SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

NATIONAL ADVISORY COUNCIL

40th Meeting

Thursday,

June 29, 2006

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chairperson]{.underline}

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

Chair/Administrator, SAMHSA

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

Rockville, MD 20857

[Executive Secretary]{.underline}

Toian Vaughn, M.S.W.

Executive Secretary, SAMHSA National Advisory Council

Rockville, MD 20857

[Members]{.underline}

James R. Aiona, Jr.

Lieutenant Governor

Executive Chamber

Hawaii State Capital

Honolulu, HI

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

Professor, Case Western Reserve University

Frances Payne Bolton School of Nursing

Cleveland, OH

Diane Holder

President

UPMC Health Plan

Pittsburgh, PA

Barbara Huff

Consultant

The Federation of Families for Children\'s Mental Health

Wichita, KS

IN ATTENDANCE:

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

Commissioner

Department of Mental Health and Addiction Services

Hartford, CT

Theresa Racicot

Former First Lady of Montana

Arlington, VA

Kenneth D. Stark

Director

Mental Health Transformation Project

Office of the Governor

Olympia, WA

Kathleen Sullivan

Journalist

Rancho Mirage, CA

[Ex Officio Members]{.underline}

Laurent S. Lehmann, M.D.

Chief Consultant for Mental Health

Department of Veterans Affairs

Washington, D.C.

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

PAGE

Welcome and Opening Remarks

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

Chair, SAMHSA National Advisory Council

and Administrator, SAMHSA 6

Administrator\'s Report

Charles G. Curie, M.A., A.C.S.W. 11

Discussion 38

Consideration of Minutes of December, 2005

National Advisory Council Meeting 52

The Leadership to Keep Children Alcohol-

Free Initiative

Theresa Racicot

Member, SAMHSA National Advisory Council,

Former First Lady of Montana, and President,

Leadership Foundation 55, 61

Michele Ridge

Member, Leadership Foundation, and Former

First Lady of Pennsylvania 55

Discussion 66

SAMHSA\'s International Activities

Charles G. Curie, M.A., A.C.S.W. 76

Winnie Mitchell-Frable

Team Leader, Policy Coordination Team

Division of Policy Coordination

Office of Policy, Planning, and Budget, SAMHSA 84

Discussion 100

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

PAGE

Update on SAMHSA\'s Access to Recovery Program

H. Westley Clark, M.D., J.D., CAS, FASAM

Director

Center for Substance Abuse Treatment, SAMHSA 109

Discussion 130

Connecticut\'s Access to Recovery Program

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

Commissioner

Department of Mental Health and Addiction

Services, State of Connecticut 130

Discussion 152

Public Comments 171

Closing Remarks

Charles G. Curie, M.A., A.C.S.W. 179

[P R O C E E D I N G S]{.underline} (9:20 a.m.)

MR. CURIE: Good morning, everybody. I know that there are a few members
about five minutes away, so we thought that we would at least start the
process. They\'re not really going to miss a whole lot, but at least we
get our process moving.

I want to, first of all, again welcome everybody here this morning, and
I\'m pleased to announce that while we\'re disappointed that Lieutenant
Governor Aiona from Hawaii, who is the co‑chair, could not be here in
person, I\'m pleased to say he was by phone most of the day yesterday,
and right now he\'s with us.

So welcome, Duke.

MR. AIONA: Thank you.

MR. CURIE: I want to acknowledge your presence by phone and your
commitment.

Clearly, it was a situation out of his control. I think anyone who was
traveling this last week by air, around here even by car it can be
tough, but recognizes that the weather patterns and the air traffic
control has been really tough, and when you\'re coming from Honolulu and
you get delayed several hours, and then you\'ve got to turn around and
come back within a day, you\'re going to be spending a lot more time in
the air and in the airports than in the actual meetings. So I appreciate
Duke\'s participation here.

I also want to acknowledge and wish Tom Lewis well. I think, as you
know, our fellow council member, Tom Lewis, has resigned his seat to
devote more time to his health and his family. Tom was very dedicated,
had been a very dedicated member of the council and is just one of those
people who is very special in terms of his value system and what\'s
important to him, and being a strong advocate for people with mental
illness and people with addictive disorders, and we will miss him. But I
definitely want to acknowledge and wish him well and thank him for his
service on the council.

I also want to note as well that the First Lady of Florida, Columba
Bush, is unable to attend due to a prior travel commitment. The great
news is that I think everybody else on the council is in attendance,
which is a great turnout. Gwynneth at the last minute was not able to
come, but she was planning to. But again, I appreciate everyone\'s
commitment and everyone\'s participation.

I understand that yesterday the council orientation was a success.
Actually, Faye, I know this is your second meeting, and I think the
orientation was actually put in place for you, primarily. But the great
news is I want to thank the council members who came, the rest of the
council members who came and attended, because I think not all of you
had an opportunity for a full orientation when you first came aboard.
I\'ll be anxious to hear more, that it gave you a lot of opportunity to
gain more insight into SAMHSA programs and meet also some of the new
individuals that are part of the leadership of SAMHSA and have an
opportunity for that interaction.

I know that SAMHSA\'s new acting deputy administrator, Admiral Eric
Broderick, provided you with an overview of SAMHSA, our current
priorities. I want to thank Ric in absentia. He\'s unable to be with us
today because he is representing me downtown at a couple of events that
conflicted with the calendar today.

Also, I know you heard from Larke Huang. As you know, Larke is our new
children\'s czar. Again, when Sybil Goldman left, I think we were
concerned about who could fill those shoes. Well, I\'ll tell you, Larke
Huang is one individual who definitely can and does, and I think
hopefully you had a chance to get a feel for her. She\'s just among the
top children\'s mental health folks in the country.

Also, I don\'t know if you had a chance to meet Arne Owens yesterday.
Arne has come aboard SAMHSA. He\'s the newest member of the SAMHSA
executive leadership team, and he\'s senior advisor to the
administrator. His portfolio, out of the chute he\'s taken on some big
issues, issues which are very important and near and dear to what we\'re
doing now, the veterans issues. Again, I want to recognize Wes Clark and
the work CSAT did in organizing and making sure we had a great
conference in March in which we pulled together 1,100 people
representing providers, as well as in partnership with the VA and with
the Department of Defense, to equip providers and local communities to
be enabled to meet the needs of returning vets, especially with National
Guard and reservists being primary forces.

We\'re going to have a lot of people returning to hometown communities
in their capacities of their regular jobs, and it\'s a somewhat
different circumstance than we\'ve seen in the past, and we want to make
sure community‑based providers are hooked into that. Arne is going to be
working with that, as well as with our community‑ and faith‑based
initiatives, working with the HHS faith‑based office as well as with the
White House faith‑based office. So again, thanks, and I\'m just so
pleased Arne came aboard.

I also want to thank Daryl Kade, who is the executive director of this
body, but also her day job is director of SAMHSA\'s Office of Policy
Planning and Budget, along with the center directors who are joining us
today. I already mentioned Dr. Westley Clark. Westley accompanied me, by
the way, to yesterday\'s hearing and did a great job representing, as he
always does, the programs of treatment.

I also want to recognize Dennis Romero, the acting director of CSAP, who
is here today, and Ted Searle, who is representing Kathryn Power from
the Center for Mental Health Services.

Also, I want to extend a warm welcome, as always, to our federal
colleagues and guests here this morning. I think it\'s indicative of the
interest our constituency groups have in SAMHSA that we have such a
generally very good turnout for these advisory council meetings, and I
want to thank you and recognize representatives from the Office of
Minority Health that are here today, friends in the National Institute
of Mental Health, the National Institute on Alcohol Abuse and
Alcoholism, and several guests again from our constituency groups.

So again, welcome and good morning, everyone.

Before I begin my detailed report this morning, we must take care of an
important order of business, and that\'s to make sure you have reviewed
the minutes of the December advisory council meeting and have a motion
for approval. Is there a motion to approve the minutes?

(No response.)

MR. CURIE: We will hold that until we have an official quorum. I\'ve
just been informed we need seven people, right? We\'ll have a quorum in
a moment.

Does Duke count?

Duke, my heart just stopped. I asked if you count, and Toian said no. I
wouldn\'t take that personally, though, Duke. You do count, Duke.

MR. AIONA: I do? Well, thanks.

MR. CURIE: I\'m pleased to hear you count.

Thank you, Toian.

Let me begin my report, then, and we\'ll take care of that order of
business as we move along.

As I begin my report this morning, I think I\'m going to be making an
announcement that all of you have heard by now, and that is that the end
of my tenure as the administrator of SAMHSA is going to be occurring on
August 5th. I did submit my resignation to the President. The decision
to resign my post, as always, those decisions are always tough when you
come to that point. While I\'m excited about moving into the next phase
of whatever I\'m going to do, which is remaining to be determined, I
just want to say it\'s been the highest privilege being in this
position. The past five years have been profound for me and it\'s been
extraordinary working with this National Advisory Council, our
constituency groups, just people who are committed and have a value
system of being invested in something outside of themselves, giving
voice to people who have no voice and helping people find their voice,
people who many times are shoved to the margins of society, people with
mental illness, people with addictive disease, people who again many
times, because of stigma, because of perceptions that aren\'t based on
fact, don\'t have the opportunities to have that full life in the
community.

Again, I\'m continually inspired by the participation of people in this
group and in the groups that we\'re dealing with ongoing who have the
energy, the passion, the concern of assuring that people find their
voice. I think there have been changes that in my view will be lasting
changes that have occurred over the past five years.

I know you can take kind of a cynical route, if you\'d like. After I
announced my resignation, the dynamic is put into place. People begin to
think who is coming in next, and okay, now we don\'t have to worry about
that matrix anymore. Now a new administrator is going to come in, and
maybe none of this is going to count for anything.

We have a quorum now. I\'m pleased. Barbara and Kathleen, welcome. I\'m
glad you could make it.

My thought, though, as we take a look at ‑‑ and again, to let Kathleen
and Barbara know, in terms of me giving my report, I just announced that
I gave my resignation as we look ahead. I\'m hopeful and I\'m confident
that many of the things that we have accomplished, many of the things
that we have in place are things that are in place not because of me but
because of the field, because we\'ve made informed decisions, because
directions we\'ve taken have been directions in which there has been
ownership from a wide range of folks that we\'re doing the right things.

As we take a look at the vision of a life in the community for everyone,
I think people understand that that begins to depict the end game, that
what we\'re about as a federal agency is more than just thinking about
developing some new programs or developing and funding programs and
people participating in programs, and as long as we get the GPRA
information and whatever we need from that, we\'re doing our job as a
federal agency, but the work we\'re doing is real work to impact the
lives of people and to make sure people have that life and that
opportunity for a life in the community.

It\'s more than just alleviating symptoms. It\'s more than just getting
people off of drugs and then we\'re done. It\'s understanding the nature
of the chronic, devastating aspects of the diseases we deal with and
that we truly have an important, fundamental part of the public health
mission, and that we don\'t accomplish our mission of building
resilience and facilitating recovery until we see outcomes in people\'s
lives in which they have found their voice, in which they have found not
only their place but they have found their life in the community.

Either those things ring true or not, whether I\'m here. If they don\'t
ring true and we just went through the motions because you had an
administrator here who talked about it a lot and staff was just wanting
to appease the administrator, then it is going to fall aside. I don\'t
happen to believe that\'s true. I happen to believe that people
throughout SAMHSA, the reason we\'ve made progress is because we have
dedicated staff and leadership and people who really do want to make a
difference, and we have people on this advisory council and the other
advisory councils who believe in this, and we have constituency groups.
As I look around the room, again I want to thank people. I\'m not going
to name everybody, but people like Henry Lozano, Rob Morrison, Linda
Crawford, or the people I see in this room who are committed through
their various associations to making a difference, that that work is
going to be carried forward because either that vision is valid or it
isn\'t.

As I\'m going to review some of the accomplishments that we have made
together, we need to look at it in the context of are those
accomplishments truly based on doing the right thing that people agree
to, and this will be carried on or not. I happen to believe that we have
been very thoughtful and open. We\'ve modified thoughts and ideas we
had, fully changed some things based on input from the field, based on
being informed, and hopefully those things I\'m confident will stand.

Again, the overall goal we have is to build a healthier, more hopeful
America, and we focused here at SAMHSA on what I refer to as the
redwoods, brought them to life as achievable goals through the SAMHSA
matrix. I\'m convinced one of the things that we have been able to
accomplish that\'s been significant is alignment, aligning our resources
around priorities. We have pretty powerful, potent, influential centers
within SAMHSA. CMHS makes a profound impact on the mental health field,
in partnership with NIMH and our other federal partners. People look to
the federal government for direction. People look to the federal
government for funding grants to see what direction they should be
going. That influences things.

CSAT. When I take a look at what CSAT does, and again this applies to
the other centers, because each of them has their technical assistance
centers and ATTCs, as I travel across the country and I see the
treatment improvement protocols on the desks of providers, and they\'re
actually worn, the pages are worn, so you know that they\'re used, and
I\'m being told, whether it\'s co‑occurring, whether it\'s the treatment
improvement protocol we talked about yesterday, number 33 that deals
with methamphetamine and synthetic drugs, that these things are of
value, and CSAT in many ways and in many dimensions shows leadership
through dissemination of information, through technical assistance,
through developing grants and putting goals in grants that help focus
people on the end results we\'re looking for.

CSAP, profound changes there with the Strategic Prevention Framework. I
think we can say in complete confidence that CSAP is the lead federal
agency for substance abuse prevention in the nation and that it does
more than just fund an array of prevention programs. Now it is actually
funding and focusing on, under the leadership of Beverly Watts Davis and
now Dennis Romero and, again, the capable prevention professionals that
make up CSAP, we truly have a Strategic Prevention Framework
operationalized, and I\'ll talk about that in a little more detail in a
moment.

But again, I can point to all three centers. I can point to our Office
of Applied Studies that still comes through with what I call the
Household Survey. I know it has a different name now, but the Household
Survey every year, DAWN, the emerging drug issues that are coming out of
emergency rooms, TEDS, the Treatment Episode Data, all of that data
which is used to inform the field, and as you find a range of not only
federal agencies but private sector folks to help inform is invaluable
stuff.

Again, as I talk about it, it makes me proud that I\'ve been a part of
that operation and that SAMHSA, I know, will continue to deliver over
and over again.

Without question, I think SAMHSA has embraced the direction that\'s been
set forth by this council and constituency groups. We talk about
consumer‑ and family‑driven systems, and I think SAMHSA has tried over
the past year to be more consumer‑driven, to be more constituent‑driven
in the sense of meeting the needs and understanding the needs of the
field that have been identified in the data, and at the same time
understanding we\'ve got to be in a position to synthesize all of that
into a direction because not all constituency groups come together all
the time and speak with one voice. So the responsibility we have is to
sort that out and to begin to find where we can best invest our
resources.

Again, we listen to Congress. I listen very carefully to the White
House, listen very carefully to the Secretary, listen very carefully to
the administration, and I feel that we\'ve been able to chart courses
where we\'ve been able to be consistent with the goals of the
administration, and I think we\'re viewed that way in everything that
we\'ve done. I think we\'re viewed by Congress \-- again, the hearing
was very positive yesterday in terms of what they had to say about
SAMHSA and the directions we\'ve been going.

I view Congress as a customer. A customer is who pays for what you do.
Congress appropriates money, so they pay. I view the President as a
major customer, my major customer, along with the Secretary, because
they make sure we get paid for what we do. Again, I view our
constituency groups as a major part of that, and I think we\'ve been
able to respond effectively.

I also believe that this council, when we talk about moving ahead, when
we talk about consolidating the gains that have been made and continuing
to build on the direction, will continue to make a major impact. I think
perhaps my leaving is even more in your hands right now, if you believe
the directions that we\'ve charted are the right directions, to assure
that the advice and directions that are given remain strong in that
direction. I know you will continue because I know many of you on an
individual basis, and I\'ve known many of you for even several years
will be committed and are committed to that.

Resilience and recovery are the focus of dialogue now. You turn the
clock back five years ago before, recovery was a concept. Very much I
call recovery, again, from the substance abuse field and the mental
health field, because recovery has been around for a long time in the
substance abuse arena. It\'s been more of an individualized process as
people talk about being in recovery and trying to understand recovery.
We have tried to bring recovery in two ways. One, an understanding of
how it can be applied to the chronic, severe, devastating illness of
mental illness and how people can use recovery concepts in understanding
how you manage your illness as you begin to manage your life, and most
importantly we tried to operationalize recovery from a public policy and
public finance standpoint, that this is what we want to see as the
outcome in people\'s lives.

In substance abuse prevention and treatment, in mental health care, I
think in terms of using recovery as the focus and as a common ground in
resilience, I think that there is stronger collaboration than ever
before among the three centers. I think the silos increasingly have been
diminished in terms of functioning as silos. I will go on record ‑‑ I
shocked folks at NASADAD a few weeks ago. Silos serve a purpose. You
never have heard me talk structurally about let\'s destroy the silos
because they get in the way, and I know people take that approach. Silos
help you keep count, and we have a substance abuse treatment field, a
substance abuse prevention field, and we have a mental health field, and
it\'s important to those constituency groups to be able to track
resources and how are we doing and are the resources going toward these
areas and arenas. I think we can\'t discount that very important purpose
of silos, that very important purpose of having ‑‑ I mean, you hear all
sorts of schemes and all sorts of ideas of people who come into
positions. I think any of us who have been commissioners at the state
level, any of us who have been around know that certain times leaders
come in and say, you know what? I want to just merge everything and get
all the money integrated together so I can just meet people\'s needs.

I think we\'ve found that while that may be appealing conceptually at a
certain level and in a certain notion it\'s like, oh wow, that makes
sense, I\'d better use the public dollar, I think we know that for so
long people have labored in the fields to bring substance abuse
treatment to a priority and having people understand that treatment
works and recovery is real. Prevention has had to make its case and will
continue to have to make its case over and over again because it\'s a
tough thing to prove, but I think we are proving that it works; and
mental health, again, is its own illness. I mean, we\'re talking
separate disorders and illnesses. We\'re talking aspects where we have
people who are strong advocates who are speaking on behalf of others. So
we need to keep count.

But then operationally we need to function, as I feel SAMHSA has
functioned with the matrix model, that we need to leverage all those
resources in a way that helps each center achieve its goals in even
better ways together.

There\'s much more collaboration, partnership and conversation, much
firmer resolve to shift the focus from ourselves, from our own unique
agendas, our turf and our budget to be focused more and more on what
truly is important to the people we serve and the families and the
individuals.

In some cases, a paradigm or a position shift like this I think can take
decades or longer. I think we\'ve been able, due to the commitment of
leadership, of staff, of people rolling up their sleeves ‑‑ I know when
the matrix first came out about four and a half years ago, people
grappled in an honest way without SAMHSA like what is this matrix? What
is matrix management? We embarked on a process of actually having
concrete sessions and training on how matrix management can work, and
people I would say were innovative throughout SAMHSA in terms of
developing, because there aren\'t too many books out there, a cookbook
approach, but in terms of creating it, and that\'s one of the most
gratifying things for me, is to see how people have taken hold of that
and see how people have made it work within SAMHSA and created it within
SAMHSA.

Also, when you turn the clock back five years ago, there were a lot of
tasks that were kind of hanging around, some things that were being
done, a lot of good initiatives, but they weren\'t necessarily being
leveraged to systemic change necessarily, and I think we\'ve been able
to more and more look at systemic change and taking on some things.

Today we have more community‑ and faith‑based providers engaged than
ever before. Access to Recovery has helped that tremendously on the
substance abuse treatment side. I think the New Freedom Initiative has
been profound, and again the Mental Health Commission. Again, we
tailored our prevention programs for producing results at the community
and family level through the Strategic Prevention Framework. One thing
we can\'t forget is we created and implemented a data strategy,
including National Outcome Measures and State Outcome Measures and
Management Systems to track success, and also identifying areas of
improvement where we need to move ahead in different ways, hopefully
serve as an early warning system too of emerging trends as we move along
in looking at such things as methamphetamine use, prescription drug
abuse.

Today we have a much clearer focus on science‑to‑services agenda. Again,
our partnership with the institutes is stronger than ever, and I think
the stage has been set to really shorten that period of time of bringing
scientific research findings to the front lines of service. It\'s going
to be an ongoing challenge. It\'s going to be a process that can be
never‑ending, but we\'ve got to continue it. We\'ve worked to reduce
that time lag.

The National Registry of Evidence‑Based Programs and Practices, we\'ve
worked to improve that and make it relevant not only in the prevention
side but also the treatment side. Again, that\'s been a long process of
getting input from a wide range of providers and associations and folks,
as well as consumers and families, and I think we have a platform
that\'s developed for informing the field about science‑based programs
and practices.

Each of these initiatives have opened the door for SAMHSA and our
constituency groups to, again, help people achieve meaningful, real‑life
results as they strive to attain and sustain recovery, build resilience,
work, learn, live and participate fully in their community. I think
overall our ability to focus on recovery as the common ground has
produced some key results. We more clearly defined recovery from mental
illness. We created the National Consensus Statement on Mental Health
Recovery, which identifies 10 fundamental components of recovery. I want
to commend CMHS for that endeavor and how they engaged the constituency
groups. I also want to commend Kathryn and CMHS for the Federal Action
Agenda for Mental Health System Transformation, which identified
recovery as the single most important goal for the service delivery
system.

Through that action agenda, never before have we had nine Cabinet‑level
departments, including over 20 federal agencies that touched the lives
of people with mental illness, have agreement around 70 specific steps
of action that the federal government can begin to take to set the stage
for transformation. That overall goal is to empower states. As I look at
Tom, as I look at Ken, as I look at folks who represent states here, one
of the frustrating things is when states try to embark on an integrated
agenda, whether it\'s around mental health, whether it\'s around
substance abuse, or both, trying to get agencies within a state to agree
and take it seriously and make it a priority is tough, because we know
many agencies touch the lives of the people for whom we\'re responsible.

But then trying to get the federal government to speak with one voice on
issues when there are different agendas makes it almost virtually
impossible, and that\'s why for years I think it\'s been difficult to
move ahead. I think we have clear hope now that there can be clear
direction of a unified way from the federal government in working with
states to empower states to move ahead.

One of those steps, of course, in transformation on the mental health
side was the State Incentive Grants for Transformation. Last year we
awarded \$92.5 million to seven states over five years. Two of those
states are represented right here at this table. Ken, I think you\'re
very much engaged in the process in Washington State, and Tom in
Connecticut. Also Ohio, Oklahoma, Maryland, New Mexico and Texas are
blazing the transformation trail, and more and more Americans with
mental illness hopefully will step out of the shadows of hopelessness,
stigma and exclusion and receive access to the care they need with the
dignity, respect and belonging they deserve.

