know that homeless veterans are a group with significant needs. One-third of veterans experiencing homelessness who were treated by specialized VA programs in 2001 had co-occurring mental and substance use disorders.
Still, I am heartened by the research which tells us that homelessness among veterans is more a function of family background, access to support from family and friends, and various personal characteristics than it is related to their military service. We can’t change the fact that they have been to war, but we can offer them the support and services that will help them reconnect with themselves, their families, and their communities.
Finally, we know that war, like mental illness, is a family affair. No one is left untouched. Some 700,000 children have at least one parent deployed to support ongoing military operations in Iraq and Afghanistan. Three out of every five deployed service members have a spouse, child, or both. Children and spouses left at home need our support, as well. When we nurture their strength and build their resilience, they become a key resource to their family members and to their communities, as well.
Transforming Mental Health Care Is Everyone’s Business
If I were to stop my remarks now, you would have every right to leave here feeling a bit discouraged. But I know, and I hope you do, too, that there is great cause for optimism. And I feel personally gratified by much of what I see happening vis-à-vis transformation of the mental health system in this country. This has been my charge—and my passion—for the past 4 years, and I know that I’m not alone. Our partners in the VA and the DoD have been right there with us, at every step of the way, helping to create a consumer-driven, evidence-based, results-oriented system in which all Americans—including our men and women in uniform—have the opportunity to live, work, learn, and participate fully in their communities.
[NFC vision slide]
Both the VA and the DoD are members of a high-level Federal Executive Steering Committee charged with implementing the fundamental transformation of the mental health system called for by the New Freedom Commission on Mental Health. In response to the Commission’s Final Report, SAMHSA led an unprecedented effort with our Federal partners to create an Action Agenda for change. This is a living, breathing document that outlines specific, actionable items to move the mental health system toward our envisioned future.
But not only are the VA and the DoD partners in our efforts—they each have their own plans and action agendas, as well. And SAMHSA is a key partner with them in their work. I think you’re beginning to see some of the synergy I mentioned earlier!
I’d like to touch briefly on some of the specific collaborative efforts in which our agencies are involved.
SAMHSA’s Role
Last March, SAMHSA convened a National Conference on the Behavioral Health Needs of Returning Veterans and Their Families. More than 1,000 participants attended the conference, which produced a set of recommendations to address the behavioral health needs of returning veterans and their families.
[Workgroup goal slide]
As a result of this conference, SAMHSA established a Workgroup on Returning Veterans and Their Families. The workgroup’s overall goal is to increase access to timely and appropriate treatment and support for mental and substance use disorders for returning veterans from Iraq and Afghanistan and their families. Without our support, these may be the homeless veterans of the future, and we must act now to prevent this from happening.
But we can’t do this alone. Working Group members have begun meeting with the VA and the DoD to determine how we can partner most effectively to meet the mental health and substance abuse treatment needs of returning veterans.
We’ve begun making some changes internal to SAMHSA, as well. Our new Resources for Returning Veterans and Their Families Web page includes statistics, materials from webcasts and conferences, resources for military families coping with trauma, and links to our treatment facility locators. You can find these materials by visiting our Web site at www.samhsa.gov and clicking on the link for “Veterans Resources.”
Further, veterans are considered a priority population for many of our grant programs, including Access to Recovery, which provides vouchers for substance abuse treatment; our Mental Health Transformation State Incentive Grants, which engage States in creating the infrastructure for systems change; and our Co-occurring Disorders State Incentive Grants, which incentivize States to offer comprehensive, integrated treatment for mental illnesses and substance use disorders.
In addition, we are already making plans for a follow-up conference on the behavioral health needs of returning veterans, to be held early next year. The conference will be called, appropriately, “The Road Home.”
