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
The Surgeon General’s Workshop on Women’s Mental Health
The State of Women’s Mental Health – What We’ve Learned
Denver, CO
November 30, 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/Cover
What have we learned about women’s mental health? To echo Dr. Nakamura, we have learned a great deal.
Of course, many critical questions remain unanswered—questions about the unique risk and protective factors that affect women...about the impact of gender disparities…about effective treatment during pregnancy and the postpartum period…about addressing problems as women age. But, thanks to some of the very studies Dr. Nakamura described this morning, we are beginning to shed new light on many of these issues. Thanks to the fine work that is happening at NIMH, and in research and service delivery organizations around the globe, the body of knowledge on the lived experiences of women is expanding everyday. After two decades of study, we know a lot about what works in women’s mental health.
We know enough right now to make real headway toward our goal: to help women and girls achieve holistic lives of greater self-determination, power, and self dignity. We know enough right now to fuel our efforts to create a system that promises the full hope of recovery for our mothers, our sisters, our daughters, ourselves. We know, right now, that recovery is possible…and, with the right treatments and supports, recovery can be the expected outcome for every woman and girl in America living with mental health or substance-use conditions.
I am here this morning, in the face of this mounting evidence, to say: It’s time... time for us to act on what we know. Study after study, in a wide variety of fields, provides strong irrefutable evidence for the interaction of mind and body…environment and biology…in women’s health and mental health. It’s time we harness the power of these discoveries to offer new hope in both treatment and prevention for women and girls. We have the tools. It’s time to put them to use.
In order to promote recovery, it is imperative that the woman, herself, becomes the director of her own treatment...since only she knows the truth about the conditions of her life. It also becomes imperative that we move from an illness/acute treatment/symptom mitigation model to a strengths-based recovery model…since virtually all behavioral health conditions will require environmental or lifestyle changes as well as biological treatments.
Our service delivery systems have not incorporated this understanding in any meaningful way. In particular, the mental health services system has neglected to incorporate respect for and understanding of the unique histories, beliefs, attitudes, and value systems of culturally diverse populations. Our efforts to bring all of the relevant health and human service components to the table to address the totality of women’s health have been haphazard at best…and clouded by stigma/discrimination.
Slide 2/Time to Change
It’s time to change the way we think about, develop, and deliver mental health services. It’s time we stop wasting so many lives…and so much money…with a piecemeal approach. It’s time we start caring for the whole woman.
Caring for the whole woman means addressing unrecognized and untreated depression. It means making routine use of self-administered depression screening tools at primary care clinics, in OB/GYN offices, by breast cancer specialists, and in prenatal and birthing centers. It means making community-wide, comprehensive, and systematic screening for major depression during late pregnancy and post partum a top priority.
Eating disorders and suicidal ideation are among the cluster of issues that are often related to depression in women. Promising advances are being made with cognitive behavior therapy methods that enlist the aid of the family to treat eating disorders. Likewise, with proactive outreach, we can avert the tragedy of suicide and its consequences.
To care for the whole woman, we must care for her children and family. So many urgent issues come to mind when we think of caring for the mental health of children and adolescents. But, one critical goal must be to keep children whose parents have depression from getting caught in the cycle…and becoming ill themselves. We know that a comprehensive, family-based approach to prevention works. We must use what we know…today…to create a brighter future for all children.
Caring for the whole woman means improving systems of care in our nation’s jails and prisons. We must develop and implement effective interventions around parenting and child custody issues…services for women inmates who are pregnant…and services and supports to resolve mental health issues related to victimization and violence.
This last issue—the inextricable link between violence and trauma and women’s mental health—is one that resonates deeply with me on a professional and personal level. I have made it my life’s work to champion women’s recovery from the impacts of violence and trauma. It is my personal mission to empower these survivors…along a continuous process of healing…to leverage themselves as their own source of power…particularly, of healing power.
