From Exclusion to Belonging:

Transforming Mental Health Care in America

The Vision: A Life in the Community for Everyone

The Substance Abuse and Mental Health Services Administration

The Centers and Offices
Transforming Mental Health Care in America
The New Federal Leadership
The Challenge
Highlights of the Federal Action Agenda
Components of Recovery
National Consensus Statement on Mental Health Recovery
Programs of Transformation
Making It Count






Programs of Transformation

Changing Forever Mental Health Care in America

In addition to its leadership role, the programs described in the following pages illustrate SAMHSA's ongoing contributions to achieve the steps to transformation highlighted in the Federal Action Agenda on Mental Health.

Principle A

Focus on the Outcomes of Mental Health Care, Including Employment, Self-Care, Interpersonal Relationships, and Community Participation

Reducing Stigma and Discrimination

Many Americans view mental illness through a lens of stigma and discrimination. This limited perspective lies at the center of why thousands of individuals across the Nation fail to access the mental health services that are available. Year after year, adults and children continue to suffer in silence from depression and other debilitating mental conditions. Where most of us would not hesitate to seek treatment for a physical illness, many of us remain paralyzed when it comes to seeking support for a mental health problem. A broad spectrum of CMHS programs, including a National Anti-Stigma Campaign, has been designed to establish a "new norm" in which individuals, without hesitation, seek out the mental health services they need and deserve. The Elimination of Barriers Initiative is paving the way in eight States—California, Florida, Massachusetts, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin—with pilot efforts to reduce stigma, including strategic marketing plans and trained teams of public speakers. Training teleconferences, a Web site, and other technical assistance is available through the CMHS ResourceCenter to Address Discrimination and Stigma. Additionally, CMHS is in the process of developing a national anti-stigma campaign in partnership with the Ad Council designed to increase caring and compassion for individuals with mental illnesses.

Preventing Suicide

Transformation of mental health service systems includes taking a public health approach to preventing suicide. Building resilience to face life's challenges is central to this approach. As part of the National Strategy for Suicide Prevention and to promote the idea that suicide prevention is a shared responsibility on all levels—Federal, State, community, and individual—CMHS is collaborating with several Federal agencies to build a public-private partnership called the National Action Alliance for Suicide Prevention.

Offering a lifeline to prevent suicide

Recently, the WB Television Network contacted SAMHSA's National Suicide Prevention Lifeline (Lifeline) about an episode of One Tree Hill, a prime time television show set to air depicting an adolescent who held his school hostage before killing himself. In the spirit of responsible programming, WB also produced a Public Service Announcement (PSA) with Lifeline's toll-free number. The PSA, which aired immediately after the One Tree Hill episode, generated more than 750 calls to Lifeline within 5 minutes of its airing. One of the calls was from a Colorado high school sophomore with a history of suicide attempts. The distressed student disclosed that he was planning an assault on his school. Through Lifeline’s coordinated efforts, a school crisis counselor facilitated an emergency intervention and escorted the young man to a hospital for evaluation. The young man is currently receiving mental health treatment.

The Garrett Lee Smith Memorial Act, a congressional action authorizing support to States, tribes, colleges, and universities to develop youth suicide prevention and intervention programs has also emboldened CMHS’s ongoing suicide prevention activities. SAMHSA’s National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: 1-800-273-TALK (8255). It is the only national suicide prevention and intervention telephone resource funded by the Federal Government.

The National Suicide Prevention Hotline Network connects certified crisis centers to this single nationwide toll-free telephone number. The Suicide Prevention Resource Center is facilitating the development of suicide prevention plans in all 50 States, as well as disseminating articles, research, and other suicide prevention resources. CMHS is also funding the development of school-based suicide prevention guidelines for use nationwide. To support the American Indian/Alaskan Native community, the SAMHSA-funded OneSkyCenter is providing suicide prevention consultation and an interagency agreement with the Indian Heath Service is helping to develop a culturally competent community suicide prevention toolkit. The transformation of the mental health care system is happening every day as States and communities use their Federal grants to implement programs that embody the best evidenced-based suicide prevention practices.

Promoting Self-Directed Mental Health Care

Involving consumers in planning, evaluating, and providing services is central to creating a transformed mental health care system that focuses on recovery. Consumer participation is ongoing at CMHS through the Consumer-Operated Services Program, which provides support through seven consumer/peer-operated programs as well as a coordinating center to evaluate effectiveness at improving outcomes and quality of life for people with mental illnesses.

