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
Triad Women's Conference 2003:
Integrated Services for Women
September 30, 2003
Tampa, FL
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Good morning everyone. It is so good to be here with you in sunny Tampa. I bring you greetings from Washington …from Charley Curie, the Administrator of the Substance Abuse and Mental Health Services Administration…and from my colleagues at SAMHSA's Center for Mental Health Services.
I want to say a special "thank you" to my esteemed colleague, David Shern, for that warm introduction. I appreciate and respect David's ongoing commitment to closing the gaps in our mental health service delivery system—gaps caused by the current maze of uncoordinated services, treatments, and supports—so that we can offer real hope to all of the people we serve.
I am delighted to join you this morning as you look back over the last five years of the Women, Co-Occurring Disorders and Violence study…and look ahead at ways to use the evidence gained in this study to help other communities continue and expand these kinds of programs. It is my sincere privilege to be a part of an initiative that has the potential to improve the lives of so many women and children in so many ways.
I began my career in mental health back in 1975. I was involved in the development of rape crisis services and direct counseling in Pennsylvania. That work—helping women cope with the trauma and psychological effects of rape…fostering healing and resiliency—was a defining moment in my career and in my life!
For more than two decades—as an advocate for women's rights…as Director of several community mental health and substance abuse organizations…and most recently, during my 12-year tenure as the Director of Rhode Island's Department of Mental Health, Retardation, and Hospitals—I have made my life's work serving and empowering our society's most vulnerable citizens…and seeking a more receptive society for the complete and full emancipation of all women.
I would like to recognize a member of my staff who has also made her life's work advocating for women with mental illnesses—Susan Salasin, Director of Women's Mental Health Programs at CMHS. Thank you, Susan, for your leadership and for your pioneering efforts on behalf of women since we launched this study back in 1998. Your vision and determination have guided our actions from then to now.
Finally, I want to take a moment to salute all of our grantees for the enthusiasm and perseverance you have brought to this project. I know that your work will continue, but as this may be our last "official" meeting, I want to take this opportunity, on behalf of SAMHSA and CMHS to say "thank you," and "job well done." The work you have done-—ooking at new treatment strategies for female victims of violence with addictive and mental health disorders…and their children—is absolutely critical to this Agency, to the field, and to the millions of women and children whose lives have been touched by these complex challenges. Thanks to you, there is new hope for these women and children to live rich and rewarding lives in their communities.
I know that this has not been easy work. In many cases, you have had to blaze your own trails...because you were leading the way. Women and trauma is one of the major social issues of our time…one of the most troubling. With this study we have found important answers about what works, and I hope that you take satisfaction in your role in developing these findings. We look forward to using our knowledge application tools to put what we've learned into practice. We look forward to working together to apply this new knowledge to deliver recovery-focused services to the women and children across this Nation who need these supports.
One of the most formidable barriers to recovery for women …and, indeed, to every person living with mental illnesses and co-occurring addictive disorders and other challenges…has been our fragmented and disconnected service delivery system. I know that this does not come as news to anyone in this room. In fact, it is a problem that we have been talking about for nearly a decade.
Back in July 1994, Pat Deegan, a well known psychiatric survivor and activist in the patient's right movement stood before a group much like this and gave a keynote address. The occasion was the Dare to Vision Conference—an event also sponsored by CMHS—that, for the first time, focused national attention on the impact of physical and sexual abuse in the lives of women diagnosed with mental illnesses. Survivors, professionals, and advocates from the fields of mental health, substance abuse, criminal justice, and homelessness came together to share their insights and experiences. They came to tell the undistorted truth of women whose lives and hearts had been shattered by sexual and physical violation and who did not get the help they needed—women who were not heard nor seen.
Ms. Deegan's remarks were entitled, "Before We Dare to Vision, We Must Be Willing to See." Telling her own haunting story of being forcibly drugged with adult doses of amphetamines between the ages of 6 and 16, and her subsequent re-victimization by the frustrating, inadequate mental health system that was supposed to serve her, Ms. Deegan suggested that those of us in the system must "stop the silent complicity of unseeing eyes and turned heads…we must dare to really see the reality" of our system.
