Hippie healthcare policy: while one government agency searches for the cure to mental diseases, another clings to the '60s notion that they don't exist.

IN 1999, 31-YEAR-OLD JULIE RODRIGUEZ drove her car into the Sacramento River, killing herself and her two toddlers. Rodriguez had been suffering from serious mental illness, including paranoia and psychosis. Her family had tried repeatedly to get her into treatment, but she had refused to go, and California had no law that would enable them to commit her to a hospital against her will.

Rodriguez's story helped prompt the state legislature to do something few states have been willing to do: wrestle publicly with a failing mental health system that is as costly as it is ineffective. As home to an estimated 630,000 severely mentally ill adults, California spends $2.5 billion a year to care for the indigent mentally ill, yet those programs reach no more than half the people who need them. Because they cannot be treated or hospitalized against their will, a scandalously high proportion of the state's mentally ill simply end up homeless or in prisons and jails instead. At least 15 percent of the state prison and jail inmates are severely mentally ill, costing the state $1 billion a year.

Among several pieces of legislation introduced in 2000 to address this growing crisis in California was a bill that would, in extreme cases, allow authorities to treat mentally ill people against their will. More than 60 people testified in support of the bill, including one man whose mother had been murdered by his unmedicated sister with schizophrenia, and it was championed by virtually every major newspaper in the state. Yet, in the end, the bill went nowhere, largely because of a campaign organized by a federally funded advocacy group.

In 1998, the primary federal agency devoted to improving mental health services, the Center for Mental Health Services (CMHS), awarded $200,000 to a group of former mental patients in California whose nonprofit organization is committed to vigorously opposing laws that would make it easier to forcibly treat and commit people like Julie Rodriguez. Strengthened by its federal grant, the California Network of Mental Health Clients organized rallies, hired vans to bring people to Sacramento, distributed T-shirts, and created the erroneous impression that there was widespread opposition to the commitment bill.

Such efforts appeared reasonable in the '60s, when scientists believed that severe mental illnesses were caused by bad mothers and social stresses. Four decades later, however, such views appear anachronistic in the face of overwhelming evidence that severe mental illnesses are brain diseases. Furthermore, research demonstrates that approximately half of all individuals with severe mental illnesses lack awareness of their condition because of damage to the parts of the brain that afford self-awareness. As a result, many severely disturbed people are fundamentally unable to ask for help or seek treatment on their own, making involuntary treatment laws both necessary and humane.

Yet the California group is not the only anti-psychiatry organization to receive federal funding for its reactionary mission. This obscure agency in the U.S. Department of Health and Human Services continues to use its nearly $800 million annual budget to fund mental health programs that largely ignore 30 years of research into the organic nature of mental illness. At its headquarters in Rockville, Md., policy wonks and grant-makers seem to be nostalgic for the days when mental health policy was inspired by Ken Kesey's book One Flew Over the Cuckoo's Nest, in which oppressed patients in a mental hospital revolted against Big Nurse and other symbols of authority.

CMHS's outlook has changed little since the days when libertarian psychiatrist Thomas Szasz asserted that mental illness did not exist, and British psychiatrist Ronald Laing argued that schizophrenia was really a growth experience. At CMHS, mental illness is still a state of mind rather than a neurological illness. Its policies are still driven by a symbiotic political relationship with a movement started in the '60s by a small group of ex-mental patients who called themselves "consumer survivors."

Like Szasz, many of them deny the existence of mental illness and see involuntary treatment as a form of social control rather than medical care. All of them are united in vociferously opposing any form of involuntary hospitalization or treatment, and CMHS has provided millions of dollars to support those efforts. An analysis of CMHS's portfolio suggests that as much as two-thirds of its $230 million annual discretionary funds are currently being used to support groups opposed to reforming the mental health system.

The result is a bizarre situation in which one federal agency funds groups that believe that mental diseases are a "healthy transformation process," while the National Institute of Mental Health (NIMH) conducts brain imaging and neuroscience research in an attempt to discover the causes of those diseases. Tragically, while CHMS pursues its hippie philosophy and obstructs reform efforts like those in California, the need for its stated mission--improving treatment for the mentally ill--has perhaps never been greater.

