[Senate Hearing 110-709]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-709
 
    TRANSFORMING MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEMS OF CARE: 
                   COMMUNITY INTEGRATION AND RECOVERY

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING COMMUNITY INTEGRATION AND RECOVERY, FOCUSING ON TRANSFORMING 
           MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEMS OF CARE

                               __________

                              MAY 8, 2007

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York     ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois               PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont         WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio                  TOM COBURN, M.D., Oklahoma

           J. Michael Myers, Staff Director and Chief Counsel

           Katherine Brunett McGuire, Minority Staff Director

                                  (ii)

  
?



                            C O N T E N T S

                               __________

                               STATEMENTS

                          TUESDAY, MAY 8, 2007

                                                                   Page
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island...     1
    Prepared statement...........................................     3
Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming, 
  opening statement..............................................     4
Kennedy, Hon. Patrick J., a U.S. Representative from the State of 
  Rhode Island...................................................     5
    Prepared statement...........................................     8
Cline, Terry, Administrator, Substance Abuse and Mental Health 
  Services Administration, U.S. Department of Health and Human 
  Services, Rockville, Maryland..................................    15
    Prepared statement...........................................    16
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  prepared statement.............................................    25
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska....    29
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina.......................................................    30
Halpern, Lisa, Consumer, Member of the National Alliance on 
  Mental Illness (NAMI), Dorchester, Massachusetts...............    34
    Prepared statement...........................................    35
McDaniel, Rodger, Deputy Director, Wyoming Mental Health and 
  Substance Abuse Services Division, Cheyenne, Wyoming...........    39
    Prepared statement...........................................    40
Allebaugh, Terry Lee, Executive Director, Housing for New Hope, 
  Inc., Durham, North Carolina...................................    49
    Prepared statement...........................................    50

                          ADDITIONAL MATERIAL

Response to Questions of Senator Enzi by:
    Lisa Halpern.................................................    59
    Rodger McDaniel..............................................    59
    Terry Allebaugh..............................................    61
Response to Questions of Senator Burr by Terry Cline.............    62

                                 (iii)

  


    TRANSFORMING MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEMS OF CARE: 
                   COMMUNITY INTEGRATION AND RECOVERY

                              ----------                              


                          TUESDAY, MAY 8, 2007

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10 a.m. in Room 
SD-628, Dirksen Senate Office Building, Hon. Jack Reed, 
presiding.
    Present: Senators Reed, Murray, Enzi, Burr, and Murkowski.

                   Opening Statement of Senator Reed

    Senator Reed. Let me call the hearing to order and first 
say that Senator Kennedy very much wanted to be here today, but 
he has been asked to represent the United States at a very 
historic meeting in Northern Ireland where, for the first time 
in our recollection, two opposing forces have come together to 
form a unity Government, and I can't think of anyone more 
appropriate to represent this country than Chairman Kennedy.
    But, we're lucky to have my friend and colleague, Patrick 
Kennedy, who will be our first witness, so let me make an 
opening statement and then turn it over to Senator Enzi, and 
then recognize Congressman Kennedy.
    I'm pleased to chair this morning's Senate HELP Committee 
hearing on SAMHSA, or the Substance Abuse and Mental Health 
Services Administration, and its upcoming reauthorization by 
this committee.
    It has been 7 years since Congress last reauthorized 
SAMHSA. With this reauthorization, we have the opportunity to 
assess the success of the programs we initiated in the last 
SAMHSA reauthorization, as well as address some of the new 
challenges that SAMHSA faces. I look forward to learning more 
about how SAMHSA has carried out its mission since that time, 
and the types of issues that SAMHSA is currently facing and 
addressing. And, I also look forward to working with the 
Chairman, Ranking Member, Senator Enzi, and other HELP 
Committee colleagues as we consider the various initiatives 
during the SAMHSA reauthorization process.
    I'm particularly interested in improving the network of 
community health providers, to strengthen the links between 
housing and supportive services for homeless populations with 
substance abuse and mental health disorders, and to explore 
ways to enhance the workforce pipeline in the mental health and 
substance treatment fields.
    SAMHSA provides valuable services to help prevent, detect 
and treat people with, or at risk for, mental health or 
substance abuse disorders. This is a significant task on many 
levels. It is estimated that more than 44 million Americans 
have a mental disorder, 22 million Americans have a substance 
abuse problem, and 7 to 10 million have co-occurring mental 
health and substance abuse disorders.
    The importance of SAMHSA funding services is sadly 
underscored by the recent tragic events at Virginia Tech. 
Mental illness and substance abuse are major National problems, 
and they deserve our close attention and strong support.
    Substance abuse and mental health problems can have a 
detrimental effect on an individual's personal and professional 
relationships, as well as on their overall physical health. A 
recent report examining eight States, including my home State 
of Rhode Island, found that Americans suffering from mental 
illness die between 10 and 25 years sooner than average 
Americans. Although the mentally ill have high accident and 
suicide rates, about three out of five die from mostly 
preventable diseases.
    The report also reveals that persons with mental illness 
were far more likely to smoke or have substance abuse problems. 
Yet, unlike a broken bone or other physical illness, those who 
suffer from mental illness and substance abuse problems often 
go undetected, even by those closest to them.
    SAMHSA is charged with the critical, and sometimes 
difficult task of improving our systems of detection and 
treatment, so that we can help people before their problems get 
worse. And while we've made significant progress toward 
reducing the stigma associated with mental health and substance 
abuse problems, we have more to do. The services that SAMHSA 
provides are vital to detecting and combating the problems 
associated with mental illness and substance abuse. Congress 
has an opportunity to improve SAMHSA's ability to serve the 
millions of Americans who suffer as a result of mental illness 
and substance abuse.
    This morning, we will hear from three panels, including my 
distinguished colleague and friend, Representative Patrick 
Kennedy, of Rhode Island, and then we'll have a second panel 
with Dr. Terry Cline, the SAMHSA Administrator, and our third 
panel will be composed of Lisa Halpern, Program Director for 
the Dorchester Bay Recovery Center; Rodger McDaniel, Executive 
Director of the Wyoming Mental Health and Substance Abuse 
Service Division; and Terry Lee Allebaugh, Executive Director 
of Housing for New Hope, Incorporated.
    During this hearing, I hope we can gain, and I do believe 
we will gain, a deeper understanding of SAMHSA and I look 
forward to the testimony of all of our witnesses. Let me 
recognize now, the Ranking Member, Senator Enzi.
    Senator.
    [The prepared statement of Senator Reed follows:]

                   Prepared Statement of Senator Reed

    Good morning. I am pleased to chair this morning's Senate 
HELP Committee hearing on SAMHSA, or the Substance Abuse and 
Mental Health Services Administration and its upcoming 
reauthorization by this committee.
    It has been 7 years since Congress last reauthorized 
SAMHSA; with this reauthorization we have the opportunity to 
assess the success of the programs we initiated during the last 
SAMHSA reauthorization as well as address some of the new 
challenges SAMHSA faces. I look forward to learning more about 
how SAMHSA has carried out its mission since that time, and the 
types of issues that SAMHSA is currently facing and addressing. 
I also look forward to working with the Chairman, Ranking 
Member and other HELP Committee colleagues as we consider the 
various initiatives during the SAMHSA reauthorization process.
    I am particularly interested in improving the network of 
community mental health providers, strengthen the links between 
housing and supportive services for homeless populations with 
substance abuse and mental health disorders, and exploring ways 
to enhance the workforce pipeline in the mental health and 
substance treatment fields. Chairman Kennedy regrets his 
absence today from such an important hearing but he has been 
asked to represent the United States in the historic proceeding 
taking place in Northern Ireland with their peace agreement.
    SAMHSA provides valuable services to help prevent, detect 
and treat people with or at risk for mental health or substance 
use disorders. This is a significant task on many levels. It is 
estimated that more than 44 million Americans have a mental 
disorder, 22 million Americans have a substance abuse problem 
and 7 to 10 million have co-occurring mental health and 
substance use disorders.
    The importance of SAMHSA funded services is sadly 
underscored by the recent tragic events at Virginia Tech. 
Mental illness and substance abuse are major national problems 
and they deserve our close attention and strong support. 
Substance abuse and mental health problems can have a 
detrimental affect on an individual's personal and professional 
relationships as well as on their overall physical health.
    A recent report examining 8 States, including my home State 
of Rhode Island, found that Americans suffering from mental 
illness die between 10 and 25 years sooner than average 
Americans. Although the mentally ill have high accident and 
suicide rates, about 3 out of 5 die from mostly preventable 
diseases. The report also revealed that persons with mental 
illness were far more likely to smoke or have substance abuse 
problems.
    Yet, unlike a broken bone or other physical illnesses, 
those who suffer from mental illness and substance abuse 
problems often go undetected, even by those closest to them.
    SAMHSA is charged with the critical and sometimes onerous 
task of improving our systems of detection and treatment so 
that we can help people before their problems get worse.
    While we have made significant progress toward reducing the 
stigma associated with mental health and substance abuse 
problems, we have more distance to cover. The services that 
SAMHSA provides are vital to detecting and combating the 
problems associated with mental illness and substance abuse and 
Congress has the opportunity to improve SAMHSA's ability to 
serve the millions of American's who suffer as a result of 
mental illness and substance abuse.
    This morning we will hear from three witness panels that 
include my distinguished colleague Representative Patrick 
Kennedy, Dr. Terry Cline, SAMHSA Administrator, Lisa Halpern, 
Program Director of the Dorchester Bay Recovery Center, Rodger 
McDaniel, Executive Director, Wyoming Mental Health and 
Substance Abuse Services Division, and Terry Lee Allebaugh, 
Executive Director, Housing for New Hope, Inc.
    During today's hearing, I hope we can gain a better 
understanding of SAMHSA's role and needs as well as have an 
opportunity to discuss recommendations for the committee as we 
begin the SAMHSA reauthorization process.
    I look forward to the testimony of our witnesses and thank 
you all again for being here this morning.

                   Opening Statement of Senator Enzi

    Senator Enzi. Thank you, Mr. Chairman, and I want to thank 
you and Senator Kennedy for holding this important hearing 
today. I want to thank the witnesses for taking their valuable 
time to come and share their ideas with us, and then hopefully 
to answer some questions, and then even have some follow up 
written questions, probably, and usually get into a lot more 
detail.
    I want to particularly thank my friend Rodger McDaniel for 
traveling here from Wyoming to represent the Wyoming Department 
of Health, glad to have you here.
    I'm pleased to be working in a bipartisan fashion to 
reauthorize the Substance Abuse and Mental Health Services 
Administration, known as SAMHSA. Congress established SAMHSA to 
strengthen the Nation's healthcare delivery system with regard 
to the prevention and treatment of mental illness and substance 
abuse and also to provide emergency disaster assistance and to 
combat homelessness.
    The issues we face in the reauthorization of SAMHSA are 
among the most important issues Congress can address, that is, 
the health and well-being of our citizens. I'm gratified that 
we've come a long way in addressing these problems through the 
many successes of SAMHSA, in recognizing that mental health and 
substance abuse are illnesses that are treatable. The committee 
needs to assess SAMHSA's operation, and make changes to ensure 
that it's operating at the highest possible level of 
efficiency. It currently measures outcomes, and that will be a 
great benefit as we work through reauthorization.
    As many of my colleagues are aware, today's system of 
services of mental health, substance abuse and homelessness is 
fragmented and disconnected. These challenges will be addressed 
in the reauthorization process. States and local communities 
can provide the best approach to prevention and treatment, 
because they're on the front lines, and in the best position to 
develop creative solutions.
    I'm also interested in evaluating the flexibility of the 
grant programs, as well as accountability measures. We need to 
ensure that scarce Federal dollars are focused where the 
greatest need exists.
    In the light of recent tragedies like Hurricane Katrina, 
and Rita, and the events at Virginia Tech last month, it's 
important, that we review the role of SAMHSA in disaster and 
emergency response. SAMHSA serves a key role in events like 
these, so flexibility in the use of these funds is key to 
ensuring that the programs can adapt to changing needs, or 
target specific situations.
    I must also mention the epidemic of methamphetamine, or 
meth, in the United States. Statistics show that approximately 
5 percent of the population in the United States is addicted to 
it. Meth is a highly addictive drug, and easily produced in 
clandestine laboratories with inexpensive, over-the-counter 
products. Wyoming is among the top third of States with persons 
age 12 or older using meth.
    Wyoming students have been hit hard. Drug-related arrests 
have doubled in Wyoming, with meth playing a large role in the 
rising rate in crime, domestic violence, and poor health. Rural 
communities and Native Americans have been especially hard hit. 
Eradication of this epidemic is in our grasp, and I hope to 
explore SAMHSA's role in this critical effort. Fixing this 
problem will require both short- and long-term strategies.
    Again, I want to thank the witnesses for their 
participation in today's hearing, and I look forward to the 
testimony.
    Senator Reed. Thank you very much, Senator Enzi.
    And now, it's my pleasure to introduce my colleague, and my 
friend from Rhode Island, Congressman Patrick Kennedy. Patrick 
is in his seventh term, serving the people of the First 
District of Rhode Island. He is a member of the Appropriations 
Committee, and has been a tireless advocate for important 
projects to my State and also for those issues affecting the 
mental health of the entire country. He has demonstrated over 
his tenure in the U.S. Congress the commitment and the passion 
to help people, particularly those who are struggling with the 
issues of mental health and substance abuse.
    We have your written testimony, Congressman, your excellent 
written testimony, and feel free to summarize, and welcome 
today to the committee.

                  Statement of Representative Kennedy

    Representative Kennedy. Thank you very much, Senator Reed, 
and Senator Enzi. Thank you very much for inviting me to 
testify.
    I particularly want to thank Senator Reed for inviting me 
and appreciate your being the committee chairman today. I'm 
proud to have a fellow Rhode Islander holding the gavel today. 
Although I'm very fond of the committee chairman who's usually 
at the gavel----
    [Laughter.]
    I'm very proud that you're, today, holding the gavel.
    And I want to thank Senator Enzi for his leadership on the 
parity legislation in the Senate and look forward to working 
with him on an opportunity to pass historic legislation in the 
Congress this year to provide mental health parity in this 
country for all Americans who are, right now, discriminated 
against in their mental health insurance coverage.
    When you get right down to it, we really do a terrible job 
in this country--as you pointed out, Senator Enzi--of 
delivering mental health and substance abuse care in this 
Country. Because, as you pointed out, it's often fragmented, 
and we do a very poor job, it's little to do with SAMHSA's 
people, because they're very dedicated, and they're swimming 
upstream in a culture and a Government that undervalues mental 
health and substance abuse treatment, very simply because, the 
fact is, of the stigma. And those that don't get the benefit 
from the latest science.
    So, what I would like to recommend today, is that we--
Congress--in reauthorizing SAMHSA, should ensure that the 
Agency be a force for transforming this fragmented and broken 
mental health and substance abuse treatment system of ours, by 
bringing this segregated, entirely divorced from the rest of 
the healthcare system, mental health and substance abuse and 
integrating it into the overall, primary healthcare system that 
we have.
    And I--with that perspective in mind, I suggest three 
overarching themes for our focus: driving the development and 
use of evidence base in the delivery of mental health and 
substance abuse treatment, dramatically improving the 
coordination of mental health and substance abuse and primary 
care, and expanding our investment in prevention.
    These are the dynamics that will help in making sure that 
SAMHSA acts as the lever of change in acting as a real catalyst 
for making the overall system work to the advantage for 
everybody.
    I've elaborated in my testimony on several specific ideas 
for reauthorization, but as Senator Reed pointed out, I'll 
really get into a few specific examples.
    The permanent Commission for Evidence-Based Mental Health 
and Substance-Use Health Care. This goes to the evidence-based 
part that I spoke of. This would be an expert, nonpolitical 
panel that would be responsible for strengthening, 
consolidating, coordinating, and synthesizing the dissemination 
of evidence-based practices.
    As you know, Senator Enzi, the big criticism of us bringing 
parity into mental health care, as people say, ``Well, we want 
to make sure we get what we pay for.'' Well, we ought to be 
getting what we pay for in regular health care, and frankly, 
the evidence shows us that we barely get 50/50 evidence-based 
medicine in normal health care in our system, forget mental 
health care.
    But, the fact is, when we do get parity, we ought to get 
the evidence-based, and that's why we should set up a 
Commission to make sure that whenever there's delivery of 
substance abuse and mental health services, that it is the 
latest and best knowledge in how to deliver those services.
    By benchmarking this evidence-based practice, and giving 
them the Good Housekeeping Seal of Approval, this Commission 
could provide the guidance to the whole entire field, as well 
as the training and professional development, so that anybody 
in this country going to get the treatment that they need could 
be sure that they are getting the latest and best of that 
treatment. It also would help us establish priorities in areas 
of future research.
    Also, just last week, USAToday ran a front-page story on a 
new report that individuals in the public mental health system 
die, on average, 25 years earlier than the general population, 
as Senator Reed mentioned in his opening remarks. This is not 
just based on suicide, but poorly-managed general health care, 
and chronic illnesses like diabetes and heart disease.
    And, improving the coordination amongst mental health, 
substance abuse and primary care is the key to this. If you 
treat someone with mental illness, you also help cut down on 
the costs of someone, treating someone with diabetes and other 
chronic illnesses. That's why integrating the care of mental 
illness, along with primary care and substance abuse is so 
crucial.
    So, without opening the doors to merging block grants, I 
would propose that we use block grants to allow providers to do 
a better job to deliver the most effective, integrated care to 
individuals who have co-occurring disorders. Right now, 
substance abuse is delivered through one block grant, mental 
health is delivered through another block grant--we need to 
point out, that as Senator Reed mentioned, so many of substance 
abuse disorders and mental health disorders are often co-
occurring disorders. But you can't expect someone to get 
substance abuse treatment here, and mental health treatment 
across town. You have to allow more flexibility for a substance 
abuse provider to treat not only the substance abuse problem, 
but the mental health problem, and the mental health provider 
to do the same for the person with the mental illness, but 
who's also suffering from a substance abuse problem.
    There's got to be greater flexibility in dollars. Right now 
those dollars are dis-apportioned. We need to look at the way 
those dollars are apportioned, and make sure they go to where 
they are best suited to treat the people who are most in need, 
as you pointed out, Senator Enzi, where they're greatest in 
need, and I would recommend that.
    And finally, establish an ongoing inter-agency mental 
health working group to collaborate around these issues, so 
that we can continue to meet the consumers' needs, in making 
sure that we have this ending of the disconnect between the 
barriers between substance abuse and the mental health base 
that currently exists.
    Finally, prevention needs to be at the cornerstone of any 
future reauthorization, and prevention means school-based 
behavioral health, and it also means making sure that we do a 
better job at preventing. And, by preventing, we know that if 
we reach a family that's at high risk--if a child comes from a 
family where the parents have substance abuse problems 
themselves, where the parents are in jail, where the parents 
have domestic violence, where the parents are in severe 
poverty--you know if those children come from those four 
characteristics of a family, those children are umpteen times 
more likely to have special education problems, substance abuse 
problems, alcohol problems, and criminal justice problems down 
the road. It's just shown by the social science evidence.
    So, you don't have to provide intervention for all 
families, we don't have the budgets for it, but you do have to 
provide interventions for those high-risk groups, and so what I 
would propose is that we really focus on making sure that we 
adequately fund the Starting Early, Starting Smart program, 
which was a pilot program in the last SAMHSA reauthorization, 
and it focuses on at-risk families. Because you can't reach the 
kids until you reach the parents, and this is really a program 
that reaches the parents who are at highest risk, and that's 
the best way to reach the kids, is to reach the mother and 
father who are at highest risk.
    And, with that, Mr. Chairman, I appreciate the time.
    [The prepared statement of Representative Kennedy follows:]

              Prepared Statement of Representative Kennedy

    Senator Reed and Senator Enzi, thank you for inviting me to 
testify today. Senator Reed, I'd like to particularly commend 
you on your leadership in this hearing. While I'm very fond of 
the committee chairman, I'm also proud to have a fellow Rhode 
Islander holding the gavel today, and exhibiting a strong voice 
for improving mental health and substance abuse care every day.
    When you get right down to it, we do a terrible job 
delivering mental health and substance abuse care in this 
country. This is not a knock on the providers, who are for the 
most part paid a pittance and are truly doing the Lord's work 
with little thanks. It's also not a knock on SAMHSA. The people 
there are dedicated and swimming hard upstream in a culture and 
government that undervalues mental health and substance abuse 
treatment, trying to improve care and create change.
    The fact is, however, most people in need of treatment 
don't get it. Those who do often don't get the benefit of the 
latest science. Care for mental illnesses and substance abuse 
is segregated, often nearly entirely divorced from the rest of 
health care and even from each other.
    Every few years, it seems, there's another blue ribbon 
report on the challenges we face on mental health and substance 
abuse. The Surgeon General's report in 1999. The New Freedom 
Commission report in 2003. The Institute of Medicine report in 
2005. The focuses of these reports differ, but the underlying 
message of all are consistent: in the words of the New Freedom 
Commission, ``the mental health services system does not 
adequately serve millions of people who need care.'' \1\
---------------------------------------------------------------------------
    \1\ President's New Freedom Commission on Mental Health, Interim 
Report to the President (2002), p. 1.
---------------------------------------------------------------------------
    Congress's goal for reauthorizing SAMHSA should be to 
ensure that the agency can be a force for transforming our 
fragmented and broken mental health and substance abuse 
treatment systems. We need to be thinking systemically, and 
asking what levers we can pull that will change the underlying 
dynamics of the mental health and substance abuse systems.
    With that perspective in mind, I would suggest three 
overarching themes for our focus: (1) driving the development 
and use of the evidence base; (2) dramatically improving the 
coordination of mental health, substance abuse, and primary 
care; and (3) expanding our investment in prevention.

