H.R. 3717 The Helping Families with Mental Health Crisis Act

A makeshift memorial of flowers, candles and stuffed animals in Newtown, CT, after 20 children and 6 adults were killed at Sandy Hook Elementary School. (Photo by: Eric Thayer/Reuters/Landov)
A makeshift memorial of flowers, candles and stuffed animals in Newtown, CT, after 20 children and 6 adults were killed at Sandy Hook Elementary School.
(Photo by: Eric Thayer/Reuters/Landov)

In the wake of the Sandy Hook Elementary School shooting in Newtown, Connecticut in December 2012, legislators were compelled to act in response to the great sense of loss and the idea that certain laws and regulations could have prevented such a tragedy and would be able to prevent future tragedies from occurring again (Miller, 2015). Unfortunately public tragedies are one of the few ways national attention is paid to the issue of mental illness and the mental health care disparities that plague the health care system (Leonard, 2014). As the only clinical psychologist in Congress, Rep. Tim Murphy, Ph.D. (R-Pa.) conducted several hearings after the shooting at Sandy Hook to investigate the federal government’s role in mental health services (Hongberg & Sperling, 2013). In 2013, Rep. Murphy unveiled the Helping Families with Mental Health Crisis Act, which initially received bipartisan support, but an opposing bill was brought forward that same session by Rep. Ron Barber, who filled Rep. Gabrielle Giffords’ seat after she was wounded in another public shooting incident (Miller, 2015). Eventually, both Murphy’s and Barber’s bills died with the end of the congressional session that December (Miller, 2015).

Two years after the shooting at Sandy Hook, the National Alliance on Mental Illness (NAMI, 2014) released a report that revealed how funding for mental health slowed in most states in 2014 after the initial reaction to the shooting in 2013 wore off. During the recession, states collectively cut mental health budgets by $4.35 billion, along with 3,222 psychiatric beds (Leonard, 2014). In 2014, Michigan cut $156 million for mental health and substance use services, while Rhode Island, Alaska, Louisiana, Nebraska, and North Carolina also joined the ranks of those cutting mental health funding in 2014 (NAMI, 2014). Although in recent years, Texas has increased its mental health budget exponentially, Texas was reported as ranking 49th in the country in 2010 for allocating less than $1 for every $3 per patient allocated by other states (Walters, 2014). On a national level, in 2013 and 2014 Congress failed to move on any measures relating to mental health.

Screenshot 2015-04-30 02.19.53

Rep. Tim Murphy is a clinical psychologist and has created a bill that contains major mental health reforms.
Rep. Tim Murphy is a clinical psychologist and has created a bill that contains major mental health reforms.

Earlier this year Rep. Murphy reintroduced a revised version of the Helping Families with Mental Health Crisis Act. Murphy’s new bill includes measures that will increase treatment options for addressing mental illness, as well as integrate mental and physical health care in order to reduce barriers and stigma closely associated with mental illness (Times-Union Editorial, 2015). His bill boldly concluded with this claim: “For the first time in 50 years, real solutions have been proposed to fix America’s broken mental health system” (Times-Union Editorial, 2015).

“It’s the most comprehensive mental health bill we’ve seen in a long, long time, and that in itself is an accomplishment,” said Keris Myrick, president of the board of the NAMI, speaking of the 2013 version of the bill (Carey, 2014).

Assisted Outpatient Treatment

Kendra's Law is named in honor of Kendra Webdale who was killed by being pushed in front of an oncoming subway by Andrew Goldstein, a man suffering from untreated schizophrenia.
Kendra’s Law is named in honor of Kendra Webdale who was killed by being pushed in front of an oncoming subway by Andrew Goldstein, a man suffering from untreated schizophrenia.

One of the major features of the bill include requiring states to authorize Assisted Outpatient Treatment (AOT) in order to receive community mental health service block grant funds. Over the last 20 years, 45 states have enacted laws allowing for involuntary treatment in particular circumstances, such as New York’s Kendra’s Law, which went into effect in 1999 (Carey, 2014). Researchers have found such laws have resulted in mental health patients having fewer incidences of hospitalizations and arrests, as well as a a nearly 50% reduction in Medicaid and other mental health care costs (Carey, 2014).

Despite these findings, thousands of former psychiatric patients remain highly critical of involuntary treatment programs. Opponents from the Bazelon Center for Mental Health Law and the Foundation for Excellence in Mental Health Care worry this approach will push medication rather than advocate for a more holistic approach to recovery (not cure). Dr. Nikkel of the Foundation for Excellence in Mental Health Care believes this provision will “drive people away from seeking services when they fear treatment will be forced on them or they’ll be locked up,” as well as “eviscerate civil right protections” (Carey, 2014).

Amend HIPAA Laws

Rep. Murphy’s bill will also amend HIPAA (the Health Insurance Portability and Accountability Act) which offers federal protection for privacy regarding medical information (Times-Union Editorial, 2015). Currently, HIPAA protects the medical privacy of all adults, which has created difficulties when parents or caregivers of adults should be integrated into treatment decisions (Carey, 2014). The amendments will allow parents or caregivers the ability to access patient medical information without the patient’s consent if the medical information pertained to the patient’s safety and welfare (Miller, 2015). Opponents to this measure fear the disparity in confidentiality for patients with mental illnesses could further stigmatize and infantilize patients, as well as place additional strain in patient-doctor and patient-family relationships (Miller, 2015).

Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA is the only federal agency responsible for funding that supports direct mental health care, an agency that many critics believe is in need of long overdue overhaul (Lieberman, 2015). In this bill, SAMHSA will be largely scaled back and required to promote evidenced-based practices (Carey, 2014). Noting SAMSHA’s annual budget of $3.6 billion dollars, Rep. Murphy said, “When something has been funded for a long time, it’s tough to let it go… What we’re saying is that if a program works, then show us the evidence that it does, and we’ll keep it. If the evidence is not there, then the taxpayers shouldn’t pay for it.”

Veteran Court Programs hear criminal cases involving military veterans arrested at least partly because of an addiction or mental illness and defer veterans to appropriate treatment programs.
Veteran Court Programs hear criminal cases involving military veterans arrested at least partly because of an addiction or mental illness and defer veterans to appropriate treatment programs.

Veterans Court Program 

Veterans Court Programs began in 2008 as an alternative process for veterans arrested for crimes related to mental illnesses, substance abuse, cognitive impairments (such as traumatic brain injuries), and combat-related mental illnesses (Justice for Vets, 2015). That 1 in 6 veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom are suffering from substance abuse disorder and an average of 22 military veterans commit suicide every day point to the mental health crisis impacting America’s veterans who are in need of substantial support and avenues for recovery (Justice for Vets, 2015). Currently there are 130 special courts across 40 states with jurisdiction over the veteran population in their areas (Hennenberger, 2013). Modeled after drug courts, veterans court programs offer specific treatments rather than incarceration, in addition to serving as a “one-stop shop” for connecting veterans to benefits, programs, and services (Justice for Vets, 2015). Rep. Murphy’s bill calls for expanding veteran court programs, as well as extending the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA), which allows for mental health courts, crises intervention teams, and diversion programs to support individuals with mental illness, rather than punishment through incarceration (Murphy, 2013).

