Surgeon General's Workshop on Women’s Mental Health
November 30 – December 1, 2005
Denver, Colorado

Workshop Report

This document summarizes the views and issues addressed by invited speakers and discussants at the Surgeon General's Women’s Mental Health Workshop. The views expressed in this Report reflect the opinions of the individual participants at the Workshop and do not necessarily reflect the official position of the Office of the Surgeon General, the Department of Health and Human Services, or other Federal entities.

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Executive Summary

The Surgeon General’s Workshop on Women’s Mental Health brought together experts from the consumer, academic, advocacy, health insurance, health care delivery, program management, and public policy communities to explore sex and gender differences¹ in mental health and to address critical mental health issues affecting girls and women. The goal of this workshop was for participants to develop practical and actionable recommendations for materials (referred to broadly as communiqués) and toolkits that could be produced by the Surgeon General to advance knowledge, understanding, and behaviors regarding women’s mental health issues – and ultimately to improve the mental health of our Nation’s girls and women.

A rich array of potential messages, materials, target audiences, formats, and dissemination strategies emerged from the day and a half of workshop discussions and presentations. Examples ranged from a Surgeon General’s Letter to the American People, to iPod messages for teens, audio materials, story-telling formats, public service announcements, messages on commonly used products (e.g., diapers), and profiles of promising practices or model companies that promote mental health. Also discussed were ways of identifying and harnessing existing resources, such as clearinghouses, assessment tools, studies, self-esteem-building models, and more. The specific ideas and recommendations are described within the chapters of this report.

A series of overarching messages and cross-cutting themes pertaining to the mental health of girls and women also resonated through the sharing of ideas that took place at this workshop. These messages and themes will serve to inform the development of Surgeon General’s communiqués or toolkits:

• Women’s mental health is essential to overall health. Both mental disorders and mental wellness should be integrated as part of primary and other health care practice.
  The disease burden of mental illness is enormous. Among developed countries, mental illness is second only to cardiovascular disease in prevalence and causes nearly a fourth of the disease burden.²
• Women's health matters. The last decade of research has underscored the importance of sex and based differences in the risk, prevalence, presentation, course, and treatment of mental disorders.
• Mental disorders must be viewed like other chronic medical conditions and are highly treatable. This message needs to be further understood to combat stigma and encourage more people to seek the treatment they need. In addition, there is a need for a broader understanding of the variety of treatments available.
  Mental health must be addressed across the life span, from early childhood to the later years. The types of risk, prevention messages, ways of building resilience, course of disease, and treatments vary according to age, reproductive events, and other life span issues. Thus there is a need for materials and messages adapted to audiences of different ages.
  There are ways to promote resilience and factors that help prevent mental disorders. We need to define good mental health and promote prevention. This means building a wider understanding of protective factors that can help girls and women build resilience – including for those who experience mental disorders – and developing effective strategies to translate that knowledge into practice.
• Culture is an important source of resilience but also of barriers related to the recognition and acceptance of mental health issues. Girls and women draw great support from cultural connections and identity but also feel the weight of cultural pressures to remain silent about personal issues, not to discuss problems outside the family, or to be strong.
  Gender must be integrated into disaster training and planning activities. The lessons of Hurricane Katrina and other large-scale disasters indicate that women are at particular mental health risk due to factors such as family responsibilities, women’s higher rates of poverty, their greater risk of depression and anxiety disorders, and their vulnerability to sexual abuse and domestic violence.³
• The importance of trauma, violence, and abuse needs to be recognized by providers, researchers, policymakers, and the general public. Trauma, violence, and abuse are far more prevalent in the lives of girls and women than commonly thought – and they may lead to serious, long-standing physical ailments, co-occurring conditions, and risky behaviors that, if left unrecognized and untreated, can compromise women’s health.
• Recovery from mental disorders or from the effects of trauma, violence, and abuse is possible. Following the recommendations of the President’s New Freedom Commission, we need to move toward a health care system that is recovery based and consumer focused.
• Health literacy is a public health and Surgeon General’s priority. It is critical to design communiqués that carry health messages in language that people use and understand. To be culturally competent, materials should be designed with the input and participation of target communities, which may represent diversity in race, ethnicity, age, geographic area, sexual orientation, or health status.

A final message that echoed throughout the meeting was the recognition that women’s mental health issues touch everyone, either directly or through the women they love. Recognizing this factor, participants shared an enormous amount of energy, expertise, and commitment to the workshop effort. The rich results of their work are a testament to their substantial and considered contributions.

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Workshop Report

Introduction: Background and Purpose of the Workshop

The Surgeon General’s Workshop on Women’s Mental Health was convened to bring together experts from the consumer, academic, advocacy, health care delivery, health insurance, program planning, and policy planning communities to address critical issues affecting the mental health of women and girls and make recommendations for the production of Surgeon General’s communiqués⁴ and toolkits. This workshop was part of a broader initiative, the Surgeon General’s Women’s Mental Health Project, designed to explore sex and gender differences in mental health and gain a better understanding of the role mental health plays in the overall health of our Nation’s women and girls. The initiative represents a joint project of the U.S. Department of Health and Human Services (DHHS) Office of the Surgeon General, Office on Women’s Health (OWH), Office of Minority Health, National Institute of Mental Health (NIMH), Substance Abuse and Mental Health Services Administration (SAMHSA), and National Institute on Drug Abuse (NIDA).

The Women’s Mental Health Project has consisted of several background activities, which have laid the groundwork for this workshop. These have included a concept mapping exercise; key-informant interviews with mental health experts and leaders; facilitated discussions with local providers, consumers, advocates, and decisionmakers; and a targeted literature review. The activities have led to the identification of major mental health issues for girls and women, which are recognized as being both high in importance and in action potential. These myriad issues have been grouped according to eight different cluster areas, encompassing personal, environmental, and health care system-related concerns. The cluster areas include:

• Biological and developmental factors
• Specific mental disorders
• Trauma, violence, and abuse
• Social stress factors and stigma
• Treatment access and insurance
• Identification and intervention issues
• Health system issues
• Protective factors and resilience

Each participant in the Surgeon General’s Workshop on Women’s Mental Health was assigned to a working group addressing one of these eight topics. Each working group was asked to review and prioritize the issues associated with their cluster area. (Note: A schematic representation of those areas and the issues which fall under them is included in Appendix A). They also were given the charge of developing recommendations for the production of Surgeon General’s communiqués and toolkits. For each cluster area, participants were specifically asked to choose three key priority issues to be addressed, describe the key messages, suggest a format for a product or toolkit, identify the audience, and highlight any cultural concerns or other cross-cutting issues.

To set the stage for the workshop discussions, participants were offered several plenary presentations, including a welcome and introduction by U.S. Surgeon General Richard H. Carmona. These presentations underscored the importance of women’s mental health not only to their own overall health, but also to the health and well-being of those around them and ultimately of our Nation as a whole. They highlighted the burden of mental disorders on the lives and productivity of individuals and revealed what we have learned about the interplay of sex and gender in the risk, course, and treatment of these disorders.

Participants were invited to become active partners, throughout this meeting and beyond, in the promotion of a mental health system that could address the mental health issues of women with an approach that is more consumer focused, recovery oriented, and focused on integrating all aspects of mental health with mainstream and primary health care.

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Day 1 – Morning Sessions

Welcome, Introductions, and Charge to the Workshop

Wanda K. Jones, Dr.P.H., Deputy Assistant Secretary for Health, DHHS Office on Women’s Health, welcomed the meeting participants. She described their task as being to develop recommendations for concrete products and toolkits that could be developed from the Office of the Surgeon General to address key mental health issues affecting women and girls. Dr. Jones explained that each workgroup was comprised of a diverse range of participants (e.g., researchers, advocates, providers, consumers) to ensure that a full range of perspectives would be represented.

“We must truly listen to the stories women tell – turn to women survivors as experts. We must replace the question ‘What is wrong with you?’ with the question ‘What happened to you?’” – Rene Andersen, Center on Women, Violence, and Trauma

Rene Andersen, M.Ed., LCSW, Center on Women, Violence, and Trauma, described her personal and professional experiences with the effects of trauma, violence, and abuse on women and families. She told of her own experience of growing up in a family that appeared to be fun and loving on the outside (the “day stories”) but that hid an intergenerational cycle of abuse (the “night stories”) filled with cries of despair and terror. Ms. Andersen told how this history led to legacies of depression, addiction, posttraumatic stress, and a host of physical ailments in her life and those of her siblings. She told of being overmedicated and subject to many diagnoses and treatments – all of which overlooked this history of abuse for many years.