                 DEVELOPING AND USING THE EVIDENCE BASE

    There are several interrelated problems when it comes to 
the evidence base. At a systems level, we remain set up to 
deliver care that is more expensive, inpatient-oriented, and in 
response to crises rather than a community- and family-based, 
recovery-oriented model of service delivery. We know that 
doesn't produce the best outcomes and certainly is not a good 
use of scarce resources, yet we inhibit the evidence-based 
approach to care delivery.
    Another problem is that far too often providers don't use 
the science we have. The IOM's report on Improving the Quality 
of Health Care for Mental Health and Substance-Use Disorders, a 
number of studies have documented the failure of clinicians to 
adhere to evidence-based care guidelines for a wide range of 
disorders. Overall, in only 27 percent of studies were adequate 
adherence rates found.\2\
---------------------------------------------------------------------------
    \2\ Institute of Medicine, Improving the Quality of Health Care for 
Mental Health and Substance-Use Disorders (2005), p. 133.
---------------------------------------------------------------------------
    A third problem is that the research is often not directly 
relevant to real-world practice. Participants in trials are 
often screened out to ensure they don't have co-occurring 
disorders or other complicating factors, and most trials take 
place in academic medical centers, not at the community based 
treatment centers where so much care actually occurs. As in the 
rest of health care, we invest very little in comparative 
outcomes research and services research, to discover which 
interventions are more cost-effective, and how to most 
effectively and safely deliver care.
    While the solutions to these problems go beyond SAMHSA, 
there are some important steps we can take to build the 
development and use of the evidence base into our mental health 
and substance abuse treatment systems.
    First, we need to support SAMHSA's efforts in recent years 
to help States transform antiquated systems. For years we have 
known that community-based systems of care produce better 
outcomes at a fraction of the cost of institution-based 
systems. In Rhode Island in 2000, a year in residential 
treatment for an adolescent cost $242,000, a year in the 
Training School cost $94,000, and a year of intensive, 
community-based services cost $14,000.\3\ SAMHSA made a few 
rounds of transformation grants to help States move to a more 
modern approach, but has been unable to implement those fully 
as the budget has been squeezed. The problem in many States is 
that the transition cannot happen all at once. Creating new 
treatment options carries a cost, but does not allow the State 
to immediately stop paying for beds it is carrying. We need to 
figure out ways for SAMHSA to support the transition, while 
ensuring that the funds carry accountability for changes to 
evidence-based systems of care.
---------------------------------------------------------------------------
    \3\ Rhode Island Public Expenditure Council, A Review of the 
Department of Children, Youth and Families (2001), p. 32.
---------------------------------------------------------------------------
    On a related note, we should expect more of States that 
have received Children's System of Care grants. These grants 
have produced islands of excellence in local communities, but 
are too often not sustained and not brought to scale. The 
program has been highly successful, but should be tweaked to 
ensure greater involvement and buy-in from the State and 
incentives to replicate local successes in other communities 
and statewide.
    Next, I propose the creation of a permanent Commission for 
Evidence-Based Mental Health and Substance-Use Health Care. 
This expert panel would be responsible for strengthening, 
consolidating, and coordinating the synthesis and dissemination 
of evidence-based best practices.
    This non-political commission would build on work being 
done at SAMHSA, as well as at AHRQ and NIH. The Commission 
would be able to provide a ``good housekeeping seal of 
approval'' to prevention, screening, diagnosis, and treatment 
practices supported by science and to create a research agenda 
by identifying areas where strong evidence is lacking.
    By benchmarking evidence-based practices, the Commission 
could provide guidance to the field to focus training and 
professional development. It would also allow for the 
development of performance measures that can, over time, enable 
pay-for-performance and other value-based purchasing strategies 
that are the most important means of improving care. Because 
the research base is thin in many areas, we need to be very 
careful not to go too far too quickly in linking payment to the 
use of evidence-based practices--we do not want to shut down 
access to effective interventions that may not have been 
adequately researched yet. But ultimately, payment drives 
practice patterns, and if we want to better use the evidence 
base and get better outcomes and a more efficient use of 
resources, we need to adjust how we pay for care.
    A complement to payment-based strategies for improving the 
quality of care is better direction by the professions 
themselves. This field is marked by a large number of different 
professions, with a wide range in terms of training, 
credentialing, and licensure. There is little consistency or 
quality control across mental health and substance abuse 
treatment.
    We should heed the Institute of Medicine's recommendation 
to create a Council on the Mental Health and Substance-Use 
Workforce, to parallel councils for physicians and nurses. This 
new council would provide guidance to graduate schools and 
State licensing bodies to ensure that professionals working in 
the field have appropriate expertise grounded in the latest 
science and that consumers have meaningful information about 
providers when seeking out care. This group could also provide 
an ongoing assessment and data to back up the widespread 
anecdotal reports of critical workforce shortages in the field.
    Finally--and this may be a bit further afield for a SAMHSA 
reauthorization bill--I believe we need to create a national 
network of mental health and substance abuse centers of 
excellence, akin to the national centers of excellence in 
cancer. We need to tie our cutting edge, institution-based 
research to community-based practice settings, and make a 
national commitment to finding new cures and treatments. While 
there's been an explosion in understanding of these diseases 
due to brain scanning technology and genomics, we are still 
essentially using variations on the same treatments we had 30 
years ago. I would like to see a major initiative that can 
dramatically expand the evidence base, building on and tying 
together the work that is happening at leading institutions 
like Brown, the University of Michigan, UCLA, and UC-Davis. I 
have spoken to leading researchers around the country and 
believe that the time is right for a national network that 
could be greater than the sum of its parts.

            DRAMATICALLY IMPROVING THE COORDINATION OF CARE

    Just last week USA Today ran a front page story on a new 
report that shows that individuals in the public mental health 
system die, on average, 25 years earlier than the general 
population.\4\ This shocking outcome is not based on suicide, 
mind you, but on poorly managed general health and other 
chronic diseases like diabetes and heart disease.
---------------------------------------------------------------------------
    \4\ Marilyn Elias, ``Mentally Ill Die 25 Years Earlier, on 
Average.'' USA Today (May 3, 2007).
---------------------------------------------------------------------------
    Part of the explanation may lie in the comorbidity of 
mental illnesses and smoking or the side-effects of medications 
commonly taken by people with mental illnesses. Undoubtedly, 
however, a major contributor is the poor coordination between 
primary health care and mental health and substance abuse care. 
The problem is severe even within behavioral health, as mental 
health and substance abuse care are often siloed, even though 
the patients are so often the same people.
    The Federal Government bears a chunk of the responsibility, 
and one thing we should seek to do with this reauthorization is 
to take down some of the barriers that we erect between primary 
care, mental health care, and substance abuse care.
    I am well aware of the historical factors at play in this 
space, and that even talking about better integrating mental 
health and substance abuse treatment makes some people's hair 
stand up on end. But I am also aware that research 
unambiguously shows that individuals' outcomes are better when 
care is coordinated and, ideally, integrated. And I believe 
that there are steps we can take that would help without 
upending our current patterns.
    For example, it is currently very difficult to use either 
mental health or substance abuse treatment block grant funds to 
pay for truly integrated care for co-occurring disorders. 
That's because the block grants carry strict requirements on 
paying only for mental health or substance abuse respectively, 
so documentation problems arise when the care is integrated. 
Without opening the door to merging the block grants, it should 
be possible to enable providers--or even better, to encourage 
them--to deliver the most effective, integrated care to 
individuals with co-occurring disorders.
    Similarly, I would like to see ways of encouraging our 
community behavioral health centers and community health 
centers to collaborate. We spend enormous sums on two parallel 
systems of community health providers. But because one is 
funded out of HRSA and the other out of SAMHSA, their 
collaboration is haphazard at best. Imagine if instead centers 
were co-located. Or even that whenever a person contacted a 
community behavioral health center for an appointment, they 
were also given an appointment at the community health center 
to check their other chronic diseases. We should build 
incentives into these funding streams to bring about 
partnerships that will bring people's care together.
    Of course, these kinds of disconnects exist throughout 
various government programs. The Federal Government should get 
its own house in order, and begin collaborating around mental 
health and substance abuse, so it can ensure that collaboration 
occurs where services actually meet consumers.
    One such success story is the Safe Schools Healthy Students 
program (SSHS). In 2001, then-Surgeon General David Satcher 
came to Rhode Island for a forum I put together on children's 
mental health. Surgeon General Satcher singled out SSHS as the 
most successful program he had seen in mental health. Now 
remember, this is just a year after his groundbreaking mental 
health report. What distinguished SSHS, he said, was that it 
was a genuine partnership between SAMHSA, the Department of 
Justice, and the Department of Education, and their 
counterparts at the local level. Because the three Federal 
departments developed and funded the program together (at least 
in the early years), it was able to require and get real buy-in 
from the police departments, schools, and mental health 
agencies and was therefore extremely effective.
    SSHS should be a model for us. We should create an ongoing 
behavioral health working group among various HHS agencies, VA, 
DOD, DOJ, Education, and perhaps even HUD and Labor. The 
mandate of this group should be to ensure that programs for 
mental health and substance abuse treatment do not conflict 
with each other and to foster collaboration in the delivery of 
services. We should ensure that the agencies have authority to 
pool their funds for interagency grants like SSHS was 
initially. Until our own Federal Government gets its house in 
order, we cannot realistically expect our systems to regularly 
deliver the kind of coordinated care consumers need and 
deserve.

                 EXPANDING OUR INVESTMENT IN PREVENTION

    With so much unmet need for treatment, it is difficult to 
carve out funding for prevention. Still, we all appreciate how 
frustrating, absurd, and inefficient it is to be waiting for 
people to crash when we have some ideas about how to keep them 
healthy in the first place.
    I would begin with a much more robust investment in the 
most vulnerable children from birth to six. The fact is, we 
know which children are most likely to be abusing drugs and 
alcohol or wind up with mental health problems when they are 
older. We know them by behaviors--just ask any kindergarten 
teacher which students are heading for trouble--and we know 
them by environmental factors. The research clearly shows that 
kids living in homes with maternal depression, substance abuse, 
and family violence are much, much more prone to developing 
problems of their own. There are actual, physical changes to 
their brains that occur as a result of the toxic stress levels 
that they are subjected to.
    We also know how to have the greatest impact on those 
children and set them on more healthy trajectory: work with the 
family. There's some fascinating research out of the NYU Child 
Study Center's Parent Corps program. They worked with the 
parents only, no intervention with the children. After 
intensive lessons and guidance in parenting and such things as 
discipline, dealing with crying babies, and the like, the 
program produced measurable changes in the children's brains--
physiological changes in the children as a result of working 
solely with the parents. And we know from studies like the 
Perry Preschool Study that intervening early can change 
outcomes for life. For example, at age 40, participants in that 
study were 50 percent more likely than their counterparts to be 
earning $20,000 per year, 44 percent more likely to have 
graduated high school, and 53 percent less likely to have been 
arrested five or more times. The investment in these young 
children's lives has thereby paid off annualized internal rate 
of return of 18 percent in additional tax revenues and 
expenditures saved.\5\
---------------------------------------------------------------------------
    \5\ Lawrence J. Schweinhart, Ph.D., The High/Scope Perry Preschool 
Study Through Age 40: Summary, Conclusions, and Frequently Asked 
Questions (2005).
---------------------------------------------------------------------------
    The Starting Early Starting Smart program, an innovative 
joint venture of the Casey Foundation and the Center for 
Substance Abuse Prevention at SAMHSA, was a family- and 
caregiver-focused approach to working with vulnerable children, 
using child care providers and pediatricians as the entry 
point. Unfortunately, it was conducted as a research demo, and 
allowed to peter out. We should resurrect that approach. 
SAMHSA's commitment to prevention should include a significant 
investment in young children with multiple risk factors and in 
their families.
    We also should bring a stronger prevention ethos to school-
based behavioral health. Approaches based on positive 
behavioral supports that help improve all students, provide 
early identification for students in need of formal 
assessments, and services along a continuum can prevent 
students from falling through cracks and reaching crises before 
their needs are recognized or met. In partnership with the 
Department of Education, SAMHSA should work to broaden the role 
of school-based mental health personnel as well as expand 
collaborative programs such as SSHS.

                               CONCLUSION

    There is no shortage of priorities in the mental health and 
substance abuse fields. In addition to the issues discussed 
above, there are plenty of other things that should happen in a 
reauthorization of SAMHSA: fostering the use of information 
technology and ensuring that the mental health and substance 
abuse field is integrated into the larger health IT systems 
being developed; reauthorizing the Garrett Lee Smith Act; 
codifying a program to focus on the mental health and substance 
abuse treatment needs of seniors; authorizing the Keeping 
Families Together Act; and developing performance measures at 
both the systems and provider levels are just some of the 
priorities that should be included.
    That said, we also must acknowledge the two major 
limitations on this bill: first that Medicaid, much more than 
SAMHSA, is driving the direction of the mental health system 
today (and currently, in the wrong direction, away from a 
recovery model), and secondly, that SAMHSA is and will continue 
to be for the foreseeable future woefully underfunded.
    Given those two realities, I believe we really must think 
strategically about how we use SAMHSA's resources. While there 
are many terrific grant programs, a number of which I strongly 
advocate for in the Appropriations Committee every year, the 
fact is that with its limitations, SAMHSA is much better off 
leveraging systems change than funding services. As we move 
forward, I would urge the committee to think carefully about 
how a reauthorized SAMHSA can put in place infrastructure, 
systems, and incentives that will drive long-term, lasting 
change in the way care is delivered.
    Thank you for the privilege of testifying today. I look 
forward to working with you to bring more accessible, higher 
quality, and more efficient mental health and substance abuse 
care to all Americans. Thank you.
    Senator Reed. Thank you very much, Congressman, for your 
insightful testimony. And your framework of evidence-based 
legislation, coordination of primary care and prevention is a 
good place for us to begin, and I thank you. I know you'll be 
working hard in the other body, where we both served, to ensure 
that this authorization proceeds forward.
    We've been joined by Senators Burr, Murkowski and Senator 
Murray, and I would--if they had questions or comments, I'd 
invite them at this time.
    Thank you very much, Congressman.
    Representative Kennedy. Thank you.
    Senator Reed. Now, I'd like to call forward for the second 
panel, Dr. Terry Cline, the Administrator of the Substance 
Abuse and Mental Health Services Administration.
    Dr. Cline was nominated by President George W. Bush, on 
November 13, 2006, and confirmed on December 9, 2006, as the 
Administrator for the Substance Abuse and Mental Health 
Services Administration. As a SAMHSA Administrator, Dr. Cline 
leads an agency with a $3.3 billion budget, and is responsible 
for improving the accountability, capacity, and effectiveness 
of the Nation's substance abuse prevention, addictions 
treatment, and mental health service delivery systems.
    Prior to his appointment, Dr. Cline served as Oklahoma's 
Secretary of Health, a position he was appointed to by Governor 
Brad Henry in 2004. At the same time, he served as Oklahoma's 
Commissioner of the Department of Mental Health and Substance 
Abuse Services, a position he held since January 2001.
    Dr. Cline also has extensive clinical experience, he was a 
Clinical Director of the Cambridge Youth Guidance Center in 
Cambridge, Massachusetts, and a staff psychologist at McLean 
Hospital in Belmont, Massachusetts.
    His professional history also includes a 6-year appointment 
as a clinical instructor in the Department of Psychiatry at 
Harvard Medical School, and Chairman of the Governing Board for 
Harvard Teaching Hospital in Cambridge, Massachusetts. A native 
of Ardmore, Oklahoma, Dr. Cline attended the University of 
Oklahoma where he earned a Bachelor Degree in psychology in 
1980, and then received both a Master's degree and a Doctorate 
in Clinical Psychology from the Oklahoma State University.
    Dr. Cline has involved himself in community service at the 
local, State and National levels, it is a pleasure to welcome 
him here today. Dr. Cline, thank you.

STATEMENT OF TERRY CLINE, PH.D, ADMINISTRATOR, SUBSTANCE ABUSE 
 AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF 
         HEALTH AND HUMAN SERVICES, ROCKVILLE, MARYLAND

    Mr. Cline. Thank you very much, Mr. Chairman, members of 
the committee. I appreciate the opportunity to present to you 
today, and to talk about SAMHSA's vision and mission.
    I came to SAMHSA in my position in January with a very 
clear understanding of the importance of SAMHSA's vision and 
mission. As an undergraduate, I had worked my way through 
college by working on an inpatient children's unit, where we 
served young kids, as young as 5 years old.
    I returned as a student several years later, to that very 
same hospital, and saw some of the same children still living 
in that institution. Some of those children hundreds of miles 
away from their families.
    As a clinician in Cambridge, I provided home-based family 
therapy to low-income housing developments, and every time I 
went to visit one family, I would walk by dozens of other 
families that were in need of services, but were not able to 
receive those services, because I was only serving one family 
at a time. So that need was very, very great.
    And then as Commissioner in Oklahoma, and as the Secretary 
of Health, I was able to see that ripple effect across our 
entire State system, to see the repercussions, what happens 
when we are not able to meet the needs of people who are 
struggling with mental illness, and who are struggling with 
their addictions, across both the private and the public 
sectors of the entire State system, very dramatic.
    Recently, we saw the results of a report from the Agency 
for Health Care Research and Quality, which highlighted the 
finding that a quarter of all hospital stays in the country--
about 7.6 million of the overall 32 million hospital stays--
involve people with the diagnosis of mental illness or 
substance abuse. This tells us that that ripple is effecting 
people being seen in general hospital settings, rather than 
being seen in more specialty services.
    We also know when we don't provide those services, that 
there is a human cost, as well as that economic cost--sometimes 
there are lost jobs, sometimes lost families, sometimes lost 
lives. There are approximately 30,000 individuals who commit 
suicide every single year in the United States of America. I 
come from a small town of about 25,000 people, in Oklahoma, so 
I try to imagine the entire population of that town being 
lost--not just 1 year, but year after year after year--30,000 
people every year, lost to suicide.
    So, even in the midst of all of these struggles and all of 
these challenges, there is good news. And the good news is that 
people can, and people do recover from mental illness, people 
can and do recover from substance abuse and addiction. There 
are evidence-based practices for treatment, and there are 
effective strategies for prevention.
    And, as an example in prevention, we know that in 2006, 
approximately 840,000 youth--fewer youth--are using drugs in 
2006 than were using in 2001. So, we're able to reach those 
young populations and to prevent them from using drugs.
    As we address these challenges and move toward a vision, 
SAMHSA has embarked on a strategic plan that includes 
accountability, capacity, and effectiveness of services, 
really, the three legs of a stool in our strategic plan.
    In our partnership with stakeholders across the country, we 
have developed national outcomes measures which reflect real-
life meaningful outcomes for people who are striving to attain, 
and sustain, recovery in their lives. These are individuals who 
are holding jobs, these are individuals who are living with 
their families, these are individuals that are able to 
participate fully in their communities of choice, and again 
this is done in partnership with stakeholders across the 
country.
    We also know, and we heard this reflected earlier in the 
testimony from Representative Kennedy, that to better serve 
these particular populations, we know that we need to 
completely transform our behavioral health systems. The 
President's new Freedom Commission on Mental Health found that 
we have an incredibly fragmented, fractured system, which is 
not effectively serving people in need in our country.
    I believe a public health approach which provides 
comprehensive services, and an entire range of services, 
including prevention, early intervention, acute treatment and 
recovery support services, is the approach that will best serve 
the people of our country. We've seen this work for other 
illness categories, and we know it will work here, as well.
    I believe that as we strive to address the needs of people 
with mental illness, and people who are struggling with 
addictions and chemical dependency, that we will be a much 
stronger country, and a healthier Nation.
    I look forward to working with you as the year progresses, 
and I again, appreciate this opportunity to present to you 
today. And, I'd be happy to answer any questions you may have.
    [The prepared statement of Dr. Cline follows:]

              Prepared Statement of Terry L. Cline, Ph.D.

    Mr. Chairman and members of the committee, I am honored to present 
to you the vision, mission, and priorities of the Substance Abuse and 
Mental Health Services Administration (SAMHSA), an agency of the 
Department of Health and Human Services (HHS).
    SAMHSA has established a clear vision for its work--a life in the 
community for everyone. To realize this vision, the Agency has sharply 
focused its mission on building resilience and facilitating recovery 
for people with or at risk for mental or substance use disorders. To 
achieve its vision and mission, SAMHSA directs a rich portfolio of 
grant programs and contracts that support State and community efforts 
to increase accountability, build capacity, and improve the 
effectiveness of substance abuse and mental health service delivery 
systems.
    The need for SAMHSA's strategic focus on strengthening service 
delivery systems is undeniable. There are economic costs of undiagnosed 
and untreated mental and substance use disorders. There are also human 
costs--measured in lost jobs, lost families and lost lives--that are 
incalculable and affect the well-being of millions of Americans. 
SAMHSA, through its offices and centers--the Center for Substance Abuse 
Prevention (CSAP), the Center for Substance Abuse Treatment (CSAT), and 
the Center for Mental Health Services (CMHS)--is working with State and 
local governments, tribal organizations, consumers, families, service 
providers, professional organizations, and the Administration to focus 
National attention and resources on prevention, treatment and recovery 
support services.
    Without prevention, treatment and recovery support services, data 
confirm the enormous role that substance use and mental health 
disorders play in increasing our Nation's health care costs. For 
example, according to a new report by HHS' Agency for Healthcare 
Research and Quality, almost one-fourth of all stays in U.S.-community 
hospitals for patients age 18 and older in 2004--7.6 million of nearly 
32 million stays--involved depressive, bipolar, schizophrenia and other 
mental health disorders or substance use related disorders. This study 
presents the first documentation of the full impact of mental and 
substance use disorders on U.S.-community hospitals.
    The significant number of hospital stays related to mental and 
substance use disorders signals the need to identify and intervene 
early before the conditions require a hospital stay. Too often because 
of social stigma or lack of understanding, individuals and health care 
providers do not recognize the signs or treat mental or substance use 
disorders with the same urgency as other medical conditions. For 
example, the full spectrum of substance use disorders can be identified 
by screening tools which can result in an intervention. The 
Administration is working to meet this need through the Screening, 
Brief Intervention, Referral and Treatment (SBIRT) program funded by 
SAMHSA. This program uses cooperative agreements to expand and enhance 
a State or tribal organization's continuum of prevention, intervention, 
and treatment by adding screening, brief intervention, referral, and 
treatment services within general medical settings.
    Also to be considered is the component of mental and substance use 
disorders that patients themselves often do not recognize or 
understand. For example, in 2005 the number of persons 12 and older who 
needed treatment for an alcohol or drug use problem was 23.2 million, 
according to SAMHSA's National Survey on Drug Use and Health. Of these, 
2.3 million received treatment at a specialty facility. Specialty 
treatment is defined as treatment received at any of the following 
types of facilities: hospitals (inpatient only), drug or alcohol 
rehabilitation facilities (inpatient or outpatient), or mental health 
centers. The survey also points to a huge denial gap. Among individuals 
with drug or alcohol dependence or abuse who have not received 
treatment, more than 94 percent do not feel they need treatment.
    Unlike an obvious broken bone, burn, laceration, or other physical 
wound, addiction and mental illnesses often do not have outward 
physical signs. Adding another layer to the complexity of seeking 
timely and appropriate treatment is the barrier of not knowing when or 
where to seek help and the lack of awareness that mental and substance 
use disorders often co-occur. Beyond these barriers, the issues of 
stigma, access, and availability of services also present roadblocks to 
early intervention, treatment, and recovery.
    Yet SAMHSA--knowing the barriers, accepting the challenges, and 
fully understanding the importance of our role in the pubic health 
approach to creating a healthier America--continues to move forward 
working to improve and save lives that otherwise might be lost to 
devastating symptoms, isolation and even suicide. SAMHSA moves forward 
with the understanding that recovery is the expected outcome, by 
identifying areas of greatest need through data collection, filling 
those needs through evidence-based service delivery, and then measuring 
effectiveness and managing agency resources through an informed data 
strategy and recovery-based outcome measures.

    RECOVERY IS THE EXPECTED OUTCOME WITH THE PUBLIC HEALTH APPROACH

    With appropriate help, individuals with mental illnesses, substance 
use disorders, and co-occurring disorders can and do recover. These 
conditions are chronic illnesses; relapses are possible; and the 
recovery process can be protracted. However, when these individuals 
take that brave step toward seeking help, and the right services and 
treatment take hold, the potential for recovery can unfold. Today, 
recovery is no longer the exception; it is the expectation. To advance 
the recovery paradigm the public health approach is required, working 
with people in the context of their environments. The public health 
model uses systems that provide a continuum of services that focus on 
an entire population rather than on individuals with individual 
illnesses. The continuum begins with an assessment of need and ends 
with a population-based, evaluated approach that extends into practice, 
research, policy, and the engagement of the public itself.

