Charles Curie
Administrator,
Substance Abuse and Mental Health Services Administration
United States Department of Health and Human Services
Thank you. I was going to make a suggestion to Maggie that maybe folks in Iowa and in Nebraska we have the same situation with a lot of corn and soybeans and we like to feed those to a lot of hogs and a lot of cattle. Maybe we just need to go out and take our hog for a walk every night. That way we would get some exercise and also reduce the fat on the hog.
It's always a pleasure to be here at the Health Chair Conference and the reason I enjoy it so much is the quality of people that we can hear from and certainly that holds true of our next guest. Charles Curie was appointed by President George Bush in November, 2001 as Administrator of the U.S. Department of HHS Substance Abuse and Mental Health Services Administration or what we refer to as SAMHSA. It's a lead federal agency for improving the quality and availability of substance abuse prevention, addiction, treatment and mental health services in the United States. I'm sure you, like we are in Nebraska, see the close, the very close tie between substance abuse and mental health. It's hard to separate the two as a matter of fact and I'm very pleased that the federal government is working also to bring those two together.
Mr. Curie has over 20 years of professional experience in mental health and substance abuse area. His core commitment to insuring that people with addictive and mental health disorders have the opportunity to realize the dream of equal access to full participation in American society and has earned him national recognition.
Mr. Curie was the Director of Risk Management Services for the Henry S. Leher Corporation in Bethlehem. President & CEO of Helen Stevens Community Mental Health Center in Carlisle, Cumberland County and Executive Director and CEO of the Sandusky Valley Center in Tipton, Ohio. His passion has been for service; started in early childhood; began to hold leadership positions in church, school, community activities. Curie is a graduate of Huntington College in Indiana; holds a masters degree from University of Chicago School of Social Service Administration. He's also certified by the Academy of Certified Social Workers. A native of Indiana, Curie and his wife Candice reside in Bethlehem, Pennsylvania. Please welcome Charles Curie.
Thank you very much, Jim. I appreciate it very much senator, the kind introduction and the opportunity to be here today with you all. As Jim indicated in my introduction, I am honored at this point to be serving President Bush and also Secretary Tommy Thompson who I know will be joining you tomorrow; the Department of Health and Human Services as administrator of SAMHSA. But I did come from a state, state of Pennsylvania, where I was Deputy Secretary for Mental Health and Substance Abuse Services under Governor Tom Ridge's Administration up until this past Fall and because of that, I do clearly bring a state perspective to this position which is one of the many reasons I was looking forward to meeting with you today because I worked with our House and our Senate very closely in Pennsylvania as we crafted an agenda for mental health and substance abuse in Pennsylvania and it had to deal with some very challenging issues; issues I think will resonate with everyone in this room; having to deal with mental health parity. Again, I'll be talking about that a little later but of course we know that last week the President made a strong statement and commitment to mental health parity, basically indicating that the White House will work with Sen. Dominici and the Congress to develop legislation to assure that mental health benefits will be on par with physical health benefits.
The good news for that for states is with the legislation passing, if there's a strong legislation which assures that type of parity, it will take the debate from state to state out of the arena from state to state. I think that's one frustration I'll be honest that I had in Pennsylvania as we were debating parity there because the federal government passed what could be called a very watered-down parity law several years ago. That debate began to occur from state to state and it became an economic development debate. If a neighboring state doesn't have parity, we're going to be less competitive with other states and I think it is an example of where it is appropriate for the federal government to basically take a strong stand on that.
Besides coming from a state perspective, I also come from a social work perspective, being a social worker by discipline. I've been in fact called at times the secretary, senior social worker in the Department of HHS and I guess I am the highest ranking. I did not realize that until some of my social work colleagues came and stopped me one day in the hall and said do you realize you're the chief social worker? I said no, but I've been called worse things than that so I said I'm pleases to definitely, in fact I'm honored to hold that title because I am proud of the discipline in social work. I think there's time that social workers have not openly proclaimed their profession; they call themselves clinical therapists; they call themselves by other names but social work I think brings a perspective, a policy perspective, a problem solving process which I think is very, very much at play in appropriateness for the development of governmental policy.
Also I think the social work perspective and having been on the front lines, I started my career as a clinical social worker in a rural setting is Fostoria, Ohio in a branch office of the mental health center. Then I eventually began working with a three county program focusing on people's serious mental illness coming out of state hospitals, helping them gain a life in the community and I remember clearly again, what it was like to be a provider in a rural area trying to apply the state of the art treatments, reading in journals, and going to conferences and hearing what really works and then trying to make it real and how challenging that was and how cutoff and isolated you could feel. Again, I've been accused of being a recovering provider as well as bringing a state perspective. But both of those perspectives I think helped me in this particular position, understand and try to grapple with being real about what we need to be about doing.
Now you all should have received a packet. Anyone not receive a packet? I think it's supposed to also be individualized to your state so hopefully you received a packet that's consistent from whence you come. Anyone not receive a packet? Very good.
I'm kind of approaching this more the old fashioned way. I'm not going to have a Power Point up here; you have the hard copy in front of you in terms of some of the remarks I'm going to be making, so feel free to follow along in that particular document of the presentation.
I think it's very important on the very first page of the Issues highlights in the packet, that Issues highlights section, that we need to think in terms of a vision. A vision which unifies the substance abuse, mental health deal; also that gives a clear direction at the federal level, to the state level, to the local level, to every person with serious mental illness, to every person with addictive disease, to every child that has a serious emotional disturbance, to every youth at risk, families, taxpayers across this country, what we're about and what we're trying to accomplish.
To me a vision needs to be a statement of the ultimate outcome that we're looking for in the lives of the people we serve and that also should guide and direct our decisions; our funding decisions. It should guide and direct our policy decisions and the Vision Statement here is people of all ages, whether at risk for addictive disease and/or mental disorders have the opportunity for recovery and a fulfilling life that includes a job, a decent place to live, family support and personal relationships. It's a very straightforward statement but again, it's an outcome. A mission is how do you arrive at the vision and so we have to be very mission oriented, but the vision tells us where we want to end up being. Again, we need to be about giving people a life in the community. I might stress that a job and a decent place to live and relationships is consistently what I've have heard throughout my career and what I hear today. Whether I'm sitting down with a patient in a state hospital in Pennsylvania; I used to spend a night in a state hospital at least once a year, sometimes twice a year; we had 10 state hospitals in the state and I learned a lot. Actually I learned a lot because I got to see the people who worked third shift in the hospitals, No. 1 and usually when you walk in and you know this in your positions as elected officials, if you visit a state hospital you're going to see what the staff there wants you to see many times and you get the grand tour during the day and you may not always see what's happening. I learned a lot when I stayed over night and I talked to patients.
We're always talking to patients in the state hospitals, talking to consumers that are in drop-in centers, to clients who are in drug and alcohol rehab or residential programs; there are three consistent things I've heard. There's been scientific surveys that indicate this that the three things people need in order to recover and to stay recovered. They don't talk about I need a case manager or I need a psychiatrist to follow me around or I need whatever; they don't even say I need access to care, though those things are very important. They bore it down to I need a job; I need a safety, someplace to live; I need a date on the weekends. Those are the things that I would sum up. So when you think about that what are the three top 4 or 5 things you want in your life. A job, a decent place to live, and I know I'm in transition and I look forward to a date with my wife on the weekends. You want to have an opportunity to have relationships with special people, that special someone, families; you want to be connected. Those three things I think need to shape our thinking about what are we're funding and what are we trying to achieve in the lives of people with addictive disease and with mental illness.
