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85–437 2013

EXAMINING SAMHSA’S ROLE IN DELIVERING 

SERVICES TO THE SEVERELY MENTALLY ILL 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

MAY 22, 2013 

Serial No. 113–47 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

RALPH M. HALL, Texas 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Missouri 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

(III) 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Vice Chairman 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

GREGG HARPER, Mississippi 

PETE OLSON, Texas 

CORY GARDNER, Colorado 

H. MORGAN GRIFFITH, Virginia 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

BRUCE L. BRALEY, Iowa 

BEN RAY LUJAN, New Mexico 

EDWARD J. MARKEY, Massachusetts 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

PETER WELCH, Vermont 

PAUL TONKO, New York 

GENE GREEN, Texas 

JOHN D. DINGELL, Michigan 

HENRY A. WAXMAN, California (ex officio) 

(V) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 4 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 6 

Hon. Fred Upton, a Representative in Congress from the State of Michigan, 

opening statement ................................................................................................ 7 

Prepared statement .......................................................................................... 8 

Hon. G.K. Butterfield, a Representative in Congress from the State of North 

Carolina, opening statement ............................................................................... 10 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, prepared statement ........................................................................... 11 

WITNESSES

Pamela S. Hyde, Administrator, Substance Abuse and Mental Health Services 

Administration ..................................................................................................... 13 

Prepared statement .......................................................................................... 15 

Answers to submitted questions ...................................................................... 165 

Joseph Bruce, Father of a Son with Severe Mental Illness ................................. 57 

Prepared statement .......................................................................................... 61 

Answers to submitted questions ...................................................................... 202 

E. Fuller Torrey, Founder, Treatment Advocacy Center ...................................... 67 

Prepared statement .......................................................................................... 70 

Answers to submitted questions ...................................................................... 206 

Sally Satel, Resident Scholar, American Enterprise Institute ............................ 82 

Prepared statement .......................................................................................... 84 

Answers to submitted questions ...................................................................... 211 

Joseph Parks, III, Chief Clinical Officer, Missouri Department of Mental 

Health ................................................................................................................... 91 

Prepared statement .......................................................................................... 94 

Answers to submitted questions ...................................................................... 213 

SUBMITTED MATERIAL

Document binder ...................................................................................................... 115 

(1) 

EXAMINING SAMHSA’S ROLE IN DELIVERING 

SERVICES TO THE SEVERELY MENTALLY ILL 

WEDNESDAY, MAY 22, 2013 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:05 a.m., in room 

2123 of the Rayburn House Office Building, Hon. Tim Murphy 

(chairman of the subcommittee) presiding. 

Members present: Representatives Murphy, Burgess, Blackburn, 

Gingrey, Scalise, Harper, Olson, Gardner, Griffith, Johnson, Long, 

Ellmers, Upton (ex officio), DeGette, Braley, Butterfield, Castor, 

Tonko, Green, and Waxman (ex officio). 

Also present: Representative Cassidy. 

Staff present: Karen Christian, Chief Counsel, Oversight; Brad 

Grantz, Policy Coordinator, O&I; Brittany Havens, Legislative 

Clerk; Robert Horne, Professional Staff Member, Health; Alan 

Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, Counsel, 

Oversight; Jean Woodrow, Director, Information Technology; Stacia 

Cardille, Democratic Deputy Chief Counsel; Anne Morris Reid, 

Democratic Professional Staff; Brian Cohen, Democratic Staff Director for Oversight and Investigations Subcommittee and Senior 

Policy Advisor; Stephen Salsbury, Democratic Special Assistant; 

and Elizabeth Letter, Democratic Assistant Press Secretary. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning, everyone. I now convene this morning’s hearing entitled ‘‘Examining SAMHSA’s Role in Delivering 

Services to the Severely Mentally Ill.’’ 

Since I became the Chairman of the Subcommittee on Oversight 

and Investigations, shortly after the December 14, 2012, elementary school shootings in Newtown of last year, we began looking 

into the federal programs and the resources devoted to mental 

health and mental illness. We did so to ensure federal dollars devoted to mental health are reaching those individuals with serious 

mental illness and helping them obtain the most effective care. 

One lesson we must immediately draw from the Newtown tragedy is that we need to make it our priority to get those with serious 

mental illness who are not presently being treated into sound, evidence-based treatments. 

2 

In 2009, the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA, estimates that about 

11 million U.S. adults had serious mental illness, and 40 percent 

of these individuals did not receive treatment. While the vast majority of individuals with a mental health condition are nonviolent, 

director of the National Institute for Mental Health, Dr. Thomas 

Insel, told this subcommittee at our March 5 public forum that effective treatments, which include medication adherence and evidence-based psychosocial psychotherapy, can reduce the risk of violent behavior 15-fold in persons with serious mental illness. 

Getting these individuals into treatment is a crucial first task, 

and SAMHSA, as the federal agency whose mission includes reducing the impact of mental illness on America’s communities, should 

be playing a central role in this effort. But based on our work to 

date, SAMHSA has not made the treatment of the seriously mentally ill a priority. In fact, I am afraid serious mental illness such 

as schizophrenia and bipolar disorder may not be a concern at all. 

Consider the 2011–2014 SAMHSA strategic plan entitled ‘‘Leading Change.’’ SAMHSA continues to think in broad terms such as 

‘‘behavioral’’ and ‘‘emotional’’ health, promoting such concepts as 

‘‘wellness’’ or ‘‘recovery.’’ Not once in this entire 117-page document 

will you find the words schizophrenia or bipolar disorder. Nowhere 

in the written testimony that was provided to this committee yesterday by the SAMHSA administrator do those words appear. And 

nowhere on SAMHSA’s Web site or in their publications can you 

learn about the increased risk of violent behavior by persons with 

untreated mental illness. It is as if SAMHSA doesn’t believe serious mental illness exists. 

If we have learned one thing from the horrible acts committed 

by Seung-Hui Cho at Virginia Tech in 2007; Jared Loughner in 

Tucson; James Holmes at the Aurora, Colorado, theater in July 

2012; or Adam Lanza, it is this: that individuals with untreated severe mental illness are a significant target for self-directed violence, including suicide or violence against others. In at least 38 of 

the last 62 mass killings, the perpetrator displayed signs of possible mental health problems. In so many of these instances, parents desperately tried to get their mentally ill loved one to help before the act. Sadly, they failed, oftentimes because the current system of care for those with serious mental illness is broken. 

Examining what SAMHSA is doing to grapple with this heartbreaking truth is the main reason we are gathered here this morning. The Center for Mental Health Services, housed at SAMHSA, 

has a budget of approximately $1 billion per year. It awards most 

of these funds through a combination of competitive and formula 

grants. I am concerned because the Committee has seen substantial evidence that too many of these grants are directed to advancing services rooted in unproven social theory and feel-good fads 

rather than science. If SAMHSA were to use an evidence-based approach to identifying how to prioritize its resources—like other federal agencies do—would their record, not to mention their strategic 

initiatives going forward, look the same as they do now? 

For example, in 2012, an annual conference that has been funded 

by SAMHSA for many years at which the SAMHSA administrator 

herself regularly delivers a keynote, a conference known as AlterVerDate Nov 24 2008 14:18 Nov 22, 2013 Jkt 037690 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-47 CHRIS
3 

natives, an hour-and-a-half workshop was held, described as follows: ‘‘Unleash the Beast is a mind/body fitness program that looks 

to the animals of the jungle for wisdom and skills that can benefit 

our lives in a myriad of ways. Through animal-inspired movements, 

behaviors, and expressions, participants are encouraged to shed 

layers of formal conditioning in order to return to their primal nature.’’ 

While mental and physical health is important, I question the 

value of this exercise in advancing the treatment for mental illness 

in humans let alone seriously mentally ill, and I question if there 

is any scientific merit at all. 

I would also ask why SAMHSA provides grant funding year after 

year in the millions of dollars in aggregate to organizations that 

are outwardly hostile to the sciences of psychiatry and psychology. 

These groups openly deny that mental illness exists, claiming there 

is nothing out of the ordinary when an individual hears voices or 

experiences extreme mental states, and that these should be celebrated as nature’s gift to mankind, contributing to artistic creativity and human diversity. 

Leaders of these organizations—including at least one of which 

SAMHSA has elevated to the status of a ‘‘National Technical Assistance Center’’ and received at least $300,000 in taxpayer dollars 

the past year—have actively encouraged supporters to ‘‘occupy’’ the 

2012 annual convention of the American Psychiatric Association, 

decrying the professional association’s role in developing the Diagnostic and Statistical Manual of Mental Disorders, otherwise 

known as the DSM. ‘‘Psychiatric labeling,’’ as they say, is ‘‘a pseudoscientific practice of limited value in helping people recover.’’ 

When SAMHSA-funded organizations are not busy encouraging 

those with mental illness to go off their prescribed medications— 

and, yes, they do that—or destroying trust between individuals 

with serious mental illness, their family caregivers, and their physicians, these taxpayer-backed groups are actively lobbying against 

effective evidence-based treatment like Assisted Outpatient Treatment—otherwise known as AOT—laws, a less-restrictive alternative to involuntary commitment is what AOT is. Numerous academic studies have shown AOT to be incredibly effective in reducing re-hospitalizations and re-arrests among, until-then, untreated 

individuals with serious mental illness. 

As an agency of the U.S. Public Health Service, we expect 

SAMHSA’s work to be firmly rooted in evidence-based practices in 

deed and not just by word, enduring high-level scientific peer review at the hands of licensed mental health professionals. Perhaps 

some of it is and I know some of it is, but much of it appears to 

fall far short of such standards. 

To get answers to our questions, this morning, we will hear from 

Pamela Hyde, the Administrator of SAMHSA since 2009, on our 

first panel. On our second panel, we will hear from E. Fuller 

Torrey, a psychiatrist and long-time observer of SAMHSA; Dr. 

Sally Satel, a member of the National Advisory Council to 

SAMHSA’s Center for Mental Health Services for 4 years; and Joe 

Bruce, a family man from Caratunk, Maine, whose life was irrevocably changed by one SAMHSA program in particular. 

4 

Joe’s wife, Amy, was murdered by their son, Will, only months 

after being released from a psychiatric hospital where he had been 

treated for schizophrenia. Reflecting on this horrific act several 

years ago, Will noted that, un-medicated at the time, he believed 

he was a clandestine operative under orders to kill his mother, an 

Al Qaeda operative. Joe believes the efforts of a SAMHSA-funded 

organization obtained his son’s premature release from the hospital 

without putting in place a mechanism for ensuring that Will would 

remain on his medication. Joe, we extend our condolences to you 

and your family, and thank you for sharing your moving story with 

us today. 

We will also hear from Dr. Joseph Parks, III, Chief Clinical Officer of the Missouri Department of Mental Health, who has substantial experience working with SAMHSA grant funded-projects. 

And I want to thank all of our witnesses for being here today. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

Since I became the Chairman of the Subcommittee on Oversight and Investigations, shortly after the December 14, 2012, elementary school shootings in Newtown, 

we began looking into the federal programs and resources devoted to mental health 

and mental illness. We did so to ensure federal dollars devoted to mental health are 

reaching those individuals with serious mental illness and helping them obtain the 

most effective care. 

One lesson we must immediately draw from the Newtown tragedy is that we need 

to make it our priority to get those with serious mental illnesses, who are not presently being treated, into sound, evidence-based treatments. 

In 2009, the Substance Abuse and Mental Health Services Administration 

(SAMHSA) estimates that about 11 million U.S. adults had serious mental illness, 

and 40 percent of these individuals did not receive treatment. While the vast majority of individuals with a mental health condition are nonviolent, Director of the National Institute for Mental Health, Dr. Thomas Insel, told this subcommittee at our 

March 5 public forum that effective treatments, which include medication adherence 

and evidence-based psychosocial therapy, can reduce the risk of violent behavior fifteen-fold in persons with serious mental illness. 

Getting these individuals into treatment is a crucial first task and SAMHSA, as 

the federal agency whose mission includes reducing the impact of mental illness on 

America’s communities, should be playing a central role in this effort. But based on 

our work to date, SAMHSA has not made the treatment of the seriously mentally 

ill a priority. In fact, I’m afraid serious mental illness such as schizophrenia and 

bipolar disorder may not be a concern at all to SAMHSA. 

Consider the 2011–2014 SAMHSA strategic plan entitled ‘‘Leading Change.’’ 

SAMHSA continues to think in broad terms of ‘‘behavioral’’ and ‘‘emotional’’ health, 

promoting such concepts as ‘‘wellness’’ and ‘‘recovery.’’ Not once in this entire 117 

page document will you find the words schizophrenia or bipolar disorder. Nowhere 

in the testimony that was provided to this committee yesterday by the SAMHSA 

administrator do those words appear. And nowhere on SAMHSA’s web site or in 

their publications can you learn about the increased risk of violent behavior by persons with untreated serious mental illness. 

It’s as if SAMHSA doesn’t believe serious mental illness exists. 

If we’ve learned one thing from the horrible acts committed by Seung-Hui Cho 

at Virginia Tech in 2007, Jared Loughner in Tuscon, James Holmes at the Aurora, 

Colorado, theater in July 2012, or Adam Lanza, it is that the individuals with untreated severe mental illness are a significant target for self-directed violence, including suicide, or violence against others. In at least 38 of the last 62 mass killings, 

the perpetrator displayed signs of possible mental health problems. In so many of 

these instances, parents desperately tried to get their mentally ill loved one help 

before the act. Sadly, they failed because the current system of care for those with 

serious mental illness is broken. 

Examining what SAMHSA is doing to grapple with this heartbreaking truth is 

the main reason we are gathered here this morning. 

The Center for Mental Health Services, housed at SAMHSA, has a budget of approximately $1 billion per year. It awards most of these funds through a combinaVerDate Nov 24 2008 14:18 Nov 22, 2013 Jkt 037690 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-47 CHRIS
5 

tion of competitive and formula grants. I’m concerned, because the committee has 

seen substantial evidence that too many of these grants are directed to advancing 

services rooted in unproven social theory and feel-good fads, rather than science. 

If SAMHSA were to use an evidence-based approach to identifying how to 

prioritize its resources—like other federal agencies do—would their record, not to 

mention their strategic initiatives going forward, look the same as they do now? 

For example, in 2012, an annual conference that has been funded by SAMHSA 

for many years—and at which the SAMHSA administrator regularly delivers a keynote—Alternatives, an hour and a half workshop was held, described as follows: 

Unleash the Beast is a mind/body fitness program that looks to the animals of 

the jungle for wisdom and skills that can benefit our lives in a myriad of ways. 

