2006-2010 Statewide Comprehensive Plan for Mental Health Services
Chapter 4
Implementing the Balanced Scorecard Approach - Aims and their Significance

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Driving OMH's commitment to accountability, best practices, coordinated mental health services delivery, and disparities elimination has been a set of integrated processes to improve service quality: gathering input from stakeholders on relevant areas of performance, collecting and analyzing performance data, reporting results, and using the data to refine programs and services. Together these processes have formed a continuous quality improvement cycle (Figure 4.1).¹

As depicted in the model, measuring the performance of the State public mental health system is critical to facilitating change and improvements in the quality and effectiveness of public mental health services, to ensuring accountability, and to reflecting progress toward attaining the shared goals of the State mental health authority, providers, individuals and families served within the system, and other stakeholders. Performance data are essential for monitoring progress, informing resource allocation and utilization, shedding light on service need and illuminating the necessity to diminish disparities in access to appropriate and effective mental health services. Performance measurement is at the heart of a person-centered, recovery-oriented focus, helping to identify the unique needs of individuals, particularly among vulnerable and underserved populations, and to enrich capacity in geographic areas where limited resources might be insufficient to meet the needs of individuals and families served by the system.²

A 2002 study of performance measurement at the state and local levels found that 70 percent of state budget office, state agency, and city/county department respondents concurred that their governmental entities were better off as a result of using performance measurement. Overall, respondents agreed that the successful implementation of performance measurement hinged on the continual use of measures to monitor progress, strong leadership at the executive level, a clear understanding of the purpose of performance management, and the availability of resources and technological support to carry out performance measurement.³

The 2004-2008 Statewide Comprehensive Plan for Mental Health Services documented strong momentum toward advancing OMH's quality agenda through shifts in policy and culture toward continuous quality improvement. It made clear OMH's intent to collaborate with stakeholders and incorporate many of their contributions for quality improvement into the OMH planning process. This impetus to sustain and improve quality pressed forward with the release of the 2005-2009 Statewide Comprehensive Plan, in which OMH took a major step forward by operationalizing the agency's strategy into a set of goals and objectives. Following a series of public forums in 2004, this set of goals and objectives was created and specified in the 2005-2009 Comprehensive Statewide Plan (see Figure 4.2).

Figure 4.2
Major Goals and Objectives 2005-2009 Strategic Plan

Goal 1
Improve the mental wellness and resiliency of all New Yorkers through an effective public education function.

1.1. Increase public awareness of the prevalence of suicide and of risk and preventive factors.
1.2. Maintain agency capacity to rapidly and effectively provide mental health support in response to natural and man-made disasters.
1.3. Improve public understanding of the causes and treatment for mental illness in adults and serious emotional disturbance in children.
1.4. Promote rapid response to the detection and treatment of the psychological aspects of eating disorders.
1.5. Promote early intervention and prevention strategies, particularly with primary care physicians and other health care providers.

Goal 2
Improve the quality of mental health services currently available to all adults with serious mental illness and all children with serious emotional disturbance.

2.1. Increase the availability of evidence-based practices in routine care.
2.2. Decrease the risk of experiencing adverse consequences resulting from harm, neglect or sub-optimal care or treatment.
2.3. Increase the State’s capacity to measure and monitor the quality of care.
2.4. Increase the State’s and counties’ capacity to improve performance based on outcomes measurement.
2.5. Maintain adequate resources to ensure that high quality services are able to be provided.

Goal 3
Increase State and Local accountability for improvements in access to services, quality and appropriateness of services, and cost of services.

3.1. Improve the State/Local mental health planning process to promote accountability.
3.2. Improve care coordination for people with multiple inpatient admissions and little connection to appropriate outpatient services.
3.3. Improve oversight of medication practices for both adults and children.
3.4. Improve the service provider certification and licensing process.

Goal 4
Reduce the burden of illness through strengthened ties with the scientific community engaged in both basic and applied research.

4.1. Improve knowledge about the causes of mental illness.
4.2. Promote the development of new treatments.
4.3. Improve culturally competent models of service delivery using consumer input.
4.4. Improve the length of time it takes to disseminate research findings to relevant audiences.
4.5. Improve the degree to which research scientists provide technical assistance (both continuing education and consultation) to service practitioners.
4.6. Improve the degree to which the agency can assess the magnitude of social cost and burden in order to prioritize resource utilization.

Goal 5
Improve outcomes for adults with serious mental illness and children with serious emotional disturbance through use of proven, effective treatments.

5.1. Increase planning efforts concerning inpatient admissions and readmissions.
5.2. Decrease use of treatments shown to be ineffective.
5.3. Increase consumer and family input and participation in the treatment planning process.
5.4. Increase use of underutilized services known to be effective.
5.5. Improve access to services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 6
Increase access to appropriate and effective services for special populations.

6.1. Improve services for children with depression.
6.2. Improve services for people with mental illness who use forensic systems of care.
6.3. Improve services for young adults.
6.4. Improve services for older adults.
6.5. Improve services for people with mental illness who reside in adult homes.
6.6. Improve services for people who require intensive levels of care coordination, including people served by the SPOA system, ACT teams, and people served through the Assisted Outpatient Treatment program.

Goal 7
Improve the capacity of State and Local governments to achieve agency goals.

7.1. Maintain sufficient resources for State and Local service delivery at levels necessary to ensure appropriate access to services.
7.2. Improve retention and recruitment to ensure a qualified workforce.
7.3. Improve system capacity for delivery of culturally competent services.
7.4. Improve system capacity for delivery of consumer-requested services.
7.5. Improve system capacity for employee skills development and competency.
7.6. Maintain system capacity to articulate cost-effectiveness.