Additional provisions

The lengthy bill contains several provisions aimed at improving access to and integration of mental health care, including:

  • Enacting the Excellence in Mental Health Act in order to improve community mental health services and integrated mental health and primary care treatment
  • Improving access to psychiatric medication through Medicaid and Medicare
  • Medicaid reimbursement expansion for inpatient psychiatric treatment
  • Reauthorization of the Garrett Lee Smith Suicide Prevention Act to provide federally funded resources for suicide prevention and postvention
  • The creation of federal interagency Council on Serious Mental Illness to provide federal coordination of mental health services
  • Support research on early detection of serious mental illness in youth through the National Institution on Mental Health, and
  • Expansion of the Health Information Technology (HIT) resources for mental health service providers (Hongberg & Sperling, 2013)

The last legislation to substantially impact the mental health care system in the nation was the Community Mental Health Act, signed in 1963, which called for the end of institutionalization in order to individuals with mental illnesses to receive care in the community (Leonard, 2015). Dr. E. Fuller Torrey, executive director of the Stanley Medical Research Institute and founder of the Treatment Advocacy Center, spoke about this movement in the 1960s and said, “They were good ideas, just not carried out very well. All we did was empty the hospitals” (Leonard, 2015).

While the Treatment Advocacy Center, NAMI, and the American Psychological Association (APA) have voiced support for H.R. 3717, especially considering the long overdue need for reforms and policy changes, groups like the Bazelon Center for Mental Health Law, the Foundation for Excellence in Mental Health Care, and the National Disability Rights Network remain concerned whether the law is in the best interest of the individuals with mental illness or in the best interest of professionals who serve them (Leonard, 2015).

Yet, an investigation done by the House Energy and Commerce Committee found that on average there is a delay of 110 weeks between an individual’s first episode of psychosis and the provision of treatment. Dr. Paul Summergrad, president of the APA, expressed concerns over seeing patients waiting for medical beds on a daily basis, and he lamented, “We would not tolerate this for any other medical condition” (Leonard, 2015).


Carey, B. (2014 April 2). Mental health groups split on bill to overhaul care. NYTimes.com. Retrieved from: http://www.nytimes.com/2014/04/03/health/mental-health-groups-split-on-bill-to-revamp-care.html?_r=0

Demoss, D. (2015 January 5). Reasons to support the mental health crisis act. HuffingtonPost.com. Retrieved from: http://www.huffingtonpost.com/dustin-demoss/reasons-to-support-the-me_b_6353994.html

Hennenberger, M. (2013 December 2). Veterans court program helps warriors battle addiction, mental health crisis. WashingtonPost.com. Retrieved from: http://www.washingtonpost.com/politics/veterans-court-program-helps-warriors-battle-addiction-mental-health-crises/2013/12/02/d44cf352-5b6c-11e3-bf7e-f567ee61ae21_story.html

Hongberg, R. & Sperling, A. (2013). Mental health legislation in Congress. National Alliance on Mental Illness. [Letter]. Retrieved from: http://www2.nami.org/Content/Microsites275/NAMI_Greater_Orlando/Home263/Welcome_to_NAMIGO!1/NAMI_National_Email_MurphyMemoFinal.pdf

Justice for Vets. (2015). What is a veterans treatment court? Retrieved from: http://justiceforvets.org/what-is-a-veterans-treatment-court

Leonard, K. (2014, December 9). Two years after Sandy Hook: Mental health funding still lags. USNews.com. Retrieved from: http://www.usnews.com/news/articles/2014/12/09/two-years-after-sandy-hook-mental-health-funding-still-lags

Leonard, K. (2015 January 27). Mental health advocates rally behind new bill. USNews.com. Retrieved from: http://www.usnews.com/news/articles/2015/01/27/mental-health-advocates-rally-behind-new-bill

Lieberman, J. A. (2015 February 25). Second change for mental health crisis act. Medscape.com. Retrieved from: http://www.medscape.com/viewarticle/839716

Miller, D. (2015 February 4). Should APA have endorsed the Helping Families in Mental Health Crisis Act? PM360. Retrieved from: http://www.pm360online.com/should-apa-have-endorsed-the-helping-families-in-mental-health-crisis-act/

Murphy, T. (2013). Detailed summary of the Helping Families in Mental Health Crisis Act (H.R. 3717). U.S. House of Representatives. Retrieved from: http://murphy.house.gov/uploads/Section%20By%20Section%20Detailed%20Summary%20of%20HR3717.pdf

National Alliance on Mental Illness. (2014). State legislation report 2014: Trends, themes, & best practices in state mental health legislation. Retrieved from: http://www2.nami.org/Template.cfm?Section=Policy_Reports&Template=/ContentManagement/ContentDisplay.cfm&ContentID=172851

Times-Union Editorial. (2015 April 21). Congress begins to tackle mental illness. Jacksonville.com Retrieved from: http://jacksonville.com/opinion/editorials/2015-04-21/story/congress-begins-tackle-mentall-illness#.VTbf7mbat4I.twitter

Walters, E. (2014). New year brings cautious hope for mental health care. The Texas Tribune. Retrieved from: http://www.texastribune.org/2014/01/02/mental-health-care-new-year-brings-cautious-hope/

Immigration Policy Center: Recommendations for Addressing Mental Illness and Disability Among Detained Immigrants

In light of May 2nd, the National Day of Action to End Family Detention, we will be discussing the detention of non-citizens, the policies governing it and how it can negatively impact the mental health of detained adults, children and families.

Close Dilley

The History of Immigrant Detention

The United States government, through the Department of Homeland Security and Immigration and Customs Enforcement (ICE), has increased its use of civil detention for non-citizens at an alarming rate since 1996  (American Civil Liberties Union, 2006).

Detention Watch Network, 2012
Detention Watch Network, 2012

The size of the immigrant detention system has increased 500% over the past 2 decades, from 6,280 beds in 1996 to 33,4000 beds in 2011 (Tan, 2011). In fact, , there was a 52.8% increase between 2005 and 2010 (Office of Immigration Statistics, 2011). Moreover, illegal immigration (46%) was the most common arrest offense across the nation in 2010 (Motivans, Bureau of Justice Statistics, 2013).

Immigration reform measures passed in the 1980s and 90s have resulted in drastic changes to the detention laws (Tan, 2011). In 1988, Congress passed the first mandatory detention statute, requiring the detention without bond of non-citizens convicted of an aggravated felony (Tan, 2011). In 1994, this statute was amended to widen the definition of aggravated felony and increase the number of non-citizens who could not be released on bond (Tan, 2011). Then, in 1996 the Antiterrorism and Effective Death Penalty Act was passed, which required the detention without bond of almost all non-citizens with criminal convictions including non-violent, misdemeanor charges (Tan, 2011). Finally, the Illegal Immigration Reform and Immigrant Responsibility Act made these changes to an aggravated felony retroactive; in other words, non-citizens who had already served time in jail or settled their court case could be detained after the fact (Tan, 2011).

ICE’s primary mission is to promote homeland security and public safety through the criminal and civil enforcement of federal laws governing border control, customs, trade and immigration.

According to ICE (2015), non-U.S. citizens who are apprehended and determined to need custodial supervision are placed in detention facilities. By law, immigration detention is different from criminal incarceration (Schriro, 2009). In fact, ICE does not classify detention as punitive, but instead categorizes it as a short-term administrative measure to ensure that non-citizens appear at their immigration hearing. Interestingly, an annual report published by the Office of Immigration Statistics (2010) defines detention as “the seizure and incarceration of an alien in order to hold him her while awaiting judicial or legal proceedings or return transportation to his/her country of citizenship.” Therefore, there are conflicting definitions of detention within the United States government and a clear contradiction between policy and practice.

While convicted prisoners are protected by the US Constitution and the 8th Amendment, which prohibits “cruel and unusual punishment,” detained immigrants are by definition non-citizens, and therefore are protected under the Constitution’s 5th Amendment, which affords everyone the right to “due process” (American Civil Liberties Union, 2006). However, up to 84% of detainees do not have lawyers, and due to policies like the Illegal Immigration Reform and Immigrant Responsibility Act, non-citizens are not guaranteed a basic form of due process, which is a prompt bond hearing before an independent judge to determine whether the detention is justified (Tan, 2011). Finally, under the Bush Administration, the Immigration and Naturalization Service department was abolished, and the Department of Homeland Security took over the process of monitoring immigration, whose sole mission is to protect American citizens from terrorism (Mukopadhayay, 2008). This shift in departmental control, as well as the above policies, have all contributed to the further criminalization of immigration.

