We haven’t yet spoken up about the Helping Families in Mental Health Crisis Act of 2013 (HR 3717), sponsored by Rep. Tim Murphy because we were hoping Congress would see through this less-than-subtle attempt to gut SAMHSA, coerce states to pass new forced-treatment laws (even if their citizens don’t want them), and create yet another huge federal bureaucracy in the Department of Health and Human Services that nobody has asked for, with no data to support its creation, and that nobody wants.
Sadly, that hasn’t happened. The least offensive parts of the bill are starting to get passed, and that suggests that there may be some momentum to pass the more offensive, egregious components in the future.
So here are the major problems with this bill, and why it stinks for everyone — especially patients.
You can kind of tell this isn’t a bill directed at patients and helping patients in the mental health system simply by its name, “The Helping Families In Mental Health Crisis Act.” You see that there — families. Not people with mental illness. This is about helping families deal with a family member who has an apparent mental illness — not about helping the actual people with a mental illness.
On May 22, 2013, Tim Murphy — the only clinical psychologist in Congress today — held a hearing to discuss the problems, as he saw it, with mental health in America and SAMHSA, the U.S. federal agency that is primarily charged with dispersing money for mental health treatment programs, substance abuse prevention programs, substance abuse treatment programs, and health surveillance. About one-third of SAMHSA’s $3 billion annual budget is devoted to mental health, and the remaining two-thirds to substance abuse — as directed by Congress.1
Federal grants from SAMHSA are how states largely pay for public mental health and substance abuse treatment, usually via community mental health centers.
You’d think when discussing the problems with the public mental health system you might have, well, some actual patients there. You know — the people who actually use the services provided by the government. What’s working with the system? What’s not?? What do you find helpful or beneficial in your treatment and recovery? But not a single patient or advocate was present at the hearing.
And you’d get this same sort of medical paternalism from the tone of some of the questioning as well. Rep. Michael C. Burgess, M.D. (R-TX) — who didn’t have the simple respect of staying in the hearing the entire time so had to have information repeated back to him — asked how many psychiatrists SAMHSA employed. As though SAMHSA provided direct services itself.
Now Burgess didn’t ask how many behavioral health professionals — such as psychologists or other similar kinds of mental health professionals — SAMHSA employed. He only asked about psychiatrists,2 which make up a small minority of the providers of mental health and behavioral healthcare services in the U.S.
Another Representative at the hearing asked about a single presentation at the annual Alternatives conference, and whether a federal agency should be funding a conference where such a presentation was given. This at a hearing to discuss a government agency with a $3 billion budget. Yes, please, let’s discuss a single $127k appropriation — that makes a lot of sense.3
A Boon for AOT, a Boondoggle for States
Should the federal government be telling states exactly how they spend their money?
Well, when it comes to “assisted outpatient treatment” — forced treatment in an outpatient setting — the answer is “yes.” A total of $60 million in funding for grant programs to states will be made, making Congress a new treatment authority in mental health care. Imagine Congress telling docs that they can get reimbursed for treating cancer — but only in the way they dictate. That’s basically what the bill seeks to do — dictating to states how they will handle the treatment of serious mental illness in their state.
But here’s the kicker about the AOT research, and Pamela Hyde, the head of SAMHSA nailed it:
On the assisted outpatient treatment, the research that has been shown for assisted outpatient treatment to be effective also is very clear that it is the treatment and service that is effective. So to the extent that, for example, in New York where there was a major assisted outpatient treatment program and an evaluation of that program that was extensive, there were also a lot of new dollars poured into that system to make it work. So to the extent that the services are there, then assisted outpatient treatment may be effective for some individuals.
That’s the key to why some research shows AOT programs to be effective — the amount of services and coverage of individuals in AOT programs is a cut-above anything available to non-AOT participants today in community mental health.
If you poured the same amount of money into non-AOT programs, who knows what you’ll find. Perhaps coercion isn’t a necessary component of what makes AOT so effective. But you wouldn’t know the answer to this question, because there hasn’t been a single study examining AOT versus treatment with AOT-level services, minus the coercion.
Let’s Create Even More Federal Bureaucracy
Since Tim Murphy doesn’t believe SAMHSA is up for the job that Congress has given it, he wants to give a lot of SAMHSA’s work to a new agency that SAMHSA would have to report to. That’s what Congress does best — when one thing isn’t working as ideally as it would like, rather than fix it, they create something else they hope will do better.
The new “Assistant Secretary for Mental Health and Substance Use Disorders” (that’s a mouthful!) will oversee the public mental health block grants given to states. And it will be tasked with collecting and analyzing outcome data, to see what’s effective (and what’s not). These are tasks SAMHSA already does.
Oh, and those public block grants? They won’t be granted to states who don’t implement AOT laws. So the federal government is basically telling states how they will treat their citizens’ mental health concerns — whether those citizens in those states want those laws or not. Justified how?
Judges, mental health professionals, and family members have had trouble getting a loved one with a mental illness [sic] because 23 states use an unworkable standard requiring a person to be “imminently dangerous” before they can receive inpatient medical care.
An unworkable standard according to whom or what research? Tim Murphy doesn’t say. Apparently we need a weaker standard such as, “My family thinks I’m crazy, therefore let’s commit me.”
And it creates yet another agency, the “National Mental Health Policy Laboratory” where all of this analysis and oversight will occur.
Is such an “Assistant Secretary” necessary in the Department of Health and Human Services? We think not. It’s just another bureaucratic layer that will detract from the government’s ability to stay focused and coordinated, and to us anyway, seems like an effort to remove a lot of the responsibility from SAMHSA — that SAMHSA itself could do just as well in its current form.