Ms. Andersen explained that the experience of trauma is central to the lives of many women and that emotional, physical, and sexual traumas are pervasive. She emphasized that violence is a social disease and not a personal issue. She also stressed the importance of helping the victims of trauma, violence, and abuse to understand that it need be neither unbearable forever nor passed from one generation to the next. Ms. Andersen offered herself as living proof that healing is possible. She noted that there are indeed many “rafts in the river” to offer help and support, including relationships with friends, service providers, recovery groups, and the like.

Everyone knows at least one woman who is a survivor of trauma, commented Ms. Andersen. She suggested that we must turn to women survivors as experts and truly listen to the stories they have to tell. She called for a fundamental shift in diagnosis and treatment founded on the belief that everyone can heal and that the question “What is wrong with you?” should be replaced with the question “What happened to you?”

Ms. Andersen concluded by inviting the audience members to conjure the image of one woman in their lives who has had to survive trauma or mental illness. She asked them to keep that image close at hand during the course of this workshop as a reminder of how closely the issues of mental disorders, trauma, and violence touch everyone directly and through the women they love.

“I see this work as more than a job. I see it as a tribute to my mother and my grandmother.” – Richard H. Carmona, U.S. Surgeon General

Vice Admiral Richard H. Carmona, M.D., M.P.H., FACS, U.S. Surgeon General, shared his experience of being a high school dropout and growing up in an environment of poverty and hardships. He spoke of his grandmother trying to raise her children and grandchildren in Harlem; his father, with no high school education, unable to sustain a life with four children; and a mother trying to instill in her children the value of education and knowledge as a way to escape poverty. The Surgeon General described a childhood living in substandard apartments, being homeless, and moving into the projects with 12 people in a tiny apartment. He talked about the critical roles his mother and grandmother played as the powerful women in his life, who continually battled to sustain their families despite poverty, homelessness, being immigrants, alcohol abuse, and other difficulties. Their continued determination to take care of their families, he explained, taught him about resilience and made him keenly aware of the roles women play in our society.

The Surgeon General told of how his mother would say that men have run this world for most of eternity – and are running it into the ground. She would point out that men see the world differently from women and that women tend to be more conciliatory and try to bring people together to resolve problems.

Dr. Carmona turned to the audience of workgroup participants and described their role as the foot soldiers in the battle to address women’s mental health and the broader issue of how it fits into their overall health. He recognized the risk they face of being marginalized by other events of the day, but he offered his commitment and support.

“The purpose of this meeting is to bring you all together as parents, providers, scientists, consumers, and so forth to guide the development of these communiqués, whatever they end up being. I welcome the opportunity to argue with you to figure out the right path so that girls and women will say we got it right.” – Richard H. Carmona, U.S. Surgeon General

Dr. Carmona noted that when he was chosen to be the U.S. Surgeon General, the President described the primary issue to be addressed as that of becoming a Nation that embraces prevention, health, and wellness – because ultimately, we all pay the price for poor health or health care crises. Thus, he explained, prevention and preparedness are the primary areas of focus in the Office of Surgeon General.

In the area of health preparedness, Dr. Carmona stressed the importance of being ready in the face of emerging infectious diseases, such as SARS, mad cow disease, and avian flu, as well as other natural and manmade threats. He pointed to the need to determine how to prepare first responders and other critical support personnel to be ready to deal with these issues. In addition, he referred to the importance of looking at prevention and preparedness at the household level – where it is almost universally the women who bear the responsibility for taking care of the health of the family, making the health decisions, and being the family health leaders.

The Surgeon General also discussed the importance of the issue of health disparities – noting that he has had personal experience with these disparities and knows firsthand what it is like not to go to the doctor for years. He underscored the need not to lose sight of the fact that ours is still a nation divided as it relates to race and health. We should be outraged, he suggested, to be living in the greatest nation in the world but one where not everyone has the same health care access and outcomes.

Dr. Carmona pointed out that we need a common currency and language to reach into the streets, into the “hood”, or among the ranks – and that often those we most need to reach are the ones furthest away from us. He stressed the need to understand that cultural competence is about more than just finding a translator – and that we must figure out ways to translate the great advances we have from science into packages that can reach people. One key factor in this area, he noted, is health literacy – the need to communicate with a language and at a level that people can understand. This is why, explained Dr. Carmona, every time a Surgeon General’s Report is published there is also an accompanying “People’s Piece” publication that takes the key messages and information from the report and presents it in a clear manner, written at a sixth-grade reading level.

The reason for convening this workshop, noted the Surgeon General, is to help guide the development of any document or materials to come out of the Surgeon General’s Women’s Mental Health Project. Dr. Carmona specified that he felt these recommendations needed to come from the ground up – from the sample of parents, consumers, policymakers, advocates, providers, scientists, and others represented at the meeting. The Surgeon General said that he welcomed the opportunity to face arguments and disagreements – to figure out the right path ultimately and come out of this together.

“Those of you taking part in this workshop, you are the foot soldiers. You run the risk every day of being marginalized by the events of the day, but I’ll be right with you. My commitment is 110 percent.” – Richard H. Carmona, U.S. Surgeon General

Dr. Carmona concluded by re-emphasizing his personal commitment to this project and the important work of this Surgeon General’s Workshop on Women’s Mental Health.

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About the Surgeon General’s Women’s Mental Health Project

“We are challenging you to help us devise ideas for new Surgeon General communiqués – a word that appropriately combines ‘communications’ and ‘unique’. I invite you to meet that challenge here.” – Wanda K. Jones, Deputy Assistant Secretary for Health DHHS Office on Women’s Health

Wanda K. Jones, Dr.P.H., Deputy Assistant Secretary for Health, OWH, gave a slide presentation providing the background of the Surgeon General’s Project on Women’s Mental Health to help set the context for this workshop. Dr. Jones began by pointing out the long history of supporting reports and documents, starting with the publication of Mental Health: A Report of the Surgeon General in 1999, which laid the scientific groundwork for this project. Subsequent supporting documents include:

• The Surgeon General’s Call to Action to Prevent Suicide (1999)
• Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda (2000)
• Mental Health: Culture, Race, and Ethnicity, a supplement to Mental Health: A Report of the Surgeon General (2001)
• Youth Violence: A Report of the Surgeon General (2001)
• Achieving the Promise: Transforming Mental Health Care in America (2003), from the President’s New Freedom Commission on Mental Health

She specified the project’s four main objectives. The first three include identifying the critical issues affecting the mental health of women and girls, assessing the state of the science, and developing a framework for a long-term strategy to address the issues. The fourth objective is the one most directly related to this workshop, namely to develop additional supporting endeavors and products to increase awareness and activity related to these critical issues.

Dr. Jones described in more detail the background activities of the Surgeon General’s Women’s Mental Health Project that were undertaken to begin to address the project objectives and lay the groundwork for this workshop. The first of these, she explained, consisted of a concept mapping activity designed to define women’s mental health and develop a conceptual framework for addressing the issues that affect the mental health of women and girls. It involved 245 participants representing experts and communities of interest who responded to this statement: “A specific issue that is relevant to the mental health of women and girls is….” Dr. Jones noted that this activity generated 107 issues, which were then rated according to their level of importance and their potential for action.

The next step, she explained, involved the development of cluster areas grouping these different issues according to common themes, which were in turn organized to create a conceptual framework. That framework encompasses individual, environmental, and systemic issues affecting women’s and girls’ mental health. Because of the central importance ascribed to protective and resilience factors by respondents, these were placed at the center of the framework. The conceptual framework was further refined during the process of two additional background activities. These included a set of leadership interviews with 25 high-level individuals representing governmental, provider, and consumer organizations along with a series of facilitated discussions in three cities with diverse groups of consumers, providers, and the local government staff. The resulting framework is presented below. A more detailed version that lists the specific issues associated with each cluster area is included in Appendix A.

Full Image Description: At the center of the image are a woman and a young girl holding hands inside an oval labeled Mental Health of Women and Girls. A ring around this oval is labeled Protective and Resilience Factors. Outside of this ring is a thicker ring of sorts that is divided into three segments labeled System Based, Individual, and Environmental. Each of these segments represents a set of issues affecting the mental health of women and girls. The System Based segment contains three ovals: one labeled Health Systems Issues; one labeled Treatment, Access, and Insurance; and one labeled Identification and Intervention Issues. The Individual segment contains two ovals: one labeled Biological and Developmental Factors and the other labeled Specific Mental Disorders. The Environmental segment contains two ovals: one labeled Trauma, Violence, and Abuse and the other labeled Social Stress Factors and Stigma.

When the eight cluster area topics emerging from this framework were cross-walked with the 1999 document, Mental Health: A Report of the Surgeon General, explained Dr. Jones, there were clear differences in identified priorities, particularly in the research base. While issues such as sex and gender differences in specific mental disorders or developmental factors were referenced in the Surgeon General’s Report, others such as “trauma, violence, and abuse” or “resilience and protective factors” barely appeared at all – reflecting the lack of research evidence on these important topics at the time.

