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
Wisconsin Department of Mental Health and Substance Abuse Treatment's First Annual Susstance Abuse and Mental Health Training Conference
Breaking New Ground: Integrated Treatment for Co-occuring Disorders
Eau Claire, WI
October 31, 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]
I’m delighted to represent SAMHSA at Wisconsin’s first combined substance abuse and mental health training. Who in the audience is a substance abuse practitioner? Who is a mental health practitioner? Do we have primary health practitioners here…or representatives from education, justice, and human services? This is a wonderfully diverse group of skilled professionals, all of whom are here to learn more about substance abuse and mental illnesses. Look around you. The future of behavioral health care sits right here in this audience.
Whatever our profession, we serve the public good. We share a bond in our commitment to improving the lives of others. We all hold firmly to a common belief—the belief that adults and children deserve every opportunity to achieve their full potential in life. We now must form a stronger bond that will help us confront a serious problem that is keeping thousands of American adults and children from achieving their dreams. That problem is the co-occurrence of mental and substance abuse disorders.
How serious is the problem? Each year, SAMHSA conducts the National Survey on Drug Use and Health. In 2004, more than 21 million American adults had a serious mental illness. Nearly 20 million adults had a serious substance abuse disorder.
[SLIDE 2. SMI/SA overlap]
Of these, more than four-and-one-half million adults had co-occurring disorders. Four-and-one-half million! That’s four times the population of Milwaukee. Let’s look at it another way. What if every individual with a co-occurring disorder lived in Wisconsin? Every person over age 18 would have a disorder…and your population still would increase by another half million people.
In addition, four-and-one-half million is a core number. It represents the estimated number of individuals who had both a serious mental illness and a serious substance abuse disorder. If we included those with less severe mental and substance abuse disorders, the number of Americans with co-occurring disorders would be much higher.
Co-occurring disorders are the most complex diseases that confront our behavioral health system. We don’t know yet why the relationship between the two disorders is so strong. Scientists haven’t yet found any conclusive evidence of a genetic vulnerability. We know that some serious mental illnesses may present an increased risk for substance abuse. We know that substance abuse may worsen or hasten psychiatric disorders in persons who are genetically predisposed.
Many adults with co-occurring disorders self-medicate with substances to relieve traumatic memories. Others report using substances to lessen the loneliness, discrimination, and loss of self-worth too often associated with a diagnosis of a mental illness. We continue to study the problem, and we continue to learn.
What we do know about co‑occurring disorders is this: If one disorder remains untreated, both disorders usually get worse. Additional complications often arise. These complications include the risk for physical health problems, unemployment, homelessness, incarceration, separation from families and friends, premature death, and suicide.
[SLIDE 3. Past-year treatment]
Despite the prevalence of co-occurring disorders… despite the risk of worsening and complicating conditions…and despite our current efforts to treat the disorders, nearly half of those with a co-occurring disorder will not receive treatment of any kind. Only 6 percent will receive integrated treatment. We must do better than this. In fact, we can do better than this. What research suggests…what our own clinical practices confirm…is that we have an approach that offers the greatest potential for recovery. That evidence-based approach is integrated treatment.
[SLIDE 4. Integrated treatment definition]
Integrated treatment is a broad term. It refers to any mechanism by which treatment interventions for both disorders are combined within the context of a primary treatment relationship or service setting. Integrated treatment is a means of treating both disorders, their related problems, and the whole person — actively and more effectively.
Our service systems must evolve to reflect the growing evidence supporting an integrated approach. This approach is our greatest opportunity to treat the most severe co-occurring disorders. It’s our opportunity to prevent the development or worsening of multiple disorders. It’s our opportunity to deal with the disorders on the same terms that consumers do. We must treat multiple disorders concurrently—not sequentially and not in parallel. Concurrently is how a person experiences these disorders―they can feed off of each other, compounding symptoms and complicating treatment and recovery.
The complexity of co-occurring disorders challenges our traditional—and frequently separate—approaches to mental illnesses and to substance abuse. Our tendency has been to put people into “disease categories,” which often have been created by funding streams. As a consequence, integrated treatment represents a radical shift in policy, programs, and resource allocation. It requires changes in training and practice by mental health and substance abuse clinicians, by primary health physicians, and by other professionals who serve children, families, and adults.
