(12-20-19) President Donald J. Trump made an unscheduled appearance yesterday at the White House Summit on Transforming Mental Health Treatment to Combat Homelessness, Violence, and Substance Abuse.
On the day after he was impeached by the House, Trump began his remarks by quipping that there was “Not much going on around the White House – you know, we’re not too busy.” Many in the by-invitation only crowd of about two hundred responded with laughter.
Trump used his appearance to announce an increase of $328 million in new spending for mental health programs, including $19 million for Assisted Outpatient Treatment and $7 million for Assertive Community Treatment programs.
Sticking mostly to a prepared script, Trump noted that “Of the 11 million Americans living with severe mental illness, 4 million receive no mental health service of any kind. Four million people.” He added that the nation needed to “give major consideration to building new institutions” but offered no specifics.
Trump recalled how as a child in Queens, he noticed “massive buildings” that housed persons with mental illnesses. “And all of a sudden, you go and you don’t see them anymore. And you say, ‘What happened to all of those beds? What happened to all of that work? And where are those people?’ And in many cases, those people are living on the streets. It’s much different..but we have to take care of our mentally ill. We have to help people that are having problems…At the same time, we need to keep very dangerous people off our streets. And we want to take care of the mental illness, but we have a lot of very dangerous people on our streets.”
Health and Human Services Secretary Alex Azar, Housing and Urban Development Secretary Ben Carson, and Presidential Senior Counselor Kellyanne Conway all spoke yesterday at the event along with Dr. Elinore McCance-Katz, assistant Secretary at the Substance Abuse & Mental Health Services Administration (SAMHSA.)
While Trump and his senior leadership claimed the center spotlight, a major unheralded star of the summit was an invitee sitting quietly in a front row seat – Dr. E. Fuller Torrey.
From the beginning of yesterday’s summit to its end, nearly all of the speakers promoted or supported ideas that Dr. Torrey has been pushing for the past several decades.
The acceptance and endorsements of his ideas is a major policy shift in the federal government from those of previous administrations.
Civil Rights Laws Criticized
Dr. Drew Pinsky, best-known as a television and radio host, launched the summit with a keynote crafted to explain the history behind our current system. Pinsky, a physician, acknowledged that he had drawn heavily from Dr. Torrey’s 2013 book, American Psychosis: How The Federal Government Destroyed the Mental Health Treatment System, in preparing his critique. (C-span coverage of the event can be found at end of this blog. Pinsky begins at 6:21 minutes)
We are currently “ossified by laws and practices that are between fifty and sixty years old and are anathema to our current understanding of these brain diseases,” he said, while criticizing civil rights laws that he claimed are helping cause “silent genocide on our streets.” (24:04 on C Span tape.)
The landmark Lanterman-Petris-Short Act in California, which established due process protections before someone could be hospitalized against his or her will, and deceased ACLU civil rights lawyer, Bruce Ennis, who sought to make involuntary commitment illegal, both drew harsh criticism from Dr. Pinsky. A director of the Mental Health Law Project, Ennis was one of the earliest backers of the Judge David Bazelon Center For Mental Health Law, which played pivotal roles in passing the Americans with Disabilities Act (ADA) (1990) and the historic case of Olmstead v. L.C. (1999), that found the needless segregation of people with psychiatric disabilities violated the ADA.
Dr. Pinsky said, “Our civil rights have outweighed our self-evident need for treatment – families are left out.” (25:16 C span) He attributed three deaths per day of homeless individuals with serious mental illnesses in Los Angeles County to society’s refusal to intervene. “What is the body count before you give up these crazy ideas…What does the body count need to be before we close the gap between harm-to-self and others and a need for treatment?”
The White House did not invite anyone from the Bazelon Center to attend yesterday’s summit.
Also missing from the program were peers – persons with lived experience – although panelist Matt Sanford, CEO of Hope and Healing Center and Institute, spoke about the importance of peers in his successful outreach in Houston, as did Ohio Department of Mental Health and Addiction Services Director Lori Criss.