Again, transformation, I think the stage has been well set. Substance
abuse treatment has undergone significant changes and fundamental
changes. I think now, and I hope I\'m not too presumptuous, but
hopefully there\'s an acceptance that we understand that there are many
pathways to recovery, that there\'s just not one cookbook approach or
treatment intervention that works, one or two, but that recovery is an
individualized process. Recovery from addiction includes people who have
gone through a range of programs and maybe have relapsed. But what\'s
interesting to hear consistently is people who ultimately attain and
sustain a long‑term recovery talk about how they gained something from
every program they were in, that every program they were in was a step
toward their recovery, and I think we need to keep that in mind.

Many times it\'s characterized as just out and out failure, and I think
we need to frame that in terms of what it really means in terms of the
recovery process. I think we need to recognize that there are very
effective science‑based clinical programs, medical‑based programs.
We\'re learning more and more. When I hear Nora Volkow talk about the
frontiers of what we\'re finding out more and more, it\'s actually
overwhelming in a positive way to think about where we can be five years
from now, ten years from now with addiction treatment services.

Also, we recognize that the transforming powers of faith play a critical
role in recovery for thousands of people in this country, and we need to
make sure we\'re not cutting off any pathway for recovery and that
we\'re opening up more pathways, that the federal government is not an
impediment to it but that we\'re a facilitator of recovery.

I believe that through the Access to Recovery program as a key addition
to the demand reduction infrastructure, thousands of people are now
seeking treatment or finding it, that because of that capacity being in
place, they have that hope and opportunity. I\'m pleased to say with the
data coming in on Access to Recovery, again we have two states here that
are implementing it, that the data is looking very, very good overall. I
know there have been people who have been impatient that the data
wasn\'t coming in fast enough, but I think we cannot forget that we\'re
talking fundamental infrastructure change in which we had to set up a
voucher system in states, a new way of doing business, an awesome,
overwhelming task, and I don\'t know if you would disagree with me, Ken
or Tom, on that, but not easy to pull off at all, probably one of the
most challenging things.

But states and the tribal organizations have done it, are doing it, and
I think we\'re going to learn a lot more from Access to Recovery.

As you know, ATR is based upon choice, states having the flexibility to
use these dollars to focus on their emerging trends. I might point out
that Wyoming and Tennessee, for example, chose methamphetamine being a
major problem and issue with their states, and they were able to direct
those dollars. Again, fundamentally federalism, the federal government
telling states you know best what your needs are, and we need to work
with you in partnership and not dictate where those dollars should be
ultimately directed.

Wes will bring more details, Wes Clark, on ATR after lunch, and we\'ll
also hear from our own council member, Tom Kirk, about Connecticut\'s
success with ATR as well, and I would welcome Ken to participate and
make observations about Washington\'s experience.

Clearly, recovery from mental illness, addiction and co‑occurring
disorders is no longer the privilege of just a few individuals, but I
think more and more we\'re seeing that the access has been increased. I
think we do stand ‑- and depending on whether you read the book
\"Tipping Point,\" I think we\'re standing at a tipping point in which
they call this the \"magic moment\" in which minds and hearts are
changed, and radical change is more than a possibility; it\'s more of a
certainty. I think we\'ve experienced that on many levels, not only the
things I\'ve just been talking about but also with regard to
co‑occurring disorders.

In the landmark 2002 report to Congress from SAMHSA, we recognized that
people in need with co‑occurring disorders should be the expectation and
not the exception, and that we have better data than ever before in
recognizing the levels of co‑occurring disorder, the type of
interventions that are appropriate depending on what\'s presented,
understanding we need to do an assessment for both when people come to
the door, and that it\'s just not a small subspecialty population but
that many of the people who have gone through our systems and have been
seen as failing many times have had co‑occurring disorders and only one
of the disorders have been treated, and so recovery can\'t be sustained
or attained unless it works.

Again, Treatment Improvement Protocol Number 42, co‑occurring disorders.
I think CSAT again needs to be commended for informing the field, and I
know it\'s being used, and there have been policy academies held to
encourage the development of state action plans. I want to thank, again,
the staff of SAMHSA. I want to thank the field. I want to thank NASADAD.
I want to thank NASMHPD. I want to thank the trade associations who have
found the common ground around co‑occurring disorders and have been able
to move that agenda ahead on behalf of the citizens of this country.

Another major change, with the backing of the First Lady, is to increase
prevention efforts and bring prevention to scale on a national level.
The First Lady, Laura Bush\'s Helping America\'s Youth Initiative is
becoming more and more an umbrella which pulls together multiple federal
prevention programs, including SAMHSA\'s Strategic Prevention Framework.
It involves juvenile justice and the Justice Department. It involves
Education. It involves virtually every department that was represented
at the first Helping America\'s Youth Conference. I\'m pleased that
SAMHSA\'s approach with implementing the Strategic Prevention Framework
is recognized as part of that and very consistent with what they\'re
striving to do with Helping America\'s Youth, and that\'s find a science
base and an evidence base for what can work to prevent juvenile
delinquency and substance abuse and those negative, destructive
consequences that exist in communities throughout this country.

We will be implementing the Strategic Prevention Framework in 40 states.
So it\'s really being brought to scale. The SPF is putting into place,
again, that science‑based approach. Now with SAMHSA owning Communities
That Care and that approach and other approaches, we have tools
available to states and communities to embark upon a process to assess
risk factors, to assess protective factors, and then to make decisions
in terms of what programs should be implemented in a community based on
the risk factors in those communities, evidence‑based programs from
NREPP, from the list with Communities That Care. There\'s a range of
science‑based decisions that can be made.

We also recognize that the best solutions to substance abuse problems
typically come from local communities. Local people solve local problems
best, and we want to empower them with knowledge. We want to empower
them with resources to make those decisions.

Looking toward our nation\'s future, the 19 percent reduction in illicit
drug use among our youth over the past four years is truly an
inspiration and tribute, and I think we need to continually recognize
the hard work of families, schools, anti‑drug coalitions, communities
and faith‑based organizations that have been speaking more and more with
one voice, more and more with a unified approach. We know that when we
push back against the drug issue and drug abuse, it works. It\'s in the
future that we\'re going to see the benefits unfold as a result of the
many new and growing initiatives that are underway. The future of
substance abuse prevention, substance abuse treatment and recovery
support services looks remarkably different and exciting.

I want to stress, too, that one of the things we learned in ATR, we\'re
learning that recovery support services play a critical role in helping
us realize the outcomes in people\'s lives and that we are looking at a
framework beyond providing treatment programs, but also what do people
need to achieve recovery.

I believe part of the success can be attributed to the message said over
and over again, loud and clear, that prevention and treatment work, and
recovery is real. I think each of you, I know, believes that. Over the
past few years I know we\'ve had some convincing to do at times. It\'s
no longer enough to show evidence of a need. We must be able to
demonstrate results in order to assure that funding for our services
that we know work is going to take place. It\'s public accountability,
and public accountability requires proof.

The most direct route to proving and demonstrating success has been
through SAMHSA\'s focus and renewed commitment to performance
measurement and management. That commitment yielded the National Outcome
Measures and the State Outcome Measures and Management System.

The National Outcome Measures are really about putting people first.
It\'s about reporting on our performance in helping people attain and
sustain a life in the community. The domains that we\'ve identified all
capture the meaningful, real‑life outcomes which combine to create a
life in the community.

The thing about it is it\'s not only outcomes that people who are
seeking recovery are looking for, but every person in this room want to
see those outcomes in their lives. I think that makes it real to all
citizens in this country.

The data collection thus far reflects strong partnership in an enormous
undertaking and demonstrates solid, early progress. As we know, it\'s
not easy to come to a consensus around what data we should be gathering.
It\'s a burden. It\'s a burden on states. It\'s a burden on providers.
It\'s a burden on systems to be gathering outcome data. I\'m not saying
burden in that it\'s an unnecessary burden, but it is work, and it\'s
not easy. We as a federal government have a responsibility to be very
clear on what we want to see, because if we just throw out a whole bunch
of measures that sound nifty or are different from grant to grant
because we\'re looking for things or exploring things, we aren\'t
painting a comprehensive, consistent picture of what our dollars are
doing, and we\'re making it even more unnecessarily hard on the states.

But if we try to give a focus around let\'s have a few domains that we
all agree reflect recovery, and let\'s consistently get those measures
on everything that we\'re funding, we have a better shot at painting
that picture. Again, I know it may not feel this way at times because
it\'s very difficult, but the goal has been to lessen the burden as we
go along. Again, that\'s hard in and of itself.

We will also continue to rely on data provided through, again, the
annual surveys, the National Survey on Drug Use and Health, the
Household Survey, DAWN, and the Drug and Alcohol Services Information
System, along with other data sets. Yet we know data alone is not
enough. The data will only guide the way. It will not improve systems.
Improving systems requires strengthening and reinventing the workforce
that delivers care. I want to stress workforce development. We\'ve added
that to the matrix. We know that approximately 80 cents of every mental
health and substance abuse dollar is spent on our workforce. We also
know that increasing the workforce capacity has a direct link to quality
improvement. Yet little progress can be shown on the workforce
development front because it\'s a tough issue.

Again and again, individual strategies are developed to tackle the
issue, but the complexity of the issues themselves creates a moving
target. To put this issue front and center, we\'ve revised the matrix to
include workforce development. There\'s been a lot of work through the
Annapolis Coalition, a lot of work out of CSAT and CMHS and CSAP to
identify what are the problems and not only focus on recruitment but
retention in the field and what type of training needs to take place in
the academic institutions, how do we prepare a workforce, what type of
incentives do we need to put in place, what type of people and
professionals need to be in place in frontier, remote, rural areas,
where the challenge is just overwhelming with workforce development in
terms of trying to find the resources that people need there.

Again, we\'ve identified models, models that are working in certain
areas that we\'re getting information on, behavioral health aides, for
example, working in the villages in Alaska Native villages. We see a
model emerging out of the University of Alaska in Fairbanks in examining
how can we bring some of those things to scale, what can we learn from
that. That\'s just one example of many.

So we need to bring a force of focus. We need to bring resources around
workforce development and really come up with a plan that\'s cohesive
and gives results.

The same will happen with suicide prevention. Again, that\'s a state
priority in the matrix now. Data from our Household Survey again
indicates that 900,000 youth had made a plan to commit suicide during
their worst or most recent episode of major depression, and 712,000
acted on that plan by attempting suicide. When faced with the fact that
the number of suicides outnumber homicides by 3 to 2 in this country,
the urgency and immediacy of the need to take action I think speaks for
itself.

I\'ve often said my role as administrator is that of being a temporary
steward, and I view my responsibility as administrator to make solid
program and management improvements that will last beyond my tenure.
You\'ve got to think beyond where you are if you\'re really going to
make a difference. I\'m hopeful, as I look around this room and see the
many stewards of these changes, that the progress made will far outlast
my tenure.

A lot has been accomplished. Much more remains to be done, obviously. I
feel like we only scratched the surface in terms of the needs that are
out there. I believe strongly that SAMHSA should continue its service
also to the international community, as we\'ve been working. It\'s
interesting that in the developed nations that have been coming together
around working together, the United Kingdom, Great Britain, Scotland,
New Zealand, Australia, Canada, as we\'ve been sharing and exchanging
ideas among countries, recovery, remarkably, is a common ground.
Recovery is guiding policy development in those countries. There\'s an
emerging commitment to really work with post‑conflict countries, where
people are traumatized in ways perhaps beyond our comprehension, in
Third World countries. I think we being part of that process is very
important, and later this morning you\'ll hear more about SAMHSA\'s
international initiatives.

Other areas that deserve continued focus and attention are our efforts
to continue reducing and eliminating coercion, seclusion and restraint
practices. We need to combat underage drinking in this country and
really see the progress made with that that we\'ve seen with tobacco and
illicit drugs. In a few minutes you\'ll hear more on underage drinking
with regard to the Leadership to Keep Children Alcohol-Free. Our own
Theresa Racicot will be participating in that, as well as Michele Ridge,
who is here with us today.

Again, the past five years have given me the privilege and opportunity
to lead an agency that I think in many ways, while it may be that
historically SAMHSA is not recognized as central to public health, I
believe it is. I believe mental health and substance abuse is very
central to public health. Again, I\'ll be forever changed and grateful
for the experience.

I wish you all the best in success as ambassadors of SAMHSA. That
concept developed with this council. I appreciate your efforts, and I\'m
going to look forward to SAMHSA\'s continued evolution in seeing the
individuals we serve and the families we serve benefit from that as
well.

Now I\'d like to open my comments for discussion. Thank you once again
for your partnership, your leadership and support in everything we\'ve
done in achieving the priorities.

I\'ll open it up to the council. Thank you.

(Applause.)

MR. CURIE: Ken?

DR. STARK: Well, Charlie, I wish you the best wherever you\'re going.
You have shown really strong leadership with SAMHSA. You know as well as
I do that there were a number of issues. Although we didn\'t always
agree on everything in terms of the states or SAMHSA, one of the things
that I know I personally believed was that SAMHSA needed to show some
leadership to sometimes drag us along in making certain decisions, and I
think you did that in a number of areas. I think probably the biggest
legacy at least I believe you will leave that will be longstanding, even
after you\'re forgotten, are the issues related to the data, the NOMS,
being able to really start measuring what we\'re doing. That is what\'s
going to have an effect over the long, long term to help people in the
community. I think that\'s a key. I think that\'s what puts SAMHSA in
the leadership role now that you can truly talk to the other federal
agencies and give them some clarity on what you\'re trying to achieve,
and that they can begin adopting those same measures so you can have
across the federal government, as we need in states across state
government entities, consistency in those outcome measures. So I really
applaud you for that and I think you\'ve done a great job there, and in
a number of other areas too.

I do want to encourage, in your short tenure that\'s left and whoever
takes over after you leave, encourage the collaboration particularly
with NIMH and the other institutes, because it\'s absolutely critical
that because SAMHSA doesn\'t have either the authority or the resources
to do the kinds of research and evaluation that we need to truly
continue to validate both the programs that we\'re currently doing, as
well as adopt other innovative research‑based projects and implement
them in the community, we need the resources of the institutes to be
directed to coordinate with the programs that are funded through the
states. The states clearly can be laboratories, as you know. If we
collaborate at the state level and at the federal level in terms of the
service dollars and the research and evaluation dollars, we can truly
maximize the credibility, if you will, of the field that\'s going to be
needed as dollars continue to get tighter and tighter.

So I appreciate what you\'ve done. I wish you the best in the future. I
hope to talk to you again sometime, wherever you land. I plan on hanging
out here and doing the best I can to continue to give input.

MR. CURIE: Thank you, Ken. I appreciate very much your kind words, and I
appreciate personally our collaboration and partnership and debates and
different things that have occurred through the years, which I think all
have been constructive and to the greater good.

I do really strongly believe that an area that needs much more further
clarity is the area of services research. I do own the fact that I made
the decision when I first came aboard that SAMHSA was not a research
agency, we\'re a services administration, and we were doing some
research‑oriented types of things that should be done in the institutes.
OMB loved that clarity, by the way, but I think it opened up a challenge
to make sure we don\'t lose sight of a services research agenda. I think
all three research entities have responded to that at various levels,
and I appreciate it.

I think the partnership and collaboration among NIAAA, NIDA and NIMH is
stronger than ever. I do think there needs to be more concrete effort to
clarify that, and also to make the distinction, and this is going to be
an ongoing process, between program evaluation and research, because I
do believe program evaluation, in terms of effectiveness of programs and
what we learn, is part of our mission, and that should not be confused
with research. So that, I think, is an ongoing dialogue and does need
further clarity.

Thank you, Ken.

Kathleen?

MS. SULLIVAN: I\'d just like to thank you, for those of us who were
sick. Thank you for respecting us, and thank you for honoring us.

MR. CURIE: Thank you, Kathleen.

Barbara?

MS. HUFF: Kathleen, you were so short, I can\'t believe it. I\'ll have
to try to follow suit.

I\'ve been around at this for a long time, Charlie, and I just have to
say thanks for your leadership, because I would say in all the years
that I have been talking as an advocate, I\'ve not had an administrator
that\'s ever listened in the same way and acted on it. I remember some
very emotional conversations we had as a council around the issue of
suicide, and it is now in the matrix. So I really feel like you have
allowed us to make a difference as advocates. You\'ve heard us, and I
will always say that I think it was really brave to have put me on this
council, knowing that it would be hard at times.

Anyway, I thank you, and I hope that it has ‑‑ to put a family member of
a child who has struggled with mental health and substance abuse
problems, I mentioned this yesterday too, that I hope it has set a
precedent and we can follow suit next time when my tenure is over.

Again, thank you for a tremendous journey. It\'s amazing to actually do
this work and see a difference. Thanks.

MR. CURIE: Thank you, Barbara. That does mean a lot coming from you, and
I appreciate it very much.

MR. AIONA: Charlie, can I say something?

MR. CURIE: Hello, Duke. Faye will go, and then, Duke, we\'ll have you
go.

Faye, go ahead.

DR. GARY: Faye Gary. I, too, would like to thank you and to thank you
for a very thorough and impressive report. I looked at the minutes and
could concur that our discussions have been very in‑depth, very pithy
and very worthwhile. The follow‑through is much appreciated.

This is just my second council meeting, and I\'d like to thank you for
making me feel welcome and for allowing my voice to be heard, and also
respected. Thank you very much.

I want to also just reflect for a moment on some of the initiatives and
acknowledge the addition of suicide and workforce. I want to reinforce
workforce, because workforce will make the difference in terms of how
all of the other principles and priorities in the matrix are addressed,
the three domains, whether it\'s the systems issue, how we communicate
with patients, or whether we are providers. So I would like to really,
really reinforce the provider and workforce issue for sure.

The other piece is that what troubles me deeply is the antecedents or
the risk factors that people are continually exposed to that lead to
mental illnesses, and also to substance abuse. Of course, in my mind\'s
eye, I think one of the greatest variables that influences people\'s
mental health is poverty. I would ask that SAMHSA and perhaps the other
institutes give more attention to poverty as an issue that forces and
shapes the lives of people, especially children, and look at perhaps how
there might be some intervention on the front end.

While we are thinking about paradigms and visions, I would also ask that
all of us begin to think about a cure for mental illness and add the
word \"cure\" to our vocabulary so that we can be hopeful that there can
indeed be a cure as well as prevention, as well as appropriate, prompt
treatment and recovery. But to the vocabulary I think we also need to
add \"cure.\"

MR. CURIE: Thank you, Faye, and thank you for your comments. I think
you\'ve articulated well why workforce development is fundamental to the
future and why if we don\'t have a focus on that, no matter what we
plan, it will be to no avail. Thank you.

Duke, go ahead.

MR. AIONA: Thank you, Charlie. First of all, I want to add my thanks to
you for giving me the opportunity to serve on this advisory council.
It\'s been a great experience for me. I\'ve learned a lot. I\'ve had
great colleagues to work with, and I thank you very much for the
opportunity.

I think you know as well as I do that when you do work in this field,
and also the systems that you\'re in, that it\'s very difficult and
it\'s a very, very big challenge, and it has been a challenge for you.
As you can see, as everyone can see from this very brief report, that
much has been accomplished, and it\'s been accomplished in the right
direction.

I maintain, based on my experience, that if we\'re going to make a
difference in our communities, our individual communities, our states,
and of course our country and the world, that we\'re going to have to do
it within, that the changes will have to be inside of people. The
environment is not going to change. Better homes, nice clothes, those
are not going to change us as a community and as people. We\'re going to
have to do it within.

So what SAMHSA has embarked upon is truly exciting, and I think I will
stay with it as long as I can. When I say as long as I can, that means
until my last breath is taken on this earth. Our lives are temporary,
but we\'re hoping that we\'re going to make life much better for those
who follow us, which means our children and our grandchildren and
everyone else. So I applaud everything you\'ve done up to this point in
time, no doubt about it. The only way that we\'re going to make
improvements is that we\'re going to have to have dialogue. We\'re going
to have to have collaboration. But most importantly, we\'re going to
have to have conflict and we\'re going to have to have challenges. If we
have that, we\'ll always be better in what we do, and we\'ll always make
improvements.

I just want to emphasize prevention. I think you\'ve done a great thing
in regards to the Strategic Prevention Framework. It\'s done a lot not
only for my state but I think for everyone who has had a chance to look
at the model and to do what it has to do with it to see a tremendous
difference within their state. That is probably the toughest thing that
we can do because of the collapse of what I would call a measurable and
something that\'s a concrete outcome. But that is the key right there,
and that\'s where my emphasis is going to be in our administration.

So again, Charlie, I just want to thank you for everything that you\'ve
done. My only regret in all of this is that I\'m not there personally to
shake your hand and to give you a hug and say how much I appreciate what
you did and wish you the best of luck for you. Thanks.

MR. CURIE: Thank you, Duke, for those kind words and for, again, being
co‑chair of this advisory council and just your passion and undying
commitment to have a lieutenant governor to take our issues on. Last
night I had the opportunity to be with NAMI, the National Alliance for
the Mentally Ill, on the Hill, and they had, Mark, I don\'t know, 10
members of Congress who dropped by, which is a great turnout for any
group. To see members of Congress speak to the issues around mental
illness, speak to addictive disorders, speak to our issues, again I put
it in the category to have governors and to have a lieutenant governor
who take these issues on in the forefront, we know our issues are such
that typically elected officials don\'t lead with mental health and
substance abuse as their issue to get the attention of the electorate
and to get elected. So you know when these issues are taken on, it\'s
because it\'s a true commitment and there\'s a level of courage, I
think, so we don\'t take that for granted.

So I just want to thank you for that, Duke, and for your participation.

Tom?

DR. KIRK: Charlie, amen to what all others have previously said. I think
probably, at least in my view, the most significant thing that your
legacy represents is change (inaudible) the choir. The vision that
you\'ve set and the things that you tied together brought people to the
table who talk about mental health, who talk about substance abuse, who
never talked about it before.

So I use the example of my next door neighbor who may have little if any
interest, but the way you presented the agenda, the way you talk about
it can get a person like that to understand why this is so very, very
important. Part of the reason why that is so critical is that I think
the kind of efforts that have been made that have resulted in more
partnerships empowering people who have mental illness, empowering
people with substance abuse disorders, the message of recovery empowers
them, gives them hope, and they represent a natural advocacy. So when
I\'m going to my local representative in such and such town, I don\'t
have to talk about these things because he or she sees that in the
people within that particular community.

What\'s the advantage of that? A couple of things. One of them is that
mental health and substance abuse issues become part of the agenda.
They\'re just core to the agenda. They\'re not something else. The
people that I have to deal with in terms of legislatures understand that
these are my citizens, these are in my community, and they see it in a
different way. The president of the senate up in Connecticut, a
conversation I once had with him was that he said your primary challenge
is, frankly, to get all the different constituency groups or
stakeholders not to form circular firing squads, because we don\'t
understand what they want. One wants this, one wants that.