Treatment is important. We absolutely need to have state of the art medications available. They psychotropic meds that are available today, the new a-typicals are alleviating symptoms beyond what we could ever imagine but while treatment is important and essential we need to then be thinking about giving folks a life and an opportunity for them to succeed in the community. The failures that have come about from people being released from state hospitals and will end up back in institutions, or end up homeless, or end up in difficulty with the criminal justice system, typically it's because those three things I mentioned weren't able to be addressed or attained but if they are able to have education toward a vocation or meaningful daily activity leading up to a vocation or becoming employed. If they find a safety, some place to live and they get connected to people, through churches, through social groups, they end up dating somebody, if they end up reconnecting with their families they're going to succeed. They overwhelmingly demonstrate that they succeed in the community. So our jobs aren't finished yet when it comes to giving supports to individuals for what we're responsible.
This vision of hope and recovery is built on a continuum from community base services to national program direction. A continuum that stretches from then prevention in early intervention as we work with children; from treatment to recovery and a continuum that stretches from science to services. You'll be hearing more about science from the NIH representatives who will be joining you I know at some point in your conferences.
But without a doubt if we're going to achieve the vision we're talking about here today we need to be going about our work together, shoulder to shoulder, as soldiers in what President Bush has called the armies of compassion. I think we're all part of those armies of compassion. You make decisions, budgetary decisions; decisions around what will be funded with state dollars prioritizing around programs which do actually save lives and give people a quality of life.
Mental health and substance abuse services are very, very critical. Let's walk through the rest of the issues that you have in front of you and it explains why mental health and substance abuse services probably are even more at the forefront and critical today because we know more today partly than we have in the past. I know some of you are aware of much of this material. Many of you may look at this and say I know this and I appreciate that. I think of it like vaccine though, re-innoculation is beneficial for all of us sometimes to examine these issues.
On page 3 mental health and substance abuse have been identified by DHHS as key leading health indicators for the nation's public health. I think it's very important for SAMHSA to break down the silos that exist in our systems. I think you're all probably very aware that through the years a mental health system, a public mental health system has emerged in our states. Many times it's been out of the state hospital system, going to a community base system of care and the Community Mental Health Centers Act of 1963 began to bring funding to community mental health centers, and then the block grants of the '80's that we continue to administer today, continues to support the mental health system.
The drug and alcohol system has come into its own and it had to come into its own because years ago, turning the clock back, drug and alcohol was part of mental health and people who were alcoholics were thrown into state hospitals and inappropriately treated and the good news is today we have a clear understanding of recovery and a strong drug and alcohol treatment system and identity. But with strong identities, while it's very important to have those strong identities and I appreciate what Jim said about substance abuse and mental health coming together, we need to be also thinking about mental health and substance abuse being part of public health and we need to be conceptualizing that more and more and this is one way that we're doing this is showing that the leading health indicators of Healthy People 2010, substance abuse and mental health are on that list.
Page 4, the next graphic, gives us a good idea why. Mental health and addictive disorders are responsible for around 1/5 of all disability associated with all illnesses in the nation, a significant percentage. In fact, the World Health Organization tells us that depression alone is the second leading cause of lost capacity and lost lives in the United States and countries with similar developed economic status. That's also been documented in the Surgeon General's Report on Mental Health from 1999.
When it comes to mental illness we see on page 5 the report of the Surgeon General, it reminds us that diagnosable mental illness alone affects around 44 million adults; 22 - 23% of those over 21 years of age and over 20% of children and youth, ages 9 to 17. There are statistics that indicate 1 in 10 children today have a diagnosable, serious emotional disturbance and conduct disorder. Many of those individuals end up in a juvenile justice system. Many of those individuals are the ones that aren't making it in schools and end up being "the headaches and the problems" of the systems that we're dealing with.
On page 6 too many people experience both mental health and substance abuse disorders and this is why the point of mental health and substance abuse coming together is so critical because as many as 2/3 of the people with a lifetime addictive disorder also experience a lifetime history of at least one mental disorder and over 50% of those with a lifetime mental disorder also have a lifetime history of one addictive disorder. What we're finding today, and I'll be talking a little more about co-occurring being one of our priority areas and being a priority that SAMHSA now has articulated clearly, we must address in this nation, we know more today that we ever have before about that issue. You turn the clock back 15 - 20 years, 10 years even, I would even say 7 years, discussions around co-occurring disorders and mental illness and substance abuse were pretty much typically that this is a small specialty sub-population that you're going to have some specialty programs for. Today we know with the percentages I just quoted what we're finding in our systems of care is up to half of the people coming to our doors, drug and alcohol treatment center doors, mental health center doors, primary care doors, have a co-occurring mental illness and addictive disease.
It's not too hard to figure out how that happens. It's not unusual and we're finding or research is telling us there's a window of opportunity that when young people in the early teens, those that may be developing a mental illness, many times begin to turn to drugs and begin to use drugs as a form of self-medication. The addiction takes hold then and the mental illness isn't diagnosed until later on. In fact, the President in his speech in Albuquerque last week used that as an example of why our system needs to become relevant. He talked about a 14 year old young man who began to use drugs in his teen years, became addicted, became a major problem, was in and out of treatment, in and out of trouble with the law, and had a history of not getting a life; at the age of 30 he was diagnosed with bi-polar disorder. Once that was diagnosed he was on the right medications; the addictive disease also began to take care of itself and the mental illness was being controlled at that point. But think about 16 lost years of a life. This is why we have to take this seriously at the federal level and we need to work in partnership with the states to identify the fact that co-occurring disorders are a real issue and that's again, a responsibility I think we play in trying to put a focus on that and determine how we can better allocate our resources to foster best practices in that area and make it the "expectation" that we will serve this population instead of it being the "exception" that we serve this population.
We also see on page 7 the need for services doesn't equal getting care. The Surgeon General's Report also found that 2/3 of the adults with mental disorders don't necessarily get any help. Only 1 in 5 of the children or youth with serious emotional disturbances get care in the mental health sector. On page 8, suicide of course can be the end result of care or equally insufficient care. The same is true in substance abuse. We focus on just substance abuse.
Page 9 demonstrates that drug abuse is a fact of life in every state in the country to a greater or lesser degree. The good news is that the rates of substance abuse have finally stopped rising. They were rising; they've begun to plateau. The leading indicators for drug use, rates of use among the youngest users, the number of new users has dropped. We hope that bodes well for the future. Overall rates of illicit drugs, marijuana, cocaine, heroin, hallucinogens, inhalants were unchanged. We're hoping this is an opportunity and of course if you're aware of John Walters and OMBCP's goals out of the drug czar's office out of the White House and we are very much close partners in working with them in attaining those goals. We're looking for a 10% decrease over the next 2 years and a 25% decrease over the next 5 years and we think we're positioned to be able to do this. It's also why it's very important for us to use data, to use what we know and begin to implement what we know.
