Murphy 2 has certainly gotten off to a better start than Murphy 1. Murphy 1 basically self destructed. It had poison pills in it that made it unacceptable to many and Rep Murphy’s political grandstanding and vehement attacks on the character and motivation of anyone who disagreed with him left others turned off and unwilling to support him. He found it matters not how many people agree if those who disagree hate you and what they believe you stand for.
The bill was not going to move with AOT as a requirement (I am not by any stretch a lawyer but after reading with the ACA that federal efforts to coerce the states violate the principle of federalism I wonder how legally defensible it would have been) so now the threat of AOT is gone and replaced with a 2% of block grant bribe. It is the difference between threatening to fail a student for failing to do something and then telling them they won’t fail if they don’t but they can get extra credit if they do. It is replacing the stick with a carrot.
Personally I have come to believe that AOT will not change much as a direct result of this bill. Those that have AOT will continue to have it. Those who don’t will not be convinced by this bill. $15,000,000 in grants over 50 states is really not much. New York alone pays $32,000,000 a year for its program. And when you consider if the federal government pays for start up costs that the state will be on the hook for continued costs I have to question how many budget starved states will go for that. Even with the 2% bribe I wonder. And finally when you consider in New York, the promised land of AOT, that their $32,000,000 serves only 1/3 of 1% of those served you have to wonder how many states will put a bigger AOT program high on their list of new things to do.
The big problem I see is that this bill legitimized the notion of AOT at the federal level. It let’s it in the door. It says the federal government confirms and legitimizes the notion of forced treatment for something other than danger to self and others. And for me the scarier question is not what now but what next. I somehow doubt Dr. Torrey or Rep Murphy will be content with this “victory.”
The other thing is that it officially ignores other options. Tennessee, for example, is rolling out an innovative program based on peer support (The Peer Engagement Project) that is based on keeping people out of psychiatric hospitals, training the staff of those hospitals in trauma informed care, and making people successful in the community. It will deal with far more people for far less money than any AOT program but Tennessee will not receive any 2% increase in block grant funding for its innovation. For all its hoopla about evidence-based practices the 2% bribe is antithetical to the spirit of continued innovation of working and effective services. If AOT qualifies for a 2% bonus other things should too.
Murphy tries to soften other things too. He wants to make it more possible for people to go into psychiatric hospitals and stay longer when they do but his bill seems to say this can only happen if it is “budget neutral”. How that is even possible is beyond me but it would seem obvious that Murphy has an angle somewhere. He is not going to say let’s do something but it is not possible to do unless it is really not impossible to do. He simply doesn’t understand that the ship of psychiatric hospitalization has long ago sailed and while they will probably continue to exist they will never be the core of the mental health system nor be seen as an essential part of the solution of major issues.
Using Tennessee as an example again, telling someone they can spend more money on something is not the same as telling them they must. There are many many costs associated with psychiatric hospitalization that Medicaid reimbursement rates don’t begin to touch. I don’t see Tennessee, which is a funding starved state, accepting the bill. They want more effective things that cost less and not less effective things that cost more.
Rep. Kennedy’s statement that psychiatric hospitalization is some kind of a right is ridiculous. If anything people have a right to have their rights respected and access to help that really helps. I have a friend who spent 24 years in a Florida state hospital. He somehow is not so sure his “rights” were respected.
The attack on Paimi has “softened”. Instead of basically ending their existence he is now content to let them exist as long as they can’t do anything to improve the system. In Tennessee the Paimi program was largely responsible for improvements to the adult group home system. Under Murphy their actions would have been illegal. I hope this provision is still the poison pill it was last year but I fear based on early reaction it is not.
AOT is not the poster child of Murphy 2 like it was for Murphy 1. I think this year there are two poster children: hippa and Samhsa.
Again Murphy has tried to soften hippa by saying the content of psychotherapy notes can’t be shared. Much of his effort is geared not to help the “mentally ill” but to in some way relieve the suffering of family members who have to cope with them. A big part of this has been to change hippa regulations which supposedly prevent this.
I see four problems.
In no particular order:
1. Hippa already has exceptions which allow the exchange of information. Perhaps we could learn how to follow the law before we try to fix it because it is broken.
2. What about people’s rights? Are we proposing to violate the rights of the terminally ill who don’t want or trust the help of their family members? Are they not any less emotionally stable? Non compliance with doctors orders is a major problem in all of medicine. That is well documented. How do we decide who is to lose their rights to make their own decisions however poor or ill considered. “Mental illness” is not the limit of personal instability.
3. Does it make it more or less likely people will seek help. Family conflict, family trauma, family victimization is a real issue for many people. They do not see family as kind support but as bad guys trying to hurt them, and they view the possibility of personal information being shared as an unacceptable risk . Will they seek help that, in their eyes makes them vulnerable to people they don’t think they can trust. I really question that. Murphy does not consider it.
4. It may make family members feel better but is there any evidence that giving family members this evidence helps. I have a friend who is a psychiatrist and his thoughts are worth sharing. “98% of the time it is a horrible idea. A very few times in my career I have met patients so out of contact with reality that I thought family needed to know personal information. These have been very rare as I said. Therapeutically it is a very bad idea to do anything that tells an adult they are not enough of an adult to deserve autonomy from their parents. It destroys trust and disempowers any effort to put them in control of their lives. Most of the parents who press the hardest are not those with the extremely psychotic kids but those with the greatest control issues. In 20 years of practice I can count on the fingers of one hand the amount of times putting a parent in charge of an adult child actually helped. It may be appropriate in rare circumstances but as a blanket strategy it has a lot of problems. ” I don’t know how much other doctors share his views but his points are worth considering.
Samhsa. This is really the core of Murphy 2 I think. He complains a lot about the way they do things. Just listening I don’t think he is the only one with concerns. But more than anything I think he complains about the way they see things. Samhsa has championed the idea of recovery. As part of that psychiatrists are no longer the owners of the only knowledge that matters. Recovery says three things sacrilegious to psychiatric faith: people can and do get better, they can and should make decisions about their own lives and people other than psychiatrists can and often do make real impact in the lives of suffering people. This view is I think the growing view and it threatens psychiatric power, psychiatric status and psychiatric profit. Doing away with Samhsa is about repsychiatrizing the mental health system. Ultimately that is the thrust of the entire bill.
Cynical people might point to all the money Murphy gets from groups that would financially profit and assume they are really calling the shots. I don’t know if that is really true or not. I suspect at minimum they are leading the cheers.
The opposition to Murphy seems fragmented to me. Mha is on board with Murphy it appears. They like screening and early intervention and I guess he offered enough of that to quiet any other doubts. And I think he will continue to try to pick off as many other organizations as he can.
Murphy 2 is much more dangerous than Murphy 1 was I think. He seems much more intent to not be his own worst enemy this time and unless the opposition can find much more consensus and unity than they have up to know Murphy may indeed win.