Gathering Stakeholder Input

Major stakeholders were invited to five regional State forums in the spring of 2005 and asked to respond to a series of questions regarding the set of goals and objectives published in the 2005-2009 Statewide Comprehensive Plan. The feedback illuminated how consumer and family expectations and satisfaction could be better met, how processes could be improved to obtain better outcomes, how workforce contributions and infrastructure could be sustained and enhanced to create the best value for New York's citizenry, and how progress and results could best be tracked, measured and reported. Specifically, this year's statewide informational briefings and hearings focused on the extent to which the goals and objectives in the 2005 Plan captured the priorities and expectations expressed by stakeholders in the previous year. Specific questions addressed included:

• Do the goals and objectives presented capture the full range of priorities for improving the quality of the public mental health system and promoting recovery for adults with serious mental illness and children with serious emotional disturbances?
• Which goals and objectives to be addressed over the multi-year planning period should receive the highest priority over the next two years?
• Which specific initiatives within the goals and objectives should be emphasized over the short- and long-term planning periods?

Extensive stakeholder input solicited during these forums, along with input from the many other forums and opportunities, was carefully documented, synthesized, and considered by OMH. In particular, the need to distinguish between individual and system perspectives was highlighted by stakeholders and recommendations were made to reflect these views in the Framework. Additionally, OMH conducted a review of the literature to survey its external environment, thereby enhancing the likelihood that the goals and objectives would be consistent with the latest science and knowledge.

What follows is a summary of the input received during this year's strategic planning forums as it pertains to the overall organization and emphasis of the Strategic Plan. The input is accompanied by brief summaries of the national and State perspectives in each area. The summaries, while not exhaustive, are intended to provide an overview of the types of information considered by OMH in scanning its environment and preparing to identify agency strategic priorities. Chapter 5 provides a summary of specific changes to the goals and objectives recommended by stakeholders and the revisions that were made following their careful consideration. Both chapters contain stakeholder perspectives on priorities for the public mental health system and recommended strategies for meeting goals and objectives.

Enhancing the Strategic Framework through the Addition of Aims

The addition of a set of aims (see Figure 4.3) to the 2005 Strategic Plan Framework is the most profound change to the structure supporting OMH's strategic direction. This change, as well as other refinements to the goals and objectives statements covered in Chapter 5, was driven largely by input received from stakeholders. The creation of these four aims validates the thoughtful insights and contributions of those individuals and groups having concern for and an investment in the State public mental health system.

Figure 4.3
Aims for the New York State Public Mental Health System

• To promote the achievement of person-centered recovery goals for children, families and adults
• To promote wellness and resiliency for individuals and communities
• To promote cultural and linguistic competence as an integral part of all mental health services
• To promote community integration and acceptance through the reduction of stigma

Described by stakeholders as "overarching goals," the four aims fundamentally reflect what OMH desires to accomplish. They emphasize the impact services and supports have on individuals, their families and communities. The goals and objectives were seen by stakeholders as representing a system perspective, specifically what needed to occur at the systems level to attain the aims highly valued by recipients of services and their families and by OMH. The aims, therefore, are not only supported by the eight goals and their individual objectives, but also by a balanced person-centered, recovery-oriented approach at the systems level. The aims, goals and objectives provide a stable structure for staying focused on what matters.

Aim 1: Promoting the achievement of person-centered recovery goals for children, families and adults

Stakeholders emphasized support for the agency's mission to focus on recovery and wellness. They stressed that central to all of the goals is the concept of recovery. They asserted that the attainment of person-centered recovery goals is the most crucial aim of the public mental health system. This recommendation is well supported by the literature.

Changing attitudes and expectations

Despite significant advancements in the field of psychiatry over the last 50 years, attitudes about recovery from mental illness continue to reflect teachings from the early 1900s when the predominant belief was that recovery was not possible. Attitudes today are complicated by social and economic forces, discrimination and violence against individuals diagnosed with mental illness, joblessness, isolation, and homelessness. The effects of such attitudes have served to foster doubts individuals have about their abilities to make competent decisions on their own behalf.⁴ Nonetheless, in spite of these challenges, progress is being made in acknowledging the central role of recovery in service provision and the importance of supporting individuals in articulating and achieving their own personal goals for recovery.

In particular, more attention over the past 20 years has been given to re-conceptualizing recovery. This may even be seen as a rediscovery of a recovery philosophy adopted in 1813 by William Tuke of York who influenced the practices of Thomas Scattergood, a traveling minister who observed firsthand the practices of Tuke. Scattergood was instrumental in the founding of Friends Asylum (known today as Friends Hospital), which opened in 1817, discharging 25 of 66 persons as "much improved" after three years and only re-admitting five patients in its first five years. The accomplishments occurred despite the prevailing belief that individuals with mental illness could not get better. The philosophy upon which Friends Asylum based its care was one of "dignity, respect, kindness, and love within comfortable, pleasant surroundings."⁵

More recently, Harding and colleagues^{6, 7} published two studies that challenged conventional wisdom about schizophrenia and its expected outcomes. In discovering that one-half to two-thirds of individuals who had been institutionalized in Vermont psychiatric hospitals improved or recovered, the researchers corroborated similar findings from Europe and elsewhere. Just seven years later, Zahniser and Harding offered empirical evidence to refute seven myths about schizophrenia and asserted clinician and trainee belief in the myths diminished treatment effectiveness, fostered a sense of hopelessness, and reduced opportunities for recovery.⁸ In a 2002 Op-Ed piece in the New York Times, Harding wrote eloquently about Nobel Prize-winning mathematician John F. Nash Jr. and his inspiring recovery from schizophrenia. "What most Americans and even many psychiatrists do not realize is that many people with schizophrenia - perhaps more than half - do significantly improve or recover. They can function socially, work, relate well to others and live in the larger community. Many can be symptom-free without medication."⁹

