SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

NATIONAL ADVISORY COUNCIL

38th Meeting

Tuesday,

December 6, 2005

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chairperson]{.underline}

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

Chair/Administrator, SAMHSA

1 Choke Cherry Road, Room 8-1065

Rockville, MD 20857

[Executive Director]{.underline}

Daryl W. Kade, M.A.

Executive Director, SAMHSA National Advisory Council

Associate Administrator for Policy, Planning,

and Budget, SAMHSA

1 Choke Cherry Road, Room 8-1083

Rockville, MD 20857

[Executive Secretary]{.underline}

Toian Vaughn, M.S.W.

Executive Secretary, SAMHSA National Advisory Council

1 Choke Cherry Road, Room 8-1089

Rockville, MD 20857

[Members]{.underline}

Gwynneth A. E. Dieter

Mental Health Advocate

U.S. Embassy Belize

Unit 7401

Faye Annette Gary, Ed.D., R.N.

Professor, Case Western Reserve University

Frances Payne Bolton School of Nursing

1099 Euclid Avenue

Cleveland, OH 44106-4904

Barbara Huff

Consultant

The Federation of Families for Children\'s Mental Health

2837 North Plumthicket Circle

Wichita, KS 67226

IN ATTENDANCE:

Thomas A. Kirk, Jr., Ph.D.

Commissioner

Department of Mental Health and Addiction Services

410 Capitol Avenue, 4th Floor

P.O. Box 341231, MS #14 Com

Hartford, CT 06134

Thomas Lewis

President and CEO

The Fishing School

7017 16th Street, N.W.

Washington, D.C. 20012

Theresa Racicot

Former First Lady of Montana

901 15th Street South #201

Arlington, VA 22202

Kenneth D. Stark

Director

Division of Alcohol and Substance Abuse

Department of Social and Health Services

P.O. Box 45330

Olympia, WA 98504-5330

Kathleen Sullivan

Journalist

Four Mission Court

Rancho Mirage, CA 92270

[Ex Officio Members]{.underline}

Laurent S. Lehmann, M.D.

Chief Consultant for Mental Health

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

[C O N T E N T S]{.underline}

PAGE

Welcome and Opening Remarks

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

Chair, SAMHSA National Advisory Council

and Administrator, SAMHSA 6

Administrator\'s Report

Charles G. Curie, M.A., A.C.S.W. 13

Discussion 34

FY 2006 Appropriations Update, HHS

\"Top 20\" Priorities, and Hill Update

Daryl W. Kade, M.A.

Executive Director, SAMHSA National Advisory

Council and Associate Administrator, Office

of Policy, Planning, and Budget, SAMHSA 51

Discussion 58

Joseph D. Faha, M.Ed., M.P.A.

Director of Legislation, SAMHSA 63

Discussion 69

New Mexico Strategic Prevention Framework

State Incentive Grant

Overview

Beverly Watts Davis

Senior Advisor on Substance Abuse

Office of the Administrator 71

New Mexico Strategic Prevention Framework

State Incentive Grant

Don Maestas

Project Director 76

Discussion 92

Public Comment 105

[C O N T E N T S]{.underline}

PAGE

SAMHSA\'s Response to Hurricanes Katrina and Rita

Administrator\'s Update

Charles G. Curie, M.A., A.C.S.W. 111

Key Elements of SAMHSA\'s Response to Hurricanes

Katrina and Rita

Daniel Dodgen, Ph.D.

Emergency Coordinator, SAMHSA 119

What is SERC and What Did It Do?

Brenda Bruun

Program Analyst, Division of Prevention,

Traumatic Stress, and Special Populations,

CMHS, and SERC Coordinator for Hurricanes

Katrina and Rita, SAMHSA 133

Discussion 155

Experiences of Deployed SAMHSA Staff

Rachel Kaul, L.C.S.W., C.T.S. Public

Health Advisor, Division of Prevention,

Traumatic Stress, and Special Populations, CMHS 168

Kevin Chapman

Project Officer, Drug-Free Communities, CSAP 180

Anne M. Herron, M.S., C.R.C., CASAC

Director, Division of State and Community

Assistance, CSAT 186

Discussion 191

Consideration of June 27, 2005

SAMHSA Council Meeting Minutes 212

Public Comment 212

Discussion on the SAMHSA Matrix 218

[P R O C E E D I N G S]{.underline} (9:13 a.m.)

MR. CURIE: Good morning, everyone. One of the biggest things that made
an indelible impression on many of us was the hurricane season this
year. The hurricane season brought people many things, including, most
importantly, hope. Many Americans lost their homes, their livelihoods,
their schools and communities, their places of worship, their social
supports and, of course, in many situations people lost loved ones,
witnessed death, witnessed destruction and violence. It basically has
been a time that is somewhat incomprehensible when you consider the
extent and scope of the devastation that hit the Gulf Coast. These
storms brought challenges beyond comparison to those who endured them.

It also brought several challenges to HHS and SAMHSA, and brought
(inaudible). I\'m pleased to say that as I take a look at SAMHSA and the
members of the staff throughout all of SAMHSA, that these challenges
were met with what I consider extraordinary skill. Virtually every
member of SAMHSA, every staff person, participated in some way. In fact,
we had over one‑half of the individuals in SAMHSA either deployed or
served in our SAMHSA Emergency Response Center. The other individuals
filled in for the individuals who responded, and it was just one time I
can clearly say with all confidence that 100 percent participation was
heard.

A new staff person that I spoke with knew they were committed to serving
not only as service to the individuals in the Gulf Coast, but they saw
it clearly as service to the nation. So it was the epitome of why
they\'re in the civil service in the first place. So it was a very
inspiring situation for me, and also I think helped a lot of us keep
going to see how everybody was pitching in.

Time has been set aside on the agenda this afternoon to discuss
SAMHSA\'s response to the hurricanes, but I wanted to start today with
these thoughts because I wanted to also mark the important role
substance abuse and mental health services play and continue to play in
the overall public health response to this tragedy. When we look over
the course of the last five years, I think we see clearly that mental
health and substance abuse are viewed as a critical, essential part of
the response to the disaster, as part of being prepared. 9/11 brought
this to the forefront, but I think Katrina and Rita in particular was
the first time we really were challenged since that period of time, and
again the attention we received from a wide range of the public at
large, from various institutions, from the Hill, and again the
unwavering support of the Secretary and the White House to assure that
mental health and substance abuse consequences were at the forefront,
and also the clear understanding that we\'ll get into this afternoon
that in one sense we\'ve only just begun in terms of dealing with the
consequences of Katrina when it comes to mental health and substance
abuse, and I think we need to keep that in mind.

A lot of the (inaudible) response was finished very quickly in the
course of the first month or so. Our process will continue on for a
matter of not only months but over the course of the next few years will
still be rather intensive as we begin to see consequences arise, based
on our experience. Again, we\'ll have more of a focus a little later on,
and this is just one indication that we\'ve made, I think, tremendous
progress in our collective efforts to assure that substance abuse and
mental health are viewed as part of public health.

I think part of our success is our determination to stay true to what we
refer to as the redwoods on the matrix that spring from the presence of
the cross‑cutting principles of each program. I have several matrix
updates for you today that I\'ll be sharing with you in just a moment.

But I also want to recognize with all of you here today that another
contributor to our success is this National Advisory Council. I\'ve
acknowledged and thanked each of you for your dedication to SAMHSA\'s
endeavors in the past, but I want to thank you again. The Advisory
Council is made up of individuals from all walks of life that relate to
mental health and substance abuse. I think you represent a collective
viewpoint which, again, has been extremely valuable.

Again, I think we\'re making tremendous progress, and your support is
cementing the changes that will continue to move this agency forward in
real valuable and life‑saving ways. I think we can keep in mind that
while our mission is a life in the community for everyone, that also
includes the fact that we are very much a life‑saving agency through the
state authorities and providers across the country.

Before I begin, I want to make sure that we welcome everyone here today.
In a more direct way, I want to first welcome Thomas Lewis back to our
meetings.

Thomas, it\'s wonderful to see you. You\'ve been in our thoughts,
you\'ve been in our prayers. It\'s just great to have you back and have
you with us again.

MR. LEWIS: Thank you very much.

MR. CURIE: I also want to extend a special welcome to a newly appointed
Council member, Dr. Faye Annette Gary. Dr. Gary is a professor at Case
Western Reserve University at the School of Nursing in Cleveland, Ohio.

We want to welcome you to your first meeting with us, and we look
forward to many positive contributions that you\'ll be bringing to the
work of the Council with your background and your perspective. Thank you
for your participation in the field. Maybe you\'d like to say a couple
of words.

DR. GARY: I would just like to say I think it\'s a privilege and an
honor to be on the Council and to participate in discussions that are so
essential for improving the health of the nation\'s people. I look
forward to learning, and I look forward to sharing. Thank you.

MR. CURIE: Thank you.

Other Council members in attendance this morning, Gwynneth. This has to
be a shock. This is different from the climate you\'re growing
accustomed to, I would think.

MS. DIETER: That\'s right.

MR. CURIE: Thank you for being here. Gwynneth Dieter is here with us
today.

Of course, Barbara Huff. Thank you, Barbara, for being back with us.

Tom Kirk, commissioner of mental health and substance abuse in
Connecticut.

Theresa Racicot. Thank you, Theresa, for all your efforts here on the
Council, and also your efforts ongoing in addressing such important
issues as underage drinking, for your advocacy.

Theresa made sure I got connected with NAMI in Montana in the last five
to six weeks.

Again, Ken Stark, director of the Division of Alcohol and Substance
Abuse, Washington State. Ken, you\'re in a new role here today. Ken has
been in substance abuse, and right now he\'s (inaudible). He has a
mental health side.

MR. STARK: I\'ll just touch on that a minute. I\'m the new director of
the Mental Health Transformation Grant, and we\'ll be looking over the
next five years toward making some changes in that.

MR. CURIE: And Kathleen.

(Laughter.)

MR. CURIE: I appreciate your participation, and also your support of
Kenneth.

(Laughter.)

MR. CURIE: Unfortunately, we were expecting Diane Holder. I just
received word that she became ill on the way to the airport, so Diane is
not going to be able to join us today.

I also want to note that my co‑chair, Lieutenant Governor Duke Aiona,
was unable to make it due to a prior commitment, as well as First Lady
Columba Bush of Florida could not join us due to a prior commitment as
well.

I also would like to recognize this morning the center directors that
will be attending with us, attending our meeting this morning. We have
the CMHS director, Kathryn Power, who will be joining us in a little
bit, as well as Wes Clark, who is here with us, the director of CSAT.
Also, I\'d like to recognize Rich Kopanda, who is the new acting
director of the Center for Substance Abuse Prevention. He\'s willing to
roll up his sleeves and pitch in in that capacity. Beverly Watts Davis
has become my new senior advisor for substance abuse, taking Stephenie
Colston\'s place. I also want to thank Wes Clark for the sacrifice of
Rich, who in his permanent capacity is deputy director for CSAT but
brings with him a depth of experience.

I also want to recognize an ex officio member, Larry Lehmann, from the
Department of Veterans Affairs.

Larry, thank you for your ongoing support and for being here today.

Larry also participates in things between these meetings. He\'s very
active in being an important liaison for veterans, and especially in
addressing the mental health and substance abuse needs there.

Thank you, Larry.

Other distinguished guests include individuals that we will recognize
later. Thank you.

(Laughter.)

MR. CURIE: Before moving on, I have a few agency updates to provide. At
our last meeting I shared with you that Andy Knapp began his position as
acting deputy administrator of SAMHSA after concluding his post as
deputy chief of staff for former Secretary Thompson. Andy is with us
actually in person this morning, and I\'m glad to have Andy here.

MR. KNAPP: I normally show up for work.

MR. CURIE: This is typical for Andy. Andy does show up for work.

But we want to welcome you to your first SAMHSA National Advisory
Council meeting, Andy.

He\'s done a tremendous job as acting deputy administrator, dealing with
issues that are the nitty‑gritty of operations of many centers. Those of
you who have been in management leadership positions know how much you
appreciate your chief operating person, because it\'s sometimes a
thankless job. Andy does very well and has put us on a very good track
with our management in general. In fact, SAMHSA received an exceptional
rating within the Department of Health and Human Services. Not every
operating division has gotten an exceptional for its management and
programmatic priorities.

(Applause.)

MR. CURIE: That goes to the whole leadership team and to all of the
SAMHSA staff who made that possible, the focus on that arena in terms of
the President\'s management agenda, in terms of the priorities of the
Department. That\'s all reflected in our matrix, which is something we
really should celebrate, and it\'s something that I\'m very proud of
with the staff and what we\'ve been able to accomplish.

Again, I\'ll announce that Beverly Watts Davis has accepted the position
of senior advisor. Stephenie Colston, for those of you who don\'t know,
was stolen by the State of Florida. She\'s the new director of substance
abuse for the State of Florida, and we wish Stephenie the best in that
position. I wish the State of Florida the best even though they stole
her from me. Seriously, it\'s a great opportunity for Stephenie, and
based on her work here at SAMHSA, I know that she will (inaudible) in
many ways. It\'s actually a win for us to be able to have her in that
position. She\'s really a trusted advisor and friend, and I\'ll miss her
very much.

Again, I introduced Rich earlier. I also want to introduce to you Kana
Enomoto to the Council. Kana is now serving as my special assistant. She
was previously special assistant to Kathryn Power in the Center for
Mental Health Services, and is basically my key right‑hand person when
it comes to keeping my engine on the right track and keeping me on the
right track. She\'s really filling in in many of those areas that Gail
Hutchings used to fill in. So I\'m very happy to have someone who knows
the field. She\'s a psychologist herself. She\'s well organized, and she
basically has the big picture in mind, as well as follows up with the
details. I don\'t want to say too many good things about her because I
don\'t want anybody to steal her, but it\'s been great.

Welcome, Kana.

Cheri Nolan has joined us this morning. Cheri is newly appointed to her
position as senior policy advisor for criminal and juvenile justice.
I\'ve known Cheri for four years. She worked for the Department of
Justice prior to this. It\'s a real coop to have Cheri come aboard. I
have the highest regard for her in terms of the work she has done, and
she\'s going to be opening even new doors of collaboration for us in
substance abuse (inaudible). She\'s also the new chair for the criminal
juvenile justice matrix work group. So I encourage you to get to know
Cheri. I view her as our new major connect with that field or arena.

Is Javaid here this morning? Dr. Javaid Kaiser has joined us this
morning. He\'s our newly appointed director of the Office of Applied
Studies. Also, we\'ve expanded that position to really be focused on the
overall SAMHSA data strategy and to be looking at all information and
data gathering throughout the system. The OAS is the home of the
Household Survey, it\'s the home of the DAWN Survey, it\'s the home of
TEDS, the Treatment Episode Data Set, and it does very important work
throughout the year in terms of informing the substance abuse and now
mental health with the mental health aspects to those instruments being
added. But again, Javaid brings with him great experience, and I\'ve
really appreciated his perspective on how we truly begin to use
leveraged data in decisionmaking.

Thank you, Javaid, for being here this morning.

Other members of the staff who have joined us this morning or who will
be joining us as the agenda moves on, as you can see following my
report, Daryl Kade and Joe Faha will provide an appropriations update,
and an overview also of the top 20 priorities, and an update of
legislative actions.

Again, honoring your past requests for more reports from grantees, we
have a presentation scheduled later this morning on the New Mexico
Strategic Prevention Framework State Incentive Grant, and then following
lunch we\'ll discuss SAMHSA\'s hurricane response efforts. Tomorrow\'s
agenda includes a critical topic of preventing underage drinking, along
with an overview of the National Child Traumatic Stress Initiative.
We\'ll also hear about recent activities of all of you as Council
members, as I know all of you do a lot of work between these meetings as
well.

Again, together I think we\'ve accomplished a lot. We\'ve established
our most pressing priorities and management principles, and to
aggressively implement them we gave those priorities some cross‑cutting
principles and identity, the matrix, and again it\'s helped us, I think,
align our focus and our resources, and it will help us operationalize
recovery. That theme is a theme that I\'ve worked on often, because I
think really what we\'re doing, what SAMHSA is doing, whether we\'re
talking to the Advisory Council or at the global policy level, making
policy decisions, finance decisions, funding decisions, creating new
grant programs, working to enhance current grant programs, it\'s all
operationalized in recovery in ways that we have never operationalized
them before from a public finance and a public policy standpoint.

We did say on the matrix that expanding substance abuse treatment
capacity was a priority. We said we had to find new and innovative ways
to grow the substance abuse treatment system into one that was driven by
the client, driven by the family, and offering more and more
(inaudible), and allowing for choice of the individual. We\'ve been able
to gain ground on that through Access to Recovery. The Access to
Recovery program is up and running. Two people around this table can
attest to that from Washington and Connecticut, who are two individuals
that are in charge of Access to Recovery in those two states. Also, I
know Wes Clark can attest to it, too, with his staff working very
diligently to implement this.

So far, approximately 38,000 individuals have used vouchers to purchase
treatment recovery support services that were among the choices for
them. Actually, being more specific about that figure, it\'s closer to
31,000 people received vouchers. Some may not have received vouchers but
may have been supported by the Access to Recovery program.

We also said improving services for those individuals with co‑occurring
disorders is a priority. I was glad to see my good friend, Rob Primrose,
here from Pennsylvania. He was very much involved when I was in
Pennsylvania, was really a part of the heart and soul of getting the
co‑occurring efforts rolling a decade ago in that state. Again, he\'s
able to share with us how well things are going in Pennsylvania with
co‑occurring disorders, and really (inaudible) to where I think we\'re
understanding how co‑occurring disorders are part of the issues we
address in the (inaudible) in our service delivery systems.

We\'re continuing to advance the Blueprint for Change. The Blueprint for
Change in SAMHSA\'s report to Congress still serves as the critical
guide on co‑occurring disorders, and also we\'ve outlined in the report
the development of the National Co‑Occurring Center for Excellence, a
co‑occurring Treatment Improvement Protocol, or TIP, and we (inaudible)
national co‑occurring policy academies. In fact, I would say the TIP on
co‑occurring disorders is one of the most talked about TIP. I know I
travel the country and (inaudible). I see it a lot, not only on a lot of
shelves but a lot of desks, opened up on a lot of desks around the
country, so I know it\'s being used.

We also said we\'d find new ways to help our state partners to begin to
interface substance abuse screening, referral and treatment services,
the same services in mental health and primary health care, to begin to
help create the Co‑Occurring Disorders State Incentive Grants. We
implemented those grants in 15 states, and again, what we\'re seeing is
more and more people are receiving the appropriate assessment, screening
and treatment as they present with co‑occurring disorders.

We\'ve also raised mental health transformation to a priority level, and
the transformation process is underway. As you know, the action agenda
was released in July. The action agenda, again, is the federal
government\'s response to the Mental Health Commission report. It\'s a
roadmap. It\'s a document that reflects the responsibility of the
federal government in making changes, and it\'s a promise to be kept;
and also the action steps will help us lay the strong groundwork across
this country to transform the system of care that crosses over and runs
through individual delivery systems and runs through the states.

We said we needed to find new ways to assist our state partners with
developing and implementing comprehensive mental health plans, plans
that are necessary to develop a strong, sustained effort. Again, we have
used the state incentive grant method for more transformation, and we
awarded \$92.5 million to seven states, which was (inaudible) in
Washington to focus on that. With the release of the action agenda, the
release of the mental health (inaudible) and the tremendous amount of
energy and support around the field, mental health transformation is
truly rolling out. Again, I\'ll probably do more talking about the
elements of transformation. Connecticut is another state that we
(inaudible) that is very much in the throes of the transformation
process.

The ability of consumers and families to participate fully in their
communities can no longer be derailed by outdated science, outmoded
financing and (inaudible) discrimination. That\'s our goal, to address
those three things. They really are the three major barriers to people
receiving treatment.

While we\'ve made significant changes in the substance abuse and mental
health systems, at the same time we\'ve been paying close attention to
the issue of prevention. We said that prevention is a priority. We
carved out a logical, common‑sense approach to align prevention
resources with more individuals and communities to really harness the
power of prevention, the benefits and the strengths. We said we needed
to step back and begin building a framework. We needed to stop just
(inaudible) prevention programs. While each program we funded had its
own evaluation criteria, it was still not a strategic approach to
prevention throughout the states. We needed to embark upon a process to
truly have a strategic prevention framework, which is exactly what we
created.

The SPF is a model for what we know works in prevention. It\'s about
setting the step by step process that empowers communities to identify
their unique risk and protective factors for substance abuse, and then
implement the programs that are best suited for meeting those particular
needs. In other words, when you take a risk and protective factor
approach to prevention, you identify what the risk factors are, and then
you identify which preventive factors can address those risk factors,
what programs reflect those protective factors and really begin making
decisions to leverage your prevention dollars toward doing the right
thing that\'s individualized for that community.

We have also reinvigorated the Drug‑Free Communities Program and
continue to build toward the promise of making that stronger. If you
take the portfolio in substance abuse prevention, we really have brought
together coalition building, brought together strategic prevention
frameworks, brought together a risk and protective factor approach. We
have our National Registry of Effective Programs for bringing together
the evidence base, and our goal is to work with our state partners to
assure every community has access to that information and has the
resources available to be able to put it in place, programs within their
own strategic prevention framework.

We also then have a baseline for each community of where they\'re
beginning so we can measure are they truly making progress in individual
communities in reducing illicit drugs, as well as reducing underage
drinking. The other thing I want to stress is we\'ll be hearing more
about underage drinking. There was a tremendous national conference.
Theresa was able to participate in that conference, as well as Columba
was able to come from Florida, and with our strategic prevention
framework, from the very beginning we explicitly stated that each of
those plans need to address underage drinking, because as we put it
before, alcohol is the most abused substance of youth in every
community. If there is a community where it\'s not, we want to visit
that community and find out what they\'re doing right to implement what
they\'re doing. So again, there\'s a focus on underage alcohol use along
with illicit drug use.

Again, to measure and report on our progress in all of these areas,
we\'re also looking to regional approaches and service agencies to make
sure we fulfill our mission as we were created and mandated by Congress.
So we need to measure and report on our progress in these areas. So
we\'re implementing the new National Outcome Measures in close
partnership with the State Substance Abuse and Mental Health
Authorities. Data for reporting on these measures is coming in from
states through the new State Outcome Measurement System, called SOMS,
and we anticipate full state reporting on all National Outcome Measures
by the end of 2007 fiscal year.

This list of accomplishments I think is a list we can all feel very good
about, that we actually can point to concrete projects, products and
progress that we\'ve made. It\'s still (inaudible) to do the (inaudible)
on any of these things, especially if you take a look at the lay of the
land and the many things you have to address in order to move an agenda
forward. Many of the priorities and cross‑cutting principles identified
in the matrix, again, are well underway, are providing a solid
foundation, and I think we have the support in place to continue that
progress.

The thing about celebrations, though, when I say we need to celebrate
things, I think celebrations should last for about a minute. Then we
need to move on and make sure that we don\'t rest for too long. We need
to rest to regain a second breath, but pausing is something that\'s very
dangerous to do, especially in the fields we\'re in and what we\'re up
against and dealing with bureaucracies at all levels.

So it\'s important that we look ahead and focus with determination on
what can and should be done in the time that remains, especially with
this administration. Three years will be going by very quickly, and we
need to make sure that we build on the gains that we\'ve made, that we
solidify our gains.

As you all have heard many times, I\'ve mentioned the matrix several
times. I view the matrix as a dynamic tool. I believe it should evolve
as the needs of the people we deal with change. Once again, it\'s time
for our annual review to take a look at how to reload the matrix. I
refer to it as the matrix reloaded after the movie title, and I\'m
seeking your input before we discuss. I would like to share some of my
thoughts about the matrix, kind of lay out some thoughts that I want to
encourage you all to challenge, to give your input and feedback on. But
I think it\'s important for us to begin thinking about making sure that
the matrix is relevant to the state of affairs currently in the field
and what we\'re facing.

For example, disaster readiness and response is a priority that\'s been
strengthened. It\'s been supported to become, I think, part of the
(inaudible) of SAMHSA. We have it down to much more of a science the way
we implemented the SAMHSA Emergency Response Center. We\'ve come a long
way since 9/11/01 when we really began to put a major focus on disaster
readiness and response and make it a priority.

It may be a priority that we view as more of a cross‑cutting principle
as we go along, that we need to be ready and prepared in all that we do,
all of our priorities. I\'ll give you an example. Our disaster response
has to not only take into account the post‑traumatic stress issues and
the issues that people that are victims of a disaster face ‑‑ that\'s a
major part of our response ‑‑ but we also need to be thinking about
continuity of care of people that have serious mental illness and need
ongoing treatment, people who are receiving treatment for addictions,
people in methadone centers, for example, people who are in therapeutic
communities who may get displaced. How do we make sure that individuals
and children with serious emotional disturbances are receiving treatment
and intervention?

All these programs, their operations, are unoperational in a hurricane
like Katrina in the impacted areas. So part of our mission also has to
be very much not only addressing overall the victims\' needs, but also
the specific people that we are responsible for all the time. So it
really is a cross‑cutting issue in that sense, our HIV/AIDS response,
substance abuse treatment capacity, mental health treatment capacity,
children and families, all those other priority areas (inaudible)
response readiness.

But I think we need to evaluate can we move that from an individual
priority, understanding it\'s something that (inaudible), and also it
opens up a space for other priorities that we need to address. This is
the (inaudible) process.

Workforce development has been a cross‑cutting principle that we need to
address in everything that we do. However, there are many tasks that
have been hanging around for years, and it seems that we keep studying
the issue, we get more clarity on the issue, we keep looking at the
issue and thinking a‑ha, we need to make this correction. I think we\'ve
done a fairly good job of analyzing the issue and have an idea about
what needs to be done. But it seems now we need to get even more serious
about making progress. So I believe that one way you make progress is to
begin saying something is a programmatic priority for a period of time.
So do we need to begin thinking about moving workforce development into
a stated programmatic priority that we begin to address? Something to
consider.

Again, these are not fait accompli. You guys can give feedback. This is
your chance to change the matrix if you want to leave your imprint on
the matrix in terms of making sure we\'re making that a priority.

I also believe we need to do more around suicide prevention. As you
know, the federal government has a national plan to address 30,000
suicides committed per year in this country. I always make the
comparison that that compares to 18,000 homicides. There\'s a lot
governments do at all levels to bring the murder rate down. We should
bring the murder rate down, or bring the homicide rate down, but I think
we also need to really focus on those 30,000 individuals, which we know
is a low count because that basically goes by reported suicides, and we
know that many times suicides are reported as accidental deaths. We need
to play an active role in rolling out that plan. Is it time to
specifically state suicide prevention as a priority? That\'s a
consideration.

Again, 90 percent of the people who commit suicide, the research shows
us, have depression or another diagnosed mental illness or substance
abuse. So what we do is very much connected to that tragedy that hits
year after year.

At the same time, when we can talk about suicide prevention, I think
it\'s important for us to be considering the fact that a major role is
to get suicide prevention into the mainstream specialties, because it\'s
something that people don\'t talk about unless they\'ve been in
(inaudible). I had the honor of participating in the first national
conference that brought together survivors, but also those
who(inaudible), and it was a profound experience to bring individuals
together. Again, I think we have a strong foundation upon which to build
the agenda.

We also need to push the seclusion and restraint agenda to a new level.
When we have firmly established that seclusion and restraint practices
are the norm in all settings, adult psychiatric settings, (inaudible)
settings, (inaudible) settings, seclusion and restraint could become a
priority that shifts to a cross‑cutting principle as well. But again,
for now, I think we need to talk about it. We\'ve made great progress on
it, and we need to continue to state that as a priority. We need to
continue to bring that home. We need to hear from you and examine that.
Again, it\'s an issue near and dear to me personally, something that has
to be addressed.

We also need to impact underage drinking in this country. As a nation
we\'re not doing enough to prevent it. As an agency working with our
good friends at NIAAA, who have done a tremendous job of bringing the
research forward and providing leadership, with also obviously the First
Spouses Program, we need to ratchet our efforts up in terms of building
a culture of prevention which does more to address this issue, to take a
hard look at underage drinking. We have the support of the Secretary.
The Surgeon General is going to be doing a Call to Action. We need to
pay attention to this and we need to talk about how do we reflect that,
reflected more directly in the matrix as well?

