Murphy just doesn’t add up. Below are a couple of older posts on the Murphy math. His proposals don’t even succeed on their own terms.
Murphys free ride….
Without intending to or even being aware we are doing it we have given the Murphy Bill a free ride on an extremely critical core question: leaving aside for a moment all questions of values and moral issues the bill touches upon– can it work. Are the solutions they propose of a magnitude and type likely to effectively address the issues they cite on anywhere close to the level they say those issues need to be dealt with? The answer I believe is resoundly no. The Murphy Bill is a fraud. It is a bridge in Brooklyn or swamp land in Arizona being sold to people desperate for a solution.
The argument on Murphy in one sense has been very simple. It has been an arguments about morals and doing the right thing. Murphy, Torrey, and Jaffe have framed their bill as a valiant uphill battle against overwhelming odds to do the right thing for people who cant help themselves and need help very badly. The battle against the Murphy Bill has also been about doing the right thing: respecting people’s rights to make their own choice in life and saving people from the specter of coercive treatment. What you conclude depends on what you think the right thing is.
But what if it was about more than that. What if it was about what works, what really solves problems and makes lives better. What if it was just a discussion based on honesty and not protecting or advancing turf or power or status or whatever. What if the question was, “Does the vehicle you have designed actually work. Can it do what you say it does? Can it do what needs to be done?
A major Murphy issue is the travesty of “mental illness” being criminalized… I think he is right. It is an atrocity. Something close to 300,000 or so people are in jails or prisons who have some sort of mental health issues or diagnosis severely impacting their life. His solution is two fold if I understand him correctly. He touts assisted outpatient treatment (aot) as a major part of the solution. He says the problem is that they dont know they have a mental illness and they need to go to treatment rather they want to or not. If that happens not nearly so many people with mental illness will commit crimes or be put in jail or so he seems to believe. Before anyone makes a remark about the simple minded and naive faith he has in the efficacy of outpatient treatment lets look at a couple of other variables.
Remember the number 300,000. That is an important number. The New York state mental health system for example serves about 675,000 people. A little more than twice as many as are in prison. The New York state mental health system is also the holy site of AOT. It is the largest program and according to the people who believe in AOT what they believe is the model for how it should be done. But this largest, best done model of AOT only serves about 2000 people– about 1/3 of 1%. It spends about $32,000,000 a year. If you assume that indeed New York is indeed how it should be done and it really AOT at its optimum and should serve as the model of how AOT can keep people out of jail you are looking at a yearly cost of $4,800,000,000 (billion with a b) if you use AOT on all 300,000 or so residents of our correctional system to save them from themselves. Obviously you may not have to use AOT on 100% of the people…. Say you only needed to do it on 10% of the correctional population. The cost then would be $960,000,000 (million with an m). What happens to the idea of AOT to “cost effective and saving money.” What states could even begin to pay for their portions of this bill. The federal grants attached to the law dont even begin to foot the bill. That money must come from somewhere and if it was the law then money would likely have to be taken from community services which would create more people who get into trouble who need AOT which needs more money which creates more people in trouble etc. etc. etc.
Obviously I have created a straw man and the truth is much more complex than I described it here. But two important points need to be considered. To blindly assume a program that serves 1/3 of 1% of a population in its biggest incarnation can be increased to serve about 50% of that population is a really big assumption. Secondly the question of cost is a real one with real impacts. Buying a car may be a real bargain. Buying a thousand cars at the same price may not be the same bargain.
Making AOT in New York the measure of all things as Murphy, Torrey, and Jaffe basically do is also a strawman. AOT is not a new thing. It is in 44 states. In most of those states it lays unused, and basically irrelevant to the operation of the wider system.
On many different levels (ignoring the very real moral questions) AOT is simply not what it is advertised to be. The biggest reason is that the problem is not what it says it is. There are not anosognosiacs running around unattended everywhere. Again if you accept the Murphy notions as truth and do the math you just get nonsense. If about 4% of the population is seriously mentally ill and about 50% of them have anosognosia as Murphy claims then about 370,000 people in New York have anosognosia. AOT in New York deals with 2000 (granting the rather large assumption that all of them have anosognosia). There are 368000 anosognosiacs missing. Come on. Does anyone really drink this kool aid?
AOT (even if you believe in it and worship it and think it is the best thing since sliced bread) is a pop-gun trying to bring down thousands of herds of elephants. It just doesnt deliver. Way too little bang for way too many bucks.
Whatever it is “a fundamental reform of a broken system” is not it.
Murphy’s other fundamental reform of a broken system is psychiatric hospitalizations. It is a little like a tank commander saying the problem with the army is that there is not enough horse calvary. The time is past. The ship is sailed.
