**Substance Abuse and Mental Health Services Administration**

**38th Meeting of the SAMHSA National Advisory Council**

**Minutes**

**December 6-7, 2005**

**Rockville, Maryland**

## 

The Substance Abuse and Mental Health Services Administration's (SAMHSA)
National Advisory Council convened for its 38th meeting on December 6-7,
2005, at the SAMHSA offices in Rockville, Maryland. The meeting was
co-chaired by Charles G. Curie, M.A., A.C.S.W., Administrator, SAMHSA,
and Daryl W. Kade, M.A., Executive Director, National Advisory Council,
and Associate Administrator for Policy, Planning and Budget, SAMHSA.

Council members present: Gwynneth A. E. Dieter, Faye Annette Gary,
Ed.D., R.N., Barbara Huff, Thomas A. Kirk, Jr., Ph.D., Thomas Lewis,
Theresa Racicot, Kenneth D. Stark, and Kathleen Sullivan.

Council members absent: James R. Aiona, Jr., Columba Bush, and Diane
Holder.

Ex-officio member present: Laurent S. Lehmann, M.D.

Council Executive Secretary: Toian Vaughn, M.S.W.

Non-SAMHSA Federal staff present: 10 individuals (see Tab B for Federal
Attendees List).

Representatives of the public present: 33 individuals (see Tab B for
Public Attendees List).

TUESDAY, DECEMBER 6, 2005

**Welcome and Opening Remarks**

SAMHSA Administrator Charles Curie, M.A., A.C.S.W., called the meeting
to order at 9:13 a.m. and welcomed attendees. He noted the significant
and tragic losses to Gulf Coast victims of the recent hurricane season.
He also stated that the hurricanes brought several challenges to the
Department of Health and Human Services (HHS) and SAMHSA. Mr. Curie
lauded the inspirational service of SAMHSA staff, all of whom
contributed to the disaster relief in some capacity. Mr. Curie observed
the critical and important role that substance abuse and mental health
services played in the overall public health response to this tragedy.
Hurricanes Katrina and Rita posed the first major national disaster
since the events of September 11, 2001, and although the acute response
was accomplished within the first months, the disasters are expected to
give rise to more consequences in coming years.

Mr. Curie welcomed back Mr. Thomas Lewis, introduced new member Dr. Faye
Annette Gary, introduced other Council members, and noted that Mr.
Kenneth Stark now serves as Director of Washington's Mental Health
Transformation State Incentive Grant (SIG). Mr. Richard Kopanda serves
as Acting Director of the Center for Substance Abuse Prevention (CSAP);
former CSAP Director, Ms. Beverly Watts Davis, serves as Senior Advisor
for Substance Abuse at SAMHSA, and Mr. Andrew Knapp is Acting Deputy
Administrator of SAMHSA. Former Special Assistant to the Administrator,
Stephenie Colston, has become the Director of Alcohol and Drug Abuse for
the State of Florida. Mr. Curie introduced Ms. Kana Enomoto, Special
Assistant to Mr. Curie; Ms. Cheri Nolan, Senior Policy Advisor for
criminal and juvenile justice, and chair of the Criminal/Juvenile
Justice Workgroup; and Javaid Kaiser, Ph.D., Director, Office of Applied
Studies.

**Administrator's Report**

Mr. Curie reported that SAMHSA has received an exceptional rating within
HHS for its management and programmatic priorities, as reflected on the
matrix. The matrix identifies SAMHSA's priorities and management
principles and helps to align its focus and resources to operationalize
recovery from a public finance and public policy standpoint. Related to
expanding substance abuse treatment capacity, in the Access to Recovery
(ATR) program, approximately 31,000 people have used vouchers to
purchase treatment and recovery support services, while an additional
7,000 persons may also have been supported by the program. To improve
services for persons with co-occurring disorders, SAMHSA continues to
advance the Blueprint for Change incorporated in the agency's Report to
Congress, which also outlines development of the National Co-occurring
Center for Excellence. The Treatment Improvement Protocol (TIP) on
co-occurring disorders is used in many places around the country. SAMHSA
has implemented Co-occurring Disorders SIGs in 15 States, enabling more
people with co-occurring disorders to receive screening, assessment, and
treatment.

SAMHSA has raised mental health transformation to a priority.
*Transforming Mental Health Care in America---Federal Action Agenda:
First Steps*, the Federal government's response to the final report of
the President's New Freedom Commission on Mental Health, was issued in
July 2005. Its 70 action steps lay the groundwork for a transformed
system of care that encompasses State and individual delivery systems.
To assist States to develop and implement plans for a sustained effort,
SAMHSA awarded \$19.8 million in mental health transformation SIGs to
seven States. In increasing its focus on prevention, SAMHSA has created
the Strategic Prevention Framework (SPF), which helps communities
identify their unique risk and protective factors for substance abuse
and then implement programs best suited to meet their particular needs.
A reinvigorated Drug-Free Communities (DFC) Program focuses on coalition
building, SPFs, and the National Registry of Effective Programs &
Practices (NREPP). DFC's goal is to work with States to assure that
every community has access to information and the resources to implement
individualized programs, with baselines from which to measure
communities' progress in reducing illicit drug and underage alcohol use.
SAMHSA is implementing new National Outcome Measures in partnership with
State substance abuse and mental health authorities, with full reporting
on all measures required by the end of FY 2007. A new Institute of
Medicine (IOM) report recommends forging new partnerships with licensing
boards and accrediting bodies to help expand the workforce and improve
core competencies by providing incentives for educational institutions
to improve the science and relevance of the content they teach.

Mr. Curie asked Council members for their input and feedback on
potential updates to the matrix that are needed to adapt to the
realities in the field. He suggested the prospect of moving disaster
readiness and response from a priority to a cross-cutting principle;
moving workforce development to a priority; and adding suicide
prevention as a priority. Mr. Curie reasserted that the elimination of
seclusion and restraint should remain a priority program that would
shift to a cross-cutting principle when non-use of these practices
becomes the norm for all age groups in behavioral health care settings,
both institutional and community-based. Mr. Curie noted the need to do
more to impact underage drinking and asked for guidance on how to
reflect this need. He spoke of the importance of consumer and
family-driven care, electronic health records, consumer choice in
voucher programs, technology for improving information in a
family-driven system, and self-directed accounts. Mr. Curie stated that
an immediate SAMHSA objective is to intensify our efforts with the
Centers for Medicare and Medicaid Services (CMS) to make self-directed
accounts possible for persons with mental and/or substance abuse
disorders. He also suggested bringing to scale the Screening, Brief
Intervention, Referral, and Treatment (SBIRT) program and asserted that
more must be done in the areas of criminal and juvenile justice.

Mr. Curie stated that SAMHSA, in acknowledging its joint responsibility
with the HHS to improve the human condition throughout the world, has
increased its international efforts to build and/or rebuild mental
health systems and substance abuse treatment capacity and prevention in
post-conflict countries, including Afghanistan and Iraq.

In closing, Mr. Curie observed the need for SAMHSA to focus on its
priorities, generate ongoing urgency and excitement in the field, and
explain to legislators the need to support SAMHSA's budget requests. He
noted that the emphasis in government on the need to curtail spending
and make program cuts demonstrates further the importance of setting
priorities.

