Moderator: Michelle Hicks
August 25, 2009
1:00 pm CT

Coordinator: . . . are in a listen-only mode. During the question-and-answer session, please press star 1 on your touchtone phone.

Today's conference is being recorded. If you have any objections you may disconnect at this time.

Now I will turn the meeting over to Ms. Michelle Hicks. You may begin.

Michelle Hicks: Thank you. Thank you everyone for joining our virtual training teleconference today, Moving Towards Social Inclusion.

First I'd like to apologize for getting started late here. We've had some technical difficulties as I'm sure most of you know, if you were trying to access our slide presentation for today.

We have not been able to upload those files, but you can access the presentation by going to the ADS Center Web site at https://www.promoteacceptance.samhsa.gov/teleconferences.

Then if you scroll down to the bottom of the page you will be able to access the presentation file in both the PDF format or the PowerPoint format.

Again, we do apologize for these technical difficulties. If you have any problems accessing this file during the training session, please contact the ADS Center and we will make sure that we provide you with those slides at a later date.

All of our presenters are online and they are ready to present. So they will be going through their information. We apologize that you will not be able to follow along with the slides if you are not able to access those files from your computers.

But we will make every effort following the call to assist you with getting these files and putting you in touch with presenters if you have future questions or additional information that you need.

At this point we're going to get started with our call. We're going to have the first—about the first 45 minutes of our time now will be spent with our presenters during their presentations.

At the end of the speaker presentation you may submit a question by pressing star 1 on your telephone keypad. You will be entered into a queue and you will be allowed to ask your questions in the order in which they are received.

Once the conference operator announces you name, you can proceed with your questions. If we are not able to get to your questions today, please feel free to email the ADS Center or the presenters directly. And that information is provided on the last slide—the last couple of slides on our Web site.

Within 24 hours of this teleconference you will receive an email request to participate in a short anonymous online survey about today's training. The survey results will be used to determine what resources and topic areas need to be addressed by future training events.

The survey will take approximately 5 minutes to complete.

Before we begin, let me say also that the views expressed in this training event do not necessarily represent the views, policies, and positions of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.

Our first presenter today is Dr. Kenneth Thompson, Medical Director of the Center for Mental Health Services at SAMHSA.

In his role, Dr. Thompson provides comprehensive medical leadership in diverse integrated planning, design, and implementation actions that relate to the CMHS programs and objectives.

In addition to providing medical consultation and assistance to CMHS programs, he monitors the application of relevant American Medical Association and American Psychiatric Association professional standards to CMHS policies and programs.

A native of Pittsburgh, Dr. Thompson has worked for the past 15 years as a community psychiatrist in a wide variety of settings including a primary care clinic, an HIV clinic, a state hospital, several disaster response teams, a homeless outreach team, and a community mental health center.

Most recently, his work with the Office of Mental Health and Substance Abuse Services in Pennsylvania providing psychiatric consultation for the Harrisburg State Hospital closure process.

Our second presenter is Dr. Lynn Todman. Dr. Todman is the Director of the Institute on Social Exclusion at the Adler School of Professional Psychology in Chicago, Illinois.

Dr. Todman earned a B.A. from Wellesley College and a master's in city planning and a Ph.D. in urban and regional planning from the Massachusetts Institute of Technology.

Dr. Todman's area of interest includes urban poverty, social exclusion, and community development.

She is especially interested in the ways in which social, political, and economic structures systematically marginalize urban populations. Her work is multidisciplinary, drawing on fields such as economics, political science, sociology, public health, and systems dynamics.

She has lived and worked in Sweden, Belgium, the United Kingdom, and most recently in Italy, where she worked with urban sociologists investigating the impact of urban transport policy on social welfare and the role of community participation in urban development processes.

Our final presentation today will be from Dr. Peggy Swarbrick who is the Training Director for the Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery, and a part-time assistant professor in the Psychiatric Rehabilitation and Counseling Professions Program at the University of Medicine and Dentistry of New Jersey–School of Health-Related Professions.

Dr. Swarbrick's early personal challenges and experiences in the mental health system led to a career focused on promoting wellness within the mental health system.

She worked for many years as an occupational therapist in a variety of settings promoting whole person wellness, recovery, and health promotion services.

She completed her doctoral work at New York University. Dr. Swarbrick continues to publish and lecture on the wellness and recovery self-sufficiency models in peer- (consumer)-delivered wellness and recovery programs as key to systems transformation.

She devotes tireless energy to mobilize the consumer-survivor movement and system to address poverty and health disparities impacting peers.

Dr. Swarbrick developed and is the co-author of a monthly newsletter Words of Wellness. Now we will hear from our first presenter, Dr. Thompson.

Kenneth Thompson: Good afternoon. Can you all hear me okay?

Michelle Hicks: Yes we can.

Kenneth Thompson: Okay, great. First of all I want to just say how pleased I am to be able to be on this Webinar. And I'm particularly happy to be on it with Peggy and Lynn who I think are going to be—and I know for a fact will be extraordinary contributors to this conversation.

I'm going to therefore, try to keep my stuff short and just try to set the stage a little bit and then let the two of them do their talks and see what kind of interactions we can get with those of you in the audience.

As you heard, I'm a psychiatrist. I work for the Center for Mental Health Services. And I'm particularly interested in this issue of social inclusion and the other side of the coin which is social exclusion because I've become convinced that a large measure of the issues related to psychiatric illnesses are related to the processes of exclusion.

And our response to that, the processes of social inclusion, are very critical to addressing the issues of mental health and psychiatric difficulties.

Just so folks have an idea about where this idea comes from, why these terms are put together, social inclusion or the concept of social exclusion, just very briefly this is a—this is actually something that we've inherited or learned from Europe, particularly the French who about 30 years ago became very interested in the idea of social exclusion, looking at the issue of the various different ways in which people both individually and as groups are extruded or marginalized from mainstream society.

And over the years particularly in the context of the European Union, that idea has grown. And the positive side of it, i.e., the process of re-including or including folks, has become a major element of European domestic policy. So the concept of social inclusion is in response to the active, the unfortunately active process of social exclusion that goes on in our society.