Further, the U.S. Court of Appeals for the Ninth Circuit has held that conditions of confinement for civil detainees must be superior not only to convicted prisoners, but also to pre-trial criminal detainees (American Civil Liberties Union, 2006). Therefore, if civil detainees are confined to conditions identical, or similar, to those of convicted prisoners, then those conditions could be considered unconstitutional (American Civil Liberties Union, 2006). However, the majority of facilities used to detain non-citizens were originally built, and currently operate, as jails and prisons to confine pre-trial and sentenced felons (Schriro, 2009).

There are two types of detention facilities, one for detaining non-citizens for 72 hours or less and those for detaining non-citizens for 72 hours or more (Schriro, 2009). While 93% of facilities are for detaining immigrants for 72 hours or more, 66% of detained non-citizens were apprehended for non-criminal charges and 88% of immigration defendants were detained in 2010 (Motivans, 2013; Schriro, 2009). Further, 39% of cases terminated in the United States were immigration defendants (Motivans, 2013). In other words, two-fifths of immigrants detained were released with their cases dropped and no charges. This supports the argument that it would be more humane and cost-effective to allow immigrant defendants to stay within the community while awaiting legal or judicial proceedings.

Immigration Forum, 2013
Immigration Forum, 2013

The cost of detaining non-citizens is exorbitantly higher than alternatives to detention (ATD), such as monitoring immigrants within the community (Human Rights First, 2012; Tan, 2011). While ATDs cost approximately 40 cents to $14 a day per individual, detention centers cost between $266 and $300 a day per individual (Planas, 2014). The ICE spends approximately $2 billion per year on detention, which is 28x the budget for alternatives (Human Rights First, 2012). Moreover, more than 90% of immigrants in Alternatives to Detention (ATD) programs have participated successfully.

Immigrant Detention in Texas

This is not just an issue for the United States on a whole, but it is also incredibly pertinent to Texas. 24% of the total population detained by ICE are in Texas facilities (Human Rights First, 2012). In fact, Texas leads in the number of beds offered to ICE through private contractors (Detention Watch Network, 2012).

Detention Watch Network, 2012
Detention Watch Network, 2012

The video below discusses the T. Don Hutto family detention center in Taylor, Texas, which was originally a medium-security state prison, and was the largest family detention center in the country (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In 2009, the Obama administration ordered the T. Don Hutto detention center to close due to substantiated claims of substandard care.

In December 2014 a new family detention center was opened in Dilley, Texas. Immigrant advocacy groups are vehemently opposed to the Obama administration’s return to family detention practices since 98% of families are seeking protection within the United States, and are eligible for asylum (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In addition to allegations of substandard child care, medical care and legal assistance, there have also been allegations of sexual abuse between detention guards and detained women (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In light of these issues, a local community organization, Texans United for Families, has scheduled a protest at the Dilley Family Detention Center on May 2nd.

Mental Health Concerns within Detention Centers

As previously mentioned, the majority of non-citizens that are arriving in the United States are fleeing unsafe living conditions within their home countries, and are eligible for asylum (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). Accordingly, it has been well-documented that non-citizens requesting asylum have been subjected to physical abuse, sexual violence and trauma prior to immigration, which all require appropriate mental health services (Sinnerbrick, Silove, Field, Steel & Manicavasagar, 1997). However, there have been numerous reports and publications documenting the severe lack of medical and mental health services for detained non-citizens (Mukopadhayay, 2008; Parker, 2010; Schriro, 2009; Tan, 2011). Reported problems include lack of a timely, or accurate, assessment, limited to no translation services, changes in mental health care, including changes to psychotropic medications due to lack of funds or accessibility, lack of appropriate treatment for serious mental illness and the segregation or isolation of those with mental illness or disability.

Research suggests that the longer a non-citizen is detained, the more significantly distressed they became, including symptoms of depression, post-traumatic stress disorder, anxiety or even suicidal thoughts (Robjant, Hassan & Katona, 2009). According to Keller et al. (2003) 86% of asylum seekers showed clinical levels of depression, 77% had clinical anxiety and 50% had clinical post-traumatic stress disorder. At follow-up, the mental health of those who were still detained had continued to deteriorate, while their were significant improvements in mental health among those who had been released.

Recently, the United States, along with other industrialized countries like the United Kingdom and Australia, have returned to the detention of children, through the advent of family detention centers, which directly opposes the UNCRC‘s policy that children should only be detained as a “last resort” and for the “shortest time possible.” Further, family detention centers are solely meant for mothers and children, and leads to the removal of fathers, even if they are apprehended together (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). Therefore, these policies do not take into consideration the trauma imposed on children due to the separation of families and disruption of attachments (Newman, 2008).

Additionally, there has been a drastic increase in the number of unaccompanied children seeking asylum in the United States; in 2011, over 21,000 unaccompanied children from Latin countries like El Salvador and Guatamala entered the United States (United Nations High Commissioner for Refugees, 2013). According to this report, over half (58%) of unaccompanied children were eligible for international protection due to exposure to violence and 22% had experienced abuse in the home. Therefore, there are significant needs among detained, non-citizens to receive appropriate, and time sensitive, mental health care and serious concerns regarding the detention of families, and more specifically, children.

The Immigration Policy Center

The Immigration Policy Center (IPC) is a think-tank associated with the American Immigration Council. IPC’s mission is to “shape a rational conversation on immigration and immigrant integration.” The IPC researches a plethora of issues related to immigration including deportation, health care, employment and citizenship. Therefore, the IPC is an expert in the field of immigration, and has published multiple reports regarding deportation and detention.

Immigrant Detention Reform & Recommendations

According to a Special Report published by the Immigration Policy Center in 2010, detention centers are not meeting the current needs of non citizens with mental illness or disability. Therefore, the IPC recommends the following changes in order to improve the current mental health services:

1. Require that non-citizens are immediately screened on admission for mental disabilities by a healthcare professional.

2. Provide professional translation services to all non-English speaking

3. Improve the overall quality of mental health services within detention centers, including appropriate levels of staffing.

4. Develop and maintain electronic medical records in order to improve the identification and documentation of non-citizens with mental disability or mental illness.

5. When feasible, release non-citizens with mental illness or mental disability into the community under the care of a guardian or family member. If not feasible, provide access to appropriate mental health services such as the accurate dispensation of medications, and avoid the current practices of prolonged isolation or segregation.

6. Ensure that non-citizens with mental disabilities are providing appropriate legal representations or counsel, as well as an appointed guardian or family member for legal proceedings.

In conclusion, the United States is currently detaining almost half a million non-citizens per year, and spending approximately $2 billion on the venture. The current system raises serious concerns in terms of providing humane care for those who are awaiting legal proceedings regarding immigration, and many non-citizens are not afforded the constitutional rights that they are guaranteed. Alternatives to detention could significantly decrease the current budget, as well as improve the overall quality of life and mental health for detained adults, families and children.


American Civil Liberties Union. (2006). Conditions of Confinement in Immigrant Detention Facilities. Retrieved from https://www.aclu.org/files/pdfs/prison/unsr_briefing_materials.pdf

Detention Watch Network. (2012). Detention Centers. Retrieved from http://www.detentionwatchnetwork.org/dwnmap

Keller, A. S., Rosenfeld, B., Trinh-Shevrin, C., Meserve, C., Sachs, E., Leviss, J. A., Singer, E., Smith, H., Wilkinson, J., Kim, G., Alden, K. & Ford, D. (2003). Mental health of detained asylum seekers. The Lancet, 362(9397), 1721-1723.

