Children s Mental Health and Systems of Care

1. Children�s Mental Health and Systems of Care August 2008 Presentation to University of Alaska

2. On the Need for Change and Innovation �We are living at a point in history when the need and desire for change is profound. Our current trajectory is no longer sustainable. We cannot ignore the compelling environment and social challenges that vex today�s world because they will undermine us all. We cannot dismiss the fractures in our own communities, or the fissures between those of us fortunate to live in comfort and the massive number of our fellow human beings who live under the crush of poverty around the world. It is a pivotal time. We need to be change-makers�and very capable ones at that.� �Young, 2006

3. Seriousness of the Problem

4. An Increase in Diagnosable Mental Disorders? Four Contributing Factors: Need of the profession of psychiatry to legitimize itself as an important branch of medicine that deals with real disorders The promotion of this by the pharmaceutical industry The increase in funding that is available contingent upon there being a diagnosable mental disorder Efforts by advocacy groups to push a medical model to reduce stigma Horwitz, A. V., 2002

5. �Recent evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise by over 50% internationally to become one of the five most common causes of morbidity, mortality, and disability among children...no other illnesses damage so many children so seriously.�

6. �Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illnesses in youth.�

7. Age on Onset Recent research from the National Comorbidity Study indicates that 50% of adult disorders had an age of onset by 14, and 75% by 24 Kessler et al., 2004

8. Suicide 3rd leading cause of death in young people between the age of 15 and 24 (11/100000)

9. Characteristics of Children with Serious Emotional Disturbances Frequently served in multiple systems Variety of diagnoses but most common are ADHD, Oppositional Disorder, and Conduct Disorder High rate of co-occurring disorders Deficits in intellectual and educational functioning

10. Characteristics of Children with Serious Emotional Disturbances (continued) Deficits in social and adaptive behavior Frequently from low income families Have often been exposed to violence, and to losses of major people in their life

11. �The major barrier to school readiness for children is often not the lack of appropriate cognitive skills but rather the absence of needed social and emotional skills.� Characteristics of Children with Serious Emotional Disturbances (continued)

12. Emotional disturbance is part of an inter-related set of problems that Lisbeth Schorr has called �rotten adolescent outcomes� � including poor school performance, delinquency, early pregnancy, substance abuse, and violence. Characteristics of Children with Serious Emotional Disturbances (continued)

13. Characteristics of Children with Serious Emotional Disturbances (continued) National Comorbidity Study shows that �it�s clear a substantial part of the drug problem, and the more severe and prolonged drug problem, is in people starting out with emotional problems.� Median age of onset for mental health disorder was 11 years old and for substance abuse was five to 10 years later.

14. Relationship of Mental Disorders to Negative Outcomes

15. �Early-onset psychiatric disorders have been associated with subsequent truncated educational attainment, higher risk of teenage childbearing, higher risk of early marriage, lower probability of later marriage, and lower family income.� Impact in Adulthood

16. Lasting Impact 60% of adult substance abuse dependence can be prevented by early and effective treatment of child an adolescent mental disorders. We know that ��child and adolescent mental disorders are much more powerful predictors of a wide array of later adverse outcomes that virtually any other potential target,� e.g., more strongly related to early child-bearing than family poverty, and more strongly related to educational attainment than low parental education. Kendall & Kessler, 2002

17. A �Productive Adulthood� The National Research Council and Institute of Medicine estimates at �at least 25% of adolescents are at risk on not achieving a �productive adulthood.� NRC and IOM, 2002

18. Many Children in Need are Not Receiving Services

19. ACES Study Conducted by Kaiser Permanente and CDC Studied relationship between childhood trauma and health risk behaviors and diseases in adulthood Sample of 9,508 adults

20. ACES (cont.) � Categories of Childhood Trauma Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse A alcoholic or drug abuser in home An incarcerated family member Someone who is chronically depressed, mentally ill, institutionalized or suicidal Mother is treated violently One or no parents Emotional or physical neglect

21. ACES (cont.) � Results Graded relationship between number of categories of childhood exposures and each of the adult health risk behaviors and diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease

22. de facto Mental Health System

23. Mental Health Funding Streams for Children and Families

24. Three Basic Questions How can we improve access to care for those in need? How can we improve quality and effectiveness of care? How can we improve the mental health status and well-being of all children?

