This Web site is a component of the SAMHSA Health Information Network

This Site Mental Health at HHS All Mental Health

About the Program 15+ Refugee Mental Health School Violence Prevention Safe Schools Healthy Students Related Topics Featured Publications In the News Related Links: Refugee Mental Health Related Links: School Violence Prevention Prevention Initiatives and Priority Programs  CMHS Programs:   Go to... Children's Campaign Community Support Emergency Services Financing HIV/AIDS Homelessness Managing Anxiety Mental Health Statistics Protection & Advocacy Special Programs State Planning Traumatic Events Suicide Prevention Programs Homepage  CMHS Activities:   Go to... 15+ School Violence Stigma Suicide Prevention Surgeon General

printer friendly page e-mail this page bookmark this page shopping cart  current or new account

This Web site is a component of the SAMHSA Health Information Network.

Special Programs and Initiatives

National Congress for Hispanic Mental Health

III. National Congress Proceedings

Introduction
Summary of Comments of Dr. Bernard Arons, Director, SAMHSA/CMHS; Ms. Josie Torralba-Romero, Chair, Steering Committee; and Other Members of the Steering Committee

On March 20-21, 2000, more than a hundred key Hispanic stakeholders convened for the first National Congress for Hispanic Mental Health, sponsored by the Substance Abuse and Mental Health Services (SAMHSA) and its Center for Mental Health Services (CMHS) within the U.S. Department of Health and Human Services (HHS). This Congress, in the words of Dr. Bernard Arons, Director, SAMHSA/CMHS, "provided an opportunity for Latino stakeholders to take charge in developing and implementing an agenda that will impact the Hispanic community and result in increased access to high-quality, culturally and linguistically competent, mental health and substance abuse services for all who need it."

The Congress had two main objectives: to develop a National Agenda for Hispanic Mental Health and to design an Action Plan for implementing the goals set forth in the Agenda. During the first day of the Congress, the workgroups focused on the areas of consumer, family, and community education; accreditation, standards, regulation, and human resources; prevention and early intervention; mental health services; and Hispanic research. During the second day, the workgroups addressed community mobilization, research, marketing/public relations, policy development, and accountability-the types of activities or actions that need to be taken to accomplish the goals in each topic area. Members of the steering committee of the Congress facilitated these workgroups. At the end of each day, a plenary session identified any overlaps among recommendations and provided an opportunity to rewrite them to ensure that they were focused, consolidated, and concrete, and captured what needs to be accomplished. The completed Action Plan (see Part V, p. ) shows which players need to implement each recommendation and what actions need to be taken.

Tenemos Voz ("We Have a Voice"): Consumer Perspectives
Much of the impetus for this Congress came from consumers, individuals who have experienced mental illness. They have become passionate advocates for accessible mental health services for the Hispanic community. Consumers point to lack of education and understanding about mental health services; lack of medical insurance; insufficient funding for mental health services; services that are rarely culturally or linguistically inviting; and discrimination and stigmatization within both the Latino community and mainstream society as the key reasons for underutilization of services.

At the beginning of the Congress, consumer advocates stressed the importance of educating other consumers so that they will become involved in mental health issues. Although it is difficult for people to admit they have a mental illness, once they do so, it is in their best interest to become involved in the advocacy movement. Including community members in local research projects and giving them the authority to make community assessments as part of such projects empowers consumers and makes them more effective advocates for their cause. Developing strong leaders within community organizations representing the best interests of consumers and bringing in more Hispanics to mental health professions further accelerates the implementation of much-needed changes.

The goal of this Congress is to address the growing mental health service needs in the Hispanic community and to create a vision for Hispanic mental health and a plan for making that vision a reality. First and foremost, health and human services for the Hispanic community must be improved by making them more accessible, more appropriate, and more responsive to the needs of the community. The need for these improvements has become even more pressing with the increasing numbers of Hispanics in the United States. It is projected that by 2050, there will be 98 million Hispanics in this country. Hispanics are a growing force in this country in terms of earning and spending capacity as well as in the political arena.

However, Hispanics are among "the poorest of the poor" in the United States. Forty percent of Latino children live in poverty, more than double the rate for non-Hispanic children. Unfortunately, too many young Hispanic males worry more about surviving on the streets than about succeeding in life. As for young women, one in three Hispanic girls has seriously considered suicide, the highest rate of any racial or ethnic group. Also, Hispanic girls outpace other girls living in poverty in substance abuse and teenage pregnancy.

Dr. Chavez cited the following possible explanations for these sobering statistics:

• In a study of the children of immigrants, it was found that, as children assimilate, the tensions between parents and children, old cultures and new, intensify. As the family-a particularly strong tradition in Hispanic culture-breaks down, other systems, such as schools or other supportive services, are not filling the gap.
• Fully one-third of the Nation's uninsured come from the Hispanic community, even though most are employed full-time and know the English language.
• When Hispanics do seek care in the mental health system, treatment can be compromised not only by a breakdown in communications but also by misdiagnosis and misunderstandings between cultures.

To rectify these problems, this Congress-representing key Hispanic stakeholders-must agree to an Agenda and an Action Plan for the Hispanic community. Dr. Chavez concluded by stating that the "plan [woven] today is tomorrow's heirloom for the next generation."

Data presented further emphasized the tremendous need for improvements in mental health services for Hispanics.

Population and Demographic Growth. More than 30 million Hispanic people live in the mainland of the United States; adding in Puerto Rico, the number rises to more than 35 million. This diverse group of Hispanics represents individuals with different political and historical backgrounds, as well as varying social contexts. Despite this diversity, all Latinos must come together to forge an agenda for action to improve mental health services.

Demographic trends also reveal that Hispanics now live everywhere in the United States. No longer just in California, the Southwest, and Florida, growing Hispanic populations have set down roots in Washington, DC, Delaware, Arkansas, North Carolina, Georgia, and Nebraska, among others. What's more, Hispanics represent the only major ethnic group in the United States with a mean age less than 30 (28.9).

Economic and Educational Status. The Hispanic community faces a great deal of poverty. About 26 percent of four-person households-two adults and two children-are living within the poverty level, which is about $16,000 a year, and 40 percent of Hispanic children are also living within this level. About 44 percent of this population is not likely to have health insurance. Among children (ages 0-17) of Hispanics who are not citizens, 53 percent are without insurance. Among Hispanics who are citizens, 29 percent do not have insurance, compared with 13 percent of other immigrant groups who have become citizens. In terms of education, according to statistics available from 1996, a little more than 50 percent of Hispanics 25 years and older have a high school education compared to 85 percent of non-Hispanics of the same age.

Documentation of the Need for Mental Health Services. Data from the Centers for Disease Control and Prevention (CDC) indicate that Hispanic youth are more likely than other young people to attempt suicide. Other data show that problem behaviors and the needs among Hispanic youth are greater than among other ethnic groups. A study conducted in Fresno, California, documented the prevalence of mental health disorders. One of the most important findings from this study was discovering the considerable differences in the prevalence rates of people who immigrate to the United States compared with those who are born here. It appears that the longer Hispanics stay in the United States, the greater the risk of mental disorders.

The lifetime prevalence rate of any disorder from the national sample was nearly identical to that of Mexican Americans born in the United States. Mexican Americans who immigrated had a considerably lower lifetime prevalence rate of major mental disorders than did Mexican immigrants born in the United States (Vega et al., 1998).

