The President's New Freedom Commission on Mental Health

The President’sNew Freedom Commission on

Mental Health:Transforming the Vision

The Nineteenth Annual Rosalynn CarterSymposium on Mental Health Policy

November 5 and 6, 2003

t t t t t

The President’sNew Freedom Commission on

Mental Health:Transforming the Vision

The Nineteenth Annual Rosalynn CarterSymposium on Mental Health Policy

November 5 and 6, 2003

t t t t t

Table of ContentsOpening Remarks

Rosalynn Carter, Chair, The Carter Center Mental Health Task Force........................................................................1Thomas Bryant, M.D., J.D. ........................................................................................................................................2

Keynote Address

Michael Hogan, Ph.D., Chair, President’s New Freedom Commission on Mental Health ............................................3Questions & Answers ................................................................................................................................................6

Panel 1: Implications of Mental Health Science for Society

Rodolfo Arredondo Jr., Ed. D., Moderator ................................................................................................................7Thomas R. Insel, M.D., Research for Recovery: The NIMH Perspective ....................................................................7David Satcher, M.D., Ph.D., The Connection Between Mental Health and General Health ......................................10Ronald Kessler, Ph.D., The Importance of New Epidemiological Findings for Policy ..................................................12Questions & Answers ..............................................................................................................................................14

Dinner Address

Charles Curie, M.A., A.C.S.W., Achieving the Mental Health System Transformation Together:SAMHSA’s Action Agenda and Partnerships..........................................................................................................16

Panel 2: Moving Science to Services

Larke N. Huang, Ph.D., Moderator..........................................................................................................................20Benjamin Druss, M.D., M.P.H., Evidence and Transformation ..................................................................................21Barbara J. Burns, Ph.D., Readiness for Evidence-based Practice in Child and Adolescent Mental Health ....................24Larry Fricks, Recovery-based Innovation ....................................................................................................................26Questions & Answers ..............................................................................................................................................28

Panel 3: Strategic Implementation

Norwood W. Knight-Richardson, M.D., M.B.A., Moderator..................................................................................29Glenn Stanton, Financing Mental Health Services in the Future ................................................................................30A. Kathryn Power, M.Ed., Implications for Implementing the Final Report’s

Recommendations for Systems Transformation........................................................................................................34Mark L. Rosenberg, M.D., M.P.P., and Margaret McIntyre, M.B.A., Building Coalitions

for Better Outcomes in Mental Health....................................................................................................................38Questions & Answers ..............................................................................................................................................42

Charge to the Work Groups ......................................................................................................................................43

Postscript

Thomas Bornemann, Ed.D., and Lei Ellingson, M.P.P.............................................................................................43

Closing Remarks

Rosalynn Carter ........................................................................................................................................................51

Biographies ..................................................................................................................................................................52

Planning Committee....................................................................................................................................................56

Participants’ List ........................................................................................................................................................57

Task Force Members ..................................................................................................................................................65

Funders ........................................................................................................................................................................66

The President’s New Freedom Commission on Mental Health: Transforming the Vision

We all were thrilled when the president announced the New Freedom Commission onMental Health. The commission was assigned a huge task: to study the whole publicmental health system and report back to the president with recommendations. From my

experiences with the Carter commission on mental health, I well understand the hours and hours oflistening and discussion about what needed to be included in the report. It is not easy. I want themembers of the commission to know that all of us in the mental health field are grateful to you.

Reading the final report brought back a lot of memories of our commission. What struck me mostwere the similarities in issues. We know so much more today, and yet the problems are still very muchthe same, with one exception: recovery. Twenty-five years ago, we did not dream that people mightsomeday be able actually to recover from mental illnesses. Today it is a very real possibility. With our new knowledge of the brain and the advances in treatment quality, we can now shift our focus to recovery. For one who has worked on mental health issues as long as I have, this is a miraculousdevelopment and an answer to my prayers.

The commission has done its work. It is now up to us, the mental health community, to mobilize toimplement the recommendations of the report. It is an enormous responsibility that is going to takeall of us – advocates, professionals, researchers, consumers, and family members – working together.No single sector can do it alone.

There could not be a better time for us to come together, with so much that needs to be done and so much new knowledge. The mental health system is still in trouble in states and communitiesthroughout our country. It is sad that all this new knowledge and these new recommendations comeat a time when resources are scarce and mental health programs are being cut. I am concerned aboutbeing able to keep what we have now. We are at risk of losing the gains that we have made for peoplewe care about and for whom we want better lives.

In the next two days, we have the opportunity to determine where we want to go from here andhow we can best leverage and implement the recommendations of the president’s commission. Nodoubt we will disagree on some of the details, but if we can go away from the symposium united andwith a new sense of mission, I believe we can develop a more effective, efficient, just, and equitablesystem of care for people with mental illnesses.

Opening Remarks Rosalynn Carter Chair, The Carter Center Mental Health Task Force

1

Opening Remarks

a

Keynote Address

Opening Remarks Carter Administration – President’s Commission on Mental HealthThomas E. Bryant, M.D., J.D.Non-Profit Management Associates, Inc.

Acouple of observations occurred to me about the difference between the two commissions.First, we did not foresee the impact of Medicaid on mental health care. The vast majorityof people who are supported by the public system are done so by Medicaid, and the vast

majority of people with mental illnesses are in the public system.

Next, the field now knows a lot more in the way of biological science about how the brain worksand how to treat certain mental illnesses. I think it is a fair statement today to say that while wehave not cured mental illnesses, recovery is now possible. The word “recovery” was not even in ourvernacular back then. There are now drugs and services like supported work and education that allow

people to function better and in a more normal environment. That boilsdown to the fact that people with mental illnesses are not just stuck inentry-level jobs mopping the floor but can go back to school and can get a degree or even an advanced degree. All of that has changed since wegrappled with some of the same problems, and that is a watershed change.

One thing that remains absolutely true is that there still is not enoughfunding. Providing quality mental health services costs money. The commission came up with somegenius recommendations about ways to spend money differently, more effectively, and efficiently.However, we still need more funding for mental health care in this country.

I think it is a fair statement todayto say that while we have notcured mental illness, recovery

is now possible.

My remarks will attempt to give you asummary of our experience on thecommission, as well as our thinking

and recommendations about the changes needed in mental health care at this time.

In considering our work, one has to start witha basic question: Why did this president createthis commission at this time? President Bushannounced the commission, accompanied by Senator Pete Dominici, in a speech inAlbuquerque at the end of April 2002. However,our clearest view of the president’s intentionscame in an informal gathering that same day.Before his prepared speech, the president metwith about a dozen local people (providers,family members, and commission leaders) for aconversation about mental health and mentalillness. This was an informal, unscripted conver-sation about problems and potential in mentalhealth. The president led the conversation.

As the president was wrapping up the meeting,he said that the message he got growing upabout these issues was to “suck it up” if you havepersonal problems. He went on to tell the storyof a close personal friend who had developed a terrible clinical depression in mid-life. Thisfriend got the treatment he needed and had a wonderful recovery. The president said thatwhile watching his friend, it became clearthis is a medical illness, and it is not right forus to treat some illnesses one way and otherillnesses another. As it is with so many of ourelected officials, I concluded it was a personalexperience that led the president to hisunderstanding of the poor way that wetraditionally treat mental illnesses.

When the commission came together, we hadto grapple with and try to understand what wewere. We understood that opportunities like thisare very rare. It had been a quarter of a centurysince the Carter commission. This led us toconclude that one important thing to do was notblow it. This meant that we had to comply withall of the rules and requirements; to be open andaccessible, taking time to listen to people; and to

collaborate with the advocates in the mentalhealth community. We also were mindful of howcommissions make recommendations and donot implement them. This is one reason why this opportunity for conversation and actionprovided by The Carter Center is so critical.

We determined that it was necessary to be“mindful of our master.” In other words, we had a responsibility to write a report that wouldbe acceptable to the administration, therebyincreasing the likelihood of good follow-through.We also were mindful of the Carter commission’sexperience: Leaving behind a menu of opportu-nities that advocates could subsequently return to and leverage might be as important in thelong run as actions by the current administration.

We were struck by how dramatically thingshave changed in mental health services sincethe time of the Carter commission. The federalrole was very limited back then. The statutesunderlying mental health care were evolvingrapidly, whether in terms of the commitmentlaws, or the laws structuring state systems of care,or legislation setting standards for mental healthcoverage in health plans. Research was in itsinfancy; the first surgeon general’s report onmental health was two decades away.

The major problems in mental health care, andsociety’s view of these problems, also have shifteddramatically. If you had asked people 25 years agoto name the biggest thing wrong with mentalhealth care, they would probably have said “those terrible state institutions.” That is not the problem anymore. Indeed, by and large, theproblems with mental illnesses people would citetoday are problems in the prisons. If we lookdeeper, we see mental illness is a major challengein juvenile justice, in child welfare, in schools,on the streets, and in both public and privatedisability programs. It is not just that the mainproblems in mental health care moved fromhospitals to communities. These days, the biggestproblems are outside the public mental healthsystem. This creates much more complicatedchallenges for advocacy and for improving care.

3

Keynote AddressMichael Hogan, Ph.D.President’s New Freedom Commission on Mental HealthOhio Department of Mental Health

Keynote Address

In our interim report, as directed by thepresident, we focused on barriers to care. Thefirst barrier we identified was that neither mentalhealth nor suicide prevention was yet a nationalpriority. The surgeon general had advancedawareness of suicide tremendously. The NationalStrategy for Suicide Prevention is now well-developed and ready to start moving forward. Butthe public has no idea, frankly, of the enormityof the impact of suicide or of the frequency of

mental illnesses and theirimpact. Measuring theimpact of suicide by thenumber of lives lost is thesimplest and starkest wayto understand the impact.

The World Health Organization’s data show thatdeaths from suicide worldwide are approximatelyequal to deaths from war and homicide puttogether. In this country, there are approximately60 percent more deaths annually from suicidethan homicide and twice as many deathsannually from suicide than from HIV/AIDS. Andwhile we understand that suicide is driven andprecipitated by mental illness and substanceabuse disorders, we still do not acknowledgethe impact of mental illnesses and suicide.

Our look at barriers to care caused us to look atthe burden of disability caused by mental illnesses.Our failure to deliver the right care for peoplewho end up on disability has an incredibleimpact. In fact, although Medicaid is the biggestpayer for mental health treatment, the biggestfederal expenditure for mental illness is over $20billion annually in payments for SSI and SSDIcombined. To put it bluntly, we are paying anincreasing number of people a huge amount ofmoney, but individually an inadequate amount –in effect to stay disabled, because of the workdisincentives in the system. Recent WHO data

looking at theimpact ofmental illnesseson disabilityshow thatmental illnessis the greatest

illness-related cause of disability, followed closelyby alcohol and drug dependence, Alzheimer’s,and dementia. Much lower levels of disability are attributable to illnesses like cancer, heartdisease, or diabetes.

Barriers to care also include gaps in careand fragmentation of care for both adults andchildren. Care delivery has become increasinglycomplex in the last 25 years. Our commissionreview found no fewer than 42 different federalprograms that might be used at different timesby children or adults. Often, obtaining servicesor coordinating these different programs –conducted by various agencies with differenteligibility standards – must be coordinated by theconsumer or family. And we expect people tonavigate this complexity when they are ill and attheir worst. This unintended complexity, coupledwith real gaps in care, is a striking problem thatled us to the blunt and perhaps controversialstatement that “the system is in shambles.”

Knowing the complexity of the mentalhealth system, the commission realized that theincremental reform that has brought us to thispoint cannot move us forward. What is needed,we concluded, is a transformation in ourapproach to care. The “mental health mess”cannot be fixed via reorganization or by addingnew programs – our conventional tools. Theconcept of transformation – implying manychanges, at every level, over time – emergedas a necessity.

But there are also new possibilities in mentalhealth care. Learning from testimony, fromresearch, from the surgeon general’s report, andalso from Mrs. Carter, we determined that theidea or paradigm of recovery is a powerful forcefor change. When the commission talks aboutrecovery, we do not mean a simplistic picture ofcomplete wellness and remission for every person,immediately. Rather, we understand recovery tomean three things:

1. Recognition that some people – more thanwe have historically appreciated – doachieve complete recovery and remission.

2. Regardless of the seriousness of illness, arecovery-oriented approach expects andfacilitates a meaningful and good life foreach person despite living with an illnessor disability.

3. The core and engine of recovery is hope –expectations for better outcomes on behalfof the person, their family, and professional.

4


These days, the biggestproblems are outside the public

mental health system.

Care delivery has become increasinglycomplex in the last 25 years, and we

expect people to navigate this complexitywhen they are ill and at their worst.

It was this understanding of recovery thatled the commission to propose a national visionfor mental health in America – a future whererecovery and resiliency are the expectedoutcomes.

Given the magnitude of this change and thecomplexity of transforming care, the commissionproposes a set of national goals backed up byrecommendations to achieve these goals. Ourlogic is: Implement the recommendations toachieve the goals, and if we can achieve thesenational goals, then transformation will beachieved. The six goals are expressed in termsof future expectations:

1. Americans will understand that mentalhealth is essential to overall health.

2. Mental health care is consumer- and family-driven.

3. Disparities in mental health services areeliminated.

4. Early mental health screening, assessment,and referral to services are common practice.

5. Excellent mental health care is delivered,and research is accelerated.

6. Technology is used to access mental healthcare and information.

We know that we must and will seefederal leadership in a number of differentareas. One of the most complicated andintriguing recommendations that we havemade is upgrading state responsibility formental health, elevating responsibility formental health to the governor’s level ona collaborative basis with the federalgovernment and others. This extends thestate’s responsibility for mental healthbeyond the block grant and the mentalhealth agency, reflecting the need to thinkabout mental illnesses in other sectors(e.g., prisons, schools, health care). Thischange is a tremendously complicatedprocess that cannot be simply legislated;it might require shifts in Medicaid,vocational rehabilitation, Social Security,and housing programs. But change may berequired in all these arenas. Some stateshave begun to think about the kind oftransformation that is required; a numberof states initiated state-level mental healthcommissions. We are greatly encouraged

by advocacy and professional organizationscoming together in Washington to create theCampaign for Mental Health Reform. Strong and well-aligned advocacy is essential to achievethe needed changes.

The commission also was mindful that muchcan be done without waiting for Washingtonto act. There are many areas where federalleadership might be helpful but is not essential.For example, I’d cite the goal of finally takingsteps to reduce disparities in access to and qualityof care, both with respect to race and place(especially in rural America). While some ofthe access questions require a broader approach,there is no reason that every mental healthprogram in the country cannot be taking stepsright now to better match our staffing with thepeople we serve and developing a welcomingattitude about people from diverse backgrounds.

Finally, if the work of the commission is tobecome real, all of us in the mental healthcommunity must embrace Gandhi’s notion that“we must become that change that we seek inthe world.” We delivered a good body of workfor all of us to advance together. Now this workis in your competent hands. We look forward tothe collaboration that will make it real.

5

Keynote Address

Que

stio

ns &

Ans

wer

s QIn thinking about the two commissions,the Carter commission and the NewFreedom Commission, how would you

characterize the most significant recommen-dation in the Freedom Commission that isdifferent from the Carter Commission?

ADr. Hogan: There are two. The firstdifference grows from the relativelynew awareness that recovery is a

realistic possibility for every individual if theright steps are taken with the right attitude. Thismeans approaching the development of everyindividual service plan collaboratively and withoptimism. It means new expectations aboutquality, such as consistent use of interventionsthat are scientifically proven. It means a focuson helping people achieve the changes theydesire in their lives. Recovery and resiliencymust become expectations, not ideals.

The second change that we see todaycompared to the time of the Carter commissionis that there is a paradox in how our well-intended reforms have made things so muchmore complicated. The issue of mental illness ispervasive. It needs attention in the schools, inprimary care, in the workplace, and in many

other sectors. Fixing the relatively narrowand separate public mental health system aloneis not sufficient. We have to work across theentire spectrum. This is more of an emergingidea than a recommendation. However, twomajor recommendations address it directly: thedevelopment of a more comprehensive stateplan backed by federal flexibility and providingfor comprehensive, crosscutting individualservice plans that provider a higher degree ofconsumer choice and control.

QWhy didn’t the commission address theconnection between alcohol and drugaddiction and mental illnesses? People

should be trained in treating both illnesses,instead of treating them separately.

ADr. Hogan: The commission said quitestrongly that treatment, where thereare co-occurring disorders, should always

be integrated. It is the person who has to betreated, not the separate illnesses. We also needto use the skills of both consumers and familiesin the service delivery system and in theprocesses of recovery.

6


Recovery is at the center of all of therecommendations of the New FreedomCommission report. When we look at

transformation of our mental health system tomaximize recovery for adults with serious mentalillnesses and children with serious emotionaldisturbances, it becomes very obvious that weneed to develop policy to coordinate systemicallythe role and functions of numerous agencies atthe state and local levels. This would increaseaccess clinically and also maximize the qualityof care.

Clinical services need to be coordinated andintegrated. Mental health is part of overallhealth, as mental health, substance abuse,and physical illness frequently co-occur.

While science has contributed significantly tothe development of new medications in the pasttwo decades, we must continue to encouragestrongly the development of new medications, notonly for mental health but also in the area ofsubstance abuse, as well as clinical and preventionresearch. I feel optimistic that with the strength ofscience and research, treatment will continue toimprove and we will enhance recovery.

7

Panel 1: Implications of Mental HealthScience for SocietyRodolfo Arredondo Jr., Ed.D.President’s New Freedom Commission on Mental HealthTexas Tech University Health Services Center

Research for Recovery: The NationalInstitute of Mental Health PerspectiveThomas R. Insel, M.D.National Institute of Mental Health (NIMH)

Iwant to focus on one of the goals of thetransformed system: “excellent mental healthcare is delivered and research accelerated.” I

am particularly committed to establishing anevidence base of treatments and services thatactually work. There have been numerous studies funded over the last decade from NIMHshowcasing which treatments are effective intreating different mental illnesses. At this pointin time, based on careful, rigorous studies, weknow that there are numerous psychosocialtreatments that work. For example, in comparingrelapse rates of different treatments for peoplewith schizophrenia, the combination ofmedication and family psycho-education hasa 20 percent relapse rate, whereas medicationalone has a 45 percent relapse rate. There issimilar data showing the effectiveness ofsupported employment.

However, this evidence base is not enough.Even when we have the evidence, thedissemination of that evidence is too

infrequent, or there is limited access to thetreatments that we know work. So it is importantto understand what barriers are impeding ourability to implement evidence-based treatment.

First, mental health needs are no longer inthe traditional mental health system. NIMHrecognizes that we must do research in the veryplaces where the public health need is greatest,such as schools, nursing homes, and the criminaljustice system.We now have aservices researchportfolio thathas begun to look at anumber ofnontraditionalsettings for mental health research. We arelearning how to do this effectively as we go. What we are trying to accomplish is thedevelopment of an evidence base of what worksin these different settings. We also need to

NIMH recognizes that we mustdo research in the very places wherethe public health need is greatest, suchas schools, nursing homes, and thecriminal justice system.

Implications of Mental Health Science for Society

8

develop the science of how to make sure thatsomething that works in the research setting canbe disseminated and practiced in a jail or aschool or in a homeless shelter.

What do we need from a research perspectiveto get to the point of recovery for the vast

majority of peoplewith mentaldisorders? Part of theneed is to providethe evidence basefor diverse settings

and implement what we know. That is still notenough. We still need the fundamentals. Wenow recognize that mental illnesses are medicalillnesses or, more specifically, brain illnesses.The problem is that we do not have the toolsfor mental illnesses that we have for most othermedical illnesses. We do not have diagnostictests that are reliable. We do not have anunderstanding of the risk architecture the waywe do for heart disease or Alzheimer’s disease.We do not have strategies for prevention basedon understanding genetic risk. Also, we do nothave treatments that are truly effective, safe,accessible, and targeted to individual needs.

While we like to say that mental illnesses arereal illnesses and that we have real treatments,the problem is that currently available realtreatments do not work for many peoplewith these real illnesses. So while there is animportant argument to be made about how toimplement the treatments we now have, it wouldbe selling all of us far too short if we stoppedwith the currently available treatments. What we really need are treatments that are far moreeffective than current treatment options.

As an example, look at what happened withchronic lymphoid leukemia recently. Nowwe have a treatment that is more like a cure.

