US Loses Psychiatric Beds for Mentally Ill

The following chart is excerpted from  “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals 2005-2010” by the Treatment Advocacy Center (http://treatmentadvocacycenter.org)

It compares public hospital beds available for people with mental illness in 2010 vs. 2005; computes the gain or loss; tells how many beds exist per 100,000 residents; and calculates what percent of the minimum beds needed the state has on hand. Based on that percentage, the state is ranked. There is a dramatic shortage of public psychiatric beds in every state. The result is that more people with mental illnesses are being sent to jails, shelters, prisons, and morgues. 

State	Number of psychiatric   beds 2010	Number of   psychiatric beds 2005	Number of   psychiatric beds lost or gained	Percent of psychiatric beds lost or gained	2010 beds/ 100,000 total pop.	Relation to target beds per capita	State Ranking per capita (worst to  to least worst)
Arizona	260	338	-78	-23%	4.1	8%	Tied for Last
Minnesota	206	464	-258	-56%	3.9	8%	Tied for Last
Iowa	149	239	-90	-38%	4.9	10%	48
Michigan	530	1,006	-476	-47%	5.4	11%	47
Arkansas	203	184	19	+10%	7.0	14%	46
Alaska	52	74	-22	-30%	7.3	16%	45
Vermont	52	55	-3	-5%	8.3	17%	44
New Mexico	171	425	-254	-60%	8.3	18%	41
North Carolina	761	1,461	-700	-48%	8.0	18%	41
Ohio	1,058	1,210	-152	-13%	9.2	18%	41
Texas	2,129	2,730	-601	-22%	8.5	19%	40
Rhode Island	108	134	-26	-19%	10.3	20%	37
South Carolina	426	443	-17	-4%	9.2	20%	37
Wisconsin	558	716	-158	-22%	9.8	20%	37
Kentucky	446	646	-200	-31%	10.3	21%	34
Maine	137	166	-29	-17%	10.3	21%	34
Tennessee	616	1,068	-452	-42%	9.7	21%	34
Mass	696	1,015	-319	-31%	10.6	22%	33
Colorado	520	776	-256	-33%	10.3	23%	29
Idaho	155	157	-2	-1%	9.9	23%	29
Illinois	1,429	1,821	-392	-22%	11.1	23%	29
Oklahoma	401	386	15	+4%	10.7	23%	29
Nevada	302	119	183	+153%	11.2	25%	28
Utah	310	329	-19	-6%	11.2	26%	27
Georgia	1,187	1,635	-448	-27%	12.3	27%	26
California	5,283	6,285	-1,002	-16%	14.2	29%	21
Hawaii	182	171	+11	+6%	13.4	29%	21
Indiana	908	1,201	-293	-24%	14.0	29%	23
New Hampshire	189	224	-35	-16%	14.4	29%	23
West Virginia	259	258	-1	0%	14.0	29%	23
Pennsylvania	1,850	2,349	-499	-21%	14.6	30%	20
Washington	1,220	1,170	+50	+4%	18.1	34%	19
Virginia	1,407	1,659	-252	15%	17.6	37%	18
Florida	3,321	2,101	1,220	+58%	17.7	38%	15
Maryland	1,058	1,203	-145	-12%	18.3	38%	15
Nebraska	337	361	-24	-7%	18.5	38%	15
Oregon	700	691	+9	+1%	18.3	39%	14
Louisiana	903	914	-11	-1%	19.9	40%	13
Montana	194	194	0	0%	19.6	42%	12
Connecticut	741	889	-148	-17%	20.7	43%	11
New Jersey	1,922	2,820	-898	-32%	21.9	44%	10
Wyoming	115	122	-7	-6%	20.4	45%	9
Missouri	1,332	1,238	94	+8%	22.2	46%	8
North Dakota	150	164	-14	-9%	22.3	48%	7
Alabama	1,119	1,001	118	+12%	23.4	49%	6
Delaware	209	281	-72	-26%	23.3	51%	4
Kansas	705	594	111	+19%	24.7	51%	4
New York	4,958	5,269	-311	-6%	25.6	52%	3
South Dakota	238	311	-73	-23%	29.2	62%	2
Mississippi	1,156	1,442	-286	-20%	39.0	79%	1
TOTALS	43,318	50,509	-7191		14.1

Federal Mental Health Funds Fail To Reach Mentally Ill

Role of Federal Government’s Attempts to Improve Services

for Individuals with Serious Mental Illness

E. Fuller Torrey, MD

(Note: The following shows how various federal funding streams for mental "health" fail to reach people with mental "illness")

1963, Community Mental Health Centers (CMHC) Act:  The passage of this legislation effectively shifted responsibility for funding public mental illness services from the states to the federal government, thus reversing a policy that had existed for more than a century. NIMH paid the new federal funds directly to local Community Mental Health Centers, thus bypassing state governments. Prior to 1963 states were held responsible for the quality of those services; since 1963 nobody claims responsibility. The CMHC Act shifted the main focus of treatment from the state mental hospitals to the new CMHCs, but almost no planning took place regarding follow-up care for the seriously mentally ill patients being discharged from the state hospitals. The 1963 CMHC Act was the beginning of the increase of mentally ill persons becoming homeless, incarcerated in jails and prisons, etc.

1965, Institutions for Mental Diseases Medicaid exclusion: When Medicaid was enacted in 1965 the federal government was afraid that states would use it to cover the costs of mentally ill individuals in state mental hospitals so these hospitals were excluded from Medicaid coverage. This was the Institutions for Mental Diseases (IMD) exclusion. However, since Medicaid did cover these same patients if they were hospitalized on the psychiatric ward of a general hospital or living in nursing homes or group homes, the IMD exclusion created a major incentive for states to empty the state hospitals, thus shifting most state costs to federal Medicaid. States had, and still have little incentive to place patients in appropriate community settings or to follow-up and insure that they receive continuing care; the fiscal reward comes simply from emptying the state hospitals. The IMD exclusion has been the single largest reason why deinstitutionalization has failed so abysmally.

Reference: Geller, J.L. Excluding institutions for mental disease from federal reimbursement for services: strategy or tragedy? Psychiatric Services 2000; 51: 1397-1403.