25. Improving Quality and Effectiveness of Care Major approach since the mid 1980s has been through the development and implementation of community-based systems of care based on a set of principles and values, and the best available research.

26. What is a System of Care?� A system of care is a comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and adolescents with severe emotional disturbances and their families.

27. Role of System of Care To provide access to effective services for a large and diverse population within a specified community

28. What System Conditions Led to Development of Systems of Care? Inadequate range of services and supports Failure to individualize services Fragmentation of system when children and families had multi-system needs Children with special needs are in many systems Lack of clear values/principles for system Lack of clarity about population of concern Inadequate accountability Lack of adequate responsiveness to cultural differences

29. Key Principles/Values of a System of Care Based on needs of child and family Promotes partnerships between families and professionals Involves collaboration between multiple agencies and service sectors Involves provision of individualized supports and services based on strengths and needs in multiple domains Promotes culturally responsive supports and services Includes system of ongoing evaluation and accountability

30. What Should a System of Care be Based Upon? A vision, and set of values, and principles developed and agreed upon by community stakeholders; A clear definition of the population to be served and a thorough understanding of the population to be served; A set of goals and desired outcomes, also developed and agreed upon by community stakeholders; Best available evidence on effectiveness of system mechanisms, and services A theory of change that makes explicit the link between interventions (at the system, organization, program, provider, and child/family levels) and desired outcomes

31. Findings and Recommendations from the President�s Commission

32. Six Goal Areas Understand that mental health is essential to overall health Mental health care is consumer & family driven Disparities in mental health services are eliminated Early mental health screening, assessment, and referral to services in multiple settings across the life-span are common practice Excellent mental health care is delivered and research is accelerated Technology is used to access mental health care and information

33. Successfully transforming the mental health service delivery system rests on two principles: First, services and treatments must be consumer and family centered, geared to give consumers real and meaningful choices about treatment options and providers�not oriented to the requirements of bureaucracies. Second, care must focus on increasing consumers� ability to successfully cope with life�s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms.

34. �Consumers and family members will have access to timely and accurate information that promotes learning, self-monitoring and accountability�when a serious mental illness or a serious emotional disturbance is first diagnosed, the health care provider�in full partnership with consumers and families�will develop an individualized plan of care for managing the illness. This partnership of personalized care means basically choosing who, what, and how appropriate health care will be provided Choosing which mental health care professionals are on the team, Sharing in decision making, and Having the option to agree or disagree with the treatment plan.

35. Goal 2 �Consumers and families told the Commission that having hope and the opportunity to regain control of their lives was vital to their recovery. Indeed, emerging research has validated that hope and self-determination are important factors contributing to recovery.�

36. �In particular, community-based treatment options for children and youth with serious emotional disorders must be expanded�segregating these children from their families and communities can impede effective treatment. Emerging evidence shows that a major Federal program to establish comprehensive, community-based systems of care for children with serious emotional disturbances has successfully reduced costly out-of-state placements and generated positive clinical and functional outcomes.�

37. Vision for Children�s Mental Health Services Comprehensive home and community-based services and supports Family partnerships and supports Culturally competent care Individualized care Evidence-based practices

38. Vision (cont.) Coordination of services, responsibility and funding Prevention, early identification, and early intervention Early childhood intervention Mental health services in schools Accountability �Huang et al., 2005

39. Translating the Vision into Reality How are we doing? What have we learned? How can we apply our lessons learned in the next stage of system transformation?

