How Should We Help the Seriously Mentally Ill?

by D. J. Jaffe
Two mental-health bills. Two different parties.

This week, President Barack Obama and Representative Tim Murphy (R., Pa.) used the anniversary of the shootings at Sandy Hook to unveil two very different views of how to serve the mental-health needs of Americans. President Obama announced $100 million in incremental spending in the usual way: more mental-health facilities and programs. The mental-health industry cheered.

Representative Murphy, a psychologist who knows what he’s talking about, announced something different and more exciting. He used the Energy and Commerce Subcommittee on Oversight and Investigations to find out where spending money would do the most good. The result is a bill that would restructure certain parts of the federal mental-health system so it focuses on serious mental illness rather than mental “health.”

He came to that conclusion because, unlike President Obama, he listened to people from outside the mental-health industry, like Joe Bruce. Mr. Bruce tried to get hospital care for his mentally ill son, William, but the federal government gave William a lawyer who “freed” him from care. Shortly thereafter, while psychotic, William killed his mother, Joe’s wife. That program continues to receive federal funding. Representative Murphy listened to leading mental-health-industry critics such as Dr. Sally Satel and Dr. E. Fuller Torrey.

In 2014 U.S. spending, public and private, on mental health will total $203 billion. Because of mission creep and lack of coordination among agencies, the funds are now spent by the unregulated mental-health industry on “improving the mental health” of all Americans rather than focusing on the 5 to 8 percent with serious mental illness. Throwing money at mental health, as Obama proposes, will not result in more funds’ being spent to treat those with serious mental illness, because the mental-health industry disguises worthy social-service programs, like helping people get better grades, find better jobs, and feel more empowered, as mental-health programs to gain access to the mental-health budget. Rather than concentrating on delivering treatment to those with serious mental illnesses, such as schizophrenia and bipolar disorder, they deliver improved happiness to the 25 to 40 percent they claim have “mental health” issues.

The industry now routinely, regularly, unabashedly classifies ordinary life experiences like being unhappy, having an unsatisfactory marriage, experiencing the death of a loved one, or this year’s favorite, bullying, as major unmet mental-health challenges that the federal government should fund. Meanwhile those who have serious brain disorders are left to sleep on street grates and forage in trash bins for food. Some 200,000 are homeless, 300,000 are incarcerated, and many are living hellish lives locked inside hallucinations, delusions, and paranoia, contemplating how to take their own lives.

President Obama would never let the banks write his tax policy, but he has no problem letting the mental-health industry write his mental-health policy. Rather than funding mission creep, Representative Murphy focuses on mission control. When President Obama took office, he said he would listen to good ideas wherever they came from. Representative Murphy has good ideas. The two of them should talk.

Following are some of the proposals Representative Murphy has included in his Helping Families in Mental Health Crisis Act.

Restructuring government agencies

Create within the Department of Health and Human Services an assistant secretary for mental health and substance-abuse disorders. This official’s job would be to coordinate services and reduce duplication and mission creep across the innumerable government agencies that have an interest in the issue. The assistant secretary will ensure that resources go to the most effective treatments, programs, and research — specifically, those that improve outcomes for people with serious mental illness. The administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) will report to the new assistant secretary.

Increase the role of criminal-justice personnel in developing mental-health policy. Representative Murphy proposed creating an advisory board to the new assistant secretary. Admittedly, a new federal advisory board is rarely something to cheer, and when such boards are populated by the mental-health industry, the “solutions” focus on improving mental health, not treating serious mental illness. This “eyes-off-the-prize” strategy has led to three times as many Americans’ being incarcerated with mental illness as hospitalized. As a result, police, sheriffs, district attorneys, and corrections officials, rather than mental-health officials, have become the strongest advocates for improved treatment for the seriously mentally ill.

Representative Murphy’s bill gives these officials a strong role in the new advisory board. In addition to the usual mental-health personnel, the membership will include a person with serious mental illness; a family member of someone with serious mental illness; and a judge, a law-enforcement officer, and a corrections officer. It also allocates money to the attorney general, the FBI, and the comptroller general to track data on the role of mental illness in attacks on officers and justifiable homicides by law enforcement. It provides funds for collecting data on the cost of incarcerating people with mental illness and developing policies to prevent it. No longer will those in charge of mental-health policy be able to ignore the criminal-justice implications of the mental-health system’s failures.

Massively reform SAMHSA and CMHS. We’ve documented the problems at SAMHSA, as has National Review. Both SAMHSA and the federal Center for Mental Health Services (CMHS) give public funds intended to help individuals with serious mental illness to groups that do not believe mental illness exists, and to promoters of non-evidenced-based programs, efforts harmful to persons with serious mental illness, and efforts designed to prevent such persons from receiving treatment. Both agencies rely onconsensus” (often achieved through the stacking of meetings with people of similar views) rather than science to guide the distribution of funds.

Representative Murphy would require the agencies to rely on “evidence-based practices” and use psychiatrists and psychologists rather than “stakeholders” to perform truly independent evaluations. His bill requires that any conferences paid for by SAMHSA or CMHS be administered by SAMHSA and that any financial assistance they provide to others be limited to evidence-based practices, including those that can reduce homelessness, hospitalization, suicide, arrest, and incarceration among persons with serious mental illness. It eliminates the programs that were most abused and transfers some of the savings to the National Institute of Mental Health (NIMH) for productive research. SAMHSA-funded beneficiaries have already lined up against these provisions.