Barriers to Providing Services. Three main barriers to providing mental health services to the Hispanic community become evident from the data. The first is insurance. In order to receive the necessary services, people must have health insurance. Another barrier is institutional. Data from the Fresno, California, study indicate that people tend to go to health specialists more than they go to mental health specialists. Therefore, mental health services need to be provided not only within mental health service agencies but also by collaborating with general health services and primary care facilities. Additional studies are currently under way that are evaluating whether training health care providers to provide quality mental health care within the primary care arena helps remove the institutional barrier. The third barrier involves the linguistic and cultural competence of providers. In one study that included Mexican Americans, it became clear that when the clinician was of the same ethnicity as the Mexican American client, there were fewer dropouts, more sessions, greater improvement in global assessment scores, and greater improvement in overall functioning. This seemed to be particularly true for non-English-speaking patients.

There is no question that great pain and despair accompany mental illness and substance abuse. Anyone who has been touched by the disease-or has seen loved ones suffer-knows of the anguish and suffering, beautifully conveyed by Raoul Longiana in a painting called La Loca. These reminders of the human element of mental illness reaffirmed the commitment of the Congress to work toward achieving its goals.

Dr. Gil placed the National Congress in the context of changes taking place in the political climate, noting that in 1998, President Clinton announced the new Racial and Ethnic Health Disparity Initiative, which recognizes the disparities in the health care delivery system. In 1998, the HHS Secretary announced the Hispanic Agenda for Action, and in 1999, the U.S. Surgeon General unveiled the Surgeon General's Report on Mental Health. Senator Edward Kennedy also introduced the Health Care Fairness Act.

The Hispanic Congress is now poised to develop its major goals and recommendations for action. The activities of this Congress reflect the commitment of its participants to changing the mental health delivery system at the national, State, and local levels.

Developing a Hispanic Agenda for Mental Health
The discussions outlined below reflect the ideas, concerns, and recommendations of each of the workgroups during the first day of the Congress.

Workgroup on Consumer, Family, and Community Education
Before beginning to frame its recommendations, group participants shared topics of particular concern, including the need to educate consumers and their families and to call on families to create a culturally and linguistically sensitive helping network; to look to the faith community for support for those with mental health needs; to provide training to leaders in the faith community so that they are more familiar with issues surrounding mental illness; to initiate antistigma training provided by consumers and their families at the community level, in churches, schools, and neighborhoods; and to help underwrite curricula for students in kindergarten through 12th grade that drive home antistigma information at a young age.

Another participant turned the conversation to the role of local government in mental health issues. Making the point that local leadership must be educated and sensitized to the great mental health care needs of the Hispanic community, one participant emphatically stated that the work will not get done without the support of this core group. In addition, advocacy groups must be educated and brought onboard to work with local leaders. Along with the push for educated leaders must come an increase in funding so that the work that needs to get done can be accomplished.

These comments led to a discussion about the role of the consumer in implementing change, a topic of great concern to this group. Several participants stressed the importance of making the consumer an equal partner in finding solutions to problems in the mental health care system. To that end, funds allocated need to be for integrated systems of support so that all people's needs are met simultaneously and consumers and families receive funding at the local level.

After this preliminary discussion, the group began writing its specific recommendations. The group came to a consensus that the topic areas of advocacy, decisionmaking, and funding can serve as the framework under which to place its recommendations. In the area of advocacy, education, training, and empowerment of consumers are essential. Education can be implemented through the development of materials that are culturally and linguistically appropriate, are holistic, and reinforce the elimination of the stigma associated with mental illness. Training can take place in all settings in the community and can be formalized through the development of a national Hispanic mental health consumer and family network. From education and training emerge empowerment, when consumers can advocate for their cause to Federal, State, and local government officials.

In the area of decisionmaking, consumers and family members need to be given the authority to guide research initiatives, and the findings from such research need to be translated and given promptly to consumers and families so that they can be used to make services more appropriate, effective, and accessible. In order for the Hispanic voice to be heard, Latinos must be included on national, State, and local mental health advocacy group boards. Because decisionmaking is an integral function of government, both government and elected officials at all levels need to receive training in Hispanic cultural competency so that they are prepared to make thoughtful decisions.

Recognizing the key role that funding plays in implementing these recommendations, the group made the decision to link funding allocations to specific recommendations. For example, before public funds are dispersed, Hispanic representation on appropriate boards must be in place; private funding should be dispersed only to those programs that are culturally sensitive and competent. Similarly, funding for Hispanics should reflect their growing numbers; to that end, 25 programs in 25 states should receive funds each year until funding for Hispanics is proportional to the growing demographics. To ensure that consumers are active players in the change process, funded programs must demonstrate their inclusion in policy development, program design, and the creation of service delivery models, as well as in leadership development programs.

In summary, through these recommendations, the group aims to ensure that consumers and their families are equal partners in developing programs and implementing them with the Federal government, national organizations, philanthropy organizations, faith-based groups, or any other group involved in mental health. In addition, consumers should be included in research initiatives, and innovative models, such as community-based research projects, should be developed. Elected and government officials need to be educated so that they can make thoughtful and culturally sound decisions. Finally, funding should be contingent on the successful implementation of these recommendations.

Workgroup on Prevention and Early Intervention
This group's discussion began with an acknowledgment that prevention is extremely important and is a way to address some of the pressing problems facing the Hispanic community-suicides, lack of access to education, the need for child care, and the need for better outpatient services. In debating these issues, it became clear to participants that a comprehensive social service network, with a focus on training people to work together, is needed. Part of the job of this network should be to remove the stigma patients often feel when they seek outpatient services, as well as to help consumers address their own feelings about their illness. Educating consumers about medication could also take place through a social service network.

One participant shared the difficulties she had getting appropriate screening and care for her young child with a serious mental illness. She stressed the need for better screening from pediatricians and for respite care, sharing that services in her home give her a break from the demands of her sick child.

Everyone in the group acknowledged the seriousness of these issues, but participants also felt that it was counterproductive to discuss them in the context of "needing to fix something that was broken." Several participants discussed the importance of approaching these problems from an emphasis on the inherent strengths in the Hispanic community. In communities that have tried this approach, researchers have observed strengthened relationships between parents and children, parents and school teachers and administrators, and even between husbands and wives.

As a way to discuss a strength-based approach to prevention and early intervention, the group came up with the acronym "FUERSA," the phonetic spelling for the Spanish work fuerza, or strength. The acronym is defined as follows:

"F" stands for focus on cultural competence.

"U" stands for utilization of community and consumer resources for informing the Hispanic community on how to develop, design, and implement particular strategies.

"E" stands for eliminating disparities in funding of services.

"R" stands for reinforcing cultural values.

"S" stands for the importance of recognizing the strengths of consumers and their families while implementing a holistic approach to services.

"A" stands for access to services for all groups.

A key element of a strength-based approach is empowerment of consumers. Also, professionals working in the Latino community must be trained to develop interventions that reinforce cultural values. To further define the strength-based approach, the group highlighted strategies in the following areas: education, community action, and specific prevention strategies, each of which is explained below.

Education. The group emphasized the need to develop a family and community focus for positive development in three age categories. First, community-based services in early childhood care and education for children between the ages of 0 and 5 should be available for those who need them. Head Start is an example of such a program, but currently it serves only 40 percent of the eligible children in the Hispanic community. Clearly, services need to be expanded.

