I'm writing to request you include the following article in DAC newsletter. "The Dark Underbelly of the President's New Freedom Commission on Mental Health" (Article on federal and state mental health system transformation).

NOTE:
The views expressed are those of the author and not necessarily DAC.   
  

  
PURPOSE
At the most general level I'm seeking to inform both national and international mental disability organizations of recent policy developments regarding mental health in the U.S. Specifically the drastic loss of public and private psychiatric bed space in the U.S.  (an old problem) and the current policy, at least in the Commonwealth of Virginia but likely in other states, of introducing the recovery model i.e. community crisis stabilization services into  emergency services.From the vantage point of disability studies it is important to track how well community crisis stabilization services under emergency services performs in either increasing or decreasing the need of public and private psychiatric bed space.
 
Personally, I think adopting the recovery model to serious mental illness as it applies to the need for public and private psychiatric bed space is questionable. As already mentioned there is a national shortage of public and private psychiatric bed space and in northern Virginia, where I live, it is serious and chronic. Rather than the insurance companies, federal government and the Commonwealth of Virginia allocating significant additional funds to offset the high demand for public and private psychiatric bed space the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse has gone forth with the recovery model with community crisis stabilization services under emergency services. If one accesses http://www.oig.virginia.gov/documents/SS-ESPFinalReportMay-August2005.pdf it states under access recommendations "1c: It is recommended that once projections can be made regarding the impact of the widespread availability of Community Crisis Stabilization, DMHMRSAS in collaboration with the VACSB and the Virginia Hospital and Healthcare Association determine what level of local acute psychiatric Inpatient Hospital care is needed and develop strategies to address any unmet need."
 
It will take time for the widespread availability of Community Crisis Stabilization under emergency services to happen and a longer time to evaluate results. All in the mean time there will continue to be an unmet need for public and private psychiatric bed space. If one accesses http://www.fairfaxcounty.gov/csb/region/2005finalreport.pdf it states, "The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) tasked the state facilities and community services boards with describing the future need for psychiatric beds and community alternatives to offset the number of public
psychiatric beds. With its rapidly growing population, Northern Virginia is challenged to predict an ever-increasing need for psychiatric inpatient beds as well as create diversion and discharge programs to reduce the number of admissions to and length of stay in psychiatric hospitals. Data gleaned from a variety of sources suggests that population will grow by 26.7% by 2020, adding over a half million people to this Northern Virginia area. As shown in Appendix A, all age groups are expected to increase:
• children and adolescents to increase by 127,500 (23.7%)
• adults by 312,000 (23.2%)
• older adults, ages 65 – 84, by 99,800 (68.3%)
• elderly persons, 85 years and older, by almost 7,000 (40.3%).
 
So despite what remedying measures Fairfax-Falls church CSB (Fairfax is the most wealthy county in Northern Virginia)  demographic projections alone dictate more inpatient psychiatric bed space will be needed irrespective of access recommendation 1c.
 
It is not rare to transfer a sick mentally ill resident in Prince William County, Virginia down to a Tidewater hospital because they are the only ones with available psychiatric bed space. It is not rare to transfer a sick mentally ill person from Prince William County to a state mental institution because there was no available private psychiatric bed space. In the latter that happened to me. I had my own physician who at the time had privileges but there was no available bed space. Instead I was shackled and transported by state troopers down to Western State Hospital. I was on B1 entry ward where potential criminal cases were kept with the less aggressive on the other wing but nothing (except common sense and the directives of nurses) to prevent one from wandering to the other side. Medically, I received proper treatment but in terms of environment it was a degrading place.
 
In terms of the mentally ill in the U.S. the focus should be on what their unmet needs are. Currently, that is not the case in this Administration in my view. Currently, the "recovery model" is being implemented in states. The "recovery model" doesn't have much substance in terms of actual policy but politically it can be used as a battering ram against the medical model of mental illness and depriving the mentally ill of services they need or providing it at much lower cost and lesser services.
 
Despite the glaring inefficiencies of America's mental health system it certainly is better than Romania, Turkey, Mexico, Paraguay and many other places. However, I'm concerned about the future of mental health in the U.S. and what directions it will lead to in the future.
 
No legal action is possible against the President's New Freedom Commission on Mental Health and the Virginia DMHMRSAS. No state or federal disability laws have been violated and nothing which would lend itself to high impact litigation. It's all political but political changes as these i.e. the "recovery model" can effect mental health services.
 
I ask is you share this information with your colleagues and others who might be interested. Although not in my state contacting central staff at DMHMRSAS (starting with the Commissioner www.dmhmrsas.virginia.gov/contactus.htm the agency you are contracted with and Specifically urge more funding for public-private psychiatric bed space (above what has already been done) and being critical of  access recommendation 1c "It is recommended that once projections can be made regarding the impact of the widespread availability of Community Crisis Stabilization, DMHMRSAS in collaboration with the VACSB and the Virginia Hospital and Healthcare Association determine what level of local acute psychiatric Inpatient Hospital care is needed and develop strategies to address any unmet need." Strategies should be currently underway to address any unmet need not contingent upon Community Crisis Stabilization widespread availability and outcomes. If Community Crisis Stabilization is successful in possibly reducing public-private psychiatric bed space (outcomes) this should be able to be determined by rates annually rather than projection. Other factors include closure of more public/private psychiatric bed space; demographics, changes in health insurance coverage, availability of services, etc. Although VOCAL specializes in consumer run programs there are many other issues which to advocate on, even if they do yield predictable results.