There is dedicated time in tomorrow\'s agenda for talking about the
matrix. So I\'m planting the seeds today so that you can contemplate. I
encourage you all to do your own examination and your own evaluation of
the matrix and bring your input and thoughts and your perspectives so
that we can have a consensus approach in terms of where we need to be
with the matrix.

We also have the opportunity to focus on consumer‑ and family‑driven
care, self‑directed accounts, consumer choice in voucher programs, the
use of electronic health records to improve health information,
technology for improving information in a family‑driven system. An
immediate SAMHSA objective is to intensify our efforts where the CMS,
the Centers for Medicare and Medicaid Services, is making self‑directed
accounts a reality for persons with mental and/or substance abuse
disorders. Consumer‑ and family‑driven care also means actively engaging
in involving parents in their role as the key decisionmakers in the
assessment and treatment of their children. The Screening, Brief
Intervention, Referral and Treatment grant program, known as SBIRT, is a
strong program that we should consider bringing to scale. I think all of
you saw firsthand in San Diego how an SBIRT program works. There was a
tremendous example of early intervention dealing with people who are
beginning to abuse substances, how these brief interventions can be
extremely effective if identified in a primary health care setting, or
needs to be done also with regard to the criminal and juvenile justice
matrix priority. Again, I know Cheri will be a tremendous asset in
bringing shape to that agenda and other initiatives, from concept to
reality.

We\'ll also continue to strengthen our partnerships and non‑traditional
partnerships with criminal justice. Already Cheri has connected us with
the National District Attorneys Association, that group from Chicago,
just within the last month. Also, we\'ve been reaching out to groups
such as the United States Conference of Mayors. Again, I think some of
the partners that we\'ve not really had as partners before I think
SAMHSA needs to engage to move our issues forward.

Integrating substance abuse treatment with mental health care, with
primary care, is also essential to public health. Again, this is a
priority for mental health transformation. SAMHSA\'s leadership can keep
it in the spotlight. Again, I think we need to be aware that we\'re the
only federal agency that has a focus on mental health services, that has
a focus on substance abuse treatment services, that has a focus on
substance abuse prevention services. NIH are critical partners in
research. We\'re responsible for program and making it happen, and we
need to remember that that\'s an awesome responsibility for lives and
how we shape that.

Also, as we transform the mental health system here in the U.S., as we
also make tremendous strides in substance abuse treatment capacity and
prevention, we should continue our efforts with the international
community as well, building and in some cases rebuilding their systems.
This is especially critical in post‑conflict countries, countries which
include Afghanistan and Iraq. Our work with these countries is a
responsibility we share with all the Department of Health and Human
Services to improve the human condition throughout the world.

One report that was just implemented or just released within the last
six weeks was a report out of the Institute of Medicine\'s report which
really took a hard look at the mental health service system and
directions that we need to address. The good news out of this IOM report
is we can begin to gain traction and effect change if we build the right
partnerships. A lot of the IOM report talks about those partnerships,
and I think that report will be released on the heels of the action
agenda being released, which puts us in a position to be able to help
influence systems in ways that we haven\'t been in a position to
influence before.

Licensing boards and accrediting bodies, for example, can become
valuable allies and can be among our strongest partners in improving and
expanding workforce. For instance, again we\'ve struggled for over a
decade to develop and institute core competencies for all conditions in
providing mental health and substance abuse treatment. It\'s even more
difficult to establish the core competencies and move them into
education programs where they can be incorporated into licensing and
certification requirements. It\'s challenging, but I think it can be
done. Again, we\'ve talked many times about when individuals enter the
field out of graduate schools, the graduate schools really aren\'t
focused on the state of the science or really what the providers are
looking for in terms of folks who are dealing with these needs, as well
as a focus on social competency and other kinds of issues.

So again, this issue basically is going to require fruitful cooperation
and partnership to resolve. Again, as I said earlier, workforce
development is no longer just a good idea. It will play a large role in
the transformation of our nation\'s mental health delivery.

Also from workforce development to suicide prevention, if you look at
that pendulum of responsibility, I\'m confident we can (inaudible) solid
ground with these priorities and with others. We actually started laying
the ground rules for many of these changes four years ago. Now we need
to focus intently on our priorities, generate ongoing energy, excitement
and urgency to the field, at the same time that we need to permeate the
(inaudible) and to secure our budget request that Daryl and Joe will
discuss in a few moments.

Again, the other challenge before us that I\'ve not spoken about but
that we\'ll be hearing more about is the fact that in reading the papers
and paying attention to what\'s occurring here in Washington, there\'s a
real focus on the need to curtail spending, the need to make cuts, and I
think it also demonstrates the great importance on us to prioritize more
than ever before what is truly important that we want to see move ahead
and move forward to be able to make that case, because the environment
is now one (inaudible) a major focus.

So again, I\'d like to now open up my comments for discussion, to give
you an opportunity to discuss further any of the priorities on the
agenda for tomorrow. Again, I want to thank you for your intense
listening at this point, your ongoing leadership, and open it up for any
comments you might have. Thanks.

Ken?

MR. STARK: Would it be possible to get copies of your printed materials?

MR. CURIE: Sure.

MR. STARK: That would really be helpful to me, because I\'m taking
notes.

MR. CURIE: You got it.

MR. STARK: Thanks.

The other thing that would really help me in my current transformation
(inaudible) the transformation grant is to get my hands on the action
document you referred to. That would be very helpful.

MR. CURIE: You got it.

MS. POWER: You want the action agenda, Ken? Okay. I was also going to
suggest that if people want a copy of the IOM report, we can probably
get that for them as well today. So those who would like the action
agenda and the IOM report, we\'ll make that happen.

MR. STARK: Both would be nice. Thank you.

MS. POWER: But it would mean I\'ll have to leave the room.

MR. STARK: The final comment I want to make, Charlie, is you covered a
tremendous amount of stuff in that talk, and I certainly didn\'t
disagree with anything you said. I think a challenge for us on the issue
is going to be privatization. I struggled myself looking at what are the
things that we can focus on, truly focus on from a national level and
SAMHSA can be a major driver working with (inaudible), versus what are
those things that from a national perspective you probably need to set
aside and (inaudible) a little more of a policy push, because the rubber
hitting the road is going to be local, and it\'s certainly the locals
that (inaudible) the effort in here, with your encouragement, pushing
the leadership, and I know that\'s going to be a struggle for you and
the SAMHSA staff to try to prioritize, and for us in the states.

For instance, workforce development as an example. Workforce development
is an issue that I think everybody is dealing with in both alcohol,
drugs and in mental health, and the question is what role, other than
the leadership and the pushing and prodding of SAMHSA, versus how much
of the real workload on that has to happen within the states and across
the counties or whatever geographies they have?

MR. CURIE: Other thoughts or comments? Faye?

DR. GARY: I thank you for your presentation. It was quite comprehensive
and (inaudible). I also want to make specific reference to the matrix
that I find to be exceptionally useful, very clear in giving direction
to people who are service providers or people who (inaudible), et
cetera.

In your deliberations about the matrix and the possibility of change, in
your presentation you did not mention stigma. At least I did not hear
stigma of mental illness and stigma as related to substance abuse. That
begins at a very early age among children, families, some communities,
but also among professionals, mental health professionals as well as
other people in primary health care. I think the literature is very
clear that individuals who have mental health problems and heart
problems get a lesser quality of care, et cetera. You can imagine how
that would happen with thought disorders given the sense and attitude
and behaviors toward individuals with mental illness.

So I\'d like to ask that we spend some time on stigma and how that
could, in fact, be a cross‑cutting piece of the matrix and other kinds
of programmatic issues. That was the one issue.

I also like the idea of collaborating in partnerships, and for example,
with regard to stigma, keeping that theme alive and collaborating on
developing partnerships with the Mental Health Association, for example,
as well as other federal agencies, state agencies, et cetera, so that we
can keep that alive, keep that in the forefront of what we also need to
address, and also with accrediting bodies and academic institutions
where they look at stigma and how it is expressed among providers, and
also among individuals and family members, because I think when you put
stigma juxtaposed with a real killer, such as suicide, we find that
stigma is one of the barriers that keep people from getting health care.

The other issue is regarding suicide, which I highly embrace. I look at
those populations where suicide is increasing yearly, and that\'s among
African American males, and American Indians where it has also been a
problem for years, and Hispanic youth, especially among adolescents and
young adults. So I would ask that we give that some special deliberation
so that we can see what the barriers are and what the protective factors
are and what kinds of programmatic issues would be useful for that
population.

MR. CURIE: Thank you, Faye. I appreciate your support for examining the
suicide arena, and also your work on stigma. That is probably one of the
biggest, in one sense, invisible barriers. It becomes visible through
discrimination and through things that are unspoken, and I think
examining its role in the matrix is critical. Currently it is listed
along with recovery as a cross‑cutting principle, but the idea is is
there a way of prioritizing it further or highlighting it and
(inaudible) the discrimination that occurs with it.

Thank you, Faye, very much.

Tom?

MR. KIRK: Let me reinforce Ken\'s comment to see a copy of your remarks,
because one of the things that strikes me about what you\'re doing and
our support of that is that Access to Recovery, transformation, state
incentive grants, the strategic prevention framework, I don\'t see these
in projects. These are major system change issues. What I find
challenging within my own state that I think is an important piece for
us to focus on is that we have these different grants. So Connecticut
has each of those three, and it\'s a marathon. It\'s not a sprint.
Trying to have stakeholders understand that we\'re truly talking about
changing the system of care, access to care, health and addictions,
cross‑linkages, and our focus is on prevention from a wellness point of
view, that our providers as well as state agency folks are not used to
grants. These are projects, and the funds are going to run out.

So I\'d be interested sometime during the next day and a half to think
about how do we take these particular change levers in terms of funding,
these funding figures begin to jump out. Here in the platform it says
building on those things, they become the core of the service system. I
think that\'s an extremely important point to communicate.

Two other points, one I cannot emphasize enough. When one looks at the
danger at least that I\'ve seen at one of the recent mental health
commissioner meetings, I may be wrong in the specifics of this, but the
lifespan of persons with serious psychiatric disabilities is somewhere
in the range of 10 to 15 years less than the larger population. As part
of Medicare Part D, we\'ve looked at the medications that (inaudible) in
Connecticut. It averages around five medications. Only two of them are
psych meds. The others are for diabetes, cardiac conditions, cholesterol
and those kinds of conditions. We don\'t link primary care for these
other disorders to our recovery mission, which is part of the picture. I
think the more we can, with your support and your leadership, tie the
emphasis on health care to a larger span, so much the better.

I want to request that sometime within the next day and a half we have
some comments about Medicare Part D, what you see at the federal level.
We were able to get our legislature in Connecticut to put up dollars to
cover co‑pays because we were so concerned about co‑pays, particularly
dual eligibles. What might be going on at the federal level through HHS
as related to Medicare Part D?

MR. CURIE: Thank you, Tom.

Any other comments?

Barbara?

MS. HUFF: Well, I could comment on everything, but I\'m going to try to
keep it to a minimum, okay?

There is one thing that I\'m also concerned about funding coming up and
how do we pay for what we\'re doing. A couple of things. Maybe it\'s
because I\'ve represented kids for so long that I just have to say this.
It feels like to me that if we could, when we fund programs, when we
fund systems change work, that the thing that I liked so well about the
transformation grants is that they covered the lifespan, so you\'re
getting a much bigger bang for your buck. You\'re not having to do
systems change for kids, systems change for older people, systems change
for ‑‑ you understand what I\'m saying.

It seems like related to seclusion and restraint and some of these other
high‑priority issues that we can do the same. It\'s not that we don\'t.
It\'s just that it feels to me like there is still ‑‑ it still feels
like the kids in seclusion and restraints are not getting the same bang
for the buck that adults are. I might be wrong in that. You know it
better than I, but in terms of what you fund, in terms of technical
assistance around that, I\'d like to see, I don\'t know, the GFAs or the
RFPs or whatever they\'re called right now deal more specifically with
kids\' issues in some of those things. I\'m not going to recommend that
you fund something related to kids on seclusion and restraint. It seems
like we could do something much more overall around seclusion and
restraint.

It should be a high priority. I\'m doing some volunteer work right now
related to kids who are dying and being hurt in unlicensed residential
facilities, and I am finding out things I never wanted to know.
Seclusion and restraint is just one piece of that, I mean just one
piece.

So I want to make that statement that it seems like we could more
broadly look at the lifespan, things that we do fund.

Secondly, around stigma, I\'m going to say this. Someday you\'re going
to miss me on this council because I say the same things every time, but
around stigma, we need to start over. In my opinion, we need to form a
group that begins to look at this differently. I totally agree with some
of the things you said. It has to start really early with really young
kids, but a lot of us on this panel had things to say about the issue of
stigma. I don\'t even like the word \"stigma,\" but I\'d like to make a
recommendation that we look deeper and broader. I don\'t think we\'re
doing it right, but that is simply my opinion, okay? So there\'s that.

Then in underage drinking we\'re going to discuss. I don\'t have to say
anything to you and this council about suicide prevention because I
always have at least one meltdown every council meeting about this. So I
don\'t think I have to say very much about that.

I do want to say that in the last few years, since Sybil Goldman has
been with us, I think we\'re in far better shape, and I want to thank
you for that because we had no shape before that. So I do want to say
that I feel like we have come much more into our own. We have a ways to
go yet. I don\'t think Sybil would disagree with me on that. We have a
ways to go, but I do want to say that I think we\'re at least getting
further along, and so I thank you. I really think that these things that
you mentioned are exactly right where we need to be, and I do understand
the need for prioritizing, but I actually think we could take a look at
what we\'re doing and be more inclusive in some of the things that
we\'re doing.

MR. CURIE: I think that\'s very good, Barbara. I think we absolutely
need to be examining this. When it comes to seclusion and restraint, we
could demonstrate what we\'ve been doing in the children\'s area because
-‑

MS. HUFF: I probably just don\'t know.

MR. CURIE: In fairness, we want to make sure people are aware, because
after we began to make great progress ‑‑ this is about three years ago
‑‑ we began to see that the adult state psychiatric institutions across
the country, with a very powerful partnership we had with NASMHPD, we
made real strides, and we made real strides in general psychiatric
settings, inpatient settings overall, again a lot of the adult settings.

We did, with the Child Welfare League and other associations, have begun
processes over the last two to three years to really put a press on
children\'s settings. I like your idea of the lifespan approach and
making sure that that\'s always embraced to move ahead.

I think what we have found, and it\'s of great concern to me, is if
you\'re talking about mental health residential settings, you begin to
make some progress. But if you\'re talking about the other children\'s
settings, and I think those are the types of things you\'re uncovering,
it is frightening and we are needing to really press very much forward.
There are too many accounts we still read about in the papers of deaths
of children in various kinds of residential settings, and they all are
directly related to improper restraint. A child being restrained so that
their windpipe gets cut off is typically what we find. Those are the
types of things we need to address, and we have been actively reaching
out and working with juvenile justice facilities.

I think the interface with Cheri, along with CMHS, can help us in that
arena. If anyone is interested, we can set that up to go over the
portfolio and begin to take a look at where we need to take it to that
next level, because I do believe we\'ve only begun to scratch the
surface on that.

MS. HUFF: Can I just say one more thing?

MR. CURIE: Sure.

MS. HUFF: I would like to just kind of make a plea for whatever does get
funded and whatever comes to the forefront related to priorities, I was
stunned when we talked about suicide prevention in this council meeting
not too long ago, and I said do we know that because we fund these
things that there are less suicides that take place, and you said we
didn\'t have a way of knowing that yet.

MR. CURIE: Yes, at this point.

MS. HUFF: At this point. I would rather have you fund less and do it to
where we\'ve got some outcomes and where we know what\'s been funded
works. I\'d rather fund less and do it right. Do you understand what
I\'m saying?

MR. CURIE: Absolutely.

MS. HUFF: Because otherwise the federal government has no accountability
related to what they\'ve funded. It doesn\'t work? Well, we don\'t know
if it works or not. Well, how can we say that we ought to put this many
millions of dollars into something we don\'t know?

It\'s like stigma. Somebody\'s got to tell me that what\'s happening now
is making a difference, and if it\'s not, then we need to figure that
out. You may be doing more, but I do know in systems of care we can
actually say that kids are in school more, they\'re doing better in
school, there\'s less juvenile justice contacts. I mean, we know those
things, and that\'s how ‑‑

MR. CURIE: I think the other issue is bringing to scale those things
that demonstrate a measurable impact, like systems of care. So I
appreciate that. Thank you.

Other thoughts or comments? Gwynn?

MS. DIETER: Yes. I just want to say I think the points you brought up to
address are right on target of things we discussed and need to move in
that direction. But I did want to in particular support the relationship
with criminal justice and juvenile justice because, as I\'ve said
several times before on this council, I think it\'s twofold. I mean,
interacting with the criminal justice system actually is a window of
opportunity, and there aren\'t going to be that many more windows of
opportunity for those people who are coming into that system, and there
isn\'t a relationship in many places at all. I think it\'s so important
and could have tremendous results if people could be screened and
assessed properly, and then judges and so forth came to act as the
people from Alabama were doing down there, where it\'s a part of their
whole approach. I mean, it just sounds like they\'re making a tremendous
difference. I was just so impressed by their program.

The other side of it is that families of individuals who have either
substance abuse, mental health or a combination, where that individual
is coming into the juvenile or criminal justice system, those police or
whatever feel the problem deeply. Their hands are tied. There is nothing
they can do. They don\'t really want to just throw them in jail.

So anyway, I\'m passionate about that, especially for young people, just
because they have still some hope there of making a change. I just think
it\'s critical. Every young person that comes into jail practically has
a substance abuse or mental health issue of some type or other. Anyway,
I just wanted to support that.

Also, we have been seeing some positive yet unmeasurable results in our
community in Colorado, where I no longer am, in terms of underage
drinking, and we\'re really pushing through this Parent Corps to work to
educate and support and unify. So I just want to support those two in
particular.

MR. CURIE: Thank you, Gwynn. Thank you so much. Very good comments on
the interface, as you described it, of the juvenile justice system,
(inaudible) some progress to bring it to a whole new level. I appreciate
your support.

I think we have time for one more comment. Is there anyone else after
Ken?

(No response.)

MR. CURIE: We\'ll give Ken the last comment on this one.

MR. STARK: Going along with what Barbara said, I too believe in
repetition, and to me repetition is like water on a stone, that over
time you\'re hopeful it will make an impression and somebody will hear
it. In the last meeting, our last National Advisory Council meeting, I
talked about an issue around language, and one of my pet peeves is the
whole issue of behavioral health and the fact that that term, although
it\'s a term that we in the alcohol, drug, and the mental health field
felt a necessity to use in order to establish ourselves within the
health arena because you couldn\'t get primary care to recognize us, in
my opinion is having an unintended consequence ‑‑ actually, two
potential unintended consequences. One is that it feeds stigma. It
negates the physiologic/biologic/genetic basis of mental illness, as
well as drug addictions.

It also, I believe, now will create a difficulty for us as we try to
align more with primary care, and many folks in primary care will
continue to say, oh, well, you\'re not really health. You\'re behavioral
health. You deal with behavioral problems rather than real health
issues. As much as it may seem like a petty issue, a lot of stigma is
about language. It\'s about impressions that you create. I know SAMHSA
doesn\'t have behavioral health in its name, and I appreciate that very
much, and I would encourage anybody else out there in the community who
is using that term to really reevaluate how that term has an unintended
negative consequence.

MR. CURIE: Thank you, Ken. I think we do need to take words seriously,
and I think when we talk about stigma ‑‑ and again, one word that I
think we use a little loosely at times is \"discrimination,\" because
that\'s the evidence of stigma. But I think the words we use many times
unintentionally do undercut our mission, and I personally don\'t believe
behavioral health says anything. It\'s a shorthand way of being able to
talk about mental health and substance abuse. Actually, my impression is
it started in the private sector more than the public sector. But I
think as we move ahead and continue to focus on substance abuse, I think
the one on co‑occurring disorders, some people felt behavioral health
would address that, and I think it only undercut that agenda as well,
because we are talking about different illnesses, different diseases,
but they co‑occur sometimes in an interrelated way, and sometimes folks
are self‑medicating because they have an underlying undiagnosed mental
illness.

But many times people truly have an addictive disorder and can also have
a mental health diagnosis, and each needs to be treated in the
appropriate way, just as you would treat somebody with diabetes and high
blood pressure. You wouldn\'t treat one and not treat the other because
their primary diagnosis was diabetes and not blood pressure, or
hypertension.

So I think we\'ve made some great strides, and we\'re going to continue
to keep (inaudible) on that. Anyway, adding behavioral health in SAMHSA
would ruin our whole acronym.

(Laughter.)

MS. HUFF: Charlie, kids are telling us that they take the language
seriously, emotionally disturbed.

MR. CURIE: That term has been around long enough that we need to examine
it anew.

At this point, thank you for your discussion, thank you for your input.
I look forward to more discussions around (inaudible). We\'ll make sure
the remarks that are in writing are available to all of you for your
perusal and consideration, and you can do your own internal
deliberations and perhaps deliberations between each other.

I\'d like to now turn it over to Daryl Kade, who will be talking about
the FY \'06 appropriations update, and also the top 20 priorities.

MS. DIETER: I don\'t think we have a copy of the matrix in our notebooks
at this time.

MS. VAUGHN: I\'m getting them.

MS. DIETER: Oh, good.

MR. CURIE: We should make sure you get copies. We could have brought
those placemats today. They\'ll thank you for that.

I\'d like to turn it over to Daryl Kade and Joe Faha. Daryl, as you
know, is the executive director of the Council, and also is director of
policy and budget and program planning for SAMHSA, a very valuable
member of my executive leadership team. Joe is director of legislation
and represents us on the Hill. The two together will give you a fairly
comprehensive update on the appropriations and the top 20 priorities for
HHS as we deal with the overall HHS programmatic and managerial agenda.

Daryl?

MS. KADE: Good morning, everybody. The appropriations update is going to
be pretty easy. We don\'t have a bill. We\'re on our second continuing
resolution, which should expire December 17. I hear from sources that we
should anticipate an omnibus bill, hopefully before the CR expires, but
at this point we\'re in a holding position. The House mark or conference
markup that we were working with several weeks ago was based on the
lower House mark plus add‑ons from the Senate, but it did not go
anywhere. We\'re anticipating, based on memos from the Department, a 1
to 2 percent recision at best. Joe will give you a little bit more
particulars about what\'s happening on the Hill in that regard.

But we need to move forward. It is December. We need to move forward on
our contracts and our grants. So what we\'ve been doing is working with
the centers to assume a President\'s budget base, to assume a markup
base, and to proceed as expeditiously as possible, get a bill in place,
and then we\'ll make the necessary changes. But we can\'t freeze up
because there are deadlines that we have to meet in the summer and in
the fall.

We are working on the \'07 budget. It\'s a confidential document right
now. I bring that up because of what you said, Barbara, that data is
absolutely key. It doesn\'t matter what discussion we have with OMB,
whether it\'s our discretionary grants, whether it\'s our block grants.
To the extent we don\'t have data that clearly portrays our effect not
only on the systems but also on individual client outcomes, we\'re at
that much of a disadvantage, which is why we are focusing on our data
strategy and focusing on investments in our data strategy and, quite
frankly, realigning other investments. This is something that keeps on
coming back to bite us, and there are other issues that we need to talk
about other than data. So if we can cover that area, we\'re in a better
position to leverage other changes and other decisions. So I wanted to
make that point, that it\'s clearly an issue.

In your folder I believe you have the top 20. What section is that in,
Toian?

MS. VAUGHN: Under \"Appropriations,\" Tab 2.

MS. KADE: I wanted to take a few minutes to go over this with you
because this is really the basis of our communication with the
Department, and the Department\'s communication with OMB. It is not only
crucial in terms of our performance assessment but also the agency\'s
and the Department\'s.

It\'s called the Top 20. Last year it was the 10 by 10, the 10 program
objectives and 10 management objectives. But Secretary Leavitt has taken
this opportunity to integrate program and management, and it alternates
between program and management. I cannot stress to you the importance of
our reaching green and scoring well on the management objective so that
we can leverage change in the program objectives. These are absolutely
key. So when I go over these, I will highlight not only the program but
the management, because they are of equal priority.

We are currently working on Mr. Curie\'s performance plan, and what we
need to do is to link these top 20 to his performance plan. That then
trickles down or cascades down to the management team\'s performance,
contracts, which then trickles down to or cascades down to the division
director and branch chief. So this is a very critical document for us.

We haven\'t finalized the draft, but obviously, number one, transform
the health care system, is a key one that we will be linking to, and in
particular 1a, increase access to high quality, effective health care
that is predictably safe. This touches on a lot of what you were talking
about, Ken, in terms of focusing on systems change that will then
increase access.

The next item, number 2, strategically manage human capital, this is
where we do have that cascading down from the top 20 to our performance
plans and our performance contracts. It is where the deadlines for
appraisals become critical for us in order to position ourselves well
with the Department to negotiate and have a common understanding and
expectation of what our goals are in the next year, and it takes place
in these very important documents.

The next one that directly affects us is also in the management area,
our competitive sourcing program. We competitive source our review
process, and we totally support whatever the Department has in line for
any other activity.

The next area that is critical to us is number 6, which is improve
financial performance. Here we refer to OMB getting green. This is where
we are judged on the effectiveness of our budget and planning
activities, and also the timeliness of our budget and planning
activities, and a new item has been put into place, the A‑123, which is
an emphasis on avoiding fraud and abuse. This is a very high‑priority
item for the Department, and as an agency we have to take a very hard
look at our internal control processes as well as our authorizations and
make sure that we are entirely in compliance with both financial laws as
well as our authorizations.

Number 7, secure the homeland; 7a, increase the capacity of the health
care system to respond to public health threats and bioterrorism, as
well as natural causes. Obviously, we have a focus on this in our
disaster program priority area in the matrix, as we expanded that, and
we need to work with the Department in order to incorporate, for lack of
a better word, behavioral health care within the plans that the
Department develops for a federal plan, as well as states, but also with
our SERC, with our state grants, with the state planning grants and
emergency grants. We do a lot of activity in this area and, quite
frankly, we\'re very well received by the Department in our Katrina
efforts. It worked very well in that.

The next area that is of particular concern to me is number 10, improve
budget and performance integration. This is, again, an area that lines
up, when you look at OMB mandated green standards for success, this
refers back to the President\'s management agenda. But here is where our
strategic plan comes into play. Here is where our data strategy comes
into play. This is not just budget. It\'s lining up our budget and our
budget priorities to the data we have, to how we all put it together.
This is absolutely critical for my operations in my office, and then how
we move to effect our program priorities and achieve progress through
objective measures, milestones, activities, measures of success. If you
don\'t have those, when are we going to have those? You could make a
very strong case.

Another area, number 11, was not in the 10 by 10 last year, but it is in
the top 20. It\'s improving the human condition around the world. Here I
would refer to 11b and health diplomacy. We\'ve been doing a lot in the
world with regard to mental health and mental illness and protecting
against and preventing mental illness in Iraq, in Afghanistan, in a lot
of areas. We\'re getting more and more involved in this area, and this
is becoming a high profile area with the Department as well, and at this
point we\'re trying to develop some sort of cohesive plan so that we can
put not only our activities but our funding in perspective.

I would refer you next to a rather delicate area, number 15. This is to
promote quality, relevance and performance of research and development
activities. We\'re not here yet. One of the sub‑bullets that is not here
is really translating research into practice, a lot of the activities
that IOM has talked about. As you may know, we released an update to our
NREP process and have collected public comments. One of the issues that
we have with the Department is why isn\'t there a sub‑bullet here that
talks about getting this research out, not just biomedical research but
the research on the effective practices out to the field? More on that
later.

Number 17, emphasize faith‑based and community solutions; number b,
expand faith‑based and community partnerships in providing effective
health care services. Last year this was a specific reference to ATR.
This year it\'s a more generic reference, a cross‑cutting area in our
matrix, and obviously ATR specifically focuses on collecting data on the
number of faith‑based providers. It appears that that\'s a metric that
the entire Department wants to work on as well.