Suddenly nobody talksabout the problems withservice delivery, becauseservices are trumped byhaving a treatment that

actually does away with the disorder. It is timefor us to begin thinking about that as a model,how we now can begin to plan for the nextgeneration of interventions that would do away

with some of these disorders and not simply turnan untreated chronic disorder into a partiallytreated chronic disorder.

We need to model ourselves after the wayresearch is conducted in the rest of medicine.In cardiovascular medicine or cancer research,we identify molecular targets based on basicresearch. Then we employ biochemical assaysto screen for small molecules that could be usedas new treatments. We then develop animalmodels to find out whether the small moleculetreatments are effective and safe. And ultimately,we go into human clinical trials. This is a processthat used to take about 12-15 years but has nowbeen condensed into a much shorter period oftime. It is proven to work. This approach hasworked in some cancers and it also has helpedreduce the rate of heart attack and heart disease.This model is now being applied globally fordeveloping interventions for Alzheimer’s disease.

For mental disorders, however, the model oftreatment development has been almost theopposite. We always have relied on chanceclinical observations and then gone to clinicaltrials. We have used animal models but theseare often not satisfying. We then attempt toidentify molecular mechanisms, althoughgenerally, the mechanisms have more to do withthe mechanisms of drug effects rather than themechanism of the disease. Finally, we come upwith essentially “me too” compounds, compoundsthat are not truly novel but developed basedon something that already works. So perhaps itis no surprise that we do not have the kind ofbreakthroughs in this area that we have seen inother areas of medicine.

This is going to change. The first reason for the change is because we now have the fullsequence of the human genome. This is alandmark event that will change everything that we do in biomedical science over the nextseveral decades. We now know that there are30,000 genes in the human genome. The genesonly represent a very small part of all DNA, onlyaround 1.5 percent, but a great number of these30,000 genes are expressed in the brain; as manyas 6,000 may be expressed only in the brain.

With the sequencing of the genome, we canactually go after individual genes to find outwhether they are involved in mental illnesses.We are beginning to discover that out of those


We need to model ourselvesafter the way research is conducted

in the rest of medicine.

We now have the fullsequence of the human genome.

30,000 genes, there are many, at least 12 so far,that appear very important for susceptibility toschizophrenia. What is fascinating is that we hadnever heard of most of these genes before; someappear to be important for brain development,but many have functions that remain largelyunknown. Research will need to explore howthese various susceptibility genes confer riskfor schizophrenia.

One remarkable example is a gene calledCOMT (catechol-o-methyltransferase). TheCOMT gene codes for an enzyme that is foundin synapses where it breaks down dopamine,especially dopamine in the prefrontal cortex.Dopamine has been implicated in schizophreniafor the last 40 years. We know that there aresubtle variations in the sequences of most genes.In the case of COMT, there are two majorversions or “alleles” depending on whetherthe DNA sequence codes for the amino acidmethionine or the amino acid valine. Sometimessuch variations are unimportant, but in the caseof COMT, this subtle change in sequence altersenzyme activity, resulting in more dopamine inthe prefrontal cortex. People with one versionof the COMT gene appear slightly more likelyto develop schizophrenia. And, even moreinteresting, “unaffected” relatives of peoplewith schizophrenia who have the same COMTgenotype show many of the same abnormalitieson physiological and cognitive testing eventhough they do not develop the disease.Apparently, the COMT gene variations biascognition, but they may not specifically lead tothe disorder of schizophrenia. NIMH is interestedin this finding because the disability in peoplewith schizophrenia is correlated more closelywith cognitive deficits, such as problems withworking memory or judgment, rather thandelusions and hallucinations. Although problemswith cognitive function may keep people withschizophrenia from being able to work andrecover, we do not yet have a drug that targetsthe cognitive symptoms of this illness. Byunderstanding the molecular basis of this deficit,we can begin to design a novel treatment.

The second major breakthrough that willpermit research for recovery is the ability forthe first time to look at the brain in-vivo, to seewhat the living brain is doing. We are no longer

talking about a black box. Originally this wastrue for studying brain structure, but now wehave gone beyond structure to look at brainfunction at very high resolution. We now canactually do in-vivo brain chemistry to look atneurotransmitter content in different parts of thecortex. Amazingly, just in the past two months,we have begun to visualize brain connectivity,providing an unprecedented opportunity to studyhow the brain develops in autism or schizophrenia.

New research with schizophrenia showcasesthe kind of work that will occur. For example, wecan now follow changes in the brain for childrenwith schizophrenia. Over the five years fromabout age 9 to age 14, there is a relativelyprofound change in the thickness of gray matter,but in people with schizophrenia, that goes out ofcontrol and theyend up with up to 10 percent orgreater deficits in the amount of gray matter insome regions. These kinds of results suggest thatthis illness is not only neurodevelopmental butalso neurodegenerative. The loss of connectivity,from either gray matter or white matter changes,may be very important to the pathophysiologyof this disorder, particularly because the areasinvolved, like the dorso-lateral prefrontal cortex,appear important for the cognitive deficits ofthis illness.

By identifying the genes that are involvedand understanding how the genes work tochange brain function, we should be able todevelop treatments as it is being done in therest of medicine. Research is our best hopethat, ultimately, every person with a seriousmental disorder will be able to recover. Let therebe no doubt, this is a long and difficult roadwith many blind alleys and many roadblocks.But we now have the tools to make progress atan unprecedented rate. While excellent mentalhealth care needs to be delivered, this is also thetime to accelerate research at a pace that canfinally deliver the real promise of recovery forthe large population of people with mentaldisorders who are not helped sufficiently bythe treatments we have today.

9

The second major breakthrough thatwill permit research for recovery is theability to look at the brain in-vivo.

Implications of Mental Health Science for Society

10

s assistant secretary for health, I had the responsibility and the opportunity for

developing Healthy People 2010. Ourfirst goal was based on the reality that our societyis aging. While we have done a great job ofincreasing the number of years of life people live,there was a need for far more focus on qualityof life. In the area of mental health, we see thatsome of the greatest challenges are in improvingthe quality of life. Our second goal was acommitment to work toward the eliminationof disparities in health among different racialand ethnic groups. Those two goals also pointout how critical mental health is, and our reporton culture, race, and ethnicity relative to mentalhealth pointed out that disparities in accesswere a barrier.

Our challenge is to find a way to get theAmerican people to focus on strategies for action.We decided to come up with a set of leadinghealth indicators similar to leading economicindicators. With the help of the Institute ofMedicine, we came up with 10 leading healthindicators. Each indicator has an objective ortwo associated with it, so there are measurableoutcomes associated with each indicator. Mentalhealth was listed as one of the 10 leading healthindicators for Healthy People 2010, recognizingthat in the context of general health challenges,mental health emerges as very critical.

I do not think that we talk about mentalhealth enough as mental health. We talk aboutmental illnesses and mental disorders. Mentalhealth should be defined as the successfulperformance of mental activities in such a wayas to be productive in one’s life and to developpositive relationships with other people.Additionally, mental health is the ability toadapt to changes in one’s environment andto deal with adversity. When I look at thatdefinition, it says two things that are veryimportant. First, it says that there is a continuum

between mental health and mental disorders.Second, it says that none of us can take ourmental health for granted.

Mental health is fundamental to overall healthand well-being. One cannot have good healthwithout mental health. We have to treat it thatway. It is amazing how far we are from that interms of our policies, in access to mental healthcare, and in the need for comprehensive parityof access. Plato said, “The greatest mistake in thetreatment of diseases is that there are physiciansfor the body and physicians for the soul, althoughthe two cannot be separated.” This was a cry forconnection, for integrating mental health intooverall health and well-being.

The fact that mental disorders are common isa big surprise to a lot of people. When you thinkabout it, one in five Americans suffers from someform of mental disorder each year. That meansthat there is virtually no family who has notexperienced mental disorders or who is notstruggling with them everyday. That statisticmeans that 44 million adults and approximately14 million children are experiencing mentaldisorders each year. Yet there are still so manypeople who do not appreciate the reality ofmental disorders. They either attribute it tocharacter weakness or, sometimes, spiritualdisorders. We have to point to all of theoutstanding brain research in the past severalyears showing the connection between mentaldisorders and changes in the brain.

Mental disorders are disabling. Researchpoints out the disability associated with mentaldisorders. This research base continues to grow aswe learn more every year about the tremendousimpact of different mental disorders, such asdepression, on our ability to be productive andto maintain positive relationships. There alsois an association between depression and otherchronic illnesses.


The Connection Between Mental Health andGeneral HealthDavid Satcher, M.D., Ph.D.National Center for Primary Care, Morehouse School of Medicine

A

The relationship between depression,especially, and chronic disorders is an evolvingscience. I participated in the InternationalConference on Diabetes in the Caribbean backin April, and one commonality was the extent to which depression interferes with the ability to successfully treat and control diabetes. Severalstudies have shown how prevalent depression is in chronic diseases. Fifty percent of people who suffer from Parkinson’s disease experiencedepression; more than 40 percent of cancerpatients and about 30 percent of people withdiabetes also have depression, according to some studies.

The connection between mental health andgeneral health plays itself out in primary caresettings. Approximately 30 percent of primarycare patients are suffering from depression but arecomplaining of other illnesses, and depression isa major factor with many patients who have anytype of chronic disorder. Recent studies show adramatic impact of depression on patients withmyocardial infarcts. We are learning moreeveryday about the role that mental disordersplay in our general physical health.

There has been a lot of work on physicalactivity for prevention and health promotionrelative to physical diseases but little attentionpaid on the impact of physical activity onmental health. Recent studies out of DukeUniversity show that physical activity as acomponent of treatment for depressionenhances recovery significantly.

The good news is that in many cases we havethe ability to treat mental disorders. We havethe ability to return people to productive livesand positive relationships, and hopefully thatcapability will improve. Tremendous research isgoing on that will greatly enhance our ability todiagnose mental disorders earlier and better treatmental disorders. The bad news is that so manypeople who suffer from mental disorders do noteven seek treatment, and the people who do seektreatment often have trouble accessing care. Soeven though mental health is a major componentof general health, people have a lot of difficultyin accessing quality mental health services.

Stigma is a critical issue in this country.Stigma has a tremendous impact not only onthe individual but on the family and community,as well. It impacts policies at the local, state,

and federal level. As we struggle to get Congressto act on legislation like the Domenici-Wellstonebill, stigma plays a major role.

Culture counts when it comes to diagnosisand treatment of mental disorders. How peoplemanifest their diseases, how they cope, the typeof stresses they experience, and whether theyare willing to seek treatment are all impactedby culture. Stigma also is greatlyinfluenced by culture. I visited aprogram in Seattle called theAsian Counseling and ReferralCenter, where they have targetedthe cultural aspects of mental health in thatcommunity. As a result, they have bridged somemajor gaps in getting people into treatment,focusing on primary care, partnering with mental health specialists, and training people in the community who speak the language and understand the culture. This has allowedthem to break down barriers inhibiting access.

Professionals also are influenced by culture.Our culture impacts upon how we hear thingswhen we talk to patients. It can interfere withour ability to make accurate diagnoses and caneven impact our judgment about treatment.This is a major component of disparities inquality of care.

In conclusion, I would like to remind us ofwhat Kay Redfield Jameson said in her bookNight Falls Fast. She wrote, “The breech betweenwhat we know and what we do is lethal.”

11

Stigma is a critical issue in this country.

The Connection Between Mental Health and General Health

12

The question aris-es whether early

treatment while adisorder was still

The Importance of New Epidemiological Findings for PolicyRonald Kessler, Ph.D.Harvard Medical School


The past decade has seen major growthin psychiatric epidemiology due to thedevelopment of new assessment methods

and the creation of a number of important cross-national collaborations that have allowed usto pool data and learn about subtle issuessurrounding mental disorders. We now know,based on these studies, that mental disorders arevery common, that they are seriously impairing,and that most serious mental disorders begin inchildhood and adolescence.

The last of the findings mentioned in the lastparagraph, that most serious mental disordersbegin in childhood or adolescence, should not betaken to imply that these disorders are alwaysserious at the time they begin. Indeed, quitethe opposite is true. Most of these disorders arerelatively mild at first. A typical pattern might bea child having school phobia at the age of 4-5, social phobia beginning in early adolescence,major depression beginning in middleadolescence, and secondary alcohol or drugabuse to self-medicate the mood problemsbeginning in late adolescence. A young personwith a profile of this sort often has secondary

problems in developmental roles, such asbecoming pregnant as a teen, dropping out ofschool, and becoming involved in a violentmarriage that ends in divorce.

This kind of profile does not begin with aserious emotional disturbance (SED), butwith a disorder (school phobia) that is usuallyconsidered mild. Indeed, the hypothetical youngperson in this example might not meet criteriafor SED at any part of her childhood oradolescence, but only in early adulthood with theonset of substance dependence superimposed onanxious-depression. Epidemiological data showthat a young person of this sort seldom seeksprofessional treatment until their disorderbecomes severe. This could be many years afterthe first onset of their disorder in childhood.

The question arises whether early treatmentwhile the disorder was still mild would helpprevent progression to a serious disorder. We donot know the answer to this question becausemild childhood mental disorders are seldomtreated. No controlled study of treating mild

13

The Importance of New Epidemiological Findings for Policy

14

Que

stio

ns &

Ans

wer

sThe President’s New Freedom Commission on Mental Health: Transforming the Vision

QDr. Satcher, how do you put legson these federal reports so we canimplement and make changes?

ADr. Satcher: People have to takethose reports and make sure they arecommunicated at every level of our

society. We need to have meetings like this andtalk about them. We also need meetings at thecommunity level, in churches and groups, andwe need to be involved in policy-making at the local, state, and federal levels. It begins byeducating people at every level of society aboutthe importance of mental health and the factthat recovery is possible.

QWill these research findings actuallychange the delivery of care, or will they primarily be a background for new

pharmaceutical research? And if they do changethe care, how do you implement that type ofparadigm shift? Is anybody directing theirattention and goals toward that?

ADr. Insel: The answer to the firstquestion is that we will have to wait andsee the extent to which these findings

will play into new treatments. These findingsmight not impact treatment only but diagnosisas well. One of the things we talk a lot about iswhether the genome era will allow us to begin to individualize treatment so we know whichtreatment is going to work for whom, and moreimportantly, which person may be particularlysensitive to adverse effects of drugs or othertreatments. How that will take place dependspartly on what the discoveries are.

How will it happen? It will happen througha number of different avenues, and one of thethings that should be happening more in the

future is to see more public-private partnerships.I have become concerned that in the last decadethe NIH has given drug development to thepharmaceutical industry. It is time for us to take back some of that and begin to think abouthow we can develop drugs not with a profitmotive but with a public health motive.

QI would like to hear you talk aboutgetting to the kids with mild disorders.In Philadelphia, we have 210,000

children in the public school system, and60 percent of them have serious behavioraldifficulties. We can identify at-risk children, butthe unwillingness of the community and thegovernment to address this issue is frustrating.

ADr. Kessler: Yes, that is true. I amspending a lot of time lately conductingepidemiological surveys in the

workplace showing the cost of mental illnesses.There has been a lot of argument in the lastdecade about how much it costs to treat mentalillnesses, and my research is showcasing the costof not treating it. We are now engaged in a verylarge demonstration project with some majorcorporations in America, screening over100,000 workers, getting depressed workersinto treatment, following them for two years,and documenting how much money it makes forthe company. It is a human capital investmentthat makes corporations money.

I also am doing similar kinds of studies withchildren, but I cannot figure out who to talk to.With the employer it is very easy, because I havethis dollar and cents impact. With the children,the school does not think it is their problem. Soit is a real tough thing to figure out who to go to.

16

childhood disorders has ever followed subjectsinto adulthood to evaluate the long-term effectsof treatment.

Even more disturbing than the pervasive delaysin treating early-onset disorders is the fact thattreatment quality is often quite poor when peoplewith these disorders finally get into treatment.Demonstration projects have shown thattreatment quality can be improved dramaticallywith relatively modest interventions. However,these model programs seldom are adopted byhealth plans due to a lack of willingness bylargely institutional purchasers to pay theadditional costs of these programs. This meansthat institutional will is needed to demand thatthese programs be put into place and to monitorthe ongoing quality of these programs.

Little evidence exists that this institutionalwill is going to develop. Indeed, an oppositeinclination appears to exist among the architectsof the American Psychiatric Association’splanned revision of the Diagnostic and StatisticalManual of Mental Disorders, who want toremove mild disorders from the diagnosticsystem. The thinking is that so many people

meet criteria fora mentaldisorder thatsociety cannotafford to providetreatment to allof

them. Triage rules are needed, which thearchitects of the DSM propose to implement by focusing treatment efforts on individuals withserious disorders.

But this might be a mistake, as the cost-effectiveness of treating mild disorders could behigh. We do not know whether this is the casebecause, as noted above, no systematic long-termresearch has been done to evaluate the long-term

effects of treating early-onset disorders. We doknow from longitudinal research, though, that a high proportion of mild cases among youngpeople evolve into more serious cases over time.

A disturbing epidemiological pattern is thatthe earlier the disorder starts, the longer it takesto get into treatment. People who developspecific phobias as children, for example, oftenget into treatment only in their late 20s, whereaspeople who have acute onset phobias in theirearly 20s typically get into treatment by theirmid-20s. This pattern is presumably due to afigure-ground problem: that people adapt toearly-onset disorders and don’t recognize themas being as much a problem once they reachadulthood as they do problems that have adultonsets. This is disturbing, especially becauseearly-onset disorders often are more severe andpersistent than later-onset disorders. This meansthat the people with the greatest need for earlyintervention are the ones who are likely to delaylongest before seeking treatment.

Despite this disturbing picture, there are somepositive trends. The epidemiological evidence isclear in showing that delays in initial treatment-seeking have decreased in recent years. Thispresumably reflects decreases in stigma andincreases in public awareness that mentaldisorders can be effectively treated. Nonetheless,delays in initially seeking treatment are stillpervasive, especially for early-onset disorders. We need to develop school-based early screening,outreach, and treatment programs to dosomething about this. We are not takingadvantage of the opportunity for earlyintervention provided by school systems. Asnoted above, we do not know if earlyintervention works. As a result, research anddemonstration projects are needed to develop,evaluate, and disseminate effective earlytreatments. Although these efforts might be seen


Too many Americans wait halftheir lifetime for someone to notice thattheir behavior was not simply a matter

of poor choices but part of an illness.

Dinner Address: Achieving the Mental HealthSystem Transformation Together: SAMHSA’sAction Agenda and PartnershipsCharles Curie, M.A., A.C.S.W.Substance Abuse and Mental Health Services Administration (SAMHSA)

17

as diverting valuable resources away fromresearch and treatment of more serious disorders,the public health implications of earlyinterventions with mild cases could be profound.

It is a privilege to be here for a variety ofreasons. One of those reasons is the fact thatThe Carter Center – and the Mental Health

Program in particular – has been a true partnerin helping us strive to build a system of care thatembraces resilience for children and recoveryfor people with serious mental illnesses. Theessential element to everything that The CarterCenter does is hope, and I see building hope asbeing one of the major tenants of your mission.In the absence of hope, recovery is lost.

It is also a privilege to serve President Bush andHealth and Human Services Secretary TommyThompson. They clearly know that treatmentworks and recovery is real! I also want torecognize the support SAMHSA has receivedfrom the White House and Secretary Thompson.Some have questioned whether we at SAMHSAwill get the support we need to achieve ourvision of a life in the community for everyone.Well, I am happy to say we already are.

When the president announced thecommission and defined the scope of responsi-bility, he spoke frankly about the poor qualityof mental health care in this country in terms ofits fragmented delivery system. He drew upon thecommon example of a14-year-old boy who suffered from severedepression and began experimenting with drugs,not realizing that he was self-medicating thedepression to alleviate his symptoms. He was anhonor student whobegan slipping in school and eventually got into trouble with the juvenile justice system.

This young man, like many Americans of allages, slipped through the cracks. Was he put intorehabilitation programs? Yes. But he was treatedfor the drug abuse and not for the underlyingissue of depression. And he ended up graduatinginto the adult criminal justice system in his 20s.He was not diagnosed until age 30 with bipolardisorder. Once diagnosed and receivingappropriate treatment, his symptoms werealleviated and he began to regain his life.

On one hand, some people describe this asa success story. But I can’t help but think aboutthe 16 lost years of his life and how the systemfailed. If he were diagnosed earlier and receivedthe right treatment, perhaps he could havecompleted high school, gone to college, and atthe age of 30, be raising a family and claiming acareer instead of just starting to think about howhe was going to fit in again once he had hissymptoms under control.