Finally, SAMHSA’s National Center for Trauma-Informed Care is seeking a paid, part-time veteran consultant to provide his or her expertise in the planning, development, and successful implementation of a situational analysis and marketing plan. The National Center for Trauma-Informed Care helps publicly funded agencies, programs, and services make the important cultural shift to a more trauma-informed environment that benefits both systems and consumers. We plan to hire a veteran who understands outreach strategies and how these will be impacted by culture and diversity. He or she will contribute to the development of products and provide ongoing review and comment on all aspects of the project.
The VA Role
The VA has been our partner from the beginning in our efforts to create a mental health system focused on recovery, rather than pathology. Yesterday Dr. Katz gave you an update on the VA’s Mental Health Strategic Plan, which was designed to drive the implementation of the New Freedom Commission’s principles and goals through more than 200 discrete recommendations.
This is a significant undertaking for the VA, but also for the broader mental health system, as well. Because the VA is the largest integrated health care system in the Nation, it is able to pioneer health care policies that could not be implemented in other systems. The VA’s experience in implementing evidence-based treatment and services—such as the integration of mental health services into primary care practice—will serve as a template for developing policies to support the adoption of these practices in other settings.
Clearly, the VA is also a leader in services for homeless veterans, something I’ll touch on in a few minutes.
The DoD Role
Finally, our partners at DoD are actively engaged in their own system transformation efforts. In June, the DoD Task Force on Mental Health released its report, called An Achievable Vision. Much as the New Freedom Commission found the mental health system in this country fragmented and ineffective, the DoD Task Force concluded that “the system of care for psychological health that has evolved in recent decades is not sufficient to meet the needs of today’s forces and their beneficiaries, and will not be sufficient to meet the needs in the future.”
[DoD Task Force slide]
In response, the Task Force, which included both military and civilian members and on which I was honored to serve, developed a vision for a transformed military system that required the fulfillment of four interconnected goals:
- A culture of support for psychological health
- A full continuum of excellent care
- Sufficient and appropriate resources
- Visible and empowered leaders
“Maintaining the psychological health, enhancing the resilience, and ensuring the recovery of service members and their families are essential to maintaining a ready and fully capable military force,” the Task Force concluded.
To implement the group’s recommendations for change, DoD last month released an action plan that calls for the Department to put psychological heath and fitness on an equal footing with physical health and fitness. This echoes the New Freedom Commission’s recommendation to “address mental health with the same urgency as physical health” and was amplified by the DoD Task Force when it said, “We fully believe that psychological health means much more than just the delivery of traditional mental health care. It is a broad concept that covers the entire spectrum of wellbeing, prevention, treatment, and health maintenance.”
Among the specific steps the DoD will take include increasing the integration of dedicated behavioral health professionals into primary care clinics. The VA and SAMHSA are pursuing the same goal, which will provide a standardized and recognizable face of care across the Federal health care system.
Further, to increase access to care, the DoD is entering into an agreement with the Public Health Service in HHS to provide uniformed mental health professionals to supplement staff at military treatment facilities around the country. Up to 200 Public Health Service officers will soon move into military communities to increase the number of providers able to care for service members and their families.
In addition, DoD is collaborating with VA to provide training in evidence-based treatment for PTSD. This training uses national experts who provide intensive training and ongoing supervision to ensure that knowledge is applied in clinical practice. Since the program began a year ago, 120 providers have been trained.
This is transformation in action! Clearly, the individual and collective actions of SAMHSA, VA, and the DoD are beginning to make a difference in the lives of some of the most vulnerable members of our society. However, the hard work of transformation takes place on the ground, in States and communities just like yours. Because of your persistence and your determination, we know what works to prevent and end homelessness among veterans with mental and substance use disorders. And I believe we have the energy to do so. I’d like to focus the balance of my comments on some remarkable, community-based work that is moving the science of recovery and homelessness prevention into practice all around this country.
We Know What Works and We’re Doing It!