The Surgeon General’s Women’s Mental Health Project’s targeted literature review and other background activities revealed several changes or developments since the publication of the 1999 report. Regarding sex and gender differences, noted Dr. Jones, there is a growing body of evidence to increase our understanding of the significant sex and gender differences in the risks, prevention, diagnosis, course, and treatment of mental illness. She added that we clearly need to address these differences not only in research but also in social policies and in the training of health providers.

Another major area that has received significantly more research attention in recent years, said Dr. Jones, is the importance and prevalence of trauma, violence, and abuse in the lives of girls and women. She referenced a new World Health Organization (WHO) study that looks at this issue and its long-term impacts worldwide.⁵ Dr. Jones also noted that this evidence further underscores the fact that women need to be screened routinely for trauma, violence, and abuse as part of their regular health care.

One of the important cross-cutting issues to emerge throughout the background activities was the importance of cultural differences and disparities. The issues of culture, race, and ethnicity clearly cut across all of the areas of the conceptual framework, explained Dr. Jones, but the scientific literature is sparse. She mentioned recent research that investigates both the protective factors of culture and potentially deleterious effects of acculturation – suggesting that culture may weigh more heavily than race or ethnicity in terms of our attitudes and behaviors regarding mental health and mental disorders.

Yet another issue to come up consistently and in a cross-cutting way is stigma that keeps families in denial and keeps individuals from seeking care, said Dr. Jones. She pointed to the need for continued education and outreach to providers, to women and girls, and to the general public.

Regarding the issue of resilience and protective factors, Dr. Jones noted that this was clearly a critical topic, in which there is so much more we need to know regarding both protective factors and successful prevention-focused activities.

Dr. Jones concluded that with the combination of the science base, these background activities, and the input from the members of this workshop, we have the potential to create an array of new products. These have been identified as Surgeon General’s communiqués – a term intentionally chosen to be broad to reflect the wide array of possibilities. Dr. Jones also pointed out that the term brings together both the words “communications” and “unique.” She presented this as a challenge to the workshop participants to debate, discuss, and craft creative ideas for ways we can communicate important issues affecting the mental health and long-term wellness of our Nation’s women and girls.

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The State of Women’s Mental Health – What We’ve Learned

“Why focus on women’s mental health? Because sex matters!” – Richard Nakamura, Deputy Director, National Institute of Mental Health National Institutes of Health

Richard Nakamura, Ph.D., Deputy Director, NIMH, presented the scientific perspective on the status of what we have learned about women’s mental health. Dr. Nakamura emphasized that while critical, research is only part of the picture, and the side that affects individuals on a personal level is equally important. Thus, he noted, the NIMH and the Center for Mental Health Services (CMHS) play complementary roles, with NIMH providing the research piece and CMHS providing the direct service that is informed by the research.

The mission of NIMH is to address the burden of mental health through research, explained Dr. Nakamura. He noted that worldwide, this burden is considerable, according to data from WHO and World Bank, and it is expected to increase. For example, the data show that within developed countries, major depression is second only to heart disease as the leading source of disease burden, and for women, it is already the number one cause of disease burden.² Schizophrenia and bipolar disorder are also among the top 10 causes of Disability-Adjusted Life Years (DALYs). Depression, alcohol and substance abuse, and self-inflicted injury also constitute major causes of disability – and taken together, mental disorders account for nearly one-quarter of the total disease burden in the United States.²

Dr. Nakamura explained that though we commonly speak of the disability burden associated with mental disorders, there is also an important elevated risk of death as well. For example, he noted that 90 percent of individuals who commit suicide have had a mental disorder – and we know that women are four times more likely than men to attempt suicide, though less likely to die from the attempt. This says much about the level of pain and hopelessness these disorders can bring.

Dr. Nakamura then turned his attention to one of the fundamental questions of this workshop; namely, “Why focus on women’s mental health?” His simple response was, “Because sex matters!” Dr. Nakamura elaborated on this point and offered a more detailed presentation of the interplay among sex, gender, and mental health issues. His presentation highlighted the following points:

• There are considerable differences in the sex ratios for selected mental disorders, with women having much higher rates of disorders such as major depressive disorder, anxiety disorders, posttraumatic stress disorder, and eating disorders.
• There are important biological differences related to hormones and brain structure that may affect mental health risks, rates of disorders, and the course of those disorders. For example, research has demonstrated that estrogen and progesterone influence brain function and stress response. These findings are interesting given that at puberty, the female-to-male ratio for depression rises from 1:1 to 2:1. Some women also experience increased vulnerability to depression during times of reproductive endocrine changes, such as the premenstrual, postpartum, and perimenopausal periods. There also are sex-based differences in the size and structure of the human brain. Men’s brains are larger than women’s. Women’s brains are lighter but more complex, with proportionately larger frontal lobes (attributed to executive functions such as judgment, language, memory, problem solving, and socialization).⁶
• Clearly environmental factors play a significant role in the risk and prevalence of certain mental disorders. Environmental factors may include both artifact (e.g., women may be more likely than men to seek treatment, there may be diagnosis bias) and psychosocial factors (e.g., gender socialization, gender roles, lower social status, reaction to social cues, experiences of abuse, gender-related differences in coping mechanisms).
• There is important overlap between biological and environmental factors, although the interplay between the two is complex. For example, in the gene that codes for the serotonin transporter, individuals with a short version of that gene seem to have a greater vulnerability to the deleterious effects of a history of maltreatment than do those with a longer version of that gene.
• There is clearly much still to be learned about social and protective factors that affect mental health, including the effects of race, ethnicity, and culture. For example, while we see that the overall ratio of female-to-male rates of depression is 2:1, there are enormous differences in range. Rates of depression are higher among Hispanic and Caucasian women compared with African-American women. Similarly, there are considerable differences among women in rates of attempted suicide. Although women are more likely on average to attempt suicide than men, the rates of suicide attempts in African-American women are very low. These differences lead us to wonder if there are social or protective factors at play and underscore the fact that we need to understand more fully what happens with groups that do well.
• New science is rapidly changing our understanding of lifetime and intergenerational cycles affecting mental health – and the extent to which environmental manipulations can lead to positive changes. For example, recent evidence shows that when a mother rat licks and grooms her pups, it actually changes their brain function and affects how they themselves parent, producing pups that are better parents.⁷ This is supported by other studies that suggest that environmental enrichments can change the brain and have long-term, intergenerational effects – potentially through epigenetic effects.

Dr. Nakamura concluded his presentation by pointing to the continued need to integrate more women and diversity effectively into academic medicine and scientific research. He pointed to the slow growth of women in academic medicine – representing one-fourth of medical faculty members in 1995 and one-third today, and still highly underrepresented among associate and full professors in academic medical institutions. Dr. Nakamura emphasized that greater participation of women, including women of color, is necessary to ensure that the research base reflects gender, racial, ethnic, and cultural diversity not only in the types of topics that are being researched but also in the interpretation of the findings.

“The continued, effective integration of women and diversity in academic medicine and research is essential for ensuring that the research base reflects gender, racial, ethnic, and cultural diversity – not only regarding research topics but also in the interpretation of the findings.” –Richard Nakamura, Deputy Director, National Institute of Mental Health, National Institutes of Health

Like the presenters before him, Dr. Nakamura noted that women’s mental health issues have a personal side that touches every family. He dedicated his thoughts from this meeting to an aunt, who was subjected to a frontal lobotomy during the 1950s as a treatment for her bipolar disorder – and shared the hope with the workshop participants that the continued work of this group and others will ensure that no one will go through that experience ever again.

“It’s time we harness the power of these [scientific] discoveries to offer new hope in both treatment and prevention for women and girls. We have the tools. It’s time to put them to use!” –A. Kathryn Power, Director, Center for Mental Health Services, SAMHSA

A. Kathryn Power, M.Ed., Director, Center for Mental Health Services, SAMHSA told the workshop participants that it is time to change the way we think about, develop, and deliver mental health services. Ms. Power emphasized that the knowledge exists now to make real headway toward the goal of helping women and girls achieve holistic lives of greater self-determination, power, and self-dignity. She argued that we know from the evidence that recovery is possible and that with the right treatments and supports, recovery can be the expected outcome for every woman and girl in America living with mental health conditions.

In order to promote recovery, she added, it is imperative that the woman herself become the director of her own treatment, since only she knows the truth about the conditions of her life. It also becomes imperative that we move from a model focused on illness, acute treatment and symptom mitigation to one that is recovery-focused and strengths-based, since virtually all behavioral health conditions will require environmental or lifestyle changes as well as biological treatments.

