The death of the Murphy Bill: On being the national spokesman
Larry Drain


The Murphy Bill as we know is dead.  The Republican leadership in the House announced a change in strategy.  They basically decided to toss in the towel on the more controversial parts of the plan and try to see if they can move forward on elements that seem to have a greater consensus behind them. There may be CPR efforts yet but it appears done.

It was a bill in trouble from the start despite the massive pr campaign that tried so hard to say it wasnt so.  It managed to unify groups that might not agree on what kind of reforms they wanted, but were absolutely sure what they didnt want and that was the Murphy Bill.

Part of the problem was Murphy himself.  He assumed that as "the only psychologist in Congress" he was the obvious and deserved national spokesman for mental health reform.  He wasnt.  Being a psychologist certainly didnt qualify for the role.  Neither did being a member of the House of Representatives.  It seemed that Dr. Torrey annointed him and for some reason they both thought that mattered.  In the end it was hard to know where he started and Dr. Torrey ended and that was perhaps a fatal flaw.

He didnt understand that leadership was built or that it was a two way street.  He alienated people who had lived mental health reform their entire adult lives.  He thought it was about them joining him and never seemed to know it was the other way around.  And he never realized that trust was everything and that when he snuck AOT into the medicare bill he destroyed his chances of trust with people whose support he needed.

He was naive.  The only people who believe federal laws change everything are federal lawmakers and most of them know better.  To say that his law was going to prevent the next shooting was simply ego.  He believed his own press clippings and his posturing before the dead were even buried just seemed like rank opportunism.

Mental health reform is an ongoing effort by many, many people with different values and priorities.  Sometimes it is its own worst enemy.  People who cant stand each other have a hard time standing together for anything.  Murphy I hope has to some degree taught people they can find unity despite their differences.  And maybe the fragile unity borne of him will be the biggest take-away from the entire thing.

He may indeed try again.  He probably will.  Dr.  Torrey most surely will.  He has won many, many short term victories and will doubtless win more, but the big prize has eluded him again. He is not the national spokesman he has annointed himself to be either.

Murphy misunderstandings

byLarry Drain, hopeworkscommunity

Rep.  Murphy has not went gently into the good night.  Dr. Torrey will never go gently into the good night.  They are trying it sounds like to provide cpr to their bill. Rather the things that didnt work the first time will work on second effort is anyone's guess.  I think sometimes it is really hard for annointed national spokesmen to realize they are not and never were.

But this post is not about that.  It is about a fundamental misunderstanding of the American mental health system that was part of the reason that may have doomed the Murphy Bill from the start.

Murphy seemed to believe we were doing far too much for too many.  He thought people who were doing better in the system were robbing those who were doing poorly of help and resources. And he thought if resources were properly allocated things would be okay. Using terms like "worried well" he seemed to want to pit one group against another or at least give worried family members someone to blame. Somehow, I never really understood how, he seemed to think that this misallocation of resources was the fault of Samsha. It was us against them, with guys in black hats, just lacking an afternoon channel from being great soap opera. People were getting rich, famous and powerful off the worried well and just abandoned those in serious need. It had drama, moral outrage, and more than a little passion. It just lacked truth.

Anyone who had watched or been part of the last few years would tell you that state after state year after year had cut their mental health budgets to the bone. In some places there was only skin. The bone had long since disappeared. It was not that too much was done for too many. Too little was done for everyone. Many people lacked insurance and couldnt even access the services that were there. It wasnt misallocation of funds. It was abandonment. Never, not once, have I ever heard anyone touting the Murphy bill ever acknowledge this.

The baggage from Dr. Torrey obscured their vision. No state bought his love affair with psychiatric hospitals. It was too little bang for way too much bucks. No one believed. It was a cash cow around their necks that threatened to bankrupt their community systems. There was little or no proof it worked. When insurance companies basically stop paying for a service that service is on borrowed time. No one drank the kool aid any more.

There will probably always be psychiatric hospitals. But they will never be the centerpiece of the mental health system again. Putting your money into backline services, what you do when things go wrong, destroys your ability to keep things from going wrong. There was never any conspiracy. People just decided what they thought mattered and all of Dr. Torrey's pr and marketing campaigns just didnt change that. In the end I dont think federal law can bring back psychiatric hospitalization as the gold standard of mental health care. The truth is that even people with "severe mental illness" can and do make it in their communities with effective support and services.

The notion that one group of people needing help was more worthy than another and that they were in competition just seemed like such a mean and stupid notion. It completely just ignored the reality of the bloody battle for funding that is the reality for so many states. It was a pseudo explanation for the fact that state after state just said "Dr. Torrey we dont buy what you say and your way will not increase the amount of services for people with severe needs but radically decrease it."

Count me cynical. Count me way cynical. Murphy lost because it was never about a battle for the "severely mentally ill." It was a battle for Dr. Torrey and a vision found lacking a long time ago.

hopeworkscommunity | June 11, 2014

Why Can’t Doctors Identify Killers?

by hopeworkscommunity

This article is remarkably absent much of the bs in so many reports about the tragedy in California.  It is nice to hear from someone who is not trying to tell you that someone died because their particular law was not passed soon enough.  Very good job I think.  Thanks Dr.  Friedman.
http://mobile.nytimes.com/2014/05/28/opinion/why-cant-doctors-identify-killers.html?emc=edit_tnt_20140527&nlid=59240565&tntemail0=y&_r=0&referrer=

hopeworkscommunity | May 27, 2014

The Murphy bottom lines

by hopeworkscommunity

When you strip away all the fancy words and the tons and tons of rhettoric about what the Murphy Bill says and simply ask yourself "What is the plan?" you get a few core ideas.  What does Rep. Murphy think we actually need to do to serve the severely mentally ill?    There are many other provisions of the bill that has nothing to do with what I am about to talk about. Many of them are the most positive features of the bill.  But this is what I think the essence of the Murphy plan is.  These are his bottom lines.  These are his "new ideas."