For school-aged children (those between the ages of 5 and 17), school-based services should be available, as should community-based programs for youth between the ages of 18 and 20. The latter recommendation recognizes the reality that not all young people who need services stay in school, so services must be offered in the community as well. All services have to originate from a family and community focus targeting positive development.

The elderly must also be reached. The goal for this population is to provide community- and home-based mental health services. To do this properly, it is important to identify what programs are in place, which are working, and how those efforts should be expanded.

Community Action refers to the need to develop a user-friendly and child-friendly mental health community education system for prevention and early intervention that is responsive to the needs of the Hispanic/Latino community. This system would provide information about what services are offered, what each service provides, and how the providers could be held accountable. The system would also connect consumers to mental health professionals and other available resources.

Specific Prevention Strategies. Suggested recommendations included forming a team of consumers to reach out to members of the community who need help; providing training for primary care providers in clinics and other settings to screen for mental health disorders; setting up a crisis hotline; educating family members who are caring for someone with a mental health disorder; and reaching out to people of all ages in all settings-day care centers, schools, community centers, and facilities for the elderly-to provide the services they need.

All of these actions must be done with FUERSA, with a strong focus on cultural competence and community involvement. The actions must be holistic, realistic, and strength-based. Finally, mental health services must cut across all ages and reach all members of the community.

Workgroup on Standards, Accreditation and Regulation
and Human Resources
This group tackled two topics: recruiting and training a culturally competent cadre of mental health professionals to work with the Hispanic community and developing standards and accreditation to address cultural competence needs. The discussion opened with the acknowledgment that insufficient numbers of Hispanics enter the mental health professions. According to the American Psychological Association and other reputable organizations, only 5 percent-63,000 of 749,000-of the Nation's social workers are Hispanic. Only 2 percent-1,519 of 84,426-of the Nation's psychologists are Hispanic, and only 7 percent of the Nation's psychiatrists are Hispanic.

Clearly, there is a tremendous need to recruit more Hispanics into the mental health professions and to build up the Hispanic leadership already in place. The group discussed the importance of looking to both traditional and nontraditional service providers to round out the Hispanic workforce and to recruit people at all educational and skill levels. The participants discussed spreading out a wide net to recruit everybody, from students, to paraprofessionals, to professional social workers and psychologists. After recruiting these workers, it is important to develop strategies for retaining them.

Reforming education also stands out as an important issue. Professionals need high-quality training to do their jobs well. For Hispanic mental health professionals, part of the training must include Hispanic mental health concerns and culturally competent curricula. Part of cultural competence must be an understanding of the social and economic differences within the Hispanic population. The group also stressed the value of working with academic institutions to develop appropriate curriculum materials and to take advantage of available traditional and nontraditional services. Along with the need for effective education programs is the need to make the mental health field attractive to the Hispanic community and to build up leadership for Hispanic mental health. A public awareness campaign is one way to reach out to the Latino community and to ask for help in recruiting Hispanics to the mental health professions; the shortage of workers is tantamount to a national crisis. In fact, SAMHSA/CMHS has allocated $1.3 million to train minorities in the upper tiers of mental health.

Following this lengthy discussion, the group worked to frame its recommendations, which are listed below:

• Attract Hispanic leadership and professional involvement in mental health and increase awareness of Hispanic needs and opportunities in our own community, in mainstream institutions, and in policy forums.
• Reform education and training to specifically meet Hispanic mental health needs through strategic partnerships with academia, the public and private sector, consumers, and families.
• Implement and enforce clinical access and outcome standards at the national and State levels and promote integration of the cultural competence standards across systems that interface with populations that may need mental health services, including justice, welfare, education, housing, and primary care.

Workgroup on Mental Health Services
This group focused on three fundamental issues: quality of care, setting policy, and funding. The discussion opened with an analysis of the delivery system. Participants agreed that it is fragmented and not culturally inviting to Hispanic clients. To "fix the system," participants discussed building and expanding existing services by drawing on the resources of both traditional and nontraditional service providers and adding to the cadre of bilingual providers. All services must also be sensitive to the diverse racial and ethnic populations within the Hispanic community. By making these changes, mental health services would become effective, efficient, and comprehensive.

Many participants viewed policy as the driver behind change. Educated policymakers will begin to recognize and address the disparity in mental health services for Hispanics. They can then begin to rectify the disparities by, for example, integrating health care services with mental health services. This kind of change reflects a change in policy.

Revised funding allocations naturally emerge from modifications in policy. Once policymakers understand that funding disparities exist, they will be more inclined to review funding models to ensure that service agencies are receiving the funds they need and that funding models are appropriate. Furthermore, funding must align with policy, and consumers can serve as advocates for policy change and a revision of funding models.

In summary, the group developed the following recommendations:

• Change public policy so that mental health services can be delivered in other settings, such as within the justice system, to meet the needs of all members of the Hispanic population. Through such changes, services delivered will be comprehensive, effective, and sensitive to the needs of the population.
• Increase the number of bilingual and bicultural staff in mental health agencies.
• Expand funding sources and create new funding streams to close gaps and eliminate disparities in the delivery of mental health services.
• Allow for greater integration between primary care and mental health services.

Workgroup on Hispanic Research
This group considered some of the challenges facing the Hispanic/Latino community in the area of research: A large number of consumers are not receiving the care they need; consumers often go to primary care physicians and not to mental health professionals and services are not well integrated; definitions about what is meant by cultural competency vary and should be standardized; more bilingual providers are needed; and research efforts need to be expanded to involve consumers and to study the impact of managed care on the Latino community. To achieve these goals, participants discussed setting aside funds for Hispanic research and establishing a new national organization to develop categories of research, prioritize the research agenda, locate multiple sites for research projects, and serve as a national clearinghouse for information. Some of these set-aside funds would also go to studying the issue of cultural and linguistic competence by evaluating the standards in place and determining whether they should be modified. Finally, funds are needed to research and develop methodologies that incorporate differing viewpoints, including those of consumers.

In addition to setting aside funds for research, the group focused on the need to promote the development of Latino researchers, perhaps through mentoring programs. After much debate, the group agreed that the need was for more Latino researchers, not simply for more research on topics of concern to the Hispanic community.

The group then worked to articulate its goals to reflect the ideas of the majority. The recommendations participants agreed on are listed below:

• Make Latino and substance abuse research a priority for funding agencies to promote effective, culturally and linguistically competent services for Latinos, consumers and their families, and the community.
• Promote training to increased the number of Latino professionals qualified to conduct research in mental health and substance abuse.
• Sponsor research to identify, evaluate, and disseminate existing and new research models and methods for conducting Latino mental health research. These methods and models should be multimodal and multidisciplinary and include built-in mechanisms for ongoing feedback from consumers, families, and other stakeholders.

Summary of the Workgroups' Recommendations
At a plenary session immediately following the breakout sessions, each group reported on its recommendations. A brief summary of each group's presentation follows.