1986, Protection and Advocacy for Individuals with Mental Illness Act: Under Senator Lowell Weicker’s sponsorship, this legislation set up a federal program to fund independent state agencies to investigate allegations of abuse or neglect of mentally ill or disabled persons residing in mental institutions. Widely referred to as the Protection and Advocacy (P&A) program, it has been administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) under the Department of Health and Human Services. As soon as the P&A program was enacted it was taken over by civil rights ideologues who believed that no mentally ill person, no matter how disabled or psychotic, should even be involuntarily hospitalized or medicated. Thus P&A programs in many states have assumed a function of protecting patients from treatment, rather than insuring that they receive appropriate treatment. The federal government has made no efforts to correct this well-intentioned-program-gone-astray, and in fact SAMHSA has encouraged it. The tragic consequences of the P&A program were highlighted by the Wall Street Journal on August 16, 2008, describing how P&A workers in Maine insisted on the discharge of a psychotic young man from the state hospital despite the objections of the treating physicians and his family; he went home and killed his mother with an axe. Others have described how P&A programs, in clear violation of the law, “have engaged in federally prohibited lobby efforts and how they have tried to defeat proposed legislation, some of which would actually benefit their clients.”

Reference: Peters, AJ. Lawyers who break the law: What Congress can do to prevent mental health patient advocates from violating federal legislation. Oregon Law Review 2010; 89: 133-173.

1990, American with Disabilities Act: Another well-meaning federal program, the American with Disabilities Act (ADA) was an attempt to prohibit discrimination based on disability, which was officially defined as “a physical or mental impairment that substantially limits a major life activity.” Thus under the ADA disabled people could not be discriminated against, for example, in hiring, promotion or termination, and employers were expected to make “reasonable accommodation” for disabled employees. The consequences of the ADA have been exactly the opposite of what was intended. Employers, fearful of endless litigation, simply stopped hiring disabled workers. In recent years the ADA has also been used by the Department of Justice to demand that state psychiatric hospitals discharge patients to live in “the least restrictive alternative” in the community. For example, in April 2011, the Department of Justice sued New Hampshire. In many cases moving patients from a state hospital to a nursing home or a group home in a crime-ridden neighborhood is just as or more restrictive as a state hospital, but the former is regarded as more acceptable to the federal government because the patients are “in the community.”

Reference: Olson, W. Under the ADA, we may all be disabled. Wall Street Journal, May 17, 1999.

1996, Health Insurance Portability and Accountability Act (HIPPA): This was an attempt to protect the privacy of an individuals’ health information and medical records; people who disclose such information without the consent of the individual involved can be fined up to $25,000 per year. HIPPA is widely regarded as having markedly reduced the information available to families as they attempt to get treatment for seriously mentally ill family members. This was recently illustrated by the New York Times Magazine cover story about a man with bipolar disorder. Blatantly psychotic, the family finally got him hospitalized but then was unable to get any information, even that he was in the hospital to which they had had him admitted:

“It took a week just to get the social worker assigned to his case on the phone. Although I had been sitting right next to my father at PESS when he was told where he would be transferred, privacy laws prohibited the nurses at the new facility from even confirming, without his written consent, that he had been admitted. I asked if someone could tell him we called and have him sign a consent form so that we could speak with his doctor or social worker.

Yes, I was told, he would be given a consent form — if he was there, which again they would not confirm or deny.

Eventually one nurse took pity and told us that he had indeed filled out the form but had granted access only to Barack Obama and Duke Ellington.”

Such examples are the rule under HIPPA, not the exception.

Reference: Interlandi, J. Love and commitment: What it takes to put your father away in a mental hospital. New York Times Magazine, June 24, 2012, pp. 26-47.

Thus, almost everything the federal government has attempted to do legislatively has made the problems associated with serious mental illness worse rather than better. And if anyone has any lingering doubts about the ability of the federal government to improve matters, look closely at the federal agency whose official mission is to reduce the “impact of substance abuse and mental illness on America’s communities.” This is the Substance Abuse and Mental Health Services Administration (SAMHSA), a $3.6 billion component of the Department of Health and Human Services. It has 537 federal employees whose average salary is $107,760. Its current three-year plan, a 41,804 word document entitled “Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014,” does not even mention schizophrenia or bipolar disorder because, in fact, SAMHSA has no interest in serious mental illnesses. What does interest SAMHSA are producing free coloring books and sticker sets for children, such as their “Mental Well-Being Sticker Sets,” and producing a musical for SAMHSA staff to celebrate World AIDS Day (cost of musical: $83,625). SAMHSA also gives away lots of money. It gives $70,000 a year to organizations in California and Pennsylvania that have lobbied against legislation making it easier to treat seriously mentally ill individuals. And it gives $330,000 a year to an organization in Massachusetts whose director claims that “the covert mission of the mental health system…is social control.” Indeed, SAMHSA has been described as “a federal health agency distinguished by the fact that the health of its clients would improve if it went out of business.”

Reference: Torrey, EF. Bureaucratic insanity: The federal agency that wastes money while undermining public health. National Review, June 20, 2011, pp. 25-26.

Conclusion: The track record of the federal government in its attempts to improve services for individuals with serious mental illnesses is a record of well-intentioned programs which have made the problem worse, not better. Rarely in the history of American government have programs conceived with such good intentions produced such bad results.

Obamacare & Supreme Court leave mentally ill uninsured

While some are condemning and others applauding the Supreme Court decision on health care reform, the decision leaves in place federally mandated discrimination against people with mental illness. As I pointed out with Mary Zdanowicz in this Washington Post op-ed

For the most severely mentally ill, private insurance is essentially meaningless. Because of their illnesses, most are indigent, and private insurance is a luxury they cannot afford....Medicaid...covers their care, except for a single exception--inpatient care in psychiatric hospitals. The federal government's Institution for Mental Diseases (IMD) exclusion prohibits Medicaid from reimbursing for most individuals who need care in a psychiatric hospital. If you have a disease in your heart, liver or any other organ and need treatment in a hospital, Medicaid contributes. But if you have a disease in your brain and need care in a psychiatric hospital, Medicaid does not.

The ruling by the Supreme Court does not change this. States will continue to declare mentally ill who are hospitalized 'well', and discharge them sicker and quicker into the community while pretending that is humane care. As a result of this, many people with serious mental illness will go shelters, others to jails and prisons, and too many to morgues.

Health Care reform that leaves out the most seriously mentally ill is a national shame.