The reason I—as I mentioned, I think that these things have a very germane, are very germane to mental health is twofold.

One of them is—and this may be particularly evident to folks in the audience—once you've got a psychiatric disorder or once you've been labeled in some fashion or form, there is an entire process by which people are in fact excluded.

We've used the term "stigma" in the past to talk about this. But it is very clear that the process of extrusion, of exclusion from society is a major component of what happens to folks who've been labeled or who have developed a psychiatric disorder particularly if it's disabling or in some way marks you as being different than other people.

That process of social exclusion I believe in and of itself is immensely damaging to people. It is a process that injures people in a myriad of ways. And I'm going to actually let Lynn and Peggy address some of that.

When we talk about the concept of social inclusion in this regard, what we're talking about, what are the things that we can do that create a pathway for people who've been excluded because of psychiatric issues and because of the stigma related to psychiatric disorders? What can we do to help create a pathway that allows folks a way back into access to the resources that mainstream society makes available to everybody else?

I want to be very clear about this. You know, when we—we've talked about this in the past and this was particularly an issue when we—at a conference in Australia where the issue of social inclusion came up.

This is not so much an effort by the mainstream to include other people in this sort of notion of, you know, bringing people into the mainstream and what's the term that I'm looking for Lynn?

Lynn Todman: (To want) —just to mainstream.

Kenneth Thompson: Yes, to mainstream, to set it up so that they have to become like everybody else. Social inclusion is not, at least in its best form, as far as I'm concerned, is not about that process. It is much more about the process of making resources available to people and that these resources are the things, they're the building blocks for getting people back the lives that they want to live in the community. So that's one venue.

The other venue that I want to mention that's important relative to social inclusion, not only does it address the issues of people who've got psychiatric disorders or who have been labeled in that way, it also is something that happens to people that puts them at risk for psychiatric disorders and labeling.

By that I mean one of the quickest ways to produce stress and make it difficult for people to have the life that they want to live and therefore subject them to the potential for psychiatric disorders is to exclude them as a group.

So issues of race, ethnicity, religion, social class, gender, age—all those things can play out in such a way and in fact, whole communities can be excluded from mainstream resources and that that process in and of itself is highly damaging potentially to people.

And if there are not resources made available to promote resiliency and to promote a pathway into accessing the resources of society, non-voluntary social exclusion is probably one of the largest sources of both distress and illness that we have in our society.

So when we talk about social inclusion, we're talking about a process that basically I would call it the health opportunity ladder. It's the process by which people are able to access the resources that people would expect to be able to access within that particular society.

This process of accessing resources is in some ways a political effort. It requires the capacity to mobilize resources.

One of the ways that I became involved in this whole idea of social inclusion was working initially with folks who are homeless who had psychiatric disorders who we were able to help, you know, get their lives in a little bit of a place where they were able to potentially move off the streets or out of the shelters into housing. We were able to do this. So this is actually many years ago in the South Bronx.

And one of the thing we ran up against immediately was that in fact there was no housing for people to move into. So while we were able to help them get to a point where they could actually potentially move forward, the rest of society had not created the space into which they could move.

And it's in that context that I think the notion of social inclusion becomes very critical. This is not just about people recovery, it's about society making space for people to recover. Or another way to say it is it's about society making a space so that people have the opportunity to pursue their health and not become ill in the first place.

So it's got a public health and a—an immediate clinical relevance to talking about psychiatric disorders.

I guess I'm going to say that on my slides I sort of make these points. And there's really not a great deal more that I would want to add to the slides or to what I've just said other than to say that our hope in talking about this at the Federal level is that we begin a conversation with folks to try to understand what this concept of social inclusion might involve in the United States and what we might do to promote social inclusion.

I do want to say that we've had a number of meetings about this in various places around the country. And one of the things that has emerged—and I'll just mention it since I'm actually currently in Lynn Todman's office here in Chicago—is that I—one of the things that we've begun to understand that at least in the American context, much of what social inclusion is about is about identifying the resources and capabilities of individuals and communities to create the kind of environments and communities that people want to live in.

It is—it's not so much a top down sort of, you know, notion from central government that you will be socially included. As I talked before, this is not about making everybody fit into the mainstream. And it's not about forcing people to be the same . . .

Lynn Todman: Assimilate.

Kenneth Thompson: Assimilation is the term I'm looking for, Lynn has reminded me. It's much more about helping people organize amongst themselves to be able to tap into the resources that they each have to produce mutual common value and a sense of community.

There is a writer by the name of Peter Block who has written a very interesting book which just the title alone I want to just cite and put in people's mind because I think it's actually absolutely correct.

The title of the book is called Community: The Structure of Belonging. And what—when we're talking about social inclusion or what we are talking about is what are the terms in which is it possible for people to be members of a society of a community and at the same time for that community to actually belong to the individuals who are its members?

So with that I'm going to stop. And I look forward to further conversation. And we'll let the other folks go forward.

Michelle Hicks: Great. Thank you so much Dr. Thompson. Before we have Dr. Todman begin her presentation, I'd like to repeat the instructions for accessing the slides from the ADS Center Web site.

If you go to https://www.promoteacceptance.samhsa.gov on the home page, under Featured Pages if you look on the left-hand side of your screen down the second half of the page, it says Featured Pages.

The first link available for you is Moving Towards Social Inclusion. That's our teleconference training today.

If you click on that and scroll down to the bottom of that page you will be able to access either the PDF or the PowerPoint slide presentation for our call today. Thank you. And Dr. Todman, if you could please continue.

Lynn Todman: Okay, thank you very much. Are you able to hear me?

Michelle Hicks: Yes, you're coming through fine.

Lynn Todman: Okay. So when I started thinking about what I would say, moving towards social inclusion, given that I am the Director of Institute on Social Exclusion, I thought I should give—start with some explanation.

So the reason why we're the Institute on Social Exclusion is that the vast—a couple of reasons. One, the vast majority of the discourse, academic and popular, refers to exclusion.