Defining recovery and moving toward transformation

While many definitions of recovery have been developed, Anthony is given credit for defining the most widely accepted view of recovery today. Recovery is "a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness."¹⁰ Implicit in this definition is the recognition that recovery does proceed even without cure. Anthony asserts that the foundation for effective mental health services is what people define as most helpful in their personal journeys toward recovery.¹¹ Simply stated and compelling, another definition of recovery offered by the Subcommittee on Consumer Issues for the New Freedom Commission on Mental Health describes the essential ingredients of recovery as follows:

Most fundamentally, recovery means having hope for the future, living a self-determined life, maintaining self-esteem, and achieving meaningful roles in society. Most consumers report they want the same things other people want: a sense of belonging, an adequate income, a way to get around, and a decent place to live. They aspire to build an acceptable identity for themselves and in the community at large.¹²

Through the work of the New Freedom Commission and other important foundational initiatives to precede it - for example, the reports of the Surgeon General and Institute of Medicine - transformation of the mental health service system today is being driven by a strong focus on evidence-based, recovery-oriented, consumer- and family-driven care aimed at building resilience and facilitating recovery. This view was most recently affirmed by the Institute of Medicine Quality Chasm Update, which recommends that a person's care support his or her decision-making abilities and preferences for treatment and recovery.¹³

In July 2005, the Substance Abuse and Mental Health Services Administration (SAMHSA), announced the Federal Mental Health Action Agenda, an ambitious program that builds upon the work of the Commission and reinforces the belief that recovery is the expectation. Among the many action steps being undertaken is the development of prototype individualized plans of care that promote resilience and recovery. Recognizing the central role that evidence-based practices play in recovery, the Institute of Medicine Quality Chasm Update also recommends a coordinated effort at the Federal level to consolidate and strengthen the synthesis and dissemination of evidence-based practices within the myriad Federal agencies dedicated to helping children and adults recover from mental illness.

Much of the drive for the commitment to recovery at the Federal, state, and local levels is the result of the active role consumers have been playing in the design and delivery of mental health services. Nationally, Pat Deegan, a clinical psychologist, activist in the consumer/survivor/ex-patient movement and co-founder of the National Empowerment Center, and other leaders have had a profound influence on keeping a focus on recovery. Deegan, for example, has drawn on her own personal experience to describe recovery as a dynamic process based on the "real life experience of persons as they accept and overcome the disability."¹⁴ Her contributions, which include developing recovery-based competencies for mental health practitioners, and the active involvement of many others in the consumer community are viewed as instrumental in facilitating the transformation of the public mental health service system.

Focusing on recovery in New York State

Within New York State, the Western New York Care Coordination Program is one model of care coordination in agreement with the recovery vision of transformation. A collaborative initiative of six County governments, OMH, providers and consumers, the program is aimed at being responsive to the interests of consumers, providing access to high-quality services, and promoting recovery for individuals diagnosed with serious mental illness. The core of service delivery is dependent on consumer- and family-driven individual services planning. Consumer-run programs in the State that also play a critical role in care coordination include a large network of clubs, employment and other recovery-oriented programs.

Commissioner Carpinello has played a vital role in laying the groundwork for a person-centered, recovery-oriented system of care, both in terms of research and policy development. She has partnered, for example, with consumer and services researchers to develop a public health model of the pathways to recovery, portraying the ups and downs and positive outcomes associated with recovery. The public health model (see Figure 4.4) developed and presented in 2000, has been important in orienting the system of care toward recovery and guiding the development of strategies to imbue recovery principles into day-to-day practice.

Most recently, as noted in Chapter 2, OMH made a substantial contribution to the field of recovery in 2004 by commissioning and publishing the White Paper of consumers, survivors, patients and ex-patients from New York State.¹⁵ The content is modeled after the Institute of Medicine's 10 rules for a quality health care system. Concepts emerging from dialogues with 200 people were reviewed and validated by more than 5,500 people. The result was an ordered list of rules for quality mental health services in the United States. The first three rules confirm strong support for services that are based on informed choice, focused on recovery, and centered on the individuals being served. Currently, OMH is piloting recovery-oriented practices indicators (ROPI) in Personalized Recovery-oriented Services (PROS) programs based on these principles.

Aim 2: To promote wellness and resiliency for individuals and communities

Stakeholders commended OMH for its emphasis on wellness, resiliency and public health. They indicated that promoting public mental health, wellness and resiliency for communities and individuals is a top priority and should be treated as another aim of the public mental health system. The importance of public health strategies to reduce the burden of mental illness through public health prevention and promotion strategies is becoming increasingly more important worldwide.

Lessening the burden through mental health promotion

Mental illness constitutes a large burden of disease worldwide, with approximately 450 million persons having mental disorders.¹⁶ In 2004, the World Health Organization (WHO) published a summary report on mental health promotion with the aim of shedding light on the mental health aspects of health promotion and encouraging strategies to guide mental health promotion. The report delineated nine key messages, which were based in part on a careful review of the evidence for the effectiveness of mental health promotion strategies from across a number of countries and cultures.

