SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

NATIONAL ADVISORY COUNCIL

41st Meeting

Thursday,

March 8, 2007

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chairperson]{.underline}

Terry L. Cline, Ph.D.

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}

James R. Aiona, Jr.

Lieutenant Governor

Executive Chamber

Hawaii State Capital

Honolulu, HI 96813

Gwynneth A. E. Dieter

Mental Health Advocate

U.S. Embassy Belize

Unit 7401

APO AA34025

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

Kenneth D. Stark

Director, Transformation Grant Division

Department of Social and Health Services

111531 Washington Street

Olympia, WA 98504-53311

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

Opening Remarks

Terry L. Cline, Ph.D.

Chair, SAMHSA National Advisory Council

and Administrator, SAMHSA 5

SAMHSA\'s Workforce Development Activities

Kathryn Power

Director

Center for Mental Health Services, SAMHSA 7

Discussion 26

Council Roundtable Discussion

James R. Aiona, Jr., Moderator and

Co-Chair, SAMHSA National Advisory Council 63

Closing Remarks

Terry L. Cline, Ph.D. 86

[P R O C E E D I N G S]{.underline} (9:07 a.m.)

DR. CLINE: Well, good morning, everyone. I\'d like to call the meeting
to order and welcome you back this morning and thank you for being here.
Hopefully, you had a pleasant evening.

I would like also to welcome Ms. Sullivan, who is on the line. Good
morning, Ms. Sullivan.

MS. SULLIVAN: Good morning.

DR. CLINE: It is quite early where you are.

MS. SULLIVAN: I remember when Duke was on the line on the last meeting.
Aloha, Duke.

MR. AIONA: Aloha.

DR. CLINE: Thank you for being here again and taking that effort to be
on the line.

We have one visitor who I\'d like to acknowledge, Bob Shelborn, who is
the Director of the Division of TANF Policy with the Administration for
Children and Families. If you\'d, please, just stand up. Thank you for
being here this morning.

As part of my opening comments, my opening remarks, I\'m going to talk
about just some of the themes that I heard yesterday. There were many
more items that we have detailed, but these are just some of the
overarching themes that I heard.

A lot of concern around the budgeting process; the importance of
partnerships on issues, as well as partnerships for resources; attention
to the needs of people in the armed services and people who are
returning from service; also the need to discuss populations at risk and
vulnerable populations; the importance of the economic impact on our
issues and then making certain that that information gets shared with
others, such as the National Council on State Leadership; also attention
to the science to service approach, as well as making sure that we have
that focus, not just science to service but also the service to science
piece of that, whether that\'s field testing or other types of kind of
promising practices that are coming from our communities, and paying
attention to informing the research and science piece of that, and then
making sure that that\'s available and attending to those opportunities
to spread those practices wherever possible. And then the last question,
which will tie in with some later discussion, is really this kind of
urging from the council about how you can be most helpful to me as the
Administrator and also to SAMHSA. So I appreciate that.

Any other kind of general themes? Again, there were a lot of specifics
and we have all the specifics. We have several follow-up items, as well,
that we have marked. But was there some kind of all-pervasive theme that
was not captured by those comments that any of you would like to
highlight right now?

(No response.)

DR. CLINE: Okay. Well, we\'re all set.

We will then move into our presentation, and this was an issue that was
highlighted several times yesterday in terms of an interest of the
council and also a pressing need for our nation as we look forward. So
we\'re very fortunate this morning to have Kathryn Power, the Director
of the Center for Mental Health Services, who will be providing us with
a presentation on behavioral health workforce development.

And, Ken, you can see it\'s going to take us a while, but your comment
is still registered with us.

Good morning, Kathryn.

MS. POWER: Good morning, Terry. Thank you very much. Good morning,
everyone.

I\'m very honored to be with you to discuss this very important topic,
and I think it\'s important to say that SAMHSA comes to this very
important issue at, I think, an important time, an important
developmental time, in terms of SAMHSA, in terms of the fields, and in
terms of the overall pressing nature of the societal demographics.
We\'ve heard for a number of years, woe is me, the sky is falling.
We\'re really worried. The workforce is changing. The workforce is
aging, et cetera.

So I think the fact that we have taken this on as an issue I think is a
credit to our leadership and it\'s also, I think, emblematic of how
important we think that people are to our business. People are the core
of our business, and it is the people-to-people connection, it is the
people-to-people work, it is the personal engagement with the
individuals we serve that really marks the quality of recovery-focused
systems. So we count on people more than any other and probably people
take anywhere from close to 90 percent of the resources in any system,
particularly in one that is intensive in terms of mental health and
addictions and substance abuse disorders.

So I think it\'s a propitious time and I really am very honored to be
named as the co-lead of the matrix area, along with Beverly Watts Davis,
who is my senior partner and senior co-lead for this matrix area.

I want to just contextually place some thoughts in your head as we talk
about this important topic this morning. The first is that there\'s been
an acknowledged shortage of health care workers in mental health and in
substance use, both prevention and treatment.

It\'s also been acknowledged that there is really a geographic
maldistribution of workers, that there are areas of the country that do
not have the number and kind of individuals that are necessary in order
to deliver these important services.

The third area that\'s been acknowledged is that there is a tremendous
lack of ethnic diversity and cultural expertise across the workforce,
and as our population in America becomes more diverse, that lack of
diversity and cultural experience really needs to be reflected ‑‑ I
mean, we need to pay attention to it in terms of focusing in on
developing the workforce. And that ethnic diversity and cultural
expertise really comes out in areas where there are vast health care
discrepancies, where there is a distinction around primary care and
behavioral health care integration.

The whole issue of older Americans and the aging issues of older
Americans is a tremendous, tremendous difficulty across the health care
spectrum and, frankly, one in four individuals who are older have some
form of psychiatric or emotional disturbance.

And then there are children in our communities who are extraordinarily
diverse and the lack of having children expertise, particularly child
psychiatry, is noted among the workforce almost everywhere and, I might
add, particularly in the military as part of the DOD task force.
They\'re having the same difficulties in the military that we broadly
are having within the major society.

Another acknowledgement is there is a recognition that much of our
education, much of our training that occurs in our universities and
academia is, frankly, outdated and not necessarily reflective in
accurate and updated training content, in accurate and updated training
methods in terms of the needs of our systems, and it is not consistent,
frankly, with what we know works in terms of evidence-based practice.

We can all look back on our own training experiences and say, was I
trained for what I do now? And I think that the workforce is asking
themselves that question. Any of us who have been working in systems or
have run systems know that there is a huge gap between those that are
trained and they come out of schools or they might be going through
specific training and the actual things we ask people to do, the tasks
we ask people to do.

I often remember when I ran the system in Rhode Island that some of my
best case managers were music therapists and art therapists who then
came out of liberal arts education and then were trained to be good case
managers by having an inoculation of a special recovery orientation or a
special training that was put on by the state or the community mental
health centers.

So we need to think about that and how are we going to accommodate the
workforce of the future, but we certainly need to be looking at the more
formal educational processes and the credentialing processes.

Finally, we know that there are a wide variety of state-to-state
variations in the scope and practice that exist and in the level of
quality and in the level of competence. Tremendous variations across the
country, across the world, across the states, and even across regions
and even across local areas. There is tremendous variation.

So those are really the important aspects of this workforce issue that I
want you to keep in mind as we go through the matrix report.

I also thought it would be helpful just to stop and think about your own
personal experience. Workforce issues really come down to thinking about
ourselves as part of a workforce, being identified with a group of
people. And our experience of being identified with a group of people
comes from our training and education and the process and experience
that we have.

I want you to kind of put yourself in the position of thinking through
systematically how you would advise us, how you would advise the
Administrator, how you would advise the council, how you would advise
the matrix area to start to grapple with some of these issues because
they\'re very broad and yet they\'re very narrow. They\'re very wide and
they\'re very deep. I think if you put yourself in the position of
saying, let me think about my own experience ‑‑ and I don\'t want to
bore you with the details of my life, but I think it\'s important that
you know that in thinking about workforce, we have to think about it
from our own personal professional perspective and then broaden out from
there.

So when I think of myself, I think of myself as a teacher. I taught
elementary school. I taught high school. When I was a teacher, I cared
very much about mental health promotion. So I was a mental health
promotionist, and I wanted to care deeply about the emotional life of
the children that were in my classroom.

Then I became a counselor and I had my own counseling practice with
another woman. And it grew out of working in the rape crisis and
domestic violence areas. So I became a crisis counselor. Then I became a
feminist counselor who believed in empowering women around their issues
about crisis and about trauma, and that\'s where I learned my whole set
of beliefs about trauma. So I became a trauma counselor.

Then it moved into working on the state level and working in
communities, and I became the head of a substance abuse business-backed
prevention coalition. Then I became a preventionist. And the business
community funded an effort so that we could take a statewide community
prevention effort like you heard yesterday from Kentucky and move out
with the business community saying we care deeply about this issue and
we want to prevent substance abuse.

And then I became the drug czar at the state level. So I had to take all
of the substance abuse programs that were in education, that were in
criminal justice, and that were in mental health and substance abuse on
the state level and combine them under an office of substance abuse.

And then I was a parent, so I cared deeply ‑‑ deeply ‑‑ about the
emotional life of my children and their life in the community and their
life in terms of their development and their future.

So all of us have those different roles. We all come at this from a
different place. We all have different experiences. So I\'m pointing
that out not to bore you with my life, but to show you that there are
very narrow times when I would think of myself only as a mental health
counselor or only as a substance abuse preventionist or only as a grief
counselor or a trauma counselor. And then I would step away and think of
myself as a policy person and as a practitioner and as an advisor and as
a guide in terms of systems development.

So we have come to the point where, in looking at this issue, we have
now developed very firmly in SAMHSA a formal process, and that formal
process is the beginning of a matrix group. I\'ve never been at the
birth of a matrix group, and I have been witness to the birth of a
matrix group in the past year.

When we were appointed, Beverly and I had a conversation about how do we
take the richness of this discussion and bring it to bear in terms of
the disciplines that are important, the fields that are important, and
how do we start organizing ourselves to think about ways in which we
should approach this for SAMHSA and for the fields.

As you all know, this was a new matrix priority area that was designated
in 2006. There had been much work done in workforce development issues
across the three centers prior to this time. That is, it had been a
cross-cutting principle that we cared about workforce issues since 2003,
and there had been some work across all three centers and particularly
in the fields of mental health services, substance abuse prevention, and
substance abuse treatment. So we had been doing some work that had, in
some cases, been isolated within that field or we had just had informal
conversations across SAMHSA.