Substance abuse, while we're encouraged by these figures, still affects millions of people, including families. Of grave importance are the numbers of children growing up in families in which substance abuse is taking place. The numbers, even though again I gave some optimistic numbers, they're still very chilling. What makes the issue all the more critical is that we know that a family is the number one risk protective factor for a child's decision to start using drugs. So bottom line, we know more today also in prevention and that's important for SAMHSA to get that word out and begin talking about prevention programs, that the family relationship and the attitude within the families is the number one risk protective factor for a child. So shouldn't we when we think about prevention, think more than just having educational programs here and there but think about how do we engage families, what types of messages should we be sending. For example one message that we're trying to send through our Center for Mental Health Services is that all parents should be spending at least 15 minutes a day, one on one, with their child. And it's amazing how many parents don't have that but that communicative factor can be significant. But we have the science to demonstrate that that's effective and that's where we should be putting our resources. We can't succeed in ending drug abuse and ending it for good if we don't have the capacity to meet the treatment need.
On page 11 it shows the current rates of drug initiation. If that continues there will be a 57% increase in the need for drug abuse treatment. We can reduce current initiation through prevention rates by 50% today. The demand for treatment will not increase. So we have to think about both prevention and treatment in terms of making an impact in those numbers that I mentioned earlier.
SAMHSA conducts each year a household survey. The President asked us early on to identify is there a treatment capacity gap that we can identify in this country. We were able to identify based on the household survey that we would estimate 3.9 million people need some form of drug and alcohol treatment based on how they responded to this survey based on their patterns of use. Out of the 3.9 million about 800,000 received treatment. We also have found that out of the 3.9 million, there's about 351,000 who recognize they need treatment and out of that there are 129,000 that recognizes they need treatment; tried to seek it and couldn't find it. So we're also trying to identify those individuals who are ready for treatment and trying to seek treatment; why didn't they get access to treatment. What prevented them and we think that's a population that's very important for us to hone in on in terms of our planning.
The cost of substance abuse and mental illness. The data alone suggests why SAMHSA shares your concern about people with co-occurring mental and addictive disorders, about prevention and early intervention for children and adolescents who are at risk for mental health problems or substance abuse. The human toll of these orders is tremendous. The economic cost of these illnesses is significant as well. Pages 13 and 14, note in particular, costs associated with crime, criminal justice and property loss of both drugs and mental illness. The cost in lost productivity in mental illness translates into lost wages, losses to the tax base; health care costs themselves are significant to Medicaid, state Medicaid dollars. If you compare those costs to both SAMHSA's budget and the national expenditures on health care, you're feeling the result in your state budgets and we're all feeling the result as well as you take a look at the particular data there in front of you.
On pages 15 and 16, compounding the problem as you are aware, funding for mental health and substance abuse comes predominantly from the public sector in contrast to all health care funding in which private sector funding predominates. So this is why you as legislators, as chairs of your committees feel a lot of pressure in these areas because the public sector is really where the action is in terms of meeting this need and the need is great and the resources are tight and the resources always have been tight in this area. I also know that right now it's tough in virtually every state. In fact a funding crisis in many states, so the pressure is even greater. And as your state mental health directors and substance abuse directors in their budget requests will tell you, state and local funding supports treatment for mental health and substance abuse disorders at a rate more than double that for all their health care expenditures.
When it comes to dollars, and page 17 depicts this, growing state mental health funds or supporting community based services, and that's a trend that I personally and professionally hope continues and needs to continue in light of not only the Olmstead court decision, but also in light of the New Freedom Initiative the President is committed to, it's clearly the right thing to do if it's done correctly because it will be a way of giving people a life in that vision we talked about earlier.
There's also again, some more good news here and that the good news is what we know. Pages 18 and 19 it indicates that we know that treatment dollars spent for mental health and substance abuse services, those dollars really do work and the treatments really do work. Treatment for substance abuse reduces rates of drug abuse. The rates of use a year after treatment are roughly half that for rates for the year before treatment
Criminal activity is reduced as a result of substance abuse treatment by 2/3 to 3/4 depending on what program you're looking at that we've studied and we've examined. Research has shown that rates of continued abstinence from drug abuse run up 40% to 60% because of treatment and treatment intervention.
The criminal justice interface is something that I can't stress enough here. In Pennsylvania about two years ago, I requested that we do a survey of our state prison system in order to determine the number of individuals in our state prison who have a drug and/or alcohol issue. We found that close to 90% of the individuals in our state prison had a drug and/or alcohol issue and that pretty well is comparable that nationally the surveys that we've seen, it's somewhere usually between 80% - 90%.
We found that out of the 12% who are considered seriously mentally ill in our prisons, 90% of them had a co-occurring drug and/or alcohol disorder. We found that over 50% of the individuals who were in prison in the state prison system were under the influence of drugs or alcohol at the time of arrest. Strong connection here; very strong connection here and if you take a hard look at the data and you all are acutely aware of this in your states, the rise in the prison population began to occur in 1990. If you take a look over the course of time and it coincides with the stricter enforcement of the drug laws. A lot of people try to make the connection that because of the downsizing of state hospitals that's why you have more people in prisons that are mentally ill because you don't have state hospitals to put them in.
If you take a look at people and again, I think there's some dueling data on that particular issue, if you take a look at the issue of data around that, there's a stronger correlation between the number of people who are mentally ill who are arrested because of drug abuse or being under the influence and I think again, the enforcement of the drug laws has had an impact on that as well. As we've seen it, what we are finding in terms of a solution, in terms of addressing this issue, one way that we can address attacking the cycle of crime is by providing treatment in prison because again, as I stated earlier, you see the reduction in criminal activity from 2/3 to 3/4, and there's documentation out there that's very clear. In many reviews that have been done in many states and the data can be available, that crime does go down, recidivism does go down if people receive treatment when they're in prison for their substance abuse and they're finding that, I might use the word coerced; I will use the word coerced and forced treatment works. In other words, you have a captive audience when they're in prison and in fact they find that forced treatment actually seems to have better results in some indications than people who volunteer. My theory on that is the people who volunteer for treatment in prison are probably finding a gamut to get out early anyway. But the people who don't volunteer but are forced in it, it tends to take hold. Then our responsibility as SAMHSA and the state drug and alcohol authorities along with the criminal justice system, is how do we bridge services as people are coming out of prison, assuring that they continue to receive the supports and treatment they need and that recovery can be sustained. If that happens, typically the person doesn't get in trouble with the law. So not only are we addressing a public health issue here with treatment, we're addressing a public safety issue as well.
We also aren't talking about "rehabbing criminal behavior"; that's not the point. We're treating a disease; we're treating an illness which gets people in trouble with the law because they haven't been able to address their addictions up until now.