FOCUS
This letter pertains to the Commonwealth of Virginia although "the recovery model" is national in focus and other states may be implementing similar comprehensive state mental health policies. The "recovery model" is contrasted with the "medical model" and although components of the "recovery model" have been around for decades and even going back to the eighteenth century it has appeared under different guises. The current "recovery model" wasn't developed and implemented until the President's New Freedom Commission on Mental Health.
 
LETTER
Having attended the June 16th Prince William County Community Services Board meeting in Northern Virginia whose purpose was to discuss possible changes to its mission statement I learned from Director Tom Geib  that Inspector General James Stewart had visited "emergency services" and discovered the staff weren't familiar with "recovery principles". I can understand the Inspector General wanting all branches to be familiar with "recovery principles" but emergency services deals with those who need help, not recovery.
 
There has been a break in the continuum of emergency services with the introduction of "community crisis stabilization" services. At present these services include:
 
Residential crisis stabilization (TDO) - Like the service below, but licensed to accept TDO's, with 24 hour nursing on site, M.D. daily and on-call for assessments and interventions. All of the current crisis stabilization programs are considering accepting TDO's.
 
Residential crisis stabilization service (voluntary) - 24 hour, CSB-operated or contracted, group home model, available in emergencies, sufficient staffing ratios to provide intensive supports to persons in crisis. Includes nursing on site and MD consultation/visits. (This model of crisis stabilization is currently used in three communities. The General Assembly funded seven additional programs 2005.)
 
In-Home residential support service – CSB staff goes to the consumer’s home and provide supports during crises, keep consumer safe and occupied. Level of support is matched to consumer need. Consumer focused, not program-focused
 
Consumer-run residential support service - “Safe house” program. CSB/consumer partnership agreement– many consumers prefer to be served by other consumers in a crisis.
 
All of these programs can be possibly effective. The report mentioned defining crisis stabilization and coming up with alternatives. This push towards community based crisis stabilization services is intended to offset the high demand for public and private psychiatric bed space. There is no denying, however, there needs to be more public and private psychiatric bed space, something the big insurance companies know but don't want to pay for. Increasing community crisis stabilization services won't be so successful that this doesn't need to be done. Absurdly, the state intends on using community crisis mid range stabilization to determine if any extra acute public and private psychiatric bed space is needed. By doing this they can delay the process of possibly funding more public psychiatric bed space.
 
Recovery principles come into play with community crisis stabilization/emergency services except as a means to prevent the mentally ill from utilizing public and private psychiatric bed space. Self determination, empowerment, and recovery are code words for saving money and keeping expenses for the mentally ill down. There is nothing inherently wrong with this if it brings better care for the mentally ill. However, at a time when many mentally ill are in jails on petty charges; there is very little low income housing for the mentally ill; and there is a serious chronic shortage of both public and private psychiatric bed space, the President's New Freedom Commission on Mental Health initiative doesn't recommend any substantial funding for mental health but allocation of existing resources. Furthermore, it seeks to lower even existing resources for the mentally ill by supporting so-called consumer operated and run services such as drop-in centers and community crisis stabilization services under the umbrella of emergency services.
 
Community crisis stabilization services shouldn't be a part of emergency services. The fact that only 21% of CSB emergency services were familiar with community crisis stabilization services (recovery mid-range services) should tell one something. Very few mentally ill need a doctor or nurse onsite and if they do they probably belong in the hospital. Community crisis stabilization services should be apart of MH residential services, not emergency services. By tacking on community crisis stabilization services to emergency services this conveys the impression "medical emergencies" will be resolved in the "community" rather than the hospital and promoting a shift against the usage of public and private psychiatric bed space. This could have negative consequences for some mentally ill. The hope of government is community crisis stabilization services under the umbrella of emergency services will ultimately lessen the need for more public and psychiatric bed space and thus requests for less funding.
 
Recent "recovery principles" stems around the motto self determination, recovery, and empowerment. The genesis of this was the President's New Freedom Commission  on Mental Health. Despite the fact the Virginia DMHMRSAS mission statement  is, "Our vision is of a “consumer-driven system of services and supports that promotes self determination, empowerment, recovery, resilience, health, and the  highest possible level consumer participation in all aspects of community life including work, school, family and other meaningful relationships”  there is little actual substance in terms of policy.
 
Given the problems in mental health, it appears these "recovery principles" which have no real substance are a purposeful distraction at the minimum and dramatically cutting or eliminating services at the maximum. The best thing about the President's New Freedom Commission on Mental Health is it  doesn't cost much money. Here are just some of the major chronic problems which haven't been dealt with sufficiently:
 
(a) There is a shortage of both private and public psychiatric bed space; in Northern Virginia it is  serious and chronic. I would think nationally it is not great.
 