In terms of what I want to just touch on today, we\'re just going to
start with the fact that the matrix area has been formulated. You all
know that one of the first things that we did in the matrix process was
that we held a workforce development conference last July. I\'m going to
talk a little bit about what happened at that conference and the
proceeds from that conference.

We\'ve also now begun to identify what we consider to be some proposed,
far-reaching goals that we really would like you to offer some ideas
about, whether or not these goals are consistent with your experience
and consistent with your notions about the way in which we should
address workforce. And we\'re also going to talk a little bit about our
contract that we have on workforce development, and then we\'ll move to
some open discussion.

Last July, we sponsored a conference called \"Building a Behavioral
Health Care Workforce for the 21st Century,\" and this was a dialogue
with 200 of our closest friends. Those friends really came from many of
the professional guild areas, many of the advocacy organizations, many
of the national players in terms of mental health promotion, mental
illness prevention, substance abuse treatment, and substance abuse
prevention. So it was a host of interested parties, many of whom had
participated in some of the individual work that had gone on across the
three centers.

At that time, we delivered basically to the group two important
documents. The first one was \"Strengthening Professional Identity,\"
which is the report about challenges of the addictions treatment
workforce which was a report that was provided as a result of a
congressional inquiry or congressional appropriations language that
requested it. And that report was out. And we had also commissioned a
report with the Annapolis Coalition, which is this thousand voices,
\"The National Action Plan on Behavioral Health Workforce Development.\"

These two substantive reports, which were basically commissioned by us,
became the vehicles really in which we asked folks at the July meeting
to look at them and to think about them and to react to them, mainly
focused on the Annapolis Coalition report and, in addition, some
additional conversation on strengthening competencies.

We had a variety of broken-out discussions relative to what they thought
SAMHSA should do in the future and what they could do in the future. And
that was really what we wanted to do, was to get these reports into the
hands of those individuals who had been saying that workforce was an
issue, but we really weren\'t quite sure where to go and what to do.

So these reports now are on the SAMHSA Web. We also have the trimmer
version of the Annapolis Coalition, which is the executive summary.
Those three documents now sit on the SAMHSA Web and are out there for
the public, for all of our stakeholders to use because they\'re
chock-full of ideas, just chock-full of strategies and goals and
recruitment strategies and retention strategies.

So go forth and do good things was the idea that SAMHSA had about making
these resource documents available to the field and moving forward.
Frankly, we\'ve heard from many, many constituency groups, particularly
some of our ATR states or our seclusion and restraint SIG states or our
mental health SIG states, that they\'re using them. And that\'s really
important and I think really essential.

Then the Administrator, Dr. Cline, sent a follow-up letter to these
conference participants in February, which included a summary of the
conference about the long-term and short-term actions by the
participants and some of the key findings. And we so noted that we would
consider all of the recommendations, and that\'s part of the pool of
information that the matrix work group is working with.

These seven goals I want to go over very quickly. These are the goals
that were derivative from the Annapolis Coalition report that we asked
participants at the meeting to mull about, to think about, and to give
us some direction. I\'m just going to briefly touch on them. These are
very broad workforce goals that are informing our contemplative
deliberations within SAMHSA for the matrix area.

Goal number 1 probably is the most significant. It says to expand the
role of individuals in recovery, and families when appropriate, in
participating in and ultimately directing or accepting responsibility
for their own care, providing care and supports to others, and in
educating the workforce. This gets to the heart of empowerment. It gets
to the heart of our systems in terms of recovery-focused,
consumer-centered systems of care.

In fact, we had much to learn from each of the fields, much to learn in
terms of prevention\'s view of this, much to learn in terms of the
addictions field in this area, and much to learn from the evolving world
of mental health recovery. And this really captured the spirit of peer
support services, consumer-directed services, et cetera.

The second goal was to expand the role and capacity of communities to
effectively identify their needs and promote behavioral health and
wellness.

The third goal is to implement systematic recruitment and retention
strategies at the federal, state, and local level. So I specifically
want to emphasize if the goal is for us to do something at the federal
level, your input for us would be very helpful because we\'re clearly
looking at CDC and HRSA and other agencies that have been looking at
workforce issues over time and looking at some of their work in the past
and saying is that an effective strategy for us to apply and to think
about.

Goal 4 is to increase the relevance, effectiveness, and accessibility of
training and education.

Goal 5, to actively foster leadership development among all segments of
the workforce, which really gets to, Faye and Tom, your comments
yesterday.

Goal 6, enhance the infrastructure available to support and coordinate
workforce development efforts.

And goal 7, to implement a national research and evaluation agenda on
workforce development issues.

So those are from the Annapolis Coalition and those are the goals that
they derived. I\'m not going to go through the process of the Annapolis
Coalition. I can do that in Q and A, if you need to know that process.

The other informed document I mentioned is \"Strengthening Professional
Identity: Challenges of the Addictions Treatment Workforce,\" also an
information resource for us. There were 20 recommendations across those
areas, and you can see listed here the areas that they focused on in
terms of a set of recommendations. Very important that again from the
addictions field perspective, these were the areas, and we have provided
you a list, which was on the table with the handouts, of the
commonalities across these two reports and the areas where they
differed. The commonalities, of course, outweigh the differences. There
were just differences in terms of scale and scope on the numbers of
individuals who were interviewed, scale and scope of the process that
was used to create the report, et cetera. But it\'s a most fascinating
crosswalk to take a look at how similar the issues are and the issues
were, and that, frankly, is of benefit to our work at SAMHSA.

I might also add just for purposes of discussion two additional
documents that we\'re using. The first is ‑‑ and I\'m sure you all have
your own copy of this ‑‑ the IOM report. This is the IOM report on the
quality of health care for mental and substance use conditions. If you
don\'t have this, I have copies of it. There is a tremendous section in
here on increasing workforce capacity for quality improvement. So the
IOM, when they took on mental and substance use conditions report, spent
time looking at how to improve the workforce, and they spent an awful
lot of time detailing some of their goals and objectives.

Then, in addition, yesterday I just received \"Mental Health and Rural
America: 1994 to 2005,\" and workforce development is one of their prime
areas in rural America and mental health. So, again, two more documents
that we will use to help inform our process and help inform our
deliberations in addition to the two that I\'m citing here today.

So we\'re looking at, from a SAMHSA perspective, what are some of the
derivative goals from what we have already read, from what we have
already described, and from what we have already conversed with folks
about, and these are the three that come to bear. Strengthening the
workforce through implementation of systematic recruitment and retention
strategies. Enhancing the infrastructure available to support and
coordinate workforce development efforts. And broadening the concept of
workforce through expanding the role of individuals in recovery, and
families when appropriate. So these consensus goals kind of came to bear
when we reviewed those documents, and those are absolutely, positively
open for your review and for discussion and for your deliberation and
for your comment.

The next area is that I was asked just to talk a little bit about the
fact that we do have a current contract, and this contract that we are
utilizing for our workforce development efforts began, of course, last
year. We have already done some tasks under this contract. We\'ve
conducted an inventory of center workforce development-related
activities and how those activities relate to the three goal areas that
we are emphasizing. And we\'re also asking the contract to work with us
to inventory and identify other future activities that might be
appropriate to offer the Administrator as part of our workforce
development matrix area.

Let me just give you some examples of some of the things that are going
on.

CSAT for many, many years has developed and instituted and performed a
leadership institute. They have an addiction technology transfer center
system in which they do an enormous amount of training, and they have
the knowledge application program.

From CMHS, we are using our Mental Health Transformation State Incentive
Grants to encourage workforce development strategies in our SIG states,
Co‑Occurring State Incentive Grants, and the National TA Center for
Children\'s Mental Health.

Let me just add here not only are the Co‑Occurring State Incentive
Grants an opportunity to do something specifically, but it is also
reflective of the larger sort of workforce approach that SAMHSA takes.
Dr. Clark and I co-chair that matrix area, and it was decided in terms
of enhancing the capability and competence of the workforce, that we
would do both a tool kit on co-occurring disorders from the CMHS
perspective and a TIP on co‑occurring disorders from the substance abuse
perspective. So that\'s an interesting way to try to influence the
workforce, which is another thing for you all to think about. Are there
ways we can influence the workforce, as well as help with direct
recruitment and retention in the workforce?

And then for CSAP, they of course have their Prevention Fellows Program,
which is a very successful effort for professional development in the
prevention community. They have Centers for the Application of
Prevention Technology, and the Coalition Institute, which are grants
that CADCA administers on behalf of CSAP.

That gives us sort of an overview of some of the activity to date and
some of the things that we are deliberating about, and these are our
next steps.

We are going to develop a final workforce matrix plan, a matrix
workforce plan. We are going to be drafting that. Actually, we\'re
drafting it now in terms of the matrix area. We are in the midst of
working on that and we hope, since the Administrator told Congress that
we would be looking at this in April, we decided April would be a good
time for us to complete this. So we are moving toward that goal and we
know we will be able to deliver that to the Administrator at that time.

But the important thing is that this is a process, and the process is
ongoing and we don\'t have all the answers. We need input specifically
from this council, in your personal roles and in your professional
roles, to help guide us in those things that you think are priorities.

Then we\'re having some internal discussion ‑‑ as well, I\'d like to
hear your ideas about this ‑‑ about some possible, potential workforce
development activities. Those would include things like possibly ‑‑
which were suggestions, by the way, in all of these reports ‑‑ that we
need to review effective recruitment and retention strategies and give
people some models to look at and some experiences that are practical.

We need to look at career path models and what would be an appropriate
career path for our field.

We need to identify existing behavioral health care competencies and
curriculums developed and being used by professional guilds, stakeholder
agencies, and consumer and other organizations.

It\'s been suggested that we might think about developing a behavioral
health website or portal to provide an expansive repository of
searchable information.

Also it\'s been suggested that we might disseminate information on
innovative practices to support the fields in promoting and implementing
their own workforce initiatives.

And then there has also been put on the table the idea of perhaps
exploring some specific authorization for SAMHSA to do a training grant
program, which harkens and pulls back to some of the ideas that worked
very effectively in the late \'80s and early \'90s about fostering the
development of specific leadership in the health care agenda.

Before me move, Terry, to the discussion, I really want to add that,
again, thinking broadly and yet thinking narrowly and then thinking
broadly and then thinking narrowly is an important dynamic here in terms
of the workforce. We not only have to get other disciplines
knowledgeable about mental and substance use conditions ‑‑ that\'s our
first challenge. I think that was mentioned here yesterday. We have to
persuade and we have to influence as many other disciplines as possible
to become knowledgeable about mental and substance use conditions, and
at the same time, we have to build and strengthen the professionals in
this particular aspect of health care. I think that that\'s our
challenge in terms of the discussion around where we proceed.

