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
Keynote Address
Generations 2004 Conference
April 15, 2004
Salt Lake City, UT
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[Slide 1: Title, speaker identification]
Good morning and thank you for inviting me here to your conference in beautiful Salt Lake City. The view of the mountains as my plane flew into the airport was awe-inspiring. I looked down on those peaks with the realization that they have endured for millions and millions of years, and yet they are still considered "young mountains." I'm told that the mountains in the Wasatch Range still may be growing.
It's interesting to think that mountains, similar to people, progress through different ages. For mountains, each age is marked by a different set of geological characteristics. People, however, are more complex in that we change both physically and mentally. Our mental health needs, vulnerabilities, and strengths change across our lifespan.
As an example, many of you who are parents will have dealt calmly with the leg-clutching frenzy of a toddler going through separation anxiety. How would you react if it were your SPOUSE screaming and sticking to your leg like Velcro? Quite differently, I'm sure. Why? Because symptoms of separation anxiety are normal in early childhood, but are signs of distress in later life. By the time a person reaches adulthood, the person would have—in the normal course of mental health development—attained the intellectual understanding and emotional maturity to cope with the temporary absence of another.
Our mental health development does not end with childhood, but continues across our lifespan. By using the word "GENERATIONS" in your conference title, you have made clear that you understand that persons at different stages of life have different mental health care needs. Without this understanding, we cannot adequately assess or promote the mental health of each generation.
This same lifespan concept is reflected in the Surgeon General's report on mental health. This report concludes that . . .
[Slide 2: Surgeon General quote]
"Just as each person can do much to promote and maintain overall health regardless of age, each person also can do much to promote and strengthen mental health at every stage."
It's important that we consider mental health at every stage in the context of the public health model. The public health model takes a community approach to preventing and treating illness. Its premise is that caring for the health of an individual protects the community, while caring for the health of a community protects the individual—with an overall benefit to society at large.
Mental health is a public health issue because it affects the overall health of a community and our Nation, as well as that of individuals. The Surgeon General's report on mental health phrased this concept quite beautifully. It states that,
[Slide 3: SG Quote]
"From early childhood until death, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self esteem. These are the ingredients of each individual's successful contribution to community and society."
Thus, not caring for the mental health of an individual denies that person a full life in the community . . . AND denies the community the benefits it could receive from that person's sound mental health. We can see the truth of this statement across the generations. Fifty percent of students with serious emotional disturbances drop out of high school. Only about one in three persons with a mental illness is employed.
[Slide 4: WHO chart-burden of disability]
The costs of mental illnesses in terms of health and lost productivity is staggering. In fact, the World Health Organization has identified mental illnesses as the leading cause of disability worldwide, accounting for 25 percent of all disability in industrialized countries.
How we care for the mental health of the current child and adult generations will determine if mental health care will become a public health crisis for the next generation. About 5 to 9 percent of American children have a serious emotional disturbance. Left untreated, these disturbances can lead to serious emotional illnesses in adulthood as well as other physical complications.
[Slide 5: Aging of America]
By the year 2010, approximately 40 million Americans will be age 65 or older. More than one-fourth of older adults have mental health issues, including mental illness, alcohol use, depression, anxiety disorders, dementia—including Alzheimer's disease—and suicidal ideation. Their mental illnesses will significantly affect their health and functioning, with a compounding effect on the care they will need and its cost.
These are critical issues that must be considered as part of our national dialogue on health care reform. The very size of the current older adult generation is already creating unprecedented challenges in organizing, financing, and delivering effective mental health services. We, as a society, need to transform how we view and provide mental health services. If we do not, the next generation will not be able to provide for the integrated health needs of those who will need care.
The Surgeon General's report on mental health also underscores the essential mind-body relationship, which is the primary focus of your conference this week. Nearly two millennia ago, the Roman Lucius Seneca wrote that "it is part of the cure to WISH to be cured." This is probably our earliest anecdotal evidence of the mind working for the body's good.
Further evidence of the mind-body connection is all around us. For example, more than 6 million pilgrims a year visit the religious shrine at Lourdes, France. Many come to pray for a miraculous cure for their afflictions. Enough of these visitors describe spontaneous cures to keep a 30-member International Medical Committee reviewing them full time. Faith, for our purposes, is a form of positive thinking that makes those with mental and substance use disorders more likely to experience recovery and for longer periods.