Lutheran Immigration Refugee Service & the Women’s Refugee Commission. (2014). Locking Up Family Values, Again. Retrieved from http://lirs.org/familyvalues/

Motivans, M. (2013). Federal Justice Statistics, 2010. US Department of Justice: Office of Justice Programs, Bureau of Justice Statistics.

Mukhopadhyay, R. (2008). Death in detention: Medical and mental health consequences of indefinite detention of immigrants in the united states. Seattle Journal for Social Justice, 7(2), 693.

Newman, L. K., & Steel, Z. (2008). The child asylum seeker: psychological and developmental impact of immigration detention. Child and adolescent psychiatric clinics of North America, 17(3), 665-683.

Office of Immigration Statistics. (2011). Immigration Enforcement Actions: 2010. US Department of Homeland Security. Retrieved from https://www.dhs.gov/xlibrary/assets/statistics/publications/enforcement-ar-2010.pdf

Packer, T. (2010). Non-citizens with mental disabilities: the need for better care in detention and in court. Immigration Policy Center. Retrieved from http://www.immigrationpolicy.org/sites/default/files/docs/Non-Citizens_with_Mental_Disabilities_112310.pdf

Planas, R. (2014). Family Detention Center In Texas Is ‘Utterly Unnecessary,’ Says Immigration Attorney. Huffington Post Latino Voices. Retrieved from http://www.huffingtonpost.com/2015/01/14/dilley-texas-detention-center_n_6473274.html

Robjant, K., Hassan, R., & Katona, C. (2009). Mental health implications of detaining asylum seekers: systematic review. The British Journal of Psychiatry,194(4), 306-312.

Schriro, D. B. (2009). Immigration detention overview and recommendations. US Department of Homeland Security, Immigration and Customs Enforcement.

Sinnerbrink, I., Silove, D., Field, A., Steel, Z., & Manicavasagar, V. (1997). Compounding of premigration trauma and postmigration stress in asylum seekers. The Journal of psychology, 131(5), 463-470.

Tan, M. (2011). Locked Up Without End: The Indefinite Detention of Immigrants Will Not Make American Safer. Immigration Policy Center. Retrieved from http://www.immigrationpolicy.org/sites/default/files/docs/Tan_-_Locked_Up_Without_End_100611.pdf

United Nations High Commissioner for Refugees. (2013). Children on the Run. Retrieved from http://www.unhcrwashington.org/sites/default/files/1_UAC_Children%20on%20the%20Run_Full%20Report.pdf

Throwback Thursday: Olmstead v. L. C. (1999)

Elaine Wilson (left) and Lois Curtis were held in a state-run institution for years because even though they were approved for discharge to community-based services.
Elaine Wilson (left) and Lois Curtis were held in a state-run institution for years even though they were approved for discharge to community-based services.

A previous post that explored to role of police in providing mental health services mentioned briefly the monumental Supreme Court decision that upheld the rights of individuals with disabilities from unnecessary institutionalization — Olmstead v. L. C. The case was the result of the experiences of two women, Lois Curtis and Elaine Wilson, and the denial of appropriate services to meet their needs (Jamieson, 2011). Both Curtis and Wilson had intellectual and developmental disabilities and were voluntarily admitted as patients into Georgia Regional Hospital, a state-run psychiatric hospital (Jamieson, 2011). After receiving treatment, both Curtis and Wilson were deemed ready for discharge and transition into a community-based services (Olmstead, 2015). However, both remained confined to the state hospital for years due to long waitlists and lack of providers that would allow for Curtis and Wilson to receive community-based services outside of the hospital (Questions and Answers, 2015).

Having lived in an institutional setting since the age of 13, Curtis made a phone call to the Atlanta Legal Aid Society seeking help (Jameison, 2011). Wilson had lived in institutions and shelters since the age of 15, subjected to treatments including shock “therapy” and psychotropic drugs (Henry, 2004).

“I want to get out!” – Lois Curtis told the Atlanta Legal Aid Society (Jameison, 2011)

“When I was in the institution, I felt like I was in a little box and there was no way out.” – Elaine Wilson testified before Judge Shoob in Olmstead v. L. C. (Henry, 2004)

In 1995, the Atlanta Legal Aid Society filed suit on behalf of Curtis and Wilson against Tommy Olmstead, the Commissioner of Georgia’s Department of Human Resources, for the Georgia Regional Hospital’s decision to keep the two women in psychiatric isolation and for the failure of the state to provide the most integrated setting appropriate for their needs, which violated the Americans with Disabilities Act (ADA) (Questions and Answers, 2015). After several years of litigation, the state of Georgia asked the Supreme Court to consider the civil rights of people with mental disabilities, especially around the question of: “Whether the public services portion of the federal Americans with Disabilities Act (ADA) compels the state to provide treatment and habilitation for mentally disabled persons in a community placement, when appropriate treatment and habilitation can also be provided to them in a State mental institution” (The Olmstead Decision, 2015).

The Americans with Disabilities Act (ADA) protects individuals with disabilities against discrimination. The ADA was signed into law on July 26, 1990, by President George H.W. Bush.
The Americans with Disabilities Act (ADA) protects individuals with disabilities against discrimination. The ADA was signed into law on July 26, 1990, by President George H.W. Bush.

On June 22, 1999, the Supreme Court ruled in favor of Curtis and Wilson, finding that the unjustified segregation of persons with disabilities constitutes discrimination and was a violation of Title II of the ADA (About Olmstead, 2015). The 6-3 decision authored by Justice Ginsburg highlighted “two evident judgments”:

1.) “…institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable of or unworthy of participating in community life.”


2.) “…confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment” (Olmstead v. L. C. 98-536, 527 U.S. 581, 1999)

A key component of the case involved the Supreme Court’s interpretation of the ADA in light of the U.S. Department of Justice’s “integration mandate,” which required public entities to provide services, programs, and activities “in the most integrated setting appropriate to the needs of qualified individuals with disabilities” [28 C.F.R.§ 35.130(d)] (The Olmstead Decision, 2015).

The Olmstead decision has allowed thousands of individuals with disabilities to live their lives integrated into within their communities.
The Olmstead decision has allowed thousands of individuals with disabilities to live their lives integrated within their communities.

The Olmstead case has transformed the lives of many individuals living with physical and mental disabilities, including Curtis and Wilson. The ADA.gov website contains dozens of stories of individuals whose lives have been impacted by this decision through a photo journal of the Faces of Olmstead. Throughout the proceedings of the case, both Curtis and Wilson were provided supportive housing within the community (The Olmstead Decision, 2015). Elaine Wilson eventually moved into her own home with a caretaker, flourishing in the community until she died in 2004 (Henry, 2004). Lois Curtis lives in her own home and is supported by her roommates and fellow artist friends. An IndieGoGo fundraiser has been set up to raise funds in order to create a documentary to tell the story of Lois Curtis. Speaking of her art work, which has received national attention, Curtis shared,“My art been around a long time. I came along when my art came along. Drawing pretty pictures is a way to meet God in the world like it is” (Jamieson, 2011).


Henry, D. (2004). Elaine Wilson, beat disability, discrimination [Obituary]. Retrieved from: http://www.legacy.com/obituaries/atlanta/obituary.aspx?pid=2907375

Jamieson, S. (2011). Olmstead champion meets the president. Office of Public Engagement. WhiteHouse.gov. Retrieved from: https://www.whitehouse.gov/blog/2011/06/22/olmstead-champion-meets-president

Olmstead: Community Integration for Everyone. (2015). About Olmstead. Information and Technical Assistance on the Americans with Disabilities Act. Retrieved from: http://www.ada.gov/olmstead/olmstead_about.htm

Olmstead v. L. C. 98-536, 527 U.S. 581. (1999). Retrieved from: https://www.law.cornell.edu/supct/html/98-536.ZS.html

Questions and Answers about the Legal Interpretations of the Olmstead v. L. C. Decision. (2015). National Disability Rights Network. Retrieved from: http://www.ndrn.org/issues/community-integration/311–olmstead-v-lc-decision-qa.html

The Olmstead Decision. (2015). Judge David L. Bazelon Center for Mental Health Law. Retrieved from: http://www.bazelon.org/Where-We-Stand/Community-Integration/Olmstead-Implementing-the-Integration-Mandate/The-Olmstead-Decision-.aspx

Any One of Us: Words from Prison

In this post we will discuss a community event, Any One of Us: Words from Prison, geared towards raising awareness about the domestic and sexual violence experienced by incarcerated women. We will also review national data regarding the incarceration of women and explore some relevant Texas legislation that is currently up for a vote at the Capital.