So as we take a look at treatment working and again, in the mental health and treatment arena, we see that we have the documentation that treatment does work, that people do recover. We also know that treatment of course spent on substance abuse and mental health can save other dollars. Research after research shows that fiscal health care costs drop when treatment for co-occurring mental illness is provided. Also we find that people who are in recovery typically, I mean we find that the data tells us that their physical health care costs drop as well once they're in recovery than when they are addicted actively dealing with their addiction. In fact I've heard various accounts of individuals talking about how their medical file was this thick when they were an active alcoholic but once they were in recovery their medical file got a lot thinner because they were taking better care of themselves overall.
By preventing or treating substance abuse early, we also lower other collateral costs, such as those associated with HIV/AIDS. Again, I talked about the criminal justice system and also the child welfare system. For example, studies have found that treating pregnant, drug-abusing women, actually resulted in a net savings in post-delivery treatment costs of over $4,600 per mother and child.
It's another example that we can either pay now or pay later and these are tough decisions because when you're faced, I know when I'm faced with those decisions at the federal level, I was at the state level, I know when you're faced with decision of budgets you're faced with trying to need to make some immediate cuts. Or you're faced with trying to make sure the budget doesn't grow too fast here in the immediate future because you have tax implications; you have a broad picture to look at. But again, just as in the corporate world when we have to be focused on our quarterly bottom lines and we may make some decisions in the short term that makes sense, sometimes the longer-term decisions don't get made and those sometimes can be tougher decisions that could end up being cost effective in the long run. I recognize the difficult position we're all in in looking at making these kinds of decisions and again, that's why the data is so important. It matters a great deal what we pay for today and the services we support, the services that you support with your state dollars and that's why again, commitment to evidence based is very, very important.
A couple of things that I might highlight before I get to a matrix, I've already been talking about the matrix and you'll know what I mean when you get there, it's another priority we have in SAMHSA and another commitment we're making is developing and defining what we're calling a science to services cycle. This feeds into the evidence base need and the data need that we have. One thing I found when I first came aboard just less than six months ago into this position, I was helping develop the tail end of the '03 budget proposal the President was going to rollout. The feedback that I received from OMB was basically that they were concerned about several million dollars SAMHSA was setting aside in what was called knowledge development and saying that's research activity and you're a services administration and the institutes are research institute. So why are you doing research? In the past what I found out is I guess SAMHSA has always fought that battle over here and we need to do services research. It's important for the nation that we are expanding our knowledge base of what really works. I agree with that principle but I decided that instead of going through this argument every year and I had other issues that I wanted to address in the process I agreed with OMB. They didn't know quite what to do with that but I said let's, let's still fight this battle. Let's say I agree, research should be done in the research institutes; we're not going to do research but the caveat is the institutes need to do real services research with an agenda that's established by SAMHSA being at the table, by our stakeholders, our providers, our consumers being at the table as well as our academic partners being at the table and establishing a research agenda that the institutes can carry off and that we as SAMHSA then need to be bridging the research to the community, to the service level; continue to pilot some programs, have strong program evaluation that's appropriate, that's not pure research. I said SAMHSA can do the impure stuff and let the institutes do the pure research and then we also will bring to scale those services that are evidence based and that's what we should be doing. So we're in that discussion right now and I've also made a commitment; the Secretary has been wonderful about this, he's been extremely supportive saying we need to clarify this, we need to move on with it and he also understands that if I'm assessing toward the end of this calendar year that we're not making progress on that; that we're going to revisit it and come up with another strategy because we do need to have an active services research agenda.
We're really looking to place a focus on enabling states to help us determine what they need and also help us determine where we should be putting our resources in the states. I also view the states and the associations that represent the states here in Washington and being partners in the science to services cycle.
Let me talk a little bit about where we're putting our emphasis with local communities in states and substance abuse prevention and treatment. We have targeted capacity expansion programs and also state incentive grant programs, along with the block grant programs that we provide to the states. Targeted capacity is one way that we try to identify those things that the researchers telling us works; trying to put some money in particular areas to expand that capacity. State incentive, very similar. We work closely with the states.
Another commitment that we're making at SAMHSA or that I'm making at SAMHSA is I think it's very important for us not to be funding programs in a state without the state being part of the process of awarding those programs. We've had a tendency at times to award programs in a local community without the state being involved at all and I think it's important for us to be clear partners with the state as we are awarding in local communities because we require states to submit plans that we approve. We need to make sure that we're not undercutting those plans and that we consistent with those plans and I think we can get at that better with a partnership with the state.
Also when it comes to the block grant, we're developing an approach called performance partnerships in which we're working with states right now to determine what are those performance measures for which we should be holding states accountable block grant dollars. Having a very open dialogue, making that determination, based upon that then we will have a way of measuring outcomes and holding states accountable, but again we think it's important to maintain a partnership and also flexibility with the states, so the states do have flexibility in meeting the needs because states do vary in their level of needs.
The matrix and I think it's in your packet somewhere. It's a one-page matrix and what that matrix is it's telling you what SAMHSA is about in one page basically. It's a one-page description of what we're about. It's in your notebook. Basically with this matrix we have the left hand side axis on the matrix are programmatic priorities and issues of which we're looking to invest any new dollars, if we're able to get new dollars in this budget cycle, as well as recycled dollars; dollars which are no longer committed because contract cycles are finished and they're freed up again, as well as existing dollars, making sure we're leveraging them appropriately. The reason we developed this matrix, well we have several reasons I should say. One is I believe if you're going to make any systemic change, whether it's in government or private enterprise, but it's especially true in government and I found this to be true in my experience in Pennsylvania; if you can't live by the philosophy of well a thousand flowers bloom. It's real easy. I mean people come to our door all the time with great intentions, great ideas and good stuff and we could put a little bit of money in a lot of different places but if you do that what happens is you don't tend to make any real systems change. Maybe you're hoping something will take hold but I think it's more important to have a focus; more critical to have a focus if you want systemic change and instead of letting a thousand flowers bloom, I'd rather have a few solid redwoods that make a difference in people's lives. So that's why we tried to boil down our priority areas as we focused on what we're going to be funding; how we're shaping policy and those initiatives and those areas are over on the right on the left hand side of the page.
Also this is a first for SAMHSA that we have formalized because we're comprised of three centers; Center for Substance Abuse Prevention, Center for Substance Abuse Treatment, Center for Mental Health Services. This brings all three centers together around these issues to develop approaches instead of the budgets coming out of those silos within SAMHSA, but let's address things in a systemic way and each center has a role in these areas. So it's a way of us beginning to model what we'd like to see occur actually out in the field.
The cross-cutting principles along the top axis are basically those principles that we want to see it play in all of our initiatives. For example, we have data in evidence based outcomes; I've talked about that. We don't need more data in evidence based separate initiatives. We need to begin applying what we know in everything we're doing and funding those things than have an evidence base and then have outcome measures around them.
Cultural competency is another example. The definition I give to cultural competency is how do our services become part of the fabric of a neighborhood so that there's access and it becomes part of that neighborhood and that's a cross-cutting principle; that's not a separate cultural competence initiative. We need to apply what we know about cultural competence to all our initiatives.
Trauma and violence; 80% of the women in our state hospital systems are victims of trauma. That's a high percentage. We find a high percentage of trauma at play with many of our populations. We need to have that in mind as we approach any intervention that the trauma issue has to be dealt with. That's a cross-cutting principle, not a separate initiative. So that gives you an idea of how we're looking to use the matrix, to develop outcome measures and to hold ourselves accountable.