All of these reports say tremendous things about what the federal
government should do or what SAMHSA should do. We now have to distill
from those things what we think is practical, reasonable and, in fact,
doable for our behavioral health care workforce development.

So with that, Terry, I\'ll end and move to discussion.

DR. CLINE: Kathryn, I\'m going to ask if you would facilitate that
discussion.

MS. POWER: Oh, certainly.

DR. CLINE: If you don\'t mind.

MS. POWER: Certainly.

Ken?

MR. STARK: One of the challenges that I see, Kathryn, and probably more
so on the mental health side than on the alcohol/drug side ‑‑

DR. CLINE: Ken, just to interrupt you for a second. Actually, Kathryn,
if you turn that off, then it allows us to record that a little more
easily. Thanks.

MR. STARK: In the public sector on the mental health side, my experience
in my meager year and a half in this new job as the transformation
project chair and, of course, my historical experience on the
alcohol/drug side working with mental health centers, is that in the
public sector mental health system, it really is not a mental health
system. It\'s a mental illness system, most of the services being tied
to the most severe and persistent.

As a result of that, many of the clinicians in the mental health centers
aren\'t really doing counseling per se. Many of them really are doing
case management. In some cases, given the caseloads, I wouldn\'t even
call it that. I would call it case monitoring with then the
relationships with psychiatrists and medical professionals with
medication management, and then, of course, a major emphasis on acute
and crisis care. Whereas, in the public sector, as you know from being a
private therapist, private therapists really are doing a lot more of the
counseling work with the private pay clients and less severe.

I really think that that presents an incredible challenge in looking at
the workforce in that in the public sector, what do we really want to be
as a field? Are we really moving to, as we hope to, a health
promotion/wellness model, a recovery model where we actually can serve
people along the range, all the way from prevention or early
intervention to crisis and acute? If that\'s really where we want to go
on the public sector side, we all know that\'s going to be a challenge
with resources and a number of those issues.

But that truly then enhances the whole issue around workforce
development and who does what and what kind of training do you need.
Things like case management can be very generically trained. A case
manager in alcohol/drugs and a case manager in mental health really
require the same kinds of skills. But when you get into the actual
clinical work, as you know, there are differences in the treatment
approaches and the etiology. So that requires specialized training.

If we make the mistake of thinking that everybody can be cross-trained
in mental illness, mental health, alcohol/drugs, then we have even a
bigger workforce development problem because we\'ve got some people that
are over-trained for what they\'re doing. Lots of challenges.

I really think we need to kind of segment it out, and I think we need to
take a look at the kinds of duties and functions that we need if we\'re
going to have a certain continuum of care, and then identify, as you
mentioned earlier when you kind of described your historical life
experiences, you don\'t necessarily need a bachelor\'s degree or a
master\'s degree even for some of these case managers. But you do need
certain competencies and you do need certain personalities, and you do
want certain amounts of enthusiasm and passion.

So I think as we look at workforce development, we\'ve really got to
kind of look at those different positions and the different duties in a
well-rounded program and train to that or recruit to that.

MS. POWER: A very rich conversation, Ken, and I hope we captured all of
that because I think that\'s very informative for all of the other
matrix members to hear. But specifically your notion that we need to
envision the system, what is the publicly funded mental health system
going to look like? What is the substance abuse treatment system going
to look like? What is substance abuse prevention going to look like?
What is primary care and mental and substance use conditions, if they
merge, going to look like? So this whole notion of trying to envision
and then plan for what that future may be is really where we are, and I
think you captured that very nicely.

We\'ve got four states basically represented here ‑‑ and I\'m including
Oklahoma, Terry ‑‑ that have tried to look at, from a transformation
standpoint or from a systems change standpoint, all of those things. And
every state will look at it differently. So that has impact then for how
Hawaii may want to think about their approach to workforce. Oklahoma\'s
transformation approach is that they have an initiative to put consumers
in the workforce. That was the initiative that they had started. What
does that mean and what are the implications for the future relative to
who is going to do what and at what level is it going to occur? So very
rich conversation.

And, Ken, we may come back to you if you all don\'t mind. We may come
back and reach back to some of you and say, can you give us a little
more idea about this segmenting issue? That might be very helpful.

Barbara?

MS. HUFF: Thank you. Thanks for your presentation, for your interest in
taking the lead on this, amongst a million other things that you take
the lead on. I said to Gwynneth, I think it was, or somebody yesterday,
she\'s like the Energizer bunny. You know, you just don\'t stop.

A million things run through my mind on this, and I want to kind of
segment it out into maybe three areas.

I live in Kansas. It\'s a very rural state, and we don\'t have what we
need there in terms of a professional workforce. Never have, probably
never exactly will. So we have a fabulous waiver, as you well know. Home
and community-based services. We\'re able to keep kids out of home
placements. Only half the mental health centers utilize that waiver. I
think if you looked real carefully, you would find that the mental
health centers are scared to open the door for fear they can\'t provide
the services in the waiver. They don\'t have the man/person/woman power
to do it. So nobody is thinking through that with them. I think they\'re
scared to even kind of broach why this is happening. Those that are
utilizing it are doing a fabulous job. And it is rural western Kansas
that is not. So that tells us something. And that\'s a general statement
about rural western Kansas.

So now I want to go to Nebraska for a second. Being the kind of rural
person that I am ‑‑

MR. STARK: Where are we going to now?

MS. HUFF: Nebraska.

My oldest daughter ‑‑ and many of you have heard me talk about her ‑‑ is
the one that has struggled with breast cancer. She was living in North
Platte, Nebraska and she was running a program. The reason she was is
because the state offered up the mental health centers in Nebraska a
grant to do business differently, kind of to promote wrap-around kind of
concepts and processes for doing business. So it was kind of a pot of
money of about \$100,000 or so for each of their regions. So they had
six in Nebraska.

So region 2 out in rural western Nebraska decided to turn that down.
They didn\'t want the money because they couldn\'t provide the services,
didn\'t want to provide the services.

So Corrie, my daughter, was hired by Omni Behavioral Health to go in and
do that work that the mental health center didn\'t want to do. She had
an assistant and she put \$50,000 in a checking account and then her
salary on top of that, but she basically had \$50,000 a year flexible
money. And she went in and provided at one time 23 families, who had
kids that were at risk of going out of Nebraska for services, the
support and services in a 17-county area surrounding North Platte. She
provided those services and supports.

In the end, when they evaluated this project, program, whatever, they
found out ‑‑ they asked the families that had been served over a
five-year period of time because finally the mental health center got
their money back and they decided to just provide those 50-minute mental
health center visits with it. And she came back to Kansas. But,
nevertheless, they asked a question. And the services that the families
most wanted and utilized were attendant care and tutoring for their
children.

Now, Corrie trained up behavioral aides to work in the schools and the
schools paid for the behavioral aides. She got managed care to pay for
some services, and she utilized Catholic Social Services and Lutheran
Social Services, places like that that were already providing mental
health services.

So for \$50,000 a year, it\'s just kind of something to think about.
These were all paraprofessional-level people. A lot of college students
provided attendant care, which also acted as respite care, which also
acted as mentoring. You understand there\'s a broad kind of definition
for whatever attendant care can be.

So the bottom line for me in all of this in watching that for five years
roll out ‑‑ and it was the kind of \$50,000 in a checkbook that you
could write a check for any service she wanted. She paid Lutheran Social
Services when she got mental health services for a child and family.
It\'s the kind of alternative that we don\'t look at for rural
communities very often, but I watched this and it was most incredible.
For \$50,000 a year, 17 counties on \$50,000 a year plus her salary, and
she had one support person kind of on the ground.

She has a master\'s degree in public administration, but she has a
sister with anorexia and drug and alcohol problems and everything that
Kristi has dealt with over the years. So she lived with it and she knows
it and she loves working in it.

But the reason I say this is because I think that we\'ve got to look at
some alternatives not just for Systems of Care, Terry, which are never
going to be in every community in my lifetime probably. I\'d love it if
they were. But what are some alternatives that we could utilize in
communities like in rural Nebraska or rural Kansas if they don\'t have a
system of care? What are some other ways that we can look at this? And
I\'m also telling you because I think there is a huge purpose for
paraprofessional-level trained-up and supported kind of people.

Now, the last thing I want to say ‑‑ and I know I am a terrible broken
record about this with these statewide family organizations. But again,
I\'m an interior designer. I didn\'t know how to run the Federation of
Families for Children\'s Mental Health. I didn\'t know how to run Keys
for Networking. I had a lot of supportive people around me that helped
me do that. We cannot throw the baby out with the bath water. If you
need from us certain kinds of data ‑‑ we are the paraprofessional
workforce running these family and consumer organizations. We\'re, most
of us, not trained up for this.

So I say to you we need the support just like other people out there
that are doing paraprofessional work need. I feel like anytime you have
this kind of rich workforce, I think you need to bring them together and
you need to talk about what it is they need from the federal government.
And if you\'re not getting what you need or what you think the field
needs from them, then we need to have some conversation about that, not
just acts in the budget.

So I make that one last point on that because I think all
paraprofessional support in the field needs a certain level of oversight
and support and training and ongoing everything. Nevertheless, it has to
be planned and utilized carefully, but it works. I swear it works. And
we are never going to be at a place that we have got psychiatrists
wherever we need them and that we\'ve got the kind of workforce we
really need out there to serve every need.

Thanks.

MS. POWER: Thank you, Barbara. I think you\'ve really triggered a couple
of things for us in terms of the matrix discussion.

The first is that this whole notion about paraprofessionals are alive
and well and are the backbone of the system, we really need to capture
that and capture that in a way that we can then speak to it and get data
about it. So I think that\'s a really important trigger.

And the other thing is in all of these reports ‑‑ and particularly, I
haven\'t read the rural one yet ‑‑ we need to give models and examples,
just like you talked about in Nebraska, and describe that. So we come
back to you and say, give us your description, or I\'ll pull it from the
minutes and say, here\'s a model of a working program that built on the
strengths of the indigenous community. And I think that\'s really an
important principle.

MS. HUFF: You know, Bill Reay, who runs Omni Behavioral Health in
Nebraska in Omaha, and Corrie put together a really wonderful
presentation about that, and I\'m sure anytime would be happy to either
send you their overheads or present it to you.