Finally, if you look at number 19, emphasize healthy living and
prevention of disease, illness and disability; sub‑bullet c, reduce the
incidence and consequences of injuries, violence, substance abuse,
mental health problems, et cetera, this is our hope for mental health
and substance abuse. How it relates to number 1, transforming the health
care system, is what we have to work on. Obviously, number 1 and number
19 are intimately related. This is where we housed our redwoods mental
health systems transformation, the Strategic Prevention Framework, ATR,
and the co‑occurring set. This is where we want to identify what our
milestones, our achievements, our progress is, and negotiate reasonable
objectives with the Department so that we\'re in a good position of
assessing our success next year.

So I wanted to share those with you, and if you have any questions about
the top 20, I\'ll be happy to either answer them or relate them back to
Mr. Curie and the Department.

MS. SULLIVAN: Daryl, are the OMB mandated green ‑‑

MS. KADE: Yes, the presidential management agenda ‑‑

MS. SULLIVAN: ‑‑ for success, are those criteria listed on a website?

MS. KADE: Yes, they are, and I can get them for you. They\'re generic.
We also have a translation of those.

MS. SULLIVAN: In abbreviated form?

MS. KADE: Yes, I can.

MS. SULLIVAN: Could we see those?

MS. KADE: Absolutely. We also have specific metrics that were given by
the Department every quarter. We\'re actually scored every quarter on
them. Let me see what\'s publicly available.

MS. SULLIVAN: So we can see what we\'re up against. Thank you.

MS. KADE: Sure.

Barbara?

MS. HUFF: Under 13b, increase the percentage of adults and children who
have access to quality health care services through private health
insurance, does that happen to include mental health as well as health?

MS. KADE: I don\'t know, and that\'s something that we can look into.
That was certainly an objective that was developed with CMS in mind, but
that doesn\'t mean that we can\'t partner with them.

MS. HUFF: It just seems like that should include mental health for kids,
as well as health care, the CHIP program and those kinds of things. But
sometimes it has to be spelled out. But I was just curious that there
was some assumption that that included mental health.

MS. KADE: When we first got this top 20 list, it was several pages long,
and they truncated it, and I don\'t know whether or not they eliminated
a bullet that might have affected children. Also, it\'s unclear how we
would work with the other OPDIVs on some shared issues, but another
OPDIV has a lead and I can convey that message.

MS. HUFF: Thank you. Thank you very much.

MS. KADE: Any other questions? Yes?

MR. STARK: A couple. On 19a, when I think of behavioral health, even
though I hate that term, I think of diabetes, obesity, asthma, heart
disease, stroke, cancer. You can throw alcohol, drugs and mental health
in there too, but it\'s a very broad definition of behavioral health.
Most people, however, when they think of behavioral health, they only
throw out alcohol, drugs and mental health.

The second one is related to 18. I\'m wondering whether or not, since
consolidation is sort of the new (inaudible) of government, I\'m
wondering whether or not 18 will result in a centralization of more
functions within HHS, and would that mean a loss of certain specific
functions within SAMHSA that will be again centralized in the broader
HHS.

MS. KADE: Yes, it does.

MS. SULLIVAN: Can you repeat that, Ken, go through what you said?
Instead of being covert.

MR. STARK: Yes, okay. Instead of being covert, say it like it is.
Bottom‑line it. So are you going to get whacked within SAMHSA, and are
some of your staff or functions going to be out of your control in the
future through a centralization process?

MS. KADE: I wouldn\'t put it that way, getting whacked.

(Laughter.)

MS. KADE: I think the Department realizes that there are certain
benefits, certain economies of scale, as well as common data needs. I
think the CIO is one function that clearly is being centralized.
They\'re trying to be sensitive to the needs of the smaller OPDIVs, as
well as the larger OPDIVs. Every now and again there is some other
conversation with regard to grants management, contracts management.
We\'ll see where we go and how we\'ll feel about it.

MR. STARK: That was a good answer, very good, very political, a very
diplomatic answer. Let\'s hope that in the end, it really is something
that will create efficiencies rather than simply assuming it creates
efficiencies and, as a result, the centralization actually results in
inefficiencies.

MS. KADE: One of the issues that has been presented at the Department\'s
management forum, Anna Marsh and myself, is the issue of performance
with regard to the STAFF/DIVs, not just the OPDIVs but the STAFF/DIVs,
one of these centralized functions and how it is important to make sure
that those contract plans are reflective of the consumers of those
centralized functions which can be improved in that regard. So I think
we\'ll have an opportunity to start inputting into those STAFF/DIV
contract plans, and hopefully that would give us the opportunity to
identify how we define success and how we define failure for those
services.

MR. KIRK: I think I asked this last time, but I don\'t remember. As a
new member of this group, from a protocol point of view, what is it that
would be appropriate for us to do to advocate on behalf of SAMHSA,
legislation (inaudible) as individual members?

MS. KADE: I\'m going to ask Toian to give you our standard advice on
this matter.

MS. VAUGHN: When you\'re here at a Council meeting and you\'re
representing the agency and advocating on a particular issue that you
have in mind (inaudible) as a Council member, unless you\'ve been in
violation of the ethics rules. When you wear a different hat at home
attending meetings, then you can share with your fellow individual
organizations that you\'re involved in issues that have been raised
here. But while you\'re on the government payroll, advocate for
SAMHSA\'s issues.

MR. KIRK: I guess what I was talking about, the Connecticut legislative
delegation, can I have conversations with the Connecticut legislative
delegation in support of things that I hear here?

MS. VAUGHN: Yes, you can, but not as a Council member, as a
representative of the state agency.

MS. KADE: Thank you.

Joe Faha is our director of legislation. He\'ll give us an update on
what\'s happening on the Hill.

MR. FAHA: Thank you.

Tom, did that make sense to you? Okay. As long as you\'re not going up
and talking to members and saying I\'m talking as a member of the SAMHSA
Council.

Daryl brought up the appropriations. This has been a fun year with our
appropriations. The House moved expeditiously in passing a Labor HHS
appropriations bill and had it done before the August recess. That\'s
the first time that\'s been done in a very long period of time. The
Senate took a little longer, but they too also passed their own bill for
appropriations in Labor HHS. There was a conference. That conference
ended about the 16th of November. They reported a conference report at
the end of the evening on November 17th, rushed it to the Rules
Committee so it could be brought up for a vote on the floor the next
day, and to everyone\'s surprise, particularly the Republicans\'
leadership surprise, it went down in a rather monumental way, by 20
votes, and it was largely because I think 22 or 24 Republicans voted
against it. So it fell. All the Democrats and the one independent voted
against it, and then 20 Republicans voted against it. So it went down.

That meant that we were on a continuing resolution, as we are through
the 17th. There is an assortment of things that Congress now has in its
pocket that it could do. It could go back and it could reconference.
They have no intentions of doing that. I can assure you that none of the
staff either on Senate or House, Republicans or Dems, are working on new
numbers at all. So we are left with what we\'ve got with going to a
conference report. Then if you followed this scenario, there would be
renegotiations and reconsiderations over the conference report on the
floor. That\'s not going to happen.

Congressman Lewis, who is the chairman of the appropriations on the
House side, has indicated that he would like to see a continuing
resolution for the entire year, which would continue funding at a lower
rate, the lowest rate, comparing what we got in \'05 to what the House
mark was, to what the Senate mark was, to what the conference report is.
So if indeed that were the chosen path, then we\'d have to sit around
and find out what the rules of the CR are before we would get a sense of
what our appropriations are.

The more common expectation is that our conference report, as voted down
by the House, would be attached to the Defense appropriations, which is
the only other appropriations bill that has not been passed and signed
into law. The Defense appropriations is also going to be ‑‑ around this
season they call them Christmas trees, because you keep putting
ornaments on it. So you get a bill, and then you start attaching other
bills to it so that it will carry through. One of those attachments will
be the conference report that has already been rejected and put on the
Defense bill on the assumption that people could not vote against it
lest they vote against defense.

Also expected to go on that is the reallocation of \$17 billion in
already appropriated funds for Katrina, and an additional \$2.3 billion
added to that, making for a total funding somewhere in the vicinity of
\$19.5 billion, and there will likely also be funding for Avian flu and
flu vaccines to prepare.

Coupled with that, everyone, as Daryl mentioned, would be a 1 to 2
percent across‑the‑board cut on all appropriations bills except for
Defense, at least right now. Just so you have a sense of what that means
to us, it potentially means a reduction of \$33 to \$67 million from our
budget, depending upon whether it\'s 1 or 2 percent. So that\'s
basically our status.

In the meantime, as Daryl indicates, we\'re on a continuing resolution
until the 17th. We fully expect that this is going to be taken care of.
Members do not like to be here the week of Christmas. Hell, they don\'t
even like being here in December. So they likely will want to get out.

Before I move on, are there any questions about that?

(No response.)

MR. FAHA: With regard to reauthorization, we\'ve discussed this at the
last Council. Reauthorization technically means that you change a couple
of dates in the statute. Pick any program that we have, be it the
children\'s mental health service program, there\'s a section that says
\"Be it authorized to be appropriated for the purpose of carrying out
this section for fiscal year 2001, \$100 million.\" I\'m making that all
up. \"And for 2002 and 2003, such sums as may be needed.\" That\'s
typical language of what you see. Reauthorization means changing that to
read, \"For the purpose of carrying out this section, be it authorized
and appropriated \$100 million for fiscal year 2006, 2007 and 2008.\"
Effectively, that program is now considered to be reauthorized.

Reauthorization, however, has a bigger meaning. Even though that may be
what technically it is about, it offers an opportunity for SAMHSA and
the Department to sit in front of Congress and have a policy discussion
and to talk about the directions of the agency and where we want to go,
especially if in order for us to go where we want to go we need some
legislative change. There is authority that we need to be able to move
in the direction that we want to move in, or we\'d like to get rid of
some of the restrictions that currently exist. So it becomes a wonderful
opportunity to have that dialogue on mental health and substance abuse
issues.

The Senate has indicated that upon completion of the Ryan White
reauthorization, which they had thought they would be able to take care
of in January but have found out yesterday will not happen until the
beginning of March, they then intend to start picking up SAMHSA
reauthorization. Briefings, et cetera, will be starting on that sometime
in January, and we will be going up to the Hill quite often to share
with them what we have been doing and what we need with regard to mental
health and substance abuse treatment and prevention services.

In our reauthorization, just so that you know, it immediately goes to
bills that are currently out there for consideration that may be brought
up in the context of SAMHSA reauthorization, and some of those bills,
just so you know issues that are likely to come up, underage drinking,
mental health transformation, methamphetamine in a big way.
Accountability is going to be a big issue with Mr. Enzi, who is
dedicated to performance measurement and accountability. Workforce
development, mental health services for homeless individuals, services
for the elderly, and some concerns from Senator Collins with regard to
why do parents have to give up custody of their kids in order to get
mental health services. So those issues will come up in the middle of
reauthorization.

One bill that did pass outside of reauthorization that should be noted
is NASPER, which would give the Secretary of Health and Human Services
the authority to run a block grant program that would provide funding to
states for the purposes of setting up prescription monitoring systems.
Unfortunately, two things. One, there\'s no money appropriated for it;
and secondly, there is an existing competing program in the Department
of Justice meant to do exactly the same thing.

Having said that, are there any questions?

MS. SULLIVAN: What do we have to do with that? I mean, why wouldn\'t
that be under our reauthorization?

MR. FAHA: It wouldn\'t. This bill has already passed separately. It\'s
not a part of ‑‑

MS. SULLIVAN: Oh, you\'re not talking about the issue with ‑‑ you\'re
going back.

MR. FAHA: (Inaudible.)

MS. SULLIVAN: Joe, when you just went through that laundry list of
what\'s important for reauthorization, can you get us a copy of that
laundry list and maybe we can see ‑‑

MR. FAHA: Sure. This is not a comprehensive list, but I can make it more
comprehensive if that would be helpful. That was just based on bills
that I know have already been introduced by, for example, Senator
Kennedy, Senator Dodd, Senator DeWine. So they would be brought up.

MS. SULLIVAN: I know I\'d like to know what specific interests those key
senators have specifically. Thank you.

MR. FAHA: Be glad to, and Toian will bother me until I get it in.

MS. KADE: Yes, she will.

MR. FAHA: Any other questions? Additions? Deletions? Subtractions?

(No response.)

MR. FAHA: Thank you very much.

MS. KADE: We\'re running a little late. I have been advised that a
10‑minute break would be a good thing to do now. So my watch says 10
minutes to 11:00. So if we can meet at 11:00, reconvene, that would be
terrific.

(Recess.)

MR. CURIE: Again, I\'d like to welcome everyone back after the break.
Our next item on the agenda is very exciting. It\'s an opportunity to
see firsthand the work that\'s being done with the Strategic Prevention
Framework.

Don, thank you for coming all the way from New Mexico. We appreciate
Don\'s leadership for quite some time, and appreciate you sharing.

First, I mentioned earlier that Beverly Watts Davis is now my senior
advisor on substance abuse in the Office of the Administrator and
already has just gotten off to a tremendous start there. Beverly did a
tremendous job as director of CSAP up to this point in time. In fact,
the Strategic Prevention Framework became a reality under her
leadership, again in the form of the state incentive grants, and also
putting meat on the bones of the idea of the concept of the framework.
Today it\'s a pleasure for me to introduce her to share with you and for
you to see what\'s happening really on the front lines of New Mexico in
operationalizing the Strategic Prevention Framework.

So, Beverly, take it away.

MS. DAVIS: Thank you all. I am just so pleased and honored, and I just
have to say this because I start off (inaudible). She said, Beverly, is
this a good thing? I have to tell you all that working for Charles Curie
is a phenomenal thing. It is one of the few jobs I\'ve ever had in my
life, seriously, where you\'re excited to get up and come to work. The
reason I say this to you all is the vision. The vision is there. We have
worked so hard to connect our systems, and we know that in communities
it\'s the fragmentation. As Mr. Curie would say, you\'ve got lots of
flowers out there, but do we have the stakes in the ground, the
redwoods, that are going to actually help create the infrastructure we
need to really make change from the state level to the community level
and help them solve local problems?

That vision was realized through the Strategic Prevention Framework. I
was so excited when I came in to interview with Mr. Curie and I saw his
vision, and he talked about the framework, and I knew he got it. He
understood that what we need to be able to do is to create flexibility
within the states, but accountability. Barbara, you talked about that
earlier. How do we make people accountable? All pulled in together with
this is the whole idea of how do we make states be able to actually
implement data‑driven decisions? Because as I shared with you all
earlier my story, we can be doing lots of things, but do we really hit
the target?

We know we have to address risk and protective factors of children.
We\'ve got to know the nature, the extent, and the scope of where our
problem is, and that\'s where we\'ve got to get those resources to if
we\'re ever going to change this frame.

What the Strategic Prevention Framework did is exactly when you see that
spinning wheel behind you, it really looked at the most effective
prevention planning process we have. It focused in on how do we make
sure that assessment is done well, that people really do understand all
the convening and converging factors that between consumption patterns
and consequences in communities really impact, that are impacted by
substance abuse, and then how do we make sure the capacity, that we
build the capacity in states to actually do what needs to be done.

Once we mobilize our resources, then we\'ve got to help our states
really come up with a plan that is driven by the data so we know that
we\'re actually hitting the target. We\'re making sure that the
resources are put where they need to be and that we\'re actually
addressing the risk and protective factors of our young people. The
whole idea, once we build the capacity and we\'ve got our plan, then we
really need to implement. We say that, and we know that that\'s what
that means, but we\'ve got to make sure that people aren\'t sitting on
the dollars and sitting on the dollars and sitting on the dollars. It\'s
about getting it out there so the communities will in fact do what they
need to do so we can move that and reduce substance abuse ultimately.

And last, this is where the accountability comes into play. Through Mr.
Curie, the whole data strategy, what we\'re going to be reporting on,
common measures within prevention and treatment and mental health,
we\'re going to be able to truly know and be able to see the result of
the work and constantly have evaluation, not as an afterthought of what
we\'ve done after we\'ve had our grant for a year or a year and a half,
we now do the evaluation part. It\'s the evaluation that is occurring
that is totally involved in everything that we implement so that we know
early on if we\'re implementing a strategy that isn\'t effective. We
don\'t wait until 12 months later to find that out. It\'s that whole
thing that we talked about, about having those evaluators accountable, a
part of what we do. It\'s changing the way we do business.

I\'ve given you all a map in the (inaudible) of really realigning
CSAP\'s resources. We were really able to move from going to implement
this in only 10 states. So I\'m very proud to report that in our first
cohort we were able to put this in 19 states. In addition to that, when
we went back and looked at our resources and figured out ‑‑ again, Mr.
Curie was fully supportive of us saying does this work? Is it needed? If
it doesn\'t match that, why are we doing it? And supported us being able
to realign our resources so that we were actually able to roll this out
in 24 total states and 2 territories.

Our goal is to have the Strategic Prevention Framework state incentive
grant in every single state. No doubt, with Mr. Curie\'s leadership and
God\'s help, we can make that happen ultimately. So I wanted to share
with you all a map. This morning we had the meeting with the five new
states. Those are the ones that are in red on your map.

This morning I think they all excited you all. They were just talking
about all the things they were going to do, and I walked in the room
they were saying we got our Framework grant, we\'re going to do this. I
mean, they were just so excited. It was just great to be here this
morning with them. And again, what was really important was that in many
of these states, as we look at other epidemics across our country,
whether it be meth, X, et cetera, the flexibility that the Framework has
is it does allow states to not just focus on a specific drug but focus
on the very multi‑complex nature of substance abuse, because it\'s
oftentimes many drugs, whether it\'s underage drinking and meth, or
underage drinking and marijuana, or underage drinking and other risk
factors that are going on. This grant allows a state to be able to
implement that.

I\'m so pleased to introduce you all to a state that has done a
phenomenal job with their SPF SIG grant, and I say that because the
other key thing about the SPF SIG grant is it is about helping states
bring others to the table who are doing similar work. Within the federal
government, we have 27 sources that actually fund substance abuse
prevention, and when they get into the states they go into not the
substance abuse and mental health service agency. They may go into
education, but their goals are the same. The SPF SIG, one of its key
components is having that state advisory council that literally brings
all those people together so that we\'re leveraging funds.

I\'m so looking forward to the brilliant work that Kathryn Power has
done with mental health transformation because it really dovetails into
this. It is about looking at all your resources to address the complex
nature of mental health and substance abuse. One person who has done
this so incredibly well is someone who I\'ve known for many years, Mr.
Don Maestas. He has a Master\'s in social work, and he is a licensed
social worker who I believe, quite frankly, are God\'s angels to the
earth, as they have been truly working in communities to really make
that difference from client to family to community. He is the project
director of our SPF SIG grant, and he has been the national prevention
networker for New Mexico since 1995. He truly helped us in the very
first round of state incentive grants to actually roll in the whole idea
of evidence‑based work, of really getting people not to have to start
all over, reinvent the wheel every time a new program was out, but to
begin to see what\'s working around the country, and then to share that.

He has worked with many state and national prevention leaders, and I
have known him for many years. He has actually built one of the
strongest prevention systems in the country, and I want to emphasize
prevention systems, where you\'re truly connecting all the programs that
you are funding in a state with other sources so that you\'re actually
able to help states help communities to solve local problems.

So with that, I\'d like to introduce you to my friend and colleague, Mr.
Don Maestas.

(Applause.)

MR. MAESTAS: Thank you very much.

Administrator Curie, members of the National Advisory Committee, thank
you for having me this morning. I\'m grateful for the opportunity to
come and present New Mexico\'s prevention system to this body.

What I\'m going to share with you is one of the best prevention systems
in the country, and as we go through it I just wanted to ‑‑ can you go
to the slide show, please? ‑‑ call your attention to the handout that
was provided to you. I think it\'s on your tables. I\'ll just start with
that.

So what I\'m going to talk about is New Mexico\'s prevention service
system, which is really a national prevention service system, and
you\'ll see why. Who is in the system? Of course, we have many partners
and collaborators in this, and those include the Department of Health,
Children and Families, Education, a long list of state partners, and
then of course the Center for Substance Abuse Prevention, SAMHSA ‑‑
they\'ve been our partner for many, many years and helped us to create
the prevention system you now see in the State of New Mexico. We also
have a lot of support from PIRE, as well as the CAPT center, the
Southwest Center for the Application of Prevention Technology, and the
Border Center for the Application of Prevention Technology. Certainly,
the NPN, where we helped out.

I was remiss in not mentioning CADCA. Certainly they\'ve been a strong
partner with us for many years as well.

What I want to start off with is to talk to you about the system in real
life. I want to give you examples of the programs, what kids we work
with, what they experience, and what happens to them afterwards.

Rocky Mountain Youth Corps is an evidence‑based prevention program in
Taos, New Mexico, and this young man is part of that program. He was
experimenting with drugs, and his best friend committed suicide. He
found meaning in participating in community service, learning with
youth. He stopped using drugs. He serves in a crew leadership position,
directing others, and wants to contribute to the community. He plans on
attending college next semester at New Mexico State University.

This young lady was struggling with peer pressure and had legal
problems, had no plans except getting a GED. She developed trust with
instructors and attended her first year of school at UNM Taos. She\'s
currently working with area children teaching substance abuse
prevention, as well as tutoring and mentoring.

This young man is from the National Indian Leadership Project, which is
a national model program through SAMHSA. This young man, Chance, is 11
years old. He\'s on his way to becoming a great National Indian Youth
Leadership Prevention Service staff youth leader. Most importantly, he
wants to experience his life to the fullest.

We\'ve worked with (inaudible) in New Mexico in terms of substance abuse
prevention and evidence‑based prevention programs. I just wanted to give
you a couple of examples of the different kinds of prevention programs
for zero to 6‑year‑olds and older kids. We have a State Incentive
Enhancement Grant in New Mexico. (Inaudible) that we\'re seeing, for
instance, the evidence‑based Parents as Teachers program. What we\'re
seeing is children are more advanced in language, problem‑solving and
other intellectual activities by three years of age; also more advanced
in social development. Eighty percent of the children in the program are
ahead of their peers by the time they reach kindergarten.

Excel Educational Enterprises, Inc. Programs. This is a program located
in Albuquerque. It\'s an Effective Black Parenting Program, which is
also a nationally recognized program, and this is a quote from Mary
Juzang, the project director. \"Any culture can use parenting skills,
but we have problems different from others in this country.\" She
characterized African American discipline as harsh and punitive,
resulting from the days of slavery and necessary to ensure instant
obedience to protect children from white harm.

What she does in her program is encourage African American parents to
help their children learn internal control instead of relying on
external control, and she\'s having a lot of positive outcomes.

Gila Regional Medical Center. While there\'s a demonstrated significant
(inaudible) very positive impacts on positive family interactions
related to bonding with a child.

The reason I brought those programs to your attention (inaudible) with
individuals and families in New Mexico. With the state incentive grant,
the emphasis is on changing community‑level indicators. So when this
grant and the opportunity to apply for it came to New Mexico, we really
felt this was the step we needed to take to have the impacts we need to
have on our populations that are experiencing problems. Governor
Richardson is a grantee. It\'s \$2.3 million per year for five years. It
includes a statewide needs assessment, helps build capacity, and
includes a comprehensive strategic plan for prevention that guides local
planning implementation of prevention activities in New Mexico. It puts
forth evidence‑based prevention programming directed at reducing risk
and promoting resiliency to reduce underage drinking and other substance
use, and to promote youth abstinence. It requires rigorous local,
statewide and national evaluation. Certainly, the primary purpose of
this grant is to look at changing community‑level indicators and
building stronger communities.

(Inaudible) to really emphasize what the framework is about. The first
portion, it\'s been a little over a year now. We received the grant in
September of 2004, and we began with a statewide needs assessment where
we profiled the population needs, resources and readiness to address
needs and gaps. We then moved on to capacity, where we helped build
capacity of community‑based prevention providers in terms of the use of
the framework, in terms of using data to identify where the problems
were, and using data to really focus on the interventions that were
going to help change some of the problems that exist in the State of New
Mexico.

We moved on to planning and developed a comprehensive strategic plan,
and we\'re currently implementing the evidence‑based programs and
activities. Of course, as part of all this is monitoring, evaluating,
sustaining, improving and replacing those that fail. It\'s very
important to New Mexico, as it is in the other six states, that
sustainability and cultural competence are part of the entire framework.
So I\'m just going to walk you through where New Mexico is at in
implementing the framework.

From the assessment, we did develop a SEW workgroup. That\'s the State
Epidemiological Workgroup, and that\'s been in place since early \'04.
Actually, we\'ve had a long‑term relationship with our division of
epidemiology. We\'ve been working with them for a number of years. So as
we walk through one of the documents in your handout, you\'ll see that
there\'s quite an extensive array of work that\'s been performed by that
workgroup to this point. Of course, the purpose was to create in a
systematic way a prioritized set of state‑level data indicators that
will drive the identification of state and local level intervening or
causal factors; support the selection of a range of effective,
evidence‑based strategies to comprehensively impact the prioritized
indicators; assess substance abuse‑related problems, risk and protection
assets and resources, gaps in services and capacity, readiness to act;
specify baseline data and identify priorities. The SEW will function
throughout the five‑year period to refine data, its analysis, and its
priorities.

They have a lot of work to do. Certainly, they\'ve done a lot of work to
date. They helped identify measurable indicators of community‑level
change. They helped to identify effective strategies that may be
implemented by community groups to address indicators. Here\'s a list of
folks that make up the workgroup. It includes the New Mexico Department
of Health Epidemiology Division, New Mexico Voices for Children,
Children Into Families Department of Underage Drinking Coordinator,
Southwest CAPT, Behavioral Services Division Prevention staff, the
Strategic Prevention Framework evaluator, and of course the SEW
coordinator and others.

In terms of the assessment, what we found in New Mexico in the past
decade is it\'s rated first or second in chronic alcohol mortality and
drug‑related mortality. Some of the substance abuse patterns included in
the assessment include chronic drinking, binge drinking, drinking and
driving, marijuana use, other illicit drug use, and tobacco use.

This is analyzed by gender, ethnicity, age, geographic location, and we
certainly utilized a logic model, including consequences of consumption,
intervening variables and strategies.

What we have here is the New Mexico Community Logic Model, which starts
off in the upper left‑hand corner with substance abuse‑related
consequences, moves on to substance use, causal factors, and strategies.
Under the substance‑related consequences are included the high rate of
alcohol‑related crash mortality among 15‑ to 24‑year‑olds. If you look
at the youths, underage and young adult drinking and driving, as well as
underage young adult binge drinking. Then the causal factors include
easy retail access to alcohol for youth, low enforcement of alcohol
laws, easy social access to alcohol, low perceived risk of alcohol use,
social norms accepting and/or encouraging youth drinking, promotion of
alcohol use, including advertising and movies and billboards, et cetera,
lower discount pricing of alcohol.

Some of the strategies we\'re going to be using to combat these problems
include enforcing underage retail sales laws, social event monitoring
and enforcement, media advocacy to increase community concern about
underage drinking, restrictions on alcohol advertising to youth markets,
bans on alcohol price promotion and happy hours, and others.

Some of the criteria that we used according to the indicators include
the severity, including the state ranking within the nation; the
severity rate per 100,000; the burden, number of persons and size of the
problem; the economic impact and social impact; as well as trend
characteristics, including increasing or stable compared to the national
trend.

What I want to draw your attention to now, and it\'s in your booklet, is
the statewide epi profile. This is what it looks like. It\'s currently
marked draft and it\'s in your packets. What this was was one of the key
products developed by the SEW workgroup. You can see that it is a very
comprehensive profile that identifies really the problems or the extent
of the problems or the extent of the problems in New Mexico related to
alcohol‑ and smoking‑related death, drug‑related death, as well as
suicide. What you see here as you go through this ‑‑ of course, we
won\'t have time to go through the entire document, but what you really
see is, by county, where the problems are in the State of New Mexico. So
this is the kind of information, the kind of data that we\'re using in
New Mexico to help target resources to really address the problem. By
utilizing this type of data, and of course using this as benchmarks,
we\'ll see in the next several years the outcomes of our efforts.