Through animal-inspired movements, behaviors, and expressions, participants are 

encouraged to shed layers of formal conditioning in order to return to their primal 

nature. 

While mental and physical health is important, I question the value of this exercise in advancing the treatment for mental illness in humans. And, I question if 

there is any scientific merit. 

I would also ask why SAMHSA provides grant funding, year after year—in the 

millions of dollars in aggregate—to organizations that are outwardly hostile to the 

sciences of psychiatry and psychology. These groups deny that mental illness exists, 

claiming there is nothing out-of-the-ordinary when an individual hears voices or experiences extreme mental states—and that these should be celebrated as nature’s 

gifts to mankind, contributing to artistic creativity and human diversity. 

Leaders of these organizations—including at least one of which SAMHSA has elevated to the status of a ‘‘National Technical Assistance Center’’ and received at least 

$300,000 in taxpayer dollars the past year—have actively encouraged supporters to 

‘‘Occupy’’ the 2012 annual convention of the American Psychiatric Association—decrying the professional association’s role in developing the Diagnostic and Statistical 

Manual of Mental Disorders, or DSM. ‘‘Psychiatric labeling,’’ they say, is ‘‘a pseudoscientific practice of limited value in helping people recover.’’ 

When SAMHSA-funded organizations are not busy encouraging those with mental 

illness to go off their prescribed medications or destroying trust between individuals 

with serious mental illness, their family caregivers, and their physicians, these taxpayer-backed groups are actively lobbying against effective evidence-based treatment like Assisted Outpatient Treatment (AOT) laws—a less restrictive alternative 

to involuntary commitment. Numerous academic studies have shown AOT to be incredibly effective in reducing re-hospitalizations and re-arrests among, until-then, 

untreated individuals with serious mental illness. 

As an agency of the U.S. Public Health Service, we expect SAMHSA’s work to be 

firmly rooted in evidence-based practices, enduring high-level scientific peer review 

at the hands of licensed mental health professionals. Perhaps some of it is but much 

of it appears to fall far short of such standards. 

To get answers to our questions, this morning we will hear from Pamela Hyde, 

the Administrator of SAMHSA since 2009, on our first panel. On our second panel, 

we will hear from E. Fuller Torrey, a psychiatrist and long-time observer of 

SAMHSA; Dr. Sally Satel, a member of the National Advisory Council to SAMHSA’s 

Center for Mental Health Services for four years; and Joe Bruce, a family man from 

Caratunk, Maine, whose life was irrevocably changed by one SAMHSA program in 

particular. 

Joe’s wife, Amy, was murdered by their son, Will, only months after being released from a psychiatric center where he had been treated for schizophrenia. Reflecting on this horrific act several years ago, Will noted that, un-medicated at the 

time, he believed he was a clandestine operative under orders to kill his mother, 

an Al Qaeda operative. 

Joe believes the efforts of a SAMHSA-funded organization obtained his son’s premature release from the hospital without putting in place a mechanism for ensuring 

that Will would remain on his medications. Joe—we extend our condolences to you 

and your family, and thank you for sharing your moving story with us today. 

We will also hear from Dr. Joseph Parks III, Chief Clinical Officer of the Missouri 

Department of Mental Health, who has substantial experience working with 

SAMHSA grant funded-projects. Thank you to all our witnesses today. 

# # # 

Mr. MURPHY. I would now like to give the ranking member an 

opportunity to give remarks of her own. 

6 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you very much, Mr. Chairman. Your passion about this issue is evident. We appreciate everything that you 

are doing to have these hearings on mental illness and gun violence. I want to join you in welcoming all of our witnesses here 

today and looking forward to hearing your perspectives on 

SAMHSA. 

As we all know, Congress has directed SAMHSA to provide services to prevent, treat, and recover from mental health and substance abuse disorders. The Agency administers a number of funding streams, including competitive, formula, and block grant programs. It also collects data on mental illness, behavioral health, 

and substance abuse. Chairman Murphy and I have been working 

together to identify areas where, on a bipartisan basis, we can 

agree to commonsense solutions. 

And in his opening statement, the chairman has identified a 

number of important issues regarding SAMHSA that we need to 

work together to address. Some of those criticisms I think really do 

merit this committee’s consideration. Other criticisms that we see 

out in the world only distract us from our real purpose, which is 

to ensure that we identify people who are living with mental illness 

before crisis situations arrive and make sure that they can get the 

mental health treatment that they so desperately need. 

For example, we will hear that SAMHSA is too focused—actually, we did hear in the chairman’s opening statement that 

SAMHSA is too focused on substance abuse programs, not dedicated to addressing serious mental illness. And in fact, mental 

health programs account for 27 percent of SAMHSA’s overall budget in fiscal year 2013 and substance abuse comprises 68 percent of 

its budget. And so if this is really a legitimate problem that is leading towards a lack of addressing serious mental health issues, then 

it is Congress’ responsibility to fix that. 

Every year, Congress determines through the appropriations 

process what SAMHSA spends on mental health versus substance 

abuse. And so if Congress wants SAMHSA to focus more on mental 

health, we should work together to provide the Agency with more 

resources to do so. And I look forward to working with the chairman and the rest of the members of this committee to make that 

happen as the appropriations process develops this spring. 

I also would be happy to work with the chairman and everyone 

on this committee to ensure that the Agency has the resources it 

needs to do the job and that we enact legislation that guarantees 

that we actually fund the programs that we think are important. 

Another criticism that we have heard and I agree with it is that 

we don’t have enough data to know what programs SAMHSA funds 

are working well with and what are not, but you will not find a 

bigger advocate in Congress for science-based research than me. I 

have been fighting for it in every area for decades: abstinence-only 

sex education, stem cell research, on and on and on. And if we 

want these programs to work, they have to be science-based. 

And so what we need to do is make sure that SAMHSA, States, 

and other grantees have clear reporting requirements and metrics 

7 

so that in fact we can measure what worked and what doesn’t work 

and that we can measure progress. 

And so I am hoping, Mr. Chairman, that we can work together 

on this, too, improving SAMHSA reporting requirements and figuring out on an evidence-based basis what really works. 

Now, I just want to raise one concern about these hearings. This 

is the third proceeding on mental health, and for the third time we 

don’t have a witness appearing to provide the perspective of people 

who are living with mental illness. We discussed this the other 

day. We keep talking about issues that affect their daily lives. We 

keep having providers and family members and others coming in 

to talk about people with mental illness but we haven’t had people 

who have mental illness directly talk to us, and I think there are 

people who would be willing to come forward and talk about their 

concerns and their issues, which of these SAMHSA programs work 

for them, which of them don’t work for them. What about the privacy provisions and what about the everything, the funding and everything? So I am hoping in our next hearing we could have a 

panel of people who have mental illness to talk about from their 

perspective what works and doesn’t work. 

Finally, as we discuss ways in which SAMHSA invests in the 

prevention and treatment of mental illness in this country, I think 

that it is important that we do not lose sight of the key role recently enacted legislation plays in advancing our shared goal of improving access to mental health services for the millions of Americans experiencing mental illness. 

The Mental Health Parity Act—which Chairman Murphy and I 

both cosponsored along with a number of other members of this 

committee—ensures that group health plans and ensures offering 

mental health and substance use disorder benefits do so in a manner that is comparable to coverage for general medical and surgical 

care. The Affordable Care Act, building on this parity legislation, 

will expand mental health and substance use disorder benefits and 

parity protections for 62 million Americans. The implementation of 

the Affordable Care Act and continued support of SAMHSA programs that work will go a long way in ensuring that people with 

serious mental illness have access to the treatments they need. 

I yield back, Mr. Chairman. Thank you for your comity. 

Mr. MURPHY. I thank the gentlelady for her comments. 

Now turning to the chairman of the full committee for 5 minutes, 

Mr. Upton. 

OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. UPTON. Well, thank you, Mr. Chairman. 

Today, we are here to examine the role of the Substance Abuse 

and Mental Health Services Administration (SAMHSA) in delivering services to the severely mentally ill, and I certainly appreciate the chairman’s interest, passion, and professional insight regarding this issue. 

In the wake of the tragic shootings at Sandy Hook, this subcommittee has stepped up to examine an important question: what 

is the federal government doing to address serious mental illness? 

And I commend the chairman for leading this investigation. 

8 

While the vast majority of individuals with a mental health condition are nonviolent, in March, the Subcommittee learned from 

Dr. Tom Insel, Director of the NIH, National Institute of Mental 

Health, the important fact that treatment can reduce the risk of 

violent behavior 15-fold in persons with serious mental illness. This 

morning, we direct our attention to the primary federal agency responsible for supporting community-based treatment services for 

mental illnesses. 

With an annual budget of nearly $1 billion, SAMHSA’s Center 

for Mental Health Services could serve as a key part of the Federal 

Government’s efforts to address the tragic impacts on our society 

of such serious mental illnesses as major depression, schizophrenia, 

and bipolar disorder. This includes connecting these individuals 

with effective treatments at a time when 40 percent of adults with 

serious mental illness report not receiving any treatment at all. 

Not doing so increases the chances that the next James Holmes or 

the next Adam Lanza will in fact fall through the cracks. 

Unfortunately, I am concerned that SAMHSA may not be directing those dollars to treat those with the most severe of mental illnesses. Further, I am also concerned about the commitment to 

science and the scientific process—including psychiatry—displayed 

by several major grant recipients. We need to be investing our dollars in the programs with the best record for treating those who 

have mental illnesses. 

[The prepared statement of Mr. Upton follows:] 

PREPARED STATEMENT OF HON. FRED UPTON

Today we are here to examine the role of the Substance Abuse and Mental Health 

Services Administration (SAMHSA) in delivering services to the severely mentally 

ill. In the wake of the tragic shootings at Sandy Hook Elementary School in Newtown, Connecticut, this subcommittee has stepped up to examine an important question: what is the federal government doing to address serious mental illness. I commend Chairman Murphy for leading this investigation. 

While the vast majority of individuals with a mental health condition are nonviolent, in March, the subcommittee learned from Dr. Tom Insel, Director of the National Institute of Mental Health, the important fact that treatment can reduce the 

risk of violent behavior fifteen-fold in persons with serious mental illness. This 

morning, we direct our attention to the primary federal agency responsible for supporting community-based treatment services for mental illness. 

With an annual budget of approximately $1 billion, SAMHSA’s Center for Mental 

Health Services could serve as a key part of the federal government’s efforts to address the tragic impacts on our society of such serious mental illnesses as major depression, schizophrenia, and bipolar disorder. This includes connecting these individuals with effective treatments at a time when 40 percent of adults with serious 

mental illness report not receiving any treatment. Not doing so increases the 

chances that the next James Holmes, the next Jared Loughner, and the next Adam 

Lanza will fall through the cracks. 

Unfortunately, I am concerned that SAMHSA may not be directing those dollars 

to treat those with the most severe of mental illnesses. Further, I am also concerned 

about the commitment to science and the scientific process—including psychiatry— 

displayed by several major grant recipients. We need to be investing our dollars in 

the programs with the best record for treating those who have mental illnesses. 

As the experts joining us today, including Doctors Torrey and Satel will share 

with us, SAMHSA’s programs do very little for those at the extreme end of the spectrum of mental illness, who lack awareness of their own condition, who deny that 

they have a disorder demanding treatment, and who see no reason to follow a medication regimen. I want to especially thank our witness, Joe Bruce, for joining us 

today to share his family’s tragic story. 

9 

I also welcome Administrator Hyde and look forward to hearing about her agency’s plans to address these concerns about the most vulnerable among our nation’s 

mentally ill. 

# # # 

Mr. UPTON. And at this point I will yield the balance of my time 

to Dr. Burgess. 

Mr. BURGESS. I thank the chairman for yielding. 

You know, the recent notorious tragedies have brought to light 

the challenges that are faced by those suffering from mental illness 

today in the United States. Certainly SAMHSA has an important 

role as the point agency to address mental health issues, but out 

of their budgets there are questions that have come up about the 

lack of oversight and accountability. Is it in the public’s interest to 

use limited SAMHSA funding to encourage alternate approaches to 

treating mental illness? Is it the best use of their funding to support an organization that lobbies against programs that encourage 

proven treatment methods such as psychiatric medication adherence? 

And now, we are going to hear from witnesses in the second 

panel who raised serious questions about the use of the funding to 

commission oil paintings and providing for an annual staff musical 

within the agency. This agency is responsible to use its resources 

to ensure that the almost 10 million Americans with mental illness 

can be productive members of society. It is our job on the committee to assess both the successes and the shortfalls of the Agency 

to determine where the Agency’s resources can be used most effectively and ensure they are doing their best job. 

I look forward to hearing about that today and I will yield the 

balance of the time to Dr. Gingrey. 

Mr. GINGREY. I want to thank you again, Mr. Chairman, for your 

leadership on this important issue. I want to thank Dr. Burgess as 

well and highlight one particular perspective that is often overlooked: adherence to a planned treatment. All too often, individuals 

suffering from mental illness, substance abuse disorders, or both 

are under the treatment of a qualified medical professional. They 

have been prescribed an appropriate regimen of medicine, yet they 

struggle to take their medication consistently. This results in relapses and, of course, disease progression. As you know, relapses 

result in significant suffering, increased cost to the patient and the 

healthcare system, and in some cases, violent, criminal behavior. 

Mr. Chairman, as we seek today to highlight the most efficient 

use of federal resources for this particular vulnerable population, 

I believe that improving adherence, whether by novel drugs or innovated management of the disease, is particularly important and 

I look forward to working with the Subcommittee to pursue policies 

particularly at SAMHSA to ensure the best possible treatment options available to providers and patients confronting mental illness 

and substance abuse in order to improve health and health economic outcomes. 

Mr. Chairman, thank you for your patience and I yield back. 

Mr. MURPHY. The gentleman yields back. I now recognize for 5 

minutes Mr. Butterfield. 

10 

OPENING STATEMENT OF HON. G.K. BUTTERFIELD, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NORTH 

CAROLINA 

Mr. BUTTERFIELD. Let me thank you, Mr. Chairman, for yielding 

time. I thank the ranking member, Ms. DeGette, for her comments 

and I want to associate myself with each word that she uttered a 

few minutes ago. She is exactly correct. 

I thank the chairman of our full committee, Mr. Upton, and all 

of you who have a profound interest in the subject. 

This is a very, very important subject not just in my congressional district but throughout the country. Let me say good morning to the witnesses and thank you so very much for coming today 

to be a part of this process. 

Funding from the Substance Abuse and Mental Health Services 

Administration—and we call it SAMHSA—has helped my State 

enormously. It has helped probably every State in the country but 

I can speak specifically to my State. For fiscal year 2012 my State 

of North Carolina received $20 million from Mental Health Services. And if my colleagues will check, you will see that there has 

been significant federal investment with this population all across 

the country. It is a good program. It is a valuable program. 