MS. POWER: Thank you very much.

Please, Gwynneth. We\'ll go right down the line here.

MS. DIETER: Yes. When you first began, of course, the first question
that came to my mind is why is there a workforce shortage. It\'s come up
over some of our meetings several times, rural locations, isolation,
qualifications for work, maybe low pay. But in listening to what Barbara
is talking about, is part of it that very fact that they\'re looking for
people who are trained at a certain level with certain qualifications?
That person isn\'t going to be paid enough there and isn\'t willing to
go there, but maybe we don\'t need to look for that person. I mean, is
that why there is a workforce shortage in part?

MS. POWER: Well, I think that the acknowledgement about the shortage
really comes with sort of the demographics of the baby boomers coming
into a retirement mode. So that\'s what I meant about hearing about the
sky is falling. Demographically there is a shift.

At the same time, there is a shift in the demands for the kind and
quality of services and what people want, which is very different than
in the institutional-based system that might have been around or very
different from long-term inpatient care or long-term residential care.
We\'ve moved into, over the last many years, a much more
consumer-focused, community-based world, and that I think also speaks to
the shortage, Gwynneth, in terms of the field saying, we\'re not
necessarily getting the numbers of people or the right kind of people in
terms of their ‑‑

MS. DIETER: No, that\'s kind of what I was thinking. It\'s not just
numbers. It\'s looking at what kind of people the workplace wants.

DR. GARY: Thank you for your continuing support about issues regarding
workforce.

When Ken was talking, it reminds me that in our workforce, we have
basically two levels, as I see it. I think we have some universal
issues, and then we have some particular issues. Another way of saying
that is we need to have generalists and we need to have specialists.
Specialists will always be fewer in number than generalists.

But if we track what happens to people, we know that people in the
public sector, poor people, don\'t get specialty care until they get
severely ill. It just doesn\'t happen. So the question then becomes
where do individuals get care. They get care at public health
departments, community mental health centers, private practice, nurse
practitioners, primary health care, or they get none at all until they
get very, very severely ill.

We have to also look at the context. If we look at the average length of
stay in a hospital, for most hospitals in the United States, it\'s
between three to five days. When I started as a psychiatric nurse,
inpatient unit, it was three to six months, sometimes a year.

So we have had a phenomenal paradigmatic shift in terms of how we treat
people, and I think every inpatient unit in my mind is a crisis
stabilization center because as soon as we stabilize them because of the
psychopharmacologic agents now, they are out. I never dreamed that I
would be discharging people to the Salvation Army or to Taco Bell, but
that\'s what happens sometimes because of the lack of resources.

Now, we do have psychopharmacologic agents that can help people sustain
themselves, but what\'s missing is the human element for helping them
with activities of daily living, monitoring, and also the co-occurring
issues such as substance abuse. So I\'m saying this to give some context
about how complex the workforce issue is and what we need to do.

But despite that complexity, I have recognized that when the federal
government changes its priorities, changes its agenda, and sets the
standards for funding, everybody else falls in line. Everybody falls in
line. So if you send out an RFA and you say these are the requirements
and there are \$3 million or \$4 million attached, people change their
curriculum, they change their hours of service for students. Everything
falls into place. And so I think a lot of the power is driven by money
and resources which is set by the federal government. So I think we need
to remember that particular kind of caveat.

We also need to do some critical thinking about reimbursement in the
real world. For an example, psychiatrists. I\'m sure Dr. Lehmann could
address this. Psychiatrists do medication checks now. One of the reasons
they do medication checks ‑‑ and all of the other kinds of services are
done by nurses, social workers, psychologists and other
paraprofessionals. One of the major reasons that that happens is the
reimbursement process. If you see patients in group therapy/individual
therapy, then you get \$50. If you have a med check and ask, how are you
doing, Joe, and whatever, then the reimbursement is much more. So
psychiatrists feel that they need to make more money, and that\'s how
they have structured their practices all over the United States. So I
think we have to look at reimbursement and rewards and incentives for
the provider.

The other piece. Ken made the point about public and private mental
health. As I see public and private mental health, what I have tracked
over time is that unless the person is the worried well, that individual
is going to eventually end up in the public sector. No one can provide
services for a family member in the private sector for any sustained
period of time. No one. It\'s just too expensive.

So my effort would be to look at the public mental health sector where
the majority of people receive their mental health care because once we
set the bar high there, I think the private sector has to at least meet
that kind of bar.

Plus, I think the private sector ‑‑ there\'s so few now because a lot of
the private hospitals, as you know, over the last 20 years, have closed
because they\'re too expensive to operate.

I also would like to propose that we give some serious thought to public
health models, to get back to what Ken said about prevention. I think we
have to address both. We have to address prevention, but we also have to
recognize that we have people (inaudible) some kind of care, various
gradations of care by specialists, by generalists, by paraprofessionals
or whatever. But they will need care. So I highly recommend that we look
at the public health model.

I also would ask that you and the committee ‑‑ and I\'d be happy to help
‑‑ look at the early blueprint for community mental health that was
designed a long time ago when I was a student. I did my thesis about it.
It had something like 12 required services: consultation, school
consultation, school services, the chronically mentally ill, hotline
services, crisis intervention. And over a period of years, all of that
got chipped away. I\'d like to state that I think that works, and it was
in communities.

The other piece I\'d like to add here is that we give some serious
thought to self-help groups, which we\'ve never really invested a lot of
time and energy in doing. That empowers individuals. That helps them to
be accountable and responsible for their own illnesses. There, again, is
a lot of good work done at the University of Vermont on self-help
groups.

But one thing we have not done is we\'ve not embraced them. We\'ve not
made them a part of our culture, and I think it\'s time for us to do
that because mental illness is, indeed, a chronic kind of condition that
can be controlled with the psychopharmacologic agents, but individuals
do not do well unless they have all of the other support systems that
the rest of us who call ourselves normal and well have every day.

I truly embrace and endorse the paraprofessionals. I think that
education needs to take place in academic communities. I agree with Ken
that it has to be competency-driven and perhaps even a licensure
associated with it. So that\'s our one way to assure levels of
competency and basic levels of performance.

In conclusion, I do not think that we can plan any program without
looking at issues regarding diversity of the workforce, diversity of the
populations of individuals who get sick. And I think we also have to
look at the social determinants that set people up for mental illnesses
and co-occurring disorders and maintain them there.

Another way of looking at this is how do people get homeless and what do
we do that helps them to stay homeless because I think that we really do
know that people need more than housing. They need education. They need
jobs. They need work. They need incentives. They need the same thing
that we do. So I think we have to look at our comprehensive programs.
That brings me to the notion of looking with what the Department of
Labor can provide, what FEMA can provide, what NIMH can provide, the
Cancer Institute, whatever.

Again, I think the trump card is at the federal government because
that\'s where colleges, universities, institutions, and service agencies
get their money. So I think if we structure our agenda, people will have
no choice but to look at this new paradigmatic shift that is going on.

Thank you.

MS. POWER: Thank you, Faye. Tremendously rich commentary.

I was actually going to try to respond to each one, and I can\'t because
I was ticking off in my brain, well, let me tell Faye about what we\'re
doing in peer support services, et cetera, but I won\'t do that. Thank
you so much for all of that rich commentary.

Tom?

DR. KIRK: I don\'t want to repeat what other people have mentioned.

What I would suggest is I think the workforce development piece can
serve as a core, if you will, center of any number of other issues. Let
me try to tie them together.

At least in Connecticut, there\'s a lot of attention to health care
plans. Universal health care plans or something in accord with that. I
think that this particular focus that you\'re working on, as well as on
the state level, is an opportunity to tie to those health care plans.
Let me give you a couple examples.

I think the distinction between the public/private sector is
increasingly small. We all can have the best wish that a parity plan is
going to pay for what it is we want to pay for, but I can\'t wait for
that for the people that need services. So we will have people who are
in the private sector with family members with substance abuse or mental
health issues, and they\'re willing to pay big-time dollars to buy their
services from the state system.

In the report you did where you went into the business community and
they were willing to buy from state systems, that to me says the
distinction between public and private is fast decreasing. So I think as
we look at this, an important premise would say that that is decreasing
and, therefore, it should affect how we go about our business.

Going back to the health care component ‑‑ I think I mentioned this
yesterday ‑‑ the data reveal that persons with serious psychiatric
disabilities have life spans as many 15 years less than other persons of
generally healthy conditions. I was talking to one of my substance abuse
providers last week, and he was saying he has a lot of recovery people
in his service system. And guess what. His health care plan costs are
extraordinarily high because of their history.

So tying it to the fact that people with psychiatric disorders, people
with substance abuse disorders have serious health care conditions
associated with that, tie it back to the health care plan. If you want
to make an investment in managing health care costs, pay attention to
these particular issues, and that would then tie it to the wellness
piece.

Two other comments. We had a brief conversation yesterday. It ties back
to your point about case management. Somebody once told me,
Commissioner, you don\'t have a treatment system in mental health. You
have a case management system. I don\'t necessarily think that\'s bad as
much as it needs to be tweaked. \"Tweak\" is probably an understatement.

And when we\'ve talked with those case managers about a
recovery-oriented model where the person and the family member have more
to say about what occurs, as one of them said, you know, I\'ve been
working with these patients, clients, consumers, whatever you\'re
comfortable with, for the last 10 years. It\'s to the point where if
they were going to commit suicide or make a suicide attempt, I will tell
you where they would go, I would know what their method was to do it,
and you want me to sit with them and negotiate what it is care should
be? Their view is that I\'ve managed those cases. I know them well, and
this thing of empowering the consumer to be more a part is going to be a
challenge.

In a similar way, when you talk about the workforce piece, again, it was
mentioned yesterday the largest amount of face time with the people we
serve is not people like me or executive directors. They are the line
staff, and they represent the largest proportion of the workforce. I\'ll
speak for myself. I don\'t think that I pay anywhere near the attention
to direct line staff and empowering them and training them as we should.
They\'re the ones that are the true change agents in a service system.
So I think that when we look at these workforce development pieces, I
think some attention should be paid to who are the true change agents in
terms of care. They\'re not the executive director types. They are the
people who were at the line level.

The last point I would like to make is that if you think of tying us to
a health care focus and health care plans and uncompensated care as the
major component, if you think of the fact that the distinction between
private and public is no longer as strong as it was before, if you think
of the fact that a large majority of the people that we try to provide
care for have continuing care disorders ‑‑ I won\'t use the word
\"chronic\" ‑‑ and just like the rest of us, they need what I call
recovery checkups ‑‑ you know, you come back and then go on ‑‑ that the
structure of our service system and the role and vision of SAMHSA as to
what its responsibility is is very, very different. I\'ll use this one
example.