40. From State Mental Health Commissions Areas of progress in every state But overall dissatisfaction with efforts to address the mental health needs of children and their families Consistent emphasis on the importance of the values and principles of systems of care Increased emphasis on prevention, based on models of risk and protective factors Greater attention to planning, accountability, and responsibility

41. Survey of Random Sample of Counties 8% of respondents indicate that a system of care exists �very substantially� in their community; 31% of respondents indicate that a system of care �substantially� exists in their community Several areas of relative strength and also some major deficiencies in areas like workforce development, accountability, financing, and performance measurement

42. Implementation Since the vision of system of care was created, there is an increased recognition of complexity and difficulty of implementing values and principles, and achieving change both at the service level and at the system level.

43. The Bridge Between Vision, Implementation and Reality

44. Implementation It is one thing to say with the prophet Amos, �Let justice roll down like mighty waters,� and quite another to work out the irrigation system.

45. Implementation �The solution is not to abandon our current work but to do it better, with more sophistication and from a more strategic vantage point�we need to be sure to invest in a continuous cycle of tracking our work, distilling lessons, applying new information, and learning as we go.�

47. Core Implementation Components

48. Differentiation and Integration Differentiation � learning new concepts and being able to distinguish between them Integration � now that they have been learned, being able to see the relationship between them

49. Systems of Care From differentiation to integration � from focus on one aspect of a system to a focus on all aspects and their alignment and inter-relationship

50. Systems Thinking �Systems are composed of numerous parts or components that interact in complex and non-linear ways that result in collective behavior that cannot be inferred from or explained by studying the components in isolation of each other.� Friedman, 2005

51. Complexity Science �The challenges of the 21st century will require new ways of thinking about and understanding the complex, interconnected, and rapidly change world in which we live and work. And the new field of complexity science is providing the insights we need to push our thinking in new directions�Complexity science has moved science away from a linear mechanistic view of the world to one based on nonlinear dynamics, evolutionary development and systems thinking. It�s a dramatic new way of looking at things; it�s not just looking at more things at once.� Westley, Zimmerman, & Patton, 2006

52. Complex Systems �All complex systems, from human beings to stock markets to global organizations, share behaviors that cannot be explained by their parts. The whole is different than the sum of the parts. You cannot fully understand a human body by describing it as a list of its parts, just as an organization chart barely scratches the surface in describing an organization. In complex systems, relationships are key. Connections or relationships define how complex systems work; an organization is its relationships, not its flow chart. And this perception is crucial in understanding how complex systems differ from simple or complicated systems.� Westley, Zimmerman, & Patton, 2006

53. Three Levels of Problems Simple � baking a cake Complicated � sending a rocket to the moon Complex � raising a child �Disasters can occur when complex issues are managed or measured as if they are merely complicated or simple� From �Getting to Maybe,� Westley, Zimmerman, & Patton, 2007

54. The Nature of Expertise Situation Recognition

55. Producing Change in Complex Systems �Develop your capacity to see and understand complex systems, and learn to draw action implications from what you see and understand; cultivate the discipline of reflective practice. Learn to value standing still long enough to see what is around you, to understand the flow of events and the context of the moment. As you act, evaluate the consequences of your actions and make adjustments accordingly. Don�t expect to get it right the first or second or third or fourth time. Indeed, keep questioning what it even means to get it right� Westley, Zimmerman, & Patton, 2006

56. Leadership and Complexity Science �We�re in a knowledge economy but our managerial and governance systems are stuck in the Industrial era. It�s time for a whole new model� (Manville & Ober, 2003) Complexity leadership theory focuses on identifying and exploring the strategies and behaviors that foster organizational and subunit creativity, learning, and adaptability, when appropriate.