HAS

**Council Discussion**

Dr. Gary observed that the matrix gives clear direction to service
providers and academicians. She urged continuing to regard stigma as a
cross-cutting principle and urged partnerships with other Federal and
State agencies, accrediting bodies, academic institutions, and advocacy
organizations. She advocated focusing special attention on populations
among which suicide is increasing yearly---African American males,
American Indians, and Hispanic youth and adults. Mr. Curie noted that
the role of stigma, which is listed along with recovery as a
cross-cutting principle, can be further prioritized and highlighted.

Dr. Thomas Kirk described the challenges to State stakeholders in
understanding that the ATR, Transformation SIG, and SPF grants represent
major system-change initiatives, with the focus changing to a prevention
and wellness approach. He also urged emphasizing the link between mental
health and primary care services and expressed interest in an update on
the Medicare Part D benefit.

Ms. Barbara Huff expressed appreciation for the Transformation SIG's
emphasis on a lifespan system change, and urged focus on initiatives
related to seclusion and restraint and other high-priority issues,
particularly the provision of technical assistance, and that SAMHSA take
a similar lifespan approach to ensure adequate focus on children and
youth. Ms. Huff noted that seclusion and restraint factor into death and
injury at unlicensed residential care facilities, and urged convening a
group to consider how stigma relates to young children. Mr. Curie
described progress in eliminating seclusion and restraint in adult State
psychiatric institutions and other inpatient settings, achieved with the
help of the National Association of State Mental Health Program
Directors (NASMHPD). The Child Welfare League and other associations
have begun to influence children's settings. Mr. Curie acknowledged the
appropriateness of embracing a lifespan approach. He noted that SAMHSA
has been working with juvenile justice facilities and suggested a
portfolio review to move to the next level.

Ms. Huff urged funding fewer programs, with more resources allocated to
evaluate effectiveness. Mr. Curie added that a related issue is bringing
to scale programs that demonstrate measurable impact.

Ms. Gwynneth Dieter expressed her belief that the work in Alabama and
that of such action groups as the Parent Corps in Colorado to educate,
support and unify the community, make a significant contribution to
reductions in underage drinking.

Mr. Stark asserted that the term *behavioral health* feeds stigma and
negates the physiological/ biological/genetic basis of mental illnesses
and drug addictions, and that use of the term also creates difficulty in
aligning with the primary care field. Mr. Curie concurred that the term
is neither descriptive nor useful. He noted that SAMHSA considers
discrimination to be the evidence of stigma, that treatment of
co-occurring disorders may be impeded by the term, and asserted that
SAMHSA will continue to focus on clarity. Ms. Huff added that young
people do not like the term *emotionally disturbed*.

**FY 2006 Appropriations Update and HHS "Top 20" Priorities**

Ms. Daryl W. Kade, M.A., Executive Director, SAMHSA National Advisory
Council, and Associate Administrator, Office of Policy, Planning and
Budget, SAMHSA, reported that Congress has not yet passed the FY 2006
HHS appropriations bill. SAMHSA is funded through a continuing
resolution that expires on December 17. Passage of an omnibus
appropriations bill is anticipated before then, with a budget
rescission. SAMHSA has made assumptions about the budget and will adjust
funding based on the new law.

Staff are working on the FY 2007 budget. Ms. Kade stated that, to the
extent that SAMHSA lacks data to demonstrate programs' effectiveness
with systems and individual client outcomes, the agency is at a
disadvantage. Strong emphasis is being placed on the data strategy.

Ms. Kade reviewed HHS's top 20 objectives for program and management,
the basis for performance assessments. She noted the criticality of
scoring well on the management objectives in order to leverage change in
the program objectives. Critical objectives that affect SAMHSA include:
objective 1(a) ---transform the healthcare system - increase access to
high quality, effective health care that is predictably safe; objective
2---strategically manage human capital; objective 4---complete the
competitive sourcing program; objective 6---improve financial
performance; objective 7(a) ---secure the homeland -- by increasing the
capacity of the health care system to respond to public health threats
and bioterrorism, as well as natural causes; objective 10(a) ---improve
budget and performance integration -- meet the Office of Management and
Budget (OMB) mandated "Green" standards for success; objective 11(b)
---improve the human condition around the world -- implement a strategy
to support emerging democracies with health diplomacy; objective
15---promote quality, relevance and performance of research and
development activities; objective 17(b) ---emphasize faith-based and
community solutions - expanding faith-based and community partnerships
in providing effective health and human services; and objective 19(c)
---emphasize healthy living and prevention of disease, illness, and
disability---reduce the incidence and consequences of injuries,
violence, substance abuse, mental health problems, unintended
pregnancies and sexually transmitted diseases.

**Council Discussion**

In response to a request by Ms. Kathleen Sullivan, Ms. Kade offered to
provide public data on SAMHSA's scores on OMB's "Green" Standards for
Success, to which the objectives are linked. Ms. Huff asked whether
objective 13(b)---increase the percentage of adults and children who
have access to quality health care services through private health
insurance---includes mental health. Ms. Kade will investigate and she
stated that it was developed with CMS in mind, but saw no reason why
SAMHSA could not partner with them. Ms. Huff asserted that the objective
should include mental health as well as primary care under the CHPs
program. Ms. Kade stated that she will convey the message to the agency
with the lead for the objective.

Referring to objective 19(a), Mr. Stark noted that *behavioral health*
brings to mind diabetes, obesity, asthma, heart disease, cancer, and
stroke, along with alcohol, drugs, and mental health. Regarding
objective 18, he asked if streamlining might result in moving some
SAMHSA functions to HHS. Ms. Kade responded that HHS is likely to
centralize the information function and there is some conversation with
regard to contracts and grants management. Issues under consideration
are performance plans for OPDIVs and STAFFDIVs and ensuring that
contracts are sensitive to consumers of centralized functions.

Dr. Kirk asked for guidance on Council members advocating as individuals
on issues of importance to SAMHSA. Council Executive Secretary Ms. Toian
Vaughn advised that when members attend a Council meeting or represent a
U.S. Government agency, they may not advocate as Council members. Under
other circumstances, members can discuss with other individuals or
organizations issues that have been raised at meetings.

**Capitol Hill Update**

SAMHSA Director of Legislation, Joseph D. Faha, announced that the
Labor/HHS/Education Appropriation had passed the House but was facing
objections in the Senate over the Low Income Home Energy Program
(LIHEAP) and aid for Katrina. The Senate expects to begin SAMHSA's
reauthorization in March 2006. Briefings are to begin in January, at
which SAMHSA staff will describe SAMHSA's activities and needs for
substance abuse and mental health treatment and prevention services.
Related bills focus on underage drinking, mental health transformation,
and methamphetamine. Other issues of importance include accountability,
workforce development, mental health services for homeless individuals,
services for the elderly, and parents relinquishing custody of their
children to obtain mental health services. A bill Congress passed
outside reauthorization was the National All Schedules Prescription
Electronic Reporting Act (NASPER), which gives the HHS Secretary
authority for a block grant program for States to establish prescription
monitoring; however, no money was allocated and a duplicate Department
of Justice program exists. In response to a request from Ms. Sullivan,
Mr. Faha agreed to compile a list of reauthorization issues in which key
legislators are interested.