I think a lot of that has served to be muted, if you will. So I think
that your vision and the way you\'ve communicated that has reinforced a
lot of what these folks said, but in many ways there is somebody named
Joe Smith, and Joe Smith lives in Stanford, Connecticut or someplace
else, who knows nothing about Charlie Curie, who knows nothing about
SAMHSA, but the emphasis on a life in the community, that\'s a benefit
to him. So to me, your biggest legacy in many ways is all the things
that I\'ve mentioned, but the thousands of people in this country who
somehow have resulted from the message that you\'ve given have a new
hope, that they understand they don\'t need to be ashamed of their
mental illness or substance abuse issues, and that that change is the
kind of thing that after you\'re gone and the rest of us move on to
whatever it is we do, Joe Smith is going to continue to move on with his
life, and that\'s an extraordinary legacy. You will never see Joe Smith,
but he\'s out there. He doesn\'t know you, but that\'s the biggest
difference in my mind. That, in my judgment, came about because of the
agenda that you set and the way you communicated that whoever the
audience was they could understand what you were saying.

I remember you came to Connecticut and sat and listened to the governor
a little bit, and you walked out of the office and you said she gets it.
She gets it not because of anything I\'ve done as much as it is the
kinds of things that you put on paper and the way you spoke with her.
She understood it in such a way that she said mental health may not be
my agenda, or substance abuse, but I now understand how it fits into my
agenda, and that\'s an extraordinary institutional change that you have
much, much reason to be proud of, and I thank you for what you\'ve done
for us. Thank you.

MR. CURIE: Thank you. Thank you, Tom. Again, coming from you, who I
consider a preeminent leader in the country and has used recovery to
shape things in Connecticut, thank you. Thank you so much.

One more? Larry.

DR. LEHMANN: Thank you, and I will be brief but do have to very much
thank you for your leadership, your openness to working with other
agencies such as the VA. I think the President\'s New Freedom Commission
and its orientation towards recovery and rehabilitation really helped us
to move our agency along in that direction, and really three things that
to me have defined your leadership, one being the President\'s New
Freedom Commission, but before that, in October and November of 2001 in
New York City, the conference for community mental health and state
mental health leaders and how one deals with disasters such as terrorist
attacks. Most of those folks have spent their lives dedicated towards
working and improving traditional mental health services. A lot of them
had never thought about these kinds of issues. That was number one.

Number two, the New Freedom Commission. Then after that, most recently,
this March 2006 conference on meeting the needs of returning veterans,
where I think a tremendous opportunity is offered for us in VA and the
Department of Defense to collaborate with our community colleagues in
helping to take some of these recovery and rehabilitation‑oriented
concepts in dealing with this newest generation of veterans, dealing
with their problems in a way that isn\'t just focused on pathology but
focusing on strengths as well as problems, and helping them to work
through that is really just a terrific opportunity for us to emphasize
and implement recovery and rehabilitation and help people improve their
functioning and their return to civilian life. Thank you.

MR. CURIE: Thank you, Larry, and thank you for your consistent support,
participation, and leadership with this council and with the
collaboration with VA. I know that Fran Murphy was there. Just her
serving on the commission and you supporting that process, again I think
it\'s as strong as it\'s ever been in terms of our relationship there,
and I appreciate that.

The other thing, you know, it\'s interesting that one thing I\'ve not
mentioned and really should, because again I think SAMHSA staff
demonstrated just a tremendous response, is after 9/11 the ongoing work
with New York, with New Jersey, with Connecticut, with the states that
were impacted directly by 9/11, and also working with every state to
develop a mental health and substance abuse consequence module to their
disaster plan is significant, and staff worked very hard with that, and
then our response to Katrina. I\'m going to have to begin incorporating
this in my remarks more. Maybe it\'s because Katrina is just so recent,
but it was a tremendous effort on the part of individuals, and we\'re
still engaged in the Katrina effort because we know that mental health
and substance abuse consequences will emerge more and more over time as
we look over the next one to two years, and we\'ve got to be in it for
the long haul.

But SAMHSA\'s response, its partnership with FEMA in terms of being out
there, we got the reputation of the orange shirts, and the folks that we
deployed ‑‑ I think over 700 people were deployed down there under
SAMHSA\'s auspices, providing support wherever people were appearing
too, in grocery stores, on the street, in parks, as well as providing
over 75,000 clinical sessions in the process. Again, I can\'t say enough
good things about all the centers\' responses. In particular, it was
centered in CMHS, and we have the leadership of Anne Mathews‑Younes,
Seth Hassett, Brenda Bruun, just to name a few key people, who just
really came through. I know the Secretary in the Department viewed
SAMHSA\'s response as just stellar, and that goes to the credit of
people who worked hard after 9/11 to really strengthen what a SAMHSA
emergency response center should look like, how that\'s hooked into the
Secretary\'s command center, and made us agile and responsive. I don\'t
want to forget that because I think that\'s going to be ongoing in terms
of capacity at SAMHSA. Again, it brought mental health and substance
abuse to the fray.

Now that we have a quorum, we can approve the minutes. Is there a motion
to approve the December minutes?

MS. HOLDER: So moved.

MR. CURIE: So moved, Diane.

DR. GARY: Second.

MR. CURIE: And Faye seconded.

Any discussion on that?

(No response.)

MR. CURIE: If there\'s no objection, the minutes will then be approved.
Thank you. That was burdening me.

(Laughter.)

MR. CURIE: I wanted to get that out of the way.

I now have the privilege of introducing two individuals.

I\'d ask Michele if you\'d come to the table, please, and Theresa.

First of all, Theresa Racicot, who you all know is a member of our
National Advisory Council. She\'s former First Lady of Montana and has
just been an unwavering advocate in terms of addressing this issue of
underage alcohol use and stopping it and preventing it. Again, she\'s
been a strong voice on this council. She\'s been a strong voice. She\'s
worked very closely with NIAAA, has really put a lot of her own time and
effort day to day into it, and really I think we\'ve been privileged to
have Theresa\'s involvement in this and ongoing advocacy. She\'s taking
it to another level with her partner here, Michele Ridge, who again
it\'s a special privilege for me to be introducing the former First Lady
of Pennsylvania. Again, I worked for her husband, Governor Ridge. I
actually blame him for giving me my start in public service directly
back in 1995.

When I talk about governors and elected officials who take stands that
aren\'t necessarily stands they take because it\'s going to gain them
more points in the polls, Tom Ridge is somebody who I point to, and he
did that at many levels in Pennsylvania. I think people look back at his
tenure that his focus was good policy that was reinforced over and over
again. Secretary Houston, the folks that worked from the governor\'s
office said they wanted sound public policy based on data. They made a
carveout decision for mental health and substance abuse, which Diane is
very familiar with, and it\'s still alive and well today. It was a
legacy of that period of time. It was not a popular decision among some
really key people, but it was the right decision that was made.

I also want to recognize Mrs. Ridge for the fact that she brought
Communities That Care to Pennsylvania in her legacy as First Lady. It
was just an ongoing passion and tenacity in assuring that 142
communities, somewhere in that vicinity, implemented Communities That
Care. I\'m not sure that any other state came close to having that many
as a concerted effort. But a science‑based approach to prevention which
again informed me a lot as I came to SAMHSA in terms of where we needed
to be moving and growing. So I credit that process and the education
Michele also gave me in terms of introducing me to that process and what
really worked, having a profound impact in why we have Strategic
Prevention Framework today.

Also, both of these leaders, again I think you\'ll hear from them today
about their passion in going beyond the First Spouses\' Initiative into
another level of ongoing support to assure we finally move underage
drinking in the same way we\'ve moved tobacco use and we\'ve moved
illicit drug use and getting society to take it seriously. So I want to
thank you for your ongoing leadership and commitment, and it\'s my
privilege to turn the floor over to you.

MS. RACICOT: Thank you, Mr. Curie, for letting us present this morning.
Michele is going to give you just a brief history of what the Leadership
Initiative is.

I realize that we\'re preaching to the choir a little bit, but this
initiative is very important at this point in time. So we\'re delighted
to have the opportunity, and I\'m going to turn it over to Michele.

MS. RIDGE: Thank you, Theresa.

I just want to provide a little context for the Leadership to Keep
Children Alcohol‑Free Initiative. There\'s a Dr. Putnam from Harvard who
wrote a book called \"Better Together: Restoring the American
Community.\" I\'m sure most of you are familiar with it. He talks about
creating social capital and bridging social capital, and when he talks
about social capital he\'s referring to social networks, norms of
reciprocity, mutual assistance, trustworthiness, and all of this takes
time and effort.

When we talk about social capital at a national or regional level,
we\'re really talking about a network of accumulation of mainly local
concerns. How this dilemma can be resolved is by creating networks
within networks, and I think that\'s the context for what\'s happening
here. Relationship building is a way of looking at the world, not just a
strategy.

In 1994, the National Governors Association spouses group, in \'93,
decided to take on the issue of breast cancer. So for two years the
governors\' spouses voluntarily took on that issue in their respective
states. As a result of that, the folks at NIAAA were looking at this
model and decided that one of the things that they thought would be good
would be if they could get the governors\' spouses to be interested in
not just underage drinking but childhood drinking, the 9‑ to 15‑year‑old
children, that particular group.

So in 1999 the Robert Wood Johnson Foundation and NIAAA of NIH started
to invite governors\' spouses to be a part of this unique coalition of
spouses, federal agencies, and public and private organizations to
prevent the use of alcohol by children ages 9 to 15. As a result of that
invitation, there were approximately about 20, a little less than 20
spouses that took this on. We know that alcohol is the number one drug
of choice of America\'s youth, and we know that with every decade that
passes the age of onset of drinking drops a whole year. A lot of us at
that time had children in that age grouping, and we heard lots of
anecdotal stories. This was an important public health issue that
affected children and families in our respective states.

So in March of 2000, the Leadership to Keep Children Alcohol‑Free
Initiative was launched here in Washington, and the governors\' spouses
took a pledge at that time, and they made a public commitment: \"To
promote the health, safety, and maximum potential for the success of our
nation\'s youth, we hereby commit ourselves to the goals of the
Leadership to Keep Children Alcohol‑Free Initiative. We solemnly pledge
to do everything in our power to ensure that the prevention of early
alcohol use by children is recognized as a priority concern for our
nation, educate the public about the many dangers posed by early alcohol
use.\"

In 2000, most journalists that these spouses encountered were totally
amazed at the statistics and at the early onset of drinking.

\"Encourage the use of research‑based strategies to combat underage
drinking at local, state, and national levels. Foster broad‑based
community involvement in prevention activities. Cultivate a coordinated
statewide approach to the prevention of underage drinking by fostering
the cooperative action of relevant state and municipal agencies, health
care and service providers, civic organizations, parents, teachers, and
our young people. Engage the energy and experience of young people in
alcohol prevention efforts, and encourage the media to portray and
report the negative consequences associated with underage drinking and
promote positive images of non‑use.\"

So this was the pledge that was taken, and it\'s really essentially the
pledge that\'s taken by all of the spouses that are involved in this
particular initiative. The initiative\'s appeal, I think, to governors\'
spouses was, first of all, the science that accompanied it. Most of us
‑‑ I\'m a volunteer. I\'m a public librarian by profession. I am not an
expert in substance issues or in mental health issues. But I do know
from looking at my own state and that it reflects pretty much what\'s
happening in the rest of the country, that this was an important public
health issue. Alcohol use by 9‑ to 15‑year‑olds is an overlooked but
very serious problem in this country, and the one area statistically
that we haven\'t been able to crack is that middle school, the 6th, 7th
and 8th grade group, and it isn\'t just the alcohol use. It\'s the risky
behaviors that accompany the alcohol use.

So having the science backing this initiative was very important to
spouses, because it gave the spouses credibility and it gave them the
opportunity to go back to their respective states and to recruit the
state agencies, to recruit advocacy groups, to recruit parents groups,
to recruit whomever they could get to the table to get involved in the
prevention of childhood drinking.

So the launch of the Leadership has also meant that we\'ve had a lot of
conferences and regional meetings, but we also have a very impressive
website. On that website, the Leadership funders and participants,
we\'ve had a lot of partners. When I talk about creating networks within
networks, I think part of the success of the Leadership Initiative has
been just that, creating networks within networks, and also in listing
the health care field, the American Academy of Pediatrics and the
American Bar Association, the American Medical Association, and using
scientific advisory groups to work with us.

I think one of the strengths of this initiative and the uniqueness of it
is that it has survived changes in leadership at the top, and party
changes, which is an extraordinary testimony because that doesn\'t
usually happen. I think you can look at Wyoming and Hawaii as two great
examples of that, where the governorship changed parties and changed
leadership. It has bolstered state infrastructure and produced concrete
strategies to combat the issue, and you can look at states like New
Hampshire and Florida, Wyoming and Ohio.

I think part of the strength of the initiative also has been its
non‑partisan basis. We set the initiative up with four co‑chairs. I was
one of the original four co‑chairs, but we picked two Democrats and two
Republicans because this is not a partisan issue. This is a very
important public health issue. So we modeled our leadership on that same
sort of non‑partisan model that the National Governors Association uses.

I think there are so many results that have come about as a result of
the initiative itself in the states. I mean, you can get on the website,
look at the weekly updates, look at how active these spouses have been
and what they have been able to get other people to do. They don\'t do
it themselves. They get other people to do it and provide leadership and
a very public kind of face on this issue of childhood drinking.

There\'s also been an impact on the national level. The initiative has
been able to have meetings with Secretary Leavitt, and also with the
Surgeon General, and that has been important in our pressing the case
that childhood drinking needs to be an American public health priority.

So the initiative exists today. You can see on the screen there is a
slide of the governors\' spouses leading the way. Those are the current
spouses. There are 40 states participating in the initiative, and it is
the issue that drives people\'s participation. It is resolving the issue
that transcends maybe our different philosophies and certainly our
different regions, but we all are dealing and grappling with the issue
of children drinking alcohol at the ages of 9 to 15 and the great peril
that it places them in.

I will turn this over to Theresa.

MS. RACICOT: Thank you, Michele.

As you can see, I always say this. I think it\'s remarkable that there
are 40 sitting spouses represented on one particular issue, because on
any given day when you\'re a governor\'s spouse, you have the
opportunity obviously to partner with many things, from the arts, a lot
of people see governors\' spouses as major leaders of health issues for
families, because traditionally until recently they were always women.
So for them to choose this and stay with it ‑‑ as Michele said, they did
breast cancer, there was a wonderful nationwide Habitat for Humanity
women\'s bill that they did at one time, they did literacy, they\'ve
done domestic violence, but never have they stayed with anything, and
we\'re talking about six years now, with changes, as we said, in
parties. So that\'s remarkable in itself.

The other piece is we now have 18 emeritus spouses. When you leave
office a lot of times, like Charlie, he\'s probably thinking this is a
fabulous experience, but I\'m done for a while, and to have these people
stay involved at the level that they have ‑‑ and they\'re all involved.
You see Michele and I a little more because we live in Washington, D.C.,
but we have a group behind us that is very involved, very committed, and
very powerful.

Because of the emeritus group that came out of the initiative, we
realized that when the federal funding went away, which is going to
happen in September of \'07, this initiative would disappear. So we
formed our own foundation, the Leadership to Keep Children Alcohol‑Free
Foundation, in October of \'04, and we have 11 board members, and we
have bipartisan officers. I\'m the president, a Republican. Vicky
Cayetano from Hawaii is the vice president. She was a co‑chair and is a
Democrat. Mary Herman from Maine is an independent. So that\'s an
interesting mix that we have going right now.

We are trying very hard to promote the work of the Leadership, and our
great hope is to get funded and absorb the Leadership initiative into
the foundation, because there\'s no place else for it to go when the
funding drops off the table, and the bottom line is it\'s the only group
addressing 9 to 15, and we all know the importance of what I call
intervention, which is a treatment and prevention when you get in early.
So it\'s very important that we don\'t lose this group.

They\'ve addressed underage powerfully, but a lot of times when you say
underage to people, they\'re thinking 17 to 20. Most people, when you
say 9‑year‑olds, they look at you like you\'ve lost every cent you\'ve
ever had. One of our spouses in Wyoming, the partner in her law firm,
she said I\'m going to be gone the next few days, I\'m doing an alcohol
conference, and he said, well, what\'s it about? She described it, and
he said why would you be bothering with alcohol and 9‑year‑olds? I think
that\'s a powerful public opinion. These are children, and they\'re not
involved with alcohol.

So to keep the science going, which as Michele said has been the driving
force for recruiting the spouses ‑‑ I have to tell you, whenever we can
get them to a conference and present the science, they sign on without
one hesitation. We have a scientific advisory board made up of Enoch
Gordis, who is the former director of NIAAA; Dr. Alex Wagenaar from the
University of Florida College of Medicine; Dr. Richard Hyman, who is the
chair of the American Academy of Pediatrics Section on Adolescent
Health; Dr. Edward Hill, who is the president of the AMA; and Stacia
Murphy, who is the former director of NCADD.

With the sitting spouses, as Michele said, we\'ve been responsible and
we pushed the General Surgeon\'s Call to Action. I know our sitting
spouses were very helpful in the success of the town hall meetings that
SAMHSA did last fall. They\'ve been supportive of the IOM
recommendations, trying to incorporate them in their states. We\'re
trying to push them more on the national level. They maintain strong
relationships with some of the people that we\'ve mentioned, the AMA,
the AAP, the National Association of Attorneys General. We were involved
with them in a meeting in San Francisco last year, and they\'re looking
at this issue very strongly, obviously from the legal side and the cost
to law enforcement and justice.

So currently we are working programmatically with this pediatrician in
Ohio who has a program out that may actually change the screening of
children in a pediatrician\'s and a family practice doctor\'s office. He
has come up with a set of five questions to ask that would open the door
to whether children between 9 and 12 are being exposed, are walking
around the area with peers or with influence in those kinds of ways.
We\'re trying to partner with him.

Let me tell you what our uphill battle is, which is everybody\'s, and
that\'s money. We\'re trying to find money publicly and privately, but
it\'s difficult. I mean, it\'s not a popular issue, and it\'s a hard one
to sell, and obviously everyone is desperate for money. So Michele and
I, who have become known as the R&R team, are knocking on every door we
can find that we think possibly might be willing to help this foundation
move forward. Frankly, as I say to people, it\'s not SAMHSA\'s problem,
it\'s not NHTSA\'s problem, it\'s not the American Academy of
Pediatric\'s problem. It\'s the community\'s problem. It\'s all of our
problem, and it\'s a major children\'s health issue in this country and
one that needs to be addressed.

So I thank you for the time today, and if you have any questions, we\'ll
be happy to try to answer them.

MS. RIDGE: I just wanted to add to Theresa\'s comments that the CDC just
came out with their 2005 Risky Behavior Surveillance Survey. Seventy‑one
percent of Americans between the ages of 10 and 24 die from car crashes,
injuries, homicide and suicide, and then they listed the substances that
are involved in that. Forty‑some percent of those incidents, alcohol is
somehow involved. So for our young children, it isn\'t just the drinking
of alcohol, although the pediatric research, the brain research that\'s
been done now helps to undergird our efforts and certainly gives us some
strength in raising this issue with policymakers at all kinds of levels
and communities.

The fact that children who drink regularly under the age of 14, 40
percent of those individuals will have alcohol addiction issues to deal
with as adults. That\'s a tremendous gamble to take with people\'s
lives. So we really thank you for the opportunity to be here and present
at your council.

MR. CURIE: Thank you.

MS. RIDGE: Any questions?

MR. CURIE: I want to note that Duke Aiona, a member of this council, on
behalf of Governor Lingul, is the representative on the First Spouses\'
initiative.

MS. RIDGE: Yes, some of the nation\'s governors don\'t have spouses and
they delegate that, and the Lieutenant Governor has been leading the way
in Hawaii, and I think that\'s a great example because Benjamin Cayetano
preceded Governor Lingul in office. That\'s a great example of this
issue transcending party.

MR. CURIE: Any questions? Diane?

MS. HOLDER: I\'d just like to commend you for your work. It\'s so
important. It was only about 15 to 20 years ago where people used to say
that children actually couldn\'t be depressed. There was a literature
that said childhood depression didn\'t exist. Over the last 20 years
we\'ve learned a lot in terms of the fact that it does exist, and I
think in the same way that you\'re confronting sort of an idyllic
national perception that somehow children are protected or that children
actually don\'t experience the kinds of things they really do
experience, because most of us actually don\'t want to believe it.

So I think that the kind of education you\'re doing, the ability to get
to pediatricians, is really critical. One of my questions is how, with
your networks within networks concept, have you been successful in
engaging education in terms of a methodology in the door to the schools
where the kids are spending a huge percentage of their time?

MS. RIDGE: Well, I think that that really varies, Diane, between ‑‑ it
depends on each state. If you go onto the Leadership website and
research that, I think you\'re going to find some examples. A lot of it
depends on the structure of each state and how active the advocacy
groups are. I think usually the education model goes through parents and
some of the parent organizations into the schools.

MS. RACICOT: The initiative is set up and has to be set up this way,
obviously, so that each spouse who signs on signs on with their degree
of commitment. Some are very, very involved. Others, as I said
yesterday, when the spouse puts their name on it, it immediately raises
the level, and just doing that in their states is valuable, opens them
up to all the prevention and education materials. But it is not a set
format that if you sign on you have to do X, Y and Z. So they all are
doing different things, very interesting, very unique, and when they
come together at the meetings that we\'ve had, they share and go back.

Mical Hoven, for instance, in North Dakota, partnered with Appleby\'s to
put table tents on their tables because it\'s considered a family
restaurant, even though it does serve alcohol, and they helped to raise
money for billboards in her state, and that was just one of the things
that a spouse came up with that was unique and not done by another
state, for instance.

We need to mention, too, that Columba Bush is one of the co‑chairs of
the sitting spouses\' Leadership initiative.

MR. CURIE: Absolutely. The council is well represented in this process.

Barbara?

MS. HUFF: This was a little before your time, Theresa, but ‑‑

MS. RACICOT: (Inaudible.)

MS. HUFF: I know. I keep saying that to myself since I have such a
history anymore.

There was a group of Congressional spouses who came together around
children\'s mental health in about 1990. The National Mental Health
Association kind of gathered them together, and they became the real
advocates for systems of care and the legislation that passed around
systems of care years ago. Without them, I don\'t know that that would
have happened. It might have, but it might have taken a lot longer. Just
the fact that this group of individuals promoted children\'s mental
health in the way they did, it just rose to the surface.

So first of all, I\'d just say thank you both for your time and energy
as volunteers in this effort. I certainly want to say that if there\'s
anything we can do to be supportive, we would want to do that. So thank
you very much.

