A Chance for Real Mental-Health Reform, If the Mental-Health Industry Gets Out of the Way

Mental-health programs received $172 billion in federal and state taxpayer funds in 2014. As a result of lobbying by the mental-health industry, however, little of it went to reducing homelessness, arrest, incarceration, and hospitalization of the 10 million who have serious mental illness such as schizophrenia and bipolar disorder. Instead, as in previous years, a vast amount went to improving the “behavioral health” of the masses. As a result, 164,000 adults with serious mental illness are homeless; 365,000 are in jails and prisons; 770,000 are on probation or parole; 95,000 who should be hospitalized can’t get a bed because of the shortage; and headlines are full of “psychotic killer on rampage” headlines.

Four smart and compassionate legislators are trying to fix the problem and help the seriously ill, but the government-funded mental-health industry is using its government funds and clout to fight them. Unfortunately, they’re having an impact. The industry wants to continue to receive mental-health dollars for their programs, often from the Substance Abuse and Mental Health Services Administration (SAMHSA) — without any obligation whatsoever to demonstrate that they work or serve the seriously ill. 

Leading the bipartisan way, Representatives Tim Murphy (R., Penn,), Eddie Bernice Johnson (D., Texas) and 100 co-sponsors introduced the Helping Families in Mental Health Crisis Act (HR 2646) in June; and Senators Chris Murphy (D., Conn.) and Bill Cassidy (R., La.) will introduce a quasi-companion bill today. The bills are not identical, and each has plusses and minuses, but both bills attempt to refocus federal spending on solving the actual problem: getting treatment to adults already known to have serious mental illness, rather than trying to improve the “behavioral health” of all others. Both bills focus existing government funding on programs that serve the seriously ill. Programs that promise merely to produce softer outcomes — such as increasing a patient’s “sense of hopefulness” — would be lower priority, in terms of funding, than evidence-based programs proven to reduce homelessness, hospitalization, arrest, incarceration, and suicide.

The mental-health industry doth protest, very much. The Children’s Mental Health Network told its members that the requirement for programs to have evidence will “drive federally funded family and youth organizations into extinction.” Not exactly. The bills simply set up a mechanism to replace programs that lack evidence with those that have it. The trade association for suppliers of “peer-support” — a program that places people with mental illness under the paid guidance of others who’ve had a mental illness — is aggressively lobbying Congress to oppose setting any standards for peer-support. The trade association for federally funded Protection and Advocacy lawyers is lobbying Congress against provisions that would require members to use their federal legal funds to reduce “abuse and neglect” of the seriously ill. They prefer to receive the funds without any limitations.

Large parts of the SAMHSA-funded mental-health industry oppose Medicaid and Medicare provisions that would make hospital care more readily available for the seriously ill who need it, merely because the interventions they offer are not for the hospitalized. Other government-funded mental-health groups are successfully lobbying against much-needed changes to privacy rules (HIPAA) — changes that would allow parents who provide care access to the medical information they need to protect the health, safety, and welfare of family members. And all the SAMHSA-funded groups are lobbying the legislators to preserve their sugar-daddy, SAMHSA, which doles out funds without any requirement that they serve the seriously ill or that provide independent evidence of meaningfully improved outcomes. 

In place of reform, the mental-health industry argues that ‘early identification,’ ‘early intervention,’ and ‘education’ will lead to ‘prevention.’ Wrong on all counts. 

Both bills provide the bare minimum of support for Assisted Outpatient Treatment (AOT), which allows judges to order a very small group (only the most seriously ill who have already became hospitalized, incarcerated, arrested, or homeless multiple times because they refused voluntary treatment) to accept six months of mandated and monitored treatment as a condition of living in the community. AOT has reduced homelessness, arrest, incarceration, hospitalization, and suicide by about 70 percent, thereby cutting long-term health-care costs in half. It’s the exact type of program that Congress should be supporting, but the SAMHSA-funded groups lobbying against it could succeed in killing it, as they have previous efforts to direct funds to serious treatment for serious mental illness. The Senate bill introduced today is particularly soft when it comes to allocating resources for AOT.

In place of reform, the mental-health industry argues that “early identification,” “early intervention,” and “education” will lead to “prevention.” Wrong on all counts. The serious mental illnesses such as schizophrenia and bipolar disorder that adults experience are not the by-product of the behavioral-health issues experienced by children. Serious mental illness in adults rarely begins before late teens and early twenties. It cannot be predicted or prevented, and education and awareness are no substitute for actual treatment.

Congress needs to understand that throwing money at mental health is not the same as delivering effective treatment to the seriously ill. America has a big problem with how it treats people with serious mental illness. This is the problem we must fix. The mental-health industry should get out of the way.