An integrated approach, however, is a necessary change in our response to co-occurring disorders. Many individuals who are seriously impaired from co‑occurring disorders cannot separate the problems of one disorder from the other. These individuals certainly should not have to negotiate separate service delivery systems for the treatment they need.
Wisconsin took a groundbreaking step a few years ago when it merged mental health and substance abuse into one bureau. This is a pivotal change—the kind of change that increases a person’s hope in recovery. Your State is well on the way to eliminating many of the traditional systemic barriers to integrated treatment and support services. What are these barriers?—separate administrative structures, eligibility criteria, and funding streams as well as limited resources for both mental health services and substance abuse treatment.
Your Bureau of Mental Health and Substance Abuse Services now stand poised to provide more comprehensive, integrated treatment. You already have created the administrative infrastructure necessary to align programs and to leverage resources. The communication pathways are open. You have greater opportunities to think and plan strategically along the same lines. This training conference is just one of those opportunities.
What you will find as you work more closely together is this: what your formerly separate bureaus will be able to accomplish together far outweighs what they might have accomplished separately. Congratulations on the vision and foresight that led your State government to this merger.
Today, I’ll tell you about SAMHSA’s evolving response to co-occurring disorders. Next, I’ll discuss some of the challenges to an integrated treatment approach. I’ll conclude my remarks by describing the many resources SAMHSA offers to support your State’s efforts.
SAMHSA has made integrated treatment of co-occurring disorders a priority for years. Think about the changes already taking place in the fields of substance abuse and mental health, such as greater access to evidence-based practices. Many of these changes have been driven by, and supported by, SAMHSA.
[SLIDE 5. Doyle quote]
I thank Wisconsinites for all that you have done and are doing for hurricane survivors. Your own Governor Jim Doyle spoke glowingly about your compassion in the wake of Hurricane Katrina. He declared, “We will help [the survivors] regain their dignity in the face of their losses. [We will] give families some measure of privacy and access to public transportation and to the culture and services that our cities provide. Those who have lived through this ordeal deserve the chance to quickly return their lives to normal.” Wisconsin has offered hundreds of fellow Americans a new home and healing in your communities.
[SLIDE 6. SAMHSA response]
We at SAMHSA also have been working diligently to promote recovery and build resilience among those affected by the hurricanes. One of our first actions was to launch a suicide crisis hotline to help survivors and emergency workers cope with the storm’s psychological after-effects. We also mobilized SAMHSA’s Emergency Response Center and put our Disaster Technical Assistance Center into overdrive.
We have awarded emergency grants to Alabama, Louisiana, Mississippi, and Texas to help them provide clinical services to individuals in need. We are extending additional help to States absorbing large numbers of people who were left homeless.
But, as Governor Doyle observed, “There still is so much more to do. It’s clear the clean-up and recovery on the Gulf Coast is going to go on well after the news coverage ends.” Hurricane response efforts now are moving into a new phase ― from rescue and recovery to mitigation and recovery. We again have both problems and opportunities. As affected States rebuild their infrastructures, they can build in stronger, more comprehensive and collaborative service networks.
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…just like they all must be involved in transforming behavioral health care.
I have great faith in Wisconsin as a leader in transforming behavioral health care. Wisconsin citizens always have been progressive and farsighted, recognizing the value and unique contributions of a diverse population. German and Swiss immigrants found a welcoming home in Wisconsin during the eighteen hundreds. More recently, Wisconsin has embraced thousands of Hmong refugees.
[SLIDE 7. SAMHSA’s four redwoods]
SAMHSA has four “redwood”—or top priority—programs. Responding to the needs of adults and youth with co-occurring disorders is one of them.
Our co-occurring disorder program is guided by our Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. The overarching theme of the report is a harsh reality: Individuals with co‑occurring disorders are the expectation, rather than the exception, in the substance abuse and mental health service delivery systems.
