Celebrating Two Decades of Progress in the Behavioral Health Field

By Rebecca A. Clay

This year, SAMHSA is celebrating its 20th anniversary and two decades of progress in the behavioral health field.

Since SAMHSA was created in 1992, people with mental and substance use disorders have seen many improvements in their lives.

The rise of the consumer and recovery movements has made it possible for individuals to be active participants in their own care and recovery. The development of community coalitions, trauma-informed care, treatment drug courts, and offender re-entry programs has helped communities and families build resilience and helped people get the assistance they need. Additionally, legislative milestones such as the Mental Health Parity and Addiction Equity Act and the Affordable Care Act will expand access to prevention, treatment, and recovery support services.

"Health Reform"

The last 20 years have seen massive changes in behavioral health financing trends.

According to SAMHSA's National Expenditures for Mental Health Services and Substance Abuse Treatment reports, these changes include the shift from inpatient to outpatient care; the growing use of medications to treat conditions such as depression, opioid dependence, and other problems; and Medicaid's ever-increasing role in funding behavioral health.

Two legislative developments are also having a major impact on the funding of such services.

The first is the Mental Health Parity and Addiction Equity Act of 2008 (See SAMHSA News Jan/Feb 2010). Designed to end discrimination in insurance coverage, the law prevents group health plans covering more than 50 people from imposing financial and treatment limitations for behavioral health services that are more restrictive than those for medical and surgical services.

SAMHSA played a key behind-the-scenes role in getting the legislation passed. Drawing on SAMHSA's expenditures report and written by SAMHSA staffers and others, an influential article in the journal Health Affairs showed a drop in private insurance spending on services for substance use disorders and highlighted the problem of unequal funding for behavioral and medical and surgical services. Additionally, SAMHSA's analysis of parity within the Federal Employees Health Benefits program, which adopted parity in 2001, showed that parity resulted in expanded access to behavioral health services, with most plans experiencing modest increases in benefit costs and no added administrative costs.

The Patient Protection and Affordable Care Act of 2010 (See SAMHSA News Sept/Oct 2010) is another recent milestone. For providers, the Affordable Care Act means a shift to new models of integrated care, such as health homes that coordinate care for people with chronic conditions and accountable care organizations that base reimbursement on outcomes. Providers will also face new payment mechanisms such as capitation, episode rates, and teambased payments focused on outcomes achieved rather than services provided.

The law also brings big changes for consumers. It brings insurance coverage to up to 32 million more Americans via an expansion of Medicaid and new state insurance marketplaces and prevents people with pre-existing conditions such as mental and substance use disorders from being excluded from coverage. The law also provides a guaranteed set of essential health benefits, including substance abuse and mental health services. It also brings a new emphasis on early screening and prevention.

The law also integrates behavioral health into the wider health care system, something SAMHSA Legislative Director Brian Altman, J.D., says is crucial for people with behavioral health problems.

"The statistics show that people with mental and substance use disorders die prematurely—often earlier than the general population," said Mr. Altman. "For one thing, people with mental illnesses have very high rates of smoking. And it's harder and more expensive to treat people with diabetes, heart disease, and other physical conditions when they have untreated behavioral health problems as well."

"The Power of Self-Help"

Twenty years ago, even some in the behavioral health field didn't think recovery was possible.

"For many years, serious mental illnesses were thought of as a never-ending life sentence of disability, with little or no hope of regaining a full and happy life," said Paolo del Vecchio, M.S.W., Acting Director of SAMHSA's Center for Mental Health Services (CMHS). "That extinguishing of hope was detrimental to people's motivation to pursue health, happiness, and wellness."

The mental health field has come a long way since then, thanks in large part to consumers themselves. Through the efforts of the consumer movement, consumer voices are now evident in policy development, services, peer support, and recovery-oriented systems change.

For example, consumers are now active partners in making decisions about their care and they have developed evidence-based interventions to promote recovery.

The consumer movement has also advocated against the use of seclusion and restraint and for community-based services and supports. In the 1999 Olmstead v. L.C. decision, the Supreme Court affirmed the right of people with disabilities to receive care in community-based settings.

SAMHSA has consistently supported the consumer movement. For example, SAMHSA has helped fund the annual Alternatives Conference since its inception, a national event organized by mental health consumers. In addition to establishing an Office of Consumer Affairs within CMHS in 1995, SAMHSA's Community Support Program continues to support community systems of care, a Statewide Consumer Network grant program, and consumer-run technical assistance centers. SAMHSA's Recovery to Practice initiative ensures that mental health practitioners get the training they need to help clients achieve their full potential.

A similar trend has taken place in the substance abuse field. In large part, the substance abuse field grew out of a community of individuals in recovery and has been based from the beginning on the assumption that recovery is possible. As a result, people in recovery have historically played an important role in the service delivery system, as managers, counselors, and more recently as recovery coaches. "An individual who has been through recovery has a way of helping peers that is unique and special," said Peter Delany, Ph.D., Acting Director of SAMHSA's Center for Substance Abuse Treatment (CSAT).