**New Mexico Strategic Prevention Framework State Incentive Grant
Overview**

SAMHSA Senior Advisor on Substance Abuse, Ms. Beverly Watts Davis,
explained that SAMHSA's SPF SIGs were designed to create accountability
within States, as they implement data-driven decisions that support
effective substance abuse prevention planning, as well as flexibility to
focus on the highly complex nature of substance abuse. The SPF
emphasizes attention to identifying risk and protective factors of
children, the nature and scope of the problem, and ways to build service
capacity in communities. The implementation phase enlists communities to
take the necessary steps to reduce substance abuse and holds States
accountable through evaluation measurements of the effectiveness of
activities undertaken. The first cohort of SPF grantees included 19
States, later expanded with a realignment of resources to 24 States and
two territories. The goal is to provide access for all States to the
SPF, which involves helping States convene and coordinate the activities
and funding streams of other organizations doing substance abuse
prevention, with State advisory councils helping to leverage the funds.

**New Mexico Strategic Prevention Framework State Incentive Grant**

Mr. Don Maestas, M.S.W., Project Director, New Mexico SPF SIG grant,
described New Mexico's Prevention Service System. Partners include State
departments, technical assistance organizations, and CSAP/SAMHSA. Mr.
Maestas presented examples of people who have turned their lives around
through SPF projects and several effective evidence-based programs. The
annual \$2.3 million, 5-year SIG puts forth evidence-based prevention
programs to reduce underage drinking and other substance use and to
promote youth abstinence. The program requires rigorous multilevel
evaluation.

New Mexico's SPF SIG began in 2004 with a statewide needs assessment and
then progressed to building capacity among community-based prevention
providers to use data to identify problems and appropriate
interventions. The next step was to develop a comprehensive strategic
plan, and currently New Mexico is implementing evidence-based programs
and activities while also monitoring, evaluating, sustaining, improving,
and replacing ineffective activities. Sustainability and cultural
competency are overarching elements of the framework.

Mr. Maestas described New Mexico's assessment activities, which include
development of indicators to drive identification of intervening or
causal factors and support selection of evidence-based strategies,
assess substance abuse-related problems, specify baseline data, and
identify priorities. Over the past decade, New Mexico has been ranked
first or second among States in chronic alcohol mortality and
drug-related mortality. Mr. Maestas enumerated the types of data
collected, the categories used in analysis, the logic model that guided
the analysis, and a number of strategies pursued.

To build capacity, New Mexico has provided problem-focused training
programs across the State, and additional training is planned for
funding recipients. An RFP was developed for distribution of services,
and eight implementation communities and five capacity communities
(communities with high need and low capacity, which will be the focus of
intensive capacity-building assistance) have been selected. In March
2006, communities will submit their strategic plans for approval. To
conduct the evaluation, a contractor is developing problem statements
and the broader prevention framework. Community-level indicators will be
measured, and development is underway of tools to measure the
effectiveness of environmental strategies. A more difficult task will be
counting the number of individuals impacted in communities.

New Mexico's successes include development of the State's third
five-year prevention plan, evidence-based prevention programming in more
than 40 communities, a strong grants management system, a comprehensive
workforce development system, and outcome evaluations that show that
evidence-based prevention is measurably effective in reducing teenage
alcohol, marijuana, and tobacco use. Mr. Maestas acknowledged the
challenges of reducing use still further. He stated that questions
remain about whether the right programs are used with the right
individuals. He noted that New Mexico has adapted most of the
evidence-based programs with their creators to achieve cultural
competency to fit its populations.

**Council Discussion**

Mr. Stark asked whether New Mexico is reviewing archival data sets to
identify improvements in school and criminal justice problems. Mr.
Maestas responded that they are gathering data on such longer-term
effects and that a report is expected to be available within six months.

Ms. Huff asked how New Mexico's SPF SIG interfaces with children's
mental health, to which Mr. Maestas responded that collaboration is
ongoing with multiple agencies that serve children, including children's
mental health.

Dr. Gary commended use of county epidemiological data to plan and
implement evidence-based interventions to solve counties' unique
problems and noted the importance of health literacy. She asked whether
data has been collected for substance use beyond 30 days, whether
booster programs are used to sustain transformation, and the extent to
which other community-based organizations are involved. Mr. Maestas
responded that New Mexico has resources to collect follow-up data at 6
and 12 months, and agreed to share the data with the Council when
available. Mr. Maestas stated that some communities conduct booster
programs and that SPF may serve as a booster in that it looks at
changing community norms among individuals and groups across the
lifespan. He noted pride in New Mexico's partnerships with tribal
communities to generate and sustain support for continuity, capacity
building, and program implementation.

Dr. Kirk observed that New Mexico also has a Transformation SIG, which
permits integration of prevention and promotion of mental health to
effect systems change. Noting that New Mexico's system is based on asset
development, health promotion, and outcome measures, he suggested that
the next stage might include system-based outcome measures.

To a question from Dr. Laurent Lehmann on diversity, Mr. Maestas
responded that ethnic breakdowns were considered in selecting urban and
rural sites for program implementation. Mr. Curie observed that New
Mexico has demonstrated the feasibility of implementing a strategy based
on outcomes, has shown that prevention works, and has offered
opportunities for messages to bring to scale.

**Public Comment**

Ms. Cheryl D. Reese, National Association of Lesbian and Gay Addiction
Professionals, commended SAMHSA for supporting LGBT issues, particularly
production of the 2001 "A Provider's Introduction to Substance Abuse
Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals," and
urged early publication of the draft training manual. Ms. Reese also
noted the impacts of exclusion, stigma, and suicide on alcohol and drug
use in the LGBT community, and pointed to emerging increases in youth
suicides in the LGBT community. She asked SAMHSA to join in a meaningful
partnership.

Ms. Susan Rogers, Mental Health Association of Southeastern
Pennsylvania, concurred with Council members on not using the term
*behavioral health* and urged using the word *discrimination* whenever
stigma is mentioned. Pennsylvania's anti-stigma campaign calls itself an
anti-discrimination campaign and does not mention stigma.

**SAMHSA's Response to Hurricanes Katrina and Rita**

-   **Administrator's Remarks**

Mr. Curie amplified his earlier remarks on SAMHSA's response to
Hurricanes Katrina and Rita. He stated that he visited the devastated
regions of the Gulf Coast on several occasions, paying particular
attention to SAMHSA's mental health and substance abuse response.

In Katrina's immediate aftermath, SAMHSA activated the SAMHSA Emergency
Response Center (SERC), which supported States and grantees impacted by
the storms. SAMHSA provided support to the National Suicide Prevention
Lifeline, which experienced a spike in calls of more than 60 percent;
held weekly conference calls to coordinate services to consumers; and
expanded the Web site to provide information and links to key resources
and organizations.