Too many Americans wait half their lifetimefor someone tonotice thattheir behaviorwas not simplya matter ofpoor choicesbut partof an illness, an illness that we can dosomething about.

Clearly, we have made progress and we willcontinue to make progress by pushing for what isright for the people we serve. The simple concept– doing what is right for the people we serve – isthe concept that steered the New FreedomCommission through many tough decisions,leading ultimately to its final report.

Now, the White House and SecretaryThompson have given SAMHSA the lead role toconduct a thorough review and assessment of thefinal report. Our goal is to implement appropriatesteps to strengthen our mental health system.The commission was asked to give the mentalhealth system a physical, and they did it. Thediagnosis: fragmentation and disarray. Thecommission report found the nation’s mentalhealth care system to be well beyond simplerepair. It recommends a complete transformationthat involves consumersand providers,policymakers atall levels ofgovernment, andboththe public andprivate sectors.

The mentalhealth systemrecovery planwill require theimplementation of a to-do

Recovery needs to be defined in theterms of the consumers, family members,children, and parents who receiveservices from our system.

Achieving the Mental Health System Transformation Together: SAMHSA’s Action Agenda and Partnerships


18

list currently being developed by SAMHSA. Theto-do list will form an action agenda to achievetransformation of mental health care in America.I recognize “transformation” is a term withdifferent meanings to different people. Often, itis just a simple synonym for change. There is alsoa mathematical definition of transformation, thechange into another form without altering thevalue. Our definition of transformation willsimply be reconsidering, reshaping, and changingthe ways in which the mental health system

provideseffectivetreatment andhow consumersand familiesrecover. Weneed to be

thinking about how we operationalize recoveryfrom the standpoint of public policy as well aspublic financing.

How we first define “recovery” is critical.Recovery needs to be defined in the terms ofthe consumers, family members, children, andparents who receive services from our system. Myfirst professional position included running anaftercare group. The goal of that aftercare groupwas to help those individuals coming out of thepsychiatric hospital adjust to the community.I remember asking them what they needed to deal with their mental illness. What wasimportant to them? It was interesting to heartheir reaction, because they did not say theyneeded a psychiatrist. They did not say theyneeded a psychologist or a caseworker. They didnot just say they needed a program. They definedwhat they needed in terms of what they wantedin their life. They wanted a job. They wantedmeaningful daily activity that helped give theman identity. They wanted a place of their ownin the community. They wanted standing inthe community, to be part of a neighborhoodand a community. They wanted a safe, decentplace to live. Finally, they wanted connectedness.They wanted to have a relationship with familyand friends.

When you think about your own life and whatyou want for those of us who are not mentally ill,for those of us who have not struggled with thatdisease, those are the things all people want: ajob, a home, and people who are important to us.This gives us an idea of what we need to begindoing in our service delivery system to helppeople truly attain recovery.

I am a little concerned that there has beensome criticism that recovery was not the rightthing for the president’s commission to emphasizein our final report. Some say we are offering falsehope, because not everybody with a mentalillness will fully recover from their disease. Well,of course, some will not fully recover. The diseasecan be very severe, chronic, and disabling. Butrecovery is both an outcome and a process. Weneed to define the process of recovery and whatwe are doing in the system to help that process,because in the process of recovering, people learnhow to manage their illness and manage theirlife. That is what we are talking about. Peoplewill be emerging and arriving at different levelsand at different stages of the process. It is not

As a compassionate nation,we cannot afford to lose the opportunity

to offer hope to those fighting for theirlives to obtain and sustain recovery.

19

false hope. It is finally realizing hope andunderstanding how hope moves the processalong.

This transformation will require a shift in thebeliefs of most Americans. It will require thenation to expand its paradigm of public andpersonal health care. Everyone from publicpolicy-makers to consumers and family membersmust come to understand that mental health is avital, integral part of overall health. Along withthis new way of thinking, Americans must learnto address mental health disorders with the sameurgency as other medical problems. We aretalking about a societal change here, one that has to begin with the professions, withgovernment, and in academia. It has to be in thegroundwater of our society.

The report also challenges us to close the 15-to 20-year lag it takes for new research findingsto become part of day-to-day services for peoplewith mental illnesses. Waiting for research tomake its journey down an already cloggedpipeline equates to losing a generation of peoplewhile we transition from what we know to whatwe do. Many Americans are done a disservicewhen their quality of life remains poor whilethey wait for the latest research to crawl intotheir communities.

The report also challenges us to harness thepower of health information technology, toimprove the quality of care for people withmental illnesses, to improve access to services,and to promote sound decision-making byconsumers, families, providers, administrators,and policymakers. And it also challenges us toidentify better ways to work together at thefederal, state, and local levels to leverage ourhuman and economic resources and put them totheir best use for children and adults living with,or atrisk for, mental illnesses. Most of all, the reportreminds us that mental illnesses are treatableand recovery can be the expectation. As acompassionate nation, we cannot afford to losethe opportunity to offer hope to those fightingfor their lives to obtain and sustain recovery.

To lead that effort, we have assembled atransformation task force. We already areworking with relevant federal agencies todetermine ways to improve the flexibility

required by the states and develop the incentivesto bring the full force of resources available tomeet the needs of people with mental illnesses.

I am counting on the relationship thatSAMHSA and other federal agencies have withour state partners. States are where the action iswhen it comes to mental health and thus stateshave an awesome responsibility. We know thatthe new state agendas must beconsumer- and family-drivenrather than bureaucraticallybogged down. Consumers ofmental health services andtheir families must stand at thecenter of the system of care and drive care. Wehave talked about consumer- and family-centeredcare for years, but we don’t really know what thatmeans. When we begin to say the consumer andtheir families must drive the care and drive thesystem, that begins to strengthen and clarify theirrole. The result should be more of our familymembers, co-workers, neighbors, and friendsliving a rewarding life in their communities.

Over time, with strong leadership, enoughpeople will be thinking of new ways anddoing things differently. The new will becomethe norm.

We need to be careful not to rush towardchange frantically, grabbing at what wecan.We need to bestrategic whilepressing onward.We need to havecarefulplanning. Irefer to aquote by Dr.Gary Tisler,who was onthe Cartercommission.Dr. Tislermade anobservationthat many of therecommendationsof the twocommissions aresimilar. It is troublingthat after 25 years we still

This commission reportgives us the opportunity tofind common ground.

Achieving the Mental Health System Transformation Together: SAMHSA’s Action Agenda and Partnerships


20

The challenge for us today is to harness thepersonal and the collective responsibilityfor the strategic implementation of this

report. To paraphrase a probably overused phrase, it will take a village to transform a system

that has been inshambles. And thisvillage must be builton collaborationsand on relationships.I think we mayanticipate that someof the relationships

will be uneasy relationships; nevertheless, wemust build on them to promote better outcomesfor people with mental health disorders.

We heard earlier about “transforming”concepts in the commission report, such asrecovery and resiliency as an expected goalof mental health care and the need forcare to be consumer- and family-driven.We heard of the urgency to providemental health care in other service systemssuch as child welfare, juvenile justice, and primary health care where we see aburgeoning of mental health problems.

Today we are going to speak aboutgoal five of the commission report –excellent care is delivered and research isaccelerated. This is another transformingconcept. Research has yielded criticaladvances in our understanding of humandevelopment and behavior; research hasbeen fundamental to the developmentof effective treatments and services.Yet we know it takes about 15 to 20years between the discovery of effectivetreatments and the implementation ofthese treatments into routine practice.While we have generated considerableknowledge regarding effective services andsupports, we are moving these practicesinto service delivery far too slowly.

This panel will address the challenges oftransporting research to practice. They willexamine the science-to-services gap and theparallel gap from services to science. They willlook at the concepts of evidence-based practiceand practice-based evidence. Structural issuessuch as financing, human resource development,or organizational inertia that impede change willbe touched upon as well as strategies for how towork with local communities and providers todevelop services that better meet the needs ofthese communities. The successful disseminationand implementation of effective treatments,services, and supports is essential to the provisionof high-quality mental health care.

Panel 2: Moving Science to ServicesLarke N. Huang, Ph. D.President’s New Freedom Commission on Mental HealthGeorgetown University Child Development Center

We know it takes about 15 to20 years between the discoveryof effective treatments and the

implementation of these treatmentsinto routine practice.

21

This symposium is really about each of uslooking within ourselves to answer afundamental question, which is what

can we do to bring about the transformationcalled for in the president’s commission report.As a researcher, I will talk about evidence, both what it can and cannot do in bringingabout change in mental health policy. I will focuson the gap between how the research communityand the rest of the world understands and usesevidence and how we might use the symposiumas a step toward bridging that gap.

The executive order establishing the President’sNew Freedom Commission on Mental Health in2002 placed evidence in a central role in howthe commission should approach its charge.This notion of grounding the report in evidenceis actually quite extraordinary. It reflectsrecognition that we are finally beginning todevelop a science base that is broad and deepenough to support clinical and policy decisions.

Evidence also plays a central role within thereport itself. Each of the subcommittees commis-sioned a background paper from a researchexpert, and these papers both help inform andbolster the recommendations of the final report.

This issue of translating science to practicehas been a major focus in recent years in a number of major federal agencies. However, this gap between evidence and practice has beenfar easier to identify than it has been to close.Why is this the case? I think it is important tolook at how we have been thinking about whattranslation actually is to understand the problem.To date, translation has been thought of as a top-down process, moving from research to practice,policy, and communities. We researchers feellike we keep speaking, but no one seems to belistening. So we look for a way to make ourvoices louder. Translation becomes a megaphonethrough which we hope to be heard among thedin of competing demands faced by clinicians,managers, and policy-makers.

But being at The Carter Center brings another metaphor to mind. This is the notion of translation as a dialogue between those whodo research and those who use the findings. Thisis translation in the most concrete sense of theword. It is the process of interpreting betweenlanguages and between the cultures of researchand practice. Most of the rest of my talk will seekto understand how these two different worldsthink about evidence.

Let’s start with a few terms. What is evidence?The answer to this question will vary considerablydepending on whom you ask. The researcherthinks of evidence primarily in terms of its levelof truth or validity. Courses in evidence-basedmedicine teach about the hierarchy of evidence,with randomized control trials as the goldstandard of truth.

Most of the rest of the world views evidence ina much more pragmatic manner. As found in theAmerican HeritageDictionary, evidence issimply a thing orthings useful informing a judgment.The key operationalterm here is useful. Itdoesn’t have to be perfect. It doesn’t have tobe supported by randomized trials. It just has tohelp us to make the best decisions we can make.

How do we decide which evidence issignificant? Anyone who has ever read ascientific article knows that results are statis-tically significant if P is less than .05, whichmeans that there is less than a 1-in-20 likelihoodthat the findings were simply a result of chance.This cutoff point, which was first proposed by thestatistician R. A. Fisher in 1925, is actually anarbitrary convention. However, this point hasbecome a very convenient way for the researcherto sort between what needs to be paid attentionto and what can be ignored. The fact thatit is called “significant” tends to give us theimpression that it is the same as clinical

Evidence and TransformationBenjamin Druss, M.D., M.P.H.Rollins School of Public Health, Emory University

We are finally beginning todevelop a science base that isbroad and deep enough to supportclinical and policy decisions.

Evidence and Transformation

22

importance. In reality, statistical significanceand clinical importance are not one and thesame thing.

The rest of the world cannot afford suchcertainty. In our daily lives we need to makedecisions under conditions of varying and oftenhigh levels of uncertainty. Most of us spend our

days making the bestdecisions that wecan under imperfectconditions. Our criticalP value is not P lessthan .05, but P less

than .5. In other words, is this decision moreor less likely to give us the outcome that weare looking for? If I check the weather in themorning and see there is a 60 percent chance ofrain, even though I am a researcher, that is goodenough for me to bring my umbrella. I do notneed 95 percent certainty to have the sense tocome in out of the rain.

The research process is slow, methodical, andconservative. And this is a great strength. Itprovides multiple safeguards that keep researchersfrom drawing conclusions that may be incorrector dangerous. However, the rest of the world doesnot have the luxury to wait 17 years to makedecisions. A recent study found that policy-makers overwhelmingly identify timeliness andrelevance as the most important qualities thatwould lead them to use information in theirdecisions. A chief executive officer’s time horizonis about a year, and chief financial officers’ time

horizon is typicallythe next fiscalquarter. Consumersimpatient with theslow pace of theresearch process

are increasingly using the Internet to learn aboutand discuss new innovations that will not bepublished in literature for many years.

When researchers think about moving evidenceinto practice, our usual goal is to transplant the innovation into the real world with as fewchanges as possible. We call this notion “fidelity.”But in real-world health and mental healthsettings, perfect fidelity is rarely practical, andI would argue that it also is not desirable.

In a recent Journal of the American MedicalAssociation (JAMA) article about disseminatinghealth interventions into routine settings, DonBerwick suggests that we substitute the notion ofdiffusion with the term “reinvention.” To work,he says, changes must not only be adopted locallybut adapted locally. Reinvention is a form oflearning, and, in its own way, it is an act of bothcreativity and courage. “For reinvention to occurwhen we researchers develop an intervention,we need not only to expect but actively toencourage local sites to streamline the modeland tailor it to their local environments.”

Let me give you an example. An enormousamount of work has been done in the area oftranslation in the treatment of depression inprimary care. More than a dozen randomizedtrials demonstrated that team-based, patient-centered approaches known as collaborative careimprove the quality of medical outcomes andtreatment for depressed patients. And yet themodels have yet to be widely adopted. Even inthe settings in which the studies are conducted,these models are not sustained after the researchprocess ends. I think one of the challenges inhelping these models be used more broadly is todemystify them by deemphasizing fidelity andencouraging more local experimentation. Weneed to help local leaders read the collaborativecare literature with an eye toward what is mostrelevant to their own organizations. We mustallow them to make incremental changes ratherthan simply offer them an all-or-none deal.

When researchers publish a study, we areconvinced about the validity and importance ofthe findings. The need for action often seemsself-evident to us. We are then often surprisedand disappointed that the articles do not havethe impact that we would hope. However,science itself warns us that evidence is only thefirst step in transporting policies and practices.Everett Rogers, who is a professor of communi-cations at the University of New Mexico, hasdescribed the many determinants of how newinnovations are widely adopted in society. Henotes that the characteristics of the innovationare only part of the story. How they diffuse or arereinvented is highly dependent on the nature ofthe potential adopters and the broader systeminto which they are being introduced.


Reinvention is a form of learning,and in its own way, it is an act of

both creativity and courage.

Science itself warns us that evidenceis only the first step in transporting

policies and practices.

23

In a recent articlein the journal HealthAffairs, politicalscientists RoganKersh and JimMorone examinedthe commonelements of publichealth policymovements across arange of issues suchas smoking andnational policies onalcohol and illegaldrugs. They describea series of what theytermed “triggers”that need to betripped beforechange can occur.Medical science isonly one of thesetriggers. Others include development ofconsumer groups, politically active interestgroups, and increased awareness and interestin the general public. As you hear these, thinkabout the parallels of mental health with thegrowth of the consumer movement. I believe theenvironment is becoming increasingly ready forthe sort of major transformation we have seen,for instance, in national tobacco policies. Weresearchers need to make sure that as these policytriggers are tripped, we have the right evidence athand for fostering constructive policy change.

If translation is a dialogue, then we from theresearch community can use this symposium tolisten to all of you to learn how to better developevidence that is useful, timely, and relevant toyour needs.

But we need to do more than just give youevidence. We need to allow you to develop anduse your own data more effectively. Examples ofthis might include helping a mental health clinicstudy its claims data to better understand itsclients. It could be guiding policy-makers doingan informed survey of the literature on key issues.It can be teaching a consumer to more effectivelyuse the Internet to understand his or her owncondition. This is the sort of homegrown

evidence that actually will be used to improvecare, because it is addressing needs that are, by definition, timely and relevant. It also willbe sustainable because done right, it can becontinued locally even after we researchers gohome. Largely what I am talking about hereis an exercise in power-sharing in which weresearchers must be willing to surrender ourmonopoly on producing and understandingevidence.

Finally, I want to challenge those outside theresearch community to think about ways ofadopting and adapting evidence in your day-to-day work. How canyou work towardgoal number five ofthe New FreedomCommission report,which advocatesadvancing the use ofevidence-based practices? And more generally,how can you use evidence as a tool in achievingthe other goals outlined in this report? Evidencemay not be the only step needed for change inour mental health system, but used properly, itcan be a powerful tool for such a transformation.

I challenge those outside theresearch community to think aboutways of adopting and adaptingevidence in day-to-day work.

Evidence and Transformation


24

Historically, it has been a challenge toconvince the public that children andfamilies have real problems and an even

greater challenge to get people to believe that weactually have some answers. What the work onthe surgeon general’s report did for me was tohelp me glean these messages of hope for kids.With that hope, we can translate our researchfindings into real-world clinical practice.

Mental disorders are prevalent in youth. InNorth Carolina, we havefollowed youth from ages 9through 16 and found that37 percent have had apsychiatric diagnosis. Wealso now know from an

ongoing national survey of 6,000 kids that in thechild welfare system at least 50 percent of thoseyouth need clinical treatment. Also, almost two-thirds of those in the juvenile justice system haveclinical needs.

So what are we doing about getting kids into care? In the last 25 years, we have movedfrom about 3 percent of children being seenin mental health services up to around 8 percent. We also have moved from an averageof three visits per treatment episode to 11 visits.However, even with this progress, there isstill a lot of unmet need. There also are racialdisparities in obtaining treatment, with Hispanicyouth being the ethnic group least likely toreceive services. In addition, there is widevariation in the rates of children receivingcare across states.

Evidence shows that we have a choice ofeffective interventions for four of the mostcommon disorders in youth: depression, attentiondeficit hyperactivity disorder, anxiety, anddisruptive behavior. This evidence has influencedservice delivery. For example, psychoanalyticapproaches are waning and behavioralapproaches have gained popularity. Ecologicalmodels are commonly applied for youth with

severe emotional disorders where multiplesystems are needed to work together andintervene. We also have respectable evidence forthe effectiveness of community-based programs.

We find that specific interventions areeffective for specific disorders. For example,cognitive behavior therapy is an effectivetreatment option for depression, anxiety, andtrauma, and behavioral approaches directed atparents and teachers work with children withADHD and disruptive behaviors. The realquestion is how many of these interventionsare being taught in graduate schools andcontinuing education? Are there even materialsfor adequate instruction?

Unfortunately, there is still a reliance oninstitutional care for children, such as hospitals,residential treatment programs, boot camps, anddetention centers. This is in spite of evidencethat suggests that institutional care is noteffective for many childhood mental disorders.Until the community-based alternatives are trulyin place, we will continue to see a significantnumber of our youth being sent away at greatcost and minimal effectiveness.

With all the different types of treatmentoptions available, is there any way to simplify? Avery clever psychologist in Hawaii by the nameof Bruce Chorpita and his colleagues looked atall the evidence-based literature for commondisorders and identified core components fornumerous types of interventions. He came upwith 26 core components of effective treatment(e.g., tangible rewards, communication skills,limit setting, and maintenance). This couldmean there are only 26 kinds of techniquesthat service providers have to learn. However,it is another matter to put them togetherappropriately. An approach to tailoringinterventions to the child on a component-basedapproach is currently being tested in Hawaii.

Readiness for Evidence-based Practice in Child andAdolescent Mental HealthBarbara J. Burns, Ph.D.Duke University Medical Center

Unfortunately, there isstill a reliance on institutional

care for children.

25

How do these interventions spread? Let’s takethe example of family preservation. There werepromising findings from uncontrolled studies, and based on them, family preservation becamefederal legislation. Then controlled research wasconducted, and the results were not very positive.It is very hard to undo federal legislation, sofamily preservation prevailed long after it wasknown to be ineffective.

A little different lesson comes from treatmentin foster care. The people at the Oregon SocialLearning Center did a great job with the efficacystudies. Professional parents are paid about$30,000 a year to take in a fairly disturbed childand work together with the natural family toavoid placement in an institution or out of thecommunity. The treatment spread and standards

were developed for implementation. Yet there is a large gap between the promise of treatmentfoster care and the reality. We have justconducted an observational study in NorthCarolina and found that treatment foster parentswere reactive to crises. They were not adequatelytrained in proactive approaches to preventingbehavioral problems. The implications here are that quality monitoring and proper trainingare required.