(b) There are mentally ill being arrested and languishing in jails on petty charges. According to SAMSA 2000 data  "Currently the prevalence of active serious mental illness among inmates admitted to U.S. jails is about 7 percent, which means that nearly 700,000 persons with active symptoms of severe mental illness are admitted to jails annually. For those persons in prison, recent Bureau of Justice Statistics reports approximately 16% or about 233,000 are also similarly diagnosed. About 75 percent of these people have a co-occurring alcohol or drug use disorder."
 
(c) There is a serious shortage of low income residential housing for the mentally ill.
 
(d) A disproportionate number of homeless are mentally ill. While only four percent of the U.S. population has a serious mental illness, five to six times as many people who are homeless (20-25%) have serious mental illnesses. Their diagnoses include the most personally disruptive and serious mental illnesses, including severe, chronic depression; bipolar disorder; schizophrenia; schizoaffective disorders; and severe personality disorders.1
 
Self determination, empowerment, and recovery won't address these chronic problems. Only an influx of state and federal funding will.and sound policy. Lawmakers have known these facts for years but nothing ever significantly improves. Instead  advocates such as me are always expecting things to worsen and at best retain services  which exist without managed care plowing through. Many accept the status quo. Unfortunately, the attention and criticism toward the President's New Freedom Commission on Mental Health was confined to the Texas Medication Algorithm Program (TMAP) and screening of children for mental illness. The colossal propagandized hoax of self determination, empowerment, and recovery and so-called consumer run and operated services has gone relatively unchallenged and have been somewhat "successful".

The President's New Freedom Commission's Final Report called into question the design of many mainstream social welfare programs serving people with serious mental illness, implying that Social Security's Supplemental Security Income (SSI) Social Security Disability Income (SSDI) are part of the problem and not the solution. It states, "Moreover, the largest Federal program that supports people with mental illnesses is not even a health services program - the Social Security Administration's Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) programs, with payments totaling approximately $21 billion in 2002." There are eligibility requirements for receiving these benefits as well as Medicaid and Medicare and without them many mentally ill would not be able to pay their rent and buy groceries. For the seriously mentally ill without SSI and/or SSDI they would be living with family or homeless on the streets. Without Medicaid and /or  Medicare they wouldn't receive any health insurance coverage.
 
Overall, in fiscal year 2002 twenty-four billion was spent on Medicare and Medicaid; twenty-one billion on SSDI and SSI; four hundred and forty three million in Community Block Grants through SAMSA and additional funding for housing, rehabilitation, education, child welfare. substance abuse, general health, criminal justice and juvenile justice. All together this information suggests around 46 billion dollars a year spent (in 2002).
 
The Final Report states, "Each program has its own complex, sometimes contradictory, set of rules. Many mainstream social welfare programs are not designed to serve people with serious mental illnesses, even though this group has become one of the largest and most severely disabled groups of beneficiaries. " This is likely measured by their rate of unemployment rather than status of mental health.  The report goes on to say, "If this current system worked well, it would function in a coordinated manner, and it would deliver the best possible treatments, services, and supports. However, as it stands, the current system often falls short. Many people with serious mental illnesses and children with serious emotional disturbances remain homeless or housed in institutions, jails, or juvenile detention centers. These individuals are unable to participate in their own communities."
 
Actually, the current system works remarkably well despite the Commission's statement to the contrary. Certainly better without these support systems. It does work in a coordinated manner and it has in some areas provided the best possible treatments, services, and supports. Because of the complexity of servicing the needs of the mentally ill in the public mental health system it is impossible to have all services coordinated at the same time. There are eligibility requirements for Medicaid, Medicare, SSI, and SSDI. If you make too much money at a job you won't have Medicaid coverage. You won't get Medicare coverage unless you have SSDI. The amount of food stamps you receive depends upon your income.
 
Many people with serious mental illnesses and children with serious emotional disturbances do remain homeless or housed in institutions, jails, or juvenile detention centers. In the cases where the seriously mentally ill are housed in jails with little or no mental health services and support it is obvious they need to be transferred to a psychiatric institution. Children with serious emotional disturbances need mental health services and support. It all gets back to money and whether we as a society think it is worthwhile to provide these services to the mentally ill. Clearly, we don't.
 
The "recovery movement"  prior to the New Freedom Commission on Mental Health goes way back to Dorothea Dix and Clifford Beers whom if they were alive today would probably  not be totally pleased with the so-called mental health movement today as artificially pumped up by the Commission. Rather than language of self-determination, empowerment, and recovery which in present context conveys a false hope any disabled person can be like Mr. Jones down the street, what the mentally disabled need are dedicated state and federal funding streams for hospital beds, lower income housing, more reimbursement to private providers, more state oversight of private providers, and heavy fines when there are violations.
 
This facade of the "consumer" being the end point must end. Without links a chain link fence will ultimately fall down. The emphasis on self-determination, empowerment, recovery and consumer operated services/peer support is a camouflage by this administration to get out of the business of providing governmental mental health services. It's proponents are well aware of this and thus it is a multi-year long term goal.