Co-occurring, this is not really in a list of priority. I suppose though if I were going to list a priority, co-occurring would be at the top of the list but that wasn't the intent here but we'll go with it for right now. Co-occurring, I discussed that earlier. We want to get real about co-occurring; how those performance partnership measures to the block grant; give flexibility to the block grants to meet co-occurring. Begin in our targeted capacity expansion, state incentive grants to be able to put monies out as incentive to develop integrated treatment models that we know work. Make sure there's assessment at the door of treatment to take into account both mental health and substance abuse, not just assessing one or the other but doing it up front.
If you take a look at the people who recycle in and out of our treatment systems, a high percentage of them and again, we haven't had a specific study on this, but I would speculate you're talking at least 3/4 of probably co-occurring and they're only getting treated for one of the disorders and not the other. It's a nettle that we're picking now. This is fraught with difficulty and any of you as chairs of health committees who have ever stepped into the substance abuse, mental health arena and discussion can know that the two fields don't always get along or they can be very threatened by each other. So again, it's been easy at times for an entity like SAMHSA and state drug and alcohol authorities and mental health authorities not to take this issue on because it steps on a lot of toes. We're beyond that now. We have to be beyond that now. We know that not everyone is going to be totally happy about this being addressed or they're going to be threatened but we have to have the dialogue on it because the data is too compelling and we can't afford people cycling in and out.
Substance abuse treatment capacity, and the other things these priorities do they're aligned with Secretary Thompson's priorities and the President's priorities, which those are my priorities. The substance abuse treatment capacity, bottom line is a major priority of the President. In the '03 budget we have proposed in front of Congress right now $127 million new dollars are going to substance abuse treatment capacity. Again lining that up with the goals I mentioned from John Walters and OMBCP trying to address that treatment gap. About half of those dollars are going to be going to the block grants of states; about half will be going into the state incentive grants and targeted capacity grants.
Seclusion and restraint; again I feel very strongly about that issue. In Pennsylvania we had a model program that we virtually greatly decreased, virtually eliminated seclusion and restraint in many of our state facilities. It's an issue which we have to raise questions why do we do it if we're retraumatizing people who are already victims of trauma? Seclusion and restraint are not treatment interventions; they're treatment failures. So let's give guidance and let's help change the culture of caring. We know what works. We don't have to rely on those coercive measures today. Again, it's applying what we know.
Prevention and early intervention; I talked about substance abuse prevention. Mental health has not had a real focus, well they they've tried to focus on prevention but the field is not as mature for mental health as it is for substance abuse. I'll be honest with you. If you take a look and many of your probably have visited substance abuse treatment programs and substance abuse prevention programs, if you look at prevention programs, you tell me what the difference is between substance abuse prevention activities and mental health wellness and promotion activities and character development and building and resiliency building. They're not only the different sides of the same coin; they're the same side of the same coin as far as I'm concerned. So we're looking at ways for SAMHSA to develop more of an integrated view of prevention and early intervention around the field and again, I mention the family being a risk protective factor. We also have been able to scientifically establish other risk protective factors that we know really work in preventing substance abuse and promoting mental health wellness. Bonding, with social organizations is another risk protective factor. Being involved in extra-curricular activities, being engaged and those are the types of things we need to think about encouraging at the local level.
Children and families; very critical priority for us. There are no more complex cross systems issues than there are with children. They're involved in schools; they're involved in the welfare system; they're involved in the juvenile justice system; they're involved in boys and girls clubs, family involvement. We need to look at the children's agenda being a cross systems agenda. SAMHSA, we've brought aboard an individual by the name of Dr. Sybil Goldman. I call her "my children's czar". She's to pull together the children's agenda for all three centers within SAMHSA. She's also reaching out to the Department of Education, Department of Justice developing children's mental health and substance abuse agenda at the federal level; again, to help empower states as we look at how things play out at the state level to assure that kids aren't frightened among different silos again.
The new Freedom Initiative; when the President announced parity last week in Albuquerque he also rolled out a mental health commission. The Mental Health Commission is headed up by a good friend and colleague, Mike Hogan. He is Director of the Ohio Department of Mental Health and the President wants an action plan within one year to give guidance to the federal government and again, in mental health and substance abuse, states is where the action is. More state funds, especially on the mental health side, go into mental health than federal funds do. And constitutionally responsibilities seem to lie with the state and some states are county based and that gets also to the country level, about 26 states. So this plan is to give guidance to the federal level, state level, county level and providers about what do we need to be funding to give people a life in the community and the President is very committed to that.
Terrorism and bio-terrorism; priority of course we know why today. There are mental health and substance abuse consequences to terrorism and bio-terrorism. We've been working closely with the impacted states; working with FEMA in funding crisis counseling. We also held a summit at the request of the Secretary in November of this year in New York City; 42 states came together. Their governor sent teams of 10 - 15 representing different agencies within the state and we had a workbook at this session. The states met at teams, plus we had a variety of plenary sessions in which we brought the best thinkers in the arena of mental health and substance abuse consequences together and actually we're creating that field right now because there is no real field of understanding the mental health and substance abuse consequence of terrorism and bio-terrorism. But we're using our experiences from Oklahoma City; our most recent experience is from 9/11 to give guidance to the states and many of the states have written in that they're using the workbook that they had as their module for the state disaster plan update on terrorism and bio-terrorism for the mental health and drug and alcohol components and we'll continue to fight with technical assistance in that area.
Homelessness; major priority of the department. Substance abuse and mental health are very much part of that because of the high percentage of individuals with disorders that are homeless and we have some effective programs like the PATH program, in which we have outcomes that demonstrate again, hooking people into vocation, hooking people into safety as a place to live and recovery and we are able to make headway on homelessness.
Aging, if it's not your issue, it will be. The aging issue has not been something that mental health has really dealt with because of lack of resources. We think it's time to do some real planning around this because we recognize a couple of things: people with mental illness are living longer and as you live longer the likelihood of a mental health problem occurring, and we all are living longer, is greater.
HIV/AIDS and hepatitis C, those have been ongoing priorities and will continue to be because our populations are at risk.
I've already talked about the criminal justice system. Why that's so important and we are working with the Department of Justice and funding programs at the state and local levels. Drug courts, mental health courts, reentry courts, we're committed to that and committed to expanding upon that working in a partnership with Justice to get at those issues that I described earlier.
So bottom line, I've given you an idea of our priorities; where we're at right now; what we're trying to pursue; how we're trying to conceptualize it. Feel free to use that matrix. I found it to be used very well not only internally; we have this matrix in our vision statement I shared earlier. There are very active tools that we actually use, our executive leadership team as we make budgetary decisions; as we evaluate proposals. I'm also finding external constituency groups are starting to use our matrix and friends are communicating what we're about in helping shape their own priorities and what we need to be doing.