MS. RACICOT: Did the spouses group not continue as an advocacy group?

MS. HUFF: I don\'t know. There\'s been talk over the years about trying
to kind of reinvent that. The National Mental Health Association is
going to be under some new leadership, and that might be an exciting
time to try that. But no, they took that on and I don\'t know if it wore
them out, and they may have taken on other issues, but not children\'s
mental health after that. That was their big thing, and being from
Kansas we had Jim Slattery\'s wife very involved, and Tipper Gore.
That\'s when she really first started in the area of mental health. So
she chaired it. It was a phenomenal effort, so I know great things can
happen when people have perceived power.

MS. RACICOT: Barbara makes a very good point. They came together, they
did it, but they didn\'t sustain. Think of where you could be today if
you had that group behind all the time. The challenge, of course, with
political people is the recruitment. I mean, we\'re facing a huge
recruitment session coming up here because we\'re going to lose a lot of
these spouses. Some of them are term limited and some of them are up for
election. So the other piece of this that we are working very hard on
that I should have mentioned is keeping the numbers up, because the
power is in the numbers. I just hate to see this group, who can bring so
many different people from so many different walks of life, power,
advocates, treatment givers, prevention and education together, slide
off the table and leave this issue with no one voicing it.

MR. CURIE: Ken, and then Faye.

DR. STARK: Just a quick question. I haven\'t tracked all the stuff you
guys have been doing. I know you\'ve been doing great stuff. I just
haven\'t tracked it in detail.

How much have you gotten involved in looking at, especially given the
tie‑in with the governors\' offices, around legislation, model kind of
legislation, beer taxes, other kinds of things in order to promote
prevention activities and to reduce access?

MS. RIDGE: I know that some of the states have actually had their keg
registration legislation go through. I think governors\' spouses
generally fly under the radar, and most times that\'s more effective.
But I know that Nancy Freudenthal in Wyoming has been very active on the
legislative front. She\'s an attorney and was involved with the
legislature even before she became first spouse. So I think it just
depends on each state. But there has been legislative advocacy both
within states as well as at the national level. We worked very hard ‑‑
we\'d have to go back to the drawing board, I think, but we worked very
hard to get a postal stamp to get research. Part of the goal of the
initiative is also to encourage pediatric research and the effect of
alcohol on children, and we need to do more research on that, the impact
of alcohol on the brain, not just on young children but how plastic the
brain is.

So that\'s a long answer to your question, but there have been some
spouses who have actually been successful at getting legislation passed,
especially as it relates to keg registration.

MS. RACICOT: Nancy Freudenthal was actually very successful with that
particular piece of legislation with a group of high school kids from
Cody, Wyoming. They pushed that keg registration. When you\'re lobbied
by young people, it\'s a very difficult thing to walk away from.

MR. CURIE: Faye?

DR. GARY: Thank you very much for your good work. I am most appreciative
for the written brochure that you\'ve given. It\'s very informative and
it\'s very well presented. Thank you for that.

I wanted to get back to the comment that Diane had made about a model,
because I think as I see and hear this discussion, it seems to me that
your model or your method, your paradigm if you will, would be very,
very useful for other people to be included in your network. That\'s the
part that\'s very intriguing to me, these inter‑networks. I wanted to
ask, for example, a network with the juvenile justice system where a lot
of children who are seen as typically hard to reach and disenfranchised,
isolated. So I would see that perhaps given this model, that the
juvenile justice system, as well as Diane\'s observation about the
school system, and also faith‑based organizations would be a part of
this network that I\'m envisioning in my head.

So I\'d just like to ask about that ‑‑ Girl Scouts, Boy Scouts, where
children congregate, recreation centers, the YWCA. I see evolving a
model that would include many, many community organizations, but I
don\'t know if that\'s what you have in mind. So I\'m intrigued about
the possibility of the model that could just paint the community, if you
will, and involve all of these different segments, because I think the
advantage that you have is that you do speak from a position of power, a
position of visibility, a position of authority, and you do have access,
not only in the state but you have access to power in the entire nation.

The other question that I wanted to ask is do you have in place a
process whereby your good works will be evaluated so that you will know
the impact that your good work and the good works of other people and
this network system have on this problem that is very problematic for
all of us?

MS. RIDGE: I think in the individual states, and I think Theresa maybe
can also answer this, I think your suggestions are wonderful. I think in
the individual states, a lot of spouses have brought together ‑‑ we
basically leave it up to the spouses, but we also provide them with a
lot of information about science‑based programming, research‑based
programming, and most of these spouses are very good at bringing
together all the elements of a community, because I think you really
don\'t get change, especially at the local level, unless you really get
all the stakeholders at the table. So I think some of the spouses have
been successful.

The initiative does that individually by state. The initiative tries to
provide as much technical support and resources for those individual
governors spouses. That\'s what\'s really going to be the mission of the
foundation, to continue that support, to continue providing governors
spouses with the resources.

Part of the incentive for people to sign up and to participate in this
initiative is also the fact that there is an umbrella organization.
Right now it\'s the initiative. Our foundation is very new. It\'s
fledgling as a way to deal with the end of the federal contract in
September of \'07. So the foundation itself is finding its way, but its
primary mission is to support the initiative.

MS. RACICOT: You know, Faye, on the evaluation question, we haven\'t
really had ‑‑ this is a novice here saying this ‑‑ a programmatic
process going that would maybe speak to the kind of evaluation that I
think you\'re saying. I guess I would evaluate the work if you look at
the amount of materials that have been requested, and out of the United
States. I think our materials are in 40 countries, and I know they were
printed and distributed in large numbers around the town hall meetings.
So in that respect I think the materials and the information is very,
very valuable, and I would base the evaluation of that on those numbers.

MR. CURIE: Any last comment or question?

Duke, do you have any comments or questions?

MR. AIONA: No, other than I thank Theresa and Michele for the work that
they\'re doing as a foundation. What they said about sustaining it is
very important. I could go on for days about what we\'re doing in
Hawaii. Like I said yesterday, we\'re making tremendous progress. We\'ve
got an aggressive campaign going on right now from the governor\'s
office, and it\'s all because of Leadership that kind of spurred us on.
I\'m just proud to be a part of it. It is a great model. It\'s something
I think everyone can learn from. So thanks again. Great presentation,
Theresa.

I\'m sorry I\'m not there. I had some nuts for you, but I\'m not there.

MR. CURIE: Thanks, Duke.

I want to thank you both for coming and presenting, informing the
council. It was an excellent presentation. Again, thank you for your
leadership and commitment, which is truly making a difference.

(Applause.)

MR. CURIE: Now let\'s take a break, a 15‑minute break.

MS. VAUGHN: Fifteen minutes, with one comment.

MR. CURIE: Toian has a comment.

MS. VAUGHN: In front of you we\'ve placed menu selections for lunch. If
you would circle the item, place your name on the menu and give me the
money, and then we will place the order. Thank you.

(Recess.)

MR. CURIE: If everyone would gather back to the table, we\'ll reconvene.
Thank you.

I am pleased to introduce the next topic, but first of all, one person I
want to recognize, Craig Love, who is a former National Advisory Council
member, here visiting us today and still very active as an advocate in
the field.

Thank you for being here, Craig, and for your years of service on the
council.

He was on the council when I first arrived, so I feel like part of a
full circle is being accomplished here.

We want to focus now on SAMHSA\'s international activities. Again, I
want to stress that SAMHSA\'s mission is primarily the focus is
domestic. All of our appropriation is geared toward domestic programs,
and by law we do not fund treatment programs or programs
internationally. So I want to go on record that our international focus
has not undercut in any way our mission here in the United States and
what we\'re to be accomplishing, but we think it has helped augment our
focus by being able to be exposed to not only in our international focus
learning from other countries what\'s working there, but also being in a
position to help provide technical assistance, help bring teams together
of experts in this country from academia, from various fields, to
provide the consultation, support and facilitation as countries look to
develop further their substance abuse treatment delivery systems, their
focus on prevention or their mental health services delivery system.

We\'ve had an international focus for many years at SAMHSA. I would say
that it has increased dramatically over the past two or three years.
Winnie Mitchell, who is the team leader and policy coordination team in
Daryl\'s office, actually, is our international officer, and again has
been I think in that capacity for several years and has seen things
emerge.

Two of the areas that we want to focus on today is the work that we have
done both in Iraq and that we\'re beginning to do more and more in
Afghanistan. Over two years ago I had the privilege of going with
Secretary Thompson to Baghdad. The coalition, the provisional authority,
as well as the emerging at that time Iraqi government and health
ministry had identified the three top health priorities of
infrastructure that they wanted to build and address in Iraq to be, one,
infectious disease management; two, oncology, addressing cancer; three,
mental health. Actually, it was quite remarkable to see one of our
issues land in that top three, and I think it showed a lot of insight on
the part of Iraq. They were concerned not only about assuring people
with serious mental illness in that country receive the care they need,
and children receiving intervention and care they need, but also
recognizing that they\'re a post‑conflict society, that they\'ve been
under tremendous trauma, if you will, under a dictatorship and a violent
situation for more than three decades, and coming out now, of course,
under a very challenging time.

Fortunately, SAMHSA has done work with Project One Billion, which is
part of WHO, and Harvard has been very much involved, Harvard University
very much involved, Richard Mollica in particular, in developing
interventions and approaches and working with health ministries of
post‑conflict countries around the world. So there are some ready models
that we can begin to use in working with Iraq and Afghanistan.

The approach that Iraq is taking ‑‑ and again, one nice thing about the
approach we\'ve taken in Iraq as we got engaged is the United Kingdom
already was beginning to engage Iraq at about the time that we were
involved. An individual by the name of Dr. Sabah Sadik, who is an
expatriate from Iraq who landed in England and was a practicing
psychiatrist at West Kent Trust in England, very much got engaged back
with colleagues that he had left behind in Iraq to help build the
infrastructure.

The way we approached it is we looked to England, the United Kingdom, to
be the lead partner in rebuilding the infrastructure in Iraq, and we
being a partner helping to facilitate that process and enabling it.
It\'s been very inspiring to see how the individuals in Iraq who are
mental health professionals ‑‑ there are approximately 90 psychiatrists
in Iraq. Probably half of those psychiatrists have been actively engaged
in the rebuilding of their mental health infrastructure. But some key
decisions that they\'ve made in terms of their approach is, one, they
want to integrate mental health with primary health care. As they build
the primary health care centers and systems there, instead of having a
separate mental health system developed and engaged, do it kind of in
the direction we\'re trying to do it now in the United States. The
disadvantage we have is we\'re not starting from scratch. We\'ve got to
overcome structures that are already in place to some extent. In Iraq,
they\'re starting anew.

The second decision, which was a very courageous decision that they
made, I believe, over a year ago in Amman, Jordan, in the way that we
structured things with Iraq is while I was in Baghdad initially because
of, obviously, the circumstances in Baghdad and various hot spots in
Iraq, we\'re not sending our teams to Iraq to meet with folks, but
we\'re bringing folks out of Iraq to come to Amman, Jordan, where we did
training over a year ago, as well as strategic planning sessions, and
then this past March in Cairo. So we\'ve had that ongoing process.
They\'re making good progress in Iraq.

The other courageous decision that they\'ve made is deciding to close
Al‑Rashad Hospital, which has been their major mental health
institution, if you will, for decades in Baghdad. Unfortunately, it was
used also as a place to put political prisoners under Saddam Hussein,
and basically the conditions were just atrocious and unimaginable. But
they had the foresight, thinking in terms of while a quick fix would be
let\'s fix up the institution and let\'s do an institution‑based
approach, they recognized that if they did that, the institutions would
be sucking all the resources and there wouldn\'t be dollars left for a
community‑based system of care and the integration of primary health
care. So they made a commitment over the next few years to actually work
towards closing that hospital as part of their plan.

Afghanistan approached us last year. I think partly they saw and heard
what we were doing in Iraq, and Dr. Fatimie, the health minister from
Afghanistan, met with me and Dr. Kakar, his deputy minister, who has a
real interest in mental health and I think helped put mental health on
the radar screen with Dr. Fatimie as well, basically came and said we
know what you\'re doing in Iraq, can you do some of the same things for
us in Afghanistan.

So again, we pulled together a team of folks, had an initial meeting in
Kabul a couple of months ago, and basically began to set the stage for
more of their planning. They have I think a 10‑point plan now that they
had developed. We put more meat on the bones of that plan. Again, the
approach we take here is they need to own the plan. It needs to be their
plan, and truly I can say with confidence that both in Iraq and
Afghanistan they don\'t view this as a plan we developed or this is how
we do things. They truly do view this as their plan, and it legitimately
is.

Again, we have a long way to go in both countries. Afghanistan doesn\'t
even have close to the infrastructure that Iraq has to begin with, so
they\'re really starting at a whole profoundly different level. To give
you an idea, I mentioned that there are 90 psychiatrists in Iraq. There
are two in Afghanistan. So again, there\'s a whole process of beginning
to think about how do you begin to build professional workforce, how do
you begin to really have mental health available. Again, the approach of
integrating mental health with primary health care is also the approach
being looked at in Afghanistan.

Both in Iraq and Afghanistan we\'re also engaging the institutions that
exist in their communities. We also recognize that much of the culture
there is very tribal. We also recognize that we need to think in terms
of cultural competence, as we do here in the United States, and also
engaging their religious leaders and faith‑based leaders, who are viewed
as an important resource in their communities. They are all actively
engaged in both Iraq and Afghanistan. So it\'s a very exciting venture.
It has, again, been a profound experience for me to really see the
commitment that folks make.

One thing that struck me in this past Iraqi consultation in Cairo ‑‑ and
my heart really goes out to the Iraqi doctors and professionals. In
Amman there was a lot of hope you could see over a year ago, and
they\'re moving ahead in excitement. Cairo, because, as we follow the
news, we know the insurgency has just been brutal in Iraq to a large
extent, that has taken a toll in terms of how they view things because
of what they\'re experiencing. I think they view that it\'s going to
come to an end at some point as the Iraqi government takes hold, so
they\'re still very hopeful, but you can tell the trying times does have
an impact on the process.

The other thing, most of them being professionals and doctors, they\'re
also targets of kidnapping. This is something I\'ve learned goes on over
there that we may not hear about in the news quite as much, but it\'s
not unusual for someone who is viewed as having an income or some means
to be kidnapped off the street, be held for ransom once the terrorists
or whoever are kidnapping, get the money, they release the person. But
it\'s still just an added stressor, obviously, that it\'s hard for us to
comprehend in our day to day life.

Of course, very much their families were on their minds as they were in
Cairo. As they got into the conference at Cairo, they very much I think
benefitted from the process. But again, it just reinforced some of the
challenges that are involved.

I would like to now introduce to you Winnie Mitchell, our international
officer. Again, she works in Daryl\'s shop. She\'ll share some of the
details of what we\'re doing internationally.

Winnie?

MS. MITCHELL‑FRABLE: Thank you, Charlie, and I\'ll just stay up here if
it\'s okay with everyone.

I just personally want to say, and I\'ve said this to Charlie, that
it\'s been an honor to be with him the last couple of years on this.
I\'ve never been so excited about my professional career and just felt
like it was a magnificent opportunity, thanks to Charlie.

I just wanted to go back to what Charlie said about him getting involved
internationally in such a big way and going to Baghdad with former
Secretary Thompson. I think that both Charlie and he talked about health
diplomacy, and I think everyone in this room, and certainly all the
members of the council, understand that when you\'re focused on the
common good of improving mental health, behavioral health, the health of
children, the health of people, the goal is bigger than one conflict and
one approach. So it\'s really common ground for us to go out and work
with our partners and colleagues in the developing world.

What we\'ve also learned is there\'s a real yearning to know what we in
SAMHSA, what you around this table know. The developing world wants to
know about how to do services. They think that research is important,
they think evaluation is important, but in the first instance what
they\'re asking for is information about how to address the needs of the
people they see right in front of them, and how to get the services
going.

Where we work, as Charlie said, I want to just show you on the map.
Where we work is in Iraq, which is in green; Afghanistan, which is in
yellow. The Central American countries, we\'ve just started a very
exciting collaboration, again under Charlie\'s leadership, with the U.N.
Office on Drug Control and their work in Central America to improve
substance abuse treatment in all the countries, and I might add Belize,
including Gwynneth Dieter, is now responsible for getting Belize as part
of that network. So the brown is where we\'re working there.

I also want to just tell you that Russia is now back on the radar for
SAMHSA\'s international work. Thomas Christina is in the background
there, but we are working through the President\'s AIDS work to really
resurrect some work that we did in Russia in the late \'90s on substance
abuse prevention and screening based on our TIP 24, with an important
component of that TIP 24 being a module on helping primary care workers
screen for substance abuse as an HIV prevention tool. So all of that
work is kind of coming back, and we\'re working very carefully to
resurrect that work.

I would also tell you that you\'ll see in red that there\'s Vietnam, and
there should be red over in Geneva. As you may know, Carl White from
CSAT is on detail to Vietnam right now, working again on AIDS
activities, and we also have a detailee, Dr. Tom Barrett, to Geneva
working on mental health activities. WHO Geneva and WHO in many of its
regional offices has become a very important collaborator with us in our
work in both Iraq and Afghanistan, certainly in Central America, and
really all over the world.

Now, the purple, you might ask, what\'s the purple? The purple are the
countries that are the members of the International Initiative for
Mental Health Leadership that Charlie co‑founded with his colleagues in
England and New Zealand, and Charlie mentioned this organization to you
before. It\'s the organization that really has put innovation and life
to recovery, and it\'s given Charlie an opportunity to really share
innovation and different kinds of how‑to\'s with his colleagues in these
English‑speaking developed countries that are members of the
International Initiative for Mental Health Leadership.

Now, let me turn to Iraq and give you some of the more bureaucratic
details to really flesh out what Charlie has already told you. As
Charlie said, one of the first things we did was to establish a planning
group, and the planning group includes not only folks from SAMHSA but
also our colleagues from the National Institutes of Health. Both NIDA
and NIMH are members of this council. We have ongoing participation from
HHS Office on Global Health. We also have membership from our Department
of Defense and the State Department. This planning group also, most
importantly, the members include Dr. Sabah Sadik, who Charlie told you
about, the national mental health advisor for Iraq, and our colleagues
in Baghdad, his deputy Dr. Mohammed Lofta, and Dr. Ronika Growley.
You\'ll see pictures of them soon.

But we have a conference call with this working group, which includes
the folks in the United States and the folks in Baghdad and the folks in
England, at least every two weeks. I\'m saying this only because at
least what I have learned is that a device like this, a tool like this
is critical when you\'re working with developing countries where things
are so difficult on the ground. Having a regular meeting every two weeks
gives them hope, gives them something to sustain, helps them over
things. It\'s basically become kind of a mentoring group, an ongoing
support and technical assistance group, if you will, for our colleagues
in Iraq, and it\'s been really an important device.

So this planning group is alive and well, and we still meet every two
weeks. We held the 2005 Action Planning Conference in Amman, as Charlie
said, and significant progress on the recommendations made there:
closing Al‑Rashad, as Charlie said; developing a code of practice for
mental health; and instituting a referral system, which was really a
trick in Iraq given all the different kinds of things that are going on.
But we were very grateful to hear when we got to 2006 that they\'ve
already institutionalized this referral system in three provinces, three
governances as they call them, and they\'re going to be expanding them
to 12 governances by the end of this year.

In 2006, as Charlie said, I wanted to tell you personally what I saw.
The first day that the folks arrived in Cairo from Baghdad, they were
nervous, they were angry, they were yelling at me. I hope they didn\'t
yell at Charlie. They may have. But everybody was like this, just
really, really anxious and full of dread and kind of tired. Well, after
they had gotten a couple of good nights sleep, they\'d had some really
good food, they all of a sudden saw people over the table they\'d never
talked with in Iraq, Shi\'ia talking with Sunni, Shi\'ia talking with
Kurds, all this kind of stuff. They were at a professional conference
for four days. They did magnificent work. Charlie led a group on mental
health services that came up with extraordinary recommendations that
built on what they had done in Amman. I saw the same thing in the mental
health policy group, extraordinary work. They were professionals at a
professional conference and they had a good time.

Then we had some problems at the end which took them back to what they
were facing when they went home, and it all kind of came to an end, and
they were nervous, and they were frightened for their families. The only
thing that it evoked in me was the way I felt about my children when we
had the sniper incident here in Washington, D.C. That was the way they
were feeling when they had to go back to Baghdad.

So I just want to show you some pictures. This is our poster. This is
the emblem of the National Mental Health Council in Iraq. The man at the
podium is Dr. John Bowersox, who is the health attache in Baghdad, who
has been really instrument to our work. The gentleman by Charlie is Dr.
Sabah Sadik, and behind Charlie is our collaborator in the United
Kingdom, Irville Miller. Here are some of the key Iraqis. These are
expatriates and people who actually work in Iraq. The gentleman
immediately right there is Dr. Santooma, who many of you may recognize.
He\'s been with the National Institutes of Health for most of his
professional life. He\'s an expatriate and has been critical to our work
in helping Iraq reestablish its research capacity. Next to him is Dr.
Mahmoud Tamor, who is a leading cardiologist from Johns Hopkins who is
intimately involved in our work and goes to Iraq every chance he can.
Next to him is a gentleman that Dr. Tuma and I are meeting with this
afternoon, Dr. Khalili, who is the cultural attachΘ for the Iraqi
embassy here in Washington, D.C. and is very instrumental to the
collaborations between the Institutes of Higher Education and the
training activities that we\'re going to be subsequently doing. Next to
him is the inspector general for the ministry of health, Dr. Otil, who
was very important to me the last couple of days in making sure that all
the people got home safely to Baghdad. Importantly, the woman there who
is on the panel is Dr. Naima Al‑Garsea, who is in charge of Iraq
activities for the World Health Organization and has been our real
partner in all this. WHO has very effectively administered \$6 million
of training money for Iraq from Japan, and we\'ve been working with WHO
in the U.K. every step of the way.

This is another scene of the conference. We were in this room for quite
a long time, so I just wanted everybody to see that.

Now, we did have fun. The point of showing you these is that the
pyramids in Egypt are really in the suburbs of Cairo, so I just wanted
you to see that you could really see that they\'re there.

These are two of my friends. These people do not speak English. The
gentleman is Dr. Tamar, who is a judge in Baghdad, and the woman is a
social worker from the ministry of labor, and they\'ve become two of my
closest colleagues even though they don\'t speak English. They\'re
wonderful. So I just wanted to show you that.

Here are the Iraqis having fun on the bus. This is in the middle of the
week when they were professionals at a conference.