Anosognosia: Lack of Insight
Dr. Pinsky cited anosognosia as a reason for why individuals with brain disorders do not believe they need help when they are ill. Anosognosia is a medical term that explains why someone – for instance someone who has had a stroke – doesn’t believe that they are physically impaired when they are. Dr. Torrey has been influential in applying anosognosia in psychiatry, stating that persons who are psychotic “lack insight” into their illnesses and therefore are incapable of seeking help without assistance.
Dr. Pinsky promoted Psychiatric Advance Directives as a way to get around barriers. He also said Americans have a double standard in how we treat individuals with brain disorders. Dementia is a progressive disease that we cannot stop or treat. Society would not allow someone with dementia to wander on the streets homeless because society recognizes that he/she has a brain impairment, he said. Unlike dementia, persons with serious mental illnesses can be helped, but because of civil rights protections we do not help those with mental illnesses – saving those who with brain impairments who can’t be helped but abandoning those who can. (31:21 C Span)
After Dr. Pinsky’s keynote, a panel addressing The Need For Reform took the stage. At least three of its four participants are practitioners of Dr. Torrey’s ideas. They included: Dr. McCance-Katz, who Dr. Torrey backed to become the first assistant secretary for mental health; Author D. J. Jaffe, a long-time protege of Dr. Torrey’s, and John Snook, the CEO of the Treatment Advocacy Center, which Dr. Torrey founded.
Jaffe: Untreated Seriously Mentally Ill Americans Are More Dangerous
Dr. E. Fuller Torrey
Jaffe, author of Insane Consequences: How the Mental Health Industry Fails The Mentally Ill, began his remarks by thanking Dr. McCance-Katz for changes that she has implemented at SAMHSA and thanking his “idol – Dr. Fuller Torrey” who is the “Godfather of the changes” that McCance-Katz is implementing. (35:47 C Span)
Speaking frankly and armed with statistics, Jaffe declared that he is not a “mental health advocate” but is an advocate for the seriously mentally ill (SMI), explaining that a hundred percent of Americans can have their mental health improved, about 18 % have diagnoses found in the DSM-5, which identifies mental disorders, but only 4% of all persons have a serious mental illness (SMI). He said the reason why homelessness, violence and incarceration among the SMI is increasing is because the mental health industry (including many in the room) no longer focuses on serious mental illness. (36:10 C span.) “I argue that we are spending way too much money on mental health and not enough money on serious mental illness,” he said, going from a hospital system that served the seriously mentally ill to a community system that rejects SMI individuals.
The system, he said, diverts mental health funds to address problems such as bullying, bad grades, and other social issues, rather than funding services for SMI patients. Jaffe said 40% of Americans with SMIs receive no treatment, which translates into about four million and explains why 140,000 Americans with SMIs are homeless, 400,000 are incarcerated and 750,000 are on probation and parole at any given time.
Continuing, Jaffe accused advocates of misleading the public when they claim that persons with mental illnesses are not more dangerous than anyone else when, in fact, studies show those with untreated serious mental illnesses are more violent and dangerous, he said.
Jaffe called for the end of the IMD exclusion, which prevents mental health facilities from receiving Medicaid payments if they have more than 16 beds, and criticized mental health groups and the government for spending money to fight “stigma” instead of using those dollars to implement Assisted Outpatient Treatment (AOT), which he said is effective in helping individuals with SMI reclaim their lives. Jaffe also cited Fountain House as the best clubhouse and one of the most effective recovery models in the nation. It is peer run.
Real Life Consequences
Panelist John Shook put a human face on the issues raised by the panel, recounting a story about a Virginia mother whose son became ill while attending the University of Virginia. When she attempted to help him, she was told that the family had to wait until he became so sick he was “in crisis” -“dangerous” (reminiscent of what happened to my son and me.) The son ended up homeless in D.C. for years until he reached a point where his family was able to get him care. He recovered – “a lightswitch went on’ – but he had lost years to the streets because of a preventible tragedy, Snook said. (43:20 C span.)
Snook criticized the dangerous threshold that must be met legally before intervention, joined Jaffe in calling for an end to the IMD exclusion, and pushed for support of AOT. He noted that 48 states now have AOT programs.
The Trump Administration announced several months ago that it would grant states waivers to the IMD exclusion if their state medical directors applied. This was prompted by a lack of treatment beds for persons struggling with opioid addictions. 28 states have been issued waivers that allow them to receive Medicaid benefits for inpatient drug treatment facilities larger than 16 beds, but only one state and the District of Columbia has been issued a waiver for mental health facilities despite a national shortage of crisis care beds.