We also have evidence that poor mental health can undermine physical well-being. We know that patients who experience a major depressive episode following a heart attack have an increased risk of early cardiac death. We know that emotions such as fear, anxiety, and depression can worsen the pain of cancer and other severe illnesses.
Mental health and physical health are inseparable. Treating the mental health needs of adults benefits them both mentally and physically, even when they have a chronic illness. Treating the mental illnesses of dual-diagnoses patients can improve their interest and ability to care for themselves. It can engage them in following their primary care provider's directions and advice, particularly about taking medications. It can transform their hope in recovery or bolster their ability to cope with illnesses from which there is little chance of recovery.
Science has substantially broadened our knowledge about the critical link between mental and physical health. Unfortunately, our society as a whole and our national health care system have been slow in making the benefits of this knowledge available to consumers at the clinical level. Our current mental health system is characterized by services that are fragmented, disconnected, and often inadequate. Too often, today's system focuses only on managing the symptoms of mental illness and accepts long-term disability as a foregone conclusion.
[Slide 6: Recovery system]
Recovery, NOT DISABILITY, should be the expected outcome for everybody. A recovery—focused system sees each individual as a unique human being—and not just as a person with a categorical disability. It focuses on the overall health of the whole person, and accepts the mind and body as integrated and inseparable. It forces the dialogue to revolve around the comprehensive needs of a person that promote recovery…including finding a job, success in work, securing a place to live, peer and family support, and expressing a spiritual and creative life.
This system understands that recovery is the hard work that consumers do.
[Slide 7: Unique aspects of recovery]
Individuals with mental health disorders undergo unique experiences while being "in recovery."
- They grow to accept having a chronic, incurable illness that is a permanent part of them, …without guilt or shame, …without fault or blame.
- After time and focused help, they can avoid complications of the condition.
- They can participate in ongoing support systems as both recipient and provider.
- They change many aspects of their lives, including their emotions, interpersonal relationships, and spirituality.
- They learn to accommodate their illness and grow by overcoming it.
[Slide 8: Most compelling element of recovery]
The most compelling element of recovery is the belief that people with mental illnesses CAN take charge of their own life, their own wellness, and their own case management. However, our current mental health care system is not focused on recovery. We will not have a mental health care system that is driven by the needs of consumers and their families—as THEY experience them—without transforming the way we do business.
What does "transformation" of a system mean?
[Slide 9: Cebrowski's definition of transformation]
Transformation is, foremost, a continuous process, without end. Transformation is not accomplished through change on the margin but, instead, through profound changes in kind and in degree. These changes result in new behaviors and new competencies. Thus, in transformation, we look at what we can do now that we were unable to do before.
Transformation is meant to identify, leverage, and even create new underlying principles for the way things are done. New sources of power emerge. Once the process of transformation begins, a profoundly different organization materializes—changed in structure, culture, policy, and programs.
[Slide 10: Achieving the Promise]
Today, I'd like to discuss the final report by the President's New Freedom Commission on Mental Health, which is called Achieving the Promise: TRANSFORMING Mental Health Care in America. In this report, the Commission asks that we undergo a complete upheaval of what we know, what we do, and how we go about delivering mental health care from the Federal to the clinical level.
[Slide 11: NFC vision]
The Commission envisions, in part, a national mental health care system when everyone with a mental illness at ANY STAGE OF LIFE will have access to effective treatment and supports. It will be a system that actively facilitates recovery and helps individuals build resilience to face life's challenges. These words have particular meaning when we consider dual diagnoses as one of life's greater challenges.
[Slide 12: Six goals, #1 highlighted]
Achieving the Promise outlines six goals for a transformed mental health care system. The very first goal is that Americans will understand that mental health is essential to overall health. The Commission's two recommendations for achieving this goal are, in part, that we reduce the stigma of seeking care and that we address mental health with the same urgency as we address physical health.
[Slide 13: Goal 1, 1.1. and 1.2]
The stigma of seeking mental health care is so strong that half of the nearly 15 million American adults who have serious mental illnesses will NOT seek treatment. Their failure to seek treatment has serious implications for their long-term health and the health of their community.
As many as half of the adults who have a diagnosable mental health disorder also will have a substance use disorder at some point in their lives. Research demonstrates that if only one disorder is treated, both usually get worse. In addition, failure to seek treatment for serious mental illnesses places adults at risk of other adverse effects, such as patient distress, impaired functioning, or heightened risk of death, pain, disability, and loss of freedom.