In my congressional district, the Durham County Health Department, for example, received funds to enhance services and support 

available to 16- to 21-year-olds with serious mental health issues 

and their families. Also, the Child and Parent Support Services, Incorporated, in Durham received funds to assist clinicians working 

with child welfare and even military families. 

But we continue to see cost-cutting measures like sequestration 

and the Ryan budget which endanger important programs like 

those in Durham and throughout my State and throughout the 

country. There is an article this morning in the Hill Newspaper 

that even warns of round two of sequestration. So many of our citizens think that sequestration was a 1-year proposition, but it is a 

9-year proposition and now we are getting ready for round two. 

And Mr. Chairman, we have done absolutely nothing to fix sequestration. I support full repeal of sequestration. 

Mr. Chairman, the 2013 spending plan that SAMHSA released 

earlier this month shows that the sequester will result in cuts of 

over $200 million in SAMHSA funding this year, a cut of almost 

6 percent, and next year, it would certainly be more. Every single 

SAMHSA program will be affected. Our citizens need to know that. 

Every SAMHSA program will be affected. The Mental Health 

Block Grant Program is being cut by $23 million. Children’s mental 

health services are cut by $6 million. Suicide prevention funds will 

be cut; programs to help the mentally ill people who are homeless 

will be cut. This will mean fewer SAMHSA grants and fewer people 

with access to mental health services. 

Mr. Chairman, we must continue to support those struggling 

with mental illness and their families by continuing to strengthen 

these very important programs. 

At this time, I will yield the balance of my time to the gentlelady 

from Florida. 

11 

Ms. CASTOR. Well, I thank my colleague for yielding and I thank 

the chairman and the ranking member for calling this very important hearing. 

It is vital that this committee provide oversight of the mental 

health services provided by the Federal Government in partnership 

with state and locals and for families. What I hear consistently 

from families and mental health professionals at home is simply 

that the needs so far outstrip the resources that are available to 

families and professionals today. That point was made by Ranking 

Member DeGette, and she is right. 

For example, just yesterday, I had about 10 emergency room 

physicians, fairly new doctors, pay a visit up here on Capitol Hill 

and our conversation got to the point of what they do every day 

when they are confronted with some of our neighbors who have 

mental health issues, and they made a point again, there simply 

aren’t enough places for people to receive counseling and treatment. They said just what we know, one of the real problems is the 

laws say unless someone is a danger to themselves or to others, 

they are going to be discharged. And that is simply not going to 

help us address the needs of our families. 

This is similar to what I hear from school districts, teachers, and 

families and schools. They know when young children have issues 

and there are great counselors out there but significantly not 

enough to provide the basic treatment and counseling that they 

need to make sure that they are healthy and can succeed in school. 

So we need to focus on what works in our community. I hope we 

will be able to address that today. 

The answers are different for the Tampa Bay area than they are 

from rural areas across the country, but what we have in common 

is that the needs far outstrip the resources available. 

And Mr. Chairman, at this time, I would like to ask unanimous 

consent to place into the record Ranking Member Waxman’s statement for this hearing today. 

Mr. MURPHY. Without objection, thank you. We have a copy of 

that now. Thank you. 

[The prepared statement of Mr. Waxman follows:] 

PREPARED STATEMENT OF HON. HENRY A. WAXMAN

Mr. Chairman, I want to thank our witnesses for coming today. I appreciate Administrator Hyde being here, and I want to particularly thank Mr. Bruce for traveling here to share his tragic story. I appreciate his bravery in joining us. His 

story—and those we’ve heard from other families—is a powerful reminder of why 

this Committee needs to act to improve mental health services and treatment. 

Mr. Chairman, I know how important this issue is to you. And I know that you 

are serious about improving mental health care in this country. 

But I do worry about our progress. After the tragic Newtown massacre, I was 

hopeful about efforts to improve the mental health care system and make sure that 

those suffering from serious mental illnesses received the diagnoses and treatment 

that they need. 

Six months later, I am much less confident. Since Newtown, Congress has done 

nothing to advance mental health proposals. In fact, we’ve lost ground. 

Last week, the House voted to repeal the Affordable Care Act—the law that builds 

on bipartisan mental health parity efforts to extend mental health and substance 

use disorder benefits and parity protections for 62 million Americans. 

And we have done nothing to fix sequestration, which represents a major reversal 

of progress. Mr. Chairman, the 2013 spending plan that SAMHSA released earlier 

12 

this month shows that the sequester will result in cuts of over $200 million in 

SAMHSA funding this year—a cut of almost 6%. 

Every single SAMHSA program will be affected. The Mental Health Block Grant 

program is being cut by $23 million. Children’s Mental Health Services are cut by 

$6 million. Suicide prevention funds will be cut. Programs to help mentally ill people who are homeless will be cut.This will mean fewer SAMHSA grants and fewer 

people with access to mental health services. 

According to Mental Health America, the sequester will mean that more than 1 

million children and adults will be at risk of losing access to any type of public mental health support . almost 30,000 mentally ill, homeless people will lose access to 

primary care referral, housing assistance, and other important services . more than 

11,000 professionals will lose access to youth suicide prevention training . and more 

than 1,500 at-risk youth will not be screened for mental health conditions. 

The list goes on and on. These cuts are mindless. They represent an enormous 

step backward in our efforts to prevent, diagnose, and improve treatment for those 

with mental illnesses. And they are happening as we speak. 

Mr. Chairman, this Committee needs to act. The sequester is creating a slow-motion crisis for those with mental illnesses, and we need to work together to end it. 

But we should not only end the sequester—we should work together to strengthen 

our laws and improve funding so those suffering from serious mental illnesses are 

identified, receive better services, and achieve better outcomes. 

This Subcommittee has done important work. Through our series of briefings, forums, and hearings, we have learned about what works and what doesn’t, and 

where the funding and legislative gaps exist in our nation’s mental health care system. 

Now, Mr. Chairman, it’s time for us to act together, in a bipartisan way, to fill 

those gaps and chart a new course in the provision of mental health services for 

those in need. I look forward to working with you and my colleagues to achieve 

those goals. 

Mr. MURPHY. All right. I would now like to introduce the witness 

on the first panel for today’s hearing. Our first witness is Pamela 

Hyde. She was nominated by President Barack Obama and confirmed by the U.S. Senate in November 2009 as administrator of 

the Substance Abuse and Mental Health Services Administration. 

Ms. Hyde is an attorney and comes to SAMHSA with more than 

35 years of experience in management and consulting for public 

health care and human services agencies. She served as a state 

mental health director, state human services director, city housing 

and human services director, as well as CEO of a private nonprofit 

managed behavioral healthcare firm. 

Welcome today, Ms. Hyde. Now, I will swear you in. As you are 

aware, the Committee is holding an investigative hearing. When 

doing so, we have the practice of taking testimony under oath. You 

have any objections to testifying under oath? 

Ms. HYDE. No, sir. 

Mr. MURPHY. And the chair then advises you that under the 

rules of the House and rules of the Committee, you are also entitled to be advised by counsel. Do you desire to be advised by counsel during your testimony today? 

Ms. HYDE. No, thank you. 

Mr. MURPHY. You probably can provide that for yourself then. 

In that case, if you would please rise and raise your right hand, 

I will swear you in. 

[Witness sworn.] 

Mr. MURPHY. Thank you. You are now under oath and subject to 

the penalties set forth in Title XVIII, Section 1001 of the United 

States Code. You are now welcome to give a 5-minute summary of 

your written statement, Ms. Hyde. 

13 

TESTIMONY OF PAMELA S. HYDE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION 

Ms. HYDE. Thank you, Congressman Murphy and Ranking Member DeGette, for holding this hearing today. It is an important conversation and I am sure, as you are aware, you have already stated 

you know that SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 

I would like to take just a few moments to remind you that 

SAMHSA is a small agency with a very big mission. While our 

funding is small, we use every opportunity to impact the public and 

private funders of mental health services. We collaborate and influence our sister agencies in HHS and across Federal Government, 

and we work with States, tribes, territories, communities, and 

stakeholders to help advance the behavioral health of the Nation. 

SAMHSA has many roles. Funding is one of them but it is not 

the only one. We also provide leadership and voice for and about 

behavioral health issues, and that includes substance abuse. It also 

includes mental illness. It includes prevention, treatment, and recovery. We also do surveillance and data reporting. We provide 

funding, as we indicated, and we also work to improve practice 

with a number of materials and trainings, and we look at evidencebased practices, as well as practices coming to science. And we provide information to the public in the field, our public awareness 

and education responsibility, and we also have some responsibility 

for setting standards and regulations in certain areas. 

I want to just make a quick comment about mental health financing because it goes to SAMHSA’s role. The mental health 

spending for mental illness in our country was only about 6.3 percent of all health spending in 2009. That is far below the importance of mental health and mental illness in our healthcare issues. 

Mental health treatment spending depends much more on public 

payers than other kinds of health spending, about 60 percent of 

mental health spending compared to 49 percent of all health care 

spending. 

For public spending, Medicaid and Medicare are by far the largest payers for services, and when you add their 40 percent to about 

26 percent of private insurance, then insurance—Medicaid, Medicare, and private insurance—accounts for about 2/3 of mental 

health spending followed by state and local governments’ out-ofpocket spending and then a small portion of federal spending, and 

that is where SAMHSA’s dollars are. So our dollars are a fairly 

small part of that larger overall effort. 

About 29 percent, as it was indicated earlier today, is SAMHSA’s—it is about $3 billion—3 plus billion dollars, about 29 

percent of it is for mental health. About 70 percent of it is for substance abuse. Of our mental health dollars, about 27 percent of our 

total budget is for mental health services, about 2 percent, give or 

take, is for surveillance data, public awareness, and other kinds of 

efforts. This distribution between substance abuse and mental 

health issues has been about the same for the last 5 years. 

Within the mental health budget of SAMHSA, about half of it is 

block grant services, which is specifically for people with serious 

mental illness and young people with serious emotional disturbVerDate Nov 24 2008 14:18 Nov 22, 2013 Jkt 037690 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-47 CHRIS
14 

ance, and the balance of SAMHSA’s mental health budget provides 

support for a range of mental health prevention, treatment, and recovery support services, all as directed by Congress. Altogether, 

SAMHSA’s mental health budget is spent on about—75 to 80 percent of it is spent on adults with SMI or children with SED, or serious emotional disturbance. 

Congress has made significant investments as well in the prevention, emotional health development, and promotion in early intervention for mental health issues, and SAMHSA does administer 

some of those programs. 

In a very short time that I have left, I just want to highlight a 

couple of programs. Our Mental Health Block Grant of course is 

about half of our mental health spending. It is a flexible but critical, important part for the States that primarily serves people 

with evidence-based approaches who are not otherwise covered by 

insurance or other efforts and who—or the services are not otherwise covered. So Medicaid, Medicare, private insurance may pay for 

the basics like medication, inpatient, those sorts of issues. The 

Mental Health Block Grant often supplements those services with 

other important and evidence-based approaches. 

We also have some approaches such as our Children’s Mental 

Health Initiative. It is a huge part of our program that has since 

1994 served over 122,000 young people with serious emotional disorders with great results. We also have a program at about $43 

million that is the National Child Traumatic Stress Network, and 

it has been in existence for about 10 years and has provided evidence-based approaches to dealing with young people with trauma. 

Our Primary and Behavioral Health Integration Program is a 

program explicitly focused on the health of adults with serious 

mental illness and we have had major improvements in the health 

impacts for those individuals in that program. We also have a program for assistance for transition from homelessness, which primarily serves adults with serious mental illness or people with 

mental illness and co-occurring disorders who are homeless. 

We also have a Youth Violence Prevention Program that Congress has provided resources for us to work on, and that federal 

grant program is designed to prevent violence and substance abuse 

among our Nation’s youth, schools, and communities. We do a lot 

of that work in conjunction with education. We also have a major 

program, about $33 million, called LAUNCH, which is specifically 

for children aged 0 to 3—to 8 to try to work on prevention, early 

intervention. 

We also do—and I want to make a point here because of what 

is going on in Oklahoma right now that one of the major issues 

that SAMHSA works on is disaster response and preparedness. So 

whether it is Tucson, Sandy Hook, Aurora, or major disasters and 

weather-related emergencies such as Oklahoma, we do a lot of response. 

Mr. MURPHY. Sorry. If you could give your wrap-up now. 

Ms. HYDE. I think I will end there and let you ask questions. 

Thank you very much. 

[The prepared statement of Ms. Hyde follows:] 

15 


85437.001

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W\\i¥HMI\lIS1l.\1(\\1 * 1·!k.""1·SAMHSA·1 fh8.77-7M,,1;121} 

Testimony Before the 

The Energy and Commerce Subcommittee on Oversight and Investigations 

"Examining SAMHSA's Role in Delivering Services to the Severely 

Mentally III" 

May 22,2013 

Statement of Pamela S. Hyde, J.D. 

Administrator 

Substance Abuse and Mental Health Services Administration 

U.S. Department of Health and Human Services 
16 


85437.002

Good moming Chairman Murphy, Ranking Member DeGette and Members of the 

Subcommittee, Thank you for the opportunity to testifY today about the mission and priorities of 

the Substance Abuse and Mental Health Services Administration (SAMHSA), including services 

for adults with serious mental illness and children with serious emotional disturbance. 

SAMHSA accomplishes its mission through partnerships, policies, products, and programs that 

build resilience, improve treatment, and facilitate recovery for people with or at risk for mental 

and substance use disorders. 

SAMHSA's Role 

SAMHSA was established in 1992 and is directed by Congress to effectively target substance 

abuse and mental health services to the people most in need of them and to translate research in 

these areas more effectively and more rapidly into the general health care system. SAMHSA's 

mission is to reduce the impact of substance abuse and mental illness on America's communities. 

SAMHSA strives to create awareness that: 

• Behavioral Health is essential for health; 

• Prevention works; 

• Treatment is effective; and 

• People recover from mental and substance use disorders. 

SAMHSA serves as a national voice on mental health and mental illness, substance abuse, and 

behavioral health systems of care. It coordinates behavioral health surveillance to better 

understand the impact of substance abuse and mental illness on children, individuals, and 

families as well as the costs associated with treatment. SAMHSA helps to ensure dollars are 

invested in evidence-based and data-driven programs and initiatives that result in improved 

health and resilience. 

