Healthy Transitions Initiative - Now you see it, now you don't!

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In 2009 the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, funded seven states five-year cooperative agreements to participate in the Healthy Transitions Initiative (HTI). This initiative was designed to integrate services and supports for youth and young adults 16-25 with serious mental health conditions and their families. One of the unique aspects of the original HTI funding is that it only went to states and the states were asked to craft practice and policy. This combination of practice informing policy and policy impacting practice is critical to replication and sustainable change to create better outcomes and create supportive state-level policies.

Here are some excerpts from the cooperative agreement description:

Sounds impressive, right?
Exactly the kind of comprehensive, forward thinking that we have come to expect from SAMHSA. And we at the Children's Mental Health Network have thoroughly enjoyed watching and learning from these seven state initiatives, especially with the growing important involvement of young adults participating in the design and delivery of services and supports that most effectively meet their needs. So we were thrilled, but by no means surprised, when we saw that proposed funding for the Healthy Transitions Initiative (HTI) was included in the President's budget proposal to Congress.

Ah, but we celebrated too early. When the Senate Appropriations subcommittee on Labor-HHS turned in their markup the HTI, budgeted for $25 million, was no where to be found. Interestingly, there was a new addition to the Community Block Grant for just under $25 million to direct funds to "evidence-based programs addressing the needs of individuals with the early signs of serious mental illness, including psychotic disorders, regardless of the age of the individual at onset."

So let's recap:

Oh my, oh my, where should we begin with our dismay at this one? 

Six months in the life (and potential demise) of the Healthy Transitions Initiative
First, let's look at the Fiscal year 2014: Budget in Brief: Strengthening Health and Opportunity for All Americans document prepared by the U.S. Department of Health & Human Services. You will note that in the table on page 39 the Community Mental Health Services Block Grant shows no increase and the Healthy Transitions Initiative shows a recommended increase of $25 million:

And then on page 41 of the same document there is specific language supporting the Healthy Transitions Initiative (highlights are ours):

But then on July 11, 2013, our puzzlement began:
From the Appropriations Bill (S. 1284) for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2014
Page 65 - Provided further, That States shall expend at least 5 percent of the amount each receives for carrying out section 1911 of the PHS Act to support evidence based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, regardless of the age of the individual at onset. 

No mention of the Healthy Transitions Initiative anywhere in this document that we could find.

And then the press release on the same day pretty much sealed the deal. In this excerpt from the Press Release by the U.S. Senate Committee on Appropriations regarding the Fiscal Year 2014 Labor, Health and Human Services, and Education, and Related Agencies Appropriations Bill - Full Committee Mark we have included the section related to mental health services.

No mention of $25 million for Healthy Transitions Initiative but a new addition of close to $25 million to the Community Mental Health Services Block Grant for "evidence-based programs addressing the needs of individuals with the early signs of serious mental illness." Note that the press release leaves out the last part of the descriptor - "including psychotic disorders, regardless of the age of the individual at onset."

What is hard to fathom is that the first two paragraphs of this section of the press release actually reinforce the need for focused attention on emerging adults - those specifically identified in the Healthy Transitions Initiative. What is unfortunate is that the opening paragraphs continue to perpetuate the myth that mental illness and violence go together like ham and cheese when there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness. Since the press release chose to lead with the linking of the horrific tragedies in Colorado and Connecticut with violence and mental illness we would be remiss if we did not counter with the comments of Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, who said in an interview with the New York Times that “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”... "Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless."

This distinction is so important for understanding what is happening to children's mental health right before our very eyes. It is being marginalized, subsumed and over-simplified into sound bites that have a level of complexity that is surface-level at best. When decisions are being made about what to fund with Federal dollars we should expect the most comprehensive approaches possible. With the removal of the HTI from the Appropriations budget we are witnessing the further dismantling of the piloting of approaches that are not just treatment based, but are equally focused on system level policy change backed by solid research at the local, state and national level. That is how we move the learning forward. In this instance, it appears we are moving backward.

The next fascinating document worthy of a closer look is the report that accompanies the Appropriations Bill (S. 1284). This report provides rational for the increase in mental health services block grant (MHBG) funding. It should be noted that we were unable to find any reference in this report regarding the decision to remove the Healthy Transitions Initiative from the budget.
Excerpt (page 114) from the report that accompanies S. 1284 providing rationale for increase in block grant funding (highlights are ours):

I can't decide when reading the third and fourth paragraph if I am experiencing vertigo or cognitive dissonance. Maybe a bit of both. Let's start with the third paragraph:

This paragraph speaks to the strength of the Healthy Transitions Initiative - the most comprehensive and targeted approach to addressing the needs of young adults with emotional challenges.

And then the fourth paragraph:

This paragraph is focused on a treatment model that apparently has great success with individuals suffering from a psychotic illness, which we have noted above is a small percentage of young adults with serious emotional challenges. Where is the complexity inherent in the HTI that shines a bright light on not just practice, but needed policy and system collaboration strategies and long term sustainable change in community health practice to ensure that young adults are getting what they need to be successful? 

Okay, so how did this happen?
Well, we actually don't know and really need the help of Network faithful to find out. We have prepared a few questions that we will be sending to the Senate subcommittee members and encourage you to send your questions as well.

But first, an important note for all of us to remember. Elected officials rely on the information provided to them to be able to make fully-informed decisions, which means it is incumbent upon us to do our job as educators to speak up and let them know what is working well and making a difference for youth with serious emotional challenges and their families. Ultimately, the responsibility lies with us as citizens of this great country to make some noise. If we don't let our voices be heard then we might as well be playin' jacks.

Here are the questions we will be asking the Senate subcommittee in a letter to be sent out early next week. Answers to these questions will help us both understand how this happened, and maybe more important, ready us to be better prepared in the future.

The Senate committee proposal calls for a new 5 percent set-aside within the Community Mental Health Services Block Grant that will allocate $24 million to States. The specific language reads "Provided further, That States shall expend at least 5 percent of the amount each receives for carrying out section 1911 of the PHS Act to support evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, regardless of the age of the individual at onset. Since the $25 million in the President's budget for the Healthy Transitions Initiative does not appear in the Senate Bill it leads us to conclude that the funds identified for HTI were moved over to the Block Grant.

Here are the questions we are asking:

 If you have actually read through this very long post then congratulations, you only have one more thing to do - get involved! 

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network


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    Peggy Sinclair-Morris
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    Which 7states received funding for the HTI?
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