If you listen to Murphy talk sometimes it seems like what he is saying is illegal, criminal activity is due to a defiency in psychiatric hospitalization. He speaks romantically about the thrill of “evidence based practices” and then touts perhaps the least evidence based practice in the world. Perhaps there is a place for psychiatric hospitals for crisis stabilization (although many people would even disagree with that) but that is in no way a fundamental reform of a broken system.
And again remember the 300000 figure. A hospital bed in Tennessee costs can depending on the level of care cost as much as $350,000 a year. Care to guess how many new beds they are going to open to serve the 300,000 (even if there is no IMD exclusion). Try zero.
The claims of the Murphy Bill are not examined nearly close enough. Too often we lose ourselves in outrage and dont take enough time to look closely and see it just isnt very good. It isnt a fundamental reform of a broken anything. His gun makes a lot of noise. It just doesnt have any bullets.
The Murphy Illusion
Our jails we are told are the new psychiatric hospitals. They are packed with people they are not equipped to deal with and with whom they don’t do well. If anything they make things a lot worse and help leave an entire population of people stuck in an ever entrenched pattern of repeat incarceration. We seem to solve problems by diminishing the people who have them.
If you listen to Murphy it is simple:
1. People are in jail with “mental illness” are there because they have not had effective treatment for their “illness.”
2. Many of them do not even accept that they are “ill.” They refuse to accept the treatment they need.
3. We feed into the problem by allowing people who don’t have the capacity to make informed decisions control over the decisions that affect their lives.
4. The answer is to force them to accept treatment rather they want it or not for the long term good of all of us.
5. This coercive treatment would come in two forms: Assisted outpatient training and psychiatric hospitalization.
There are only about a million problems with this view. Chief among them:
1. The assumption that criminal behavior is the result of a lack of effective treatment is naive to the max. It ignores things like poverty, homelessness, drugs, gang affiliations, racism, unemployment, past history of trauma, poor education and other things. It makes crime a medical issue instead of a human one. It makes it a response to illness instead of a response to life. And it drastically overestimates the effect of treatment far past anything there is proof of. The best way to address the choices of desperate people in the long run is to address the factors that make life desperate.
2. Murphy says that 5% of the population has a serious mental illness and that 50% of them don’t know it. This is a major part of his justification for the need for coercive treatment. If this is not true the case he makes for coercive treatment is suspect on the very grounds he chooses to argue on. These figures are sacred myth supposedly well grounded in scientific truth according to the Treatment Advocacy Center. It literally astonished me the gullibility with which so many people accept them. If you do the math in Tennessee there are 162,399 people with severe mental illness who don’t know they have it, who need treatment because of the negative life impacting symptoms of their illness. They also seem to be invisible since no one seems to know they exist. You would think 162,399 disruptive people would make somewhat of a splash but there seems to be none. There is a pilot AOT program in East Tennessee I guess to find as many of the 162,399 as possible. They served one person last year.
3. People according to Murphy can’t make informed decisions because they don’t know they need help. And again he is not talking about a few people although he sometimes tries to soften criticism by saying he is. 50% of 5% is what he is talking about. A lot of people. If you could find the missing 162,399 people in Tennessee and add them to the mental health system you would increase the people served by 50%. In New York if you do the math 368,000 anosognesiacs are running around missing somewhere. (Many of the numerical claims Murphy makes are just not given close enough scrutiny. He gets a free ride on way too many things.) This is a critical point of argument. If Murphy can’t prove that a large substantial group of people can’t make decisions then his argument for coercion as an integral part of major mental health reform falls according to his own terms.
4. The phrase “accept treatment” implies that there is widespread agreement about what effective treatment is. That is not even close to the truth. The medical model supported by Murphy with a heavy emphasis on the use of psychotropic medication is hotly debated and criticised. Many techniques that are increasingly used and found effective by many providers are regarded by Murphy as being fraudulent. When he uses the term “accept treatment” he means treatment according to his criteria. And if that treatment is still widely debated on the professional level how can there be a law dictating that people must accept a treatment even professionals can’t agree on.
5. Psychotropic medication may help some people and it may help some people a lot but it without question is ineffective for some people, harmful to some people and poses risks to maybe all people. To make it illegal to refuse medication that may cause harm and even life threatening consequences to you seems to me to be a basic violation of human rights. If you start by saying we don’t have the right to question the decisions of our doctors where does it end and who draws the limits. Whatever else doctors are they are not God and to legally have to treat them as they are is an assault on all of us.