The key messages of the report outline important concepts of health promotion that must be taken into consideration when evaluating the feasibility of strategies for individuals and communities. Underlying these messages is the belief that mental health promotion, which translates to good overall health, is a vital element of health promotion.¹⁷The messages include:

• Mental health is an important component of overall health.
• Mental health is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community."¹⁸
• A combination of social, psychological, biological, economic and environmental factors influences mental health. Factors such as poverty and poor education, for example, are associated with the risk of mental illness.
• Interactions among mental, social and behavioral health may have a heightened effect on behavior and well-being. Substance abuse, for instance, may be more prevalent in the presence of high unemployment, poverty, and discrimination.
• Mental health can be influenced positively by policies and practices (for example, housing initiatives) in the same way lifestyle changes can improve heart health.
• The ability to act collectively to improve mental health comes not only from practices and strategies based on the best scientific evidence, but also from shared values.
• Mental health depends on respect for and protection of individual rights.
• Mental health promotion policies and programs at all levels of government, business, and society are central to improving mental health.
• "Mental health is everybody's business." Individuals, families, communities, policymakers, and health professionals all have a stake in promoting mental health.

The report also provides a structure for promoting mental health, the Ottawa Charter of Health Promotion, which is characterized by a positive, strengths-based approach.¹⁹ Viewing mental health affirmatively, the Charter facilitates improvements in mental health through engagement and empowerment. The structure includes healthy public policies, supportive environments, strong community action and resiliency, improved mental health literacy, services based on a complementary medical and holistic approach, and a model for implementing philosophy and strategies at the society, community and individual levels. Importantly, the WHO report provides recommendations for a number of public mental health interventions with demonstrated effectiveness, urges collaborative approaches for quality programming, recommends stakeholder involvement to sustain mental health promotion programs, calls for more research to increase the evidence base, and urges international collaboration to disseminate research findings and assist with the implementation of effective programs.

Countering the national burden of mental illness

In the United States, Canada and Western Europe, mental illness accounts for 25% of disability and is a prime cause of premature death.^{20, 21} In the United States, about 1 in 5 individuals has one or more diagnosable mental disorders in a given year. Lifetime prevalence rates for mental disorders among the U.S. adult population are approximately 29% for anxiety disorders, 25% for impulse-control disorders, 21% for mood disorders, 15% for substance-use disorders, and 46% for any of these disorders.²² Among children in the United States, an estimated 1 in 10 has a mental disorder associated with some level of impairment. The effects of mental illness are seen across the life span, among all ethnic, racial and cultural groups, and at every socioeconomic level. Not counting the costs of research, mental illness costs approximately $150 billion annually in the United States.²³

Recognizing the significant effects of mental illness for individuals and society as well as the knowledge that mental health is a part of overall health and well-being, the U.S. Surgeon General and the President's New Freedom Commission on Mental Health strongly advocate that mental illness be treated with the same urgency as physical health. The public health challenges associated with promoting mental health and resiliency cited by the U.S. Surgeon General and the New Freedom Commission include identifying risk factors, increasing awareness about mental disorders and treatment effectiveness, reducing and eradicating the stigma related to treatment, eliminating health disparities, and improving access to mental health services, particularly among populations that are vulnerable and underserved.^{24, 25}

As noted in the Surgeon General's 1999 report, a public health approach is critical to conducting epidemiologic surveillance, promoting mental health, preventing the development of disorders, and ensuring access to appropriate services. While research has provided a base of knowledge on mental illness that is stronger than that for mental health, more attention to a public health approach is expected to be central in identifying risk factors for mental health problems, implementing interventions that may prevent severe illnesses from developing, and actively promoting good mental health and well-being.

The Federal Action Agenda of 2005 highlights several public education initiatives that build upon the work of the New Freedom Commission. Even before the Action Agenda was announced, SAMHSA introduced in 2004 a national public education campaign to improve public understanding of mental illnesses and emotional disturbances and to encourage individuals to feel comfortable about seeking needed services. In particular, the campaign, which is a three-year initiative in eight states, is designed to increase awareness of the stigma and discrimination associated with mental illness. Another important initiative outlined in the Action Agenda is increasing suicide awareness and promoting prevention strategies through the development and implementation of a national strategy for suicide prevention.

Promoting public mental health in New York State

The importance of a public mental health approach became readily apparent in the immediate aftermath of September 11. With Federal support, OMH and Local mental health authorities rapidly implemented a large-scale public mental health intervention aimed at ameliorating the traumatic stress experienced by residents of the declared disaster area of New York City and counties within commuting distance of the World Trade Center. The resulting program, named Project Liberty, provided free public education and crisis counseling services to tens of thousands of New Yorkers in its initial months of operation. Individuals who received services as well as providers of services expressed appreciation for the public health approach, which featured non-stigmatizing confidential services, including an array of linguistically and culturally relevant public education materials, delivered through a community outreach model.

An important legacy of New York's experience with Project Liberty is the State's commitment to public health strategies aimed at promoting wellness, preventing the onset of traumatic and other psychiatric disorders, and enhancing individual and community resiliency. In 2004, OMH published a series of informational booklets for the public on the important topics of anxiety, attention deficit hyperactivity, and bipolar disorder as well as depression, schizophrenia, and treatment of children diagnosed with mental illness with medications (see http://www.omh.state.ny.us/omhweb/booklets/).

Most recently, OMH has continued to build on this legacy through a partnership with Sesame Workshop and Wal-Mart. The collaboration involves adaptation of the successful Sesame Street "You Can Ask! Kit" developed for children dealing with the aftereffects of the September 11 disaster. Through a donation of nearly $1 million from Wal-Mart, Sesame Workshop will develop outreach video, print and online resources featuring the Muppets. The resources will be made available at no cost to help young children from families serving in the U.S. Armed Services, National Guard and Reserves cope with the various stresses of military life, including a parent's deployment to a war zone and reunification after a period of absence due to military service.