Clearly you need to know it's not by chance that I'm here today with you. I wanted to be here today with the invitation because I know you play a key role both in the day to day policy decisions you make within your states and in the broader intergovernmental policy. Your constitutional responsibilities as I mentioned earlier make you key actors in helping us resolve the matters around mental health and substance abuse and the challenges that we face and I look upon hopefully the dialogue today with the council as a beginning as we work in partnership. I work very closely with both NASADAD, the drug and alcohol program directors association representing states; NASMHPD, the National Association of State Mental Health Program Directors and I served on their board so I'm very familiar with their association. And I work very closely with, I don't know if any of you know, Denny O'Brien was the state representative who was Chair of the Health and Human Services Committee when I was in Pennsylvania; I worked very closely with Denny and then Sen. Bob Thompson, who is now Chairman of the Appropriations Committee in Pennsylvania. We couldn't have pulled off what we did in Pennsylvania without that collaborative role between the Legislative and Executive branch and you have a lot of the same people pounding on your doors. I think it's important for us to have an open dialogue, especially looking at the data and also remember that our responsibilities don't end just in terms of assuring that there's treatment levels but we aren't doing our jobs unless we're focused on the outcomes of peoples lives and that gets back to a job, a decent place to live and a date on the weekends and those are the factors and when people attain that they don't come cycling back into our systems and we know drop-in centers, clubhouse models, a lot of things out there really work to help attain those things as well.
QUESTION: You talked a lot about the correlation between substance abuse and mental disorders. It seems to beg the age-old question of which comes first, the chicken or the egg. Does addictive behavior breed mental disorders and mental disorders breed addictive behavior.
Yes and yes. I'm glad to help clarify that for you. It depends. The example the President gave in his speech last week and I just highlighted, clearly I think that's an example that there was an underlying mental illness developing. He began experimenting with drugs and the longer-term crenicity that occurred with his drug use seemed to be a self-medicating aspect and it's not unusual for us to see what I would call self-medication. Alcohol for example is a depressant and I don't think it's unusual, someone may not necessarily be alcoholic in the sense of the genetic pre-disposition, but they end up drinking a lot because they have an anxiety disorder and they actually begin to feel better and it helps them deal with and it's a form of self medication.
But we also are aware that there are people who have long-term addictions because of the toll it takes on their brain, mental illnesses and symptoms of mental illness do develop; both depression, even a psychosis. So we do see that occurring as well. So I think part of what we're finding is at that the causes may be somewhat different but the one thing that we're finding is both the assessment and the integrated treatment seems to be effective regardless of what came first and the good news is that the integrated treatment, treating both concurrently in an integrated way seems to be the most effective approach. And that's where part of the debate you're going to see occur because there are those in the drug and alcohol side who say that's a very small part, they need integrated treatment. There are those on the drug and alcohol side though, I mean there are mixed opinions there, who understand that it's a larger segment. Some believe that parallel but separate treatment can work. I think that's real iffy, if it's a mild mental disorder, maybe. But I think it's difficult when you think and put it in simplistic terms and mental health, you come to a mental health group and you're told take your meds. Those in the drug and alcohol group, they say stay off drugs. And bottom line you've got to somehow bring that together because the cultures can be somewhat different.
QUESTION: I have a couple of questions about in the prison system. You mentioned about well first of all we also recognize that 90% or more in prison have some kind of a substance abuse problem, but you talked about treating in prison. It's always been my experience that if you're going to treat alcoholism or maybe any substance abuse, it has to be voluntary and that in prison not only is it not voluntary but you can't get it, supposedly. You don't get the drug or you can't get the alcohol or whatever and so it's no giving something up, it's being forced to give up. Why do you think treatment really works in prison?
I base that on the data in terms of programs that have been set up to provide the treatment in which they've actually measured the outcomes of people who came in with an addictive disorder and they had groups of individuals, in fact control groups if you will, individuals who volunteered for treatment, individuals who didn't volunteer but it was part of their program and the results in terms of them not only ending their use once they were out, especially if there was a bridge in place of them coming into the community and having supports to sustain their recovery, the outcomes were clear that they did not go back to using drugs. Again, you had to have the support systems in place as they left as well. It is counterintuitive. It is very counterintuitive to think that forced treatment works and when I first heard the statistics, it was kind of like a light bulb, it was kind of like wow, that doesn't fight because you're right, the whole issue of recovery many times in dealing with alcohol and drugs, the person has to hit bottom and get out and get through the denial because denial is a big part of it. I think in the prison system though what they've found is just forcing the folks into it and making them go through a treatment program. The results actually were very impressive. So it's based on actual programs that have been implemented.
QUESTION: The other question is and what do you do about those that are really mentally ill in prison?
I think first of all you need treatment. Pennsylvania for example we became very blessed because we received, an individual was hired by Marty Horner was then the Commissioner of Prisons, he's now in New York City as I think the Commission of Probation, but hired a psychiatrist who understood mental illness, came in and began assuring that there were treatment components in every prison. There were some prisons that specialized more in it than others, so I think you need that. I think you also then need that bridging as people are coming out to make sure, and this is a real disconnect; we're not there yet as a system as far as I'm concerned. We struggled with it in Pennsylvania. As people are coming out of prison that they have the same supports as people who come out of state hospitals have.
I tried to come up with a concept in Pennsylvania, we had a concept in Pennsylvania called CHIP, Community Hospital Integration Program, and that's as we closed down wards in the state hospital; we kept the money; we didn't just put it back in the savings. We transferred it to the county who is responsible in Pennsylvania for providing community mental health services, for them then to develop the supports based on the evidence of what worked, to the individuals coming out as well as coming up with diversion programs. Thank gosh, if we can knock out 10% of the beds in the state hospital system, is there a way we could like convert the dollars going to support those prison beds into treatment in the community and have kind of a criminal justice CHIP. I think we need to look at treatment inside the walls, outside the walls and then I think diversion court, reentry courts as well as mental health courts and drug and alcohol courts have a lot of promise for us to really consider. I say that somewhat cautiously though because we're now just getting the data in more and more the effectiveness of drug and alcohol courts. I'm anticipating it's going to look good but we haven't got solid data systemically yet on it. But if it continues to look promising I think that offers some hope to assure people get the treatment once they're in trouble with the law.
QUESTION: So you think every prison needs to have a mental health treatment program because the mentally ill play havoc in a prison.
Absolutely! I think every prison needs to have a capacity for assessment and a level of treatment. I think again, pragmatically it would probably be difficult to have every prison have a specialty ward, but then I think there needs to be capacity within every prison system to assure people are transferred to the appropriate treatment setting. But I do think there needs to be a certain capacity in every prison, absolutely.
QUESTION: Sen. Paula Hollinger, MD. About 5 or 6 years ago when we started discussing the percentages of people in prison that were there for drug related offenses and I started doing some research and realized we had zero treatment in the prison system which made no sense and these people get out (and come right back in). I did get legislation passed that basically states it's optional but 6 months before they're eligible for parole they either have to go into drug treatment or they lose their good time. That's been pretty effective. The original bill had a six month treatment follow up which got cut back to 6 weeks because of budgetary constraints but for the longest period of time there was nothing. At least now these people do have a chance.
I think that sounds like a very appropriate response because you do have the elements of; I mean they're kind of forced to make a choice and it's an important resource. I'll be interested to hear more as that continues to be implemented, the effectiveness of it.
