This is a quote from a prison psychologist. She was not joking or exaggerating—many of her imprisoned psychiatric patients had committed a fake crime to get "three hots and cot." And even more had been arrested for nuisance crimes easily avoided had they received anything approaching adequate treatment and housing.
This is the cruel paradox haunting our mental health non-system—we deliver way too much care to basically normal people who don't need it, while providing way too little care to the really sick people who desperately do.
The result is bad for both groups, but especially terrible for the severely ill. Because of draconian mental health budget cuts, the colossal misallocation of resources, and poor coordination of services, we have almost 400,000 adults with serious mental illness living in jails and prisons and 200,000 others who are homeless, living precariously on the streets.
I get a strong and encouraging response whenever I write or talk about saving normals from excessive treatment. I get almost no response when I write or talk about the shameful and wasteful neglect of the severely ill. We mistreat them barbarously and almost no one seems to care.
So I was delighted to receive the following passionate and enlightening email from DJ Jaffe; Executive Director of Mental Illness at Policy Org., a non-profit, non-partisan, science-based think-tank on serious mental illness. Mr. Jaffe writes:
"While 25 percent of the population might qualify as having a mental disorder in any given year, only 4 percent have a severely disabling mental illness. To its shame, the mental health industry has consistently focused on the former, not the latter.
The latest egregious example is its opposition to the widely supported and much needed Helping Families In Mental Health Crisis Act (introduced by Rep. Tim Murphy along with 77 co-sponsors). This bipartisan bill would encourage federal agencies to prioritize in favor of the most seriously ill—sending them to the head of the line for services.
Unhappy about this, the mental health industry convinced Representative Ron Barber to propose an alternative—the Strengthening Mental Health in our Communities Act. This has some of the same provisions that are in Murphy’s bill but is stripped of the changes that focus care on the most seriously ill.
Here are four crucial provisions the industry convinced Barber to drop:
1. Medicaid Reform: Medicaid prevents states from receiving reimbursement for people with mental illness who need to be hospitalized for an extended period. So states tend to kick the seriously ill out of hospitals and many wind up incarcerated or homeless. The original bill makes small revisions in Medicaid so that those who need hospital care can receive it. The Barber bill does not.
2. Assisted Outpatient Treatment (AOT) helps a small subset of the most seriously ill who have a history of getting into trouble when they stop the treatment needed to prevent decompensation. After full due process, AOT allows judges to order severely ill patients into six months of community treatment, often including medications. AOT markedly reduces homelessness, arrests, hospitalizations, incarcerations, and cuts costs in half. Funding for AOT is in the original bill, but not the Barber bill.
3. HIPAA and FERPA are useful laws that keep patient records confidential—but doctors sometimes hide behind them to avoid having to spend time telling parents about the treatments and pending appointments for their children. Parents of the seriously mentally ill need this information to help make sure their loved ones have medications, stay in treatment, and make it to the appointments. The original bill includes narrow exceptions to HIPAA and FERPA so parents of the seriously mentally ill who are providing care and housing can get this information. The Barber bill does not.
4. SAMHSA should be the government agency most dedicated to the welfare of the severely mentally ill—but it is not doing its job. As Representative Murphy pointed out: 'SAMHSA has not made the treatment of the seriously mentally ill a priority....serious mental illness such as schizophrenia and bipolar disorder may not be a concern at all to SAMHSA...its strategic plan continues to think in broad terms of behavioral and emotional health, promoting wellness and not once in its entire 117-page strategic document will you find the words schizophrenia or bipolar disorder.'
Dr. Fuller Torrey told Congress that SAMHSA has only one psychiatrist among its 574 employees. Dr. Sally Satel told Congress only four of the 288 programs in SAMHSA’s National Registry of Evidence Based Programs and Practices are designed to help people with serious mental illness.
The original bill returns SAMHSA to its proper and primary mission of helping the seriously ill and prevents it from funding non-evidenced based programs. The Barber bill does not.
The lobbying against the Murphy bill is led by mental health groups receiving funding from SAMHSA under its current disordered priorities. Mental Health America which receives nearly 20 percent of its funding directly or indirectly from SAMHSA testified against the bill (and on questioning admitted to not having read it). The SAMHSA funded Technical Assistance Centers emailed their members, 'Tell your Representative NOT to Co-sponsor the Murphy Mental Health Bill.' To oppose provisions in the Murphy bill that help ensure the seriously ill can get a hospital bed when needed, The National Coalition for Mental Health Recovery put out a press release declaring 'It would bring America back to the dark ages before de-institutionalization, when people with mental health conditions languished in institutions, sometimes for life.' NCMHR ignores the fact that without hospitals, many are languishing for life in jails.
The mental health industry supports the Barber bill because it gives them mental health dollars, while freeing them from the responsibility to use those dollars to help the seriously ill. For example, it proposes higher Medicare reimbursement for marriage counselors engendering support from American Mental Health Counselors Association. But having a marriage you wish to improve is not a mental illness.
Rather than promoting mission control, the Barber bill promotes mission-creep. It’s an eye-off-the-prize, head-in-the-sand approach that pretends the seriously ill don’t exist. It is cruel to individuals with serious mental illness and those of us who love them."
Thanks Mr. Jaffe for defending those who most need and deserve defending and for helping us to get our priorities straight.
Budgeting is a zero sum game. When dollars are spread out too widely, there is far too little left to provide decent and cost effective care for those who most need it. In mental health treatment, as in everything else, the rich are getting richer and the poor are getting poorer and winding up in prison or on the street.
Many institutions and organizations should be doing a great deal more for the severely mentally ill and share in the shame of our current neglect. The National Institute Of Mental Health has become a future directed brain institute indifferent to the disastrous state of current patient care. The American Psychiatric Association has produced a DSM 5 that dilutes mental illness even further—deflecting attention away from the really ill and toward the worried well. I am all for the efforts of psychologists and counselors, but their professional associations don't include the severely ill as a core constituency. And social workers have been strangely passive. The National Alliance on Mental Illness started life as an organization dedicated to advocacy for the severely mentally ill but has dropped the ball and done very little for the imprisoned and homeless.
Two hundred years ago, Pinel freed the mental patients from their chains and initiated enlightened and respectful care. Now we imprison patients again or relegate them to the streets in a new disgusting dark age.