Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
The Judges Leadership Initiative Annual National Meeting
Judges As Champions in System Transformation at the Interfaces of the Mental Health and Criminal Justice Systems
April 5, 2006
Boston, MA
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
Slide 1/Cover
Thank you, Hank, for that kind introduction. And thank you, members of the Judges Leadership Initiative, for inviting me here to speak to you today.
Over the past three years, I have traveled across America, speaking to policymakers, providers, advocates, members of the business community, and consumers and their families about the urgent need to transform our nation’s public mental health system. At every stop, I have urged these audiences...leaders from every sector of society…to join me…to join SAMHSA and its federal partners…as agents of change…agents of transformation.
This afternoon, it is an honor and a distinct privilege to stand before you…leaders of the judiciary who have taken the role of “change agent” to the next level. You are champions…champions of transformation.
Judges as champions …defenders…supporters… advocates for the more than a quarter of a million men, women, and juveniles with serious mental illnesses who encounter the criminal justice system each year. What a powerful image this evokes! I am here today to salute each of you for the extremely important work you are doing to re-direct lives…to restore hope…to, literally and figuratively, offer the promise of a better, brighter future for so many Americans.
I am here today because I am on a mission to solve the systemic problems that have allowed adults and juveniles with serious mental illnesses to fall through the cracks of our fragmented mental health and social service systems and land in your courtrooms as systems of last resort. I am on a mission to create a transformed, recovery-focused mental health care system with the capacity to deliver the services these individuals need to live their best, most empowered lives in the community. Themany interfaces of the criminal justice and mental health systems are critical points of opportunity to realize this vision.
Improving outcomes for people with mental illnesses—our consumers, your defendants—is a cause we can…and we must…champion together. I am here today to enlist your continued leadership around these urgent issues.
We need champions…champions like you, Justice Evelyn Stratton and Judge Steven Leifman. In addition to doing pioneering work in promoting jail diversion in your own States, you are leading this critically important effort…bringing together judges who are committed to this work and giving them the tools and information they need to increase their effectiveness in their communities. One needs only to look around this room…at how large this Judicial Leadership Initiative has grown…to understand the value of your stewardship.
We need each of you: honored members of the bench who already embrace the recovery model...who already emphasize “therapeutic jurisprudence” or “transformative justice” in your courtrooms...who are already leading the charge for an integrated approach to mental health and criminal justice issues. You are absolutely essential to the transformation agenda. We need champions, like you, to mobilize others to take up the cause.
As we have worked with communities across the United States, directly via our Targeted Capacity Expansion Jail Diversion Grants and indirectly through the GAINS and TAPA Centers and the CMHS CSG Center for Leveraging Change, we have seen...firsthand...how often judges are the most effective catalysts for community innovation. There are places that judges can reach…sectors you can influence and persuade…that others simply cannot. Judges are an extraordinary resource for systems change.
No one in State and local government has greater integrity, commands more respect, or inspires more confidence than judges. You have a way of overcoming obstacles...a keen ability to resolve differences…to break through the barriers. Whether you are urging key stakeholders to attend planning meetings...encouraging elected officials to “find” the necessary funding...acting as credible spokespersons for the media…or bringing a holistic, team approach to court involvement on special dockets…nobody does it better.
You have had remarkable success so far...and, your efforts have not gone unnoticed. The resolution that the Conference of Chief Justices passed a few months ago signals real interest and commitment from the nation’s pre-eminent judicial organization. I am very excited about your work with this group to identify and support teams at the State level. where the Chief Justice will take on a critically important role—convening the heads of relevant agencies and encouraging them to see the shared responsibility they have for improving outcomes for people with mental illnesses involved in the justice system. I was pleased to learn that this initiative has also attracted the attention of private foundations. Their willingness to support these efforts demonstrates how federal, State, and private dollars can be cobbled together to multiply the impact!
The Judges Leadership Initiative is a key element of our strategy, at the Federal level, as we work to engage stakeholders inside and outside the circle of mental health in the transformation of our national system as envisioned by the President’s New Freedom Commission on Mental Health.