Workgroup on Consumer and Family Issues and Community Education

• Develop and implement throughout the Nation specific Hispanic mental health education and training programs in partnership with Hispanic community support networks, such as the faith community, community-based organizations, and practitioners.
• Ensure that national, State, and local mental health advocacy groups include Hispanic representation on boards and address Hispanic issues and concerns in all programs and policy recommendations.
• Ensure funding for Hispanics proportional to the growing demographics and to the needs of the population. The group recommended putting into place 25 programs in 25 States each year until this goal is reached.
• Educate government and elected officials about Hispanic needs and issues.
• Create and finance a national Hispanic mental health network of consumers and families.
• Train and educate Hispanic consumers and family members to become advocates for mental health services, paving the way for legislation supporting mental health services for the Hispanic community. Local residents, through education, can become the movers and shakers of their communities and assume responsibility for making changes.
• Educate funding sources on the importance of supporting relevant issues for consumer- and family-driven community-based research.

Workgroup on Standards, Accreditation and Regulation
and Human Resources

• Develop an adequate cadre of culturally competent personnel who can work to resolve the national crisis in mental health services for Hispanics.
• Actively recruit and retain a Hispanic mental health workforce including both traditional and nontraditional service providers at all educational and skill levels. To accomplish this goal, spread out a wide net to recruit everybody from students, to paraprofessionals, to professional social workers and psychologists. After recruiting these workers, it is important to develop strategies for retaining them.
• Reform education at all levels by incorporating Hispanic mental health concerns and culturally competent curricula in partnership with academia, the public and private sectors, consumers, and families.
• Implement the national Hispanic mental health cultural competence standards in the National Performance Measures within the the Centers for Medicare and Medicaid Services (CMS), clinical and professional accreditation bodies, and other relevant groups.
• Implement and enforce clinical access and outcome standards at national, State, and local levels.
• Promote integration of cultural competency standards and accountability measures across systems that interface with mental health. These systems include the justice department, welfare agencies, substance abuse agencies, and education entities. All these groups have common clients, so it is important that they are aware of and can implement cultural competency standards when appropriate.

Workgroup on Prevention and Early Intervention

• Develop community-based services in early childhood care and education for children between the ages of 0 and 5 by expanding Head Start and similar programs.
• Develop school-based activities for school-aged children (those between the ages of 5 and 17) and community-based services for youth between the ages of 18 and 20. All services should originate from a family and community focus targeting positive development.
• Develop community- and home-based mental health services for the elderly by identifying what programs are in place and are working, and how those efforts can be expanded.
• Develop a user-friendly and child-friendly mental health community education system for prevention and early intervention that is responsive to the needs of the Hispanic/Latino community. This system would provide information about what services are offered, what each service provides, and how the providers could be held accountable. The system would also connect consumers to mental health professionals and other available resources.
• Form a team of consumers to reach out to members of the community who need help; provide training for primary care providers in clinics and other settings to screen for mental health disorders; set up a crisis hotline; educate family members who are caring for someone with a mental health disorder; and reach out to people of all ages in all settings-day care centers, schools, community centers, and facilities for the elderly-to provide the services they need.

Workgroup on Mental Health Services

• Create and/or change Federal, State, and local policy to eliminate Hispanic/Latino health disparities and support the delivery of efficient, effective, and innovative mental health services in all settings. The services include both traditional and nontraditional and refer specifically to policy, funding, and programs. In all programs offered, the consumer should be considered an active partner.
• Using both public and private funding sources, new and existing funding streams must close gaps and eliminate disparities in mental health services for Hispanics/Latinos.
• Create programs that deliver high-quality, comprehensive, efficient, and effective mental health services, providing innovative interventions that are culturally and linguistically competent and available to all Hispanics.

Workgroup on Hispanic Research

• Promote research, effective services, and improved outcomes for Hispanics/Latinos by making mental health and substance abuse research an immediate priority for funding agencies. Effective services mean those that are culturally and linguistically competent and have earmarked outcomes relevant to Hispanic/Latino consumers, families, and the community.
• Increase the number of Hispanics/Latinos who conduct research in mental health and substance abuse.
• Identify, develop, evaluate, and disseminate innovative research models and methods that are appropriate for use in Hispanic/Latino consumers.

Consensus about the National Agenda
Recognizing that the workgroups had just completed their deliberations and that all goals, key issues, and recommendations had not yet been synthesized into a single document, the Congress received an overview of the results and an assessment from the meeting facilitator about how the final Agenda would look. After discussion on specific details, the Congress agreed that the Steering Committee would develop the final Agenda overnight so that work could proceed on the Action Plan immediately on the following day. In an unprecedented effort and in a manner most consistent with the good work of the Congress, the final Agenda, identical to the document found in Part IV, was presented to the Congress at 8:30 a.m. the next morning and passed out to all participants. To rousing applause from the entire Congress, the Congress Chair announced, "The Agenda is done."

Creating an Action Plan
On the second day of the Congress, Hispanic stakeholders were joined by representatives from HHS and other Federal agencies; State and local officials; foundation representatives; members of national organizations; and partners from the mental health community, among others. In addition, a number of representatives from technical assistance organizations, including those from self-help technical assistance groups, joined the Congress to ensure that they, too, were partners in this effort.

Reflections on the National Agenda for Hispanic Mental Health: Returning to the Consumer Perspective
[Note: Still waiting for approval for these pieces.]
Ms. Maria Mar, representative of Tenomos Voz, or the voice of the consumer, opened the second day of the National Congress for Hispanic Mental Health. She welcomed two speakers: Maria Duarte, Activities Director and Arts and Crafts Coordinator of New Beginnings, a self-help center run by mental health consumers in California, and Luis Principe, a community leader from New York.

Ms. Duarte gave a moving presentation of her personal experience with mental illness. She recalled a time when she was suicidal and went to a rehabilitation center in El Centro, California, asking for help. The center referred her to a mental health clinic for which referrals were needed; individuals could not get help by simply walking in and asking for help. That clinic stabilized Ms. Duarte with medication.

As she got better, Ms. Duarte became a mentor to her peers from the clinic. Shortly thereafter, she became a leader in a drop-in center and is now part of a nationwide crusade for Latinos. Indeed, Ms. Duarte was one of the founders of Tenemos Voz, a grassroots organization designed to get Latinos involved in this growing national movement for effective mental health services. Through Tenemos Voz, consumers now have a voice in opening doors for all Latinos who need mental health services.

Mr. Principe also has a history of mental illnesses. He explained that he suffered a great deal and did not realize for quite a while that he was ill. He also was a veteran, and after he left the army, it was hard to get established again. But through a program called Casa L'Esperanza, he rediscovered joy and a sense of purpose in life. Since that time, he has come to feel that being an advocate for mental health services in the Hispanic community is his personal calling.

As part of Tenemos Voz, Mr. Principe is committed to producing a national agenda that will meet the needs of all stakeholders and will maintain a balance between services and research. Both are needed to address the urgent mental health issues in the Hispanic community. A comprehensive knowledge base that feeds back into an improved service delivery system also is needed. Mr. Principe then outlined the following four needs, which he feels represent the interests of Tenemos Voz:

1. Ongoing support
2. Technical assistance
3. Networking
4. Organizing development

Mr. Principe concluded by saying that addressing these needs will allow Latino consumers nationwide to contribute in a meaningful way to making the Hispanic agenda a reality.