We\'re rebidding our service system, and one of the points we were
trying to make was how do we have more access types of approaches in the
front end and how do we have more continuing care approaches in the back
end. Someone came up with the idea of we should not continue to fund
solely mental health treatment centers, substance abuse treatment
centers. We should go ahead and put in place something we call
continuing care centers. A person would move from the intensive
treatment component to some variation thereof, and they come back for
continuing care support, very, very community-focused, sort of playing
off the SPF/SIG. But that\'s very different from our service system. I
think it also would serve to diffuse, if you will, some of the stigma
that\'s associated with the field.

My last comment is that if you think of things from this point of view
‑‑ and I may not be very clear in these things ‑‑ it seems to me that
this has extraordinary implications for who and what SAMHSA is. I think
my mental health folks will tell me, you know, Commissioner, you\'ve got
to pay attention to the fact that these persons with serious, persistent
mental illness will always be shortchanged in our larger health care
system. And that\'s why we need to continue to focus just on them. The
mental health transformation piece, in my judgment, says that has to
change, but it\'s not to shortchange those persons with serious,
persistent mental illness as much as it is to have a more responsive
service system at every tier, so whether it\'s disparities or others.

And for all those reasons I think there\'s a confluence of context
factors that says the vision and role of SAMHSA ‑‑ I think, Dr. Cline,
what you\'re saying in terms of the vision and mission, I think that
they\'re right on the mark. But what the infrastructure is that supports
that is different. So as we continue with what you might call a
visioning process, or whatever it is ‑‑ just a side comment.

When you look at the data, at least in my state, for why people are
dying at such a premature age, it\'s not the suicide. It\'s not drug
overdose. It\'s related to diabetes, respiratory problems, the things
that you and I are likely to die from. I grieve, if you will, when
critical incidents come across my desk, as they do, at a 50-year-old
person in our service system has died from a heart attack. As a
psychiatrist in a forum that I was at recently said, it\'s gotten to the
point where he frankly can say to a person, I can tell you you\'re not
going to die from your psychiatric disorder. You\'re going to die from a
diabetic condition, and I don\'t know how to treat diabetic conditions.
It\'s a whole different framework.

And I think that as you look at SAMHSA for the next X number of years ‑‑
and I don\'t understand things like reauthorization and what that means,
but it seems to me the role of SAMHSA in accord with the mission that
you have or the vision that you have ‑‑ there\'s an opportunity for
redefinition and not simply continuing to do what we\'ve been doing for
all this time. And I think the workforce piece is a great, great vehicle
to run the course, so to speak, run the agenda.

So I applaud the fact you\'re taking it on. There\'s no doubt that if
you look at it just from a workforce development point of view, it\'s
there. My point is I think it\'s an opportunity to tie things to health
care, to the other kinds of components, to broaden the focus, and I
think we can get the choir to be broader because someone may say, I
could care less about mental health addiction issues. Do you care about
health care? Yes, I do. Then fine. Tie it to that.

So that\'s my comment.

MS. POWER: Thank you very much, Tom.

Ken?

MR. STARK: Keying off that, when I think about the tremendous sort of
community process we went through the first year of the transformation
grant, many, many public meetings and 6,000 pages of transcription from
those community meetings, which was totally overwhelming, the message
that truly came out from family members and consumers was that we really
do need whether you want to call it an addition to or a transformation
of the existing system. The consumers and families wanted to see some
significant availability of like recovery support centers and programs
that were run by families and by consumers who had specific training and
experience and that it didn\'t have to be a real expensive, big,
professionalized trained program with psychiatrists and doctors,
although as part of the system, they needed to be there.

But many of the consumers felt for the stability of their recovery ‑‑
without having that system in place, some of them got through with
family and with the faith community and other friends that helped them
when they had a crisis. But others ended up having to go to the
professional system who has a standard operating protocol of
interventions, which they didn\'t feel was helpful to them at that time.

So that kind of ties in yesterday with the comment I made about, if
nothing else, looking at the Access to Recovery Grants on the
alcohol/drug side, the ATR grants, and seeing about their usefulness in
the mental health community.

When I then kind of look at Washington State and see our system, I
recall during that process we had interviews with physicians and health
plans. There\'s this group of health plans we have in Washington State
called Healthy Options. Those are managed care, physical health plans
that are available mostly to TANF families. It does have a small mental
health benefit in it, up to 12 visits, but most of it\'s really tied to
medical.

When you talk to the physicians in those health plans, their feeling was
that they as physicians were more than adequately confident that they
could basically deal with sort of the walking wounded, if you will. I
hate that term, but I think most of us know what it means in terms of
not the severe, persistent mental illness diagnosis, but people who are
having challenges with daily life and whatnot that may, in fact, get
worse if somebody doesn\'t intervene. But those physicians felt that
they could handle those cases. But they clearly didn\'t feel that they
handle the more severe diagnoses, and they would then send them off to
the other system, the mental health system.

I keep thinking to myself that we\'ve got to figure out and agree. Are
we going to part of a health system, going back to what you said, Tom,
and my harping, if you will, on this terminology of behavioral health ‑‑
are we or are we not going to be part of the health system? If we are,
we\'ve got to vision that. We\'ve got to change our language and support
that so that we really are seen as part of the health and wellness
system.

Then we\'ve got to figure out how we sort of integrate some of that
primary care stuff on both the prevention and intervention side, along
with the alcohol/drug stuff, along with the mental health stuff. And
that doesn\'t mean merge all these systems. What it means is integrate
the care when and where appropriate. And I\'ll give a simple example of
something that\'s fairly low cost to do.

If you\'re running a mental health center, for instance, and given the
research that Tom speaks of, of the fact that many people with severe
and persistent mental illness die 15 years younger than folks without
severe and persistent mental illness and die at an average age of 54 ‑‑
and they do die from things like diabetes and stroke and heart disease,
and if you look at the risk factors of those individuals, the risk
factors are around smoking and substance abuse and obesity, lack of
exercise, that sort of thing.

What that tells me is that, okay, fine, as a strategy within our mental
health centers, shouldn\'t we be looking at, in addition to the
traditional mental health services, some pretty strong sort of health
and wellness programs within those centers that talk about simple things
like ‑‑

MS. POWER: Nutrition.

MR. STARK: Yes. Training and teaching people about how to cook
nutritious meals, how to buy low-cost, but nutritious meals. They come
to the center, and as part of coming to the center, maybe you can have
some low-impact aerobics stuff going on on a regular basis and maybe you
can do walkabouts in the neighborhood kind of a thing.

But those are simple, low-cost things that are preventive, and they are
health and wellness, and they are ways of sort of integrating services
without breaking the bank and then, at the same time, having these
recovery support sessions, whether you want to call them tune-ups or
whatever you want to call them for individuals. But they don\'t always
have to be tied to mental health centers either. They can be tied to
community, family, and consumer organizations.

So it is going to take a transformation. I think we all need to talk
about that. We all have our biases. When I talked to those physicians,
by the way, and we talked about, well, where would you refer, many of
the physicians aren\'t comfortable with paraprofessionals. They won\'t
even refer to psychologists, some of them. They want a psychiatrist,
only a psychiatrist. So we\'ve got to kind of get past those biases too,
as we move forward.

MS. POWER: Thank you very much, Ken.

Larry?

DR. LEHMANN: Yes, just a few things. I\'m extremely lucky to work in a
system like VA where mental health and other health care are kind of
together a lot more than in a lot of other public and certainly private
systems.

But we still have our work cut out for us, and one of the things that
we\'re doing is actually putting some money into models of collocated
and collaborative care where mental health clinicians of a variety of
stripes ‑‑ there are some psychiatrists, mostly social workers, nurses,
and psychologists ‑‑ are actually going to be working with the primary
care folks. It will decompress them tremendously. Wherever you see these
programs popping, they\'re really appreciated by the primary care folks.
So it\'s part of the idea if you fund it, people will use it. That\'s
much more difficult to do, I think, outside a system like ours.

But the other thing is for ourselves within the mental health provider
community, we really have to educate up our folks into the value and the
power of the recovery-oriented activities. And we have some very, very,
very good examples of that, certainly within VA where we have in our
network ‑‑ three in New York ‑‑ they had like 100 people who were like
long-term stay people in their facilities, and they whittled them down
to about 13 using a pure recovery-based system where these folks were
helping to run each other\'s programs.

Now, sure, in VA, the patients have all been in the military. They hark
back to those kinds of things. But you can develop comparable approaches
to this. Certainly that\'s what AA has been doing for years.

So we\'ve got to train up our people. This gets back to the issue of the
curriculums. We\'ve really got to train up our people in high school, in
university, in the medical and nursing schools about the value of these
approaches so that people who go into primary care will be able to
accept it and people who go into the mental health professions will be
able to accept it, kind of a second nature. So this whole business of
having to focus on workforce development is really something we can
capitalize on. It\'s come at a marvelous time.

The other thing is the fact that second-generation antipsychotics have
these problems of a metabolic syndrome of increasing cholesterol and
triglycerides is kind of a blessing in disguise because it\'s been a
tremendous kick in the pants to the mental health professionals who are
saying, oh, my gosh, I\'ve got to look at diabetes. I\'ve got to look at
health promotion because otherwise these folks who really may need this
medication are going to start dying from something else, which is what I
don\'t want.

So it\'s a two-way street and just a lot of opportunities for presenting
the range of models that may work in different areas and teaching that
to people as they\'re coming up in their education, but then also using
‑‑ and I hark back to the presentation yesterday about the train the
trainer models. If you can start working with people who are actively
engaged in care now, that\'s a very, very, very good model. We\'ve been
using this since the 1970s in prevention and management of disturbed
behavior, for example. And you\'ve got a cadre of folks who are master
trainers and people who are trained up in our facilities for doing that.
It builds generations of people who understand how to use a particular
model. So in a sense, what I would suggest is use train the trainer for
the people who are in the professions now and then teach the ones who
are coming up these concepts so that they\'ll be able to pick that up
and use it in the future.

MS. POWER: Thank you very, very much. I know we are running out of time.

MS. SULLIVAN: Kathryn?

MS. POWER: Yes, I was going to ask Kathleen if you wanted to say
something about the workforce strategy.

MS. SULLIVAN: Thank you. Two things. One on early retirees and the
second on continuing education, one, a personal note.

And Barbara, you know, I love your personal notes.