Our current mental health services system, Ms. Power argued, has neglected to incorporate respect for and understanding of the unique histories, beliefs, attitudes, and value systems of culturally diverse populations. Our efforts to bring all of the relevant health and human service components to the table to address the totality of women’s health have been haphazard at best – and clouded by stigma and discrimination.

Ms. Power called for an integrated, holistic approach to mental health services that cares for the whole woman. She described this approach as including such things as making routine use of self-administered depression screening tools at primary care clinics, in OB/GYN offices, by breast cancer specialists, and in prenatal and birthing centers to address unrecognized and untreated depression. Ms. Power also noted that in order to take care of the whole woman it is important to take care of her children and to help keep them from getting caught in a cycle of mental illness themselves. She said that a comprehensive, family-based approach to prevention works. She also noted that there are promising treatment strategies for eating disorders that use cognitive behavior therapy methods and involve family members.

Ms. Power also brought up the need to improve systems of care for women in our nation’s jails and prisons, including effective interventions around parenting and child custody issues; services for pregnant inmates; and services and supports to resolve mental health issues related to victimization and violence.

As the Director of CMHS, Ms. Power explained that one of her personal and professional priorities is to open the Nation’s eyes to the impacts of trauma on women’s lives and to the power of recovery. Through the work of its National Center on Women, Violence, and Trauma, SAMHSA is developing leadership networks to spread information about emerging best practices and to stimulate local change. In FY 2006, the CMHS Women’s Coordinating Committee – a group charged with promoting the importance of health issues of women across SAMHSA – is planning a series of activities, including trainings focused on the integration of trauma-informed services in public health facilities. CMHS is making a major investment of resources in the issue of women and trauma, explained Ms. Power. CMHS’s groundbreaking Women and Violence Study is a shining example.

“What do we know about trauma interventions? We know that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts.” – A. Kathryn Power, Director Center for Mental Health Services, SAMHS

Ms. Power also cited the Kaiser Permanente/CDC-sponsored Adverse Childhood Experiences (ACE) Study, which provides strong evidence of a causal link between violence-induced neurological damage, the use of self-medicating measures, the adoption of health risk behaviors, and consequent chronic disabling health morbidity and early mortality.⁸ She noted that the ACE Study is just one example of the substantial body of research investigating the impacts of trauma, particularly on women. Ms. Power emphasized that what we have learned about the pervasive lifelong impacts of violence and trauma in women and children brings urgency to our need to act now.

She supported that statement by offering the following highlights about what is known regarding the impact of trauma:

• Trauma is no longer regarded as an anomalous experience. It is increasingly seen as a widely prevalent experience of public mental health and human service recipients.⁹
• Addressing trauma is increasingly recognized as essential for recovery for other mental health disorders such as substance abuse. Improvement in symptoms such as depression and substance-use disorders will not occur without integrating a focus on an underlying history of trauma.¹⁰
• A recovery-oriented system is not possible if we do not integrate trauma into mental health services.
• The failure to address trauma results in major and costly human service systems failures, such as seclusion and restraint, self-injury in adult criminal and juvenile justice, repeated failures to maintain housing or employment, heavy use of health care services, and suicide.
• Childhood physical and sexual abuse may lead to harmful coping strategies such as dissociation, self-injury, eating disorders, running away, and substance use that may delay development and create a legacy of lifetime disabilities associated with chronic mental health problems, addictions, and major health problems.
• The intergenerational and historical costs of trauma are being increasingly recognized.
• “Treatment as usual” that does not address trauma results in spiraling costs, lack of reduction in symptoms and misery, and continued cynicism regarding recovery on the part of consumers.

Ms. Power went on to discuss effective interventions for trauma. She noted that multi-target, multi-modal treatment approaches and coordinated community responses have had the most positive impacts. She explained that SAMHSA sponsored a five-year Women and Violence Study, which has provided the most authoritative and comprehensive view to date of what can be accomplished in the public health system with women who have histories of physical and sexual abuse, who are in need of services for both mental health and substance-use disorders. She explained that this groundbreaking study featured a trauma-integrated counseling approach that addressed both mental health and substance-use conditions. Findings suggest that integrated counseling (e.g. group and individual therapy that addressed trauma, mental health, and substance-use disorders issues) was the key element associated with better outcomes, which improved significantly over a 12-month period.

“The Report from the President’s New Freedom Commission on Mental Health challenges us to change the way this nation thinks about, delivers, and finances mental health care. It calls on us to create a new, recovery-oriented national mental health system that meets the needs of every American living with mental illness.” A. Kathryn Power, Director Center for Mental Health Services , SAMHSA

Citing the findings and recommendations of Achieving the Promise: Transforming Mental Healthcare in America, the landmark final Report of the President’s New Freedom Commission on Mental Health, Ms. Power said that she saw our Nation as being on the cusp of a new evolution in mental health services. Achieving the Promise, she explained, calls for the creation of a new, recovery-oriented national mental health system that meets the needs of every American living with mental illnesses.

Ms. Power warned, however, that this change will require true transformation – a revolution, as she described it, in how we do things, how we think, and how we work together. She commented that with this type of change, new sources of power emerge that create a profoundly different system that is changed in structure, culture, policy, and programs. 

Embedded in transformation is the core belief in recovery and the belief that adults with mental illnesses can take charge of their own lives, their own wellness, and their own care, said Ms. Power. It is the belief that systems should help children and their families build on existing strengths, foster resilience, and create promising futures.

She described her vision of a transformed mental health system as one in which:

• Services for women and girls will recognize the complex linkages between biology and environment and the role of violence and poverty in health conditions – and new treatments will grow out of this recognition.
• Culturally relevant, strengths-based approaches, which encompass creativity and spirituality and address the unique needs of refugees and immigrants, will be commonplace.
• The power of technology will be tapped to connect women to, and educate them about, the wealth of effective recovery-focused services that are available to them.
• Cooperation and collaboration, noted Ms. Power, are the lifeblood of transformation. She asked the workshop participants at the local, State, and national level to act and to advocate for the comprehensive, coordinated, consumer-centered mental health system that will give women, and all Americans, access to the full range of services they need to recover.

In closing, Ms. Power quoted the American-born Buddhist nun, Pema Chödrön, “Now is the only time. What we do accumulates. The future is the result of what we do right now.” She called on participants to act, one person, one program, one community at a time, so that those actions do accumulate and lead to a point when recovery is the expected outcome for all. She challenged them to seize this moment rife with promise and use the power of it to transform the lives and future of millions of Americans.

“Women should be considered as a special-need or vulnerable group during periods of disaster. Gender role differences and power differentials between men and women must be integrated into disaster preparedness training and planning activities.” – Cheryl Bower-Stephens, Assistant Secretary, Office of Mental Health, Louisiana Department of Health and Hospitals

Cheryl Bowers-Stephens, M.D., M.B.A., Assistant Secretary for the Office of Mental Health, Louisiana Department of Health and Hospitals, described her experience of leading a mental health care system impacted by a severe natural disaster. She noted in her presentation that she was speaking not only as a person in charge of mental health for the State of Louisiana but also as a wife, with a husband who is Director of Health for the city of New Orleans, and as a mother. Through the lens of each of these perspectives, Dr. Bowers-Stephens shared the story and lessons of trying to meet mental health needs in Louisiana before and following Hurricane Katrina.

Prior to the hurricane, Dr. Bowers-Stephens explained, she and others had been planning strategic objectives for transforming the State mental health system to address more fully the need for mental health services. Pre-Katrina State figures indicated that of Louisiana’s 4.5 million people, more than 900,000 were estimated to have a mental disorder – including nearly 180,000 adults and 65,000–77,000 children with a serious mental illness. Of these, only 46,000 were being served by the State Office of Mental Health. Thus, even before the storm, there was a great unmet need for mental health services.

With warnings that the storm was on its way, the Office of Mental Health acted to evacuate psychiatric units and hospitals, said Dr. Bowers-Stephens. She noted that though the public heard mainly about those left behind in New Orleans, it is important to understand that 1.5 million people were evacuated from the city through a huge and largely successful effort. The Office of Mental Health disaster preparedness had included disaster response drills, evaluation plans, disaster training for employees, and a staff callout registry. Prior to and during the storm, multiple command centers were activated; mobile crisis teams and call centers were put into place; Southeast Louisiana State Hospital, Charity Hospital Acute Unit, and New Orleans Adolescent Hospital were evacuated to other systems in eastern and central Louisiana; and special-needs shelters were activated across the State.

Dr. Bowers-Stephens reminded the workshop participants that Hurricane Katrina was the most destructive natural disaster in U.S. history. As a category IV storm with winds of nearly 150 miles per hour, it ripped apart homes, destroyed infrastructure, and toppled hundred-year-old trees like saplings. This was followed by a storm surge of nearly 30 feet, which caused levees to give way and sent people scrambling to rooftops and attics in desperate attempts to avoid the rising water. New Orleans and cities and towns across eastern Louisiana were devastated.