Currently, the major public health initiative in which OMH is engaged is suicide prevention. In September 2005, the OMH New York State Psychiatric Institute was one of 14 institutions to receive a grant to fund a youth suicide prevention and early intervention program. In addition, three universities in the State were among 22 academic institutions receiving campus suicide grants. These grant awards from SAMSHA are contributing substantially to OMH's campaign to reduce the prevalence of suicide through increasing public awareness of risk factors and proven, preventitive measures that can be taken when suicide warning signs are present.

Notable accomplishments include introducing in May 2004 and disseminating widely the Suicide Prevention Education Awareness Kit (SPEAK), development and publication in May 2005 of Saving Lives in New York: Suicide Prevention and Public Health and its 88 recommendations; launching a pilot program for the 2005-2006 school year with the New York Association of School Psychologists to increase suicide awareness and education among New York's teachers, administrators, school psychologists, social workers and counselors; and convening the first-ever Statewide Summit on Suicide Prevention in November 2005 to aid communities in developing capacity and plans to reduce the incidence of suicide across New York.

Aim 3: To promote cultural and linguistic competence as an integral part of all mental health services

Stakeholders indicated that effective mental health services and supports are the result of achieving person-centered recovery goals and community wellness and resiliency. They pointed to the value of facilitating these goals within the context of an individual's and a community's cultural and linguistic frameworks. This concern has been addressed through the addition of the "D," Disparities Elimination, to the Strategic Plan Framework.

Addressing and managing differences and eliminating disparities

Over the past two decades, the effects of culture, race and ethnicity on the identification and treatment of mental disorders has been of increasing importance to stakeholders of the public mental health system. Cultural competence is central to addressing and managing differences and eliminating disparities. As defined by Cross and colleagues, cultural competence is a "set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations."²⁶

This definition has provided the basis for a more nuanced understanding of the term in which cultural competence incorporates the dimensions of service outcomes, quality care and recovery. In 1995 Adams described cultural knowledge as familiarity with certain characteristics, values, beliefs and behaviors of individuals belonging to particular ethnic groups, and cultural awareness as the process by which an individual comes to understand and develop sensitivity to specific ethnic groups through a change in personal values.²⁷ Cultural sensitivity, on the other hand, indicates greater action on the part of the individual who shows an "ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic or cultural heritage."²⁸ Cultural competence represents more than any of these ideas alone.

Cultural competence is the ability of the mental health system to provide care that is consistent with an individual's values, beliefs and behaviors and takes into account each person's social network, cultural and ethnic considerations, and language assistance needs.²⁹ It promotes access to quality care and enables individuals to work with their caregivers to create recovery-oriented individualized plans of care. Linguistic competence, which is closely related to cultural competence, is defined as the capacity "to effectively communicate with persons of limited English proficiency, those who are illiterate or have low literacy skills, and individuals with disabilities" of sensory impairments.³⁰

A catalyst for change occurred in 1999 with the first Surgeon General's Report, which recognized serious deficits in the mental health system's ability to adequately meet the needs of racial and ethnic minority groups. It noted a number of barriers that discouraged individuals from seeking and/or accessing treatment and services. Moreover, it illuminated the reality of inappropriate treatment when individuals were successful in obtaining services. The awareness that members of racial and ethnic minority groups did not share equally in "the hope for recovery" spurred action at the national level to better understand the scope and nature of disparities and create strategies for eliminating them. The result was a supplement to the original report of the Surgeon General in 1999, which showed inadequate scientific study of disparities. Despite this finding, the scientific evidence available did indicate a disproportionate share of disability from unmet mental health needs being shouldered by individuals from minority communities.³¹

Further study by the Institute of Medicine in 2003³² confirmed the findings of the Surgeon General and urged use of evidence-based practices to guide health care decision making and ensure consistency and equal care for all individuals. Further, it called for an increase in minority health care providers to meet the health care needs of members of minority groups and underserved communities, and it recommended attention to meeting linguistic needs through readily available interpreter services.

Employing data to reduce disparities and improve care

A data-driven initiative aimed ultimately at reducing health care disparities and improving the quality of care, better known as the National Healthcare Disparities Report, is being led by the Agency for Healthcare Research and Quality (AHRQ), in collaboration with multiple agencies within the Department of Health and Human Services (DHHS). The first report was released in 2003 and one year later, while acknowledging the pervasive nature in disparities and gaps in knowledge, the report did note more positive, albeit limited, progress in general health findings (e.g., eliminating differences in late-stage breast cancer for black and white women between 1992 and 2001). The report shows promise in demonstrating improvement, although the pace of progress has been gradual.³³

Steps being taken as part of the Federal Action Agenda, which builds on the President's New Freedom Commission Report, include developing a partnership between a Task Force of the Federal Executive Steering Committee on Mental Health and the DHHS Health Disparities Council that links to the DHHS's overall public education initiative called "Close the Health Gap"; examining federally funded behavioral health care education and training programs to strengthen recruitment and retention of individuals from minority groups, promote cultural and linguistic competence in clinical practice, and advance the use of evidence-based practices; and bringing together select behavioral health care leaders from the public and private sectors to work on a national strategic plan to improve the capacity of the mental health workforce to better deliver culturally competent, evidence-based, recovery-oriented care.

Another important way in which the Federal government demonstrates its commitment to cultural and linguistic standards of care is through funding opportunities it offers. Grants aimed at exploring issues related to the uptake of evidence-based practices, for example, have provided researchers with an ability to increase our understanding of how culture, race, ethnicity, and language all affect the delivery of evidence-based treatments and supports and ways in which services might be tailored to meet unique individual and community need.