But one of my former producers, believe it or not, at CBS and then she
was also at NBC, is now living in Montecito of all places. She got her
master\'s in social work after she left CBS, and now she works with
substance abuse and the mentally ill in Santa Barbara. For her, it\'s
her secondary career.

I see this as a great opportunity now for those people who have left one
career. They have early retirement and they want a secondary career. As
you said, many people come from other arts or from music and want to
once again contribute to the society. And how do you make that aware to
people?

I was thinking I live in an area of actually now early retirees where
we\'re seeing people retiring here at 50. And, Ken, you\'re up in
Washington with a great amount of affluence in the Seattle area. And
there are pockets now of people who want to recontribute to society, and
we see the turnover of occupations where in the continuing education
realm, with continuing education classes being offered all over the
country now through universities ‑‑ I don\'t know, Kathryn, do you have
an arm that has reached into the Department of Education or how that
works actually. If continuing education classes can be created ‑‑ and,
Faye, you would know much of this. How it could stimulated where people
could get this training at least through continuing education courses at
the community colleges so that the retiree group, the fifties, people
who are 50 years old can see this as an opportunity. I\'m not looking at
the 20s and the 30s, but the 50-year-olds who see it as a secondary
career.

MS. POWER: Yes, I think it\'s absolutely something that we need to look
at and consider. I just saw a monograph yesterday about how we should
take on and look at that cohort in terms of training for second and
third careers relative to giving back to society and kind of looking at
it from not only the paraprofessional approach. So, yes, we\'ll look at
that and take it under consideration.

Actually, there are some model programs in some communities that have
been cited in the Annapolis Coalition report where they did do a
particular recruitment strategy towards that. So we can cite some of
those.

I know, Faye, you want to make a comment and then, Governor, if you
wanted to make any comment about workforce before we end, and then
we\'ll move to the end of this discussion. Thank you.

DR. GARY: This is very, very quick. I just wanted to add to what Tom and
Ken were talking about, and also when I heard Kathleen, I thought that
one of the other pieces that we haven\'t mentioned here today regarding
workforce ‑‑ and as we look at workforce as a major, major catalyst to
transformation, I would ask that we also integrate into any plan a
specific agenda to do more teaching with the patients and with their
families. I encounter patients who have had schizophrenia for 20 years
and they don\'t know anything about the illness or the families who feel
so disenfranchised because they say the professionals won\'t talk with
them about the illness. I know there are issues of confidentiality, et
cetera. But beyond that, I think we have to engage families.

If you look at some of the earlier work done by a man named Lamb ‑‑ he
was at UCLA. I don\'t know now ‑‑ where he used to literally invite the
families of the patients into the auditorium at the university and they
would have these one-on-one lectures. And I\'ve done the same kind of
thing with families, and they really love it and appreciate it, feel
empowered, much more cooperative with their families, and perhaps it
even decreased the need for hospitalization.

The other and final comment is that as we look at models that would
integrate primary health care, the mind and the body as one, and we look
at public health models, I think we need to examine what the World
Health Organization has done in many of the other countries throughout
the world. There are some excellent, excellent models that involve
communities, families, self-help groups, community health workers, et
cetera.

Thank you.

MS. POWER: Thank you, Faye.

Governor?

MR. AIONA: Very briefly. We had a great discussion. A lot of merit to
what everybody has said. I\'m just here maybe just to summarize what I
envision and what I see.

I would just say that SAMHSA can\'t drop the ball on this. We\'ve heard
this term being used the last couple of days. I really believe that
there\'s urgency to workforce development. I just hope SAMHSA doesn\'t,
one, first of all, define workforce development in its traditional
sense, which is we need to train up more psychologists or psychiatrists
or substance abuse counselors and these are the skills and the knowledge
that they need because it\'s much more than that, as we\'ve seen through
this discussion, about what workforce development is all about.

When I listened to everything and I tried to sum it up, I came away with
this. I keep thinking this, that it seems like everyone in this room is
a part of this workforce. We\'re all a part of it, and we all, to some
extent, have degree of knowledge and skill in regards to what is needed
to help people who have ‑‑ and we\'ll use our traditional terms here ‑‑
substance abuse problems and mental health problems.

So you have an opportunity. Or I should say SAMHSA ‑‑ not an
opportunity, but SAMHSA needs to take the lead in making sure that when
we talk about workforce development and where we\'re going to go, we\'re
going to change this paradigm and we\'re going to make it now such that
it\'s broad enough for the simple lay person to be a part of this, and
they need to be a part of it.

And that\'s basically all I have to say. Everything else was just a
great discussion.

MS. POWER: Thank you very much. Terry, I appreciate the opportunity to
come before the council. I want to thank all of the council members for
your tremendous engagement in this discussion, and I look forward to
following up with you.

DR. CLINE: Thank you, Kathryn. Thank you, members of the council. That
was very rich. And thank you for the summary as well, which I think hit
the nail right on the head.

At this time, we don\'t have a scheduled break, but I would like to
check with the council to see if you would like to take a 10-minute
break and reconvene or whether you would prefer to charge ahead. What\'s
the will of the council?

Time for a break? Okay, let\'s go with the two people who spoke first.
We\'ll take a 10-minute break and reconvene in 10 minutes. Thank you.

(Recess.)

DR. CLINE: We\'re going to jump right back into it here. Thank you for
coming back to the table.

We have about 35 minutes remaining before we need to adjourn. I know
some people have flights and other commitments.

The good news on this is the precursor to our work started during our
last conversation. So this is like priming the pump, to use an Oklahoma
expression. I don\'t know how often it gets used here, but I think the
pump is primed.

The other good news is we have another good facilitator, much as we had
with Kathryn, now and we are in the hands of Governor Aiona. So I will
turn it over to you at this point.

MR. AIONA: Thank you, and let\'s not waste a minute of the 35 minutes
that we have.

We actually started this yesterday. When we opened up, I had asked that
we all think about issues or topics that we wanted discuss at our
subsequent meetings.

Then yesterday we started talking about how as an advisory group we
could help you, Dr. Cline, and SAMHSA in its role and in accomplishing
its mission and its vision. So I\'d like to open up discussion on those
two topics, and I guess if we could summarize it and put it under one
heading, I guess the line of discussion would be how can we, as the
advisory group, develop and assist and advise or create a vision for
SAMHSA in the subsequent meetings that we have from today.

As an example, yesterday we had great discussion on the budget. Everyone
was very much in tune with it. We understand, I think, as a body how the
budget will drive the mission and the vision of SAMHSA, and I think we
all want to be a part of it. For me ‑‑ now I\'m speaking on behalf of
myself ‑‑ if it\'s at all possible, I would like to be a part of
developing that budget in a more relevant setting and time constraints.
I mean, in other words, I know it\'s a little too late for this new ‑‑
is it a biennium budget that SAMHSA has?

DR. CLINE: Yearly.

MR. AIONA: A yearly budget? Well, being a part of it before it happens
when discussion is happening so we can kind of shape it that way, I\'d
like to be a part of that. I understand the policy constraints that the
agency has, but nonetheless, I think we can add because of our diversity
here in not only what we do, but where we come from. I think we could
add a lot to how the budget is shaped.

So I throw that out for discussion, and anything else that would come to
mind to our members here. So I open it up to anyone, or we can go down
the line. It doesn\'t matter, however we want to do it.

Ken?

MR. STARK: I would agree, Duke. The issue for me yesterday was just as
you described it a minute ago, and that is, that it really would be nice
to feel like, talking for myself, that I had an opportunity to have
input into and possibly influence the future agenda. And I, too,
understand all the constraints. I\'m not interested in trying to be a
decision-maker around individual budget items. I mean, that\'s not
appropriate for an advisory group.

But clearly, in looking at your future budgets, are there ways that I
and the other members can actually take a look at some of the program
areas, some of the focus areas that you might be looking at relative to
priorities for the 2009 budget or the 2010 budget?

I\'ve already sort of mentioned some of the things both this morning and
yesterday that I clearly want to recommend, and that\'s looking at
things like ATR and SBIRT for both mental health and alcohol/drugs and
looking at the prevention arena across SAMHSA so that it\'s looking at
prevention and early intervention for mental health and alcohol/drugs.

And then there are other things that I\'d be very interested in
understanding, the kinds of criteria that was applied to different
programs as you talk about elimination of those programs. Again, just
feeling like I\'m making a difference, and knowing that having an
opportunity to give input and getting my way are two different things, I
clearly understand that.

DR. CLINE: Governor, if I could just make a quick comment.

MR. AIONA: Sure.

DR. CLINE: Ken, as you mentioned all those program areas or areas of
focus, what would be helpful, in addition to identifying those, is going
that one step further. What would you want those to look like in five
years or ten years? And then as we get input from multiple stakeholders
and others, then we can try to put that together and try to
operationalize some of those ideas so that they\'re consistent with the
vision and mission for SAMHSA.

Because you outlined those so clearly, could you take a couple of those
and just say briefly what you would hope those would look like in the
future?

MR. STARK: Just quickly, and not just focusing on SBIRT or ATR, for
instance, or necessarily just prevention specifically. And this is
sometimes heresy as a state person to say this to a federal agency, but
I go back to the alcohol/drug system and one of the things that SAMHSA
did in order to promote prevention was, in fact, to push the issue via a
requirement. And I hate set-asides, but at the same time, I also know as
a manager, when you\'re trying to influence systems that already feel
buried with where they\'re at and already have their own stakeholder
pressures and politics, that sometimes those with the money need to use
the money to influence and shape future policy.

So from a strategy perspective, if I\'m looking at, say, prevention and
if we truly believe that mental health and alcohol/drugs both need to
have a continuum from prevention, early intervention to crisis and
acute, it seems to me that somehow getting that written into SAMHSA\'s
vision and then that vision gets translated into the block grant that
gets translated into discretionary funds that are available ‑‑ I mean, I
look at the transformation grant. One of the ways that SAMHSA is trying
to transform states\' mental health systems is through a grant program.
If we want to look at things like ATR and SBIRT on the mental health
side, then similar to what you did on the alcohol/drug side, you used
the resources as an incentive and made it a competitive process.

And I think that those are the ways that a federal agency as a funder,
as a payor is going to cause systems change. As sad as it is to say that
it\'s done through money, it is done through money. I mean, that\'s the
way states do it with their locals. That\'s the way substate regions do
it with their providers or community organizations. One of the ways to
influence policy change is by the incentive called \"resources.\"

So I think that that\'s something that I would encourage even though it
may be somewhat heresy coming from a person from the state to tell a
federal agency to require that of us or push us in that direction.