As part of our efforts to eliminate stigma, the Substance Abuse and Mental Health Services Administration (SAMHSA) has created the Center Addressing Discrimination and Stigma. This Center, known as the ADS Center, is making information about recognizing and eliminating stigma available to you and others at the community level. You can access this information at this Web address.
[Slide 14: ADS Center logo & address]
One manifestation of stigma is reflected in the disparity between insurance payments for primary care and mental health services. Mental health care services have traditionally been more limited than other medical benefits. This situation affects State mental health care services, in particular, because the States are increasingly relying on Medicaid programs to support their mental health care system. Medicaid is now the largest payer of mental health services in the country.
[Slide 15: Trend in State mental health Care--Medicaid financing]
SAMHSA is working with the Centers for Medicare and Medicaid Services (CMS) to investigate alternative financing models to align payment with what we know works in mental health care services. At the State level, you can advocate for better cooperation and collaboration between your State Medicaid Office and State or local service providers.
The Surgeon General's report on mental health identified another way the mental health field can work to eliminate stigma . . . and that is to find causes and effective treatments for mental disorders. This report states that,
[Slide 16: Surgeon General Quote]
"When people understand that mental disorders are not the result of moral failings or limited willpower, BUT ARE LEGITIMATE ILLNESSES THAT ARE RESPONSIVE TO SPECIFIC TREATMENT, much of the negative stereotyping may dissipate." As mental health professionals, you can help eliminate stigma by focusing on the use of evidence-based practices and documenting their effectiveness . . . by demonstrating to consumers and non-consumers alike that RECOVERY is a real possibility.
Stigma is something that you, as mental health professionals, must fight aggressively. Stigma is an antiquated byproduct of fear and ignorance that has no place in the 21st century! It is preventing people from receiving the treatment they need; it is denying adults their path to recovery; it is undermining effective, integrated services for adults with illnesses that are often disabling when left untreated.
[Slide 17: Goal 2: 2.1-2.5]
Goal 2 of the New Freedom Commission report is that mental health care will be consumer- and family-driven. As envisioned by the Commission, a transformed mental health system will respond to an individual's diagnosis of a serious mental illness with a highly individualized plan of care.
This plan will recognize the individual in his or her entirety, wholeness, and wellness. It will integrate the full range of the individual's needs to support recovery, such as housing and supported employment. To ensure that the needed resources are available, States will develop a comprehensive mental health plan outlining responsibility for coordinating and integrating programs.
I'm pleased to say that these Comprehensive State Mental Health Plans are already moving from the Commission's vision to a reality. President Bush's fiscal year 2005 proposed budget contains $44 million to help States begin to develop plans that can transform mental health care at the local level. When your State is debating the best elements of its comprehensive plan, make certain that representatives of your organizations speak to what you believe will benefit the needs, desires, and demands of your consumers.
[Slide 18: Goal 3, 3.1-3.2]
Goal 3 of Achieving the Promise is that disparities in mental health care are eliminated. One disparity is the care available in rural areas. Another is racial and ethnic disparities. Minorities in the United States face many social and economic barriers to health care, including racism and discrimination, violence, and poverty. Each of these conditions adversely affects both physical and mental health.
Mistrust of mental health services is another major barrier that discourages minorities from seeking treatment, even when it is available. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping. Studies show that racial and ethnic minorities tend to receive less appropriate diagnoses and are less likely to receive effective, state-of-the-art treatments.
I have an example of what transformed mental health care will be like when disparities are eliminated.
John is a 65-year-old American Indian. He has relied on a native healer for years, but he became so debilitated and despondent in recent weeks that his family drove 4 hours from their frontier area of South Dakota to a rural Indian Health Service clinic. During an examination, the primary care doctor discovered numerous medical conditions, including diabetes and hypertension, that were going untreated. The doctor also tentatively diagnosed John with severe depression, but thought he might have bipolar disorder.
Uncertain of the diagnosis of John's psychiatric illness, and the potential for interactions with the other medications he wished to prescribe, the doctor arranged for a psychiatric consultation via telehealth. Through video and other telecommunications equipment, John was interviewed by a psychiatrist 500 miles away at another Indian Health Service facility. The psychiatrist was able to assess John's appearance and body language. Having been advised by a cultural competence advisory committee, the psychiatrist knew how and what types of questions to ask John about his use of native healers and herbal remedies. The psychiatrist also was part of a program experienced in medication algorithms for mental disorders.