He believes, in effect, that many of the severely mentally ill suffer from a defiency of psychiatric hospitalization.  He seems to see that as the answer to so many people with "mental illness" being in jails and prisons.  He thinks that way too many hospital beds are gone and it is time to increase hospitalization radically.

 Perhaps I am wrong but I believe that ship has sailed.  A mental health system with psychiatric hospitalization as its corner stone is not financially sustainable in this country.  Insurance companies pay less and less for it.  They do not see it as medically necessary but in the most extreme circumstances and then for brief periods of time.  In Tennessee I believe most psychiatric hospitals are struggling to break even and most of them are losing that struggle.   States are getting out of the business.  They realize that a large hospital system leaves them unable to finance a community system and if you dont have a community system to serve the people coming out of the hospital what is the point of the hospital.  If you look at how often and how quickly people leaving the hospital system end up back there you begin to realize the impact of disemboweling the community system.  I cant even imagine the circumstances under which Tennessee would act to increase the beds in any kind of dramatic way, indeed in any way at all.   It is far too little bang for way too many bucks.  

His method for making psychiatric hospitalization possible is to remove the IMD exclusion on medicaid funding.  Basically it makes it possible for medicaid to then pay for state psychiatric hospitals.  One question comes to me immediately.  If Congressman Murphy thinks that medicaid funding is such an important part of mental health reform why did he vote to repeal the ACA over 50 times?  That bill through its provisions for medicaid expansion would have given millions of people with "mental illness" access to programs and services that if he has his way they will never access.

A couple of other questions come to mind.  What about the people who dont have medicaid access?  Many people with "mental illness" and particularly many people who are having serious problems in life simply dont have insurance.  Another question is the response of states to finding out now that medicaid funds can pay for psychiatric hospitals.  In most states that I am aware the medicaid program eats up a considerable portion of their state budget and I really question, particularly in the states that choose not to expand medicaid, how receptive they will be to finding out that medicaid expenses are about to soar through the roof.  In Tennessee the most likely two responses are to adopt the private insurance definitions of medical necessity and decide not that many people need hospitalizations and/or cut benefits and provider payments to pay for any any expenses the increase in hospitalization is likely to cause.  The provider rates for psychiatric care, at least in Tennessee, are so low that very few people will even provide services anyway and there is a serious real question about where the professionals to do all this treatment are to come from.

Even if you start to use medicaid funding it does not begin to pay for all the new costs.  The state institutions in Tennessee for example are aging. There is a need for new buildings and new spaces if beds are added.  Who pays for new hospitals??  What about the cost of new staff??  Who pays?  I can only speak to Tennessee but there is no commitment to psychiatric hospitalization, especially on a massive scale, as the answer to anything by state officials, by mental health professionals. by anyone that I know and removing the IMD exclusion is unlikely to change that.  The strong perception is that the community system is the most cost effective and effective means to help people meet their needs and that it is defiencies in that system that lead most to people falling through the cracks.

And even if it was possible would it work?? I know of no evidence, that other than providing a place for stabilization, that psychiatric hospitals work in any enduring fashion. They dont, if you look at return rates, even work well enough to keep people out of psychiatric hospitals.

I dont know but would be willing to hazard a guess that many of the "mentally ill" in the prisons and jails have had considerable psychiatric experience with little or no solid gains. Criminal behavior is not a symptom of mental illness and the "put them in the hospital" solution ignores things like poverty, drug addiction, racism, lack of work, homelessness and history of trauma and other adverse events that lead to someone actually committing criminal acts. The other thing to consider is not the degree to which "mental illness" causes criminal behavior but the extent to which incarceration causes "mental illness." Is treatment needed?? Are mental health resources needed and might for some people those resources be inpatient resources??? Of course. I wonder what percent of those people in jail would even meet the criteria for hospitalization?? I dont know the answers but tend to believe it is the lack of effective and accessible community resources that engender emotional involvement with the people they serve that is the root of the great numbers of "mentally ill" in jails and prisons.

Another core point of Murphy is that he believes that too many people get mental health services and that it is the "worried well " that are basically stealing resources that are better used by the severely mentally ill. Given the fact that most mental health systems have been starved and cut back over the last few years it seems a little like telling one person eating bread and water that the the person next to him is eating too much bread and water and not considering that the problem is the diet of bread and water. It is an argument of little integrity that resorts to an us vs. them argument as a pseudo explanation. It ignores totally the fact that state legislature after state legislature has sacrificed their mental health system on the fires of "financial responsibility" over the last few years.

There are without question people who are victims of a psychiatric system eager to diagnose every event in life as an enotional illness. There is a reason that pharmaceutical companies make money. But there are also people who struggle every day with serious mental health issues, trauma, and distress and to dismiss those people as dupes or malingers is stupid, dishonest and evil. If you think the biggest problem in the mental health system is that too many people need or are seeking help then you are a simple minded person not worthy of being taken seriously.

If you take the notion of "worried well" seriously it takes you to some strange places. How do you decide who is "worried well"? Who decides? Based on what criteria? What do you do to the "worried well"? Do you limit their access to services? How? How much and why? If you dont limit their access to services arent you being complicit in the people who need help being hurt?? And how much is all this going to cost?? Do we need programs to make sure that people who need services get them and another program to make sure those that dont are kept out. This is a treacherous notion that if you take serious leads to nightmares.

Another core notion is making assisted outpatient treatment a law in every state. They tell you that aot is a major problem solver but dont really explain why most of the 45 states that have it dont really use it. And they dont really explain why you need to make something a federal law that is already a state law. And they dont really explain why if 45 states can choose to have it 5 states cant.