Then I also want to show you that our two colleagues from Iraq, Dr.
Mohammed Lofta, who is the gentleman with the red tie, and Dr. Ranak
Agroui, the woman in the purple jacket, are the two that join us every
week on the planning group call. But we have expatriates from a whole
variety of communities in Washington, D.C. The gentleman in the red
shirt is Dr. Hussan Al‑Atari, who is a practicing psychiatrist from
Fairfax, and right here is a gentleman from NIDA, Dr. Al‑Kashef, who
does the work on medications from NIDA and is intimately involved in all
of our work with Iraq.

Here\'s Charlie with our colleagues from Iraq, Dr. Sadak in the light
shirt, Dr. Lofta, and Dr. Agroui. Here he is again with some more of our
colleagues. I just wanted to point out the young man in the brown jacket
right here is Dr. Nazar. One of the things we\'re going to be doing over
the coming years is supporting emerging leaders in Iraq like Dr. Nazar
and giving them extra opportunities for training.

Here are our colleagues from the U.K. and from Egypt. The gentleman with
the tie on the far end is the minister of health from Egypt, and then
here is Dr. Sadak, and then our two colleagues who have been intimately
involved with us, Mr. Miller and Mr. Wilkes from the U.K. with Charlie.
Here we are with our key collaborators from Iraq.

Now I\'ll move on to Afghanistan. I just wanted to tell you that it\'s
all about people for me, and I know for Charlie, and those are the
wonderful people that we\'re working with from Iraq.

In Afghanistan, as Charlie said, an instrumental meeting about a year
ago with Minister Fatimie and Deputy Minister Kakar. We established a
similar workgroup on Afghanistan mental health, actually almost the same
cast of characters from the National Institutes of Health, DOD, the
State Department, our Office of Global Health Affairs, and most
importantly some expatriates Afghan Americans on the workgroup, along
with the embassy of Afghanistan.

We held a meeting at the embassy in December to further our plans, and
I\'ll never forget when Deputy Minister Kakar asked Charlie, well, do
you want to come to Kabul? And Charlie said, sure, why don\'t we do it
in a couple of months? Anyway, we did get the conference going and we
had the Partners\' Conference on Behavioral Health in Kabul recently.

I\'m sorry this is such a dense slide. There are handouts that will give
you all the background. I just want to tell you briefly about the
handouts. There are two pages on Iraq and two pages on Afghanistan. One
of them is a summary of the overall effort, and one of them is a summary
of the highlights from the conferences that we just had. But this
partners\' conference was really interesting. It was the first time
people across Afghanistan working on mental health had come together.
The non‑governmental organizations that are doing all the service
provision there had never met up with each other. This is the first time
they ever came together. The funding partners who are sponsoring all
these activities in Afghanistan had never met up with each other. So the
real significant thing is that all of them came together in one room.

The lessons learned are obvious. Short‑term training is not enough. They
need ongoing support and supervision. Finding and keeping staff is a
challenge. Women and children are the most vulnerable groups, and
everyone in Afghanistan has experienced violence and trauma.

The challenges are how to define standards for interventions, how to
screen, how to provide substance abuse services, another challenge for
Iraq as well, and limited public awareness of substance abuse and mental
health problems.

Recommendations are obviously to build human capacity, to integrate
behavioral health into primary care, and to increase public awareness.

What we\'re going to do in Afghanistan is very much like what we hope to
do with Iraq, targeted support for the implementation of their national
strategic plan and support for training, both in Afghanistan and
training here for emerging leaders.

Here\'s what it looks like. This is Dr. Kakar, the Deputy Minister of
Health, and Charlie. One of the things they do in Afghanistan is they
hire local painters who make these big banners, and they put them in the
front of the hall in the Ministry of Public Health so everybody knows
that there\'s a big conference going on there.

Here are the people who came. I would say that the young women in back
are very interesting. The woman with the glasses in white is a
psychologist who was trained very elegantly in Southeast Asia and gave a
really important presentation on PTSD and trauma in Afghanistan. She\'s
going to be an emerging leader, clearly, there.

The gentleman right here in front has participated. His name is Dr. Tim
Moshamosham. He runs the one mental health hospital in Afghanistan and
has been a participant in the Project One Billion Harvard Program on
Refugee Trauma master classes for the last three years. We sponsored him
to go there, and he\'ll be going back.

I would also tell you that I\'m showing another picture because the
gentleman right in front of the picture is Dr. Azimi, who is the WHO
lead in Kabul, Afghanistan and will be very instrumental in the work
that we\'re going to be doing with Afghanistan because we\'re going to
be working very carefully with WHO. We\'ve already had offers from both
the offices in Geneva, the offices in the Middle East, and then offices
in Kabul. So they will be very instrumental to our work.

Now, here are some of the people, the emerging leaders, and you\'ll
recognize Dr. Anita Everett on the end there. Dr. Rahula Nasiri is the
mental health coordinator who is our key person and who is on our calls
with the working group every week. Next to him in the red shawl is Dr.
Nahid Aziz, who is an Afghan American professor at Argosy University
here in Washington, D.C. She\'s our ticket. She\'s the person who can
teach us how to be culturally appropriate in everything that we do, and
she has just been an amazing person. She\'s a clinical psychologist.

Next to her is Dr. Peter Ventavogel, who is with HNI, an NGO. He was the
person who really taught Dr. Nasiri everything about mental health and
how to set up institutions, and Dr. Ventavogel is now doing this kind of
work in Africa but came back for our meeting.

Next to him is Dr. Monsouri, who works for an NGO in northern
Afghanistan, and he was just an amazing leader. I just do this to show
you that there\'s really amazing potential and talent in Afghanistan.

Here\'s Charlie with key actors, Dr. Kakar on the end, Minister of
Public Health Fatimie, who I know as a real colleague of Charlie\'s and
a wonderful man, and then Dr. Nasiri. There\'s Charlie giving him his
certificate.

Then I end with the one thing that I was able to do in Kabul, which was
visit a women\'s hospital. I attended a very impressive case conference
there. I think you would all have been amazed at the standards of care
and supervision and clinical team work that goes on in that hospital. I
just wanted to show you the women who participated in the morning case
conference that we had. It was very significant and important what they
were talking about, disease and infection control, the mental health
kinds of interventions they would do with the women who are at this
women\'s hospital.

Then just as kind of a way to leave you on the key point about
Afghanistan is there\'s hope. This was one of the most beautiful babies
I ever saw. They let me take pictures of these gorgeous babies in this
women\'s hospital, and I just wanted to share that with you because
that\'s kind of the way Afghanistan felt. No matter what we hear on the
news right now, these people are amazing, and the opportunity they have
to overcome a lot and not make the mistakes that we had as they
integrate mental health into primary care is really significant with
their talent and with their hope.

I just wanted to tell you briefly about the International Initiative for
Mental Health Leadership, because this is a significant effort that
Charlie really brought to SAMHSA that I think really has potential for
all of you, and it is really our professional organization for mental
health leaders in the developed world. It\'s just really significant
what they were able to do.

The innovation shared ‑‑ Charlie has really brought the elimination of
seclusion and restraint to these countries. We\'ve talked about mental
health systems transformation. Kathryn Power talked to them. The peer
support and employment programs, the programs for native and indigenous
peoples, it was really amazing. They used these things called exchanges
in open spaces, and when I went to their conference I was going what do
they mean by that? Exchanges are people like you. You would meet your
colleagues in these countries and really see what they do on a daily
basis. It\'s just extraordinary. The open spaces gave everyone an
opportunity to talk about what was really important to them, who had
participated in this conference with their colleagues.

One thing that happened to me, all of a sudden I was in a room with a
bunch of people who do the same kind of work I do in developing
countries, and now we have our own little workgroup. I\'m going to learn
from them really a lot. So that was just truly amazing for me.

But I just wanted to tell you that the whole thing was made possible by
Charlie and his commitment and leadership in this. It\'s been an
extraordinary opportunity for me personally, and I think for all of us
in SAMHSA. We\'ve had amazing help from Wes Clark and his folks on
substance abuse treatment, and I\'m really looking forward to continuing
working with them.

I would go back to Richard Mollica, who Charlie mentioned from the
Harvard program on trauma, for the lessons that I\'ve personally
learned. I know that I\'ve learned from Charlie and I\'ve learned from
Dr. Mollica and others that what you need to do is provide small,
targeted support ‑‑ I wouldn\'t even say dollars ‑‑ support over a long
period of time. The problem in the past with many things that we\'ve
done is we\'ve gone in with a lot of money and we left, and what we\'ve
learned is you just go in with a little bit of money every year and you
sustain the effort. You also go in on a regular basis. You have regular
meetings. You give people things to do. You say, okay, we\'re going to
meet in two weeks, we\'re going to have this meeting in a month, we\'re
going to come back in a year. So you structure the effort so it gives
you a way to do things, a way to accomplish things, and you provide
hope.

Charlie, as I\'ve heard you all say, has left an enormous legacy in this
area, and I\'m really hopeful that we can continue to do it. I don\'t
know, without his leadership it\'s going to be tough, but we\'re going
to try.

I just thank you personally for this, Charlie. Thanks.

(Applause.)

MR. CURIE: Thank you, Winnie.

I think you can see she has a lot of passion. We try to get her more
excited about it.

(Laughter.)

MR. CURIE: But Winnie has just done a tremendous job in bringing focus
and structure around this and the ongoing efforts.

Let me open it up now for our council discussion. Any thoughts,
comments? Barbara?

MS. HUFF: You might know I\'d have to ask this. Winnie, are there
advocacy organized efforts forming?

MS. MITCHELL‑FRABLE: Yes.

MS. HUFF: Yes? All right.

MS. MITCHELL‑FRABLE: And Charlie can tell you about that. We have seen
that be a critical recommendation in both Iraq and, interestingly,
Afghanistan. You know, we made an effort to have a consumer in Cairo. He
was a psychiatrist, but he was also a consumer. So it was really
interesting.

I don\'t know, Charlie, if you want to add anything to that.

MR. CURIE: Clearly, I think where we\'re seeing the impetus for that
occurring is for the International Initiative for Mental Health
Leadership as we partner with them. Again, the United Kingdom is a
partner with us in Iraq, and I\'m anticipating also Afghanistan, and
Italy. We have other partners there as well.

But at the International Initiative for Mental Health Leadership, this
was the third or fourth conference that we\'ve had. We had over 600
people, which is remarkable. I still consider IIMHL a fledgling
organization, that we\'re still at the beginning, but this year really
took hold. I want to say over 80 matches, but we have family members and
consumers as part of that 600. In fact, they\'re developing their own
tracks in terms of sharing among those countries how the consumer and
family movements are ‑‑ how they\'ve developed, how they\'re emerging.
Clearly, that\'s going to be a major part of the discussions as we
continue to work with Iraq and Afghanistan of empowering consumer and
family voices in participation in the policy development process, and
then ultimately in the treatment that occurs.

Any other thoughts, comments or questions? Oh, Kathleen.

MS. SULLIVAN: Winnie, thank you. Did the health workers find themselves
to be security risks? Did they find themselves in danger?

MS. MITCHELL‑FRABLE: Well, as Charlie mentioned, they clearly do.

Charlie, I\'m sorry to tell you this, but there\'s been increased
violence against doctors these past couple of weeks, to the point that
there have been some murders. They haven\'t been just held for ransom.

Dr. Khalili, the cultural attache that I showed you, was the target of a
kidnapping effort, and he and his wife had to flee Iraq with nothing but
the clothes on their backs. So, yes, they\'re in significant danger.

MR. CURIE: It\'s very sobering. When you\'re talking to them and working
with them, it\'s actually hard for us to be able to relate to that when
we hear it, what they\'re up against.

MS. MITCHELL‑FRABLE: The only thing, as I mentioned, was the way I felt
about my children during the sniper episode in Washington, D.C. a couple
of years ago. That\'s the only thing that evoked the kind of terror that
they feel.

MR. CURIE: Other thoughts, comments or questions?

MR. AIONA: I\'m just curious about that.

MR. CURIE: Yes, Duke.

MR. AIONA: Are they a target of attack because the terrorists have
identified them as a key part to rebuilding the country or rebuilding
the community, or is it just because everybody is a target basically?

MR. CURIE: No, I think they\'re strategic targets. I think two things. I
think they are viewed ‑‑ anyone who is helping rebuild the government in
a constructive way is viewed as an enemy of the insurgency. So clearly,
again, the folks we\'re working with are very much engaged with the
health ministry of the current Iraqi government, trying to be
constructive and really build a new future for Iraq.

Secondly, I think it also goes back to the fact that these folks have
means and are viewed as having more of a solid income and way of making
a living than a vast percentage of the Iraqi population. So it makes
them also targets in that arena. I think it\'s both, but probably, based
on what we just heard from Winnie and what we\'re seeing, I think the
fact that they are viewed as part of the establishment of the new
government trying to really make things work and bring stability ‑‑ and
they do represent stability there. I mean, they\'re a professional
cadre. They\'re very excited. Keep in mind that these psychiatrists,
many of them that stayed there and that are in Iraq who are in their 30s
and 40s, they were forced to be officers in Saddam Hussein\'s army.
There was no real civilian or medical doctor workforce. So these folks,
that\'s been their life and professional career. Now they\'re looking
forward to having a civilian professional life and developing that for
themselves and Iraq.

So that\'s been very exciting for them, and they\'re very excited about
democracy. When you meet with them, you become enthused about democracy
all over again because it\'s very precious to them.

MS. SULLIVAN: Charlie, I saw that the World Health Organization was at
the table, but I didn\'t hear ‑‑ should UNICEF, or should there have
been an arm of the United Nations ‑‑ was there representation at the
table, or should there have been?

MS. MITCHELL‑FRABLE: Well, in essence, WHO is the health arm of the
U.N., and we work with WHO in very close collaboration, and when it\'s
appropriate they bring in other entities. We also work with UNODC, the
U.N. Office on Drug Control. So we work very carefully with Geneva and
WHO, and they kind of bring in UNICEF. So they\'re kind of our lead
partner.

MR. CURIE: And they\'re both active in Iraq and Afghanistan as well.

Well, Winnie, thank you very much for the presentation. Thank you for
the discussion.

I believe we\'re ready for a lunch break.

Let me have Toian guide you now. I\'m not going to assert anything right
now.

MS. VAUGHN: We are ready for a lunch break, but the food has not
arrived. So maybe you want to go to the restroom, or there are some
little appetizers in the back. As soon as the food arrives, then we will
distribute the meals.

MR. CURIE: Thank you.

(Whereupon, at 12:15 p.m., the meeting was recessed for lunch, to
reconvene at 1:15 p.m.)

[AFTERNOON SESSION]{.underline} (1:25 p.m.)

MR. CURIE: Let\'s reconvene for the afternoon session. Welcome back,
everybody.

Duke, I know you\'re there as well. Correct?

MR. AIONA: Yes, I am.

MR. CURIE: Great. Thank you for hanging in there with us. That\'s always
challenging teleconference-wise.

MR. AIONA: No. It\'s okay.

MR. CURIE: This afternoon in our session, I think we have a very
interesting session planned. It\'s an opportunity to really focus on a
presidential initiative that SAMHSA has been responsible for
implementing, and that\'s Access to Recovery. We\'re going to be hearing
first from our Director from the Center for Substance Abuse Treatment,
Dr. Westley Clark, the center which is responsible for the
implementation of Access to Recovery for the development of and
implementation of the RFA and, after the awards, the ongoing monitoring
of Access to Recovery.

Then we\'ll be hearing from Tom Kirk, our own advisory member, who is
the Director for Mental Health and Substance Abuse Services for the
State of Connecticut, and ATR was awarded to Connecticut.

Again, I would encourage Ken to share his perspectives from the State of
Washington as well in this process. Ken is a veteran of the beginning
implementations of Access to Recovery as well.

I might mention here at the outset that I want to remind folks ‑‑ and I
shared this yesterday in the hearing that Congressman Souder held
yesterday around methamphetamine treatment and approaches in discussing
Access to Recovery. The President originally proposed \$200 million for
Access to Recovery and came the second year of Access to Recovery at the
\$200 million level and for the third year, asking for \$150 million. I
point that out because Congress appropriated \$100 million each year for
Access to Recovery in the first three-year cycle. Again, I think the
context is many questions have been raised about the fact Access to
Recovery is only in 14 states and one tribal organization. It\'s very
limited. There are 66 states, territories, and tribes that applied. So
there\'s great interest in it. How can we do more?

Again, I want to remind folks that I think we received \$200 million the
first year, and the original plan was the President had made a
commitment to increase substance abuse treatment capacity by close to a
half a billion dollars over a four- to five-year period, and Access to
Recovery and some dollars in the block grant were a way of doing that.
And there have been some increases in the block grant along those lines
as well. But, unfortunately, we didn\'t realize that full amount.

That said, I know there\'s great interest on the part of members of
Congress and others in the field to see the results of Access to
Recovery. Overall, you\'ll be hearing more about the data today. The
data is very encouraging in terms of more people receiving access to
treatment, to care, to recovery and recovery support services.

Again, the future of Access to Recovery is kind of in question right now
if you take a look at the House mark currently where the President\'s
proposed budget was for \$98 million, about \$100 million, to begin a
second cycle of three-year grants. Again, there was a goal set in this
Access to Recovery model, the second one, to give incentive to states to
leverage block grant dollars for vouchers, and I think that whole issue,
again, kind of compounded and complicated people\'s perception of Access
to Recovery.

Ultimately the House mark ended up keeping the money in the SAMHSA
budget, but putting \$75 million in the block grant and setting aside
the \$25 million. And we did have \$25 million set aside in ATR for
methamphetamine exclusively for use of vouchers. They kept the \$25
million for methamphetamine but says it doesn\'t have to be voucherized.
It can be; it doesn\'t have to be. So they really made it more of a
Targeted Capacity Expansion typical grant for us. So the money is there
for treatment capacity, but not in the context of ATR.

So I just kind of lay that out that I think there are concerns that
even, as we find successes with ATR and lessons learned with ATR, there
would remain a question mark whether ATR is going to continue to be as
it has been, as one leg on the stool of financing which uses vouchers.

In any event, I\'m excited about the fact that I think there are a lot
of lessons we can learn from Access to Recovery. I\'m excited about the
fact that for the first time we have funded recovery support services in
a real meaningful way, meaning not just treatment services of treatment
interventions, but helping pay for individuals to access supports and
services, pay for individuals in terms of vocational areas and
educational areas and housing areas and ways of assuring they have the
supports they need to sustain recovery. Again, I think we\'re going to
learn a lot of lessons from that and we have a lot to learn today.

So with that type of background, I\'d like to now turn it over to Dr.
Clark, our Director for CSAT, to discuss SAMHSA\'s Access to Recovery
program. Wes.

DR. CLARK: Thank you, Charlie. I want to commend Charlie for his support
for the Access to Recovery initiative and for leading the effort on this
presidential initiative, which, of course, as he stated, the Congress
approved only \$100 million for this program.

We have discussed ATR before. It is a voucher-based program that
emphasizes consumer choice, accountability, and effectiveness, which fit
very nicely within the SAMHSA paradigm of accountability, capacity, and
effectiveness.

The issue with Access to Recovery is, again, a focus on recovery.
Research shows that providing holistic, community-based support services
enhance treatment outcomes. We recognize that substance abuse disorders
are often chronic, relapsing diseases, and we recognize then we need
something in addition to an acute episode of treatment. Experience shows
that ongoing community support is important to sustaining recovery.
We\'ve learned that lesson not only from the mental health consumer and
HIV peer communities support focus on recovery, but also research on and
lessons learned from nearly 65 years of 12‑step groups and other
self-help organizations in terms of support.

AA would often say if you avoid slippery places, it helps you avoid
relapse. In many cases when I ran an acute substance abuse, a 28-day
program, when I worked for the VA, I would wonder what happened to the
clients on day 29. And then when I ran an intensive outpatient program
and I would see people three, four times a week, Friday would be the
last day I would see them. I would wonder what would happened to them on
Saturday. The key issue is that community support is inextricably linked
to recovery.

As Charlie is fond of pointing out, there are many pathways to recovery.
Treatment helps facilitate. Some people have solo recovery. Others
require medication-assisted treatment, peer-to-peer recovery support
services often facilitate recovery. There is faith-based recovery,
12-step and other community-based recovery, and court and criminal
justice facilitated recovery. It\'s important thing for us to recognize
that there is no cookie cutter that applies to all individuals. In fact,
some people may wind up having a number of these items in their recovery
portfolio that helped to facilitate their recovery. As Charlie pointed
out, you hear people saying, I tried this, it set the stage for that, I
tried something else, and I was able to build on that, and eventually I
arrived at a point where I was in recovery.

In fact, I was in San Francisco doing a conference on chronic
inebriates, which is a small group of people who consume a lot of
resources as a result of their alcohol problem, and they had a little
skit. In the little skit, they had some gentlemen doing the
presentation, and one of the gentlemen, before he went on to do his
particular role, pointed his finger at me and said, I know you. Okay. So
he got up and he announced, I am in recovery. I am seven years in
recovery, and I want to thank Dr. Clark, which was of course me. He
said, 10-15 years ago ‑‑ it\'s been that long ‑‑ Dr. Clark tried to help
me, and I want him to know that even though I did not enter recovery
right away, as a result of his efforts, I have now been clean and sober
for seven years.

In other words, you never know when you have an impact, and the recovery
process is not simply a model where you go into a treatment facility or
you get exposed to a counselor or a psychiatrist or whomever and, bingo,
you\'re recovered. So I was quite impressed by that because, indeed, it
captures the notion that there are many pathways to recovery.

What are recovery support services? They\'re services designed to help
people in recovery and/or their family members and significant others
initiate and/or sustain recovery from alcohol and drug use disorders and
related problems and the consequences by providing social support.

The Access to Recovery program goals were to increase treatment capacity
by expanding access to treatment and support services critical to
recovery; to ensure genuine, free, and independent client choice for
clinical treatment and recovery support services at the appropriate
level of care; and to ensure that assessment, clinical treatment, and
recovery support services funded by ATR are provided pursuant to a
voucher being given to and presented by the client.

So we empower the client by giving the client the ability to purchase
services. That\'s a key issue, and we often talks in terms of recovery
being an individual responsibility or \"this individual needs to get
it,\" but financing actually is not given in such a way that the
individual does have the power to make the decision. Voucher programs
permit that.

The Access to Recovery goal is to increase treatment capacity by
expanding access to recovery. Again, recovery means that I\'m
participating in that process if I\'m the affected individual.

We expect that the administration expects the program to address the
treatment gap in other substance abuse treatment programs, and the
administration is committed to expanding access to care to ensure that
faith-based organizations are utilized. And the administration is
cognizant of the need to intervene and address concerns of fraud and
abuse. It\'s a new program without precedent. This was a bold, new
experiment. We think it has been a successful experiment, but it\'s a
bold, new experiment to reach out and bring an individual who is
affected by alcohol and drugs into a critical period in the
decision-making process.