Lynn Shuster: Hero of Mental Illness Advocacy

I once wrote an essay on my hero, Dr. E. Fuller Torrey. Today, it's about another hero: Lynn Shuster. Lynn Shuster (and her partner in crime, Mary Kirkland, who I don't know as well, but admire from afar), were until recently leaders of NAMI/Buffalo. They are so extraordinary that the Buffalo News ran an article on their decision to step down.

Lynn has been my idol ever since I joined the movement (CA 1982) to improve care for the most seriously ill. She was older than me, and different than every other NAMI member. How? Lynn doesn't --as she would say, "take any shit". She makes these bald, impolitic, truthful statements about how horrific the mental illness treatment system. Everyone else was pulling their punches and ignoring the elephant in the room: treatment for the most seriously ill sucked and no one was doing anything about it. And she would reel in horror when others who called themselves 'advocates', tried to say how nice Commissioner so-and-so was. "He could be the nicest man in the world. Our job is to make him do his damn job and give the seriously ill better care!" she would say (usually followed by "sheesh").

I once wrote an article, "NAMI's Delusions: Counterproductive Beliefs Held by Mental Health Advocates" almost entirely based on what Lynn taught me.

Lynn has this ability to focus on the most important issues, even while all other advocates are focusing on feel-good ones. While they were trying to create pretty brochures, Lynn was trying to save psychiatric hospitals. While they were criticizing the lack of "people first" language, she was trying to stop the system from jailing people merely because they had mental illness.
Lynn taught me that being at the table isn't as important as making progress and that the two are often inversely related. In a note about her retirement, she wrote:

Never trust a bureaucrat. It's THEIR money (and power and prestige, it's just our loved one's lives. And we know which comes out on top. "Making nice" makes you feel good, but doesn't result in success. News reporters are our friends. Tell the truth, the REAL truth.... Maintain a sense of humor even in dark days--we all need to laugh. Persevere. Persevere some more.... 

 Lynn (and Mary): You're right. I'm gonna "persevere". I'm gonna start a new Facebook Group called, "Bring Lynn and Mary Out of Retirement".

Mental Health Industry, 2. Mentally Ill, 0.

In New York State the battle to improve care for people with serious mental illness has become increasingly polarized. On the one side, favoring improved care for people with serious mental illness are families of the mentally ill, people with serious mental illness, law enforcement, and the general public. On the other side, is the New York State community-based mental health industry, funded by the New York State Office of Mental Health.

The community-based mental health system won two victories. Earlier this year, they won the battle to close state psychiatric hospitals which only serve the seriously ill. Last week, they had their second success: They preserved cracks in Kendra’s Law that allow them to deny services to people with serious mental illness.

The Kendra’s Law Improvement Act had been proposed by Assembly member Aileen Gunther and State Senator Young. It would have improved the information flow so local mental hygiene directors were made aware of involuntarily committed psychiatric patients and mentally ill prisoners who were being discharged to their jurisdictions. That would have allowed mental health directors to triage the individuals to see they get the right voluntary or Kendra’s Law care to enable them to function in the community.

The mental health directors vigorously opposed Kendra's Law and they were joined by mental health trade associations who feared that if new people with serious mental illness were identified, they would have to treat them rather than being allowed to offload to jails, prisons shelters and morgues. (There are more mentally ill in a single NY jail, Riker’s Island, than all state psychiatric hospitals combined. The opposition to treatment was led by NYAPRS a trade association that has now moved on to lobbying for less medical care for people with serious mental illness (NYAPRS only provides non-medical care).

 As a result of this ‘victory’

•  Involuntarily committed patients will continue to be released into the community without treatment 
• Mentally Ill prisoners will continue to be released into the community without treatment 
• Officials will be allowed to continue to ignore reports of mentally ill persons when those reports come from families 
• Individuals who do well in Kendra’s Law, will continue to be able to get out from under the court order merely by moving to a different county 
• Individuals who do well in Kendra’s Law will continue to have their orders expire without a review of whether that is safe or not. 
• We will have more incidents of violence by and to individuals with serious mental illness like the 90 Preventable Tragedies that might have been prevented had the cracks been closed.

Perhaps Vanessa Bellucci said it best. Her mentally ill brother killed both their parents and that gave her the unique ability to see the issue from both perspectives: the perpetrator's and victim's. In an op-ed she wrote:

As a result of the cracks in Kendra’s Law, my parents are dead and my brother remains in prison, adjudged as being incompetent to stand trial. Perhaps with the proper support from the mental-health system, this all could have been avoided and I could have had parents to give me away at my wedding next year, and my nephew could have had his uncle and grandparents around to watch him grow up. It’s too late for my family, but not too late for others.

The law sunsets in two years. Advocates for improved care will be back to improve Kendra's Law and the community mental health system will come back and defend the status quo.

June Update: Mental Illness Around the Country

1. Make Greater Use of Assisted Outpatient Treatment

• Assisted Outpatient Treatment is less expensive, less restrictive, and more humane than it’s alternative: inpatient commitment or incarceration.
• AZ: He met his case manager on Monday and was dead by Friday, showing the need for AOT.
• NY: As the result of police stabbings by people with mental illness, the bill to close cracks in NY’s Kendra’s Law (A6987/S4881) gathered new attention. The bill sponsors wrote an op-ed in the NY Post on how their legislation would require mental health authorities to evaluate mentally ill prisoners and involuntarily committed psychiatric patients before they are discharged from prisons and hospitals to see if they need Kendra’s Law or other treatment to stay healthy and safe. Research shows it works. It is supported by virtually everyone (public, patients in the program, families, and law enforcement). The only opposition is from the mental health system itself, which simply does not want responsibility for the most seriously ill when they can offload them to shelters, jails, prisons and morgues. Thanks to Mental Illness Policy Org., op-eds and editorials have appeared in Albany Times Union, NY Post, NY Daily News, Staten Island Advance, Buffalo News, Ithaca Journal, Schenectady Gazette, NY News, and elsewhere. We identified 90 tragedies that might have been prevented had the cracks in Kendra’s Law been closed in 2005 when first identified. Call Assembly speaker Sheldon Silver at 518-455-3791 and Governor Cuomo at: (518) 474-8390. Urge them to Pass the Kendra's Law Improvement Act (A 6987) to Close the Cracks In Kendra's Law
• CA:    Laura’s Law has had tremendous results in California, but a powerful anti-treatment coalition is preventing widespread adoption of the law. The Fullerton Homeless Task Force recommended Orange County adopt Laura’s Law. Laura’s Law is up for renewal and the California LPS Reform Task Force is urging supporters to send letters in support of Laura’s Law  to the Senate Health Committee c/o State Capitol, Room 2191; and to the Assembly Health Committee in Room 6005, Sacramento, CA, 95814.  Articles and op-eds on the importance of Laura’s Law appeared in San Luis Obispo,
• NJ put out a contract to start Gregory’s Law
• TN passed a pilot AOT program
• Bexar County, TX is considering starting an AOT Pilot and a jail In San Angelo is trying to send mentally ill back to the mental health system

