Congress is being misled by the nonprofit mental health industry, which argues that ordinary life events like bad grades, being unemployed, having an unhappy marriage, and this year's cause célèbre, bullying, are the mental illnesses worthy of congressional funding. They ignore the homeless and psychotic who can't get treatment, sleep on the streets, forage dumpsters for food, and scream at voices that only they can hear.
Prior to the 1960s the U.S. mental health budget was primarily spent on providing treatment to people with serious mental illnesses. Today, at the behest of the mental health industry, we've largely abandoned the most seriously mentally ill and use the budget for everyone else. In 1955 there were half a million public psychiatric beds for the seriously ill. Today there are less than 50,000. Because of the shortage, about 200,000 mentally ill are homeless, and according to a recent report by the Treatment Advocacy Center and National Sheriff's Association, 10 times as many mentally ill persons are incarcerated as hospitalized.
The community-based mental health industry is not serving the same populations as those who would be served by hospitals. Community programs only accept voluntary patients and generally choose the higher-functioning. Instead of providing services to treat the seriously ill, many community programs focus on creating stigma campaigns. Michael Biasotti, the immediate past president of the New York State Association of Chiefs of Police, recently told Congress that this shunning of the seriously mentally ill is forcing police to pick up the slack:
We have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility. ... [M]ental health officials seem unwilling to recognize or take responsibility for this second more symptomatic group.
Money is not the problem; mission creep is. Mental health spending totaled $100 billion in 2003, representing 6.2 percent of all health care spending. By 2014 it is expected to double to $204 billion. The elephant in the room is getting treatment to the most seriously ill. Instead of treatment, the nonprofit mental health industry argues for Congress to fund public education. This is based on the mistaken assumptions that the reason that people do not get care is that they are so asymptomatic that the public needs special training to identify them, and that once they're identified, treatment will be available. Neither assumption is true for the seriously ill. As Creigh Deeds learned, families can -- and do -- beg for treatment for loved ones already identified as being ill. And yet they still can't get it.
If Congress wants to improve care, save money, and reduce violence, it should stop funding groups working to improve people's mental health and use the savings to treat people with serious mental illness. Replace mission creep with mission control.
That's the idea behind H.R. 3717, the Helping Families in Mental Health Crisis Act. Introduced this past December by Rep. Tim Murphy (R-Pa.), with the support of 74 other representatives from both parties, the legislation would:
- Get treatment to people who are too sick to accept voluntary treatment. H.R. 3717 requires states to have an assisted outpatient treatment (AOT) program in order to access federal mental health block grants. AOT is limited to the most seriously ill who have a past history of violence, incarceration, or needless hospitalizations caused by going off treatment. It allows courts, after extensive due process, to order them to stay in mandated and monitored treatment as a condition of living in the community, and equally importantly, to order community programs to provide the care rather than turn them away. New York's AOT program (also known as "Kendra's Law") reduced homelessness, arrest, and incarceration in excess of 75-percent each and cut costs in half by reducing the use of more expensive incarceration and hospitalization. The Department of Justice certified AOT as an "effective crime prevention program."
- Free parents of the seriously mentally ill from HIPAA handcuffs. Parents need information about the diagnosis, treatments and pending appointments of their children in order to facilitate care. But the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) prevent parents from receiving it. School authorities identified Jared Loughner as being mentally ill and potentially dangerous before he shot Gabrielle Giffords, but HIPAA and FERPA laws kept his family in the dark. H.R. 3717 writes exceptions into the law so that that won't happen again.
- Require the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Mental Health Services (CMHS) to focus on serious mental illness. The Wall Street Journal editorial "The Definition of Insanity" outlined the massive problems at SAMHSA. H.R. 3717 requires all SAMHSA grants to be evidence-based and reviewed by persons with clinical experience in mental health treatment, and it prohibits SAMHSA from making grants not authorized by Congress. These reforms are needed because SAMHSA and CMHS fail to focus on serious mental illness, fund programs that lack independent evidence of effectiveness, and award taxpayer money to organizations that lobby against treatment for the most seriously ill. For example, in spite of the fact that getting the correct diagnosis is key to getting the right medication, SAMHSA distributes millions to "peer" groups that believe "psychiatric labeling is a pseudoscientific practice of limited value in helping people recover."
- Create an Assistant Secretary for Mental Health and Substance Abuse Disorders. More than anything, this individual is needed to end mission creep, reduce duplication, coordinate piecemeal federal agencies, and stop the federal funding of non-evidenced-based programs.
- Preserve psychiatric hospital beds. H.R. 3717 rejects the mental health industry shibboleth that everyone can survive safely in the community by preserving a few inpatient psychiatric beds for those who can't.
- Increase the role of the criminal justice system in setting mental health policies. Many of the policies espoused by the nonprofit mental health industry, like closing hospitals and making civil commitment more difficult, increase the incarceration of people with serious mental illness. H.R. 3717 gives criminal justice powerful representation on federal advisory boards so that they can prevent these policies from being adopted.
- Refocus the Protection and Advocacy for Individuals With Mental Illness (PAIMI) Program. Started with the noble purpose of providing representation to persons with serious mental illness who were being abused, PAIMI has morphed into a political advocacy machine that ignores the psychotic and assumes that all persons with mental illness are well enough to "self-direct" their own care. Joe Bruce told Congress that PAIMI lawyers "freed" his son William from involuntary hospital care over the objections of his mom and dad. William then killed his mom. H.R. 3717 returns PAIMI to its original focus of helping people who need help, and it prohibits PAIMI groups from using federal funds to lobby for other agendas.
- Empower NIMH. Under Dr. Thomas Insel, the National Institute of Mental Health has forsaken mission creep and now focuses on serious mental illness. H.R. 3717 turns over certain funds that were misspent by SAMHSA to NIMH, so that they can find cures for serious mental illness.
There is a crisis. Solving it requires getting treatment to people with untreated serious mental illness, not all others. Throwing money at mental health as Congress has done will not help those with serious mental illness. Passing H.R. 3717 is the best chance Congress has at addressing the real problem.
This is an updated version of a post that originally appeared in the Ripon Forum, published by the Ripon Society. It is reprinted with their permission.
DJ Jaffe is Executive Director of Mental Illness Policy Org., a nonpartisan, science-based think tank focused on serious mental illness (not mental health).