Authorized to make available up to 2.5 percent of its discretionary
funding for emergency services, SAMHSA was able to allocate only
\$600,000 to Louisiana, Mississippi, Florida, and Texas because it was
the end of the fiscal year. Funds were disbursed in response to States'
assessments of their needs with specific focus on continuity of care,
children with serious emotional disturbances, and individuals with
addictions who needed treatment. Working with FEMA, SAMHSA made
recommendations to award 29 full and 2 partial grants to States for
immediate services, for a total of \$20.5 million. The SERC coordinated
mobilization of more than 300 field workers on mental health and
substance abuse issues. Thirty States are eligible to apply for regular
services program grants, which provide funds for up to nine months after
disaster declarations. SAMHSA will continue to work with States to
ensure that mental health assessment and crisis counseling are readily
available to residents and evacuees and to establish a longer-term plan
to address post-traumatic stress disorders (PTSD), particularly for
first responders and vulnerable populations. SAMHSA also will continue
its work with Federal partners to help people with chronic disorders.
Mr. Curie expressed pride in SAMHSA's staff, who worked long days and
weekends throughout the first several months of the disaster. Nearly
half the staff were either deployed to affected areas, or worked in the
SERC, while others filled in to continue the usual work.

-   **Key Elements of SAMHSA's Response to Hurricanes Katrina and Rita**

SAMHSA Emergency Coordinator Dan Dodgen, Ph.D., presented an overview of
the National Response Plan (NRP) that governs the activities of all
Federal departments and agencies, including the American Red Cross, in
emergencies. The plan, invoked when States request assistance, provides
for an Interagency Incident Management Group (IIMG) that sets policy for
disaster responses. Recognizing the importance of mental health and
substance abuse issues in the aftermath of Katrina and Rita, the HHS
requested that SAMHSA be allowed an additional representative seat on
the IIMG. The NRP provides for 15 emergency support functions (ESF), of
which the most critical to SAMHSA include: ESF6---mass care housing and
human services; ESF8---public health and mental health services (led by
HHS); ESF14---long-term community recovery and mitigation; and
ESF15---external affairs, where SAMHSA provides consultation in public
education and information.

Dr. Dodgen reviewed SAMHSA's interactions with FEMA, including the
mission assignment process, among whose key components are
"deconflicting" (information sharing across systems) and the Crisis
Counseling Program. CMHS's 30-year history of emergency response work
has established SAMHSA's credibility to lead mission assignments. SAMHSA
meets with its ESF8 partners to deconflict information in order to
provide the best response to States. SAMHSA maintained communications
with Federal and State agencies, nongovernmental organizations, and
other stakeholders. Existing partnerships fostered SAMHSA's impact in
addressing local concerns with States. In addition, SAMHSA took the lead
in working with the Occupational Safety and Health Administration (OSHA)
to develop strategies that support people in the field and those who
have experienced trauma.

SAMHSA assists local communities to respond to emergency situations;
coordinate resources, assets, and activities; provide subject matter
experts; provide planning grants; and facilitate getting services on the
ground. In response to a question from Mr. Stark about SAMHSA's plans in
the case of decimated State infrastructure, Dr. Dodgen stated that
extensive planning was essential for SAMHSA to be able to respond as it
did, but that the scale and impact of the disaster were unanticipated.
He asserted that States performed above and beyond expectations.

-   **What is the SERC and What Did It Do?**

Ms. Brenda Bruun, CMHS, Program Analyst, Division of Prevention,
Traumatic Stress and Special Programs and SAMHSA SERC Coordinator for
Hurricanes Katrina and Rita, stated that the SERC coordinates with other
partners and agencies, including the Centers for Disease Control and
Prevention, Red Cross, National Association of State Mental Health
Program Directors (NASMHPD), National Association of State Alcohol/Drug
Abuse Directors (NASADAD), and major mental health guilds, to deliver
mental health and substance abuse services after a disaster to support
State and local efforts. She explained that immediately after Katrina
struck, Mr. Curie activated the SERC, which mobilized all resources in a
streamlined management structure. Through the Incident Command System
(ICS), a standardized structure was implemented to eliminate duplication
of effort, coordinate communications, and clarify lines of authority and
command. The ICS helps to mobilize all resources quickly---personnel,
logistics, planning, finance, public information, recording, and
communication. Each function is staffed by trained persons who report to
the incident commander.

Incident command functions, as described by Ms. Bruun, included triage
and assigning tasks; coordinating with emergency coordinators outside
the agency; preparing a plan of the disaster's impact to project
allocating resources; managing logistics, made difficult because of a
lack of housing and transportation and the need to provide
nontraditional supplies to protect SAMHSA staff; tracking financial
activities; providing accurate public information; and deploying,
briefing, and providing support to field personnel. Ms. Bruun stated
that she considered the key to a successful ICS to be well-trained staff
empowered to make decisions.

SAMHSA provided many staff on a continuous cycle for affected locals and
conducted a survey to learn about destroyed facilities in order to
assess needs and target resources; the data was posted on the SAMHSA Web
site. To Mr. Stark's question about whether funds were used to support
local clinicians, Ms. Bruun responded that hiring local displaced
clinicians was a priority that was accommodated when possible.

Ms. Bruun provided data concerning clinical sessions, counseling
sessions, and referrals to mental health and substance abuse services.
Service use is expected to rise at this point after the disaster.
Sixty-nine percent of referrals were for additional services such as
housing assistance. Many interns staffed the database function, which
offered an incomparable professional experience, especially to interns
deployed to the field.

**Council Discussion**

Dr. Gary asked whether focus was given to health professionals and first
responders who might experience PTSD, the identity of other stakeholders
with which SAMHSA is partnering, whether literacy level and cultural
world views are considered when materials are prepared for diverse
target audiences, how stigma affects people's choice to accept or reject
help, and who were the recipients of the grants awarded. She also
requested information on requirements and restrictions related to
outcome data and accountability for emergency response grants; asked
that the lessons learned document to be developed, which has
implications for professional training, be shared with Council members;
and suggested that SAMHSA open a discussion of poverty as a risk factor
for mental illnesses and substance abuse.

Dr. Dodgen responded to the question about worker care by pointing out
how SAMHSA supported its own workers and modeled that behavior. A system
of orientation and debriefing was established to prepare people in the
field and to permit them to talk about their experiences. A brochure was
disseminated on stress and its management to staff in the field. SAMHSA
is working with the Occupational Safety and Health Administration (OSHA)
on a model for all deployed workers and federalized civilians. Under
SAMHSA's guidance, OSHA is preparing materials for family members and
workers to help facilitate reentry into the workforce. Ms. Bruun added
that contractors involved in the response were required to take the same
care as did SAMHSA staff. In addition, SAMHSA provided services to give
local providers a break to go home or to listen to them.

Dr. Dodgen noted that SAMHSA's stakeholder partners include its ESF8
partners, SAMHSA's traditional partners in the mental health and
substance abuse fields, and some new partners, including the
Administration on Children and Families and the Department of Education,
among others. The public information office has worked to develop
materials that are linguistically and culturally appropriate for various
audiences, including parents, children, teachers, and others.

Dr. Dodgen acknowledged that the issue of stigma is multilayered, but
that SAMHSA has broken new ground in terms of recognition at the State
and local levels of the importance of substance abuse and mental health
in emergency response. He stated that SAMHSA plans to prepare an
integrated lessons learned document whose executive summary might be
useful to the Council.