                    DATA COLLECTION TO DEFINE NEEDS

    SAMHSA reports to the Nation on the prevalence of substance use and 
mental health problems in the United States. One of those measures is 
provided by our National Survey on Drug Use and Health. The survey 
provides national and comparable State-level estimates of substance 
use, abuse, and dependence. It also provides an ongoing source of 
nationally representative and State-level information on mental health.
    The analysis of trends over time from the survey, alone and in 
combination with other data sources, provides an invaluable tool to 
measure outcomes of the National Drug Control Strategy and to report 
our progress to Congress. Two other major national surveys conducted by 
SAMHSA include the Drug Abuse Warning Network (DAWN) and the Drug and 
Alcohol Services Information System (DASIS). The DAWN obtains 
information on drug-related admissions to emergency departments and 
drug-related deaths identified by medical examiners. DASIS consists of 
three data sets developed with State governments. These data collection 
efforts provide national and State information on the substance abuse 
treatment system.

              EXPANDING SUBSTANCE ABUSE TREATMENT CAPACITY

    The cornerstone of the Nation's substance abuse prevention and 
treatment activities is the Substance Abuse Prevention and Treatment 
Block Grant funded by SAMHSA which is designed to support and expand 
substance abuse prevention and treatment services, while providing 
maximum flexibility to States. It provides support to 60 eligible 
States, territories, the District of Columbia and the Red Lake Indian 
Tribe. SAMHSA's CSAT also funds an array of discretionary grants 
through the Programs of Regional and National Significance to build 
treatment capacity, including innovative financing (e.g., Access to 
Recovery Program) and increased use of screening, brief interventions, 
referral and treatment services.
    SAMHSA has partnered with health care professionals to expand use 
of screening and brief interventions to identify the full spectrum of 
substance users as a routine part of standard health care and provide 
brief, cost-effective interventions to help them cease substance use 
once discovered. The modality, called Screening, Brief Intervention, 
Referral and Treatment (SBIRT), has been deployed to hospitals, health 
clinics, college campuses and school-based clinics across the country. 
Under SBIRT, medical professionals conduct brief screening in a general 
health care setting such as a hospital, a health clinic or a 
university-based clinic. Under SBIRT, once a problem is detected, a 
medical professional immediately performs a brief intervention, lasting 
less than 30 minutes. Brief interventions assist patients in 
recognizing the impact of unhealthy drinking or drug use and commit 
them to a plan of action to cease use. Studies show that this brief 
intervention can reduce substance abuse significantly, thus improving 
overall health. These interventions are very cost-effective as they 
reduce re-admission into emergency departments and re-hospitalizations. 
In many cases, the brief intervention is sufficient for the non-
addicted user. Those with scores that fall into the range of dependence 
are referred to more intensive treatment.
    To date the Federal SBIRT program has screened 504,334 people in 
healthcare settings in 10 States in the Nation. A positive screen was 
obtained in 21.2 percent of people screened, and these were 
subsequently provided with brief intervention (15.1 percent), brief 
treatment (2.7 percent), or were referred to treatment (3.3 percent). 
Six-month follow ups on a sampling of those receiving an intervention 
show promising reductions in substance use, depression and improvements 
in other parameters.
    For those referred to treatment because they have become addicted, 
SAMHSA has expanded options for treatment. The Access to Recovery (ATR) 
program, a Presidential initiative, is a key source of innovation in 
the field of addiction recovery. Through the use of vouchers, ATR 
provides clients with the opportunity to choose among a broad array of 
substance abuse clinical treatment and recovery support service 
providers. ATR is designed to: (1) allow recovery to be pursued through 
personal choice and many pathways; (2) require grantees to manage 
performance-based outcomes that demonstrate client successes, (3) 
expand capacity by increasing the number and types of providers who 
deliver clinical treatment and/or recovery support services. The 
outcomes for clients served through the ATR program are very 
encouraging. As of December 31, 2006, the ATR program had served 
137,579 clients, exceeding the initial target by 10 percent. After 
receiving services through ATR, 81 percent of clients are abstinent 
from substances and 51 percent are in stable housing.
    Expanding substance abuse treatment capacity also has a direct link 
to shrinking rates of criminal recidivism. Upon discharge from the ATR 
program, 97 percent of clients have no involvement with the criminal 
justice system. This impressive rate reflects an 81 percent reduction 
among those who were involved with the criminal justice system at 
intake. Additionally, drug treatment courts provide a successful 
alternative to incarceration and help to break the cycle of addiction, 
crime, incarceration, release, relapse, and recidivism. These courts 
enable stakeholders to work together to give individual clients the 
opportunity to improve their lives, including recovering from substance 
use disorders and developing the capacity and skills to become full-
functioning parents, employees, and citizens. Close supervision, drug 
testing, and the use of sanctions and incentives help to ensure that 
offenders stick with their treatment plans while public safety needs 
are met.
    Other CSAT Programs of Regional and National Significance (PRNS) 
include: Targeted Capacity Expansion Grants (TCE-General) which have 
focused on treatment for methamphetamine use, minority populations, and 
rural areas, to name a few; Grants to Benefit Homeless Individuals; and 
the Minority HIV/AIDS and Substance Abuse Treatment Grant program. 
SAMHSA has focused its grant resources on activities that directly 
demonstrate improvements in substance abuse outcomes and increase 
capacity while eliminating less effective or redundant activities 
within the Substance Abuse Prevention and Treatment PRNS.

   STRENGTHENING AND STREAMLINING SUBSTANCE ABUSE PREVENTION EFFORTS

    While expanding substance abuse treatment capacity and recovery 
support services is critical, it is imperative not to lose sight of the 
importance of preventing addiction in the first place by stopping 
substance use before it starts. SAMHSA will continue the Strategic 
Prevention Framework grant program to accomplish the President's goal 
to reduce youth drug use in America, thereby leading to a healthier 
populace. By focusing our attention, energy and resources we, as a 
nation, have made real progress toward reaching the President's goal. 
The most recent data from the 2006 Monitoring the Future Survey 
confirms that we have reduced youth drug use by 23 percent by 2006. 
What this means is approximately 840,000 fewer youth used illicit drugs 
in 2006 than in 2001. Although our work is far from over, prevention 
remains key and SAMHSA's Strategic Prevention Framework (SPF) will 
continue to play an important role in achieving the goals of the 
President's Healthier US Initiative.
    To more effectively and efficiently align and focus our prevention 
resources, SAMHSA launched the SPF State Incentive Grant Program in 
fiscal year 2004. It is systematically implementing a risk and 
protective factor approach to prevention across the Nation. The success 
of the framework will continue to be determined by, in large part, on 
the tremendous work that comes from the Office of National Drug Control 
Policy's (ONDCP) grass-roots community anti-drug coalitions. Along 
those lines, SAMHSA expects to continue working with ONDCP to support 
the over 750 grantees funded through the Drug-Free Communities grant 
program. Moreover, with SAMHSA's State Epidemiological Workgroups, we 
will target funding to areas of greatest need for various prevention 
interventions and services. Funding to States, communities and tribal 
organizations will be data driven.
    Additionally, SAMHSA will continue to focus energy and take a 
leadership role in the prevention of underage drinking. According to 
the Surgeon General's Call to Action to Prevent and Reduce Underage 
Drinking, alcohol is used by more young people than tobacco or illicit 
drugs. An estimated 10.8 million young people between the ages of 12 
and 20 (28.2 percent of this age group) are current drinkers. Nearly 
7.2 million (18.8 percent) are binge drinkers, and 2.3 million (6.0 
percent) are heavy drinkers. Each day, more than 10,000 young people 
under the age of 21 take their first drink. We know that we need to 
change how America thinks about underage drinking if we are to see a 
significant reduction in the problem. SAMHSA and HHS' National 
Institute on Alcohol Abuse and Alcoholism (NIAAA) collaborated with the 
Office of the Surgeon General to produce the Call to Action, which was 
released on March 6, 2007. The Call to Action provides a public health 
approach to stimulate action in all sectors of society to prevent and 
reduce underage drinking.
    SAMHSA's Center for Substance Abuse Prevention supports a range of 
activities that address the substance abuse prevention needs of 
community-based populations. For example, CSAP supports over 148 grants 
that work to expand the capacity of community-level domestic public and 
private non-profit entities to prevent and reduce the onset of 
substance abuse and transmission of HIV and hepatitis among minority 
populations and minority re-entry populations. In addition, CSAP 
supports a $9.8 million Fetal Alcohol Spectrum Disorders Center for 
Excellence that identifies best practices and builds on evidence-based 
prevention for pregnant and postpartum women, assistance for those with 
developmental disabilities, and support for other populations invested 
in serving those with, or affected by Fetal Alcohol Spectrum Disorders 
(FASD). Through subcontracts, the FASD program will implement system-
wide prevention approaches through States, tribes, communities and 
territories that have high FASD incidence and prevalence rates. CSAP 
also has initiatives targeting Native American Populations and oversees 
the Federal Drug Free Workplace Program.

          IMPLEMENTING THE FEDERAL MENTAL HEALTH ACTION AGENDA

    Today, there is unprecedented knowledge enabling people with mental 
illnesses to live, work, learn, and participate fully in their 
community. The President's New Freedom Commission on Mental Health 
found in its 2003 report that the time has come for a fundamental 
transformation of the Nation's approach to mental health care. It 
reported that the current system is unintentionally focused on managing 
the disabilities associated with mental illness rather than promoting 
recovery, and that this limited approach is due to fragmentation, gaps 
in care, and uneven quality. These systemic problems frustrate the work 
of many dedicated staff, and make it much harder for people with mental 
illness and their families to access needed care.
    SAMHSA's Center for Mental Health Services (CMHS) is leading the 
Federal effort to achieve the vision of a transformed mental health 
system. Among the tasks are: helping Americans understand that mental 
health is essential to overall health; reorienting the system toward a 
consumer-and-family driven system; eliminating disparities; providing 
appropriate mental heath assessment and referral; delivering excellent 
mental health care and accelerating research; and utilizing technology 
to access mental health care and information through electronic health 
records.
    Instead of focusing on a few grants that promote transformation, 
SAMHSA has worked to ensure that the principles of mental health 
transformation are present throughout all SAMHSA grant activities 
including the Community Mental Health Services Block Grant, which 
continues to support comprehensive, community-based systems of care for 
adults with serious mental illness and children with serious emotional 
disturbance. Within the CMHS Programs of Regional and National 
Significance (PRNS), the Mental Health Transformation State Incentive 
Grants are supporting States in developing a comprehensive mental 
health plan and improving their mental health services infrastructures. 
States receiving awards expand the use of evidence-based practices, use 
technology to improve access to care, and engage consumers in shaping 
the system to meet their needs.
    A transformed mental health delivery system will have a direct 
impact on SAMHSA's ability to improve services around suicide 
prevention, school violence prevention, children's mental health, the 
transition from homelessness to stable housing, and protecting the 
rights of individuals with mental illnesses.
    Starting with suicide prevention, suicide is a preventable tragedy 
and is a high-priority status within the agency. The reason for the 
priority is clear: in the past year, approximately 900,000 youth aged 
12-17 during their worst or most recent episode of major depression 
made a plan to commit suicide, and 712,000 attempted suicide. Currently 
SAMHSA funds a total of $36 million for suicide prevention, including 
activities authorized by the Garrett Lee Smith Memorial Act, suicide 
prevention for the American Indian and Alaska Native youth populations, 
a Suicide Prevention Resource Center, and a 24-hour national hotline. 
The hotline is available to all those in suicidal crisis who are 
seeking help. Individuals seeking help through the hotline are routed 
to 1 of over 120 crisis centers across the country which creates a 
nationwide lifeline. Approximately 36,000 calls per month are answered 
by the hotline and responded to by trained counselors.
    In regard to preventing school violence, SAMHSA collaborates with 
the Departments of Education and Justice through the Safe Schools/
Healthy Students (SS/HS) program to support local partnerships that 
promote healthy childhood development and prevent substance abuse and 
violence. There is tremendous opportunity in the area of early 
identification of mental health problems as part of a comprehensive 
approach to prevention. For example, youths aged 12 to 17 who 
experienced depression in the past year were twice as likely to take 
their first drink or use drugs for the first time as those who did not 
experience depression. Among youths who had not used alcohol before, 
29.2 percent of those who experienced depression took their first drink 
in the past year, compared with 14.5 percent of youths who took their 
first drink but did not have a major depressive episode. And 16.1 
percent of youths who experienced depression and had not previously 
used illicit drugs began drug use; in contrast, 6.9 percent of youths 
who did not have a major depressive episode began drug use.
    It is clear young people with serious emotional disturbances who 
receive help for their condition are far more likely to experience 
success in school and far less likely to enter the juvenile justice 
system or the institutional care system. The Agency's Children's Mental 
Health Services grant program develops comprehensive, community-based 
systems of care for children and adolescents with serious emotional 
disorders and their families. Of children receiving services under this 
program last year, nearly 70 percent did not require interaction with 
law enforcement and nearly 90 percent attended school regularly.
    In addition to its system transformation activities, the CMHS PRNS 
also includes funding for National Child Traumatic Stress Initiative 
and the Minority HIV/AIDS and Mental Health Programs. Homelessness also 
continues to be a priority program area for SAMHSA. Approximately one-
fifth of homeless individuals also have serious mental illnesses. 
Individuals with serious mental illnesses are homeless more often and 
have greater difficulty transitioning from homelessness to stable 
housing than other people. The Agency continues support for an array of 
individualized services to this vulnerable population through Projects 
for Assistance in Transition from Homelessness (PATH) and through 
SAMHSA's Mental Health and Substance Abuse Programs of Regional and 
National Significance.
    Additionally, individuals with mental illnesses and serious 
emotional disturbances who reside in treatment facilities are 
particularly vulnerable to neglect and abuse. In response, SAMHSA 
provides support for State protection and advocacy systems to protect 
these individuals from abuse, neglect, and civil rights violations. 
Approximately 80 percent of substantiated allegations of abuse and 
neglect that are reported to protection and advocacy systems result in 
positive change for the client.

         MEETING NEEDS THROUGH EVIDENCE-BASED SERVICE DELIVERY

    The success of SAMHSA's programs and service delivery systems 
clearly hinges on collaboration. No single agency can do it all. 
Without exception, partnerships among private sector and Federal, State 
and local public sector agencies are key to helping provide people with 
mental and substance use disorders the opportunity to achieve a 
fulfilling life in the community.
    One of our public partners is the National Institutes of Health 
(NIH). In brief, the NIH Institutes and Centers, including the National 
Institute on Drug Abuse, the National Institute on Alcohol Abuse and 
Alcoholism and the National Institute of Mental Health, develop 
evidence-based practices through research, and SAMHSA supports 
implementation of evidence-based practices through grants that support 
service delivery. This partnership forms the basis of our Federal 
efforts to ensure the best science is used in our service delivery 
systems. Working both independently and collaboratively, we are 
committed to establishing pathways to move research findings into 
community-based practice and to reducing the Institute of Medicine 
reported 15-20 year lag between the discovery of more efficacious forms 
of treatment and their incorporation into routine patient care.
    To advance ``Science and Service'' and to ensure the public, and 
consumers and providers of mental health and substance abuse services 
are aware of the latest information, prevention interventions, 
treatments and recovery support services SAMHSA operates in its Health 
Information Network. SAMHSA also created and funds the National 
Registry of Evidence-based Programs and Practices (NREPP). NREPP is a 
web-based decision support system designed to help States and 
community-based service providers make informed decisions about 
interventions they select to prevent and treat mental and substance use 
disorders. The NREPP system is the culmination of a multi-year process 
that included input from numerous scientific and health care service 
experts and the public. It currently provides information on 27 
interventions. Two-thirds of these received NIH funds for development 
and testing.

MEASURING EFFECTIVENESS AND MANAGING RESOURCES THROUGH A DATA STRATEGY 
                  AND RECOVERY-BASED OUTCOME MEASURES

    Performance measurement and management is a challenging and complex 
issue. Our goal at SAMHSA is to achieve a performance environment with 
true accountability focused on a limited number of national outcomes 
and related national outcome measures. This goal is built on a history 
of extensive dialogue with our colleagues in State mental health and 
substance abuse service agencies and, most importantly, the people we 
serve.
    The domains we have identified embody meaningful, real life 
outcomes for people who are striving to attain and sustain recovery, 
build resilience, work, learn, live, and participate fully in their 
communities. In collaboration with the States, we have identified 10 
domains as our National Outcome Measures, or NOMs.
    The first and foremost domain is abstinence from drug use and 
alcohol abuse or decreased symptoms of mental illness with improved 
functioning. Four domains focus on resilience and sustaining recovery: 
getting and keeping a job or enrolling and staying in school; decreased 
involvement with the criminal justice system; securing a safe, decent, 
and stable place to live; and social connectedness to and support from 
others in the community such as family, friends, co-workers, and 
classmates. Two domains look directly at the treatment process itself 
in terms of available services and services provided: increased access 
to services for both mental and substance use disorders; and increased 
retention in services for substance abuse treatment or decreased 
inpatient hospitalizations for mental health treatment. The final three 
domains examine the quality of services provided: client perception of 
care, cost-effectiveness, and use of evidenced-based practices in 
treatment.
    Data for reporting on these measures come from the States. States 
are supported in their efforts by SAMHSA with infrastructure, technical 
assistance, and financial support through the new State Outcome 
Measurement and Management System (SOMMS) Program, which is funded 
through the set-asides for the mental health and substance abuse block 
grants.
    Among the States reporting data to SAMHSA in the Retention and 
Perception of Care domains for mental health, the NOMs data 
demonstrates a low percentage (8 percent) of patients returning to 
State hospitals 30 days after discharge and a high percentage (71 
percent) of consumers of mental health services who reported they were 
doing better as a direct result of services received. With regard to 
substance abuse, the NOMs data reported to SAMHSA demonstrates 
significant success in the abstinence domains for both alcohol and drug 
use with over 94 percent of reporting States indicating improvements in 
client abstinence. Similar successes were reported in improved client 
employment and reduction in arrests. Ultimately, SAMHSA will be able to 
report State-level, consistent, cross-year data which will allow us to 
examine the impact of programs and changes over time.
    We have collected and reported to Congress the data that are 
available at this time. The NOMs are also available on the SAMHSA Web 
site, www.samhsa.gov. Each outcome measure is detailed in a table, and 
State profiles are available as well. The consensus that was needed to 
develop and implement the NOMs now needs to become widespread and used 
to guide the daily operations of provider organizations and individual 
providers to continue to improve service delivery systems.

                               CONCLUSION

    As the Administrator of SAMHSA, I am steadfast in my commitment to 
lead SAMHSA and the people we serve toward achieving the best outcomes 
possible. Each of us lives and works in a time when behavioral health's 
impact on everyday life and overall health can no longer be set aside 
with a clear conscience.
    SAMHSA's National Survey on Drug Use and Health indicates that 
nearly 21 million Americans who needed treatment for an illicit drug or 
alcohol use problem did not receive treatment. In addition, there were 
over 11 million adults who reported an unmet need for treatment or 
counseling for mental health problems in the past year, including 5.7 
million adults who did not receive any mental health treatment at all. 
Helping more Americans achieve a healthy and rewarding life in the 
community in ``the land of promise'' is not a vague or lofty goal. It 
is an achievable milestone in our Nation's story which is already 
underway through advancements in science and research, the introduction 
of promising and effective treatments, systems transformation, public 
outreach and education, and strong national leadership and commitment.
    Thank you for the opportunity to appear today. I will be pleased to 
answer any questions you may have.

    Senator Reed. Thank you very much, Dr. Cline.
    We'll take 5-minute rounds and, let me begin.
    One of the issues that is highlighted both by your 
testimony and Congressman Kennedy's testimony was the 
interaction between mental health and physical health. And the 
reports recently--and we've cited them, about shortened 
lifespan of people with mental health problems, should give us 
pause. It raises many, many questions, but among those--what is 
your sense of the ability of primary care providers to 
recognize and effectively treat mental health issues? And, on 
the other side of the equation, the ability of mental health 
workers to recognize physical issues, and get that patient into 
some type of health screening?
    Mr. Cline. I believe that we have been sorely inadequate on 
both fronts. I think that there is a great deal of potential 
that is just now being recognized. Again, this public health 
approach really emphasizes the need to address the 
comprehensive needs of individuals. We have many qualified 
experts who have been doing an incredible job of providing the 
services they provide, but those services have been so narrowly 
focused, that we have missed that broader picture of 
individuals.
    I heard a very compelling story of someone who had 
struggled with their recovery, with mental illness. On the path 
to recovery, doing very well, only to die of a heart attack in 
their early fifties. So, I think there is, there's increased 
recognition across the States and communities about the need to 
integrate and address these needs, wherever possible.
    Senator Reed. I presume, also, that raises the stakes for 
the training programs that will allow both medical 
professionals and mental health professionals to recognize 
different disorders and at least recommend treatment, is that 
correct?
    Mr. Cline. I think that's absolutely true. And again, 
that's the opportunity--if you're working with an individual, 
and you have that person, and you have a relationship, and 
you're providing some aspect of their care, what a great 
opportunity, then, to broaden that to address these other 
areas, or make sure that, at least, that's coordinated with 
other aspects of care.
    Senator Reed. One of the areas that we're all concerned 
about, I know you are, Doctor, is measuring outcomes, which is 
a very difficult proposition in any endeavor, public or 
private.
    Recently, there's been a transition from a performance 
partnership grant initiative that was directed by Congress 
during the last reauthorization, to the new national outcomes 
measures system. Why don't you give us an idea of the rationale 
behind the change, what you hope to accomplish, and why is this 
a better approach?
    Mr. Cline. The approach we have now is focused on 
recovery--recovery for individuals. What makes a difference in 
an individual's life, and for that person's family? And, that 
has changed in emphasis from kind of a quantitative, counting 
numbers of services, to a more qualitative aspect, and how is 
that making a difference?
    These are the types of things that we know are important to 
help an individual obtain and then sustain their recovery, 
things like having a job, things like connecting with their 
family, decreased contact with the criminal justice system. 
Those types of issues which are meaningful in a person's life 
and are very, very relevant to their recovery.
    So, it's a change from a focus on, specifically on 
treatment, and measuring that treatment, to a focus on 
recovering, and measuring recovery.
    Senator Reed. Now, do you think you have the information 
systems and the metrics to make this system work?
    Mr. Cline. These outcome measures have been in development 
for several years, again, this is a partnership that I 
referenced, with the States. The majority of States have been 
voluntarily submitting that data already to SAMHSA. There are 
10 domains for getting all of those demands. For some States, 
that has been quite a struggle, in terms of developing that 
infrastructure. They have not had that capacity. So, SAMHSA is 
providing technical assistance, trying to work with those 
States so they will have that capacity to provide those data to 
SAMHSA. We're not there yet, but we're well on our way.
    Senator Reed. And, in that regard, in terms of outcomes, 
the Access to Recovery Program has been on the books and in the 
field for a few years now. Have you looked at outcome measures 
in that program relative to other programs? Have you drawn any 
preliminary conclusions?
    Mr. Cline. The preliminary outcomes are looking very good 
for the Access to Recovery Program. When the Program--and it's 
still in its relative infancy--so we'll track that data over 
time, as well. But, the initial data shows approximately a 70-
percent abstinence rate for individuals who are discharged from 
the Access to Recovery program, a significant increase of about 
20 percent for individuals, in achieving housing--independent 
housing--and over 25 percent increase in employment for those 
individuals. So, the preliminary data are looking very 
encouraging.
    Senator Reed. And, you're drilling down to the different 
treatment modes that they're using, and making connections in 
terms of what treatments they're getting and leading to success 
or failure?
    Mr. Cline. What we know so far is that we have broadened 
the number of providers who have been involved in that. We 
believe that that is significant. We don't have a large enough 
pool of that data yet to draw conclusions from that.
    Senator Reed. Thank you, Doctor, very much.
    Senator Enzi.
    Senator Enzi. Thank you for your testimony, and also the 
excellent answers to those questions.
    I want to delve a little bit more into the recently 
released principles that included using the public health 
approach to deliver services, which eliminates funding silos, 
among other things. I want to know how you plan on carrying 
that out, but mostly what tools you need to carry out those 
objectives. What do we need to ensure that these funding silos 
can result in a better approach to delivering services? The 
coordination that was talked about?
    Mr. Cline. Thank you for that question.
    I have more detail on this issue than I might have 
otherwise. Oklahoma was one of the States, one of the initial 
seven States that had received a transformation grant through 
SAMHSA several years ago. As part of that process, that allowed 
us to develop a plan, by State, individually to address the 
needs, recognizing that the structure in Oklahoma may be very 
different than the structure in Wyoming, or Arkansas, or 
Massachusetts, and so we don't have a one-size-fits-all. What 
that allows us to do is to identify the needs within those 
particular States, that allows us to then develop a 
comprehensive plan which looks--not only of the needs within 
the behavioral health system--but looks at the needs across the 
entire community, and the State.
    As you know, there are many other entities that are 
involved in providing behavioral health care. So, that 
transformation is much broader, and that's where we get into 
the public health model, in terms of involving schools, and in 
terms of involving employers, and practitioners in hospitals, 
and other people in the community. So, some of the tools that 
are needed are that technical assistance to the States, to help 
them develop their own resources, to help them explore their 
own needs and develop that plan, and then to implement that 
plan.
    There also has been a great deal of sharing of that 
information from those seven States--now nine States, two other 
States were added--for that initial transformation effort, and 
we are spreading that even beyond that pool of nine States, and 
showing that. We recently had a conference where individuals 
from the States that have been actively engaged in this, were 
sharing this with other States. So, they can learn from the 
lessons that have been learned the hard way in some of those 
other States.
    But, it's a very exciting transformation, there is a 
recognition across the board that we have not made the gains, 
even though people have been working incredibly hard and 
putting resources to meet those needs, we have not been as 
effective as we might be, if we had that more comprehensive 
public health approach.
    Senator Enzi. I think this is related, and we talked about 
national outcomes just a moment ago, too, so this is a little 
bit of a follow up to that question, as well. For individuals 
with co-occurring conditions, is SAMHSA working with the States 
to develop the NOMS management system that will reduce the 
duplication of records? Such as duplication of information in 
paperwork?
    Mr. Cline. Well, there are two pieces, I think, that 
address that. There's the 10 domains that basically apply, 
although there are a couple with variations, applied to both 
the substance abuse and the mental health populations. So, that 
provides some equitable data, and that's why this was such a 
remarkable feat, to have consensus from both fields, across the 
country on these 10 domains for the National Outcome Measures.
    We also are exploring, and helping States explore, the 
possibility of electronic medical records, which is a serious 
issue in terms of looking at some of that interoperability 
between those records. As you know, there are some 
confidentiality restrictions, in terms of 42 CFR for substance 
abuse services, and other things that present some challenges 
that may be unique to this field. But, I believe that, the 
people engaged in that process--and we're seeing great progress 
with that.
    Senator Enzi. Yes, we're working on the Health IT, we put 
out a bill last year, and we're working from that basis and 
moving forward, trying to get some of the tools that are needed 
there, plus provide the confidentiality.
    So, I'll yield the balance of my time.
    Senator Reed. Thank you, Senator.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman, and I 
would like to submit my opening statement for the record.
    Senator Reed. Without objection.
    [The prepared statement of Senator Murray follows:]