And the reference to inclusion at least initially was politically motivated and motivated by a perception to highlight the positives as opposed to the negative in public policy and programming.

And the other point that's worth noting is that social inclusion can be itself exploitative. And the terms of the inclusion become very important.

So for instance people, you know, people are understood to be excluded when they're not in the labor market when they're unemployed.

But then there are many people who are in our labor market in particular at the very low end. And they're included but that term—the terms of their inclusion is—are exploitative.

And I'm talking about people who are in very, very low-wage jobs, people who are in jobs that don't have access to benefits like vacation, sick leave, and medical care.

And the third reason why I think, you know, why we focus on exclusion is that I would argue that you have to understand how exclusion happens in order to develop policy and programmatic responses to promote inclusion.

So I just wanted to say that up front that, you know, we had some very clear reasons for focusing our work on exclusion, all with the goal ultimately of promoting inclusion nevertheless.

So I'm sorry that you don't have my slides because there's a very important visual. But hopefully you'll be able to—you can access it from the Web site, the SAMHSA Web site.

So with that in mind about this being the Institute on Social Exclusion, I'm going to start off with a definition. There are a number of definitions for the concept. But the one that we use is that social exclusion is a dynamic multidimensional process in which entire groups of people are actively marginalized from key resources and opportunities and rights that are normally available to members of society and that are essential for a social integration.

It's a relative concept. And fundamental to it is ruptures in relations among people and groups of people.

So for instance social exclusion refers to the experiences and conditions of communities of people who are disproportionately homeless or in precarious housing; people who are hungry or malnourished or are food insecure; people who are unemployed, underemployed, or poor; people who are unable to enjoy the normal cultural and recreational amenities that a society has to offer; people who are shut out of social networks through which information and contacts and other important resources flow; and people who are unable to tap public services like health care, education, social welfare support, housing, transportation. And of course people who are physically isolated.

These are examples of the ways in which people can be excluded.

And ultimately it's worth noting that many of these experiences are interconnected and they're mutually reinforcing, so that one form of exclusion say for instance if you're excluded from social networks, can lead to another kind of exclusion.

So you could be—end up being excluded from employment because you don't have a social network where information about job opportunities are shared. And then that of course can lead to other kinds of exclusions.

If you're unemployed you may not be able to have, get access to decent housing and food. And it goes on and on and on.

So all these various forms of exclusion, this is very important, are cumulative and mutually reinforced—reinforcing.

It's not that anyone who is social inclusion—that a person that's socially excluded has to experience all these, but they tend to occur in bunches like that.

So a central theme in the social exclusion discourse is its activeness. Ken referred to that, the idea that exclusion—exclusionary processes have a life of their own that undermine the self-determination of individuals.

So another way of thinking about it is that exclusion is constructed. It's created. It's a logical outcome of the way in which we have elected to organize our society.

And the results of that organization, the way we've organized our society is that some groups are in, some groups are out, some groups are included and some groups are excluded.

So then the next question then is how is exclusion constructed? How is it created?

Well I would argue that it's constructed by what I would call the social architecture, the rules or the guidelines that organize the functionings of our society.

So these structures are like the political, economic, social, and cultural structures. They determine who gets what, how much, when, and who's included and excluded.

So I would argue that efforts to address exclusion or to promote inclusion requires identifying and dismantling these underlying structural causes of exclusion.

And so this is where my slides will be very helpful. But I'm going to give you an example of how this works, this process of exclusion.

So I would argue that we have in our culture, you know, our cultural structures are made up of a variety of attitudes and values and beliefs and principles and ideologies, for instance. And they play a key role in causing exclusion.

So take for instance our culturally ingrained deeply held attitudes about people with mental illness. And these attitudes are reflected in things like social stigma, stereotypes, and biases.

Well these attitudes and values are used to inform the development of other societal structures like our laws and our public policy. And they're used to inform the behaviors of our public and private institutions.

So putting this all together, cultural values or beliefs such as stigma and stereotypes and bias relative to people with mental illness can lead to—especially those stigmas and bias that suggest that people with mental illness are for instance dangerous people—that leads to laws and public policies that criminalize or pathologize people with mental illness. And as a result they disproportionally experience a range of social exclusion—homelessness, joblessness, incarceration, banishment from public places.

And those banishment from public places is legally sanctioned through laws and regulations about no lingering, loitering, sleeping in public places.

So we have laws that actually allow us or encourage law enforcement to banish people who are homeless and perhaps mentally ill from public spaces.

So my point is that stigma, stereotype, bias, our cultural kind of structure about people with mental illness can lead to laws and policies that criminalize or pathologize people with mental illness and lead to a range of exclusion.

If we add to that our other beliefs, like our ideological commitment to the principle of personal responsibility and individual initiative, these things are also used to inform our laws and policies and the behaviors of our institutions with the result that people with mental illness who find themselves marginalized in the ways I just talked about are held personally responsible for their predicaments. They are blamed for their predicament.

And as a result, again through laws and policies, are given very meager social and other supports that would facilitate their inclusion or fuller participation in society.

And so often they will exist in this netherworld of our society.

So according to the social exclusion discourse, the way to bring about social inclusion is to identify the structural origins of exclusion and then work to dismantle them.

So I've just spent, you know, a few minutes talking to you about both how social structures can lead to the social exclusion of people with mental illness.

There's another argument here of a relationship between social structures and mental illness. And that is those same structures can actually cause mental illness which can in turn predispose and set people up for exclusion.

So in the best of all worlds, we would organize our society, that is, we would create these structures, these political, economic, and cultural structures in a way that they do not create the condition for or predispose people to mental illness.

But we don't. There are many ways in which we socially construct, we create, conditions for mental illness.

So this perspective on the social construction of mental illness is reflected in a framework that is growing, the public health fields called the Social Determinants of Health.

And the Social Determinants of Health is defined by the World Health Organization for instance, as the conditions in which people are born, brought, live, work, and age.