Ms. Huff asked how Ms. Bruun and Dr. Dodgen took care of themselves. Ms.
Bruun acknowledged that self-care is a difficult thing to model, but
that her years of disaster relief experience, eating healthy food,
drinking a lot of water, continuing to exercise, and sleeping well
helped, along with support from colleagues, friends, and family. Dr.
Dodgen echoed her remarks and emphasized friends, family, and faith,
along with debriefing with trusted friends and colleagues.

**Experiences of Deployed SAMHSA Staff**

Three SAMHSA staff members described their experiences in the field: Ms.
Rachel Kaul, L.C.S.W., C.T.S., Public Health Advisor, Division of
Prevention, Traumatic Stress, and Special Populations, CMHS; Mr. Kevin
Chapman, D.M., Project Officer, Drug Free Communities, CSAP; and Ms.
Anne M. Herron, M.S., C.R.C., CASAC, Director, Division of State and
Community Assistance, Center for Substance Abuse Treatment, CSAT.

Ms. Kaul explained that when a presidentially declared disaster occurs,
she contacts the State disaster mental health/substance abuse
coordinator, reviews the application process for the Crisis Counseling
Program (CCP), and provides technical assistance. States have just 14
days from the time of declaration to apply for CCP funding. Ms. Kaul and
two colleagues traveled to the affected States to assist in the
assessment of how they would amass and apply resources. She described
Mississippi's disrupted mental health infrastructure and the vast
magnitude of need evident in the affected areas. Staff's ability to
apply regulations creatively to fill gaps in financial, human, and other
resources was critical. For example, the magnitude of the problems
warranted the unusual step of enlisting consultants to help States write
grant applications to expedite funds for services. The CCP, which will
provide services in the affected areas for about a year, relies on
existing strengths to help communities find or create resources and
hires and trains indigenous professionals and paraprofessionals to
assess needs and solve problems.

Ms. Kaul distributed copies of SAMHSA's "A Guide to Managing Stress in
Crisis Response Personnel," designed to help States increase their focus
on first responders and nontraditional responders. She highlighted the
importance of SAMHSA staff as a supportive, listening presence, able
also to help solve problems with community resources and to help think
in nontraditional ways. She found mental health and substance abuse
consumers in community centers frequently to be among the first people
to respond, and they did so creatively and effectively. She asserted
that SAMHSA can help States learn to use consumers as a resource.

Mr. Chapman described his experiences on a relief team in Houston that
consulted on providing professional mental health services to responders
and evacuees, and helping Harris County with long-term planning.
Historically a minister specializing in pastoral counseling, Mr. Chapman
said he engaged his clinical and spiritual background in the
consultative and assessment process and used his organizational skills
to assist the group. He recognized that the alcohol/drug community was
not involved in the county planning meetings and drew in the Council on
Alcohol and Drugs to participate. He also served as liaison to the
SAMHSA SERC.

Mr. Chapman recounted his feelings in the stressful time that Houston
evacuated the evacuees from elsewhere on the Gulf Coast in the face of
approaching Hurricane Rita. Once the evacuees had departed, his team
drove to San Antonio. He experienced a reaction to the stress; the team
discussed options, and Mr. Chapman was offered the opportunity to return
home. Physically exhausted and mentally fatigued, he realized he had
taught persons for years about the necessity to take care of themselves
in order to help others. He asked to come home, feeling guilty about
leaving his teammates behind, not completing his 14-day deployment, and
being afraid.

Ms. Herron explained that in her work with single State authorities for
substance abuse, she has responsibility for issues, such as co-occurring
disorders, homelessness, and prisons, which emerge with hurricane
experiences. Two weeks after Hurricane Katrina hit, Louisiana's mental
health authorities requested SAMHSA's consultative assistance on command
and control function; provide support, care, and debriefing services to
a stressed executive team; ensure that the work of the State mental
health office for first responders was appropriate, sustainable, and the
right thing to do; and review needs of the system-of-care for the next
three to five years. Ms. Herron stated that she traveled to Louisiana
with a command and control expert to review organizational structure,
issues the State had dealt with, and anticipated events and activities.
And while they engaged executive staff to gauge the department's values,
priorities, functions, initiatives, and relationships, they made time to
allow staff to talk about the affect of their experiences. Ms. Herron
presented recommendations that were adopted by the department regarding
long-term planning, media response, and staff functions from an
integrated mental health, substance abuse, and developmental
disabilities perspective. This request for similar assistance was
repeated by Louisiana's Secretary of Addictive Disorders, which SAMHSA
provided.

Ms. Herron observed that a great number of State agency staff were
impacted significantly by the hurricanes, to an extent not seen even
following September 11. She considered as an accomplishment providing
brief administrative respite to the staff.

**Council Discussion**

Mr. Stark asked whether the 14-day deadline for the CCP application
survived the hurricane experience. Ms. Kaul responded that the deadline
remains intact and that the immediate deadline helps States to place a
high priority on securing short-term support in times of crisis.

Dr. Gary offered suggestions for novel, nontraditional partners with
whom to work in response to crises, including beauticians, storefront
and other ministers, historically Black institutions, sororities,
fraternities, Masonic Lodge members, and similar organizations that are
relevant to Hispanic and disenfranchised Caucasian populations. Ms. Kaul
mentioned other nontraditional partners, including postal workers,
bartenders, waiters and waitresses, and flight attendants. She noted
that significant partnerships were established quickly with faith-based
groups and groups that focus on rebuilding and conduct outreach
community case management, and that these kinds of linkages are expected
as part of the CCP application.

To a question from Ms. Sullivan, Ms. Herron responded that the deployed
SAMHSA staff had no awareness of animosity between the Federal and State
governments. Ms. Kaul noted that people expressed frustration with the
bureaucracy, but the focus always was on moving to the next step.

Dr. Kirk asked about lessons learned regarding the dramatic modification
of SAMHSA's operations during the emergency response. Ms. Herron
responded that the limited duration of staff deployments protected them
from wanting to do too much. The limit also enabled remaining staff to
know that they would need to do extra work for only a short period of
time. Mr. Curie added that SAMHSA played a major role in helping its
people shift their role and mission to focus on the emergency response,
and that SAMHSA staff gained support and energy from caring about each
other. He noted the importance of cultivating an attitude and a culture
that celebrate accomplishments, news, and progress in daily briefings.

Dr. Kirk asked whether formal debriefings were part of the September 11
experience. Ms. Herron responded that everyone in the field had routine
debriefings and then follow-ups upon return from deployment. Ms. Kaul
noted that the SERC established a buddy procedure to foster every-day
communication. Ms. Bruun described efforts to support staff and other
people in the field. She observed the receptivity of leadership to
flexibility in giving people time off, purchasing unorthodox supplies,
and creating a safe environment to acknowledge feelings and the need for
help and to solve problems. Ms. Kaul stated that the SERC worked with
best practices, using extensive research on deployment to the field. Dr.
Kirk observed that between the organization's culture of care and
staff's personal and professional experience, SAMHSA has been
strengthened. Ms. Theresa Racicot and Ms. Dieter acknowledged panel
members' willingness to talk about their feelings, which they expected
to contribute to more healthy responses by others.

Dr. Lehmann expressed appreciation for the work SAMHSA staff
accomplished. Ms. Huff noted the importance of acknowledging the
challenges of re-entry into routine after crises, an issue for
individuals and organizations engaged in support of families in which a
member has mental health problems. Mr. Curie acknowledged that SAMHSA
has been changed, although it is not yet clear in what ways.