SAMHSA applies strategic, data-driven solutions to field-driven priorities. To this end, 

SAMHSA helps states, territories, and tribes build and improve basic and proven practices and 

system capacity by encouraging innovation, supporting more efficient approaches, and 

incorporating research-based programs and best practices into funded programs so they can 

produce measureable results. In addition, SAMHSA's longstanding partnerships with other 

Federal agencies, systems, national stakeholders, and the public have uniquely positioned 

SAMHSA to collaborate and coordinate across multiple program areas, collect best practices and 

develop expertise around behavioral health services, and, understand and respond to the full 

breadth of the behavioral health needs of children, individuals and families across the country. 

Substance abuse, addictions, poor emotional health, and mental illnesses take a toll on 

individuals, families, and communities. These conditions cost lives and productivity, and strain 

families and resources in the same way as untreated as physical illnesses. SAMHSA works to 

focus the Nation's attention on these preventable and treatable problems. 

2 
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85437.003

Mental Health and Substance Abuse Data 

Health surveillance is critical to SAMHSA's ability to develop new models of care to address 

substance abuse and mental illness. SAMHSA provides decision makers, researchers and the 

general public with enhanced information about the extent of substance abuse and mental illness, 

how systems of care are organized and financed, when and how to seek help, and about effective 

models of care, including the outcomes of treatment engagement and recovery. 

It is estimated that almost half of all Americans will experience symptoms of a mental health 

condition - mental illness or addiction - at some point in their lives. Yet, today, less than one in 

five children and adolescents with diagnosable mental health problems receive the treatment they 

need. 1 And according to data from SAMHSA's National Survey on Drug Use and Health 

(NSDUH), only 38% of adults with diagnosable mental health problems - and only 11% of those 

with diagnosable substance use disorders - receive needed treatment.2 

With respect to the onset of behavioral health conditions, half of all lifetime cases of mental and 

substance use disorders begin by age 14 and three-fourths by age 24.3 

Currently, SAMHSA supports national surveys and surveillance, including the National Survey 

on Drug Use and Health, Drug Abuse Warning Network, and Drug and Alcohol Service 

Information System. SAMHSA also supports the behavioral health field by sharing information 

about evidence-based practices through tools such as the National Registry of Evidence-based 

Programs and Practices. SAMHSA also uses the Web, print, social media, public appearances, 

and the press to reach the public, providers and other stakeholders, including people in recovery 

and their families. 

Practice Improvement 

SAMHSA supports innovation and practice improvement by disseminating key evidence-based 

mental health and substance use practices, such as Treatment Improvement Protocols, Technical 

Assistance Publications, The National Registry of Evidence-based Programs and Practices, and 

evidenced-based toolkits, to the mental health and substance abuse delivery system and 

facilitates practice improvement by engaging in activities that support mental health system 

transformation and reform. One of SAMHSA's roles is to provide grants and contracts 

consistent with congressionally-appropriated funding. SAMHSA uses this crucial funding to 

create, test, and disseminate models of services and programs to improve the Nation's behavioral 

health care delivery systems as well as the promotion of mental health and the prevention of 

mental illness and addictions in children and adults. Additionally, SAMHSA holds policy 

academies for states, tribes and territories, provides technical assistance, training, and guidance 

I Unmet Need for Mental Health Care Among U S. Children: Variation by Ethnicity and Insurance Status 

Sheryl H Kataoka, M,D" M,S,HS,: Lily Zhang, M.s, Kenneth B. Wells, M,D" M,P,H" Am J Psychiatry 2002:1591548-1555, 

10.1 1 76/appLajp, 1 59,9, 1548 

2 Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Dntg Use and Health: Mental Health 

Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12~4725, Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2012. 

) Kessler, R. c., Berglund, P., Demler, 0" Jin, R., Merikangas. K R., & Walters, E E. (2005). Lifetime prevalence and age~of-onset distributions 

of DSAI-1V disorders in the National Comorbidity Survey Replication. Archiws o.fGeneral Psychialry, 62(6), 593-602, 

3 
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85437.004

for the behavioral health field, supports innovation in evaluation and research, moves 

innovations and evidence-based approaches to scale, identifies and disseminates new and 

emerging practices from the field, and cooperates with national and international partners to 

identifY promising approaches to supporting behavioral health. 

Public Education and Awareness 

Today in the United States, opportunities to prevent or intervene early to reduce disability and 

death associated with mental illness and substance use disorders are often missed. The tragedy at 

Sandy Hook Elementary School in December 2012 underscores the importance of educating the 

American people about mental health and what we can do to connect people in need with 

services. By learning to recognize the signs and symptoms of mental illness and substance 

abuse, friends and family members can help their loved ones take action and seek care. Trained 

health professionals can also work with individuals and families to identifY problems early. 

To help with its public education effort, SAMHSA supports public awareness campaigns, 

produces and distributes public education materials, releases data from its surveillance and data 

collection efforts, and increasingly uses electronic and social media to help disseminate 

information to the public and the field. By confronting fear and misunderstanding with facts, 

raising awareness about the effectiveness of prevention and treatment, and improving knowledge 

about when and where to seek help, SAMHSA helps bring mental illness and addictions out of 

the shadows and helps the nation achieve the full potential of the science behind the prevention 

and treatment of mental illnesses and substance abuse. 

Policy Development and Oversight 

SAMHSA protects and promotes behavioral health through regulation and standard setting. For 

example, SAMHSA works to prevent tobacco sales to minors through the Synar Program, 

administers the Federal drug-free workplace and drug-testing programs, oversees opioid 

treatment programs and accreditation bodies, informs physicians' office-based opioid treatment 

prescribing practices, and partners with other agencies at the U.S. Department of Health and 

Human Services in development and review of regulations and guidance documents affecting 

prevention, treatment and recovery support services that address mental health and substance 

abuse. 

Overview orthe Nation's Mental Health Spending 

According to SAMHSA's National Expenditures for Mental Health Services & Substance Abuse 

Treatment 1986 - 2009, at $147 billion, mental health spending accounted for 6.3 percent of all 

health spending in calendar year 2009, while substance abuse spending accounted for 

approximately one percent. Mental health treatment spending depended more on public payers 

than spending for all-health care in calendar year 2009; public payers accounted for 60 percent of 

mental health spending compared to 49 percent of all-health care spending. 

Medicaid and Medicare (40 percent) and private insurance (26 percent) accounted for 

approximately two-thirds of mental health spending in 2009, followed by state and local 

4 
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85437.005

governments at 15 percent, out-of-pocket at II percent, other Federal spending at 

five percent (including SAMHSA funding), and other private sources at three percent. 

Ilistrlbution 01 Spending on Mil Treatment by Payer, lOll9 

SAMHSA 's Budget 

In FY 2013, approximately 29 percent ($957.7 million) of SAMHSA's funding was appropriated 

or designated for mental health programs and activities, with the remainder directed to substance 

abuse programs and activities. This distribution of funding between substance abuse and mental 

health has been consistent for the last five years. Of the SAMHSA mental health funding, 

most ($915.3 million) supports prevention, treatment and recovery support programs and 

activities within SAMHSA's Center for Mental Health Services (CMHS). In addition to the 

CMHS funding, a portion ($42.4 million) ofSAMHSA's funding for the Health Surveillance and 

Program Support (HSPS) programs is used for the mental health activities. 

Center for MenIal Health Services (CMHS) 

Approximately 48 percent ($436.81 million) of CMHS funding is directed toward the 

Community Mental Health Services Block Grant, which provides services and supports for 

adults with serious mental illness4 and children with serious emotional disturbance.5 

The balance of the CMHS budget (52 percent) provides support for a range of mental health 

prevention, treatment and recovery support services as directed by Congress. In FY 2013, 

approximately 81 percent of the CMHS budget will support adults with and at risk for serious 

mental illness and/or children with serious emotional disturbance. 

4 Pursuant to Section 1912(c) of the Public Health Servke Act, SAMIISA's definition ofSMI can be found at: 

http://\V\\'w,samhsa,Qo\/hcalthreform/hcalthhomcs/Dclinitions SIM SLID 50S,pdf. 

5 Pursuantto Section 1911(c) of the Public Health Service Act, SAMHSA 's definition of SED can be found at: 

http://w\\\\,samhsa,Q,,,/healthrci()rm/hcalthhomcs/Dclinitions SIM SliD 50S,pdf. 

5 
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85437.006

Within the CMHS budget over the last five years, 75-80 percent of appropriated funding has 

been used for mental health programs in support of adults with serious mental illness and 

children with serious emotional disturbance. 

CMHSBudget 

FY 2013 Full Year CR 

CMHS Discretionary Programs 

Examples of SAMHSA Programs with National Impact 

To accomplish its work, SAMHSA administers a combination of competitive discretionary 

programs and block grant programs. This portfolio provides states and communities with 

support to establish or expand organized community-based systems of care for children with 

serious emotional disturbances and adults with serious mental illness through training, technical 

assistance, and provision of evidenced-based clinical and recovery support services. 

Community Mental Health Services Block Grant 

The Community Mental Health Services Block Grant is a key source of funding for communitybased services for adults with serious mental illness and children with serious emotional 

disturbances. In Fiscal Year (FY) 2013, $408.9 million, was awarded to states through the 

Community Mental Health Services Block Grant. It is a flexible funding source used by states to 

provide a range of mental health services and system infrastructure and capacity supports. States 

use these limited but significant funds to support planning, administration, evaluation, 

educational activities, and direct service delivery. Services typically are for those not covered by 

Medicaid, insurance or other sources, and for services not otherwise covered, and include 

rehabilitation services, erisis stabilization and ease management, peer specialist and consumerdirected services, wrap around services for children and families, supported employment and 

housing, jail diversion programs, and services for special populations. By law, states are not 

allowed to utilize these funds for inpatient services. 

Each state's Community Mental Health Services Block Grant application is based on a plan 

developed in collaboration with state mental health planning councils, which are required in 

order to receive block grant funding. Planning councils' membership is statutorily mandated to 

6 
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85437.007

include consumers, family members of adult and child consumers, providers, and representatives 

of other principal state agencies delivering, paying for, or impacting mental health services. 

The Community Mental Health Services Block Grant supports services and infrastructure for 

state mental health authorities that serve almost seven million adults with serious mental illness 

and children with serious emotional disturbance. 

SAMHSA has placed a strong emphasis on ensuring that Block Grant funds are expended in a 

manner consistent with the statutory and regulatory framework, including providing states the 

flexibility to address service needs and approaches they believe are most critical for the 

populations of adults with serious mental illness and children with serious emotional 

disturbances. Currently, the primary goals of SAMHSA program integrity efforts are to: 

(I) promote the proper expenditure of Block Grant funds; (2) improve Block Grant program 

compliance nationally; and (3) demonstrate the effective use of Block Grant funds, including 

using National Outcomes Measures such as readmission to any state psychiatric hospital within 

30 days and 180 days; proved functioning; and employment status. 

Children's Mental Health Initiative 

The Children's Mental Health Initiative (CMHI) provides $111.4 million in FY 2013 to states 

and communities to support the development of comprehensive, community-based systems of 

care for the estimated nine to 13 percent of children and youth with SED and their families. A 

system of care is a strategic approach to the delivery of services and supports that incorporate 

family-driven, youth-guided, strength-based, and culturally and linguistically competent care in 

order to meet the physical, intellectual, emotional, cultural, and social needs of children and 

youth. 

CMHI has served over 120,000 children and youth with serious emotional disturbance since the 

inception of the program. Data from the CMHI National Evaluation demonstrates that the 

system-of-care approach is effective. For example, school attendance and perfonnance 

improves, behavioral and emotional strengths are increased, and children and youth have more 

stable living conditions. Within six months of service in CMHI, the number of youth reporting 

suicide attempts or thoughts of suicide decreased. And, there were decreased contacts with law 

enforcement. Specifically, for youth involved in the juvenile justice system, arrests decreased by 

nearly 50 percent from intake into the program after 12 months of service in CMHI. 

The National Child Traumatic Stress Network 

Through the National Child Traumatic Stress Initiative (NCTSI), SAMHSA supports a national 

network of grantees-the National Child Traumatic Stress Network (NCTSN)-that works 

collaboratively to develop and promote effective trauma treatment, services and other resources 

for children and adolescents exposed to an array of traumatic events. The NCTSN Centers 

collaborate to develop, implement, and evaluate effective trauma screening, treatment and 

services, and partner with other community agencies to promote service delivery approaches so 

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that trauma services are effectively implemented within local child-serving community service 

systems. 

To date, NCTSI has developed and implemented 20 effective interventions to reduce immediate 

distress from exposure to traumatic events, developed and provided training in trauma-focused 

services for use in child mental health clinics, schools, child welfare and protective services, 

among other service areas; and developed widely used intervention protocols for disaster 

victims. In FY 2012,2,367 children and adolescents received trauma-informed services through 

the NCTSI program, and over 121,310 people were trained in annual training education events. 

In the same year, 76.1 percent of children receiving trauma-informed services reported positive 

functioning at six-month follow-up. 

Primary and Behavioral Health Integration 

SAMHSA administers the Primary and Behavioral Health Care Integration (PBHCI) program. 

The purpose of the program is to improve the physical health status of adults with serious mental 

illness by supporting communities to coordinate and integrate primary care services into publicly 

funded community mental health and other community-based behavioral health settings. The 

program supports community-based behavioral health agencies' efforts to build the partnerships 

and infrastructure needed to initiate or expand the provision of primary healthcare services for 

people in treatment for serious mental illness and co-occurring serious mental illness and 

substance use disorders. 

Since September 2009, the program has awarded 94 grants, and 55 percent of awardees are 

partnering with at least one Federally Qualified Health Center (FQHC). The Health Resources 

and Services Administration (HRSA) and SAMHSA collaborate to fund a national technical 

assistance center to help these grantees and FQHCs integrate primary and behavioral health care 

in both types of settings. This integration of care and agency efforts has resulted in significant 

physical and behavioral health gains as well as reduced health care expenditures. Some results 

that are based on grantee-reported outcome measures from February 20 I 0 through 

January 7, 2013, include: 

Health: The percentage of consumers who rated their overall health as positive increased 

by 20 percent from baseline to most recent reassessment (N=3737). 

Tobacco Use: The percentage of consumers who reported they were not using tobacco 

during the past 30 days increased by 6 percent from basel ine to most recent 

reassessment (N=3787). 

Illegal Substance Use: The percentage of consumers who reported that they were not 

using an illegal substance during the past 30 days increased by 12 percent from baseline 

to most recent reassessment (N=3568). 

