The existing federal mental-health agency actually opposes efforts to treat mental illness.
By E. Fuller Torrey & D. J. Jaffe
This article originally appeared in National Review (8/15/2013)
Pity President Obama. During his predecessor's eight years in office, only one high-profile mass killing occurred, when Seung-Hui Cho killed 32 and injured 17 at Virginia Tech. During President Obama's first term alone, there were three. In January 2011, Jared Loughner killed six and injured 13, including Representative Gabrielle Giffords, in Tucson. In July 2012, James Holmes killed twelve and injured 70 in Aurora, Colo. And in December 2012, Adam Lanza killed 27 in Newtown, Conn. All of these tragedies were carried out by perpetrators who had an untreated severe mental illness, and President Obama and the nation in general now seem to realize that America has a major problem with untreated severe mental illness. Following Newtown, Obama promised to make "access to mental health care as easy as access to guns."
Obama's first step was to set up a task force under Vice President Biden to make recommendations. Biden, in turn, asked the lead government agency on mental-health services for direction. That agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), is a $3.1 billion component of the Department of Health and Human Services. SAMHSA's official mission is to reduce "the impact of substance abuse and mental illness on America's communities." The only problem is that SAMHSA knows nothing about severe mental illness and, indeed, is not even certain that it believes such illnesses exist. That was the beginning of President Obama's problems.
What is severe mental illness? According to the National Advisory Mental Health Council, in response to an inquiry from Congress, severe mental illness includes schizophrenia, schizoaffective disorder, bipolar disorder, autism, and severe forms of depression, panic disorder, and obsessive-compulsive disorder. One measure of SAMHSA's lack of interest in these disorders is its current three-year planning document, "Leading Change: A Plan for SAMHSA's Roles and Actions 2011–2014." Despite being 41,804 words in length and acknowledging that 9.8 million Americans are afflicted with what it refers to as "serious mental illness," the SAMHSA plan includes not a single mention of schizophrenia, schizoaffective disorder, bipolar disorder, autism, or obsessive-compulsive disorder.
So, when it was asked to provide direction for the Biden Task Force, SAMHSA had nothing relevant to offer. It invited Daniel Fisher to provide testimony as a psychiatric expert. Fisher, director of the National Empowerment Center in Massachusetts, to which SAMHSA has given $330,000 a year for many years, has publicly stated that what is called severe mental illness is really just "severe emotional distress" and "a spiritual experience." He also believes that "the covert mission of the mental health system . . . is social control." Fisher's former deputy similarly asserted that "mental illness is a coping mechanism, not a disease."
Such views are consistent with views expressed by many invitees at SAMHSA's annual conference. In 1995, for example, one speaker claimed that "schizophrenia is a healthy, valid, desirable condition — not a disorder . . . what is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated." Similarly, in 2010, another speaker extolled mental illnesses as "extreme states of consciousness that are mad gifts to be nurtured and cultivated," and he advised people with mental illnesses to stop taking their medication.
That the federal agency charged with reducing the impact of mental illness on America's communities is sponsoring forums at which severe mental illness is extolled as a good thing has overtones of Lewis Carroll. But the situation is even more bizarre than that. SAMHSA's only recommended "treatment" for all mental illnesses is the "recovery model" — in other words, everyone should simply recover. This is similar to the Caucus race in Alice in Wonderland in which the Dodo declares that "everybody has won, and all must have prizes." The "recovery model" was officially defined by SAMHSA in 2004 as including ten "fundamental components," the most important being that it is "self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals." The "recovery model" includes no mention of the need for medication or other specific treatments. It makes no allowance for the fact that many individuals with severe mental illness are unaware of their own illness. This is an ideology, not a treatment. Under the "recovery model," John Hinckley was defining his own life goal — the attention of Jodie Foster — when he shot President Reagan. Similarly, Cho, Loughner, Holmes, and Lanza were presumably attempting to define and achieve their life goals, too. Their actions would meet SAMHSA's definition of "recovery."
How important is the "recovery model" for SAMHSA? In its three-year plan, the word "recovery" is mentioned 206 times, when not a single study shows that it is effective for individuals with severe mental illness. By contrast, assisted outpatient treatment is not mentioned once, despite the fact that the Department of Justice classified it as an evidence-based program that reduces crime and violence, and 20 studies have reported that for individuals with severe mental illnesses it is effective in markedly reducing hospitalizations, arrests, homelessness, victimization, and violent behavior. (It also saves money. For example, for every dollar invested in assisted outpatient treatment in one California county, officials estimated that they saved $1.81. A recent study of assisted outpatient treatment in New York showed that there too assisted outpatient treatment yielded dramatic savings, especially of Medicaid funds.) And so the federal agency charged with reducing the impact of mental illness promotes a solution that, by definition, would be ineffective for severely mentally ill individuals such as Cho, Loughner, Holmes, and Lanza and ignores a solution that has proven to be effective.
But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass.