                  Prepared Statement of Senator Murray

    Mr. Chairman and Senator Enzi, thank you for holding this 
hearing as we begin updating our Nation's policies on substance 
abuse and mental health.
    Unfortunately today, most of the agency's authorities have 
expired, and that lapse is occurring at a critical time. We 
have veterans coming home from combat who need help with PTSD 
and other mental health challenges. They face the same stigma 
that many others face when they seek mental health care.
    And we've all been horrified by what occurred at Virginia 
Tech. We have to make sure that people at risk of violence get 
the attention and treatment they need, and that those affected 
by the tragedy in Blacksburg get counseling and support.
    I've been pleased to work on past SAMHSA reauthorizations. 
In 2000, we improved our focus on the needs of young people and 
created a grant program to address methamphetamine abuse. Since 
then, we've targeted underage drinking and preventing youth 
suicide.

                          MY THREE PRIORITIES

    As we begin to update the act this year, I'm focused on 
several points.
    First, we've got to make help more accessible. That means 
keeping up with the demand for services and making it easier 
for everyone to get those services--whether they have insurance 
or not. It means making sure that grant programs have 
sufficient funding to meet the needs of our communities.
    Second, it's all connected. Individuals are not just 
individuals; they're part of a broader community. Mental health 
is connected to substance abuse to housing to employment and 
more. As I look at SAMHSA's programs, I see that it's all 
connected, and that's why our approach has to be comprehensive 
and coordinated.
    One example of that is mental health parity. We know mental 
health is connected to physical health, and it should be 
treated that way by insurers. The inability to treat mental 
illness the way we treat physical illness has resulted in a 
fragmented treatment structure. It has also created a shortfall 
in the availability of services.
    I'm pleased that our committee has passed mental health 
parity, and I'm eager to move that bill forward so that our 
entire country can begin to see the benefits of it. And I want 
to thank Chairman Kennedy and Senator Enzi for their work on 
mental health parity.
    Third, when it comes to substance abuse and mental health, 
early intervention makes a difference. I'm especially 
interested in the support we can provide to young people. The 
truth is we can pay now--or we can pay later. Let's be 
proactive and help individuals and communities address these 
challenges early while there's still time to help them lead 
longer, healthier, and more productive lives.
    I really want to thank our witnesses for testifying today 
and sharing their insights. In the fields of mental health and 
substance abuse, I've met so many people who are quietly 
working to help individuals change their lives and reclaim 
their futures. They do difficult work, and they don't often get 
the public credit they deserve. And I just hope that as we 
update the policies, we never lose sight of the people they 
serve, and how their work--and ours--can make a difference.

    Senator Murray. Dr. Cline, my home State of Washington is 
facing a meth epidemic, no matter who I talk to--whether it's 
law enforcement, or drug counselors, or social workers, or 
community leaders, they bring this up to me as the No. 1 issue 
that they are trying to deal with in their community, and I 
wanted to know if you could update me on what work your agency 
is doing to address the meth epidemic, and more specifically, 
do you think we need to provide more funding or more authority 
from Congress to deal with that issue?
    Mr. Cline. My belief is that the authority exists. We've 
been providing a great deal of technical assistance, as well as 
some grants, and Washington State, in particular, the Access to 
Recovery Program that we talked about earlier, is thriving and 
serving many individuals who are struggling with 
methamphetamine, specifically, in that State.
    Again, we've provided that technical assistance, we've had 
grants to make certain that States were able to implement 
evidence-based practices. At one time, there was a 
misunderstanding or a myth in the field that people who were 
struggling with methamphetamine could not be treated, the 
treatments were not effective. It simply was not true, there 
are effective treatments for methamphetamine addiction. So, 
it's important to get that message out there, as well.
    When we look at the national data, what we see is that the 
initiation, those people who are using methamphetamine for the 
first time, is actually on the decline. But, at the same time, 
we're seeing a significant increase in the number of people who 
are being admitted for methamphetamine treatment. So I know 
that many States are struggling to respond to meet that need, 
which is great.
    Senator Murray. Do we have enough resources? Do you think 
we need more resources for that?
    Mr. Cline. There is great variability by States on that, so 
I wouldn't feel comfortable generalizing for the whole country. 
I know in some areas of the country, the methamphetamine 
epidemic is absolutely devastating, and those States have 
reported ongoing struggles in terms of meeting that need, in 
terms of workforce to actually meet the need, and treatment 
facilities that are trained with the workforce to be able to 
use those evidence-based practices, and other States where that 
has been less of an issue.
    Senator Murray. I'm also very concerned, and have been 
working for some time on the issue of our children getting 
access to treatment services for mental health and substance 
abuse, and I know that SAMHSA has started to shift some 
resources more toward children, but we still have a really long 
way to go.
    In my State, one of the challenges we have is not enough 
service providers for children, so that's a real barrier. Can 
you talk to us a little bit about your efforts to improve 
service and treatment options for children?
    Mr. Cline. Sure, and thank you for that question.
    As part of this public health model, one of the areas of 
focus for SAMHSA is really to intervene as early as possible in 
that cycle of addiction, or mental illness. We know that if we 
can reach people at the early stages of their illness, the 
prognosis is much better, and the negative impact on the 
individual and family is greatly decreased.
    SAMHSA, I think most people are aware, has a strong track 
record in terms of the systems of care approach, which is an 
innovative program for children and their families to address 
the needs of those children who are struggling with serious 
emotional disturbance, which is a program that is comprehensive 
in nature that emphasizes collaboration of multiple sectors.
    Most often children who are struggling with either 
addiction or mental illness, are not engaged with only one 
provider--they have special ed services through the school, 
they may be involved in child welfare, they may be involved 
with the mental health system. So, there's an effort through 
that particular grant program to make certain that all of those 
individuals are coming together to create one team that's 
focused on the needs for that particular family, rather than 
working in the silos.
    And also, in the area of addictions, a great deal of 
concern, now, about underage drinking. And we worked with the 
Surgeon General's Office to release his Call to Action, which 
is focusing on the reduction and elimination of underage 
drinking, which is a persistent problem in our culture today.
    Senator Murray. OK, I appreciate that. And finally, let me 
just ask you about Veterans--we know there's a high number of 
men and women coming home with PTSD and other mental health 
issues, and we're hearing more and more reports that are very 
disturbing. I know that the VA focuses on that, but I wanted to 
find out from you what SAMHSA is doing, if anything, and if 
there's anything else we should be looking at, as we get this 
influx of soldiers home.
    Mr. Cline. Thank you, again, for that question. SAMHSA is 
very concerned about this issue. We sponsored a conference, 
just within the last year, that focused on returning vets, we 
pulled people together from all over the country, asked States 
to have representatives from their VA systems, and from their 
mental health systems so that they could work together in a 
focused way to address those needs back in their States, again 
recognizing that we wouldn't simply be saying what is best for 
that particular community--we are an ongoing collaboration with 
the Department of Defense as well as the VA and the National 
Guard, and are actively engaged in that process, in terms of 
formulating any kind of contribution that SAMHSA could make 
toward that response.
    Senator Murray. One of the big issues is the stigma 
attached to it, particularly for, ``tough Army guys.'' Is there 
anything we should be doing to help our community better 
understand that, so that people will get the help that they 
need?
    Mr. Cline. SAMHSA has been engaged in an anti-stigma 
campaign, and again, partnering with several communities across 
the country, trying to encourage individuals to ask for help 
when that help is needed. We've had ongoing collaboration with 
Ad Council, trying to do PSAs that get out there and reach 
everyone, not just Vets, but everyone in those communities, 
because that prejudice is, of course, deeply rooted in our 
culture.
    Senator Murray. Can you share some of those PSAs with the 
committee, so that we can take a look at them?
    Mr. Cline. Absolutely.
    Senator Murray. Great, okay. Thank you very much.
    Mr. Cline. Thank you.
    Senator Reed. Thank you very much, Senator Murray.
    Senator Murkowski.

                     Statement of Senator Murkowski

    Senator Murkowski. Thank you, Mr. Chairman.
    Dr. Cline, I appreciate your testimony here this morning, 
and all that you do with SAMHSA.
    You mentioned the suicide rate, and as you know, that is 
something that we, in the State of Alaska, continue to struggle 
with, particularly in our more remote communities, and our 
villages, and particularly with our young Alaska Native men. 
Our statistics are, needless to say, very, very, very 
troubling.
    And you mentioned coming from a small town in Oklahoma, and 
knowing the impact to a small community. When we have two young 
men or three young men take their lives over the course of a 
winter in a village where you only have a couple hundred 
people, it doesn't just bring down that family, it destroys 
that whole community.
    I feel helpless as to what we can do in a State like Alaska 
where we are so remote, our villages are so small and our 
problems with substance abuse are literally killing our people 
and our communities.
    I would like for you to comment on how, from a rural 
perspective, we can better work with SAMHSA on--particularly 
our suicide rate--to reduce that to the extent possible. We're 
utilizing some tele-medicine, tele-behavioral health 
technology, I think we're starting to make a difference, but 
it's difficult when we don't have the facilities.
    We can have the programs, and--I'll ramble for just a 
moment, if I might--when you're talking about the national 
outcome systems, and the way that we address accountability, 
focus on a qualitative rather than quantitative approach. I 
appreciate that, but I get concerned that if we have to adhere 
to an accountability standard, we're going to lose our ability 
to really cater some programs that would work in a very 
different setting, like a remote Alaska Native village, than 
what we do here in Washington, DC.
    Can you give me some level of assurance on that, that we 
will still have the ability for Manilic Health Corporation to 
have their treatment camp, utilizing cultural and their Native 
ways to provide for a level of treatment, that we're not going 
to be bumping up against a one-size-fits-all approach, because 
we have to be able to account for these moneys?
    So, my question is two-fold--what can we do on the suicide 
front, and with this focus on a National Outcome System, will 
we still have the flexibility that we need in many rural parts 
of the country to provide for culturally sensitive programs?
    Mr. Cline. Thank you for the question.
    I had a brief conversation with someone from Alaska 
earlier, before this meeting, who talked about the challenge of 
the nearest center being several hundred miles away for those 
individuals to access any type of care. So, and obviously in 
that situation it's difficult to engage the entire family, in 
any kind of family-oriented treatment, which we know has often 
been most effective, in many situations.
    The outcomes that you talk about, I believe are helpful 
tools, if you're managing a State system, or whether you're 
managing an individual program, so that you have an idea of the 
effectiveness of your programs, and you use that, then, as a 
management tool for yourself. And I've managed both those 
programs, and at the State level, and that information is very 
helpful.
    There has been a great deal of concern about the 
disparities that you're mentioning, SAMHSA has specifically six 
suicide grants that are targeted for tribes and Alaska Natives, 
so we're working hard to make sure that those grants are as 
available as possible. And again, in ensuring that the tribes 
are using those dollars and those grants to provide culturally 
competent services within their community, it's not a cookie-
cutter approach in doing that.
    SAMHSA has also has been engaged in developing and updating 
a National Registry of evidence-based programs and practices, 
this is a larger registry that looks at evidence-based 
practices that actually encourage those communities and others 
to submit designs that they know have been successful, in their 
particular communities. So, an individual community could go to 
this registry, look at this registry, and say, ``Here are some 
similar characteristics that we share from our community with 
this particular community, and it worked there, so we may try 
that.''
    The threshold is a little bit different, you're not looking 
at, necessarily, randomized controlled studies, or a threshold 
that is so incredibly high that it doesn't address the cultural 
competency issues of other programs or communities, so we're 
very hopeful about that being a useful tool for communities, as 
well.
    Senator Murkowski. I can't pass up the opportunity to make 
sure that you're invited to come up to the State and visit some 
of our communities, so that you can appreciate some of the 
challenges that we face. We look forward to it.
    Mr. Cline. Thank you very much, I appreciate that 
invitation.
    Senator Murkowski. Thank you, Mr. Chairman.
    Senator Reed. Thank you, Senator.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    She usually invites you in the dead of winter, I'll just 
warn you.
    [Laughter.]
    Mr. Cline. The travel rates will be cheaper, that will be 
good.

                       Statement of Senator Burr

    Senator Burr. Dr. Cline, welcome. We're delighted to have 
you at SAMHSA. I think it's apparent, sitting here and 
listening to all of the members field questions to you, that 
everybody's problem is a little bit unique, it changes a little 
bit State to State, region to region. It probably highlights 
why your job is vitally important, and why in the functions of 
SAMHSA we should, very much be focused on outcomes, and less on 
process, because the objective here is, how do we help as many 
people as possible, and how do we keep them part of their 
communities, and more importantly, productive parts of their 
communities? But, we do that with the real understanding that 
we've got challenges.
    I want to go into two areas, the first one, homelessness, 
chronic homelessness, specifically. Because we know SAMHSA 
partners with the Department of Education under the Safe 
Schools, Healthy Students initiative. I think it's safe to say 
Senator Reed and I, and I'm sure others, think that SAMHSA 
should also partner with the Department of Housing and Urban 
Development to provide targeted funding for mental health and 
substance abuse services at permanent supportive housing 
facilities, to help end this cycle of chronic homelessness that 
exists.
    The city of Portland recently reduced the number of 
chronically homeless by 70 percent, when the city, the county, 
the Housing Authority partnered to provide resources so 
agencies could open 480 new units of permanent, supportive 
housing. And I know SAMHSA has the authority to provide some 
funding to organizations providing services to homeless 
individuals, but how much of that currently supports this 
highly cost-effective model, like Portland?
    Mr. Cline. I don't have an exact figure for you, Senator, 
but what I can tell you, the key word that I have heard in your 
question was really around partnership, and the effectiveness 
of the program that you describe.
    What we found is that when we provide that flexibility, 
especially in the area of homelessness, that is a community-
based issue and challenge, that there are so many individual 
characteristics, by community, that we want to ensure that we 
are not locking in one particular remedy that we feel can 
address that issue. So, that flexibility, that partnership 
through multiple agencies, we feel, has been the most effective 
tool in addressing homelessness.
    Senator Burr. Well, as you know, Washington has a long 
history of thinking that they know best. And, I think what 
you've heard up here, is that communities know best. And those 
partnerships, I believe, are absolutely valuable.
    Area two--disaster response. It's my understanding, if 
correct, that SAMHSA is authorized to take up to 2\1/2\ percent 
of your overall budget, the discretionary budget, and to surge 
that to address mental health and substance abuse needs in 
response to an emergency. In addition, FEMA receives funding 
from the Federal Government for mental health and substance 
abuse, in the case of emergencies.
    One, is my understanding correct, and can you share with us 
the process that both agencies go through, if they do at all, 
to coordinate the activities, and specifically, who calls the 
shots, when you've got two entities like that involved?
    Mr. Cline. Well, in answer to the question of who calls the 
shots, the majority of these disaster response dollars, when 
they go to the States are actually implemented, then, by the 
States. So, SAMHSA is not actually providing the services, 
although we have provided technical assistance, and we have 
also deployed staff. After the hurricane, I believe we had 
about 250 of the 500 staff at SAMHSA who were actually deployed 
to help provide, you know, in that particular crisis.
    The FEMA dollars that come, of course, from FEMA, travel 
through SAMHSA and are provided for crisis counseling response 
in an emergency situation.
    We also have other dollars through the surge grant, which 
is available, but is not administered through FEMA.
    Does that help with that?
    Senator Burr. Sure.
    Let me ask, SAMHSA-specific, what kind of pre-event 
research, planning, training goes on to prepare for and respond 
to the mental health needs of a disaster?
    Mr. Cline. There's a great deal that goes on, and SAMHSA 
has actively partnered, again, with the States to ensure that 
they have plans in place that they are ready to implement. 
There have been several national conferences, and using the 
same model that I described earlier around the returning Vets, 
where States have been encouraged to bring teams of 
individuals, those very same teams that would be utilized in an 
emergency, not just the behavioral health individuals, but 
other individuals that would be involved from FEMA and other 
emergency preparedness response organizations within their 
State, could be members of Red Cross and others, to make sure 
that they have that plan in place and ready to go.
    So, we've encouraged that, we've provided, again, resources 
and technical assistance to make sure that the States are 
prepared.
    Senator Burr. Last thing, as it relates specifically to 
SAMHSA's experiences in Katrina and Rita--what three things 
would you say that SAMHSA learned to improve the provisions of 
mental health and substance abuse services, post those 
disasters?
    Mr. Cline. I think one of the, and this is really from my 
own perspective, and not necessarily from SAMHSA's, but I think 
that one of the lessons learned has been the regional impact of 
disasters, and the importance to make sure that there is 
coordination and communication across States and across 
jurisdictions. I think that was less clear than before, when 
specific disasters were much more focal in their nature, and so 
the response was much more focal.
    What we saw from the hurricanes was that incredible ripple 
effect, that went across multiple States, States that were 
directly impacted by the hurricanes, and also the States that 
were impacted by the exodus of individuals leaving, so I would 
say that was the biggest lesson learned.
    I think another lesson learned was the importance of having 
a flexible workforce who can be deployed to meet that need in 
time of crisis. What we saw with this hurricane response was 
that many of the professionals left, and didn't return to their 
communities, which left an incredibly fragile system without an 
adequate workforce to address that need. And that had not been 
anticipated.
    Senator Burr. Thank you, Dr. Cline.
    Mr. Cline. Thank you, sir.
    Senator Burr. Thank you, Mr. Chairman.
    Senator Reed. Thank you very much, Senator Burr.
    Dr. Cline, thank you for your testimony, I know we all look 
forward to working with you through this reauthorization, and 
all of your endeavors. Thank you.
    Mr. Cline. Thank you, Mr. Chairman.
    Senator Reed. Let me now ask the third panel to come to the 
witness table, please.
    I would like to first introduce Ms. Lisa Halpern, and 
welcome you, Lisa, here today.
    Lisa is currently the Program Director of the Dorchester 
Bay Recovery Center in Dorchester, Massachusetts, and she works 
very closely with the National Alliance for the Mentally Ill, 
and she is a representative of NAMI today.
    She has a very distinguished academic and professional 
biography. But, while she was a student of the Kennedy School 
in 1999, Lisa was diagnosed with schizophrenia. After a year's 
leave, Lisa was able to return to Harvard, and with the support 
of school administrators and faculty, completed her studies at 
the Kennedy School of Government in 2001. So, as a fellow 
alumni of the Kennedy School, I'd like to welcome you here 
today. Thanks.
    Lisa has worked at the Office of the Commissioner of Mental 
Health in the Commonwealth of Massachusetts. She is an active 
volunteer in NAMI's Massachusetts affiliate, volunteering as a 
Peer Mentor Program Coordinator/Trainer, and doing much to help 
so many people, we thank you for that.
    Lisa is a 1995 summa cum laude graduate of Duke University 
with a double major in economics and public policy, and she's 
the recipient of numerous awards including the 2006 
Massachusetts Behavioral Help Partnership Recovery Award. We 
thank you for being here today.
    I would now like to also recognize and introduce Roger 
McDaniel.
    Roger, Senator Enzi had to leave for the floor, he's 
managing the FDA bill, he so much wanted to introduce you 
personally, I know you're old friends from Wyoming.
    Roger has a remarkable background, also, he's the Deputy 
Director of the Wyoming Department of Health, he's responsible 
for mental health and substance abuse services. He began his 
public life at the age of 22 in the Wyoming Assembly, where he 
served for 10 years. In 1980, he received his law degree from 
the University of Wyoming. Together with his wife, Patricia, 
they have been very active in numerous philanthropic endeavors, 
including Habitat for Humanity, and then in 1996, Roger 
enrolled in a Master's of Divinity Program at Iliff School of 
Theology in Denver, where he was ordained as a Minister in 
1999.
    Welcome, Reverend.
    And, he was a fellow at the Cathedral College at National 
Cathedral in Washington, DC. We look forward to your testimony.
    And now, I'd like to defer to Senator Burr to introduce Mr. 
Allebaugh.
    Senator Burr. Thank you, Mr. Chairman, let me at this time 
welcome all of our witnesses, and we're particularly pleased to 
have a Duke graduate. If you can't live in North Carolina, at 
least we like to educate you there.
    [Laughter.]
    Terry Allebaugh is a founder and Executive Director of 
Housing for New Hope, located in Durham, North Carolina, as 
well. Terry founded Housing for New Hope in 1992, after several 
years of leading a community shelter. I had the privilege to 
visit his organization, whose mission is to encourage and 
assist homeless people, and other persons in crisis, to move 
toward stable, hopeful and independent lives.
    Under Terry's leadership, Housing for New Hope established 
transitional housing programs, The Phoenix House, and the Dove 
House, as well as permanent supportive housing facilities for 
folks with disabling conditions, such as mental illness.
    They also provide crisis assistance for families with 
children, and disabled adults who are at risk of becoming 
homeless.
    Terry operates a substantial Project for Assistance and 
Transition for Homelessness, the P.A.T.H. Program for outreach 
to the chronically homeless who are mentally ill. Terry is a 
Board Member of the North Carolina Council to End Homelessness, 
and is Chair of the Council to End Homelessness in Durham, 
North Carolina.
    He earned his Bachelor Degree at Buria College, and has 
completed 2 years of education at Duke University Divinity 
School.
    Terry, it is a delight to have you here to testify, as it 
is for all of our witnesses.
    Thank you, Mr. Chairman.
    Senator Reed. Thank you, Senator Burr.
    Ms. Halpern, why don't you begin, and then we'll go to Mr. 
McDaniel, and then Mr. Allebaugh.