QUESTION: In a way we just passed two parity bills at two levels; one for adults and one for children/adolescents and I'm assuming that if we do have a federal law that they will preempt all the state laws in terms of requirements.
I would assume so.
QUESTION: Okay. In a _________ the opponents of course have always been, well from the business community and health insurance providers that these are unfunded mandates. In Hawaii they always bring up our consent decree under IDA where we have a federal act that doesn't provide any type of resources for services in the school and yet we're forced to comply. One of the questions is if we were to have this set of legislation and mandate, can we also expect any federal funds for mental health and substance abuse treatment.
You mean in the context of parity? I think basically, I'm not sure that that would be necessarily a given in that legislation. I think you've articulated well though what I think the remaining major sticking point is on parity and that is employers looking at this being a mandate on them. I think what needs to be part of this is an examination of those states that have passed parity. For example, Vermont is one example. I know there are other states that have passed parity and we're studying what are the exact costs of this. And they've got some important information to get out. What we're finding and what we seem to be finding preliminarily is that in looking at all things being equal and trying to get a handle on what is the net impact of parity on premiums, the figure that keeps coming out is a 1% impact it has actually on premiums and that 1% is based on a utilization management managed care scenario because I think virtually where parity has been passed it's always been under a utilization management and I think it has to be. I would anticipate that's going to be happening at the federal level. Again, part of the issue with the federal level parity at this point is details remain to be worked out at this point. In other words, the President is taking a strong stand on parity. Now as you know, you're all familiar with it at the state level, the fun begins in terms of the negotiation between Congress and the White House and with all the constituency groups.
What's interesting on the parity issue, my wife is the President and CEO of the Bethlehem Chamber of Commerce and we had interesting discussions about parity around the dining room table coming at it from somewhat different angles. She was empathetic to my viewpoint though. It was a tough issue and it continues to be but the data seems to be coming out on our site. Now I struggle with the data I hear coming out from the mandated site because I hear all sorts of major increases that our people are saying occur. We've just not been able to substantiate that that actually happens when it comes to mental health parity. I think they kind of extrapolate from some other kinds of studies and try to apply it to that is the impression I'm having.
QUESTION: I have sort of a quick detail question and then I have more policy question. The detail question is when you went through the programs and issues on the matrix, you went over HIV/AIDS fairly quickly and I'm still not sure I understand its context.
People who have used substances are at very, very high risk of contracting HIV/AIDS because of the nature, especially through needles in particular they're at a high rate of exposure to that. Also people who are mentally ill who are on the streets and there's a real connection with the homeless population in that as well. So we need to make sure our systems of care take that in consideration.
The other reason I might mention, Hepatitis C has been added to that is because that's really an emerging epidemic that we're not talking about. I mean we still have a little focus on HIV/AIDS. It's related to same type of behavior if you will and also the same type; it can be contracted the same ways. The other things that's occurring, which I don't know if you've heard about this in your states yes, but as you talk to drug and alcohol providers, many of our drug and alcohol agencies, a high percentage of individuals who are counselors on those staffs are people in recovery. We're finding a high rate of Hepatitis C began to evidence itself in that work force because of past lifestyle when they weren't in recovery and it's now evidenced itself years later. So we're also very concerned about the clientele of the work force.
QUESTION: My other question is broader. I can certainly understand from ERISA and so forth, getting into parity, we've had parity in Minnesota for a long time, but I find it's sort of intriguing listening to you in some respects on the fundamental question of the role of the state v the role of federal. In some respects I hear you bringing with you your state view of things and having carried a mental health act of 2001 I have my own sort of feeling, but I worry a little bit, I even look through this book I have here about the direct grants to places and I think now wait a minute; I don't remember being directly involved in those in my committee. I guess I feel like this is an area from a general point of view in the whole substance abuse and mental health that is a state domain; there is a federal relationship. Could you comment a little bit on it because you really get down to detail level in some respects scares me.
I understand. Actually I'm in agreement with you. As a federal agency I do believe in federalism in terms we need to partner with the states number one, and is a partnership. Number two, you are right. It's in the state domain. Mental health and substance abuse in states is where the action is and we need to, for example, what you picked up on in terms of grants you saw and we wanted to make you aware of what's happening in your states, I'm not surprised to hear you say that. When I Commissioner of Mental Health in Pennsylvania I would become aware of a SAMHSA grant in Pittsburgh let's say of $1,000,000 that I didn't know anything about and in fact it was with an agency that we were reviewing because we had concerns about their mismanagement of state dollars and I called SAMHSA and said why did you fund this? Now I'm getting calls with the why did you fund this? But we are trying to I guess turn that ship around to where, that's why my focus on the block grants, state incentive grants and when we do do targeted capacity grants which is typically what you're seeing going directly to communities, that the state does more than just a signoff. Again, I think there are times at the federal level, there's been a perception, well we require the states to sign off on those grant applications and the states are included. Well I know what's that like. I get a call a 4:00 pm saying oh there's a grant application that's hit your desk and it's due to SAMHSA by 10:00 and it means $500,000 to our community for this mental health service; you've got to sign off on it or we're going to lose it. What do you say? And I'll say well Mr. Mayor of course I'll sign it. Bottom line you end up being very politicized by that and I think that the state needs to have a more upfront role early on in those decisions.
My comment on the parity issue, I was just give you an example there where I think the federal government coming out with a strong stance on parity, it eliminates one less debate. You have to do it at the state level on that but I think you and I are probably in agreement. I do feel the federal government does play a role for the field and I think SAMHSA plays a role of leadership; you might want to call it the "bully pulpit" as well. For example, co-occurring; I think it's important for us to put funding in those areas to give incentive in the right areas but also I think we need to be articulating the issues for the field and I think people do look to the federal government in that realm but again I think that's done in partnership with the states because I think each state director of mental health and substance abuse also has the same role in your state to reshaping it.
QUESTION: My name is (Sen.) Pat Thibaudeau from Washington State. We haven't been able to achieve parity so a colleague of mine and I, a very good moderate republican and I'm a very liberal democrat, sponsored a bill to give children parity and the reason I bring this up is it didn't go anywhere. So following that, public employees benefit board adopted limited parity and they found that to do that for kids would cost like $.90 a month per member per month. $.90, it was even less than that.
I'd like to have that data; it would be helpful.
QUESTION: Be happy to. The other thing that I need to mention is everywhere I go, every social problem, for example, child abuse, I'm very interested in an agency I'll tell you about later, 85% of our kids come from drug impacted families. My colleague and I just agreed; it's just economic to provide this kind of service.
I like what you're saying. I'm actually a republican social worker. Some people say that's an oxymoron. I said there are like 3 of us in the country and we have a great convention. They're all good people.
QUESTION: I guess one of my concerns is that the disparity between what parity is and what treatment protocol definitions are and your ability to get the word out in terms of what treatment is is an example for substance abuse which in most cases is time related. Managed care companies define it like they want to define it which is significantly less in most cases than what you would define a treatment protocol for substance abuse or a severely severe schizophrenic case in a juvenile as an example, which we know that the longer is treatment is the better chance of not going back into a hospitalization situation and better chance there is of going home and yet they're defining these treatment periods as very, very short and becoming shorter and the numbers of cases that aren't being helped or cured continue to rise. I'm not sure, when I talk to people about what your protocols are for substance abuse as an example, they don't have them. They don't understand; they don't get it.