As a final example, let’s look at eye movementdesensitization and reprocessing (EMDR). Theuse of EMDR spread like wildfire; however, therewas little evidence for the technique. Very littleformal training was required, and it was easy tolearn, thus accounting for its spread.

Readiness for Evidence-based Practice in Child and Adolescent Mental Health


26

According to Backer, the principles offacilitating the dissemination of interventionsare:

1. User-friendly communication. Weneed readable training materials that areinteractive and utilize electronic capabilities,such as the Internet.

2. User-friendly evaluations. Keep theresearchers at some distance until youknow what outcomes you want and youhave a sense of an approach to monitoringquality. Quality monitoring is essential,but do not let the research weigh theintervention down.

3. Resource adequacy. We need enough policysupport and enough funds to provide thetreatment, to provide the training, and toconduct the evaluation. I see exampleswhere all three are neglected. Neglectingany one of them is a risk for failure.

4. Addressing the complex human dynamicsof change. Change is not easy, and manyproviders may resist change. Change makespeople anxious, especially if they are alreadycomfortable with the way things currentlywork. It is important to communicateclearly the benefits of change and providean environment in which staff cansuccessfully change.

An elaborate initiative by SAMHSA inthe adult arena for effectively spreadingtreatment innovations was the development

of implementation resource kits. This involvedcreating a state-level infrastructure for training inconjunction with training materials that are user-friendly and comprehensive. The kits took abouttwo years to develop with a lot of input from allthe stakeholder groups. They include a video tointroduce the intervention, a video to train theclinician, a manual for the administrator, and amanual for the clinicians. In one state, anotherlocal approach is mentoring utilized for ongoingtraining, where established community treatmentprograms act as a mentor to new ones. It is mygreat hope that we will be able to utilize theabove model to engage in similar work forselected evidence-based child interventions inthe near future.

To conclude, here are the big future questions:

• Can consensus be achieved about appropriateand effective clinical practice?

• Can necessary and effective training beintegrated into graduate and continuingeducation?

• Will critical stakeholders support theimplementation of evidence-based practice?

• Can we create a better balance betweeninternal and external validity in treatmentdevelopment research?

I do not have the answers. I do hope we cancome up with them together.

Recovery-based InnovationLarry FricksGeorgia Department of Human Resources

If you believe that we can and do recoverfrom mental illnesses, everything changes.You shift from a system founded on symptom

reduction and custodial care to a strength-basedsystem. And you call forth a potential of self-directed recovery and services such as supportedemployment to replace institutions thatpromote hopelessness.

An outgrowth of the 1999 Surgeon General’sReport on Mental Health has been therealization of the value of peer-to-peer support

in the acquisition of real recovery. Certified peerspecialists (CPSs) provide hope and model thatpossibility to every consumer they serve. The roleof the CPS is to transition ownership of recoveryinto the hands of the consumers.

Dr. Jim Saben, in his article about strengtheningthe consumer voice in managed care publishedin the April 2003 edition of Psychiatric Servicessays, “The primary responsibility of the certifiedpeer specialist is to provide direct services designedto assist consumers in regaining control over

27

their own lives and control over their recoveryprocesses. Peer specialists are expected to modelcompetence in the possibility of recovery and toassist consumers in developing the perspectiveand skills of facilitated recovery.” He goes on tosay, “The aim of peer support is to provide anopportunity for consumers to direct their ownrecovery and advocacy process and to teachand support each other in the acquisition andexercise of skills needed for management ofsymptoms and the utilization of natural resourceswithin the community.”

The program started with leadership from theconsumers. We were fully at the table when werewrote our Medicaid service plan under therehabilitation option. It was the consumers whoasked that we go after a Medicaid billable servicecalled peer support and created a new providercalled a certified peer specialist, a recovery agentwho helps consumers develop the potential tomanage their own recovery.

Here is how we developed Georgia certifiedpeer specialists:

1.Training and certification. First we had todevelop the training certification and a codeof ethics. Our certified peer specialists sign acode of ethics, and if they are accused of analleged ethics violation, they go in front of atribunal of peers to decide whether or nottheir certification gets pulled.

2. Technology. The certified peer specialistshave their own Web site where they can goonline and support each other, sharinginformation and best practices across the state.

3. Recovery mediation. One of the thingsthat we are about to begin is recoverymediation. We are in the process of bringingin mediation training from the University ofSouth Florida, so we peer specialists can betrained as recovery mediators to go in andhelp traditional staff and consumers worktogether toward recovery.

4. Continuing education. We have continuingeducation every three months.

5. Values. You need leadership that standsbehind the program, believes in it, and sayswe are going to do this, we are going tomake changes and grow. You have got tohave that kind of commitment from the topdown when starting something new like this.

I went out to talk with many of our mentalhealth providers and review the individualservice plans of the consumers they serve.You cannot believe how far removed thosewritten plans were from what consumers saythey want for their real recovery goals. Weare training our certified peer specialistshow to determine what the consumer is mostdissatisfied with in his or her life and, therefore,what they want to change most. We then flipthat into recovery goals and tie them back tothe treatment plan.

Peer support is 55 percent cheaper than otherforms of day support services and more effective.Currently, we have 163 certified peer specialistswho serve 2,500 consumers with this newMedicaid service. The billing this year for peersupport will be $5.5 million, and we have beendoing this for three years. Preliminary outcomedata for 500 patients, ages 18 to 55 withschizophrenia and bipolar illness, found a 5percent greater improvement for those servicedby peer supports than other day services in threeareas: skills, functioning, and resources.

The National Mental Health Association cameout about a month ago with a national policy tosupport peer support as a recovery service. Intheir policy, they say that every state shouldprovide adequate funding to develop this newrecovery service. Where else but at The CarterCenter should we kick off a national recoveryinitiative that calls forth the potential andresilience of consumers to lead us to higherground? This is where the dreams of hope areborn, right here at The Carter Center and wherethe human spirit is unbound to soar.

Recovery-based Innovation


28

Que

stio

ns &

Ans

wer

s QLarry, I wonder if you would commenton how the ideas that you’ve been ableto actualize in Georgia shift that culture

away from symptom management and towardreally genuine recovery. How do you see thatoccurring in other states, and what role do yousee consumers, advocates, and family membersplaying in that sort of shift?

AMr. Fricks: I am awarethat there is a shift insome states. We have

had nine states send peopleto our training certification,and South Carolina now hasMedicaid-billable peer support.The shift is coming. Thisrecovery stuff is going tochange the system.

QWe have been strugglingfor 20 or 30 years toimplement practices such

as supported employment andother kinds of recovery supportservices but constantly comeacross huge barriers. No one isresponsible for identifying thosebarriers, whether it is fundingsilos, regulations, stigma, staffturnover, or training. We needthat dialogue happening atfederal, state, and local levels. Doyou think assigning responsibilityfor that is something we couldever make happen?

ADr. Druss: I think yourpoint is on target andwell-taken. There

certainly are efforts from theresearch community within theNational Institute of MentalHealth to try to be more appliedand attempt to identify andthink about barriers to dissemi-nation. But I think what you aresaying is that there are problemswithin the research communities,issues that kind of parallel what

is going on in the mental health servicesdelivery community. Then what is requiredis the same kind of transformation in terms of how researchers see what they are doing asneeded in the mental health system. The issueis how you change a system that is stuck in itsconservative ways.

29

The treatment and cure of mental diseasesat times appears quixotic at best, forstigma and shame inhibit proselytes

to our cause. And ignorance and fear fosterdiscrimination, which acts as a deterrent toprogress at all levels of our effort.

I choose this field of care because it involvesthe brain, the most complicated and demandingof human organs. The brain holds sway overfunctions from heartbeat to our sense of well-being. It mediates our perceptions of reality andnegotiates our social interactions. When itsprocesses are off, we are off indeed.

In the field of mental health, there is nowasted or superfluous knowledge. All that we canknow must be brought to bear in the discoveryand implementation of palliatives and cures forthis devastating spectrum of illnesses.

President Bush commissioned us to explorenew solutions and bring to light existingsolutions. At the end of the day, when thecommission had sunsetted, we put forth 19well-considered and thoroughly debatedrecommendations, believed to be essential forachieving some of those solutions. Nonetheless,as in the biblical quote, faith without works isdead; so it is that recommendations withoutimplementation are dead. We now embark uponthe implementation phase of our work. Thiswill be the most difficult and frustrating part,requiring determination, stamina, tolerance,political dexterity, cooperation, and partnership,as well as a large volume of interfaith prayer, inorder to achieve even partial successes.

In another life, before I became a psychiatricphysician, I was an international banker andfinancial analyst. I viewed work through adifferent set of lenses, which I sometimes finduseful to put on again. As an internationalbanker, I came to understand the financialprocesses underlying most of the infrastructuresthat support a complicated and interdependentmodern global society.

One of the financial mechanisms used whenthere is a need for large-scaled, multilayeredfinancing is called project financing. Simplified,in this arrangement the suppliers of operatingcapital and funds evaluate the project’s concept,organizational structure, economic viability,credit worthiness, and financing requirements.This evaluation requires that the financiers,under the guidance of a lead institution, not onlyreview the integrity of the goals of the projectbut also consider whether those goals can meetthe needs of a targeted market or consumers.Failure to meet the consumer’s needs invariablyleads to financial failure.

During the finance stage, financiers havesignificant influence over the eventual scope,structure, goals, and roll out of the project. It isimportant to understand that many projects faildue to a key financial participant pulling out forvarious reasons, often because they could notinsert requirements they wanted. To minimizethis type of risk, the financiers meet and discussterms they want in the financing agreement.As each institution brings to the table its own setof requirements, there is an attempt to minimizethe risk of conflicting covenants, which maycause an inadvertent breach in the agreementand, consequently, trigger a default. Such adefault can trigger a cascade of defaults in otheragreements. When this happens, the project canbe seriously jeopardized.

They also meet to ensure that their covenantsor terms of participation do not put undue stresson the project by requiring conflicting accountingor reporting forms and procedures or over-burdensome interference in the managementof the project. There is a process of continuedreview and evaluation that ensures that thefinances remain in synchronization.

While I am very cognizant of the fact that notall of the challenges we face in improving mentalhealth and curing mental illnesses in Americaare related to finances, one cannot, in a capitalisteconomy, argue the relevance of the adage “no

Panel 3: Strategic ImplementationNorwood W. Knight-Richardson, M.D., M.B.A.President’s New Freedom Commission on Mental HealthRichardson Group

Strategic Implementation


30

pay, no play.” For too many decades, we havehad too little pay to play well. When we considerthe financing of mental health, we discoverconflicting covenants and requirements ofparticipation that often burden the consumer

with layers ofbureaucracy andwhich inhibittheir obtainingand evenknowing aboutavailable

services. We also discover covenants that createhuge service gaps, as are found in services tochildren and families and in the juvenileand criminal justice systems. The conflictingcovenants also place service providers at riskof breaking a rule. The sheer complexity of therules fosters a fragmented system. It inhibitsdevelopment of new services, especially incommunities of color and rural areas where thereis already a dearth of providers. Complexity maydrive fledgling or developing service providersout of the field altogether.

In view of this reality, I suggest a modestproposal, that federal, state, and localgovernments convene a meeting much like thatof a project financier to discuss not only theelimination of conflicting rules of participationwhere they exist, but to evaluate ways they canbetter facilitate the provision of services toconsumers and their families. There should bean interagency, transgovernmental council onmental health financing that meets biannually.I believe this level of coordination andcooperation is a cornerstone of our success inachieving further progress in mental health. Letus then pull together toward this goal of financialcooperation and revision and enhancement ofcovenants of participation. Let us pull togetherin the halls of our federal Congress. Let us pulltogether in the offices of our federal bureaus andour statehouses and governors’ offices and ourfoundations and other nongovernmental agenciesand among ourselves in whatever role we play inthis vital undertaking.

Conflicting covenants and requirementsof participation often burden the

consumer with layers of bureaucracyand create huge service gaps.

Financing Mental Health Services in the FutureGlenn StantonCenter for Medicare and Medicaid Services

Medicaid is a very flexible program thatsupports services for persons who havemental illnesses. There are, however,

50-plus different Medicaid programs. So, if youhave seen one Medicaid program, you haveseen…one Medicaid program. Georgia actuallydeveloped this peer support program model. Noother state in the country has done it. That doesnot mean it is not possible. It just means thateach state drives its own Medicaid program.

Medicaid is unique in that it is a federalprogram in which federal dollars simply followwhere the state wants to go. The state defineswhat is in the state plan. The state decides whatthe rates are within broad federal parameters.Many of the recommendations included inthe report to the president are not solelyfederal recommendations but state and localissues as well.

But it is not only a federal, state, or a localissue. It is also a matter of public versusprivate financing. If we want the commission’srecommendations to be implemented, there hasgot to be a dialogue with the purchasers. As youmove forward with implementation, I encourageyou to talk not only about the gap betweenscience and service but from science to serviceand financing.

In the future:

• Financing will have to come from multiplesources.

• Financing will support evidence-basedservices.

• Financing will support the achievement ofpersonal and private outcomes.

• The individual will direct health carepurchasing more frequently.

31

One of the quotesfrom the report that Iuse frequently when Ispeak about this is: “Tobe effective and compre-hensive, mental healthcare must rely on manysources of financing.Flexible, accountablefinancing that pays fortreatment and servicesthat work and result inrecovery is an essentialaspect of transformingmental health carein America.”

Currently, 57 percent ofmental health care in thiscountry is funded in thepublic sector. Medicaidand the states pick up thelargest portion of that tab. We estimate that thefederal share of mental health care payments wasapproximately $32 million in 2000.

This morning I want to talk about financingstrategies. And I am going to spend most ofthe time talking about those that can be doneimmediately. There are those that are midterm,and these include demonstration approaches fornew financing mechanisms in service deliveryapproaches. And then there has to befundamental long-term reform.

Immediate Financing Strategies.Medicaid Eligibility Maintenance. One of the

key issues around mental health treatment andsupport, particularly for persons with seriousmental illnesses, is that many people havetheir Medicaid eligibility linked to their SocialSecurity income (SSI). If that person goes intoa public institution like an institute for mentaldisease, after a certain period of time – 30 days –they can lose their SSI eligibility. Therefore,many states have taken the approach that onceyou go into an institution, they discontinue yourMedicaid eligibility. You do not need to do that.

There is a great deal of confusion surroundingeligibility maintenance. Therefore, one of thethings we will be doing this year in technicalassistance is a reminder to the state Medicaid

agency that you do not need to revoke someone’sMedicaid eligibility when they go into publicinstitutions, particularly for short periods of time.

Medicaid Buy-in Provisions. In 1997,Congress granted the ability for people whoreturned to work to have a state option, or thestate could create the ability for someone to buyinto the Medicaid program. There are now 28states in the country that have the Medicaid buy-in option and more than 50,000 people in thecountry who are participating. It is somewhatdisappointing that some states that haveimplemented the Medicaid buy-in option havedone it in a way that it either had a very slowtake-up rate or it was developed in such a way tobe fairly limited in its application. This is a toolthat is out there, and it is going to take workingwith the states to try and take advantage of thisparticular option.

TEFRA Eligibility Option. Switching topicsto a children’s issue that was discussed by thecommission in the report is the tragedy of child custody relinquishment. There is often aconfusion that child custody relinquishment is aproblem within the Medicaid program. In fact,people are relinquishing their custody to getaccess to public services that Medicaid provides.There is an option that only 18 states have takenadvantage of called the TEFRA option. It is notas broad-based as what is probably needed acrossthe country, but it is a limited option where kids

Financing Mental Health Services in the Future


32

who need an institutional level of care can havetheir eligibility up to 300 percent of the federalpoverty level. So families can in fact keep theirkids at home and get access to Medicaid services.

Utilization of Existing Sources to SupportEvidence-based and Emerging Practices.We are currently developing technical assistanceto the states on how you can support evidence-based practices such as medication management,supported employment, and family psycho-education. Available options include managedcare options in 1915(b) programs where statescan use the savings they have accrued through amanaged care approach to provide services thatwould not normally be covered with a state plan.

The basic parameters that Medicaid asks of anyservice are:

• It must be a medical service that isnonduplicative. Therefore, the servicecannot replace the responsibility of anotherfederal agency.

• The service must be provided to a Medicaid-eligible person.

• There has to be evidence of a free choice ofqualified providers.

• The service has to be in an amount,duration, and scope sufficient to achieveits purpose.

• There has to be comparability of servicesacross populations.

• There has to be a reimbursementmethodology that is consistent with theeconomy, the efficiencies, and the quality of care.

Based on the above criteria, the question iswhether Medicaid will pay for evidence-basedpractices? The answer is maybe. Here’s a look atsome of the issues for some practices:

• Assertive community treatment is a well-established model with more than 30 statesconducting programs. At least 23 of thesestates are using the Medicaid program tofund it in some way. States took numerousapproaches to obtaining funding. Some haveobtained funding under the rehabilitationoption, while others have combined otherstate plan options such as clinic services andtargeted case management.

• Medication management. The description ofthe practice says that nonphysicians conductsome monitoring activities. Under Medicaidprograms, we need to know who is doing thatmonitoring and whether or not that practiceis within your own state practice act.

• Family psycho-education. We have to besure the Medicaid beneficiary is the primarytarget for the intervention. The point atwhich family psycho-education treatmentfor a family member who is not Medicaid-eligible begins to become an issue. This is abig issue in children’s services. For example,when does the treatment of the family unitbecome a substance abuse treatment for dad,who is not Medicaid eligible?

• Supportive employment. We do not pay fortraining, but we can pay for the supportsaround it.

• Integrated treatment of co-occurringdisorders. This is a good example of whereclinical practice and insuring coveragepolicy do not match very well. The practiceof delivering treatment for multiple, co-occurring disorders in a single site isoutside of the Medicaid parameter. So thecoverage policy based on clinical practiceis sometimes quite tricky to figure out.

Mid-term Financing Strategies. Demonstrations in the President’s 2004

Budget. There are a number of Medicaiddemonstrations specifically referenced in thepresident’s budget:

• The “money follows the person” initiative,where Medicaid would pay at 100 percentof the slots per person for one year as longas the state would pick up that cost on anongoing basis in the subsequent years.

• Respite care for children and adults.

• Alternatives for residential treatmentfacilities for children.

• Maintaining independence within the workprovisions, which we are trying to find a wayto apply to the mental health population.

33

Demonstrations in the President’s CommissionReport. There are currently two proposeddemonstrations. The first is a demonstration overfive or 10 years that would look at building acommunity-based system for persons in institutesof mental disease where the money being spentcan follow the individual. I am not sure exactlywhat model we will eventually try to develop andpropose. But I do have to note that whatever themodel or method, it has to be a true demonstrationand not one that simply cost-shifts what iscurrently being spent by the state to thefederal government.

There also is a demonstration proposedfor self-directed supports and services.Hopefully we can find a way to giveindividuals with mental illnesses morecontrol over the resources available. Oneexample is looking at the rehabilitationoption as an alternative to day treatment.For example, under a demonstrationproposal, you could cost funds thatotherwise could not be matched and takethe money that Medicaid is currentlyspending on day treatment to allowindividuals to self-direct their rehabili-tation benefit.

Long-term Financing Options.What is really going to be required for us

to move the mental health agenda and therecommendations of the report is the waythe financing is done. The commission hadtwo strong recommendations here:

1. As part of the national debate anddialogue on Medicare/Medicaidreform, issues of importance to themental health community must beincorporated. Within care reform, we need a distinction between acutemedical care and long-term care. Inthe long-term care process, we need to get away from trying to medicalizethe process so that if you want to, for example, develop a peer supportmodel, you do not have to develop five layers of sign-off in order for it to occur.

2. Medicaid and Medicare, as well as privateinsurance programs, must address thedelivery of mental health care. Medicare orMedicare and public funding cannot do italone. Hopefully, as we have this continueddialogue, we can get to a place where wehave agreements on the covenants offinancial participation to support the service delivery system for people withmental illnesses.

Financing Mental Health Services in the Future


34

The New Freedom Commission’s finalreport presented us with the vision of anational mental health care system for

adults with serious mental illnesses and childrenwith emotional disturbances that is unified,consumer-driven, and focused on recovery. Thisis a beautiful vision embraced as a necessity by all of us here. Our challenge and the theme ofthis symposium are transforming this vision into reality.