Promoting cultural and linguistic competence in New York State

Efforts continue to focus on strengthening the planning infrastructure through the integration of cultural and linguistic principles into standards of care endorsed by OMH. Critical to these efforts is sustained attention at all levels of the service system to promoting "an asking stance," wherein natural curiosity for learning about people and communities and the information collected are used to develop clinical standards and practices, skills, service approaches, and marketing techniques to match the service population and to ultimately improve the quality and appropriateness of mental health care.³⁴ The goal then is to work in partnership with individuals and communities to seek those approaches most likely to promote recovery.

Under newly enacted PROS certification regulations, OMH now requires PROS programs to design and operate their programs consistent with and appropriate to the ethnic and cultural backgrounds of the populations to be served. Agencies have been charged with creating cultural competence plans and are being provided with technical assistance to ensure that the plans address issues relevant to culturally competent care such as accountability for implementing and sustaining culturally competent care; processes to use demographic and community composition information in planning and implementing treatment and support services; disparities identification through data collection and analysis and appropriate revisions to planning as indicated; removal of linguistic and other barriers to community living; and continuing education in cultural and linguistic issues for professional staff, and individual and organization cultural competence continuous quality improvement initiatives.

Another important aspect of promoting cultural competence systematically includes visible and innovative leadership within OMH not only at the State but also the national level. In October 2005 at a national training conference, OMH's Director of Cultural Competence co-presented a services model designed to aid administrators in reaching new heights in managing organizational cultural competence. Known as SOAR, the model provides a structure for transformation specific to the individuals and communities served at all levels of the system.³⁵ The acronym SOAR emphasizes Self-directed education by administrators about the people and communities they serve, Ownership of all change processes, Articulation of a vision and expectations, and Responsibility for leadership and accountability. SOAR encourages administrative leaders to use data and current knowledge to tailor skills, community outreach, and clinical approaches so they are culturally and linguistically appropriate.

OMH is also contributing to the research base on evidence-based practices through its SAMHSA-funded evaluation to tailor the national Family Psychoeducation Evidence-Based Practice Implementation Resource Kit to three diverse communities in New York State. The Kit was designed to encourage the use of evidence-based practices in mental health. The evaluation in New York is examining aspects of implementation such as cultural competence and the impact on individuals and families who receive family psychoeducation. Currently in its second year, the project is expected to yield substantive recommendations for adapting the model for African American, Hispanic and Chinese communities.

Preliminary findings indicate considerable variability in the way practitioners establish trust, demonstrate respect, address felt needs, and present mental health education within the African American, Latino and Chinese communities. Factors critical to the delivery of culturally and linguistically competent care are being identified (e.g., establishing trust in a formal mental health institution is a critical challenge grounded in the African American experience of racism and discrimination; understanding the nature of social warmth and inclusion of family members throughout service delivery for individuals in the Latino community; balancing the need for self-disclosure, which is part of the Resource Kit model, with the reality that individuals in the Chinese community avoid public conflict, shame and embarrassment; acknowledging the diversity within each group influenced by language, spirituality, history and immigration). Additionally, the study is bringing to light implications for tailoring the Family Psychoeducation Resource Kit to each community and more effectively engaging families in services (e.g., decisions about when and where to meet, how and when to bring consumers and family members together, the structure of meetings, the length of the family psychoeducation intervention, problem-solving approaches). Knowledge gained through this study has the beneficial effect of helping to shape the agency's ongoing family and community work.

Aim 4: To promote community integration and acceptance through the reduction of stigma

Stakeholders expressed a desire to promote recovery by reducing and eliminating the stigma associated with mental illness, thereby encouraging individuals to seek and remain engaged in treatment and supports based on their individual needs and desires. The call for an emphasis on reducing stigma is often cited in the literature as inherent to quality care.

With the launch of the New Freedom Commission in 2002, President Bush identified the stigma surrounding mental illness as a major barrier to quality mental health care. Among the consequences of the stigma associated with mental illness are low self-esteem, disruptions in family relationships, an inability to build and sustain community supports, poor school performance and failure, and difficulties in getting and keeping housing and jobs.

The view that stigma serves as a significant obstacle to quality mental health services reinforced findings from the 1999 White House Conference on Mental Health and the Report of the Surgeon General,³⁶ which both cited substantial negative effects for individuals, families, and communities from the stigma and discrimination associated with mental illness and its treatment. Despite having effective treatments for mental illness, the Surgeon General added, the fear of shame from having a diagnosable mental illness and being stigmatized often dissuades individuals from acknowledging the existence of mental problems, seeking assistance, and remaining engaged in treatment.

Also, in 1999, a National Institute of Mental Health (NIMH) work group on stigma assisted the Institute in shaping a research agenda to address mental illness stigma and discrimination. The two areas of research identified by the group included one to investigate and disseminate effective strategies and approaches to reducing stigma and discrimination. The other was aimed at examining the influences of the media on public attitudes and knowledge about mental illness and its treatment. In 2002, NIMH convened a conference on "Stigma, Mental Illness, and the Media," to examine how the media portrays mental illness and its effects. One year, later, the Center for Mental Health Services introduced the "Elimination of Barriers Initiative," to effect public education approaches to overcome the stigma and discrimination associated with mental illness. Importantly, this initiative reflected the ongoing commitment to change at the Federal level, building on the work of the New Freedom Commission, which established in 2003 a seemingly simple, yet crucial goal, to reduce stigma by helping Americans understand the essential nature of mental health to overall health.³⁷ The Commission stressed its belief that mental illness should be addressed with the same importance as other medical problems. It called for the elimination of stigma and support for recovery and resilience.