Community- and faith-based organizations are expected to be participants
in this program as clinical treatment and recovery support service
providers. If we talk about expanding the realm of care, the number of
participants, we need to make sure that we expand the opportunities for
care so that when we empower the individual, there are those entities
within the community which can play a critical role in the recovery of
that person. I saw this when I visited some of the mission programs.

I visited one in Santa Barbara and they were offering all sorts of care.
What they were saying is we can\'t get state funds because we are a
faith-based organization. We handle detox. We handle job placement. We
handle literacy training. We handle skills development, but we are shut
out of state funds and block grant funds, for that matter, because we
are a faith-based organization. I thought, gee, that just seems
unfortunate because, indeed, they were offering a full spectrum of
interventions, interventions that would assist a person.

And I particularly liked their focus on literacy because it reminded me
there\'s an operating assumption, especially in a cognitively oriented
strategy. Many of our treatments are cognitively oriented, keep a
record, keep a log, keep a diary, read the big book, read this, read
that. And it\'s all predicated on one assumption, that you know how to
read, you know how to write. If you can\'t read and you can\'t write, a
lot of the interventions will be lost. So this was a faith-based
organization that says, look, we realize that this is an issue and
we\'re putting something in place to address that, and that was one of
the first times that I had seen that issue addressed so aggressively.

So the summary of ATR requirements include assuring client choice of
service providers; implement a voucher system for clients seeking
substance abuse clinical treatment and/or recovery support services; and
to conduct significant outreach to a wide range of service providers
that previously have not received federal funding, including faith-based
and community providers. Even though this is not direct funding, it
allows the individual to purchase care from providers who traditionally
did not get funding.

Examples of services that could be paid for using the vouchers included
detoxification, which is a traditional service, brief intervention,
group counseling, case management, family services, sober housing,
employment coaching, 12-step groups facilitation, recovery coaching,
spiritual support, traditional healing. This again opens the door for a
wide range of strategies.

Now, as the council knows, ATR grantees are some 14 states and one
tribal organization, the California Rural Indian Health Board. These are
the states, and as Mr. Curie pointed out, we\'ve got Tom Kirk from
Connecticut and Ken Stark from Washington, but the other states are on
this list, as you can see on the slide.

We\'re requiring data. We want the grantees responsible for quarterly
data reporting to SAMHSA, including financial data, performance, and
outcomes data. We have a requirement in this for seven domains. The key
issue is by focusing on outcome measures, we allow the grantees greater
diversity in their choices because the focus is not on did you use this
specific intervention, but as a result of the intervention that you
used, what were the outcomes.

We required some provider-level data. Participating providers will be
reporting GPRA data to the grantee, as well as performance and outcome
data, so that we have from the contact list the client by the provider,
up through the grantee, back to us.

We expect that the grantees are managing their ATR programs based on
performance. The whole focus is outcomes. ATR grantees report financial
and outcomes data to SAMHSA on a regular basis, monthly reports and
quarterly reports. There is considerable targeted technical assistance
to grantees on this issue. Plus, we have site visits and grantee
meetings when necessary. We have an upcoming grantee meeting in July
addressing the next year\'s expectations for ATR.

The GPRA performance and outcome data are collected at baseline, i.e.,
admission to the program; and then every two months during the treatment
episode, that is, between admission and discharge; and then finally
again at discharge. Our hope is to be able to characterize what we\'re
doing in this program.

Let me give you a quick overview of the current state of ATR programs,
where we are now, the status of ATR. For the first time, all grantees
have been able to successfully upload all data through March of this
year. All technical problems related to upload into the Services
Accountability Improvement System have been resolved.

While we have our ATR team here, can the ATR team stand? There\'s Roula.
There\'s Andrea. Anybody else back there at ATR? Well, Andrea Kopstein
is the lead CSAT staff person on ATR. Deepa is our lead SAIS. Is Pat
Roth back there? Did you stand, Pat? Trying to get data from programs,
as many people know, can be, shall we say, an interesting experience,
and the ATR team has worked very closely. The states have been pitching
in to make sure that we get this information so we can tell the story.

The ATR program has exceeded its target of clients served of 50,000
clients by this particular juncture in time. As Mr. Curie pointed out,
for the life of the three-year grant, we expect to see 125,000 clients.
We\'re supposed to see roughly 50,000 clients by this point in time.
However, we\'ve seen over 62,000 served by the program since its
inception. This represents 26 percent more clients than originally
projected. So the key issue is that we are seeing people.

And you get variations and you\'ll see variations in the structure
because we\'re actually dealing with 15 different projects. That\'s
something I\'d like to remind people. 15 different projects. It\'s a
nightmare to try to harmonize data from 15 disparate projects. We\'ve
got an adolescent program over here. We have a criminal justice program
over there. We\'ve got all parties over there. When you say, well, how
are these programs similar, the fact is they are similar based on a few
basic points, and then the similarities disappear.

Over 56 percent of the clients for whom status and discharge data are
available have received recovery support services. As of March 31st, 43
percent of dollars redeemed were redeemed for recovery support services.
So we\'ve got a strategy which in a sense we\'ve pilot-tested with our
RCSP program that we\'ve integrated into the Access to Recovery program,
and we\'re seeing the results of that.

On average, 70 percent of those who use substances were abstinent at
discharge. 31 percent of those unemployed were employed at discharge,
and an average of 62.2 percent of those who were socially not connected
became socially connected by discharge. An average of 81 percent of
those involved in the criminal justice system were not involved at
discharge. An average of 30 percent of those without stable living
became housed by discharge.

So you can see that we are having an impact, particularly in the area of
abstinence and social connectedness. We\'re working to get people
through our efforts employed and housed although, again, each program is
different. So we can\'t say, the program has got to have a major housing
component or a program has got to have a major CJ component. We are
working on our GPRA efforts.

Some people ask, well, what about the faith-based component? As of March
31st, SAIS data indicates about 30 percent of the dollars redeemed for
clinical and recovery support services provided by ATR had been redeemed
by faith-based organizations. That\'s roughly \$48 million.

And faith-based organizations accounted for approximately 21 percent of
all recovery support service providers who have redeemed vouchers.

Faith-based organizations accounted for approximately 33 percent of all
clinical treatment providers who redeemed vouchers. For example, let\'s
just use one faith-based organization example. Teen Challenge providers
are enrolled in 9 of the 15 ATR programs. The total amount of ATR monies
that have gone to this particular faith-based group of providers is
about a half a million dollars.

Again, one of the things the council needs to be aware of, there\'s a
delay in the voucher redemption. So these data are always a little
behind what\'s actually going on because of the reporting delay

But the fact is we have met our target in terms of serving clients.
We\'ve expanded the number of providers. We\'ve expanded the involvement
of community- and faith-based organizations. So we are achieving what it
is that we set out to achieve.

In the start-up months of ATR, CSAT contracted with nine faith-based
liaisons who offered the grantees technical assistance for recruiting
faith-based providers. These efforts made a significant impact on the
program as evidenced by the percentages of faith-based providers that
had redeemed vouchers.

In the upcoming months, CSAT will begin a new contract aimed at
improving clients\' access to faith-based treatment and recovery support
services through the use of faith-based transition coordinators. They
will become available for each grantee to assist in client care,
transition from assessment to treatment or recovery support services,
and other duties such as following up on client referrals. So what we
are attempting to achieve is broadening the strategies that we employ.

Now, some people ask about, well, what about methamphetamine, Dr. Clark?
Tennessee and Wyoming deal with methamphetamine. When they competed for
the grants, they made specific reference to this. But other
jurisdictions are encountering methamphetamine as a part of their
efforts, and so we don\'t want to minimize even though they did not list
methamphetamine as their target. I think Idaho clearly points that out.
A lot of the people that we see suffer from methamphetamine abuse and
dependence.

So let us look at ATR grantee-specific activities. California has client
satisfaction surveys that indicate a high degree of satisfaction with
their particular model, their CARE services. The developed a process to
connect youth in juvenile facilities to recovery support services during
and after incarceration, as you can see from the chart, the target,
which is in yellow, and the clients served, which is in green.

The California Rural Indian Health Board has been enrolling clients and
requesting vouchers online using an updated voucher management system
that significantly reduced the time requirement for these activities.
And recovery support service provides and faith-based organizations have
been solicited in rural areas of the state.

We look at Connecticut. I won\'t dwell on Connecticut. We have Tom Kirk
here who is going to talk about the Connecticut experience. But it\'s
excelling at maximizing the funding resources it\'s received, and the
state is on track with expending its unobligated funds. The program
initiated the matrix model of enhanced cocaine/methamphetamine intensive
outpatient treatment, and CSAT is providing technical assistance to the
state in preparation for this initiative.

Florida continues to conduct aggressive recruitment in the following 10
counties: Charlotte, Collier, Glades, Hendry, Lee, Citrus, Hernando,
Lake, Marion. This recruitment aims to build a more diverse provider
base which will facilitate choice for clients. Florida reports that
expenditures for direct services are continuing to increase, and the
state anticipates hitting its monthly expenditure targets by the end of
the summer of this year.

Idaho has exceeded by 53 percent its target number of clients served.
Residents of many rural communities can now receive services without
traveling long distances outside of their community. Idaho ATR has
facilitated access to culturally sensitive services for Native Americans
and increased access for Hispanic communities.

Illinois is working directly with recovery support services providers to
refer individuals directly into ATR assessment services and has
increased and expedited referrals for recovery support services
providers. The program has restructured its electronic system by turning
off unnecessary functions and adding new functions supportive of ATR.
Providers have been trained on the system and have begun entering their
own data, reporting, and billing.

Louisiana has exceeded its target number of clients served by 38
percent, and it recently added outpatient treatment with buprenorphine
services as another clinical treatment service.

In Missouri, the provider meetings have resulted in a significant
increase in the use of recovery support services vouchers. Joint
meetings with clinical treatment providers and recovery support
providers continue to facilitate cooperative working relationships.

New Jersey will use carryover funds to offer small funding opportunities
to the New Jersey AI community and faith-based providers struggling to
get started or expand services. New Jersey has developed internships for
four undergraduate students to interview clients, collect GPRA data, and
spot-check for completeness and accuracy in collected data.

New Mexico has increased the recovery support service voucher value and
expanded the services offered under the voucher to include housing. A
system-wide case management structure has been implemented to enhance
outreach, retention, and follow-up for ATR clients. In its third year,
the state plans to use innovative strategies for meeting its target
client number.

For Tennessee, through a contract, the University of Memphis is
conducting client satisfaction surveys six months after a person\'s
admission to ATR, and Tennessee has exceeded its target client number by
serving 4,783 clients as of March 31st.

Texas. A brochure of providers contains descriptions of each provider,
hours of operation, languages spoken, religious orientation, if any, and
other information about the program. Texas has conducted training for
all enrolled providers, as well as participating courts.

The State of Washington, which Ken can comment on. One of Washington\'s
ATR counties, Clark County, has recently added two new points of entry,
allowing the program to reach more clients. Washington has established a
strong collaboration with faith-based providers and partners who provide
points of entry, housing, drug-free activities, and many more services.
It has also exceeded its target number of clients.

Wisconsin. The Governor\'s liaison to faith-based organizations and
community organizations held meetings to educate the community about
ATR. Its faith-based Community Advisory Council developed a Web site as
a resource to faith-based organizations, and to encourage new treatment
and recovery support providers, Wisconsin has an open and ongoing
application process.

Wyoming ATR has effectively integrated with existing mental health and
substance abuse providers, thus expanding capacity. And it streamlined
the approval process for new providers.

There are, obviously, ongoing challenges, ongoing support for peer
leaders. There are, of course, ongoing issues of ethics and risk
management. We\'re working with jurisdictions on these issues of
coordination and collaboration with other systems of care. Monitoring
and evaluation. And, of course, as we enter the third year of this
project, it\'s the issue of sustainability. Those will be some of the
themes that we\'ll be discussing at our next meeting.

SAMHSA has been a resource to the grantees. They\'re not out there by
themselves. We\'ve provided technical assistance on screening
assessment, ASAM training and software, ASI training and software,
development of a recovery support service screening instrument, and on
recovery support services in terms of rate-setting, screening for these
services, and eligibility criteria.

We are trying to make sure that we increase faith-based and
community-based organization participation through outreach,
recruitment, and marketing.

We are also providing to our grantees financial management on
expenditure management, the burn rate of the grant, fiscal management,
and of course, the issues of fraud, waste, and abuse, which we have not
had any significant issues of fraud, waste, and abuse, but it\'s always
an ongoing issue in large grants. So we continue to stress the
importance of this.

We\'re providing general technical assistance, in short, to our
grantees, including client follow-up, clinical services, cultural
competence, developing provider networks, GPRA, motivational
interviewing, Native American and Alaska Native issues, performance
incentives, performance management and quality improvement, and other
things that you see on the list on the slide.

ATR in the future. Mr. Curie has made reference to the Choice Incentive
Program and the methamphetamine program. I won\'t dwell on that at
length, given the time. But as we know, the President proposes using
\$70 million for a Choice Incentive Program that would provide up to 25
grant awards of \$1 million to \$5 million to applicant states and
tribal organizations to expand choice through vouchers. The grants would
be up to three years, and it\'s intended to accelerate the progress
achieved by ATR.

Priority to the states that voluntarily commit to using a portion of the
SAPT block grant funds would be prioritized. Grant award recipients
would be able to use up to 30 percent of their award for technical
support to convert their treatment systems to vouchers. And states and
tribal organizations that previously received an ATR grant would be
eligible only if they commit the lesser of 20 percent of the block grant
or \$20 million to vouchers.

Now, again, Mr. Curie pointed out that the CIP program did not fare well
in the House in the full committee. This issue still is on the table.
Our hope is that the CIP program will get some support from the House
when the full House votes, and then also from the Senate. We\'ll just,
obviously, have to wait and see, but the key issue is this \$70 million.

If we do get this program, when the applications come in, applicants
will receive additional points during the review process according to
the proportion of their SAPT block grant dollars and/or other state
funds that they agree to redirect to vouchers. We\'re trying to leverage
funds so that we can make this program even more successful than it has
been.

The funding criteria would align the award size with the size and
complexity of the state, territory, or tribal organizations to be
funded.

We expect outcomes. Applicants will have to identify and commit to
milestones and a three-year goal. Data will be collected documenting
block grant funds that have been redirected toward voucher systems or
other state funding toward the new systems. And the results of the
changed system will be documented through our NOMs.

We are trying to promote innovative drug and alcohol treatment and
recovery through our CIP program, should it be funded, and provide a
wide array of treatment provider options, and introduce into the
substance use disorder treatment system greater accountability and
flexibility.

And Mr. Curie also made reference to the specific methamphetamine
voucher program which would fund up to 10 grants, roughly \$2.5 million
each. The program would focus on applicants from those states where
epidemiologic data and treatment data indicate high methamphetamine
prevalence and treatment prevalence. The state data would be used.
Community Epidemiology Workgroup data would be used, and our NS data
would be used.

Now, the House full committee has supported a program of \$25 million
for methamphetamine. In that program that they\'ve supported, the use of
vouchers is optional. So we\'ll see how that works with the full House
and then the Senate, and then we\'ll, obviously, have to develop
guidelines for grants under this program, should both the House and the
Senate approve of a program and the President signs it.

We\'re going to use the methamphetamine funds to support clinical
treatment, support recovery support services, and increase focus on
participation of community-based and faith-based organizations.

Thank you.

(Applause.)

DR. CLARK: Do you want to let Tom Kirk give his presentation and let Ken
Stark comment, and then I can answer questions?

MS. VAUGHN: Kathleen has a question.

MS. SULLIVAN: It\'s just a quickie because, Wes, I\'ve always wanted to
know this. Natrona, Wyoming and in Appalachia, just explain to me why
the methamphetamine epidemic in those two areas.

DR. CLARK: Well, actually, if you look at the epidemiology of
methamphetamine, it\'s essentially swept across western and midwestern
states. Those jurisdictions just chose to write their applications on
that. Idaho, for instance, did not choose to write its application, but
is providing methamphetamine services, and other jurisdictions are
seeing people with methamphetamine. We can probably do methamphetamine
the next time we have a council meeting, and we can review the
epidemiology of methamphetamine.

Tom.

DR. KIRK: Good afternoon. We are one of the AtoR states. But what I\'d
like to do at the beginning is give you a brief idea why we went after
it, why it fits into our larger vision.

My term as Commissioner began in May of 2000, and prior to that I was
Deputy Commissioner for Addiction Services. One of the things that we
did was that we went to the mental health advocacy community. We went to
the addiction advocacy community, people in recovery, and said, tell us
what the system should look like. Tell us what the values and design of
the system should be. They gave us what we call recovery core values,
and those recovery core values, in terms of programming, direction, and
so on, financing, we\'ve used as a template to measure, if you will,
what we do. So that was one of the pieces.

The second piece is that I\'m very much of the opinion that we should be
thinking of substance abuse and mental health issues as health care, but
I would put quotes around health care, health care in the broadest
sense, and I\'ll tell you why in a minute. So if you come into our
agency, we are a health care service agency. Our prevention services are
geared toward promoting health and recovery and sustained health through
the treatment and recovery support services.

I\'m a psychologist by training. I worked in the addiction area for a
long, long period of time, as well as mental health. Frankly, I think
some of the messages we use, we are responsible for some of the stigma
that is often associated with the field. We use these kinds of terms. We
talk about serious, persistent mental illness and so on. And the basic
message to Joe Q. Public is, doesn\'t anybody get better? And I think we
have to move a different agenda. That\'s why I was particularly
interested in going toward the health care framework, but it also ties
in with why Access to Recovery was very important to us.

If you\'ve seen one state, you\'ve seen one state. If you\'ve heard this
from one state director, you\'ve heard it from one state director. I
think as a field, sometimes as a funder, as well as a service provider,
we are treating a health care condition which requires continuing care
as an acute care model. So as one lady told me, when I get too
functional, I lose my services. So in my view this is the way our system
has been funded, and what we need to do is move it towards something
like this.

Sorry. This is the way it is now. So I go into detox. It\'s a crisis
service. You pay X number of dollars. It\'s relatively expensive. I go
into the hospital. I get through there, and then there\'s a slope. We
don\'t bridge between the two episodes of care. As a result, we have
this type of cyclical piece. Furthermore, if I go to a detox program at
this point of the state and then I discharge and I move to another part
of the state, there\'s no continuity of care. There\'s no one who owns
my care, and that doesn\'t give us good results.

A rule of thumb that I use ‑‑ and it\'s very, very oversimplified, but
we\'ve looked at some of the data. In our system, we were spending
probably 80 percent of our resources on 20 percent of the population.
It\'s high, expensive, inpatient and residential detox types of care.

This is what I was interested in moving us toward. The gaps between the
acute care, between the crises, find services that will link people to
appropriate follow-up care in the community such that we don\'t have
those repeat episodes. So one of the things we had done was we looked
over X number of years of data and said, let me find out those persons
who have gone into detox more than X number of times within three
months. Let me find those persons who have gone into inpatient psych
admissions acute care X number of times within a certain number of
months. Those are very, very significant numbers. Our view was that we
were undertreating or possibly poorly treating those folks and we wanted
to find ways to give us more effective responses.

As Dr. Clark mentioned, many paths to recovery. Some people can have a
substance abuse issue, never went to formal treatment, whether it\'s a
spiritual community, whatever the avenue is, but there are any number of
people who never went into treatment but they\'re in a path toward
recovery.

The overall, single overarching goal of our agency is toward what I call
a value-driven recovery-oriented system. \"Value,\" as used in this
term, is not things like honesty and faithfulness and all that sort of
stuff. \"Value-driven\" means the highest quality of care at the most
reasonable cost. So when we look at services and someone comes in and
says, I want to add a new service, my question to them is, show me the
value added that\'s going to come from this particular service as
compared to just throwing money at an issue. So there\'s a strong
quality component. Are we as sophisticated in that as we would like to
be? No, but that\'s part of the vision.

The recovery-oriented. My view of recovery orientation is I am
responsible for my own recovery. I\'ve managed my own recovery. It is a
process. How I handle that is my responsibility. My responsibility as a
funder or as a provider of service is to offer the person in recovery
the tools that they can use to move on and stay in recovery.

The collaborative tools. Collaborative tools means partnerships with the
recovery community, partnerships with other state agencies, partnerships
with collaborative funding sources. Those are the three drivers that
support our overall strategic goal.

My point is to us AtoR is not just a program. We\'re not just interested
in chasing dollars to support services unless they fit into the larger
vision. So the major focus has been what I tell the staff working on
this: tell me how we can use AtoR to mesh it into the rest of the
service system based upon the things that we learn from that. So it fits
in our overarching goal. Recovery or in the service system, AtoR is
supposed to drive that.

The second thing was building on previous infrastructure types of
activities. One advantage we had was that there\'s a carve-out of
dollars from the social service agency, something called a general
assistance program. It\'s about a \$70 million pool of funds for persons
who receive general assistance, and we\'re responsible for the
behavioral health care. One of the big advantages ‑‑ what does that have
to do with Access to Recovery? Built into that model is something known
as the Administrative Service Organization that we fund. They do the
authorizations. They pay the bills and other kinds of things based upon
our standards. That clearly gave us a step up when we moved into Access
to Recovery.

The Connecticut system, as far as substance abuse, oversimplified, maybe
165 agencies of one type or another around the state. The state is
really divided into five regions. We don\'t have counties. We have 3.5
million people. So when we went into the AtoR, we said, we will fund a
single network in each of the five regions, and we did it based upon an
RFP. So these providers had to come together, sign agreements, and
clearly show their options, in terms of choice fitting in with the
voucher approach, and the other kinds of things in accord with AtoR. Two
of the provider networks that came through we would not accept their
proposal at first glance. They didn\'t seem to reinforce choice. They
didn\'t seem to have some of the qualifications. We said we will put it
back out to bid unless you can come up with these other qualifications,
and they eventually did.

Part of the reason why I mention that is that as we go through funding
over the next couple years, we\'re being mandated by our legislature to
take our entire service system and rebid it. This may well give us the
opportunity to use AtoR principles as a driving force and rebidding of
the service system.

Five networks. Notice 135 recovery providers, including peer and
faith-based, as well as the clinical. One lead agency in each of those
networks, if you will, owned the network, and they had responsibility
for management, if you will, of the overall piece.

One of the things we did was that we looked at what are the agencies or
portals where the folks are that we would like to engage, particularly
those who are not in the service system. They\'re earlier in their
substance use and we would like to reach them. So we identified these X
number of agencies.