The first step in the process is to understandwhat transformation means. We are engaged intransforming our capabilities to better conquer

mental illnesses throughincreased treatment aswell as strategic andtactical crusades forprevention. Accordingto current research,transformation is a

continuous process without end. It is meant tocreate or anticipate the future. Transformation isnot accomplished through change on the margin,but instead through very profound changes inkind and in degree. These changes result in new behaviors and new competencies. Thus intransformation, we look at what we can do nowthat we were unable to do before. Transformationwas meant to identify, to leverage, and even tocreate new underlying principles for the waythings are done. Transformation is meant toidentify and leverage new sources of power. Once the process of transformation begins, a profoundly different organization emerges,including changes in structure, culture, policy,and program.

If we accept that transformation meansprofound changes in the form and function of ournational mental health care system, then how dowe effectively manage what amounts to majorchange at all levels of health care service? DavidNadler, one of our nation’s leading experts onorganization change, wrote, “The truth is thatchange is inherently messy. It is always

complicated. It invariably involves a massivearray of sharply conflicting demands, and despitethe best-laid plans, things never happen inexactly the right order. And, in fact, few thingsturn out exactly right the first time around.”Most importantly, the reality of change in theorganizational trenches defies rigid academicmodels as well as superficial management fads.Why? Because change in real organizations isintensely personal and enormously political.

This is a realistic overview of systemstransformation. It will help us navigate the roughwater ahead if we can accept that change willtake time, we will have false starts, and it willrequire massive amounts of collaboration andoccasional relinquishment of traditionalphilosophies and turf.

This brings me back to my original questionabout how can we effectively manage transfor-mation. I think we should approach it in thesame way we approach other advances in healthcare – by looking to research, by examining whatpractice has proven effective.

There are several examples of effectivetransformations within large systems that canhelp guide us at the federal, state, and local levels through the necessary changes ahead. I amgoing to focus on one particular example: DavidLawrence, former CEO of the Kaiser PermanenteHealthcare System, recently led KaiserPermanente through systems transformation that is relevant to our challenge. KaiserPermanente is a loosely governed collection ofautonomous, local health care programs alliedwith local medical groups. Its mission is todeliver high-quality, affordable health care to itsmembers and communities through innovativedelivery systems. It also is heavily involved inresearch, particularly in studying the outcomes of treatment among different populations. It traditionally has had a highly politicizedmanagement culture with decision-making

Implications for Implementing the Final Report’sRecommendations for Systems TransformationA. Kathryn Power, M.Ed.Center for Mental Health Services

Transformation was meant toidentify, to leverage, and to evencreate new underlying principles

for the way things are done.

35

rooted in consensus rather than control. This isall very similar to the framework of our nationalmental health care system.

In the early 1990s, Kaiser Permanente wasforced by external economic forces to undergosystem transformation as a condition of survival,and this transformation is still ongoing. Lawrencelooked back on the years of change managementto compile 10 lessons from the battlefront. I amgoing to discuss these observations in terms ofwhat the states, the federal government, localauthorities, and all the constituency groups cando to change and manage the change withintheir mental health care systems.

Lesson one: Do not expect people to embraceeasily the need for change. We all acknowledgethat a very serious impediment to change is thatpeople will resist doing things differently untilthey personally come to accept that radicalchange is needed. Lawrence was not able to buildthis sense of readiness until after he came upwith the data that forced the people involved to recognize, accept, and own the problems and solutions. The lesson he learned was thatreadiness comes through a process of educationand personal insight.

I think some of the research we have seen atthis symposium has helped build that insight. For states, this means coming up with hard andfast facts about consumer needs, about serviceprovider capabilities and capacities, and the gapsbetween the two. States can use this informationto energize the public as well as the health carecommunity and to argue for the additionalresources needed to support the most pressingprevention or treatment needs.

Lesson two: Sometimes it is better to experimentthan to plan. Traditionally, Kaiser Permanente had been a risk-averse organization. We can say the same thing about the federal and stategovernments, which are extremely reluctant toinvoke public criticism. Lawrence came to therealization that systems transformation demandsthat organizations become more willing to takerisks, to fail, and to learn from their mistakes.States, as well as the federal government, need to take risks in developing new delivery systemsand then in forming new collaborations with the tools at hand.

One way that SAMHSA intends to encouragea culture of innovation at the state level is byrestructuring its mental health block grants into performance partnership grants. Under this proposed structure, states will have greaterflexibility in administering our block grantprograms. In return, however, we will be askingfor greater accountability in the progress beingmade by states in serving the mental healthconsumers. States will respond annually to acommon set of mental health performancemeasures already agreed to by SAMHSA andstates. The new commission advocated thisapproach under goal two when it called forproviding incentives to the states by grantingincreased flexibility in exchange for greateraccountability and improved outcomes.

Lesson three: Pay close attention to the timing ofchange. In retrospect, Kaiser Permanente admitsthat its leadership frequently mistimed the paceof change because it was dealing with verydifficult issues both internally and externally.“The unavoidable fact,” said Lawrence, “is that in health care, it takes a long time to figureout what to do and how to do it well.” Changerequires very careful pacing, which he defined as “moving simultaneously in a variety of areasand keeping each area progressing so that the combined cadence does not tear the organization apart.”

Pacing mental health care transformation will require states to establish priorities forservice changes. They will need to do so incareful collaboration with all of the stakeholdersinvolved so there is broad-based acceptance and support for which issues need to be addressed first.

Lesson four: When the need to remove people becomes clear, do not put off the inevitable.Lawrence notes that not all people adapt well tochange. Some are not going to mesh well withthe new structures, processes, or cultures. Statesmay need to replace people in senior decision-making positions with those less wedded totraditional methods, services, and practices. Itmay be necessary for states to abandon alliancesthat impede progress and forge differentpartnerships to support the change process itself.

Lesson five: You cannot succeed without a seniorteam that thinks and acts like a team. Within theSubstance Abuse and Mental Health Services

Implications for Implementing the Final Report’s Recommendations for Systems Transformation


36

Administration, we have a strong leader inadministrator Charles Curie. He sets ourdirection and gives us a framework for actionthrough the SAMHSA priority matrix. He haspulled together an executive team that unites all three centers within SAMHSA as a singleresponsive organization. In addition, I chair anaction agenda work group. This team, along with other important partners, is going to makerecommendations about ensuring that the federal government implements the goals and recommendations of the New FreedomCommission. We also are looking at public-private partnerships that can help shape the newparadigm of organization and services support forconsumers in need of mental heath services. Thegoal of these partnerships will be to ensure thatconsumers will be able to access the care theyneed through any door in any system.

States need to create their own action teams to guide systems transformation. Like the SAMHSA team, it needs to containrepresentatives from different areas that have a key stake in mental health care outcomes,including children’s services and a variety ofother areas. Individuals with serious mental

illnesses need more than treatment. They needemployment, education, and housing. In otherwords, they need support systems that often arenot recognized as part of the mental healthtreatment system. Although there is currentlysome relationship between the mental healthsystem and these agencies, the New FreedomCommission report is emphasizing the need for usto intensify those relationships so everyone worksmore closely together. Engaging all keystakeholders and planning a change process willhelp ensure that they recognize, accept, and ownthe problems and devise the solutions together.

Lesson six: Enlist your board of directors asactive partners in change. Lawrence discovered an ally in systems transformation in KaiserPermanente’s board of directors. He exposed theboard to major issues and to developments andtrends within the health care field. He shiftedtheir focus from operational details to strategicissues. In so doing, he created a knowledgeableand aggressive partner for change.

The board of directors for the federalgovernment is the Congress, just as the board of directors for the states is the state legislature.

37

Engaging the legislature is critical to the changeprocess and must be at the forefront of plannedefforts. In addition, legislation authorizingcommunity mental health block grants mandatesthat states establish a mental health planningcouncil that will review and make recommen-dations concerning state mental health plans. In many respects, this planning council can actas a board of directors for the state’s behavioralhealth care authority. Its members represent your shareholders. You can plan a critical role inidentifying and promoting action within priorityhealth areas. Expanding and involving yourcouncil at the state level as a sounding board anda crucial source of information and support onvery difficult decisions is most appropriate.

Lesson seven: Give coherence to the changeprocess by clearly articulating a central mission and a consistent set of themes. David Lawrence used to think that “vision” was just an empty term.Experience taught him very differently. In the health care system, each locality and eachconstituency had traditionally set its own agenda,pursued its own set of interests, and developed its own themes. States need to eliminate thisfragmentation of purpose by creating a compre-hensive state transformation agenda built aroundgoals and objectives tied to a common missionwith the consumers at the heart. The missionshould epitomize the ultimate goal, leading tobroad-based discussions on how to achieve it.

One case history about system transformationdescribes a rather vivid statement projected bythe CEO of a different health care system. Shewanted to drive her organization toward a focuson wellness, prevention, and delivery of patientcare and away from institutional settings. Hervision statement was: “We will be successfulwhen I can walk down the halls of the hospitaland there are no patients.”

We will be successful when we have a systemgrounded in recovery, one that reflects a belief in recovery, demonstrates a commitment toproviding recovery-based services, and, throughits actions, inspires in consumers and theirfamilies the hopefulness of recovery.

Lesson eight: Even though the content of change may be radical, the building process must be methodical. Lawrence admits that one of hisorganization’s initial mistakes was to set out to doeverything at once and to do it well. It did not

work. The primary reason it did not work wasbecause he had failed to assess his organization’scapacities. Most theories of change do notsufficiently emphasize an initial analysis of anorganization’s capacity. Where is the organizationin relation to where it has to go? Which capacitiesmust be added or enhanced before the organi-zation can get there? How should each buildingblock be put into place and in what sequence?

The answers to those questions about how you can, in fact, make an assessment of yourorganization’s capacities should be the foundationof a comprehensive state plan called for in theNew Freedom Commission report. In addition,those plans should reflect accountability throughperformance measures. Kaiser Permanente is anonprofit organization, so it could not use profitas a performance measure. However, Kaisereventually was able to create a plan thatinstituted performance measures tied to specificoutcomes. It linked detailed objectives to growth,cost, quality, and customer satisfaction. Neitherthe federal government nor the states differ fromKaiser in the need to incorporate each and everyone of these factors in their comprehensivemental health transformation.

SAMHSA is looking at ways it can help thestates develop more comprehensive plans. We arein the process of developing mental health stateinfrastructure grants, or SIGs, to support states inthis effort. As proposed, SIG resources wouldbecome available, hopefully, in fiscal year 2004.

Lesson nine: Think of change as a fluid anddynamic campaign that must be waged simultaneouslyon a variety of fronts. It is vitally important to seechange in terms of a campaign. It is not only thecontent and planning that are important. It alsois how a corporation goes about winning peopleover. As Lawrence noted, an organization has to use a range of tactics, all aimed at winningvery broad support for a common vision. It isimportant to embrace the concepts of branding,social marketing, and public relations as it relatesto this campaign.

States need to build their own mental healthcoalitions within their local and neighborhoodcommunities. They need to engage participationand support among all key stakeholders,including those who may not be considered tohave an equal stake in achieving a mental healthvision. These stakeholders, of course, will include

Implications for Implementing the Final Report’s Recommendations for Systems Transformation


38

criminal justice, education, faith-based organizations, businesses, and community leaders. Systems transformation cannot beachieved at any level without recruiting a lotmore foot soldiers to fight at the front lines.

Lesson 10: This race may not have a finish line,so keep looking for a reason to stop and celebratealong the way. I do not think changing a mentalhealth care system has a finish line. It mustcontinue to evolve as we learn from the research,as we move science to service, and as we respondto the changing needs of the consumers we serve. However, we still need to find reasons tocelebrate progress along the way. I think this isan important item not just for mental healthproviders and for mental health consumers whomight get discouraged by the pace of change, but it is important for others as well. The more often we can trumpet success in treating mentalillnesses, the more apparent it will become tolegislatures and to the general public that mental

illnesses are just that:illnesses that can be cured,treated successfully, or at least mitigated. Mostimportantly, this lessonreinforces the hopefulness

in recovery that people currently living withmental illnesses and their families need to hear.It helps create more positive messages that inthemselves will build greater momentum.

The mental health care system is not a single,isolated corporation. It does not have a profit-making bottom line. It does have, however,customers who count their cost in terms ofhuman misery, and it does take real resources todeliver quality care. Changing the current mentalhealth care system will lower their cost, and then we as a collective nation will profit fromincreased human joy, less suffering and sorrow,and general improvements in social well-being.

We need to embrace the idea that problems are opportunities dressed up in work clothes.Many of the problems that the New FreedomCommission identified exist because thesolutions are either not evident or they are noteasy to accomplish. Some, such as the stigmathat prevents persons from seeking the mentalhealth treatment they need, are rooted in age-oldignorance and fueled by myths and fears. Others,such as the fragmentation of services amongfederal and state agencies, stem from the gradualand well-meaning evolution of services thatfollowed upon new advances in science and newfinancing mechanisms.

Our search for solutions to these problemsoffers us incredible opportunities for innovation,collaboration, and success in improving mentalhealth care across the nation. I am veryprivileged and very excited to be a part of thisgreat crusade to alter forever and continuouslyour mental health care system so that it reflectsthe key promise of recovery for each and everyAmerican.

We need to embrace the ideathat problems are opportunities

dressed up in work clothes.

Building Coalitions for Better Outcomes inMental HealthMark L. Rosenberg, M.D., M.P.PMargaret McIntyre, M.B.A

Task Force for Child Survival and Development

There are many challenges to implementingthe report of the New FreedomCommission on Mental Health. The first

challenge is the gap between known science andpractice – between what we know and what weactually do. Mental health care delivery mustchange, not only to close that gap, but also to

close the gaps between what we used to do and what we are doing now and between whatwe are doing now and what we should be doingin the future.

Because mental health deals with challengesthat are very complex, it cannot be addressed inisolation. Overcoming the challenges requires

39

that we work very closely not only with theprofessionals who deliver this care but also withthe consumers, the purchasers, and the otherproviders. All these stakeholders have to be atthe table. Many different talents must cometogether from many different areas – frominvestment banking to psychiatry to nursing,from the scientists to the practitioners. We haveto work together if we’re going to be successful.

One important lesson we have learned inpublic health is that an independent task forcethat can take on the role of a neutral convenercan play an important role in bringing abouteffective collaboration. Good collaboration does not happen by itself. It is a team processbringing together people from differentdisciplines to share their perspectives and toprovide the creativity needed to overcome themany challenges that inevitably arise. Thisrequires leadership and strong facilitation. When a coalition works, what can be achievedcan far exceed anyone’s expectations.

Bringing together the right people alsoenhances learning. Because we are working in aworld that is consistently changing, successful

coalitions require continuous learning. We must be diligent to find ways to improve mentalhealth practices.

The first coalition that the Task Force forChild Survival and Development createdinvolved former President Jimmy Carter. Whenhe left the presidency, he and Bill Foege, the firstexecutive director of The Carter Center, startedlooking at the gap in childhood immunizationsbetween the developed and developing world.Eighty percent of children in the developedworld were immunized against the commonchildhood diseases. But in developing countries,the rate was less than 20 percent. If this gapcould be closed, the lives of 3,000 children couldbe saved every single day. So, the visionaries whosaw the possibilities went to the organizationsthat were involved – UNICEF and the WorldHealth Organization – and asked how to beginwork on closing the gap.

Initially, they were met with resistance. Thepeople at UNICEF and WHO said they raised$35 million a year for immunizations and thatwas as good as it could get. Bill Foege looked atthis and realized that these organizations were

Building Coalitions for Better Outcomes in Mental Health


40

not collaborating; they were competing. Instead,Bill asked, what if we all worked together to raisemore funds and close that gap? The organizationsagreed to come together, and with leadership

support from the very top of these organizations, they built a coalition thatincluded UNICEF, WHO,the World Bank, the

Rockefeller Foundation, and the United NationsDevelopment Programme, forming the TaskForce for Child Survival. In the first year, they raised $100 million. The second year, they raised $200 million. By the sixth year, they had raised more than a billion dollars, andthe immunization levels of children around theworld were at 80 percent. We learned that a clear vision and commitment from top leadershipare critical to be able to shift potential partnersfrom a competitive position to collaboration and cooperation.

The task force also launched the Mectizan®

Donation Program, another program in whichThe Carter Center played a very important role.Merck developed a drug to prevent heartworm inpets but found that this drug also could get rid ofa blight in Africa, a parasitic disease called riverblindness. This disease infects people through thebite of a black fly that lives on rapidly flowing

rivers. If a person is infected, the parasitemultiplies in the blood and over years creates anintense inflammatory reaction in the eye thatleads to blindness. In many parts of WesternAfrica, all the old men were blind from riverblindness, and the young boys could not go toschool because they had to lead the old menaround. Old, in this case, meant over 40.

Merck came to the task force and asked forhelp in distributing this drug. A lot of people saidnot to get involved because joining forces with apharmaceutical company would be like workingwith one’s opposition. But the coalition said“yes,” and last year the Mectizan DonationProgram celebrated the 15th anniversary of thiscoalition. It now has treated more than 250million people in Africa. The young boys aregoing to school, and the old men are able tofarm. We learned from this project that a trustedneutral convener can bridge the gap betweensuspicious partners, especially when you havedifferent perspectives like those of pharmaceuticalmanufacturers and public health organizations.

We have had a number of other coalitions thathave been very effective and have provided uswith valuable lessons. In suicide prevention, for example, we learned that a coalition is an effective way to develop and implement anational strategy. In fact, the President’s New

FreedomCommission onMental Healthrecommendsforming a national-level private-publicpartnership toadvance the goalsand objectives of the nationalstrategy for suicideprevention. Andthis private-publicpartnership wouldemphasize buildingvoluntary coalitionsto address suicideprevention incommunities andwould include localleaders, businesses,school personnel,

Successful coalitionsrequire continuous learning.

41

and representatives of the faith community. The main purpose of collaboration is to do somethingtogether that is not possible when we workindependently.

Coalition building is not easy. Collaboration isfundamentally about the quality of relationships,and we think of a coalition like a marriage – it is easy to get into a marriage, but it is difficult to make it work. Coalitions are much the same,especially when bringing people together fromdifferent sectors with different needs, desires,outcomes, and organizations. Building successfulcoalitions takes energy. It needs moremanagement attention than our individualorganizations. But so frequently, we givecoalitions even less management attention than we give our individual organizations.

There are four areas a coalition leader shouldfocus on to build successful partnerships:

Strategy. Setting strategy builds a clear valueproposition for the coalition as well as for eachmember. The strategy also should define specific,agreed-upon objectives so that the membersunderstand their common purpose. A coalitionmust stay focused in scope so that the task is manageable.

Social Capital. This is the glue that holds acoalition together: the social connections andrelationships among the members. Developingthe ability to resolve the conflicts that willinevitably arise within the coalition is oftenoverlooked in starting a coalition. It is importantto foster trust and open communication andeffectively manage conflicts and disputes.

Structure. It is important to establish thecoalition’s structure and how it will be managedso that the roles of each organization are clear. Italso is important to have a plan addressing howthe coalition itself will be funded. Without thesetwo components in place, it is difficult to sustainthe coalition for any length of time. It also iscritical to pick the right number and mix ofcoalition members to maximize the coalition’seffectiveness. If there are just a few people in thecoalition, it is fairly easy to make decisions andcoordinate. But if the number is too few, we riskexcluding key constituencies that can obstructwhat we want to do and create a barrier.

Management. The coalition must haveaccountable leadership and effective resourcemanagement. It also must have a clear operatingplan and measurement of outcomes.

In addition to the four areas just mentioned,another important way to think about a coalitionis its life cycle. Activities vary depending on thestage of development of the coalition. The phasesand core activities in each include

• Preformation. An initial scoping of the issues and needs must occur. Activitiesinclude establishing what the coalition willaddress and identifying the critical playerswho should come together.

• Formation. Once the partners have beenselected, the coalition will formalize a projectplan, rules, roles, and procedures.

• Implementation. In this phase, the coalitionbegins taking action based on priorities andimplements the project plan.

• Maintenance. During this time, the coalitionreflects on the health of the coalition.

• Completion phase. At the completion of the project, the coalition can reflect onlessons learned and evaluate the results ofproject efforts.

Effective collaboration is like the art ofpsychotherapy. They both depend on skills inanalyzing and developing relationships. Theseskills cannot be transferred in a brief lecture,through a book, or by reading a handout. Theymust be built over time and integrated into apractice. In addition, to build these skills, weneed other people to help us overcome our ownblind spots, so it often is useful to have an adviser– like a supervisor in psychotherapy – to helpwith the process.

