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The Death Knell Has Been Sounded: New SAMHSA Technical Assistance Grant Guts the Values and Principles of Systems of Care

January 20, 2020

One of the hallmarks of the systems of care movement that helped frame the Child Mental Health Initiative (CMHI), was, and is, the unrelenting focus on the values and principles that guide the work taking place in communities across America. The CMHI was heavily influenced through the involvement, sometimes peaceful, sometimes not, of a rowdy group of advocates in the early 1980’s. The participation of these advocates helped form a federal initiative, that since 1992, had embraced the commitment to push communities and push itself to be more responsive around such essential issues as cultural inclusion, family and youth involvement, a commitment to utilize natural and community supports as a first line of defense, and to earnestly encourage local communities to develop innovations in collaboration. If you are new to this work, or the concepts behind “systems of care,” I encourage you to visit this archive of founding documents on systems of care to get you oriented.

SAMHSA Releases Grant Announcement for Technical Assistance Contract for CMHI Grantees
Last month, SAMHSA released a new grant announcement for a Technical Assistance Center that will provide resources and support for CMHI grantees. The current contract for the provision of technical assistance is with the TA Network at the University of Maryland and ends this year.

Unfortunately, with this announcement for something  as seemingly straightforward as a notice for a five-year grant award for the provision of technical assistance to CMHI grantees, we are witnessing the gutting of the heart and soul of the systems of care movement – all with the stroke of a pen. Yes, systems of care as we know it could be a thing of the past, just like that. The death knell has been sounded. Here is why.

Surely, There Is More Substance in the Announcement
When I first read the new grant announcement, I assumed I was missing something. I hoped that I was, so I read it several more times, and was perplexed. Whoever wrote this announcement could not have had any context for systems of care, and knowing the caliber of the employees of the Child, Adolescent, and Family Branch, I am hard-pressed to think that it originated there. I have no knowledge of this, but the document is so void of any language that would suggest the work of the CMHI and system of care efforts across the nation and several territories over the past 28 years, I just can’t imagine this grant announcement being written by anyone other than someone who has no context with the mandate of the federal legislation (page 349) that put the CMHI in place.

Purpose Statement from the Grant Announcement Lacks a Soul
When you read the Purpose statement from this new grant announcement that provides the foundation for understanding what the federal government is looking to fund, it reads as follows:

The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), is accepting applications for fiscal year (FY) 2020 National Training and Technical Assistance Center for Child, Youth, and Family Mental Health. The purpose of this program is to provide training and technical assistance (TTA) to increase the access to, effectiveness of, and dissemination of evidence-based mental health services for children, youth and young adults (through age 21) with Serious Emotional Disturbances (SED)/Serious Mental Illness (SMI) and their families and to promote the coordination of these services. This Center is a key component of the SAMHSA Children’s Mental Health Initiative.

Okay, you say. What’s wrong with that? SAMHSA is looking for applications for the TA Center. Seems pretty straightforward to me.

Here’s the big problem.

That’s all the grant announcement says about the substance of the effort. There is no background, no history of how the CMHI has evolved over the past 30 years, and no discussion of the values and principles that are the bedrock of the work these grants do. My interpretation of what SAMHSA is saying is, “Don’t worry about the past 28 years of learning about what works and what does not. Just wing it. You get the general idea of what we want. Give us your best guess at what you think will work.”

Here are a few glaring examples:

Family Involvement
The grant application has NO mention of family involvement. The word “family” is found in a total of six places in the entire announcement:

  • Four times the word is used in the title of the grant announcement – “National Training and Technical Assistance Center for Child, Youth, and Family Mental Health.”
  • One time in the Data Collection section – “Identify from whom you will collect data (e.g., from participants themselves, family members, teachers, others).”
  • One time in the “Sample Justification for Contracts” section –The Marketing Coordinator will develop a plan for public education and outreach efforts to engage clients in the community about recipient activities; and provide presentations at public meetings and community events to stakeholders, community civic organizations, churches, agencies, family groups, and schools.

But it gets worse.

Youth Involvement
Over the past ten years, there has been a steady growth in youth involvement in these grants. And that involvement has not come easy. Many bumps and bruises along the way, many opportunities to question whether or not the strategies employed for youth involvement were the most effective, but never a question of commitment to trying to figure it out. Youth involvement was one of the hallmarks of the previous Branch Chief, Gary Blau’s tenure at SAMHSA. Well, Dr. Blau has moved on, and it appears that youth involvement is being swept under the rug.