Eve Ensler, Tony Award winning playwright, performer, and activist, author of Any One of Us: Words from Prison.
Eve Ensler, Tony Award winning playwright, performer, and activist, author of Any One of Us: Words from Prison as well as The Vagina Monologues.

Any One of Us: Words from Prison by Eve Ensler

At the beginning of April two local non-profits, Empower Art and Conspire Theatre, put on a collaborative production entitled Any One of Us: Words from Prison by Eve Ensler. Any One of Us is part of V-Day, a global activist movement to end violence against women and girls. This play in particular is part of a community campaign to raise awareness about the issues of domestic violence, sexual violence and childhood trauma and how it relates to the incarceration of women.

Empower Art is a local non-profit that facilitates healing and empowerment for victims of domestic and/or sexual violence through creative expression while Conspire Theatre is an Austin-based theater company dedicated to working with incarcerated women and previously incarcerated women. Conspire Theatre has created a supportive community as well as a safe space for incarcerated women to explore their traumatic past through creative writing and theater arts. Even though Conspire Theatre works primarily with women in the Travis County Jail, the stories performed in Any One of Us: Words from Prison were actually a compilation of stories from incarcerated women across the US, namely Michigan, New York, Florida and California.

conspire_LOGO_final Screen Shot 2015-04-19 at 2.58.57 PM

National Data about the Female Prison Population

As previously discussed, the number of people being incarcerated in the United States has drastically increased since the 1980s primarily due to the War on Drugs. For example, drug offenses account for more than 50% of the current prison population growth (Snell & Morton, 1994). Consequently, the number of women in prison has grown at an astronomical rate between 1980 and 2010 (646%), even faster than the rate of incarceration among men (419%) (Guerino, Harrison & Sabol, 2011). Even more disturbing is the disproportionate rate at which women of color are incarcerated; black women are imprisoned at nearly three times the rate of non-hispanic, white women and hispanic women are imprisoned at nearly twice the rate of non-hispanic, white women (Guerino, Harrsion & Sabol, 2010).


As explored within Any One of Us: Words from Prison, the social and psychological circumstances that proceed the incarceration of women is somewhat different than men (Moloney & Muller, 2009). For example, the Department of Justice (1999) reported that 23-36.7% of incarcerated women have experienced sexual abuse during childhood, compared to 16.8% of the general population (Gorey & Leslie, 1997). Further, 34-43% of female inmates have experienced either physical or sexual abuse prior to incarceration, and of those who had experienced abuse, almost 50% experienced it at the hands of an intimate partner (Snell & Morton, 1991; James & Glaze, 2006). Another study found that 60% of incarcerated women in California had been physically assaulted during adulthood (Bloom, Chesney-Lind, & Owen, 1994). This all provides support for the creation of preventive policies and/or programs that provide economic, social or psychological services for women at risk.

The Continuation of Marginalization during Incarceration

Copyright: Conspire Theatre.
Copyright: Conspire Theatre.

One major issue explored within Any One of Us: Words from Prison is the prevalence of rape and sexual misconduct among female prisoners at the hands of male prison guards. In fact, in 2003, the Prison Rape Elimination Act (P.L. 108-79) was passed, which requires that the Bureau of Justice Statistics collect national data on the prevalence of sexual violence within correctional institutions (Beck, Harrison & Adams, 2007). According to Beck, Rantala & Rexroat (2014), 48% of substantiated incidents of sexual assault involved staff and inmates. And while women represent approximately 7% of all state or federal inmates, they account for 33% of staff-on-inmate incidents of sexual victimization (Beck, Rantala & Rexroat, 2014). While there have been some strides in terms of collecting information regarding sexual assault within prison, there is major criticism for the lack of consequences faced by perpetrators and overall impunity for prison guards (Buchanan, 2007). Scholars have been pushing for gender-appropriate policies since the 1990s, although little change has been enacted (Bloom, Owen & Covington, 2004). In fact, one paper argued that the sexual abuse of imprisoned women is a modern corollary to slavery, particularly due to the disproportionate arrest of women of color (Smith, 2005). Needless to say, this is still a major issue that needs to be addressed on a county, state and federal level.

Mental illness is another prevalent issue among inmates. The number of individuals with serious mental illness in prisons and jails now exceeds the number in state psychiatric hospitals tenfold (Torrey et al., 2014). One study found that 56%-64% of state and county inmates had some type of mental health problem, not included substance dependence or abuse (James & Glaze, 2006). Once substance abuse and dependence were included, rates jumped to 74%-76% of all state and jail prisoners (James & Glaze, 2006). A more recent study found that 34%-38% of female inmates had a serious mental illness (Steadman, Osher, Robbins, Case, & Samuels, 2009). However, only 17%-33% of state and county inmates with mental illness received some type of mental health services even though 42%-49% had previously received mental health services prior to incarceration (James & Glaze, 2006). 

Lifelong repercussions of incarceration

ywcaAfter the production of Any One of Us: Words from Prison, the producer of the show conducted a talk back with a panel that consisted of a program manager, social worker and counselor from the YWCA as well as a professor of Theater and Dance from Texas State University. One of the major issues discussed was the reintegration of formerly incarcerated women into the community, and the services that could be provided to improve the process. For example, the YWCA offers a group to women released from prison in order to create a supportive community and decrease recidivism rates. 

In the United States, people who are found guilty of a crime and sentenced to prison do not have the same rights as average Americans. For example, some states prohibit ex-offenders from voting or driving while federal restrictions include the inability to receive social welfare like food stamps or even public housing (depending on the crime) (Petersilla, 2005). While there are some safeguards in place to prevent employer discrimination of ex-offenders, research suggests that discrimination still occurs (Demleitner, 2002; Lam & Harcourt, 2003). Therefore, it is no surprise that rates of recidivism are as high as 68% within 3 years of release and 77% within 5 years of release (Durose, Cooper & Snyder, 2014).

Relevant Texas Legislation 

So why is a community event like Any One of Us: Words from Prison relevant to social policy? Social justice is a major component of social work, as it ensures that disenfranchised populations are given an opportunity to advocate for their needs. Many times this opportunity is provided during a legislative hearing in order to influence change within current policies. Therefore, understanding current state and federal policies is essential, since changes in social policy can improve the lives of hundreds or even thousands of people.

HB 1083: Mental health assessment for inmates

This piece of legislation has two major goals:

1) identify inmates with mental illness through standardized screening,

2) restrict the confinement or segregation of inmates with mental illnesses.

As mentioned above, mental illness and substance use disorders are highly prevalent among prisoners; therefore, it is imperative to screen all inmates in order to identify mental health issues, as well as provide access to appropriate treatment. Additionally, solitary confinement has been increasingly used as a way to manage difficult prisoners, sometimes for months or even years at a time (Metzner & Fellner, 2010). While isolation by itself can lead to significant or even severe psychological harm, solitary confinement also limits the services that an inmate can receive (Grassian, 2006; Metzner & Fellner, 2010).