The impact of Katrina on the State’s mental health system was enormous and far reaching, and Dr. Bowers-Stephens presented some numbers to illustrate its severity. She noted the following:

• An estimated 3.2 million individuals were in need of crisis counseling services.
• More than 1 million registrations were submitted for Federal Emergency Management Agency assistance through local parishes.
• Among those moderately exposed to the destruction, estimates are that 5–10 percent will experience clinically significant mental health issues and an additional 5–10 percent will experience subclinical issues that still will require support.
• Among those in severely exposed communities, an estimated 25–30 percent of the population can be expected to experience clinically significant issues, with an additional 10–20 percent experiencing subclinical ones.

While these numbers are significant, Dr. Bowers-Stephens explained that the impact of Hurricane Katrina was particularly severe for women. She noted that research on gender and natural disasters has found that women are more vulnerable than men in these situations and indeed should be considered a “special population.” This is due to a host of historical, social, cultural, and societal factors, such as domestic and economic burdens, lower incomes, lower social status, male flight, and increased risk of violence and abuse.³ In addition, women face an interaction of biologic and social risk factors, such as a higher baseline prevalence of depression and the risk of adverse reproductive events (e.g., there were numerous premature deliveries during and after Katrina).

Dr. Bowers-Stephens pointed out that the research evidence was indeed confirmed in the case of Katrina and its aftermath, where women were left behind by men to take care of the family, meet immediate survival needs, and face the risks of disorganization and increased violence that characterized the post-storm situation in New Orleans. Dr. Bowers-Stephens noted that with her husband immediately called to the Superdome, she herself was left to make the family decisions regarding where to evacuate with their three children to meet both her family and professional responsibilities.

Dr. Bowers-Stephens highlighted the fact that there are many important lessons that should be drawn from the experiences of Hurricane Katrina in terms of emergency planning and preparedness. Specifically, she offered the following recommendations:

• Anticipate postdisaster male flight in disaster preplanning, including first responder support. Ensure that there are special supports for women and families (e.g., there were no schools or day care on the cruise ships supplied for evacuees in New Orleans).
• Ensure that specific structures, policies, and procedures are put into place to address postdisaster domestic violence and sexual assault prevention and intervention.
• Institute policies to support the care of children. More than 1,000 children were listed as missing after Katrina and many were separated from their families. Predisaster planning must address the need to prevent family separations and lost children.
• Teach families to be prepared. Incorporate messages into public health policies and messages about the importance of making emergency plans as a family before disaster hits.

Dr. Bowers-Stephens concluded by noting that the lessons of Hurricane Katrina must serve as a timely reminder of the critical need to incorporate gender into emergency preparedness planning and training.

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Breakout Group Sessions

Each participant in the Surgeon General’s Women’s Mental Health Workshop was assigned to one of eight workgroups. The basis for these assignments was not associated with individual specialties or areas of interest; rather, it was designed to ensure diversity and even numbers across each of the workgroup topic areas. These topic areas reflected the eight “cluster areas” identified through the series of background activities leading up to the workshop. As described above, these activities included a concept mapping exercise, key-informant interviews, facilitated discussions, and a targeted literature review. The breakdown of the eight workgroups was as follows:

Group 1: Biological and developmental factors

Group 2: Specific mental disorders

Group 3: Trauma, violence, and abuse

Group 4: Social stress factors and stigma

Group 5: Identification and intervention issues

Group 6: Treatment, access, and insurance

Group 7: Health systems issues

Group 8: Protective and resilience factors

The workgroups were given the task of addressing three major objectives. These included:

• Objective 1: Review and prioritize the significant issues affecting the mental health of women and girls within the identified cluster area.
• Objective 2: Develop practical recommendations for the production of communiqués and toolkits related to the issues of that cluster area.
• Objective 3: Prepare a series of PowerPoint slides highlighting three key priority issues from the cluster area. In addition, for each key priority issue identify the major messages, suggested format, target audience, dissemination strategy, funding sources, and any overarching cultural concerns to be taken into consideration.

Each workgroup was composed of 12–14 participants and facilitated by two individuals, including one Federal representative and one expert from the field. The facilitators conducted introductions, reviewed the workgroup objectives, and conducted a prioritization exercise to determine the highest priority issues within their cluster area. A list of potential communiqués and toolkits, based on recommendations from the background leadership interviews and facilitated discussions, was distributed to the workgroup members to spur ideas and discussions. This list is included in Appendix B.

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Workgroup 1: Biological and Development Factors

The Biological and Developmental Factors Breakout Group was given the list of issues to prioritize indicated in the following box.

Defining sex and gender

The group began with a discussion of the distinctions between sex and gender, leading to the following definitions: Sex is a biological construct defined by the organs with which a person is born. It changes little over time or across different cultures. In contrast, gender is a societal construct that reflects a person’s sex as it figures in a context of culture, family, and social environment.

It was noted that these definitions are further complicated by the need to incorporate lesbian, gay, bisexual, and transgender (LGBT) concerns.

The role of biology versus environment

A major point of discussion for the group was the role of biology and the question of whether biology should be viewed separately or within a social context. The point was made that biological factors often unfold in a way that is influenced by the environment. However, as one researcher noted, some mental illnesses are responsive to medical treatment, so that the role of biology cannot be ruled out – especially since much information has been gained through studies and clinical trials on the role of biology. This raises the issue, which constitutes an ongoing debate between scientists and advocates, regarding who should be the source of expertise.

Taking a life span approach

It was noted that while the morning workshop presentations had focused on adults there also is a need to understand and transmit the message that women and girls are not the same. The importance of looking across the continuum of women’s lives and taking a life span approach to mental health issues was highlighted. Workgroup members also commented on the importance of acknowledging that there are critical high-risk periods during a woman’s life when mental disorders are more likely to occur. This concept of a life span approach was threaded throughout the workgroup’s discussions and ultimately was identified as a priority issue.

Following this discussion, the group was able to synthesize and redefine three priorities from the eight under consideration. Their resulting key priorities are listed below.

Key Priority #1: Understanding the biobehavioral bases of sex and gender differences as related to mental health

Discussion

It was suggested that there is a dearth of research regarding sex and gender differences in the brain and that the brain must be understood before addressing environmental factors. The group discussed the need for a clear understanding of cognitive processes, emotions, and interpersonal functioning.

Audiences

Participants discussed the need to address several different audiences, including the medical research community, the general public, and policymakers. One suggestion was that messages targeting policymakers also could be put into language for the general public. There also was discussion about targeting specific audiences within the general population, such as families, teachers, and researchers. In the end, the group agreed to target two primary groups comprised of:

• The general public
• A combination of policymakers, research funders, providers, and trainers

“Clinical experience is an essential part of evidence-based practices. What is lacking now is an understanding of the full scope of the existing evidence base. There is a tension between clinical and empirical data. The clinical data on biological differences may be stronger than most suspect, even if there is a shortage of empirical data.” – Breakout group member

Messages

The group crafted several messages, adapted to different target audiences. These include the following:

Message to the general public

Biobehavioral factors underlie sex and gender differences in the way people think and feel.

The point was made that the sex and gender differences referred to in the above message would have to be further specified and demonstrated.

Message to policymakers

Biobehavioral differences between men and women are known through a small but growing body of research. Greater knowledge will enhance our capacity to understand the etiology, treatment, and prevention of mental health issues and to inform sex and gender based prevention and treatment efforts.

Message for all audiences

Greater knowledge will enhance our capacity to understand the etiology, prevention, and treatment of mental health disorders and to inform sex and gender based prevention and treatment strategies.

Formats

The group’s recommended formats included:

• A report including facts and implications of sex and gender differences that also would include a list of organizations supporting sex and gender specific treatment and awareness
• A pamphlet, which would accompany the report and include empirical data on selected mental health conditions for ethnic minorities and underserved populations

Cultural Concerns

Participants noted the importance of having providers, the general public, and trainers understand that mental health symptoms manifest differently for ethnic minorities. Gaps in care for minorities need to be addressed as well, it was argued, though there is concern that the existing data are uneven. One participant shared the information that several fact sheets already exist on the topic and can be obtained through the Society for Women’s Health Research.

Key Priority #2: Taking a life span approach to understanding sex and gender differences in the etiology, course, and high-risk periods of mental health conditions

Discussion

One participant emphasized the importance of examining the ways in which different periods in a woman’s life affect her mental health; another added that mental health problems carry different economic, social, and personal costs at various points of the life span. The point was also made that there are sex and gender differences in the etiology, course, and high-risk periods of mental health conditions over a life span.

It also was noted that taking a sex and gender based approach to mental health can be beneficial to both men and women, including understanding more about what causes mental health problems at different times in a person’s life.