Slide 2/NFC Report & Action Agenda
As many of you know, two years ago, SAMHSA/CMHS launched an unparalleled movement at the Federal level to transform the way mental health services are perceived, accessed, delivered, and financed in this country...a vision outlined in the New Freedom Commission’s final report, Achieving the Promise: Transforming Mental Health Care in America. Today, we are making real strides toward realizing the vision. We are giving it legs.
In partnership with agencies from nine federal departments, we have released the Federal Action Agenda—the roadmap that will guide our steps as a nation toward this wholesale transformation. These are the first, time limited, realistic steps that SAMHSA and the federal partners can take during the next year to move transformation forward.
But transformation of this magnitude will take resources beyond what SAMHSA can provide…beyond what State mental health systems have at their disposal. Champions outside of mental health will be key to our success.
As a result, we are heavily invested in understanding how to effectively partner with you to nurture your continued involvement in system transformation. We want to know how we can be more supportive to those of you already taking the lead on issues at the intersection of mental health and criminal justice. We want and need your counsel and assistance in engaging more judges in this critical endeavor.
This morning, I would like to take a few moments to share some of what we have learned as we have developed the evidence base for effective service system models in jail diversion and other aspects of community living critical to justice-involved consumers. These are issues that will be important for you to understand and address as you consider new options for working with adults and juveniles with mental illnesses and serious emotional disorders. Afterward, I hope you will share your thoughts about issues that will be germane to us, in mental health, as we advance the transformation agenda.
Slide 3/Trauma-Crossroad of MH/CJ
I believe that one critical focal point for our future work together is around women’s mental health—specifically, services and supports to resolve mental health issues related to victimization and violence that complicate the lives of so many female offenders...offenders who too often do not benefit from traditional sentencing.
I believe this is the emerging issue at the crossroads of mental health and criminal justice. The GAINS Conference agenda bears out this point: there are 18 different sessions being devoted to trauma at this conference, alone.
The Council of State Governments recently released an Issue Brief on Seriously Mentally Ill Women and Crime Victimization that confirms the urgency of this issue. The Council is convening a broad policy-oriented group to develop recommendations for various constituencies, which importantly, will involve the coordination and collaboration of mental health, domestic violence, rape, health, substance abuse, and criminal justice and victim assistance.
This issue—the inextricable link between violence and trauma and women’s mental health—is one that resonates deeply with me on a professional and personal level. I have made it my life’s work to champion women’s recovery from the impacts of violence and trauma. It is my personal mission to empower these survivors…along a continuous process of healing…to leverage themselves as their own source of power…particularly, of healing power.
In the early 1970’s when the women’s movement raised our collective consciousness about the impacts of the traumas of rape and domestic violence on women’s lives, I steered my mental health counseling and professional experience toward women who experienced violence and trauma. I learned again and again that a woman’s searing exposure to the raw trauma of physical or sexual assault put her overall emotional health at very high risk for both the short and long term. I learned, too, that the power of violent and traumatic life events to destabilize individuals had been systematically missed by the mental health field almost altogether.
This was a heady time for the emerging issues related to the emancipation of women. Women told us that they wanted to recover from the traumas of rape, incest, and domestic violence, but that they needed support and time to heal. This is when I began to understand that, as a caregiver, it was my job to find a way to move with them on their journey of recovery. For recovery to occur, however, it was necessary for the choice, direction, and leadership of recovery to flow from the woman herself.
Slide 4/SAMHSA Women & Trauma Activities
Today, as Director of SAMHSA’s CMHS, it has been one of my personal priorities to open the nation’s eyes to the impacts of trauma in achieving emotional health and recovery. Today, we are making real progress toward creating a trauma-informed national system of care. Through the work of our National Center on Women, Violence, and Trauma, SAMHSA is developing leadership networks to spread information about emerging best practices and to stimulate local change. Today, the SAMHSA/CMHS Women’s Coordinating Committee—a group charged with promoting the importance of health issues of women across SAMHSA—is planning a series of activities, including trainings focused on the integration of trauma-informed services in public health facilities. We are committed to helping States, and others, respond to these intertwining issues with integrated, community-based solutions.