MR. AIONA: Anyone? Go head, Faye.

DR. GARY: In the future, I think it would be also helpful for us if we
would be able to get more information about our programs that SAMHSA
funds, supports so that we can see what the outcomes are and probably
spend time discussing those outcomes, what makes that work, and why
things did not work. In other words, I think we would be getting at the
crux of core issues in substance abuse and mental health if we were to
be more involved in that and to use those kinds of data, again, to shape
future strategic plans, policy, content for RFAs, et cetera.

And for some specific kinds of areas on our matrix, I think that we
should know what specific activities relate to our matrix and what is
the profile of those particular activities, whether you\'re talking
about homelessness, if you\'re talking about restraints, seclusion and
restraint, or we\'re talking about child mental health issues, so we can
have some general view of what we do have. And then we can talk from a
more informed posture about what it is that we need.

MR. AIONA: Thank you.

Yes, Barbara?

MS. HUFF: I, too, think it would be a great idea if we did have some
input into the development of the budget. It\'s not really the
development but some response to what you\'re funding, as they said,
based on what you think the outcome is and things are or are not.

I\'m probably not going to be on the advisory council long enough to
maybe get totally engrossed in that or invested in it, if you do it. If
I could envision what it might look like, for me I think it would be a
marvelous idea to bring four family leaders in to sit in front of this
council and talk about ‑‑ I think SAMHSA is lacking huge in family
involvement in mental health. There is no family involvement across
substance abuse treatment and prevention.

I sat in the room before Sandra took my position at the federation and
had some discussion with the leaders, but the leadership has changed in
some areas too. But to just kind of sit down and have some conversation,
listen to what it is they say they do and need and what kind of support
they need from you ‑‑ but also if you read ‑‑ do you remember reading
\"Blamed and Ashamed\" at all when we had the Tulsa conference? And
there was a huge, big focus on co-occurring with kids. SAMHSA funded
\"Blamed and Ashamed,\" and it was around co-occurring mental
health/substance abuse issues with kids and with adolescents.

I think it would be a great idea to hear how families think they\'d like
to be involved at the local or state level, community level, and at this
level around both substance abuse treatment, prevention, and mental
health. I also think they could provide some conversation with you at
some point in time. I think that we need to sit back.

I think Systems of Care is wonderful and it\'s moving along and it
continues to be funded. Evaluation still tells us it\'s worth doing. But
like I said, I think there may be a place and time that we want to bring
forward some other ideas and options for service delivery for kids in
different kinds of communities, whether it be urban or rural or
whatever. I think it would be a good idea to hear from families, where
they think this is at right now.

You\'re new and I think it would just be phenomenal to bring in ‑‑ and
I\'ll even tell you that New York, Georgia, Mississippi, and Kansas will
give you a huge diversity of people to listen to and very strong family
leaders who have been around for a while. I think it would be well
worthwhile to bring a few people together and have some conversation
with you about the value of families across SAMHSA.

Thanks.

MR. AIONA: Thank you, Barbara.

Gwynn?

MS. DIETER: Yes, I agree with what Duke said and several other people
that we would all like to feel that we\'re making a contribution and
helping SAMHSA in whatever way possible.

The vision or your plan really drives the budget. At this point in time,
there is a transformation agenda going on. So there are items in the
budget, of course, that are from an earlier time and place.

I think what I was struggling with yesterday ‑‑ and just thinking about
the budget, I also do not want to look at any line items and say, this
program ‑‑ I have no idea. But I would like to get a sense of how the
vision, a newer vision for SAMHSA, follows into that budget. I would
like to see that happening and would like to be, hopefully, involved in
that way.

We\'re talking about a shift in the paradigm of the workforce also in
relation to transformation of mental health, substance abuse, treatment,
or an overall health model more than a crisis intervention/treatment
model. I think that\'s why the budget was an item that got some
discussion before because we\'re all wondering how does this reflect
what we\'re trying to do here. And a lot of times, just as in a
household, okay, now my daughter is going to college, there\'s going to
be shift in my budget. We\'re no longer going to go on vacation because
we\'re going to put this money to her. Things happen and I\'m interested
in seeing how we can help in assisting in this somewhat of a shift in
strategy and vision and how that\'s then reflected through into the
budget.

MR. AIONA: Ken?

MR. STARK: Kind of the way I see that potentially happening, in terms of
a process standpoint, is ‑‑ I mean, we have to get the timing right,
given obviously all of time lines that SAMHSA has to meet in developing
their plans. But it sure seems to me that we could have an annual work
session. I won\'t call it a retreat because that makes it sound like
we\'re partying on the beach, but an annual work session where we\'re,
as a group, able to take a look at some future time, whether that\'s
looking at 2010 or 2011 or however far out we have to go, where the
decisions haven\'t been made yet. And you can kind of use us as a body
to help give you some feedback on some of the priority areas that we
might see that maybe you can take a look at.

At the same time, depending upon how that\'s set up, if you\'ve already
done with your staff and whatever mechanisms you\'ve had and gotten some
input on that and have some ideas of direction you\'re already wanting
to go, that could be brought to us. You can give us that input, and then
you can get some feedback from us. Then from there, you go forward with
whatever else you need to do. And then the rest of that year for us
could be dealing with issues more in the current day of getting to know
what\'s happening now, this year, including some of the stuff that
Barbara talked about and getting us more educated on some of those
program areas of national significance. There\'s a whole lot of
different stuff.

The more we ‑‑ and when I say \"we,\" I\'m even talking about future
advisory council members as we go off. The more we as council members
understand about the programs that are out there and how those programs
tie into the ultimate vision and mission and how well they\'re working,
the more we\'re going to be effective at giving you input into the
future budgets in terms of program areas and whatnot, again, from our
perspective. So that\'s just an idea.

MR. AIONA: Yes, sir? Tom.

DR. KIRK: The impression I have from the last day and a half is that the
issues related to mental health and addictions, whether you want to call
it transformation, system change, whatever, that there are some very,
very significant differences. I think, at least what I\'ve picked up,
the definition of what a service is is different than what it used to
be. Access to Recovery got us into housing, transportation, other kinds
of things, and we concluded ‑‑ and the evidence is there ‑‑ those are
significant components to improve the quality of life, stability,
recovery, and so on.

Mental health transformation. We\'re looking at things in mental health
transformation that in a traditional sense would never be considered
services.

The structure of the service system. We go back to the health care and a
side conversation. What\'s the structure of the service system that goes
beyond just the mental health clinic and the substance abuse treatment
agency or the regional prevention component? So what\'s the definition
of a service in this new system? What\'s the structure of the way we
deliver services, how we deliver them, and who is the target population?
Is it an individual? Is it a family? Is it a community?

My point is that when you look at all those different dimensions, the
traditional system that most of us were either trained on or grew up on
over all these years, it\'s not the same.

And when I look at this piece here, I thought one of the striking ‑‑ and
apparently you all were thinking about this, whoever put this together
‑‑ coordinating the content. We\'ve got COSIG grants. We\'ve got
homeless initiatives and all these kinds. How does it tie together?

What I would hope or propose is that ‑‑ and I\'m not disagreeing with my
colleagues\' comments relative to the budget thing. I\'d be interested
in having a budget discussion not in terms of the budget itself as much
as how the things, the allocations, if you will, overall are promoting
this new system as compared to individual things.

I\'ll just use a concrete example. I don\'t know what your discretionary
grant portfolio is, but it\'s a big piece of change. One of the things
that we\'re experiencing is that ‑‑ let\'s use mental health
transformation as an example or Access to Recovery or anything else.

Instead of the approach that says, well, you\'ve got a five-year grant,
and you get to a certain point, then the dollars end, and so on, suppose
SAMHSA took the position that we want to build into our grant
discretionary portfolio linkage points or connect the dots together. So
a provider, whoever gets the funds ‑‑ it\'s not so much of talking
sustainability as to where they\'re going to get the new funds to
support it as much as maybe they\'re required in the last year of their
grant to submit ‑‑ one of the deliverables has got to be the strategic
plan as to how it\'s going to be carried out after that, not just the
dollars. How do you take what it is that you\'ve been doing for the last
three years that you folks supported and have a strategic plan in place
that sees how this stuff is tied together? Otherwise, it comes across as
a project.

So whether it\'s a family component system of care or whatever the
descriptor is, it has a life. It has legs, if you will, post that. And
the good Lord willing and we all hit the lottery, then maybe you think
about, as part of that, what you might call transitional grants or
linkage grants that are not just tied to COSIG and they\'re not just
tied to homelessness, but something that ties it together which
essentially says that if I\'m an applicant, I have mandated a partner
with different people than I used to partner with because you\'re
looking at a person-centered system in a larger sense than just the
narrow thing that you have on the table. I think that that type of
paradigm modeling, if you will, at your level could help to inform the
powers that be in Congress and the people that you have to report to.

I remember Mike Hogan coming to Connecticut and he did a presentation to
our legislators and a bunch of other folks relative to mental health
transformation. Almost one of the first things out of his mouth was that
many of the things that are important to people with psychiatric
disabilities are not in the state mental health authority. We don\'t
have any control over them. If you want to reframe the system,
transform, whatever it is, you\'ve got to pay attention to those other
things.

Last week I was up before my appropriations committee. They think in a
very narrow sense, in part, the way they do their business. They don\'t
see how these things tie together. So I think the more that you folks at
the national level can help to reframe or redefine what a service system
is that is person-centered and that it\'s reflected on the basis that
these things coordinate the content in such a way that you truly do give
people life in the community, but it\'s not like I did when I practiced
my psychology or practiced whatever it is I did. It\'s a very different
system.

So if I was to leave a bumper sticker, I\'d love to have a session that
you all have at one of our subsequent meetings. Maybe it is a day-long
session. You may want to call it a strategic planning or a strategic
discussion session. Given the content that you have, the paradigm or
system change, building off the things that you have been funding and
your own vision, what does that mean then in terms of fiscal
considerations as well as what we as a body could help to provide some
counsel to you for? We could get overwhelmed by program presentations.
And you know, you\'ve seen one. You\'ve got 999 that you didn\'t see.

I would hope that SAMHSA ‑‑ and to me, you\'re doing it through these
things, you\'re doing it through any number of things. You are truly
laying a different groundwork for the issues related to mental health
and substance abuse. But I\'ve been doing this for a long period of
time, and I frankly believe that what we have on the table now from a
health care point of view and so many other points of view is the most
exciting and opportunistic framework that I\'ve seen in my field to this
date in time.