In a very real sense, I have no need to tell you what works to end homelessness among veterans. The VA’s major homeless-specific programs constitute the largest integrated network of homeless treatment and assistance services in the country. These efforts—including the Grant and Per Diem Program; the Domiciliary Care for Homeless Veterans Program; and HUD-VASH, a joint supported housing program with the U.S. Department of Housing and Urban Development—offer a continuum of evidence-based services and supports that include:
- aggressive outreach to those veterans living on streets and in shelters who otherwise would not seek assistance;
- clinical assessment and referral to needed medical treatment for physical and psychiatric disorders, including substance abuse;
- transitional assistance, case management, and rehabilitation;
- employment assistance and linkage with available income supports; and
- permanent supportive housing.
There are several VA programs that I think deserve special mention because they epitomize the community connections being celebrated at this conference.
First is the Stand Down program, begun quite fittingly by a group of Vietnam veterans in San Diego in 1988. In wartime Stand Downs, front line troops are removed to a place of relative safety for rest and needed assistance before returning to combat. Similarly, peacetime Stand Downs give homeless veterans 1-3 days of safety and security where they can obtain food, shelter, clothing, and a range of other types of assistance, including VA provided health care, benefits certification, and linkages with other programs such as housing, employment, and substance abuse treatment. Stand Downs are collaborative events, coordinated among the local VA, other government agencies, and community organizations that serve the homeless. Just in the 6 years between 1994 and 2000, Stand Downs reached more than 200,000 veterans and their families.
It’s appropriate that this year’s first Stand Down was in San Diego. Today, Stand Downs are beginning in Bakersfield, California; El Paso, Texas; and Tucson, Arizona.
The VA’s Stand Downs served as a model for National Project Homeless Connect, begun in San Francisco and promoted by the U.S. Interagency Council on Homelessness.
Project Homeless Connect is a 1-day, one-stop event sponsored by Mayors and other community leaders and designed to provide housing, services, and hospitality in a convenient setting directly to people who are homeless, including veterans. More than 150 events in over 115 cities have been held in the past 2 years. Events catalyze community involvement, generating new partnerships, commitment, and investment to end homelessness.
Today, a National Project Homeless Connect event is taking place in Denver, Colorado, and one was held earlier this week in Contra Costa County, California. Both were sites in the Federal Collaborative Initiative to Help End Chronic Homelessness, which I’ll highlight in a moment.
First, I also want to give a nod to the VA’s CHALENG program. That stands for Community Homelessness Assessment, Local Education and Networking Groups. The guiding principle behind CHALENG is that no single agency can provide the full spectrum of services required to help homeless veterans become productive members of society. Project CHALENG enhances coordinated services by bringing the VA together with community agencies and other Federal, State, and local governments that provide services to homeless people to raise awareness of homeless veterans’ needs and to plan to meet those needs.
The ultimate goal of Project CHALENG is to empower local communities to help homeless veterans regain their mental and physical health, re-build meaningful interpersonal relationships, secure employment and stable housing, and ultimately return to society as productive citizens.
Clearly, it’s working. The 2006 CHALENG report reveals that last year along, 433 new interagency collaborative agreements between VA and community agencies were developed. Veterans received dental care, eye care, and mental health and substance abuse treatment as a result of these agreements. This is transformation in action!
Finally, I would be remiss in not pointing to the wonderful work of the 207 community-based Vet Centers located in all 50 States, the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. The Vet Centers are staffed by small multidisciplinary teams of dedicated providers, many of whom are combat veterans themselves. Veterans helping veterans is the essence of a consumer-driven system of care.
I recently came across an interview with Doonesbury cartoonist Garry Trudeau about the research he did to create the experiences of his character B.D., a Vietnam vet, reservist in the first Gulf War, and now Iraq War amputee. Among the places he visited were Vet Centers, where he talked to counselors and veterans and sat in on counseling sessions.
I was especially struck by the fact that in one strip, Celeste, a VA receptionist, greets B.D. and all visitors with “Welcome home.” She says, “We don't think vets can hear it often enough.”