Now most of the discussion on the Social Determinants of Health focuses on how our social contact impacts physical health. And a lot less attention has been focused on how our social contacts can predispose people to mental health issues.

And moreover, when we do think about, when we do think about, when there is some thought about or discussion about the impact of social contact on mental illness, the focus is typically on the individual, the family, or the community context.

Very little attention, by comparison is paid to the larger social, political, economic, and cultural forces that play a critical role in causing mental illness.

So one second here. I would argue that focus on the social determinants of health would redirect our attention from the individual. We would de-pathologize the individual and locate the pathology in the social context in which that individual is located.

So it makes sense to me that, you know, if we look at the issue of mental illness through the frame of the Social Determinants of Health, we would locate the point of intervention not necessarily or exclusively with the individual that is suffering, but the social environment that's making the individual sick.

So, for those of you who do have access to the slides, slide 5 is a schematic of the point that I'm trying to make, that often, we focus on manipulating those factors that are at the micro level. We focus—with respect to mental illness, trying to address it—we focus on the individual, his or her family or household, and sometimes the focus is at the meso level, the neighborhood or the environment.

Rarely do we focus on these larger forces when in fact they have a profound affect on people and individuals and neighborhoods, their community, their family, their household. And part of the reason why we do that is because it's often difficult to see the relationship between those large forces and what happens to the individual, but I'm going to give you a few examples of why we should pay attention to those larger forces because they do shape the context that in turn impacts mental health.

So for instance what's really clear now is that we know that our economic system, you know, and our laws and public policies, you know, you know, really things that seem very distant from mental health, pose a clear and present danger to mental health through its impact on job losses, migrations of people who are looking for work. The performance of our economic system has increased levels of stress, anxiety, depression, substance abuse, domestic abuse, and other kinds of violence. Then another one of those large systems is our cultural system, again, our attitudes and beliefs about people.

So attitudes and beliefs about race, gender, sexual orientation, national origin, these things, these attitudes and beliefs about things cause great emotional harm to people of color, communities of color, the LGBT community, immigrants to this country, for instance.

Then again our criminal justice laws and policies and institutions, our courts, our jails, our detention centers, have had devastating psychological impacts on the psychological well-being of entire communities of people. The African American, Latino community, come to mind immediately.

Then we have a social welfare system that's punitive, and it's based on the notion of, you know, personal responsibility, and it undermines the emotional well-being of people who have to rely on our social welfare system.

And then we have lots of forms of public policy that undermine mental health. We have HUD housing policy that puts people in high-rise, high-density units. We have HUD housing policy that segregates people or locates people in environmentally toxic places.

We have wage policy and employment policy that induces stress, depression, anxiety, and substance abuse due to people having to work multiple jobs to, you know, make ends meet because we have such a low minimum wage policy or the behave—corporate practices that allow businesses to hire people part time and contract work and then not give them benefits like sick leave and vacation leave or healthcare insurance. All these things have impact on people's mental well-being.

And of course we have healthcare policies and institutions that make it hard for people to manage their mental health. You know, whether it's insurance companies, not allowing people with pre-existing conditions to get—to get insurance or dropping people after, you know, an illness.

But my point here is there are larger forces that are far removed, seemingly far removed from the individual and the person's community that have an impact on mental health.

And that the point of intervention with respect to mental health might not be that individual that is experiencing the challenge but may well be these larger forces that define the social context that the person is located in.

So those of you who are able to look at the inverted pyramid and see that, that, you know, obviously a lot of these issues are issues that people who are trained to address mental health problems are not equipped to deal with.

And so you'll see on the pyramid as you move up to those larger forces, actually let me see if I have it in front of me, as you move up say for instance to those larger forces on the right side of the pyramid, you'll see that the need for collaboration, building alliances, cooperation, networks, is greater.

So you have to work with people who are in other fields, other professions, have different skills and knowledge bases to deal with some of these larger forces that impact people's mental health. On the left side of that triangle symbol, inverted triangle, you can see as you go up the individual has a lot less control over that in those environments.

They have declining degrees of agency and choice and personal responsibility, influence, and there again is why you have to build these alliances and networks and cooperatives with, you know, people from different fields and different professions to deal with some of these larger forces that impact mental health.

So that's essentially what I have to say today about social exclusion: the notion that it's structured, it's not accidental. We've organized our society in ways through our cultural, political, economic, and social systems that systematically marginalize entire groups of people, including people with mental illness. And then also we think about how to move to inclusion.

We have to really understand well, there are larger forces that do marginalize people and we have to intervene at those larger levels and we have to build alliances with people who can help us intervene and change the social context that creates conditions that are right for mental illness in various populations.

And then I'll just add that that theme is going to be a topic of a conference that we'll be hosting in a year. Dr. David Satcher is the keynote who was one of the commissioners who helped the World Health Organization develop the Social Determinants frame.

Obviously he was also one of the surgeon generals, the Surgeon General under Clinton. And he's been a very, very strong advocate for mental health issues. In fact it was under his watch that the Surgeon General's Office issued the first reports on mental health. And he's been a strong international and national advocate for mental health issues for a while now.

So he will talk to us about how social context does impact mental health. And how we need to think about reorganizing the social context to enhance mental health and then of course by doing that promote social inclusion. So those are my few comments.

Michelle Hicks: Thank you so much Dr. Todman. Our final presenter for this day will be Dr. Peggy Swarbrick. Dr. Swarbrick.

Peggy Swarbrick: Yeah. Yeah. I want to thank everybody for participating today. And what I really wanted to talk about in a little bit of time is in what I have up there on the slide that you can refer to as it points to it.

But here really the—this rare, why we need to really look at this whole framework and start to really look at our service system, any role that we have in terms of the roles that we all have played in terms of mental health delivery, mental health receiving services, designing, deliver, evaluating.

We need to start to look at this framework and it is very exciting to me to have this thing finally be something that the system is really looking at. So I'm going to share a little about from a personal perspective and personal experiences of working with people, along with people, but also from a personal perspective having experience of living with the illness.