My first job as a teacher in both elementary school and high school provided the impetus for my interest in the human potential for change. As I worked with children in the classroom, it became clear to me that a child’s emotional health serves as a regulator for his or her intellectual, academic, social, and health-related behavior. I witnessed the impact of traumatic life events that disrupted a child’s emotional health and how it directly affected behavior in and out of the classroom. I kept asking myself, “What can I do to help these children recover from traumatic blows to their emotional health?”
These and other questions led me to subsequently return for further education in pursuit of knowledge on these topics. This was in the early 1970’s when the women’s movement raised our collective consciousness about the impacts of the traumas of rape and domestic violence on women’s lives.
As a consequence, my own consciousness was raised, and I steered my mental health counseling and professional experience toward women who experienced violence and trauma. I learned again and again that a woman’s searing exposure to the raw trauma of physical or sexual assault put her overall emotional health at very high risk for both the short and long term.
By that time, my interest encompassed not only the recovery and resiliency of children’s emotional health, but also women’s recovery from the trauma of physical and sexual abuse. I had learned that the power of violent and traumatic life events to destabilize individuals had been systematically missed by the mental health field almost altogether.
This was a heady time for the emerging issues related to the emancipation of women. Women told us that they wanted to recover from the traumas of rape, incest, and domestic violence, but that they needed support and time to heal. This is when I began to understand that, as a caregiver, it was my job to find a way to move with them on their journey of recovery. For recovery to occur, however, it was necessary for the choice, direction, and leadership of recovery to flow from the woman herself.
Slide 3/Women, Violence & Trauma
As Director of SAMHSA’s Center for Mental Health Services (CMHS), it has been one of my personal priorities to open the nation’s eyes…to the impacts of trauma…and about achieving emotional health and recovery. Today, we are making real progress toward creating a trauma-informed national system of care. Through the work of its National Center on Women, Violence, and Trauma, SAMHSA is developing leadership networks to spread information about emerging best practices and to stimulate local change. In FY 2006, the SAMHSA/CMHS Women’s Coordinating Committee—a group charged with promoting the importance of health issues of women across SAMHSA—is planning a series of activities, including trainings focused on the integration of trauma-informed services in public health facilities. SAMHSA/CMHS is making a major investment of resources in the issue of women and trauma. Our groundbreaking Women and Violence Study is a shining example. We are committed to helping States respond to these intertwining issues with integrated, community-based solutions.
A public health, community-based approach that stresses the links between health and the physical, psychological, cultural, and social environments in which people live, work, and go to school is critical. The fundamental premise is that it is inherently better to promote health and prevent illness before it begins. We know we must address the impact of trauma on women to promote health and prevent illness.
Of course, this is not a new idea. The Kaiser Permanente/CDC-sponsored Adverse Childhood Experiences—or ACE—Study provides strong evidence of a causal link between violence-induced neurological damage, the use of self-medicating measures, the adoption of health risk behaviors, and consequent chronic disabling health morbidity and early mortality.
The ACE Study is just one example of the substantial body of research about the impacts of trauma, particularly on women. What we have learned about the pervasive lifelong impacts of violence and trauma in women and children brings urgency to our need to act now. I would like to offer a few highlights about what is known.
Slide 4/ Impact of trauma
What do we know about the impact of trauma? We know that trauma is no longer regarded as an anomalous experience. Trauma is increasingly seen as an almost universal experience of public mental health and human service recipients (Bloom; Jennings). Addressing trauma is increasingly recognized as essential for recovery! Providers as well as consumers are beginning to see that, without integrating a focus on trauma, improvement in symptoms such as depression and substance-use disorders will not occur…and, without this integration of services, a recovery-oriented system is impossible.
Major and costly human service systems failures—for example, seclusion and restraint in psychiatric and other facilities, self-injury in adult criminal and juvenile justice, repeated failures to maintain housing or employment, heavy use of health care services, and suicide—can often be traced to ignoring or treating trauma with the wrong clinical paradigm.