**Consideration of the June 27, 2005, SAMHSA Council Meeting Minutes**

Council members unanimously approved the minutes of the meeting held on
June 27, 2005.

**Public Comment**

Ms. Marian Schineholts, American Occupational Therapy Association,
reported that occupational therapists were refused by the Red Cross when
they tried to volunteer their services. She noted that practitioners
work with people with serious mental illnesses and with older people
with mental health and substance abuse problems. She observed that their
services are likely to be helpful in the extended recovery effort to
rebuild communities.

Dr. Mary Knipmeyer, MCK Consultants, who conducts grief counseling for
the loss of companion animals, noted that some people refused to leave
their homes because they could not take their pets to shelters. She
expressed hope that the mental health aspect of how people relate to
companion animals and their role in terms of survival are better
understood.

Ms. Susan Rogers, Mental Health Association of Southeastern
Pennsylvania, asked about actions people with mental illnesses can take
in disaster response situations. Ms. Kaul responded that once people are
safe, people with mental illnesses in community outpatient situations
and people experiencing substance abuse disorders often are valuable
resources in the disaster response.

**Matrix Update**

Mr. Curie invited additional feedback from Council members on updates to
the matrix discussed earlier in the day. Ms. Sullivan suggested
broadening SAMHSA's *disaster* response to a *crisis* response approach
in order to include assistance in military base closings, unemployment,
and major plant closings. She suggested adding crisis response to the
matrix as a cross-cutting principle. Ms. Dieter advocated for adding
suicide prevention to the matrix.

Dr. Gary suggested devising a way to highlight the redwoods on the
matrix. Mr. Curie identified the "big redwoods"---substance abuse
treatment capacity expansion, co-occurring disorders, mental health
systems transformation, and SPF---as systemic priorities that help set
priorities for the budget process. He entertained suggestions from the
Council on making further distinctions or on bringing others into the
major redwood area. He expressed hope that co-occurring disorders within
a few years will no longer be a major redwood. Dr. Gary suggested that
SAMHSA communicate visually to the States a sense of urgency to
transform their systems accounting to make possible widespread
implementation of appropriate screening, assessment, and treatment
modalities for co-occurring disorders.

Dr. Gary advocated for integrating stigma---a major barrier to seeking
mental health care---and alleviation of poverty into the matrix.

To a question from Ms. Huff, Mr. Curie responded that HIV/hepatitis is a
priority because intravenous drug use is a major cause of the spread of
HIV; mental health needs of persons with or at risk for HIV is an
important issue; and SAMHSA must be part of the public health response
to prevent HIV. Dr. Gary added that young adults and adolescents use
alcohol and substances to prepare themselves to participate in unsafe
sex.

**Adjournment**

The meeting adjourned at 5:10 p.m. and reconvened the following day at
9:00 a.m.

**WEDNESDAY, DECEMBER 7, 2005**

**Opening Remarks**

Ms. Kade welcomed Council members to the continuation of the Council
meeting.

**Medicaid Modernization Act**

SAMHSA Medical Advisor Anita Everett, M.D., explained aspects of the new
Medicare prescription drug benefit. Fourteen percent of the 42 million
Medicare recipients are disabled. About 7 million are dually eligible
for both Medicare and Medicaid benefits, many in association with a
mental illness and some because of substance abuse. As of January 1,
2006, these individuals no longer will receive medications through
Medicaid and must switch to Medicare. SAMHSA has been working closely
with CMS on effecting the transition.

Distinct from Medicare individuals who meet State requirements for
Medicaid eligibility, low-income individuals who earn 150 percent of the
federal poverty level or less will benefit from this change. This
low-income group will pay no premiums and have limited co-payments.

Because of concern that certain populations may be impacted highly by
the benefit itself---which encourages competition among companies and
making arrangements for individual prescription drug plans---CMS created
six special categories that provide extra access to certain medications.
Three of the six categories include medications often needed by persons
with mental illnesses---antidepressants, antipsychotics, and
convulsants. All the medications in these categories must be covered by
each of the insurance plans.

SAMHSA has undertaken a wide variety of education and outreach
activities to explain the benefit, including, among others, contacts
with the public, State leads for the benefit, and substance abuse
groups; Web site links to relevant pages; partnership grants to several
advocacy organizations; and a *SAMHSA News* issue dedicated to the
benefit.

**Council Discussion**

Dr. Kirk expressed concern about changing formularies that may require
dual eligibles to change medications involuntarily. Dr. Everett
responded that CMS has been sensitive to the need to keep antipsychotic,
antidepressant, and anticonvulsive medications on the formulary. CMS has
established safeguards against people having to change, plus an appeals
process to place a medication on the formulary, and another appeals
process for the co-pay level of a medication. Dr. Kirk pointed out that
the co-pay for multiple medications can represent a significant cost for
some individuals. Dr. Everett stated that the Federal government and
pharmaceutical companies cannot waive the co-pay because of kickback
laws, but pharmacies can agree not to bill at the point of sale, and
charities can cover the cost of co-pays. Some companies have expressed
interest in creating opportunities to offset co-pays. Dr. Kirk stated
that Connecticut has appropriated \$5 million for 1-year to help with
co-pays and expressed concern that the legislature may decide in the
future no longer to do so. He asked whether it would be possible to
extend the enrol1ment date, and Dr. Everett responded in the negative.

Dr. Gary asked about possible policy and patient-care effects of the
National Institutes of Mental Health's (NIMH) Clinical Antipsychotic
Trials of Intervention Effectiveness (CATIE) study of the efficacy of
atypical antipsychotics. Dr. Everett stated that the study might prompt
reconsideration of the older antipsychotics as feasible, legitimate
treatment, but noted that only preliminary data have been published. CMS
has defended against changes to the medications access rules, but Dr.
Everett acknowledged that vigilance among advocacy communities may help
preserve the benefit without the need for "fail-first" policies. Dr.
Gary urged devising a mechanism to track the potential for fail first.
Dr. Everett agreed to provide information on tracking mechanisms.

Ms. Sullivan identified the need for simple, State-specific brochures
about the benefit. She observed that people who are indigent or
illiterate may have least access to explanations. Dr. Everett noted that
dual eligibles have been enrolled automatically, with an option to
change plans. Ms. Sullivan responded that it is unclear how to change
plans and how to get help to do so. Council members suggested a
conference call to discuss the issue. Dr. Kirk noted that his State
recognizes the importance of case managers who understand the benefit.
He noted NASMHPD's efforts on the issue and urged tracking. Mr. Stark
urged tracking both eligibility and access. Dr. Everett stated that she
will provide information on tracking individuals' transition to the new
plan and will investigate and report on individuals' experience with any
influence by insurance plan gatekeepers to change psychotropic drugs in
response to findings of effectiveness studies.

Ms. Dieter supported the strategy of devising short synopses of the
benefit for broad dissemination, but noted that tracking the issue is
likely to be costly. Dr. Everett reiterated that dual eligibles already
are enrolled and should be able to access their medications. Ms. Huff
suggested the Federation of Families for Children's Mental Health and
other organizations as partners in providing information. Dr. Gary
suggested also tracking quality of treatment, for example, by systematic
assessment of movement disorders. Ms. Kade stated that she will report
to Mr. Curie on the discussion, with an eye to convening a SAMHSA
Council conference call together with CMS representatives, on the issue
prior to the June Council meeting.