Consider the numbers! Fifty to 75 percent of patients in substance abuse treatment programs have co-occurring mental illnesses. Twenty to 50 percent of those treated in mental health settings have co-occurring substance abuse. Are you seeing similar numbers in your systems? What about the children you see? O ne recent study found that nearly 43 percent of youth receiving mental health services had been diagnosed with a co-occurring substance abuse disorder.
We have a serious problem here…but we also have tremendous opportunities to make a difference in the lives of adults and children with co-occurring disorders. How? By ensuring that anyone with a co-occurring disorder, at any stage of life, will have access to the practices that are most effective in promoting recovery.
[SLIDE 8. SAMHSA’s three centers]
SAMHSA’s has a 5-year plan of action to address co-occurring disorders. All three of SAMHSA’s centers are involved in carrying out our plan. The Center for Substance Abuse Treatment and the Center for Mental Health Services are involved, but so is our Center for Substance Abuse Prevention. Prevention is our first line of defense against multiple disorders.
SAMHSA and its centers have been funding grant programs and holding policy academies to help States improve their capacity to provide integrated treatment. We have awarded State Incentive Grants for Co-occurring Disorders to 15 States. We have held co-occurring disorder policy academies for 28 States.
Wisconsin has received Targeted Capacity Expansion Grants as well as an Access To Recovery Grant from SAMHSA's Center for Substance Abuse Treatment. These grants can help to reduce co-occurring disorders even though their primary focus is substance abuse. This is one lesson everyone should take away from this training conference. Mental and substance use disorders are linked closely. Efforts to prevent, diagnose, and treat one disorder will help to prevent the development or worsening of multiple disorders.
I’m now going to describe SAMHSA’s most dramatic and far-reaching initiative, which is to transform our national mental health system. You may recall that mental health transformation also is one of our redwood programs.
The concept of mental health transformation originated with a report by the President’s New Freedom Commission on Mental Health. The New Freedom Commission called its report Achieving the Promise: Transforming Mental Health Care in America. The “promise” is a full life in the community for people with disabilities, including those with co-occurring disorders. It is a life that includes a job or an education, a home, and meaningful relationships with others.
Achieving the Promise declares that millions of Americans with mental illnesses—including those with co-occurring disorders—are being denied this promise. How? — through stigma and discrimination, through fragmented and inadequate services, and through lack of choice and equal access to effective services. The New Freedom Commission reached a staggering conclusion. The only way we can keep our promise to all Americans is to fundamentally transform our mental health system. The ultimate goal of transformation is to create a system that is consumer and family driven, with a focus on recovery and resilience.
[SLIDE 9. Federal Partners Workgroup]
The New Freedom Commission on Mental Health released its report in 2003. Since then, SAMHSA has engaged nine Federal departments and the Social Security Administration in an unprecedented effort to change the status quo of mental health. The U.S. Departments of Transportation, Agriculture, and Defense are the most recent additions.
[SLIDE 10. Federal action agenda]
Together, we will be taking 70 specific steps that we believe can achieve immediate improvements in mental health care. The steps are summarized in a document that is available to you today. Its title is Transforming the Mental Health System: The Federal Action Agenda.
Our report, similar to the report by the New Freedom Commission, primarily addresses co-occurring disorders in the broader context of transformed mental health services. There is a reason for this. Transforming services for individuals with co-occurring disorders is as basic to mental health transformation as equal opportunity is to civil rights.
Prevention and treatment of co-occurring disorders define what is meant by consumer-driven recovery. We will achieve the promise of transformation when we fully develop our capacity to provide the full spectrum of services and supports that offer the greatest opportunity for recovery to anyone with or at risk of multiple disorders.
- Consumer-driven recovery becomes possible when individuals are able to seek treatment willingly, openly, and with hope.
- Consumer-driven recovery becomes possible when we offer evidence-based treatments that work for different populations and in different settings.
- Consumer-driven recovery becomes possible when we screen for disorders across the lifespan and across systems, such as child welfare, homeless services, and criminal justice. It becomes possible when individuals receive appropriate treatment no matter where they enter the system.
- Consumer-driven recovery becomes possible when multiple systems, such as mental and substance abuse treatment, housing, juvenile justice, primary care, and education, take advantage of shared opportunities to help prevent and treat multiple disorders.