Ms. Deegan said, then, that transformation—personal and systematic—was required. She emphasized that "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 a call to action. I urge everyone in this room today to take the next step and dare to do.
I want to suggest that right now…in September 2003…we are on the cusp of a new evolution in mental health services that makes this the most opportune time in the history of mental health to do something about the problems that we have seen and talked about for so long.
I am confident that we are all in agreement that the field needs to address the subject of integrated systems of care for women. I would like to focus my remarks on the unprecedented window of opportunity that is opening…right now…for women and for all Americans who live with mental illnesses, and who may also have addictive disorders, be victims of physical or sexual abuse, be homeless, have HIV/AIDS, or other complex challenges.
I suggest that now is the 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… and to deliver on the advocacy with personal action.
What makes this the right time?
When I began to think about the notion of "timing," I was reminded of a geological phenomenon I read about some years ago. I am referring to the theory of "tectonics" that explains how the plates that make up the Earth's outermost layer have moved throughout history creating our current-day continents and mountain ranges.
Scientists don't know exactly what drives this movement—perhaps heat within the Earth's mantle pushes the plates. But they do know that when conditions are favorable…when the right set of circumstances occurs…at the right moment…the edges of these plates move against each other and create great waves of energy. These waves of energy have resulted in earthquakes and volcanic eruptions…and in the formation of great mountain ranges such as the Alps and Himalayas.
Scientists call this activity "transforming" plate movement. I suggest that much like this process has shaped our Earth, we are in the midst of our own transformational process in mental health services…a transformation that will reshape our service delivery system and usher in a new era of care in which integrated systems will become the standard of care.
Conditions are favorable for this transformation...more favorable than at any time in the history of mental health…perhaps more favorable than they will be again in any of our lifetimes.
This morning, I want to talk about three of the critical forces that I believe are converging right now in mental health to make this the right time…the best time…to pursue the integrated services agenda…for women and for all Americans.
The first of these forces is science. More so than at any other time in the history of mental health research, we have strong new scientific support for the concept that integrated services work. This new knowledge has broadened and deepened the dialogue about the value of providing integrated services for people with multiple and complex vulnerabilities.
The second is dollars and cents. Integrated services make good economic sense. In this time of mounting fiscal pressures, that is a powerful catalyst for system transformation.
And finally, just a few months ago, we received a clear mandate for integrated services from the highest levels of the national government. The Final Report of the President's New Freedom Commission calls for a complete overhaul of our current system and states decisively that we must integrate programs that are fragmented across many levels of government and among many agencies if we are going to truly serve people. This Report provides the wave of energy necessary to fuel the transformation of mental health services.
This morning, I will explore each of these three paths more closely. Let's start with the science.
Services integration is not a new idea. But new information indicates that integrated services are effective.
In 2002, SAMHSA submitted a seminal Report to Congress on the prevention and treatment of co-occurring disorders. The Report highlighted current barriers to care and identified a host of recommendations for change. SAMHSA interviewed investigators working at the cutting edge of mental health services research to assemble the current state-of-the-science in reaching, assessing, and providing treatment and other services for persons with co-occurring disorders.
For the first time, national attention was focused on the need for an integrated, system-wide response to meet the multiple and complex needs of millions of Americans. For the first time, what we know about people with co-occurring disorders, about the disorders, themselves, and about treatment was assembled into one comprehensive resource. Most important, after so many years of "turning our heads," the Report addressed, head-on, the systematic barriers that have prevented people living with co-occurring disorders from receiving the services they need.
The Report documents an increasing number of evidence-based interventions and programs that demonstrate improved outcomes with integrated services and treatments. It cites a number of studies that suggest that integrated interventions—including time-sensitive screening, comprehensive assessment, specific medications, and community-based services and consumer support—are successful in…
- retaining individuals who have co-occurring disorders in substance abuse treatment…
- reducing substance use disorders…and
- reducing symptoms of mental disorders.