How this really very much resonates with our experiences, but being proactive, looking toward strategies for us to start to think about this framework and see where it fits. Because we may—we can read about all this and we look at it and it seems really great and I think immediately people think, well we just have to advocate for this or we just have to do this.

And we definitely have to do these, some kind of advocacy. But I think what we need to do and hopefully one of the things that I have in this talk is to start to even look at where we are in this work and how we are excluding people or including people and it's something that we need to start to work on consciousness raising.

So people as we know, it's no surprise to anyone probably on this call that the—living with the diagnosis, people are excluded on many levels. And it's multiple levels of exclusion and a lot of it is the societal, the structures. But there's also the systematic exclusion that happens within programs, with—and then there's also on the level of the individual, how we start to create conditions where we exclude ourselves.

And I think that's another important thing to be thinking about this because many of us as we move into recovery and we start to work on our recovery, we continue the whole issue of self-stigma really plays a role in this whole conversation.

People are not encouraged to participate in communities and we have things such as people, high rates of homelessness, significant rates of under- and unemployment among people living with mental illness. We have many issues related to people not participating in communities.

And what happens also is programs tend to exclude people and create, the solution many times to these kinds of conversation is we'll create another program and segregate this population further.

We place a lot of focus on just helping a person take medication, go to a program and not even think about working because someone's going to get sick. So how this whole framework has a very importance, relevance to the experience with people. People are facing multiple challenges.

The whole issue of poverty is one that living with an illness, being on social security, it's a package plan that includes poverty, living in substandard housing if housing at all. And many times it's going to cause other kind of social and financial strains on the person.

And the other piece with this too is when we think about financial, we think about people are not—many people are un-banked. Many are not participating in the mainstream financial world that can really help in terms of moving forward and contributing to society and it's not happening.

One of the things we as—from our experience working at Collaborative Support Programs of New Jersey we found—we systematically have designed housing services and also financial services to help people because we saw the impact of poverty being far worse than the impact of just the illness itself.

And as an agency, peer-run agency we saw this as a problem and we looked around, and we said who's going to do something about it and the mental health system wasn't doing anything about it.

So as a peer-run agency we started to look at creating partnerships with existing community base, community development organizations and local community to start to partner around housing, developing housing programs that were not segregating people, integrating people more in mainstream scattered-type housing as well as we started to work on financial self-sufficiency programs for people.

And no real hard evidence to share but a lot of experience of people that I know and I work with and I care for, see tremendous impact on their life as they become more involved in the fabric of the society.

So as Dr. Todman talked about the Social Determinants of Health I—and being a very strong impact on physical health, I think that this is a framework in terms of mental health service delivery we need to be thinking about more strongly.

Looking at the impact of income and social status on impact of onset of illness as well as mental health recovery. Those have very strong impact issues of underemployment, unemployment, access to health services, access to services.

In terms of Social Determinants of Health framework, many of these things we know are problems for people in getting access to these things and/or many times not having access to these things potentially has often—potentially could be viewed as contributing to the onset or exacerbation of people's illness.

Another area that I think has relevance that we need to be thinking about, more in the social inclusion framework, is the whole idea of literacy. Because that's another real excluding factor in terms of a lot of people in the experience that many people have the onset of illness impacting at a time when people are pursuing educational pursuits and literacy issues as well as the whole notion of health literacy, that I think is also part of this framework, that has a lot implication for our work in helping people learn about their health and taking care better of their health and being able to then be in a good position to participate more in society.

What I wanted to say a lot—in terms of this discussion is that I guess from a personal perspective having this experience, I don't—I want—and also as working in the field at a peer-run organization trying to address issues of poverty, trying to promote opportunities for wellness of people.

One of the things I thought in terms of this conversation today, because you've had a lot of information to take in, I have outlined on a slide there that those of you may have it if you don't I definitely look—encourage you to look at is as Dr. Todman said I think we need to be sitting down and looking at this information and seeing how we perhaps are—how exclusion is happening within our own fears of working, living, learning.

So what I've done is I've outlined on some slides some potential strategies because I think a lot of times you may come away from learning opportunities like that and figuring out well what can I do. What I encourage you to do is to take this framework that I've laid out and a series of questions that I have here and I think that it would be important to see about how our—how is exclusion happening in your sphere.

Where—how behaviors, attitudes, and beliefs maybe excluding people and/or how are we excluding ourselves because I think a lot of us with personal experience often exclude ourselves from things and I think that that's another part of this that we want to be thinking about how we might be excluding ourselves because the perception is, you know, people know that I have this illness so I can't participate whereas there may be communities that may be more accepting of us and we just don't take the risks to move into that or take risks.

So I think in terms of looking at some of the questions I think it'd be important to start some dialogue for ourselves or the people that we work with or we support. To think about how we are looking at this notion of social inclusion and social exclusion and think about the way we are for possibly in terms of our attitudes or behaviors maybe excluding people.

And how that relates to the culture that we live, learn, or love and the different cultures that are—what is—how is that impacting us and how is it impacting the people we serve? And the biggest thing we can do as we start to come to some awareness of patterns of attitudes and behaviors and practices that may be excluding people, what do we start to do to role model more inclusive behaviors and practices.

So I have a framework that kind of helps organize your thinking around this to sit back down and see about what are some of your attitudes, behaviors, services, policies, and procedures that might be impacting—is excluding people and what—and also what are including people.

So think about what are the things that we might want to continue to do that are excluding people that are helpful in this way and then think more clearly about what are some of the practices that clearly are excluding people and think about how to stop or change or alter these practices and potentially move towards having to do some type of reaching out to communities, other communities outside of our spheres of just mental health.

Starting to partner more and start to work more collaboratively with communities rather than creating separate—separating people and continuing to separate people.

I pretty much wanted to just really share that this framework is a framework I believe is very important as we think about recovery for people with serious mental illness and are creating a recovery-oriented service delivery system which many States and agencies and families and consumers are trying to advocate for this framework is definitely something that I think is going to help to move our transformation efforts forward, I believe strongly.