In conclusion, the mental health communitystands at a great spot today, a spot where it hasthe chance to use this commission report as aplatform for important improvements in mentalhealth care. And to implement that platform,effective partnerships and coalitions will becritical elements for making progress.

Building Coalitions for Better Outcomes in Mental Health

Que

stio

ns &

Ans

wer

sThe President’s New Freedom Commission on Mental Health: Transforming the Vision

42

QI am troubled by theabsence of the concept ofcultural sensitivity in the

talks. How are we going to dealwith people who are likely to fallthrough the cracks because ofcultural differences and gaps?

ADr. Knight-Richardson: I was chairman of theCultural Competence

subcommittee. We maderecommendations and consider-ations to the other subcommitteesto consider the aspects of cultureand ethnicity. We understand thatwe have not done enough in thiscountry. We understand that peopleof color and minority ethnic groupstruly are not serviced as well as they might be. We have maderecommendations in order to cometo some solutions in that regard.

I think the solution, however,will not be just the recommen-dations of the committee. We have a problem with racism in this country, not just in mentalhealth. So this issue needs to beembraced in our hospitals, teachinginstitutions, and social organizationsacross this country. Until we address theproblem of racism, we will not effectively addressthe problem within mental health.

AKathryn Power: We are looking at howto get a mental health work force that is not only interested and engaged

in mental health care but that reflects theconsumers that we serve. CMHS just hosted an

African-American summit in Washington,which was the first time that we had African-Americans come in as a group to talk aboutspecialized needs and the approaches we need to consider. I think we need to do this across all ethnic groups. We need to concentrate onwhat the cultures are and how we adapt that in our mental health care systems. Furthermore,we need to try to develop the work force of the future.

43

Postscript

The President’s New Freedom Commissionon Mental Health was chartered toaddress the problems in the current

mental health service delivery system. It comes25 years after The Carter Commission on MentalHealth. Both were formed to assess the conditionof the public mental health system and to addressthe needs of people who have mental illnesses.This comprehensive review brought to lightmany problems facing our nation, including the availability and quality of services for peoplewith mental illnesses, as well as the lack offunding for mental health services. The findingswere troubling, but a thorough appraisal wasmuch needed. The report’s findings andrecommendations are useful for guiding thefuture of the public mental health system.

The Carter Center Mental Health Program waspleased to focus on the report for the NineteenthAnnual Rosalynn Carter Symposium on MentalHealth Policy. It is extremely important that theentire mental health community take action onthese findings. Speakers and panelists reviewedthe advances that have been made in research,described ways of translating this knowledge intopractice, and discussed possible policy changes tofacilitate system reform. After hearing from theexperts in their respective fields, the participantsof the symposium broke into work groups toidentify and address the challenges and opportu-nities that lay ahead. The symposium concludedwith participants offering ideas for building the necessary elements to promote action. The President’s New Freedom Commission onMental Health and its report offer a platform, butthe biggest challenges lie ahead. The hard work

is just beginning, as we start to examine the waysin which we can act upon these identifiedproblem areas.

Five themes run throughout the final report of the President’s New Freedom Commission on Mental Health: recovery, integration of mentalhealth and physical health, fragmentation, translatingscience to services, and stigma. By focusing onthese central areas, it is more manageable totackle the challenge of finally providing peoplewith mental illnesses the treatment services they deserve.

The concept of recovery has been one of themost promising developments in mental health.As Rosalynn Carter observed during a meetingwith the commissioners in February 2003, “Wehave made enormous strides in the science andresearch of the brain, as well as of treatmentservices that promote recovery.” All of this wasunimaginable years ago. But we still have roomfor further successes, and recovery could benefitfrom the following action steps suggested by theworking groups:

• Define recovery: A clear definition ofrecovery is needed to communicate and acton the vision of recovery or set an actionplan for systemic change. Defining recoveryas the ability for a person to function in theirinterpersonal relationships and on the joband enjoy their life, instead of debatingwhether or not the illness is completelyeradicated, is essential and may require newresearch or the better use of existing researchand data to establish standards and tointegrate these standards into indicators.

Charge to the Work Groups

Five themes appear throughout the final report of the President’s New Freedom Commission on Mental Health:recovery, integration of mental health and physical health, fragmentation, science to services, and stigma.Identify action items to address the challenges and opportunities for all five themes.

PostscriptThomas Bornemann, Ed.D.Lei Ellingson, M.P.P.The Carter Center Mental Health Program


44

• Redefine the funding system to supportrecovery: Currently, recovery and billingsystems are mismatched. Recovery measuresmust be established and linked to financingto provide an incentive for people to makerecovery and resilience part of the system.This can be achieved by working withpurchasers to develop more flexibility for preapproval processes that will support thecontinuum of care required for recovery or byshowcasing the cost-effectiveness of aligningfunding with an emphasis on recovery.

• Empower the consumer and familymovement and peer support: Peer support isa model recovery strategy for consumers thatcan help reduce the cost of recovery care.Recovered members can be an alternative,empowering, and less expensive source ofemployment in the mental health system.

• Increase public awareness: The notion of recovery is still not well-known orunderstood within the mental health systemand throughout the community. In order tochange decision-making, policies, and buildcoalitions based on common vision and acommon theme, a shift must occur in howour culture views these problems. Thechange should begin by featuring faces of recovery. In addition, to increase

understanding and support of mental health, education can be directed atcommunities by: reaching out to communityleaders, developing a speaker’s bureau tomove out into the communities, formingcoalitions to campaign for mental healthissues, and involving the state mental healthauthority for support. To help raise publicawareness, useful action steps would be tobetter use electronic communications, createa national recovery symbol such as the AIDSred ribbon, and make sure we do not forgetabout minorities and ethnic groups whenaddressing audiences.

• Reach out to professionals, facilities, andinstitutions outside the traditional mentalhealth system: Without understanding that recovery is an option, underservedpopulations may not present themselves to the mental health system. Therefore, it is important to not only involve theprimary health care system but also reach outto the general public, such as communityorganizations and schools, with the messageof recovery.

• Transform education and training formental health professionals: Currenttraining and academic education has notkept up to date with the notion of recovery

Postscript

and resilience. To ameliorate this situation,we must develop curricula based aroundrecovery in academic settings and includerecovery processes in the standards of accred-itation as well as implement continuingeducation requirements. Successful educationand training programs can be used as models.To support these additional programs,funding sources must be developed.

• Build the science supporting recovery:Especially important in the achievement ofsupport and funding is the availability of realevidence that recovery works and is possible.We must become aware of existing researchand use it to drive standards and processes forrecovery. The addiction field can be used as asuccessful model.

• View this as a cultural transformation:Learn from other cultural transformationslike the feminist movement that the visionof recovery involves a profound change inthe language we use. We must abandon thelanguage of the permanency of mentalillnesses while developing a new languagethat is more pro-recovery.

• Garner community involvement foreffective recovery: Recovery goes beyond the mental health system to deliveropportunities required for people who wantto recover, such as employment and housing.Relationships must be garnered in thebusiness community to supply initial jobs fornewly recovered consumers.

The integration of mental health and physical health is a crucial next step in the fight to overcome the obstacles that people withmental illnesses encounter every day. To ensureadequate mental health care, the followingaction steps are recommended:

• Integration must be tied to funding:Integrative health care must be tied to anongoing system of funding to be sustainable.Without that, progress beyond modelprograms and research projects will not beachieved. Another possibility for receivingnecessary funding is to work with Medicaidand other payers to support the creation of teams, both mental and physical healthcare and social services, around patients.Strategies for people who are uninsured

should also be taken into consideration.Further, primary care physicians will notattend to mental health issues if they arenot fairly reimbursed for their effort.

• CDC survey should include mental health:Mental illnesses should be tracked andtreated like other illnesses by the CDC sothat the mental health field can benefit fromtheir epidemiological expertise.

• Educate all stakeholders that mentalillnesses are real, how they can recognizeand address mental health problems, andwhat services are available: Generalists suchas family physicians, primary care physicians,and nurse practitioners must be educated onhow to recognize mental illnesses in theirsettings. These professionals are most oftenthe first contact for people with mentalillnesses, and they must be accurately awareof mental health problems and provided withtools for effective treatments. In the samemanner, outreach to nonmedical settings,such as schools, the justice system, faith-based organizations, and communityorganizations, with awareness campaigns is needed.

• Develop coalitions for common co-occurring illnesses: Coalitions and alliancesbetween the mental health system andorganizations that deal with other illnessesthat have a high co-occurrence with mentalillnesses, such as Alzheimer’s, diabetes, andepilepsy, can help drive greater integration ofphysical and mental health.

• Provide education and training: In additionto training our primary care practitioners,especially pediatricians, to identify mentalhealth disorders and make appropriatereferrals, we must encourage medical schoolcurricula to include more cross-disciplinarytraining. Partnering with medical associationscould aid in educating and disseminatingcritical mental health information.

• Learn from other health care models:Models already have been implemented thatshowcase effective delivery of multidisci-plinary care. A helpful example would bechronic disease, social work, and hospicework models that place the patient or

45

46

consumer at the center of treatment andensure that resources are mobilized to addressthe full needs of the patient.

• Bridge the differences between the mentaland physical health communities: Thecultures of mental and physical healthcommunities differ, which contributes to the difficulty of integration. However, byaddressing the differences in the languageuse (such as “patient” with HIV as opposedto a “consumer” with depression) and thevariation in practice models (40-minutesessions as opposed to six-minute officevisits), a necessary common ground can bebuilt between the two fields.

Fragmentation has long been an enormousbarrier to progress in the mental health field.Integration is not only necessary within themental health community itself but also with the physical and public health fields. To facilitatethis process, the following actions are suggested:

• Develop state strategic plans to reducefragmentation: A first step should be involvingthe National Governors’ Association orsimilar representative organizations tocoordinate all the various stakeholders sothat care can be centered around individualsinstead of in fragmented silos. The push must be made from the bottom up as well asthe top down. Another possible plan is tohave statewide conferences and summitmeetings that include the governor,legislators, health professionals, communityorganizers, and consumers focusing onreducing fragmentation.

• Develop better funding streams that crossagencies: Because funding issues are drivingcompetition and acting as one of the keybarriers to eliminating fragmentation, wemust join a unified vision that includes atransformational approach (as opposed to anincremental approach) and a financial modelthat showcases the costs of fragmentation vs. the costs of collaborative care as a basisfor advocacy.

• Identify areas of fragmentation: Areas offocus include fragmentation that occurs inprevention, across the life span (from childthrough old age), across mental disorders,and in hospitals (where different departments

work independently of each other instead of coordinating care for the patient).Fragmentation is especially evident amongthe federal, state, and local levels of agenciesand includes restrictive legislative languagethat exacerbates fragmentation.

• Learn best practices: Sharing information,including the best practices on successfulprograms, can be achieved by usingcommunications technology (such as theInternet) and learning from outside themental health community.

• Drive information out to the local level:Providers in the field must understandchanges in funding as well as the opportu-nities and flexibility of services accessible tothe community, such as possible Medicaidwaivers that may be available.

• Create a federal advisory team: Developinga diverse team responsible for advising andaiding states in the development of theirstrategic plans is important. This group couldserve to brainstorm creative ways to use state and federal funding across barriers andfragmentation to develop a more cohesivesolution. Similarly, a model state Medicaidplan could be initiated by creating collabo-rations between Medicaid and mental healthdirectors to brainstorm a plan that states canuse to develop their own strategic plans.

The idea of translating science to service isanother important theme that needs improvement.Currently, the gap between the level of scientificknowledge and implementation is 15 to 20 years.This gap must be shortened in order for policypractices to match the knowledge gained fromresearch. To help mental health services reachtheir potential, the following action steps are recommended:

• Translate science into service: It is crucialto have people with the skills to work withfront-line organizations translating scientificresearch into something they can put intopractice. It is important to integrate researchfrom multiple areas to address communityand individual needs as well as to exploreand report the social relevance of researchfindings instead of just the research results.Encouraging federal efforts, such as collabo-rations between SAMHSA and NIMH and


47

their respective initiatives of “Center forMental Health Services Moving Science toServices” and “Bridging Science andService,” represents concrete progress andneeds full funding and support.

• Communicate between and among variousstakeholders: Information must be shared,not only from science to service but fromservice to science. Consumers, families, and other stakeholders must be involved.This process could be aided by havingscientists, trainers/educators, and programdesigners/developers work in the same settingso there are opportunities for collaborationand closer interactions. Similarly, organizingdialogues among people who are doingresearch, providers, and consumers couldassist in mutual learning from each other.Lastly, the Internet is a valuable tool forinformation, knowledge, and experiencesharing.

• Develop strategies to produce newknowledge: All types of research, not onlyrandomized clinical trials but also mixedmethods that would include the life stories

and experiences of mental health consumers,need to be explored. Possible avenues towardachieving this task of driving science toservices include: funding multiple ways of obtaining knowledge, which would speedup time to service and increase the socialrelevance of findings; advocating formultisystemic change in how research isfunded through NIMH and SAMHSAgrants, state agencies, and research centers;and broadening the scope of research toinclude sociological, psychosocial, social-environmental, and sociopolitical factorsthat can affect mental health (e.g., povertyand racism).

• Build a research agenda: Researchersand stakeholders much join together fordiscussion and the building of a researchagenda that supports recovery. Possibleactions to be taken could includeimplementing change management strategies and programs into scientific organizations to include the idea of recoveryin research models.

Postscript


48

• Develop a clearinghouse for information:Research information must be easily disseminated in a form and style accessible to front-line providers and organizations.Hence, it is important to simplify the ability for field personnel to gain researchinformation and to present the informationin a manner relevant to the field.

Reducing the stigma of mental illnesses hasgained much attention in the past years, butunfortunately stigma remains a great barrier inthe mental health field. Continued work isnecessary to overcome this barrier. For thatreason, the following actions are suggested:

• Showcase positive portrayals of people withmental illnesses: It would be advantageousto utilize the media and public programmingin order to put positive portrayals of mentallyill people before the public.

• Link to recovery: Research from Australiaindicates that permanency of mental illnessesincreases stigma, while the optimism ofrecovery reduces it. Thus, we shouldadvocate for the rights of people in recovery from mental illnesses to reduceprejudice and bias in insurance, housing, andoccupational opportunities.

• Understand the social aspects of stigma-tizing mental health issues: Basing ourpolicy on European social policy, which isbuilt around the concept of social inclusionof populations previously excluded, we couldreduce the process of stigma. Developingoutreach programs to marginalizedpopulations also will help.

• Normalize care for mental health: The lackof parity in insurance promotes the idea thatpeople with mental illnesses are less worthyof care than those with other illnesses. Bynormalizing the care we provide, we willnormalize the attitudes and consequentlyreduce the stigma that follows mentalillnesses.

• Develop a social marketing strategy: Aneffective strategy would guide widespreadpublic education efforts by ensuring thatanti-stigma campaigns are positivelypromoting recovery and not actuallyreinforcing the negative stereotypes they are trying to combat. Also important ischampioning the idea that mental illnessesare part of the human experience.

• Combat ignorance: In order to combat thestigma of mental illnesses, strong action andevidence must be supplied to the public and

49

policy-makers. This includes using science todispel the myths of mental illnesses, insistingon using proper language and terms whendiscussing mental illnesses, and beingproactive in correcting misinformation andmisuses of terminology.

• Learn best practices from examples ofovercoming stigma: Plans of action can be based on past examples of how otherdiseases, such as cancer and AIDS, overcame stigma.

Following the work groups, an open discussionwas held, moderated by Bill Emmet, the projectdirector for the National Association of StateMental Health Program Directors (NASMHPD).Emmet is the current campaign coordinator anda driving force behind the Campaign for MentalHealth Reform, which has been organized as the mental health community’s united voice onfederal policy. It is a unique organization, with its unprecedented collaboration of nationalmental health organizations, in the fight foraccess, recovery, coherence, and quality inmental health services. The campaign’s partnershave been brought together by a commonrecognition that the current challenges andenvironment present an unavoidable need, aswell as the best opportunity in a generation tomake a well-functioning mental health system a national priority.

With the goal of the Campaign for MentalHealth Reform in mind, members of the general discussion expanded on the action stepsdeveloped through collaboration in the workgroups. The following ideas are a sampling of thesuggestions made:

• Examine the social context of mental healthcare. For example, we know thatunemployment is the major marker fordemand for mental health services. It is

important to talk about and recognize thatthe focus must be on efforts that will lowerunemployment.

• Examine the major campaign currently beinglaunched in Europe to address the problem of what is termed “social exclusion.” This is a process by which community regeneration,health promotion, health services, andmental health services are packaged togetherin an effort to help people who are strugglingwith various illnesses or problems, as well astrying to prevent those circumstances.

• A significant part of this transformationprocess will be retraining providers early onwith the idea that mental illnesses touch thelives of virtually everybody. This message hasto be expressed and reinforced continuously,for as a society, there needs to be a firm andconsistent voice for change.

The President’s New Freedom Commission on Mental Health has focused the spotlight onsignificant problems within the public mentalhealth system but also identified six goal areas as the foundation for transforming mental healthcare in America. The commission further offeredspecific recommendations for achieving thesegoals. We are aware of the condition in which wefind our public mental health system, specificallyregarding the five main themes of the report:recovery, integration of mental health and physicalhealth, fragmentation, translating science to services,and stigma. The findings were troubling, but the work groups and open discussion from thesymposium have offered ideas to change theoutlook for the public mental health system. This is an exciting time, for it is now our turn for action. We must take these suggestions and execute them and keep going untilsignificant changes are achieved in the mental health system.

Postscript

51

Closing Remarks

Closing RemarksRosalynn CarterChair, The Carter Center Mental Health Task Force

It has been 25 years since the previous, and first, presidential commission on mental health, whichwas held during Jimmy’s administration. While I am gratified to help roll out the final report forthe President’s New Freedom Commission, it would have been preferable if additional

commissions had been formed during the last quarter century. Mental health is an issue affecting allAmericans and certainly is worthy of national attention from the highest office in the land.

The findings contained in the commission’s final report illustrate how terrible the situation hasbecome. The interim report declared the public mental health system is in shambles. The final reportasserts that the system cannot be mended. Reforms around the edges are no longer enough to ensurethat people with mental illnesses and their families get the treatment services they deserve. Instead, itsays that the entire system must be transformed.

Unfortunately, presidential commissions do not carry with them the means for implementing theirrecommendations. It is overwhelmingly the responsibility of the larger community to ensure that theissues identified stay in the forefront of policy-makers’ and the general public’s minds. It is up to all ofus in the mental health community to take the recommendations from the final report of the NewFreedom Commission and make sure that they are not forgotten, but are acted on and integrated intoour organizations’ activities. Government at all levels will be charged with the mechanics of thetransformation. Our responsibility is to help them where we can and to take the recommendationseven further than they are able.

Today we have explored how we as individuals and as part of our organizations can contribute tothis effort. Our challenge is for each organization represented here today to implement at least one ofthe recommendations from the New Freedom Commission’s final report. The Carter Center MentalHealth Program will follow up to track your progress.

The President’s New Freedom Commission report on mental health presents us with a hugeopportunity to reform a woefully inadequate system of care. As individual organizations, we candetermine what works and what does not and positively impact our communities. Working togetherunder the commission’s sphere of influence, we can create broad reforms and improve the quality ofcare for all Americans with mental illnesses for generations to come.


52

Rodolfo Arredondo Jr., Ed.D.

Dr. Arredondo is professor of neuropsychiatry at Texas Tech University HealthSciences with a secondary appointment to the Department of Health OrganizationManagement. He is the director of the Southwest Institute for AddictiveDiseases. Dr. Arredondo is a licensed professional counselor and a licensedmarriage and family therapist. He served on the President's New FreedomCommission on Mental Health. Dr. Arredondo is an appointee of Secretary

Tommy Thompson to the National Advisory Council for the National Institute on Drug Abuse. He is a gubernatorial appointee to the Texas Department of Mental Health and Mental Retardationwhere he currently serves as chairman of the board. Dr. Arredondo also serves as a consultant to theTexas Medical Association Committee on Physician Health and Rehabilitation and is appointed tothe American Cancer Society, Texas Region, Tobacco Control and Governmental Affairs committees.

Thomas E. Bryant, M.D., J.D.