HB 569: Providing inmates with reentry information

This piece of legislation proposes that jails and prisons should collaborate with organizations across the state of Texas that provide reentry programs in order to create county-specific resource guides for prisoners released on probation, parole or otherwise. While some counties already offer a resource guide (check out the Travis county guide here), it is important to make this a state wide requirement because there is not guarantee that someone serving time in a Travis county jail or prison will live in the Travis county area upon release.

As mentioned above, it can be very difficult for the formerly incarcerated to reintegrate back into society, and recidivism rates are as high as 37% within the first 6 months (Durose, Copper & Snyder, 2014). Therefore, it is important to “front load” post-prison services in order to decrease recidivism rates (Petersilla, 2005). Additionally, this type of legislation may lead to higher rates of mental health or substance abuse treatment for formerly incarcerated individuals that either did not receive adequate services during their sentence, or require a continuation of care (i.e./ medications, therapy, group interventions, etc.). If enacted, it would be important to keep track of any changes in recidivism rates to inform future policies or changes. 



Beck, A. J., Harrison, P. M., & Adams, D. B. (2005). Sexual violence reported by correctional authorities, 2004. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Beck, A. J., Rantala, R. R., & Rexroat, J. (2014). Sexual victimization reported by adult correctional authorities, 2009-11. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Bloom, B., Chesney-Lind, M., & Owen, B. (1994). Women in California prisons. San Francisco: Center on Juvenile and Criminal Justice.

Bloom, B., Owen, B., & Covington, S. (2004). Women Offenders and the Gendered Effects of Public Policy1. Review of Policy Research, 21(1), 31-48.

Buchanan, K. S. (2007). Impunity: Sexual Abuse in Women’s Prisons. Harv. CR-CLL Rev., 42, 45.

Demleitner, N. V. (2002). Collateral damage: no re-entry for drug offenders. Vill. L. Rev., 47, 1027.

Durose, M. R., Cooper, A. D., & Snyder, H. N. (2014). Recidivism of Prisoners Released in 30 States in 2005: Patterns from 2005 to 2010. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Gorey, K. M., & Leslie, D. R. (1997). The prevalence of child sexual abuse: Integrative review adjustment for potential response and measurement biases.Child abuse & neglect, 21(4), 391-398.

Grassian, S. (2006). Psychiatric effects of solitary confinement. Washington University Journal of Law & Policy, 22(24), 325-383.

Guerino, P., Harrison, P. M., & Sabol, W. J. (2011). Prisoners in 2010. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Harlow, C. W. (1999). Prior abuse reported by inmates and probationers. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Glaze, L. E., & James, D. J. (2006). Mental Health Problems of Prison and Jail Inmates. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Lam, H., & Harcourt, M. (2003). The use of criminal record in employment decisions: The rights of ex-offenders, employers and the public. Journal of Business Ethics, 47(3), 237-252.

Metzner, J. L., & Fellner, J. (2010). Solitary Confinement and Mental Illness in US Prisons: A Challengefor Medical Ethics. Journal of the American Academy of Psychiatry and the Law Online, 38(1), 104-108.

Moloney, K. P., & Moller, L. F. (2009). Good practice for mental health programming for women in prison: Reframing the parameters. Public health,123(6), 431-433.

Petersilia, J. (2005). Hard time: Ex-offenders returning home after prison.Corrections Today, 67(2), 66-71.

Smith, B. V. (2005). Sexual Abuse of Women in United States Prisons: A Modern Corollary of Slavery. Fordham Urb. LJ, 33, 571.

Snell, T. L., & Morton, D. C. (1994). Women in prison. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates.psychiaTric services, 60(6), 761-765.

Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, R., & Pavle, J. (2010). More mentally ill persons are in jails and prisons than hospitals: A survey of the states. Arlington, VA: Treatment Advocacy Center, 2010.

Throwback Thursday: Social Security Disability Insurance (SSDI)

After decades of planning, Social Security Disability Insurance was enacted into law in July of 1956. During the development of the Social Security Administration, planners debated how to define disability, as well as how to ensure disability was distinguished from unemployment (Berkowitz, 2000). In 1938, an actuary serving on the Social Security Advisory Council reported, “You will have workers like those in the dust bowl area, people who have migrated to California and elsewhere, who perhaps have not worked in a year or two, who will imagine they are disabled”(Berkowitz, 2000). Others believed disability was an “elastic concept,” and that the creation of too strict of a system would only invite pressure to polarize its implementation (Berkowitz, 2000).

This 1940 poster highlighted one of the programs created under the Social Security Act of 1935. (Retrieved from the Social Security Administration History Archives)
This 1940 poster highlighted one of the programs created under the Social Security Act of 1935. (Retrieved from the Social Security Administration History Archives)

The delay of SSDI’s integration into the social welfare framework of the nation is a reflection of the nation’s focus on WWII and the availability of public assistance at the time (Berkowitz, 2000). After the war, attention shifted to the necessity of rehabilitation rather than allowing individuals with disabilities to retire from the labor force and simply receive cash benefits (Berkowitz, 2000). A 1950 compromise Congressional measure created a new public assistance category: Aid to the Permanently and Totally Disabled. Prior to this, Aid to the Blind was the only disability-related public assistance program (Berkowitz, 2000).

The House, the Senate Finance Committee, and President Eisenhower’s administration spent several years passing and opposing a series of laws that set the stage for the passage of SSDI in 1956. One of the biggest compromises was to allow states to determine for themselves what qualified as a disability (Berkowitz, 2000). A lingering understanding from the early planners of SSDI that remained at this time was the stance that no benefits were to be offered to those with mental disabilities, arguing that mental disabilities were under the purview of state hospitals (Berkowitz, 2000). By believing that the provision of benefits for individuals with mental disabilities would encourage malingering, the structure of SSDI was unprepared to face the deinstitutionalization movement of the 1960s and beyond.

A poster from 1968 informing the public of the social security disability insurance program, which passed Congress in 1956 (Retrieved from the social security agency historical archive).
A poster from 1968 informing the public of the social security disability insurance program, which passed Congress in 1956. (Retrieved from the Social Security Administration History Archives)

It would not be until 1972 that SSDI would be expanded to include mental health disabilities (Drake et al., 2009). Congress also created the Supplemental Security Income (SSI) program, a needs-based disability program for disabled children and adults. In short, SSI is open to individuals who are disabled, poor, and unable to work, while SSDI is open to individuals who are disabled or unable to work and who have worked in the past (or have parents who have worked) and have paid into the social security trust fund (NAMI, 2009). While benefits include coverage under Medicaid or Medicare along with cash payments, one of the most important benefits is the connection between SSI or SSDI enrollment and the eligibility for other local or state programs (NAMI, 2009).

SSAIn 2013, an estimated 3.5 million U.S. adults and children were enrolled in SSDI and 3.7 million enrolled in SSI had a diagnosis of a mental disorder (e.g. autistic disorder, Alzheimer’s disease, intellectual disability, mood disorders, schizophrenic and other psychotic disorders, etc.), accounting for about a third of total enrollees (SSA, 2014). The number of beneficiaries whose primary diagnosis is a mental disorder has increased over the last several decades, from 13.5% in 1982-1983 to 25.7% in 2002-2003 (Duggan & Imberman, 2009). Many point to the Social Security Disability Benefits Reform Act of 1984, which broadened acceptable definitions of disabilities, for the growing numbers of SSDI beneficiaries.

“It maintains our commitment to treat disabled American citizens fairly and humanely while fulfilling our obligation to the Congress and the American taxpayers to administer the disability program effectively” said President Ronald Reagan, at the signing of the Social Security Disability Benefits Reform Act into law in 1984 (Roy, 2013)

Currently, SSDI and SSI cash benefits are modest and its standards, according to the OECD, are considered the strictest in the developing world (Vallas, 2013). Aimed at replacing less than half of an individual’s previous earnings, SSDI benefits average $1,130 per month or about $35 per day, just above the federal poverty level for a single person (Vallas, 2013). SSI benefits average just over $500 per month or $17 per day, which is nearly half of the federal poverty level (Vallas, 2013). For most of the SSDI and the SSI’s beneficiaries, these cash benefits are the primary source of income (Vallas, 2013). Although estimates are uncertain for those specifically with mental illness, SSI income keep nearly 3.4 million Americans above poverty levels (Vallas, 2013).