And I think that there's a lot in other types of strategies that we—I could share but I think what I wanted to just say today that we need—one of the things I just think that hopefully those of you who are participating in this call can start to look at this framework and start to look more at home and in our own, you know, working environments of how we may want to start to look towards examining more closely what we are doing and how we are constructing and designing our services or—and how that might be impacting people.

Because it could have a big impact on, you know, people's participation more respectively in communities of their choice. So I think that's about my piece.

Michelle Hicks: Great. Thank you so much Dr. Swarbrick and I'd like to thank all of the presenters today. That concludes our presentation portion of our session and at this time we have time for questions from the participants.

If you do have a question for our presenters we ask that you please dial star 1 on your telephone keypad to be placed in the queue. Dial star one and remember that once your question is posed, the operator will mute your line unless you have a follow-up question. Do we have any questions?

Coordinator: We do have some questions. We'll take the first question, Colleen, your line is now open for your question.

Colleen: I just would really like to know the approximate date and place of the conference with Dr. Satcher next year because I might be able to go if I plan now. That was from the second speaker . . .

Michelle Hicks: Okay.

Colleen: Dr. . . . how do you say her name?

Michelle Hicks: Dr. Todman?

Colleen: . . . Todman, yes.

Michelle Hicks: Dr. Todman, are you there?

I have the date here; she may have had to leave the call. I know she had something . . .

Colleen: Oh thank you.

Michelle Hicks: It is on the slide and it is scheduled for June 3rd and 4th.

Todman: Okay, can you hear me?

Colleen: Yes.

Todman: Okay. But go ahead. You're correct.

Michelle Hicks: Oh. I'm sorry. I couldn't hear you before. Go ahead please.

Todman: It's scheduled for June 3rd and 4th and Dr. Satcher's actually speaking on the morning of the 3rd.

Colleen: And is it in—at the East Coast?

Todman: It's in Chicago.

Colleen: Oh Chicago. Okay.


Michelle Hicks: Thank you.

Coordinator: Our next question comes from Karen. Your line is now open.

Karen: Okay. I've been in the mental health field for 22 years as a provider and I've spent a much smaller part of that time as a consumer. Would you tend to agree that mental health agencies help to perpetuate mental illness in their clients?

Kenneth Thompson: I'm happy to answer that at least a little bit and Peggy you might have some thoughts as well. Just, you know, I think one of the things that we've been engaged in for the last 4 or 5 years now is an effort to transform mental health services. And the reason that we're doing that is because there's a belief that the way we have been doing services has not in fact focused on helping people get the lives that they want to live in the communities that they want to live in.

So I would, I guess another way to say this that's a positive frame. That's an effort to move things forward but the, implicit in that is the idea that some of the ways in which we have I think internalized mental health services and ways in which we have segregated them have not contributed to making people healthier.

Peggy Swarbrick: Yeah. I would add to that. I've wanted to talk about—probably should have talked more about that, but I was under the assumption that everybody thought that, because much of the way services have been designed and delivered, we promote people taking their medication and going to programs and keeping them in programs for 20 and 30 and 40 years, which does much more about excluding people.

And as I said, typically when conversations come up, the conversation is how can we create this separate program for these people because people are so special and we don't want to—we don't want them to be, you know, in mainstream programs because they're so very different.

And I think this whole framework really helps us to see that no, we need to help people to participate in what's out there in the community and it's going to be better for everyone.

Karen: Thank you.

Coordinator: Our next question comes from David. Your line is now open.

David: Good afternoon. How are you? I am from South Texas, from a rural area of less than 80,000 people. And we're getting so much issues when it comes to transporting individuals to come to either Kingsville (unintelligible) MHMR Centers there.

And it's a very, very big issue. And another issue is the lack of support from case managers in general in regarding to educating our family, loved ones, and neighbors.

Now the question is going to arise is that we are so underfunded, we're deleted most of the time when it comes to applying for a scholarship to enter—to go to a main—a conference, to go to a State conference, and they just don't even include anyone from this area. And we have 80,000 people, 90 percent are Hispanic, very, very low-wage income, very little educated individuals.

And of course the culture doesn't help us at all. But we have to deal with the segmentation not only from the family culture but case managers themselves where they still believe that we should just sit and listen and don't say anything.

And that's—and I belong to a partnership that we're now empowering consumers. But yet we're still lacking the transportation and the segmentation and the lack of invited individuals from my area to come to workshops and apply for scholarships and give us, you know, hey we want to go too but we're just not being heard.

We feel that we're just being blown off and put off to the end. Thank you.

Michelle Hicks: Thank you. Do any of our presenters have comments or a response? Or should we move to the next question?

Kenneth Thompson: Well this is Ken. I'll just say I think that's a pretty good example of the social exclusion that—processes that Lynn was talking about. When resources are not made available to folks to allow them to be participants in things that are a critical concern to them you—we obviously have a problem.

Michelle Hicks: Yes. Thank you.

Coordinator: Go ahead.

Michelle Hicks: I'm sorry I was going to say operator, next question.

Coordinator: Our next question comes from Harvey. Your line is now open.

Michelle Hicks: Hi Harvey. Go ahead. Are you there?

Coordinator: Please check your mute button Harvey. Your line is open. I'm sorry we're unable to hear you Harvey. If you'd like to ask a question please go ahead and re-enter it.

Lauren your line is now open for your question.

Lauren: Yes I'm wondering what are the most important solutions that you can recommend at a Federal level? And if possible I'd like to hear from each speaker. Thank you.

(Coordinator) : Do I need to repeat the question? Are you all ready?

Lynn Todman: That's a really challenging question. Let's think—with the Federal level. Well, I'm happy with the (unintelligible) to do is integrate this language.

Well and you know one of the things that actually we could do is start to use the language of inclusion/exclusion more actively. And I mean to the extent—one of my colleagues who's practiced law for 28 years and did work with traumatic brain injury wasn't able to really change attitudes and behaviors around treating people with that injury until that phrase, TBI became kind of institutionalized and embedded in statutes, Federal and State government statutes, and I think that that is one thing that could happen, that we start using this language or embedding it in statutes so that people start thinking in terms of who's included and who's excluded. In terms of specific policy or programmatic interventions, outside of the field of mental health I can tell you some of our housing policy with respect to people who have felony convictions, you know, changing some of that policy so that, you know, we don't find a lot of these people homeless and on the street, reoffending and back in jail.