What is the foundation of transformation? ― Collaboration! Consumers and families living with mental illnesses and substance abuse have complex and multiple issues. These issues cut across departments, agencies, and systems. As a result, the speed and extent of transformation hinges on how well we all work together for change. Every sector of the behavioral health care community must be represented, from policymakers and clinicians to consumers and family members. We all bear some responsibility—some accountability — for bringing about needed changes in programs, policies, and funding schemes.
Having said that, I’d like to digress for just a moment. Our Nation recently experienced a series of tragic hurricanes, beginning with the catastrophic Hurricane Katrina. These hurricanes presented a stark reminder of how many systems are involved in our daily lives…and how many must be involved in the recovery effort.
[SLIDE 11. Hmong in Wisconsin]
Wisconsin is fertile ground for new people, new ideas, and new directions. Isn’t that why your State motto is “Forward?” I believe the character of Wisconsinites is captured by these words, which Zona Gale included in These United States, a book written in 1924. Gale quotes the regents of the University of Wisconsin, who were defending a professor’s right to question existing economic theory. The regents chided those who opposed a challenge to the status quo. They proclaimed
[SLIDE 12. Regents’ quote]
“We cannot for a moment believe that knowledge has reached its final goal or the present constitution of society is perfect….Whatever may be the limitations which trammel inquiry elsewhere, we believe the great State of Wisconsin should encourage that continual fearless sifting and winnowing by which alone truth can be found.”
Wisconsin steadfastly has followed the regents’ charge. In behavioral health care, you continuously have challenged old ideas and moved forward with new ideas. I already mentioned the recent merger of your mental health and substance abuse bureaus as a positive change.
Long before that, Wisconsin developed the PACT model, which is an acronym for Program for Assertive Community Treatment. PACT provides integrated, long-term treatment to persons with severe and persistent mental illnesses. It has evolved into a nationally recognized evidence-based practice. SAMHSA has made it the basis for the Assertive Community Treatment model that we now are distributing the States. As long as consumers are at the center of care, PACT is an example of transformation in action.
Wisconsin also has worked to provide behavioral health care that is culturally appropriate, which is another characteristic of a transformed mental health system. For example, Wisconsin is using a Targeted Capacity Expansion Grant to provide mobile outreach and mental health treatment for elderly Hmong who are homebound. Think for just a moment about this program. How many deviations from the status quo are involved? Many elderly Hmong experience Vietnam-related depression, post-traumatic stress disorder, and difficulty adjusting to a culture vastly different from the one into which they were born. This grant program is consumer driven. It revolves around the unique needs of an individual. It moves the point of care from the clinic to the home, which carries less stigma. It takes into consideration Hmong values and customs. This program is transformation in action. Your ongoing Targeted Capacity Expansion Grant to expand substance abuse treatment capacity among the Menominee Indian Tribe is built on the same transformational principles of care.
I’d now like to address some of the challenges your State faces in expanding its integrated treatment program.
[SLIDE 13. What challenges lie ahead?—Financing]
Let’s begin with financing—the way it’s structured and the way it’s allocated. Separate mental health and substance abuse funding systems present challenges for States, providers, clinicians, and consumers. We are working to align funding streams at the Federal level, but similar efforts need to be made at the State level and within community behavioral health organizations. Funding inequities between services must be eliminated. The services provided at the clinical level should be driven more by the needs of the people being served than by financial structures.
Another financing issue is the commitment of resources for workforce development, continuing education, community outreach, and program and policy alignment. Just as you can’t jump a 20-foot chasm in two 10-foot jumps, a State can’t make a half-hearted leap toward an integrated approach. The commitment has to be there… and it has to long-term… and it has to be supported by administrators to clinicians. Buy-in at every level of an organization is essential. Without it, the gains made—such as the crosstraining at this conference—will erode.
I’m delighted by Wisconsin’s efforts to transform financing. Look at your new outpatient mental health rule. Many individuals do not qualify for PACT but still need more than outpatient care. Your new rule expands psychosocial rehabilitation benefits under Medicaid. These individuals now will have access to more comprehensive services.