She arrived at a diagnosis of bipolar disorder and recommends a medication regimen that will not negatively interact with the diabetes and hypertension medications. Because of John's older age, she recommends extremely low doses of the psychiatric medications. She suggests that the primary care physician work with John's native healer to monitor John carefully and to avoid giving him certain herbal therapies that might interfere with his medications.
Now THAT is a vision of transformed mental health care: integrated care made possible via technology to individuals living in remote areas. John's care also acknowledges that several factors, including gender, culture, and age, influence the diagnosis, course, and treatment of illnesses.
As I mentioned in the beginning, our mental health needs, vulnerabilities, and strengths change in response to our place along the lifespan continuum. Research shows us that anxiety, depression, and schizophrenia present special problems for older adults. The rate of suicide is highest among older males. These are the facts that any health care practitioner must be sensitive to in working with adults, which highlights the importance of Goal 4 of the Commission's report.
[Slide 19: Goal 4, 4.1-4.4]
Goal 4 is that early mental health screening, assessment, and referral to services will become common practice. Recommendations 4.3 and 4.4 are particularly relevant to your conference objectives. In this goal as in others, the Commission emphasizes the need to treat both dual-diagnoses disorders as primary illnesses. Integrated treatments can improve patient engagement, reduce substance abuse, improve mental health, and reduce relapses for all age groups. These benefits apply not just to mental illnesses combined with substance use disorders but to mental illnesses and other physical disorders.
One aspect of this goal that deserves special attention is its emphasis on the long-term effects of untreated behavioral disorders in children. The Commission notes that "If the system does not appropriately treat and screen [children] early, childhood disorders may persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood." Thus, treating children's behavioral disorders is preventive treatment for later adult mental illnesses.
The Commission goes on to say that one of the many factors that can affect the emotional health of young children is the mental health status of their parents. In this instance, treating the mental illnesses of adults becomes preventive treatment for children's disorders. The Commission recommends that we initiate mental health screenings in all settings in which a high occurrence of behavioral disorders exist. Given the high incidence of substance use disorders among parents of children in the child welfare system, the Commission suggests that these parents be screened for co-occurring disorders and linked as needed with appropriate treatment and supports.
I want to reiterate here that transformation of our mental health care system requires that we change how we provide care, including building stronger partnerships among those with a stake in the mental health care of the community. The screenings recommended by the Commission involve not only primary and mental health care providers, but also the education, judicial, and child welfare systems, among others.
Transformation is not, and cannot be, a solitary effort by any single system, or by any branch or level of government. Transformation is an ongoing process, one that requires the continuous and collaborative assessment of where our mental health care system is in relation to where it should be. It will not be accomplished by further fragmentation of care into specialized niches. Instead, we will achieve transformation when integrated mental and primary health care—focused on recovery and based on evidence-based practices—is the standard of treatment for everyone.
[Slide 20: Goal 5, 5.1-5.4]
Goal 5 of the report focuses on the need to transform mental health care by accelerating research and, in particular, shortening the time lag between when an effective form of treatment is discovered and when it becomes part of routine patient care.
SAMHSA is taking steps to more rapidly identify and disseminate evidence-based practices. One important and recent advance is the expansion of NREP—the National Registry of Effective Programs. NREP conducts expert evaluations of programs to identify promising evidence-based interventions. These programs are then included in a national registry. Last year, we expanded NREP by adapting its criteria to mental health and co-occurring disorder treatment programs. We are now doing the same thing with mental health promotion and prevention programs. You can access NREP at this Web address.
[Slide 21: NREP]
Goal 5 highlights another critical issue of mental health care in America: workforce adequacy, both in terms of sufficient numbers and skills. Not only is there a shortage of providers, but many of the system's most experienced providers are not trained in cutting edge, evidence-based practices. There is a serious need to cross-train primary care providers to be more knowledgeable participants in providing mental health care. Primary care providers are now prescribing the majority of psychotropic drugs for both children and adults. About 70 percent of the care for common mental disorders is delivered in general medical settings.
The growing workforce crisis is compounded by our changing national demographics. More people are living longer, which means that we have a growing population of older adults dealing with mental health issues related to aging. We need more specialists trained to identify and work with these issues, such as depression and suicidality.