Presenting the National Agenda for Hispanic Mental Health
Dr. Bernard Arons, Director, SAMHSA/CMHS

The National Congress for Hispanic Mental Health is crossing a bridge from setting goals for the future to actually developing an Action Plan to realize those goals. The draft National Agenda for Hispanic Mental Health is very concrete and focused, and now an Action Plan must be developed that identifies steps to be taken, resources to be committed, and a timetable to be followed to implement these goals. The task of participants during the second day was to put the goals that were set on the first day into an Action Plan.

Charting a Course for Change
Dr. Nelba Chavez, Administrator, SAMHSA

This Hispanic Congress represents a major step in helping to meet the mental health needs of Hispanic Americans. Participants are part of a critical mass needed to give new direction and renewed hope to millions of Hispanic Americans at risk for mental illness or who are currently experiencing some form of mental illness.

The current political environment is ready to take action. The Administration is committed to a Hispanic Agenda for Action for health and human services. As part of that agenda, last year the White House convened the first mental health conference. Also last year, the Congressional Hispanic Caucus held an historic meeting that focused on mental health and substance abuse in the Hispanic community. As a result, the Caucus made mental health a priority.

A few months ago, the groundbreaking Surgeon General's Report on Mental Health was released. SAMHSA and CMHS were instrumental in ensuring that the report was completed. SAMHSA and CMHS are now developing companion pieces to this report. The first piece focuses on the effects of culture and race on access to quality mental health services. The report is looking at African Americans, Hispanics/Latinos, Native Americans, and Asian Americans/Pacific Islanders. Both reports can serve as a springboard for action, in much the same way as the Surgeon General's Report on Smoking did in the late 1960s. The reports also are important tools for documenting that Hispanics and all ethnic groups have the right to demand quality mental health care services. The National Agenda for Hispanic Mental Health, in conjunction with the Surgeon General's Report on Mental Health, can make the voice of the Hispanic community heard.

Congresswoman Napolitano began her remarks by noting the situation in her own district. When she first took office as a member of the California Assembly in 1992, the State was determined to shut down as many State mental hospitals as possible. Individuals needing mental health services were supposed to receive them at the local level. Unfortunately, local mental health services were not in place. Without a safety net, many people were left without the proper care to which they were entitled under the law. It quickly became clear that the lack of appropriate mental health services was having a profound effect on communities, families, and individuals, including children, veterans, and seniors.

Congresswoman Napolitano shared her shock at the release of the SAMHSA/COSSHMO report, "The State of Hispanic Girls," which noted that nearly one out of three Hispanic girls has seriously considered suicide - the highest rate for any racial or ethnic group in the country. She stressed the need for Latinos to recognize that mental illness must be treated like any other illness. The stigma attached to mental illness has been counterproductive, preventing many Latinos from getting the help they or their loved ones need.

She pointed out the critical importance of a comprehensive agenda for Hispanic mental health that in forms Congress of the real and urgent service needs of under-served populations like Hispanics/Latinos.

The Congresswoman noted that she was successful in adding language this year to the House Labor, Health and Human Services, Education Appropriations bill, which identified suicide as a major crisis among Hispanic girls and directed Federal health agencies to deal with this problem more aggressively. She also noted that legislation she sponsored (HR 4439) - the Latina Adolescent Suicide Prevention Act - would fund efforts by community groups and schools to address the mental health needs of Latina adolescents and their families.

On behalf of Mrs. Gore, Mrs. Haynes stated her commitment to improving mental health nationwide. As many as 51 million Americans experience some form of mental illness during any given year, and as many as one in five children have a mental illness. Furthermore, advances in our understanding of the brain have proven conclusively that mental illness can be treated just like any other illness and that people with these diseases can live full and very productive lives.

Over the last 7½ years, the Federal government has significantly increased its investment in mental health services. Congress passed the Kassenbaum-Kennedy bill, which ensures that people can keep their health insurance when they change jobs. It also ensures that people with a preexisting condition will not be denied the coverage they need. The landmark Kennedy-Jeffords bill allows people with mental illness who qualify for Medicaid and Medicare to keep their benefits and return to work, and the creation of the ambitious State Children's Health Insurance Program (S-CHIP) provides health coverage for millions of uninsured children. Furthermore, the program offers a strong mental health benefit. Finally, by passing the Mental Health Parity Act of 1996 and expanding mental health parity to Federal Government employee health plans, the Federal Government has made significant progress toward achieving this goal.

Other changes in mental health care policies are evolving. A national antistigma campaign will soon release its first Public Service Announcement (PSA), which is specifically targeted at young people. There is an ongoing dialogue about policies that expand coverage to every uninsured person in America, as well as work on a strong patients' bill of rights, which puts the power of medical decisions into the hands of patients and medical providers. As part of this effort, the mental health community is working to improve the information they give parents who need to make informed decisions about mental health treatment for their children.

Despite more effective laws and programs nationwide, stigma and fear continue to surround mental illness, preventing people from seeking treatment or helping their loved ones get treatment. Therefore, when prominent people come forward, as Congressman Kennedy recently did, to share their own experiences with mental illness, it goes a long way toward debunking the stigma and opening doors for everyone who has had similar experiences.

Mrs. Haynes concluded her remarks by stating that we all have much work to do to obtain the culturally sensitive and responsive mental health system that everyone needs. There is a tremendous need for more research, more diversity in professional communities, and greater understanding of the needs of people from all races and backgrounds. This Congress's work represents an important step toward achieving these goals. Therefore, Mrs. Gore and her staff are looking forward to learning about the recommendations that emerge from this Congress.

Developing an Action Plan for Hispanic Mental Health
Following keynote presentations in the morning, the Congress divided into workgroups to develop an Action Plan to support the National Agenda. Action items were cross referenced with the agenda items developed on the first day.

The key points discussed by each workgroup are described in the following sections.

• Community mobilization
• Research
• Marketing/public relations
• Policy development
• Accountability

Community Mobilization
The group focused on five recommendations: to train and educate Hispanic consumers and family members to become skilled in educating and informing decision makers in order to create policy changes; implement consumer-focused research; develop community-based services across the life span; develop strategies to help improve prevention and early intervention services in the community by providing school-based services, including before- and after-school services and community-based programs for children and youth 5 to 20 years of age; and provide strength-based community- and home-based mental health services for elderly care, with a family and community focus.

The discussion opened with the suggestion that representatives from Federal and State agencies, as well as consumer and family members, national organizations, providers, universities, and colleges form partnerships to establish training programs in the Hispanic community. These programs would educate Hispanics so that they could work to influence local, State, and Federal policy makers.

Another participant suggested that CMHS fund Tenemos Voz and other consumer groups to conduct national training for Hispanic consumers, so they can be trained to be local advocates. Following the training, opportunities and funds should be provided for creating consumer groups at the local level. Another participant stepped forward and added that consumers could also be educated through advocacy organizations, such as the National Mental Health Association (NMHA), which can provide technical assistance and outreach to local Hispanic communities. Both Federal- and State-funded organizations also could be tapped to do specific outreach to Hispanic communities. Participants added to this idea, saying that Hispanic individuals can be trained to lead a major outreach effort. Alternatively, the Consumer Organization Network and Technical Assistance Center (CONTAC) model could be utilized and adapted for Latino populations. Many participants felt strongly that a partnership model should be developed in such a way that the local residents become the "movers and shakers" of the communities and the ones making the changes. But groups at all levels-Federal, State, and local-need to interface and partner with each other.