I think the truth is that most states who are not willing to throw $32 million a year at it like New York find it more irrelevant than anything. It costs too much and does too little and in an environment of increasingly limited resources is not something that a lot of people are going to turn to to solve many things. And none of this even begins to touch on the questions of choice and coercion that so many people find so fundamentally troubling.

Another core notion of the Murphy Bill is that too many people complain about the human rights of people in the system being important and those people need to be quiet. It would basically eviscerate the protection and advocacy programs like Paimi and legislate away their voice. The idea that people in the system dont need protection is naive and self serving and something you might figure a psychologist or psychiatrist might come up with. Ask anybody in the system. See how safe they feel in the system.

The final key element is to do away with the notion of recovery and the best way to do that is to cut the legs out from under Samsha. Samsha is as close to a boogeyman as there is in this play. They are blamed for everything bad that has happened or will happened. The fact that thousands of people have found recovery to be a real thing is explained away by saying they probably didnt need help anyway or that they are in a remission that would have happened anyway regardless of what they did. If you dont like what you see it works really well to convince yourself that it was really something else.

Samsha is blamed for many things it doesnt decide about. The state of Tennessee decides what kind of services it will offer the people it serves....not Samsha.

Like I said at the start there is more to the Murphy Bill than what I have described here. He took a lot of peoples good ideas and made them part of his bill. None of them seem though to be core elements that define the bill and that is a shame. He has told people he will work with them on a better bill but no one knows what that means because he has compromised on nothing. I have been told by a lot of people I know that is bill is in trouble and very unlikely to be passed as written. I dont know how true that is, but know it is in everybodies best interest to know the bottom lines of what he proposes and decide what that means for them and the way they would like to see the mental health system change.

hopeworkscommunity | May 16, 2014

Larry Drain, Legislative Liaison for DBSA Tennessee, offers this blog with its many references that provides points for and against the Murphy bill. Please take time to self educate. Larry gives us a good start.

[Children's Mental Health Network

The Morning Zen]

Congressman Tim Murphy introduces controversial Helping Families in Mental Health Crisis Act of 2013

2 Comments | Posted December 15, 2013

On Friday, one day before the anniversary of the Newtown school shooting tragedy and on the same day of yet another tragic shooting at a school in Colorado, Congressman Tim Murphy introduced the Helping Families in Mental Health Crisis Act of 2013, a bill that would effectively rewrite how the Substance Abuse and Mental Health Services Administration (SAMHSA) operates and significantly narrow the focus of the types of mental health services and supports it helps promote through its grant programs. While the bill is at this point just a proposal, it is an important read for Network faithful as it sheds a light on the thinking of many individuals across the country about how to improve mental health services in America. Unfortunately, with the continued tragedies occurring at schools across the nation the tendency to equate guns and violence with mental illness leads to recommended solutions in this bill that are narrow in focus and could potentially set back the advances in the field of mental health 20 to 30 years.

What makes writing this Morning Zen piece difficult for me is that I have the utmost respect for Congressman Murphy. A child psychologist by training, co-author of two books ("The Angry Child: Regaining Control When Your Child Is Out of Control" and "Overcoming Passive-Aggression), it is obvious that Congressman Murphy cares deeply about improving mental health services. For that he is to be applauded. But what is in this proposed bill for the most part is either mystifying or antithetical to what the research tells us works best for young people with emotional challenges and their families. In fairness, at the end of this post I have included links to position statements on the proposed bill from national organizations and thought leaders both for and against the bill. As always, we pride ourselves on providing as many perspectives as possible so that our educated readers can make up their own minds and respond to their elected officials accordingly.

The response from mental health advocates and provider groups both for and against the bill was swift. As is the general approach of the Children's Mental Health Network we took the weekend to read and digest the 135-page bill before making our comments. The list is long so grab a cup of coffee for this one.

The proposed bill is complex in that mixed in with proposals that are administratively bureaucratic, relying on reference resources that in some cases are twenty years old and frankly dismissive of anything outside of the realm of narrowly defined evidence based practice, are some excellent proposals such as continuing funding for the Garrett Lee Smith and National Child Traumatic Stress initiatives.

However, overwhelmingly the recommended changes in the bill set the advances made in knowledge about what works for youth with mental health challenges and their families back a good twenty to thirty years.

Clouding the picture of how to interpret this proposed bill was the timing of its release – on the eve of the anniversary of the Newtown tragedy and on the day of yet another shooting at a school in Colorado, where emotions were already running high and the popular press was flooded with news stories about guns, violence and mental illness. Even though research shows that those with a mental illness are significantly more likely to be a victim of violence than a perpetrator of violence, discussions in Congress about what to do tend to fall too easily into the guns + violence = mental illness equation.

Note: Be sure to read Lisa Lambert's Morning Zen post for a parent’s reflection on the anniversary of the Newtown tragedy.

Okay, with all of this in mind as a backdrop for what is in the proposed bill, let’s take a walk through some of the highlights. The 135 page document is one I encourage you to read to get your own sense of its merits and drawbacks. In this post I will focus on some of the key areas that are important to highlight. Page numbers of the bill are cited so that you can read the full text in the copy of the proposed bill that you can download here.

Additional layers of bureaucracy added while diminishing the decision-making role of key SAMHSA personnel (Page 4)
The position of Assistant Secretary for Mental Health and Substance Use Disorders would be created. This individual would directly supervise the Administrator of the Substance Abuse and Mental Health Services Administration. Reading through the responsibilities that this individual would have left me perplexed, as the duties described appear to already be in place under the responsibility of the Administrator.