Projects for Assistance in Transition from Homelessness 

The Projects for Assistance in Transition from Homelessness (PATH) is a unique program that is 

specifically authorized to address the needs of individuals with serious mental illness and/or 

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serious mental illness with a co-occurring substance use disorder who are experiencing 

homelessness or are at risk of homelessness. PATH funds community-based outreach, mental 

health, substance abuse, case management and other support services, as well as a limited set of 

housing services to connect homeless individuals to housing services and support them in 

community housing settings. In the past 5 years, the PATH program has reached approximately 

170,000 individuals each year, with an average of about 68,000 of those individuals becoming 

enrolled in the PATH program each year. 

Youth Violence Prevention 

The Safe SchoolslHealthy Students program is a unique Federal grant program designed to 

prevent violence and substance abuse among our nation's youth in schools and communities. 

Since 1999, this program has been jointly administered and supported by SAMHSA and the 

Departments of Education and Justice. The Safe SchoolslHealthy Students initiative implements 

an enhanced, coordinated, and comprehensive plan of activities, programs, and services that 

promote healthy childhood development, prevent violence, and prevent alcohol and drug abuse. 

A key element of Safe SchoolslHealthy Students activities is the expansion of school-based 

mental health services, as well as referral to treatment to community health providers. SAMHSA 

is in the process of completing a national cross-site evaluation of Safe Schools/Healthy Students. 

Preliminary findings include: 

• The program has seen significant increases in the number of students who received 

school-based mental health services, and community-based services. 

• Nearly 90 percent of school staff stated that they were better able to detect mental health 

problems in their students and more than 80 percent of school staff reported that they 

observed reductions in alcohol and other drug use among their students. 

• Over 90 percent of school staff saw reduced violence on school grounds and nearly 

80 percent reported that Safe SchoolslHealthy Students had reduced violence in their 

communities. 

President's Now is the Time Initiatives 

In addition to the programs discussed above, I would like to share some of the initiatives related 

to mental health included in the President's proposed plan, Now is the Time. which emphasizes 

early intervention and treatment for young people struggling with mental health problems. 

On January 16,2013, the President announced his plan to ensure that students and young adults 

receive treatment for mental health issues. These proposals are included in the President's 

FY 2014 Budget. Specifically, SAMHSA will take a leadership role in initiatives that would: 

1. Reach 750,000 young people through programs to identify mental illness early and refer 

them to treatment: To support training for teachers and other adults who regularly 

interact with students to recognize young people who need help and ensure they are 

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referred to mental health services, the Administration has proposed a new initiative, 

Project A WARE (Advancing Well ness and Resilience in Education), to provide this 

training and set up school-community partnerships to promote mental health, and 

facilitate referrals when needed. This initiative, which will be coordinated with related 

proposals at the Departments of Justice and Education, has two parts: 

a. Provide "Mental Health First Aid" training for teachers: Project A WARE 

proposes $15 million for training for teachers and other adults who interact with 

youth to detect and respond to mental illness, including how to encourage adolescents 

and families experiencing these problems to seek treatment. 

b. Ensure students with sigus of mental illness get referred to treatment: Project 

A WARE also proposes $40 million to help states and school districts work with 

community leaders, law enforcement, mental health agencies, families and youth, and 

other local organizations to assure students with mental health issues or other 

behavioral issues are referred to and receive the services they need. This initiative 

builds on strategies that, for over a decade, have proven to decrease violence in 

schools and increase the number of students receiving mental health services. 

2. Support individuals ages 16 to 25 at high risk for mental illness: The Administration is 

proposing $25 million for a new initiative, Healthy Transitions, to support innovative 

state-based strategies to support young people ages 16 to 25 with mental health or 

substance abuse issues. Efforts to help youth and young adults cannot end when a 

student leaves high school. Individuals ages 16 to 25 are at high risk for mental illness, 

substance abuse, and suicide, but they are among the least likely to seek help. Even those 

who received services as a child may fall through the cracks when they leave school or 

turn 18. 

3. Train more than 5,000 additional mental health professionals to serve students and young 

adults: Experts often cite the shortage of skilled mental health service providers as one 

reason it can be hard to access treatment. To help fill this gap, the Administration is 

proposing $50 million to train social workers, counselors, psychologists, behavioral 

health paraprofessionals, marriage and family therapists, nurses, and other mental health 

professionals. This would allow SAMHSA and HRSA to provide financial support to 

train more than 5,000 mental health professionals to serve children, adolescents, young 

adults (including individuals aged 16-25 years old), and their families, in our schools and 

communities. 

As part of his plan to reduce gun violence, President Obama directed Secretaries Sebelius and 

Duncan to launch a national conversation to increase understanding and awareness about mental 

health. As part of that effort, on June 3

fd, the President and Vice President will host a National 

Conference on Mental Health. The conference will bring together people from across the 

country, including mental health advocates, educators, health care providers, faith leaders, and 

individuals who have struggled with mental health problems, to discuss how we can all work 

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together to reduce negative attitudes, and help the millions of Americans struggling with mental 

health problems recognize the importance of reaching out for assistance. 

In addition to these initiatives where SAMHSA is taking a leadership role, other offices in the 

Department of Health and Human Services have been taking steps - as outlined in the 

President's Now Is the Time plan, to expand coverage of mental health services. Additionally, 

the Department of Education has proposals to help 8,000 schools create safer and more nurturing 

school climates and address pervasive violence. 

Ensuring Efficiencies and Effectiveness 

Evaluation, Outcomes and Quality 

SAMHSA has a long history of conducting evaluations designed to ascertain information about 

programs funded with Federal dollars. More recently, SAMHSA has embarked upon a course to 

enhance the rigor of its evaluations in order to use data to examine the effectiveness of programs, 

the quality of program implementation, and to better understand how certain interventions or 

activities influence behavioral health outcomes in co~munities across the nation. To this end, 

SAMHSA evaluations are examined to ensure that the methods are appropriate to the evaluation 

questions and that the right data is collected to inform our understanding of the results of 

programs. 

Recently SAMHSA completed an inventory of all evaluations currently ongoing in the agency. 

These evaluations will be closely monitored by evaluation staff and will be strengthened where 

indicated and possible. These evaluation experts are collaborating with program staff to develop 

reporting mechanisms to ensure that the data collected in an evaluation are used to inform 

policies and practices for the future. 

SAMHSA has also undertaken to develop a National Behavioral Health Quality 

Framework (NBHQF), modeled after the National Quality Strategy, to guide behavioral health 

services and programs throughout the country and to provide a consistent set of validated 

measures at the payer, practitioner/program and population levels. The six goals articulated by 

the NBHQF are: (l) effective services; (2) person-centered care; (3) effective care coordination; 

(4) use of best practices; (5) safe care; and (6) accessible and high-value care. The draft NBHQF 

will soon be in its third round of public input with expected release later this year. 

SAMHSA Stewardship 

SAMHSA takes its role as a steward of taxpayer dollars seriously. SAMHSA has closely 

examined its portfolio to find efficiencies and as a result has reduced redundancy or duplication 

of programs. For example, in 2012, SAMHSA evaluated its contracting process to achieve 

purchasing efficiencies and leverage similar contracting vehicles. As a result, SAMHSA 

consolidated three state technical assistance contracts into a single contract resulting in both 

programmatic as well as administrative efficiencies. In 2011, several similar consolidations took 

place. SAMHSA constantly evaluates its programs via review of grantee performance and data 

collection. Program adjustments, in scope or focus, are directly affected by that data. 

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Technical Assistance 

Technical assistance is a key activity provided by SAMHSA in order to ensure that systems, 

services, and programs are delivered in the most effective and efficient way possible, and to lead 

the field toward the use of processes and practices that obtain the best outcomes. SAMHSA 

provides technical assistance not only to its grantees for the implementation of specific grant 

programs but also to the field at large for system-wide change and enhancement. SAMHSA's 

technical assistance is provided through staff subject matter experts as well as through a 

combination of grants and contracts for technical assistance centers and independent 

organizations that are managed by SAMHSA staff. The provision of technical assistance 

encompasses a series of strategies, processes, techniques, and activities (e.g., training, 

consultation, expert guidance, etc.) designed to maximize overall performance and result in 

improved outcomes. SAMHSA has developed principles to guide its technical assistance efforts. 

This approach ensures that SAMHSA's technical assistance activities are delivered in the most 

effective and efficient way possible, leading the behavioral health field toward the use of 

processes and practices that obtain the highest level of outcomes. 

Conclusion 

We have made important strides in the prevention, treatment, and recovery supports for mental 

and addictive disorders. However, much work remains to be done. The Administration 

continues to advance our work on this important issue and we look forward to continuing to 

work with the Congress on these efforts. 

12 
27 

Mr. MURPHY. Thank you so much for being here today and for 

your work. 

I want to just clarify a couple things. I note your testimony in 

written and oral states several times that SAMHSA supports evidence-based programs and practices and even data-driven solutions. So does this mean SAMHSA requires evidence and data before making a grant award? 

Ms. HYDE. Congressman Murphy, thank you for the question. 

Yes, we require in our request for applications we ask individuals 

either to use an evidence-based practice that we have identified or 

to tell us what approach they propose to use and to explain to us 

how they think that it has evidence behind it or how it is moving 

into science as they are developing evidence of it working for them. 

Mr. MURPHY. Do you use models like NIH has where there are 

professionals, experts in the field with advanced degrees who are 

the majority of panelists to review grants? 

Ms. HYDE. That is correct. We use experts to do those reviews. 

Mr. MURPHY. By experts, I mean people with MDs or PhDs who 

have the scientific credentials as the majority of panelists in each 

grant review? 

Ms. HYDE. Each of the grant reviews use people who are experienced in that area. What their degrees are, I don’t have that in 

front of me. 

Mr. MURPHY. Experience, I am talking about the majority of the 

panelists. This is a yes or no. Are the majority of panelists people 

who have specific advanced training and academic and professional 

credentials in those fields versus just experience? 

Ms. HYDE. They have training and experience. I do not have with 

me what their degrees are. 

Mr. MURPHY. I am just asking is the policy of SAMHSA that the 

majority of people reviewing grants have advanced degrees and 

academic credentials and license credentials in reviewing these 

grants? 

Ms. HYDE. It is our policy, Congressman, to have individuals 

with the experience and—— 

Mr. MURPHY. But that is a no? It sounds like—— 

Ms. HYDE. I will repeat—— 

Mr. MURPHY [continuing]. That is a no. 

Ms. HYDE [continuing]. That I don’t have with me and I don’t 

have the information about what their degrees—— 

Mr. MURPHY. OK. That would be a major issue because that is 

a major part of your work. Do you fund competitive or discretionary 

grants that are part of the mission of SAMHSA or do you also fund 

grants that run diametrically opposed to the mission of SAMHSA? 

Ms. HYDE. I think all of our grants and all of our efforts, whether 

grant-based or not, are working toward our mission. 

Mr. MURPHY. OK. Thank you. What is the evidence that 

SAMHSA used to fund an advocacy group that encourages the 

mentally ill not to take their medication? 

Ms. HYDE. I am sorry, Congressman. Can you repeat the question? 

Mr. MURPHY. I just wonder what evidence did you use as the decision-making process when you fund advocacy groups that encourages the mentally ill not to take the medication? 

28 

Ms. HYDE. I don’t think we fund advocacy efforts explicitly to tell 

people not to take the medication. 

Mr. MURPHY. You just told me that you don’t fund things that 

run counter to your mission, and we will here today from people 

who have evidence that SAMHSA does fund organizations that encourage people not to take their psychiatric medication. So I am 

just wondering what the evidence is that SAMHSA relied upon to 

fund such a grant. 

Ms. HYDE. We fund lots of organizations who have missions or 

who have opinions or value bases that may not necessarily agree 

with SAMHSA or with the field. What we fund are specific grants 

for specific purposes related to the mission of SAMHSA. 

Mr. MURPHY. I still want to know, and we are going to continue 

to pursue this because it is an important issue. And I note in your 

testimony you do not even mention the title psychiatrist, and as I 

noted in my opening statement, you don’t mention the words bipolar, schizophrenia, or other forms of severe mental illness to talk 

about a lot of things. And many of those things are good, but we 

are here today to talk about severe mental illness. Does SAMHSA 

acknowledge that there was a scientific evidence basis provided by 

SAMHSA’s sister public health agencies such as NIH and the FDA 

that support the effectiveness of medical treatment for mental illness? 

Ms. HYDE. Absolutely, Congressman. We work closely with 

NIMH, with NIDA, with NIAAA, with other institutes within NIH, 

with FDA, and other agencies and we work hard to take what they 

learn from the research and use it in the efforts that we do. 

Mr. MURPHY. One of those that you fund is the National Empowerment Center whose director espouses anti-science, anti-psychiatry views and your agency also funds the alternatives, which 

is that in your workshop or symposium which regularly features 

workshops and speakers who advised people with serious mental 

illness to go off physician-prescribed medication. 

And as I said before, your testimony today does not even mention 

the psychiatry or get into medication issues. So I once again want 

to know where is the evidence that this approach to treating severe 

mental illness has any scientific, evidence-based, data-driven background that would support what you continue to fund? 

Ms. HYDE. Congressman, there are a number of ways to provide 

treatment and services, and we fund a number of conference efforts 

and others. We do not go inside each individual presentation to 

identify whether or not we agree with each individual—— 

Mr. MURPHY. But you continue to fund it—— 

Ms. HYDE [continuing]. Presenter—— 

Mr. MURPHY [continuing]. And you oftentimes speak at an opening or part of those conferences? 

Ms. HYDE. Yes, we do, and we fund other conferences for the 

American Psychological Association, for ASAM, for other organizations also that we don’t look at every single presentation—— 

Mr. MURPHY. I mean yes or no, is it medically possible to prevent 

the onset of schizophrenia? 

Ms. HYDE. I think the biomarkers are not there yet. I think 

NIMH is working hard on biomarkers about that. We know that we 

can prevent a lot of the salient conditions about schizophrenia and 

29 

we know that there are a number of people with schizophrenia who 

can in fact get to a point where they are living without the symptoms of the illness that they first experienced. 

Mr. MURPHY. Thank you. Thank you. Ms. DeGette, 5 minutes. 

Ms. DEGETTE. Let try to clear some of this up, Administrator 

Hyde. It is not in the mission of SAMHSA to tell patients not to 

take their medication, is that correct? 

Ms. HYDE. That is correct. We—— 

Ms. DEGETTE. OK. So what happens is Congress has mandated 

that some of the groups that SAMHSA fund are patient advocacy 

groups, correct? 

Ms. HYDE. That is correct. 

Ms. DEGETTE. And some of those patient advocacy groups may 

in fact tell their people not to take drugs, is that correct? 

Ms. HYDE. They very well may. 

Ms. DEGETTE. And that is not SAMHSA’s policy; that is those 

groups’ policy, right? 

Ms. HYDE. Those groups may have that policy. 