A lot of our criminal codes for instance could be changed at the Federal level to decriminalize behaviors that for instance homeless people typically engage in because they don't have any other place to sleep or to sit. I don't think I'm giving you the best answers but off the top of my head it's that kind of thinking.

Kind of looking at Federal legislation and policy and undoing it so that it doesn't harm people the way it often does. Maybe Ken can give you a better answer.

Kenneth Thompson: Yeah. Of course I had a few moments to think while Lynn was talking to contribute to this. You know, there's a number of things that I would suggest.

On one level at the Federal level to be honest with you we're kind of doing this right now. We're really struggling with this, with the health reform issue.

And that is, you know, how are we going to make sure that the way we set up what has become increasingly an essential service for, you know, for human beings to have a life that they want to live, i.e., health services, we have large numbers of people who are fundamentally excluded from health insurance. So a socially inclusive move obviously is to figure out how to include all the people who currently are off, don't have access to health insurance.

Or for that matter the whole parity bill was at some level I guess an effort to be—increase the inclusion of folks with psychiatric disorders being able to access services that were hopefully useful. Of course as we've talked about we're in the process of trying to transform those services.

And I think Lynn made the point that, you know, having access to services is not always a wonderful thing if those services actually do not help you. Or are not targeted in a way to make your life be what you're hoping your life will become.

So those kinds of things I think are critical. But at the larger level this issue of how we are going to begin to understand the intrinsic value of people who are here in this country, how we tap into the resources and capabilities that they have and how we make sure that we provide resources to them that range from education to transportation to housing to access to jobs.

I think all these things probably need to take a framework that is built out of this concept of social inclusion and an awareness of social exclusion. That we are in fact working to actively reach out and make available resources to people who at the present time are not able to or are not being permitted to access them.

So it's a much more proactive stance. The way this is being done in Europe is that, you know, they're identifying populations of people who are not accessing what would be considered mainstream resources.

And they are, you know, developing targets to make sure that they do what they can to help those individuals and those communities get access to those resources. So in the case of psychiatric disorders, you know, a clear, clear, critical one—I'll name two, but, you know, the first one is vocational opportunities.

This is going to be a really big struggle given the fact that right now, you know, we're facing unemployment across the board and that is one of the major social determinants of health as it is. But we need to as we reinvent our society here I think actively work on a labor market approach that will make it possible for people to not have to be locked into disability in order to get their health care.

But that they can actually potentially find work and participate hopefully on terms that are better than the exploitative terms that Lynn mentioned earlier. So there's lots of levels of struggle to this and lots of levels of work that we have to do to make these things available to people.

But I think ultimately the question is, you know, does the Federal Government have a role in this? And I think the answer that we got out of our last conference is the Federal Government has a critical role in helping shape what the national ideals are and orchestrating the conversation and then doing what we can to support local initiatives to make it possible for people to contribute in their own way with their own capabilities and capacities in their own communities.

Michelle Hicks: Thank you so much. Dr. Swarbrick did you have something to add to that? I think I heard you in the background.

Peggy Swarbrick: (Unintelligible) but I just think that it—the fact that we're having a call and a conversation about that is a very—I see it as an extremely positive step from a Federal level. But this—allowing this conversation to happen.

And then help—I think—it seems to me that there will be a lot more. And so from a consumer provider perspective and a movement, I think that we need then to start to mobilize from the ground up more of this dialogue and discussion.

So for those of us in the audience that are part of the consumer movement or the movement, we need—this is a really great opportunity I believe for us to continue this and start to work towards figuring out strategies that we can potentially work with on a Federal level, on a local level, and on our own, you know, within our own spheres. I think that we have this conversation going and perhaps we can then start—get it going and bringing ideas to the table that we can bring to fruition.

Michelle Hicks: All right. Thank you so much. Operator, the next question?

Coordinator: (Patricia) your line is now open for the next question.

(Patricia Dobbins): Hi this is (Patricia Dobbins) in Juno, Alaska. And I'm calling as the Co-President of our State NAMI organization.

Our State government has finally recognized the importance of peer-to-peer programs. However they have dropped our NAMI State organization, which has the evidence-based program training for people who will be the presenters of these programs.

And at the July NAMI convention there was a new emphasis on rural inclusion for our programs using distance learning and/or telemedicine to bring to them consumer peer-to-peer support groups and trainings and our family-to-family classes. But of course we're low on funds because we weren't funded this year or last year or the year before.

So my question is what can we do about that? You know, we're looking for other funding.

Hello? Am I being heard?

Michelle Hicks: Yes. I think they're thinking and . . .

(Patricia Dobbins): Okay.

Kenneth Thompson: Unfortunately at least when I think it's—unfortunately silence. There's no grinding of gears, although that probably would be a better . . .

(Patricia Dobbins): Yeah. Or just turning of wheels.

Kenneth Thompson: Yeah the—I guess one thing that I would say is that, you know, we—and maybe this is another way in which this question about the Federal role could be important. I'm not sure how easy it's going to be for each State to figure out that it really needs to have, and some States obviously more than others, that they need to have a rural initiative of inclusion around issues of mental health.

But it is very clear that any State that has any significant size to it and any population that is living in rural areas, that the dilemmas of—related to rural life and mental health are very significant. Our hope is that a—that folks in the various things working with things like the Rural Mental Health Association and NAMI and other things, that we really reinvigorate the effort around improving and helping address the mental health issues in rural America more than has been happening in the last number of years.

And hopefully what we'll do is we'll just make Alaska so ashamed that it doesn't provide support for this kind of activity that it'll sign up and use some of that oil money to do that.

(Patricia Dobbins): Well unfortunately when we're paying high prices at the pump, Alaska's doing well. But other times it's not.

Michelle Hicks: Great, thank you. Did someone else want to respond?