Consumers are also providing services to peers with the support of five national technical assistance centers and a manual for States on implementing peer-support services. Finally, self-direction impacts nearly every aspect of the mental health care delivery system, including planning, financing, workforce training, provider networks, and oversight and quality improvement.

Disseminating Knowledge to the Public: The National Mental Health Information Center

SAMHSA's National Mental Health Information Center (NMHIC) is a one-stop, national clearinghouse for free information about mental health, including publications, references, and referrals to local and national resources and organizations.

The Information Center was developed for users of mental health services and their families, the general public, policy makers, providers, and the media. Staff members are skilled at listening and responding to questions from the public and professionals. The staff quickly directs callers to Federal, State, and local organizations dedicated to treating and preventing mental illness. The Information Center also has information on Federal grants, conferences, and other events. For more information, visit or call 1-800-789-2647 (English and Español) or 1-866-889-2647.

Principle B

Focus on Community-Level Models of Care that Coordinate Multiple Mental Health and Human Service Providers and Private and Public Payers

Focusing on Children, Youth, and Families

The CMHS Systems of Care grants are based on the premise that the mental health care needs of children, adolescents, and their families can best be met within their home, school, and community environments. CMHS continues to fund Systems of Care grants and other activities to develop coordinated and integrated systems of care in counties across the Nation, including the Systems of Care Research Conference and a series of State policy academies to help States design and implement new child mental health policies. The Caring for Every Child's Mental Health campaign is also providing information and technical assistance to system of care communities. For those youth who have serious emotional disturbances, CMHS provides support through Partnerships for Youth in Transition, a series of cooperative agreements to States, to help youths ages 14-25 who so often need individualized treatment plans as they transition to adulthood.

Elevating Prevention Approaches

Armed with the knowledge gained from research and motivated by the need to prevent senseless death and disability caused by suicide, violence, or mental health problems, mental health researchers and policymakers are bringing prevention to the forefront of their approach to public health. The Federal Action Agenda on Mental Health recognizes that a comprehensive system of mental health care requires both treatment and prevention. CMHS embraces the National Institute of Mental Health definition as not just prevention of the onset of a disorder, but also the prevention of comorbidity, relapse, and disability. Some examples of how CMHS is promoting prevention-based activities are the Youth Violence Prevention grants, the CMHS Anti-bullying Campaign, and targeted capacity expansion Prevention and Early Intervention grants.

The Safe Schools/Healthy Students (SS/HS) Initiative is an unprecedented collaborative grant program supported by three Federal agencies—the U.S. Departments of Health and Human Services, Education, and Justice.

Promoting peer-driven recovery among youth

People who recover from mental illness often act as vectors for leading others into appropriate mental health services. Many of these "helping hands" are young people. During this past year, the CMHS-funded National Youth Development Board (NYDB), composed of 15 young people across the United States who themselves are consumers of mental health services, has emerged as a national youth leadership force. The NYBD has provided leadership trainings, created youth-guided principles and policies, and developed training tools, guides, and other documents. Most recently, the NYDB changed its name to Youth Move (Youth Motivating Others through Voices of Experience) and is seeking to establish its own national organization. More information about this Board and their activities can be found at:

The grant program is designed to develop real-world knowledge about what works best to promote safe and healthy environments in which America's children can learn and develop. This issue is critical to effective system transformation. A SAMHSA study confirms that one-fifth of elementary, middle, and high school students receive some type of school-supported mental health services during the school year. School districts are using these funds to help communities design and implement comprehensive educational, mental health, social service, law enforcement, and juvenile justice services in an effort to strengthen healthy child development.

Serving Older Adults

Many older adults who need treatment do not receive it because of their own and others' ingrained attitudes about mental illnesses. Yet by 2030, the population of Americans over 65 is expected to double. Late-life depression is just one reason that the Federal Action Agenda on Mental Health addresses mental health needs across a life span. Nine CMHS-funded Targeted Capacity Expansion Grants are implementing evidenced-based programs and responding to the needs of older adults. CMHS’s Positive Aging Resource Center (PARC) is assisting the sites in selecting screening instruments and models of care that are effective for older adults. CMHS’s PRISM-E, the acronym for Primary Care Research in Substance Abuse and Mental Health Services for the Elderly, is a multi-site study, which concluded that integrated primary care settings were preferable to enhanced referral care for older adults with severe psychiatric disturbances and substance abuse problems. In addition, several State teams to promote healthy aging are working on State-specific plans to enhance community care systems for older adults. Finally, SAMHSA and the Administration on Aging (AoA) are working collaboratively to support States in their efforts to improve access, coordination, and integration among health and social support services and to shift resources from institutions to home- and community-based long-term care options.