57. Does Your Organization Have a Learning Disability? �It is no accident that most organizations learn poorly. The way they are designed and managed, the way people�s jobs are defined, and, most importantly, the way we have all been taught to think and interact (not only in organizations but more broadly) create fundamental learning disabilities.� Senge, 1995

58. Alternative Model Based on research/theory from fields of organizational development, systems theory, and complexity theory Systems are iterative, evolving, changing, dynamic, always emerging Frequent reflective processes, based on multiple sources of data and multiple perspectives, is essential Relationships/connections/integrative mechanisms between agents and components are critical

59. Alternative Model (cont.) Responsiveness to context issues is a key Values, principles, culture, and goals are the key foundations Causal relationships are primarily non-linear and complex The �system� exists in the eye of the beholder Key to understanding systems is relationships, recurring patterns, and implicit as well as explicit rules

60. Revised Definition of Systems of Care �A system of care is an adaptive network of structures, processes, and relationships grounded in system of care values and principles that provides children and youth with serious emotional disturbances and their families with access to and availability of necessary services and supports across administrative and funding jurisdictions.� Hodges et al., 2006

61. Theory of Change The underlying assumptions that guide a service delivery strategy and are believed to be critical to producing the desired outcomes for a particular population of concern Requires a clear statement of population of concern, goals for that population, and methods for attaining the goals

62. Theory of Change When complete, a theory of change logic model can serve as a guide for implementation, ensuring that community plans for service delivery remain true to their intent Hernandez & Hodges, 2005

63. How do we Believe we can Best Achieve Those Goals? Review of knowledge in field Use of consultants Input from key stakeholders Identification of strengths of community and system Referral back to values and principles New ways of thinking � new mental models, new frameworks!!!

64. One General Theory Meaningful and ambitious goal Strong family voice Effective individualized treatment planning Strong and transparent performance measurement system with feedback loops I. Burnim

65. The Quality Chasm: Three Central Themes Use the science we know �including the science of �improvement� Center care on the patient -- put patients in the lead on care design communities and develop and use care plans that incorporate the patients� goals Cooperate as a system � a culture of teamwork

66. From Hodges et al. Create an early and consistent focus on values and beliefs. The emphasis on Values and Beliefs factors provides a significant anchor for system development regardless of the challenges faced. Translate shared beliefs into shared responsibility and shared action. Most importantly, share a commitment that things really can be done differently and that local stakeholders can be empowered to make change. Recognize that opportunities for action are not linear. Take advantage of opportunities to leverage system change when and where they occur.

67. From Hodges et al. (continued) 4. Know that being concrete does not mean being static. Being concrete about values and strategic about action allows stakeholders to be flexible in system response and proactive in system development. 5. Be aware that structural change, without a solid anchor in values and beliefs, rarely has the sustained positive impact that system of care implementers seek. 6. Remember that the system emerges from the choices and actions of stakeholders throughout the system, including family members, front-line staff, and community partners.

68. Data-Based and Value-Based Systems of Care Involves the systematic collection of data on system performance and outcome for purposes of improving system functioning Involves creating a culture that promotes data-based accountability

69. Data-Based Systems of Care (Continued) Utilization and improvement-focused Combination of in-depth and aggregate information Use of both qualitative and quantitative information Focus on a few key measures Feedback loop to all participants An intervention itself�not just a measurement

70. Differentiating Between Data-Based Systems of Care and Evidence-Based Practices Data-based systems of care involve collecting data in the present time, and in one�s own community for purposes of assessing how the system is performing and identifying areas in need of improvement Evidence-based practice refers to interventions that have met a specific criteria of effectiveness at some other time and in some other place

71. Relationship Between Data-Based Systems of Care and Evidence-Based Practices Data on system performance helps guide system stakeholders to determine if they need to make changes. It should come before efforts to make change. If the need for change is identified, then stakeholders should examine alternative approaches to making change.