The Chronic Homelessness Initiative
Perhaps one of the most significant examples I can share with you of transformation and synergy is the Collaborative Initiative to Help End Chronic Homelessness, or the Collaborative Initiative for short.
The 3-year Collaborative Initiative, begun in 2003, was coordinated by the U.S. Interagency Council on Homelessness. Funding was provided by HUD, SAMHSA, the HHS Health Resources and Services Administrations, and the VA. The national outcome performance assessment is headed by the VA’s Northeast Program Evaluation Center, directed by Dr. Robert Rosenheck.
The Collaborative Initiative was designed to address the complex needs of the most disenfranchised and hard-to-serve homeless people—the “chronically homeless”—those who are homeless for long periods and who need a disproportionate amount of services. We know that many veterans are in this group.
[Collaborative Initiative sites slide]
Eleven sites around the country received funds to develop a comprehensive plan to end or reduce the prevalence of chronic homelessness in their community through the development of sustainable, cost-effective partnerships among providers in the private and public sector. The specifics of these plans varied across communities but each plan included strategies for providing permanent housing; linking comprehensive supports with housing; increasing the use of mainstream services; integrating systems and services; and, ensuring the sustainability of these efforts beyond the funding period. I know that each of these practices will sound familiar to those of you working in VA homeless programs.
The Collaborative Initiative was an example of transformation in action. Many local sites included VA staff as part of the interdisciplinary treatment teams that conducted outreach to and engaged homeless people, many of whom were veterans. Some of these teams were assigned to specific housing sites, for example in San Francisco’s Tenderloin District, and others conducted outreach to streets, encampments, and under bridges, such as the Assertive Community Treatment (ACT) team in Contra Costa County, California. In other Collaborative Initiative sites, VA staff acted as consultants to the treatment teams.
Three of these sites, all of which had active collaboration with the VA, just won SAMHSA grants to serve chronically homeless individuals with serious psychiatric conditions and those with co-occurring mental and substance use disorders who live in supportive housing settings. They are Contra Costa County, New York, and Central City Concern in Portland, OR.
But while Federal money acts as a catalyst for these system change efforts, the real work is done by community providers and by individuals who see a need and set out to meet it. Individuals like Susan Storti. Individuals just like you.
I know you are likely familiar with the oft-quoted comment attributed to U.S. anthropologist Margaret Mead, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.” The familiarity of her remarks makes them no less powerful or true. Individually and working together, we can effect the type of changes necessary for veterans with mental and substance use disorders to live full and productive lives in their communities. More important, we must do so.
Wrap-up and Conclusion
I know that the work you do each and every day is difficult. Helping homeless veterans with mental and substance use disorders requires you to stretch limited dollars, work long hours when you would rather be home with your family, and try to resist the sadness that often comes with witnessing broken lives. However, I also know there is joy in seeing someone take those first tentative steps to resume working, put the key in the front door of their own apartment, or hug a loved one they thought was lost to them forever.
[Teddy Roosevelt quote slide]
I’m reminded that a century ago, Teddy Roosevelt observed, “Far and away the best prize that life offers is the chance to work hard and to have work worth doing.” Few jobs in life are worth more than what you do on a daily basis.
I’d like to close today by borrowing some very sage advice from our previous speaker, Nan Roman, when she addressed the National Alliance to End Homelessness conference in July. Since we didn’t coordinate our remarks beforehand, I realize there is a chance I’m reiterating something she just said, but these comments bear repeating.
Nan told her audience at the Alliance national conference, “While there will always be differing priorities and varieties of approach [among us], most important are shared goals, a desire to learn what works, a shared sense of mission, and unfaltering determination. We are challenged to run our programs based on the best information we can get about what works and not to see ourselves only as people whose mission is to help those in need, but also as agents of change [emphasis added] to alleviate that need.
Well said, Nan, and well done each and every one of you, who are agents of change in the lives of the people you serve.
Thank you. If we have time, I’d be happy to take your questions.
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