Eliminating barriers

The Elimination of Barriers Initiative under way in eight states includes consumer- and community-developed demonstration programs working to identify effective and transportable models and materials for eliminating the stigma and discrimination associated with mental illness.³⁸ To support this strategic direction, the Federal government has created and is supporting the Resource Center to Address the Discrimination and Stigma Associated with Mental Illness, known as the ADS Center, which provides information and assistance to individuals, states, and public and private organizations in developing, initiating, and conducting programs to counter discrimination and stigma. In addition to being the companion to the Elimination of Barriers Initiative, the Center web site (http://www.stopstigma.samhsa.gov ) is richly structured with policy, research, and best practices information for key mental health audiences.³⁹

A parallel program at NIMH - the Stigma and Health Disparities program - is aimed at increasing our knowledge about methods to effectively reduce stigma and discrimination and their consequences. The program's request for proposals calls for partnerships between consumer and/or advocate organizations, communities, or state and local agencies with hands-on experience in developing and implementing stigma reduction programs and strategies and with social, behavioral, and/or communication scientists who have expertise in stigma research design and methodology.⁴⁰

The recent Institute of Medicine Quality Chasm Update also points out the importance of improving the competencies of mental health and substance use providers in working to reduce stigma. It notes that stigmatizing attitudes and practices by health care providers interfere with a person's ability to manage illness and work toward recovery. It urges the development of a set of core competencies for mental health care workers.

Achieving synergy with public and private stigma reduction initiatives

Complementing the many efforts to increase public understanding of mental illness at the Federal level are a number of nationally prominent private initiatives. A primary goal of the National Mental Health Association and its affiliates, for example is "to reduce stigma and improve public understanding, attitudes, and actions regarding mental health and mental illnesses."⁴¹ Its commitment is clear in its "Children's Mental Health Matters" campaign, which focuses on reaching educators, primary care providers and families to increase public awareness of children's mental disorders and illness, reduce stigma, and improve the detection, early intervention and treatment of mental illness. The National Mental Health Association also sponsors a "Stigma Watch" program that monitors the entertainment industry and broadcast and print media to work with these outlets to correct and prevent advertising, television and radio programming from carrying stigmatizing images.

Another organization at the forefront of stigma reduction is the Carter Center, founded in 1983 by President Jimmy Carter and his wife Rosalyn. Championing the cause of stigma reduction since the early 1970s, Mrs. Carter has made the reduction of stigma and discrimination against individuals diagnosed with mental illness and promotion of public awareness about mental health and mental illness two facets of the strategic direction for the Carter Center's programming. In noting the "tremendous potential for journalists to improve the public's understanding of mental health issues and to play a critical role in reducing stigma and discrimination against people with mental illnesses," the Carter Center annually funds mental health journalism fellowships and sponsors yearly symposia. The 2004 symposium was devoted to transformation of mental health for children and families.⁴²

The importance of the role of the media in shaping positive public attitudes toward illness, including mental illness, is exemplified by an initiative undertaken by Univision Communications, the leading Spanish-language media company in the United States. In 2004, Univision introduced a comprehensive health education campaign called "Salud es Vida...Enterate!" (Health Is Life...Inform Yourself!)⁴³ to promote healthy lifestyles and encourage the early detection and management of chronic health conditions affecting individuals of Hispanic heritage. In July 2005, Univision received a Voice Award from SAMHSA in recognition of its contributions to promoting awareness, reducing stigma and discrimination, and giving voice to individuals with mental health problems by portraying them with accuracy, dignity and respect.^44,45

Addressing stigma in New York State

The stigma associated with mental illness has long been a concern of OMH and continues to be a priority for the public mental health system. In particular, stigma reduction is an important secondary goal of suicide preventions activities. The SPEAK campaign, which was launched in 2004 to reduce the rate of suicide in the State, is aimed not only at reducing suicide, but also the stigma associated with getting help for emotional problems or mental illness. An important aspect of the campaign has been to convey the reality that mental illness is successfully treated and that recovery is possible. This has been achieved primarily through the dissemination of information about suicide and suicide prevention, the risk factors and warning signs, and resources about how to seek help and how to help others. To date, more than 32,000 English and Spanish versions of SPEAK have been distributed both within and outside the traditional mental health services system. Chinese kits will be available this month.

At the first State Summit on Suicide Prevention in November 2005, OMH was awarded the Suicide Prevention Action Network (SPAN) "Fire and Ice Award," symbolizing the grief survivors experience following the death of a loved one and the conversion of grief into suicide prevention activities that will spare others grief. The award recognized the pioneering efforts of OMH in partnering with prominent organizations and agencies to implement the Saving Lives in New York⁴⁶ suicide prevention plan, a product of the combined effort of the New York State Suicide Prevention Council and OMH. The conference also featured activities at reducing stigma, most notably a panel discussion that included a question-and-answer period with five members of the print and broadcast media. Panelists discussed the difficulties of reporting on suicide and offered unique insight and new solutions to contribute to objective rather than stigmatizing reporting.

Chapter 5 will continue to examine input from stakeholders received during 2005, specifically in relation to the individual goals and objectives contained in the Strategic Plan.