2. Focus more resources on serious mental “illness” rather than mental “health”

• National:  Articles by Marvin Ross in Canada, Dr. E. Fuller Torrey in Washington, Carlat Psychiatry Blog, and MIPO, all criticized Robert Whitaker’s, Anatomy of an Epidemic for using pseudo science to make the case that medicines don’t help people with mental illness. Natasha Tracy wrote “Why it’s ignorant to write off psychiatry” And the Lancet published a meta analysis that shows Whitaker is wrong. Meds do work
• Are we arbitrarily diagnosing people with mental health problems? Asks Pete Earley.
• AZ may see more mental health resources invested in the community as a result of a recent lawsuit settlement
• NH: We criticized New Hampshire officials for patting themselves on the back when there are more mentally ill incarcerated than hospitalized in that state.
• NY As incredible as it sounds, NYAPRS, a trade association of mental health providers in NYS actually started lobbying for less medical treatment for people with serious mental illness.
• WA: A seriously mentally ill man who was without treatment shot 5 in Seattle and then himself.
• California is unique in that it has plenty of money as a result of Proposition 63 which funded the mental health services act which is supposed to help people with serious mental illness. Unfortunately county and state officials continue to squander the money.

3. Preserve enough hospital beds so seriously ill can get access

• Bloomberg News ran a terrific piece picked up in Business Week and elsewhere suggesting that we have gone too far in cutting hospital beds for seriously mentally ill. And Dr. Stephen Moffic criticizes the American Psychiatric Association for failure to focus on inpatient crisis.
• CA mentally ill languish in jail due to budget cuts.
• GA sheriff argues to keep mentally ill out of jail

 

4. Change Not Guilty By Reason Of Insanity So it Helps People

• Legal argument why people with mental illness should be exempt from death penalty
• Not guilty by Reason of Insanity is likely to get more attention as the alleged killer of Etan Patz may plead mental illness.
• TX has a grizzly plan to medicate someone so they can execute him

5. Reform Involuntary Treatment Laws so they prevent violence, rather than require it

• CA: The LPS Reform Task Force issued their latest report. Sign up for their emails.

In Brief

 

• 3 Reasons I didn’t celebrate Mental Health Awareness Month
• Dr. E. Fuller Torrey on how to reduce stigma
• Peer Support can hurt people with mental illness
• In 2008, Vince Li, who has schizophrenia and rejected treatment beheaded someone on a Greyhound Bus. In this jailhouse interview he says he wishes someone would have forced him to stay in treatment.
• Stigma campaigns may decrease chance mentally ill get treatment
• Saying Goodbye to someone with mental illness: When not to help

NYAPRS proposes reducing funding for medical treatment of mentally ill

Medicaid realignment in New York is expected to generate $10 billion in savings over five years and the plan is to spend much of it on medical care for people with serious mental illness. That's good news to everyone except the NYS Assoc. of Psychiatric Rehabilitation Services--the trade association for providers of non-medical services to voluntary mental health patients. In a blog, NYAPRS wrote

(C)oncerns have been raised (about) a general emphasis on medical approaches that provide insufficient attention to expanding rehabilitation, peer support and culturally competent ones.

As if giving medical care to someone is the opposite of cultural competence.

As a result of the lack of medical care more people of color are incarcerated for mental illness than hospitalized. And disproportionately so. That is one reason why Kendra's Law is supported by groups made up almost entirely of people of color, like the local Harlem Alliance on Mental Illness. (Consumers too). Extensive Kendra's Law research shows it helps those enrolled, get well and stay well. Yet the trade association is trying to preserve cracks in Kendra's Law that allow their members to avoid treating people with serious mental illness.

I recognize that the trade-association only provides non-medical rehabilitation services and focuses on mental health not mental illness. And I understand that when you see a bucket of money, you want to divert it to your own members. But many people with schizophrenia need, gulp, medical services. Specifically, symptom amelioration. That is what enables them to reach the point where they can benefit from rehab services. NYAPRS wants to take those medical services away, so the funds can go to their association members. The employees of association members are then urged to also lobby for more money for their members.

What is especially disingenuous is that in an op-ed the trade association, as part of their continuing battle against Kendra's Law (a less restrictive, more humane alternative to incarceration or commitment) recently wrote that instead of Kendra's Law

A better approach is to back new programs designed by the governor’s Medicaid Redesign Team to make our mental-health services more effective.

On the one hand they argue that Medicaid Redesign is going to help the most seriously ill and on the other write they don't want the Medicaid used for medical care.

You can't have it both ways. But that's unlikely to stop them from trying.

New York Needs Kendra's Law: You can help

(May 2012, New York) Kendra's Law allows courts to order a small subset of people with serious mental illness who have a past history of violence to accept treatment as a condition for staying in the community. Kendra's Law has been very successful at keeping patients healthier and preventing needless deterioration to violence. See Kendra's Law op-ed in Albany Times Union.

But Kendra's Law has giant cracks in it that send the most seriously ill to jails, prisons, shelters and morgues. A bipartisan Kendra's Law Improvement Act has been proposed to close the cracks that has wide-ranging support including by NAMI/NYS, NYS Chiefs of Police and many others who want better care for people with mental illness. But it is being vigorously opposed by OMH funded community mental health providers and county mental health directors who don't want to have to treat the most seriously ill. They prefer to cherry-pick the easiest to treat for admission to their programs and bury their head in the sand about the most seriously ill.

Please call Assembly speaker Sheldon Silver at 518-455-3791 and Governor Cuomo at: (518) 474-8390.
Urge them to Pass the Kendra's Law Improvement Act (A 6987) to Close the Cracks In Kendra's Law
We have generated media attention, but not enough calls
This is critical.