Tom Bryant, trained as both physician and attorney at Emory University, chairsthe organizational management firm he founded, Non Profit ManagementAssociates Inc., in addition to conducting a part-time, health-related law practice.He is also the chairman of the Aspirin Foundation of America Inc. Dr. Bryantbegan his career in Washington at the end of the Johnson administration when he directed the Emergency Food and Medical Services Program of the Office ofEconomic Opportunity and continued as the director of the Office of Health

Affairs of the OEO, directing programs designed to improve the health of poor Americans. In 1977,he was named by President Carter as chairman and executive director of the President'sCommission on Mental Health, where he began a long association with Rosalynn Carter, whichcontinues to this day as a member of both The Carter Center Mental Health Task Force and theRosalynn Carter Institute for Human Development at Georgia Southwestern College in Americus, Ga.

Barbara J. Burns, Ph.D.

Dr. Barbara Burns is professor of medical psychology and director of the ServicesEffectiveness Research Program in the department of psychiatry and behavioralsciences at the Duke University School of Medicine. She also holds academicappointments at the University of North Carolina at Chapel Hill, the Universityof Arkansas for Medical Sciences, and the Medical University of South Carolina.Dr. Burns is a nationally recognized mental health services researcher with morethan 200 publications in this area. For nearly a decade at the National Institute of

Mental Health, she pursued a range of topics directed toward improving mental health care for all agegroups, but focused on community-based services. Dr. Burns prepared a review of effective treatmentfor mental disorders in children and adolescents for the U. S. Surgeon General’s Report on MentalHealth and is currently conducting research on the dissemination of effective clinical interventionsfor youth with severe emotional disorders.

Bio

grap

hies

Charles G. Curie, M.A., A.C.S.W.

President George W. Bush appointed Charles Curie in November 2001 as administrator of the U.S. Department of Health and Human Services’ Substance Abuse and Mental HealthServices Administration. Curie has more than 20 years of professional experience in the mental health and substance abuse arena. His core commitment to ensuring that people withaddictive and mental disorders have the opportunity to realize the dream of equal access to full participation in American society has earned him national recognition. Before joiningSAMHSA, Curie was appointed by former Governor Tom Ridge as deputy secretary for mental

health and substance abuse services for the Department of Public Welfare of the state of Pennsylvania. Curie’spassion and commitment for service started in his early childhood when he began to hold leadership positions atchurch, school, and community activities. Curie is a graduate of Huntington College, Ind., and holds a master’sdegree from the University of Chicago’s School of Social Service Administration. He also is certified by theAcademy of Certified Social Workers.

Benjamin Druss, M.D., M.P.H.

In January of this year, Dr. Druss joined the faculty at the Rollins School of Public Health andthe department of psychiatry at Emory University. Prior to that time, he had been on faculty at Yale University since 1996. As the first Rosalynn Carter Chair in Mental Health at theRollins School of Public Health, Dr. Druss is working collaboratively with The Carter Center tobridge gaps between research and mental health policy, between clinical and public healthmodels of care, and between the health and mental health systems. Dr. Druss has published morethan 50 peer-reviewed articles; his work has led to several national awards, including the 2003

Alice S. Hersh New Investigator Award for the top junior investigator in the field of health services research.

Larry Fricks

Larry Fricks currently serves as the director of the Office of Consumer Relations for the GeorgiaDivision of Mental Health, Developmental Disabilities and Addictive Diseases. He is a founderof the Georgia Mental Health Consumer Network Inc., that now has some 3,000 members; afounder of the Georgia Consumer Council; a founder of Georgia’s Peer Specialist Training andCertification; and a founder of the Georgia Peer Support Institute. He served on the planningboard for the Surgeon General’s Report on Mental Health and currently serves on the board of directors of the Depression and Bipolar Support Alliance and the board of directors of the

National Mental Health Association. He is also on the National Advisory Council for the Center for MentalHealth Services and the Advisory Board for the Rosalynn Carter Fellowships for Mental Health Journalism.

Michael Hogan, Ph.D.

Dr. Hogan has served as director of the Ohio Department of Mental Health since 1991. He hasheld leadership positions and led mental health reform in three states. He was appointed inApril 2002 by President George W. Bush to chair the President's New Freedom Commission onMental Health. He is also a member of the MacArthur Foundation Network on Mental HealthPolicy Research and served from 1994 to 1998 on the NIMH National Advisory Mental HealthCouncil and from 1989 to 1999 as the president of the National Association of State MentalHealth Program Directors Research Institute.

53

Biographies


54

Larke N. Huang, Ph.D.

Dr. Larke Nahme Huang is a senior policy associate in the National Technical AssistanceCenter for Children's Mental Health and the director of research at the Center for Child andHuman Development in the department of pediatrics, Georgetown University Medical Center.She has worked in the field of mental health for more than 25 years with a primary focus onmental health services for children and underserved culturally diverse populations, research andevaluation of mental health services, and policy development. Currently, she provides technicalassistance to states and communities to build their capacity to plan, implement, and evaluate

systems of care for children with mental health needs. She is a member of The Carter Center Mental Health TaskForce and, most recently, was a commissioner on the President's New Freedom Commission on Mental Health.

Thomas Insel, M.D.

Dr. Thomas Insel is director of the National Institute of Mental Health. Dr. Insel sees aspriorities for NIMH the discovery of susceptibility genes and diagnostic biomarkers for the major mental disorders; research that will lead to a reduction in suicide, which today is globallyresponsible for as many deaths as wars and homicides combined; enhanced behavioral strategiesfor reducing HIV/AIDS transmission; and elucidating causal risk processes that will enableprevention of mental disorders.

Ronald Kessler, Ph.D.

Dr. Ronald Kessler is a professor of health care policy at Harvard Medical School. He is theauthor of more than 300 publications and the recipient of numerous awards for his research. Hisresearch deals broadly with the psychosocial determinants of mental health and the comparativesocietal costs of illness. Dr. Kessler is the principal investigator of the U.S. National ComorbiditySurvey, the first nationally representative survey of the prevalence and correlates of psychiatricdisorders in the United States, as well as of a series of follow-up surveys based on the NCS. He isalso the co-director of the WHO World Mental Health survey initiative, an international

comparative epidemiological study of the prevalence of psychiatric disorders, patterns of help-seeking for thesedisorders, and barriers to treatment for these disorders in 28 countries around the world.

Norwood W. Knight-Richardson, M.D., M.B.A.

Dr. Norwood Knight-Richardson is chief executive officer of the Richardson Group, a privatelyheld consulting company, and associate professor at Oregon Health and Sciences University inPortland, Ore. Tommy Thompson, the secretary of the Department of Health and HumanServices, appointed him to serve on two national advisory councils. These are the NationalAdvisory Mental Health Council for the National Institute of Mental Health, NationalInstitutes of Health in January 2002 and the National Advisory Committee for InjuryPrevention and Control for the Centers for Disease Control and Prevention in November 2001.

55

A. Kathryn Power, M.Ed.

A. Kathryn Power is the director of the Substance Abuse and Mental Health ServicesAdministration’s (SAMHSA) Center for Mental Health Services (CMHS). As director, Ms. Power leads the SAMHSA/CMHS staff in addressing both the challenges and opportunitiespresented to the nation’s system of quality mental health care – from developing approaches toreduce disparities in access to services and negotiating the complexity of financing and fundingconcerns to building on presidential priorities such as the New Freedom Initiative, the

President’s New Freedom Mental Health Commission, and growing support for mental health parity. Prior to herappointment as SAMHSA’s CMHS director, Ms. Power served for more than 10 years as director of the RhodeIsland Department of Mental Health, Retardation and Hospitals, a Cabinet position reporting to the governor,which was responsible for four systems of care serving individuals with serious disabilities: mental illnesses,substance abuse and addiction, developmental disabilities, and long-term medical needs.

Mark L. Rosenberg, M.D., M.P.P.

Dr. Mark Rosenberg serves as executive director of the Task Force for Child Survival andDevelopment, a nonprofit public health organization that combines public health expertise with skills in collaboration to promote global health and human development. Before assuminghis current position, Dr. Rosenberg served 20 years with the Centers for Disease Control andPrevention, including early work in smallpox eradication, enteric diseases, and HIV/AIDS. Hecontributed his public health perspective to violence and unintentional injury prevention andwas instrumental in establishing a national center at CDC to focus on injury surveillance,

research, and prevention. Dr. Rosenberg was named acting associate director for public health practice when theNational Center for Injury Prevention and Control was formed, became the first permanent director in 1994, andserved as director until 1999.

David Satcher, M.D., Ph.D.

Dr. Satcher completed his four-year term as the 16th surgeon general of the United States inFebruary 2002. He also served as assistant secretary for health from February 1998 to January2001. From 1993 to 1998, Dr. Satcher served as director of the Centers for Disease Control and Prevention and administrator of the Agency for Toxic Substances and Disease Registry. InJanuary 2002, Dr. Satcher was named the director of the new National Center for Primary Careat the Morehouse School of Medicine in Atlanta, Ga.

Glenn A. Stanton

Glenn Stanton is currently the acting director for the Disabled and Elderly Health ProgramsGroup within the Center for Medicare and Medicaid Services. He has 20 years of service withinthe public health care sector at the county, state, and federal levels, much of that time devotedto assisting persons with disabilities. His experiences have included managing the directprovision of supports and services as well as policy development and oversight. In his currentrole within CMS, he provides leadership and organizational management for a highly skilledstaff devoted to issues related to Medicaid state plan and waiver services directed to older adults

and persons with disabilities. In particular, he has served as the alternate CMS commissioner on the President’sNew Freedom Commission on Mental Health, has provided leadership for the Health and Human Services’ self-directed initiative Independence Plus, and has led several emerging initiatives regarding quality in home andcommunity-based services. He accepted this position in January 2001.

Biographies


56

Pla

nnin

g C

omm

itte

e

Kemp BakerVice President, Client ServicesNon Profit Management Associates Inc.

Thomas E. Bryant, M.D., J.D.ChairmanNon Profit Management Associates, Inc.Member, The Carter Center Mental Health Task Force

Kathryn E. Cade Member, The Carter Center Mental Health Task Force

H. Stanley Eichenauer Deputy Executive DirectorPresident's New Freedom Commission on Mental Health

Carol Emig Executive Director Pew Commission on Children in Foster Care

Bill EmmetProject DirectorNational Association of State Mental Health Program Directors

Wayne S. Fenton, M.D.Deputy Director for Clinical Affairs, Division ofMental Disorders, Behavioral Research and AIDSNational Institute of Mental Health

Larry FricksDirectorOffice of Consumer RelationsGeorgia Department of Human Resources

Claire HeffernanExecutive DirectorPresident’s New Freedom Commission on Mental Health

Larke Nahme Huang, Ph.D. Director of Research/Evaluationand Senior Policy AssociateCenter for Child Health and Mental Health Policy National Technical Assistance Center for Children'sMental HealthGeorgetown University Child Development CenterMember, The Carter Center Mental Health Task ForceMember, President’s New Freedom Commission on Mental Health

Gail HutchingsSenior Adviser to the AdministratorCenter for Mental Health Services

Thomas R. Insel, M.D.DirectorNational Institute of Mental Health

Anne MichaelsFilm ProducerMNA Inc.

Leslie J. Scallet, J.D.Member, The Carter Center Mental HealthTask Force

Joel Slack Executive DirectorRespect International

57

Participants’ List

Katherine L. Acuff, J.D., Ph.D.,M.P.H.Senior Health Policy Consultantto The Carter Center

Gail Adams, LPC, LMFT,CCMHCPresidentAmerican Mental HealthCounselors Association

Jane Adams, Ph.D.Executive DirectorKeys for Networking Inc.

Renato D. Alarcon, M.D.,M.P.H.Consultant, Mayo ClinicMedical Director, Adult Psychiatry Teaching UnitProfessor of Psychiatry, MayoMedical SchoolMember, The Carter Center Mental Health Task Force

Mary Jane Alexander, Ph.D.Research ScientistCenter for the Study of Issues in Public Mental HealthNathan Kline Institute

Rodolfo Arredondo, Ed.D.Professor of PsychiatryDepartment of Neuropsychiatry Southwest Institute for Addictive DiseasesTexas Tech University HealthSciences Center

Gary Bailey, M.S.W.PresidentNational Association of Social Workers

Kemp BakerVice President, Client ServicesNon Profit ManagementAssociates Inc.

Michael Barnett, M.D.Washington, D.C.

William R. Beardslee, M.D.Psychiatrist-in-ChiefChildren’s HospitalMember, The Carter CenterMental Health Task Force

Carl C. Bell, M.D., FAPA, FAC. Psych.President and Chief Executive OfficerCommunity Mental Health CouncilDirector of Public and CommunityPsychiatry and Public HealthUniversity of IllinoisMember, The Carter Center Mental Health Task Force

Susan BergesonDeputy Executive DirectorDepression and Bipolar SupportAlliance

Deborah Bergman, LMFTDirector of Sales and MarketingRidgeview Institute

Robert Bernstein, Ph.D.Executive DirectorBazelon Center for Mental Health Law

Richard C. Birkel, Ph.D.Executive DirectorNational Alliance for the Mentally Ill

Efrain Bleiberg, M.D.Staff Psychiatrist, Medical DirectorPIC ProgramThe Menninger Clinic

Marsha Block, CAEChief Executive OfficerAmerican Group PsychotherapyAssociates Inc.

Iris Bolton FounderThe Link Counseling Center

John Book, M.D.Chair/Board of DirectorsAmerican Managed Behavioral Healthcare AssociationExecutive Vice President andChief Medical OfficerMagellan Health

Brian J. Boon, Ph.D.President and Chief Executive OfficerCommission on Accreditation ofRehabilitation Facilities

Thomas H. Bornemann, Ed.D.DirectorThe Carter Center Mental Health Program

Jack BoyleSenior Vice President and Chief Operating OfficerMental Health Association of Southeastern Pennsylvania

Margaret BradfordDirectorOffice of Mental Health andAddictive DiseasesDivision of Mental Health,Developmental Disabilities andAddictive DiseasesGeorgia Department of Human Resources

Jon BrockBirmingham, Alabama

Thomas E. Bryant, M.D., J.D.ChairmanNon Profit ManagementAssociates Inc.Member, The Carter Center Mental Health Task Force

Peter F. Buckley, M.D.Professor and ChairmanDepartment of Psychiatry andHealth BehaviorMedical College of Georgia

Barbara J. Burns, Ph.D.DirectorServices Effectiveness Research Program Department of Psychiatry andBehavioral SciencesDuke University Medical Center

Paula Byars-Stockdale Paris, Tennessee

Kathryn E. Cade Member, The Carter Center Mental Health Task Force

Jean Campbell, Ph.D.Director, Program in ConsumerStudies and TrainingMental Health Systems ResearchMissouri Institute of MentalHealth

Par

tici

pant

s’ L

ist


58

Sylvia Caras, Ph.D.CoordinatorPeople Who

Mary Cesare-Murphy, Ph.D.Executive DirectorBehavioral Health Care ProgramJoint Commission onAccreditation of HealthcareOrganizations

Elizabeth Chadwick, J.D.Executive DirectorDevereux Georgia TreatmentNetwork

Sewell Chan ReporterThe Washington PostRosalynn Carter Fellow for MentalHealth Journalism 2003-2004

Brenda Cibulas DeKalb Community Service BoardRichardson Health Center

Elizabeth J. Clark, Ph.D., ACSW, M.P.H.Executive DirectorNational Association of Social Workers

Michael T. Compton, M.D.Assistant ProfessorDepartment of PsychiatryEmory University School of Medicine

Colette Croze, M.S.W.Secretary of the BoardAmerican College of Mental Health AdministrationPrincipal, Croze Consulting

Charles G. Curie, M.A., ACSWAdministratorSubstance Abuse and MentalHealth Services AdministrationDepartment of Health and Human Services

Thomas Curwen Feature WriterLos Angeles TimesRosalynn Carter Fellow for MentalHealth Journalism 2002-2003

Robert DellChairman of the BoardMental Illness Network, UnitedChurch of ChristPathways to Promise

Deborah Donaldson, LCP,M.B.A.Director of Human ServicesNational Association of CountyBehavioral Health Directors

Benjamin G. Druss, M.D.,M.P.H.Rosalynn Carter Endowed Chair in Mental HealthAssociate Professor of HealthPolicy and ManagementRollins School of Public HealthEmory UniversityMember, The Carter CenterMental Health Task Force

Brian L. Dyak President and Chief Executive OfficerThe Entertainment IndustriesCouncil Inc.

Holly Echo-HawkSenior Mental Health ConsultantNational Indian Child WelfareAssociation

Robert Egnew, M.S.W.Director of Public PolicyNational Association of CountyBehavioral Health Directors

H. Stanley Eichenauer Deputy Executive DirectorPresident’s New FreedomCommission on Mental Health

Lei Ellingson, M.P.P.Assistant DirectorThe Carter Center Mental Health Program

Carol Emig Executive DirectorPew Commission on Children in Foster Care

Bill Emmet Project DirectorNational Association of StateMental Health Program Directors

Mary Jane England, M.D.PresidentRegis CollegeMember, The Carter Center Mental Health Task Force

Timothy English Chief Executive OfficerMetropolitan Atlanta ChapterAmerican Red Cross

Silke von Esenwein, M.A., Ph.D. CandidateGraduate InternThe Carter Center Mental Health ProgramDepartment of Psychology,Neuroscience and AnimalBehavior, Center for BehavioralNeuroscienceEmory University

Michael M. FaenzaChief Executive Officer and PresidentNational Mental HealthAssociation

Jacqueline Maus Feldman, M.D.PresidentAmerican Association of Community PsychiatristsPatrick H. Linton ProfessorUniversity of Alabama atBirmingham

Paul Jay Fink, M.D.ProfessorTemple University School of MedicineAdvisory Board Member, TheRosalynn Carter Fellowships forMental Health Journalism

Cherry FinnAdult Mental Health Program ChiefDivision of Mental Health,Developmental Disabilities andAddictive DiseasesGeorgia Department of Human Resources

59


Elizabeth E. FinnertyExecutive DirectorSkyland TrailGeorge West Mental Health Foundation

Daniel B. Fisher, M.D., Ph.D.Executive DirectorNational Empowerment Center

Gail Fisher Senior Photo EditorLos Angeles TimesRosalynn Carter Fellow for MentalHealth Journalism 2003-2004

Judy Fitzgerald Executive DirectorNational Mental HealthAssociation of Georgia

Cynthia Folcarelli Executive Vice PresidentNational Mental HealthAssociation

Larry FricksDirector of the Office of Consumer RelationsDivision of Mental Health,Developmental Disabilities andAddictive DiseasesGeorgia Department of Human Resources

Bob Friedman, Ph.D.Professor and ChairDepartment of Child and Family StudiesLouis de la Parte Florida MentalHealth InstituteUniversity of South Florida

Kathleen Garcia Executive DirectorRecovery Inc.

Preston J. Garrison Secretary General/Chief Executive OfficerWorld Federation for Mental Health

Robert W. Glover, Ph.D.Executive DirectorNational Association of StateMental Health Program Directors

Marcia Kraft Goin, M.D.PresidentAmerican Psychiatric Association

Sybil K. GoldmanSenior Adviser on ChildrenSubstance Abuse and MentalHealth Services AdministrationDepartment of Health and Human Services

Irene Saunders GoldsteinEditorWashington, D.C.