Slide 5/The Public Health Approach
A public health, community-based approach that stresses the links between health and the physical, psychological, cultural, and social environments in which people live, work, and go to school is critical. The fundamental premise is that it is inherently better to promote health and prevent illness before it begins. We know we must address the impact of trauma on women to promote health and prevent illness.
What we have learned about the pervasive lifelong impacts of violence and trauma in women and children brings urgency to our need to act now. I would like to offer a few highlights about what is known.
Slide 6/Impact of Trauma
What do we know about the impact of trauma? We know that trauma is no longer regarded as an anomalous experience. Trauma is increasingly seen as an almost universal experience of public mental health and human service recipients (Bloom; Jennings).
One study conducted through the National Association of State Mental Health Program Directors and funded by SAMHSA reports that up to two-thirds of both women and men in substance abuse treatment programs report childhood abuse or neglect. Nearly 90 percent of women who are homeless and who also have a mental illness experienced severe abuse as both children and as adults. Between 30 and 60 percent of women who abuse substances meet the criteria for post-traumatic stress syndrome. Most often, their syndrome is rooted in a history of repetitive childhood abuse.
Addressing trauma is increasingly recognized as essential for recovery! Providers as well as consumers are beginning to see that, without integrating a focus on trauma, improvement in symptoms such as depression and substance-use disorders will not occur…and, without this integration of services, a recovery-oriented system is impossible.
Major and costly human service systems failures—for example, self-injury in adult criminal and juvenile justice, seclusion and restraint in psychiatric and other facilities, repeated failures to maintain housing or employment, heavy use of health care services, and suicide—can often be traced to ignoring or treating trauma with the wrong clinical paradigm.
In mental health services there are spiraling costs for “treatment as usual” for consumers with trauma histories. Their entrenched symptoms necessitate repeated returns to ineffective services that do not reduce their overall misery, and contribute to cynicism regarding recovery. The same holds true when these individuals cycle in and out of the criminal justice system.
Slide 7/Trauma Interventions
What do we know about trauma interventions? We know that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts (Shepard; Briere) . Proven models and tools for intervening and treating trauma-related problems have been developed (Harris; Najavits; Miller; Ford). These tools are now available to the mental health systems and practitioners, and increasingly, are being adapted to other populations and systems, including juvenile justice, jails and prisons, and domestic violence shelters.
We know that to fully address the needs of survivors of trauma within the public mental health service system, we must adopt a systemic approach...an approach characterized both by trauma-specific diagnostic and treatment services and a “trauma-informed” environment capable of sustaining these services. This change to a trauma-informed service system environment represents a profound cultural shift in which consumers and their conditions and behaviors are viewed differently. Effective systems for service delivery must embrace policies and practices that create emotionally safe and personally empowering conditions and choices for trauma survivors and staff. This requires a new management orientation, for which several trauma-informed organizational change guides are now available (Harris and Fallot) .
Time and again, hope and self-determination have proven to be essential elements for consumer recovery. Speaking one’s voice, the freedom of choice, and the willingness to seek personal solutions for the challenges raised by the crisis of violence are fundamental to recovery.
Consumers have become “trauma champions”—helping to develop systems and services for ongoing treatment. Their powerful personal stories have shaped treatment that is trauma-responsive to the wide range of their needs (Veysey) . Programs to train and support emerging “consumer champions” who have survived trauma have been developed and successfully pilot-tested ( McKinney) .
Slide 8/Trauma Outcomes
What do we know about trauma outcomes? I am proud to say that the SAMHSA-sponsored, five-year Women and Violence Study has provided the most authoritative and comprehensive view to date of what can be accomplished in the public health system…with women who have histories of physical and sexual abuse…who are in need of services for both mental health and substance-use conditions.
This groundbreaking study featured a trauma-integrated counseling approach that addressed both mental health and substance-use conditions. Findings at both six and 12 months suggest that integrated counseling—for example, group and individual therapy that addressed trauma, mental health, and substance-use conditions—was the key element associated with better outcomes.
Given this impressive body of knowledge about trauma and recovery, where do we stand now in terms of readiness for action?