The legislative session is coming to an end and Cuomo, Silver and Skelos will be deciding whether or not to help people with mental illness by closing cracks. The NYS mental health industry is lobbying them heavily to preserve the cracks.

Thank you for all you do. Spread the word. Forward to friends.

The media is on our side, but we need more calls:

Op-ed in Today's Albany Times Union
Op-ed in Yesterday's Buffalo News
Editorial in NY Daily News
Op-ed in NY Post by Bill Sponsors
Op-ed in Ithaca Journal:
Letter in Schenectaday Gazette
Op-ed in NY Daily News
Editorial in Staten Island Advance

DJ Jaffe
Executive Director
Mental Illness Policy Org.
http://kendras-law.org

California Bill To Extend Laura's Law Scheduled For Vote

ALERT FROM CALIFORNIA TREATMENT ADVOCACY COALITION
FROM: Carla Jacobs, Randall Hagar, Chuck Sosebee & Mark Gale
May 22, 2012

We need your help now! AB 1569, a bill to extend Laura's Law, will be heard in the Senate Committee on Health June 13 at 1:30 p.m. at the state capitol, Room 4203. Please reach out to the committee and your senators and urge them to support the bill.

(Laura's Law allows courts to order a narrowly defined group of seriously ill individuals to stay in treatment as a condition of living in the community. It also allows courts to order the mental health system to provide the treatment.)

Send or direct letters of support to Senator Ed Hernandez, chair of the Senate Committee on Health and to Senator Tom Harman, vice chair. Let them know that Laura's Law saves money - and lives. Contact information is below:

Senator Ed Hernandez, chair (Senate district 24)
Fax: (916) 445-0485
Mailing address: State Capitol, Room 4085, Sacramento, CA 95814-4900
Phone: (916) 651-4024
Email: senator.hernandez@senate.ca.gov

Senator Tom Harman, vice chair (district AD 73)
Fax: (916) 319-2173
Mailing address: State Capitol, Room 5094, Sacramento, CA 95814-4900
Phone: (916) 651-4035
Email: senator.harman@senate.ca.gov

Mail and Fax are Preferred to Email.
--
Visit http://treatmentadvocacycenter.org/lauras-law or http://lauras-law.org/ to learn more.

NYS Mental Health "Leaders" Race to Avoid Mentally Ill. Call Now

Please call Assembly speaker Sheldon Silver at 518-455-3791 and Governor Cuomo at: (518) 474-8390 and urge them to Close the Cracks In Kendra's Law. This is critical. Now is the time. Tell others to call too.

Research shows there are giant cracks in Kendra's Law and these cracks are putting patients, public, police and families at risk:

1. People with mental illness who are being released from Involuntary Treatment (i.e, were already danger to self or others) are not being evaluated by hospitals for inclusion in Kendra’s Law or other community treatment.
2. Mentally Ill Prisoners who are being released from jails and prisons (i.e, already committed a crime) are not being evaluated for inclusion in Kendra’s Law or other community treatment.
3. Mentally Ill people who have previously attacked family members, are not being considered for Kendra’s Law or other community treatment, especially if the family has not reported attacks.

Kendra’s Law (court-ordered outpatient commitment) is proven to reduce violence, arrest, incarceration, hospitalization, homelessness and suicide when used, but is not used for the most seriously ill because neither hospitals, prisons, jails, local mental health directors or NYS OMH wants to accept responsibility.

NYS Senator Catherine Young and Assemblywoman Aileen Gunther introduced The Kendra's Law Improvement Act (A6987/S4881) to close these cracks by requiring officials to accept responsibility for the most seriously ill, but mental health officials oppose it.

Head in the sand" approach to the seriously ill.
The main sticking point is that mental health officials do now want to even know about people with serious mental illness, much less be obligated to provide treatment.

1. Hospitals are objecting to provisions that ask them to evaluate patients prior to release to see if they could benefit from Kendra's Law.
2. Jails and prisons are objecting to provisions that ask them to evaluate the incarcerated mentally ill prior to release to see if they could benefit from Kendra's Law.
3. Local Mental Health directors are objecting to being informed by families, hospitals, or prisons about people with serious mental illness who may need help.
4. OMH is objecting to having to oversee and monitor Kendra's Law to ensure people with serious mental illness who could benefit form Kendra's Law gain access.
5. The trade association for those who provide non-medical voluntary mental "health" services (NYAPRS) objects to more attention being paid to those not well enough to volunteer for treatment.

Since no one wants responsibility, individuals with serious mental illness are being sent to the streets, jails, prisons and morgues instead of treatment.

Please call Assembly speaker Sheldon Silver at 518-455-3791 and Governor Cuomo at: (518) 474-8390 and urge them to pass A6987 to Close the Cracks In Kendra's Law. This is critical. Now is the time. Spread the word. Tell others to call too.

Providing services to the most seriously ill should be, the core function of mental hygiene directors and the office of mental health. Their raison d’etre. Unfortunately, this core function of providing services to the most seriously ill is often ignored in favor of providing services to others. This approach sends the most seriously ill to jails, prisons, shelters and morgues and puts public and police at risk. Improvement of care for the most seriously ill is almost always and exclusively obtained by legislation or law suits. The Kendra’s Law Improvement Act is one such piece of legislation. It not only allows courts to commit the seriously ill to accept treatment, it commits the mental health system to meeting their core responsibility of providing it.

Assemblyman Felix Ortiz and Lack of Care for Mentally Ill

Earlier this month New York City Police Officer Eder Loor was stabbed in the brain by Terrence Hale, 26, a young man allegedly with untreated mental illness. His mom had tried unsuccessfully to get mental health authorities to treat him. They wouldn't. The stabbing ensued.

It was oh so predictable. And it's likely going to happen again possibly because of Brooklyn Assemblyman Felix Ortiz who heads the Assembly Mental Health Committee. Over the last few years, I and other advocates for the mentally ill and advocates for public safety have met with Assemblyman Felix Ortiz to urge him to pass legislation that would strengthen New York's Kendra's Law. As I explained in a New York Daily News op-ed this week

Kendra's Law allows courts to order a very small group of seriously mentally ill patients who have a history of violence or incarceration to accept violence-preventing treatment as a condition of living in the community. Courts can also order the recalcitrant mental health system to provide treatment to these seriously mentally ill people .

The results of Kendra's Law have been outstanding in terms of reduced dangerous behavior, violence, arrest, trial, incarceration, homelessness, hospitalization, suicide and more.