You make a very good point. No absolutely and it's even true with public sector Medicaid dollars in managed care which you would think we would have a natural link. It doesn't always happen because it's kind of turned over sometimes to managed care companies. The good news with this is that there are protocols that could demonstrate that they do work and have results. Again, going back to my experience in Pennsylvania, we did achieve a carve out of Medicaid dollars for mental health and substance abuse, gave the counties the right of first opportunity and we called it to manage those dollars, many of them partnered with a managed care organization but we set the standards at the state level which established protocols which were qualitative in nature and outcome oriented and our goal was to have both access, quality and cost containment coming together. It's a tough thing to do but it's not impossible to do and I think what happens is managed care begins many times to get focused on the cost cutting side, not even cost containment side. If you do that without the qualitative end of things, again you're going for some maybe short term gain but some longer-term ongoing chronic demands.
QUESTION: We have a mental health parity law in New Mexico but it has some limitations and it treats the chronic, biologic and psychiatric disorders. However, you can't write the whole DMS 4 or 3 or whatever we are on now in law. So the question really becomes is how do we write mental health parity laws that really are meaningful; that really get to the heart of the treatment. I mean we don't write diabetes is going to be a 6 months disorder. It's a lifelong situation. So how do we get the same kinds of interpretations so that those laws subsequently become effective?
That's a great analogy. One thing we're looking at right now I think the place to begin with that to be informed is again, the studies we're doing where parity has been adopted and has a track record now 3 or 4 years; begin to see not only the cost issues I talked about earlier, but the issues you're raising. Are people getting access to care and adequate care that's addressing it under parity? I know there have been some studies done in Minnesota as well, in which I think we can be informed about what works in those existing laws and what doesn't and begin to determine those elements. We at SAMHSA are taking results of that study, feeding it to the White House as part of the on-going debate and discussion. So you point is well taken. I think that's where we can learn how to really make it real.
QUESTION: I guess the third part of the question is in almost all mental health parity bills, substance abuse is written out. Somehow substance abuses and treatment thereof, there's some sort of a personality defect and so we don't include that in any of those disorders.
And you're exactly right. I don't know if there's anywhere where there's been a substance abuse parity passed. First of all, two things: I met with the substance abuse leadership group here in Washington that represents the National Substance Abuse Advocacy Groups and actually I met with them about 2 weeks before the Albuquerque meeting. I was going to say, I know what was going to happen when the President's plan was announced but I couldn't say anything, so I didn't. They didn't know and it was interesting they made the comment we want to let you know that we're taking the position that we're supporting mental health parity because we know that has a better chance of getting support and passing, with the idea that once that's rolling we're going to come back and really talk about substance abuse parity and that's kind of the position the field took. I think they're pragmatists. We're not going to stop mental health parity from going forward if substance abuse is not a part of it. But I do know, well now I've gotten the phone calls form them since Albuquerque saying okay, now we're ready to talk about substance abuse parity. I said well mental health hasn't passed yet but we'll keep working on it. I couldn't agree with you more. Again we have to take a look; we have the data, what I shared today. I think if we had substance abuse parity with physical illnesses, in fact I think you address a lot of the physical illnesses that we're paying for under health insurance and still not getting at the underlying issue of the substance abuse, which is perpetuating the physical illnesses.
The tough thing is quantifying things in this arena as you know. Trying to quantity what are the actual costs that these diseases have. We have some idea; we are trying to quantify them but it's really tough to do in the debate.
QUESTION: I have a question about one of the facts that you have saying of the 63% of adults over 65 have an unmet need for mental health services. What all would be included to make that number what it is and what kinds of treatments do you see. It's a big number for an aging population.
That would include depression, for example. The onset of depression we're finding is not uncommon and that's due to many things, including isolation, including getting older and not being as connected. We're also seeing it manifesting itself in substance abuse, prescription drugs abuse; we have some real concerns about that manifesting itself. Also we're seeing dementia and Alzheimer's being very much at play in terms of mental health needs. So again, as the population gets older we're seeing those types of things manifesting themselves. We're not necessarily seeing schizophrenia or bi-polar, that type of disorder; that is occurring at the younger ages but it's mainly high rates of depression and then Alzheimer's and dementia that's occurring.
QUESTION: We have a tremendous shortage of medical care workers in our field. It's sort of the same thing as with mental health and substance abuse and also we have a shortage of substance abuse counselors and the counselors that we have, I don't know if they can recognize the mental health part of that substance abuse. How do we get there?
I think a couple of things. Those are very good observations. We do have a work force development crisis in the human services field overall and especially mental health and substance abuse. First of all there are models out there which provide in-service training, that you can train your current work force without going through a major formal academic program to help people identify, not only identify and diagnose mental health but also treat it effectively. Dr. Ken Menkoff is an individual out of Massachusetts who I've been very impressed with his models. We used them extensively in Pennsylvania through appropriate in-service training, helping develop that capacity.
I also think another potential solution for helping with our work force development crisis in the field is I think we could meet a lot of needs with more para-professionals in the field than we use and I think if we take a look at, for example, you may be familiar with wrap-around services for children. I think under the guidance of a trained psychologist, someone that has a one year certificate or a two year associate degree who has been trained specifically in skilled development with a child could do a lot more good than certain requirements we have now for a bachelor's degree, even if it's a BA in History doing some sort of mental health stuff in a clinic.
I think we need to rethink how we're delivering services and if we developed arrangements with community colleges to develop one y ear and two year associate programs, that would also be a great opportunity for people who are in recovery who may have a high school diploma, who as a result of recovery want to get in the field instead of going through a four year program or a doctoral program, get intensive training for competencies in the area of substance abuse counseling, I think we could perhaps attract more people to the field and help address the issue. But there are models to help develop capacities for both without going through all the training. And I'm not trying to say dumb down our work force at all. In fact I think we've already done a nice job of that without trying. We require a bachelor's degree at least. Well many times we don't specify what kind so it's not unusual to see someone with a BA in History or BA in English who gets hired on as a group home worker or counselor and I think you might be better off hiring someone with a one or two year degree specifically around psychiatric rehab and what do you need for that and then you're going to have a longer term employee, because the person with the BA in History is typically going to get frustrated or go to grad school and you're going to lose them anyway. So I think there's some things we need to think about somewhat creatively along that line. We're having those discussions right now with some of the work force.
QUESTION: Just a comment. One of the things I think and maybe you're already doing this, NCSL has gotten really wonderful statistics on what the states, and there are some states that have done the substance abuse and mental health parity or types of parity for the last few years. Iowa is not one of them. We can't even get mental health parity but I do think possibly politically mental health parity is saleable easier than substance abuse parity, even though they are absolutely connected at the hip. Finally, I wanted to tell you I also am a republican social worker.
Great, let's join. That's great. Well thank you very much; I appreciate it
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