Saturday, December 15, 2012

Five Point Action Plan for President Obama to Reduce Violence by Mentally Ill

President Obama said the federal government has to do something meaningful to prevent future shootings like the twenty-six in Newtown, Connecticut.  Here is what the federal and state governments can do to prevent violence related to mental illness.

What Washington can do


1. Start demonstration projects of Assisted Outpatient Treatment (Kendra's Law in NY, Laura's Law in CA) throughout the country. AOT allows courts to order certain individuals with mental illness to stay in treatment as a condition of living in the community. It is only available to the most seriously ill who have a past history of violence, incarceration or needless hospitalizations. AOT is proven to keep patients, public, and police safer. The Department of Justice certified  'AOT as effective crime prevention program'.  But mental health departments are reluctant to implement AOT because it forces them to focus on the most seriously ill. Demonstration projects would help mental health departments see the advantage of the program.

2. Write exceptions into the Health Insurance Portability and Accountability Act (HIPAA) so parents of mentally ill children can get access to medical records and receive information from their children's doctors on what is wrong and what the children need. Under the rubrick of "confidentiality' doctors won't tell parents what is wrong with their kids or what treatment is needed, while simultaneously requiring parents to provide the care.  When a child goes off treatment, the parents' hands are tied. They have all the responsibility to see the person is cared for, but none of the information or authority to see it happens. We have to change the patient confidentiality laws so parents can help prevent tragedies rather than become a punching bag for the public when something horrific happens.

3 End the Institutes for Mental Disease (IMD) Exclusion in Medicaid Law. This provision tells states "If you kick someone 18 to 64 years old out of a state psychiatric hospital, we will pay you 50% of the community care costs." This causes states to lock the front door of hospitals and open the back regardless of whether the community is an appropriate setting. If you have a disease in any organ of your body, other than the brain, and need long-term hospital care, Medicaid pays its' share. Failing to pay when the illness is in the brain is federal discrimination against persons with mental illness and results in acts of violence by those kicked out or denied admission, plus greater use of more expensive jails and prisons. I wrote on Medicaid discrimination for the mass market in the Washington Post, but John Edwards wrote a more scholarly paper on ending the IMD Exclusion. Relatedly, a proposal made by former vice-presidential candidate Ryan, whereby Medicaid was block granted could solve this problem.

4. Create a federal definition of serious mental illness, and require the vast majority of all existing mental health funding go to it. The mental health establishment is going to clamor for more money to prevent future Newtowns. It's not needed. We already spend over $100 billion. That is more than enough money in the mental health system to prevent Newtown type incidents, provided it was spent on people truly ill, not the worried-well. But mission creep and the propensity to diagnose normal reactions of people as a mental 'health' issue needing government intervention have sent the money to anyone who claims they have trauma, feels sad, is going through a divorce, lost a parent, or wants a better job. 5-9% of Americans have a serious mental illness. That's where we should be spending our money--on the 5-9% who are most likely to become violent and need help the most, not the worried well. I wrote on this for a mass market on Huffington Post, but a much more scholarly paper was written by Howard H. Goldman and Gerald N. Grob. With the fiscal cliff approaching, prioritizing the most seriously mentally ill for services is more important than ever.   

5. Eliminate the Substance Abuse and Mental Health Services Agency (SAMHSA). As Dr. E. Fuller Torrey wrote in National Review, SAMHSA is the epicenter of what is wrong with the American mental health system. SAMHSA actively encourages states to engage in mission creep and send the most seriously ill to the end of the line rather than the front. They provide massive funding to organizations that want to prevent mentally ill individuals from receiving treatment. They have nothing positive to show for their efforts in spite of a massive bureaucracy that meets and meets and meets and never accomplishes anything. I wrote on this for a mass market in Washington Times and Huffington Post. But Amanda Peters wrote a terrific scholarly piece on SAMHSA for a law journal.

If Obama is serious about wanting to do something, the steps above would be the best first step. True, the mental health industry may throw a hissy fit as they find themselves obligated to serve the most seriously ill, but it's the right thing to do. Anything else could be deadly.

Here is what states should do.

    1. States should make greater use of Assisted  Outpatient Treatment, especially for those with a history of violence or incarceration. AOT allows courts to order certain seriously mentally ill people to stay in treatment as a condition of living in the community. AOT works.  Connecticut  does not have a law., California has not implemented theirs, and New York's is full of cracks that need to be closed and 40 other states rarely use it.

     2. States should focus resources on the seriously mentally ill, rather than stigma campaigns and anti bullying programs. This is especially true in California where voters passed the Mental Health Services Act, a 1% tax on millionaires to help people with "serious mental illness.The mental health system accepted the money but not the responsibility to spend it on the seriously ill.

    2. States should, with proper due process, expand civil commitment beyond just "danger to self or others". The only civil commitment standard used in every state is "danger to self or others'. People who are so ill they don't know they are ill--those screaming at voices only they can hear, can not be treated until after they are dangerous. Rather than prevent violence, the law requires. it. Think Jared Loughner who shot Gabrielle Giffords. To assist people before they become a "psychotic killer on rampage headline" every state should allow courts to order civil commitment when an individual is

      (A) "gravely disabled", which means that the person is substantially unable, except for reasons of indigence, to provide for any of his or her basic needs, such as food, clothing, shelter, health or safety, or
      (B) likely to "substantially deteriorate" if not provided with timely treatment, or
      (C) "lacks capacity"  which means that as a result of the brain disorder the person is unable to fully understand or lacks judgment to make an informed decision regarding his or her need for treatment, care or supervision.

    When the "dangerousness standard" is used, it must be interpreted more broadly than "imminently" and/or "provably" dangerous.

    State laws should also allow for consideration of past history in making determinations about icourt-ordered treatment, since past history is often a reliable way to anticipate the future course of illness.