Fostering student success in school and at home

HILLSBORO, Oregon—Aggressive and defiant, with poor social skills, preschooler Bill S. was clearly at risk for severe difficulties. His "First Step" Coach at Washington County's "Enhanced First Step to Success," a local effort funded under the Federal Safe Schools/Healthy Students program, worked with both his Kindergarten teacher and his parents, who were both recovering from addiction; his mother was also suffering from depression. The Coach helped Bill’s mother to re-enter mental health treatment and to complete the HomeBase parent training program. Eventually Bill's mother returned to school and work and Bill joined a sports team. After careful first grade placement and support from both his mother and father, Bill has built a record of success in school and at home.

Reducing the Effects of Trauma and Disaster

New research is revealing that traumatic experiences—physical abuse, sexual abuse, severe neglect, loss, or the witnessing of violence or disaster—can affect anyone at any time, and that the effects of trauma are not always recognized. One effect can be posttraumatic stress disorder or PTSD. Other effects can include anxiety and depression. We are just beginning to understand the full effects of terrorist activities, natural disasters, and an array of other violent "assaults" on million of adults and children.

In response to national disasters, SAMHSA works closely with the Federal Emergency Management Agency to administer its crisis counseling program. SAMHSA also funds the Disaster Technical Assistance Center (DTAC), which helps prepare States, Territories, and local entities to deliver an effective behavioral health response during disasters.

CMHS funds the National Center for Post Traumatic Stress Disorder to develop disaster mental health intervention models, evaluation methods, and data collection tools to build effective evidenced-based mental health disaster response capabilities. CMHS also works with the National Child Traumatic Stress Network (NCTSN) to raise the standard of care and improve access to services for traumatized children, adolescents, and their families. The Network consists of three components: a NationalCoordinatingCenter, Intervention Development and EvaluationCenters, and CommunityTreatmentServiceCenters in the majority of States and the District of Columbia. Every month, thousands of victims of trauma, all children and adolescents, are treated within the NCTSN with the most up-to-date methods and the latest scientific knowledge.

Reinventing the Workforce

The Federal Action Agenda on Mental Health warned of a national crisis in the mental health care workforce, not just because of a shortage of professionals, but also because of a lack of diversity, cultural competence, skills essential to practice in contemporary health systems, and knowledge of evidence-based and emerging best practices.

CMHS is currently coordinating SAMHSA's national behavioral health workforce development strategy. Through a public-private partnership with the Annapolis Coalition on Behavioral Health Workforce Education, SAMHSA is working to build new competencies among providers and educators, among health care organizations and academic institutions, and among Federal and State agencies, accrediting bodies, health care insurers, and professional organizations.

Through Workforce Training Grants to Reduce Racial and Ethnic Disparities in Mental Health Services, CMHS is also identifying effective training models to improve the capacity of the mental health care workforce to engage, treat, and support racial and ethnic minority persons with mental illnesses.

Principle C

Maximize Existing Resources by Increasing Cost Effectiveness and Reducing Unnecessary and Burdensome Regulatory Barriers

Leveraging Resources: The Community Mental Health Services Block Grant

The Community Mental Health Services Block Grant is the single largest Federal contribution dedicated to improving mental health service systems across the country. Based on a congressionally mandated formula, CMHS awards grants to States, Territories, and the District of Columbia to provide mental health services to adults with serious mental illnesses and to children with serious emotional disturbances. CMHS works in close collaboration with each State to develop and implement its own State Mental Health Plan for improving community-based services and reducing reliance on hospitalization. The program stipulates that case management be provided to individuals with the most serious mental disorders and encourages appropriate partnerships among a wide range of health, dental, mental health, vocational, housing, and educational services. The program also promotes partnerships among Federal, State, and local government agencies. SAMHSA continues to work toward linking Block Grant resources with transformation activities.

Working to End Homelessness

Approximately 200,000 individuals annually are chronically homeless. Research shows that integrated mental health services, substance abuse services, and supportive housing work together to end chronic homelessness. CMHS has a rich history of efforts to reduce homelessness, most recently through a Federal partnership between the U.S Departments of Health and Human Services, Housing and Urban Development (HUD), and Veterans Affairs (VA).