After empowering Latino consumers, the group acknowledged that their ideas must then be included in policy statements to educate and inform both national and State legislatures. By engaging individuals in community-based groups who have knowledge of media advocacy, contacts in the corporate world, and contacts in faith communities, the Hispanic community can become a more forceful messenger. Social marketing and implementing social change in order to create social marketing campaigns around these issues.

Another participant pointed out that one of the biggest problems facing consumer groups is the difficulty in identifying Hispanic consumers at the local level who are willing to come forward to participate in training programs. The group discussed who should be involved in identifying these individuals. Group members suggested national organizations, States, communities, and health care providers.

Another suggestion that emerged from the discussion was that a focused effort on developing local Latino youth leadership, largely because they are the ones who often engage and educate their parents. Developing and funding a national mentorship program could be an effective way to get Latino youth involved.

The response to that suggestion was that a needs assessment, funded by the Federal government, should be done to identify what organizations already exist, what kind of work they are doing, and at what skill level. Once the organizations are identified, they could be brought together in a coalition to give greater strength to those already advocating for mental health issues.

The group then turned to another issue-how to implement consumer-focused research. The recommendation in this area was to ensure that community-based initiatives are based upon research programs that have been determined to be valid and effective. Identifing sources that already are funding this kind of research, such as pharmaceutical companies, providing incentives for them to fund research in the Hispanic community was viewed as important. Furthermore, government agencies such as SAMHSA should help ensure that Hispanics are invited to review grant proposals that determine the allocation of funds for programs.

In discussing the Federal government's role in community mobilization, several participants pointed out that agencies such as the National Institute on Drug Abuse (NIDA) and the National Institute on Mental Health (NIMH) should hire Hispanic researchers to conduct research focused on the Hispanic community. Also, private funding sources, such as The Robert Wood Johnson Foundation and the Ford Foundation, should hire Hispanic project officers who are educated to support consumer- and family-driven community-based research and the whole ecology of mental health. The research also needs to address issues related to cultural competency, which should become a criterion for funding. Participants then discussed the idea of linking funding to appropriate, research-based interventions. In addition, the research should be reflective of the emerging demographics of the population served.

The group then moved on to recommend that community-based services be developed across the life span. To implement this recommendation, participants suggested that the National Head Start Association partner with HHS to identify unserved and underserved Hispanic populations in the country. This idea was further clarified by stating that Federal, State, and local agencies should provide funding and technical assistance to Latino community-based entities to operate Head Start programs targeting Latino children ages 0 to 5. The group suggested that current and future Head Start grantees should be required to demonstrate that they are serving Hispanic populations. Furthermore, the consultation and technical assistance provided to all 0 to 5 programs-not just those run by Head Start-must be competent and able to effectively serve the diversity of the populations in their communities.

The group then brainstormed about strategies to ensure that culturally and linguistically appropriate prevention and early intervention services are available for everyone-young children, school-aged children, youth, and the elderly. Participants suggested that school-based services, including before- and after-services and community-based programs, be provided for children and youth 5 to 20 years of age. The group explored expanding this recommendation to include forming a partnership with the National Association of School-Based Health Centers to provide culturally and linguistically appropriate mental health services for the Hispanic population. In addition, community-based organizations should be encouraged to partner with schools to provide a large array of mental health support to young people. Moreover, the Department of Education should be encouraged to support community-based mental health services. Finally, as a way to reach high-risk Latino children and their families, the Federal children's systems of care should be targeted for funding creative school-based programs.

To ensure that all members of the Hispanic community are being reached, the group proposed identifying potential mental health prevention providers and expanding mental health prevention by funding technical assistance program development for these providers. The group also discussed ways to address the critical issues of the over-representation of Latino youth in youth offender or juvenile justice programs. As part of the effort to reach this population, the group recommended that funding be allocated to provide community-based forensic mental health services for adolescents and adults focusing on recovery and reintegration into community life.

The final recommendation the group addressed was providing strength-based community- and home-based mental health services for elderly care. Several participants recommended that faith-based programs, senior citizen centers, and mental health and health care providers provide these services. Pharmaceutical companies also could be called upon to increase the distribution of medication samples to health care providers for elderly populations.

Other participants thought that a public awareness campaign about mental health should be initiated for elderly Hispanics. The campaign would inform this population about the symptoms of mental illness and appropriate care through culturally and linguistically competent mental health education materials. To organize and fund such a campaign, the group suggested forming a partnership with a national advocacy organization to promote the agenda of intergenerational reciprocity.

In summary, the group agreed that all members of the community should be reached through appropriate culturally and linguistically competent programs. Such programs could be available through Head Start, schools, community centers, senior citizen centers, and mental health care providers. As a way to ensure that more research targeted at Hispanics is initiated, the participants proposed that both Federal and private funding sources hire more representatives from the Hispanic community.

Research
The group focused on three recommendations: (1) make Latino mental health and substance abuse an immediate priority for funding agencies in order to promote effective culturally and linguistically competent services and outcomes directly relative for Latinos, consumers, families, and the community; (2) substantially increase the number of Latinos who conduct research in mental health and substance abuse; and (3) identify, develop, evaluate, and disseminate innovative research models and methods that are appropriate for use in Latino communities. These multimodal and multidisciplinary research models should be built into the mechanisms for ongoing feedback from consumers, communities, and other stakeholders.

The first suggestion was to conduct a needs assessment of the Latino mental health community. Then it was suggested that CMHS and NIMH convene a meeting with consumers, providers, policymakers, and legislators at the local, State, and Federal levels to present data on the needs of the Latino community and the importance of addressing Hispanic mental health. This meeting would be followed by a session with public agencies and private foundations for the purpose of having them make concrete commitments and creating set-asides for Latino mental health research. The percentage of the budget allocation should reflect the proportion of Latinos in the United States and its territories. To make the argument that this will be money well spent-making communities safer and advancing public health-demographic data and other available data on services and unmet needs should be utilized. University researchers can become involved by developing a report on the state of Latino mental health in preparation for these meetings.

As a way to learn what research projects are currently in place, one participant suggested doing a needs assessments on mental health and substance abuse research. Also, it is essential to bring the voice of the consumer to new research projects. This could be done by allowing consumers to actually gather the data and work on the research project. It then becomes important to compare the impact of consumer participation on research with more traditional protocols. All consumers represented felt strongly that they should be included in research projects from the onset. An important way to enhance research is to carry it out through partnerships between consumers and providers.

Because mental health in this country is State funded, State mental health commissioners should convene a national meeting twice a year to discuss important issues, such as who enters treatment, who stays in treatment, and which programs are most effective. To facilitate such a meeting, perhaps the National Association of State Mental Health Program Directors (NASMHPD) should be contacted.

Another participant brought up the point that a group of Latino consumers, providers, and researchers should review and evaluate mental health data to ensure their usefulness in providing information about services for Latinos. For example, data from all States could be analyzed specifically for Hispanic access to services, utilization, representation across services, and diagnosis, resulting in a comprehensive report explaining the findings. That report could then be given to the CMHS National Advisory Council and incorporated into the process of bringing in funding agencies. Also, NIDA,NIMH, and SAMHSA should provide an inventory of currently funded Latino mental health projects and document the number of Latino investigators on those projects. In addition, the group recommended that every mental health and substance abuse professional organization and university survey its academic units to identify current Latino researchers by area of research and professional needs.