SAMHSA has encouraged the recovery movement and the continued inclusion of recovering individuals in the service delivery system. SAMHSA's creation of an Office of Consumer Affairs within CSAT and a Recovery Community Services Program both support these peer-to-peer efforts.

Each September, SAMHSA celebrates Recovery Month to promote the idea that recovery is possible. SAMHSA has also created a Bringing Recovery Supports to Scale Technical Assistance Center to help states, providers, and systems adopt "recovery supports," such as peer-operated services, supported employment, recovery coaches, and shared decision-making.

Plus, SAMHSA announced a new working definition of recovery from mental and substance use disorders in 2011: "A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential."

"Data: Just the Facts"

The transition of SAMHSA's Office of Applied Studies to the Center for Behavioral Health Statistics and Quality (CBHSQ) last year represents much more than a change of name. It also underscores SAMHSA's commitment to analyzing as well as collecting behavioral health data and the role of surveillance and other data sources in SAMHSA's public health mission.

"SAMHSA's vision is to promote collaboration on data collection activity across all SAMHSA Centers and programs," said CBHSQ Acting Director H. Westley Clark, M.D., J.D., M.P.H. "That way information can be used not only to talk about the nature of the problem but also to help pursue solutions."

Of course, SAMHSA has been collecting, analyzing, and utilizing data since its creation.

Each year, for example, the National Survey on Drug Use and Health (NSDUH) surveys Americans ages 12 and older about their drug use and more. Originally called the National Household Survey on Drug Abuse, NSDUH has expanded its focus over the years to include mental disorders—a reflection not just of SAMHSA's scope, but of the frequent overlap between substance abuse and mental health issues.

The survey's methodology has also changed. In fact, NSDUH was the first large, national survey to collect data via computerized interviews, an approach that enhances accuracy by allowing interviewees to admit drug use via laptops rather than to human interviewers.

It is not just researchers who use NSDUH data. The Office of National Drug Control Policy (ONDCP) relies on the findings to inform the nation's drug policies. When NSDUH revealed that only a small percentage of those who need treatment receive it, ONDCP used that data to call for expanded access to treatment. The data have also pointed to new populations needing attention, including underage drinkers and tobacco and marijuana users, people dependent on prescription pain relievers, and aging baby boomers who have used drugs their whole lives.

Like NSDUH, other SAMHSA data efforts also reflect a growing recognition of the interplay among substance use, mental health, and physical health. For example, Mental Health, United States, a biennial look at mental health consumers, treatment facilities, and payers, will become Behavioral Health, United States in its 2012 edition. SAMHSA's Drug and Alcohol Services Information System, which provides the information for SAMHSA's Treatment Locator and its Treatment Episode Data Set, are expanding to include mental health.

Practitioners and communities benefit from SAMHSA's data-related efforts, too. The National Registry of Evidence-Based Programs and Practices (NREPP) is a searchable online database of successful intervention programs. After launching in the mid-1990s with substance abuse interventions, NREPP now features more than 230 mental health promotion, substance abuse prevention, and treatment interventions, with three to five new entries each month.

"Trauma and Justice"

"It's hard to believe that when I worked in mental health crisis centers two decades ago, we never inquired about trauma," said Larke N. Huang, Ph.D., Director of SAMHSA's Office of Behavioral Health Equity. "Now we better understand the centrality of trauma in behavioral health conditions."

Today, trauma-informed approaches to care acknowledge the presence of trauma symptoms and the role trauma plays in people's lives.

SAMHSA helped promote that idea by sponsoring the 1994 Dare to Vision conference, which spotlighted high abuse rates among women in the public mental health system. In 1998, SAMHSA funded a study exploring the relationship between violence and co-occurring mental and substance use disorders in women. This led to the creation of the National Center for Trauma-Informed Care in 2005.

SAMHSA has also created other resources focused on trauma. In 2001, SAMHSA established the National Child Traumatic Stress Network , a collaboration among researchers, service providers, and families dedicated to improving access to high-quality care for children and adolescents exposed to trauma. The following year, SAMHSA created the Disaster Technical Assistance Center, which helps prepare states and other entities to meet behavioral health needs after disasters. Most recently, SAMHSA established an additional center, Promoting Alternatives to Seclusion and Restraint Through Trauma-Informed Practices, to reduce coercive practices in behavioral health and related settings.

The last two decades have also seen growing awareness of behavioral health issues and trauma among people involved with the criminal and juvenile justice systems. This has led to new partnerships between behavioral health and justice systems.

A key development has been the growth of both drug and mental health treatment courts, which divert nonviolent offenders to treatment rather than to jails or prisons. Emerging evidence shows this approach not only helps offenders to get better but reduces recidivism. SAMHSA has provided extensive training and technical assistance to this initiative. Since 2004, SAMHSA has awarded grants to expand and enhance diversion and treatment efforts for mental health and drug court clients. SAMHSA has also supported offenders transitioning back to their communities through re-entry grant programs that focus on community-based behavioral health services and supports.

For more information about SAMHSA's Eight Strategic Initiatives, visit www.samhsa.gov/about/strategy.aspx.