As the ACE Study has demonstrated, childhood physical and sexual abuse creates a legacy of lifetime disabilities. In addition to countless developmental complications, childhood trauma is associated with persistent mental health problems, addictions, and major health problems. Early abuse can lead to coping strategies such as dissociation, hyper vigilance, and others that assist survival at the time. As a child grows older, risk taking and running away, self-injury, eating disorders, and other addictions may develop. These coping strategies ultimately block or delay further development.
We are increasingly recognizing the intergenerational and historical costs of trauma in such diverse groups as American Indians, Japanese internment survivors, returning war veterans, African-American families, immigrant and refugee groups, and survivors of captivity.
In mental health services there are spiraling costs for “treatment as usual” for consumers with trauma histories. Their entrenched symptoms necessitate repeated returns to ineffective services that do not reduce their overall misery, and contribute to cynicism regarding recovery.
Slide 5/ Trauma Interventions
What do we know about trauma interventions? We know that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts (Shepard; Briere) . Proven models and tools for intervening and treating trauma-related problems have been developed and manualized (Harris; Najavits; Miller; Ford). These tools are now available to the mental health systems and providers/practitioners, and increasingly, are being adapted to other populations and systems, including juvenile justice, jails and prisons, and domestic violence shelters.
We know that to fully address the needs of survivors of trauma within the public mental health service system, we must adopt a systemic approach...an approach characterized both by trauma-specific diagnostic and treatment services and a “trauma-informed” environment capable of sustaining these services. This change to a trauma-informed service system environment represents a profound cultural shift in which consumers and their conditions and behaviors are viewed differently. Effective systems for service delivery must embrace policies and practices that create emotionally safe and personally empowering conditions and choices for trauma survivors and staff. This requires a new management orientation, for which several trauma-informed organizational change guides are now available (Harris and Fallot) .
Time and again, hope and self-determination have proven to be essential elements for consumer recovery. Speaking one’s voice, the freedom of choice, and the willingness to seek personal solutions for the challenges raised by the crisis of violence are fundamental to recovery.
Consumers have become “trauma champions”—helping to develop systems and services for ongoing treatment. Their powerful personal stories have shaped treatment that is trauma-responsive to the wide range of their needs (Veysey) . Programs to train and support emerging “consumer champions who have survived trauma” have been developed and successfully pilot-tested ( McKinney) .
Slide 6/ Trauma Outcomes
What do we know about trauma outcomes? I am proud to say that the SAMHSA-sponsored, five-year Women and Violence Study has provided the most authoritative and comprehensive view to date of what can be accomplished in the public health system…with women who have histories of physical and sexual abuse…who are in need of services for both mental health and substance-use conditions.
This groundbreaking study featured a trauma-integrated counseling approach that addressed both mental health and substance-use conditions. Findings at both six and 12 months suggest that integrated counseling—for example, group and individual therapy that addressed trauma, mental health, and substance-use conditions—was the key element associated with better outcomes.
The gains at six months in substance use behaviors and mental health and trauma symptoms were largely maintained or improved between the 6- and 12-month follow-up. The overall effects at 12-months are more significant than those found at 6-months.
At 12-months, the effect sizes for mental health and posttraumatic symptoms show statistically significant improvements. Further, at 12-months, the mental health effect size doubles and the post-traumatic symptoms effect size increases by almost half.
Given this impressive body of knowledge about trauma and recovery, where do we stand now in terms of readiness for action?
Slide 7/Achieving the Promise
We are on the cusp of a new evolution in mental health services! Achieving the Promise: Transforming Mental Healthcare in America, the landmark final Report of the President’s New Freedom Commission on Mental Health, called for a trauma-informed transformation of our public mental health system. The report challenges us to change the way this nation thinks about, delivers, and finances mental health care. It calls on us to create a new, recovery-oriented national mental health system that meets the needs of every American living with mental illnesses. Achieving the Promise urges everyone with a stake in mental health care to work together to realize this vision.
