What Harry Reid and John Boehner Should Do in Wake of Giffords Shooting

For over 20 years, families of people with mental illness have been advocating for various reforms that would prevent seriously mentally ill individuals from becoming violent. Former Senators Kennedy (Democrat), Wellstone (Democrat) and Domenici (Republican) were frequent supporters, but they are no longer around. Hopefully Senate Majority Leader Harry Reid and House Speaker John Boehner can honor them (and Gabrielle Giffords) by taking action.

As Thomas Insel, Director of the National Institute of Mental Health wrote in reaction to the shooting of Gabrielle Giffords by Jared Loughner:

Is violence more common in people with serious mental illness? Yes, during an episode of psychosis, especially psychosis associated with paranoia and so-called "command hallucinations", the risk of violence is increased. People with serious mental illness are up to three times more likely to be violent and when associated with substance abuse disorders, the risk may increase much further.

The conclusion is obvious. To prevent people with serious mental illness from becoming violent, we have to prevent them from becoming psychotic or abusing drugs.

Here is how Congress can help:

  1. Don't spend more. Spend Smarter. Prioritize the seriously mentally ill. Federal mental-health dollars go to an astonishing variety of social programs for the worried-well, with little left for the seriously ill. Congress should establish a federal definition of "serious mental illness" that covers no more than 5 percent of the population and require all programs that get federal mental-health funds to use at least 60 percent of those funds for the seriously mentally ill. While state leaders regularly criticize Congress for imposing "unfunded mandates", federal mental health aid to states is more like a "funded unmandate", states can use the funds for anything they want. That has to stop. If Washington can't spend smarter, then yes, they should spend more.
  2. Save money. Eliminate the Substance Abuse and Mental Health Services Administration. This federal agency wastes its funds on everything but serious mental illness. SAMHSA just e-mailed to alert me that its children's book, Play Day in the Park, which "reinforces positive, healthy choices for children ages 3 to 4," is back in print. This, when seriously mentally-ill people are going homeless and untreated.
  3. End or greatly restructure the Federal Protection and Advocacy for Mentally Ill Individuals Program (PAMII). The lawyers in this program occasionally do good work -- but more often, they defend the right of people with mental illness to go off treatment and be psychotic. They are the major impediment to reforming involuntary-treatment laws. Congress should ban the use of any PAMII funds for lobbying against reform of involuntary-treatment laws or working to prevent family members from helping their loved ones, an especially big problem here in New York.
  4. Provide seed money to states that want to make use of Assisted Outpatient Treatment Laws (AOT). These laws allow courts to order someone with mental illness and a history of violence to stay in treatment if he wants to stay in the community. By cutting down on arrests, incarcerations and hospitalizations (not to mention dangerous), these laws save money and lives while helping the mentally ill live successfully in the community. They are less expensive, less restrictive and more humane than the alternative: involuntary inpatient commitment.
  5. End the Institutions for Mental Disease Exclusion in Medicaid law by supporting HR 619 sponsored by Representative Eddie Johnson (D-TX). The IMD Exclusion prevents states from providing long-term care for people with mental illness. If you need long-term care for a disease that resides in any organ other than the brain, Medicaid reimburses states for half the cost. But not if the disease is in the brain. So states lock the front door and open the back -- patients wind up in jail after committing some illegal act only because they were left untreated.
I laid out the proposals states should adopt in a symposia in
They involve reforming involuntary treatment laws so people can be helped before they become "danger to self or others" rather than waiting until after:
  1. When the "dangerousness standard" is used, it should be interpreted more broadly than "imminently" and/or "probably" dangerous. Running around with a knife ought to qualify. You shouldn't have to use it first.

  2. Supplement the "dangerousness" standard with broader, flexible standards that would allow for involuntary commitment when an individual is:

 "Gravely disabled" (substantially unable, except for reasons of indigence, to provide for any of his basic needs, such as food, clothing, shelter, health, or safety), likely to "substantially deteriorate" if not provided with treatment, or
 "lacks capacity"(unable to fully understand or lacks judgment to make an informed decision).
  3. Laws should allow for consideration of past history of the patient, since past history is the most reliable way to anticipate the future. If someone has a history of deteriorating off medications, the courts should know that.

  4. The legal standard for initial 24-to-72-hour commitments should be "information and belief." For commitments beyond then: "clear and convincing evidence."

  5. Patients should be given strong due-process protections, including the right to an attorney, and the commitment decision should be made by judicial or quasi-judicial bodies.

  6. It is vitally important that every state adopt and use Assisted Outpatient Treatment (AOT). It is a cheaper, more humane substitute for involuntary inpatient commitment. AOT allows courts -- with proper due-process protections -- to order individuals with a past history of violence to stay in treatment as a condition of living in the community. The court order also "commits" the mental-health system to providing the treatment. Most mental-health providers turn the seriously mentally ill away so they can "serve" less symptomatic individuals. Under AOT, the court can order the mental-health provider to do more than write "discharged" when a seriously mentally ill individual fails to show up.

If Congress and states will make these reforms, they can save money, improve care, and keep the public safer.