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).

References:

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/

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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.”

and

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).

References:

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

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/

References

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

memorial
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).

t1larg.health.depression.workplace
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.

References:

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: Conversion Therapy Bill

Rep. Celia Israel (D-Austin)
Rep. Celia Israel (D-Austin)

Two weeks ago, Texas State Representative Celia Israel (D-Austin) filed House Bill 3495, which would prohibit mental health providers in Texas from attempting to provide services aimed at changing a child’s (under age 18) sexual orientation, gender identity or expression. “No child should be subjected to this extremely harmful and discredited so-called therapy,” said National Field Director Marty Rouse of the Human Rights Campaign. “These harmful practices are based on the false claim that being LGBT is a mental illness that should be cured, using fear and shame to tell young people that the only way to find love or acceptance is to change the very nature of who they are. Psychological abuse has no place in therapy, no matter the intention” (Nueces County Record Star, 2015).

Speaking to the Texas Observer, Rep. Israel explained: “To suggest that some young kid that happens to be gay is less than normal is very hurtful and harmful and dangerous, and I think I put myself back in those years when I was first discovering who I was. … I felt strongly about introducing a bill that was a counter to that, to say, ‘We don’t need fixing. We just need your love’” (Wright, 2015).

Rep. Israel acknowledges HB3495 may not pass the Republican-majority legislature, but felt the bill was a necessary response to the Texas GOP’s endorsement of conversion or reparative therapy in their 2014 platform. A draft of the platform plank cites the GOP’s stance: We recognize the legitimacy and value of counseling which offers reparative therapy and treatment to patients who are seeking escape from the homosexual lifestyle. No laws or executive orders shall be imposed to limit or restrict access to this type of therapy (Temporary Platform Committee Report, 2014).

Christopher.Bryan_-e1426274978889
Texas native Bryan Christopher experienced conversion therapy as a youth and young adult.

The Texas Observer shared the story of Waco native, Bryan Christopher, who spent 18 years of his life attempting to change his sexual orientation through religious and mental health counseling. At one point in his struggle, he felt compelled to jump off a cliff. Christopher received help through a crisis hotline and psychiatric services. He would eventually claim his own identity 6 years later.

Now 45, Christopher has written about his experiences in his book, Hiding from Myself, and supports bills like HB3495.

Christopher believes the bill will “protect the children from being forced into a therapy that just reinforces the fear and the shame that most of these kids already have, and it leads to people taking their own lives. There’s nothing good that ever comes out of it” (Wright, 2015).

Licensed counselor, David Pickup, practices reparative therapy in Dallas and Los Angeles, and was also the plaintiff in an unsuccessful lawsuit in California that challenged a ban of reparation therapy. Pickup describes himself as an “ex-homosexual” whose methods are effective, and he feels the proposed ban in Texas is a violation of the freedom of speech of counselors, parents, and children (Wright, 2015).

If HB3495 were to pass, those who violated law would be held accountable to disciplinary actions from state licensing boards. Nearly all major medical and mental health associations (e.g. American Psychological Association, American Medical Association, American Counseling Association) have publicly stated their opposition against conversion or reparative therapy.

The American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation conducted an investigation and review of SOCE: sexual orientation change efforts. They found these efforts are “unlikely to be successful and involve some risk of harm, contrary to the claims of SOCE practitioners and advocates” (APA, 2009).

This is a summary of their finding:

Screenshot 2015-03-27 00.08.26
Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation (2009)

 

Similar bills have passed in California, New Jersey, and Washington, D.C., protecting children and youth from conversion therapy. These laws have been upheld by the Ninth and Third Circuit Courts (Nueces, 2015). The Southern Poverty Law Center (2015) identified and mapped at least 70 therapists in 20 states that advertise as practicing conversion therapy.

References:

Conversion therapy (2015). Southern Law Poverty Center. Retrieved from http://www.splcenter.org/conversion-therapy

Glassgold, J.M., Beckstead, L., Dresher, L., Greene, B., Miller, R. L., Worthington, R. L. (2009). Report of the American Psychological Association task force on appropriate therapeutic responses to sexual orientation. American Psychological Association: Washington, D.C. Retrieved from http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf

Israel, C. (2015). H. B. 3495. 84th Texas Legislation. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/billtext/pdf/HB03495I.pdf#navpanes=0

Temporary Platform Committee Report (2014). Republican Party of Texas. Retrieved from https://s3.amazonaws.com/s3.documentcloud.org/documents/1182339/temporary-platform-committee-report.pdf

Wright, J. (2015). Lesbian lawmaker introduce bill to ban “ex-gay” therapy for minors. Texas Observer. Retrieved from http://www.texasobserver.org/lesbian-lawmaker-introduces-bill-to-ban-ex-gay-therapy-for-minors/

Nueces County Record Star (2015). Bill passed to stop conversion therapy. Retrieved from http://www.recordstar.com/recordstar/article_5612a2f0-b8da-50e0-9f29-bbda2d673691.html

 

Hogg Foundation: Recommendations for Addressing the Texas Mental Health Workforce Shortage

The Hogg Foundation for Mental Health is an Austin-based foundation dedicated to promoting mental health in Texas through focusing on key strategic areas, including advocacy and public policy work to implement systemic changes that impact mental health services and conditions.

As the 84th Texas Legislative Session is underway at the Capitol, the Hogg Foundation has highlighted its 2014-2015 Mental Health Policy Priorities. The last (but certainly not least) of these priorities will be the focus of this post.