The next thing I wanted to call your attention to is that this is what
we use, this tool that\'s currently on the screen, and it\'s in your
packets, of course. It\'s a tool that we use to prioritize the data
indicators. So we convene focus groups throughout the State of New
Mexico, we share with them the data profile, we walk through the profile
and show them how to use the document. We then use this tool to identify
the priorities for the state incentive grant for the State of New
Mexico.

So really what we came up with as we went through this process is the
two that we chose in New Mexico to focus on are alcohol‑related chronic
disease death and alcohol‑related morbidity, as well as alcohol‑related
mortality, the chronic disease death.

Go on to the next slide, please.

So that would indicate the focus, and this is part 2 of that form.
There\'s part 1 and part 2. We couldn\'t get it on one form. This is the
tool used to identify, and once again using the data and focus groups,
this is what determined our focus for what we would be funding for
prevention programs in the State of New Mexico as related to this
project.

In terms of capacity, we felt it\'s really important to build capacity
throughout the State of New Mexico to be able to implement this
framework. So we\'ve developed and implemented problem‑focused training
1 and 2 provided throughout the state in multiple locations.
Problem‑focused training 3 will be provided to successful bidders in the
first 30 days of the award. This SPF SIG framework is being incorporated
into overall workforce development programs, as well as our assessment
training, capacity training, and planning training.

In planning, we held our 11th annual state prevention planning meeting
on May 11th in 2005. I put this on the screen just to illustrate to you
that New Mexico has been in a process of building one of the strongest
prevention systems for a number of years, and we were one of the
recipients of the initial state incentive grants, and you\'ll see some
of the outcomes at the end of the presentation from that grant.
Certainly, we have really strived to promote evidence‑based prevention
programs in the State of New Mexico, and that\'s really our standard at
this stage. Really, we had to overcome some concerns about that from
local providers, but most of the providers are (inaudible) 100 percent
as they\'ve seen the outcomes of the efforts, and certainly that\'s done
through strong, rigorous evaluation.

So we developed the strategic plan. The strategic plan was presented to
our advisory committee in May, and it was approved by CSAP. Of course,
it\'s been incorporated also into the strategic plan for the New Mexico
Behavioral Health Plan for the State of New Mexico.

A continuum of prevention services, development of RFP for distribution
of services, the resources to be distributed based on statewide needs
assessment, evidence‑based prevention programming directed at reducing
risks and promoting resiliency to reduce DWI and underage drinking and
other substance abuse, and to promote youth abstinence. We\'ve gone
through that process, and we selected eight implementation communities,
as well as five capacity communities. We\'re currently still in the
process of our procurement process, so I\'m not able to share those
communities with you today. Hopefully in the next several weeks, as soon
as all the contracts are signed and sealed and delivered, it will become
public information.

But certainly we just wanted to emphasize in terms of these
implementation communities, what they will be doing in the month of
December is we\'re bringing them together and providing an all‑day
training to them, as well as going over all the expectations. These
communities were selected because we felt they\'re ready to implement
the framework. We just want to make sure we\'re all on the same page and
pushing forward together in order to have the maximum input with this
program.

January we\'ll be focusing on capacity with these implementation
communities, and February we\'ll be really focusing on planning. By the
end of February, beginning of March, we\'ll be asking our communities to
submit strategic plans to us for approval so they can move forward with
implementation.

Really what we want to see in those strategic plans is how they\'ll use
the epi data, how they build capacity within their communities, how they
develop a strategic plan, and how they begin to move forward with the
implementation of the program. So we\'re really excited about these
communities and the opportunities they have to create change in the
communities in New Mexico.

We recently selected five capacity communities. (Inaudible) proposals
that were submitted, but certainly communities with high need and low
capacity. We\'re going to work intensively with these communities for
the next seven months to help build capacity, with the hopes of making
them full implementation grantees beginning July 1 of \'06. So we\'re
going to be moving a little slow with them, going through that same
process in terms of getting them up to speed on the assessment and use
of data, on building capacity in communities, and on putting together a
strategic plan for the implementation.

In terms of evaluation, we have a contract with behavioral assessment,
and we\'ve worked with them for about seven years now. They\'re our
primary evaluator for the state incentive grant, the original state
incentive grant for New Mexico, and they\'ve been working with us to
develop problem statements, as well as really working well with us on
the actual prevention framework.

The evaluation system is to be enhanced to measure community‑level
indicators. This is something that many states are really challenged
with. We can and have measured successful individuals and families.
It\'s difficult to measure change in community‑level indicators, and
certainly this is the task we feel that we\'re up for, we\'re ready to
take on, and certainly with our partners we feel we\'ll be successful in
doing this.

We\'re in the process also of developing tools to measure the
effectiveness of environmental strategies, and of course we need to be
able to consistently count the number of individuals being impacted by
environmental strategies. Certainly, as I\'m called to the legislature
to talk to them about what we\'re doing and who we\'re doing it with, an
intelligent thing to do, once we get (inaudible) focus on individuals
and families, we are going on when we talk about communities, who we\'re
impacting and how we\'re impacting them.

(Inaudible) the presentation and just talk to you about some of the
successes in the system (inaudible). Certainly we\'ve seen reductions in
substance use and abuse in New Mexico. We\'re working on our third
five‑year prevention plan. We funded evidence‑based prevention
programming in over 40 New Mexico communities. We have a strong grants
management system, a comprehensive workforce development system, and
we\'ve been doing outcome evaluations since 1996.

Some of the outcomes, just to give you an idea of the outcomes we have
achieved, if you look at this graph what you see is in the pink is the
comparison group. The darker color is our intervention group. On the
pre‑test, you see the intervention group is about 24.6 percent, and our
comparison group is a little over 23 percent. We saw increases in our
implementation group, as well as increases in the comparison group. So
this shows the efficacy of prevention programming in the State of New
Mexico, and this is the percent of past 30‑day alcohol use.

This is very similar. This is in terms of the past 30‑day marijuana use,
and we see a similar occurrence here, where we see reduction in use for
the implementation group and an increase in the comparison group.

The next slide is percent of past 30‑day tobacco use, very similar as
well.

What these slides show us is that evidence‑based prevention is
effective, it can be measured, it has been measured, and certainly I
think we would all like to see greater increases in use regarding those
programs. Certainly, there are more factors that we need to look at as
we (inaudible) our prevention programs on an annual basis. The pre‑test,
for instance, just to give you an example of the high‑risk individuals
who we\'re working with, the pre‑test shows you that 23 percent or
greater were already using, and we saw the increases in use at our
post‑test.

One of the things (inaudible) are we using the right programs for the
right individuals? There are a lot of evidence‑based programs out there,
but (inaudible) on an annual basis take a look at those programs, how
effective they were and whether or not they were the right programs for
the right populations. That\'s certainly something we\'re doing in New
Mexico.

One of the other things I\'ll just mention since I\'ve got the
microphone is that the evidence‑based programs that we\'re doing,
certainly we support them, but certainly in New Mexico we adapted most
of those programs while working with the creators of the (inaudible)
program. So that\'s really key to make them culturally competent, make
them fit our populations. So I don\'t think we have a single
evidence‑based program that\'s a canned program, just so the group is
aware of that as well, because I think that\'s real important and
that\'s one of the knocks against evidence‑based prevention programs
that I hear over and over again.

That\'s it for my presentation. Once again, thank you for the
opportunity to come here to Washington and to talk to you about the New
Mexico prevention service system.

(Applause.)

MR. CURIE: Ken?

MR. STARK: A question for you, Don. It sounds like you all have done
some really, really good work there in doing the documentation. Are you
looking at taking it to the next level to look at, for those individuals
who have participated in these programs, are you seeing any changes
relative to some of the other risk factors, looking at archival data
sets? For the kids, have you seen any improvements in school
participation, in grades, reduction of school dropout, reduction of
school attendance problems or reductions in criminal justice? I\'m not
looking at that from a self‑report standpoint but using existing
archival data sets to truly do that analysis and match up these
participants with those databases to be able to then sell it to
legislatures as cost‑effective programs?

MR. MAESTAS: Yes. Thank you for the question. We have, in fact. When we
received the state incentive enhancement grant, that was one of the
things we were going to do with it, or we are doing with it. So
certainly the data from that will be made available shortly. Really what
we did is we took ‑‑ because that\'s always a concern and a question.
You have an impact over a 30‑day use. What about the long‑term impacts?
So certainly we\'re in the process of gathering that information, and we
should be able to report on it probably in the next six months or so.

MR. STARK: Yes, it sounds like you\'re well positioned to be able to do
that.

MR. CURIE: Barb?

MS. HUFF: Two or three comments. First of all, thank you for coming and
sharing that with us today. It\'s really exciting.

One of the things I just wanted to kind of point to, on one of your
slides here on page 7, you talked about assess the substance
abuse‑related problems, risk and protection assets, resources for
services and capacity, and readiness to act. I just want to thank you
for mentioning readiness to act.

I\'ve been around this town for a long time. I\'m 60 years old now, so
I\'ve been doing this for a long time, and I just want you to know that
I have seen so many communities get money who were not ready to act. I
came from Wichita, Kansas 20 years ago. They gave back their local CASSP
grant because they just could not ‑‑ they just said don\'t send us any
money because they couldn\'t act.

So you can do a lot of things, but I love it that you put down here
readiness to act. It\'s so important.

Then the next thing I want to mention is the whole issue around
evidence‑based practices and how they translate to stigma in New Mexico,
which has such a diverse population of people, and what we as families,
parents with kids with mental health and substance abuse problems, have
been saying for a long time that we\'re nervous about that. We\'re
nervous about whether or not evidence‑based practice really does
translate into all communities. Will what works as an evidence‑based
practice in inner‑city New York go to New Mexico?

So I\'m glad you\'re recognizing that, and I know you want to say
something, but I like to hear that.

MR. MAESTAS: Well, in terms of the first, in terms of the readiness to
act, certainly that was a big part of the Request for Proposal that went
out. Certainly the communities were selected for high capacity or high
readiness to act and high need. Certainly that was the focus.

MS. HUFF: But sometimes people have great grant writers that can produce
a readiness to act that really aren\'t ready to act. I\'m sorry, but
people pay a lot of money for grant writers.

MR. MAESTAS: And actually that\'s one of the things that we\'re going to
determine in the first three months of the grant as well, because we\'re
going to make sure ‑‑ that\'s what\'s different about this grant as
well. Prior to even allowing them to implement it, which all of us, CSAP
and SAMHSA, did with the states, they will be ready to act before they
act. That\'s one of the things we really just shared.

Your second question was regarding adaptation of programs. Certainly
that\'s something that initially, going back seven years, eight years
ago, there were a lot of programs in communities that had some real
concerns about this, and (inaudible) evidence‑based programs.

One of the things that we\'ve been doing is working very, very hard with
those communities to adapt them. But also we\'ve been working with our
communities to bring in what we call the homegrown programs and helping
them to get to model programs. So we have about five of those in New
Mexico that obtained that status over the past several years. So we\'re
really proud of that because here we have programs that have evaluation
tied to them, and we worked with them to achieve the model program
status.

I got an interesting thank‑you letter from one of our programs, one that
I highlighted before, one of the first model programs in New Mexico. The
first model program was a home‑visiting program, and initially when they
received the grant, they were doing good work. We saw that; we funded
them. But they were real hesitant and really concerned about putting 10
to 20 percent of their grant money into evaluation. Well, I got a
thank‑you letter last week thanking me for emphasizing the need for them
to do that, and they appeared in last week\'s Social Work Journal in
terms of model programs. So a great success for the families and program
that are working in Silver City, New Mexico.

MS. HUFF: Can I just ask one more?

MR. MAESTAS: Please.

MS. HUFF: How are you interfacing ‑‑ I\'m real familiar with the
language of (inaudible). How does this interface with mental health,
children\'s mental health, and the fact that you have kids with mental
health problems (inaudible)?

MR. MAESTAS: Thank you for asking that question. As I was going down
that list, I knew I was going to be remiss in not mentioning people.
Certainly I work within the same division that does the children\'s
mental health, and then also we have in New Mexico the Behavioral Health
Collaborative, which is really 17 state agencies working together to
purchase behavioral health services in the state. Also, we\'re working
very closely with my colleagues who are administering the ATR grant, the
SBIRT grant, the co‑occurring SIG grant in the State of New Mexico. In
fact, the project director is in the office next door to mine.

MS. HUFF: Ken Martinez used to be there. He was a good friend of mine.

MR. CURIE: Other questions? Yes, Faye?

DR. GARY: Thank you for your presentation. I think it\'s very insightful
and also very encouraging.

I also want to comment that I\'d make the epidemiological data ‑‑ it\'s
a very excellent set of data on which to build a program. So I wanted to
just comment that this is the kind of data that we need that provides
evidence so that people know what the issues are in states of what
should be addressed, and also to have it by county, because as I looked
at this and look at your very excellent program, it seems to me that if
you wanted to get specific and really do evidence‑based practice that
improves the lives of people, that the interventions might change county
by county based on the epidemiological data. So I think that\'s a real
strength of what you present and you bring here. So I just wanted to
commend you for that kind of insight and that kind of thoroughness in
your thinking and in your program.

The other is I was wondering about health literacy with regard to
individuals that you work with. Even though you did not address it
directly, I think it\'s underneath. I think it\'s under‑girded here,
because when we talk about prevention, especially with adolescents and
young adults, but also with any human being, to address head‑on their
health literacy, their understanding of the responsibilities of the
self‑care behaviors that they can implement based on informed
information from health care providers goes a long way in helping to
sustain the kinds of behaviors, the kinds of thinking and the
transformation that we\'re really looking at with regard to the
behaviors that we wish to change.

The other question I have is with regard to marijuana use, alcohol use,
give us data about the 30 days post. Do you have data beyond the 30
days? And the second question is do you have involved in your program
boosters to sustain this kind of transformation that you have gotten in
your program?

A final question is to what extent would you address the involvement of
other community‑based organizations, tribal chiefs, et cetera, in the
community to help sustain the kinds of gains that you have seen?

MR. MAESTAS: Thank you for your questions. In terms of the answer to
your first question, I think I addressed it earlier and emphasized that
it\'s part of the state incentive enhancement grant. We do have
resources to follow up on some of the individuals who benefitted in our
30‑day use grants. So we\'ll be seeing that data probably in the next
several months.

DR. GARY: For what period of time will you follow up to see the
sustainability?

MR. MAESTAS: What we\'re seeing is I think there\'s three data points
we\'ll look at six months after and a year after.

In terms of boosters, throughout this process we really worked ‑‑ and I
didn\'t emphasize it enough, and I should have, really the community
empowerment, the community partnership that occurred throughout this
process. Certainly we look to our communities to show us what they feel
the needs are, and certainly this data helps that. But when we start
looking at booster assessments, for instance, we do have some in many
communities. In fact, there are some communities that are doing it, the
middle schools in Santa Fe, for instance. They do Botvin\'s life skills
through 6th, 7th and 8th grades throughout, so we can start looking at
the progression and the booster assessments that they\'re adding to that
program. Other programs vary, so not all of them have booster sessions.
But certainly we\'re hoping the Strategic Prevention Framework state
incentive grant becomes our booster, because what it\'s really doing is
looking at changing and creating norms towards alcohol use, et cetera.
So we\'re hoping we can continue to work with individuals, including the
zero to 6‑year‑old population, parents and families, our middle school
kids, as well as 17‑year‑old kids, as well as adults as individuals and
families.

But certainly this SPF SIG grant really gives us the opportunity to help
provide boosters to the entire community and really provide that
insulating factor for those individuals and families.

In terms of the work within farm communities, thank you for asking that
question. We\'re proud of the work we\'ve done over the past several
years, and we worked really hard to build partnerships with them. We
worked with a consultant named Nadine Fafoia for the past seven years,
and what we did is we recognized in the State of New Mexico, and this
occurred several years ago, is what we\'ll call an (inaudible) in terms
of funding the services, et cetera, in Native American communities.

What I mean by that is every year we go out and do site visits in these
tribal communities, and because of a lot of factors, including tribal
leadership changes, and many of them change governors on a yearly basis,
some every other year, what we saw is the lack of continuity in service
programming. What would happen when we would do the site visits is we
would take money away from them every year because they weren\'t
performing to the level they needed to perform.

So what we did in prevention is we convened a group of tribal leaders
that had been successful in maneuvering the federal and state prevention
systems, and we asked them for assistance, and they\'ve been working on
this now for probably the past six years to help build capacity in
Native communities.

In fact, this past year, we held our fifth annual Native American summit
in Albuquerque, New Mexico, and really the purpose of the summit is
bringing together tribal leaders to help build capacity, let them know
what\'s going on, get their input into what needs to happen in the State
of New Mexico, and we have some really strong Native American programs
as a result of that.

MR. CURIE: Yes, Tom?

MR. KIRK: I thank you very, very much. Very, very impressive program.
Congratulations.

I want to make a comment and see whether other members will resonate to
this one. What you mentioned before about system change, many of the
things that you have built into this are geared toward what are called
asset development, promoting health. I think New Mexico is one of those
mental health transformation states; is it not? That kind of
collaboration you have built into that actually represents a great
stepping stone so that in the mental health transformation initiative,
health promotion/prevention types of activities like you talk about can
be part of the infrastructure built in.

Part of the reason why I say that\'s so critical, and we\'re struggling
with that, struggling in the sense of identifying it as a challenge that
we need to build upon, people with serious prolonged mental illness, as
we work to get them stable in terms of illness, building off the
recovery approach, many of the things that are built into health
promotion activities such as you\'re talking about can precisely do
that, sustain their health in the community.

When we looked at our Access to Recovery initiative under the guise or
the umbrella of what we call recovery support services, health
promotion, i.e. prevention activities, would fit in there also. I think
we can connect the dots on these types of things to produce a system
change that we\'re all interested in. So I think what\'s striking about
your presentation is that it flags those pieces. It is assets based.
It\'s health promotion. It is a collaborative type of piece, and not
just based upon the members of who is in the system, but your question
before about the outcome measures, the next stage may be what\'s the
next level of outcome measures that are more system based and that are,
if you will, targeted to what I call the covered lives approach.

I don\'t know how many people are in New Mexico, but one of the things
that I use in my \"stump speech\" is that Connecticut has got 3.5
million people, and I see myself as the director of a health care plan.
So the penetration rate in that health care plan, quality of life for
people in Connecticut is tied to this thing. I think the more we can tie
some of those things together, so much the better.

But kudos to you in New Mexico for the type of initiative that you put
into place, because it goes back to somebody\'s question before, I guess
it was Barbara\'s question. A lot of people say they\'re going to do,
but clearly it\'s far easier to say you\'re going to do than actually
do, and you\'re going about doing it. So congratulations.

MR. MAESTAS: Thank you.

MR. CURIE: Other questions or discussion? Larry?

DR. LEHMANN: (Inaudible.)

MR. MAESTAS: Yes, absolutely. We have sites that we selected that
include both rural and urban. Then also, as you know, we have 1.8
million people in the State of New Mexico, and of course we have a very
diverse ethnic rate as well. Certainly that\'s also apparent in terms of
the sites that were selected. Once again, once we complete the
procurement, I\'ll make sure that Beverly has that information and they
can share it with this advisory council as well.

MR. CURIE: Other comments, questions, discussion from the Council
members?

(No response.)

MR. CURIE: Don, I just want to say thank you so much for taking the time
and effort to come and share with us your program, the results. I think
you\'ve answered the comments made by the Council members that clearly
you\'ve demonstrated that you can implement a strategy that\'s based on
outcomes. You show prevention works. That\'s one of the toughest
messages to convey, one of the biggest challenges when we\'re appearing
before Congress when we\'re trying to make the case with the budgeters.
Proving that you prevented something from happening is a tough thing to
do, but you\'ve been able to demonstrate a real impact on the lives of
young people, and we thank you for offering the model, and we think
there are a lot of lessons here that we can bring to scale. So thank you
for your invaluable work.

MR. MAESTAS: Thank you for having me.

(Applause.)

MS. KADE: Thank you very much.

Now is our time for public comment. I think we have a Cheryl Reese.
Please, come up.

MS. REESE: Good morning. My name is Cheryl Reese. I\'m a licensed
professional counselor in the D.C./Maryland area. I have a background in
addictions and served with the Marine Corps for 23 years. So I\'m a
retired Master Sergeant, and I\'ve worked with behavioral health, and
I\'m on the national board of Lesbian and Gay Addiction Professionals. I
want to thank SAMHSA first of all, and CSAP in particular, for their
support of LGBT issues in the past, especially production of the 2001
\"A Provider\'s Introduction to Substance Abuse Treatment for Lesbian,
Gay, Bisexual, and Transgender Individuals.\"

Since 2001, CSAP promised a subsequent training manual to accompany the
Provider\'s Introduction document. We know that a draft exists, but
emails and letters have not produced any additional progress on that
matter. Last spring our vice president, Phil McKay, and members of the
LGBT community national health coalition met with Wesley Clark and
others from your agency, and we were assured that LGBT issues, including
the training manual, were still going to be addressed.

Now, what I\'m going to talk about in the next few minutes are
specifically pointed to the comments made by Council members earlier
regarding inclusion, stigma, and suicide associated with alcohol and
drug use and behavioral health. That struck home with me because in the
LGBT community, stigma, inclusion and suicide are issues that affect our
community and contribute to the increase in abusive drinking and drug
use, and certainly impact the nature of our health. We\'re talking about
health care for those that are underserved or underinsured.

Statistics clearly show an emerging increase of youth suicide in the
LGBT community. We\'re asking SAMHSA to simply join us in a viable
partnership that recognizes the value of our advocacy and our resources
to the community. NALGAP wants a seat at the table not as an
afterthought but as a primary team player. We\'d like you to respond to
our letters and emails and publish the training manual. If you\'re
sincere about acknowledging the issue of stigma and inclusion, begin
with us. Thank you.

MS. KADE: Thank you very much.

Are there any other public commenters in the audience? Yes, please.

MR. CURIE: This is Susan Rogers from the Southeastern Pennsylvania
Mental Health Association.

MS. ROGERS: Hi. Thank you very much.

I have two comments. I wanted to, first of all, talk about the seclusion
and restraint comments that Mr. Curie made earlier. I\'m from
Pennsylvania and, as you know, Mr. Curie was responsible for our very
effective initiative to move toward zero use of seclusion and restraint
in Pennsylvania, and I wanted to alert people to the fact that there\'s
a wonderful section in the September issue of the Psychiatric Services
magazine that includes actually an article by Mr. Curie. It\'s about
seclusion and restraint, and it\'s a variety of articles that are all ‑‑
it\'s not a very balanced section. It\'s all very much talking about why
seclusion and restraint is a bad thing and why we need to get rid of it,
and the evidence that getting rid of it is effective.

Mr. Curie has said in the past that seclusion and restraint is not
treatment. It\'s a treatment failure, and the section is all about that,
and it includes the voices of people who have experienced seclusion and
restraint. So I think that\'s important for people to know about. I hope
they can get the September issue, and if they can\'t, I can send one. I
have a copy of it, and I can send people a copy of it.

The second thing I wanted to talk about was following up on something
Ken Stark said about language. He was talking about the use of the
phrase \"behavioral health services,\" and I actually agree with him
about that. But I also wanted to mention the use of language when it
comes to the word \"stigma,\" because the word \"stigma,\" as some
people here have actually said, they don\'t like that word, for good
reason. I\'d like to urge that people, as the Center for Mental Health
Services habitually does, I\'d like to urge that people use the word
\"discrimination\" when they say the word \"stigma,\" refer to both
stigma and discrimination, because it\'s really the discrimination that
is the killer. It doesn\'t matter what you think about me, but just do
not discriminate against me.

In fact, Pennsylvania\'s anti‑stigma campaign doesn\'t even use the word
\"stigma.\" It\'s called Open Minds, Open Doors. It calls itself merely
an anti‑discrimination campaign, and I\'d like to recommend people look
at our website, which is www.openmindsopendoors.com, not .org, it\'s
.com. It\'s a really good website with wonderful anti‑discrimination
messages, and it also has extremely useful information for employers.
It\'s very much focused on the issue of employment because, as we know,
employment is extremely important in helping people with their recovery.

So those are the two comments I wanted to mention. Thank you.

MS. KADE: Thank you very much.

Anyone else?

(No response.)

MS. KADE: Okay. So we\'re at the point where we\'re going to break for
lunch, and I think Toian ‑‑ yes, please.

DR. GARY: May I? I just wanted to link the whole issue of seclusion and
restraint to workforce issues. Hopefully we can talk about that
sometime, because when you talk about seclusion and restraint, we\'re
back to assessment and how do we treat, how do we respond. That is
directly linked to the sophistication, the knowledge and the training of
the workforce. So I think you can\'t get away from that. So could we
please talk about those?

MR. CURIE: Absolutely.

DR. GARY: Thank you.

MS. KADE: Sure.

Lunch.

(Whereupon, at 12:05 p.m., the meeting was recessed for lunch, to
reconvene at 1:30 p.m.)

[AFTERNOON SESSION]{.underline} (1:50 p.m.)

MR. CURIE: I\'d like to welcome everybody back, and I\'d like to delay
the consideration of our hurricane response and an opportunity for you
to meet some of the key individuals that SAMHSA was instrumental in
providing the leadership and management of SAMHSA\'s response to
Hurricane Katrina.

Before I introduce our presenters, I\'ve already shared briefly with you
my own observations and thoughts on our response to Hurricanes Katrina
and Rita, but I\'d like to go a little bit more in‑depth just for a few
moments in terms of my own observations.

I had the privilege of accompanying Secretary Leavitt to the Gulf Coast,
accompanied him on at least two occasions. Once I made a trip on my own
to the Gulf Coast, and the fourth time I accompanied Secretary of
Education, Margaret Spellings, each trip having somewhat of a different
focus but really homing in on the public health response, what was
needed, and of course more specifically the mental health and substance
abuse response that we had with SAMHSA.

It allowed me really several opportunities to meet one on one with
mental health and substance abuse officials, state officials in the
affected states in particular, as well as local officials. I also was
able to visit several shelters in the process, shelters located in the
impacted states as well as those states that were taking evacuees and
victims of Katrina who needed to move out of the state for a time
because they were, in essence, having no home. It was clear to me during
each trip that the providers, the officials consistently were having a
sense of (inaudible) the magnitude of the disaster.

That said, it was remarkable the tremendous work these individuals did
in the process in terms of addressing needs as they were manifesting
themselves. First responders, the emergency medical teams, firefighters,
law enforcement, physicians, nurses, all were very much engaged in the
process. What was an additional challenge above and beyond many
disasters we\'ve seen, especially when compared to 9/11, while that was
a disaster of horrendous magnitude, the locations of those disasters
lent themselves to a lot of resources already being readily available,
New York City and Washington, D.C., for example. The nature of Katrina
and Rita was such that they were devastating communities that were
already somewhat remote from resources once their own resources were
destroyed. That in and of itself I think presented a challenge which was
very different from what we had seen before.

The one thing that struck me as we looked at the devastation and we
looked at how overwhelmed folks were was the level of resiliency
demonstrating the pressing needs, and I think that\'s a major message
that we can\'t forget in this process. The word \"unprecedented\" was
used in an unprecedented way, legitimately so around Hurricanes Katrina
and Rita. The level of resiliency and the strength that individuals
demonstrated through this process was remarkable.

One thing that we did at SAMHSA in the immediate aftermath of the
hurricane is we immediately activated the SAMHSA Emergency Response
Center supporting those grantees that were impacted by the storms, and
additional support was provided immediately for a national suicide
prevention lifeline, which experienced a spike in calls. In fact, I
think the average number of calls we received on the lifeline a day is
somewhere in the vicinity of anywhere from 100 to 120 calls per day. The
average spike in call volume in the period of time after the hurricane
hit was an over 60 percent increase. In fact, one day the volume hit
900. It leveled off, the data is showing us, somewhere from 180 to 230
calls per day. But as you can see, that\'s still a higher level than
what was experienced pre‑Katrina.

We also held weekly conference calls with SAMHSA constituents to keep
them apprised of our efforts and answered questions that they may have
had and addressed any concerns that they had, and these calls were
coordinated with CMS, the Centers for Medicare and Medicaid Services,
made the coordination with emergency response services to the same
consumers, if you will, as transparent as possible.