Find out more about SSDI & SSI through the Social Security Administration’s website: http://www.ssa.gov/disability/


Berkowitz, E. D. (2000 July 13). Disability policy & history: Statement before the subcommittee on social security of the committee on ways and means. Official Social Security Website. Retrieved from: http://www.ssa.gov/history/edberkdib.html

Drake, R. E., Skinner, J. S., Bond, G. R., & Goldman, H. H. (2009). Social security and mental illness: Reducing disability with supported employment. Health Affairs, 28(3), 761-770. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2828629/pdf/nihms175731.pdf

Duggan, M. & Imberman, S. A. (2009). Why are the disability rolls skyrocketing? The contribution of population characteristics, economic conditions, and program generosity. In D. M. Cutler & D. A. Wise (Eds.) Health at older ages: The causes and consequences of declining disability among the elderly. Chicago: University of Chicago Press. Retrieved from: http://www.nber.org/chapters/c11119.pdf

National Alliance on Mental Illness. (2009). Social security benefits: Are you or your relative entitled to social security disability benefits? Retrieved from: http://www2.nami.org/Content/ContentGroups/Helpline1/Social_Security_and_Disability_Benefits.htm

Roy, A. (2013 April 8). How Americans game the $200 billion-a-year ‘disability-industrial complex.’ Forbes.com. Retrieved from: http://www.forbes.com/sites/theapothecary/2013/04/08/how-americans-game-the-200-billion-a-year-disability-industrial-complex/

Social Security Administration. (2014 September 2014). SSI annual statistical report, 2013. Retrieved from: http://www.ssa.gov/policy/docs/statcomps/ssi_asr/2013/ssi_asr13.pdf

Social Security Administration. (2014 December). Annual statistical report on the social security disability insurance program, 2013. Retrieved from: http://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf

Vallas, R. (2013 October 16). Nine facts that prove disability insurance isn’t a giant boondoogle. ThinkProgress.org. Retrieved from: http://thinkprogress.org/economy/2013/10/16/2787821/facts-disability-insurance/

Mental Health Disclosure & the Workplace

A memorial of candles, flowers, and other items created in Düsseldorf, Germany, the destination airport of the Germanwings flight that crashed, killing all 150 passengers and crew on board.

On March 24, 2015, the world learned about a Germanwings flight that ended tragically. The plane crashed into the French Alps, killing all 144 passengers and 6 crew members (Calamur, 2015). In the search for answers, indicators point to how the plane’s co-pilot may have intentionally crashed the plane, which has caused many to wonder about his mental health status and history (Kulish & Ewing, 2015). Although Lufthansa (Germanwings’ parent airline company) was aware of the pilots history with severe depression, Lufthansa reported that the pilot passed its “state of the art” screening process, which includes testing of their technical ability and their psychological fitness (Kulish & Ewing, 2015). Further investigation into the pilot uncovered discarded doctor’s notes in the pilot’s apartment that had indicated he was too sick to work on the day of the crash (Kulish & Ewing, 2015).

The horrific incident with Germanwings and its pilot has raised debates regarding what measures employers can take to identify the mental health history of its employees. The current aviation system depends largely on pilots to disclose any medical or psychological issues they have or are currently experiencing (Goode & Mouawad, 2015). Many worry any new restrictions may deter those who need help from actually seeking help due to increased stigma around mental health (Goode & Mouawad, 2015).

Speaking to the Bloomberg Report, policy director of the National Alliance of Mental Illness (NAMI), Ron Honberg, says:

“We could be trying to create an environment that’s more knowledgeable and accepting of mental health conditions and doesn’t cause people to be ostracized if they admit to it.” (Tozzi, 2015)

Aviation is just one of many professions where one’s mental health may seriously risk theADA_2 life of not just the employee but also the lives of many others. Doctors, school bus drivers, law enforcement, utility workers, and many other professions involve high stakes. Yet, the Americans with Disabilities Act (ADA), which was established in 1990, prohibits employers from asking job applicants information regarding their medical status, including mental health (Tozzi, 2015). In the wake of the Germanwings tragedy, a looming question still remains: Why, when, what, and how should information regarding a person’s mental health be disclosed to others?

Mental Health & the Workplace 

The World Health Organization (2001) identifies mental illness as one of the leading causes of disability around the world. According to the National Institute of Mental Health (NIMH, 2012), major depression carries the “heaviest burden of disability among mental and behavioral disorders.” The NIMH (2012) estimates that 43.7 million adults suffer from mental, behavioral, or emotional disorders, and of those, 16 million, nearly 7% of all adults in the U.S., had at least one major depressive episode in the past year. Experiences of depression is estimated to cost the U.S. $23 billion in lost productivity annually (Harding, 2010). Michael Blanding, Assistant Professor at the Harvard Business School, estimates that workplace stress accounts for 8% of national health care spending, even contributing to 120, deaths each year (Blanding, 2015).

The National Institute of Mental Health estimates 16 million adults in the U.S. experience at least one episode of depression in 2012.

Recognizing the need for integrated mental health care, many employers offer Employee Assistance Programs (EAPs), a voluntary resource that allows employees free and confidential assessments, short-term counseling, follow-up services, and referrals for addressing a wide range of issues, including substance use, bereavement, and psychological disorders (OPM, 2015). Johnson & Johnson employees are invited to use the corporate gym to relieve stress and stay healthy, and General Mills provides mindfulness training and on-site guided meditation in its efforts to promote mental and physical wellbeing (Blanding, 2015).

Dr. Michelle Riba, professor of psychiatry at the University of Michigan
Dr. Michelle Riba, professor of psychiatry at the University of Michigan

However, the majority of workplaces do not carve time out for meditation, and mental health is often an afterthought rather than a component of its preventative health care strategies. Dr. Michelle Riba, M.D. serves as a professor of psychiatry and the associate director for the University of Michigan’s depression center. Dr. Riba believes careful thought and preparation are crucial for employees who are considering disclosing their health information to their employers.

“…for the individual who’s working in an office or another situation, one really needs to think about why any medical condition would be discussed. Not that there’s anything wrong with disclosing, but one has to be really clear about what one hopes to gain” – Dr. Michelle Riba, (Harding 2010).

In addition to barring employment discrimination on the basis of an individual’s disabilities, the ADA also requires employers to provide appropriate accommodations for employees with disabilities. It is, however, up to employees to disclose their disability and to identify what accommodates are necessary (Harding, 2010). For this reason, Dr. Riba and other advocates recommend employees carefully consider what is to be accomplished by self-disclosure. If an individual’s illness or medication may benefit from flexibility in terms of work hours or uses of sick days, this may be accomplished through self-disclosure.

Psychologist and assistant professor of psychology at Duquesne University, Susan G. Goldberg, offers 5 factors to consider before disclosure:

  1. How supportive is the person you are disclosing to likely to be?
  2. What type of culture does the company have?
  3. Do you have a proven track record?
  4. What is happening in the society as a whole? (i.e. current events)
  5. Do you need to disclose everything about the condition, or would it be better to be selective? (Tugend, 2014). 

Although, each place of employment has its own “culture” in terms of its receptiveness to discussions and accommodations around mental health, employees are protected by the ADA and other laws, including the Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPAEA of 2008 prohibits companies (with 50+ employees) from charging higher deductibles or co-pays for mental health and substance abuse services as compared to other medical services (U. S. Dept. of Labor, 2015). The recently implemented Affordable Care Act (ACA) includes provisions for the treatment of mental health and substance use disorders to be considered an “essential health benefit” and prohibits insurance companies from denying individuals coverage based on a history of depression or any other preexisting mental health condition (Harding, 2010).