72. Individualized Care Based on a belief in the uniqueness of each individual and family Research findings show tremendous diversity in the strengths and needs of children with mental health challenges and their families A long-held belief carried to previously unimaginable levels during the past 20 years

73. Individualized Care (Continued) Developed through a team-process, often called �wraparound,� involving child and parents, important other individuals in natural support system, care coordinator, and other key representatives of service system Based on strengths, needs, culture, and choices of child and family, in partnership with team

74. Individualized Care (Continued) Enhanced by creative and participatory team process, and facilitated by availability of flexible funding, broad range of services, and extensive provider network The application of system of care principles and values at the child and family level

75. Active Agents of Change/Components of Service Effectiveness Those elements or components of interventions which contribute to positive outcomes � the same active agents of change may be present in different forms or structures within different interventions

76. Active Agents of Change/Components of Service Effectiveness (Continued) The very characteristics that are likely to make services effective � they are comprehensive, individualized and flexible � make them more difficult to describe and to evaluate. Schorr, 1995

77. Active Agents of Change/Components of Service Effectiveness (Continued) �Not all the studies show that the improvements resulted from the intervention specifically. Family engagement may play a stronger role in outcomes than the actual intervention program.� Thomlison, 2003

78. Active Agents of Change/Components of Service Effectiveness (Continued) Operated by people with a commitment and intensity to their work and a clear sense of mission Based upon quality staff with effective models of training and ongoing technical assistance

79. Active Agents of Change/Components of Service Effectiveness (Continued) �Strong bonds between families and providers appeared to be critical, whether the providers were case managers, therapists, parent advocates, or other staff. These bonds had their beginning in the engagement process� providers built trust and confidence by listening carefully to what families identified as their primary needs and treated family members as full partners in the treatment process, focusing on their strengths rather than on their deficits� Worthington, Hernandez, Friedman, & Uzzell, 2001

80. Active Agents of Change/Components of Service Effectiveness (Continued) ��the effectiveness of services, no matter what they are, may hinge less on the particular type of service than on how, when, and why families or caregivers are engaged in the delivery of care�it is becoming increasingly clear that family engagement is a key component not only of participation in care, but also in the effective implementation of it.� Burns, Hoagwood, & Mrazek, 1999

81. Active Agents of Change/Components of Service Effectiveness (Continued) Comprehensive, flexible, and responsive to the needs of participants View children in the context of broader ecologies�families, schools, neighborhoods, churches, and communities Link with other systems of support and intervention to ensure they can produce and sustain their impacts over time Greenberg, 2002

82. Community-Based Interventions with an Evidence-Base Function as service components in a system of care and adhere to system of care values Are provided in the community, homes, schools, and neighborhoods, not in an office With exception of multisystemic therapy and sometimes case management, direct care providers are not formally clinically trained Their external validity is greatly enhanced because they were developed and studied in the field with real-world child and family clients Burns, 2000

83. Why Family Choice? The right thing to do Providing choice may improve the outcomes of intervention Family choice of services and providers may create a more effective, efficient, market-driven, customer-oriented and accountable system Subcommittee on Family Choice, 2005

84. Choice The right thing to do but often a neglected thing An evidence-based process in and of itself

85. Integration of Systems of Care, Individualized Care, Evidence-Based Practices, Family Choice, and Performance Measurement

86. Evidence-Based Practices Provide an important focus on outcomes and accountability � however, often times studies have focused more on �efficacy� rather than �effectiveness�

87. Effective Interventions The evidence points to an array of beneficial and richly complementary programs for promoting adaptive behavior and positive mental health, preventing dysfunction, and ameliorating distress and disorder. Despite the scientific support for such programs, most youths in the world outside university trials still have little access to the programs in part because of gaps in the evidence base and in part because a marked divide between research and practice persists. We have proposed several steps toward filling these gaps and breaking down this divide. In our view, treatment will be good for science, good for practice, and good for children, adolescents, and their families. Weisz & Sandler, 2005

88. �The President�s New Freedom Commission on Mental Health emphasizes both the importance of individualized plans of care, and the application of evidence-based practice. This is very significant because long-term meaningful improvements in outcomes for children with serious mental health challenges and their families will depend on a coming together of these two important approaches.� � Friedman and Drews

89. �There were relatively few instances identified where there had been a systematic effort to integrate evidence-based practices with individualized care. In most cases, the policy emphasis in a local community was either on promoting the development of systems of care and individualized care, or on promoting the use of evidence-based practices. The good news is, however, that there were some very positive examples of such an integrated approach.� � Friedman and Drews, 2005