  STATEMENT OF LISA HALPERN, CONSUMER, MEMBER OF THE NATIONAL 
  ALLIANCE ON MENTAL ILLNESS (NAMI), DORCHESTER, MASSACHUSETTS

    Ms. Halpern. Thank you all. Senator Reed, and members of 
the committee, I am Lisa Halpern. I currently work as Program 
Director of the Dorchester Bay Recovery Center run by the 
VinFen Corporation in Dorchester, Massachusetts. At the Center, 
I coordinate and provide peer-directed services, support, and 
education to promote recovery for consumers living with mental 
illness and substance abuse. I also work at NAMI's 
Massachusetts affiliate as manager of In Our Own Voice, an 
outreach and support program in which consumers help educate 
the public about mental illness.
    My story, like each of the millions of Americans living 
with serious mental illness, is unique, but what it 
demonstrates, as do so many others, is that recovery is an 
achievable goal if you are able to access the necessary 
treatment and support services.
    The overt onset of my schizophrenia occurred when I was in 
my mid-twenties and had completed undergraduate studies at Duke 
University, graduating summa cum laude with double majors. I 
then received two prestigious merit-based fellowships to study 
at Harvard.
    However, when I began studies at the Kennedy School in 
1998, I started getting lost on a three-block walk to school. I 
then realized I was unable to count simple change, all the 
coins look identical to me. So, I began to pay for everything 
with $20 bills. It was clear that I would need a break from 
graduate school and I took a 1-year medical leave, as by that 
time, I had lost the ability to read, to write, and my I.Q. was 
measured at 70, borderline mental retardation.
    During this time in June, 1999, I was first diagnosed with 
schizophrenia. When I returned to Harvard that fall, I was 
fortunate to receive extraordinary support from school 
administrators and faculty. So, I was able to complete my 
graduate studies in 2001, and then I worked for 2 years at the 
Office of the Commissioner of Mental Health in Massachusetts.
    In 2003, I became the first peer counselor for an 
innovative, newly created, assertive community treatment 
program run by Westridge Community Services, that targets 
individuals with co-
occurring mental illness and substance abuse. While working at 
Westridge, I also became active in NAMI's Massachusetts 
affiliate as a speaker, manager, and trainer for the In Our Own 
Voice Program, a recovery-based consumer speaking program.
    Senators, what has really made the difference in my path 
toward recovery is not just being able to access medication to 
manage the symptoms of my illness, but also being able to 
engage in self-
directed care and having peer support. This is central to what 
proven evidence-based models, such as Assertive Community 
Treatment--often called ACT--are all about.
    In examining the current State of publicly funded mental 
health services across the Nation, NAMI has found that there is 
an almost total absence of uniform gather-reporting systems, 
designed to measure whether or not States are investing in 
effective models, such as ACT, and whether or not there's 
fidelity to evidence-based programs.
    NAMI urges the committee to include in SAMHSA 
reauthorization legislation an initiative to establish, in 
consultation with all stakeholders, especially consumers and 
families, outcome measures for States that will provide 
consistent, reliable information on State systems and services.
    Having worked as a peer support specialist for a number of 
years and having benefited personally from peer-led support 
groups and human services training, I can tell you that ACT 
works. Unfortunately, only a small percentage of people living 
with schizophrenia and bipolar disorder are accessing evidence-
based, recovery-
oriented services, such as ACT.
    NAMI's Grading the States Report, published last year, 
found that less than 10 percent of people with serious mental 
illness lived in communities that had ACT programs available.
    Mr. Chairman, in my full written statement there are a 
number of suggestions from NAMI for SAMHSA reauthorization. For 
the time being, I will stop. Thank you for the opportunity to 
share my story with the committee.
    [The prepared statement of Ms. Halpern follows:]

                   Prepared Statement of Lisa Halpern

    Chairman Kennedy, Senator Enzi and members of the committee, I am 
Lisa Halpern. I currently work as Program Director of the Dorchester 
Bay Recovery Center, run by the Vinfen Corporation in Dorchester, 
Massachusetts to provide peer-directed and operated services, support 
and education to promote recovery. I also work at NAMI's Massachusetts 
affiliate as Manager of In Our Own Voice, an outreach and support 
program in which consumers help educate the public on mental illness.
    Mr. Chairman, my story--just like that of millions of Americans 
living with serious mental illness--is unique to me. But what it does 
share in common is an overriding theme that recovery is possible, if 
the right systems and supports are in place. First, a little background 
on my personal story:
    Unlike many people living with schizophrenia, the overt onset of 
the disorder occurred for me when I was already in my twenties and had 
already completed undergraduate studies at Duke University, having 
graduated summa cum laude and Phi Beta Kappa, with double majors. I 
then received two merit-based fellowships to study at Harvard. It was 
there, in June 1999, that I was first diagnosed with schizophrenia and 
had two stays at McLean Hospital that year. This devastating thought 
disorder had a profound impact on my functioning and resulted in memory 
loss and the inability to manage even the most basic tasks such as 
counting change, reading and other activities of daily living.
    After 1 year of medical leave, I was able to return to the Kennedy 
School of Government at Harvard. I was fortunate to receive 
extraordinary support from school administrators and faculty (for 
example, more time for examinations and class credits for summer 
research). With continuing support through a Kennedy Fellowship and the 
Paul and Daisy Soros Fellowship for New Americans, I was able to 
complete my graduate studies in 2001. After completing my graduate 
studies, I spent 2 years at the Office of the Commissioner of Mental 
Health in Massachusetts.
    In 2003, I joined a newly created assertive community treatment 
program in Cambridge run by Westbridge Community Services and worked as 
the program's first peer counselor. At Westbridge, I got my first 
experience supervising and working with other peer specialists, 
participating in a Wellness Recovery Action Plan (WRAP), offering staff 
training on mental illness, and providing family and participant 
outreach, education and therapy for people with severe and persistent 
mental illness and substance abuse disorders. In 2003, I also became 
active in NAMI's Massachusetts affiliate as a speaker, coordinator and 
trainer for NAMI's In Our Own Voice, a recovery-based consumer speaking 
program.
    Mr. Chairman, at the outset I would like to express NAMI's strong 
support for S. 558, the mental illness insurance parity legislation 
reported by the committee back in February. NAMI strongly supports this 
important measure to require employers and health plans to cover 
treatment for mental illness on the same terms and conditions as all 
other health conditions. This legislation has been stalled in the 
Congress for too many years. NAMI applauds your efforts to move this 
bill forward early in the 110th Congress. We look forward to working 
with you to move it to the full Senate as soon as possible.

                       REAUTHORIZATION OF SAMHSA

    Before sharing with the committee NAMI's recommendations on 
legislation reauthorizing SAMHSA, I would like to echo the sentiments 
of the President's New Freedom Initiative Mental Health Commission 
report in noting that our Nation's public mental health system remains 
a ``system in shambles.''
    In March 2006, NAMI released a comprehensive report on the 
performance of States in meeting the needs of adults with serious 
mental illness. Our report ``Grading the States'' is the first 
comprehensive survey and grading of State adult-public mental 
healthcare systems conducted in more than 15 years. Public systems 
serve people with serious mental illnesses who have the lowest incomes.
    NAMI's report makes clear that nationally, the system is in 
trouble: the report gives the Nation a grade of D for its system of 
care for people with serious mental illness. The report also documents 
that too many State systems are failing--only 5 States received a B 
(Connecticut, Maine, Ohio, South Carolina, and Wisconsin), 17 States 
received Cs, 19 States got Ds, and 8 got Fs (Iowa, Idaho, Illinois, 
Kansas, Kentucky, Montana, North Dakota, and South Dakota).
    Each State grade is based in part on a ``take-home test,'' in which 
survey questions were submitted to State-mental health agencies. All 
but two States responded. Colorado and New York declined. They have 
been graded ``U'' for ``Unresponsive.'' Based on the surveys and 
publicly available information, States were scored on 39 criteria. 
Consumer and family advocates also provided information through 
interviews that contributed to State narratives.
    The report also included a ``Consumer and Family Test Drive,'' a 
unique, innovative measurement. NAMI had consumers and family members 
navigate the Web sites and telephone systems of the State-mental health 
agency in each State and rate their accessibility according to how 
easily one could obtain basic information. The report contains a 
narrative for each State that also includes a list of specific 
``Innovations'' and ``Urgent Needs'' to help advocates and policymakers 
further define agendas for action. An overall list of innovations 
provides an opportunity for States to learn from one another. As the 
grade distribution in the report demonstrates, our Nation still has a 
long way to go to achieve a ``New Freedom'' for people living with 
serious mental illness--a freedom based on recovery and dignity. NAMI 
is planning a follow up report in 2008 and we hope to see long overdue 
improvements in the results.
    As this committee moves forward on SAMHSA reauthorization 
legislation, NAMI would urge you and your colleagues to keep these 
goals of recovery and independence foremost in mind. Along those lines, 
NAMI would make the following recommendations.
Establishment of State Outcome Measures and Accountability
    SAMHSA should be required to establish outcome measures for States, 
building on previous initiatives such as the National Outcomes Measures 
initiative (NOMS), the State Pilot indicator Grant Project, and other 
related initiatives. In consultation with providers, consumer and 
family organizations, and State-mental health agencies, SAMHSA should 
be directed to develop measures that will provide consistent reliable 
information on State systems and services.
    Obviously, State and local public mental health systems will need 
some time to adopt and implement such measures. However, as a nation we 
need to set ourselves toward reaching a goal for meaningful outcome 
measures that allow us to assess the performance of State-mental health 
agencies and local public sector programs. In NAMI's view, the most 
effective means of achieving this is to have SAMHSA require every 
State, as a condition of receipt of funding for services and supports 
from the mental health block grant, Transformation State Incentive 
grants, and child mental health systems of care grants, to report on 
all outcome measures developed by SAMHSA.
    It is also worth noting that while some reporting on the types of 
services provided is required under current law, these reporting 
requirements are not generally linked in any way to evidence-based 
practices that are designed to deliver measurable outcomes in terms of 
recovery such as integrated treatment for individuals with co-
occurring mental illness and substance abuse, assertive community 
treatment (ACT), peer counseling and supports, multi-systemic therapy 
for children and adolescents, and family psychoeducation, to name just 
a few.
    Despite years of discussion in the mental health field about 
evidence-based practice, we are still falling short on uniform data on 
the availability of these services across States or regions or the 
degree to which programs that provide these services achieve fidelity 
to standards developed by SAMHSA itself. SAMHSA authorization provides 
us with an important opportunity to make progress toward this 
objective.
Establishment of Federal Interdepartmental Task Force on Mental Health
    NAMI supports the creation of a Federal Interdepartmental Task 
Force on Mental Health that should include involvement from the vast 
array of Federal agencies that administer programs that touch the lives 
of children and adults living with mental illness and substance abuse 
disorders. This should include the Secretaries of Housing and Urban 
Development, Labor, Education, Veterans Affairs, Health and Human 
Services (including CMS, SAMHSA, CDC, NIH and HRSA), the Social 
Security Administration, and the Attorney General. The goals of this 
Task Force should include:

    1. improved coordination of mental health policy in the operation 
of pertinent Federal programs;
    2. identification of policies and practices that contribute to 
fragmentation in care-delivery and barriers to care-integration;
    3. development and implementation of interagency demonstration 
programs to foster mental health promotion, early intervention, and 
recovery-focused services; and
    4. an annual report to Congress from the respective Secretaries 
which shall include recommendations for fostering improved 
collaboration and coordination of mental health policy, financing and 
management of recovery-focused service-
delivery.
Program Sustainability Through Consumer and Family Engagement
    SAMHSA has made enormous progress in recent years integrating the 
views of consumers and families into every major activity at the 
agency. This is a tremendous step forward. Unfortunately, this progress 
is not always mirrored at the State and local level. In order to jump 
start this process at the State and local level, SAMHSA and CMHS should 
be granted the authority to require State and local government 
recipients of SAMHSA funding above a specific threshold to allocate at 
least 5 percent of such funds to one or more not-for-profit 
organizations that represent consumers and families, to ensure that 
such organizations are able to participate in all aspects of planning 
and implementation of the SAMHSA grant or program.
Reducing the Use of Seclusion and Restraint
    When SAMHSA was last reauthorized by Congress in 2000, this 
committee included a new Part H that contained requirements pertaining 
to the rights of residents of hospitals (private and public), nursing 
facilities, intermediate care facilities, or other health care 
facilities that receive Federal funds, including restrictions on the 
use of restraints and seclusion. NAMI supports expansion of these 
requirements through establishment of a new training and technical 
assistance center to focus on the prevention of seclusion and restraint 
in public and private facilities that provide mental health services to 
adults and children. Such training and technical assistance should 
include assisting States in facilitating the use of psychiatric advance 
directives for consumers in the community and the implementation of 
PADs by facilities.
    It must also be pointed out that although the Children's Health Act 
of 2000 required that regulations be promulgated to give effect to Part 
H within 1 year of enactment, these regulations have never been issued 
by SAMHSA. Although some progress has been made in reducing the 
inappropriate use of restraints and seclusion, far too many children 
and adolescents continue to die or suffer serious injuries resulting 
from the inappropriate use of these aversive measures. Thus, we urge 
the committee to include in statute specific standards pertaining to 
restraints and seclusion in facilities and programs covered under Part 
H. At a minimum, these should include:

     Requiring that thorough and comprehensive face to face 
evaluations of all individuals placed in restraints or seclusion be 
conducted by a physician or licensed independent practitioner within 1 
hour of the time that these measures are instituted.
     Continuous monitoring of individuals in restraints or 
seclusion, either face to face, or using video and audio equipment.
     Debriefing of staff involved in the use of restraints or 
seclusion after each incident, preferably involving the individual 
subjected to these measures as part of the debriefing process. 
Debriefing has been shown to be very effective in sensitizing staff to 
alternative, less draconian measures for de-escalating crises.
     Limits on the length of orders authorizing the use of 
restraints and seclusion to 1 hour for individuals under 18 and 2 hours 
for adults.
     Requirements that all deaths and serious injuries that 
occur within 1 week of the time restraints or seclusion are used must 
be reported by the facility in which these measures were instituted to 
the designated Protection and Advocacy agency located in the State in 
which these deaths or serious injuries occur. Additionally, all deaths 
and serious injuries that occur beyond 1 week of the time restraints or 
seclusion that can reasonably be assumed to be related to the use of 
these measures should be reported as well.
Separate Legislative Proposals for SAMHSA Reauthorization
    NAMI recommends that this committee consider amending any SAMHSA 
reauthorization bill to add separate legislation that would improve the 
performance of our Nation's mental health system and benefit the most 
vulnerable children and adults living with mental illness.
    Reauthorization of the Garrett Lee Smith Memorial Act.--Suicide 
remains the third leading cause of death for those between the ages of 
10 and 24 and the second leading cause of death for American college 
students. Programs under the Garrett Lee Smith Act (first authorized by 
Congress in 2004) have been highly successful helping States and 
localities, as well as colleges and universities address this epidemic. 
This committee should reauthorize and expand this highly successful 
program.
    Keeping Families Together Act (S. 382).--Every year, thousands of 
families across the country are forced to give up custody of their 
children to the child welfare and juvenile justice systems to secure 
mental health services. The Keeping Families Together Act--introduced 
by your colleague Senator Susan Collins--is an important effort to keep 
children with mental illnesses who are in need of services at home and 
in their communities and most importantly, with their families. It 
encourages States to build effective systems of care for children with 
mental illnesses and their families and move away from costly 
residential and institutional services that too often require families 
to transfer custody of their children to the State to access these 
costly services.
    Services for Ending Long-Term Homelessness Act (S. 593).--In order 
to make continued progress toward the national goal of ending chronic 
homelessness by 2012, it is critical for HHS and SAMHSA to step up and 
increase investment in services in permanent supportive housing that 
are needed to help people with mental illness and co-occurring 
substance abuse disorders from falling back into chronic homelessness. 
SELHA--introduced by Senators Richard Burr and Jack Reed--achieves this 
critical goal and should be a part of SAMHSA reauthorization 
legislation.
    Thank you for giving me this opportunity to provide input to the 
committee.

    Senator Reed. Thank you very much, Lisa, not only for your 
story, but your courageous example. Thank you so much.
    Mr. McDaniel.

 STATEMENT OF RODGER McDANIEL, DEPUTY DIRECTOR, WYOMING MENTAL 
HEALTH AND SUBSTANCE ABUSE SERVICES DIVISION, CHEYENNE, WYOMING

    Mr. Daniel. Mr. Chairman, Senator Burr, thank you for the 
opportunity to speak with the committee as you consider the 
reauthorization of SAMHSA.
    I want to begin by acknowledging the excellent work that is 
being done by SAMHSA, NASADAD, NIDA, and others, to advance 
substance abuse practice and policy beyond the myths, using 
science to improve the outcomes.
    Mr. Chairman, over the last 40 years, I have viewed the 
substance abuse system, in particular, from several 
perspectives--as a State lawmaker, as a lawyer, a jail 
chaplain, and working in child welfare. I have worked with 
addicted persons, and the programs that serve them.
    However, it was not until I experienced these problems as a 
parent, that I began to really seek the answers to hard 
questions, such as--why do people use drugs when the 
consequences are so dire? With excellent treatment, our family 
member did well and has gone on to enjoy a good life, 
interrupted only briefly by substance abuse.
    But while that was happening, I saw countless addicts in 
corrections and the child welfare system living out actively 
hopeless lives, getting either no treatment, or ineffective 
treatment. Myths such as, an addict really wants to have it 
before treatment will work, effectively substitute for the 
responsibility of the system to provide outcomes. Contrary to 
popular notions that addiction is the result of character 
defects or bad parenting, addiction is a chronic, relapsing 
brain disease characterized by compulsive drug seeking and use, 
despite harmful, even catastrophic consequences. While the 
initial decision to use drugs is a choice, there comes a time 
when continued abuse turns on the addiction switch in the 
brain. That time can vary, depending on factors ranging from 
genetics, to environment, to the type of drug, and frequency of 
use, but it is an actual rewiring of the brain chemistry that 
trips the switch. Choice is then replaced by a brain-driven 
compulsivity to use drugs.
    An important goal of the current research is to understand, 
through the use of various scanning technologies, the changes 
in the brain that facilitate a transition from occasional, 
controlled drug use, to the loss of behavioral control over 
drug-seeking and drug-taking that defines chronic addiction.
    I have provided for the committee a picture of some of the 
brain scans from a NIDA publication that dramatically depict 
the changes that physically occur in a brain as a person 
transcends from nonuse, to addiction, and then the regeneration 
of the brain out into abstinence following treatment.
    The brain science should be the foundation of treatment, as 
well as public policy. The brain scans demonstrated, for 
example, why typical probation programs do not work as well as 
fully supervised drug courts and why the 15/22 rule of the 
Adoption and Safe Families Act can be a very effective tool in 
coercing addicted parents into treatment and recovery.
    Mr. Chairman, Senator Burr, there's a really remarkable 
story in yesterday's Washington Post about the tragedy at 
Virginia Tech. Headline, Cho Didn't Get Court-Ordered 
Treatment, which amply demonstrates some of what representative 
Kennedy and others have talked about, about the fragmented 
system. There's a quote in the story that talks about how Mr. 
Cho did not receive treatment, was court-ordered to receive 
treatment, and it says, quoting a counseling center official, 
``When a Court gives a mandatory order that someone get out-
patient treatment, that order is to the individual, not the 
agency.'' And, then it concludes with this remarkable statement 
that demonstrates the problems in the system at the ground-
level. ``The one responsible for ensuring that the mentally ill 
person receives help in these sorts of cases,'' he said, ``is 
the mentally ill person.''
    Mr. Chairman, that reality is also in substance abuse, as 
well. And, it demonstrates the significant fundamental gap 
between the science and the practice.
    Mr. Chairman, I also want to say that Wyoming and the other 
States feel as strongly as any Member of Congress about 
accountability. The States working with SAMHSA and NASADAD have 
made excellent progress on the establishment of National 
Outcome Measures.
    In Wyoming, the Governor and the legislature have enacted 
legislation, the legislature has enacted legislation at the 
Governor's recommendation, requiring the use of the National 
Outcome Measures, and requiring that we withhold funds from 
providers until we have agreements on measuring those outcomes.
    Finally, I encourage the Congress to provide flexibility. 
As Senator Burr and others acknowledged, substance abuse is 
ultimately a local community experience. The problems of 
substance abuse are different, not only from State to State, 
but within States from community to community, and they will be 
solved more by local community leadership. Those who live in 
the neighborhoods affected have more at stake than do 
Government agencies.
    My time has expired and, Mr. Chairman, I'll close by 
encouraging greater diffusion of the scientific knowledge of 
the nature of addiction, incentives for continued 
accountability, and a system flexible enough to encourage and 
empower local community-based leadership as partners with the 
Congress and the States to do this urgent work.
    Thank you.
    [The prepared statement of Mr. McDaniel follows:]

                 Prepared Statement of Rodger McDaniel

    Mr. Chairman, Ranking Member Enzi and members of the committee, I 
am Rodger McDaniel. I am the Deputy Director of the Wyoming Department 
of Health with responsibility for the Mental Health and Substance Abuse 
Services Division. I am also a member of the National Association of 
State Alcohol and Drug Abuse Directors (NASADAD). I am grateful for the 
opportunity to share my thoughts with you as you consider legislation 
reauthorizing the Substance Abuse and Mental Health Services 
Administration and am appreciative of the work of this committee and 
your colleagues in the Congress to help the States meet the growing 
challenges of substance abuse and addiction.
    Some time ago I came across a May 9, 1897, issue of the Saratoga, 
Wyoming newspaper, The Saratoga Sun. A front page editorial read in 
part:

          ``There is entirely too much drunkenness in this town for the 
        comfort of peaceable and law abiding people. It is hardly 
        possible for a lady to pass along the street without having 
        drunken and profane language issuing from the saloons there. 
        Drunk men and lewd women should be made to keep their places.''