**Preventing Underage Drinking**

Ms. Kade stated that SAMHSA plans to focus additional attention on
prevention of underage drinking. Secretary Leavitt convened the
Interagency Coordinating Committee on the Prevention of Underage
Drinking (ICCPUD), and Surgeon General Richard Carmona has announced his
intention to launch a call to action on the prevention of underage
drinking. Expert teams from most States and many territories attended an
October 31, 2005, ICCPUD meeting.

Data show declines in teen drug and tobacco use, but underage drinking
remains a problem. Alcohol is the most widely used substance of abuse
among America's youth, and underage drinking is the leading public
health problem in the United States. Measurable targets are to be set
for reducing prevalence of underage alcohol use, reducing binge alcohol
use, and increasing age of first use. Underage drinking has been
accepted as a right of passage, but it is time to change the culture
from acceptance to abstinence, and for parents talking to their children
early and often.

-   **SAMHSA's Underage Drinking Prevention Effort**

SAMHSA Associate Administrator for Alcohol Prevention, Mr. Stephen Wing,
enumerated SAMHSA's main activities in reducing underage drinking:
ICCPUD, a standing committee to coordinate federal activities; SPF SIGs,
with emphasis on underage drinking; Reach Out Now, a collaboration
between SAMHSA and *Scholastic Magazine,* which provides underage
drinking prevention materials for all U.S. fifth and sixth graders and
their parents; community teach-ins (www.teachin.samhsa.gov); town hall
meetings to raise awareness of evidence on consequences of underage
drinking and to foster creation of local coalitions; Web site on
underage drinking (www.stopalcoholabuse.gov); report to Congress on
underage drinking; and Ad Council PSAs.

-   **Underage Drinking Prevention Advertising Campaign**

Alvera Stern, Ed.D., SAMHSA Office of Communication Team Leader,
described the Ad Council Underage Drinking Prevention Program, including
a research review that revealed, for example, that about 29 percent of
underage people ages 12 to 20 reported monthly alcohol use. Of underage
people, 40 percent were ages 12 to 17. The death rate among underage
youth caused by alcohol is 6.5 times more than deaths from all other
illegal drugs combined. Young people who drink before age 15 are more
than five times more likely to develop alcohol problems than those who
start after age 21. Among alcohol-dependent adults in treatment, about
95 percent say they had their first drink before age 21. Studies show
that protective factors from parents are significant. Young people are
less likely to drink if their parents are bonded with them, talk with
them, enforce neither very rigid nor loose rules, and set boundaries
that change as they mature. Parents underestimate their influence and
have difficulties in knowing what to say. The campaign's objective is to
encourage parents to speak with their children early and often to delay
onset and reduce underage drinking.

Focus groups found that most parents thought drug use and sexual
activity to be more critical than underage drinking, and thought other
kids were drinking, but not theirs. Although parents display denial,
they are concerned about such safety issues as drunk driving. The
statistic that drinking before age 15 linked to alcohol dependence after
age 21 resonated with parents. The Ad Council PSAs' target audience is
parents of children ages 11 to 15. The key message is that the chances
of young persons developing a problem increase the younger they start
drinking. The action message is to talk with kids before they start
drinking. Dr. Stern showed several PSAs, which include TV, radio, and
print ads. The materials will be made available along with training of
prevention workers in the regions of planned town meetings to enlist
media in running the PSAs. The campaign also will ensure that
*Scholastic Magazine* handouts highlight the work and resources of
www.stopalcoholabuse.gov.

**Council Discussion**

To questions from Ms. Racicot, Dr. Stern responded that SAMHSA is not
buying air time, but that the Office of National Drug Control Policy
(ONDCP) acceptance of the campaign will ensure greater play time. The
campaign has been mounted with consultation of the alcoholic beverage
industry and advocates. Mr. Wing noted that the campaign reflects IOM
recommendations to target parents. Mr. Stark stated that it is good that
alcohol is on the federal agenda, but *not* good that the government has
not bought time for the ads. Ms. Dieter concurred with Mr. Stark's
assessment.

Ms. Sullivan commented on a *New York Times* report that alcohol
companies target young drinkers with promotions. Dr. Kirk stated that
Connecticut works with community and State colleges in Connecticut to
reduce binge drinking. Ms. Racicot noted that beer companies post video
games on their Web sites, an advertising ploy about which most parents
are unaware. She pointed to the paradox of vociferous protests of lead
in paint and water, and laws requiring infant seat use, yet alcohol
represents the worst poison in kids' lives---a legal substance supported
by a powerful lobby. She noted the need to urge parents to talk about
their children's alcohol problems to empower other parents to talk about
their own families' similar issues. She anticipated that the Surgeon
General's call for action will carry power.

Ms. Sullivan noted that alcohol ads appear on cable networks and asked
about related research. Mr. Wing responded that studies are ongoing, but
that a recent National Institute on Alcohol Abuse and Alcoholism (NIAAA)
study has found inconclusive evidence on the influence of broadcast
alcohol messages on drinking behaviors. Ms. Dieter supported Ms.
Racicot's remarks and concurred with the need for appropriated funds to
purchase air time for prevention ads. Ms. Huff related her family's
personal story about alcohol and drug abuse and the importance of
knowing how to talk to young children about alcohol use.

Dr. Gary suggested the need for evaluation of the impacts of teach-ins
and the Reach Out program. Mr. Wing reported that *Scholastic
Magazine*'s evaluation shows that materials are well received, but not
as well received as SAMHSA would like. One challenge is to ensure wider
usage. Ms. Dieter suggested the need for reinforcement of prevention
programs in middle school and then high school. Council members
expressed praise for the PSAs.

**National Child Traumatic Stress Initiative Programs**

-   **Overview**

SAMHSA Senior Advisor on Children, Ms. Sybil Goldman, described
effective community programs related to the National Child Traumatic
Stress Initiative. The National Child Trauma Stress Network develops
effective approaches for treating people exposed to trauma by providing
training and direct services in communities. The \$25 million
congressional initiative incorporates the National Resource Center, a
collaboration by UCLA and Duke University; treatment and service
adaptation sites (category II); and community service sites (category
III). The initiative covers all aspects of trauma, including improving
access and quality of treatment. The National Resource Center involves
families at all levels to provide leadership, develop and maintain the
network structure, provide technical assistance, and coordinate
education and training. Category II sites develop, implement, and
disseminate effective programs, and play a role in training, developing
products, adapting trauma interventions in special populations and
settings. Category III sites provide services in various child-serving
systems in communities and conduct evaluations of interventions in
various communities.

-   **Kennedy Krieger Institute Family Center (KKFC), Baltimore,
    Maryland**

Dr. Elizabeth Thompson, Ph.D., Director of Division of Clinical
Services, KKFC, explained that the center traditionally worked with
children with developmental disabilities in foster care, but has
expanded to offer programs for children and families impacted by
violence. KKFC serves 1,000 children annually in clinic, home, and
school settings in high crime areas. About 91 percent of the children
have experienced at least 1 of 45 types of traumatic events, and the
average child has experienced three traumas.