90. Barriers to Integration of Systems of Care, Individualized Care, and Evidence-Based Practices Research requirements for description of intervention vs. system requirements for flexibility Accountability Populations served Attitudes and interests

91. Successful Models Hawaii Milwaukee Indianapolis Westchester County Central Nebraska Travis County Placer County Erie County

92. Hawaii System of care values and principles as the foundation Team-based Family-driven Performance-measurement Evidence-based practices and active agents of change Culturally competent Transparent system of accountability

93. Milwaukee Blended funding Extensive provider network Extensive range of services Family choice Provider accountability Continuous quality improvement Care management organization

94. Dominant Research Paradigm in Mental Health Randomized clinical trials (or quasi-experimental studies) Quantitative only Non-representative participants High on internal validity � much lower on external validity Limited voice of participants Outcome-oriented and not also implementation/process oriented

95. Traditional Research/Evaluation Model The �system of care� is the independent variable It should be static It should be easily measureable It should be replicable Measures should be objective Causal relationships are primarily linear Researchers/evaluators should be non-participants Researchers/evaluators are the experts who determine how to study the system

96. Research Methods �The issue of selecting methods is no longer one of the dominant paradigm versus the alternative paradigm, or experimental designs with quantitative measurement versus holistic-inductive designs based on qualitative measurement. The debate and competition between paradigms is being replaced by a new paradigm�a paradigm of choices. The paradigm of choices recognizes that different methods are appropriate for different situations.� Patton, 1980

97. Continuum of Research From particularistic and specific to holistic and pattern-focused Langhout, 2003

98. Research/Evaluation on Systems of Care: Implications of Complexity Theory Longitudinal, holistic with a specific focus on inter-relationships, non-linear effects, and �rich� points Contextual and in-depth Multi-method and multi-source Participatory and collaborative Iterative Ongoing � multiple streams Action and change-oriented

99. Conditions that Challenge Evaluation High innovation Development High uncertainty Dynamic Emergent System change Patton, 2008

100. Newer Approaches to Evaluation Developmental Multi-method, multi-source Contextual Participatory and collaborative Continuous rather than discrete Extensive use of multiple streams of ongoing data collection

101. �We need to place less emphasis on discovering the one objective truth about a program�s worth and more attention to the multiple perspectives that diverse interests bring to judgment and understanding� Brown, 1995

102. �The earmark of a quality program or organization is that it has the capacity to get and use information for continuous improvement and accountability. No program, no matter what it does, is a good program unless it is getting and using data of a variety of sorts, from a variety of places, and in an ongoing way, to see if there are ways it can do better� H. Weiss, 2003

103. Agent-Based Modeling�One Approach to Research from a Complexity Science Perspective Agent-based modeling � using computer technology the simulate the likely real-life behavior of the system being studied � now being viewed as the �third� way of doing science with traditional experimentation and observation/description being the other two Agent-based models require knowledge of the �agents� or components of the system as well as the written and unwritten rules by which they operate � after the model is built, it is possible to run simulations on many different aspects of the system to see how anay given change will affect the interdependencies and overall dynamics of the whole system Sanders & McCabe, 2003

104. Leadership and Organizational Development Implications for systems of care

105. The Need for Leadership �The need for leadership in serving persons with severe mental illnesses has never been greater. As we begin the twenty-first century, change seems to be the only constant in the mental health system. We need leaders to take advantage of the opportunities that accompany environments characterized by a change so constant and dramatic that the very foundation of the mental health system is being built anew.� Anthony, 2008

106. Learning Organizations (from Senge) Personal mastery Shared vision Systems thinking Mental models Team learning

107. Eight Principles of Leadership Leaders communicate a shared vision Leaders centralized by mission and decentralized by operations Leaders create an organizational culture that identifies and tries to live by key values Leaders create an organizational structure and culture that empowers their employees and themselves

