The Definition of Insanity
How a federal agency (SAMHSA) undermines treatment for the mentally ill.
Wall Street Journal March 31, 2014
Every time a mass shooting happens in the U.S.—Sandy Hook, Virginia Tech, Aurora—we have the same national discussion: Why can't we identify and treat the dangerously mentally ill before they kill? Here is one infuriating answer.
Inside the U.S. Department of Health and Human Services sits an agency whose assignment since its creation in 1992 has been to reduce the impact of mental illness and target services to the "people most in need." Instead the Substance Abuse and Mental Health Services Administration, known as Samhsa, uses its $3.6 billion annual budget to undermine treatment for severe mental disorders.
Health professionals agree on the need to provide medical intervention for serious psychiatric disorders—schizophrenia, bipolar disorder, severe depression. The National Institute of Mental Health does evidence-based research and promotes medically driven models of care, including early intervention, intense psychiatric treatment and drugs. Doctors have promoted reforms such as "need for treatment" standards in civil-commitment laws, or assisted-outpatient laws so courts can require the mentally ill to receive treatment to avoid hospitalization. These reforms help the mentally ill and reduce crime, incarceration and homelessness.
Instead of being part of this solution, Samhsa is in the vanguard of the legal-advocacy and anti-psychiatry movement that sprang to life in the 1980s, and it continues to waste taxpayer dollars on programs that undercut efforts to help the world's Adam Lanzas.
Known generally as the "consumer/survivor" movement (as in having "survived" psychiatric treatment), this movement largely opposes drug treatment, psychiatric care, civil-commitment laws or even the reality of mental illness. Samhsa pushes the "recovery model," an approach that puts the patient in charge of crafting his own recovery plan and stresses "empowerment" and coping rather than medical intervention.
For instance, Samhsa's Guide to Mental Illness Awareness Week suggests schools invite as speakers such radical organizations as MindFreedom, which rejects the existence of mental illness and stages "human rights" campaigns against drug treatment and commitments. Or the National Coalition for Mental Health Recovery, which "holds that psychiatric labeling is a pseudoscientific practice of limited value in helping people recover."
Samhsa underwrites the Alternatives conference, which in 2013 included a session titled "Dance Your Way to Wellness and Recovery" and a presentation from the "Hearing Voices Network," which "believes that hearing voices is a part of human experience."
The recovery model can help people with minor mental illness. But Samhsa's allegiance to it neglects or harms individuals with severe psychiatric disorders. Most of Samhsa's annual $460 million in grants goes to community mental-health centers aimed primarily at the "worried well."
Samhsa's grants prioritize "prevention"—though there is no known way to prevent severe mental illness. Samhsa spends millions on anti-bullying coloring books and online kids games and pamphlets on how to handle emotional distress after floods: "Take care of pets . . . Nature and animals can help us to feel better when we are down."
E. Fuller Torrey, who runs the Treatment Advocacy Center devoted to helping the severely ill, has noted that Samhsa's most recent long-term planning document is 42,000 words but contains not one reference to bipolar disorder, schizophrenia or schizoaffective disorder.
Sally Satel, a psychiatrist who served on an advisory committee to Samhsa, told a House committee last year that her review of the 288 programs on the agency's registry of "evidence-based" programs turned up only four aimed at severe mental illness. Most were aimed at helping substance abusers, or enhancing parenting skills, or helping kids recognize "anxiety." Samhsa had even refused to put assisted outpatient therapy on the list, though this is the most-effective program for severe illness.
Ms. Satel told the House how Samhsa leadership routinely rejected advice from the medical professionals on its advisory council. Jeffrey Geller, the director of public sector psychiatry at the University of Massachusetts Medical School, related to Dr. Satel: "Most members who served [on the Samhsa advisory council] during the years I served gave up attempts for meaningful input and left in disgust."
Pennsylvania Rep. Tim Murphy spent a year reviewing federal mental-health policies and in late 2013 introduced a thoughtful overhaul. One proposal would create a new HHS assistant secretary for mental health to streamline federal programs and take over Samhsa's grant-making—requiring that money go to evidence-based practices. The position would have to be filled by a medical professional.
Some conservatives oppose this new government position, but the status quo is worse—and dangerous. Samhsa is out of control and would be better off abolished. But if that can't be done, the Murphy bill would reorganize government to make it more effective and accountable. And as long as the government spends billions on mental health, it needs someone to streamline and make more effective its dozens of programs.
At the very least, someone needs to assure Americans that their tax dollars aren't feeding a culture of nontreatment. The risk to society from untreated mental illness is tragically obvious. It's well past time for Washington's politicians to clean up HHS's absence of oversight at Samhsa.