[Slide 22: Goal 6, 6.1-6.2]
Goal 6 of the Commission's report is that we use the technology that is available to us to access mental health care and information. The previous example I used for transformed mental health care described how John, who lived in a remote frontier area, had his mental health assessed via telehealth. Nearly 60 million Americans live in rural and frontier areas. Each of these individuals faces a range of life challenges and deserves the same quality of mental health care as our urban citizens. But in areas without an adequate supply of mental health professionals, most mental health care is delivered by primary care physicians. Telehealth is rapidly emerging as our opportunity to cross-train and support primary care physicians, to offer specialized care long-distance, and to integrate evidence-based practices at the local level.
I have just given you a brief overview of the New Freedom Commission on Mental Health's final report and its vision of a transformed system. SAMHSA and other Federal agencies are now taking the first tangible steps toward turning the Commission's vision into a reality.
[Slide 23: Transformation Workgroup]
An executive team of 18 Federal partners has been meeting during the past several months to analyze the Commission's recommendations and how Federal agencies can respond. The team has just recently completed a National Mental Health Agenda for Action.
Our agenda is based on the conviction that mental illnesses are treatable, and recovery should be the expectation. It identifies the first practical steps that we can take at the Federal level to initiate change in response to Achieving the Promise. Our Action Agenda is not a universal document. Instead, we made a conscious effort to set time-limited, realistic priorities for Year 1 of what we see as a 5-year arc for transformation.
The Action Agenda defines the first steps of the Federal role in transformation. Federal agencies can act as leaders, facilitating and promoting shared responsibility for change at the Federal, State, and local levels. STATES will be the very center of gravity for system transformation. State-level leadership in planning, financing, service delivery, and evaluation of consumer- and family-driven services will significantly advance the transformation agenda.
Utah is one of the States that understands the urgency of taking action. Utah has created a steering committee that is concentrating on the New Freedom Commission's recommendations, not just in terms of mental health but also for substance abuse in the State. Next month, the combined Utah State Public Mental Health Conference and the Rocky Mountain Council of Mental Health Centers Conference will focus on the New Freedom Commission's report and on "Achieving the Promise in Utah."
The most important agent of change, however, is each of you. You and others who care about individuals with mental illnesses will be the deliverers of treatments and supports, hope and recovery, in a transformed mental health care system. But to be an effective change agent, YOU must first be willing to change…to transform what you know, what you do, and how you are used to doing it.
- You must be willing to learn—about new and emerging evidence-based practices, about cultural and gender-based differences, about consumer- and family-driven care.
- You must be willing to teach—to share your specialized knowledge with other practitioners and primary care physicians, to teach consumers and their families how to be stronger advocates for their own care.
- You must be willing to be part of a team of practitioners and consumers engaged in individualized plans of integrated care. Adults with dual diagnoses need a seamless system of care in which "any door is the right door" to get the full range of health care they require.
The reason to begin this transformation is both simple and profound—all individuals deserve to lead as full a life as possible in the families, their communities, and our country. Their ability to participate must no longer be derailed by outdated science, outmoded financing, and unspoken discrimination against those with mental illnesses.
We are the generation that must bring about this transformation—the one that must scale this mountain for the good of all the generations to follow. There is an old Chinese proverb that doing good is as hard as climbing a mountain, while doing evil is as easy as rolling with an avalanche. Yes, transforming our mental health care system will be difficult, even though it is a good that urgently needs doing. But we can achieve new heights in caring for the mental health of Americans, and it will be easier if we all do our share.
It is not just for the good of individual consumers that we need to transform our health care system to focus on recovery. Our Nation and our communities will benefit, and every American should work toward this goal.
I want to close with the words of one individual "in recovery" whom I truly admire. Nancy Fudge has been a participant, a board member, and an advocate of an adult mental health consumer self-determination program. She says that:
[Slide 24: Recovery quote]
"For years, I allowed myself to be managed based on someone else's perspective of what I needed. I have [since] discovered my potential, and willingly accept the successes and consequences of the choices I make. Mistakes are no longer signs of failure but opportunities to learn and move forward. I no longer allow myself or the quality of my life to be defined by my 'illness'. . . From my perspective, life isn't about just 'being,' it's about 'becoming'—becoming all that you are destined to be."
This is a woman who says she is now discovering abilities and talents she didn't know she possessed. She has become not just a contributing member of her community, but a LEADER. When we create a mental health care system that supports every American in becoming all that they can be, our Nation will become all that it can be. Thank you.
[Slide 25: Thank you]
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