The 11 priority issues are:

  1. Recovery-Focused Treatment and Support
  2. Integration of Behavioral Health and Primary Care Services
  3. Mental Health Funding
  4. Peer Support Services
  5. Mental Health Services for Individuals with Intellectual and Other Developmental Disabilities (IDD)
  6. Creation of a Forensic Director Position at the Department of State Health Services
  7. Mental Health Services for People in and Recently Released from Jail
  8. Child Relinquishment
  9. Self-Directed Service Delivery Option for Mental Health Services
  10. “Normalcy” for Children and Youth in Foster Care
  11. Mental Health Workforce Issues (Hogg Foundation, 2014)

The Hogg Foundation’s policy recommendations as to how Texas can best address its mental health workforce shortage is grounded in its understanding that recovery for people experiencing mental illness “does not happen in isolation. It may require treatment and support from family, friends and mental health professionals such as psychiatrists, licensed professional counselors, social workers, psychologists, psychiatric nurses or advance practice registered nurses, certified peer-to-peer specialists and community health workers. (Hogg Foundation, 2014).”

Texas has a dire need for an educated, trained, and sufficiently sizable workforce of mental health professionals to serve its community. In 2011, the Hogg Foundation published the report, “Crisis Point: Mental Health Workforce Shortages in Texas.” The report revealed that the Texas Department of State Health Services (DSHS) estimates that less than one-third (44,787 or 28.9%) of Texas children who experience severe emotional disturbance received treatment through community health services. Similarly, 33.6% (or 156,880) adults who experience serious and persistent mental illness received services through the community health system. In other words, roughly two-thirds of the state’s population with mental illness are not receiving services.

State records also reveal that more than 200 Texas counties are without one practicing psychiatrist, resulting in 5.5 million people without adequate access to mental healthcare (Pierrotti, 2014).

Austin news station KVUE spent seven months investigating the state of mental health care in Texas. KVUE shared the story of Joann Kennedy, a women who lived with debilitating effects of schizophrenia and bipolar disorder for 26 years (Pierotti, 2014). Kennedy’s family regret the difficulties they encountered attempting to access resources, including the Austin State Mental Hospital, just one of 9 public mental hospitals in the state of Texas. Kennedy finally did receive care when she was arrested and held at the Travis County Jail. Over a 20-year period, Austin police arrested Kennedy over 38 times for minor offenses, resulting in over 1,3444 days spent in jail, costing an estimated $189,000 over a 20-year period to provide Kennedy with medication and counseling (Pierrotti, 2014).

http://www.kvue.com/story/news/investigations/defenders/2014/09/28/the-cost-of-troubled-minds/16115871/
Austin police arrested Kennedy 38 times, resulting in 1,344 days spent in jail over a period of several years.

Kennedy was not alone. Between 2007 and 2013, the number of inmates with chronic mental illnesses increased by 78% in Travis County. Additionally, Kennedy was one of hundreds of thousands of Texas residents with mental health issues without insurance (Pierrotti, 2014). The issue extends beyond the ability of hospitals and jails serving individuals suffering from mental health. On all levels, Texas has not created the capacity to serve the reality of the mental health needs of its residents.

 “You look at the psychiatric nurses or social workers, psychologists, licensed chemical dependency counselors. About 200 of our counties are considered health professional shortage areas.” – Texas DSHS Deputy Commissioner Mike Maples

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In light of this need, the Hogg Foundation sees great social and economic value in providing appropriate mental health services to avoid the burden of staff and costs already placed on hospitals and the criminal and juvenile justice systems (Hogg Foundation, 2014).

The following are recommendations the Hogg Foundation has presented to the Statewide Health Coordination Council last February in order to advocate for investment in the Texas mental health workforce:

  • Increase education and training opportunities, particularly training based on the recovery model of care
  • Identify and implement changes needed to expand the use of certified peer specialists
  • Increase reimbursement rates for all disciplines
  • Analyze best-practices in tele-mental health and identify barriers that limit its expansion
  • Provide education, reimbursements, and provisions of flexible service in order to expand integrated health care
  • Additional workforce considerations:
  • Cultural and linguistic competency
  • Data collection
  • Geriatric mental health specialists
  • Mental health providers for individuals with intellectual and other developmental disabilities (Hogg Foundation, 2014)

Recent legislation has been submitted by Sen. Charles Schwertner of Georgetown seeking to address the workforce shortage. If approved, the SB 239 will offer tuition reimbursements to college graduates who obtain degrees in the mental health profession and agree to work in the underserved areas of Texas (Schwertner, 2014).

 

References

Hogg Foundation. (2011). Crisis point: Mental health worker shortages in Texas. Retrieved from: http://www.hogg.utexas.edu/uploads/documents/Mental_Health_Crisis_final_032111.pdf

Hogg Foundation. (2014). Mental health policy priorities. Retrieved from: http://www.hogg.utexas.edu/uploads/documents/2014-15%20mental%20health%20priorities-1.pdf  

Hogg Foundation. (2014). Policy analysis and information. Retrieved from: http://www.hogg.utexas.edu/initiatives/policy_analysis.html

Hogg Fundation (2014). Policy recommendations: Addressing the Texas mental health workforce shortage. Retrieved from: http://www.hogg.utexas.edu/uploads/documents/MH%20Workforce%20Recommendations_031213-1.pdf

Pierrotti, A. (2014). Legislation filed to fix mental health worker shortage. KVUE.com. Retrieved from: http://www.kvue.com/story/news/investigations/defenders/2014/12/18/legislation-filed-to-fix-mental-health-care-worker-shortage/20599683/

Pierrotti, A. (2014). The costs of troubled minds. KVUE.com. Retrieved from: http://www.kvue.com/story/news/investigations/defenders/2014/09/28/the-cost-of-troubled-minds/16115871/

Schwertner, C. (2014). Senate Bill 239. 84th Texas Legislation. Retrieved from: https://legiscan.com/TX/bill/SB239/2015