Case in point? The word “youth” is found a total of eighteen places in the entire announcement:

  • Four times the word is used in the title of the grant announcement – National Training and Technical Assistance Center for Child, Youth, and Family Mental Health
  • Fourteen times the word is used in stock sentences such as “… mental health services for children, youth, and young adults” in the context of things that will be done to youth (disseminate, survey, compile, treat, etc.).

In both family and youth examples, there is not even the slightest hint of the importance of involvement. The meager references to youth and families (beyond the title of the announcement) refer to things that should be “done to” rather than “done with,” or God forbid, “directed by.”

Reading this grant announcement transported me back to the mid-1980’s, when I was getting ramped up in this work. In those days, there was plenty of discussion about what the mental health community could do “for” families, but the concept of “with” families, was fuzzy at best. And back then, we weren’t even talking about youth. Welcome to the 80’s, youngin’s. This grant announcement is rife with opportunity for those in charge to dictate what they think is best, regardless  of what those receiving services and community partners say they need. 

An Example of My Patronizing Smugness in Advancing Systems of Care
In 1986 or so, I was working for the North Carolina Division of Mental Health in the Child and Family Services Section. My boss, Lenore Behar, was a heavy hitter on the national level in Children’s Mental Health. The family movement was stirring, and she wanted to do something that would better involve families in North Carolina, so she asked me to write a grant announcement for a family organization that could help increase family involvement in North Carolina. I wrote it, she got it approved, and we hired a family member to be the voice for families in North Carolina. And it was terrific. For us. I’m not so sure it was so terrific for the family member we hired. In hindsight, her job became something of a dog and pony show, where she would go all over the state, representing the voice of families. Except, what was going on was that, for the most part, what she was doing, was making us (the state) look good. We didn’t enter the arrangement planning for that to be the case, but, for the most part, that is how it turned out. Yes, good things happened, and the person chosen for that first grant was highly competent, but at the end of the day, those of us at the state level were making the decisions about when and where she would go, and what topics she should focus. The idea of having families decide what was best for them and then how system providers could help with that, was an idea that was not even close to being in our consciousness.

Patronizing families was a common problem in the early days of the family involvement movement, and several states who started to hire family members found themselves playing out the same dynamic that we did in North Carolina. Families began to (rightfully) grumble about the inequity, and groups like the Federation of Families for Children’s Mental Health emerged, and focused their energy on ensuring that families were front and center in changing the dynamic about what would be done “to them” to what would be done “with them.”

This is a very brief summary of a very complicated dynamic between those who provide services and those who receive services. But it illustrates one of the essential points about the CMHI. The CMHI is a laboratory for encouraging innovation and change. And the only way you do that is by being fully inclusive in all aspects of decision-making. That is the beauty of the CMHI. The federal government is providing much-needed funding to states and communities to embrace the values and principles of systems of care to find innovative ways to improve services and supports for youth and families. Values and principles that focus on inclusion, collaboration, and partnership.

This new grant announcement suggests none of that, and frankly is a slap in the face to the thousands of Americans involved in these grants over the past 28 years. Have they all been successful? Of course not. But many have, and much learning has taken place over the years. What is most important for me is that there continues to be a dynamic tension between receivers (families and youth) and givers (professionals) in these grants. That is the only way there will be growth. This current announcement does away with all of that. We now, apparently, have a homogenized grant announcement that reeks of professionals (who know better) designing a technical assistance approach for children, youth, and families that doesn’t require or even ask them to be involved in any aspect of decision-making.