We also launched an expansion of our website to provide quick access for
the victims and to provide some topics about where to get help, to
publications and assessment tools, training guidelines, other technical
assistance materials, and also other links to other key resources and
organizations.

Within the first week of Katrina striking, we began the process of
making available SAMHSA Emergency Response Grant dollars. SAMHSA has the
capacity and the authority under its authorization and statute to be
able to make available up to I think it\'s about 2.5 percent of
appropriated dollars for emergency response services. It\'s
discretionary dollars.

One thing to keep in mind is this occurred at the end of the fiscal
year. So taking a look at dollars that were available, it was more
limited than it would have been if it had occurred at the beginning of
the fiscal year. Of course, we don\'t coordinate (inaudible) schedules
in terms of the amount of dollars being available. But the good news is
we were able to find \$600,000, albeit the scope of the disaster seemed
like a small amount. It was a lot of money we found immediately that we
were able to allocate to the four major impacted states, Louisiana,
Mississippi, Alabama and Texas, and I think they actually had the
dollars within 14 days after landfall of Katrina.

These funds were specifically given to fill gaps that would be left by
the FEMA dollars. FEMA doesn\'t (inaudible) resources available for
crisis counseling. SAMHSA is responsible for the application process for
the crisis counseling dollars that FEMA makes available in the aftermath
of a disaster.

However, you aren\'t able to use those dollars for such things as
ongoing treatment of people with serious mental illness or ongoing
pharmaceuticals or ongoing interventions or, as I mentioned earlier,
methadone, for individuals receiving methadone treatment. Those FEMA
dollars are not eligible to be used toward those needs. The initial
dollars we provided were able to be used for that.

So we allowed states the opportunity to assess where they had these
needs with a specific focus on how to do the care issues with
individuals that were displaced who were seriously mentally ill,
children who had serious mental disturbances, as well as individuals
with addiction that needed treatment.

We also, as I mentioned earlier, working with FEMA, awarded 29 full and
2 partial grants to states for immediate services. Those grants total
\$20.5 million. Then on top of that we coordinated the mobilization
through our SAMHSA Emergency Response Center of over 300 people to work
in the field on mental health and substance abuse issues. In fact, in
one two‑week deployment in Louisiana and Mississippi, volunteer
providers counseled 1,889 evacuees and made 2,020 referrals. Of these,
17 percent were in mental health services, 3 percent to substance abuse
services, and 80 percent to other services such as the Red Cross.

Additionally at this point in time, 30 states are now eligible to apply
for regular services program grants. We\'re in the process of reviewing
applications for these grants which will provide funds for up to nine
months following the disaster declarations. We\'re going to continue to
work with states to ensure that mental health assessment and crisis
counseling are readily available to residents and evacuees of the
impacted areas; also to establish a longer‑term plan to assure that
post‑traumatic stress disorders are addressed. We\'re especially going
to have a focus on first responders (inaudible) and vulnerable
populations.

We\'re going to continue to work with our federal partners (inaudible)
chronic disorders. We know from past experience and we also know from
research that the psychological impacts of the recent hurricanes can be
very extensive. We\'re able to estimate in those areas impacted directly
by the hurricane that 25 to 30 percent of those individuals will
experience clinically significant mental health needs. An additional 10
to 20 percent may experience sub‑clinical but not trivial needs that
need some form of support. With those figures in mind, that could mean
close to half a million people from the impacted areas may need some
sorts of supports and interventions.

Again, we don\'t want to forget the fact of resilience. Most individuals
will come through this, and most individuals will be able to come
through this in a healthy way. But again, we also recognize that there
are those individuals, especially those who are right in the target
areas, so to speak, and experienced the most devastating impacts, those
individuals who (inaudible) are the ones we are concerned about.

What\'s critical right now in the recovery operations phase is assisting
those who need help. We need to continue to make sure that we\'re making
connections to the services. Looking back at those initial days and
weeks after the hurricane, again I\'m proud of the job SAMHSA staff did.
We\'re talking a commitment that people made, many working 12‑ to
16‑hour days with virtually no break during the week, no weekends.
Again, that couldn\'t go on forever. People worked hard to also make
sure people were taking care of themselves (inaudible). But again, as I
mentioned earlier, nearly half the people on the SAMHSA roster either
were out in the field or in SAMHSA\'s Emergency Response Center, and the
other half were filling in and helping out to make sure the work could
continue.

This afternoon we have the opportunity to hear directly also not only
from those that led and managed our process but the people who were on
the front lines providing services. Two individuals I want to highlight
at this point, one you\'re going to hear from immediately after me, Dan
Dodgen. Dan is the SAMHSA emergency coordinator. During those first few
days on site, he also was an individual who not only helped us get
things started here ‑‑ and also I want you to know that the planning
that has been done for disaster, Dan was very active in that, along with
a division of CMHS that has focused on emergency response services, and
also (inaudible) for the three‑center process, CSAT and CSAP (inaudible)
involved along the way as well.

But from tabletop exercises to thinking through what an emergency
response needs to look like, all that work that they\'d done prior to
Katrina paid off in terms of us being in a much better position to be
able to activate an emergency response and activate the Emergency
Response Center. On top of that, Dan was our representative downtown at
the Secretary\'s operation center and command center that the Secretary
(inaudible) was linked into and is part of the Secretary\'s operations.
So Dan was our eyes and ears and conduit down there, and he did just a
tremendous job.

We\'re also going to hear from Brenda Bruun, who I can\'t say enough
good things about Brenda Bruun and the leadership she brought as
incident commander of SAMHSA\'s emergency response team and center. She
was extremely reliable, organized, had a deft knowledge and sensitivity
about who would fit best in what type of deployment, and just led our
efforts in a magnificent way.

So I\'m really pleased that you\'re going to hear from these two
individuals today, and it\'s my privilege to turn it over to Dan Dodgen.

DR. DODGEN: I\'ll speak into the mike more so that you can hear me say
flattering things about everybody, because they\'re well deserved.

Let me just start by saying that I\'m going to try to keep what I say
fairly brief because you want to hear from the people who have been out
on the field, as well as Brenda got all of her wonderful work here at
the SAMHSA Emergency Response Center.

What I\'m going to do is just really give you kind of a bird\'s eye view
from a national and from a Department perspective on what\'s happening
and how it is that SAMHSA fits in to all of those things. I think all of
you at this point have heard of the National Response Plan. That\'s the
national plan that was approved about a year ago, just right about this
week in December of \'04, that is the plan that governs what all of us
in the federal government, as well as the American Red Cross, do in an
emergency. In theory, when an emergency affects a state such that two or
more federal departments have to be involved in helping that state
respond, that\'s kind of a minimum threshold. But as you can imagine,
it\'s really up to the prerogative of the President and others at the
Cabinet level should they choose to invoke it in another circumstance.
But that\'s the basic threshold.

Clearly, that was a criteria that was met very, very quickly. One could
argue that before Katrina, we knew before it hit, just after it hit
Florida and before it passed through the Gulf, we knew that we were
going to use more than two departments or agencies. So what is in there
particularly that\'s relevant to us? This IIMG ‑‑ and I apologize. I can
never remember what the second I stands for. I think it might be
Incident. I think it might be Intergovernmental Incident Management
Group.

But the IIMG is basically the group that sets the policy for the
disaster response in terms of how that\'s going to work.

The reason that it\'s a key for us to talk about here today is this is
the group that has a representative from each department. Most
departments only have one representative at the table. Actually, for the
first time ever during this response, the Department of Health and Human
Services and said mental health issues are so critical that we would
actually like to have a second seat, and we want it to be occupied by a
SAMHSA person. That had never happened before. I don\'t know how our
colleagues at other HHS agencies felt about that, but I think it
reflects how important the Department viewed this.

Now, because of space limitations, we ended up making that essentially a
virtual seat in that we had people here at SAMHSA that were on call to
respond to the needs of the IIMG because we couldn\'t actually put more
people in that room. It\'s a small space with some very, very senior
people in it. But I think the fact that we were notionally there, the
fact that the Department invited us to have names that would be on call
to represent that second HHS representative is indicative of how
important the mental health and substance abuse issues became very, very
early on in this response.

Another aspect of the national response that I think you may have heard
about is incident and command, ICS. I think Brenda is going to talk a
little bit more about that, so I won\'t say too much other than just to
say that\'s really the model that governs how we set up an incident
response so we make sure everybody knows what they\'re supposed to do.
Of course, the NRP also (inaudible) the roles and responsibilities of
various federal departments, and I\'ll talk a little bit more in a
second about what the HHS ones are.

One of the key aspects of the National Response Plan is the emergency
support functions. There are 15 emergency support functions. The ones
that are most critical to us, of course, are Emergency Support Function
6, EFS6, which is (inaudible). As you see, the lead agency for that is
the American Red Cross. But as you can imagine, mass care human services
clearly includes a mental health component. So one of the things that we
do is provide support to the Red Cross in their ESF6 function.

In addition the ESF8 function, HHS is the lead agency for that, and
that\'s really where the bulk of the activities that we\'ve been engaged
in have happened, under this ESF8. Two others that you might want to be
aware of are ESF14, the long‑term community recovery and mitigation. In
many ways that\'s the phase that we\'re in now, although certainly there
are still some acute things happening on the ground. This is actually an
emergency support function that historically has not paid very much
attention to human service and mental health, and frankly even public
health and substance abuse issues as well. That\'s changing now. I think
for the first time people are realizing that it isn\'t just about
applying for small business loans and rebuilding houses and bulldozing
damaged property, et cetera. So I think that we\'re going to see this
ESF changing a great deal over the next year. I think one of the things
that\'s going to happen is we\'re going to see our issues included more
than they have been in the past.

ESF15 is external affairs and public affairs, and that includes public
education and information, which we also provide a consultative role on.

So where do we fit in in terms of other pieces of it? I know everybody
has heard all the horror stories about FEMA, the Federal Emergency
Management Agency. I do want to say also that the folks on the ground at
FEMA continue to do very good work, and we\'ve been able to work with
them in a number of different ways. One of those is through a mission
assignment process, which is the process by which ‑‑ I do have some
acronyms up there so you all can get used to it. When you do disaster
work, it\'s alphabet soup. There\'s acronyms for everything. ARFs are
action request forms. MAs are mission assignments. ESFs are emergency
support functions. We\'ll have a quiz at the end of the day today for
those of you who aren\'t paying attention.

But anyhow, these are three acronyms that you\'ll hear quite a bit about
in this particular area. Basically, a state completes an ARF, an action
request form. If it\'s approved there\'s a mission assignment to the ESF
lead agency to decide what they want to do with it. I think Brenda is
going to talk a little bit more about this process, so I won\'t say too
much more other than there is a process that\'s in place, and it\'s a
process that SAMHSA has not historically taken advantage of. I\'m going
to talk about one very strong program that we do with FEMA, but we
haven\'t historically taken advantage of the mission assignment process.
This is the first time that we have, and I think it was also astounding
what we\'ve been able to do. Brenda is going to talk more about what
those accomplishments are.

I do just want to say again that the crisis counseling ‑‑ yes, go ahead.

MR. STARK: Can you, in this context, define \"deconflicting\"?

DR. DODGEN: You know, I love the word \"deconflicting.\" I use it all
the time, much to the chagrin of some of my colleagues, I think. But in
this context, when people use the word \"deconflicting,\" what they\'re
talking about is when you have information that\'s inconsistent and you
need to get to the bottom of what\'s really going on. As you can
imagine, in a disaster that\'s an extremely common experience where one
person says we need 1,000 psychiatrists on the field, and the next
person says, well, we need 1,000 people who can address mental health
issues, but that doesn\'t mean we need 1,000 psychiatrists. So what do
we really need, and how do we get to the bottom of the confusing
information that we\'re getting so we can actually make sense of it and
respond to it?

MR. STARK: So it really gets back to basically sharing information
across systems so that you all understand what you\'re saying when you
say it.

DR. DODGEN: Right, and making sure that the information that you have is
brought to the table, because as you can imagine, 99 percent of the
problems that we experience, whether it\'s internal to the organization
or anywhere in these kinds of events, it\'s usually because everyone is
acting to their best of their ability according to the information they
have, but often people don\'t have the same information. So people end
up butting heads because they don\'t share information. So that\'s what
you do when you deconflict.

As I was saying earlier, the importance of our crisis counseling
program, the last bullet there, cannot be overstated. That\'s really
been the bedrock of our disaster response work for 30 years, more than
30 years now, through the relationship we have with FEMA, and it\'s
really the incredible work that folks at CMHS and the Emergency Mental
Health and Traumatic Stress Services Branch has done under Seth Hassett,
and before that lots of other people who have also done great work, that
really has in many ways established the credibility of SAMHSA to now be
able to move well beyond that and do the issue assignments and have the
credibility so that people know when we say we\'re going to do something
or we weigh in on something, we\'re weighing in on the basis of our own
experience and expertise as a result of the work that the agency has
done in the past. So it\'s an important bedrock of the work that we do.

Just very quickly, in terms of where SAMHSA fits within the Department,
obviously it\'s very important to make sure that we communicate with all
of our ESF8 partners, which includes the Department of Defense, Veterans
Administration and other agencies, some of whom have mental health and
substance abuse workers. Some don\'t, but they may have other things
such as the ability to transport workers, which is a key factor. So
there are all kinds of things that are involved in the discussions that
take place with ESF8 and FEMA\'s involvement, and the Emergency Response
Center that brings (inaudible) that Mr. Curie referred to earlier. It
was also (inaudible) as well, daily, maybe twice a day, to allow us to
really (inaudible) what people are doing.

The Secretary\'s operations center Mr. Curie has already talked about.
That\'s the hub in town where all of the ESF8 partners, as well as all
the agencies within HHS ‑‑ the CDC, HRSA, FDA, the Administration on
Children and Families, the Public Health Service Corps ‑‑ everybody has
a presence at the operations center, and the idea is if you can bring
everyone together, you can deconflict problems and you can make sure to
provide the very best response to the states.

In addition, of course, we talked about our own Emergency Response
Center. We also have the Secretary\'s emergency response teams. These
are the units on the field, the eyes and the ears of the Secretary,
(inaudible) people for the response. So SAMHSA made sure we would always
have people on those teams in the field, and we have people in Louisiana
and Mississippi and in Texas during the time when the teams were stood
up there. Those folks on the ground were really, really critical. The
people in most of the states rotated, so it wasn\'t always the same
person. I won\'t give you the whole list, but that was really critical
to have someone there on the site who could work the states as well as
who could provide leadership within the Secretary\'s team on the ground.

Then, of course, there was a policy group that was developed that also
met downtown that SAMHSA was represented on.

So where else do we fit in? I hope it doesn\'t feel overwhelming yet,
but I want you to get a sense of the scope of SAMHSA\'s involvement in
all the different things that we were doing. In addition to the ESF8
calls, which I mention there again just because they are such a critical
point of communication, we also, of course, maintain communications in
ways that Mr. Curie has described with other agencies and with
non‑governmental organizations, and we actually have a great success
story with the Red Cross.

Brenda is going to say more about that.

Unfortunately, I can\'t say a lot, but I want you to get a sense of the
way that SAMHSA did incredible things, but part of why we were able to
do such incredible things was because we were really able to take the
relationships that we already had with significant partners and build on
them and advance them and use those relationships to really address
concerns that were happening at the local level with the states.

For example, a situation where we couldn\'t get the right people into
Red Cross shelters because (inaudible) and some things we were able to
do to deconflict that situation.

Another thing that I wanted to mention is I\'m sure most of you are
familiar with OSHA, the Occupational Safety and Health Administration,
which is really responsible for worker safety in the United States.
It\'s part of the Department of Labor, and OSHA has the responsibility
for making sure that people working in the field are properly taken care
of and receive what they need to receive in order to be able to do their
work, as well as when they return if they have any physical, or mental
or (inaudible) issues, that those are addressed. The Department actually
appointed SAMHSA as the agency to work with OSHA on developing
strategies for how we\'re going to support people.

As you can imagine, coming back from these deployments, particularly
people who very early on were in Camp Swampy, didn\'t even have water or
toilet facilities, much less other things, as well as just (inaudible)
like having to do with human remains and having to deal with a number of
other things. There were some very traumatic things that people who were
working in the field were exposed to, not to mention just being around
people who had lost everything. So OSHA is working on this, and SAMHSA
has developed materials that OSHA is going to be using, and we have a
whole program developed for how we\'re going to provide support to these
workers. I think again it speaks to how much people are appreciating the
importance of behavioral health issues, as well as what a good job
SAMHSA has been doing, that the Department asked us to take the lead on
doing that.

We kind of talked about the cost, so let\'s move on to the next slide.

I just wanted to say I love this slide. Douglas Fairbanks riding in on a
white horse. That\'s not SAMHSA\'s job, actually, but there\'s a little
bit of that component because we do so much want to be able to help. But
really our role is to assist local communities in being able to respond,
and as part of that, of course, our job is to coordinate the resources,
assets and activities to provide subject‑matter experts, to provide
grants for planning, for response, and to facilitate getting services on
the ground through the (inaudible) process.

So how does all of that translate into action?

MR. STARK: Just a quick question. If you had an example, and I\'m not
sure if Katrina or Rita provided that, but if the role is as you
described it, and I would agree that it would be, what about those
circumstances where maybe the state, who usually would be who you would
coordinate with to help get those grants and those resources out to
their locals, what would happen if their state infrastructure had been
decimated and so they really couldn\'t do it? I would imagine some of
that happened. So is that kind of part of your crisis plan, disaster
plan?

DR. DODGEN: We\'ll foreshadow a little bit, because I think there are
two answers to your question. The first answer is you\'re going to hear
more about what we did. But I think the more complete answer is I think
that all the planning that we did was incredibly helpful in being able
to activate the SERC, in being able to have our own plans in place, in
being able to establish the relationships that we needed to have.

But the truth is I don\'t think any of us could have anticipated the
scale of the disaster that befell us and the impact that it had because
of the number of people that were impacted and the geographic spread. I
mean, we\'re really talking about the entire Gulf Coast, essentially
from Houston/Galveston to Pensacola that was impacted by Katrina and
Rita. Then, of course, you\'ve got Wilma, which extended the impact down
pretty much through most of the bottom half of Florida. So I think all
of the planning was incredibly helpful, but I think we faced a situation
that was bigger than any of us really anticipated, and I think that\'s
where some of the things that Brenda is going to talk about ‑‑ you\'ll
hear about how we expanded our mission and how we really saw ways to do
things that we hadn\'t done before in order to address the very question
you\'re asking, which is what do you do when the needs are so extreme
that the local and state agencies that you would expect to be able to
play a significant part in responding may not, at least in that very
initial phase, have been able to do as much as they would normally do.

That\'s not to say they weren\'t doing a lot, because they were, even
with the under‑resources. The states and locals were performing above
and beyond in incredible ways. But nevertheless, it was really beyond
what any of us expected. As a consequence, they weren\'t able to do as
much as they normally would be able to do. So I think SAMHSA was able,
in some very creative ways, to try to help meet that need and facilitate
the states getting back on their feet and getting their infrastructure
back together, and that really gets to my last slide, my hero.

This is James Bond, who always knows what to do in any circumstance. Of
course, what we really need to think about, he was a man of action. So
how did we, in fact, turn all of these things I\'m talking about into
action? I think when you hear Brenda Bruun\'s comments, and then when
you hear the comments of the panel that\'s going to follow us, I think
you\'ll get a much better sense of how we really turned all of these ‑‑
our defined mission and our defined goals and all these calls and
networks and phone calls, how did all that really make a difference, and
what did it really mean in terms of what we were really doing on a daily
basis to assist the impacted states and the evacuees. I think that
you\'ll know the answer to that question by the time you\'ve heard
Brenda and the next panel.

So if there aren\'t any further questions, I\'ll turn it over to Brenda,
and then I think we\'ll be available for questions later on.

DR. GARY: I don\'t know if it\'s appropriate to ask these questions and
make one or two comments. So if it\'s the wrong time, just tell me and
I\'ll wait.

MR. CURIE: Well, I think we\'re going to have questions for everyone
after Brenda presents.

DR. GARY: I\'m willing to wait.

MS. BRUUN: I think as we go through these presentations, you\'re going
to see that we\'re starting off with the macro perspective of disaster
response across the nation. My job is to bring you what the agency did,
and then the folks behind us will talk about their individual
(inaudible) on behalf of SAMHSA to provide consultation to health
services directly.

I\'m going to start our presentation with some slides that were taken
from some of our staff that were deployed to the field so you can get a
sense of what we experienced as we started to prepare for this disaster.
So if you could just run through the slides.

When this disaster happened, Mr. Curie activated the SAMHSA Emergency
Response Center right away, which mobilizes all of the resources in a
very streamlined management structure. This is something that, while
we\'ve done pieces of it before, this disaster actually required the
mobilization of everyone in SAMHSA. So we had to implement the structure
that was similar to that being used by the Department, by the Department
of Homeland Security, and this in fact started to be replicated at the
state level, not only with their emergency management agencies but also
the departments of mental health and substance abuse.

The Incident Command System is really a standardized structure for
organizing and controlling the response. It helps eliminate duplication
of effort. It is the coordinated way of communicating messages,
especially when the communications systems may be disrupted. It
clarifies lines of authority and command so that there\'s no ambiguity
in terms of who is in control and who is making decisions, but it also
(inaudible). So in that case it\'s also very effective at being able to
identify who is responsible and to get to that person quickly.

This is actually how SAMHSA\'s emergency response system fits in with
the Department\'s response. You have the Administrator, who reports
directly to the Secretary. We have Dan, who reports to the Secretary\'s
operations center and represents SAMHSA at that table so that our
efforts within the agency are coordinated with all of the other agencies
within HHS. The incident commander, which in this case was me, reports
directly to the Administrator and coordinates very closely with the
emergency coordinator to make sure that what I\'m doing is consistent
with the policies and guidelines and doesn\'t start to encroach on other
agencies\' missions. Then his job is to help them not encroach on ours.

Within the Incident Command System you have seven functions. These
functional areas are basically streamlined parts of the agency that help
us mobilize all of SAMHSA\'s resources very quickly. We have a personnel
function, a logistics function, a planning function, a finance function,
public information, a recording function, and we included phones in
there because phones ended up being such a large job. Each of these
functions is staffed by people who have background in this, who are
trained in this, and are fully prepared to make decisions on behalf of
the agency, and those functions all report to the incident commander.

In addition, we coordinate with CDC Emergency Response Center, other
partners and agencies like the Red Cross. We coordinate directly with
the emergency management agencies, with national organizations who have
an interest (inaudible) like the National Association of Mental Health
Program Directors, the National Association of Directors and
(inaudible), and a lot of the major (inaudible) like the American
Psychiatric Association, the American Psychological Association, and
many, many others. All of them have resources to offer in an emergency,
and our role is not just to provide services. In many cases, we actually
don\'t do that. This was an incident that required that on our part, but
we actually just coordinate the delivery of behavioral health care
services after a disaster to support state and local efforts.

Next slide, please.

This is just a brief description of each of the incident command
functions, and I see that it\'s too dark to read, but I\'ll basically
tell you kind of what they do. The incident commander and the deputy
incident commander are responsible for all operational decisions within
the Emergency Response Center. We triage and assign tasks, coordinate
with the emergency coordinator and other departments responding to all
kinds of requests from the public and from other agencies for resources.
We have a planning function whose job it is to prepare an overview of
the impact of the disaster. I think that this is one of our most
difficult functions but one of the most critical in organizing our
response effectively because you really have to know what it is you
truly (inaudible) and how (inaudible) where resources are going to be
(inaudible), what resources we have versus the resources we will have to
get from (inaudible).

We have a logistics function that does everything from creating the
emergency operations center (inaudible), additional phone lines, fax
machines, copiers, printers, laptop computers, videoconferencing to
preparing all of the travel arrangements for staff that need to be
deployed, giving them the equipment and supplies they need, (inaudible)
in the field, being a resource in the field (inaudible), shipping
materials to places that need (inaudible). They also have a very
(inaudible) job, (inaudible) a difficult job considering the lack of
housing, how difficult it was to get transportation into the impacted
areas, having to find supplies we don\'t normally buy in this agency,
like sunscreen to put in (inaudible) because people were spending so
much time in the field under (inaudible) intense heat, and that\'s to
protect our staff to the best of our ability from the dangers that can
occur while they\'re working in such a disaster area.

The finance function tracks all of our spending related to the disaster
activities, including overtime and travel for the staff, supplies and
equipment, funds to cover printing materials, contracts that are
awarded, grants that are awarded. Anything that we do related to this
incident they can track, and they also oversee the internal controls to
be able to respond to audit requests and information about our
expenditures related to this disaster.

The public information office has a tremendous role in providing
accurate information about the mental health needs and the mental health
response capabilities in providing information that can actually help
people through, a psychoeducational approach to promoting resources that
we have, such as using public service announcements to promote the
National Suicide Prevention Lifeline as a resource for people to call
for help if they\'re in a crisis after the disaster, to preparing fact
sheets, answering media requests, legislative requests, and I think
rumor control is a huge one that needs to be mentioned. Sometimes their
job is tracking down misinformation and then getting the correct
information back out there. Rumors can be incredibly damaging to
response efforts.

The personnel function identifies staff within the agency and others to
deploy to the field. They match the people\'s skills with the functions
they\'re going to be deploying to the field. They\'re also responsible
for briefing and preparing folks before they go out about what to
expect, what their role will be, who they\'re going to report to in the
field. They\'re responsible for checking in on them, the (inaudible)
check system where you can call folks in the field every single day to
find out how they\'re doing, what they\'re working on. This allows us to
be able to make sure that they\'re staying within the scope of our
mission, help them problem solve things that they might be running up
against in the field, and also assess where they\'re at health‑wise. Are
they taking care of themselves? Are they feeling supported in the field?
This is a very big and time‑consuming role, but we\'re finding it not
only incredibly valuable to the agency\'s efforts at maintaining and
supporting our staff and those of the people we deploy from outside of
SAMHSA, but also it\'s a really gratifying role to be able to talk with
the folks who are doing it face to face with those who have been
impacted on the ground.

A reporter and recorder maintain and prepare all reports, data, track
SERC activities, prepare reports for the Administrator, reports that are
sent down daily to the Secretary\'s operations center, and do planning
research. They also have started to prepare a lesson document, helping
with that. There are many things that we can continue to learn from and
adapt to as we get better at this.

I think it\'s important that there\'s no correlation between the
incident command structure and the organizational or administrative
structure of the agency necessarily. I think some functions seem
relatively clear that we have these capabilities within, but they don\'t
necessarily have that (inaudible) within the agency. Each of these
functions can be subdivided as needed, although we didn\'t. We\'re a
very small agency. We were able to operate within those broad functions.
If you came into the Emergency Operations Center for the first few
weeks, you would have found at least 25 people in a very small room, a
lot of noise, a lot of activity, everybody working incredible hours in
tight quarters and doing some really incredible things. When you see
some of the things we were able to accomplish in about eight weeks,
we\'re truly impressed with what we were able to pull off. It\'s a very
small agency within HHS working on such a large disaster and a large
need.

I think the key to an incident command structure being successful is not
only having a well trained staff who can serve in these functions, being
able to identify an incident commander who is given the authority to
make those decisions, but it has to be very streamlined. Most people
might look and say, well, why isn\'t the Administrator the incident
commander? Because clearly he\'s the head of the agency. Well, he has as
very important role to fill after a disaster, and much of it is outside
of the agency and he can\'t be here to follow up on all of the millions
of details that come up in a disaster response. So he has to put in
place people he trusts to carry out his vision of how this agency is
going to respond, and we thank him for putting that trust in his SAMHSA
team, because I think everybody stepped forward in a deliberate
(inaudible), and we appreciate the work that he did on the agency\'s
behalf but also on the impacted areas to meet the mental health and
substance abuse needs of the victims of Hurricanes Katrina, Rita, Wilma,
and all the others.

Next slide, please.

Our role is really to just mobilize and manage resources, provide a
coordinated response, a coordinated message, and to provide a consistent
operational structure that made it easier for Dan to deal with a
consistent person when he was trying to get information to take back to
the table. It became something that you really relied on not only
coordinating with Dan and the Secretary\'s operations center, but I
think the folks in the field also really came to rely on the structure
in place, I\'m not out here by myself. There\'s an entire agency and
department behind this effort, so there are places to go when you need
help, and you know exactly where to go to get that help. There was no
ambiguity about that.