108. Eight Principles of Leadership (Continued) 5. Leaders ensure that staff are trained in a human technology that can translate vision into reality 6. Leaders relate constructively to employees 7. Leaders access and use information to make change a constant ingredient of their organization 8. Leaders build their organization around exemplary performers

109. Transformational Leaders Externalize strongly held values to shape and articulate a unifying vision for the future Inspire others to see their place in that future Motivate others to look beyond their own interests to achieve goals Act as role models Develop others to higher levels of ability and potential Encourage collective decision making Create energizing environments that incubate ideas, actions and other leaders Think and plan backward from an envisioned future to take action A. Kathryn Power, Director, Center for Mental Health Services

110. Transformation Leadership Competencies Wheel With transformation leadership competencies in the middle, the spokes are: Individual leader attributes Knowledge and information management Transformation management Business acumen Process �toolkit� Future trends in mental health

111. Leadership Challenges of Transformation Identifies six major types of change: Reframe core cultural values; Create improvement capability; Collaborate across competitive boundaries; Create a business environment that simultaneously drives business results and community benefit; Drive system-level rather than project-level results; Maintain constancy of purpose of the long-term transformational journey.

112. Eight Steps to Transforming Your Organization Establishing a sense of urgency; Forming a powerful guiding coalition; Creating a vision; Communicating the vision; Empowering others to act on the vision; Planning for and creating short-term wins; Consolidating improvements and producing still more change; Institutionalizing new approaches; Kotter, 2007

113. On Transformation of Organizations and Systems Transformation of entire organizations and systems is a leadership task requiring an extraordinary depth and breadth of change. Since it hasn�t been done before, no one can claim to have a �recipe� for how to achieve it. But for those leaders who want to take on this daunting task, it would be better to proceed with some theory of what it would take to lead such a transformation than to simply muddle along. This paper is written to provide such a theory, in the hopes that it will be helpful to health care leaders as they plan their transformational work, and to the advisors who coach them. And it is clearly offered in the spirit of �All theories are wrong, but some are useful.� Reinertsen

114. Implications for Academia Can we/should we continue to operate as we have, given the scope of need, the new models that have developed, and the incomplete fit between our existing models and the issues we need to study? If we are to change, what type of change is needed in our research, our teaching and student training, and our relationship with communities? What change may be needed in our mental models?

115. Transdisciplinary Approaches Seek to develop �new hypotheses for research, integrative theoretical frameworks for analyzing particular problems, novel methodological and empirical analyses of those problems, and ultimately, evidence-based recommendations for public policy� Stokols, Fuqua & Gress, 2003

116. National Mental Health Advisory Council Report A major impediment to progress in the insularity of many of the disciplines involved in clinical practice and research

117. Enhancing the Influence of Psychologists/Social Workers and Others on Mental Health Policy Students should study the research on policy development and implementation, including a focus on strategies for achieving system change; Students should study policy analysis and evaluation techniques; Students should be knowledgeable about the policies that serve as the foundation for the mental health and related fields; Students should study complexity theory and how complex systems operate; Graduate education should include a strong multi-disciplinary focus.

118. If We Can�t Predict What Will Happen In Systems, At Least We Can Learn How to Dance with Them! Get the beat Listen to the wisdom of the system Expose your mental models to the open air Stay humble. Stay a learner. Honor and protect information Locate responsibility in the system Make feedback policies for feedback systems Pay attention to what is important, not just what is quantifiable Go for the good of the whole Expand time horizons. Expand thought horizons. Expand the boundary of caring Celebrate complexity Hold fast to the goal of goodness.

119. Where Does This Leave Us? A serious and complex problem to deal with but one in which progress is being made; Systems of care as one important part of the solution; Importance of focusing on implementation and integration; Openness to new mental models, and their implications for system development, collaborations within academic disciplines and between academics and community change agents, research and evaluation, and leadership and organizational development;

120. Where Does This Leave Us? (cont.) Importance of our role in preparing and being role models for the next generation of leaders, of innovators, of change agents