National Mental Health Policy Laboratory (page 7)
The proposed bill calls for the creation of a National Mental Health Policy Laboratory (NMHPL) headed by a Director. The purpose of this Director position would be to:

• (A) Identify and implement policy changes and other trends likely to have the most significant impact on mental health services and monitor their impact in accordance with the principles outlined in National Advisory Mental Health Council’s 2006 report entitled ‘The Road Ahead: Research Partnerships To Transform Services’;
• (B) Collect information from grantees under programs established or amended by the Helping Families in Mental Health Crisis Act of 2013 and under other mental health programs under this Act, including grantees that are federally qualified community behavioral health clinics certified under section 201 of the Helping Families in Mental Health Crisis Act of 2013 and States receiving funds under a block grant under part B of title XIX of this Act; and
• (C) Evaluate and disseminate to such grantees evidence-based practices and services delivery models using the best available science shown to reduce program expenditures while enhancing the quality of care furnished to individuals by other such grantees."

The description of the NMHPL goes on to say that "In selecting evidence-based practices and services delivery models for evaluation and dissemination under paragraph (2)(C), the Director of the NMHPL 

• (A) Shall give preference to models that improve the coordination, quality, and efficiency of health care services furnished to individuals with serious mental illness; and
• (B) May include clinical protocols and practices used in the Recovery After Initial Schizophrenia Episode (RAISE) project and the North American Prodrome Longitudinal Study (NAPLS) of the National Institute of Mental Health.

On page 10 the language continues with "In carrying out the duties under this section, the Director of the NMHPL shall consult with representatives of the National Institute of Mental Health on organization, hiring decisions, and operations, initially and on an ongoing basis; (B) other appropriate Federal agencies; and (C) clinical and analytical experts with expertise in medicine, psychiatric and clinical psychological care, and health care management.

The Children’s Mental Health Network is troubled that there is no mention of youth and family involvement in such a consulting pool, especially with the impressive track record achieved by SAMHSA in cultivating a family-driven, youth guided approach through its system of care grants and cooperative agreements over the past 20+ years.

Interagency Serious Mental Illness Coordinating Committee (page 14)
Yet another bureaucratic layer is added to the decision-making process with the recommendation to establish an Interagency Serious Mental Illness Coordinating Committee to "assist the Assistant Secretary in carrying out the Assistant Secretary's duties.

The responsibilities of this Committee include:

• (1) Develop and annually update a summary of advances in serious mental illness research related to causes, prevention, treatment, early screening, diagnosis or rule out, intervention, and access to services and supports for individuals with serious mental illness;
• (2) Monitor Federal activities with respect to serious mental illness;
• (3) Make recommendations to the Assistant Secretary regarding any appropriate changes to such activities, including recommendations to the Director of NIH with respect to the strategic plan developed under paragraph (5);
• (4) Make recommendations to the Assistant Secretary regarding public participation in decisions relating to serious mental illness;
• (5) Develop and annually update a strategic plan for the conduct of, and support for, serious mental illness research, including proposed budgetary requirements; and
• (6) Submit to the Congress such strategic plan and any updates to such plan.

There is a long list of required members for this committee (page 15), including the Director of NIH, the Attorney General of the United States; the Director of the Centers for Disease Control and Prevention and more. Members of the Committee serve 4-year terms and would be required to meet a minimum of two times per year. In addition, the Committee “may establish subcommittees and convene workshops and conferences "to enable the subcommittees to carry out their duties."

And finally, with regard to administrative duties, on page 70 it is noted that the administration of block grants would be removed from the Director of the Center for Mental Health Services and shifted to the Assistant Secretary for Mental Health and Substance Use Disorders. Gonna be one busy Assistant Secretary if this proposal goes through!

I can't help but think that if this plan were to come to fruition there would be bureaucratic gridlock. Two new significant leadership positions assuming key duties of currently existing high ranking officials within SAMHSA and a large Committee with sub-committees to "assist the Assistant Secretary in carrying out the Assistant Secretary's duties" (Page 14). In my mind, this is a huge duplication of duties already ascribed to the SAMHSA Administrator, the Director of the Center for Mental Health Services and others within SAMHSA.

Let's move away from administrative duties to some of the new grant programs proposed, specifically the Assisted Outpatient Treatment Program. The proposed bill calls for up to 50 grants each year for a 4-year pilot program to focus on assisted outpatient treatment programs (Page 19). Each grant would be eligible for one million dollars per year for four years - $15,000,000 per year would be authorized totaling $60,000,000 over the four-year period.

Assisted outpatient treatment is a controversial topic, with some saying it is the best option for an adult with a mental illness who "lacks capacity to fully understand or lacks judgment to make informed decisions regarding his or her need for treatment, care, or supervision." Others, including the Children's Mental Health Network, see this as a potentially dangerous road to travel in that it could have wide-ranging impact on those who might be swept up unnecessarily. You can review both sides of the argument regarding Assisted Outpatient Treatment at the end of this post.

Number of seriously mentally ill who are imprisoned (page 63)
Section 405 focuses on reports of the number of seriously mentally ill who are imprisoned. An important topic for sure, the intent is to "calculate the number and type of crimes committed by persons with serious mental illness each year, and detail strategies or ideas for preventing crimes by those individuals with serious mental illness from occurring… For purposes of this section, the Attorney General, in consultation with the Assistant Secretary of Mental Health and Substance Use Disorders shall determine an appropriate definition of ‘‘serious mental illness’’ based on theHealth Care Reform for Americans with Severe Mental Illnesses: Report’’ of the National Advisory Mental Health Council, American Journal of Psychiatry 1993; 150:1447–1465. The link is provided though you will need to pay the journal for the download. We can only hope that this document, written 20 years ago, reflects the evolution of thinking about mental health challenges since then. Of greater concern is the proposed process for decision-making about defining "serious mental illness." Should this just be left to the Assistant Secretary and the Attorney General? This is much too vague for our liking.

Reducing the stigma of serious mental illness (page 79)
It is hard to even comment on this section when the entire document is stigma-laden, focusing primarily on a narrow subset of those individuals with a diagnosis of serious mental illness when describing what needs to happen within a federal agency charged with looking at the full spectrum of behavioral health issues. However, Network faithful should read it and decide for themselves.