6. AOT is portrayed as a basic service for large groups of people. Again remember 50% of 5%. It is already a nationwide program and it’s track record just doesn’t support that. In most state’s it lays unused and irrelevant. Not enough people talk about this. Again Murphy gets a free ride on many numerical claims. In New York were it is supposedly a huge success it serves 1/3 of 1% of the population served by the mental health system (I don’t know what happened to 50% of 5 %). Does the magnitude of the solution match the magnitude of the problem? Not even close.
7. The Murphy Bill in part would have us replace the new hospitals with the old hospitals. And somehow that would solve the problem. It is a fraud and a cruel fraud. Ask a simple question. Does the magnitude of the problem match the magnitude of the proposed solution? The figure normally thrown out is about 300,000 people with mental illness in jail. There are a lot of questions:
A. How many of these people are supposed to be served in psychiatric hospitals? 50%….25%….maybe just 10%. Most state hospital beds run about $150,000 a year. Many run more than that. At 10% hospitalization you are talking an expense of $4,500,000,000 a year. Who is paying?
B. The repeal of the IMD exclusion which is floated as one way to pay for all this has its own questions. Medicaid reimbursement of anything largely never pays the full cost of anything. Are the state’s to be stuck with the remaining cost? Even if you make Medicaid funds available it simply means state’s can pay….not that they must. I find it highly unlikely that in Tennessee for example which is counting every Medicaid penny 4 times before they spend it that they will agree to a huge new expense for something that shows so little evidence that it is effective. This is particularly true when the Dept of Mental Health and Substance Abuse shows little support for increasing psychiatric hospital beds.
C. And related again to the IMD exclusion what about the state’s that have not expanded Medicaid. (I find it extraordinary that Rep Murphy would be for increasing the use of Medicaid funds but would vote innumerable times against increasing people’s access to Medicaid). Does that not mean that for over 20 state’s the entire cost of increased hospitalization for individuals that would be covered in other states be borne by the state’s. Again where is the money coming from if not from community based programs and if you reduce community programs are you not creating the very problem you claim to be solving?
D. There is no particular reason that I am aware of to assume that all these people in jail meet the criteria for hospitalization. That is a huge assumption Murphy makes. In Tennessee there are no voluntary admissions into state hospitals. The criteria is danger to self or others and then most people only stay a maximum of 8-10 days. I don’t see any of this changing. The ship on psychiatric hospitalization has simply sailed and it isn’t coming back. Murphy, Torrey, and Jaffe just missed the boat. When Tennessee had a psychiatric hospital going full steam in East Tennessee it served about 90-100 people at a time (hardly an answer to jail overcrowding). When they closed the hospital those funds stayed in the community and served 10 times the amount of people they had before. When they looked at the “chronically mentally ill” that had been about half the population they found the defining characteristic was not severe mental illness but severe poverty. They had no where to go. They helped find them places to go. In the 2 years since the hospital closed only 2 of the so called “chronic patients” have been rehospitalized.
This is only a very small slice of ways in which the Murphy Bill misses the boat. It probably should be called the Murphy-Torrey-Jaffe- Treatment Advocacy Center Bill since it is just basically a long fax of things the TAC has been saying for years. It is probably, in the end, less about what is done in the mental health system and more about who is in control of what is done. The common thread throughout the Bill is to make anyone who would question TAC influence impotent in opposing It….all the way from dismantling Samsha, disemboweling paimi to changing hippa requirements to institutionalizing coercion as the basic value of the mental health system.
The political skills of TAC are well tooled and effective. They sell and sell well. Considering the suspect quality of what they sell they are master salesmen.
It is a simple 3 step plan:
1. Identify the problem in dramatic, emotional terms and clearly outline the catastrophe the problem is leading to.
2. Offer deliverance. Offer a plan that will take us from the edge of the cliff, that will restore goodness and justice to a situation lacking both.
3. Deliver up a boogeyman. Make sure people understand that the boogeyman has a personal stake in keeping the problem going. Explain that anyone who disagrees with you has fallen under the influence of evil forces and that anything critical they say is proof of the power of the boogeyman. Anything critical is proof of how bad the problem is and the length evil people will go to prevent it from being solved.
A key element is the boogeyman. And the boogeyman for TAC has been the “psychiatric survivor” movement or at least their caricature of it. They actually have tried to sell the Murphy Bill as an effort to rescue the mental health system from the grips of “psychiatric survivors” and to put it back in the hands of professionals. The total stupidity of that claim has never stopped them from making it loudly. It is called megalomania when you have delusions of your grandeur. I dont know what it called when you have delusions of someone elses grandeur.
The Murphy Bill is a bad thing that will do much damage to people already damaged. Their is no difference that people who oppose this Bill should have between themseves that should or would stop them from working together to defeat this Bill. It is that important.