Audiences

The group worked to identify key periods of the life span, which deserve special attention regarding mental health concerns. Members agreed that in tailoring the message across the life span, the following audiences should be targeted:

• Adolescents
• Postpartum mothers
• Parents
• Caregivers
• Researchers
• Policymakers
• Providers

Messages

The group crafted several messages, adapted to different target audiences. These include the following:

Message to the adolescent audience

Early puberty is a high-risk period for specific mental disorders.

Message for all audiences

Research shows that important events and times of a woman’s or girl’s life increase the likelihood of developing a mental disorder. Sex and gender specific prevention and treatments targeted to specific events across the life span are more effective.

Formats

The group brainstormed about ways to reach the various age-group audiences. One participant emphasized the importance of bringing the message to the audience, rather than expecting the audience to request a Surgeon General publication. Suggested potential venues for reaching different audiences included:

• Web sites
• MTV and informational programming concerning emotional crises
• Public service announcements that could be delivered through community centers and churches, especially targeting adult women
• 1-800 phone numbers

Cultural Concerns

Participants noted that any materials produced should be translated into multiple languages. Furthermore, they recommended that the message should consider and incorporate cultural concerns and mores and be disseminated in age and culturally appropriate settings.

Key Priority #3: Understanding male and female differences in biobehavioral response to psychotherapeutic and behavioral mental health treatment (including efficacy, side effects, and compliance)

Discussion

Participants noted that there are new treatment models that are person centered and others based on a social model of disability. It is important, they commented, for the general public to know that treatment models are transitioning; women have the right to multiple options and should assert themselves when it comes to their own treatment.

Further points that were raised on this topic included the following:

• There are multiple treatment options, and it is important to understand that what works best for women might differ from what works best for men.
• There are limited data suggesting that the response to a given treatment may differ among men and women. More research is needed that is not merely secondary analysis.
• There are choices for treatment that allow consumers to pursue different options if a particular treatment is not working. Having options is empowering to the consumer.
• An important takeaway is that there are a variety of treatments available that may or may not be influenced by sex and gender.

The group worked to identify health issues germane to women that should be considered when receiving mental health treatment. Their list included:

• The menstrual cycle
• Menopause
• Medications
• Pregnancy
• Age-related hormonal fluctuations

Audiences

For issues related to sex and gender differences, the group identified the following audiences:

• Educators
• Researchers
• Members of the general public
• Providers – with special emphasis being placed on mental health providers

Messages

The group crafted one message for all audiences:

There is evidence that interventions may have different effects on men and women with selected mental health conditions. Women should be aware that a variety of treatments are available and should be encouraged to pursue the ones that best meet their needs.

Formats

The workgroup identified the following channels for disseminating the message:

• Following the Bodywise Model (developed by OWH) – producing and adjusting a two-page fact sheet to target specific audiences
• Using the 4-Women Web site (developed and maintained by OWH)
• Listservs
• Information Clearinghouse – developing a high-level, government-supported clearinghouse of information that the public could access.

Cross-cutting cultural concerns

In formatting the message, the group discussed how to incorporate culturally sensitive and accurate material. They recognized that cultural attitudes may cause shame and associate stigma with mental illness. There was agreement that the message should include information regarding different ethnicities’ responses to treatment and incorporate and validate the use of alternative healing methods.

Workgroup 1 Participants

Facilitators:

Cora Wetherington, Ph.D., National Institute on Drug Abuse
Kimberly Yonkers, M.D., Yale University School of Medicine

Participants:

Cheryl Bowers-Stephens, M.D., M.B.A., Louisiana Department of Health and Hospitals
Sylvia Caras, People Who
Nereida Correa, M.D., Albert Einstein College of Medicine
Mary Gee, B.A., Eating Disorders Coalition for Research Policy and Action
Melva Green, M.D., American Psychiatric Association
Phyllis Greenberger, M.S.W., Society for Women’s Health Research
Gail Hutchings, M.P.A., SAMHSA
Nadine Kaslow, Ph.D., Emory University School of Medicine
Ruby Martinez, R.N., National Latino Behavioral Health Association
Caroline Mazure, Ph.D., Yale University School of Medicine
Richard Nakamura, Ph.D., National Institute of Mental Health
Eileen Ouellette, M.D., J.D., FAAP , American Academy of Pediatrics

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Workgroup 2: Specific Mental Disorders

The Specific Mental Disorders Workgroup was given a long list of issues to consider. They were asked to prioritize 3 from the 20 presented in the box below.

Language and stigma

The group began by discussing the consequences, both positive and negative, of diagnosing and assigning a title to an individual’s symptoms. Some voiced concerns that certain diagnoses carried a stigma that might prevent women from seeking treatment – especially in some ethnic communities. The question was raised regarding whether consumers were being pathologized by terms such as “disorders”. There was a push by some participants to be less label-oriented in favor of being more distress-oriented or reframing issues in a more positive way; for example using terms such as “seeking peace”.

Others were in favor of embracing a diagnosis. One participant suggested the creation of a crosswalk that could expand the understanding to incorporate physical symptoms and subsequently a more holistic view of a given disorder.

Another comment was that more consideration should be given to thinking outside the box. The concern was voiced that consumers would not pick up a pamphlet titled “Mood Disorders” voluntarily – underscoring the need for tools besides labels and diagnoses to reach the targeted audiences that may already be underserved.

Ultimately, it was noted that the two approaches were not incompatible in terms of disseminating the message. Emphasizing the importance of targeting particular audiences, the suggestion was made that educational materials could be tailored for primary care providers; an overall piece could be crafted to address mental health in relation to overall well-being; and a third educational piece could target communities with high prevalence. It was pointed out that there needs to be a balance between the two approaches and emphasis placed on disseminating specific information.

“There is a need for alternative tools besides labels and diagnoses to reach targeted audiences who may already be underserved. Otherwise, if all you have is a hammer, everything is going to look like a nail.” – Breakout group participant

Prioritizing the issues

After much discussion about cross-cutting issues, audiences, and what types of tools might be most effective coming from the Surgeon General, this workgroup ultimately identified three major areas of concern:

1. Mood and anxiety disorders, including cross-cutting themes such as culture, faith, family, resiliency, and available treatment options
2. Trauma, including such cross-cutting themes as culture, recovery, and resilience
3. Co-occurrence of mental disorders with medical issues

Overall audiences and messages

The workgroup identified several cross-cutting themes:

• Culture is an essential consideration.
• Promotion of resilience is an important goal.
• Critical life events can challenge coping.
• Mental health is essential to overall health.

Although the workgroup identified three major age groups as their primary focus for the development of communiqués and toolkits, they also noted the need to address multiple audiences with messages regarding each of these age groups. Those audiences included not only consumers and members of the public but also providers and policymakers.

There was considerable discussion about the types of messages to be conveyed to different audiences – particularly for the general public and underserved audiences. The concern was expressed that messages should be crafted in a language that people use and can understand, and that is culturally appropriate. For example, one person noted that most people do not use many of the terms used in the list of priority issues; they refer more to terms such as “illness”.

Another participant commented that patients do not care about their Beck Depression Inventory score but rather about whether or not they can get up in the morning. This led to the suggestion that messages be reviewed from the bottom up to ask people themselves in venues such as peer-to-peer interviewing questions such as “How do they understand the message?” and “Do we need to develop different tools?”

Building greater communication between providers and consumers

Another point raised was the need to design tools that could help build bridges between providers and consumers. This was seen as important in helping to move the clinical community to be more responsive and communicative with consumers. It was suggested that this would mean not only incorporating consumer terms into provider materials, but also including clinical terms in materials for consumers. One person added, however, that in order to get providers to pay attention to messages, “you have to come with a hammer” with substantive information and with strategies such as incorporating messages or changes through credentialing bodies or CME credits.

Translating research and best practices into practice

The issue of how information is translated from research into practice was discussed. The point was made that there is a dearth of hard information on knowledge transfer and that anecdotal evidence would suggest that the translation is not occurring. This led to the suggestion that more information is needed on what it takes for people to become comfortable with a tool, what works, what does not, what should be replicated, what type of training is needed, and where information is distributed.

The hope was shared that the bully pulpit of the Surgeon General would offer a greater opportunity to be heard and discuss mental health in terms of whole health. The suggestion was made that messages with the backing of the Surgeon General then could be distributed through the pipelines and networks of existing organizations – including those represented at this meeting.

Looking across the life span

As a result of the discussion of specific mental disorders, cross-cutting themes, and target audiences, members of the workgroup began to move toward a developmental and life course approach. Thus, rather than prioritizing specific disorders from the given list, participants felt it was important to give priority to different age ranges and life transitions, emphasizing how those relate to the risks, course, prevention, and treatment of these disorders.