Discussion also focused on the need to attract young people to research. One way to do this would be to approach potential sources of scholarship funding for the development of research scholarships at the advanced undergraduate and graduate levels. Other participants thought that recruitment should also include those in high school and the early college years. The overriding concern was to ensure that there are enough individuals in the pipeline with the cultural and linguistic skills to conduct sound research. Finally, the group decided to state in the recommendation that Latino-owned businesses, national corporations, and a wide range of other funding sources in the private sector should be asked to provide funds for the training of Latinos to enter the field of research in mental health and substance abuse. One way to do this is through mentorship research programs in which junior researchers are paired with paid senior researchers.

The group then discussed how to develop, evaluate, and disseminate innovative research models. To accomplish this goal, NIMH and SAMHSA should develop a partnership for innovative community-based research methodologies, leading to the establishment of national Latino mental health research centers. These centers should bring together researchers from different parts of the United States to work on research methodologies. These research centers could do their work in CMHS Community Action Grant Latino sites. Eventually, a joint SAMHSA-NIMH center could be established to bring information to consumers, organizations, universities, and other players.

Another recommendation was for SAMHSA to increase the level of funding to partnerships between Latino community-based organizations and universities to replicate and/or develop novel programs to respond to the needs of the local community. In addition, effective, culturally competent services need to be developed; research findings need to be disseminated to communities; and faith communities need to be included in this partnership.

In summary, the group concluded that NIMH and CMHS should develop a partnership for innovative, community-based research methodology, which will result in at least five regional Latino mental health centers with the following objectives:

• Enhanced partnerships with State agencies, consumers, faith communities, Latino community-based organizations, and across academic disciplines.
• Assessment of the effectiveness of culturally specific services.
• Evaluation of cultural competence and effectiveness of services for Latinos, including the refinement of the SAMHSA cultural competence guidelines.
• Dissemination of findings of Federal research projects to Latino communities.
• Establishment of centers "without walls" that are interdisciplinary and include providers, consumers, and researchers from all disciplines.

• Increase the relevance of the research.
• Speed the development of mental health research considered valuable to public health.
• Translate the research in ways that will be embraced by various constituencies. Focus on research that has the potential of having an impact on public policy.
• Obtain knowledge about relevant research among different mental health services agencies.

The report highlights the importance of taking action promptly to oversee improvements in the delivery of mental health services to the country's Latino population, to create a culturally and linguistically appropriate model of service delivery, and to use the resources in the community to accomplish these goals. Although following this model can be time-consuming, the end result will be a new model of service delivery based on data that can be extended to other ethnic groups. Making these changes is essential; the Hispanic community has a staggering number of unmet needs, as well as under-utilization of services, stemming primarily from lack of knowledge about where to receive treatment, the distance between treatment centers and local residences, lack of transportation to treatment centers, and the lack of Spanish-speaking professionals. To reach the people who need help, it may be necessary to develop a very comprehensive outreach program, even to the point of purchasing buses and sending fully equipped vehicles on the road to find people in need of mental health services.

The discussion then turned to the issue of accountability. One participant stressed holding Federal agencies accountable, perhaps by having them join with SAMHSA to organize a second Congress. The importance of beginning action at the local level with groups already established within the human services system and among community advocacy groups was also identified as critical. These local groups could then connect with national organizations.

One participant suggested that part of the problem is that often there is a poor match between what people need and what is offered. Also, when seeking mental health services, people feel they have limited options, rather than feeling as though the services provided give them an opportunity to grow and develop. Asking consumers what they need could help bring about much-needed changes.

The group then focused on recommended actions. Participants discussed PSA's as a way to educate consumers, but also stressed the importance of knowing what message is being conveyed and translating the message into good Spanish. Participants also suggested appointing Hispanics to key policy positions and involving Hispanics in clinical trials and study groups, including initial review groups (IRGs). Participants also recommended creating a Hispanic Commission on Mental Health that is well represented by a cross-section of all who are interested and concerned, including consumers.

This Hispanic Commission could also take the lead in developing a comprehensive summary of data about mental health issues in the Hispanic community, as well as an inventory of Latino organizations at the Federal, State, and local levels. After determining what data exist, the Commission could help determine what direction to take and how to link with the President's Initiative on Eliminating Disparities in Mental Health Services. Dissemination could take place through presentations given at universities, to providers, and to national organizations. Also, a website would be effective for disseminating information to large numbers of people. Finally, the Proceedings from this Congress should be disseminated to all Federal agencies that support mental health-related programs.

At the State level, it is essential to appoint Hispanics to planning advisory councils, committees, and study groups and to develop executive summaries to key research findings in order to practice and utilize recommendations. At the local level, families and consumers need to plan, develop, and support chapters and other self-help group activities.

Other recommendations included the following:

• Appoint Hispanics to national, State, and local boards of national mental health associations.
• Connect with other national organizations to share recommendations for further dissemination.
• Conduct aggressive provider outreach to identify and network with Hispanic mental health professionals.
• Provide educational opportunities in universities and colleges to learn about multicultural issues for faculty, staff, and students. Funding for scholarships at all levels should be increased.
• Review salaries for bilingual/bicultural social workers or mental health professionals. Provide incentives for people to enter those professions.

The group then addressed the issue of standards. One participant described standards as guidelines for ensuring that there is representation at various levels and that the unique needs of Latinos are considered in the way mental health services are delivered. Participants also outlined criteria for creating certain kinds of services, such as bilingual and bicultural crisis lines, and for ensuring that minority health specialists are available. The group concurred that all States should establish cultural competence standards. Furthermore, Federal dollars should be attached to standards, and accountability for implementation of standards should be built into the performance of grants, programs, and contracts. Academic institutions should then teach and train providers and administrators on meeting the standards.

As a way to educate public officials, one participant suggested bringing together several organizations and developing a kit for dissemination. Furthermore, specific announcements and materials developed should be targeted to Latino issues. The group concluded by noting that designing creative dissemination vehicles is essential for educating the Hispanic community on these important issues.

Policy Development
The group began by looking at developing action steps for the recommendations. The first recommendation focused on changing Federal, State, and local policy to eliminate Hispanic health disparity and to support the delivery of efficient, effective, and innovative mental health services in all settings. One participant suggested that an attempt be made to mandate all States to include mental health services in the CHIP legislation. Another participant added that States must provide a mental health benefit that is equal to or better than a benchmark plan, which is typically the State personnel insurance program. With regard to substance abuse, however, there is no mandate for a substance abuse benefit in CHIP.

Participants discussed how to make States accountable for implementing CHIP programs. Suggestions offered included having Congress submit a formal request to CMS to be more aggressive in monitoring the implementation of these plans, having CMS assign a project officer to each State, and having each plan reviewed by the State representative and an advocate organization. The group also said that communities need to be aware of how the CHIP is being implemented and raise red flags if they see problems. Another participant said that SAMHSA and CMS should produce a biannual accountability report on how funds for the CHIP program were used to provide services to Latino populations. One participant made the point that only 3.7 percent of Medicare expenditures go for mental health. An estimated 9 to 12 percent of Medicaid goes to mental health and substance abuse. These issues should become a high priority at the local level.