I particularly would like to have you look at the DMHAS-funded Outreach
& Engagement Urban Initiatives, particular in the New Haven area, which
is what you call the south-central area. It\'s in the other areas also.
There\'s very strong outreach and engagement efforts for the chronic
homeless. These are persons sleeping under bridges and all those sorts
of things. They are heavy users. They are heavy users of emergency
departments and other types of services. We already fund the case
management services and outreach for them, but we wanted to bring to
them types of services, recovery support, which would maybe move them
into stable housing, move them into other kinds of services which would
have sustained value.

Clinical services, self-explanatory in terms of the range, the usual
types of pieces.

Brief treatment was really something new for us. I know in some other
states it\'s much more the rule, but we\'re particularly interested in
trying to get to the college population who is early-stage use, the EDs,
emergency departments also, where there\'s earlier-stage substance
abuse. Most of the others are fairly part of our usual, but we wanted to
put a greater emphasis on them.

You\'ll notice here no residential treatment was part of our clinical
services. Why? Because our funding sources through other funding sources
already supported that particular type of approach.

Recovery support services. Self-explanatory, but let me give you some
more specific examples. Transportation. We\'re talking about folks who
any number may not have transportation. They can\'t get to various kinds
of appointments. They don\'t have the resources to go for employment
opportunities. They don\'t have resources to buy tools and so on.
Transportation, housing, vocational/educational services and those basic
needs were very, very important pieces. I\'ll give you an example. It\'s
not evidence-based, but it\'s anecdotal. But it struck me as extremely
important.

One of the things that our director of research did in looking at women
with children and coming into care was that she noticed that women with
children coming into care, in late August and September, the admissions
dropped down. Why would that be? Kids are going to school. One of the
things that they built into that particular research project was buying
a backpack for the child, buying a decent set of clothes to go to
school. Those two things were more important to those women than telling
them that they could have an appointment next Tuesday for services. Were
they in services then? No. Where they identified for services? Yes. That
type of approach, what might be called a recovery support service, was
more meaningful to those persons than, if you will, treatment on demand.

So we played off of that. So food, clothing, personal care. You get a
voucher. If I was getting a voucher, it would come from a provider. I
would go to my provider. They would say that I would get a voucher for
food or clothing or personal care. I would be told to come on Tuesday
between 1:00 and 4:00 to pick up the voucher. Literally, it\'s a real
thing. I\'d take that voucher to vendors that we had pre-authorized to
provide these things, Target, all the bigger stores. I go in with my
voucher for clothing, for example, which was worth, I think, 50 bucks. I
could get one of those one time a year. I present the voucher, buy the
clothing that I needed. That vendor then takes the receipt for the
purchase tied to the voucher and sends it to our administrative
services. They get paid for that. So that\'s the way we control it. The
personal care items the same way.

Faith-based services, peer-based services. The faith-based services ‑‑
my own point of view ‑‑ were one of the most significant ‑‑ not so much
the services. The faith-based community was one of the most significant
sources of new persons coming into services as compared to our usual
system. Sometimes it was because my wife may have said to her spiritual
leader, he has to get into care, and the route came through that. For
other people, whatever the reason was, but it was an extremely important
part in reaching a whole new group of people that we had not reached
before.

Peer-based services in Connecticut is a very strong recovery community.
Some of it falls under something known as the Connecticut Community for
Addiction Recovery, as well as the larger group. They are great in terms
of mentoring. They are great in terms of community types of services.
They clearly say we are not in the treatment business. We do not want to
be in the treatment business. But those particular services are critical
to the sustained recovery. Notice two-thirds of all of our money in
Access to Recovery goes to the recovery support services, not to the
clinical services.

If you can read this from where you are, what are recovery support
services? It\'s an important piece. There\'s another slide that probably
gives you a better definition. But it goes back to, again, my view of
recovery. If I have a substance abuse disorder, it is the provider\'s
responsibility to help to decrease the symptoms, to put the symptoms in
remission so I don\'t use. But in addition to that, it\'s also their
responsibility to offer me the opportunity for things that will sustain
my recovery. We call those recovery support services. The recovery
community calls it recovery capital. We\'ll come back to that in a
minute. Very important.

Bill White, recovery capital. \"The quantity and quality of both
internal and external resources that a person can bring to bear on the
initiation and maintenance of recovery.\"

Natural recovery, natural supports. In the recovery community, the
12-step recovery community, what\'s one of the most important pieces?
Giving back. From the Bill White point of view and from our point of
view, giving back earns recovery capital. It builds up recovery capital.
It furthermore, reinforces the person\'s self-worth.

Look at these examples. Here is probably the one slide that I would say
pay particular attention to because it demonstrates the efficacy and the
true value of recovery support services. Child care transportation. The
lady cannot come to care because of what\'s going on in her life. As one
lady told me when she was in an intensive outpatient program, she says,
I like the program, but you need to understand my life is so
dysfunctional back where I live and trying to get here, I simply can\'t
fit this into my life. So providing child care, transportation to get
her from point A to point B is extremely important. That was a personal
barrier, an environmental barrier to her coming into care and staying.

Participation in the recovery community. Connecting people to treatment,
12-step, and other mutual support/recovery-oriented groups. There is a
group in Connecticut I mentioned, CCAR, that in the Willimantic area, on
Main Street, Willimantic, there\'s something called the Recovery
Community Center. People go to the Recovery Community Center, family
members and others, a variety of things related to how to fill out job
applications, putting together resumes, and so on, all the kinds of
things. But in addition to that, there\'s a whole social component
that\'s built into it. When you look at the NOMs or other things, being
reintegrated with the community is an extremely important piece. That
builds into that. A person\'s recovery capital, giving back to the
community and gaining employment, represents an energy that takes its
place after the formal treatment is no longer there.

Overall, over 10,000 people unduplicated were served through the first
two years. I guess we\'re about a month or so away from the first piece.
Year 1 total, a total of 106 people. I would imagine if you talk to some
of the other AtoR states, to implement such a major, major system change
in the way we provided services is, in the words of one of my staff, a
megillah. And getting it straight from an implementation point of view
so that it\'s well managed was probably the most significant piece in
the first year. So I\'m sure from the Feds\' point of view, you\'re
moving too slow. You\'ve got to get it going. Well, the reality was if
you want it done right, you\'ve just got to work with us and help us to
get through this. We continue to fine-tune, if you will. Sometimes it\'s
more than a fine-tune.

Year 2, after only having 106 in the first year, we moved up to 10,000
in the second year. I think our goal, according to the grant proposal,
is something like 16,500, and we would expect to meet that by the end of
the third year.

75,000 service level. That\'s not 75,000 different people. You\'ll see
in some of the vignettes about \$10 million put into claims.

These are not data directly related to AtoR. They\'re from another
piece, but I offer it to you because it\'s one of those examples of why
do we pay attention to housing and employment. The housing piece here,
if you notice ‑‑ I can\'t read it, but supportive housing that we have
in Connecticut where good supportive housing decreases the inpatient
mental health and substance abuse costs, increases employment. Good
return on investment.

Why pay attention to vocational types of services? Another piece of the
study we had done. Give people vocational training, you double the rate
of employment among them. Is that part of the usual substance abuse
clinical picture? No, at least not what I\'m used to. So investing in
that particular piece is one of those things that will decrease the
likelihood of those acute care episodes or high repeat admissions.

Let me give you some examples of what has been done. York Correctional
Institute is one of the women\'s prison facilities in Connecticut. What
happens here is that we have a couple case managers who are part of
Access to Recovery that literally go into York and meet with the women.
So they\'re up there a couple days a week.

So this is one particular lady that they saw. This is a real example.
The name is not real. So they saw her a couple months before she was
supposed to go. In concert with the correctional staff, they identified
what she needed. In accord with the choice, you can go to this
particular program; you can go to this particular program. Those
programs were not there to market, if you will. These are the two
programs. We\'re not recommending one over the other.

She says, well, I can\'t go back to my usual home environment. I need a
housing situation. So we will give her up to two months of housing
support when she first comes out. The other piece is food, clothing,
personal care items, bus passes, and she goes to the IOP program. It\'s
a wraparound type of approach, clinical as appropriate, where it\'s not
being funded by other sources, wraparound the other services, but she
walks out of York not with a pass in her hand, but she knows exactly
where she\'s going to go, how she\'s going to get there. She\'s got the
transportation. And that in our judgment not only promotes access to
care, but also effective engagement care.

Judicial branch. History of substance abuse. Wanted to return to his
work as an electrical contractor. I think this was a situation where he
was already in actual treatment, and we funded that from another source.
But what he needed was equipment to go back or tools to go back to his
trade. That\'s a recovery support service.

Another lady, a non-AtoR. She was getting her treatment from other
funding sources we had. She was interested in classes, going back to Dr.
Clark\'s piece that some of these types of treatment,
cognitive-behavioral approaches, if you can\'t read, if you can\'t
write, some of these types of things, it\'s a short circuit to say the
least.

Frank. Faith-based men\'s retreat. This particular individual had more
of a spiritual orientation. That\'s what he wanted to choose. So here
again, options were given to him.

The last lady. I think she was getting her services already in the
system from other funding sources. Her treatment was being funded by the
general assistance funds. So whenever she was in outpatient, whatever
the care was, it was already being taken care of. What she wanted was
vocational types of services.

What are the challenges? Real quickly. The administrative infrastructure
tied up with this is a megillah. And we\'ve gone through the first two
years, and even with all the infrastructure that we had built into
providers, it still was a major, major piece.

The voucher program. The voucher program for us was probably easier than
some other states because we already were using a voucher type of
approach in something known as the Basic Needs Program as part of
general assistance. So if you were a general assistance eligible
candidate, which dollars we had set aside, we were used to providing
some money for housing, we\'re used to providing to some money from
other kinds of pieces for those persons. This gave us an opportunity to
really amp it up to a totally different level. So in other states where
you didn\'t have a provider system or a state agency that had some of
that infrastructure, it was much more of a challenge.

Grassroots organizations, faith-based. The paperwork, GPRA, and that
type of stuff for these folks was a whole different ball game. They were
not used to billing for services, and this was a challenge for them.

Some of the lessons learned. Self-evident. System change. Recovery
support services, building infrastructure, getting the data that we
want. So we\'ve invested quite heavily in technical assistance to
particularly the faith-based community. You cannot get the dollars
unless you go through the training. We didn\'t do that in the beginning
and that was our mistake. Now we\'ve gone through a whole
recertification process of all of our providers, and they have to get
that as part of that.

Some recovery support service providers over-extended themselves. As far
as they were concerned, these dollars were going to be forever. We think
they got themselves in a situation where, God help us, when the recovery
support dollars are not there and they can\'t pay their mortgage. But
we\'ll see how that turns out.

Impact. Broaden the clinical care system by the pieces we just
mentioned. Recovery support services, much broader. Non-traditional
provider base.

Third and fourth were probably the most important, at least from my
perspective. It offers us the opportunity to take AtoR and some of the
principles that are built into that and infrastructures and look at the
rest of our service system that\'s funded through GA, look at the rest
of the service systems funded through grant funds, and see how the three
of them can be matched. So as we go to the next stage and the question
is, well, what\'s going to happen after you run out of AtoR dollars, we
are looking at how the same types of processes and procedures and so on
could be applied to some parts of our block grant, some parts of our
general assistance dollars to make more sense, not to replace the
dollars so much as play off of the things that effectively engage people
in care and decrease this high volume of readmissions to care.

Improve the continuity of the care. Let me give you one example of that
last one here. It\'s a provider in Hartford that runs a detox program. I
think he\'s got a 20-bed program. He was complaining about relatively
low utilization because our contracts require a certain level of
utilization, and there were lots of reasons why. We said, okay, let\'s
load you up, the whole Hartford region. We will provide 24/7 access by
phone. Somebody can call us and say, I need care. Secondly, we will
provide transportation as part of it. Thirdly, there was a couple of
other pieces. We also focused on the high volume readmissions into that
detox program. Without changing the total number of beds that he had in
his program the year after we implemented those recovery support
services, he had a 50 percent increase in the number of people being
admitted to the program.

Why did that occur? Because those people of the high-volume
readmissions, we tied them up with what we now call recovery support
services. They were not going back. That gave us a better investment in
our dollar from our point of view. We\'ve maximized the capacity of the
system without actually putting in new dollars.

What I call the challenge of all this is to move people into a recovery
zone. We had the conversation before about ‑‑ I think Dr. Gary mentioned
this. Our view of recovery is not necessarily equivalent to cure. We\'re
not saying recovery results in a cure. What we\'re saying is that
recovery moves the person in a stage of their life where they can manage
their disorder despite the condition of the disorder. Some people then
have difficulty with that. So my view is that the challenge is to keep
the person within a recovery zone.

Let me give one other example. A couple in the New Haven area, married,
five years into recovery or thereabouts. Their child died, the infant.
Their first child died. Devastating, devastating effect on them. Part of
the stress of that, frankly, was that their finances, their life simply
was falling apart. The recovery support part in terms of housing support
was critical to them to keep them in their recovery, so to speak, to
keep them in the recovery zone. So despite the enormity of having lost
an infant and the effect on that, their first child, providing the
recovery support so they did not lose their house was an extremely
important piece. You call that a relapse prevention strategy. We see it
in that fashion.

Next steps. We are recredentialling all of our service providers,
particularly those from the faith community, paying attention to the
points that we mentioned here.

We are looking at possibly using the network approach as the basic
framework for the other funding sources that we use in our system.
We\'ll see whether that will work out.

A very important part is the third one. Charlie has mentioned that.
Clearly, Dr. Clark. Does this represent a cost effective model? So one
of the questions I ask my folks is that this recovery support services
seems to represent a good investment. Does it represent a good
investment over a longer period of time, or are we simply just moving
dollars from one side of the table to the other? So we\'re working with
some folks out of Yale to take a look at the cost model that\'s
associated.

The last piece, expanding recovery support services into other funding
sources. Some other options here that come back to us.

So that\'s what it\'s about, but as I said, if you\'ve seen one state,
you\'ve seen one state. I\'m sure Ken can add some points.

The enormity of the challenge from an implementation point of view is an
extraordinary one. But from our point of view, if those efforts can
result in someone not going back into high-volume repeat admissions with
whatever the care is ‑‑ we use the example if you or I had a family
member that was in inpatient acute stays for a supposedly psychiatric
condition five times in six months, or if you had a family member that
was into a detox program for X number of times within three or four
months, we would be going to whoever the health care provider is. At
least I would be. I would be raising holy hell. What is it we\'re
missing? Why does this person keep going into the hospital? It\'s not
that the care is ineffective or inappropriate as much as it is we must
have been missing something. And our view is that tying these recovery
support services to it, number one, results in a stabilization of that,
and instead of paying \$600-\$700 a day for an inpatient hospital bed or
\$300 a day for a detox bed, I\'ll take \$50 of that or these others,
tie it to the recovery support services, and we have fewer readmissions.

Thank you for your attention.

(Applause.)

MR. CURIE: Thanks so much, Tom, and thank you, Wes.

I just wanted to say I think we can all recognize and see how Tom Kirk
is just exceptional at operationalized recovery. What he\'s done with
Access to Recovery in Connecticut I think is profound. I\'m going to ask
in a moment Ken to reflect and make some comments based on his
experience in Washington State. But I just want to say, Tom, thank you
for what you\'ve done there. I think the presentation really gets at
what was envisioned and some of the very things the President was
looking for in some of the discussions early on in terms of how do you
truly operationalize recovery, make access to recovery real for
people\'s lives, not just access to another program, but truly impacting
all aspects of one\'s life.

I also want to just stress real quickly that I appreciate what you had
to say about the implementation of ATR and, probably for the record,
just stress that I know on SAMHSA\'s part, we tried over and over and
over and over again to clarify with a range of other federal agencies
and offices the notion of implementing a voucher program, especially if
you didn\'t have the infrastructure in place, was going to take quite a
bit of time and focus that first year. And while there were targets set
and it was anticipated that 50,000 individuals a year could be served
with Access to Recovery, based on \$100 million, the reason we came up
with a three-year goal of 125,750 was we were able to make the case that
no one should anticipate a voucher being even issued in the first six
months in any state. Some states did get some issued in the first six
months, but the first year would be a very low year because of what you
described. I appreciate you pointing that out. I do think it\'s
something we have to stress again even now over and over.

I am pleased to say OMB is one office that understands it and gets it.
So that helps us out tremendously. I won\'t mention any other offices.
But I am pleased that OMB understands it.

And actually ONDCP came out with a very positive letter about Access to
Recovery, and I appreciate it. They did their own site visits, came back
I think more impressed than they thought they were going to be. I know
Connecticut and Washington absolutely got visits in that process. So I
appreciate their, what I consider, fairly objective opinion going out
because they weren\'t really going out to prove that it was good or bad.
They just wanted to see what was there. So ONDCP on Access to Recovery
came through.

So, again, the data that\'s coming in now looks very promising overall.

Ken, I\'d like to give you a few minutes to just reflect and share your
perspective.

DR. STARK: Well, I\'ll try to keep it brief, and I will keep it brief. I
won\'t try.

I think Tom covered it in a very comprehensive and clear way. Even
though each state is truly different, there were some commonalities
among the states relative to the concern on the administrative structure
to be able to carry out a voucher-based program, as you already
mentioned, Charlie, and as Tom stated quite clearly.

In Washington State, because much of the money from the state outside of
residential treatment goes from the state through counties and/or
tribes, we have a second level governmental structure that we also had
to deal with when passing money down to direct service providers.
Governments are typically used to things like contracts and requests for
proposals and those kinds of things. That\'s what generally keeps them
out of trouble around ethics issues and around abuse and fraud or at
least the perception of abuse and fraud.

And a voucher program created a whole new opportunity, if you will, one
that I think on the one hand most states and their local sub-state
agencies were interested in, but also one that they were challenged with
through their contracts offices, their prosecuting attorneys, and other
legal folks that had some worries about how are you going to do this,
how are you going to keep control, how are you going to ensure
accountability, and also just having the staffing to be able to change
the systems on both your billing and payment structure mechanisms.

That aside, I think people in Washington State were truly excited about
seeing the ATR money as an opportunity for more flexibility than we had
ever seen before, the kind of flexibility we would hope for the future
for the Performance Partnership and block grant. But that will be a
challenge to get there, but we would hope that we could eventually see
that kind of flexibility in the block grant.

So in Washington State\'s mind, we saw this ATR as twofold: one, to be
able to fill some of the treatment gap where we had those major gaps;
and two, to be able to provide those services that essentially could be
recovery support services or, put another way, relapse prevention kinds
of services, services that could, in fact, help people who started
treatment complete treatment, and two, those that completed treatment to
stay out of treatment in the future and retain their recovery.

The second year, the State of Washington actually got a bunch of new
money for treatment expansion. So we shifted the focus of what we saw
ATR for, and it continued to be the relapse prevention and keeping
people in treatment and spending a little bit of the money on treatment.
But it became a major focus for doing outreach, looking at providing
recovery support services in the community even before people got into
treatment and then using that intervention and engagement as a mechanism
for those that either wanted to or needed to to go ahead and go into
other treatment that was funded by the new money. So it filled a lot of
gaps.

We used it for a ton of unique things, things that might raise eyebrows
in some people\'s minds if they didn\'t understand the need for recovery
support services. We used it for one individual to fix his car. It was
cheaper to spend the money to fix his car so he could commute back and
forth to his treatment provider and other services than it was to pay
for bus service and that sort of thing.

In another case, a person had a bad, bad toothache and needed some
dental work done and wasn\'t eligible for any of the other public
programs, and getting that dental work done was a major priority. I
mean, you and I both know if you have a major toothache, you\'re not
going to be able to benefit from treatment or any other recovery support
service. You\'re going to be focused on that pain. So getting that
service was something that helped this individual stay focused on the
rest of his recovery plan.

And, of course, we used it for some child care and the traditional
transportation and employment and some transitional housing. Those are
very, very important issues.

But the main thing that Access to Recovery provided was choice, as you
talked about, Charlie, choice that wouldn\'t otherwise have been, in
many cases, available through traditional funding sources, although in
some cases I think the other thing we have to be careful of is to not
take the government source and fund something that other people are
already providing and now, all of a sudden, they see money available. So
they stop providing that and then take this money. And that\'s a danger.
That\'s always a danger. So you\'ve got to pay attention to that.

But having increased flexibility among all of the fund sources would
certainly be a desire of, I think, anybody administering dollars. I
worry about the loss of ATR if it goes away in the future, and I assume
it probably will. I hope that as it goes away, other fund sources get
more flexible to be able to continue some of those services.

MR. CURIE: Thank you, Ken, and I appreciate your caution at the end. I
find myself wondering very much now will this first three years be all
we see of ATR. If that\'s the case, then I think what we need to do is
learn lessons.

Tom, I appreciated your mentioning the evaluating aspect of really
taking a look at the efficacy and cost effectiveness of recovery support
services. I think as we talk about certain levels, I think we\'re
finding investing dollars in those areas very well may be more cost
effective than what our regulations allow in other kinds of situations
in terms of getting results. I know it\'s thinking out of the box. I
know it makes people who are traditional auditors maybe a little fearful
in terms of should \"treatment program\" dollars be spent on things like
car repair or equipment for electricians. On the other hand, ATR is
going to give us the opportunity to evaluate that and determine these
may be shorter pathways to actually one\'s attaining and sustaining
recovery because we truly are helping them achieve the goals they need
to prevent relapse and to attain it. I think that\'s an exciting feature
that\'s there.

I guess I would also encourage constituency groups, SAMHSA, the advisory
council to really keep its eye on Access to Recovery, not forget Access
to Recovery, advocate. I think there\'s openness on the part of Congress
as I talk to members of Congress who are very interested in seeing the
outcomes of ATR. I know Chairman Regula of our appropriations
subcommittee has made no secret. He talks publicly about the fact he
doesn\'t like vouchers and he\'s open about that. Though, even at that,
he still has supported \$100 million for ATR for three years. His
comment has been let\'s see what the data tells us, what we learn. It
may be a very good thing. And I think that\'s reasonable, and I think
it\'s important for us to listen carefully to that type of feedback and
really take the outcome data from ATR and see what we can learn and
apply and the issue of where do we need further flexibility.

Let me open it up for council discussion, questions, or feedback.
Barbara?

MS. HUFF: Hopefully, I didn\'t just miss this along the way, but is
there a comprehensive evaluation that goes with this that somebody is
contracted to do, or is everybody doing their own evaluation?

MR. CURIE: Wes?

DR. CLARK: There was no comprehensive evaluation planned for ATR. We did
ask for some funds in \'07 to do an evaluation, but it wasn\'t built
into the original program. We\'re using our GPRA data to monitor, and in
a sense, the GPRA data becomes a tool for evaluation, but not in the
classic evaluation context.

