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Almost Committed

The House GOP inches toward mental-illness reform.

Jun 10, 2013, Vol. 18, No. 37 • By MARK STRICHERZ
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When his House subcommittee held the forum “After Newtown: A National Conversation on Violence and Severe Mental Illness” in March, Rep. Tim Murphy (R-Pa.) received bipartisan praise for what was to be the first of three hearings on the topic. Murphy, chairman of the Energy and Commerce Committee’s oversight and investigations subcommittee, took the job in December, a few days before the atrocity in a suburban Connecticut elementary school. He earned good will from both sides of the aisle simply by examining the links between violence, severe mental illness, and federal policy, something Congress hadn’t done in decades. “You’re my hero for raising these issues,” Dr. Harold Koplewicz, a member of Vice President Biden’s task force on mental illness, gushed at the time. “I commend your leadership on this issue,” said Rep. Henry Waxman (D-Calif.).

Rep. Bill Cassidy

Rep. Bill Cassidy

Newscom

Murphy is an unusual politician. With his wireless oval glasses and smooth baritone voice, the 60-year-old comes across more like the child psychologist he was than a legislator. Few politicos quote from memory the medical journal the Lancet, and his knowledge of the topic has not been lacking.

At the subcommittee’s latest hearing, on May 22, his opening statement was crisp and dispassionate. He described the nub of the problem: “In 2009, the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA, estimate[d] that about 11 million U.S. adults had serious mental illness, and 40 percent of these individuals did not receive treatment,” he said. “If we’ve learned one thing from the horrible acts committed by Seung-Hui Cho at Virginia Tech in 2007, Jared Loughner in Tuscon, James Holmes at the Aurora, Colorado, theater in July 2012, or Adam Lanza, it is this: that individuals with untreated severe mental illness are a significant target for self-directed violence, including suicide, or violence against others.” And he pointed to a solution: “Assisted Outpatient Treatment (AOT) laws—a less restrictive alternative to involuntary commitment. Numerous academic studies have shown AOT to be incredibly effective in reducing re-hospitalizations and re-arrests among, until then, untreated individuals with serious mental illness.”

But for every Tim Murphy in the House Republican caucus, there is a Billy Long. The Missouri congressman serves on Murphy’s subcommittee and has a background in talk radio; he not only represents the Tea Party wing of the party, but the faction that has no professional or emotional link to the 62 mass shootings that have taken place in 30 states since 1982. Long won his seat in 2010 partly by pledging to support a balanced budget amendment to the Constitution. He makes no pretense that his priority in Congress is anything other than to reduce federal spending.

At the last hearing, Long told a roundabout story that had no direct connection to mental-illness reform. It was in response to a complaint from SAMHSA administrator Pamela Hyde, the lead witness, that sequestration had wiped out 5 percent of the agency’s $3.4 billion annual budget. A bear of a man who speaks in a flat Missouri twang, the 57-year-old former auctioneer said he bought a copy of Bob Woodward’s The Price of Politics at a Barnes & Noble bookstore in downtown Springfield on September 12, 2011, finished reading the book two or three months later, watched Woodward on TV, and ran into the esteemed journalist the same day. “I believe, but I’m not sure, it was on page 326, because I don’t know how to read a book on an iPad. But on page 326 it talks about where sequestration came from. Do you know where it came from? Whose idea it was?” he asked Hyde.

Long’s disquisition befuddled even seasoned legislators. Democrat Diana DeGette, who has represented her Denver district for nearly 17 years, moved her head back and narrowed her eyes at Long. Murphy and other House Republican leaders on mental-illness reform don’t admit this on or off the record, but their legislative plans seem crafted with the caucus’s Billy Longs in mind.

The leading experts in mental illness agree on two facts. First, severely mentally ill people are different not only from you and me, but also from those with severe physical illnesses. As psychiatrist E. Fuller Torrey noted at the March 5 hearing, “at least half of them have an impairment of their understanding of the fact that they are sick, and the reason is they have damage to the parts of their brains that they use to think about themselves.” This is anosognosia, or lack of self-awareness, which afflicts not only patients with Alzheimer’s disease but also those with bipolar disorder and schizophrenia. He discussed his late sister, Rhoda, a schizophrenic who thought she had been put into a mental hospital because of a cold. Koplewicz, who also serves as president of the Child Mind Institute in New York, affirmed Torrey’s conclusion at the hearing.