Next slide.

Part of this was doing briefings. I think that it\'s very easy to get
myopic in a disaster response, to get so bogged down in your own niche
or your own specialty that it\'s hard to see the big picture. So we
instituted twice‑daily briefings for everyone. Anybody at the agency was
welcome to attend those as well, but certainly it was open to anybody
working in the response center so that you would have an idea of what\'s
going on, what the other agencies are doing. The information is being
shared from the field, and everybody hears it. That way they know how
their function and their role fits into the larger picture.

Since August 29, we have deployed or worked in the (inaudible) 257 of
SAMHSA\'s staff, which is just about 50 percent of the agency\'s staff,
as Mr. Curie noted earlier. The other 50 percent were back behind these
folks so that the agency\'s regular business could continue, because we
do actually have dual roles in a disaster, an agency this small. You can
feel it when a disaster hits of this size and requires so much of the
agency\'s resources to be redirected.

We awarded four emergency grants within 14 days, totaling \$600,000. We
reviewed 29 crisis counseling grants and made recommendations to FEMA,
and they awarded 29 full and 2 partial awards to the states. These funds
could be used to do psychoeducation, outreach, crisis counseling and
intervention, assessment, referral, to help ease the load on the health
system. I think as you asked earlier, what do you do when a state\'s
infrastructure itself has been destroyed or so severely impacted that
they can\'t mount a response on their own, part of that is this program,
although with this program there is a slight lag time in getting it up
and running because of the way the funding structure works. In this
case, in this disaster, SAMHSA was actually able to fill that gap
through the (inaudible) process, which is as a lead agency for
behavioral health care. A state can come forward to FEMA and say we
don\'t have enough clinicians, we don\'t have enough psychiatrists,
psychologists, social workers, addiction counselors, anything they need
in the behavioral health care realm, and say we need you to provide it
for us. FEMA goes then to the lead agency for that response or for that
function and says we want you to go do it, here\'s the money to do it.
That\'s what the mission (inaudible) process really does. We mount that
response. We supplement the state\'s response capabilities using
resources.

In this case, the mission assignment funds have been put into a contract
where we then set up contracting with guilds like the National
Association of Social Workers, both APAs, and I think five others across
a variety of disciplines ‑‑ pastoral counselors, addiction counselors,
addiction medicine. Then the state came to us and said ‑‑ for instance,
in Louisiana, I need five psychiatrists in Baton Rouge to do X, and our
job was to go to (inaudible) and say give me a list of psychiatrist who
are willing to deploy and volunteer their time. They came from across
the country. They came from private practice. They came from state
hospitals in other states. We deployed them to the impacted area for
14‑day deployments, which is the standard, and they provided the
services that weren\'t able to be provided by local providers.

In this instance, we had seen such a large number of providers so
directly impacted that they needed time to take care of their own
personal needs. Many of them stayed on the job for weeks, sleeping in
their offices, attending to their clientele, their normal clients on a
daily basis, or 12, 14, 16 hours a day, seven days a week, until we were
able to step in and provide some relief so they were able to attend to
their own needs. That, I think, I hope, answers your question about what
do you do when a state has been so overwhelmed by the impact.

We also served as an important gap filler to the crisis counseling
programs. Now that\'s up and running in all the states. We shift our
focus a little bit, not to be doing any of the outreach and the crisis
counseling (inaudible), but again supplementing state resources that
have been lost to this disaster and providing clinical services that
can\'t be provided by the crisis counseling programs. So it\'s
constantly working with not only other agencies and organizations that
are providing these types of services, but also working with other parts
of this agency to make sure that we are not (inaudible) so that we can
provide complete contingent care until the state is ready to assume all
of the responsibility for mental health and substance abuse (inaudible).

We provided an awful lot of staff. It was a continuous cycle. Three
staff went to the Secretary\'s operation center primarily then, but we
had some down time too. We have to look out for each other here, so we
also had to send some people down to substitute for him so he could get
a break. We sent staff to the Secretary\'s emergency response teams in
the field. Those were typically a two‑week deployment, although we had a
few that stayed much longer than that. Our Commissioned Corps staff
frequently were extended well beyond two weeks, from 14 days to 30 days,
and in a few cases even longer.

We had staff who went and served (inaudible) in Austin. We had staff who
went out to serve as clinicians and provided direct care services, and
that is something that we don\'t do often, but we were glad to be able
to step forward when there was such a crying need.

We sent out 4,000 emails, 4,000 faxes, and 4,000 snail mails for a
survey, the Critical Infrastructure Data System, which was designed to
help us collect information on facilities that were destroyed so we
would have a better understanding and picture at the national level of
what the capacity was prior to the disaster and what it is now so that
we would be able to better mobilize and target our resources into those
areas.

We worked onsite to utilize the data that\'s already collected by SAMHSA
around capacity and utilization. We put it into a precise place on the
Web where states were comparing multiple grant applications in order to
access it quickly.

Planning function. I\'m just going to highlight a few things in each of
these functions we were able to accomplish. The planning function
developed a couple of important papers on assessing what the potential
impact was in the disaster area by utilizing various data sources plus
the research that we know about the likelihood of post‑traumatic stress
disorder following a traumatic event. This in no way, of course, covers
everything that they did. They did a lot of mapping of facilities to
figure out where our (inaudible) facilities were, how many of those were
functional, and operational, tracking those and mapping them so that we
can target resources and help the state if the state was not necessarily
able to gather all of that data, with many responsibilities on their
shoulders. So this is information we could feed back to them to help
them prepare and utilize their resources.

Skip to the next one, please.

The logistics function. As I said earlier, it created 72 government
tribal orders. I don\'t know how many they do in a week typically, but
that was a significant number.

Go bags. This picture here is actually of packing go bags. The first six
weeks of the disaster, the physical environment our folks were working
in was incredibly harsh, so they were often in the field with a backpack
that had a first aid kit and other resources, bottled water that they
had to carry themselves because they didn\'t have access to it. So this
was something that we weren\'t used to doing here, but they were very
good at getting all that material packed and ready to go as we were
shipping people out the door.

Go ahead and skip this one.

I mentioned earlier the finance function tracks all of our finances. For
fiscal year \'05, this is the amount of funds that we spent, \$916,000
in SERG grants and money for the Department in mission (inaudible)
funds. We were actually awarded \$5 million in \'05 to provide medical
services to the State of Louisiana around the state, another \$1 million
specifically to provide services on cruise ships in New Orleans. This
year we just accepted another \$5 million for substance abuse services
in Louisiana, getting prepared to accept \$300,000 for the cruise ship
in Mississippi that is housing 1,200 evacuees, and we\'re looking at
probably another \$2 million to support Alabama and Mississippi also for
mental health services. This is probably a little bit unusual at this
stage in the disaster in that it seems like the emergency basis is over,
except that the devastation to their critical infrastructure was so
severe that we\'re still at a point where they\'re still needing
assistance for direct clinical support.

I mentioned earlier the public information function. This was staffed by
our Office of Communications, some wonderful folks who just had
tremendous skills in taking information and collapsing it into a very
readable, very useable ‑‑ I think we did some great documents that
people just had to reprint and reprint and reprint in this disaster.
Also, our legislative coordinator spent some time in there as well
helping us respond to questions from the Hill about what SAMHSA\'s role
and responsibilities were.

I\'m going to skip forward.

The personnel function, as I mentioned, has been one of the largest. In
fact, probably between personnel and logistics, it\'s the biggest
function still active. We operated the Emergency Response Center seven
days a week from 8:00 a.m. to 8:00 p.m. until October 21st. After that
point we scaled back services to those functions that are still active,
which is primarily the incident commander, the logistics personnel, and
the finance for tracking. All the other functions have gone back to
their normal jobs. I do want to make it clear that we are still very
active in our response, and the incident commander and the Emergency
Response Center is basically still operating. It\'s not (inaudible) in
the Emergency Operations Center, but it still gets responded to 12 hours
a day. It\'s actually closer to 24 between the folks calling in from the
field needing assistance to the phone (inaudible). So we are sharing
that burden across the agency still.

I thought you would like to know that we deployed nearly 500 people in
12 weeks, 92 of them federal staff, 65 SAMHSA, and the others from HRSA,
NIH, and the VA, in addition to well over 160 private clinicians from
across the country.

MR. STARK: Quick question on the clinicians that you were able to deploy
through the KAP contract. Was it in virtually all cases folks outside
the disaster area, or did some of that money actually go to pay for
clinicians in the area who might otherwise have lost their ability to
get a paycheck from their regular employer because their building got
destroyed and all kinds of other things, but they still wanted to help
and they just needed somebody to cover their costs?

MS. BRUUN: Well, the system itself was severely impacted. So many of
those clinicians were directly impacted. Either they lost their own
homes or they lost their jobs related to it. So in that case there was a
real need to bring in outside resources because they just weren\'t
there. Many of them evacuated and couldn\'t get back to the area to
provide services, so they weren\'t there. Both the States of Louisiana
and Mississippi have asked us to prioritize hiring their local
clinicians that may have been displaced from the hurricane first, and
we\'ve tried to accommodate that whenever possible. There has not been a
huge wave of folks coming forward and saying I\'m from Louisiana. I
think we\'ve done about 15 in Louisiana and I think three in Mississippi
that have come forward and said I\'m a displaced physician and I\'d like
to stay, can you pick me up, and we\'ve done that.

But I think we also have to be very careful with some of these folks to
make sure we really look out for their well‑being in the fact that they
have been so directly impacted. So we take extra care of them, but we do
think it\'s important to help them return to normal as best as possible
by getting them back to work in their home area, if that\'s possible. So
we do provide that support.

I want to update some of the data that we have collected so far. All of
our clinicians are required to report on the kinds of services they
provide. This is from Louisiana only, but we provided well over 17,000
clinical sessions; 91 percent of them were individual counseling
sessions, 26 percent get referred to local mental health services. In a
traditional disaster you might see that being much higher, but right now
those services are still of such a limited capacity that you can\'t
refer (inaudible). That\'s why we are (inaudible) so high. Five percent
were referred to substance abuse services. I would expect that number to
actually start going up now at this point in the disaster. Part of it is
the timing. Part of it is the fact that we now will be able to provide a
lot more substance abuse clinical services on the ground. Then 69
percent are referred to other kinds of disaster relief services such as
housing assistance, unemployment insurance, things like that.

I mentioned earlier that our reporting function prepared all of the
situation reports from our activities, which is forwarded to the
Secretary\'s special (inaudible). They prepared all kinds of special
reports, so minutes from conference calls and things like that.

I had to mention our (inaudible) database function because it was
staffed so well by many of our interns. This is an intern opportunity I
think that doesn\'t come around very often, and we had some really truly
outstanding interns working in the operations center that were an
invaluable help to us. In fact, we actually gave some of them an
opportunity to go into the field with more seasoned staff so they would
have a direct (inaudible). All of them have come back and said they had
no idea that they would get an opportunity like this and how grateful
they were to have been a part of this response effort.

Fifty‑one hundred emails have come in so far and are still coming,
although not quite as fast as they were in the initial response,
thankfully.

I wanted to close with two photos, because I think that while I started
the presentation with some pictures of the level of destruction, I just
recently came back from a trip between ‑‑ I basically covered Ann
Mathews‑Younes, who works on our personnel team and manages the KAP
contract, from Lake Charles, Louisiana to Pascagoula, Mississippi, the
entire coastline. In many of those places, those pictures are exactly
the same today as they were taken weeks ago by people who were initially
deployed in the field, and that\'s a pretty devastating environment to
live in, and I think it helps give people an idea of the kinds of
emotional trauma that people might still be carrying with them, just
because they\'re still surrounded by all this devastation.

But what I think is so important to recognize is the incredible
resilience of some of these folks. The previous picture that said \"We
Shall Return,\" it\'s just such a positive sign of strength, and that\'s
one of the things that our job here is to promote and support as well,
the strength of the community, the strength of the individual, and the
gratitude.

So I wanted to point out why I\'m wearing this orange shirt. Mr. Curie
in his many visits to the field recognized that there are a lot of
relief organizations, a lot of services being provided to the
communities, and they all have a shirt. So we thought we should have a
shirt because we wanted to make sure that not only was our presence
known and that people understood that the mental health and substance
abuse needs of the community were being recognized, but they were also
being responded to. The orange color actually came out of a process of
elimination because all the other good colors were taken. But it turns
out this is the best color of all. It\'s highly visible in the field, so
you can spot it from blocks away.

But when Ann and I were out in the field, we had the experience ‑‑ and I
can honestly say I\'d never had this before ‑‑ where people would walk
up to me and say, \"You\'re one of the orange shirts. You\'re one of the
good guys.\" We were an agency that didn\'t walk in and promise
anything, but we also didn\'t take anything away. All we offered was a
supportive place to talk and pointing people towards resources and
connected them and empowered them, and the gratitude for that was just
incredibly overwhelming. I don\'t think I\'ve ever felt so proud to work
for an agency, to have people be that responsive and know that they are
‑‑ in the cruise ship in Mississippi they run commercials on their TV
channel that just runs on the ship. They run commercials that say, \"You
need to talk? Find an orange shirt.\"

The same in the communities. There are signs posted like that. There are
articles in the local newspapers or local newsletters that say if you
need somebody to talk to, find an orange shirt. So I think that we
really are having a direct impact and effect, and part of it is the
visibility which people can access us.

MR. CURIE: Thank you, Dan. Thank you, Brenda. I appreciate you sharing
the ins and outs of the operations of the emergency response.

I\'d like to begin with Faye, who has been very patient. Please ask any
questions or make any comments. We\'ll open it up now.

DR. GARY: Thank you very much. I just had (inaudible) reactions, but
because you\'re talking about such a phenomenally devastating kind of
event that we\'ve all experienced in our lives (inaudible), thank you
for hearing that.

I just had several questions. Some may be answered now, some may
(inaudible), though I\'m not sure. But one of the questions was what
kind of focus is being given to health professionals who might also
experience some emotional and physical responses to working in such a
devastated environment (inaudible)? I was thinking primarily about PTSD
among professionals, not only mental health professionals but social
workers, firemen, (inaudible) who might have had an overwhelming
experience.

The other is you talked about other stakeholders that you were
partnering with and provided assistance to other stakeholders. I would
be interested in knowing who the other stakeholders are, and that\'s
very much related to Ken\'s question about the extent to which local
people were used when possible vis‑α‑vis people from outside of the area
(inaudible) on the white horse.

The other question, I know that in times of disaster, in times of
distress, when you give literature to people, sometimes it makes a lot
of sense, and at other times it doesn\'t. Let\'s say in Texas and New
Orleans, Louisiana and Alabama and Florida, the populations are in some
ways (inaudible), but in other ways they\'re very diverse and very
different. My thinking is that perhaps when you\'re talking about
looking at reading levels based on what we know now, since we really
developed some kind of database about who is affected, what are the
reading levels of the individuals, and what are their cultural
worldviews, and how is it that the literature that we prepare for people
who are at risk would fit some kind of predetermined criteria so that
when they read it they understand and would know what to do? Back to
your concept of deconflicting, that\'s a way that we could program
ourselves to minimize the possibility of having the conflict in
information and not having to deconflict.

Again, the issue about stigma, how is it that people who (inaudible)
services because of the stigma issue, and what kinds of lessons learned
that you could share with us about stigma or reluctance to get help,
because it\'s related to mental disorders and substance abuse.

The other is you said that there was a list of grants awarded, and I\'m
asking if you could tell us or give us a sense of who got those grants
and what kinds of requirements and restrictions are placed upon the
grants, especially as it relates to outcome data and some kind of
accountability, if you will.

I think (inaudible) mentioned this lessons learned document. I think
that is a critical document, and if it can be shared with the Council,
no one else is interested, I certainly would be interested in knowing
about the lessons learned and the implications that it would have for
professional development and training across the professions that SAMHSA
works with, as well as when Mr. Curie talked about educational training.
What is it that we can learn from the lessons you learned that should be
infiltrated into academic institutions so it would help us, we\'d be
better prepared in the future for disasters, hurricanes and other kinds
of disasters, in our learning, in our education, in our training? Again,
what kinds of literature could grow out of that?

The final issue is I like the concept of resilience, because I think
that\'s why we all keep coming back every day, because we know the human
experience is willing to heal and move on. But there was no discussion
of poverty, and in my mind I think poverty is probably one of the
greatest devastating factors that mitigates against mental health. I
would like for us to have some discussion about poverty and what
position it is that we can take to at least raise the conscious
awareness about what poverty does to people. It creates its own
hurricane when there\'s no wind, no rain, no storm. How can we integrate
and fold into mental health and substance abuse prevention and treatment
the issue of poverty, and what can be done with our interventions and
our thinking along those lines?

Thank you. I think it\'s very (inaudible) and very (inaudible).

DR. DODGEN: Well, thank you. Fortunately, I had a pad and a pen with me
because I\'m not sure I could have gotten it all otherwise. But I\'m
going to do my best, and I know Brenda will have comments to make as
well. I think some of your questions are really matters of discussion
for the Council that we may not be able to respond to necessarily. But
let me try and take your questions in order.

You asked first off about the issue of worker support. I think that
there are a couple of things that are important to say about that. First
I think all you have to do is listen to Brenda\'s remarks to know that
one of the hallmarks of the SAMHSA activities within the SERC was with
the support of our own workers. If we\'re going to speak to OSHA and
other people about that, we had darn well better be modeling it, and I
think we were, very much thanks to Brenda\'s good work.

In fact, I don\'t know if Dr. Cynthia Hanson is still in the audience.
But anyhow, Cynthia is actually a fellow working at SAMHSA this year
with a great deal of experience in this area and was part of the team
that was providing both orientations before deployment and debriefings
after deployment so that people who were in the field could be better
prepared, as well as have a chance just to talk about that afterwards.

In addition, we have a brochure that Rachel Kaul is going to be sharing
with you during the next panel that is specifically about stress and how
people can manage stress better while they\'re in the field. This is a
brochure that we have provided to every single person going out into the
field to have as part of that go pack that Brenda has talked to you
about that was really incredible. I mean, she didn\'t tell you, but in
addition to sunscreen and first aid, they had granola bars and all kinds
of other things in there as well, gum, Altoids. We took care of our
people when they went into the field, and it\'s really coming out in the
course of the work we\'re now doing with OSHA to provide a model that
will be for all employee workers, whether they are federal employees or
employees who are federalized just for the purpose of this deployment,
so people who volunteered through the Katrina (inaudible). They all fall
under the same mandate from OSHA. So OSHA is actually under SAMHSA\'s
guidance developing brochures and sets of materials that will be not
only for workers but also for family members and for bosses and
supervisors to use when people return to help facilitate their reentry
into the workforce.

So I think that there are a number of things that are very much
groundbreaking that SAMHSA has been a part of.

MS. BRUUN: I just have two things to add to that real quickly. One is
that the work that we did in trying to take care of our own workers, we
actually required a contractor who was setting up (inaudible) on behalf
of the KAP contract. They did the same thing: shirts, go bags,
out‑briefings, in‑briefings, follow‑ups to make sure that (inaudible)
very well once they returned home.

But I think that your question also was a general question about the
workers that (inaudible), if there were any special programs for them. I
think the struggle here is that they\'ve been so directly impacted that
(inaudible) the population has been impacted. I would say right now,
other than the attention we\'re getting from (inaudible) responders,
especially those in New Orleans who are on cruise ships, our efforts
around supporting the health care worker, the state mental health
workers, the (inaudible) workers, (inaudible) officials, has been to
provide mental health and substance abuse services to either give them a
break by (inaudible) them and letting them go home for a few days or to
be there to listen to them and support them as they work, to help them
work shorter hours, because there does seem to be (inaudible). Some felt
that they couldn\'t take a break, but we allowed them to (inaudible). I
think we\'re still actually at that phase.

DR. DODGEN: I\'m aware that it\'s break time just about, so let me try
and respond to the rest of your questions, and then perhaps if we want
to talk about some of this at the break, then we can.

But the issue that you also asked about regarding stakeholders and who
are our partners and who we work with, it would be the folks that we
talked about in the slides. So all the ESF8 partners, as well as all of
SAMHSA\'s traditional partners. So the professional groups, national
organizations in the mental health and substance abuse field, as well as
some new partners such as the work that Mr. Curie has been doing to
collaborate more with the Administration on Children and Families, the
Department of Education, et cetera. So in addition to all the
traditional partners, we really expanded into some new arenas.

You asked also about the appropriateness of materials, particularly
vis‑α‑vis language and reading level, and I think one of the things that
our public affairs office has really done is make an effort to develop
materials that are geared at a number of different audiences. One the
nice things about our long history with the crisis counseling program is
that many of our prior crisis counseling program grantees have developed
materials related to disaster response in a number of different
languages, for parents and for children, as well as teachers, different
audiences. So we actually have a pretty good library of materials that
can be available in that regard.

You asked if we worried about stigma, and I think that there are so many
layers to a question like that because it\'s such a complicated issue,
but I do think that we have certainly broken some new ground in terms of
the recognition at the state and federal level of the importance of
behavioral health issues as integral to the response.

As an example of that, I cite the fact that we did have, for example, a
seat at the IIMG, which is really unprecedented, the fact that we did
get the ‑‑ I think it\'s \$11 million already in mission assignment.
We\'ve never had even a penny in mission assignment dollars before to
SAMHSA. So I think that there are a number of things that indicate that
while of course stigma still exists, that the walls are really breaking
down. People are recognizing that these issues are important in ways
that they may not have in the past.

You also asked about lessons learned, and I think that it will be of
interest to all the Council members to know that we are going to be
doing what\'s called a \"hot wash,\" another one of those disaster
terms, here at SAMHSA, just to go over our own internal lessons learned,
and we\'re actually going to be bringing someone in to write up really
an analytical look at our lessons learned so that it isn\'t just the
minutes of the meeting but to really do an integrated look at that. We
talked about how we can prepare that, or at least an executive summary
of that, that might be useful for Council.

Then I think your last issue is one that I would really prefer to direct
to Council, because I think what you\'re really asking is for a
discussion of these issues on the relationship between resilience and
poverty and other things. We could comment on that, but I think that is
perhaps something that merits a separate discussion because it\'s such a
large issue.

I didn\'t know if Brenda wanted to make any other concluding remarks,
and certainly I\'ll be happy to respond.

MR. CURIE: Barbara?

MS. HUFF: I\'ve known you, Daniel, since way before SAMHSA, probably 15
years; and Brenda, I\'ve known you through your work with Ann
Mathews‑Younes as a stellar project officer. So with that in mind, I\'d
like to just, on behalf of the Council, say thank you to both of you for
your (inaudible) work with us.

(Applause.)

MS. HUFF: (inaudible) how you took care of yourselves (inaudible). I can
only imagine what this has been like.

MS. BRUUN: I think the hardest thing to do in this role has been to
model self‑care. So I\'m just going to be direct about that and honest
about it up front. I think that I\'ve been serving as in‑state commander
since September, and there are a couple of things I\'ve done well for
self‑care. One is I have probably 12 years so far in disaster experience
and (inaudible), so I kind of know how to pace myself through the
disaster, and I think that helped.

The keys for me are eat healthy food, make sure it\'s available, easy to
get, drink a lot of water, try to continue your exercise routine if you
have one, and sleep well. Those are definitely a challenge. I think for
the most part I was able to do almost all of them, but I also think that
what can keep you going for longer than you think through a time like
this is to have such wonderful colleagues who support you and work with
you. This is a 520‑person team, and that\'s what makes anything seem
doable, to know that you\'re not doing it all yourself and that you have
a tremendous amount of support professionally, and even offers from
outside of our agency were backing us up and supporting us. Even if we
weren\'t always able to utilize those resources, it at least meant a lot
to have people who were trying to look out for us as well.

Then I would have to say my family and friends really tried to step up
and make sure that they cooked at night or little things like figuring
out how to get your laundry done. That\'s a tremendous help and just one
less thing to worry about so that my downtime was spent resting and not
taking care of the little business of life.

MS. HUFF: Thanks.

DR. DODGEN: Thanks. Thanks for helping us keep it real, Barbara. It\'s
nice to talk about all these things.

I really echo all the things that Brenda has said. I think in terms of
the self‑care ‑‑ and I do want to say, too, I think Rachel is going to
talk a little bit more about that, so I think you\'ll hear more about
what an important factor that is in the response. I think on a personal
level, I always talk about the three Fs ‑‑ friends, family, and faith ‑‑
as the things that help you through.

But I think also I\'m fortunate, like Brenda, to have been in this field
for a long time. My first major national disaster response was the L.A.
riots in \'92. So I\'ve been doing this for a long time, and before that
I worked at a child abuse shelter doing interviews of the kids when they
were first brought in. I think I\'m fortunate to have a lot of
colleagues in this area who know mental health and know trauma. The
other thing I do is I debrief with people who have been in the field as
long as I have that get depressed. I think that for all of us in this
work, everybody in this room have very high‑pressure jobs that take a
lot out of you, and we all know that debriefing people who have been
there is incredibly helpful.

So I think we are ready for a break, but the next panel is going to be
wonderful, and I think Brenda and I will be around during the break to
take more of your questions.

MR. CURIE: Thank you.

Let\'s take a 15‑minute break.

(Recess.)

MR. CURIE: If we could reconvene, I think you\'ll find the next
(inaudible). Sharing with us today is Ms. Rachel Kaul, Mr. Kevin
Chapman, and Ms. Anne Herron. Each individual, again, I think represents
a perspective of what it was like. We\'ve seen the macro end of things.
We\'ve seen the, if you will, 15,000‑ to 20,000‑foot level view of what
happened and how SAMHSA\'s emergency response occurred. This is going to
give us more of the ground view of what actually was occurring there.

So, Rachel, it looks like you\'re up first.

MS. KAUL: I\'m up first. Thank you so much, Mr. Curie, for letting me
take some of your time to tell you a little bit about my experiences.
You have heard quite a bit about the macro. I am going to try and give
you some detail and anecdotes to address some of the issues that were
raised not only during the presentations but by the Council members
themselves.

I am a project officer with the Emergency Mental Health and Traumatic
Stress Services Branch, which is part of CMHS, and we do disasters all
the time. That\'s what we do. My job is that when a presidentially
declared disaster occurs, I immediately get in touch with the state
disaster mental health behavioral health coordinator and start looking
at their application process for the crisis counseling program, which is
funded by FEMA but monitored in the long term by SAMHSA, and we also
provide the technical assistance and recommendation during the
application process. So as soon as the declaration occurs, and often
before, when I hear a hurricane is bearing down on the Gulf Coast, I\'m
on the phone generally with one of my colleagues and with the disaster
folks in the targeted states.

The thing I want you to know from a state level is that the states have
a very short timeline to apply for the disaster emergency funding, the
CCP funding. Basically, the timeline is 14 days from the day of the
declaration. So I want you to think about Katrina for a minute and the
fact that when Katrina hit on August 29 and devastated hundreds and
hundreds of miles of coastline, destroying service centers, homes,
businesses, schools, universities, transportation, communication,
infrastructures, the state still had 14 days to apply for a crisis
counseling program, each state.

So my colleagues and I were on the phone with state people pretty
quickly, but they weren\'t easy to find. They were evacuating their
families. They were trying to find elderly relatives that were in
nursing homes in harm\'s way. They were trying to figure out how they
were going to staff emergency centers. We were preparing to start
emergency operations, and so were they, and it was very stressful, as
disasters always are. But this one, once it hit, we realized that the
level of devastation it created was even more so. The scope and scale
was beyond what we normally deal with. However, it didn\'t change the
timelines. It just doesn\'t do that.

So our agency decided to deploy myself and two of my colleagues down to
the states to assist the state personnel in assessing how they were
going to amass resources and apply the resources and start this process
rolling. Normally we would wait. We wouldn\'t go down right away after a
disaster. For one thing, often you\'re in the way, right? The people
working the disaster need to be doing what they\'re doing, and they
don\'t really need their federal partners, whom they appreciate and
truly adore ‑‑

(Laughter.)