Madness in the Streets

CMHS had a modest $3.5 million birth in 1977 as the Community Support Program within NIMH. It was created because of the failure of NIMH's Community Mental Health Centers program to address the problems of the increasing numbers of severely mentally ill individuals being discharged from state psychiatric hospitals. In true Washington fashion, the failure of one program was addressed by creating another program rather than by fixing the first.

The mandate of the Community Support Program, according to a 1978 report, was to coordinate services "for one particularly vulnerable population--adult psychiatric patients whose disabilities are severe and persistent." This mandate, which focused on severe mental illness, was quickly forgotten as the Community Support Program expanded to encompass all forms of unhappiness and social ills, vaguely referred to as mental health.

In 1992, the Community Support Program and related activities of NIMH were transferred to the newly created CMHS when NIMH was reincorporated into the National Institutes of Health. CMHS, in turn, became a component of the Substance Abuse and Mental Health Services Administration. And, of course, it continued to grow, and grow, to its present annual allocation of $782 million, even as mental health services in this country have deteriorated markedly.

Today, approximately one third of the country's homeless--200,000--are severely mentally ill. An additional 276,000 severely mentally ill individuals reside in jails and prisons. Mentally ill individuals who are not receiving treatment commit an estimated 1,000 homicides a year. Despite these dismal statistics, CMHS continues to pursue a 1960's social agenda in the name of mental health, with little accountability of how its funds are spent.

CMHS collects almost no information on how the funds allocated under its largest single program, the $420 million mental health block grant to states, are spent on how many patients and with what diagnoses are served. Similarly, CMHS collects virtually no national data on the incidence of mental disorders, and is unable to answer such basic questions as, for example, whether schizophrenia is increasing, decreasing, or remaining constant.

Among most professionals who are aware of its existence, CMHS is ridiculed as an agency and widely regarded as more dysfunctional than the individuals it is supposed to serve. Not only is CMHS the major funder of groups opposed to involuntary treatment, it spends millions on programs of dubious merit that offer little help to the critically ill.

For instance, in 1998, CMHS awarded $1.3 million over three years to the National Empowerment Center (NEC) in Lawrence, Massachusetts, for a "National Consumer Technical Assistance Project." NEC's extraordinarily vague grant application had claimed that it would "improve the mutual understanding between consumers and other stakeholders" and "nurture and strengthen national leaders of color." In fact, the federal funds to NEC have been used to support the salaries of anti-psychiatry radicals. NEC employee Judi Chamberlain, for example, claims that "the kinds of behavior labeled `mental illness' have far more to do with the day-to-day conditions of people's lives than with disorders in their brain chemistry." And NEC co-directors Laurie Ahern and Dan Fisher have written, respectively, that "mental illness is a coping mechanism, not a disease" and that "the covert mission of the mental health system ... is social control."

When asked to describe his program, Fisher says he likes to call the project an "education center that brings inspiration and hope to individuals who have recovered from a mental illness."

All three appear to share Ms. Chamberlain's belief that any person "who can express his or her own wishes and desires, no matter how irrational they may appear to others, deserves to have those wishes respected." Thus, psychotic individuals who think they can fly should be allowed to try, and homeless ill people who believe that the voice they hear is God telling them to eat from garbage cans should be provided with napkins. What would Ms. Chamberlain do with John Hinckley, who wished to impress Jodie Foster, or with Russell Weston, who wished to obtain the "ruby satellite" in the U.S. Senate Office Building so that he could make time go backwards and instead killed two police officers in 1998?

The centerpiece of the NEC program is the Alternatives Conference, which NEC has sponsored using CMHS funds. At the 1995 conference, speaker Al Siebert gave a talk entitled "Successful Schizophrenia," in which he claimed that "schizophrenia is a healthy, valid, desirable condition--not a disorder ... what is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated." Two CMHS staff members were on the conference advisory committee and apparently approved the talk. At the 1999 conference, CMHS funded a separate, two-day "National People of Color Consumer-Survivor Network" meeting to discuss "how discrimination and oppression are related to stress."