Jack Gordon PresidentHospice Foundation of AmericaMember, The Carter Center Mental Health Task Force

Pamela Greenberg, M.P.P.Executive DirectorAmerican Managed Behavioral Healthcare Association

Claire Griffin-Francell, M.S.N.Member, Board of DirectorsNational Alliance for the Mentally Ill

Paul Hackman Executive Vice President/ChiefOperating OfficerRidgeview Institute

David Haigler, Ed.D.Deputy DirectorRosalynn Carter Institute for Human DevelopmentGeorgia Southwestern State University

Susan E. Hamilton, Ph.D.Senior AssociateDisaster Mental Health ServicesAmerican Red Cross

Henry T. Harbin, M.D.Chairman of the BoardMagellan Health Services

George T. Harding, M.D.Professor and ChairDepartment of PsychiatryLoma Linda University

John Hardman, M.D.Executive DirectorThe Carter Center

Linda Hatzenbuehler, Ph.D.Board ChairNational Association of Mental Health Planning and Advisory Council

Dorothy Hawthorne, R.N., Ph.D.Assistant Professor of NursingBrenau University School ofHealth SciencesSubstance Abuse and MentalHealth Services AdministrationMinority Fellowship ProgramAmerican Nurses Association

Timothy Hays, Ph.D.DirectorOutreach Partnership ProgramNational Institute of Mental Health

John HeadFreelance WriterThe Rosalynn Carter Fellowshipsfor Mental Health Journalism,Advisory Board Member andFellow, 1999-2000

Kevin HeldmanFreelance JournalistRosalynn Carter Fellow for MentalHealth Journalism, 2003-2004

Margaret Heldring, Ph.D.President and Chief Executive OfficerAmerica’s Health Together

Michelle Herman Policy AssociateNational Council of State Legislatures

Ted W. HirschChief Executive Officer/ChiefOperating OfficerPathways Treatment CenterKalispell Regional Medical Center

Sara Hodgson Program Development Coordinatorfor Health ProgramsInstitutional DevelopmentThe Carter Center


60

Michael F. Hogan, Ph.D.Director, Ohio Department ofMental HealthChair, President’s New FreedomCommission on Mental Health

Larke Nahme Huang, Ph.D.Director of Research/Evaluationand Senior Policy AssociateCenter for Child Health andMental Health PolicyNational Technical AssistanceCenter for Children’s Mental HealthGeorgetown University Child Development CenterMember, The Carter Center Mental Health Task ForceMember, President’s New FreedomCommission on Mental Health

Kevin Ann Huckshorn, R.N.,M.S.N., CAPDirectorOffice of Technical AssistanceNational Association of StateMental Health Program Directors

Barbara HuffExecutive DirectorFederation of Families forChildren’s Mental Health

Ruth Hughes, Ph.D., RPRPChief Executive OfficerInternational Association ofPsychosocial RehabilitationServices

Gail P. Hutchings, M.P.A.Senior Adviser to theAdministratorSubstance Abuse and MentalHealth Services Administration,Department of Health and Human Services

Andrew D. HymanDirector of Government Relationsand Legislative CounselNational Association of StateMental Health Program Directors

Liisa K. HyvarinenFreelance ReporterRosalynn Carter Fellow for MentalHealth Journalism, 1999-2000

D.J. Ida, Ph.D.Executive DirectorNational Asian American/PacificIslands Mental Health Association

Julie Nelson Ingoglia, M.P.H.Senior AnalystNational Association of Countyand City Health Officials

Thomas R. Insel, M.D.DirectorNational Institute of Mental Health

Ethleen Iron Cloud-Two Dogs,M.S.Project Director/PrincipalInvestigatorNAGI KICOPI (Calling the Spirit Back)Children’s Mental Health ServicesMember, The Carter Center Mental Health Task Force

Dottie JeffriesDirector of Public AffairsAmerican PsychoanalyticAssociation

Mark JohnstonDeputy DirectorOffice of Special Needs Assistance ProgramsDepartment of Housing and Urban Development

Lasa Y. JoinerInterim Executive DirectorGeorgia Psychiatric PhysiciansAssociation

Eileen Joseph, M.S., CPRPPresident-electInternational Association ofPsychosocial RehabilitationServices

Martha Katz, M.P.A.Director of Health PolicyHealthcare Georgia Foundation

Thomas E. KeaneDirectorDivision of Behavioral HealthNew Hampshire

Ronald C. Kessler, Ph.D.ProfessorDepartment of Health Care PolicyHarvard Medical School

Maureen Reed Killeen, Ph.D.,APRN, FAANDirector, Child and Adolescent DivisionInternational Society of Psychiatric Mental Health Nurses

Sherry Knapp, Ph.D., CBHEOfficer, National Association ofCounty Behavioral HealthDirectors Chief Executive OfficerHamilton County Alcohol andDrug Addiction Services Board

Elizabeth Knight, M.S.W., CGP,FAGPAAmerican Group PsychotherapyAssociation

Norwood W. Knight-Richardson,M.D., M.B.A.Chief Executive OfficerRichardson GroupAdjunct Associate ProfessorOregon Health and SciencesUniversityMember, President’s New FreedomCommission on Mental Health

Harold S. Koplewicz, M.D.DirectorChild Study Center Bellevue Hospital CenterNew York University School of Medicine

Nicole KruseChief Development Officer of Health ProgramsInstitutional DevelopmentThe Carter Center

Lawrence A. Kutner, Ph.D.Co-director, Harvard Medical School Center for Mental Health and MediaAttending PsychologistMassachusetts General Hospitaland McLean HospitalAdvisory Board Member, TheRosalynn Carter Fellowships forMental Health Journalism

61


David Lambert, Ph.D.PresidentNational Association for RuralMental Health

Juli Anne LawrenceMember, National AdvisoryCouncilConsumer/ Survivor SubcommitteeCenter for Mental Health ServicesSubstance Abuse and MentalHealth Services Administration,Department of Health and Human Services

Irene LelandWriter and SpokespersonIndependence Center, St. Louis

Lydia Lewis PresidentDepression and Bipolar Support Alliance

Maury LiebermanBoard ChairSuicide Prevention ActionNetwork, USA

Don R. Lipsitt, M.D.Professor of PsychiatryHarvard Medical School

Beverly LongChair, Promotion and Prevention Biennial Conference CommitteePast PresidentWorld Federation for Mental Health

Diane M. LoucksHavertown, Pennsylvania

Maria Maceira-Lessley Salida, California

David MajicAssistant CommissionerBureau for Behavioral Health andHealth FacilitiesWest Virginia Department ofHealth and Human Resources

Stephen D. Mallory, M.D.PresidentGeorgia Psychiatric Physicians Association

W. Victor Maloy PresidentAmerican Association of Pastoral Counselors

Ronald Manderscheid, Ph.D.Branch ChiefSurvey and Analysis BranchCenter for Mental Health ServicesSubstance Abuse and MentalHealth Services Administration,Department of Health and Human Services

Cathrine S. ManegoldJames M. Cox Jr. Professor of JournalismEmory UniversityAdvisory Board Member, TheRosalynn Carter Fellowships forMental Health Journalism

Anthony J. Marsella, Ph.D.,DHCProfessor Emeritus of PsychologyUniversity of HawaiiPast DirectorWHO Field Psychiatric Research Center Honolulu, Hawaii

Christopher C. MarshallConsumer Affairs SpecialistCenter for Mental Health ServicesSubstance Abuse and MentalHealth Services Administration,Department of Health and Human Services

Matthew Mathai Deputy DirectorNew York Association ofPsychiatric Rehabilitation Services

Stephen W. Mayberg, Ph.D.DirectorDepartment of Mental HealthCalifornia Health and HumanServices AgencyMember, President’s New FreedomCommission on Mental Health

Christopher McGowan Co-chair, Public PolicyAssociation for Ambulatory Behavioral Healthcare

Lauren McKenzieDocumentary ProducerThe Primrose GroupRosalynn Carter Fellow for MentalHealth Journalism, 2002-2003

Allison Metcalf, M.S.W.Executive DirectorChildren’s Home Society of Florida

Anne MichaelsFilm ProducerMNA Inc.

Angela Mitchell, M.A., LCSWFreelance JournalistRosalynn Carter Fellow for MentalHealth Journalism, 2001-2002

Haydee Montenegro, Ph.D.Representative, United NationsWorld Federation for Mental Health

Nuala S. MooreAssistant Director, GovernmentAffairsAmerican Academy of Child and Adolescent Psychiatry

Dawne R. Morgan ChiefChild and Adolescent MentalHealth ProgramDivision of Mental Health,Developmental Disabilities andAddictive DiseasesGeorgia Department of Human Resources

David G. Moriarty, BSEEProgram AnalystDivision of Adult and Community HealthCenters for Disease Control and Prevention

John A. Morris, M.S.W.DirectorDepartment of Neuropsychiatryand Behavioral SciencesUniversity of South CarolinaSchool of Medicine

Frances M. Murphy, M.D.,M.P.H.Deputy Undersecretary for Health Policy CoordinationDepartment of Veterans Affairs


62

Joyce P. Murray, Ed.D., FAANProfessor of NursingAdult and Elder HealthDepartmentEmory UniversityDirector, Ethiopia Public HealthTraining InitiativeThe Carter Center

Sandra Naylor-Goodwin, Ph.D.Executive DirectorCalifornia Institute for Mental Health

Suzanne K. Nieman Associate Legislative DirectorAssociation of CountyCommissioners of Georgia

Jenn O’ConnorPolicy AnalystHealth Policy Studies Center for Best PracticesNational Governors Association

Freida Hopkins OutlawDirector, Children and Adolescent ServicesTennessee Department of MentalHealth and DevelopmentalDisabilities

Dwight Owens, M.D.Medical DirectorFulton County Department ofMental Health, DevelopmentalDisabilities and Addictive Diseases

Rebecca Palpant, M.S.Assistant Program CoordinatorThe Carter Center Mental Health Program

Rick Peterson, Ph.D., LMFTPresident-electNational Association for RuralMental Health

Chester M. Pierce, M.D.Professor of Education andPsychiatry, EmeritusGraduate School of Education Harvard Medical SchoolMember, National AdvisoryCouncilThe Carter Center Mental Health Program

Jo M. PineDirector, Policy and PlanningOffice of Mental HealthLouisiana Department of Healthand Hospitals

Mark Pope, Ed.D.

PresidentAmerican Counseling Association

A. Kathryn Power, M.Ed.DirectorCenter for Mental Health ServicesSubstance Abuse and MentalHealth Services AdministrationDepartment of Health and Human Services

Warren Taylor Price Jr. CommissionerOffice of Mental HealthLouisiana Department of Healthand Hospitals

Kathy Puskar, M.S.N., M.P.H.,Ph.D., CS, FAANPresidentAmerican Psychiatric Nurses Association

Lynne RandolphProgram Development CoordinatorThe Carter Center Mental Health Program

Charles G. Ray President and Chief Executive OfficerNational Council for Community Behavioral Healthcare

Jerry Reed, M.S.W.Executive DirectorSuicide Prevention ActionNetwork, USA

Dori B. Reissman, M.D., M.P.H.Senior Adviser for Disaster,Terrorism, and Mental HealthNational Center for InjuryPrevention and ControlCenters for Disease Control and Prevention

Barry E. Riesenberg PresidentAmerican Aging Concern

Dave Robbins Acting Division DirectorDivision of State and Community Systems DevelopmentThe Center for Substance Abuse PreventionSubstance Abuse and MentalHealth Services AdministrationDepartment of Health and Human Services

Josie Torralba Romero, LCSWPresident and Executive DirectorHispanic Institute for Family DevelopmentNational Latino Behavioral Health Association

Douglas M. Ronsheim, D.Min.Executive DirectorAmerican Association of Pastoral Counselors

Mark L. Rosenberg, M.D., M.P.P.Executive DirectorThe Task Force for Child Survivaland Development

Richard N. Rosenthal, M.D.PresidentAmerican Academy of Addiction Psychiatry

E. Clarke Ross, DPAChief Executive OfficerChildren and Adults withAttention Deficit/HyperactivityDisorder

Elizabeth Rubin Senior Associate, Public AffairsEli Lilly and Company

George Rust, M.D., M.P.H.Deputy DirectorNational Center for Primary CareMorehouse School of Medicine

Marc A. Safran, M.D., FACPMChair, CDC Mental Health Work GroupCenters for Disease Control and Prevention

63


David Satcher, M.D., Ph.D.DirectorNational Center for Primary CareMorehouse School of MedicineMember, The Carter Center Mental Health Task Force

Leslie J. Scallet, J.D.Member, The Carter Center Mental Health Task Force

Doreen Schultz, M.A.Associate DirectorThe Link Counseling Center

Karl H. Schwarzkopf, Ph.D.Division DirectorThe Division of Mental Health,Developmental Disabilities andAddictive DiseasesGeorgia Department of Human Resources

James H. Scully, M.D.Medical DirectorAmerican Psychiatric Association

Steven S. Sharfstein, M.D.President and Medical DirectorThe Sheppard and Enoch PrattHospital

Robert P. Sheehan President and Chief Executive OfficerBoys and Girls Home and Family Services Inc.Board President, NationalAssociation for Children’sBehavioral HealthNational Association of PsychiatricTreatment Centers for Children

Marion E. Sherman, M.D.,M.B.A.Chief Clinical OfficerTwin Valley Behavioral HealthcareOhio Department of Mental Health

Lewis E. SilvermanExecutive DirectorConsumer Satisfaction Services Inc.

Joel C. Slack DirectorRespect International Inc.

Mary V. SloanExecutive DirectorNational Alliance for the Mentally Ill, Georgia

Bob Smith III, Ph.D.ChairmanPsychological AssessmentResources Inc.

Cathy SmithPsychological AssessmentResources Inc.

Mickey J.W. Smith, M.S.W.Senior Policy AssociateNational Association of Social Workers

Sue L. Smith, Ed.D.DirectorGeorgia Parent Support Network Inc.

Thurston S. Smith Vice President, Southeast RegionAssociation for AddictionProfessionals

Antonia J. Spadaro, Ed.D.Senior Research AdministratorPrevention Research Centers OfficeNational Center for ChronicDisease Prevention and Health PromotionCenters for Disease Control and Prevention

Nancy C. Speck, Ph.D.Telehealth Regional Consultant

Glenn A. StantonActing DirectorDisabled and Elderly HealthPrograms GroupCenter for Medicare and Medicaid Services

Bradley D. Stein, M.D., Ph.D.Associate DirectorRAND Center for Domestic andInternational Health SecurityUniversity of Southern California

James W. Stewart III Immediate Past PresidentNational Association of CountyBehavioral Health DirectorsExecutive Director, Henrico AreaMental Health and MentalRetardation Services

Andrea Davis Stiles, Ed.M.Director of Clinical AssessmentFloyd Medical Center

Beth A. Stroul, M.Ed.Vice PresidentManagement and Training Innovations

Linda Sturdivant, CEAPresidentEmployee Assistance ProfessionalsAssociation Inc.

Ronda C. Talley, Ph.D., M.P.H.Executive Director Rosalynn Carter Institute for Human DevelopmentProfessor, Georgia SouthwesternState UniversityMember, The Carter CenterMental Health Task Force

Terri Tanielian, M.A.Associate Director of Mental and Behavioral HealthRAND Center for Domestic andInternational Health Security

Eugenie P. Taylor, LICSWActing CommissionerBureau for Behavioral Health andHealth FacilitiesWest Virginia Department ofHealth and Human Resources

Stacy Taylor Senior Associate Director forHealth ProgramsInstitutional DevelopmentThe Carter Center

Edward Thomas Director of ResearchKaiser Permanente

Kenneth S. Thompson, M.D.SOROS Physician Advocate FellowAssociate Professor of PsychiatryUniversity of Pittsburgh


64

Valrie ThompsonSenior SecretaryThe Carter Center Mental Health Program

Henry Tomes, Ph.D.Executive DirectorAPA Public Interest DirectorateAmerican PsychologicalAssociation

Julie Totten PresidentFamilies for Depression Awareness

Mark TrailChief, Division of Medical AssistanceGeorgia Department ofCommunity Health

Beth Vesel Literary AgentNew York, New York

Cynthia WainscottChair-elect, National MentalHealth AssociationVice President, North Americaand the CaribbeanWorld Federation for MentalHealth North

Nancy E. Wallace, CSWUnited Nations Representative World Federation for Mental Health

Gemma M. WeiblingerDirectorOffice of Constituency Relationsand Public LiaisonNational Institute of Mental Health

Gary Weiskopf Executive DirectorNew York State Conference of Mental Hygiene Directors

Marilyn E. White MajorThe Salvation Army

David Wiebe Executive DirectorJohnson County Mental Health Center

Tingsen Xu, Ph.D.Associate ProfessorWoodruff Physical Education CenterEmory University

Sharon YokoteMember, Consumer/SurvivorSubcommittee National Advisory CouncilCenter for Mental Health ServicesSubstance Abuse and MentalHealth Services Administration,Department of Health and Human Services

65

Task Force Member

The Carter Center Mental Health TaskForce Members

Rosalynn Carter, Chairperson

Renato D. Alarcon, M.D., M.P.H., Consultant,Mayo Clinic; Professor of Psychiatry, MayoMedical School; Medical Director, AdultPsychiatry Teaching Unit, Psychiatry andPsychology Treatment Center, Mayo MedicalCenter

William R. Beardslee, M.D., Psychiatrist-in-Chief, Gardner Monks Professor of ChildPsychiatry, Harvard Medical School

Carl C. Bell, M.D., FAPA, FAC.Psych.,President and Chief Executive Officer,Community Mental Health Council, Universityof Illinois

Mary Jane England, M.D., President, RegisCollege

Jack D. Gordon, President, Hospice Foundationof America

W. Rodney Hammond, Ph.D., Director,Division of Violence Prevention, NationalCenter for Injury Prevention and Control,Centers for Disease Control and Prevention

Jeffrey Houpt, M.D., Dean and Vice Chancellorfor Medical Affairs, School of Medicine,University of North Carolina, Chapel Hill

Larke Nahme Huang, Ph.D., Director ofResearch/Evaluation and Senior PolicyAssociate, Georgetown University ChildDevelopment Center

Ethleen Iron Cloud-Two Dogs, M.S., ProjectDirector, NAGI KICOPI (Calling the SpiritBack), Children’s Mental Health Services

Nadine J. Kaslow, Ph.D., ABPP Professor andChief Psychologist, Department of Psychiatry andBehavioral Sciences, Emory University School ofMedicine

Sally Engelhard Pingree, Trustee, The CharlesEngelhard Foundation; Member, The CarterCenter Board of Trustees

David Satcher, M.D., Ph.D., Surgeon Generalof the United States and Assistant Secretary forHealth and Human Services, 1994-2001;Director, National Center for Primary Care,Morehouse School of Medicine

Leslie Scallet, J.D.

Joel Slack, Executive Director, RespectInternational Inc.

Cynthia Ann Telles, Ph.D., Assistant ClinicalProfessor, Department of Psychiatry andBiobehavioral Sciences, The University ofCalifornia at Los Angeles School of Medicine

Ex Officio Members

Thomas Bryant, M.D., J.D., Chairman,President’s Commission on Mental Health, 1977-78; Chairman, Non Profit ManagementAssociates Inc.

Kathryn Cade, White House Projects Directorfor First Lady Rosalynn Carter, 1977-80

Benjamin G. Druss, M.D., M.P.H., RosalynnCarter Endowed Chair in Mental Health,Associate Professor of Health Policy andManagement, Rollins School of Public Health,Emory University

Ronda Talley, Ph.D., Executive Director,Rosalynn Carter Institute for HumanDevelopment, Georgia Southwestern StateUniversity

Fellows

William Foege, M.D., Director, Centers forDisease Control, 1977-83; Health Policy Fellow,The Carter Center

Julius Richmond, M.D., Surgeon General of theUnited States and Assistant Secretary of Healthand Human Services, 1977-81; John D.MacArthur Professor of Health Policy, Emeritus,Harvard University

National Advisory Council

Johnnetta B. Cole, Ph.D., President, BennettCollege

Jane Delgado, Ph.D., President and ChiefExecutive Officer, National Alliance forHispanic Health

Leon Eisenberg, M.D., Pressley Professor ofSocial Medicine and Professor of Psychiatry,Emeritus, Harvard Medical School, Departmentof Social Medicine

Tas

k F

orce

Mem

bers


66

National Advisory Council, continued

Antonia Novello, M.D., Commissioner ofHealth for New York State Department ofHealth; Surgeon General of the United States,1990-1993

Robert D. Ray, Governor of Iowa, 1969-83;President Emeritus, Drake University

Richard Surles, Ph.D., Commissioner, NewYork State Office of Mental Health, 1987-1994;Head of Operations, ComprehensiveNeuroScience Inc.

Joanne Woodward, Actress; Director

Fun

ders The Nineteenth Annual Rosalynn Carter Symposium on Mental Health Policy is made

possible by funding from: The Annenberg Foundation; Bristol-Myers Squibb Company;

The Charles Engelhard Foundation; Freddie Mac Foundation; Healthcare Georgia

Foundation; The John D. and Catherine T. MacArthur Foundation; National Institute of

Mental Health; Substance Abuse and Mental Health Services Administration, Center for

Mental Health Services; U.S. Centers for Disease Control and Prevention; WXIA-TV 11

Alive, Gannett Foundation, Inc.

One Copenhill453 Freedom ParkwayAtlanta, GA 30307

(404) 420-5100 • Fax (404) 420-5145

www.cartercenter.org

Documents

The President's New Freedom Commission on Mental Health