But the law has giant cracks in it that New York State Assemblymember Aileen Gunther-a former nurse with psychiatric room experience, and State Senator Catherine Young proposed closing. Their bill (now A6987/S4881) would

• Close the crack in the system, whereby prisoners who relied on mental health services while imprisoned or have been involuntarily committed are discharged without determining if they need mandatory treatment to stay healthy and prevent them from becoming dangerous again.
• Close the loophole whereby if a person under court order moves to a different county, the new county isn't informed so it can continue to provide treatment.
• Close the crack in the system whereby court orders can expire without a review of whether they should be renewed.
• Clarify that a county should investigate reports of individuals in need of Kendra's Law services received from family members.
• Require physicians to make a reasonable effort to gather useful information from the patient's family or significant others.
• Allow doctors to presume under certain conditions that patients who materially violate their treatment orders should be taken to a hospital to see if they need admission.

Had these been in place, Officer Loor may not have been stabbed. Terrence Hale's mom did try to get mental health authorities to treat her son and they did not listen. Terrence Hale had been released from a jail without local officials being alerted he may need community-based mental health treatment. The bill would have made both those scenarios less likely. But Assemblyman Ortiz is still waffling. The mother of Kendra Webale whom Kendra's Law is named after told a Daily News reporter she

blamed Ortiz, chairman of the Assembly's Mental Health Committee, for bowing to pressure from advocates for the mentally ill and blocking the Young/Gunther bill. "I have gone head to head with Ortiz and his office, and at times he has seemed extremely, genuinely supportive. And then the tune would change."

In an editorial the Daily News wrote

As chairman of the Mental Health Committee, Brooklyn Assemblyman Felix Ortiz bears responsibility for squashing Young and Gunther's measure. He bottled it up without a vote despite a mountain of evidence showing that severely disturbed mental patients who enter court-ordered treatment are less violent, less likely to be homeless, less likely to abuse drugs or alcohol and less likely to attempt suicide than those who do not.

In a follow-up editorial they explained

For too long, supposed mental health advocates have prevailed in Albany with the preposterous argument that mandating medicines for the mentally ill to save their lives and the lives of others is a violation of civil rights.

How true. One trade association for providers of non-medical services to people with mental illness said we need better trained police units, as if the problem was Officer Loor didn't duck the knife well enough. Assemblyman Felix Ortiz released a statement echoing these 'advocates' by claiming the important battle is not knives in the hands of untreated mentally ill who stab cops, but the use of 'stigmatizing' language.

I have a mentally ill relative. This bill is supported by the Alliance on Mental Illness of New York State and many others who like me, love people with mental illness and want to keep them, the public, and the police safer. The mental health committee should immediately pass this legislation to prevent the next tragedy. Assemblyman Ortiz can be reached at (718) 492-6334 or (518) 455-3821.

Three Reasons I Won't Celebrate Mental Illness Awareness Week

1. MIAW is based on the false premise that there is stigma to having a mental illness.

This first full week in Week in May is being celebrated as Mental Illness Awareness Week. In celebration, well meaning mental health advocacy organizations are busy hosting events to reduce the “stigma” of mental illness. But there is no ‘stigma’ to having a mental illness. Serious mental illnesses, like schizophrenia, are real biologically based disorders that are no ones fault. Serious mental illness or ('consuming mental health services') is not, “a mark of shame or discredit”, or “a mark or token of infamy or disgrace”.

It used to be said there was stigma to being “black”, “gay”, “short”, ”tall”, “lefty”, “righty”, inny, outy or having cancer.

But over time all these groups found a cure: they simply decided that there was no stigma to having being gay, lesbian or lefty or having cancer. It was not, as some claimed, a "mark of shame" or "token of disgrace."

They killed stigma and recognized that what they were really suffering was discrimination. It’s time for mental health advocates to do the same. Fight discrimination (what others do to you) and stop running ads about how you feel about yourself (suffer stigma).

2. MIAW diverts attention away from those who are most seriously ill

The second reason I won’t celebrate MIAW is that it diverts attention away from the most seriously ill. The anti-stigma campaigns are premised on the belief that the key to reducing ‘stigma’ is to convince the public that “the mentally ill are just like you and me” and “with proper supports can recover and become productive members of society”. Hence, only the high functioning and happy appear in the promotional materials and PSAs. They focus on the 40% who may during their life have a mental “health” issue.

The efforts focus on mental “health”, not mental “illness”.

But what about the three percent to five percent of Americans who are the most seriously mentally ill -- like those suffering from untreated schizophrenia or treatment-resistant bipolar disorder? And what about the homeless psychotic, eating out of garbage cans, sleeping in cardboard homes, and living with festering wounds under layer after layer of filthy clothes because they have a mental illness than makes them unable to help themselves? You won’t find them in the Mental Illness Awareness Week PSAs.

Trying to gain sympathy and resources for serious mental illness, by only displaying the highest functioning individuals, is like trying to end hunger by showing the well-fed. And new research shows it doesn't work. There is no less 'stigma' today than when these efforts started.

Try this test. Google "mental illness" and Google "mental health". Look how many results are returned.

Hardly anyone is still fighting for people with serious mental illness. In fact, it is no longer even considered politically correct to use the term "mental illness". One must say "mental health". You are not allowed to say "patients", you are supposed to say "consumers" as in "consumers of mental health services."

The homeless people we see under twelve layers of smelly lice-infected clothing talking to themselves, fearing their hallucinations as they forage through garbage cans looking for food are not "consumers". They should be patients, but no one wants them.

MIAW is premised on the false belief that the major problem we face is that people won’t self-identify.

That is small potatoes and possibly true for those with mental “health” isssues, but it is not true for those with serious mental illnesses.

People with serious mental illness almost always self-identify. They do it through their psychotic ramblings, delusional explanations, ritualistic behaviors. It is not hard to identify people with serious mental illness, it is hard to get them treatment.

In 1955 there were 340 public psychiatric beds available per 100,000 U.S. citizens. By 2005, the number plummeted to a staggering 17 beds per 100,000 persons.

If someone is so ill they don’t know they are mentally ill, current law requires them to become ‘danger to self or others’. Rather than prevent violence, the law requires it.

While services are available to a wider swath of people with “mental health” issues as we medicalize normality, services are rarely available for the most seriously ill.