Mental health stigma continues to prohibit individuals from disclosing their disabilities.
Mental health stigma continues to prohibit individuals from disclosing their disabilities.

New federal regulations specifically require employers, specifically federal contractors and subcontractors (20% of U.S. work force) to regularly encourage employees to voluntarily disclose their disabilities (Tugend, 2014). The Partnership for Workplace Mental Health, an initiative of the American Psychiatric Association, is dedicated to raising the awareness of employers on how to support employees after disclosure, including strategies for reducing stigma in the workplace.

While Lufthansa considers what differences in its corporate structure could have prevented such a tragedy from occurring, employers around the world are also wondering how to protect their stakeholders, including their own employees from harming themselves and others. An integrated approach to mental health care and screening offers opportunities for intervening and providing services to employees, as well as address the issue of stigma and work place stress, which for many, continue to be an obstacle on the path to wellness.


Blanding, M. (2015 April 6). Will the Germanwings crash affect how employers approach mental health? Forbes.com. Retrieved from: http://www.forbes.com/sites/hbsworkingknowledge/2015/04/06/will-the-germanwings-crash-affect-how-employers-approach-mental-health/

Calamar, K. (2015 March 24). As night falls, officials call off search operation for German plan. NPR.org. Retrieved from: http://www.npr.org/blogs/thetwo-way/2015/03/24/395011737/germanwings-a320-crashes-in-french-alps

Goode, E. & Mouawad, J. (2015 March 28). Germanwings crash raises questions about shifting ideas of pilot fitness. NYTimes.com. Retrieved from: http://www.nytimes.com/2015/03/29/world/europe/germanwings-crash-andreas-lubitz-mental-illness.html

Harding, A. (2010 September 20). Depression in the workplace: Don’t ask, don’t tell? Health.com. Retrieved from: http://www.cnn.com/2010/HEALTH/09/20/health.depression.workplace/

Kulish, N. & Ewing, J. (2015 March 31) Lufthansa says Germanwings pilot reported deep depression. NYTimes.com. Retrieved from: http://www.nytimes.com/2015/04/01/world/europe/lufthansa-germanwings-andreas-lubitz.html?_r=1

National Institute of Mental Health. (2012). Major depression among adults. NIH.gov. Retrieved from: http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml

U. S. Office of Personnel Management (2015). What is an employee assistance program (EAP)? OPM.gov. Retrieved from: https://www.opm.gov/faqs/QA.aspx?fid=4313c618-a96e-4c8e-b078-1f76912a10d9&pid=2c2b1e5b-6ff1-4940-b478-34039a1e1174

Tozzi, J. (2015 March 27). Does your boss have a right to know if you’re mentally ill? Bloomberg.com. Retrieved from: http://www.bloomberg.com/news/articles/2015-03-27/does-your-boss-have-a-right-to-know-if-you-re-mentally-ill-

Tugend, A. (2014 November 14). Deciding whether to disclose mental disorders to the boss. NYTimes.com. Retrieved from: http://www.nytimes.com/2014/11/15/your-money/disclosing-mental-disorders-at-work.html

U.S. Department of Labor. (2015). Mental health parity. DOL.gov. Retrieved from: http://www.dol.gov/ebsa/mentalhealthparity/

World Health Organization. (2001). Mental health: A call for action by world health ministers. 54th World Health Assembly. Retrieved from: http://www.who.int/mental_health/advocacy/en/Call_for_Action_MoH_Intro.pdf

Throwback Thursday: Affordable Care Act of 2010

obama and aca

The Patient Protection & Affordable Care Act (ACA) was passed by Congress and then signed into law by President Barack Obama in March 2010. This is considered the largest overhaul of the US healthcare system since Medicaid and Medicare were passed in 1965 (Samora & Hettrich, 2012). In general, the ACA was passed in order to expand accessibility to health care coverage, as well as improve the quality of care provided. More specifically, the legislation required that “marketplaces” be set up in all states so that the uninsured can shop for individual plans. While most “blue” states have set up their own marketplace, most “red” states did not, and allowed the federal government to do so instead (Sanger-Katz, 2015). We will discuss why this has caused problems later in the blog post.


The Affordable Care Act has had three major implications in terms of the expansion and improvement of mental health care:

1. It has expanded mental health and substance abuse benefits to 62 million Americans.

2. Health care plans are now required to cover preventive measures like depression screenings or behavioral assessments, as well as provide mental health parity. In other words, many health insurance plans are now required to provide equal access to mental health care as provided for other chronic conditions like diabetes.

3. Health care plans and insurers can no longer deny coverage based on preexisting conditions, including mental illness.

Current research suggests that the Affordable Care Act has been effective in terms of decreasing the number of uninsured Americans and providing more affordable options (Sanger-Katz, 2015). However, more progress is needed as 12.9% of American adults are currently uninsured (Levy, 2015).

Current Controversy surrounding the ACA

Currently, middle and low income Americans can quality for federal subsidies in order to receive affordable healthcare through the Obamacare marketplace. Specifically families with an annual income between 100% and 400% of the federal poverty line can qualify for federal subsidies (Health Insurance Marketplace, 2015).

King v. Burwell is a Supreme court case regarding whether federal subsidies can go to all insurance purchasers, or just those managed by the state government (Sanger-Katz, 2015). This discrepancy has com from the ACA legislation as it stipulates that the health care subsidies should flow through the marketplace “established by the state.” However, only 13 states are currently managing their own marketplace, while 3 states have federally supported, state marketplaces and the remaining 34 are completely managed by the federal government. Therefore, this ruling could have a major impact on who can afford health insurance. The Kaiser Family Foundation (2015) estimates that approximately 7.5 million people in 34 states qualify for subsidies and some estimates suggest that approximately 7 million Americans could lose their subsidies if the Supreme court rules against the government (Sanger-Katz, 2015).

If the Supreme Court rules against the government, it could create a major problem by setting the precedence for reading each legislative bill literally. Intentionality of a law is the current standard for interpretation; often, constitutional lawyers will refer to the founding father’s ‘intentions,’ instead of literal interpretation. Further, some laws and policies are hundreds or even thousands of pages long and some politicians may not even read a bill, especially in its entirety. Therefore, this case could open a floodgate of additional lawsuits for any bill that is currently enacted.


Health Insurance Marketplace. (2015). Income levels that qualify for lower health coveragehttps://www.healthcare.gov/lower-costs/qualifying-for-lower-costs/

Kaiser Family Foundation. (2015). Marketplace Enrollees Eligible for Financial Assistance as a Share of Subsidy-Eligible Population. Retrieved from http://kff.org/health-reform/state-indicator/marketplace-enrollees-eligible-for-financial-assistance-as-a-share-of-subsidy-eligible-population/

Levy, J. (2015). In U.S., Uninsured rate sinks to 12.9%. Gallup. Retrieved from http://www.gallup.com/poll/180425/uninsured-rate-sinks.aspx

Samora, J. B. & Hettrich, C. M. (2012). Where the Candidates Stand on Healthcare. Retrieved from http://www.aaos.org/news/aaosnow/oct12/advocacy2.asp

Sanger-Katz, M. (2015). Is the Affordable Care Act Working? New York Times. Retrieved from http://www.nytimes.com/interactive/2014/10/27/us/is-the-affordable-care-act-working.html?_r=0#/

Sanger-Katz, M. (2015). Obamacare, Back at the Supreme Court: Frequently Asked Questions. New York Times.  Retrieved at http://www.nytimes.com/interactive/2015/02/03/upshot/obamacare-back-at-the-supreme-court-frequently-asked-questions.html?abt=0002&abg=0