The largest portion of CMHS funds given to antipsychiatric groups and those opposed to assisted treatment is the $30 million per year allotted through the Protection and Advocacy program. Although the Protection and Advocacy program began in 1986 as a well-meaning attempt to prevent abuse of patients in psychiatric hospitals, many of its state programs quickly evolved into being "playgrounds for anti-psychiatric activists," according to Rael Jean Isaac and Virginia Armat in their 1990 book Madness in the Streets. In 1999, for example, the Vermont Protection and Advocacy organization changed a state law, thus making it more difficult to medicate seriously mentally ill individuals.

And currently in Wisconsin, that state's Protection and Advocacy organization has filed an amicus curiae brief to change the state's commitment law. The current law, the brief argues, is deficient, because it does not require a person's dangerousness to be "imminent," and allows people to be treated to avoid psychiatric deterioration. Furthermore, the brief says that psychiatric treatment is "of questionable benefit."

Although civil rights is a dominant theme in the distribution of CMHS funds, minorities and women's issues are also prominent. Blacks, Hispanics, Asian Americans, and Native Americans are so predominant among recipients of CMHS largesse that the program might easily be mistaken for one specifically directed to these groups. For example, among 35 Community Action grants awarded by CMHS in 2001, seven (20 percent) were given to Native-American groups, despite the fact that Native Americans constitute only 1.5 percent of the population. One CMHS program specifically aimed at Native Americans is called "Circles of Care"; this program, which spends $3 million of CMHS funds annually, is intended to promote "culturally appropriate mental health services" for Native-American children.

The Cheyenne River Sioux tribe in South Dakota, for example, receives $249,540 per year for what they call the "Restoring the Balance Project" to implement mental health services that take into consideration the "unique history and culture of the Cheyenne River Sioux tribe." How a Sioux child with a serious mental illness differs from other American children with these diseases is unclear, and no one involved with the project could be reached by The Washington Monthly, despite more than a handful of phone calls. (The number on the group's grant application directed callers to an unrelated housing program.)

A strong representation of minority group members appears to be de rigueur for successful funding by CMHS. The application from the California Network of Mental Health Clients, for example, boasts that it has "a board of directors notable for its diversity, with 50 percent of the board identifying as representing an ethnic group [sic] and 43 percent representing other special populations: gay/lesbians, seniors, and physically disabled." In reading CMHS grant applications, one has the impression that if words such as "community stakeholders," "people of color," and "cultural competency" are included sufficiently often in the application, it will be automatically approved for funding.

Among the more prominent CMHS recipients of funds are the National Mental Health Association (NMHA) and the Bazelon Center for Mental Health Law. In 1998, NMHA received a three-year grant for $820,000 entitled "Consumer Supporter Technical Assistance Center." The purpose of the center was to create "coalitions of community care" to "build bridges--create respect, trust and working relationships--between consumer supporters, consumers and professionals."

How the money is actually being spent is unclear from the application, other than brief mentions of an 800-line newsletter and "fact sheets [that] will provide information on topics such as enhancing leadership skills, supporting recovery, and changing systems to make them more responsive to women and cultural minorities."

CMHS has been especially kind to the Mental Health Association. In addition to the above grant, in 2001 CMHS awarded Community Action grants to New York's and six other states' MHAs, totaling over $1 million. The National Mental Health Association has, in turn, been especially kind to CMHS. NMHA has been one of CMHS's major champions on Capitol Hill, urging Congress to allocate it ever more funds. In April 2001, for example, NMHA decried the Bush administration's proposed reductions in one CMHS program, saying the cuts "would prevent the agency from moving forward on an initiative aimed at resolving the disparities in mental health experienced by different minority groups." In time-honored Washington fashion, NMHA labeled the proposed cuts "very troubling" and urged its members to immediately contact their representatives in Congress.

The Bazelon Center for Mental Health Law, an offshoot of the American Civil Liberties Union's mental health project, has also done very well by its close association with CMHS. Over the past five years, the Bazelon Center has received CMHS contracts to review state Medicaid waiver policies, conduct a "national advocacy forum for older adults with mental health needs," hold "a meeting of older adult mental health consumers," carry out "a major study on custody relinquishments," and to provide "targeted technical assistance" to six states.

The precise amount of CMHS financial assistance to the Bazelon Center is difficult to ascertain from public records, but it constitutes a substantial portion of the organization's income. Such ascertainment is made more difficult because some CMHS funds are given to other agencies, which then subcontract with the Bazelon Center. For example, a current large "Targeted Technical Assistance Project" contract is given by CMHS to the National Association of State Mental Health Program Directors (NASMHPD), which, in turn, subcontracts the work to the center, the National Mental Health Association, and two other agencies.