Slide 8/ Transformation
Transformation will require conversion, renovation, an entire makeover of the system we presently know. Transformation calls for a literal revolution in how we do things, in how we think, and in how we work together. Transformation is a never-ending process of breaking the old molds, shifting our thinking, and discarding the traditional ways of doing things. New sources of power emerge, most importantly, in transformation. And once the process of transformation begins, a profoundly different system materializes…a system changed in structure, culture, policy, and programs.
Slide 9/ Recovery
Embedded in transformation is the core belief in recovery. I think of recovery as the journey of hope through which lives will be transformed. Recovery is a process…a continuum of personal achievements as each person moves toward his or her greatest potential. Perhaps the most compelling element of a recovery-focused system is the belief that adults with mental illnesses can take charge of their own lives, their own wellness, and their own care. It is the belief that systems should help children and their families build existing strengths, foster resilience, and create promising futures.
These beliefs have extraordinary implications for transforming mental health care. When we change the focus from system-directed to self-directed, we begin to look at what is required to empower women and girls living with mental health issues to develop and reach their uniquely individual life goals.
In a transformed mental health system, services for women and girls will recognize the complex linkages between biology and environment and the role of violence and poverty in health conditions. New treatments will grow out of this recognition. In a transformed system, culturally relevant, strengths-based approaches, which encompass creativity and spirituality, and address the unique needs of refugees and immigrants, will be commonplace. In a transformed system, we will tap the power of technology to connect women to, and educate them about, the wealth of effective recovery-focused services that are available to them.
The newly released Federal Mental Health Action Agenda—the roadmap that will guide our first steps as a nation toward this wholesale transformation—calls for the development of toolkits for evidence-based trauma-informed systems and services to help to spread what we know about assisting people to survive trauma. In addition, the Federal Action Agenda proposes the development of a cooperative plan of action by CMHS with the Office of Justice Programs at DOJ to better serve victims of crime.
(pause)
Cooperation and collaboration are the lifeblood of transformation. Through transformation, we are looking forward to creating a new social culture...not just a new program or network. To do this, we need to encourage diverse organizations within our communities to become a part of the continuum of care. We must move beyond our current members of the choir and build partnerships throughout health and social services…and across all of the people-serving agencies and organizations.
Protecting the health and mental health of women is not a women’s issue. It is a national issue. It is an international issue. It affects all of us. We’ve learned a very important lesson from globalization: economic development, stability, and growth depend on the health and education of women. Women serve as the caretakers and doorkeepers to the health and welfare not only of children, but also of men and older adults. Each of us must embrace this profound change if the profound results we seek are to be achieved.
Back in July 1994, Pat Deegan, a well-known psychiatric survivor and activist in the patient's rights movement stood before a group much like this at the Dare to Vision Conference—a CMHS sponsored event that, for the first time, focused national attention on the impact of physical and sexual abuse in the lives of women with mental illnesses. Ms. Deegan told the group, "Trying to change a system while refusing to change ourselves amounts to
re-arranging the chairs on the deck of the Titanic—all we achieve is a better view while going down." Each of us, she said, “must be willing to change…to dare to see, and to say.”
This morning, I want to reaffirm Ms. Deegan's challenge, and take it a step further. This morning, I am sending out an urgent call to action. It is time for each of us to do something about the problems we have seen and talked about for so long. An unprecedented window of opportunity is opening…right now. It’s time for all of us…at the local, State, and national level…to advocate for the comprehensive, coordinated, consumer-centered mental health system that will give women…and all Americans… access to the full range of services they need to recover. It’s time to deliver on our advocacy with personal action.
Slide 10/ Quote
I’d like to leave you with a thought from American-born Buddhist nun, Pema Chödrön, whose writings inspire and encourage practitioners around the globe.
She has said, “Now is the only time. What we do accumulates. The future is the result of what we do right now.”
This moment is ripe with promise. W hat we do right now to kindle hope in the hearts and minds of women and girls so that they can experience personal recovery will accumulate…one person, one program, one community at a time…until the point when recovery is the expected outcome for all! Let’s seize this moment and use the power of it to transform the lives and future of millions of Americans. Thank you.
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