Certainly, more research is needed. But, I suggest, that we know enough to take action…now! We know that people with multiple needs can and do experience recovery. We know that systematic barriers to the integration of substance abuse and mental health treatment are difficult, but can be overcome. We know that the most successful programs feature comprehensive service systems capable of responding to most or all of the needs of individuals with co-occurring disorders.
The news is spreading. Scientific evidence on the value of integrated treatment and services is finding its way to the community level. Many state and local substance abuse and mental health authorities are planning, implementing, and or enhancing systems of change approaches to address co-occurring disorders.
Initiatives such as the Women, Co-Occurring Disorders and Violence Study will help to ensure that this new knowledge is shared and used, and will profoundly affect the responsiveness of our care systems.
The Women and Violence study has both challenged and encouraged widely held views about how to empower women with co-occurring disorders who have histories of violence to make positive changes in their lives. We will hear more about the preliminary findings later today. But I can say, with confidence, that the early feedback has been very encouraging. The women in the sites have responded very positively to the coordinated services and support.
The fruits of your labor are already visible. We have already learned some very valuable lessons:
- This kind of integrated treatment is achievable;
- These women can achieve lives of greater self power and dignity;
- Active involvement by the women themselves seems to improve the chances of collaboration and increase research relevance; and most important…
- Recovery is possible!
I want to take a moment, here, to clarify the way we define "recovery." Similar to substance abuse models for rehabilitation, when individuals with mental health disorders are "in recovery" they experience unique aspects.
Individuals in recovery accept having a chronic, incurable illness that is a permanent part of them…without guilt or shame…without fault or blame.
They avoid complications of the condition.
They participate in ongoing support systems as both recipient and provider.
People in recovery change many aspects of their lives including emotions, interpersonal relationships, and spirituality both to accommodate their illness and to grow through overcoming it. Recovery is an individual journey and we still have much to learn and respect from each person's journey.
In the near future, I believe that you will see your efforts pay off in very significant ways. Knowledge gained from this study will advance policy…at the local, state, and national levels…that promotes recovery for women with co-occurring disorders who have histories of violence…and their children. We expect to see more consumer-centered community-based programs that provide integrated services for women living with these multiple challenges…including more integration between physical health—particularly primary care—and mental health services because despite the social and medical presentations, women often do not separate their emotional and their physical lives.
In the transformed mental health system, trauma services will be part of every mental health service program—bringing real hope for recovery to the millions of women with mental illnesses who are victims of violence.
We are not there, yet, but we are moving in that direction. We are already incorporating trauma services into programs designed for homeless women who live with co-occurring mental illnesses and addictive disorders. We are currently developing a number of contracts to help the field make use of the knowledge gained in the study and to spread the word about the value of trauma-informed services.
- One example—Policy Research Associates (PRA) the coordinating center for the five-year study, is doing a sixth year of data analysis to completely analyze the findings.
- The National Mental Health Association (NMHA) is also developing media messages for national women's magazines and websites and providing wide-reaching training and technical assistance.
- NASMHPD is disseminating the study results to its member agencies across the country and providing technical assistance to the States around building trauma informed and trauma sensitive service systems. We are also going to ask ourselves about the "sustainability" of such services and processes for embedding them in our practice/systems of care.
- Witness Justice, a virtual organization that provides online legal, medical, and emotional resources to victims of crimes, is being funded to disseminate the important messages of the study to its audience …worldwide…over the Internet.
This study has created a significant ripple effect. And, this study is only one example of what we can achieve when all of the systems that serve people work together.
These kinds of integrated, gender-specific, trauma-informed interventions provide powerful fuel to transform the mental health system. They are important first steps toward creating a system that works…one that promises hope of recovery for women, and for all Americans.
Which brings me to my second point. Even though we know a lot more about what works in mental health services, we do not have unlimited funds at our disposal. With many States' just beginning to recover from dramatic budgets cuts made a decade ago, many are asking, "How can we more wisely invest our resources to provide optimal care."
Mounting fiscal pressures are forcing all of us to look for ways to make the most of existing resources. I suggest that today's fiscal climate is "ripe" for systems integration because better integration of the many systems that serve our citizens with mental illnesses will increase cost effectiveness in addition to reducing unnecessary and burdensome barriers.