Title XI-SAMHSA Reauthorization and Reforms (page 99)
Mentioned earlier is the fact that the Assistant Secretary for Mental Health and Substance Use Disorders would be in charge of SAMHSA. One of the more fascinating recommendations is that "At least 30 days before awarding a grant, cooperative agreement, or contract, the Administrator shall give written notice of the award to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate.’’ This suggests adding yet another layer of review, more opportunity for delay and added bureaucracy. Though not specified, one could assume that a member of either Committee could block a grant award.

In addition, it would be required that "Before awarding a grant, cooperative agreement, or contract, the Secretary shall provide a list of the members of the peer review group responsible for reviewing the award to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate." This is yet another opportunity for delay and bureaucratic red tape.

Transfer of all functions and responsibilities of the Center for Behavioral Health Statistics and Quality to the National Mental Health Policy Laboratory (page 102)
This section discusses the transfer of "all functions and responsibilities of the Center for Behavioral Health Statistics and Quality to the National Mental Health Policy Laboratory. Why would one do this? In addition, in this section responsibilities currently assigned to the Administrator are reassigned to the Assistant Secretary. I am beginning to wonder what is left for the Administrator to do?

Establish a clearinghouse of evidence-based practices  (page 106)
In this section there is mention of the establishment of "a clearinghouse of evidence-based practices, which has first been reviewed and approved by a panel of psychiatrists and clinical psychologists, for mental health information to assure the widespread dissemination of such information to States, political subdivisions, educational agencies and institutions, treatment and prevention service providers, and the general public, including information concerning the practical application of research supported by the National Institute of Mental Health that is applicable to improving the delivery of services..."

Unfortunately there is no mention of consumers, families or youth involved in this review.

Limitations on Authority (page 133)
The section on Limitations on Authority includes some questionable items. For example, in this section it is stated that in order for SAMHSA to host or sponsor a conference they "must give at least 90 days of prior notification to the Committee on Energy and Commerce and Committee on Appropriations of the House of Representatives and the Committee on Health, Education, Labor, and Pensions and Committee on Appropriations of the Senate." Again, this seems like yet another unnecessary layer of bureaucracy.

No financial assistance to any program without evidence-based practices (page 133)
Continuing on page 133 is the directive that the Administrator of SAMHSA "shall not provide any financial assistance for any program relating to mental health or substance use diagnosis or treatment, unless such diagnosis and treatment relies on evidence-based practices."

If you have made it this far in this lengthy post you know that this leads back to the question "What is an evidence-based practice and who is involved in deciding that?" From reading the full text of the proposed bill the decision makers are definitely skewed toward the medical community with a strong focus on a narrow slice of the overall population of individuals needing mental health services.

Elimination of unauthorized SAMHSA programs without explicit statutory authorization (page 134)
Saving one of the more controversial items for last (at least as based on the tenor of emails sent to the Network over the weekend) is the section on the elimination of unauthorized SAMHSA programs without explicit statutory authorization. The language is clear that no new programs are to be created that are not explicitly authorized or required by statute and that "by the end of fiscal year 2014, any program or project of the Substance Abuse and Mental Health Services Administration that is not explicitly authorized or required by statute shall be terminated."

The proposed bill goes on to say "The Assistant Secretary for Mental Health and Substance Use Disorders shall seek to enter into an arrangement with the Institute of Medicine under which the Institute (or, if the Institute declines to enter into such arrangement, another appropriate entity) agrees to submit a report to the Congress not later than July 31, 2014, identifying each program, project, or activity to be terminated under subsection (a).

So, there you have it. Quite a bit to chew on and I cut this post down significantly. Please take the time to read the proposed bill. Whether it gains traction in the House or not it is important to remember that this proposed bill reflects the thinking of many. If you are concerned about this, as we are, then you might want to consider an education campaign.

Next week we will share our collaborative efforts with Maryland-based mental health providers, adult and youth representatives with experience receiving mental health services, and family advocates and other agency representatives to put together a site visit for Senate and House Appropriations Committee staff to not only show them what a coordinated system of care approach looks like in the effective provision of services and supports for young adults with mental health challenges, but also to provide them the opportunity for one on one dialogue with youth and adults who utilize mental health  services, families and the amazingly dedicated professionals who work side by side with them. We began organizing this effort for Senate Appropriations staff as a result of our inquiry into the Healthy Transitions Initiative in August of this year. Senate Appropriations Committee staff have agreed to come and we will be extending an invitation to House Appropriations Committee staff this week. I will give you full details in the Morning Zen post this coming Friday.

What is so important about our education campaign is that it is not focused on one grant or particular service. We are not bringing staffers to a visit to ask for money. We are bringing staffers to a visit to let them experience firsthand the importance of a comprehensive approach to meeting (in this case) the needs of young adults with mental health challenges. Sounds like a systems of care approach to me!

And finally, here is a sampling of different individual and organizational analyses and reactions to the proposed bill, both pro and con. Remember, an educated voice is a powerful voice.

For the proposed bill

• How Should We Help the Seriously Mentally Ill?
• NAMI NY State Position Statement  
• NAPHS Applauds Rep. Tim Murphy for Introduction of Comprehensive Mental Health Reform Legislation

Against the proposed bill

• National Coalition for Mental Health Recovery press release jointly issued with the National Disability Rights Network and the Bazelon Center for Mental Health Law
• Involuntary Outpatient Commitment (IOC)1 Myths and Facts
• Mental Health America statement

Time to do your homework folks!

Scott Bryant-Comstock
President & CEO
Children’s Mental Health Network

Submitted by Jennifer Dochod, Legislative Liasion for DBSA Tennessee. The brief summary by Mr. Murphy's office highlights the points in the proposed Bill he drafted.