What a Difference Five Years Makes
Let’s take a look at the contract for technical assistance that was awarded five years ago. Yes, it was a contract back then, and not a grant, which allowed SAMHSA to be more prescriptive in their request. The 2015 language that described the purpose of the award will give you an idea of how they focused on the importance of the system of care values and principles so that potential bidders would have the appropriate context for crafting their proposals. Here are a few examples:

  • The Contractor shall describe a system for operationalizing family-driven and youth guided care in developing the TA Center and in designing and implementing TA activities.
  • The Contractor shall articulate meaningful roles for family and youth leadership, with the assurance of collaboration between professionals and families at every level of decision-making.
  • The Contractor shall describe how TA Center policies and operations will ensure full family and youth involvement in designing and carrying out TA and will encourage family and youth involvement reflecting the cultural and ethnic diversity of families in the system of care communities.
  • The Contractor shall describe how it will ensure communication and collaboration with system partners, such as the contractors for evaluation and social marketing and other related research and training centers or TA centers.
  • A system for TA that promotes all system of care values and principles.
  • Develop and implement a strategy to provide national leadership and engagement among youth who have been involved in mental health systems…
  • Provide administrative support to ensure that youth engagement/participation in system reform efforts occurs in states across the country.
  • Develop and maintain youth community networks crucial to the operation and function of the organization and develop services and supports as needed to ensure youth voice and empowerment is created and sustained across the country.

You can see in the examples shown, how the values and principles are interwoven in what is being requested. The federal government has invested in the CMHI for so many years for a reason – they are about promoting what works. The 2015 contract requirements embedded new learnings from the field into the request. The 2020 grant does none of that. What it does is potentially much worse.

2020 TA Contract Collaboration Examples Stay Within the Oversight of SAMHSA
The only examples of collaboration identified in the new grant application are other SAMHSA funded TA providers. The announcement does reference “external partners and constituency groups” but does not give examples of what those might look like. The announcement does, however, provide plenty of examples of SAMHSA-funded TA efforts. Here is the paragraph that references collaboration:

Collaborate with external partners and constituency groups, including other SAMHSA TTA providers, such as the Mental Health Technology Transfer Centers (MHTTCs), Addiction Technology Transfer Centers (ATTCs), Prevention Technology Transfer Centers (PTTCs), and the Clinical Support System for Serious Mental Illness (CSS-SMI).

My concern with this wording is that there is a subtle message to keep things in-house. And that is entirely antithetical to the spirit behind systems of care and the CMHI.

Okay, What Can Be Done About This?
Proposals are due February 4th, and I would guess that most organizations that are applying are almost finished writing their proposals. At minimum, it would behoove SAMHSA to hold an orientation call where someone with knowledge of the CMHI history, including innovations and growth in knowledge that have occurred over the past 28 years, could discuss the importance of this TA grant, and how it should support the values and principles of systems of care.

Or… If that is too much work, how about just copying Section A: Background Information from the Statement of Work (RFP# 280-15-0451 Attachment 1) written by SAMHSA five years ago. Here is one of the many excellent paragraphs in that statement of work.

The CMHI supports the development of more accessible and appropriate service delivery systems for children and adolescents with SEDs and their families. Training and TA to support and enhance service system development and skill enhancements is critical to advancing the program’s mission to expand and sustain community-based systems of care. Systems of Care are located in a diverse selection of communities throughout the United States, including urban, rural, Tribal and non-English speaking communities. The hallmark of systems of care is that they are family-driven, youth-guided and culturally and linguistically competent. Outreach efforts and interagency collaboration serve to increase access to mental health services among diverse populations.

That paragraph is quite a bit different than the description in the current grant announcement. Now you see what a difference a mere five years makes, and how we can so quickly lose the gains we have made if we do not stay vigilant.

A Death Knell Does Not Have to Come True
A death knell is a sign of something foreboding about to happen. But it is not a foregone conclusion. The signs of the demise of systems of care are front and center, but we can do something about it. I firmly believe that SAMHSA wants to do the right thing. But I also think that the leadership of SAMHSA may have lost there way. We need to help SAMHSA find their way and ground themselves firmly to the values and principles of systems of care.

I, for one, plan to share this post with members of Congress who are champions for mental health as well as the non-federal members of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). The ISMICC is charged with oversight responsibilities related to SAMHSA. Let’s hope they take this on.

I invite you to speak out about this as well.

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About the Author

Scott Bryant-Comstock

My passion is helping to shape policy and practice in children’s mental health. For the past 40 years, my journey as a mental health advocate has traveled from volunteering at a suicide and crisis center, professional roles as a therapist in an outpatient clinic, in-home family therapist, state mental health official, Board Chair for a county mental health program, and national reviewer of children’s mental health systems reform efforts. As the founder of the Children’s Mental Health Network (2009), I lead the Network’s efforts to grow a national online forum for the exchange of ideas on how to continually improve children’s mental health research, policy and practice.

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