    Of course, these problems were not new to the 19th century west. 
From ancient times, societies have grappled with the problems caused by 
the excessive use of mind altering substances. For the better part of 
all of those efforts over many centuries, there was little in the way 
of science to illuminate the path. In the last decade, that has changed 
primarily because of an explosion of good science to provide guidance. 
However, it remains the case that both policy and practice are based, 
more often than we would like, on myth than on science.
    The preface to Rethinking Substance Abuse: What the Science Shows 
and What We Should Do About It, a 2006 book edited by doctors William 
R. Miller and Kathleen M. Carroll includes this ``to the point'' 
history of attempts to remedy substance abuse and addiction.

          ``Historically, problem drinkers have been whipped, dunked, 
        shocked, poisoned with potions, chained, dialyzed, terrorized, 
        drugged with hallucinogens, Interferon, and all manner of 
        psychiatric medications. More recently, the users of illicit 
        drugs have been lectured to, fined, imprisoned, `scared 
        straight,' given `attack therapy,' and sent to boot camps. * * 
        * The bad news is that very little science has found its way 
        into practice.'' \1\
---------------------------------------------------------------------------
    \1\ Rethinking Substance Abuse: What the Science Shows and What We 
Should Do About It, William R. Miller and Kathleen M. Carroll editors, 
Guilford Press (2006) at page xi.

    The problems associated with substance abuse have cut a wide swath 
across our society limiting the potential of individuals and 
institutions. According to the National Conference of State 
Legislatures, drug abuse costs exceed $350 billion each year, 
accounting for more than 550,000 deaths.\2\ The neglected and abused 
children of addicted parents overwhelm the foster care system. Spending 
increases in the corrections system and Medicaid are driven in large 
measure by drug abuse and addiction. Homelessness and addiction are 
interrelated as well. A May 2005 report on homelessness in Wyoming 
found substance abuse a major factor in 22 percent of the homeless 
population.\3\ I have attached a copy of this report to my testimony 
for the committee record.
---------------------------------------------------------------------------
    \2\ Substance Abuse as a Cross-cutting Issue by Matthew Greer, 
National Conference on State Legislatures (November 30, 2006).
    \3\ Homelessness in Wyoming, Wyoming Interagency Council on 
Homelessness (May 2005).

    [Editor's Note: Due to the high cost of printing, previously 
published materials are not reprinted in the hearing record. The report 
``Homelessness in Wyoming may be found at http://uwyo.edu/wind/connect/
---------------------------------------------------------------------------
newsletter/past.asp?issue=vol8iss1.inc#spotlight.]

    The Wyoming Department of Health is currently completing a study of 
the mental health and substance abuse needs of veterans of the wars in 
Iraq and Afghanistan. Those wars aside, it is recognized that the rate 
of alcohol dependence is greater among the veteran population than 
among others. The New York Times reported in March of this year that 
alcohol, though ``strictly prohibited by the American military in Iraq 
and Afghanistan, is involved in a growing number of crimes committed by 
troops deployed to those countries.'' \4\ The well known linkage 
between post traumatic stress disorders and substance abuse and 
addiction is also a reliable predictor of the additional weight 
returning servicemen and women will put on already strained State 
substance abuse and mental health treatment services.
---------------------------------------------------------------------------
    \4\ New York Times newspaper March 13, 2007.
---------------------------------------------------------------------------
    Despite the cause for concern, we are beginning to see signs of the 
success of the combined State, Federal and local community efforts. 
First time meth use among Wyoming high school students has declined. 
Given the uniquely addictive nature of this dangerous drug, this is a 
significant success of our joint prevention efforts. From 1999 through 
2006, first time meth use among high school students in Wyoming 
declined by about one-third. Importantly, Wyoming has also seen 
effective law enforcement efforts reduce the numbers of clandestine lab 
operations by more than 80 percent since 2001. Certainly meth continues 
to enter the State from Mexico and other places but the decline in 
State located labs is a meaningful development given the health and 
environmental dangers posed by these labs.
    Five years ago Wyoming had few meaningful standards for providers. 
Today we have research-based standards applicable to any provider 
receiving State funds or court referrals. Providers certified under 
those strong standards have increased by 63 percent in the last 5 years 
meaning there are more providers who are better qualified than ever 
before. During that time, Wyoming has gone from three struggling drug 
courts to having 25 successful drug courts across the State with 
documented outcomes saving tax dollars and holding addicted offenders 
accountable while encouraging them into recovery.
    Despite these successes, the challenge presented by the abuse of 
alcohol and other drugs continues to be daunting and costly. Addiction 
affects all Americans and virtually all public services.
    I want to especially note the partnership we have experienced in 
Wyoming as Governor Dave Freudenthal, the First Lady, Nancy 
Freudenthal, and the State legislature have played key roles in 
providing necessary leadership and resources for treatment. The First 
Lady has been an especially strong voice raising the level of awareness 
about the problem of underage drinking. The Governor and the 
legislature have responded quickly and decisively to the high rates of 
methamphetamine use in our State.
    State funding of treatment and prevention have increased 
significantly. In 2000, the $2.4 million received by the State in the 
Substance Abuse Prevention and Treatment Block Grant represented more 
than one-third of Wyoming's expenditures on treatment and prevention. 
In fiscal year 2007 the Block Grant's contribution has dropped below 10 
percent even though it increased to just over $3.3 million. Our State 
now funds more than 90 percent of the treatment and prevention costs.
    I would like to offer the committee three recommendations. The 
first involves strategies to replace the myths with the science in 
order to promote more effective prevention and treatment and more 
relevant public policy. The second is that Congress give States and 
local communities the flexibility they need to make the best use of 
their resources and community leadership to address their own unique 
substance abuse problem. Finally, I recommend that we stay the course 
on accountability, recognizing the progress that has been made and 
working together on a continual quest to improve client outcomes.

                      MOVING FROM MYTH TO SCIENCE

    I am not a clinician nor am I an expert on brain science. I am a 
systems person which is to say I think in terms of broad systems and 
how they can interact to achieve certain objectives. Far too often, 
systems such as the judicial system, child welfare, public benefits, 
correctional and educational systems operate in isolation from one 
another. People suffering from addictive disorders, however, live in a 
different world, one where their use of drugs is a part of a life 
organized around a combination of experiences. Addicts often exhibit 
failure in the school system and on the job, in their families, 
financial dysfunction, encounters with civil and criminal court 
systems, child abuse and neglect, sexual issues, health problems and 
more. The world of the addict is one in which systems self-organize and 
interact negatively around seeking and using drugs. Prevention and 
treatment efforts are often somewhere else, isolated from the many 
different systems that comprise the complicated world of addicted 
persons.
    Mr. Chairman, over the last 40 years, I have viewed the substance 
abuse system from several perspectives. As a State lawmaker for 10 
years, as a lawyer practicing family law for 20 years, as a jail and 
prison chaplain for 5 years, I worked with addicted persons and the 
programs that serve them in several capacities. However, it was not 
until I experienced these problems as a parent that I began to study 
substance abuse enough to ask hard questions like ``why do people use 
drugs when the consequences are so dire? '' Because our family had the 
resources necessary to purchase the best treatment in America, our 
family member did well and has gone on to enjoy a good life interrupted 
only briefly by substance abuse.
    But while that was happening I was serving as a jail chaplain. 
There I saw countless addicts in the corrections and child welfare 
systems, continuing to live out actively hopeless lives, getting either 
no treatment or ineffective treatment. I began to look at the system 
and to ask questions about the science and what worked and why. In some 
measure, the difference between those who got help and those who did 
not were resources. But there was something more troublesome. 
Operational myths such as ``the addict really has to want it before 
treatment will work'' effectively substituted for the responsibility of 
the system to produce outcomes. Additionally, the known science was 
either ignored by or not known to many of the clinicians and 
policymakers whose decisions directly impacted lives.
    While many operate on popular notions that addiction is the result 
of character defects or bad parenting, the science teaches that 
addiction is a chronic, relapsing brain disease that is characterized 
by compulsive drug seeking and use, despite harmful, even catastrophic 
consequences for the addict and those around him or her. An important 
goal of current neurobiological research is to understand, through the 
use of various scanning technologies, the neuron-pharmacological and 
neuron-adaptive mechanisms within specific neuron-circuits that mediate 
the transition from occasional, controlled drug use to the loss of 
behavioral control over drug-seeking and drug-taking that defines 
chronic addiction.
    Although significant work remains to be done, we have determined 
that drug dependence negatively impacts the orbito-frontal cortex 
rendering the individual to be insensitive to the future consequences 
of their behavior. The research has identified that part of the brain 
that is critically involved in the evaluation and inhibition of 
stimulus-reward associations, emotion processing, and decisionmaking 
and the regulation of social behavior.
    In other words, while the decision to use and abuse drugs is a 
matter of choice, there comes a time when continued abuse turns on the 
addiction switch in the brain. That time can vary depending on factors 
ranging from genetics to environment to type of drug and frequency of 
use. But it is an actual re-wiring of the brain chemistry that trips 
that switch. Choice is replaced by a brain-driven compulsivity to use 
drugs as the addiction literally rewires the brain and ``desensitizes'' 
the addict from the consequences of their behavior.
    A key SAMHSA goal is to identify ways of bringing this constantly 
changing and growing neurobiological knowledge to the treatment field 
in the form of evidence-based practices based on individual need.



(Reprinted from ``Drugs, Brains and Behavior: The Science of 
Addiction', a publication of NIDA, page 19.)

    If lawmakers, policymakers, judges, social workers, therapists, 
parents and others could achieve a common understanding of addiction 
based on the science, we would be in a far better position to find real 
solutions.
    As I listen to legislative debates, read child welfare caser plans 
or watch courtroom dramas involving drug use and addiction, I feel at 
times as though I am watching the six blind men describe the elephant. 
Everyone is using the same terms; e.g. addiction, drug abuse, 
accountability, treatment. But to each speaker, those words have a 
different meaning. If you ask the key players in the courtroom or many 
State legislative committees where they get the information upon which 
to decide matters of substance abuse, they will repeat the myths, talk 
about personal life experiences or reference the popular cultural 
images. Ask them sometime how much of their information actually comes 
from the scientific literature and the data. In truth many of the 
players in this arena continue to be guided in whole or in part by the 
myths instead of the science.
    I am often asked, ``What is the one thing that could be done to 
solve the challenges posed by substance abuse and addiction? '' I used 
to caution against looking for a ``magic bullet.'' But I have come to 
believe there is one thing that would make a huge difference and that 
is exchanging myth for science in therapy, in courtrooms, and in law 
making. A former colleague of mine in child welfare work called this 
``the need to update people's stereotypes.'' Indeed if we could update 
the stereotypes related to addiction, countless lives and dollars could 
be saved.
    Relying on the myths that have been debunked by good science is not 
simply a neutral activity. Resorting to myth when science would lead to 
a better decision is harmful both in terms of wasted lives and wasted 
dollars. I found a helpful, working definition for the word ``myth.'' 
Myth is a lesson in story or anecdotal form which has deep explanatory 
or symbolic resonance for preliterate cultures, who use myths to 
preserve and cherish the wisdom of their elders.''
    In the context of substance abuse, the term ``preliterate'' can be 
read to refer to those who have not brought recent science to their 
thinking and practice. In my experience there are at least five such 
lessons frequently told in story or anecdotal form which have deep 
explanatory or symbolic resonance for these preliterate cultures who 
have used these myths to preserve the wisdom of their elders . . . 
deadly myths which are often at the heart of poor judicial and 
legislative decisions and harmful therapeutic practices.

    1. The myth that ``a person has to hit rock bottom before they are 
ready for treatment.'' Consider for a moment what that means. It means 
we watch while the addict both suffers and causes others to suffer. 
Hitting rock bottom often means the loss of jobs, health, homes and 
families en route to the bottom where addicts commit crimes, acts of 
domestic violence and child abuse, where there are victims of their 
acts and costly criminal processes or oftentimes death. Waiting for an 
addict to hit rock bottom ignores the fact that there is ample science 
to permit the use of early intervention. Courts can see the signs of 
addiction in the persons who appear before them for minor criminal 
acts. Schools, employers, the faith community and others are aware long 
before the addict hits rock bottom that a person needs help. The myth 
about hitting rock bottom is an excuse for doing nothing when it would 
matter most.
    2. The myth that a person ``really has to want treatment before it 
will work'' is one that I find especially troubling. One of the most 
successful interventions, particularly for chronic, serious, high risk 
addicts is drug court. It is successful for a number of reasons but in 
general because the drug court judge creates an environment that 
coerces the addict into disrupting his or her pattern of drug use for a 
long enough period of time that the addict integrates other, healthier 
behaviors into his or her lifestyle, eventually replacing drug use 
altogether. The research is clear that coerced treatment works. Courts 
are not the only place where coerced treatment can be effective. 
Employers have great capacity to force addicted employees to make hard 
choices.
    3. The myth that addiction can be resolved by longer and mandatory 
jail sentences and other penalties such as the loss of student loans or 
other government benefits. One of Wyoming's outstanding law enforcement 
professionals is the Chief of Police in Casper. Tom Pagel says it well. 
Chief Pagel says there are criminals who commit drug crimes for profit 
and there are drug addicts who commit crimes to feed their addiction. 
He cautions against treating them all the same in the criminal justice 
system. When I served as a jail and prison chaplain, I grew weary of 
watching the offenders and their families walk repeatedly through the 
revolving jail house doors. Addicts sentenced to longer, even mandatory 
minimum terms. Families left with children divided among relatives or 
placed in foster care by a system that knows children who have that 
experience are considerably more likely to have addiction problems 
themselves. Part of effective treatment means holding addicts 
accountable but there is little accountable about spending time in jail 
without treatment. As the brain imaging clearly demonstrates, addicts 
have a brain disease and jail sentences, regardless of length, will not 
change that unless accompanied by effective treatment for the neuron-
chemically caused brain damage.
    4. The myth that teaches addiction is a character defect exhibited 
by those who simply refuse to exercise self control. As a young lawyer 
I knew nothing about the science of addiction. Yet I often represented 
clients who would be threatened by judges with the loss of their 
children or with prison sentences if they took one more drink or used 
drugs one more time. To me, it seemed like a no-brainer. After all who 
would choose to use again when the consequences were so clearly 
contrary to their own best interests. But use again most of them did. 
The science explains the way in which addiction is characterized by the 
compulsive need to use even though there are such dire consequences. 
When you look at the brain scans of active addicts, it is clear even to 
a lay person that the changes wrought by drugs to key parts of the 
brain are significant. Legislative decisions and judicial practices 
built around the science of addiction are far different from those 
built on a belief that addicts should ``just say no.''
    5. The myth that addicts should not use medications because that is 
``only trading one drug for another.'' This is among the more 
discouraging of all myths because I hear it often from certified, 
trained therapists who would know better if they had updated their own 
stereotypes for the science. Because addiction is a disease 
characterized, in part, by relapse, new prescription drugs have been 
developed that reduce the cravings and, therefore, the risk of relapse. 
This is an important example of how an understanding of the brain 
science leads to helpful therapies.

    I do want to especially commend the National Institute on Drug 
Abuse, HBO and the Robert Wood Johnson Foundation for their recent work 
to make this important knowledge more understandable and accessible to 
citizens and policymakers alike. NIDA has published a remarkable 
booklet entitled ``Drugs, Brains and Behavior: The Science of 
Addiction.'' It is an inviting, informative, reader friendly work that 
joins the HBO/Robert Wood Johnson film documentary entitled 
``ADDICTION'' as two of the most important public efforts in recent 
years to change the thinking on this critical issue.
    The key to developing effective public policy as well as effective 
treatment and prevention is the ability to articulate the changes in 
the brain's reward system is the cornerstone. I am not an expert on the 
working of the brain but I do not think policymakers need to be if they 
can grasp the basic concepts. I have read books and listened to 
presentations that make all of this very complicated. I have also heard 
lay persons describe the neurobiology of addiction in a way that I can 
understand.
    My first exposure to the brain science came during a 
methamphetamine conference in Walla Walla, Washington. I was seated 
with a group of Washington State legislators one of whom was a member 
of their Appropriations Committee. We watched a presentation that 
included slides of brain scans showing the progression from non-use to 
abuse to addiction and on to treatment and recovery. Especially 
informative are the brain scans of those persons who are fully and 
actively addicted. Even a lay person can see that in key parts of the 
brain where we make decisions and exercise judgment, the lights are 
off. Yet this is the picture of the brain of those who enter treatment. 
The Washington legislator looked at that slide and said, ``Ah ha . . . 
so that's why our 28-day programs don't work! ''



(Reprinted from ``Drugs, Brains and Behavior: The Science of 
Addiction', a publication of NIDA, page 25. Attachment B is a larger 
image of this brain scan.)

    The slide supports other conclusions as well such as why typical 
probation programs do not work as well as fully supervised drug courts 
and why the 15/22 rule of the Adoption and Safe Families Act can be an 
effective tool in coercing addicted parents into treatment and recovery 
if better understood by social workers and judges.
    It is helpful of course that scientists and researchers have come 
to understand the way in which increasing, continuous drug use paves 
the way in the brain for addiction by altering the reward system but 
what is critical is that lawmakers, judges, social workers and 
probation officers have a working knowledge of this information. 
Knowing that chronic drug use lowers the threshold of the brain's 
reward system and that withdrawal raises that threshold is information 
that should be used to design probation programs and clinical 
practices.
    I would encourage Members of Congress to consider using the 
reauthorization of SAMHSA as an opportunity to explore strategies for 
expanding the knowledge of addiction-related brain neuron-chemistry to 
those on the front lines, e.g. judges, social workers, corrections 
officials, therapeutic community and others working directly with 
addicts and their families. Unless those in the trenches are provided a 
basis for understanding this science, it will be many more decades and 
countless millions of lost lives and dollars before the science is 
integrated enough in the actual work of these systems to make a 
difference.
    In fact, SAMHSA already has two important structures designed to 
infuse the latest science into our service systems: the Addiction 
Technology Transfer Centers (ATTCs) and Centers for the Application of 
Prevention Technologies (CAPTs). These regional entities, located 
throughout the United States, work to translate the latest substance 
abuse science in order to create learning opportunities to improve the 
practices of States, counselors, prevention professionals and community 
coalition members. The CAPTs and ATTCs sponsor regional conferences, 
workshops, and training of the trainer events regarding evidence-based 
practices, provide customized technical assistance, develop training 
curricula and products, and create online courses and classes. 
Unfortunately, the ATTC's and CAPTs are under-funded, with the proposed 
fiscal year 2008 budget seeking to eliminate funding for the CAPTs 
altogether.
    These strategies should be pursued even as additional funding is 
provided to expand the brain and genetics research related to addiction 
disorders. But it is not enough that a select group of scientists are 
aware of the genetic impacts on brain development leading to addiction. 
The development of the science must be accompanied by a diffusion of 
the knowledge so that it can replace the myths that too often drive 
therapeutic practices and public policy choices. NIDA and other 
researchers knowing that brain development makes some folks more 
susceptible to addiction than others and that the reward circuitry of 
the brain may control one's reaction to chronic drug use . . . is 
important but it is not sufficient. It is when I start to hear 
discussions of the way in which chronic drug use changes the brain in 
the coffee shops around rural Wyoming, that I will know we have a 
winning strategy.

              SYSTEMS IMPROVEMENT THROUGH FLEXIBLE FUNDING

    Providing effective treatment and making good public policy also 
requires a recognition of the fact that drug use is generally 
experienced as a part of a larger universe of social problems. Drug use 
is usually accompanied by school failure, mental health issues, family 
dysfunction, domestic violence, problems with health, housing, jobs, 
child behavior and more.
    People who chronically use drugs en route to addiction are 
frequently clients of the correctional, public welfare or child welfare 
systems. They come to the early attention of lower level criminal 
courts. Some are chronically homeless or out of work. As a result, 
addicts and chronic drug abusers fill the ranks of the clients of a 
variety of public service systems. Therefore, neither prevention nor 
treatment should be an endeavor isolated to a group of the usual 
suspects.
    SAMHSA has been especially cognizant of the systems issue. 
Sponsoring training opportunities such as the June 2007 conference 
entitled ``Achieving Common Goals'' bringing together relevant agencies 
to discuss innovative ways to address common client problems is an 
example of their responsiveness.
    It is equally true that the problems presented by drug abuse are 
different in different communities. For example, the 2005 Youth Risk 
Behavior Survey concluded that while 8.5 percent of high school 
students had tried methamphetamine during their lifetime, 77 percent 
had already used alcohol. A 2005 survey of law enforcement officials 
disclosed that in 10 of Wyoming's 23 counties, 59 percent of all 
arrests involved alcohol.
    A number of Wyoming communities are experiencing high rates of meth 
use. Even more have continued to experience high rates of alcohol 
abuse. In others, there is a growing concern about prescription drugs. 
States and communities need flexible funding streams that allow them to 
address their unique substance abuse challenges.
    Virtually all of the ``systems'' necessary to comprehensively treat 
and prevent substance abuse are local systems. They include the local 
court system, a local public and private treatment provider system, 
local child welfare system, local schools, public health, housing, 
business and faith communities and family systems. Systems improvement 
is vital to positive outcomes for addicted persons. While the Federal 
and State governments can encourage local systems improvement, it will 
actually happen only through the empowerment of local community 
leadership.
    Accordingly, my State and others would benefit from a flexible 
funding approach giving States room to navigate through their unique 
drug problems, their unique political and economic systems, their 
unique geography, and their unique set of resources.
    Wyoming's drug court program is an example of the sort of 
flexibility that allows funds to be used creatively in different 
communities to achieve broad common goals. The State legislature has 
provided funding within a framework that requires local drug courts to 
use the 10 components of an effective drug court. Beyond that, local 
communities and courts may decide how to use the State funding to meet 
local needs. In some communities there is a priority for adult felony 
courts, in others the need is for juvenile courts, or family treatment 
of DUI courts. A critical ingredient of the success has been the fact 
that the legislature has provided for coordination of the program 
through the office of the single State authority.
    Another example of our approach to systems improvement coupled with 
flexibility is our new contracts with substance abuse providers. Each 
public treatment provider is now being asked to enter into a memorandum 
of understanding with their local child welfare, public welfare and 
corrections systems to create a shared set of goals and practices to 
assure effective treatment of common clients across their systems. At 
the end of this process, we expect there will effectively be a single 
system, single case plan, and single set of shared values that persons 
who need services will experience when they walk through anyone of 
those doors with a mental health or substance abuse problem.
    This flexibility should be applied to the Substance Abuse 
Prevention and Treatment Block Grant which has been an effective and 
efficient funding stream to support vital services to Wyoming citizens. 
The drug problem is much more a community problem than a national 
problem. No one has more at stake in meeting the challenge than the 
neighbors of those who are addicted and their families. No one has more 
to lose or more to gain than the folks who live in the community or the 
neighborhood where drug use causes chaos. Given flexibility, these 
community leaders will make the right choices.