                     Tim Murphy

                U.S. Congressman

    for the 18th District of Pennsylvania

Short Summary of The Helping Families In Mental Health Crisis Act (H.R. 3717)

Ensuring Psychiatric Care for Those in Need of Help the Most Rep. Tim Murphy, PhD

Mental illness does not discriminate based on age, class or ethnicity. It affects all segments of society. More than 11 million Americans have severe schizophrenia, bipolar disorder, and major depression yet millions are going without treatment as families struggle to find care for loved ones.

To understand why so many go without treatment, the Energy and Commerce Subcommittee on Oversight and Investigations launched a top-to-bottom review of the country’s mental health system beginning in January 2013. The investigation revealed that the approach by the federal government to mental health is a chaotic patchwork of antiquated programs and ineffective policies across numerous agencies.

Not only is this frustrating for families in need of medical care, but when left untreated, those with mental illness often end up in the criminal justice system or on the streets. The mentally ill are no more violent than anyone else, and in fact are more likely to be the victims of violence than the perpetrators, but individuals with untreated serious mental illness are at an increased risk of violent behavior. Tragically, undertreated mental illness has been linked to homicides, assaults, and suicides.

The Helping Families In Mental Health Crisis Act (H.R. 3717) fixes the nation’s broken mental health system by focusing programs and resources on psychiatric care for patients and families most in need of services. The legislation:

EMPOWERS PARENTS AND CAREGIVERS

What the investigation found:

Physicians are often unwilling to share or receive information with loved ones about an individual who has a serious mental illness and is experiencing a psychotic break because of complicated federal rules on communicating with immediate family members and caregivers. This scenario is especially problematic for parents of young adults with mental illness because psychosis begins to manifest between ages 14 and 25.

Clarifies Health Information Portability and Accountability Act (HIPAA) privacy rule and the Family Educational Rights and Privacy Act so physicians and mental health professionals can provide crucial information to parents and caregivers about a loved one who is in an acute mental health crisis to protect their health, safety, and well-being.

2332 Rayburn House Office Building | Washington, DC 20515
Murphy.House.Gov | (202) 225-2301 | (202) 225-1844 | @RepTimMurphy | Facebook.com/RepTimMurphy

The Helping Families in Mental Health Crisis Act (H.R. 3717), Rep. Tim Murphy 2

FIXES THE SHORTAGE OF INPATIENT PSYCHIATRIC BEDS

What the investigation found:

There is a severe lack of inpatient and outpatient treatment options. Seventy years ago, the country had 600,000 inpatient psychiatric beds for a country half the size. Today, there are only 40,000 beds.

What the legislation does:

Increases access to acute care psychiatric beds for the most critical patients by making two narrowly tailored exceptions to the Institutions for Mental Disease (IMD) exclusion under Medicaid. The IMD exclusion is what originally caused the shortage of psychiatric beds.

ALTERNATIVES TO INSTITUTIONALIZATION

What the investigation found:

Approximately forty percent of individuals with schizophrenia do not recognize they have a mental illness, making it exceedingly difficult for them to follow through on a treatment regimen.
What the legislation does:
Promotes alternatives to long-term inpatient care such as court-ordered ‘Assisted Outpatient Treatment,’ which has been proven to save money for state and local governments by reducing the rates of imprisonment, homelessness, substance abuse, and costly emergency room visits by the chronically mentally ill.

REACHING UNDESERVED AND RURAL POPULATIONS

What the investigation found:

The delay between a first episode of psychosis and the onset of treatment averages 110 weeks. Early diagnosis and medical intervention improves outcomes dramatically, but there is only one child psychiatrist for every 7,000 children with a mental illness or behavioral disorder.

What the legislation does:

Modeled on a successful state project in Massachusetts, the bill advances tele-psychiatry to link pediatricians and primary care physicians with psychiatrists and psychologists in areas where patients do not have access to mental health professionals.

DRIVING EVIDENCE-BASED CARE

What the investigation found:

The federal government spends $125 billion annually on mental health, but there is little interagency coordination on programs, nor does the federal government collect data on how mental health dollars are spent or whether those dollars are resulting in positive health outcomes.

What the legislation does:

Creates Assistant Secretary for Mental Health and Substance Use Disorders within the Department of Health and Human Services to coordinate federal government programs and ensure that recipients of the community mental health services block grant apply evidence-based models of care developed by the National Institute of Mental Health. The Assistant Secretary will ensure federal programs are optimized for patient care rather than bureaucracy.

The Helping Families in Mental Health Crisis Act (H.R. 3717), Rep. Tim Murphy 3

What the investigation found:

STABILIZING PATIENTS BEYOND THE ER

Access to physician-prescribed medication is vital for vulnerable individuals in avoid acute mental health crisis. Current policies that permit only “one drug” per therapeutic class policy ignore the clinical needs of individuals with mental illness who rely on vital, non-interchangeable prescription drug therapies.

What the legislation does:

Protects certain classes of drugs commonly used to treat mental illness so physicians have prescribe the right medication for those on Medicare and Medicaid similar to the protected classes for persons with epilepsy and cancer.

ADVANCES CRITICAL MEDICAL RESEARCH

What the investigation found:

The National Institute of Mental Health measures public health outcomes to develop medical models of care. For example, the Recovery After Initial Schizophrenia Episode (RAISE) project shows earlier intervention with treatment for a person at risk of developing full-blown schizophrenia allows patients to lead functional lives. The NIMH also excels at basic medical research, but lacks the financial resources.

What the legislation does:

Authorizes the BRAIN research initiative at the National Institute of Mental Health and encourages the agency to undertake additional research projects on serious mental illness and self- or other-directed violence.