Your State also is finding new ways to pool resources, which truly is transformational. Why? ― because multiple agencies are collaborating to create a seamless delivery of services. Your State has combined State funding, county block grant funding, and child welfare funding with an Access to Recovery Grant from SAMSHA. Your grant program works with female offenders who have substance abuse problems. Mulitple agencies are involved in offering wrap-around services to a woman and her family…before she re-enters her community. That’s transformation in action.
[CLICK—Workforce development]
Another challenge is to integrated treatment is workforce development. This challenge involves credentialing and licensing as well as cross-training. Mental health and substance abuse professionals have tremendous potential to complement each other by sharing the strengths and training each field brings to treatment. Science and practice, however, tell us we have so much more to learn about the complexities of co-occurring disorders.
For example, unresolved trauma has significant implications for diagnosis, treatment, and recovery from co-occurring disorders. Trauma is one of several clinical issues that transcend the traditional borders of the substance abuse and mental health fields. I notice that one of your workshop topics is “Trauma Treatment Across Gender and Across the Lifespan.” Once again, Wisconsin is demonstrating foresight in transforming behavioral health care.
[CLICK—Effectiveness and accountability]
Another challenge is how to evaluate program effectiveness. We serve the public. We are accountable for both the services we provide and the results we achieve. Congress sees SAMHSA as a business, and Congress is evaluating our success as a business. The Office of Management and Budget is looking to us for stronger data measures and positive, measurable outcomes. Our response is the National Outcome Measures for substance abuse and mental health.
Last year, SAMHSA incorporated National Outcome Measures, or NOMs, into State mental health and substance abuse block grant reporting requirements. The NOMs reflect a transformed view of effective mental health care because they focus on positive outcomes for consumers.
[SLIDE 14. Selected NOMs]
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 Wisconsin 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. Your State, in turn, has extended this responsibility to contractors. Wisconsin is requiring outcome measures from any contractor who provides direct mental health and substance abuse services.
Outcome data collection and assessment 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 your State ensure that consumers will have access to the treatments and supports that offer the greatest potential for them to achieve and sustain recovery.
[SLIDE 15. More challenges—Alignment of approaches]
A primary challenge to integrated treatment is the traditionally separate approaches taken by mental health and substance abuse clinicians. Traditional addiction programs tended to be confrontational. Many individuals who have a serious mental illness are too fragile to benefit from this approach. Standard addiction programs also require abstinence from all chemicals, which sometimes includes prescribed medications. Persons with mental heath disorders, however, often need medication to stabilize or improve their condition. Two separate treatment approaches and philosophies can cause conflict, both for the clinician and the consumer. Integrated treatment has the power and potential to remove many of these conflicts.
Integrated treatment, however, fits with within a comprehensive service system that value both fields of treatment. Mental health transformation is based on the concept of consumer-driven services. Each consumer will receive treatment and supports that respond to his or her unique needs. Integrated treatment services are critical for those who have multiple disorders. Single-diagnosis services are equally essential to those who have a single disorder. Integrated treatment is an enhancement of—and not a replacement for—current mental and substance abuse practices.
[CLICK—Leadership]
I’ve left for last an overarching challenge to an integrated approach. Up to this point, I’ve talked primarily about the system—how to transform policies, programs, and practices. However, the most important challenge is not systemic—it is personal. We are the system! Our attitudes and our beliefs guide the actions we take.
Change does not just happen—someone makes it happen. As Robert Quinn observed in his book, Deep Change: Discovering the Leader Within, a system evolves only when a few individuals—a few leaders―are willing to take risks. They leave their comfort zone and step outside of their normal roles. They explore new areas, try new methodologies, and strive for new goals. They break new ground in advocating for change. I am asking each of you to discover the leader within. We will be able to provide more integrated approach when you take responsibility for making it happen.
This brings me to the concluding section of my remarks, which is how SAMHSA can help the States expand and enhance their integrated treatment capacity.
A primary effort is to accelerate the development and distribution of evidence-based practices. One outcome of our efforts is available at this training conference. You have the opportunity to attend a two-part session on TIP 42. This is the shorthand title for SAMHSA’s Treatment Improvement Protocol 42: Substance Abuse Treatment for Persons With Co-Occurring Disorder.