As a result, the group agreed to prioritize their message, audience, and suggested communiqués or toolkits according to three age ranges, including childhood and adolescence, adult women, and older women. These age groups became the framework for the discussion of specific products and the focus of the group’s identified priority areas, as indicated below.

The group discussed issues related to particular age groups, such as the importance of focusing on prevention with children and youth. They also looked at issues that cut across different age groups, such as the importance of mental health to overall health. The point was made that this workshop presented an opportunity to get away from the usual silos, defined by funding streams, to make a more integrated, holistic-oriented product.

Key Priority #1: Communiqués and toolkits focused on children and adolescents

Several participants viewed the period of childhood and adolescence as an important one for promoting resilience and prevention. They noted that effective toolkits for girls exist – including tools for at-risk girls – that are designed to help build self-esteem and self reliance. It was noted that these types of toolkits would be given more force if the Surgeon General was behind them.

Another topic that generated discussion had to do with girls and young women who are at risk or already living with mental or co-occurring disorders, including those who may not make it always onto the radar screen (e.g., runaways, the growing population of young women in junior college). Several life events and challenges were identified as being particularly associated with this age group, including the effects of trauma, illness, and family breakup or loss. The positive and negative coping mechanisms that girls employ in the face of the challenges were discussed, including behavioral problems, substance abuse, mood symptoms, and resilience.

Message

The key message for materials focusing on this age group was:

Mental health is essential to health.

Audiences

The identified audiences for this message include:

• Consumers
• Family members
• Health care providers
• Policymakers
• Educators

Dissemination strategies to reach these audiences were mentioned, such as working through schools, teacher associations, and parent-teacher associations.

Formats

The suggested formats include:

• For girls: Information downloadable to an iPod and Web-based tools
• Toolkits for group facilitation
• For parents: Educational kits
• For teachers and parole officers: toolkits
• For providers: Continuing education units (CEUs) and Board exams

Cross-cutting cultural concerns

The priority cross-cutting cultural concerns highlighted by this group included:

• The need to improve the pipeline of minority providers
• The need to increase the understanding of cultural and age-specific modes of expression among providers, teachers, and others who interact with children and adolescents

Key Priority #2: Communiqués and toolkits focused on adult women

Message

The key message for materials focusing on this age group was:

Mental health is essential to overall health. Recovery is the goal.

Audiences

A wide audience was identified for this message, including:

Consumers, families, faith-based organizations, providers, policymakers, employers, community organizations, women’s groups, child care providers, criminal justice system, educational institutions, welfare-to-work programs, peer educators and lay home visitors, public housing, vocational rehab programs, AARP, and caregivers

Formats

• The suggested formats to reach the identified audiences with the identified message include:
• Visual, nonliteracy materials (e.g., film, video, sound)
• Facilitator’s guides (e.g., tool associated with a video) designed with something to deal with emotional reactions that may be triggered through use of this tool
• Self-assessment tools
• Print materials, including multi-language and low-literacy products

Cross-cutting cultural concerns

One focus of discussion on this topic was the need to understand points of intervention for particular groups of women. For example, it was noted that self-determination and self-reliance are key within the African-American community and lack of these can be seen as a real failure. Thus, to break down stigma, it is important that mental health tools be adapted to different cultural groups in ways that address how they view mental health and illness.

The group stressed the importance of ensuring that tools are reviewed and developed by members of specific communities and cultures – and that these reflect knowledge of how individuals can be reached within their cultural context. Examples were shared of materials that successfully bridge different cultures, such as the book Woman Who Glows in the Dark, which was written by Elena Avila, a nurse who practiced both Western medicine and indigenous folk healing.

Key Priority #3: Communiqués and toolkits focused on older adult women

Message

The key message for materials focusing on this age group was:

Mental health is essential to overall health. Good mental health is possible even in the absence of good physical health.

Audiences

Numerous audiences were identified for this message and this age group. They included:

AARP; employers; nonclinical retirement communities; faith-based organizations; beauty parlors; bingo parlors; adult day care centers; community services for the elderly; areawide Agency on Aging; nursing centers and assisted living centers; and public health services, such as Medicare, SSI, and Medicaid

Formats

The recommendations regarding formats included:

• Large-print materials
• Audio and low-vision materials
• Information that is short and sweet
• Videos
• PSAs (celebrity voices may resonate more with harder to reach populations)
• No acronyms
• Color contrast
• Storytelling and oral histories

Cross-cutting cultural concerns

A number of issues were identified as relating particularly to this group. One set of issues had to do with generational differences, respect for elders, caring for other family members or being cared for by family members, and end-of-life concerns. Others included issues of poverty and restricted income, privacy, indirect communications, and the use of multiple medications.

Opportunities for collaboration

This topic generated considerable discussion and development of partnering opportunities. Suggestions regarding potential funders and partners included:

• Private foundations (e.g., Kaiser, the Robert Wood Johnson Foundation, the Commonwealth Fund, Pew, Ford)
• National Foundation for Mental Health
• American Psychological Association
• National Association of Mental Health
• Business partners such as Estee Lauder, Ford, The Body Shop, Avon, Amway, and Tupperware
• Interdisciplinary partners, such as the National Hispanic Medical Association, National Hispanic Nurses Association, and faith-based groups, women’s organizations
• Accreditation organizations
• Women’s athletics organizations
• International groups that have shown an interest in mental health and women (e.g., World Bank, WHO, the United Nations)
• Educational organizations
• Migrant centers
• National Association of Commissioners for Mental Health
• National spokespersons, such as Oprah Winfrey or the head of women’s health for Aetna

Workgroup 2: Participants

Catherine Roca, M.D., National Institute of Mental Health
Ellen Frank, Ph.D., University Of Pittsburgh Medical Center

Participants:

Andrea Blanch, Ph.D., Center for Women, Violence and Trauma
Silvia Canetto, Ph.D., Colorado State University
Linda Chaudron, M.D., M.S., University of Rochester
Judith Cook, Ph.D., University of Illinois at Chicago
Helen Coons, Ph.D., Women’s Mental Health Association
Charlene Doria-Ortiz, Center for Health Policy Development, Inc.
Linda Frisman, Ph.D., University of Connecticut
Susan Gorin, C.A.E., National Association of School Psychologists
Barbara Hylard, Depression and Bipolar Support Alliance
Frances Murphy, M.D., M.P.H., Veterans Health Administration and President’s Mental Health Initiative
Linda Prescott, Sister Witness International
Barbara Yee, Ph.D., University of Hawaii

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Workgroup 3: Trauma, Violence, and Abuse

The workgroup was presented with a list of seven topics from which to identify key priorities. They are listed in the box below.

Defining trauma

There was considerable discussion based on this list regarding the need to broaden the definition of trauma, violence, and abuse to include things such as impersonal trauma (e.g., effects of war, natural disasters) and the impact of trauma, violence, and abuse on productivity, business, and the workforce. Similarly, several participants commented on the need to look at trauma, violence, and abuse within the cultural, historical, and political context of how and where they occur – not just as isolated incidents. They also considered the role of poverty as a context – though the group agreed that poverty was a mediating, not a causal, factor associated with these events.

Provider concerns

Another topic that generated a great deal of conversation centered on developing tools for providers to enable them to appropriately assess trauma, violence, and abuse. Participants noted that providers, particularly general practitioners, need a better understanding of how to ask questions about trauma, violence, and abuse and what to do with the answers – especially since they may be the only providers that consumers encounter. Several participants explained that there are many myths and misconceptions about how to deal with individuals who have suffered these events, and providers worry about such concerns as whether consumers will fall apart, how to develop a trusting atmosphere, and whether a provider should show emotional reactions. Participants expressed the need to develop tools and protocols that providers can use to deal with the fallout of a revelation of past trauma, violence, or abuse.

“Providers don’t want to open that can of worms [assessing trauma, violence, and abuse], because they do not know how to deal with it and don’t have the referral services necessary. They need protocols to know how to ask the questions and deal with the fallout.” –Breakout group participant

One participant noted that in her experience, it is easier to inform criminal justice workers about trauma, violence, and abuse than it is mental health professionals. Another participant added that it is not possible to train all providers to become trauma professionals. There are three levels of awareness regarding trauma: trauma aware, trauma sensitive, and trauma competent.

The group further reviewed the issues to prioritize to see if some could be eliminated or condensed. They discussed the need to add elder abuse and emotional abuse to the list of issues under the top priorities. Ultimately, the workgroup agreed to highlight the following three priority areas.

Key Priority #1: Developmental and mental health effects of trauma

Message

There was a great deal of discussion about defining a message for this priority area, starting with the need to define trauma. Other points that participants wanted to convey in the message touched on the idea that trauma harms us all, that recovery is possible and widespread, and that people who have experienced trauma should not feel ashamed or at fault.