Assisting individuals on the journey from chronic homelessness to housing and recovery

Contrary to the widely held notion that chronically homeless individuals are beyond help and destined to never-ending dependency, SAMHSA's collaboration with HRSA, HUD, VA, and the Interagency Council on Homelessness is setting the record straight. The 3-year, $55 million joint initiative to help end chronic homelessness is effectively linking and coordinating mental health and substance abuse services, primary health care, permanent housing, and veterans services. A designated planning and operations "lead" agency also networks with other community service agencies as needed. The stunning results from the 11 communities participating in the groundbreaking SAMHSA initiative are forever changing the face of homelessness: Of the 493 persons served during one year, 456 (92%) were in their own housing, 71 (14%) were in salaried jobs, and 383 (78%) were receiving appropriate services.

Programs of Transformation

The Collaborative Initiative to Help End Chronic Homelessness funded projects in 11 communities to develop comprehensive systems of services linked to permanent housing. Individuals participating in one of these programs can enter the system through any door to gain access to all the services they require, whether it's primary health care, mental health care, substance abuse treatment, housing, or veterans services. Even more recently, CMHS, under the Projects for Assistance in Transition from Homelessness (PATH), a formula grant program to States, conducted site visits, provided technical assistance, initiated a PATH outcome and evaluation study, and held panels to explore ways to ensure cultural competencies in homeless service systems.

Finally, SAMHSA's second national training conference, HOPE: The Key to Ending Homelessness for People with Mental Illnesses and/or Substance Abuse Disorders, brought together participants and faculty from across the country to focus on evidenced-based and promising practices for providing support to homeless individuals.

Principle D

Use Mental Health Research Findings to Influence the Delivery of Services

Moving Science to Services: Evidence-Based Practices

SAMHSA's Science-to-Services Agenda was born from SAMHSA's ongoing commitment to build on the effectiveness of programs, practices, and policies delivered in communities, and to reduce the time lag between the development of scientific interventions and their application in service settings.

Evidenced-based practices are practices that have been proven by research to be effective. They are vital to the mental health and substance abuse professions in an age of increased accountability and tightened budgets.

CMHS is funding three aspects of a National Evidenced-Based Practices (EPB) Project, a public-private partnership focused on developing the capacity for evidenced-based practices within the public mental health system. The three aspects of the project are a series of comprehensive EPB implementation resource tool kits, a national demonstration project, and a NationalCenter for Evidenced-Based Practices. Numerous Evidence-Based Practice grants are also in place to initiate state-of-the-art training and continuing education for State mental health care providers and other stakeholders.

Through its partnership with the National Institutes of Health—including the National Institute on Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism—SAMHSA developed and implemented the National Registry of Evidence-Based Programs and Practices (NREPP). NREPP is a comprehensive system to screen, select, and disseminate evidence-based prevention and treatment programs, policies, and practices.

Treating People with Co-occurring Mental and Substance Use Disorders

According to SAMHSA's 2004 National Survey on Drug Use and Health, an estimated 4.6 million people experienced co-occurring mental and substance use disorders during the year. Nearly half of the adults with co-occurring disorders received no treatment for either problem, and only 6 percent received treatment for both. The resulting human and societal costs are high. People with co-occurring disorders are at greater risk for HIV/AIDS, homelessness, contact with the criminal justice system, violence, and suicide. To better serve individuals in need, States and communities must strengthen their systems to address both substance abuse and mental health disorders.

In a landmark 2002 Report to Congress, SAMHSA recognized that people with co-occurring disorders are the expectation, not the exception, in substance abuse and mental health treatment systems. In this report, SAMHSA outlined its commitment to ensure that States and communities have the incentives, technical assistance, and training they need to effectively serve people with co-occurring disorders. To this end, SAMHSA has awarded Co-occurring State Incentive Grants to help States develop or enhance their infrastructure to provide accessible, comprehensive, and evidence-based treatment services to people with co-occurring substance use and mental disorders. SAMHSA has also established the National Co-occurring Center for Excellence, published a new Co-occurring Treatment Improvement Protocol (TIP 42), and held policy academies to encourage the development of State action plans.

Co-occurring Center for Excellence

SAMHSA created the Co-occurring Center for Excellence (COCE) as a vital link between the agency and States, communities, and providers. COCE provides the technical, informational, and training resources needed for the dissemination of knowledge and the adoption of evidence-based practices in systems and programs that serve persons with co-occurring disorders.