Another participant suggested that additional data are needed, and one way to get that information is through a website survey. The new data would enable providers to reach consumers who have not been accessed before through the mental health planning councils. By creating new data, new policy could be developed that would result in increased funding for mental health services. The Steering Committee from this Congress could direct this effort. A partner from the National Mental Health Consumers Self-Help Clearinghouse said that the Clearinghouse could help develop the website. A representative from the National Mental Health Association volunteered to distribute the data currently available on the CHIP plans and on coalitions currently working on this issue.

The group then turned its attention to the issue of cultural competence, agreeing that this issue should be a priority and that cultural competency standards should be promoted. Furthermore, States should require that providers meet cultural competency standards in order to participate in the Medicaid program and that CMS should take the lead in monitoring whether the States are using the standards. To implement this suggestion, however, funding must be appropriated. In addition, a representative from the Latino Behavioral Health Work Group, which developed the standards, should be part of the monitoring team. One participant pointed out that NASMHPD could become involved in promoting the implementation of the standards with State mental health program directors.

Then the group moved on to the issue of funding. A suggestion was made to request a set-aside from SAMHSA for Hispanic mental health programs. Congress participants then added a request for additional funding from all Federal agencies for Hispanic mental health services to their list of action items. In addition, the group suggested that the SAMHSA Administrator request that the Agency's Centers earmark a certain amount of money to address the technical assistance needs of Hispanic consumers. The group agreed that consumers need to be educated so that they demand better services.

The group also discussed new ways to reach consumers. One idea was to ask SAMHSA to fund innovative mental health programs that are culturally and linguistically competent in settings such as juvenile detention centers and consumer-operated groups. Another participant suggested that CMHS support innovative models of consumer self-help as a way to provide limited services to those who do not have access to health care practitioners. To reinforce this idea, another participant suggested that SAMHSA and HRSA require in their cooperative agreements that the schools of public health or the entities with which they are developing a grant include cultural competency training in their grant activities.

The next issue discussed was the need to mandate Latino representation on all boards within government, including advocacy groups, review committees, policymaking committees, and advisory committees. To implement this recommendation, the group suggested that the Steering Committee identify individuals from key groups who would help ensure that Latinos are adequately represented.

In summary, the group suggested that the Steering Committee form a task force composed of various stakeholders to implement these suggestions. Perhaps SAMHSA could also dedicate staff to this project. It is key that adequate funding within an appropriate timeframe be determined to implement the stated agenda.

Accountability
The first recommendation addressed was to implement and enforce clinical access and outcomes standards at the national, State, and local levels. A participant suggested that cultural competency within the accrediting bodies and organizations, including the Joint Commission on Accreditation of Health Care Organizations and the National Committee for Quality Assurance, be assessed as part of a process to implement cultural competence standards nationwide. Furthermore, Federal funding from all agencies should be contingent on demonstration of cultural and linguistic competence. The American Psychiatric Association could help ensure cultural competence, as could other professional organizations, national organizations, local chapters of The National Alliance on Mental Illness and other local consumer groups, provider associations, and licensed mental health professionals. Federal, State, and local funding entities should include cultural competence in performance expectations, including contracts and subcontracts. Insurance companies also should be required to adhere to cultural competency standards. In addition, consumers need to be involved in overall decisionmaking, including decisions related to funding.

Another issue discussed was the goal of having every State mental health authority establish a management-level position for enforcing cultural competence, with Hispanics appointed to these positions. In addition, Latino staff should be encouraged to pursue further education as well as leadership development training.

In terms of funding, the group discussed the importance of defining where the money needs to go and who is to receive it. To expedite the Agenda, it was suggested that HRSA, CMS, and SAMHSA direct an increase of training funding to Hispanic communities. Furthermore, there must be mechanisms in place to ensure that funding is proportional to the needs and numbers of the Hispanic community. Also, Congress should authorize and fund SAMHSA to support community training and education for the Hispanic consumer community.

The group then agreed that a representative body, described as the Steering Committee, should be formed to continue the work of this Congress. Part of the Steering Committee's charge would be to promulgate a report card on cultural competence and to obtain a signed executive order from the President pledged to implement the National Agenda for Hispanic Mental Health. The report card agreement would include assurances of a bilingual staff, training in cultural competence, consumer reports on cultural competence, penetration rates in relation to the demographics of the community, retention rates of Hispanic patients, performance data by race and ethnicity, and written policies with clearly delineated standards.

Dr. Satcher opened his remarks by stating that mental illness is real and affects one in five Americans, a number that shocks many people. Of the 44 million Americans afflicted, 13.7 million are children. Of these children, many either are not getting treatment or are getting medication without appropriate diagnostic assessment. This situation must change, which can happen only if families work in partnership with physicians and mental health professionals.

Furthermore, mental illness is debilitating, resulting in lost productivity, unsuccessful relationships, and significant distress to everyone it touches. It affects every age group, from the very young to the very old. Therefore, primary care practitioners are critical players in the early diagnosis of certain mental illnesses, such as depression. In the best of all possible worlds, mental health professionals would establish partnerships with primary care physicians, pediatricians, and teachers.

The issue of access to mental health services was addressed by President Clinton when he announced at the White House Conference on Mental Health that all health plans covering Federal workers-affecting about 9 to 10 million workers-will have to provide parity of access to mental health services in their programs. In addition, since the release of the report, many States have introduced legislation for parity of mental health services.

Dr. Satcher concluded by saying that all of us-consumers, mental health professionals, primary care practitioners, leaders in government, lawmakers, and community activists-must work together to build a strong health care system, "brick by brick." In doing so, the Federal Government is committed to increasing Hispanic/Latino representation within the health professions and to funding more community-based programs.

Dr. Chavez brought the Hispanic Congress to a close by commending everyone on the tremendous accomplishments of the past 2 days and reminding participants of the story of The Three Little Pigs. Everyone knows that the house that survived was the one made of bricks. In the case of the Hispanic mental health agenda, it is key that this "house" is built solidly of "the bricks and mortar of collaboration. What you have done today, joint action, this can last a lifetime." Therefore, the group must remain united, strive to collaborate and coordinate efforts, and work together "from the community up, not from the Nation's Capital down."

Conclusion
This report documents the discussions and thought processes behind the National Agenda and the Action Plan as developed by the National Congress for Hispanic Mental Health. The National Agenda for Hispanic Mental Health truly represents the consumers' voice and, by consensus, was adopted by this Congress. The Agenda also highlights the key recommendations made by leaders of every faction of the Hispanic mental health community. The Action Plan for Hispanic Mental Health focuses on what changes need to take place in these areas:

• Consumer, family, and community education
• Accreditation, standards, regulation, and human resources
• Prevention and early intervention
• Mental health services
• Hispanic research

The Action Plan, linked to the National Agenda, focuses on how to implement the Agenda. This must take place by use of the following strategies:

• Community mobilization
• Research
• Marketing/public relations
• Policy
• Accountability

The National Agenda is clear about what steps need to be taken in each area. Partners worked with stakeholders to plan those steps. Continued commitment building, partnering, and accountability are needed at the Federal, State, and community levels to ensure that the actions identified at the Congress are carried forward to make an impact on the mental health of the Hispanic community.

Stakeholders from the Congress plan to move forward with their National Agenda and Action Plan. They welcome the opportunity for collaboration with others committed to responding to the mental health care needs of the Hispanic community.

SAMHSA plans to continue to work within the agency to improve mental health for all Americans, including Hispanics.

8/9/00