                             ACCOUNTABILITY

    I am comfortable that I speak for all State administrators when I 
say we are as concerned as any Member of Congress about the 
accountability of all of us to produce good outcomes.
    Wyoming has experienced technical problems in getting its system on 
line but we are there now and so is nearly every other State. I believe 
the States, working with SAMHSA and NASADAD, have made excellent 
progress on the establishment of the National Outcome Measures. I 
especially want to recognize the hard work of our Governor and the 
Wyoming Legislature in demanding outcome data as they have supported 
greater investments in the treatment system.
    NASADAD can tell you more about the other States but in Wyoming the 
legislature has enacted statutory requirements that the Department of 
Health use outcome measures for treatment programs. We are using the 
National Outcome Measures (NOMS). The legislature further enacted a 
measure requiring that I, as the SSA, withhold funds from all provider 
contracts until and unless we have a written agreement on measuring 
outcomes. Finally, the Governor and the legislature have demanded that 
our system measure outcome data across agency systems in order to 
broadly assess outcomes on a longitudinal basis.
    The provider community has stepped up and agreed to measure 
outcomes based on the NOMS. Our contracts require each provider to 
report NOMS quarterly on all clients. As this data accumulates, we will 
be in a better position to improve services, identify best practices in 
our rural State and to inform policymakers as they grapple with funding 
and legislative decisions.
    Wyoming and other States are fully committed to NOMS reporting. Yet 
I do want to express concern about a fiscal year 2008 budget proposal 
to penalize 5 percent of the Substance Abuse Prevention and Treatment 
Block Grant for those States that are unable to report NOMS by the end 
of this year. If we are unable to do so, and I do not currently expect 
that to be the case, it will not be because of any reluctance to do so 
on the part of the State agency or the providers. It would result from 
gaps in our data infrastructure and the ongoing technical challenges of 
effectively integrating data collection and reporting technologies.
    I agree with NASADAD that providing positive incentives is better 
and more effective public policy than imposing block grant reductions 
that will directly impact our ability to provide necessary treatment 
and prevention services to citizens.
    Additionally, we are exploring the use of a process similar to the 
Children and Family Services Reviews under the Adoption and Safe 
Families Act. Under that process every State child welfare system is 
evaluated using a common tool to determine the extent to which the 
States are meeting the safety, well-being and permanency needs of 
children in State care.
    One of the tools used to improve performance of the child welfare 
system is the Citizen Review Panel enabling consumers and other 
citizens, along with child welfare professionals to actually 
participate in case reviews in order to have the sort of transparency 
that actually improves systems. We are considering a process that would 
mimic that same consumer centered process in order to review treatment 
practices for the purpose of enhancing accountability by making the 
substance abuse treatment system less mysterious and more transparent.

                               CONCLUSION

    Thank you for this opportunity to appear before your committee and 
to offer my views on the important work before you. Please know that 
the Office of Wyoming Governor Dave Freudenthal and the Wyoming 
Department of Health welcomes any opportunity to be of assistance in 
your work. Additionally, NASADAD stands ready to support and work with 
this committee on issues related to substance abuse and mental health--
including SAMHSA reauthorization. NASADAD's expertise and commitment to 
improve service delivery represents a wonderful resource.

                              Attachment A

                       Wyoming Substance Abuse Prevention and Treatment Block Grant Awards
----------------------------------------------------------------------------------------------------------------
                                      SAPT Award                 State        Total
                                         [in                  Funding [in  Funding [in      SAPT        State
            Federal Year               millions   State Year    millions     millions   Funding [in  Funding [in
                                     of dollars]              of dollars]  of dollars]    percent]     percent]
----------------------------------------------------------------------------------------------------------------
FY 2007............................   $3,305,977    SFY-2008  $30,965,682  $34,271,659         9.65        90.35
FY 2006............................    3,299,412    SFY-2007   23,293,913   26,593,325        12.41        87.59
FY 2005............................    3,333,448    SFY-2006   19,753,778   23,087,226        14.44        85.56
FY 2004............................    3,333,335    SFY-2005   15,466,986   18,800,321        17.73        82.27
FY 2003............................    3,193,795    SFY-2004   15,393,328   18,587,123        17.18        82.82
FY 2002............................    3,048,693    SFY-2003   15,209,480   18,258,173        16.70        83.30
FY 2001............................    2,751,260    SFY-2002    8,303,744   11,055,004        24.89        75.11
FY 2000............................    2,452,377    SFY-2001    4,755,678    7,208,055        34.02        65.98
----------------------------------------------------------------------------------------------------------------


                              Attachment B



    Senator Reed. Thank you very much, Mr. McDaniel.
    Mr. Allebaugh.

 STATEMENT OF TERRY LEE ALLEBAUGH, EXECUTIVE DIRECTOR, HOUSING 
           FOR NEW HOPE, INC., DURHAM, NORTH CAROLINA

    Mr. Allebaugh. Thank you, Senator Reed.
    My name is Terry Allebaugh and I'm the founding director of 
Housing for New Hope, a nonprofit organization rendering 
services and building housing for the homeless in Durham, North 
Carolina.
    I'm joined here this morning by Alfonso Williams, a 
formerly homeless man, who's now serving as our Program 
Director for one of our transitional housing programs.
    Two years ago, my organization began outreaching through 
our P.A.T.H. program to two valuable men who are living in 
Durham. The men were living in a makeshift tent in a narrow 
strip of woods between Main Street and the railroad tracks near 
a thriving area of Durham called Lane Street. Being also near 
Duke University, the area provided a fertile ground for the 
men's panhandling efforts.
    We suspected immediately upon outreach, that one man, who 
was called ``Concrete'' because of the seemingly resilience to 
the harshness of living year round outside, was schizophrenic. 
We also believed that the other, called White Mike for what I 
think is probably obvious reasons, suffered from--was 
clinically depressed. Both men were self-medicating with 
alcohol, both men had given up hope that anything else was 
possible for them in their lives.
    For our first year, we visited and talked with them, we 
took them sleeping bags, we'd take them occasional food, we'd 
take the toiletries, and they graciously accepted our gifts, 
and they would also continuously decline our engagement to see 
service providers and to go into housing. They had given up 
hope that anything else could be possible for them.
    The business owners in the community around begrudgingly 
accepted their presence and said pretty much, ``Well, you know 
what? Some people just choose to be homeless. What can you do? 
''
    Then White Mike's health status grew worse as his exposure 
to all the elements continued and he was transported twice by a 
rescue squad to the emergency room where he was hospitalized 
for internal bleeding. Soon Concrete moved out of the tent and 
he was found sleeping at night, soon afterwards, behind the 
bike rack at Kinko's.
    Unfortunately, these stories of Concrete and Mike are not 
unique. They are only two of 744,313 in our country each night 
who are homeless. They are only two of the 11,165 people in 
North Carolina, and only two of the 539 counted in Durham. Both 
the despairing homeless and the confused citizenry are looking 
to us here in this room for leadership, commitment, and 
increased funding to improve services.
    Through our work, Housing for New Hope has come to believe 
one thing. And if you remember nothing else from my testimony, 
I hope it's this. No one, nobody, not at any time, chooses to 
be homeless. There are plenty of people, however, that have 
settled for homelessness. They have settled for that because 
they have given up hope that those services which will help 
them best, that housing which they can afford and is tailored 
to their needs, will provide a solution to their homelessness. 
Piecemeal services, congregate shelters, and spare change do 
not lead to transforming these systems of care.
    Homeless people, especially those with disabling 
conditions, need real services that are comprehensive. They 
need real homes where their name is on a lease and they have 
rights and responsibilities. They need real change, not spare 
change.
    Data collected nationwide reveals that 23 percent of our 
homeless in this country are chronically so, meaning that 
they've been out there for a long time. They are there because 
they are poor, and they lack the financial access to housing 
and services. The longer they remain homeless, the more 
debilitating their chronic conditions become. Additionally, the 
more expensive their treatment and response to them becomes for 
our systems.
    As you probably know, many of the chronically homeless, as 
with these gentlemen, seek healthcare from emergency rooms, 
where they're transported by a rescue squad. They're 
temporarily housed in our jails and prisons, and they seek 
periodic help for mental and primary health in hospitals for 
chronic health conditions. We can no longer fool ourselves that 
by providing minimal support to this population, that we're 
saving our tax dollars.
    Housing and Urban Development has been stepping up to the 
plate in the area of permanent housing. They are providing 
resources and require that folks build permanent housing if 
they're going to receive HUD funding.
    I'm here today mainly to encourage you all to include a 
part of a bill that's called SELHA, which is Services to End 
Long-Term Homelessness Act. It was introduced by our North 
Carolina Senator Burr and co-sponsored by Senator Reed, into 
the SAMHSA funding. Put SELHA in SAMHSA and this will make a 
difference for us, where we have housing, we have P.A.T.H. 
programs, but we do not have the ongoing clinical support the 
people need in our communities.
    We did visit Mike when he was in the hospital--just a few 
minutes, and I'll finish this part of the story, Senator Reed, 
if that's okay--and he did decide to go into treatment, and he 
did decide to enter our transitional housing program and he's 
now living in one of our efficiency apartments where he's 
working at his job. He's actually started doing outreach on the 
P.A.T.H. team. Concrete committed himself to a hospital, mental 
health hospital for 7 days. He was released with 7 days of 
medication, given the name of a service provider. He 
disappeared for a while and he has now reappeared, sleeping 
behind the bike rack at Kinko's. I think we can all work 
together to do better for Concrete and also to make sure we 
prevent, so that Mike and Concrete and others like him around 
the country are not left out there.
    Thank you.
    [The prepared statement of Mr. Allebaugh follows:]

                 Prepared Statement of Terry Allebaugh

    My name is Terry Allebaugh and I am the founding director of 
Housing for New Hope, a 15-year-old nonprofit organization rendering 
services and building housing for the homeless in Durham, North 
Carolina. At Housing for New Hope, we work to prevent and end 
homelessness one valuable person at a time.
    Two years ago, we began outreaching to two such valuable men 
through our P.A.T.H. program (Projects for Assistance in Transition 
from Homelessness, administered by SAMHSA). The men were living in a 
makeshift tent in a narrow strip of woods between Main Street and the 
railroad tracks near a thriving area of Durham, called 9th Street. 
Being also near Duke University, the area provided a fertile ground for 
the duo's panhandling endeavors. We suspected immediately, and it was 
later confirmed by psychological testing that ``Concrete'', so named 
because of his seeming resilience to the harshness of year-round street 
living, suffered from schizophrenia, and ``White Mike,'' so named for 
obvious reasons, was clinically depressed. Neither man was receiving 
treatment and both were self-medicating with alcohol. Both men had 
given up hope that there could be something different in their lives.
    For over a year we visited and talked with them at their tent or on 
9th Street. They always thanked us for visiting and graciously received 
our periodic gifts of sleeping bags, blankets, toiletries, and food. 
They also repeatedly declined our offers to connect them to services, 
housing, and hope for tomorrow. The business owners and their patrons 
begrudgingly accepted them, with a few exceptions, and most everybody 
seemed resigned to the fact that well, ``some folks just choose to be 
homeless.''
    Then ``White Mike's'' health status grew worse as his exposure to 
all the elements continued, and twice he was transported via rescue 
squad to the emergency room, and then hospitalized for internal 
bleeding. Soon, ``Concrete'' moved out of the tent and was found 
sleeping at night behind the bicycle racks outside Kinko's on 9th 
Street.
    Unfortunately, the stories of Mike and Concrete are not unique.
    They are only two of the 744,313 homeless people in the country on 
any given night who are looking to us, here in this room, for real 
change by ensuring access to mental health services and affordable 
housing. They are two of the 11,165 on a given night in North Carolina, 
and two of the 539 counted in Durham. Both the despairing homeless and 
the confused citizenry are looking to us for leadership, commitment, 
and increased funding leading to improved services.
    Through our work, Housing for New Hope has come to believe that 
nobody chooses to be homeless. Some people settle for homelessness 
because they have given up hope that anything else is possible. 
Piecemeal services, congregate shelters, and spare change do not lead 
to transformative systems of care. Homeless people, especially those 
with disabling conditions such as mental illness, substance addiction, 
and poor physical health need real services that are comprehensive. 
They need real homes where they are leaseholders with rights and 
responsibilities. They need real change, not spare change handed out by 
those more privileged who themselves are looking for a temporary fix 
for their guilty feelings.
    Data collected nationwide reveals that 23 percent of the homeless 
population are chronically homeless, meaning they have been living on 
the streets with disabling conditions for long periods of time. They 
are there because they are poor and lack access to needed health care 
systems and affordable housing. The longer they remain homeless, the 
more chronic and debilitating their health conditions become and the 
more expensive our piecemeal, temporary, and spare change services cost 
us. Many of the chronically homeless receive their primary health care 
in the emergency rooms and are transported there by a rescue squad. 
They are housed periodically in jails and prisons, transported by law 
enforcement officers, and adjudicated by the courts and court-appointed 
attorneys. They are frequent, short-term visitors to primary and mental 
health hospitals with high per diem rates for the doctors, nurses, and 
tests.
    We can no longer fool ourselves that we are being frugal and 
prudent with our tax dollars by only giving minimal attention to the 
chronically homeless population.
    Housing and Urban Development (HUD) has been stepping up to the 
plate in the area of permanent housing and chronic homelessness by 
requiring that at least 30 percent of all funds awarded nationwide 
through the Supportive Housing Program be for the creation and 
provision of permanent housing. Additionally, HUD makes a bonus award 
available for each community that targets permanent housing projects 
for the chronically homeless. My own organization, Housing for New 
Hope, has 40 units of permanent housing partially funded by three HUD 
grants, and we have just been awarded a capital grant for the 
construction of another 10 unit apartment building to house the 
chronically homeless.
    However, HUD has made clear that they intend to fund what they do 
best, namely housing, and that we cannot look to them for the provision 
of service dollars. We need SAMSHA to step up to the plate and provide 
the core service dollars that will make the housing dollars more 
effective in our communities.
    In a report produced by the U.S. Department of Health and Human 
Services entitled, ``Ending Chronic Homelessness: Strategies for 
Action,'' the authors concluded that no mainstream program is 
comprehensive enough to adequately serve chronically homeless people. 
Therefore, agency budgets need to target dollars to this population. In 
a bill called Services for Ending Long-term Homelessness Act (SELHA) 
that was introduced and championed by our North Carolina Senator 
Richard Burr, and was co-sponsored by Senator Jack Reed and others, 
there is a detailed plan for needed services for this population that 
can be coordinated with other systems that are delivering housing, 
jobs, and primary health. The bill provides mental health and substance 
abuse treatment as well as health education and recovery activities. I 
strongly encourage you to increase funding within the current homeless 
programs by $80 million and include the goals and funding for SELHA in 
the reauthorization of SAMHSA.
    It's easy to remember: put SELHA in SAMHSA.
    I can tell you unequivocally that the main ingredient currently 
missing in our work to end and prevent homelessness in Durham for the 
chronically homeless is mental health and substance abuse services. Our 
P.A.T.H. program is doing remarkably well to outreach and engage, and 
is making some incredible things happen. With the help of HUD and our 
city and State governments, we are putting housing on the ground. 
However, without the presence of clinical teams who are trained, 
committed, and dedicated to the issues confronted by the chronically 
homeless, we, like many others around the country, are part of the 
piecemeal, spare change system of care.
    Our Local Management Entity, The Durham Center, and our State level 
Department of Health and Human Services are working hard in a tough 
environment to squeeze out a few dollars to target resources in this 
area. However, they need SAMHSA's help in order to make real and 
substantial change that will create the necessary infrastructure and 
coordination of social services.
    There is an amazing thing happening in our country right now. 
Business leaders and folks from congregations, people in nonprofit and 
government agencies are working together like never before to implement 
strategies that will end homelessness as a statistical reality in our 
country. Major cities are reporting significant decreases in the number 
of homeless people living on the street. But there are many miles to 
travel before we reach our goal.
    Along the way, we will keep reaching for our goal one valuable 
person at a time.
    Our team visited Mike while he was hospitalized, and he decided to 
seek substance abuse treatment. Then, he decided to come into one of 
our transitional housing programs. Then he moved into one of our 
efficiency apartments where he pays his rent, works his job, and has 
started working on our P.A.T.H. outreach team as a peer specialist. 
What a distance he has traveled--from living in the woods with no 
access to the mental health care that he needed, to living in his own 
place, helping others access the services they need to regain their 
hope for a better life.
    Concrete recently committed himself to mental health 
hospitalization. He was there for a few weeks, given a 7-day supply of 
medication, an outpatient referral slip to a mental health provider, 
and released. He disappeared, but recently reappeared on 9th Street. He 
has run out of medication, has never seen the provider, is back to 
being mistrustful of help, and is sleeping behind the bike rack.
    I don't think you, or I, are comfortable leaving him out there.
    We know what it will take to bring ``Concrete'' and others like him 
into housing and services. We know what it will take to prevent Mike 
and Concrete from being out there all those years. I urge you to 
include SELHA within the SAMSHA reauthorization to allow us to provide 
the services that will give hope, opportunity and stability to our 
citizens who have so little.
    Thank you.