Ms. DEGETTE. And so really Congress should look at do we want 

to be telling SAMHSA to fund patient advocacy groups, right? 

Ms. HYDE. It is certainly a congressional authority and a congressional program—— 

Ms. DEGETTE. The other issue is a great amount of the money 

that SAMHSA spends is block granted to the States, is that right? 

Ms. HYDE. That is correct. 

Ms. DEGETTE. And so once those funds go to the State, then the 

governors decide how those funds are going to be spent and 

SAMHSA doesn’t really exercise discretion over the groups that the 

States give those block grants to, right? 

Ms. HYDE. That is correct. We have a plan that the State provides to us—— 

Ms. DEGETTE. Right. 

Ms. HYDE [continuing]. But the State makes that decision. 

Ms. DEGETTE. Right. So that is, again, something else Congress 

should look at is do we really want to be just sending that money 

to the States without the scientific control of where those funds go, 

right? 

Ms. HYDE. Correct. And we do ask them to do evidence-based 

practices and data-driven processes. 

Ms. DEGETTE. Of course you do. Now, let me ask you this because you talked quite a bit in depth in your opening about the 

percentages of SAMHSA’s budget that go to mental health versus 

drug control and so on, and that again Congress has made those 

requirements on SAMHSA, right? 

Ms. HYDE. That is our—— 

Ms. DEGETTE. I mean, it is not you that sits there and says I am 

going to spend 27 percent of my money on serious mental health; 

it is Congress that says that, right? 

Ms. HYDE. That is correct. 

Ms. DEGETTE. OK. Now, I read the testimony of the second panel 

and some of those witnesses—I am sure you have read it, too—they 

have strong criticisms of SAMHSA and I want to ask you about it. 

Dr. Torrey says that serious mental illness has a very low priority 

at the Agency because in the 3-year planning document that you 

30 

have, there is no mention of a number of conditions. So I want to 

ask you a question. Does the Agency have a very low priority for 

serious mental illness? 

Ms. HYDE. No. As I indicated, about 75 to 80 percent of our mental health dollars go towards substance abuse—I mean, excuse 

me—toward serious mental illness and serious emotional disturbance. 

Ms. DEGETTE. And so why in that document did you not specifically mention schizophrenia, schizoaffective disorder, bipolar, severe depression, or obsessive compulsive disorder. 

Ms. HYDE. That planning document is about behavioral health 

systems and directions that we are taking and it has to do with developing quality frameworks and developing public awareness and 

approaches. It has to do with prevention and a number of other 

things. We don’t have any references to any diagnoses in that particular—— 

Ms. DEGETTE. Oh, I see. OK. So it is just because of the nature 

of that document—— 

Ms. HYDE. That is correct. 

Ms. DEGETTE [continuing]. Not because there is not an emphasis. 

Now, Dr. Torrey also says—and this is a quote from his testimony—‘‘nobody among SAMHSA’s 574 staff has experience in severe mental illness.’’ Is that true? 

Ms. HYDE. No. 

Ms. DEGETTE. Why do you say that? 

Ms. HYDE. Because we have a number of people ranging from social work, psychologists, internists and others who work—have 

been working in this field for years in these areas, so they have extensive experience. 

Ms. DEGETTE. And now, is it true that SAMHSA has only employed one psychiatrist? 

Ms. HYDE. We don’t employ a lot of psychiatrists. We are not the 

direct provider of services like IHS or others. We did actually just 

announce this week—we have been working on it for 2 years—we 

announced the arrival on June 3 of our chief medical officer, who 

is a psychiatrist and will be joining—— 

Ms. DEGETTE. So what you saying is because you are not focusing on actual treatment, you don’t feel you necessarily need people 

with those credentials for every position? 

Ms. HYDE. Not for every position—— 

Ms. DEGETTE. OK. 

Ms. HYDE [continuing]. Absolutely not. 

Ms. DEGETTE. Now, I want to ask you what is the impact on 

SAMHSA’s budget by the sequester and what are you anticipating 

for fiscal year 2014? 

Ms. HYDE. The sequester results in about $168 million reduction 

in our programs. It was required that we take it across all programs so it didn’t matter which ones. We had to take it against all 

of them. We expect or anticipate that that will result in about 

330,000 less people getting services—— 

Ms. DEGETTE. Wow. 

Ms. HYDE [continuing]. And the benefits of SAMHSA’s programs. 

So it will significantly reduce that. For 2014 the President’s budget 

proposes to undo the sequester and so to take us back to a point 

31 

where we have more funding for services and programs, and he 

also proposes new funding and services as a result of what we have 

learned in our efforts out of the Sandy Hook effort. 

Ms. DEGETTE. Thank you very much. 

Mr. MURPHY. I recognize the gentleman from Texas, Dr. Burgess, 

for 5 minutes. 

Mr. BURGESS. I thank the chair for the recognition. I am sorry 

I had to step out for a moment. I had a group of doctors out there 

I was talking to. But it brings up a good question. How many people work in your agency? 

Ms. HYDE. Congressman Burgess, about 600 people, give or take. 

Mr. BURGESS. And of that cadre of 600 individuals, how many 

M.D. psychiatrists are working? 

Ms. HYDE. We have one. We also have a number of—— 

Mr. BURGESS. I found one on the internet, so good, we are 

aligned. 

Ms. HYDE. We just announced the arrival on June 3 of our chief 

medical officer, which we have been seeking for a couple years. She 

arrives and will start and she is a psychiatrist in addiction psychiatry, board-certified. 

Mr. BURGESS. So if I have it correct, I mean you are the mental 

health agency and substance abuse agency for the entire country, 

and up until a week or two ago, you had one psychiatrist on your 

staff? 

Ms. HYDE. As I said—you might have been out of the room, but 

I did say that, yes, we don’t do direct services. That is not what 

our charge is so we have a number of psychologists, social workers, 

counselors, other behavioral health professionals, addictionologists, 

and others in addition to other professions that we need to do our 

work. 

Mr. BURGESS. Yes, but just speaking from someone who has 

spent a life in clinical practice, I mean, there is no substitute for 

that. Yes, I am in a position now where public policy is all that I 

think about, but at the same time, it is that time spent in the clinical practice of medicine that informs the policy, and your agency, 

it just strikes me we are really thin there. Is that a fair assessment? 

Ms. HYDE. Given what our charge is and what we do and to be 

quite honest with you what we are able to pay, we have had a difficult time achieving any higher percentages of those individuals. 

We do have internists and others who work in other areas where 

it requires that kind of clinical expertise in order to do the program. We have, as I said earlier, a number of other behavioral 

health professionals who do work in our grant programs, and then 

we have people like statisticians and accountants and others who 

do other parts of our programs. 

Mr. BURGESS. And all those people are important, but again, I 

would just submit that there is no substitute for someone who has 

spent time in the clinical realm of practicing medicine. I am not a 

psychiatrist but I know that because of that time in clinical medicine, someone who has practiced psychiatry is going to be invaluable to your agency as far as informing the policy and one or two 

folks aren’t going to get it in an agency as large as yours with the 

32 

enormous footprint that you have in the country as regards to mental health services. 

Now, I accept the part about psychiatrists are expensive. I have 

always thought they have been overvalued, but we can get into 

that discussion later on. But, you know, you are talking now about 

you need to train additional people in the mental health services, 

correct, in SAMHSA? 

Ms. HYDE. In conjunction with HRSA, that is correct. 

Mr. BURGESS. And about how many? 

Ms. HYDE. The President’s proposal for 2014 would produce 

about 5,000 more professionals. 

Mr. BURGESS. And of that 5,000 what is the cohort of clinical psychiatrists that would be part that? 

Ms. HYDE. In that particular cohort, that is not what it is directed towards. HRSA’s programs are directed more toward those 

clinical-level individuals. 

Mr. BURGESS. Well, with all due respect to the President, he has 

never practiced clinical medicine either and I think that is apparent from the state of healthcare in this country today. But nevertheless, you need to have the expertise of someone who has accepted the responsibility for diagnosing and treating patients, following 

through on a treatment plan, and lacking that, it is hard to know 

how to advise you to do your job better. Without the basic tool, 

without that basic person involved at the clinical level, I just don’t 

know how you deliver on the promise that you are supposed to do. 

Now, my understanding is that years and years and years ago 

Congress in its wisdom separated out the research side from what 

you do, is that correct? 

Ms. HYDE. That is correct. 

Mr. BURGESS. So the research goes on at the National Institute 

of Health, but without a clinical psychiatrist on the staff, it is hard 

for me to know how you are going to be able to evaluate those 

things that are developed by that great research institution up 

north of town and make them applicable to the people who are suffering that you are supposed to be taking care of. 

Ms. HYDE. Well, I have two comments about that, as I said earlier, we spent a couple of years and finally were able to recruit a 

new clinical psychiatrist to be the chief medical officer to do that 

kind of consultation. We also work very closely with Tom Insel and 

all of his staff at NIMH on issues about clinical care and about evidence-based practices. 

Mr. BURGESS. Well, look, the President has announced a big 

brain mapping initiative, but without the people there to deliver 

the goods, I am afraid it is an empty promise. 

Mr. Chairman, thank you. I will yield back. 

Mr. MURPHY. Mr. Butterfield, you are recognized for 5 minutes. 

Mr. BUTTERFIELD. Thank you very much, Mr. Chairman. And I 

am going to try to get through this very quickly. 

Again, thank you for your testimony. Let’s talk a little bit about 

sequestration. You mentioned it just a few moments ago. Did I understand you to say that it is had a $168 million impact on your 

agency? 

Ms. HYDE. That is correct. 

Mr. BUTTERFIELD. That is in fiscal year 2013? 

33 

Ms. HYDE. Correct. 

Mr. BUTTERFIELD. And what is the projection, if you know, for 

2014 and beyond? 

Ms. HYDE. I don’t know explicitly. My understanding is that it 

would probably result in somewhere like another 2 or 2–1/2 percent 

reduction but we don’t have those numbers finalized. 

Mr. BUTTERFIELD. And that translates into some 300,000 people 

or more? 

Ms. HYDE. Just for 1 year, correct. 

Mr. BUTTERFIELD. All right. Now, the House Labor HHS Appropriations Subcommittee has proposed an 18 percent cut. Are you 

aware of that? 

Ms. HYDE. I have heard that. 

Mr. BUTTERFIELD. And that translates into some $624 million. 

What impact would that proposal have on providing care to individuals with serious mental health illness? 

Ms. HYDE. Well, it would—Congressman, it would have a profound impact. Just on our agency alone it would have a profound 

impact, not to mention on all the other agencies that provide services. 

Mr. BUTTERFIELD. The Affordable Care Act has provided young 

adults with access to health insurance through their parents’ plans, 

and that is a good thing, and it will provide people with access to 

health insurance in 2014 when the exchanges actually go into effect. With the full implementation of the Affordable Care Act in 

2014, will it increase the ability of people to access mental health 

care? 

Ms. HYDE. Absolutely. And about 62 million people will have access to coverage for mental and substance abuse disorders that 

don’t have it now by a combination of the Affordable Care Act and 

the Mental Health Parity and Addiction Equity Act. And of those 

62 million, we anticipate that about 11 million of them have mental health and substance abuse issues. 

Mr. BUTTERFIELD. I am encouraged that SAMHSA has helped assist disadvantaged communities through discretionary grants. And 

as you may know, I represent a rural congressional district in 

North Carolina where nearly 1 in 4 people are below the poverty 

level. Can you describe for me some of the programs that SAMHSA 

has which are effective in addressing mental health in rural and 

low-income communities? 

Ms. HYDE. Congressman, rural areas, I think, do have higher levels of—sometimes have higher levels of poverty. They have often 

less workforce available, so less people to provide those services. 

We have worked hard with HRSA and their rural program to try 

to see how we can stretch that workforce, how we can do telemedicine and other kinds of approaches for rural areas and then our 

Mental Health Block Grants obviously provide to the States dollars 

that they can use as they see fit. So for States with a higher rural 

proportion, they certainly could do that. 

I come from the State of New Mexico. I understand the rural 

areas out there. And the block grant is an important part of that 

effort. 

Mr. BUTTERFIELD. Thank you. North Carolina is home to more 

than 700,000 veterans and has one of the largest veteran popuVerDate Nov 24 2008 14:18 Nov 22, 2013 Jkt 037690 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-47 CHRIS
34 

lations in the entire country. Seymour Johnson Air Force Base in 

my district and both the Coast Guard station and the Marines have 

installations who have supported us. Can you describe some of the 

crucial programs that SAMHSA supports for returning service 

members and their families? 

Ms. HYDE. Thanks for that question. Yes, we have had—in fact, 

in that Leading Change document we were just talking about earlier, military personnel and veterans is a huge priority for us. We 

have done everything from Policy Academies, helping States really 

get their arms around how they can provide services for those individuals. We support and work very closely with the Veterans Administration on suicide prevention efforts and our international 

lifeline is tied to them electronically. We have incorporated military 

families and veterans as a priority population within about half of 

our funding requests. We have really put a major effort there. 

Mr. BUTTERFIELD. And can these programs be affected by sequestration? 

Ms. HYDE. Absolutely. 

Mr. BUTTERFIELD. It is my understanding that SAMHSA provides support to state mental health agencies on the ground in the 

wake of natural disasters. In the last year, my district was dramatically impacted by two hurricanes. Most recently, we have seen 

terrible destruction out in Oklahoma where I was on Tuesday of 

last week where the total impact won’t be known for quite some 

time. Can you describe the important work that SAMHSA does 

with the relationship to the storms? 

Ms. HYDE. Yes. Our disaster preparedness and response efforts 

have become very well-known. To FEMA, to the Red Cross, and to 

others we provide a 24/7 disaster distress helpline that is available 

anytime there is a major disaster like this. It is available all over 

the country but we target it to the area that is hit. We have all 

kinds of materials that help people know how to work through disaster issues and prepare psychologically for them. We do training 

and technical assistance for first responders—— 

Mr. BUTTERFIELD. Let me interrupt you because I am going to 

have to get this last question in—— 

Ms. HYDE. Absolutely. 

Mr. BUTTERFIELD [continuing]. And it is important. I think you 

will agree. It is my understanding that for many insurance companies, preexisting conditions include any conditions which a patient 

has been treated for in the last 6 months. Under the Affordable 

Care Act, insurance companies cannot deny coverage due to preexisting illnesses. Our mental illnesses currently considered a preexisting condition by insurance companies? 

Ms. HYDE. In many insurance companies, they are. 

Mr. BUTTERFIELD. Once the law is implemented, will more individuals with mental health issues and now have access to care 

under the Act? 

Ms. HYDE. Yes. 

Mr. BUTTERFIELD. Thank you. Thank you, Mr. Chairman. 