Another SAMHSA-funded program that works to block effective treatments for individuals with severe mental illness is its consumer-grants program. For example, the SAMHSA-funded California Network of Mental Health Clients, which receives at least $70,000 per year from SAMHSA, has lobbied successfully to block the widespread use of assisted outpatient treatment in that state. In Pennsylvania in 2011, the SAMHSA-funded Pennsylvania Mental Health Consumers' Association testified in opposition to a bill that would have made it easier to treat individuals with severe mental illness. Indeed, SAMHSA may be the only federal agency that not only fails to remedy the problem assigned to it but actually opposes efforts likely to ease it.
So what does SAMHSA do with its $3.1 billion, other than promote ineffective approaches for the treatment of severe mental illnesses and attempt to block the utilization of effective treatments? It focuses much attention on three population groups, which it apparently considers to be in great need of improved mental health: Native Americans, residents of American territories (most of whom live in Puerto Rico), and the lesbian, gay, bisexual, and transgender (LGBT) community. The first two each received 132 separate mentions in the SAMHSA three-year plan, and the third received 50 mentions. This is the same plan in which individuals with schizophrenia, bipolar disorder, and other severe mental illnesses are not mentioned at all.
SAMHSA also devotes much of its resources to the prevention of substance abuse and mental illness. For substance abuse, there is a modest scientific basis for prevention activities, but for severe mental illness there is virtually none. The idea of preventing mental illnesses was popular in the 1960s and 1970s, as part of the community-mental-health-center movement, but it was later discredited when we realized that we did not yet understand the biological causes of these disorders. Nevertheless, SAMHSA requires its grantees, including the states that receive block grants, to spend the federal funds on prevention. The states are instructed to "make general prevention and primary prevention priorities." In addition, the states are told that "the focus is about everyone, not just those with illness or disease, but the whole population. The focus is on prevention and wellness activities." And those should include "community-wide interventions, changing [sic] in cultured norms, or other types of efforts [to] reach broad segments of the population" — language reminiscent of 1960s social activism.
Many of SAMHSA's internally initiated programs do indeed focus on such "prevention activities for persons not identified as needing treatment." It produces and distributes free of charge reading books for children, such as Play Day in the Park for three- and four-year-olds and Look What I Can Do! for five- and six-year-olds; coloring books, such as Wally Bear and Friends; and "mental well-being sticker sets" with stickers saying "My smile is beautiful" and "I listen well." SAMHSA's website also makes available online children's games such as The Great Weather Race and Boogie Band Studio. SAMHSA also makes freely available hundreds of publications including everything from Oil Spill Response: Making Behavioral Health a Top Priority and Hurricane Recovery Guides Preparedness Planning to What a Difference a Friend Makes and American Indian and Alaska Native Culture Card. There are six publications on "peer pressure," eight on "social marketing," 25 on "employment services," and 40 on "health promotion." However, if you query the SAMSHA website for publications on schizophrenia or bipolar disorder, you will be told that these are covered by a single generic product: Core Elements for Responding to Mental Health Crises. But it is out of stock.
Even though SAMHSA is contributing almost nothing to the improvement of mental-health services in the U.S., it has taken on responsibility for advising other countries regarding theirs. SAMHSA has its own "international officer" and has been actively engaged in helping to plan mental-health services for Iraq and Afghanistan. In 2004 and 2005, it sponsored "Action Planning Conferences on Iraq Mental Health" in Amman, Jordan, and Cairo, Egypt. Since 2008, SAMHSA has funded visits by at least eleven Iraqi "behavioral health providers" to SAMHSA-designated facilities in the United States, including those specializing in "trauma-informed care" and "school-based mental health services." One outcome of these visits was a decision by Iraq to close its main mental hospital, despite the fact that virtually no community treatment facilities exist for the sickest patients. In 2006, SAMHSA also began discussions with Afghanistan. According to the SAMHSA administrator at that time, Charles Curie, "SAMHSA can use its expertise . . . to help Afghanistan build its mental-health programs and capacity."
Finally, in keeping with its emphasis on "prevention activities for persons not identified as needing treatment," SAMHSA cares for its own employees' mental health. The agency's average salary, $109,000, surely helps. In 2011, SAMHSA commissioned for its headquarters a $22,500 painting of Native Americans by a Native American artist, "to help raise awareness about the roles of families and the community in mental and substance abuse disorder prevention." Until recently, SAMHSA also put on an annual musical each December to celebrate World AIDS Day. The 2010 musical, which was attended by most of SAMHSA's 574 employees, cost over $80,000 to produce.
Pity, then, President Obama, who would like to address the problem of untreated mental illness and prevent future tragedies like Tucson, Aurora, and Newtown. Saddled with SAMHSA as his lead federal agency, his efforts have predictably come to naught. The Biden task force ultimately made two recommendations for "increasing access to mental health services": (1) "Ensure coverage of mental health treatment" by clarifying coverage under Medicaid and private insurance plans; and (2) "Make sure students and young adults get treatment for mental health issues," by early identification and referral of such individuals. Neither of these recommendations is likely to have any effect on future tragedies, because they ignore the main issue.