[SLIDE 16. TIP 42 cover scan/Web address]
TIP 42 provides more than 500 pages of state-of-the-art treatment guidelines and case examples for counselors and others working in the fields of substance abuse and mental health. Wisconsin held one of the Nation’s first training about TIP 42 soon after its release. I’m pleased that Stan Sacks, my colleague from SAMHSA, will be conducting a second training session at this conference.
SAMHSA also has produced a resource kit that approaches screenings for co-occurring disorders from the perspective of community mental health clinics.
[SLIDE 17. Six toolkits]
Our toolkit is called Co-occurring Disorders: Integrated Dual Diagnosis Treatment . It is one of six toolkits that we created last year. Each kit includes the resource materials needed by providers to replicate the evidence-based practice, including implementation guidelines and fidelity measures.
These kits still are being refined. More than 50 community mental health programs in 18 pilot States currently are helping to evaluate their use in practice. We have asked the pilot States to give us feedback on how effectively the treatments work for different populations in different community settings.
Toolkits are available through SAMHSA’ National Mental Heath Information Center. Request a copy and send us your feedback. For the record, we have received more requests for our integrated treatment kit than we have for any other. The demand clearly indicates a need. States and providers are seeking guidance on how they can best serve consumers with co-occurring disorders. We’re elated that integrated treatment increasingly is recognized as the best approach possible.
[SLIDE 18. NREPP Web site]
Another useful resource is the National Registry of Effective Programs and Practices, or NREPP. We created NREPP in 1998 to review and evaluate substance abuse prevention programs. Those designated as model, effective, or promising are included in this online national registry.
Last year, we expanded NREPP by adapting its criteria to mental health and co-occurring disorder treatment programs. We now are doing the same thing with mental health promotion and prevention programs.
[SLIDE 19. COCE Web site]
SAMHSA also sponsors the Co-Occurring Center for Excellence, which is known as COCE. SAMHSA’s Center for Substance Abuse Treatment and Center for Mental Health Services are leading this initiative.
COCE is the first national resource on co-occurring disorders. It provides materials needed by the behavioral health field to increase our knowledge and to examine evidence- and consensus-based practices for serving individuals with co-occurring disorders.
[SLIDE 20. COCE services]
COCE is a resource immediately available to every single person in this audience. COCE offers cross-training, technical assistance, publications, meetings and conferences, and evaluation of the Performance Partnership Grant measure. I encourage you to explore the COCE Web site to find out more about its resources, including your opportunity for free technical assistance.
Integrated treatment of co-occurring disorders is a challenge to States and to us as individuals. As public servants, we have made a commitment to promoting the well-being of others. We certainly are not in our professions for huge financial gain. Our primary role in helping consumers seek recovery is to help them believe that a better life is possible…and to help them work toward recovery by providing them with the best tools available. The hope—the expectation—that life will improve is one of the most powerful incentives that guide consumers in seeking and remaining in treatment. Consumers want hope in recovery; many consumers report that having hope was and is vital to their recovery.
Too often, people with multiple disorders have been excluded from treatment or have received ineffective treatment. They often are demoralized by the systemic barriers they’ve encountered and the limitations imposed by their multiple disorders. It’s a great achievement for a consumer to walk through the door—any door—of a treatment program without fear of rejection. That achievement alone needs to be acknowledged and in some way celebrated. We can begin by making any door the right door to the services that best meet each person’s comprehensive service needs.
Wisconsin has been breaking new ground in behavioral health care for decades. We at SAMHSA applaud your progress and your leadership. Keep digging for new opportunities. Freshly broken ground is a fertile environment for innovation and can produce a prolific harvest of new ideas.
Undoubtedly, you will continue to challenge the status quo of behavioral health services. Progressive thinking is part of your State’s history; it is your future. What else should we expect from a State’s with “On, Wisconsin” as the State song?
The progress you make will not be confined to your State borders. Just like your PACT model, your ideas can inspire, guide, and enhance efforts made by other States. Ultimately, every State will come to understand, embrace, and begin acting on the essential need to provide integrated services for those who need them. When we have achieved that glorious goal, we will have transformed the lives and future of millions of Americans.
[SLIDE 21. Thank you]
Have a successful training conference. Thank you.
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