Mr. MURPHY. Thank you. We now recognize the gentlelady from 

Tennessee, Mrs. Blackburn, for 5 minutes. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and we thank you 

for being with us today. I want to ask you a little bit about this 

35 

Alternatives Conference out in Portland, Oregon. You gave the keynote address at the conference in October 2012, is that correct? 

Ms. HYDE. That is correct. 

Mrs. BLACKBURN. OK. Would you mind submitting a copy of your 

remarks for us? Would that be possible? 

Ms. HYDE. Congresswoman, I would be happy to. I don’t usually 

have prepared text. I usually do overheads but I will give them to 

you. 

Mrs. BLACKBURN. OK. That would be awesome. And you all sponsored that. I have got a copy of the program; I see you all sponsored this. This is one of your initiatives, correct? 

Ms. HYDE. It is one of the many conferences and meetings we 

support, that is correct. 

Mrs. BLACKBURN. OK. And I would assume in page 11 of your 

written testimony you talk about SAMHSA’s stewardship, and 

since you brought up the sequestration a couple of times, my assumption is you are reviewing your sponsorship of such activities. 

Would that be right? 

Ms. HYDE. We have been reviewing our sponsorship of all conferences and meetings, and in some cases we are continuing them 

but with reduced effort. 

Mrs. BLACKBURN. OK. 

Ms. HYDE. In other cases, we are just not doing them at all. 

Mrs. BLACKBURN. How much did you spend to sponsor this conference? 

Ms. HYDE. You know, I don’t have that information in front of 

me—— 

Mrs. BLACKBURN. Would you submit that to us? 

Ms. HYDE [continuing]. But I can get it to you, certainly. 

Mrs. BLACKBURN. OK. I think that would be great because if you 

are looking at a 168 million impact to your budget, then I think 

that all of these conferences and the programs would be something 

that we would want to look at very closely. 

One of the hour-and-a-half long workshops from the October 13, 

2012, session is titled ‘‘Unleash the Beast: Primal Movement Workshop.’’ It is described in this brochure right here as follows: ‘‘Unleash the Beast is a mind/body fitness program that looks to the 

animals of the jungle for wisdom and skills that can benefit our 

lives in a myriad of ways. Through the animal-inspired movements, 

behaviors, and expressions, participants are encouraged to shed 

layers of formal conditioning in order to return to their primal nature.’’ So is it true that SAMHSA provided funding for this? 

Ms. HYDE. As I indicated, we provide funding for the conference. 

That is correct. 

Mrs. BLACKBURN. OK. Are you able to provide us—did you attend this workshop? 

Ms. HYDE. No, ma’am. 

Mrs. BLACKBURN. You did not? OK. Can you give me any idea 

of specific examples of such animal-inspired movements, behaviors, 

and expressions and discuss what studies where evidence has 

shown them to be effective in treating mental illness and humans? 

Ms. HYDE. As I said, I didn’t go to that conference or that particular workshop. I can tell you that things like meditation, yoga, 

other kinds of movement is appropriate for—— 

36 

Mrs. BLACKBURN. So that is animal movement? 

Ms. HYDE [continuing]. Developing stress—for releasing and developing and—— 

Mrs. BLACKBURN. That would be animal—let me move on. 

Ms. HYDE [continuing]. To manage stress. 

Mrs. BLACKBURN. When did you begin sponsoring the Alternatives Conference? 

Ms. HYDE. I don’t remember the first year. We can find out for 

you. 

Mrs. BLACKBURN. OK. We would like to know that and I think, 

you know, one of your exhibitors here, Mind Freedom International 

is one of the groups that had a table there. They encourage people 

to come off their meds, and I think we would be concerned about 

that. 

I also want to know how much money you have spent since the 

inception of this Alternatives Conference and in conferences in general? Let us help you with this budget gap that you have, and this 

may be a way to find out. Would you please submit that to us? 

Ms. HYDE. I am sorry. Can you clarify what you would like to 

see? 

Mrs. BLACKBURN. Money, how much have you spent on the Alternatives Conference and how much do you spend on conferences in 

total? And do you pay speakers’ fees and travel? Is that covered out 

of what you are paying? 

Ms. HYDE. Congresswoman, it depends on the conference what 

we pay for. We have reduced our conference support significantly—— 

Mrs. BLACKBURN. OK. What about scholarships to the conference? Does SAMHSA cover scholarships to the Alternatives Conference? 

Ms. HYDE. We do sometimes provide—— 

Mrs. BLACKBURN. OK. Could you submit that amount to us? 

Ms. HYDE [continuing]. Scholarships to this and to other conferences. 

Mrs. BLACKBURN. OK. And I would assume they are going to the 

Unleash the Beast Primal Movement Workshop on taxpayer funds. 

March/April 2011 SAMHSA newsletter highlighted the Agency’s 

use of art to raise awareness around behavioral health. Specifically, an award-winning artist, Sam English, was commissioned for 

$22,500 to create a painting because of his familiarity with prevention and recovery populations. What value—I want you to tell— 

what value do the American people obtain from SAMHSA’s funding 

of a piece of artwork such as this? 

Ms. HYDE. We have a responsibility, Congresswoman, to get the 

word out about behavioral health to all kinds of populations. In 

this case, the tribal populations are very clear that the way to do 

that is to use people from their tribes and nations. This was a tribal—— 

Mrs. BLACKBURN. $22,500 for a piece of art? 

Ms. HYDE. That number is not correct, but this tribal leader is 

actually a person in recovery and has produced documents and opportunities in the past for other substance abuse programs. 

Mrs. BLACKBURN. Please submit the correct number. 

And I yield back my time. 

37 

Mr. MURPHY. Thank you. The gentlelady’s time expired. I now go 

to the gentlelady from California, Ms. Castor, for 5 minutes. 

Ms. CASTOR. Thank you, Mr. Chairman. 

I would like to focus your attention on mental health care for 

children and teens, particularly in schools because what I have 

heard from so many of my school districts at home and the teachers and parents there is that the schools are a terrific place to identify the emerging issues for the child’s mental health or it is the 

teacher on the front line that understands very well the emotional 

health of that child day in and day out and that, you know, many 

schools are able to maybe have a guidance counselor or a school 

psychologist, maybe just part-time, and they get identified. But 

there seems to be a real lack of resources available for the true 

treatment and counseling that that student needs. So many of the 

parents I hear from, they don’t have health insurance or they have 

a policy that does not provide it. That is going to get better under 

Mental Health Parity and the Affordable Care Act. 

But I still think that what I am hearing from back home is the 

schools would have the capacity to do more with having psychiatrists and some counselors available. In your testimony—and I understand SAMHSA has some oversight or has oversight of the Safe 

Schools and Healthy Students Initiative and also Children’s Mental 

Health Initiative. What I have heard from folks back home is while 

they value those dollars, it is just a drop in the bucket and that 

resources that were available in the past just aren’t there anymore. 

Could you speak to that and give us a summary of the Safe Schools 

and Healthy Students Initiative and Children’s Mental Health Initiative? 

Ms. HYDE. That is correct. The Safe Schools, Healthy Students 

is a very effective program that we have worked with the Department of Education and the Department of Justice on over the 

years. It brings together communities, parents, schools, and others 

to make sure that young people are safe. The program has resulted 

in great outcomes. We have seen less violence, more perception of 

safety, more referrals by about 500 percent, more referrals to behavioral health treatment, so as people are able to identify young 

people in need. So it is a very effective program. 

The President has proposed to build on that program in the fiscal 

year 2014 budget by Project Aware, which would not only expand 

Safe Schools, Healthy Students statewide in some States, but also 

add a mental health first aid to help teachers and parents, first responders, and others identified mental health issues early. 

Ms. CASTOR. But what is your feeling on or what is your understanding about the needs? As I mentioned earlier in my opening 

statement, the needs are far outstripping the resources that are 

available at the local level, state level, and federal level? Or is it 

a fact that policymakers simply haven’t made mental health services a priority and haven’t provided the investment that is necessary? 

Ms. HYDE. That is absolutely correct. There is not enough. I 

started out in my testimony, as you may remember, with saying 

that only about 6 percent of health care spending is mental health, 

and that is far below what the need is. The President has proposed 

additional dollars to do additional workforce and has also proposed 

38 

additional dollars to try to implement the efforts that we have. We 

also know that the Affordable Care Act will add a lot more coverage for this, but the workforce needs to grow to meet that need. 

Ms. CASTOR. How do you collaborate with the Department of 

Education? Outside of Safe Schools, Healthy Students, what is your 

understanding of what the Department of Education is able to provide when it comes to mental health care to our schools? 

Ms. HYDE. They actually provide a lot of in-school programs, so 

they support, as does HRSA and other school-based health clinics 

and others. We provide assistance in the community with the referrals and the connections in the community-based programs. We 

work with them to provide the materials when they need it for evidence-based practices, and we work to provide training for teachers 

and others—— 

Ms. CASTOR. Does that include the IDEA, Individuals with Disabilities Education Act? 

Ms. HYDE. In some cases, yes, but we are focusing on not just 

individuals with identified needs but individuals who haven’t yet 

been identified. We also provide in-school training for teachers to 

try to help manage behaviors in the classroom. 

Ms. CASTOR. Do you really believe when you look at the needs 

all across America when it comes to mental health for our young 

people that we are even with all of these initiatives we are really 

being effective? I mean how do we increase capacity to serve children and need to really be effective and integrated in the schoolbased setting? 

Ms. HYDE. Well, I think we need more programs like Safe 

Schools, Healthy Students, and more like Project Aware that the 

President is proposing. The fact is we just have a significant undercommitment to mental health and mental illness treatment and recovery in our country and we need more of that. The Affordable 

Care Act will help with that but only as we continue to build up 

the workforce to be able to meet those needs. 

Ms. CASTOR. Thank you very much. 

Mr. MURPHY. Thank you. I now recognize Mr. Olson from Texas 

for 5 minutes. 

Mr. OLSON. I thank the chair and thank him for holding this 

very important hearing. 

America’s mental health problems that lead to violence may lose 

control every day in America. The violence doesn’t just happen at 

Virginia Tech; it doesn’t happen in a parking lot in the Safeway in 

Tucson, Arizona; it doesn’t just happen in a movie theater in Aurora, Colorado, or at a school in Newtown, Connecticut. They happen 1.5 miles from my hometown, my home, my hometown of 

Sugarland, Texas. 

At about 9:00 p.m. on Sunday, April 7, of this year, a 31-yearold constituent hit the wall. He had been sick for about 13 years 

and was in the process of moving back home with his parents. He 

had been seeking painkillers from doctors but his doctors did not 

give him the drugs. He became angry with his parents and threatened them with a hatchet and a rock. Terrified, they fled their own 

home and called 911. The Sugarland police showed up. The son 

was barricaded in his parents’ house. 

39 

Eventually, he emerged with a rifle, and when he pointed it at 

the Sugarland police, he was shot and killed in his front yard. His 

parents heard the gunshots that killed their son. And we can never 

accept what happened in my hometown of Sugarland, Texas. 

Administrator Hyde, I know that SAMHSA is a small agency. 

You have an important role to play. You mentioned earlier this 

year in your testimony before the House Appropriations Committee 

on children’s mental health on March 20 that the President has directed his Secretaries of Health and Human Services and Education to foster a national dialogue on mental health. What if it all 

is SAMHSA’s role in this dialogue being coordinated with the $130 

million in new SAMHSA-led programs that the President announced on January 16 of 2013? Basically, how is that money being 

used in this new initiative? 

Ms. HYDE. Congressman, that money that is being proposed is 

for fiscal year 2014 so we don’t have those funding—that funding 

yet. It would require Congress to act for us to have it. 

The description of the incident that you described is a huge tragedy. These are not things that we want to happen. We have models 

out there of mental health and crisis intervention working with police and we have been working a lot with police and sheriffs association. We don’t have a program specifically around crisis intervention. I wish we did. It is something we know that we can do 

better about but we don’t have the funding to do. States use some 

of their block grant funds for these dollars but they don’t stretch 

nearly far enough. 

So this is an area where we have some evidence-based practice 

and we don’t have the resources to put it into place all over the 

country as we should. 

Mr. OLSON. Thank you, ma’am. I will have some questions for 

the record but I yield the balance of my time to my colleague from 

Texas, Mr. Burgess. 

Mr. BURGESS. I thank the gentleman from Texas for yielding. 

I just had a follow-up question on what Mr. Butterfield was pursuing on to the effects of the sequester. I mean we hear a lot about 

that in this committee and I just have to tell you I am struck by 

the fact that it seems that nowhere in the federal agencies is anyone responsible for the prudent management of taxpayer money. In 

private business when you are struck with a budget reduction, 

which happens and certainly happened to me when I ran my practice, the first thing I did was not sacrifice customer service or sacrifice activities that were central to the core mission of my business. 

And yet, we hear it time and time and time again from the CDC, 

from HHS, now from your agency that because of the sequester you 

can’t perform the functions of your core mission, and yet there are 

ancillary activities that are occurring that consume large amounts 

of dollars. I mean it is basic Six Sigma management. You do your 

core mission first and everything else is secondary to that. And, 

you know, we hear stories over and over again about incompetence 

of the federal agencies. I would just urge you to be certain that 

your number one mission needs to be fulfilled and everything else 

comes secondary. 

I thank the gentleman for yielding and I will yield back. 

40 

Mr. MURPHY. I now recognize Mr. Green for 5 minutes. 

Mr. GREEN. Thank you, Mr. Chairman. Administrator, welcome. 

I guess because you have a lot of Texans on the committee, you got 

my neighbor and Dr. Burgess of North Texas. I have a district in 

Houston, and previously, my colleague Ranking Member DeGette 

touched on a criticism from our second panel on your agency, and 

I would like to pursue that a little bit more. 

Dr. Torrey claims that incarceration of mentally ill people in jails 

in your presence is not a priority for SAMHSA. One, is this true? 

And are incarcerated mentally ill people not your priority? What 

agency do you work with that addresses the concern of this particular population? 

Ms. HYDE. Thank you for the question. We do have criminal justice programs in our budget. We do a lot of work with Sheriffs Associations, with jail and corrections practitioners. We have done a 

significant amount of work with juvenile justice and interfaced 

with the Department of Justice on that. 

The dollars appropriated for these activities are fairly small compared to some of the other dollars we have, but to the limits of our 

Appropriations, we have done a lot of work in the criminal justice 

area both with substance abuse and mental health. 