Notes:

1. New York State Office of Mental Health. (2005, January). 2005-2009 statewide comprehensive plan for mental health services. Albany, NY: Author.
2. Woodward G, Manuel D, & Goel V. (2004). Developing a balanced scorecard for public health. Toronto: Ontario: Institute for Clinical Evaluative Sciences.
3. Melkers JE, Willoughby KG, & James B. (2002, November). Performance measurement at the state and local levels: A summary of survey results. Prepared by Georgia State University Young School of Policy Studies for the Government Accounting Standards Board Service Efforts and Accomplishments Initiative. Available online at http://www.seagov.org/sea_gasb_project/1998_Survey.pdf  (PDF)
4. Institute of Medicine. (2005, November). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington DC: National Academy of Sciences.
5. Friends Hospital (2005, October). A history of Friends Hospital. Philadelphia: Author. Available online at http://www.friendshospitalonline.org/History.htm .
6. Harding CM, Brooks GW, Ashikaga T, Strauss JS, & Breier A. (1987). The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry, 144(6), 718-726.
7. Harding CM, Brooks GW, Ashikaga T, Strauss JS, & Breier A. (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144(6), 727-735.
8. Harding CM & Zahniser JH. (1994). Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatrica Scandinavica, 384, 140-146.
9. Harding C. (2002, March 10). Beautiful minds can be reclaimed [Op-Ed]. New York Times Sunday Edition.
10. Anthony WA. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11-23.
11. Anthony WA. (2000). A recovery-oriented service system: Setting some system level standards. Psychiatric Rehabilitation Journal, 24, 159-168.
12. Fisher D (Chair). (2003, March 5). Report of the subcommittee on consumer issues: Shifting to a recovery-based continuum of community care. President's New Freedom Commission on Mental Health. Available online at http://www.mentalhealthcommission.gov/subcommittee/Sub_Chairs.htm .
13. Institute of Medicine. Improving the quality of health care for mental and substance-use conditions.
14. Deegan PE. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11-19.
15. See Appendix 4 of the 2005-2009 Statewide Comprehensive Plan for Mental Health Services. Available online at http://www.omh.state.ny.us/omhweb/statewideplan/2005/appendix4.htm
16. Williams SM, Chapman D, & Lando J. (2005). The role of public health in mental health promotion. Morbidity and Mortality Weekly, 54(34), 841-842.
17. World Health Organization. (2004). Promoting mental health: Concepts, emerging evidence, practice. Summary Report. Geneva: Author.
18. World Health Organization. (2001). Strengthening mental health promotion. Geneva: Author.
19. World Health Organization. (1986). Ottawa charter of health promotion. Geneva: Author.
20. World Health Organization. (2001). The world health report 2001: Mental health: new understanding, new hope. Geneva: Author.
21. U.S. Department of Health & Human Services. (1999). Mental health: A report of the Surgeon General-Executive summary. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health.
22. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, & Walters EE. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
23. Williams SM et al. The role of public health in mental health promotion.
24. World Health Organization. The world health report 2001: Mental health: new understanding, new hope.
25. U.S. Department of Health & Human Services. Mental health: A report of the Surgeon General-Executive summary.
26. Cross T, Bazron B, Dennis K, & Isaacs M. (1989). Towards a culturally competent system of care, volume 1. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.
27. Adams DL (Ed.). (1995). Health issues for women of color: A cultural diversity perspective. Thousand Oaks, CA: Sage.
28. U.S. Department of Health & Human Services. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: Public Health Service, Office of Minority Health.
29. Betancourt J, Green A, & Carrillo E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.
30. Goode TD & James W. (2004, November). A definition of linguistic competence (revised 2004). Washington, DC: Center for Cultural Competence, Georgetown University Center for Child and Human Development University Center for Excellence in Developmental Disabilities.
31. U.S. Department of Health & Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
32. Institute of Medicine. (2003). Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
33. See the National Healthcare Disparities Report section on mental health and substance abuse treatment for 2004 online at http://www.qualitytools.ahrq.gov/disparitiesreport/documents/nhdr2004.chap3.pdf .
34. Davis, K. (1997). Consumer driven standards and guidelines in managed mental health for populations of African descent: Final report on cultural competence. Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
35. Cave C & Delphin M. (2005, October 27). Cultural competence: Administrative strategies for effective leadership. Presented at the Third National Training Conference on Addressing Homelessness for People with Mental Illnesses and/or Substance Use Disorders: Preparing People for Change. Washington, DC.
36. U.S. Department of Health & Human Services. Mental health: A report of the Surgeon General-Executive summary.
37. New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, MD.
38. Substance Abuse and Mental Health Services Administration. The elimination of barriers initiative: Mental health. It's part of all our lives. Rockville, MD: Author. Available online at http://www.allmentalhealth.samhsa.gov/thefacts.html .
39. Center for Mental Health Services. (2005). Resource center to address discrimination and stigma. Rockville, MD: Author. Available online at http://www.stopstigma.samhsa.gov/index.html .
40. Health and Behavior Research Branch. Stigma and health disparities program. Rockville, MD: National Institute of Mental Health. Available online at http://www.nimh.nih.gov/dahbr/96-bh.cfm .
41. National Mental Health Association. Campaign for America's mental health. Alexandria, VA: Author. Available online at http://www.nmha.org/camh/index.cfm .
42. The Carter Center. A mental health organization combating the stigma of mental illness. The Carter Center mental health program. Atlanta, GA: Author. Available online at http://www.cartercenter.org/healthprograms/program6.htm .
43. See http://www.univision.com/content/channel.jhtml;jsessionid=H51HXKLWRXWB0CWIAA4CFFAKZAAGAIWC?chid=2&schid=8241&secid=0 .
44. Resource Center to Address Discrimination and Stigma Associated with Mental Illness (ADS Center). (2005, September). Models, programs, and TA tools: Univision's Salud es Vida...Enterate! campaign. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Available online at http://www.adscenter.org/memoranda/pdfs/September2005Memorandum.pdf .
45. Program partners of the Voice Awards include the American Psychiatric Foundation, the American Psychological Association, the National Association of State Mental Health Program Directors, and the Mental Health Media Partnership.
46. See http://www.omh.state.ny.us/omhweb/savinglives/ to obtain copies of Saving Lives in New York Volumes 1-3.

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