COCE’s mission is to:

  • Receive, generate, and transmit advances in substance abuse and mental health treatment that address mental health and substance use disorders at all levels of severity that can be adapted to the unique needs of each client
  • Guide enhancements in the infrastructure and clinical capacities of the mental health and substance abuse service systems
  • Foster the infusion and adoption of evidence- and consensus-based treatment and program innovation into clinical and organizational practice.

Partnering with the Criminal Justice Community

SAMHSA shares common goals with the criminal justice community and is committed to improving both public health and public safety. To address the inescapable link between mental illness, substance abuse, and crime, SAMHSA is focused on leveraging partnerships and building infrastructure. SAMHSA had developed a Criminal Justice and Juvenile Justice Framework that focuses squarely on the needs of consumers who are involved or are at risk of becoming involved in the criminal and juvenile justice systems. Through the Framework, SAMHSA is determined to develop effective reentry efforts, reduce recidivism, and increase the coordination of treatment between providers in prisons and in communities. In addition to its collaborations with the Department of Justice, SAMHSA continues to strengthen partnerships with criminal justice organizations such as the Association of State Corrections Administrators, the American Correctional Association, and the National District Attorney’s Association.

CMHS also supports a jail diversion grant program to develop model diversion programs in more than two dozen sites across the country. Preliminary results from a SAMHSA study of nonviolent offenders indicate reduced rates of re-arrest, decreased incidence of psychiatric symptoms and substance abuse, and increased quality of life among people who are diverted from the justice system. SAMHSA also supports Family, Juvenile, and Adult Treatment Drug Courts, as well as the Youth Offender Reentry Program, which funds community partnerships that plan, develop, and provide services in the community to promote recovery, and prevent recidivism.

Principle E

Ensure Innovation, Flexibility, and Accountability at All Levels of Government and Respect the Constitutional Role of the States and Indian Tribes

Transforming State Systems

SAMHSA is working with States to develop comprehensive statewide mental health plans by releasing an unprecedented grant program known as the Mental Health Transformation State Incentive Grants Program. Eligible to States and Tribes, these grants are made to Governors’ offices and are financing the costs of planning and infrastructure development needed to achieve systems improvements across programs, agencies, and departments.

The goal of these grants is to achieve a fundamental shift in how we view and provide mental health care. This shift will require changes of great magnitude to policies and programs, to planning and partnerships, and to the traditional boundaries and beliefs maintained by different stakeholders. Consequently, the State transformation grants focus on broad-based systemic change—what a grantee must do to unite multiple systems behind a single vision of a consumer-driven, recovery-oriented system.

The expected payoffs will be better cross-agency coordination, more effective blending and use of available resources, and incredible improvements in the infrastructure for delivering services to adults and children in need. Offering these grants reinforces that transformation can occur only through collaboration and an ongoing commitment to change by all the systems that deliver, fund, or administer services and supports used or needed by individuals with a mental illness and their families. This is what is meant by transformation: profound change that occurs at the very core of the larger mental health system and other relevant systems and not through piecemeal reform around the margins.

Eliminating Seclusion and Restraint

For many years, coercion, seclusion, and restraint have been used in a wide range of psychiatric settings. Recently, CMHS has published materials to educate mental health care providers about the need to obviate these practices and to recognize their use for what it is: treatment systems failures when not involving issues of safety. Furthermore,

State Incentive Grants to Build Capacity for Alternatives to Restraint and Seclusion are enhancing State efforts to adopt best practices to reduce and ultimate eliminate their use in institutional and community-based settings that provide mental health service. These grants are collecting data to document systems and services changes in the specific grantee States including Hawaii, Massachusetts, Illinois, Kentucky, Louisiana, Maryland, Missouri, and Washington.

Enhancing Protection and Advocacy

In 1986, Congress passed the Protection and Advocacy for Individuals with Mental Illness (PAIMI), currently serving nearly 22,000 individuals. CMHS funds and oversees PAIMI, which is administered through State Protection and Advocacy (P&A) systems. P&A's advocate for individuals with mental illnesses who reside in public or private facilities or in the community who may be abused, neglected, or whose rights are violated. State P&A systems carryout investigations and class litigation, and respond to thousands of requests for information and referrals. They are empowered to use legal, legislative, systemic, and other remedies for correcting violations. P&A's monitor and act upon reported allegations of inappropriate use of seclusion and restraint, thus supporting the goal of the New Freedom Commission on Mental Health to protect and enhance the rights of people with mental illnesses.