Several participants commented on the fact that there is a lot of shame associated with being abused (or being an abuser) and that the message of this key priority would need to be reassuring, empathy building, and presented in a way that victims of abuse will not immediately reject.

The suggestion was made that the goal of the message should be to help change behavior, including for individuals at the precontemplative stage of change (i.e., those who have no intention of changing their behavior in the near future). One individual noted that the message needs to be brought to peoples’ doorsteps and shaped to resonate with the target audience. Thus, one angle that was suggested was to talk about safety and how violence, abuse, and trauma affect all aspects of our lives (e.g., how we work, how we learn, how we raise our children). In the end, the group agreed that the message should do the following:

• Define trauma
• Recognize the prevalence of trauma
• Convey the message that recovery is possible
• Use a common language that is directed to the individual and community level to take action
• Put a human face on trauma

Audiences

There was much discussion of potential audiences for a Surgeon General’s communiqué on violence, trauma, and abuse. Some of the suggestions included State mental health commissioners or governors, social workers, churches/faith-based organizations, individuals and communities, other sectors (e.g., business), and the general public. Eventually, the group decided to focus on two priority audiences:

• The general public (at the individual and community levels)
• Providers (from multiple sectors)

Format

The workgroup participants proposed that the format of this communiqué take the form of a two-step process:

Step 1: A letter from the Surgeon General to the general public addressing the centrality of trauma, violence, and abuse in women’s lives. It was suggested that this letter could go out to every household, similar to the Surgeon General’s letter on HIV/AIDS that was disseminated in the 1980s.

Step 2: A series of follow-up activities that could include PSAs targeted to specific audiences, toolkits, an Institute of Medicine (IOM) report on trauma, fact sheets on the myths and misconceptions about trauma, an emphasis on in-service training, and State trauma plans (as integrated into State mental health plans).

Many potential resources and models were cited by workshop participants to help guide the development of communiqués, including:

• The 1986 Surgeon General’s letter on HIV/AIDS
• Lessons from breast cancer campaign models
• A domestic violence campaign through hairdressers
• Real Men and Real Depression Campaign
• Trauma certificate program at the University of Maryland
• The Ohio business case on mental health report, soon to be released

Key Priority #2: Integration of mental health and overall health

The group discussed the question of how to address what some participants referred to as “a mind/body breakdown” – or the prevailing tendency to separate mental health and overall health in language, financing, service delivery, and common perceptions. The point was made that this separation increases stigma. The group grappled with developing suggestions on how the Surgeon General could address the issue of needing to integrate mental health more fully with overall health and stress the interoperability between the two.

Message

Numerous issues were raised during the discussion of how to frame a message, or several messages, related to the mind/body connection and importance of mental health to overall health. The first had to do with making the case for the connection and integrating the two as part of overall health. There was much discussion on the topic of the stigma associated with mental health. One participant noted the need to explain to people that there is a “range of normal or healthy behavior.”

Another suggestion was to look at the use of stigmatizing language associated with mental health issues; for example, one person commented, we never hear of “serious cancer,” so why refer to a “serious mental disorder”? Similarly, the point was made that the terms mental and substance use conditions carried less of a stigma than terms such as mental disorder and substance abuse. Ultimately, the group crafted the following messages related to addressing the mind/body dichotomy:

• Mental health is an essential part of overall physical health.
• There is no separation among the mind, body, brain, and behavior.
• There is a need to develop psychological literacy around the mind-body connection.

“We never hear of a serious cancer, so why refer to a serious mental disorder?” –Breakout group participant

Audiences

Participants felt that communiqués should be developed for the general public as well as for providers from multiple sectors. In addition, workgroup members highlighted the importance of reaching out to particular age groups that may be traditionally underserved or left out. Specifically, the group proposed to focus on:

• Younger audiences (e.g., through Boys and Girls Clubs, 4H, etc.)
• Older adults, who may be particularly affected by issues of stigma and could benefit from more understanding about the mind-body connection

Format

Several ideas regarding formats were proposed, including:

• Fact sheets on how the brain works – on how psychosocial factors affect the brain and how that affects behavior
• An animated version of how the brain works for children and youth (e.g., the blue part of the brain reacts like this when this happens)
• An interactive video

Resources

The workgroup raised the question of how to leverage other groups that are addressing some of these mind-body issues (e.g., anger management).

Key Priority #3: Effects of emotional abuse

Message

There was considerable discussion regarding how to convey messages about the importance and severity of the consequences of emotional abuse, which some participants also referred to as “soul murder”.

Participants shared thoughts and concerns regarding the effects of emotional abuse – how it negates one’s existence, damages self-esteem, and can be as damaging as or worse than physical or sexual abuse. They also noted the difficulties of getting people to recognize the importance of emotional abuse; for example, one workgroup member commented that Child Protective Services will respond to cases of physical or sexual abuse but, when it comes to emotional abuse, will say that it “is not really going to stand up.” One person cited the work of Maxine Harris (e.g., Trauma Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups) as a good resource on the damaging effects of emotional abuse.

Workgroup members also talked about the role of emotional abuse in the context of sports. They discussed the need to train athletes to talk to kids and teach about rules and understandable lines that need to be respected. Participants noted the importance of teaching children and youth that you can act both aggressively on the field and respectfully off the field.

Although they found it difficult to define emotional abuse and craft succinct messages, the workgroup did come up with three key messages regarding emotional abuse, including:

• Emotional abuse is “soul murder”.
• Emotional abuse includes neglect, which is the “violence of silence”.
• Emotional abuse negates your existence.

Audiences

The following audiences were identified for messages relating to emotional abuse:

• Students
• Parents
• Older adults
• Coaches
• Teachers

Cross-cutting cultural concerns

Several workgroup members grappled with the question of how the definition and concept of emotional abuse may differ across diverse cultures (e.g., effect of spanking) and through the process of acculturation. They noted that there was a tension between what may be accepted in a particular culture and what may be personally damaging. As one participant commented, “Simply because something is accepted by a cultural group does not mean that it is right.”

The group discussed the importance of education, helping to identify what is abuse, and giving parents – including those who honestly believe that they are doing what is best for their child – an alternative that might be better. Participants also acknowledged the flip side of this type of awareness and education. For example, one workgroup member explained the risk of having a woman who suddenly learns that what she has been experiencing in her family is abuse but who is then disowned by her family, because they do not believe that their behavior toward her is inappropriate.

Dissemination

The group came up with numerous suggestions regarding strategies for disseminating messages about emotional abuse. These included:

• Having the Surgeon General include in his speeches that emotional abuse is a serious issue that needs to be addressed
• Developing a fact sheet including a definition of emotional abuse, prevalence, and examples
• Developing a film about emotional abuse
• Developing a CD-ROM teaching tool with a discussion guide
• Developing illustrative vignettes
• Getting these messages into pop culture (e.g., reality shows, Superman, etc.)
• Developing a list of how to identify emotional abuse for different age groups

Workgroup members also cited numerous opportunities that they saw for building on existing vehicles or venues to further disseminate messages about emotional abuse. These included:

• Building on the clearinghouse capacity of the newly formed Center on Women, Violence, and Trauma
• Increasing knowledge about what is already out there, such as existing clearinghouses and resources
• Developing an article (brief summary) about this Surgeon General’s Workshop on Women’s Mental Health that can be used for developing activities around women’s health month
• Developing a cadre of responders for the aftermath of crisis – possibly taking the form of a National Guard of Responders composed of individuals interested in helping to address trauma
• Supporting current leaders and developing emerging ones (e.g., on college campuses, in research positions at the NIH or the CDC) to carry the trauma message forward

Workgroup 3: Participants

Facilitators:

A. Kathryn Power, M. Ed., Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
Rene Andersen, M.Ed., Center on Women, Violence, and Trauma

Participants:

Elizabeth Clark, Ph.D., M.P.H., ACSW, National Association of Social Workers
Susan Cochran, Ph.D., University of California, Los Angeles
Rachele Donnell, R.N., Red Lake Comprehensive Health Services
Rachel Fleissner, M.D., American Academy of Child and Adolescent Psychiatry and University of North Dakota
Joan Gillece, Ph.D., National Technical Assistance Center, National Association of State Mental Health Program Directors
G. Grijalva-Gonzales, Substance Abuse Services, San Joaquin County Health Care Services
Maxine Harris, Ph.D., Community Connections
Ruta Mazelis, Cutting Edge Newsletter, Sidran Institute
Pamela Mulder, Ph.D., Marshall University
Susan Nolen-Hoeksema, Ph.D., Yale University
Karen Peterson, M.D., Uniformed Services University of the Health Sciences
Rick Peterson, Ph.D., Texas A&M University, National Association of Rural Mental Health
Carole Warshaw, M.D., National Training and Technical Assistance Center on Domestic Violence, Trauma, and Mental Health

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