Experts also concur that assisted outpatient treatment laws work. A 2001 RAND report, which summarized the findings of two clinical trials, found that a “sustained outpatient commitment order (180+ days), when combined with intensive mental health services, may increase treatment adherence and reduce the risk of negative outcomes such as relapse, violent behavior, victimization, and arrest.” Forty-four states have adopted such a program, including New York, whose “Kendra’s Law” is the best known. There is wide agreement that states need to provide adequate funding for assisted outpatient treatment laws to yield the outcomes the RAND study described. “We agree that [these laws] need to focus on services, but most states don’t fund them,” Michael Fitzpatrick, executive director of the National Alliance on Mental Illness, said in an interview.

What leading practitioners disagree on is the extent to which the severely mentally ill need better access to treatment—and whether they should be forced to take medication. Koplewicz noted the country has only a few thousand child psychiatrists, while Fitzpatrick said schoolteachers and counselors often fail to recognize the symptoms of severe mental illness in students. By contrast, Torrey argued that a lack of access to treatment is not the main problem; the Virginia Tech, Tucson, and Aurora shooters had been diagnosed as severely mentally ill. He contends courts and local agencies don’t force a severely mentally ill person to take his meds unless he has committed violence.

President Obama, who will lead a White House conference on mental illness June 3, proposes spending $235 million to help teachers, counselors, and first responders at schools and universities identify symptoms of mental illness. A bipartisan Senate proposal, which the upper chamber passed as an amendment April 18, mirrors the administration’s plan, but without the funding. Neither proposal addresses the problem Torrey identified: Cho, Loughner, and Holmes had been diagnosed at their schools as psychotic, yet none was forced to remain on medication.

Unfortunately, the House Republicans’ version is little better on this score. A Murphy aide indicated that the congressman will seek to eliminate a $36 million SAMHSA grant awarded to civil-rights organizations that advocate for mentally disordered patients who avoid taking their medication. “I’m supportive of assisted outpatient treatment, but we have to make a clear lobbying effort,” Murphy said.

Rep. Bill Cassidy of Louisiana, a physician, has two further suggestions: Family members of the mentally ill should be able to get full access to their records from doctors, who typically cite a 1996 federal health-privacy law to block them; and they should have greater discretion in committing their mentally ill children to institutions. “A family requesting therapy for their child whose doctor does not feel it’s appropriate should be able to go before a judge to get treatment,” Cassidy said.

Torrey has a better plan. He would give states a $200 million block grant they could use to fund assisted outpatient treatment laws. “I think what we can do is use federal money that’s already available and out there to provide models so that we can understand what proper treatment can and should be,” he said at the March forum, arguing that AOT “decreases hospitalization, decreases violence, and also saves money. This is a proven way to treat people, especially those who are not aware they are sick themselves.”

Torrey is not a natural ally of the GOP. A registered Democrat, he has urged new federal dollars to help treat the severely mentally ill. Yet he has emerged as a serious policy wonk for conservatives seeking to respond to the Tucson, Aurora, and Newtown massacres. He called for the abolition of SAMHSA in an op-ed for National Review Online two years ago and criticized the federal government’s role in the deinstitutionalization of the mentally ill in the pages of the Wall Street Journal. In his heavily liberal profession, he has long been considered an iconoclast. “People don’t see Fuller as representing the conservative movement, but they do think of his approach as conservative,” said Charles Curie, the director of SAMHSA for the first five years of the George W. Bush administration.

Torrey’s plan would cost less than the Obama administration’s proposal. It would not add to the federal debt. It would not change the nation’s gun laws. It would result in government savings in the long run. And it would help prevent mass shootings.

The public is not indifferent to the plight of the mentally ill. In a December Gallup poll, 82 percent said they would support increasing government spending for mental health programs for young people; 67 percent of those were Republicans. Adopting Torrey’s proposal would seem to be a no-brainer for congressional Republicans. Yet not a one—not Murphy, not Cassidy—has. The post-compassionate-conservative GOP is ignoring a golden opportunity to appeal to suburban swing and independent voters without alienating deficit hawks and gun-rights supporters.

Torrey is not crushed by the absence of patronage for his plan: “Actually, I’m encouraged,” he says. 

“Congress hasn’t looked at the issue in 30 years.”

Mark Stricherz, author of Why the Democrats Are Blue (Encounter Books), is Washington bureau chief of the Colorado Observer.

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