Like NMHA, the Bazelon Center returns its CMHS favors by lobbying Congress to increase CMHS's budget. In early 2000, after it had, in its own words, "received an unprecedented $67 million increase in funding from Congress for FY2000," CMHS publicly thanked the Bazelon Center, the National Mental Health Association, and three other organizations for their support.

It is understandable why CHMS showers fiscal favors on the Bazelon Center; the center, like CMHS, is caught in a time-warp. Its origin as an ACLU-led attempt to prevent all involuntary hospitalization and involuntary treatment of individuals with psychiatric disorders is right out of Cuckoo's Nest. The continuing extremist views of CMHS and the Bazelon Center in this regard are illustrated by a proposal put forth at a 1997 CMHS meeting on the involuntary treatment of psychiatric patients. As reported by CMHS:

"One proposal to end involuntary intervention was to make individuals initiating involuntary commitment financially liable for its cost ... with special attention put on real and personal property. A method by which CMHS could prove this end would be to work with ... the Bazelon Center for Mental Health Law to identify and promote a test case regarding financial liability for unwanted treatment."

In other words, the Bazelon Center was to investigate how a family involuntarily committing a loved one with severe mental illness could be sued and have their house taken away.

Stuck in the '60s

Taken alone, a few million dollars spent allowing former mental patients to staff a referral hotline or to hold conferences and network about stress doesn't seem all that scandalous--no different, really, from a few pork-barrel transportation projects that keep congressional constituents happy. To put it bluntly, the real problem lies not so much in what CMHS is funding but rather in what it is not.

The United States has a serious and growing crisis with severe mental illness, a crisis visible in the hundreds of thousands of mentally ill individuals on our streets and in our jails. CMHS is the lead federal agency that is supposed to be helping solve that problem. A relatively small portion of its $782 million budget is being used constructively in this regard, such as the $37 million PATH program for the mentally ill homeless. But the list of what CMHS is not funding but should be is long indeed.

It includes means for keeping seriously mentally ill individuals on medications that will prevent them from relapsing; documenting the revolving door for such people between the streets, jails, and hospitals; ascertaining the best methods for implementing evidence-based treatments; and collecting basic statistics on the magnitude of the problem and who is being treated.

How do federal programs such as CMHS fit into the Bush administration? To date, the administration has said little about mental health issues other than promising to create a commission to look at the problems. The plight of mentally ill individuals who are homeless or incarcerated would appear to be an ideal situation to demonstrate the president's compassionate conservatism. The recently released proposed Bush budget for fiscal 2003 would trim CMHS's $230 million discretionary budget programs by $7 million, suggesting that the administration is at least aware of the problems in this troubled agency. The budget proposed to freeze the funding of most other CMHS programs at their present level except for the PATH program, which serves the homeless. PATH would receive a 17 percent increase; not coincidentally, PATH is the one CMHS program for which there are good data on how well it works and how many homeless people it serves.

What should happen? CMHS is probably one of the few federal agencies that could be abolished and virtually nobody would notice. A better plan would be to ask CMHS to do what it was originally intended to do--provide national leadership to improve services for individuals with severe mental illnesses rather than focusing on social problems. The pending Presidential Commission on Mental Health presents an excellent opportunity to reassess services. Block granting mental health-related Medicaid funds to the states and then holding the states responsible for services by rigorously measuring the outcomes deserves consideration. The criteria used to judge CMHS as an agency should include a measurable decrease in the number of severely mentally ill persons who are homeless, in jails and prisons, and responsible for acts of violence.

In the final analysis, everyone except a few favored grantees loses by the fact that CMHS is stuck in the 1960s. People with serious mental illnesses lose because less information is available on how to provide adequate treatment. Taxpayers lose because the economic cost of mental illness, not including substance abuse, was estimated to be $161 billion in the most recent federal survey. Even small improvements in the treatment of these disorders could bring about major improvements in the quality of individual lives and in dollars saved.

E. Fuller Torrey is President of the Treatment Advocacy Center in Arlington, Virginia (www.psychlaws.org)