Snook took a moment to mention recommendations from the Interdepartmental Serious Mental Illness Coordinating Committee, especially those promoting more services for children and adolescents. Snook serves on that committee as do I. Another member, David Covington, also attended the summit.
Snook also mentioned that former Rep. Tim Murphy (R-Pa.) was in the audience. Before he resigned, Murphy pushed through his Helping Families in Mental Health Crisis Act that called for most of the changes that Dr. Torrey, Jaffe, Snook and McCance-Katz support. His bill was watered down in the Senate. Proposals to eliminate the IMD and modify HIPAA – to give parents and caregivers access to medical information – were removed because of objections by Bazelon, other civil rights groups and disability organizations. I asked Rep. Murphy during the summit what it would take to convince Democrats, who blocked his efforts, to change their minds. He replied Democratic members needed to be approached and educated one-by-one. This is something that no one in Congress is doing. The best way to foster changes would be for family members, who want the IMD eliminated and HIPAA modified, to find an advocate in Congress to speak to his/her peers about the need for change. He also said families should share their frustrations with their local leaders by telling them personal examples of how a lack of beds and HIPAA became barriers to treatment.
Successful Programs and A Change in Culture
Shannon Royce, the Trump Administration’s Director of the Center for Faith and Opportunity Initiatives inside HHS, helped plan the summit and Matt Sanford, CEO of Hope and Healing Center and Institute, spoke about the importance of educating and including clergy and faith based groups in helping those with mental illnesses. He said members of the clergy are often the first person a family contacts for help. A neuroscientist by training, Sanford described himself as being “jaded,” explaining there really is no mental health system in our country. Instead, he said, we have a “disjoined set of resources” that are impossible to access and disconnected from one another with no entry point. Those seeking help often must wait until they are in Stage Four of their illness, which requires them to be hospitalized, after which they fall off a cliff and end up returning broken to their families. He explained how his program is coordinating care and involving faith based recovery models. (54:18 C-span)
Although he did not speak, local Pastor Brandon Thomas, whose ministerial work with the mentally ill in Winchester, Va., was recently featured on this blog ,was in the audience.
Sanford said solutions will come from the bottom up, which dovetailed nicely into the second panel featuring local leaders who have found creative ways to overcome barriers to treatment. Jane Nelson, a state Senator from Texas District 12, discovered that Texas taxpayers were spending some $8 billion on mental health and drug programs without any coordination between different state agencies, leading to duplication and waste. She insisted the state draw up a strategic plan to insure coordination and better track expenditures. Chatham County, George County Commissioner Helen Stone spoke about how her community was about to open a drop-off center for individuals who were clearly ill rather than jailing them. Kootenai County Sheriff Ben Wolfinger from Idaho said it had taken law enforcement more than 30 years to realize that persons with mental illnesses who are repeatedly arrested are not criminals but are ill and in need of treatment. He described that awareness as a much needed cultural change.
In her closing statements, Presidential Counselor Kellyanne Conway talked about the administration’s drug fighting efforts. She spoke about visiting a company where employees found to be using drugs were not automatically fired but urged to seek treatment. She described how treating an addiction requires a full array of coordinated services – housing, jobs, transportation, access to medication. Hopefully that awareness will extend to mental health recovery as well.
Before the summit, rumors spread that President Trump would use the event to blame mass shootings on persons with mental illnesses and to call for the rounding up of homeless individuals for interment in federal camps, but there were no such specifics mentioned.
Pounding On The Door
In a 2001 profile published by The Washington Post, the then director of the National Alliance on Mental Illness, described Dr. Torrey as an outsider constantly criticizing the government, his own profession and mental health groups.
“Ten years ago, (NAMI) was outside the door pounding to get in,” Laurie Flynn said. (Dr. Torrey played a key role in building up NAMI at the time.) “Now we’re at the table and people expect us to have good manners. But Fuller is still — and always will be — outside the door, pounding to get in.”
At age 82 and stricken by Parkinson’s Disease, Torrey remains a disruptor but based on yesterday’s summit, he has broken through the White House’s door.
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