MR. CURIE: The other thing I might mention is ATR really is our first
treatment program that we operationalized national outcome measures,
along with the GPRA data, the 10 domains. So that will be a form of
evaluation in terms of are people really attaining and sustaining
recovery as defined by those 10 domains.

But Wes is right. In terms of comprehensive evaluation, we look to \'07.
As we looked at the second cohort of ATR, we actually had proposed \$3
million of the dollars to be set aside for that type of evaluation.
Again, that\'s not realized at this point in the House mark.

Ken.

DR. STARK: Well, one of the things I would mention ‑‑ and it sounds like
Tom and Connecticut are looking at the same thing ‑‑ is at some point in
Washington State, as Washington State does with virtually all of its
programs, they will be looking at outcomes, comparing administrative
databases and trying to look at these consumers who received services
through Access to Recovery to similar clients who didn\'t receive the
recovery support services and see what the difference in outcomes are
relative to arrests and relative to hospital emergency room recycling
and associated costs and employment. How comprehensive that evaluation
will be will be dependent upon the resources that the state has at the
time.

But clearly, Washington State will be looking at those kinds of outcomes
to see whether this makes a difference because the other issue that
Washington will face, as will Connecticut and the other states, and the
rural Indian tribal program in California, is if they are going to
sustain any of these services, we\'re going to have to be able to
justify that.

MS. HUFF: I know.

DR. STARK: Nowadays, you don\'t justify it based on popularity. You
justify it based on cost effectiveness or value as Tom referred to
earlier in terms of being that nexus with quality and cost.

DR. KIRK: Barbara, one of the things that we\'ve focused upon is what we
call continuity of care, and by that I mean that a person discharges out
of, let\'s say, a detox program. How long before they\'re hooked up with
the next level of care? We had done some data separately from Access to
Recovery that demonstrated that if the person was admitted or linked to
the next level of care within 7 to 10 days of discharge from that, the
results in terms of decreased readmission to that instability were
extraordinary.

So, let\'s say from our evaluation point of view, one of the things we
would be looking at ‑‑ I didn\'t go into it, but on the housing piece,
there are four different levels of housing that we supported. One of
them would be what we call a recovery house where I\'m leaving the detox
program and I can\'t get a residential bed for two weeks. I go to the
recovery house, which is a little bit more peer and light staff. It\'s
not a treatment program. And I stay there in a stable, drug-free
setting, and then I can go to my residential treatment program two weeks
from now.

Those recovery house beds cost something like ‑‑ I don\'t know ‑‑ \$28 a
day. That promotes continuity of care because if you didn\'t have that,
I\'m going to get readmitted to detox within a relatively short period
of time. So it\'s the cost/benefit type of approach that I think we need
to make sure we pay attention, as well as quality of life.

MR. CURIE: Thank you.

Any other questions? Faye.

DR. GARY: I wanted to just say thank you for these very, very actually
inspiring and hopeful kinds of programs that are in place. I\'m most
appreciative for that.

My question is I didn\'t hear much discussion about the overlap between
mental health, substance abuse, and forensics, especially given the fact
that many people who are very poor and underserved might be in jails and
in prisons. Is there any way that you have access to those populations,
or when those populations are discharged from prisons or jails, how can
they access your service? So it\'s either way. Do you go to the jails,
prisons? I\'m talking about juvenile centers as well as for adult
services.

I know one of the major concerns is that when people are discharged from
prisons and jails, who have substance abuse problems, they frequently
relapse and get involved too. So I\'m just wondering how that comes full
circle.

DR. KIRK: I\'m glad you brought it up because that\'s what I forgot to
mention. The largest pool of referrals into Access to Recovery for us
are from corrections and probation, the criminal justice system. One of
those levels of housing, the one we call Recovery House, is particularly
geared toward persons who have special needs, i.e., could be special
medical needs, criminal justice involvement, and need a different level
of supervision.

Furthermore, in Hartford, there\'s something known as the Hartford
Community Court, and the court is run by the judge who operated the
first drug court in Connecticut, Judge Simone. We located a person who
would be an outreach person for Access to Recovery in his court and said
we were going to give him one day. He now has him there three days a
week. These are folks with nuisance kinds of offenses, often with
co-occurring mental health and substance abuse issues. So I think the
clearest answer to your question is that that\'s probably more of a
focus in our portals than any other areas.

Part of that ties to a larger agenda in Connecticut that Connecticut
decided they were not going to build any new prisons. So we went through
this spending billions of dollars on prisons. So over the last three
years, through the legislature, there\'s something known as the
Prison/Jail Overcrowding Commission. Maybe as a result of that,
Connecticut has been in the top three in the nation within the last
couple years in decreases in its prison population, but some of it\'s
based upon diversion and some of it\'s based upon what some people call
\"back door.\" So this was consistent from a policy point of view with a
focus on those particular populations.

Can we do better? Yes. If I was going to express a disappointment, where
we really have not been able to have as much inroad as we\'d like is
actually the child welfare system, and I\'m not sure why. I don\'t know
whether it\'s because if the referral comes from the Department of
Children and Families through a person, that somehow that just has such
a stigma to it. I don\'t want your services if it\'s coming from DCF.
But probation, corrections, parole have actually been the largest
sources of our referrals, but our juvenile population is not part of the
mix at this point in time.

MR. CURIE: Ken.

DR. STARK: I would say that\'s historic in virtually almost all of the
alcohol-drug programs regardless of fund source, whether it\'s ATR or
otherwise. Even if you don\'t target that population group, those
referral sources target you if they know you have resources. So you\'ll
get a lot of them. As Tom said, does that solve the problem? No, because
we never get enough money to reduce or eliminate the gap to the extent
that we would like to.

But clearly, I don\'t think you can find any alcohol-drug programs
across the country on the public sector side that won\'t have criminal
justice as one of its major, if not the major referral source.

Referring to ATR in Washington State, we actually targeted the child
welfare system as part of our population group in that grant, as I
recall, when we first wrote it. I got to tell you that is a tough nut to
crack. The child welfare system is very, very difficult to work with for
a variety of reasons, not the least of which are the pressures around
lawsuits and litigation on child welfare to either make a darned
decision and put the child in foster care or reunify in a short period
of time, and that short period of time is not always consistent with the
faith that people have in people getting into recovery.

And this being a chronic, relapsing condition, I think that\'s one of
the ‑‑ Tom, again, alluded to this in his presentation. We tend to
stigmatize ourselves. Although addictions are, in fact, a lifelong
condition and recovery is lifelong, and as I\'ve heard Tom say before,
treatment is a point in time, but sometimes when we say this is a
chronic, relapsing condition, we take all the faith out of anybody
outside of our system believing that a referral to us is not a risk. So
I think that\'s the biggest challenge we have with our child welfare
system, whereas the criminal justice is desperate for resources.
They\'ll refer anybody to anybody. It\'s a very different situation.

MR. CURIE: Wes, and then Barbara.

DR. CLARK: I just wanted to point out that we have Texas and California
and Wyoming that are involved in either the criminal justice system or
juvenile justice system as grantees. As a larger number, when we look at
the referral source for substance abuse treatment, as Ken pointed out,
roughly 50 percent of the people who are referred for methamphetamine
treatment to the substance abuse treatment delivery system come from the
criminal justice system. So in the aggregate for all substances, the
criminal justice system is the largest point of referral. So as Ken
pointed out, there\'s a well established partnership and relationship.
The only question is availability of services.

MR. CURIE: Ken, and then Barbara.

DR. STARK: This is not related to ATR, but I want to throw it in because
I know we\'re about ready to leave. It\'s related to the medication
that\'s out there that\'s being promoted by some folks called Premeda.
Because there are some fairly well-known, nationally recognized folks
who have gotten into promoting this treatment approach and promoting it
strongly with legislatures and drug courts and others around the
country, I think it\'s really, really important that SAMHSA take a look
at the evidence-based practice data that\'s out there because there\'s
going to be potential political pressure that\'s going to be put on
states to look at that medication. For states who don\'t have a strong
knowledge base or strong relationships, they could easily be pushed into
spending some resource that may or may not be the appropriate way to go
at this point in time.

MR. CURIE: Thank you, Ken, for that.

Wes, do you want to comment? And then Barbara.

DR. CLARK: Back to the criminal justice system, with regard to ATR,
Cheri Nolan is working out a deal with the Department of Justice and the
Department of Labor with regard to ATR making sure that we pair up some
of our ATR grantees with some of the discretionary grant programs that
Labor and Justice have dealing with the issue of reentry into the
community. So we\'ll be discussing that at our July meeting. So, again,
this partnership that Ken mentioned. We\'ve got SAMHSA staff working on
all aspects of it, doing the best we can with the resources we have.

MR. CURIE: In terms of, Ken, your recommendation, I would ask that CSAT
take this under advisement, the working partnership with NIDA in
particular, to evaluate to how we might inform. I see this as part of
our responsibility with ATTC technical assistance, and I think we can
offer an economy of scale of that information. So thank you, Ken.

DR. STARK: Thank you.

MR. CURIE: Barbara.

MS. HUFF: I just can\'t help but wonder, not like this is going to be a
surprise that I\'m asking this. What percentage of the grantees are
serving young people? I heard you mention college-age students. I was
thrilled to hear that. That was neat. I think it was you that mentioned
it. Are most of them serving young people coming out of juvenile
justice, or are any youth being served?

DR. CLARK: Yes. The ATR program is fairly diverse. So California has
targeted adolescents. Wyoming has targeted adolescents. Others have
targeted outcomes.

MS. HUFF: I knew they have that ability to do that.

DR. CLARK: And then we should also mention that we do have a separate
portfolio for adolescents. So with the SAPT block grant, adolescents
receive care. We have some of our TCE grants that target adolescents,
and we have a specific adolescent portfolio. So, again, while some may
say there\'s not enough money going to adolescents, we are committed to
that at SAMHSA.

MS. HUFF: I wasn\'t questioning that.

DR. CLARK: And then we work in partnership, of course, with CMHS and
CSAP to address both our prevention and treatment needs in adolescents.

MS. HUFF: Thank you.

DR. CLARK: So we have the age range for ATR.

MR. CURIE: Again, I think that\'s, if you will, the double-edged sword
of state flexibility. On the one hand, I believe fully states are
flexible to address what populations that they prioritize and what needs
they prioritize. Theoretically, it could end up, though, that no state
identified necessarily adolescents or youth in a particular program, but
that doesn\'t mean it\'s not a priority. So that\'s why we have a
diverse portfolio to make sure there is some focus on adolescents and
youth and some direction in that area, as well as a balance of state
flexibility.

Any other closing thoughts or comments on what I think has just been a
remarkable presentation with, again, tremendous approaches in leadership
on the part of Tom, on the part of Ken. I\'ve appreciated Wes and his
staff.

You have to keep in mind for all these people, including the CSAT staff,
this is new territory. This is forging into the unknown. This has not
been easy. There\'s been blood, sweat, and tears through implementing
Access to Recovery. The gratifying thing is we\'re seeing outcomes
beginning to occur in a positive way, and I think we\'re going to have a
rich field of data in which we can learn about how choice, recovery
support services, and truly operationalizing recovery can really work
and work better. So thank you.

It\'s now time to have a time for public comment. I will say I think
this is the first National Advisory Council meeting which no one has
signed to make public comment, but that does not preclude the
opportunity for spontaneity, for people who want to come up to the
microphone, introduce themselves and who you represent to make a public
comment. So I would now open the floor to the public for anyone who
would like to step up to the mike.

Oh, Art Dean did raise his hand, but we have someone else first, and
then we\'ll ask Art. Okay, go ahead, Art. Go ahead. Okay, don\'t worry,
Art. You\'ll go second. Thank you.

MS. THIEL: I\'m Thelma King Thiel. I\'m the Chairman and CEO of the
Hepatitis Foundation International. I\'m really here today to thank Dr.
Clark and Beverly Watts Davis for embracing our Liver Wellness approach
as a good strategy for promoting prevention and recovery. We have
trained over 2,000 of their grantees and we have many more planned and
scheduled to come up. We\'re just getting tremendous response.

There are a couple of studies that are going to be reported soon that
involved injection drug users and also homeless children that are really
identifying and supporting the fact that the Liver Wellness concept is
actually changing people\'s behavior. So we\'re very, very excited about
that, and we\'re looking forward to working more with SAMHSA.

But we\'ve done some of our own studies doing evaluations of each of our
presentations. We found that 89 percent of those who attended learned
new information about the impact a damaged liver can have on one\'s
health. 77 percent were more concerned about their own risk of infection
with hepatitis B and C, and of course, with our Liver Wellness, we
always talk about hepatitis. 62 percent were alerted to the fact that
they themselves need to be tested for hepatitis C and B. So we\'re
really motivating people to assess their own risk behaviors and to act
upon that.

Again, you can\'t change what you don\'t know, and the information about
the liver has been missing for many, many years in schools, et cetera.
So we feel that it is the missing piece. As a matter of fact, we\'re
going to be training 50 methadone counselors up at the Rhode Island
School of Medicine, their addiction program, and there is interest with
the Yale University Medical School, their rehabilitation program.

So we\'re very excited about having this kind of support and interest in
what we\'re doing, but I feel the urgency to do so much more, and we\'re
really looking for easier ways to reach more of the people that are
working on the front line that really need this information to enhance
their programs. Right now, there are no RFAs coming down that support
training with SAMHSA. They\'re all to the community organizations. So
what it means is we have to go out and try to plug our program to your
grantees to get them to pick up on it, and it\'s just a circuitous route
when I think that we know we have something that is effective and we
would like to make it much simpler. So we really need to collaborate
with you on a better basis.

Thank you.

MR. CURIE: Thank you, Thelma, and thank you for your ongoing work, a
very important priority on our matrix, and I appreciate collaboration
and you specifically pointing out Dr. Clark and Ms. Watts Davis in terms
of your key lead collaborators. Thank you for what you do.

Art, would you like the floor? Please.

GENERAL DEAN: But something did go wrong because about three weeks ago I
officially asked to give a public comment. So I\'m not sure what
happened, but that\'s perfectly okay.

MR. CURIE: Toian owns responsibility. She\'s the big person that she is.
So we apologize.

GENERAL DEAN: Not a problem.

But it\'s really great to have the opportunity to speak to such an
important group of leaders that are providing significant leadership and
support for this important field. I wanted to come by just to give you a
short update on things that are going on particularly in the community
coalition field.

I hope that you would agree with me that our collaboration and work with
SAMHSA and our community coalitions is one of the reasons why we believe
that we\'ve had this tremendous reduction in substance abuse over the
last three years. We believe that community coalitions have directly
contributed to that, and we give SAMHSA, its centers, and their support
a great deal of credit for providing that kind of assistance to us.

I want to give you just a short update on some activities and events
that I think are important to you, and I won\'t be very long. But I did
bring some publications along that we will share with you, and Dr.
Hernandez, who works with the National Institute, will share those with
you.

One of them is our summer newsletter that highlights the National
Leadership Conference that we had back in February. Fortunately, we had
over 3,000 attendees at that. It was, as it is every year, supported
significantly by SAMHSA and its centers, and without their support, I
can tell you that we would not have 3,000 coalitions here because they
would not be able to come.

We have started a few years back having a mid-year institute, which is
designed to give one-, two-, and four-day-long seminars versus our
National Leadership Forum is built around workshops that are two hours
in length. The one this year is going to be August 14th through the 17th
at the Hyatt Regency Lake Las Vegas Resort and Spa in Las Vegas, and we
will be in training there for four days.

We\'ve just recently put out our call for proposals for the National
Leadership Conference that\'s going to be in February 2007, and I know
that SAMHSA and its grantees and other agencies will be submitting
topics for us to consider. We just recently had some discussions with
Dennis Romero in the Center for Substance Abuse Prevention and we will
again be hosting as a part of our National Leadership Conference
SAMHSA\'s Community Prevention Day, which has turned out to be a
wonderful addition to the National Leadership Conference.

Also, I will report to you that I take great pride in this and I\'m
generally a very humble kind of guy, but during our watch over the last
few years, we have had participation from all three of SAMHSA\'s centers
in the National Leadership Conference. I will say to you about seven
years ago, it was very heavy CSAP. A few years back, three, four, five
years, CSAT became a significant player. In the last two years, the
Center for Mental Health has been a significant player as well, and we
are very pleased that the whole family is a part of that activity and we
are quite pleased about that.

Something that is very new for us is we have been doing some
international work, and we\'ve actually started some coalitions in South
America. But in August, in San Diego, we\'re going to have our first
training in Spanish and we\'re going to have foreign attendees in that
training, as well as those community coalitions that have a heavy
concentration of those that speak Spanish as a language. We\'re excited
about that taking place August 21st to the 23rd.

The National Coalition Institute, which is our first grant that we got
from the federal government going back three years, is administered,
along with the Drug-Free Community program, by SAMHSA. We trained over
5,000 people last year. We currently have 100 coalitions in a yearlong
training program, and that\'s in coordination with the National Guard.
And we\'re very excited about that.

What we\'ve done is, working with our friends at CSAP, we have published
the first primer on the framework for the Strategic Prevention
Framework. We started with evaluation, and we will be publishing this
year the four remaining ones. So by the end of this year, we will have a
primer with great details that covers each of the steps of the Strategic
Prevention Framework in all of our training, to include the Coalition
Academy uses as its basis for training the Strategic Prevention
Framework. We are very, very excited about that.

We are working closely with the underage drinking initiative that SAMHSA
has. We support that. We supported their town hall meetings. And working
with our friends at the National Institute on Alcoholism and Alcohol
Abuse, we just published an evidence-based practical theories on
underage drinking, and it\'s called \"Using Science to Combat Underage
Drinking,\" which is something that we care very dearly about and will
continue to partner with SAMHSA on that issue.

The last thing that I wanted to say is that we will continue to work
with SAMHSA in the interagency coordinating committee to make sure that
this effort is, in fact, worked. Substance abuse in its totality is
having a tremendous impact on our communities. Illicit drugs, illegal
drugs are having a tremendous impact. But I would be remiss if I didn\'t
tell you that alcohol is causing the greatest problem out in our
communities. So it\'s important that we work that issue together and we
will continue to do that.

As I close, Charlie, can I get you to come up? I don\'t know if Charlie
will agree with me or not, but since he arrived at SAMHSA back in
November of 2001, not only has he been a leader that has cared about
this total field and has worked diligently to cause people to have a
life in the community, but he\'s reached out to CADCA, to our board of
directors, to our advisory committee. He\'s been involved with community
coalitions. He\'s supported us in a very dedicated, professional way.
But beyond that, we have established, I believe, what is an outstanding
friendship and partnership.

I wanted to give him this on behalf of the board of the directors, on
behalf of our advisory committee, our staff, and the more than 5,000
community coalitions that have benefitted significantly from his
leadership, from his dedication and his professionalism. I\'m convinced
that coalitions are stronger today and in more numbers today because of
Charlie\'s leadership, and I wanted to come by and personally, in front
of his advisory committee, thank him for that and say we\'re going to
miss you and thank you for your great work.

(Applause.)

MR. CURIE: Thank you so much. That means a lot.

GENERAL DEAN: Thank you all very much. Well, again, thank you all for
your leadership and your support.

MR. CURIE: Thank you, Art, for those kind words and the recognition. It
means a lot coming from CADCA. I think CADCA is foundational and is
truly the backbone of grassroots anti-drug efforts and prevention in
this country. I appreciate very much our friendship and partnership.

Henry, would you like to have the mike? Henry Lozano.

MR. LOZANO: Thank you, General Dean, on behalf of the board of the
directors of CADCA.

I\'d like to just take you back for one moment, Charlie, to September
4th, 2001. And all of us were sitting with Dr. Clark and the National
Recovery Month Program, Ivette Torres in the room with Secretary Tommy
Thompson, and we were all in there dreaming a dream. It was a critical
week, a complex week for this nation, for this world, and that dream
from that point in juncture till today has been an incredible adventure.
As just one of those many folks out there in this field that had the
privilege to work with all these fine folks, it\'s been an honor, sir. A
true honor. Thank you.

MR. CURIE: Thank you, Henry.

(Applause.)

MR. CURIE: Any other public comment?

(No response.)

MR. CURIE: If not, just in terms of making a couple closing remarks, I
first of all just want to one last time thank this council for its
ongoing commitment, dedication, support. It personally has meant a lot
to me on both an individual basis, as well as a council as a whole, the
way you\'ve taken the business of SAMHSA so seriously, moving the agenda
ahead on behalf of people in this country with addictive disease, with
mental illness, children and youth who are at risk. It, again, has been
a true honor.

I wish continued success for the council. I absolutely want the best for
SAMHSA as it moves forward in the future.

I want to recognize a couple folks, Daryl Kade, who is the Executive
Director of this council, and also, again, Director for Policy and
Budget Development, playing the key role on the executive leadership
team. I give her tremendous credit for helping synthesize and integrate
and helping develop the concept around matrix management and helping
weave that full integrated picture that we have today. I just appreciate
her support and leadership.

(Applause.)

MR. CURIE: And, of course, the council knows Toian Vaughn quite well.
Toian is the one that toils on the logistics, striving to keep all of us
organized and on track. I don\'t know of anyone who takes her job more
seriously than Toian in terms of really wanting to put forth the best. I
just want to thank you for your ongoing efforts and what you do.

One last person I\'m going to surprise right now, I think, to recognize.
He\'s been sitting quietly out there, and actually his issue was
addressed earlier by Theresa Racicot and Michele Ridge. But one of the
unsung heroes I think of SAMHSA ‑‑ and there are many, probably 525,
which is about the number of our employees ‑‑ is somebody who, again,
toils day in and day out, many times in his very quiet way but a very
effective way, pressing the issues around alcohol abuse in this country
and underage drinking, and again, the town hall meetings, the
Interagency Council for the Prevention of Underage Drinking, moving
ahead with the Surgeon General\'s call to action ‑‑ I can just go on and
on and list the types of things that he\'s been instrumental in really
helping us pull off and lead and advise. And that\'s Steve Wing. Steve,
would you stand up?

(Applause.)

MR. CURIE: I have appreciated his counsel.

When I first came aboard, one of the things that really wasn\'t real
active with SAMHSA was the alcohol agenda. It was there. There were some
things occurring and going on. I think we have a real life and priority
now, and it\'s my hope that five years from now we\'re going to be able
to look back and say, there\'s a decrease in underage drinking like
we\'ve seen in illicit drug use and tobacco. I know that\'s very, very
possible. It\'s a societal change that\'s going to occur. And I think
with the help of everyone in this room ‑‑ and this is where CADCA is
going to play a critical role, the Strategic Prevention Framework,
Steve, and of course, you heard all the commitment today earlier from
folks.

But anyway, thank you, everybody, and may God bless you in your ongoing
efforts.

(Applause.)

MS. VAUGHN: We are adjourned.

(Whereupon, at 3:20 p.m., the meeting was adjourned.)