HIGH QUALITY COMMUNITY BEHAVIORAL HEALTH SERVICES

What the investigation found:

Community Mental Health Centers receiving funds from the federal government receive lower reimbursements federal insurance programs than comparable care facilities.

What the legislation does:

Applies rigorous quality standards for a new class of Federally Qualified Community Behavioral Health Clinics (FQCBHC), requiring them to provide a range of mental health and primary care services.

DEPARTMENT OF JUSTICE REFORMS

What the investigation found:

Between twenty and fifty percent of the incarnated system inmates have a mental illness. Mental health courts have provided a cost-effective and responsible alternative to incarcerating the mentally ill.

What the legislation does:

So patients are treated in healthcare system and not warehoused in the criminal justice system, the bill reauthorizes mental health courts and requires the Department of Justice to collect more data on interactions between the police and the mentally ill. The bill also authorizes Byrne Justice Assistance Grants (JAG) to be used for mental health training of law enforcement and corrections officers.

The Helping Families in Mental Health Crisis Act (H.R. 3717), Rep. Tim Murphy 4

BEHAVIORAL HEALTH AWARENESS FOR CHILDREN AND TEENS

What the investigation found:

Despite increased medical and scientific research into the nature and source of serious mental illness, a mental illness stigma persists.

What the legislation does:

The Department of Education, working with mental health stakeholders, will undertake a national campaign aimed at reducing the stigma of severe mental illness in schools. The bill also reauthorizes the Garrett Lee Smith suicide prevention program.

INTEGRATES PRIMARY AND BEHAVIORAL CARE

What the investigation found:

Low-income individuals with serious mental illness and addiction disorders have high incidences of cancer, heart disease, diabetes and asthma. Untreated depression increases the risk of chronic diseases, and can double the cost of healthcare for health disease and diabetes. Integrating mental healthcare providers into electronic medical records systems will result in better coordinated care for patients as well as cost savings.

What the legislation does:

Extends the health information technology incentive program to mental health providers so they can communicate and work with primary care clinicians.

INCREASES PHYSICIAN VOLUNTEERISM

What the investigation found:

Health centers and mental health clinics are experiencing a staff shortage. Clinicians and healthcare professionals can volunteer at federal free clinics, but federal legal barriers and the high cost of medical malpractice insurance prevent them from doing so at community health centers and mental health clinics.

What the legislation does:

Eliminates federal legal barriers under the Federal Tort Claims Act preventing physician volunteerism at community mental health clinics and federally-qualified health centers.

REFORMS THE SUBSTANCE ABUSE & MENTAL HEALTH SERVICES ADMINISTRATION

What the investigation found:

Unauthorized in the last decade, the Substance Abuse and Mental Health Services Administration has lacked mission focus. Grant programs are not evidence-based or guided by the best available medical science.

What the legislation does:

Emphasizes evidence-based treatments, sunsets unauthorized programs, and strengthens congressional oversight of all federal behavioral health grants.

Murphy stuck????

by Larry Drain

GOP Newtown bill hits impasse | TheHill
http://thehill.com/blogs/healthwatch/mental-health/204125-gops-newtown-bill-hits-impasse-in-house#.U1g8L-DtN98.facebook
【from Next Browser】

It sounds based on reports like these that the Murphy Bill is not going to pass as written.  Things change I know, but it looks that way.  There is I understand a democratic bill being written by Rep.  Barber.  Things dont seem to look really great.  The really interesting thing is that it might not matter rather or not the Torrey crowd thinks they have made a great case.  It may only matter whether or not they find common ground with people up to now they have shown no interest in finding common ground with.  Rhettoric that they are so good with may not be their friend.  Winning the battle may cause them to lose the war.

The next few weeks, next few months may be interesting.  Common ground.... what a weird approach to American politics.

hopeworkscommunity | April 23, 2014

I'm sharing the news of my being among national Award Winners for accomplishments over the past year. It has been a pleasure to serve as State Director and local chapter President. And I consider it an honor to be recognized by DBSA national.

I appreciate all the wonderful support I was given by my fellow officers, Board members, and the chapter membership throughout the year. You may view the announcement on the national web site athttp://www.dbsalliance.org/site/PageServer?pagename=peer_chapter_spotlights

                       Congratulations to our 2013 Chapter Service Award Winners!
The DBSA Chapter Service Awards recognize exemplary service by DBSA 
chapters, state organizations, and their leaders. Winners will be honored at the 2014 Chapter Leadership Forum in addition to receiving a cash award.

Steve Brannon of DBSA Jackson (TN) and DBSA Tennessee - Outstanding
Leadership
Steve is an excellent role model for pursuing a wellness-focused life while living with a mood disorder. He fights stigma by openly sharing his journey in the local newspaper, on DBSA’s website, and on his weekly online newsletter. He has worked with the local police department to help educate and train police officers for crisis response teams. Steve was selected for DBSA Peer Advocacy Training and was a representative of DBSA for Hill Day in Washington, D.C.
At his local chapter, DBSA Jackson (TN), Steve gently encourages, trusts, and believes in support group participants. He instituted a monthly “share your inspiration” night in which group members report on what keeps them going, creating an environment of hope and personal growth. Steve is dedicated to further advancing DBSA’s mission into surrounding communities and across the state. The number of support groups has doubled in the past year under his direction, encompassing all major cities and some smaller cities across the state. He has traveled hundreds of miles at his own expense to conduct local chapter visitations as state director. Steve’s passion for the advancement of DBSA’s mission in Jackson and the state of Tennessee is so strong that he has diligently dedicated his time and resources for over a decade.