MS. KAUL: ‑‑ they don\'t need to have them watching them do it. But in
this case, they knew that they needed a lot of help. This (inaudible)
the fact that about three nights in I was trying to reach the
coordinator for Mississippi. His name is Andrew Day. I called the office
number I had. I had been calling; there\'d been no answer. Finally,
it\'s 9 o\'clock, 9:30 at night, somebody answers the phone. I said,
great, I\'m looking for Andrew Day, and this very nice gentleman tells
me that Andrew is somewhere on the coast. Every staff person that could
had gotten into their cars to go down to the coast to find other staff
people, because there was no other way to reach people and they didn\'t
know where their people were. So they went down to find people, and he
didn\'t know when he\'d be back.

Now Jackson, just so you know, is where the mental health agency is, and
the Department of Mental Health and Mental Retardation. It\'s three and
a half hours from the coastline. So everybody was out, and I asked him,
well, does a cell phone work? Is there any way I can get him a message?
And he says, ma\'am, I\'m sitting in the dark, we have one phone that
works, there\'s no water here, and I don\'t have anything to write with.
And I said, I\'m really sorry; how are you doing?

We talked, and I realized this was the deputy commissioner for mental
health I was on the phone with. He was so kind and so patient, and he
was sitting there trying to man this one phone in case somebody called
to say we found one of our staff people. That\'s how intense the
disaster was. Days later, when I was talking to folks in the states,
they were living at their operation centers and at their community
mental health centers. They were living there because gas was
unavailable. So they couldn\'t drive home because they might run out of
gas. So it just made more sense to just stay where you had to be, and
these were people with small children, with spouses, with elderly
parents, with neighbors, with damaged homes, and that\'s what they were
doing.

So from our perspective, normally we would provide technical assistance,
sending documents out, reviewing grant applications. It\'s a pretty
organized system, and we\'re pretty good at this. But it was clear we
needed to do more, and we went down and I started in Louisiana, landed
in Baton Rouge at 10:30 at night, was in a car and at the shelter at the
airport outside of New Orleans by midnight because the disaster
coordinator needed to go down to check on some of his people that he\'d
sent out and wanted us with him, and we wanted to go.

I have had the benefit and the great privilege of being involved in
disaster response for over a decade now, and I\'ve seen a lot of
disasters. I\'ve been on the ground early and I\'ve had a lot of
exposure to disaster situations. But walking into that airport shelter
was unlike anything I\'ve ever experienced before. There were almost
5,000 people in that shelter when we got there. There were people who
had been plucked off of roofs and interstates and walked there or
however they could get there, and it was almost silent because people
didn\'t even have the energy to talk, you know? They were just sitting
there.

I remember Linda Ligenza, my colleague and I, it was hard to acclimate
to this environment and figure out who to talk to. But the amazing thing
is you do acclimate and start talking to people, and they tell you
amazing things, and they\'re grateful.

The one thing I remember most about that first night was how many people
said thank you for just being there, for walking in and looking at
people and asking them how they\'d come to be there and what they needed
now and what they were hoping for. We couldn\'t make any promises
because we didn\'t know what was going to happen next, but we just
wanted to hear it so we could communicate that back and figure out how
to prioritize this.

After that, Mr. Curie came down almost the next day with Secretary
Leavitt, and again what struck me was we were in another shelter and how
grateful people were to see people from out of state, from the federal
government that weren\'t coming in to promise anything at that moment.
They were coming in to listen, and they were asking questions and
(inaudible). Then what happened was I went to Mississippi thinking that
that was as intense an experience, and it left me with so many things
that I could work on and think about and plan for and do, and I went to
Mississippi and spent a day with my colleague, Cecilia Casale, who had
been deployed there, and the disaster folks down there, and I\'d never
seen devastation to that degree. It was as impactful to me. I\'d never
seen 60, 70, 80 miles from the coast of a hurricane telephone poles
snapped in two, cars spun around as if they\'d been hit directly by a
tornado. This went on for miles. It was (inaudible) along the coast, and
that was shocking.

So what we are facing here is so huge and complex, and then I look at my
state colleagues and compatriots and I say what do you need, and at that
time they were still very much in shock. They\'d been working for well
over a week with very little sleep, away from their families, away from
their own concerns. But everybody\'s primary concern was we want to do
this right, we want to take care of these people. And everybody was
saying, no matter what they faced, how much more concerned they were
about the people who had experienced more devastation. It was truly
remarkable.

What I am grateful for about that period is, as project officers, we\'re
going to be involved with these states for a long time to come. We were
able to work with our agency and work with FEMA and change not the
regulations around the crisis counseling, around SERG grants, but to
creatively apply regulations and look at where the gaps were and make
resources, financial resources, become mobilized very quickly, and then
human resources get mobilized very quickly. I\'ll give you another
example.

For these crisis counseling grants, we normally don\'t have consultants
go in and help people with these grants. These people know how to write
these grants. They\'re trained to do it. But because of how much every
worker was being asked to do and what that meant to the stress level,
the energy level, the time level, what it did to their cognitive
abilities, we did mobilize people from out of state to go in and support
and help these people get what they needed to get these grants written
in such a way that we could get them money and get these programs
started to get services on the ground.

So those are just some examples of what I was really, really grateful
for. What I know now, this many weeks out, is that this was important to
the state folks. They were so grateful for our energy, for the fact that
we came in, we were able to help them problem solve. We didn\'t tell
them what they needed. We asked. We tried to work with the resources
that were available, that we\'re familiar with, that we know how to use
well and make them fit in a neat way in the impacted areas. I know
they\'re doing better now because their sense of humor has returned.

The other day I called Mississippi, and I was tight for time. I was late
for a meeting, and I had a piece of information I really needed, and I
called the crisis counseling program called Project Recovery. I called
Project Recovery, and the project director and disaster coordinator were
both on the phone with me, and they said, yes, Rachel, what do you need?
And I said, well, I\'m getting ready to go to a meeting and I need some
numbers. But first, Jenny, how was your weekend? And she said, well, it
was pretty good. It did some Christmas shopping. And I said great,
that\'s excellent. Andrew, what about you? Did you get some time with
your son? He said yes, actually we played ball. And then he laughed and
said, Rachel, you\'re learning the southern way. I said, yes, I am, I\'m
learning, this is how we do things. The fact that there is now time to
stop for a minute and find out if somebody went Christmas shopping is a
really good thing, and it gives me a lot of hope.

So a couple of things I wanted to talk about were the importance of the
crisis counseling program in the states is that it\'s going to provide
services in these areas for basically a year, give or take a few months.
It addresses some of the concerns you brought up already. The crisis
counseling program is designed to rely on people\'s strengths, on a
community\'s existing strengths, help a community re‑find its sources.
Maybe it\'s lost, maybe it\'s forgotten about. Help them create
resources if they need to.

The crisis counseling program hires folks indigenous to the community.
That\'s a key feature of it. Paraprofessionals and professionals. We\'re
hiring the indigenous workers and we\'re training them to ask their
community members what they need and help them come up with the problem
solving, the resources that they need to help their communities start
what is going to be a long and very, very difficult road to recovery.
Yes, they\'re (inaudible). The crisis counseling program is not going to
be (inaudible). But the other thing that has been very gratifying about
this experience is that the level of involvement of the entire agency
(inaudible), and the cooperation and communication among every center
and every program has been very high.

What that means is that we can start to identify aspects of other
programs, other grants, other resources that can work in conjunction
with crisis counseling to really help staffs and to help these
communities start building what they (inaudible) in terms of capacity to
recover. So that\'s part of it, and I\'m very grateful for that.

Another piece that I wanted to talk about was something I\'m left with
that we\'re always working on. Our branch has been concerned about
emergency responders for a long time, firefighters, police officers,
medical professionals, public health responders, disaster responders. We
asked for and had a guide created by the (inaudible) called \"A Guide to
Managing Stress in Crisis Response Personnel.\" The publication, this
guide got launched serendipitously right at the same time as Katrina. So
we were able to get this into the field and help states also increase
their focus on responders, because the other piece of this that\'s
important to remember is the non‑traditional responder.

It\'s the SAMHSA personnel or the NIH personnel or the private therapist
or the church volunteer that goes out to a devastated area with
unbelievable amounts of trauma and just has never exposed themselves to
this before, and works and works their hearts out, and then come back
with the stories and the images that they\'ve heard and seen, and they
grow from that experience but there\'s a cost to it as well. I think we
need to help all of these agencies and our colleagues and our neighbors
and our friends recover from these experiences.

So I\'m giving this to you so that you can see a resource that we\'re
very proud of, but also in case you know someone, or maybe you yourself
have been down there and impacted, close to folks who have been
responding. You may find that there\'s really important information in
here for you. I hope you do. I know our state people are grateful for
it. So I\'m going to start passing that around for you.

MS. VAUGHN: Rachel, TaRaena will pass them around.

MS. KAUL: Great. Whatever is extra can go to anybody else.

Finally, just in closing, I do want to say that that message of caring
for ourselves, of caring for others, we really did go down to the states
to show them that we were there to support them in any way that they
needed. I think it was our ability to walk in and to be a supportive
listening presence, but also to help them problem solve, but without
promising or even suggesting things that were not already within that
culture and community. It\'s really about asking them what is it that\'s
going to work for your community and work here, and helping them think
of nontraditional things.

I was speaking with someone else about this earlier, that we find that
our consumers and the people that we service in our community centers
are frequently somewhat almost some of the first people that want to
come forward to help respond, and they\'re some of the most creative and
effective at responding.

These are people that are used to reaching out for resources, used to
linking people with resources, and they\'re certainly not separated from
the community at large. Those lines and barriers are broken down by the
disaster and that creates opportunity.

So these were people with mental illness, people with substance abuse
issues in prevention, who were able to make a big impact in helping
their community members, their families, and their friends. So this is
the kind of thing that we can help the states focus on as a resource to
really rely on and start utilizing.

I\'m going to stop there. We could all go on for a long time about
disorders we\'ve heard, but I feel really good about the response of
this agency and that I\'m going to get to continue to interact with
these states as time goes on.

I\'m happy to take questions at the end after my colleagues have gone
and to give you more information. Thank you.

MR. CURIE: Thank you so much, Rachel.

I\'d now like to ask Kevin Chapman if he would share his experiences.
Kevin is from our Center for Substance Abuse Prevention.

Kevin?

MR. CHAPMAN: I had the opportunity to serve SAMHSA in the hurricane
relief effort in Houston, Texas. Presently, at work at CSAP in the
Division of State and Community Assistance as a project officer.
Historically, I am a United Methodist minister specializing in pastoral
counseling with a Doctorate of Ministry in pastoral care.

We are a team of ten. We began our journey in Houston. Our team
initially made contact with the Harris County Department of Mental
Health and Mental Retardation Authority. We consulted with the Executive
Director and the Director of Adult and Child Services to provide
professional mental health services for personnel who responded to the
crisis and delivered services to evacuees and to help the county do
long-term planning.

We began this process by touring two of the largest shelters in Houston,
the H.R. Brown Convention Center and the Reliant Center at the
Astrodome. To assist in this process, we attended daily meetings with
the Mayor of Houston and the Harris County Executive, followed by the
Community Medical Working Groups. We also met with other federal
personnel who were deployed in Houston, attended the Behavioral Health
Provider Network meeting, and offered assistance in any way that we
could.

Many times we heard from the mental health providers that their system
was already at or beyond capacity. We are trying to strategize and
discover ways to provide the extra services that will become necessary
in the weeks ahead.

Professionally, I had two assignments, one to use my clinical and
spiritual background in our consultive and assessment process and to use
my organizational skills to assist the team leader and the group. In
evaluating my assignments, I believe my main missions have been
accomplished.

Initially we had contact with the Harris County Department of Mental
Health and Mental Retardation, but it became noticeable to me that we
were not talking with the alcohol/drug counterpart. So I lifted up this
concern and our team leader gave me an assignment.

This became a very positive part of my journey. I contacted Mr. Mel
Taylor, President and CEO, and Mr. Leonard Kincaid, Chief Operating
Officer of the Council on Alcohol and Drugs in Houston. I invited them
to meet with our team. We did meet with them, and we learned from them
that initially they had been there. They had been on the front lines
providing referrals and services for persons in need of methadone
treatment and other treatment services.

But after the initial crisis subsided, the council was informed that
their services were no longer needed. According to the council, the
American Red Cross was the gatekeeper, and it would not recognize
licensed clinical dependency counselors to provide services to the
evacuees. It was also reported at that time that the medical community
did not see the need for substance abuse services.

The council could also not access the shelters to conduct 12-step
meetings. Eventually, volunteers from the community just went in on
their own to the shelters and formed 12-step meetings, even though they
did not have the privacy they desired.

Mr. Taylor and Mr. Kincaid kept in contact with other agencies to
provide their services. This is the reason, from what I just said, why
we did not see the council in Houston.

Through this initial meeting with the council, we were able to get in
and reconnect to the Houston agency group and the council willingly
participated in the initial steps. I also visited the council\'s office
and with their staff we learned about the appropriateness.

Secondly, I was able to assist in making important connections back to
the SAMHSA SERC, which leads to my second accomplishment. I wanted to
preface this accomplishment by saying with my background as a minister
and a therapist, I tend to integrate the thoughts and behaviors, so some
of this experience is personal in nature. I\'m not bringing this up to
you to call attention to myself.

Our deployment was scheduled for 14 days. Our team leader and two other
members left after the first week. Dynamically, this changed the group
process, along with Hurricane Rita threatening to hit Houston. More
members from our team came from Phoenix, from Value Options, and
provided direct services to the evacuees.

Three of the Phoenix team, and I will call them the Phoenix 3, came to
me on Monday of the second week and asked me directly to work with
SAMHSA to get us out of Houston. We were watching in the evening the
weather forecast that Hurricane Rita was on its way and it was going to
hit the Houston area. One of the Phoenix 3 had experiences living
through hurricanes in Texas and she said, \"Kevin, you have to get us
out of here.\" She knew that if the hurricane did not hit Houston
directly, the power would certainly go off, and it would take us hours
to try to get out of the community.

This was a very difficult part of the journey, and eventually became the
reason I left the deployment. I personally also felt unsafe and wanted
to move deeper into the state.

It was a very conflicting experience. On the one hand, in Houston, we
watched the remaining evacuees being told that there was another
hurricane coming. They were offered to go to a military base in Arkansas
by plane or by bus, or they were given a one-way ticket to anywhere in
the continental United States.

We watched the evacuees lined up with their few belongings in the
sweltering heat in rows as they waited. The next day, we, on the other
hand, drove in an air conditioned car to San Antonio. We made the drive
in a few hours. The next day motorists sat in hours and hours of
traffic.

By this time, I personally was having a stressful reaction. I found
myself reversing and mispronouncing words. I kept thinking once we
arrived in San Antonio, I would feel safe.

On Wednesday evening, a couple of hours after we arrived, we attended a
meeting with other federal personnel about the relief effort in San
Antonio. During this meeting, the convener, who was also a native of
Texas, talked about the hurricane. (Inaudible.)

That was the moment that I was stopped in my tracks, literally. I
thought we were safe, and now we were going to be dodging another
hurricane. We walked out of the meeting, and a team member (inaudible).
It was a very eerie experience. Our team discussed how would we deal
with this situation? Basically, would we stay or leave?

By this time, I was physically exhausted, mentally fatigued, and asking
God, are you calling me? The answer for me emerged immediately, but it
took time to accept it. I had taught persons for years that you have to
take care of yourself to be able to help others. I was now faced with
the question of how I was taking care of myself. My wife and dog,
especially my dog, depends on me.

(Laughter.)

MR. CHAPMAN: I asked to come home, which I did on Thursday. After plane
delays, I headed back to D.C. late that Thursday. I felt guilty for
being the only remaining team member to leave, for not completing the 14
days, for being afraid.

On Friday, I came into SAMHSA and I was relieved (inaudible) Houston
team. That Friday, two of the Phoenix 3 from San Antonio. They told me
two things. \"We wish you were here, and Kevin, you made the right
decision.\"

MR. CURIE: Thank you, Kevin, very much for sharing that.

Anne Herron, who is in our Center for Substance Abuse Treatment, is here
to share her experience and thoughts.

MS. HERRON: My job in CSAT, the Center for Substance Abuse Treatment, is
as director of the Division of State and Community Assistance. So I have
the honor and pleasure of working with the states. I\'m also responsible
for issues of co-occurring disorders, homelessness, and prisons that
clearly come up because of these hurricane experiences.

About two weeks after Hurricane Rita, we assisted the Secretary of the
Office of Mental Services in the State of Louisiana. She was having some
conversations with some folks at SAMHSA. She actually said very
specifically that she would like some assistance.

Her needs were around, first, the command and control system that is
operation in the State of Louisiana for disasters. At one point, they
were separate state responses that were operating. So there was some
confusion about the actions. So that was one thing that she would like
some assistance for.

The second thing she wanted some assistance with, and this is two weeks
after the hurricane hit, was noticing that her executive team was really
needing some support because they were spending up to 14, 16 hours,
seven days a week, providing both direct care services and providing
support to her staff. So she wanted some support for her.

She wanted to make sure that the work stayed in the Office of Mental
Health (inaudible) supporting first responders was appropriate, it was
long term sustainability, and that it was the right thing to do. That
was the fourth issue.

The fifth issue was looking at the system of care and what the needs
where over the next three to five years, and she said, \"Can you give me
some assistance, give me some options, with a fresh pair of eyes?\"

So I went down with another colleague, an expert in the area, and he
focused on that particular issue and provided a number of options and
recommendations to the state agency about mental health services.
Together we looked at the organizational structure. We looked at the
important issues that the state had been dealing with and what was going
to come in the future.

In the State of Louisiana, the Office of Mental Health, Office of
Addictive Disorders, and Office of Mental Disabilities are all together
in the Office of Mental Health. So there was an opportunity to do some
significant work around long-term planning, around media response, and
around the integrated options review and for staff functions. So it was
a great opportunity to at least be in the discussion around some of
these issues.

What we did find was that in our planning of speaking with staff about
their values and their tasks that they needed to solve and that they
needed address, we figured maybe a half hour for it. It took easily,
easily, an hour and a half for each person because the first hour was
spent talking about their experiences. Eighty to 90 percent of the staff
in central office in the State Office of Mental Health were directly
affected. They\'d lost houses, their family was displaced, and it was
huge, huge.

So we were able to provide some recommendations. We were able to talk to
the Secretary of the Department on the Assistant Secretary\'s behalf and
they began to implement the recommendations.

About two weeks later, SAMHSA received a request from the Assistant
Secretary of the Office of Addictive Disorders. He said, \"Some work
that you have done with the Office of Mental Health impacted us as well.
We\'d like to have an assessment of our function, of our planning over
the next three to five years. Give us some recommendations for how to
streamline these processes and reorganize our system in order to begin
to respond to this massive effort.\"

So we went and did a similar thing for the State Office of Addictive
Disorders. We looked at their functions, values, projects, initiatives,
and how they needed to build relationships with some of the local
district staff. Again, very interesting for us, a fascinating process of
engaging with this macro systems assessment and to have staff then say
to us this makes sense. They have since begun implementing some of those
recommendations and have asked for additional consultant help.

So I feel that we have been quite successful in a fairly short period of
time, and letting them implement at their pace, and not taking over
responsibility (inaudible) fix it.

A personal observation. One of the things that was astounding to me, and
I mentioned it to the Office of Mental Health, was the number of staff
in the agency who were themselves very significantly impacted. This was
something that I had not seen. (Inaudible.)

As a result, the first time I went down, I focused on crisis response. I
focused on trying to help people get a break, as Rachel and Kevin
mentioned, from their work they were doing really all the time. To try
and get them to back away and take care of themselves is very, very
difficult.

By the second time I went down, there was a significant improvement in
that process. It was then five weeks after the hurricane, and they
started reengaging in the sense of routine, which was not present the
first time. Having that routine back, having achieved some
predictability to their jobs and to their lives, that was so, so
important.

Another thing that I mentioned that I think really was a great
accomplishment was providing some administrative respite to the
assistant secretaries and to their executive secs. In crisis response,
(inaudible) just by a very, very short period of time, our being able to
be there and to begin to turn around the focus gave them enough of a
buffer to deal with that situation.

Those are some of my experiences.

MR. CURIE: Thank you, Anne.

Now I\'d like to open it up to council for any comments, questions,
interactions.

MR. CURIE: Ken?

MR. STARK: Just a quickie. So in all of that process, the 14-day rule
survives. Is that true?

MS. KAUL: I\'m sorry. Say that again.

MR. CURIE: The 14-day deployment?

MR. STARK: The 14-day process of the state having to make the request. I
keep thinking about, in times of crisis or times of disaster, it is
truly an opportunity to reevaluate the bureaucracy we\'ve created. I
mean that for me and everybody else.

MS. KAUL: Fourteen days is the crisis counseling program. I really
encourage you to go to our website to look up everything about the
crisis counseling program at some point because it is a really, really
interesting program. I believe in it from many levels.

The 14 days is for the immediate grant. The crisis counseling program is
in two grants, an immediate services grant and a regular services grant,
and the idea is you put in place something that\'s very quick. The
application is not as extensive as the longer one, but the design of
that first application and the first program is to allow you to do more
assessment, whether or not you need a longer term.

What I will say is I have written these grants, I have read these
grants, I have worked these programs. As much as I have heard people say
we should change the application or change the timeline, there is
something about it that just works, though. It\'s 14 days. They knuckle
down. They get it done in the middle of a crisis. You always think
they\'d never get it done, that this would never take priority over
everything else. So you try to make it easy, you try to give them help,
and you try to be on the phone at 11:00 at night when they\'re still
working.

But yes, it is sort of something that seems counterintuitive, but it
kind of works in this aspect. We\'re not asking for an application for
the longer term. We do give them more time for that and for other needs
assessment.

MR. CURIE: Faye?

DR. GARY: I wanted to thank each of you for sharing your personal
stories, especially Mr. Chapman, for such a very personal and touching
story. Thank all of you for doing that.

My question relates to the crisis counseling, which I truly believe in
that concept, and I also believe in the concept of the closer you have
the services to the people who need the services, the more likely you
will get the outcomes that are the outcomes that you were wishing for.

So with that kind of background statement, have you thought about how
you can forge partnerships that might be considered new and novel that
you may not have had before, or that you could strengthen with some
people in the community that have not been connected to SAMHSA? I don\'t
know who they are, but I would just suggest, for example, and you can
inform me, partnerships with, let\'s say, beauticians in the community,
storefront ministers, as well as ministers with the Ph.D.s, or the
historically black institutions in Louisiana, especially in New Orleans,
Southern, Dillon, Xavier, et cetera, the sororities, the fraternities,
the Masonic Lodge people, all of whom have great influence with the
people that they are in constant contact with.

The same with the Hispanic community. The same with disenfranchised
Caucasian communities. Many people there are very poor, and they cross
the ethnic minority spectrum in our country.

So I was wondering if that\'s one of the lessons that was learned, or
could be learned about the new partnerships that we could forge with
people in the community, and if you don\'t mind, I\'d like to hear some
dialogue about that.

MS. KAUL: Just briefly, I\'m really pleased you brought that up, because
the crisis counseling program is often perceived of as people going out
and talking to people one on one and in small groups, but that\'s in the
very early stages. The real kind of push and what it transitions to, and
part of the actual model, is starting to community build and to
establish linkages across, and partnerships.

It means that we encourage and that the outreach programs are encouraged
to be very creative in this. Other groups beyond, and you mentioned a
lot of really good ones, postal workers. Something that\'s a little
counterintuitive, making sure that bartenders receive information on
problem drinking and substance abuse as related to disaster response,
and waitresses and waiters, flight attendants.

I mean, there are all kinds of people, guilds, groups, that yes, we
encourage, through previous programs and the lessons we\'ve learned, we
encourage our programs to take a look at these groups, but then they are
also much more creative than we could ever be. Anybody outside, they can
tell you who in their state.

A huge partnership that is established very quickly is always with
whatever religious and faith-based groups, volunteer organizations, the
UMCOR\'s, the groups that are doing rebuilding and outreach community
case management.

So these kinds of linkages are expected as part of the application, and
it has to be part of the program. Then what I find is ‑‑ particularly as
you\'re hiring people that are indigenous to the community that are
paraprofessionals and don\'t have some sort of concept of the way things
should be, and they\'re just creating it ‑‑they will do amazingly
creative things.

So yes, that\'s part of it, and then we produce reports and we bring
people together whenever we can and send things out via email and
documents to share that knowledge around the states.

So that is what we do. But I appreciate your emphasis on that, and I
need to write down some of those groups you talked about because I
hadn\'t thought about some of them.

MR. CURIE: Kathleen?

MS. SULLIVAN: Rachel and Anne, could you tell me while the fight was
going on, were you watching television at the same time? Because you had
no communications where you were, correct?

MS. HERRON: Right.

MS. SULLIVAN: So that played both sides. The state providers and the
people you were working with had no idea of the foment and the screaming
and yelling that was going on on the television at the same time,
correct?

MS. HERRON: Early on.

MS. SULLIVAN: Early on? So there was a nice, agreeable relationship
actually between the federal partners and the state. So you were getting
along at this time, and everything was all fine, correct?

Were there some bumps in the road once, you know, people found out about
this hostility that had been public between the Governor and the federal
government?

MS. HERRON: I can speak from my experience with the state agencies and
going in and speaking with some of the district staff as well. There was
absolutely no negative interaction at all with SAMHSA or any of the
SAMHSA staff. People would come up to us, and I think Brenda talked
about this earlier, when they found out who we were and who we were
representing and thank us for being in the state. Not once did we see
any kind of negative interaction related to this.

MS. SULLIVAN: And even when you were working around the state offices?
You were never approached, no one screamed at you, nothing?

MS. KAUL: No, and actually this is a point I would make when I came
home, because my family and my friends, people would say, \"Oh, was it
hard? Were you a target of any kind of hostility?\"

One of the things, and I have always seen this in disaster, if only when
you\'re working in it. You\'re too busy. What is going on in the media
is frequently at that political level, at that level. We\'re not at that
level. What we\'re seeing is the everyday work that people are doing.

So could people talk philosophically about the fact that they thought
this agency or that agency could have done a better job ‑‑

MS. SULLIVAN: This wasn\'t philosophical.

MS. KAUL: Right. No, no, no, but it\'s more that what\'s happening on
the ground level, everybody you see is working so hard, and you\'re
physically there, that it just becomes an interaction that\'s really
more personal than that.

So it\'s like a background. I was aware of it by reading the paper, but
I wasn\'t aware of the intensity of it.

MS. SULLIVAN: So in your dialogue with the states, it was always let\'s
get it done, let\'s work. You were working around regulations, you were
working in partnership around regulations, and you weren\'t sending
nasty memos. Did nasty memos come to you? You didn\'t send nasty memos
to anyone, even though there are 100,00 nasty memos that arrived on the
Hill the other day?

MS. HERRON: Not one.

MS. KAUL: A lot of people said that, and I do want to say of course I
deal with a hugely bureaucratic program. People were expressive of their
frustration of some of the bureaucracy, but more in terms of what can we
do about this?

I mean, normally we\'d want to say we can change this right now. Do we
want to look at lessons learned and address things? Absolutely, but I
was hearing frustration, but part of it is being there and being so
accessible that we were talking from that perspective of how can we get
this to the next level?

MS. SULLIVAN: Well, thank you so much for what you both have done, and
Anne, the story that you are now creating is just a magnificent story,
and one that I hope Marcus Gray, once he gets everything all done ‑‑ I
mean, I hope that one my friends, Edie Magnus or Robin Roberts, maybe at
ABC, maybe back to Mississippi, she could go back with you, because you
have some wonderful post-Katrina stories.

But completely revamping the system is just a marvelous story and
partnership between state and federal. You all should be lauded for
creating these wonderful, wonderful relationships. Really, thank you so
much.

MR. CURIE: Other questions? Tom?

MR. KIRK: One of the things that is striking to me from an
organizational point of view, one of the reasons I had to call SAMHSA
over the last couple of months, and it was almost in some of the
introductory comments when you talk about maybe somebody I\'ve known, it
was almost without exception. Everyone (inaudible).

My point is that I understand that part of this comes with activities.
It\'s part of some people\'s day jobs, but for many people at SAMHSA,
they already had day jobs.