Insurance coverage for mental-health treatment has not been a problem in any of these tragedies. Seung-Hui Cho at Virginia Tech and James Holmes at the University of Colorado were covered by their university health services; Jared Loughner in Tucson was covered under his mother's medical-insurance plan with Pima County; and Adam Lanza's family was financially able to cover all psychiatric-treatment costs. Similarly, the early identification of these mentally ill individuals has not been a problem. Cho, Holmes, and Loughner were all identified as having major psychiatric problems by their educational institutions. Indeed, Loughner's problems were so overt that one of his Internet acquaintances even told him that he probably had schizophrenia. Lanza's problems were also apparently visible to the multiple schools and special classes in which he was placed. Almost none of the perpetrators of these increasingly frequent tragedies were flying under the radar. On the contrary, most of them were like Goodyear blimps flying a sign saying, "I need psychiatric treatment."
So if insurance coverage and early identification are not the problem, what is? The critical issue, quite simply, is getting these mentally ill, potentially dangerous individuals into psychiatric treatment before they carry out mass killings. Accomplishing this involves two things: having sufficient psychiatric beds available so that such individuals can be hospitalized for evaluation, and having adequate commitment laws that allow for such evaluations before the individual has demonstrated dangerousness.
There are major impediments to both measures. As a result of the closing of state mental hospitals, the United States has only 5 percent of the public psychiatric beds that were available 50 years ago. Virginia, Arizona, Colorado, and Connecticut all have major psychiatric-bed shortages. Even if decisions had been made to hospitalize Cho, Loughner, Holmes, or Lanza for an evaluation, it is doubtful that a public psychiatric bed could have been found. Lanza's case is especially ironic, as one of Connecticut's three state mental hospitals was located in Newtown a short distance from his home — until it closed in 1996.
Having adequate state commitment laws is even more problematic. In recent decades, under intense lobbying by civil-rights organizations, commitment laws for mental illness in most states have been made increasingly strict. In many states they permit involuntary commitment of mentally ill individuals only after they have demonstrated dangerousness. Involuntary commitment and treatment are necessary because in some cases schizophrenia and bipolar disorder impair the parts of the brains we use to think about ourselves. Individuals thus afflicted lack the capacity to appreciate their own illness or need for treatment. They think that the voices commanding them to kill are really coming from God, or that the CIA is really trying to kill them. This unawareness of one's own illness is a neurological condition called anosognosia. It clearly affected Cho, Loughner, and Holmes and probably affected Lanza. This means that any evaluation or care they might have received — that is, before they committed mass murder — would have had to have been carried out by means of an involuntary commitment. It was the only effective means by which these tragedies could have been prevented.
The Biden task force did not address either of these problems because they are not on SAMHSA's agenda. Instead, the task force recommended that the Obama administration ask Congress for an additional $235 million, most of which is to be used to train teachers to identify the signs of mental illness in their students and to provide "mental health first aid," whatever that is. This recommendation was enthusiastically applauded by school administrators who are always looking for new sources of federal funds, but it will have no effect on the problem of untreated severe mental illness.
The Obama administration then followed up the task force on June 3 with a one-day National Conference on Mental Health, at the White House. This conference brought together the usual leaders of the mental-health community, who appeared to agree on only one thing — that the federal government should do more. There was also much discussion of widespread stigmatization of individuals with severe mental illness by the general public. Since studies have shown that the largest cause of such stigma is high-profile homicides committed by untreated individuals like Cho, Loughner, Holmes, and Lanza, that aspect of the problem was not discussed.
At the same time that the failed Biden task force was holding hearings, another set of hearings, which are more likely to produce significant change, was taking place in Congress. These hearings were convened by Representative Tim Murphy (R., Pa.), a psychologist by training and the chairman of the Subcommittee on Oversight and Investigation of the Committee on Energy and Commerce. The hearings were titled "Examining SAMHSA's Role in Delivering Services to the Severely Mentally Ill." In contrast to the Biden task force and White House conference, Murphy said:
One lesson we must immediately draw from the Newtown tragedy is that we need to make it our priority to get those with serious mental illnesses, who are not presently being treated, into sound, evidence-based treatments. . . . [Such treatment] can reduce the risk of violent behavior fifteen-fold in persons with serious mental illness. . . . SAMHSA has not made the treatment of the seriously mentally ill a priority. In fact, I'm afraid serous mental illness such as schizophrenia and bipolar disorder may not be a concern at all to SAMHSA. . . . It's as if SAMHSA doesn't believe serious mental illness exists.
During her testimony before the subcommittee, SAMHSA administrator Pam Hyde appeared to do nothing to persuade the members that Representative Murphy was wrong.
What happens next remains to be seen. Members of Congress looking for places to cut the budget should look closely at SAMHSA's low-hanging fruit. The one thing that is certain is that nothing has changed and that the tragedies of Virginia Tech, Tucson, Aurora, and Newtown will be followed by another, and another, until things do change. It is not a question of if, merely when.
— Fuller Torrey, M.D., is the founder of the Treatment Advocacy Center and author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. D. J. Jaffe is the executive director of MentalIllnessPolicy.org.