DBSA Tennessee - State Organization Service 
DBSA Tennessee's amazing accomplishments made 2013 a rewarding year! 
They supported chapters in their state by hosting educational presentations and training programs, giving them the tools necessary for successful chapters. With help from DBSA Tennessee, five local chapters were interviewed on television or radio to promote DBSA to the community. Leaders encouraged one chapter’s community outreach, resulting in a city-wide Mental Health Day declared by their mayor. DBSA Tennessee’s robust plan to help new chapters in the startup process helped find free meeting locations, assistance in affiliation fees and paperwork, and provided a sponsor from an already established chapter to assist the new chapter.
Five members of DBSA Tennessee attended DBSA’s Peer Advocate Training in Washington, D.C. and then created an advocacy plan for their state including a campaign against proposed budget cuts to close all 45 of Tennessee’s Peer Support Service Centers. DBSA Tennessee is a growing, thriving organization. With its advocacy for peer support and local chapter start-up, community outreach and commitment to peer education, DBSA Tennessee is one of the most energetic affiliates of DBSA.

DBSA Murfreesboro (TN) - Rookie Chapter Service
DBSA Murfreesboro began in July of 2013 with support from DBSA Tennessee. 
The chapter started out with one support group, which saw its attendance 
double in fewer than six months, becoming one of the fastest growing local 
chapters in the state. The growth of the chapter can be attributed to the forces behind it that work tirelessly to get the word out about the group. Flyers and pamphlets are distributed to agencies and health care providers, the Salvation Army, local hospitals and businesses, and more. DBSA Murfreesboro provides post-hospitalization support for those who would otherwise have none. Educational materials, resources, and wellness tools are provided to each chapter participant. They have also started a family and friends support group.

Members of DBSA Murfreesboro participated in the state chapter meetings and backing of their U.S. Representative. For a chapter that achieved all of this in six months, DBSA Murfreesboro has a fine resume of accomplishments, but they consider their greatest success to be the level of support offered to each person who walks through their doors.

http://www.dbsalliance.org/site/PageServer?pagename=peer_chapter_spotlights

 
The National Council has just received word that the Centers for Medicare and Medicaid Services (CMS) is abandoning its recentproposal to strip mental health drugs and immunosuppresants of their protected status in Medicare.
 
CMS said its decision came in response to massive vocal pushback from healthcare consumers, advocates, and congressional leaders.
 
Congratulations - your efforts paid off!
 
Members of the National Council and the Partnership for Part D Access submitted well over 1,000 comments to CMS opposing the drug restrictions. Grassroots advocacy is one of the most powerful ways to influence public policy - and your efforts have once again demonstrated our collective strength.
 
Thank you for your hard work! I hope you will take a moment today to celebrate this success. You deserve it.
 
Sincerely,
 
Chuck Ingoglia
Senior Vice President, Public Policy & Practice Improvement
National Council for Behavioral Health

Medicare Rule Changes May Restrict Drug Choices for Seniors
http://guardianlv.com/2014/02/medicare-rule-changes-may-restrict-drug-choices-for-seniors/
(from Easy Browser)

The CMS decisions about which drugs to protect were supposed to be based on whether the drugs were needed to prevent increased doctor visits, hospitalizations, persistent disability, incapacitation or death that would otherwise occur within seven days if the drugs were not given. The choices about which drugs to remove from protection fail that test because, with acute mental illness, seven days without medication could easily lead to hospitalization, incapacitation or death. The same constraint exists for some 500,000 transplant patients. Seven days without the right medication could result in transplant rejection.

The quote above is from the article linked.  My jaw dropped when I read it.  CMS is proposing to drop certain drug classes from the status of protected medication.  The idea is to save money.  The article says it may save around 10% I believe.

My jaw dropped when I read the criteria.  It basically says that if doing without a drug for 7 days wont kill you, incapacitate, or put you in the hospital you really didnt need it to the point where your access to the medication is guaranteed to begin with.

WHAT ABOUT THE EIGHTH DAY??

Is it just me or does this not sound simply stupid, simply arbitrary and simply mean?  How in the world do you decide as a matter of cost containment that if someone doesnt die fast enough that dont really need a medication?  Who should have that kind of power??  Should anyone??

I read all the stuff about percents...percents of cost...percents of savings.  There is another "p" word-- PEOPLE.  Somehow it seems like it got lost.

Larry Drain at HOPEWORKSCOMMUNITY

A big step backward into the future: mental health “reform” Washington style

by hopeworkscommunity

The new mental health reform bill introduced by Rep Murphy provides for the following according to the Treatment Advocacy Center:

" Requires states to have commitment criteria broader than “dangerousness” and to authorize assisted outpatient treatment (AOT) in order to receive Community Mental Health Service Block Grant funds.

Allocates $15 million for a federal AOT block grant program to fund to 50 grants per year for new local AOT programs.

Carves out an exemption in HIPAA (Health Insurance Portability and Accountability Act) allowing a “caregiver” to receive protected health information when a mental health care provider reasonably believes disclosure to the caregiver is necessary to protect the health, safety or welfare of the patient or the safety of another. (The definition of “caregiver” includes immediate family members.)"

TRANSLATION:

What does it mean?

1.  States will be substantially limited in their control over their own mental health policy.  This, in and of itself, represents a radical change of immense implications.  It is a wall once breached that will never be rolled back.

2.  The future direction of mental health policy will basically be in the hands of the Treatment Advocacy Center.  After years and years of failing to get states to follow their policy of coercion first to the degree they want their view would effectively become federal policy.  What they could never win by choice they will win by force.

3.  Much gains in knowledge about what really works and helps people with mental health issues would be rendered unimportant and out of fashion.  The notion of recovery would be given a death blow.

4.  States by federal statute would have to agree to commit more and more people.

5.  Failure to do so would make you ineligible for federal block grants that are the backbone of so many state mental health budgets.

6. Privacy laws would not allow so much privacy.  Confidentiality would have holes big enough to drive a hole through.

And that is only the beginning.  It is a step back into an era of mental health care that was a national disgrace and one in which a diagnosis of mental illness was a life sentence.

hopeworkscommunity | December 13, 2013