By spreading the false meme that the problem is identification, rather than the provisioning of services for the most seriously ill, Mental Illness Awareness Week celebrants—as well intentioned as they may be—do the seriously ill great harm.

Laura's Law could save California's mentally ill and keep public safer

The murder of 61-year-old Earlene Grove by her mentally ill daughter Sunni Jackson, in Paso Robles, San Luis Obispo most likely wouldn’t have happened if the San Luis Obispo Board of Supervisors had implemented Laura’s Law.

Laura’s Law allows courts to order certain individuals with serious mental illness – like Sunni, those who have a history of non-compliance with psychiatric treatmen and a history of violence – to stay in treatment as a condition of living in the community. They get full due process and the right to help develop their own treatment plan.

Laura’s Law helps patients and keeps the public and police safer. When Nevada County implemented Laura’s Law it found it reduced incarceration of people with mental illness by 65 percent. It reduced hospitalization, 46 percent; cut homelessness 61 percent, and emergency contacts 44 percent. That’s why it is supported by organizations as diverse as the California State Sheriff’s Association, California Psychiatric Association, and San Luis Obispo Alliance on Mental Illness.


The supervisors can’t claim they didn’t know Laura’s Law saves lives. In 2010, when mentally ill Cliff Detty died in restraints at a mental health facility that he wouldn’t have been in had he received community treatment, his father told reporters Laura’s Law would have saved his life. Op-eds by experts said the same thing.

In 2011, after mentally ill Andrew Downs was committed to a hospital for the Christmas Day shooting of two women, Diane O’Neil, the past president of a local National Alliance on Mental Illness chapter wrote an op-ed on behalf of parents of the mentally ill explaining how Laura’s Law would have prevented the tragedy. It goes on and on. The supervisors don’t have to wait for the next death to act. But they probably will.

The supervisors can’t claim there is no money to implement it for two reasons. First, Laura’s Law saves money. Nevada County found it saved $1.81 to $2.52 for every dollar invested. Los Angeles County estimated it saved taxpayers 40 percent for the care of each person enrolled. The savings come from reduced hospitalization, arrest, trial and incarcerations.

The second reason is that San Luis Obispo County receives well over $2 million annually in Proposition 63/Mental Health Service Act proceeds they are supposed to use to help the most seriously ill get treatment. But rather than use it provide services to people with serious mental illness and implement Laura’s Law, the Mental Health Services Agency used a chunk of it to fund a documentary on “stigma” to put on a website and then congratulated themselves for doing it.

Is that why Californians voted to tax themselves with Proposition 63? They didn’t feel there were enough documentaries on websites? And think about it. Will a documentary on a website saying there should be no stigma ever be enough to overcome the stigma caused this past week by letting mentally ill Sunni Jackson go untreated and ultimately commit matricide?

As the Surgeon General’s report on mental illness pointed out, it is fear of violence by people with untreated serious mental illness that causes stigma. If San Luis Obispo wants to reduce stigma, implement Laura’s Law.

What the supervisors will most likely claim is that a recommendation didn’t come from the mental health department. They don’t have to wait for one. They can lead. Few mental health departments want to implement programs that require them to focus on the most seriously mentally ill as opposed to the worried well. Don’t wait. Act.


The county Mental Health Services Agency may tell the Supervisors that MHSA proceeds can’t be used for Laura’s Law, echoing opponents of the law. But as California mental health advocate Mary Ann Bernard notes, the now extinct State Department of Mental Health issued a regulation saying they can. As Carla Jacobs of the California Treatment Advocacy Coalition points out, “Nevada County uses their MHSA funds for Laura’s Law. Los Angeles County uses their MHSA funds for Laura’s Law. Why can’t San Luis Obispo County?”
--
Ed. Note: DJ Jaffe is the executive director of Mental Illness Policy.

Assemblyman Felix Ortiz puts police, public and mentally ill at risk

A version of this appeared in NY Daily News on April 18.

Yesterday, the mother of Terrence Hale called New York’s Finest about her mentally ill son who was off medicine and acting out. When Officer Eder Loor arrived to help, Mr. Hale stabbed him. Earlier this month, Easter Sunday, Benedy Abreu’s mother called police about her mentally ill son, who was also off medications and barricaded in the apartment. When officers William Fair and Phillip White of the 50th precinct knocked on the door, Mr. Abreu opened it and lunged at them with a knife stabbing both.

Why are so many people with serious mental illness being allowed to deteriorate and become violent, putting themselves and public at risk? Why has the mental health system turned over care of the mentally ill to the police making their already dangerous job, even more dangerous?

Who’s to blame? I nominate Felix Ortiz, Chairman of the New York State Assembly Mental Health Committee. Back in 1999, at the request of families of people with serious mental illness, New York State politicians came together and passed Kendra’s Law, named after Kendra Webdale who was pushed to her death in front of a train by a young man with schizophrenia who the mental health system also allowed to go untreated.

Kendra’s Law allows courts to do two things. They can order very seriously mentally ill patients who have a history of violence or incarceration to accept violence preventing treatment as a condition of living in the community. This keeps them healthier and happier. Perhaps more importantly, courts can also involuntarily commit the recalcitrant mental health system to provide the treatment to these seriously mentally ill people, something they are notoriously reluctant to do.

It’s been a huge success. By requiring certain seriously mentally ill people to stay in treatment—with full due process protections, Kendra’s Law reduced arrest, dangerous behavior, violence, incarceration, homelessness and suicide. It saved money and improved the quality of life for those living with serious mental illness. It keeps the public and the police safer.

So what’s the problem? Kendra’s Law is rarely used. Less than 2,000 seriously mentally ill people are in Kendra’s Law because the mental health system refuses to ask courts to use it. Terrence Hale was never on it and Benedy Abreu was on it, but allowed to go off. As a result, neither was on the medicines that could have prevented the horrors experienced by the officers, and preserved their own ability to live unincarcerated.

To fix this problem, two years ago Assembly member Ailleen Gunther and Senator Catherine Young introduced a bill (A6987/S4881) that would require officials to investigate claims of family members, like the parents of Mr. Abreu and Mr. Hill instead of sending them to the police. It would require jails to notify mental health officials when releasing a prisoner who was on psychiatric medications while incarcerated so the officials can determine if they should be in Kendra’s Law. That might have helped prevent Mr. Hale from stabbing Officer Loor yesterday as Mr. Hale had a rap sheet. Another provision requires hospitals to notify mental health officials when someone who was involuntarily committed-- already been determined to be 'danger to self or others-- is being released. Again: that allows mental health officials to see if they need mandatory treatment in community. The bill would also require that mental health officials to review expiring court orders to see if they should be renewed. That might have kept Benedy Abreu in treatment and prevented Officers White and Fair from being stabbed.