Woman: No.

Michelle Hicks: Okay. Operator we'll take another question. And if I could just ask the presenters, we're going to take a few more questions, I know your time is limited. If you could spend a couple of minutes after the questions on the line and we'll have a brief closure.

Coordinator: Thank you. Our next question comes from (Vanessa). Your line is now open.

(Vanessa): Yes. Can I be heard? Am I heard?

Coordinator: Yes. Please go ahead.

(Vanessa): You called this a movement toward a—some type of Federal strategy. My question is just for clarity's sake, are you asking how—us to come up with strategies to give some type of detail or direction on how we're to go about making these changes of breaking free from these types of attitudes?

In other words the culture of organizations is really not conducive to addressing these types of issues, not without that individual being perceived themselves as a problem, from wanting to address them in the first place. So—and I believe a man earlier hit upon this briefly, however my second question is are you—or are you simply asking us to examine the attitudes itself rather than coming up with strategies on how to deal with it?

But to examine the attitudes themselves that create these cultures, these exclusions? My question is how to you address these—this on an organizational, cultural, even community level without some type of open—larger open forum than this? Or is this just the beginning?

You know, not without like TV, radio, Internet, chat, Facebook. Something that will—everyone can address without it becoming an individual thing.

Because it seems to me as though, community level, there would have to be a lot of people involved in the discussion in order for it to be addressed in a concisive [sic] way. I don't know how better to put it.

Lynn Todman: So this is Lynn and I'll respond briefly to that. That was a point that I was trying to make, that a lot of these issues are much larger than any individual or even small group of individuals can address.

And that building alliances and coalitions is critical, and especially alliances of people who think differently from you, who have different skills.

(Vanessa): Right.

Lynn Todman: Clearly you're going to have to engage the media on this. I mean I'm just looking at one set of structures.

You know, you're talking about cultural, the culturally based attitudes and values, those kinds of things. The media plays a huge role in shaping our—those cultural attributes.

So your point is this is not something one takes on by themselves?

(Vanessa): Exactly.

Lynn Todman: Do you—yeah. I mean it's like any social movement. If you look at the civil rights movement or the women's suffrage movement it was building coalitions among unlikely partners.

So the civil rights movement wasn't—would not have ever been successful had it not reached out to other constituents, had it not reached out and worked with white people in the country and people who were not black. And so I would say that same kind of model is appropriate here.

We're changing attitudes and beliefs around what people with mental illness can and cannot do. It's—I think you—you know, you can think of it as a social movement.

And it would require the same kind of galvanizing of energies, a broad base of energies and skills as other social movements have in this country.

Michelle Hicks: Great. Thank you so much. We have time for one more question. And just to let those of you who are still waiting in the queue to ask your question, please feel free again to email your question to the ADS Center and we will forward them to the presenters.

Or if you were able to access the slides you will note that their email addresses are provided at the end of the slide presentation. We'll have our last question.

Coordinator: Our last question comes from (Jarock). Your line is now open. And for others in the queue if you'd like to press star 2 that will remove your name from the queue.

(Jarock): I think you actually answered my question which went to the context of what we're doing now in the larger social movements. And that's really what you just said.

My other question is how do we begin to do the work of economic inclusion? I think of Grameen Bank, I think of some of the things that I think that Dr. Swarbrick organization has done.

How do we involve maybe the Small Business Administration? Are some of those connections and that kind of thinking being done?

Lynn Todman: This is Lynn. And this is maybe a radical way of thinking about it but I think a lot of those, you know, not the Grameen Bank obviously but I think a lot of—a presumption or assumption behind your question is that the existing framework is sufficient.

So for me small business development is not helpful in a context where people who work for small businesses are ineligible for health care. Or a lot of the other kind of protections, health-related protection.

So I guess the point I'm trying to make is, you know, the structure that you're trying—is the question the structure you're trying to work in. You know, I think when I hear you saying—implicit in what you're saying is you're trying to work with the existing parameters.

And what I'm suggesting is maybe the parameters are wrong.

(Jarock): I would agree that parameters are wrong. I'm trying to figure out how do we exploit them.

Kenneth Thompson: This is . . .

(Jarock): If at all.

Kenneth Thompson: Yeah, this is Ken. You know, I—we had a little bit of this going on right now relative to the economic downturn and the efforts to provide some stimulus to unemployment, to address the issue of unemployment. By the movement towards green technologies and things like that.

Specifically though I think the question would be, you know, for folks who have got psychiatric disabilities who have been off or out of the labor force for some period of time or are finding it hard to get back into the labor force because of the absence of work or absence of training or absence of non-exploitative relationships in the workforce—in the workplace that they would like to go to.

That maybe one of the things that we can do and take as a lesson out of this whole effort that the Federal Government is making right now to (unintelligible) to work, is that it is possible to have a society where people decide that they're going to help support people working.

We could actually move to a society that does that and doesn't quite treat people as the disposable objects that we appear sometimes to treat them as. And if we could move that, you know, there's a ton of work that needs to be done in our societies, in our communities.

Helping each other and, you know, improving and developing our environment and making this place a better place to live. We could certainly do a lot more work in that area.

It would require that the—that we had policies in which the capability and capacity to work was something that the—that we all as a society felt was something that needed to be supported. And that we didn't have the luxury of wasting people's energies and capabilities.

Michelle Hicks: Thank you so much. And with that we're going to close our call for today.

I thank everyone for participating. I thank again our presenters for their presentations and their points of view.

And I'd just—I'd like to remind all that have participated today to please take the survey once you receive that email. And if the presenters could just hang on the line for just a couple of minutes so once we close the call I can talk to you. Thank you.

Coordinator: Thank you. That concludes our call today. If you are not a presenter please disconnect your line at this time. Presenters one moment please for post-conference.

Kenneth Thompson: Not everybody disconnects so they listen (unintelligible).

Michelle Hicks: Can you hear me?

Kenneth Thompson: Yeah.

Coordinator: One moment please. We're not in post-conference.

Michelle Hicks: Sorry.