After receiving SAMHSA funding in 2003, the Center joined the trauma
network. Participation involves submitting data to a common data pool
and forming links with childhood trauma experts. KKFC runs a clinic that
provides trauma-focused mental health treatment adapted for children who
are deaf or hard of hearing. KKFC's involvement with the network also
has led to full engagement of families and service providers as partners
in program development and service delivery, staff improvement, adoption
and adaptation of best practices, evidence-based treatment practices,
training, and effective implementation. KKFC has focused on its staff
participating in a training program to conduct and embed trauma-focused
cognitive behavioral therapy systemically in communities. To serve as a
change agent, KKFC has trained about 800 people in communities to work
more effectively with traumatized children and families in their
respective service sectors. The community advisory board includes
caregivers and people who have received treatment.

Lessons learned from KKFC's work with relocated Hurricane Katrina
evacuees---teenagers who had been traumatized by the
experience---include: (1) trauma changes you forever, despite healing
and recovery, and (2) mental health professionals should never lose
sight of the hope and resiliency that families bring when they come for
treatment.

-   **DePelchin Children's Center (DCC), Houston, Texas**

Mr. Robert Hartman, M.S.W., Executive Vice President and Chief Operating
Officer, DCC, described services provided by DePelchin Children's
Center, including early intervention and mental health treatment and
services for homeless mothers. The center serves 27,000 children and
families annually; about 5,000 children have experienced multiple,
complex traumatic incidents. The SAMHSA grant became a catalyst for
transformative change for his organization, whose goals include
increasing accessibility, developing a community network of
professionals, improving outcomes for children in child welfare and
mental health services, and translating research into the organization's
practice. Mr. Hartman highlighted major accomplishments, including
establishing an internal core trauma team to change the culture to a
learning organization. A community trauma network involving more than
200 Houston organizations conducts training and disseminates materials,
and network counselors are accessible on the Web site to increase
access.

As part of the network, DePelchin has participated in workgroups on
foster care, data, public policy, school intervention, system
integration, residential, and training. Information sharing is a
highlight, particularly on financing for a child welfare service,
monitoring psychotropic drugs in the child welfare system, workforce
issues in implementing trauma care, and establishing community services
around trauma services. Network training has included trauma-focused
cognitive behavioral therapy, parent/child interactive therapy, and the
Sanctuary model for residential care. Statistics conclusively
demonstrate the value of that model, including reduced length of stay by
50 percent---lower than the State average---and an 89 percent reduction
in seclusion and restraint for disruptive behavior. He acknowledged that
the changes are linked directly to participation in the network.

In addition to continuing care for 400 children in foster care and more
than 50 children in residential centers, DePelchin coordinated mental
health services following Hurricane Katrina to children of the 30,000
evacuee families in the Astrodome and convention center. Texas and
Houston have arranged for DePelchin to provide a variety of services
related to disaster response, and the organization coordinates with the
national network in distributing materials to foster that process. Mr.
Hartman showed a PSA developed for the disaster response. To help field
media questions, the national center provided points of discussion, and
DePelchin has fielded 1,600 telephone calls per month as a result of the
PSAs.

**Council Discussion**

In response to Ms. Huff's question about how to eliminate remaining
seclusion and restraint from DePelchin's work, Mr. Hartman explained
that the reduction was achieved by a focused effort to review and track
every restraint on multiple dimensions. Weekly training meetings
centered on alternative ways to talk to kids that involve prevention and
anticipation, helping staff recognize their own emotions, and requiring
staff to facilitate turning to each other if one is "hooked" by a
child's behavior. Each child and staff member debriefs for each episode.
Staff are told that property damage is acceptable, but not
retraumatization of a child. Some restraints are protective, to prevent
harm to self or others. DePelchin is looking at its case plans and
working with a mental hospital for partnership and mutual respite care.
Therapy has shifted from therapists to youth care workers who develop
relationships with the children. Ms. Huff suggested the need to
disseminate this kind of information. Ms. Goldman observed that the
centers and providers that have made this conversion are the best
trainers of others. Noting that seclusion and restraint is a major type
of trauma, she suggested that this training may be conducted through the
national network.

Dr. Gary suggested the need to move the discussion beyond network
participants to facilitate learning by nonmember organizations. She also
asked how DePelchin assists staff to handle their own trauma, anxieties,
fears, and frustrations about aggression. Mr. Hartman responded that
child welfare organizations provide training on these issues. In
addition, DePelchin has changed the hiring interview process; applicants
talk about their own experiences and how they respond to people getting
angry or using provocative language. The topic is discussed at staff
meetings, and debriefing sessions nurture culture change among veteran
staff. Dr. Thompson stated that KKFC has a secondary trauma support
group for staff, and awareness of diverse cultural perspectives is an
important topic for staff discussion. Ms. Goldman noted that Dr. Marlene
Wang at the National Center talks about compassion fatigue and the work
necessary with caregivers and providers.

**Race Against Drugs**

Mr. Ron Steger explained that Race Against Drugs engages young people's
interest in motor sports to convey an anti-drug message. Race Against
Drugs has disseminated 450,000 activity books on behalf of SAMHSA to
Texas, Alabama, and Mississippi. NASCAR drivers Richard Pettit, Daryl
Waltrip, Bobby Hamilton, Jr., Ricky Rudd, and the Andretti family are
spokespersons, and the program is in discussion with Dana Patrick. Race
Against Drugs partners with 24 sanctioning organizations, including
IndyCar, NHRA, and Grand Prix.

**Public Comment**

Dan Fisher, M.D., Executive Director, National Empowerment Center,
reported that SAMHSA- supported work in Louisiana includes peer support
training for consumers to provide training to others. His organization
worked with Louisiana's mental health commissioner to include peer
support in emergency training in the FEMA grant. Peer support and peer
counseling, highly developed practices used with beneficial effect after
Oklahoma City and September 11, have promoted establishment of
consumer-run organizations and peer support capability. Other States are
using the new information to establish crisis planning that engages
consumers as peer counselors. In some parts of the country, consumers
are providing trauma-informed peer support similar to the themes
discussed in the previous panel.

Ms. Susan Rogers, Mental Health Association of Southeastern
Pennsylvania, noted that Pennsylvania is working toward a policy of zero
seclusion and restraint.

Ms. Thelma King Thiel, Chief Executive Officer, Hepatitis Foundation
International, stated that her organization has trained CSAP and CSAT
grantees as well as counselors in Florida.

Ms. Carolyn Stuart, Consumer National Technical Assistance Center
(CONTAC), West Virginia, urged cultural awareness in planning by the
Race Against Drugs to ensure that the message reaches large segments of
the population.

**Closing Remarks**

Ms. Kade recapped highlights of the meeting and commitments to provide
Council members with additional information.

**Adjournment**

The meeting adjourned at 12:06 p.m.

I hereby certify that, to the best of my knowledge, the foregoing
minutes and the attachments are accurate and complete.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date Daryl Kade

> Executive Director, SAMHSA National Advisory
>
> Council, and Associate Administrator for Policy, Planning and Budget,
> SAMHSA

Attachments:

Tab A -- Roster of Members

Tab B -- Attendees