Several studies have documented that people with mental health disorders have to navigate nearly a dozen different systems to live in the community. The duplication of effort engender costs—costs associated with administering a dozen separate sets of regulations, eligibility requirements, provider structures, funding streams, and delivery models—which are staggering.
Imagine the efficiencies that could result from integration of just the administrative function of these eleven systems. Then imagine how many people could be helped if even a percentage of the funds that are typically used to support the disjointed administrative structure of the current system could be redeployed and used, instead, to deliver integrated, evidence-based services.
I should mention here that integrated services, themselves, also appear to be cost-effective. There is limited data on the costs, cost-effectiveness, and cost offsets of various types of co-occurring treatment, but some studies have begun to show that specific interventions for co-occurring disorders may be cost-effective, and that societal costs to care for these individuals may be reduced as well.
The science supports integrated services. Integrated services are sound economic policy. But, perhaps, the most significant reason that I say there has never been a better time to take action is because of the mandate we received with the release of the Final Report of The President's New Freedom Commission on Mental Health.
Many of you have seen the Report. We also have copies for you today. The Report calls for a fundamental overhaul of how mental health care is delivered in America—a change more dramatic than any we will likely see again in our lifetimes.
Thirteen years ago, The Americans with Disabilities Act opened the door to greater hope and dignity for people living with disabilities. Since then, the Supreme Court's Olmstead decision, the Surgeon General's Report on Mental Health, and the IOM Report have built on that progress. Now, the New Freedom Commission's Final Report takes another crucial step on that hopeful path…giving cause for real optimism around the prospect of a full life in the community for women…and every individual…living with multiple challenges.
The Commission's report calls for a transformed system…one in which services and treatments will be consumer focused—not oriented to the requirements of bureaucracies.
In this transformed system, a woman diagnosed with a mental illness and/or substance abuse disorder complicated by a history of trauma will benefit from a highly individualized, highly coordinated health management plan that will lead toward recovery. The transformed system will ensure that she and her children have access to the resources they need in the community. The burden of care will rest on the system, not on the woman and her family who are already struggling with her illnesses. Her needs will drive the types and mix of services provided.
Routine screening for co-occurring mental illnesses and substance use disorders as well as integrated treatment strategies are specifically recommended in the Report. The Women, Co-Occurring Disorders and Violence Study responds to the Report's call for highly individualized services…services that recognize the significance of gender and involve consumers at every level. It also dovetails with the Report's recommendation to provide integrated treatment strategies for people with multiple vulnerabilities.
The Commission's Final Report provides a strong endorsement for transforming the existing patchwork of mental health services into a coordinated, consumer-centered, recovery-oriented system. The Report calls for collaboration from all parties who deliver and use mental health services...under the mantle of Federal leadership.
That is the job that SAMHSA Administrator Curie has brought me here to do—to lead the Federal efforts to transform the mental health system and to prepare this Agency to facilitate those changes so necessary across our Nation's system of care. In fact, I like to say that my job description can be found in the Report's title: Achieving the Promise: Transforming Mental Health Care in America.
The goals and recommendations included in the Final Report will provide a roadmap for SAMHSA, CMHS, and for the entire field as we move forward. We have already begun to look at how well our programs map with the Commission's recommendations. If a program fits, we will expand and enhance it accordingly. If a program does not fit, as it exists today, we will change its focus. We may even align the entire Center to better fit the actions anticipated in the Report. That's how significant this Report is to SAMHSA. The next step is to devise an Action Agenda…a master "to-do" list for implementing the recommendations in the Report.
This is a pivotal time for all of us who advocate for integrated services for women. The state-of-the-science research supports our efforts. The fiscal climate is favorable. The Final Report of the New Freedom Commission provides the impetus to move forward.
Like the tectonic plates that have converged throughout Earth's history to shape the continents and form great mountain ranges, an extraordinary set of circumstances are aligning in mental health services that promise to bring about a transformation of similar magnitude. Let's seize this opportunity. Let's build on the work that we have started here with the Women, Co-Occurring Disorders and Violence Study. Let's dare to do. Thank you.
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