Focus mental-health block grants (MHBGs) on people with the most serious mental illnesses. MHBGs are the primary way that SAMHSA dispenses federal funds to the states. Unfortunately, the distribution process encourages states to spend the money on unproven programs and ones that fail to improve meaningful outcomes. SAMHSA encourages states to fund programs for relatively high-functioning individuals, which means they will starve programs like Fountain House that serve the seriously mentally ill. Representative Murphy’s bill makes the assistant secretary for mental health, rather than SAMHSA, the distributing authority for the funds and helps ensure that the funds will be used to help the most seriously ill.

Empower NIMH. Under Dr. Thomas Insel, NIMH has done a stellar job in turning its formerly amorphous research portfolio into one more focused on serious mental illness. In light of that, the bill combines the savings from eliminating certain SAMHSA programs with incremental funds and directs them to NIMH so it can do more of this type of research. These projects include efforts to diagnose serious mental illness as early as possible and ensure help as soon as possible after a first psychotic break. It also provides funding for studies directed at reducing violence to self or others by people with untreated serious mental illness.

Refocus the Protection and Advocacy for Individuals with Mental Illness (PAIMI) program. PAIMI was started with the noble purpose of providing representation to persons with serious mental illness who were being abused by the system. Unfortunately, the program has become a political advocacy machine that promotes a system that assumes that all persons with mental illness are always well enough to make their own decisions. Instead of helping the most seriously ill, they would abandon them. These advocates use their federal funds to lobby state and federal agencies in favor of systemic change compliant with their ideology. Representative Murphy proposes to return PAIMI to its original focus of helping people who need help, and prohibit PAIMI groups from using federal funds to lobby for other agendas.

Programs to help the seriously mentally ill now

In addition to restructuring government, Murphy’s bill creates new programs that can help people with serious mental illness now. None of these are accomplished by Obama’s proposals, which merely fund the status quo.

Address the shortage of psychiatric hospital beds. There is a nationwide shortage of 100,000 beds in state psychiatric hospitals. This creates a dangerous Catch-22: Anyone well enough to walk in for care isn’t considered sick enough for admission, which makes becoming a “danger to self or others” the only way to obtain treatment. Many persons with mental illness are forced to become dangerous in this way, but once in the hospital, they are discharged before they can be stabilized. The lucky ones will get back in, while the others will end up in jail, prison, a shelter, or the morgue. This is all due to an obscure provision of Medicaid law (the “IMD exclusion”) that prevents Medicaid from reimbursing states for most mentally ill patients who need long-term hospital care. Representative Murphy’s bill fixes this. President Obama has required private insurers to provide parity for mental-health coverage, and he should require Medicaid to stop denying hospital care for those with serious mental illness.

Encourage the creation of assisted outpatient treatment (AOT) pilot programs. AOT allows courts, after full due process and with strong protections, to require certain narrowly defined individuals — those with serious mental illness and a prior history of arrest, violence, or needless hospitalization caused by going off treatment — to remain in treatment (usually involving medication), under supervision, as a condition of living in the community. Perhaps more important, it allows courts to order the mental-health system to provide the treatment. The mental-health industry does not like being told that it has to serve the most seriously ill, and therefore opposes AOT. Civil-liberties zealots oppose requiring patients to take their medicine even when it can free the psychotic from the Bastille of their own psychosis.

But research shows that AOT works. After enrollment in AOT, significantly fewer recipients engaged in suicide attempts or physical harm to self (down 55 percent); physically harmed others (down 47 percent); damaged or destroyed property (down 46 percent); threatened physical harm to others (down 43 percent); experienced homelessness (down 74 percent); experienced arrest (down 83 percent); experienced incarceration (down 87 percent); or abused alcohol and drugs (down 48 percent). AOT cuts cost in half and is more humane and less restrictive than the alternatives: inpatient commitment and incarceration.

Provide money for mental-health courts and for training police officers, corrections officials, EMS, and other first responders to recognize individuals who have mental illness and learn how to intervene in a way most likely to prevent escalation.

Free parents who are caregivers from HIPAA handcuffs. To provide care for their mentally ill loved ones, families need information about their future treatments and doctor appointments. But doctors and mental-health programs routinely keep parents in the dark, hiding behind the patient confidentiality law known as HIPAA (the Health Insurance Portability and Accountability Act of 1996) to prevent them from getting the information. Neither James Holmes’s family nor Jared Loughner’s was informed about their loved one’s deterioration before their shooting rampages. This bill allows information to be disclosed to family-member caregivers if that information is needed to “protect the health, safety, or welfare of such individual or the safety of one or more other individuals.” It provides similar exceptions under the Family Educational Rights and Privacy Act of 1974, which guides what information educational institutions can provide to family members of students.

These solutions will improve care for people with serious mental illness while keeping patients, the public, and the police safer. They will also save taxpayers money and make the mental-health industry scream in protest. Sounds like a plan.

— D. J. Jaffe is a family member of someone with serious mental illness and is executive director of Mental Illness Policy Org., an independent, nonpartisan, research-based think tank on serious mental illness (not “mental health”).

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