Makes sense? Of course it does. That’s why it’s endorsed by the Alliance on Mental Illness of New York State, made up of parents of people with mental illness who want better treatment for their loved ones, and the New York State Association of Chiefs of Police, who want to keep the public and officers safer.

But Assemblyman Felix Ortiz Chair of the Mental Health Committee, for the second year in a row is refusing to bring the bill up, pass it, and refer it to the legislature so it can become law. He can be reached at 718-492-6334 or 518-455-3821.

Connecticut tries to help treatment providers hear from parents of people with mental illness

A big problem that people with serious mental illness have in getting the best possible care, is the treatment providers rarely have complete information, and many treatment providers specifically reject sharing information with, or receiving information from families of the ill person. This is absurd.

Families tend to have the most comprehensive information about the treatment of their loved ones. Only by receiving this information can doctors give the best possible care. For example, a doctor needs to know if a medication they are suggesting has been used in the past and whether it worked or not and what the side-effects, if any, were. Sometimes the individual with mental illness can't or won't communicate that and the records are incomplete.

In addition, people with mental illness are often released from facilities to go back to live with their parents, yet information on diagnosis and treatment is withheld from the parents. As Rael Jean Isaac famously said in "Madness in the Streets": the family has become the institution, but they are an institution without training, without financing, and without the ability to enforce compliance" (although I did the quote from memory so check me on it.)

Some doctors and treatment providers say they can't share information because of federal Health Insurance Portability and Accountability Act, commonly referred to as HIPAA (pronounced Hip-a). It is arguable as to whether HIPPA prevents providing information to parents of people with serious mental illness, but it is inarguable that it does not prevent doctors from receiving information.

Connecticut Senate Bill 452 attempts to clarify this. It revises certain laws pertaining to the treatment of people with mental illness. Connecticut law already says

Every patient treated in any facility for treatment of persons with psychiatric disabilities shall receive humane and dignified treatment at all times, with full respect for his personal dignity and right to privacy. Each patient shall be treated in accordance with a specialized treatment plan suited to his disorder. Such treatment plan shall include a discharge plan which shall include, but not be limited to, (1) reasonable notice to the patient of his impending discharge, (2) active participation by the patient in planning for his discharge, and (3) planning for appropriate aftercare to the patient upon his discharge.

But this bill adds a section stating:

Subject to the privacy protections afforded a patient under federal law, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, the head of a facility may direct that any person involved in the formulation of the patient's treatment plan or discharge plan communicate with, and obtain medical records from inpatient and outpatient health care providers who have previously treated the patient. In addition, when formulating such treatment plan or discharge plan, persons involved in the formulation of such plans may also communicate with any person with whom the patient has resided in the twelve-month period prior to being admitted to the facility and with the patient's spouse, parents, siblings or children in order to better understand the patient's medical needs.

It's a smart idea.

Statement on Kingsboro Psychiatric Hospital Not Closing

The provision that would have closed Kingsboro Psychiatric Hospital in Brooklyn was removed from the New York State budget, meaning the hospital will stay open for the time.

"We are very happy that at least some New Yorkers who have serious mental illness will have a hospital to go to as the result of saving Kingsboro, but New York State is still short 4,311 beds for seriously mentally ill"

DJ Jaffe
Executive Director
Mental Illness Policy Org.

Our op-ed calling for saving Kingsboro:
http://articles.nydailynews.com/2012-02-23/news/31092984_1_mental-illness-mental-health-psychiatric-beds

Study showing NYS Psychiatric Hospital Bed Shortage of 4,311 beds.
http://mentalillnesspolicy.org/imd/shortage-hospital-beds.html

Study showing in NYS you are more likely to be incarcerated for mental illness than hospitalized
http://mentalillnesspolicy.org/NGRI/jails-vs-hospitals.html

Department of Justice Certifies Crime Prevention Program for People with Serious Mental Illness

Today the Department of Justice (DOJ) Office of Justice Programs certified Assisted Outpatient Treatment (AOT) as an Effective Crime Prevention Program. This comes on top of previous recognition by the DOJ Office of Community Oriented Policing Initiatives.
AOT allows courts to order mental health departments to provide treatment to certain people: those with serious mental illness who are likely to become dangerous or gravely disabled without treatment and who have a history of violence and refusing treatment. Historically, many mental health departments like California and New York elected to require psychotic individuals who don't recognize they are ill to become "danger to self or others" or "gravely disabled" before offering treatment. Because of this "no-treatment" policy, seriously mentally ill individuals who refuse treatment deteriorate and the police are forced to intervene. Too often, this is after the individual becomes a "psychotic killer on rampage" headline and has resulted in three times as many people being incarcerated for mental illness as hospitalized. AOT laws allow courts to require departments to provide treatment before that happens. In California, Laura's Law reduced hospitalization 46%, reduced incarceration 65%, reduced homelessness 61% and reduced emergency contacts 44%. Results in New York on Kendra's Law were equally impressive.

AOT laws were proposed by families of people with mental illness. The Department of Justice researched implementation of AOT programs like Laura's Law in California and Kendra's Law in New York. DOJ noted

The goal of AOT is to improve access and adherence to intensive behavioral health services in order to avert relapse, repeated hospitalizations, arrest, incarceration, suicide, property destruction, and violent behavior.

Police Chief Michael Biasotti recently released a major survey of senior law enforcement officers that found police and sheriffs are being overwhelmed "dealing with the unintended consequences of a policy change that in effect removed the daily care of our nation's severely mentally ill population from the medical community and placed it with the criminal justice system." A sheriff in Summit County, Ohio recently took action to prevent seriously mentally ill people from entering his jail arguing they need treatment instead. A Sheriff in Illinois is threatening to sue the mental health department to get them to treat people with mental illness. States are closing psychiatric hospitals in record numbers, further shifting the burden of care from the mental health system to the criminal justice system.

AOT programs exist in many states but are rarely used. The Department of Justice lists resources for states that want to implement AOT or expand existing programs.