I\'m interested in your point of view, and Charlie, also you, in terms
of lessons learned, what was the organization of care that occurred that
somehow helped say yes, we have day jobs, but this is so extraordinary
that the charge of the agency, the charge of SAMHSA, bona fide, so to
speak, what did you experience in terms of support for you that somehow
made this less traumatic, if you will?

Because any number of things ‑‑ particularly from the state agency point
of view, different things happen. You know, the mental health
commissioner title, we\'ll do mobile crisis. We\'ll crisis, but not for
any duration like you\'re talking about. Most of the time, I can get my
agency to respond in a very intensive way for five days, seven days.
This has gone on for months. What is it that SAMHSA has done that it has
learned from the organizational care point of view that will help the
rest of us?

MS. HERRON: One of the things that I think is very important is we
limited amount of time that people are going out on deployments. We
talked about a 14-day period of time to go out to the field. Some went
for seven days. Some went for 14 days. If you for some reason have a
particular kind of skills that were needed for more than a single
deployment, you couldn\'t go back out right away. You had to be back for
a period of time.

That was helpful in a couple of levels. It was helpful from a personal
level. It protected ourselves from ourselves from doing too much. But
from an organizational perspective, what we told the rest of the staff
is you only have to take up some extra work for this amount of time.

That\'s the other component. I know this from myself, but I know I can
speak for the others. The staff who were not deployed at the same time
that somebody else was absolutely without question, without looking
twice or complaining, picked up our work. Picked it up. It was really
amazing.

MR. CURIE: I would add, along with that, I think from the very beginning
it was clear that we needed to have a real focus as to what was
involved. How was SAMHSA involved? What was our mission? How did this
change our day-to-day mission?

It came out clearly with a focus on providing support to those who would
be traumatized by the hurricane, and then an equally important part of
the mission, for those people that day in and day out we worked for,
people with serious mental illness, people with serious emotional
disturbance (inaudible).

So I think being able from the very beginning being able to pinpoint
that this is very much in line with our overall mission, the one thing
that drives SAMHSA employees, and I think what drew them into public
service in the first place, what drew them into mental health and
substance abuse, which are somewhat sacrificial fields in one sense to
go into, is being invested in something outside of yourself and having a
sense of serving the country.

I think there have been two points in my tenure here, 9/11 and Katrina,
that really brought out that sense of we are here to serve our country.
That was an initial, I think, unifying sense, and the fact also that we
had support from the Secretary of HHS in terms of SAMHSA being
prioritized in our issues from the very outset in terms of substance
abuse and mental health consequences being recognized, and the fact that
we were clearly a part of that, playing a critical role, I think also
played a major role in helping people shift their focus and their
mission in making Katrina response their day jobs during that period of
time.

I also think people, we basically gained a lot of support, energy, and
maintenance from each other. I know for myself, I was downtown a lot at
meetings. That\'s why the SERC structure and the center response with
Brenda as the commander was so critical, because I wasn\'t able to be
here onsite. I was in touch continually, but when I come in and I\'d be
perhaps tired from a long day, the energy in the SERC and watching
people going would keep me buoyed and I think we kept each other buoyed
in that process.

But also on a personal level, there was a lot of interaction and talk
about our people taking care of yourselves. That was an element that we
really tried to bring from the beginning. I think the fact that we\'re a
bunch of mental health and substance abuse specialist folks kind of
makes it maybe a little more likely, that an organization like SAMHSA
would be tuned in to that area a little more quickly.

But again, I appreciated the number of people who would ask about me. I
know that I saw people that I worried about, and I asked about them. It
was a natural thing that occurred in terms of team effort.

So a lot of it is an attitude. A lot of it is a culture that you try to
establish. Brenda and Dan were consistently preaching take care of
yourself, and then as Anne described, trying to build in automatic ways
of also taking time to celebrate. I think those daily briefings and
bringing people together twice a day, they were able to celebrate
accomplishments, see what progress they made, and any good news and
positive feedback from the field, from the Secretary, from Homeland
Security, we shared openly. I think that was all very important as well.

Rachel?

MS. KAUL: The only thing I was going to add, I think that that comes
from an attitude and goes into how you operationalize that attitude.
Brenda and Cindy Hanson and other folks in the SERC were really good
about recognizing what was working and operationalizing it.

That\'s the key. Often we think that we are mental health or human
service professionals, so we are good at taking care of ourselves. But
actually what tends to be shown is we\'re not as good as other people,
because we\'re good at taking care of everybody else, and there can be
an element of shame to needing something.

So those of us who have done more crisis work that know this know that
you have to make it a protocol, you have to make it procedure, and
people have to talk to you when they come back from a deployment. They
have to take a phone call from you. Then it becomes something that
becomes part of the culture and becomes much more natural.

But it was the fact that people in leadership roles that, A, are kind of
like this anyway, and B, were able to understand this has to be
operationalized or it\'s not just going to happen magically every day.
That was really it.

MR. CURIE: Tom?

MR. KIRK: Just based upon this 9/11 experience that Connecticut went
through with people going down there every day, do you have formal
debriefing types of processes in place? How did that work?

MS. HERRON: We did have formal debriefings. Anybody who came back from
the field went through a debriefing process, and then was it was
followed up to make sure that even if everything was okay the second,
third day, fourth day after you get back, you were contacted. It\'s a
formal process, a routinized, formal procedure.

MS. KAUL: Just to add one more thing, as well as formal check in
procedures, the SERC had established a procedure where people were
checked in on on a regular basis. So even if you\'re somebody that\'s
not going to sit down necessarily and say that much, or you\'re going to
pretty much say you\'re fine, the regular, everyday telephone ‑‑ you
know, it gave you multiple options for checking in and being heard. It
gave people more than just one option.

MS. BRUUN: I\'m sorry. I can\'t resist. I have to jump into this
particular discussion, because I think anytime you get involved in a
disaster response, the first thing that you lose sight of is the people
working around you, because everybody is engaged, and they\'re your most
precious asset.

So I think that we organizationally worked very hard to make sure that
we took care of not only the staff, but the people we were trying to
support in the field. If you put yourself in harm\'s way, you\'re no
good to anyone else.

So we did do a lot of operationalizing of saying things that really took
a tremendous amount of time in managing that we could have sent people
home earlier in the day, except that we thought that this was one of the
most important things that we could do was make sure that we called
people at night in the field and checked in.

Debriefings per se, I don\'t believe in mandatory debriefings, because I
think that people have to come them voluntarily or it\'s not an
effective tool. We have to acknowledge that people do have different
strikes and different resilience levels, and some people are more
tolerant of this kind of work assignment than others.

But I think that we have offered the kind of support in a way that makes
everybody actually want to use it voluntarily, in the sense that you
have to take some mandatory rest time when you come home. You then come
back in and you check in with the SERC and you do your little
administrative things. You turn in your comp time forms, and you check
in your equipment, and then you get to talk to somebody who just says
what worked for you out in the field? What kind of supports did you
need? What more training? And then out of that process, came a dialogue
that was incredibly rich for learning experiences for us, and other
things that we needed to be doing in support.

I think as an agency how that worked to operationalize it and become an
entire agency function to support the staff is through the Incident
Command System. The leadership here had to take and give up a lot of
control to the decisionmaking of the SERC process and the Incident
Command Structure.

What I found was so helpful was the incredible receptivity of the
leadership when I brought issues forward to say, hey, I think we need to
be more flexible in how we give people time, or I think we need to buy
supplies we don\'t normally buy. We don\'t normally by Vicks Vaporub.
Being able to say this is why we need this, and oh, no question, do it.
Just take care of them.

I think having that leadership support, having people feel an
environment where it is safe to acknowledge when they do need help, when
they do need to come home earlier than perhaps their deployment was
supposed to end, that\'s okay. It\'s creating an environment that feels
safe.

One of the things that I think that we try to tell everyone is there is
no such thing as a perfect disaster response. So if you make a mistake,
you need to tell us right away so we can work with you to fix it.
That\'s it. Then we are going to support you through that process and do
active problem solving.

So I just wanted to let you know that this is something that we took
very seriously as an entire organization. I think that I\'m still
personally proud that some of it worked and some of our folks that were
deployed out felt that it was supportive of them. I appreciate your
comments on that.

MS. KAUL: And can I just say one other thing, Brenda, is that you guys
work with best practices. We have a lot of research and writing on what
is best in terms of bringing people in and out of the field and
deployment. They really work from a best practice model within the
National Center for PTSD and the VA and groups that are used to doing
this. I think that was important, too. They weren\'t just identifying
some system that didn\'t have something behind it.

MR. KIRK: I think on that note, on the debriefing piece, what we found,
again based on 9/11, is that you have to work with them.

The second observation is that, and I\'m not sure if it was you,
Charlie, our experience with some of this stuff, in just listening to
what you say, is that SAMHSA is never going to be the same
organizational culture and the ways that you do things. Life has changed
in ways that ways that may not have figured on and it\'s so
extraordinary. I would hazard a guess that between your organizational
care culture and your own professional personal spirit says that SAMHSA
is not going to be the same much longer.

MR. CURIE: Thank you.

Theresa?

MS. RACICOT: Kevin, I want to thank you very much for sharing your story
and for helping us all remember and teaching us that self-care is the
first thing, and as the oldest of eight children, the older girl of
eight children, and I\'m Irish Catholic with a corner on guilt ‑‑

(Laughter.)

MS. RACICOT: And older than you, too. I think it\'s a generation that
that was not something that was taught, and not something anyone cared
about. You were supposed to put up, shut up, and get to work.

So I thank you very much, because I think we\'re learning this, and I
think the younger generation is going to bring this to the forefront,
because they\'re not willing to do what some of us old folks did.

(Laughter.)

MS. RACICOT: Which wasn\'t very healthy, I don\'t think.

I\'m surprised to hear you say that you think that the mental health
people are good about that, because the worst patients in my experience
are doctors and nurses. If this group is doing that, my hat is off to
you. But I thank you very much.

MS. DIETER: Right. I really appreciate that, too, Kevin, because I can
also see the little bit of anguish of even telling what your feelings
were. I really appreciate that. Thank you.

MR. CURIE: To clarify, Theresa, I do think we\'re lousy at taking care
of ourselves, but I do think there is an overriding sensitivity that I
was hearing from the group, and I think it\'s because of the commitment
to best practices that Brenda was talking about, of people checking on
others. Yes, the point is well taken.

Larry?

DR. LEHMANN: I\'d be remiss if I didn\'t make just a brief comment in
congratulating Dan and the rest of the team here at SAMHSA. Not just for
the work that you all did in helping to keep in some of these calls
different organizations talking to each other. It is extremely helpful
and useful for all of us because some of the prework that you have been
doing as an organization, particularly since that first meeting after
9/11 and a number of the things that are ongoing now, as well as the
things you put together in helping us respond, it is a really terrific
interagency organizational job, and it\'s very much appreciated.

MR. CURIE: Thank you, Larry.

Barbara, we\'ll make this the last comment.

MS. HUFF: I also thank you, all three of you, especially Kevin with your
own personal story.

I can\'t remember, and I think it was you, Rachel, that mentioned this,
but I really appreciate you bringing it to the forefront because it\'s
not an easy thing to talk about. Being a family member myself and
representing families with kids who have serious mental health needs on
the council, one of the things that we don\'t talk about very easily or
very often, but it gets in the way of our lives a lot is that whole
issue about crisis and how we deal with it and then how you not then
deal with it. After you deal with it and deal with it, and then when
there is not a crisis, how do you then come down after the crisis?

I think it is really was helpful for me to hear you acknowledge it,
because I kind of talk about it in corners, but we don\'t lay that out
on the table, not about ourselves, or about people we work with, or
anybody else.

It is huge. It is huge in my business, having been the director of the
Federation of Families for Children\'s Mental Health for 15 years in
just the fact that it is a huge obstacle in our work. For our staff and
for our family organizations across the country, we have not
acknowledged a couple of things, and one of them is our own mental
health issues, and how that plays out in our work, and then the issue of
not being able to get out of the crisis, and how that is in the way of
our work.

The fact that you acknowledge it today, I really appreciate it, because
I know it deep down, the loss, and I have experience in watching people
around me all the time. It was really helpful for you to say that, and I
can\'t remember which one of you said it.

MS. KAUL: Anne.

MS. HUFF: It was you, Anne?

MS. HERRON: It\'s all the same.

MR. CURIE: Well, thank you, everyone.

Tom, getting back to your remarks, I think we don\'t know yet totally
how SAMHSA has been changed by this. I agree with you, it has been
changed. I think one thing is people recognize the importance of the
team. I think in my whole professional career it is the best team effort
I have ever witnessed firsthand. Just the caliber of commitment and
professionalism that came forth was something that made me extremely
proud and privileged to be a part.

So I want to thank all of you for sharing today. Thanks to the panel.
Thank you, Brenda and Dan, for your tremendous ongoing leadership. Thank
you to the council for your interest.

Now we have a piece of business to take care of real quick, and that is
the approval of the minutes, the June 27th minutes. Do I hear a motion
of approval?

PARTICIPANT: So moved.

PARTICIPANT: Second.

MR. CURIE: All those in favor?

(Show of hands.)

MR. CURIE: The minutes are approved.

We would now like to take time to see if there are any public comments.
We have none pre-registered. Yes? Please introduce yourself.

MS. SHINEHOLTS: I was hoping the emergency people wouldn\'t leave. Can
you stay?

My name is Marian Shineholts. I represent the American Occupational
Therapy Association. Occupational therapists started their practice in
mental health, but somewhere along the way I guess we got mistaken.

But like the substance abuse treatment professionals, we were also
refused by the Red Cross when our practitioners stepped forward to help
in the disaster, which is rather unfortunate. A number of our therapists
in the Gulf States continued to mobilize and assist in the recovery
effort. While occupational therapists may not be first responders, we
certainly are trained in mental health to work with people with serious
mental illnesses, we work with older people with mental health problems,
and people with substance abuse problems.

In addition, the extended recovery effort is probably where the
community building, where we are most likely to be helpful in terms of
our real unique focus on function and assessment of function.

So I just wanted to speak up and also say I appreciated the discussion
this afternoon. It was very interesting about the response. Thank you.

MR. CURIE: Thank you.

Any others? Yes?

MS. KNIPMEYER: My name is Mary Knipmeyer. I\'m struck by the discussion
about how SAMHSA will change. I think we have to remember that there are
going to be all kinds of segments of society that are going to change.

For me personally, since one of the things I do is grief counseling for
people whose companion animals are either in a hospice situation or have
died, and in most cases they have died, frequently in a traumatic
situation, that I think we were all struck by the initial response when
animals were torn out of children\'s arms. People refused to leave their
homes because their animals were there.

I hope a positive thing that may come out of this is a better awareness
of the animal/human bond. As I understand it, with Rita, there was some
relaxation of the shelter rules. I don\'t know if that\'s a 14-day issue
or not, but I\'m really hopeful that the mental health aspect of how we
relate to our companions and where they fit in terms of our own survival
will be better understood as a result of what has happened.

MR. CURIE: Thank you.

MS. KAUL: Mary, can I just tell you that my mother was very concerned
about the animal situation, and the first thing I did when I was in the
shelter, when I had a minute, was most people were concerned about their
dogs, and it did relax.

MS. KNIPMEYER: It did relax.

MS. KAUL: The rule did relax, and she was very happy to hear that,
because we talked to people about getting their animals out. It was a
huge issue.

MS. KNIPMEYER: It was a huge issue. I really think that photograph of
that one child, of the guard, the national guardsman, ripping, really,
the dog out of his arms, a four- or five-year-old child. That child is
going to need some sort of special assistance.

I don\'t know how many of you know this, but at least 400 or 500 of the
animals did come to Montgomery County and are in foster care or are
being placed. Some of them are actually being held until January or
February with the hope that their original stewards will find them.

So I just had to make that comment.

MR. CURIE: Thank you. Thank you very much.

Susan?

MS. ROGERS: Hi. I\'m sorry that Kevin left, actually, because I wanted
to say I think I was on the road from Houston with him, because my
agency, the Mental Health Association of Southeastern Pennsylvania, had
sent a team down to Texas for the purpose of training people who might
help survivors of Katrina, and essentially especially people who
themselves are survivors of psychiatric trauma and illness.

So we were down there in Texas, and then Rita was coming. We were in
Houston. I was supposed to speak in Beaumont the next day, which was
right where Rita was going to hit, and so my boss told us to get out of
town. We were on the road from Houston going west Wednesday, the same
day that Kevin was, and I felt terrible and my colleague felt terrible
that we were leaving. But we had gone to the Astrodome, and they said
well, they\'ve all evacuated.

But the thing is, I\'m glad you stayed, because I\'d like to ask you to
expand on the subject of people who themselves have mental illnesses,
and what they can do, or what they have done in a disaster response
situation.

MR. CURIE: I would encourage for you and Rachel and Susan have that
discussion. If you want to make a couple of brief comments for the
record, I\'d appreciate it.

MS. KAUL: Yes, because I was going to say, Susan and I can talk offline
more, but I do think that looking at people with mental illness who are
in community programs, in outpatient situations, as well as people
suffering, people experiencing substance abuse disorders, et cetera, are
often a really valuable resource to look to, as opposed to an issue to
take to handle. You know, oh, this community we\'re serving is an issue
we need to handle.

Once people are safe, there are really good resources to use for
reaching out and pulling them back together. So we can talk more about
it, but they are really resilient. They already know how to access
services in a way that most of the community does not in a disaster.

MS. HUFF: They\'ve had to.

MS. SULLIVAN: Isn\'t that a riot?

MR. CURIE: Thank you, Rachel, and I want to thank everyone for their
public comments.

I have just been informed that I\'m going to be unable to be here really
all day tomorrow. I have been called downtown for media interviews and
I\'m going to be meeting the Secretary prior to the press conference as
well. So Daryl will be chairing the meeting. And that\'s good stuff.
It\'s a good thing.

MS. SULLIVAN: That\'s a good thing.

MR. CURIE: That\'s what it is. I think the Secretary will be on CNN and
I\'ll be on NBC.

MS. SULLIVAN: Really?

MR. CURIE: You seem awful happy about me not being here. I don\'t want
to read too much into that.

(Laughter.)

MR. CURIE: A couple other changes for the agenda tomorrow. We have at
9:15 a.m. the Medicare Modernization Act, based on Tom\'s request, to
talk about changes in Medicare, the update around our constituencies,
and what SAMHSA has been doing with CMS in the process. So tomorrow
morning, Anita Everett, who has been our point person with that, will be
here. We\'ve added that.

Plus, Alvera Stern will be here instead of Mark Weber to talk about the
underage drinking prevention advertising campaign. Mark will be with me.

We could take maybe, and again, this won\'t do justice, but I\'d like to
at least hear a little bit of feedback, five minutes, from folks to talk
about the matrix, thoughts you may have on the matrix, because tomorrow
you will have time to talk about that in a roundtable discussion, but I
won\'t be able to be here. I\'ll definitely be paying attention to the
record of the meeting and looking for your input.

Kathleen?

MS. SULLIVAN: I talked to a couple of people on the board about it. As
far as taking what we now know about the center, widening it a little
bit, not just being disaster response, but opening it to a crisis
response that\'s almost active in kind of a full mode that\'s more
toward a 24/7 feeling, and expanding it a little bit, putting it into
the matrix, as you said, and the cross-cutting principles, Daryl, and
opening it up to base closings, military base closings, unemployment,
Ford Motor plant closings, 40,000 people unemployed here, 20,000 people
unemployed when Ford closes a plant.

We\'re seeing also with cities now, being out for employment for
different companies, that city are just losing immediately manufacturers
and have huge unemployment overnight affecting down the line different
areas of mental health. You know, the whole gamut for families\'
interaction, complete crisis management.

So my thought is to, like you said, to put the disaster response team
into the matrix and expand it, though not call it disaster, to make it
crisis, and make one of its goals also to take care of people who are in
crisis mode because of unemployment.

MR. CURIE: Thank you. I think we\'ll examine that in light of how we
have made a wide range of express reactions, crisis reactions, a major
focus of implementing what we\'ve learned from the research. I
appreciate your comments.

Other thoughts? Gwynn?

MS. DIETER: Suicide is not on our issues.

MR. CURIE: That\'s correct. It\'s not.

MS. DIETER: Wasn\'t it?

MR. CURIE: No, it never was.

MS. DIETER: But we did make it ‑‑

MR. CURIE: That\'s why I brought it up, though. Maybe we should put it
on.

MS. DIETER: That\'s exactly what we\'re sitting here saying. Because we
did make it ‑‑

MR. CURIE: We\'ve never been explicit about it on the matrix.

MS. DIETER: Right, but we did make it a priority or initiative or action
item about a year ago, specifically, I thought. So I guess I haven\'t
looked in my matrix as closely, but we feel like it ought to be on
there.

MR. CURIE: No, I appreciate that. There are certain things that we have
to say that are included in mental health transformation, but we
haven\'t been explicit about certain things. One purpose the matrix
serves is over time it gives us an opportunity to bring things to the
forefront, to really put a focus on for maybe a two- or three-year
period of time, even though it has been represented in a more inexplicit
way, if you will.

So what I\'m hearing you say is it\'s time for now to focus on it and to
bring suicide prevention to a more prominent place on the matrix.
That\'s what I\'m hearing.

MS. DIETER: Yes.

MS. HUFF: Yes.

MS. DIETER: Now, does that involve removing one of the other items?

MR. CURIE: Yes.

MS. DIETER: It does?

MR. CURIE: That\'s why, again, if we move to disaster response as a
cross-cutting principle, we\'ll lose a slot.

MS. DIETER: Well, I could see a couple.

MR. CURIE: Well, if you want to remove something, we can put that on the
table, too,

MS. DIETER: Well, I mean, if we need to. I would prefer having ‑‑ okay.

MR. CURIE: You\'d prefer having it all on. I hear you.

MS. DIETER: Yes. I\'d prefer having all of these on with the addition of
suicide. I also think it\'s foolish to make long, long, lengthy lists
because then you can\'t really attend to ‑‑

MR. CURIE: It doesn\'t prioritize.

MS. DIETER: No, it doesn\'t prioritize. So in terms of priorities, and I
hope I don\'t offend anyone by giving my priority, I would prefer to
have suicide rather than homelessness.

MS. HUFF: No.

MR. CURIE: I appreciate that.

Faye?

DR. GARY: As you know, I have followed the matrix very closely, and have
found it very, very useful.

MR. CURIE: Thank you, Faye.

DR. GARY: Very, very useful. Easy to follow, easy to use it to discuss
with a variety of different people who may or may not be the person
about these issues.

I just had one kind of procedural question. I\'m just learning a bit
more about the redwoods.

MR. CURIE: The redwoods, yes.

DR. GARY: The redwoods. I was wondering if you\'ve given any thought to
how they could be identified in the matrix.

MR. CURIE: Well, that\'s a very good question. I mean, the actuality is,
I know I reviewed all of those, I think 11 priorities ‑‑ I believe there
are 11 of them ‑‑ in the blue axis as, really, they are all redwoods.
There have been formed what I have called the big redwoods in terms of
prioritizing, and those would include Substance Abuse Treatment Capacity
Expansion, Co-occurring Disorders, Mental Health Systems Transformation,
and Strategic Prevention Framework.

Those are viewed as definitely priorities that are systemic in nature,
and clearly, as I talk about, as an issue\'s time comes, we try to move
toward it to a tipping point to really make a difference, and those are
the four big redwoods we\'ve identified, and that helps us prioritize
further the budget process, because even among all these redwoods, so to
speak, we are not able to fund new money each year into each one of
these. So we\'ve got to prioritize which ones do we feel are the big
redwoods, if you will, that represent that systemic change. That is how
they have basically been sorted out so far, those being the four big
ones.

Now, I would also entertain from the council thoughts you have if there
are any thoughts of making any sort of distinction of these priorities,
and to bring any others into the major, big redwood area.

Again, I think co-occurring is an example of one that I\'m hopeful that
in a two- to three-year period that we have solidified in our systems a
predisposition toward accounting for co-occurring disorders through
assessment, through treatment and treatment modalities, so that perhaps
it won\'t always have to be a big redwood, and maybe someday not even be
on the priority list because it\'s the normal way we do business.
That\'s how we hope some of these things will drop off over time.

MS. HUFF: Maybe they should be in a different matrix.

DR. GARY: I was thinking that I think you made a very excellent point
about the budget and if we were to say what the redwoods are, how could
we communicate that visually to people who might be considering writing
grants focusing a program for states. I was thinking that visually if
there is a way to capture these redwoods, so that people would know
that, because it is going to drive the bottom line, and it\'s going to
drive what you\'re funding. That would be helpful.

MR. CURIE: Yes.

MS. KADE: Actually, the first year that Mr. Curie was here and
introduced the matrix, what we did was to translate the budget so that
it is organized by various matrix categories. One of the issues in this
gets to be lifespan continuum. One of the issues is that it had to be a
forced choice of more than one redwood or you\'d be double counting for
the budget. As a result, some children\'s programs were showing up in
HIV/AIDS, et cetera.

One of the issues that we\'re facing in the last couple of years as we
put more and more money into those four redwood categories, we\'re
seeing that a lot of the lifespan target populations that are on the
matrix are being addressed in the four redwoods, but you can\'t tell
from the budget, because it is a forced choice budget.

So one of the questions is how do you integrate a lot of these priority
areas into our redwoods because they are being addressed by, for
instance, ATR, and a lot of the target populations for juvenile and
critical justice. It is showing in treatment capacity, but it is also
criminal justice, and it\'s also children.

DR. GARY: The other observation that I would like to make is that I
would like us to somehow integrate stigma. We have it cross-cutting, but
I think it is more pervasive than being cross-cutting. I think it is one
of the major barriers that prevent people from seeking mental health and
from sustaining themselves in the program.

Of course, the other comment is that someplace, perhaps in a letter, the
idea of poverty, the alleviation of poverty. I think it is, too, one of
the major barriers to well-being in this country or anyplace in the
world. I would want us to just be in front about it. People who are
impoverished just don\'t have good mental health, and are at risk for
everything. Heart disease, diabetes, mental health, substance abuse,
crime, you name it.

So I think we need to take the national lead and say that and put that
in some kind of language, so it is communicated to everyone. So that
would be another recommendation that I would make.

MR. CURIE: Thank you, Faye. Thank you very much.

DR. GARY: Thank you for listening.

MR. CURIE: Does anyone want to give one final thought? I\'m thinking
Barbara would be the appropriate person.

MS. HUFF: Well, unfortunately, we\'re having a sideline conversation,
and I don\'t like sideline conversations, but we\'re trying to figure
out the HIV/AIDS and hepatitis on here, are we talking about mental
health needs for HIV and hepatitis? Explain that.

MR. CURIE: We\'re actually talking about the fact that one of the
biggest reasons HIV spreads in this country, and also hepatitis C, is
because of needles and drug use. So that\'s a major part of it. It is
also the answer of yes, it has to do with the mental health needs of
those individuals.

MS. DIETER: No, but we have discussed that once before, though, how it
is addressed (inaudible).

MR. CURIE: If we\'re going to prevent HIV from happening, it requires a
public health response.

DR. GARY: I just wanted to add, too, that especially with young adults
and adolescents, one of the issues that happens is the use of
substances, alcohol and substances, as a method of preparing themselves
to participate in unsafe sex. That\'s a problem with the party life. You
can\'t address HIV/AIDS unless you address substance abuse and alcohol
in adolescents and young adults, and probably older ones, too.

MR. CURIE: So that\'s why it\'s there. Thank you.

Is that it? Okay. I want to thank you all for your thoughts and
encourage you to continue the dialogue tomorrow.

I also encourage you, even if you want to express your thoughts to me
informally, you have my phone line, my email, and my door is always
open. We\'re very interested in your thoughts.

MR. STARK: Can we leave our stuff in the room?

MS. VAUGHN: Oh, yes.

MR. CURIE: Yes, you may leave the stuff in the room.

MS. VAUGHN: We\'re going to lock the room, so if you want to leave your
items, they will be protected.

MR. CURIE: Very good. Have a nice evening everyone, and I will see you
at 2:00 tomorrow.

(Whereupon, at 5:12 p.m., the meeting was recessed, to reconvene at 9:00
a.m. on Wednesday, December 7, 2005.)