So if we can build the infrastructure, if you will, and redefine the
agenda ‑‑ one of my previous Governors said, those who control the
policy define what the agenda is going to be. And if we could help you
within your own vision to redefine what that agenda is, I think that
would be a major contribution. What I\'ve heard in the last day and a
half is a redefinition of the agenda, all in support of your vision and
mission, but in a different sort of way. All of us know the bureaucratic
and all the kinds of stuff that you all have to deal with.

As I said when we had our last session with Charlie Curie, I thought
that one of his major accomplishments was that he served to move the
agenda in a different way. This is a legacy. We all build on the
shoulders of people who came before us. How do we move it to the next
level?

MR. AIONA: Kathleen?

MS. SULLIVAN: Duke, I missed the opening question. Is it a bumper
sticker?

MR. AIONA: The opening question you mean by me?

MS. SULLIVAN: Yes, to the group.

MR. AIONA: We were just opening it up for discussion amongst the members
as to what we would like to see in the future or what we would like to
discuss in the future, if anything, what issues we\'d like to take up.
We opened it up yesterday asking the members to just think about what
future issues they\'d like to bring up. And yesterday we had some great
discussion on different things. One of them was the budget.

MS. SULLIVAN: Yes. That\'s what I was guessing. When Kirk, or Captain
Kirk, did the bumper sticker, I was thinking of, Ken, something I would
just love to see ‑‑ I can\'t tell you guys how much I miss it. I hear
all your voices and I have so much fun looking at your faces as you\'re
talking. I\'m sitting here, I just have to tell you, looking at all your
faces, just having a blast. I see Ken. I see Tom, Barbara, Gwynneth. I
see all of you in the room, and it\'s very enjoyable ‑‑ and Kathryn ‑‑
to see all of you and your reactions to things and to hear you. It\'s
just such an enjoyable conversation and I miss you all.

I want Steve Mayberg at the next meeting. If you had \$300 million out
of the blue, what would you do with it? I want to know what he\'s doing.
Steve Mayberg of California. Ken, Tom Kirk, don\'t you want to know?

DR. KIRK: I was asked in appropriations if I hit the lottery, what I
would do with the money. They didn\'t like my answer.

MS. SULLIVAN: But don\'t you guys want to know? I mean, I want to know
what Steve Mayberg is doing with \$300 million. In a perfect world, all
of a sudden he\'s got all this money and he can come up with anything he
wants. So he\'s, all of a sudden, looking at transformative care. Is
Kathryn in the room still?

DR. CLINE: Kathleen, this is Terry Cline. You can\'t imagine my face
because we haven\'t met yet, but I look forward to meeting you in
person.

Part of the visioning I think that we can do is when we think about life
in the community for everyone, what does that really mean? And then our
responsibility is to figure out how to help individuals and families get
there. That\'s where I think we tap into all the various levels of
expertise that we have in terms of best thinking around evidence-based
practices, around systems that help support people and families, and how
would you construct that.

MS. SULLIVAN: Wait. Dr. Cline, don\'t you want to hear? If you were
given \$300 million tomorrow out of the blue and someone said, okay,
here you go, go do something with it, I mean, wouldn\'t that be just the
most wonderful thing in the world? And don\'t you want to hear what
Steve Mayberg is doing with it? I would just love at the next meeting to
hear Steve Mayberg, his vision, what he\'s doing with it. California is
the 13th largest country in the world. I would love to hear what he\'s
doing. That\'s my thought. I think it would really help all of us.

MR. AIONA: Okay. Well, thanks, Kathy. We can just envision your face
right now.

(Laughter.)

MS. HUFF: I just want to say we both cannot come off this council at the
same time because you need one or the other of us on here. I told Terry
there\'s only one person any more outrageous than I am on this council,
and it\'s Kathleen. So, Kathleen, I just appreciate that so much. I just
want you to know how much I miss you here across the way.

MR. AIONA: And it\'s all meant in a good way.

I think we\'re running out of time right now. Did you have something
else, Faye?

DR. GARY: When Tom and Ken were talking, I also thought about us giving
some serious theoretical, intellectual, practical thought to
sustainability, community sustainability, and capacity-building as
related to the programs that SAMHSA funds. In that, I would hope that we
would also discuss what ‑‑ when we get these grants, we know all about
the background and significance. We know how terrible things are before
the money comes. But I think we should begin to think about asking
people to project about what will happen to individuals and families
when the grant goes. That part we don\'t ask, and we don\'t really know.
We get a summary statement and then that\'s it.

But I\'m back to Tom\'s issue about these linkages. I think if we did
that, we would begin to help people to think about linking with other
organizations, with other community-based services, building family
capacity or whatever to address what these mental health and these
substance abuse issues are when the grant begins.

The other piece is that as grants or contracts are constructed, I would
like for us to have in the guidelines that individuals who are writing
the grants or the contracts have to respond to something about the
evidence of communication with, support from, and assistance from
individuals who are the targeted populations that will be serviced, that
that has to be written out what did happen rather than getting the money
and then going and saying, okay, now we have to do this and we have to
do that. I think that makes a collaborative effort that moves the
program. On a scale from 1 to 10, it automatically moves it to 3 before
it ever gets started.

Then the one thing that we\'ve not discussed at all much today is
interdisciplinary learning in academic institutions. I think we probably
need to spend a good bit of time because one of the phenomenon that one
sees is that physicians are trained over here, nurses are trained over
here, social workers are trained over here, psychologists are trained
over here. Then all of a sudden, we graduate and then we\'re expected to
work together in a team. If you\'re in mental health and substance
abuse, you must develop the capacity to work in a team. But that\'s not
a requirement in the academic institution at all. Now, if it happens
serendipitously, that\'s fine.

Of course, that automatically forces people to understand, respect the
kinds of knowledge and skill sets that different disciplines have. And
it also forces some sharing of power and authority, which many times is
a real issue in all of health care, as well as psychiatry. But if we\'re
going to have collaborative services and if these systems are going to
be transformed, mental health/substance abuse professionals are going to
have to learn how to respect and talk with each other at a different
level. And I think we need to spend some time talking about that.

MR. AIONA: Thank you.

Tom?

DR. KIRK: A comment and a question really. We have in statute in
Connecticut ‑‑ in my agency, there\'s a whole bunch of statutes that
apply to the agency in terms of what the agency is supposed to do and so
on and so on. As we\'ve continued to work on the things we\'re working
on, it is clear that the wording in those statutes is increasingly
antiquated.

(Laughter.)

DR. KIRK: So the population to be served ‑‑ I got your attention,
Kathleen.

MS. SULLIVAN: Tom, the reason why I think Mayberg would really be great
is maybe he could also show all of us the importance of a public
referendum and why it communicated so well to the State of California.
You know what I mean as far as mental health and the transformation and
how ‑‑ when that was put on the ballot, that connected. And I was
shocked. I was shocked. I was amazed that mental health screamed to the
people of California on an election, and they immediately funded it.

As we go into an election year on \'08, I would like to hear what he
says and how the people responded. It would be very interesting I
believe, and that\'s why I\'d like to hear from you and Ken. It would be
interesting for you and also Dr. Cline to hear from the state
perspective is this really resonating and is this a new source of
revenue now.

DR. KIRK: Let me just finish one quick point, partly to tie to what
Kathleen is mentioning, but then something else.

My point is that there are statutes, if you will, which define what the
responsibility of an agency is. So that\'s the way it is in Connecticut.
I don\'t understand really what reauthorization is, but I would imagine
if my example for what describes what I\'m responsible for and the
parameters, et cetera, if something similar to that applies to you, then
when we talk about this new system, if you will, does that mean that we
should be thinking about a new discussion of what\'s in reauthorization
for SAMHSA?

I don\'t know what reauthorization really means, but I presume it sort
of defines what you\'re supposed to do with the framework within which
you work. And if we\'re talking about a different kind of framework, is
that an opportunity then to frame the reauthorization of SAMHSA that\'s
more consistent with where it is you want to go? Otherwise, you\'re
going to keep hitting these barriers of services.

What a service is in a traditional mental health/addiction system in my
judgment is not the definition of services that we\'re talking about
now. How do you do that? Or does some legislator or Congressman say,
that\'s not a mental health/addiction service? You can\'t fund that.
Somebody else should do that.

We talked about yesterday that other agencies are supposed to pick up
some of these services. They already have their mission. They identify
what\'s important to them. So chances are, support of something that we
think is appropriate for people with psychiatric or substance abuse
issues is on the bottom of their list.

MR. AIONA: Thank you. I think we\'ve run out of time. Sorry, Ken, but
we\'re out of time.

Well, Doctor, you\'ve heard the council members. So now I\'m going to
turn it back to you and you can summarize or tell us where you want to
go from here. Thanks.

DR. CLINE: Great. Thank you, Governor. Thank you, members of the
council. I appreciate your candor, as well as your creative thinking on
these issues.

You\'ve given me a lot to think about. We will have discussions
internally about constructing the agenda in the future to make that as
useful, as beneficial as possible for SAMHSA as we move forward.

I think you\'ve identified several challenges, which are not easy
challenges. Some of the issues that were discussed are things that will
literally take years to influence, and some things, as Barbara said
yesterday, may or may not happen in our lifetimes even.

But the next step we take is very important. And is it a step in the
right direction? Even though it may not be at the end of the path, it is
moving us in a direction, and we want to make sure that that thread is
moving forward in a way that really helps us achieve that mission. So
every single step is important, whether it\'s a program decision,
whether it\'s a funding decision, whether it\'s a strategic decision, or
it\'s entering into the conversation with our partners that we may not
be able to influence today, but we might be able to tomorrow, depending
on what we say in that next conversation.

So you\'ve given me much to think about, and I appreciate your guidance
and your advice. This has been very helpful for me. I know it has been
for the other staff. I hope that you as well take something back to your
respective roles and responsibilities, whatever those may be.

And again, you are contributing a huge amount in terms of your volunteer
time. The folks that I do know around the table I know are very busy
individuals whose time is precious. So the fact that you have traveled
this distance and are offering your time to us I think speaks to your
commitment and your dedication to literally save lives across the
country.

So with that, I will close. Again, thank you for being here today. As
council members, I want you to know that I have an open door policy. I
would love to hear from you in the future. Please don\'t wait until the
next council meeting to engage in that dialogue with me.

So with that, I\'ll close the meeting. Thank you very much.

DR. GARY: Dr. Cline, did we have any public comment?

DR. CLINE: There were no public comments that were registered.

(Whereupon, at 11:32 a.m., the meeting was adjourned.)