    Senator Reed. Thank you very much, I want to thank the 
panel for the excellent testimony, and let me say how pleased I 
am to be working with Senator Burr on this issue of providing 
services to the homeless. I think Rich and I share the same 
sense of frustration, that we spend money on housing, but 
without these services, it seems to be not adequately utilized. 
Might you want to comment on that, Mr. Allebaugh?
    Mr. Allebaugh. Well, I think we are fortunate that HUD has 
stepped up and is providing some funding in this area, but if 
people don't receive the supportive services that they need for 
recovery, as you've heard many of the other people testify here 
today, the housing tends to be short-lived. And so, we have 
found that true in Durham, and I'm sure they're--and from what 
I hear they're finding out around the country.
    So, it's an important effort to complement, where there's 
already some initiative happening.
    Senator Reed. I think your testimony makes the point, this 
is not just a ``big city'' phenomenon, this is everywhere in 
the country, and you also, I think, make an excellent point 
that if you look at the cost of homelessness, emergency room 
treatment, incarceration, it far exceeds the cost of treatment, 
we just have to make sure we get the numbers right, and do it 
right.
    Mr. Allebaugh. Well, as Senator Burr mentioned in his 
opening statements, Portland has done enough now that they have 
some comparative costs that show that they're saving about 
$16,000 per person, per year, providing this type of housing, 
instead of allowing people to continue to cycle through our 
various systems.
    Senator Reed. Just one other question, Mr. Allebaugh, and 
again, let me commend you for your great work. What proportion 
of your population are veterans who served the country, and now 
are on the streets?
    Mr. Allebaugh. We typically run about 15 to 20 percent of 
our population in Durham, are homeless Veterans.
    Senator Reed. And that is a sad commentary for individuals 
who have served their country.
    Mr. Allebaugh. It is, and we try to take advantage of every 
opportunity of funding that targets that population.
    Senator Reed. Thanks, so much.
    Lisa, let me thank you for your excellent testimony, and 
for the courageous example that you've shown, not only in 
moving forward in your life, but helping so many others. Could 
you elaborate on what you found most helpful in your recovery, 
please?
    Ms. Halpern. I would say accommodations and high 
expectations, the two together. In my return to graduate 
school, I received accommodations to help me further my 
education. For example, extra time on tests, and being in a 
different, quiet room during tests, because the sound of a 
pencil is too much stimuli for me to listen to.
    And the other critical piece to my recovery, and my ongoing 
recovery has been the high expectations of my family, and the 
high expectations of my doctor. Before I could read and write, 
my doctor believed that I was going back to Harvard. And it was 
just a simple question of how do we get from A to B? And, my 
family's been a terrific support, as well, so it's--I've been 
very fortunate, in some ways, I've been blessed, so----
    Senator Reed. Well, one of the things you've just mentioned 
is the flexibility of being able to take time off and having a 
support system, but I would imagine that's not the case in all 
of the people you work with?
    Ms. Halpern. Right.
    Senator Reed. And, that's something we should probably 
think about in terms of how we structure our programs, is there 
any advice you might give us?
    Ms. Halpern. The program that I work for in Dorchester, the 
population is men with substance abuse and mental health 
concerns and worries, and that population is different in its 
needs and abilities and aptitudes than what another population 
might be, so I think what I've learned from working on the 
P.A.T.H. team at Westbridge is a strength-based approach, where 
you meet everyone where they are, and that's what I try to do 
when I'm on the peer counseling side of things, is to meet 
people where they are, and accentuate their strengths.
    Senator Reed. Well, thank you very much, Lisa, again for 
your great testimony and for your great work.
    Mr. McDaniel, you have an array of perspectives--you're a 
lawyer, and a minister and an administrator, and thank you for 
bringing along the scientific evidence that should be 
underlying all of our decisions.
    I wonder if you might comment on, SAMHSA basically has two 
block grant streams, the substance abuse and the mental health, 
and everyone has concluded that it has to be coordinated. From 
a State level, do you have any specific advice how we might do 
that, and in addition, coordinate with the larger medical 
community?
    Mr. Daniel. Mr. Chairman, in particular, the latter part of 
your question is, I think, very important. Because I think one 
of the real issues in mental health and substance abuse is the 
extent to which mental health and substance abuse services have 
been isolated from primary care, and even to the extent of 
those services taking part in another part of time, and we see 
that impacting the workforce as well as front-line services.
    Mr. Chairman, I know there's been some discussion about 
merging the two block grants, I guess I would conclude that 
that's not a particularly important thing to do. I think in 
terms of what happens on the ground, in the States, when the 
block grants flow through to services, that the States are 
probably the best place to figure out how to funnel those 
moneys together.
    In Wyoming, we've worked with SAMHSA for the last couple of 
years to assess our services for the co-occurring population, 
for example, and how to merge services and funding streams in 
order to accomplish that. And, I think at the State level, 
people can generally figure out how to do that.
    In 1999, the then-Governor of Wyoming chose to divide 
substance abuse from mental health, because substance abuse 
needed a greater priority. This Governor, this year, has chosen 
to re-integrate mental health and substance abuse 
administratively, in order to eliminate some of the silos that 
had grown up around the separation of the two programs. So, I 
think, at the State level, and even more particularly, at the 
community level, those who are involved in delivering the 
services--practitioners as well as policymakers--can figure out 
how to integrate those funding streams, so long as the Federal 
legislation is flexible enough to allow them to do that.
    Senator Reed. And just a brief comment, if you might, in 
terms of outcome measurement. Because, you're down there where 
the outcomes have to be measured.
    Mr. Daniel. Well, Mr. Chairman, it's a critical issue with 
us. I spent the last 4 years as the head of the State Child 
Welfare Agency where we experienced, as a result of the 
Adoption and Safe Families Act, and the Citizen and Family 
Reviews, that experience of having a Federal review drive us 
toward a strategy where data became the way in which we changed 
services.
    I believe we'll accomplish the same thing in substance 
abuse and mental health working with SAMHSA and NASADAD and 
others on the National Outcome Measures. When communities see 
the data, when providers see their outcome data, they'll figure 
out the strategies that need to work.
    I don't believe that any State is dragging its feet on 
National Outcome Measures, I believe--I know there's a budget 
proposal that would penalize the block grant 5 percent for 
those States who don't measure outcomes, I would urge that that 
not happen, because I--to the extent that there are problems, 
from my experience, there really are problems in information 
technology and trying to figure out how to make the systems 
compatible with the myriad of provider systems that are used to 
report--that's the struggle we've had in Wyoming. Neither the 
providers, nor the State policymakers are dragging their feet 
on reporting the measures, they want that done, it's a 
significant strategy for improving services.
    Senator Reed. Thank you very much, thank you all.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Lisa, thank you for that very personal testimony, and on 
behalf of the organization as well.
    Roger, it's not easy to talk about personal experiences, 
especially when they affect your family, and we appreciate you 
doing that. And, I'm particularly thankful to you for 
continuing to mention outcome, because in this town, we don't 
hear ``outcome'' we hear ``process'' and that's disturbing to 
me.
    Terry, thank you for Mike's and Concrete's story. And, you 
know, the great thing is, in Durham, North Carolina, you've got 
a long list of names of lives that you've affected. Some of 
them, not with the word permanently. And that's the tough 
thing. That's the gap that, I know you know is out there. And, 
my question to you is quite simple--can the word ``permanent'' 
really go in front of this population of homeless, 
homelessness, without those services wrapped around it?
    Mr. Allebaugh. I think it's real important that we are 
focusing on permanent housing, it is an outcome that we can 
measure, as we've heard here today, and I think that the 
provision of permanent housing provides a good base for someone 
to make changes in their lives as we all use our homes as a 
place where we attain our self-esteem, our sense of self-worth, 
our sense of purpose. With the chronically homeless, when they 
have a disabling condition, permanent housing, to have them in 
there is the start. It gives them a place where they know 
they're going to be the next day and the next day, it 
delineates rights and responsibilities that they have as a 
leaseholder there.
    However, they can not sustain that unless there's support 
for them in their ongoing process of recovery. Whether that's 
from substance abuse, mental illness, or recovery from physical 
health, so unless that complements that housing, we will find 
that our numbers, as they go down, they'll go back up. And so, 
we cannot fool ourselves into thinking that any one piece of 
that is enough.
    It is important that the services be distinct from the 
housing. They're there as leaseholders, they're there in 
permanent housing, and our service provision needs to be 
enticing, engaging, assertive--it doesn't need to be required, 
if you don't attend a meeting, you don't get put out of your 
housing, that's not a good practice, it's a bad practice.
    But, it is important that we have services that are 
constantly engaging. And what I have found that people who are 
homeless need above everything else, is a chance to participate 
in a community, to see their individual lives as part of the 
larger whole, and to have the ability to contribute back to 
that. And, I think permanent housing, with supportive services, 
gives the individuals that opportunity, and thus makes our 
communities better places to live.
    Senator Burr. Well, I think it's safe to say that Jack and 
I understand the cost argument that you made, which is very 
compelling. Unfortunately, in Washington, there is no dynamic 
scoring, so we don't get this benefit of being able to go out 
and prove how much money we save, by going out and spending 
money, which is insane. And, I'm proud to say that many members 
on this committee get it, and they don't let that be a 
limitation. So, I think--my hope is that we will do some things 
out of the box, we will find some ways to get new moneys so 
that services can be provided, and you can have more people 
with ``permanent'' in front of it.
    And Roger, you highlighted the importance of basing 
substance abuse treatment on brain science research evidence. 
Let me ask you, specifically--how can SAMHSA coordinate, or how 
can SAMHSA contribute to developing and disseminating this 
evidence?
    Mr. Daniel. Mr. Chairman, Senator Burr, thank you for that 
question.
    I think SAMHSA is doing a lot of that through the Addiction 
Technology Transfer Centers, and I think additional funding, 
perhaps, for that process would be very helpful. But, I think 
there are other strategies, as well, that are probably outside 
of SAMHSA.
    In our State and many other States, the key people that 
make this work, are usually judges. Many times, lower-level 
judges. In the context of drug courts, and Wyoming now has 25 
very successful drug courts--you have teams of people, 
including judges, who exercise the judicial leadership in 
bringing together the prosecutors and the defense bar and the 
treatment community and housing and education and the others, 
around the science of addiction. And their outcomes are so 
significantly better than what occurs in other contexts in the 
court room, where particularly in the lower-level courts, drug 
offenders are usually, initially found,--that--I think the 
lesson drawn from the drug court experience would be very 
important to the committee. It's a part of that whole process 
thing where unless the addiction is treated with a 
comprehensive approach, then what will happen is that those 
offenders who are in municipal court, graduate to the District 
Court and the Federal court on more serious charges.
    And so, earlier interventions are important, but somehow, I 
think, we have to do better in both the medical schools and the 
law schools in making that a part of the curriculum, so that 
lawyers who graduate from law school, and doctors coming out of 
medical schools, have that integrated in the view of the people 
that they will help.
    Senator Burr. Good point.
    Final question, Lisa, what service, education, programs are 
needed for us to make sure that individuals with a mental 
illness actually take medication? The medications, as you know, 
change significantly, almost yearly. And one of the biggest 
challenges is, those individuals that are afflicted, many 
times, go off their medications. Then you start back at square 
one. Is there anything that we can do, that we're not doing 
today, that would help alleviate that challenge?
    Ms. Halpern. Tough question, Senator Burr.
    I would have to say that the most important aspect of 
trying to encourage one to take medication would be an alliance 
between the medical provider--whether it's a psychiatrist, or a 
therapist, or whoever the key provider is--there needs to be an 
alliance between the individual with illness, and the doctor. 
And that alliance is sort of a conundrum--how do you build 
trust with one who does not trust? With a lot of these 
illnesses, with psychosis, with schizophrenia, there's a basis 
for a distrust. So, trust has to be built up in order to get an 
individual to take medication. And sometimes that takes time, 
it takes time that emergency room doctors may not have the 
luxury of having. But, if possible, sometimes just having time 
to form a relationship between patient and doctor is, I think, 
the most secure way to our indirectly getting to the endpoint 
of someone wanting to take their medication, because it's the 
combination of pills that makes them feel well.
    Senator Burr. Well, I thank you for that.
    And, Mr. Chairman, I think it's something that we already 
know, is that many Americans don't have a relationship with a 
healthcare professional, at all. And, you're right, the 
emergency room is not the model of primary care delivery, it's 
a model of trauma, and it has now really become a facility that 
provides every type of health care imaginable. And some, they 
do well, and some they don't do very well at all. But, it sort 
of puts us back in the mode that we have a health care system 
that's designed only to trigger when you get sick. It's not 
triggered to keep people well, it's not triggered to do 
prevention. And the only way that we will change it is if we 
start up here, restructuring the health care model in this 
country, so that it promotes wellness, it promotes prevention, 
and part of that is paying for wellness and prevention and 
establishing a relationship between a patient, and a healthcare 
professional, so that they begin to build that trust with 
somebody in the healthcare community. So, we thank you for 
that.
    Thank you, Mr. Chairman.
    Senator Reed. Thank you, Senator Burr.
    I want to thank the witnesses, all of the witnesses, for an 
excellent hearing. It strikes me that the themes that 
Congressman Kennedy outlined initially, evidence-based 
programs, and Mr. McDaniel has pointed out very graphically how 
important these programs are, and then coordination, between 
substance abuse, mental health, the larger medical community, 
the legal system, the housing community--we have to enhance 
that coordination, and that means information systems that are 
reliable, outcomes that we can measure. It means enhanced 
training for many participants, both in the legal profession, 
the medical profession, the substance abuse profession as well 
as the mental health profession. And, the goal is to provide 
the programs that will provide adequate treatment, and also, we 
hope, prevention.
    So, I thank you, we've learned a lot, I have, and I thank 
you all. The committee record will be open for 14 days to allow 
others who wish to submit written statements to do so, and also 
to allow my colleagues on the committee who might have follow 
up questions to address them to the witnesses.
    Thank you very much, and the hearing stands adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

         Response to Questions of Senator Enzi by Lisa Halpern

    Question 1. In your testimony you said that the mental health care 
system is ``in trouble.'' What specifically is broken with the system? 
Is it lack of funding, to many hurdles, too much bureaucracy, etc.? Why 
are so many States doing so poorly?
    Answer 1. As both the 2003 White House New Freedom Initiative 
Mental Health Commission report and NAMI's 2006 Grading the States 
report found, the Nation's public mental health system is plagued by 
fragmentation and lack of coordination. While a lack of available 
resources is a problem in many States, in many others it is failure to 
properly invest in evidence-based treatment models that maximize 
opportunities for recovery. The reality is that the array of services 
that adults with mental illness need--medication, case management, 
housing, income supports, employment, etc.--are spread across multiple 
service systems, with very little coordination.
    The poor performance of State systems--27 States in the NAMI report 
received a grade of either D or F--is based largely on the absence of 
comprehensive supports and services that are oriented toward recovery. 
At the same time, there are many pockets of innovation across the 
country, including supportive housing, jail diversion, integrated 
treatment for co-occurring mental illness and substance abuse, and 
elimination of restraint and seclusion in inpatient facilities. SAMHSA 
reauthorization affords us an important opportunity to prod States 
toward investment in these innovative approaches.

    Question 2. Ms. Halpern, you were able to access and receive 
services and supports. Why do so many other Americans have a difficult 
time receiving similar services?
    Answer 2. Unfortunately, effective supports and services such as 
Assertive Community Treatment (ACT) are simply not available across the 
country. In order to effectively engage people with mental illness in 
treatment it often takes a willingness to meet people on their terms, 
where they live. This includes outreach and engagement on the streets, 
in homeless shelters, board and care homes, etc. Involvement of peer 
support and peer outreach is critical to making this kind of assertive 
engagement effective. We simply cannot allow community-based providers 
such as CMHCs and local public mental health service agencies to sit 
back and wait for consumers to voluntarily seek out treatment. Finally, 
we cannot lose sight of the fact that social withdrawal and social 
isolation are part of the very constellation of ``negative'' symptoms 
associated with an illness such as schizophrenia. These negative 
symptoms can have a profound effect on the ability of consumers to seek 
treatment on their own. This requires us to constantly be developing 
creative approaches to reach the most disabled and isolated people 
living with mental illness.

        Response to Questions of Senator Enzi by Rodger McDaniel

    Question 1. In your oral and written testimony you encourage 
flexibility in the approach to funding effective treatment and 
prevention at the local level. One of the issues we are discussing in 
reauthorization of SAMHSA is the elimination of ``silos'' of service in 
exchange for more flexibility. Please explain in more detail what the 
optimum roles are for the Federal Government versus the local 
government in prevention and treatment from your experience in Wyoming.
    Answer 1. In my view, the Federal Government can continue to play a 
very useful leadership role in steering the service system toward 
broad, comprehensive goals. Access to Recovery is an example of the use 
of funding to provide an incentive to involve the faith community as 
well as to expand the provider base beyond the usual set of State 
providers. The mental health system has, for example, used the 
President's New Freedom Commission ideas as the basis for transforming 
the mental health delivery system. The Federal Government also has an 
important role in defining not only client outcomes, but also 
performances measures for our systems of care. Accountability will be 
served if the State-Federal partnerships can implement standardized 
measures, are using common outcome measures such as the NOMS, to 
demonstrate the effectiveness of our services
    The Federal Government can also play an important role by 
adequately funding research and the application of best practices. It 
is not helpful to cut the Addiction Technology Transfer Centers budget 
as proposed by the President. Nor is the proposed elimination of 
funding for Best Practices Coordination and Evidence Based practices. 
Any federally funded research needs to take into account the variation 
in needs from State to State given demographic and other defining 
differences. Finally the Federal Government needs to be consistent 
about its message. If Congress believes something is a priority, it 
needs to fund it. Establishing priorities without funding serves only 
to further overburden State and local systems that are generally 
straining under the pressure for services.
    The role of the local community is a largely untapped resource in 
this effort. The opportunity for real progress toward meeting the 
challenges of substance abuse and mental health is at the community 
level. There are business and faith leaders, non-profit organizations, 
members of the recovering community, and other citizens who want to be 
involved. The SPF SIG program has been a good example of community-
State-Federal partnerships. Restrictive State and Federal grants have 
served to limit and dis-empower local leaders. Community leaders are 
closest to the problems and given flexible funding, they can identify 
the real needs of their neighborhoods and make the necessary choices. 
The environmental and cultural changes that are required to change 
negative trends are largely controlled by local communities. If they 
are not recognized for their key roles and given both the authority and 
the responsibility to make change, long-term solutions will remain 
elusive.

    Question 2. It is clear that meth is fiercely addictive, and that 
individuals can be hooked from using just once. This makes it more 
difficult to target one specific population at risk for meth use. 
Therefore, how does an individual have access to treatment that fits 
that individual's need?
    Answer 2. The balance between designating and serving priority 
populations vs. an open door policy to serve any individual in need of 
treatment is delicate. Ultimately decisions to treat should be based 
upon medical and clinical necessity which takes into account the unique 
needs of the client who desires or is in need of service. Every person 
should be screened, assessed and evaluated for services and if in need 
of treatment should be delivered in the lowest level of care possible.
    In Wyoming, we are putting a great deal of emphasis on social 
marketing geared toward young people. Our hope is to raise awareness 
toward the severe impact of meth use on health, physical appearance, 
and all aspects of their development. Prevention is critical in meth 
because of the highly addictive nature of this drug.
    Additionally, Wyoming has been working toward the regionalization 
of services. While not every county or community can afford to provide 
a full continuum of services, we believe it is important to recognize 
that service availability close to the client's home is essential to 
optimal recovery. Thus, we are gradually funding the continuum to each 
region. We are also expanding the availability of strategies such as 
tele-medicine.
    Access to Recovery funds have been a tremendous help to us in the 
effort to provide meaningful early intervention for youth with meth or 
other drug or alcohol problems. Given the hideous nature of meth's 
addictive qualities, this early intervention with young people is a 
critical capability.
    Finally, we are partnering with the departments of Corrections and 
Family Services to provide targeted, wrap-around services for mothers 
with young children. We intend to make use of para-professionals as 
family resource advocates. By recruiting, training, and certifying a 
workforce composed of recovering addicts, we can provide intensive in-
home services to families. I see this as one effective answer to the 
problems of small communities recruiting a professional, therapeutic 
workforce.

    Question 3. How have you worked to ensure that areas, especially 
rural areas have access to the most up-to-date information and 
resources to treat and prevent substance abuse?
    Answer 3. The State of Wyoming contracts with the Center for 
Applied Science and Technology (CASAT; an organization independent of 
State government) to provide training, technical assistance, and 
certification of all substance abuse providers practicing in the State. 
A major portion of their work is conducting training events targeted at 
specific needs of individual centers, particularly those located in 
rural and frontier areas. Our State licensing law requires continuing 
education for license or certification retention, and these training 
events conducted by CASAT meet the required criteria for continued 
education.
    The State recently invested in tele-medicine technology and 
workforce development, which will provide an additional opportunity for 
staff in remote areas to link with the educational presentations, 
training, specialized consultation and supervision that is essential in 
the implementation of evidence-based practices.

    Question 4. Can you explain the 15/22 rule that you referred to in 
your written testimony?
    Answer 4. Under the Adoption and Safe Families Act, if a child is 
in foster care for 15 of the last 22 months, the State is required to 
initiate legal proceedings to terminate parental rights. There is a 
broad, almost engulfing exception for what the law calls ``compelling 
circumstances.'' Research shows that one of the strongest motivating 
factors causing people to enter and remain in treatment is the loss of 
their children. If the system is able to make treatment available as 
quickly as possible after the children have been placed in foster care, 
more parents may be successfully reunited with their children.
    The failure of judges to understand the brain science means that 
too often, addicted parents are simply court ordered into treatment 
with little or no meaningful supervision. In a family treatment court, 
the progress of the parent is closely monitored, unlike in most general 
family courts. If you study the brain scans, you will note that serious 
brain damage has occurred in the brain of the active addict. The neuro-
biological damage to that portion of the brain where a person makes 
choices and exercises judgment precludes the addicted parent from 
following through without close supervision, drug testing, and a system 
of swift sanctions for violations. The addiction has also hijacked the 
brain's reward system. As a result, the person has come to rely on 
drugs to simply feel normal. There are research-based practices that 
re-institute the reward system, allowing the person to feel rewarded by 
engaging in positive, healthy behaviors. I have attached the research 
on the strategy known as ``contingency management.''

    [Editor's Note: Due to the high cost of printing, previously 
published materials are not reprinted in the hearing record. The above 
referenced document may be found at http://
www3.interscience.wiley.com.]

    The primary point of my testimony was that the 15/22 rule can be 
effectively used along with best practices to significantly reduce the 
numbers of children removed from parental custody, and/or to greatly 
reduce the length of time children are in State custody. However, 
social workers, judges, and others need to understand the brain science 
so that our system contains programs with a greater likelihood of 
success.

        Response to Questions of Senator Enzi by Terry Allebaugh

    Question 1. In your testimony you commented on the success your 
organization, New Hope, Inc., has seen through the Projects for 
Assistance in Transition from Homelessness (PATH) program; has your 
organization ever applied for the Grants to Benefit Homeless 
Individuals through SAMHSA?
    Answer 1. Housing for New Hope has twice been part of a 
collaborative application for SAMSHA demonstration projects focusing on 
the chronic homeless in 2004 and 2005. Both applications were done with 
partner agencies in neighboring Wake and Orange Counties (along with 
Durham County, we are known as the Triangle), and were submitted by the 
Triangle United Way. Each Grant Opportunity had a very limited number 
of project awards, and though we received a relatively high score, we 
were not funded.

    Question 2. Mr. Allebaugh, in your testimony, you mention that both 
men, Concrete and White Mike, declined offers that would connect them 
to services. Mike's story resulted in a positive outcome but it appears 
that Concrete has not been as successful thus far. How does your 
organization handle cases like Concrete and how does the Projects for 
Assistance in Transition from Homelessness (PATH) program help you in 
these endeavors?
    Answer 2. It is through our operation of the PATH program that we 
made contact with Mike and Concrete. Through PATH we are able to 
outreach and connect some of the chronically homeless to services and 
housing. However, PATH staff cannot do any continued services once a 
person is referred to a clinical team. What SELHA would fund is 
clinical teams focusing on the homeless. This team could either 
intercede when Concrete was being released from the hospital, or work 
with the PATH team to engage, and then continue to render psychiatric 
services, thus providing a continuity of services, which is essential 
for this vulnerable population.

    Question 3. One comment many States have expressed is that the 
flexibility of the grant programs within SAMSHA is one of the best 
characteristics of the program. Can you speak to the degree of 
flexibility within the PATH and reasons why PATH does not provide the 
flexibility New Hope identified in the Services for Ending Long-term 
Homelessness Act (SELHA) bill?
    Answer 3. Re-stating from above, PATH is limited to providing 
outreach only, and we are prohibited from continuing services once we 
have referred a person to a clinical services provider. By requirement, 
PATH personnel are nonclinical. The problem arises that the existing 
pool of service providers have limitations in their capacity to serve 
the homeless. These include: inability to conduct outreach and engage 
the homeless and lack of knowledge and motivation to respond to the 
special characteristics and needs of the homeless. What we have learned 
from our experience is that too many of the homeless we refer are not 
served by the current system and once again they fall through the 
cracks. With a clinical services team (funded through SELHA) working 
with the PATH outreach team, and with the availability of the housing 
units we have built and are building, we could outreach, house, and 
provide ongoing services, and thus bring stability into the lives of 
the chronically homeless, and end chronic homelessness in Durham.

          Response to Questions of Senator Burr by Terry Cline

    Question 1. In an effort to make the most of limited Federal 
resources by leveraging funding partnerships, such as your partnership 
with the Department of Education under the ``Safe Schools-Healthy 
Students'' initiative, Senator Reed and I think SAMHSA should provide 
targeted funding for mental health and substance abuse services at 
``permanent supportive housing'' facilities to help end the cycle of 
chronic homelessness.
    The city of Portland recently reduced the number of chronically 
homeless by 70 percent when the city, the county, and the housing 
authority partnered to provide resources so agencies could open 480 new 
units of ``permanent supportive housing.''
    I know SAMHSA has the authority to provide some funding to 
organizations providing services to homeless individuals, but how much 
of that currently supports this highly cost-effective model?
    Answer 1. SAMHSA helps support services in permanent supportive 
housing primarily through two mechanisms. First, SAMHSA is a primary 
partner in the recently completed Collaborative Initiative to Help End 
Chronic Homelessness, the 3-year collaboration between HHS (SAMHSA and 
HRSA), HUD, and VA that addressed the mental health, substance abuse, 
primary health care, supportive housing, and other service needs of 
individuals experiencing chronic homelessness.
    The very poignant example that you used regarding the success of 
the city of Portland in addressing chronic homelessness is germane to 
the Chronic Homelessness Initiative. Central City Concern, located in 
Portland, was one of the 11 sites under the Initiative. SAMHSA is 
gratified that one of our grantees helped contribute to helping to 
reduce chronic homelessness in their community.
    In fiscal year 2007, SAMHSA issued a new funding announcement, 
titled the Services in Supportive Housing Program. This 5-year 
initiative will help end chronic homelessness by funding services for 
individuals experiencing chronic homelessness and families in 
coordination with existing permanent supportive housing programs and 
resources. The service grants are intended to fund programs that use 
services or practices that have been shown to be effective and that are 
appropriate for the target populations. Program and client outcome data 
will be collected and reported in accordance with the Government 
Performance and Results Act. Fiscal year 2007 funding of $3.5 million 
will allow SAMHSA to award eight grants.
    While providing services to individuals living in permanent 
supportive housing has proven to be successful in addressing the needs 
of homeless individuals, it is not the only successful model for 
providing services to this population. SAMHSA also supports residential 
treatment programs that provide services to individuals who were 
homeless at intake. While supportive of services in permanent 
supportive housing, we want the flexibility to address the needs of 
homeless individuals in other settings that have proven to be 
successful as well. There are many ways to achieve our shared goal.
    We also want to highlight that SAMHSA in its programs is focusing 
on recovery. As we look at recovery across our substance abuse and 
mental health portfolios, including the block grants, we are focusing 
on key elements of recovery including whether the individual has stable 
housing.
    SAMHSA's total budget that addresses homelessness including the 
Projects of Assistance in Transition from Homelessness and 
discretionary grants focused on homelessness is $99,876,000 in fiscal 
year 2007.
    Second, SAMHSA administers Grants for the Benefit of Homeless 
Individuals (GBHI) using its authority under Section 506 of the Public 
Health Service Act (PHSA).
    The purpose of the program is to award grants, contracts and 
cooperative agreements to community-based public and private nonprofit 
entities for the purposes of providing mental health and substance 
abuse services to homeless individuals.
    From a survey of grantees conducted in April 2007, we know that 20 
percent of current GBHI grantees deliver supportive housing services. 
Therefore, we may estimate that $7,639,000 in 2006 funds for GBHI and 
$7,694,000 in 2007 funds will be used for supportive housing services. 
The remainder of GBHI funding supports services involving other types 
of housing.
    In guidance given to grantees for the survey, supportive housing 
involves three essential elements:

    (a) Permanent affordable housing, in any housing configuration 
(scattered, clustered, dedicated or mixed use single site [e.g., 
apartment building or SRO], units obtained from private landlords using 
tenant-based rent subsidies, etc.). [Permanent housing means no limit 
on length of stay and no requirement that tenants move out if their 
service needs change.]
    (b) The housing is intended for, and for the most part actually 
occupied by, people who have been homeless or are at risk of 
homelessness and who have special needs including substance abuse 
problems or mental disorders, or other substantial barriers to housing 
stability.
    (c) Supportive services attached that are designed to help people 
maintain the housing.
    Thus, supportive housing does NOT include transitional (time-
limited) housing or residential treatment, or projects that primarily 
help clients get housing subsidies after they complete a grant-funded 
treatment program. Supportive housing includes only the simultaneous 
provision of permanent housing and treatment services to homeless 
people.

    [Whereupon, at 11:35 a.m., the hearing was adjourned.]

                                    

      
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