The new Federal Mental Health Action Agenda calls for the development of toolkits for evidence-based trauma-informed systems and services to help to spread what we know about assisting people…the same people who come before you in your courtrooms…to survive trauma.
A number of States and communities are already integrating gender and trauma services within their jail-diversion programs…with measurable success. You can learn more about some of these programs during the conference sessions. I urge you to check the Agenda and sit in on a few of these presentations. I think you will be intrigued by what you hear.
Slide 9/Program Examples
Connecticut , for example, has developed a jail diversion model specifically for women affected by trauma who have substance use disorders and mental illnesses. The Women’s Support Program in Hartford and New Briton targeted high-risk repeat offenders…women who judges would ordinarily have been reluctant to return to the community. Initially, the community court judges that were asked to participate in the study were skeptical. But, once they recognized what trauma does and the cyclical, self-defeating behaviors it causes…once they saw the early success of this program…these judges became believers. And their confidence has proven to be well founded. The 128 women who participated in the program evaluation showed significant improvements in substance use, employment, arrests, trauma symptoms, and importantly, in hopefulness.
Maryland ’s TAMAR—Trauma, Addictions, Mental Health, and Recovery) Project—treats trauma disorders in incarcerated women in 12 of the State’s detention centers and one State hospital. The project, originally funded through the SAMHSA Women and Violence demonstration grant, has continued to expand across the State well after the Federal funding ended. A second project, TAMAR’s Children, provides comprehensive inpatient and community-based supports for incarcerated pregnant or postpartum women with trauma histories who have co-occurring mental and substance use disorders. This program is designed to foster secure mother-infant attachments by allowing these women to keep their babies. States from Ohio to New Hampshire have expressed interest in the TAMAR model.
A post-booking jail diversion program in Hawaii County, on Hawaii’s Big Island provides another promising example. The State mental health department recognized that it was serving a large number of detainees with trauma histories in its jail diversion program. Yet, the Department knew little about how to help this population. It worked with the TAPA Center to learn about the components of a trauma-informed system, to select a flexible model upon which it could develop trauma-specific services and, then, to train case managers in implementing trauma-specific treatments with consumers who returned to the community under the supervised release program. The results of this program are very promising. In fact, the program now serves as a model for three additional state-funded programs on Hawaii’s three other largest islands.
Each of these examples demonstrates a critical point: To eliminate trauma and reduce its impact, we must expect and anticipate trauma histories in the populations we serve…and we must be prepared to meet their needs with trauma-informed, trauma-specific treatment and services. The criminal justice system is a key component of that strategy.
Which, brings me back to you...the champions. You are essential to this endeavor. We need you to help us find the common ground on which we can base future collaborative efforts with the justice community. We need you to think outside the box, and help us to identify new allies and supporters. We must seize every opportunity to work together...to involve every stakeholder in the community...to enhance the health and safety of all our communities. This is transformation…and it begins within each of us.
I want to assure you that SAMHSA stands ready to provide all the resources at our disposal to assist you in implementing the kinds of transformative activities I have described today in your communities. For instance, CMHS has funded the National Association of State Mental Health Director’s and the National Technical Assistance Center for State Mental Health Planning (NTAC) to develop a “train-the-trainer” curriculum on trauma-informed care in social services settings. These and other resources are available to help spread the word about these transformative programs and strategies.
Change of this magnitude will not be easy work. But, you—in your positions of influence and authority—are uniquely suited to take the lead in this dimension of transformation.
Slide 10/Bennis Quote
Transformational leadership—or leadership in the new paradigm, as leadership expert Warren Bennis describes it—“is not about great leaders alone, but great leaders who exist in a fertile relationship with the Great Group.” In these creative alliances, he says, “the leader and the team are able to achieve something that neither could achieve alone.”
I urge each of you...leaders, champions at the interface of criminal justice and mental health...to continue to work with us to forge the creative alliances that are necessary to empower the adults and juveniles we both serve. Continue to reach out to your colleagues and enlist their support for this endeavor. Together, we can do something that none of us can do as effectively, alone—transform lives! Thank you.
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