Mr. GREEN. I appreciate it. And, well, if you could get me anything that you have worked on in Texas so I could see it. In an earlier life I did mental health as an attorney representing folks and 

I have worked with our sheriff. I watched last year as they were 

trying to divert people in Houston Harris County from, you know, 

being incarcerated and literally walk them two blocks to a federally 

qualified health clinic that also sets up an appointment, get them 

on their meds, looks for housing, and things like that. So we don’t 

provide most of that funding. It comes locally, I guess, but it would 

be good if we could just provide resources to particularly in urban 

areas but I know rural areas have the same problem. 

Dr. Satel, another panelist, alleges that SAMHSA’s guiding philosophy of care is the recovery model and its tears policy away from 

the needs of those living with serious mental illnesses. Administrator, can you describe the recovery model and your views on 

whether it is an adequate guiding principle for the Agency? 

Ms. HYDE. Thank you, Congressman. The recovery is important. 

It is part of what we are about. We do want people to recover. I 

think there is an assumption that recovery means not getting 

treatment. That is not true. Recovery includes getting the kind of 

treatment and services a person needs to maintain their symptoms 

as well as their lives. 

We separate recovery into four areas: the treatment or health 

area; as well as housing to make sure that people don’t end up 

homeless; and to make sure that they have the social networks 

they need to survive in the community; and then that they have 

the jobs or the education that they need to make a living. So we 

support all of those in the recovery effort 

Mr. GREEN. Well, and I understand recovery is important but, 

you know, I consider mental illness something you manage, too. 

And, you know, sometimes I am not going to recover from a heart 

condition. I may manage my illness and I would hope that is part 

of your recovery method, being able to manage that illness because 

41 

that was our problem of getting people to realize their illness and 

you can manage it and function to sometimes a higher level instead 

of being able to recover from your particular mental illness issue. 

One of the issues that came up and Dr. Burgess touched on it 

that Dr. Torrey claims your agency spent 22,000 on commissioning 

artwork to hang in your offices, and I hope that was before sequester and it was something you couldn’t get out of, but that is what 

Members of Congress and O&I Committees are looking at. And can 

you explain that expenditure? 

Ms. HYDE. You know, Dr. Torrey and I have known each other 

for a long, long time. He claims many things, not always that I 

agree with. We have an obligation to try to do public awareness 

and support. One of the things that we did is some special approach to try to get information out to tribal communities. We used 

a person in recovery from substance abuse and mental illness who 

has provided other efforts and other art for posters which we produced. We produce posters for a lot of places in a lot of ways, and 

the combination of those efforts was what you are referring to. The 

dollar amount is not correct but we will be glad, as requested, to 

provide that to you later. 

Mr. GREEN. OK. Mr. Chairman, thank you. 

Ms. DEGETTE. Would the gentleman yield? 

Mr. GREEN. I would be glad to yield my last 2 seconds. 

Ms. DEGETTE. And when did the Agency purchase that artwork? 

Ms. HYDE. It was a couple of years ago. 

Ms. DEGETTE. So it was before sequester took place? 

Ms. HYDE. Absolutely, yes. 

Ms. DEGETTE. And I am going to back up what Mr. Green was 

saying and say I am hoping that those kinds of expenditures aren’t 

being made right now with sequester and other cuts looming. 

Ms. HYDE. I think it is fair to say that we have had to cut a lot 

of our public awareness efforts, yes. 

Ms. DEGETTE. Including things like that? 

Ms. HYDE. Including things like that. 

Ms. DEGETTE. Thank you. Thank you. I yield back. 

Mr. MURPHY. Thank you. The gentleman’s time has expired. I 

now recognize the gentleman from Virginia, Mr. Griffith, for 5 minutes. 

Mr. GRIFFITH. Thank you, Mr. Chairman. Thank you for being 

here today. Appreciate it. 

There is substantial evidence that court-ordered assisted outpatient treatment can reduce hospitalization and length of stay, increasing the receipt of psychotropic medications in intensive case 

management services, among other improved policy-relevant outcomes. Does SAMHSA provide financial support to organizations 

that oppose efforts to expand court-ordered outpatient treatment 

programs nationwide? 

Ms. HYDE. Again, we provide resources to organizations that may 

have positions that are not consistent or that we don’t necessarily 

espouse one way or another. So I can’t really answer that question. 

My guess is that there are probably some of the organizations that 

receive some dollars and don’t appreciate that approach. 

Mr. GRIFFITH. Because there appears to be some data that some 

SAMHSA-supported statewide programs such as the Pennsylvania 

42 

Mental Health Consumers Association and the California Network 

of Mental Health Clinics actively lobby against proposed expansion 

of assisted outpatient treatment in their home States. And I have 

to wonder while supporting prominent skeptics of assisted outpatient treatment, have you all launched or do you have any plans 

to launch an assisted outpatient pilot program to maybe encourage 

folks to be in favor of these types of programs? 

Ms. HYDE. I am sorry. Let me comment first that no one using 

our dollars has the right to use federal dollars for lobbying. So to 

the extent there is an organization that we find that is doing something of that nature, they should be either using other dollars or 

not doing it. So—— 

Mr. GRIFFITH. Yes, ma’am. 

Ms. HYDE [continuing]. We don’t support that. On the assisted 

outpatient treatment, the research that has been shown for assisted outpatient treatment to be effective also is very clear that it 

is the treatment and service that is effective. So to the extent that, 

for example, in New York where there was a major assisted outpatient treatment program and an evaluation of that program that 

was extensive, there were also a lot of new dollars poured into that 

system to make it work. So to the extent that the services are 

there, then assisted outpatient treatment may be effective for some 

individuals. 

Mr. GRIFFITH. And you certainly don’t oppose in those cases 

where it is necessary involuntary treatment? 

Ms. HYDE. We do not oppose any kind of treatment that is effective, absolutely not. 

Mr. GRIFFITH. OK. And you don’t have any problem with having 

those folks then put on a list to not be able to purchase firearms? 

Ms. HYDE. I don’t have an objection to that. I do have objection 

to some of the language that is in the law about that, but I think 

everybody is working on that. We are looking at it, things like mental defective and things of that nature don’t make a lot of sense 

today, so we do need to revise that law in some ways. 

Mr. GRIFFITH. Well, we certainly need to make sure that those 

who have severe mental illnesses with a tendency or either the individual has a history or the diagnostic area, that those folks are 

put on a list so that they can’t purchase firearms lawfully. 

Wouldn’t you agree with that? 

Ms. HYDE. I think our department is working with the Department of Justice on the language around that law, yes. 

Mr. GRIFFITH. All right. And if I can be of any assistance on that, 

please don’t hesitate to contact me because we have serious concern. I represent the 9th District of Virginia and the Virginia law 

had to be changed when I was in the state legislature because we 

let Mr. Cho slip through the cracks. And he had been told by a 

court to go get help but nobody ever made sure he got that help. 

And we had to make sure that we changed the law because not 

only did he not get the help but that he was never placed on the 

list of folks who weren’t able to buy guns. And so after he was 

court-ordered to get the help, he went out and purchased firearms 

and he wasn’t on anybody’s list as a no. So we had to change that 

law. 

43 

I would be happy to help in any way that we can on that. And 

in regard to the folks that were doing some lobbying, I know they 

are not supposed to and certainly not supposed to use SAMHSA 

funds for that, but I have read some reports that indicate that 

might be happening, and one of the suggestions is that Congress 

could consider giving you all more authority to regulate those individuals and to regulate patient advocates both on lobbying and 

other issues. Would you welcome that additional responsibility? 

Ms. HYDE. Mr. Congressman, if you have any information that 

suggests someone is using our dollars to lobby, please let us know. 

We will take a look and we will exercise whatever authority you 

give us to do the right thing. 

Mr. GRIFFITH. All right. I appreciate that as well. These are very 

serious issues. I do note that when you were talking about funding, 

maybe we need to do something because I noticed in your written 

report that you are doing some kind of a study that indicates folks 

are using less tobacco, particularly in your youth programs. And 

while I certainly don’t advocate that young people be involved in 

the use of tobacco and recognize that that is a substance, when we 

are dealing with serious mental illness versus tobacco use, I would 

rather put the money on serious mental illness. Do we need to put 

that into the language of your appropriations or is that something 

that you have the power to do? 

Ms. HYDE. Well, once again, 70 percent, give or take, of our dollars are about substance abuse, and tobacco use, especially among 

young people, is a substance of abuse and addiction does cause 

health issues. About half the deaths—— 

Mr. GRIFFITH. Can you give me the dollar amounts that you all 

use on your tobacco programs? 

Ms. HYDE. On tobacco? 

Sure. 

Mr. GRIFFITH. I would appreciate that. And with that, Mr. Chairman, I see that my time is up and I yield back. 

Mr. MURPHY. Thank you. The gentleman from Missouri is now 

recognized, Mr. Long, for 5 minutes. 

Mr. LONG. Thank you, Mr. Chairman. 

Thank you, Mr. Chairman. And in full disclosure, Ms. Hyde, I 

think it is important that we state for the record that you and I 

both lived in Springfield, Missouri, for a while. Is that correct? 

Ms. HYDE. That is correct. I grew up there. 

Mr. LONG. So did I so welcome to the Committee. Glad to have 

you here. 

You mentioned earlier that sequestration had cost SAMHSA I believe $168 million out of the budget? 

Ms. HYDE. That is correct. 

Mr. LONG. And that is a budget of what size? 

Ms. HYDE. It is about $3.2 million, 3.3. It depends on the year. 

It depends on where—before or after sequester. It is about $3.4 

million, all sources. 

Mr. LONG. OK. Growing up in Springfield, Missouri, you are familiar with—— 

Ms. HYDE. I am sorry. I am sorry. Excuse me, 4 billion. It is about $4 billion. 

Mr. LONG. Four billion for SAMHSA? 

44 

Ms. HYDE. About $3.4 billion altogether, but remember about 70 

percent of that is substance abuse. 

Mr. LONG. Is what? 

Ms. HYDE. Is for substance abuse. 

Mr. LONG. Substance abuse. There is been a lot of talk about sequestration today and you are familiar with Springfield, Missouri, 

growing up there as I did. And at the corner of Glenstone and Battlefield, the Barnes & Noble there you could find myself and my 

wife and our daughters in there about 3 nights a week. And I read 

a lot. And especially in this occupation we fly out here on Monday 

and fly home on Friday, you read a lot. And I am kind of old-fashioned. I don’t read the I whatever Kindles and I-books and things 

like that. I like the pages in my hand and all of that. I don’t know 

why but I just like that. 

And so one book that I bought was Bob Woodward of Watergate 

fame. He wrote a book last year. It came out September 11, same 

day that our consulate was attacked in Benghazi. But anyway, I 

can get a picture of it on my iPad. I can’t read it on my iPad that 

I can get a picture of the book, ‘‘The Price of Politics.’’ And that is 

pretty good for me, wasn’t it? 

So I probably bought it on September 12, because I was anxious 

to get the book because it was kind of my first 2 years up here and 

what went on in Congress and all of the budget battles we had 

where we spent 42 percent more than we take in every day in this 

town. And no one, as you know in Springfield, Missouri, where you 

grew up, where I grew up, you can spend 42 percent more than 

they take in. 

So the book I was anxious because I knew it was going to walk 

us through the process and when Speaker Boehner would talk to 

the President and Eric Cantor would be involved in back-and-forth 

and everything. 

So I got a hold of the book, read it, and then I happened to run 

into—I was watching Morning Joe one morning and then I saw Bob 

Woodward on there being interviewed about a different topic, and 

then, as fate would have it, I am walking across the Hill here and 

get to a stop sign on a corner and there stands Bob Woodward, still 

has his makeup on from Morning Joe. And I went up to Mr. Woodward and I said, Mr. Woodward, I have got to tell you. I said I just 

read your book ‘‘The Price of Politics’’ and loved it. I said I am 

going to say something to you—and this is like in November/December last year—and I said I don’t know about the meetings that 

I wasn’t in, but the meetings that I was in I said it was like you 

had a tape recorder in the room. That is how accurate your reporting was. He said, well, thank you. Thank you very much. And in 

that book where we can only assume, I think, that if the reporting 

was accurate in the meetings I was in that you would be safe to 

assume that the reporting was accurate in the meetings I was not 

in. 

And I believe—I am not sure but I think it is on page 326 but 

I don’t know how to read a book on my iPad—but I think it is on 

page 326 talks about where sequestration came from. Do you know 

where it came from, whose idea it was? 

45 

Ms. HYDE. Congressman, I think these are issues that are going 

on between you and the White House and others and I think that 

you should take those questions and comments to them. 

Mr. LONG. Well, I think that you have used sequestration of a 

lot here today and 168 million out of your budget, and, you know, 

according to Mr. Woodward who was accurate in the meetings that 

I was in, it came from the White House. It came from the President, sequestration. And now that it has gone into effect, we have 

a lot of different agencies coming to us on a lot of different issues 

and so I just want to point out for the record where sequestration 

came from so that when we are talking about it in hearings like 

this, and we may talk about it later in the second panel today, I 

just thought that was important to bring out. And I yield back. 

Ms. HYDE. Yes, Mr. Congressman, I think sequestration came 

from a number of different drivers and I think it is very clear that 

Congress had the authority to make a decision that it would not 

go into effect. I think everybody wanted it not to go into effect. I 

think everybody assumed to that there would be another—— 

Mr. LONG. Isn’t that kind of—well, I am not going to get into a 

discussion with you and I am controlling the time, but I think it 

is kind of bad to come up with a law that you are going to pass 

thinking it won’t go into. And I yield my time back to the chairman. 

Mr. MURPHY. The gentleman yields back. His time is expired. 

And I now recognize the gentleman from Georgia, Dr. Gingrey, for 

5 minutes. 

Mr. GINGREY. Mr. Chairman, thank you very much. Administrator Hyde, can you understand the criticism leveled by some 

against SAMHSA that the Agency’s focus on behavioral health 

being such a broad and amorphous category has come at the expense of prioritizing resources for treating those with serious mental illness? 

Ms. HYDE. No, I don’t agree with that. And again, behavioral 

health is a broad term that we use for both substance abuse and 

mental health and mental illness. It is about prevention, treatment, and recovery. So it is a broad term. Our budget is about 70 

percent substance abuse. The other part of our budget is about 75 

to 80 percent about serious mental illness and serious emotional 

disturbance. So no, I don’t understand the criticism. 

Mr. GINGREY. Well, in other words, look, to me it has drawn attention away from the biological basis behind the most serious of 

these illnesses focusing instead on environmentally driven behaviors. One example of this is something called Leading Change, 

SAMHSA’s plan of action for 2011 through 2014. In this document 

of over 100 pages setting out the Agency’s eight core strategic initiatives for the coming years, the word of schizophrenia or bipolar 

disorder do not appear at all. Are these conditions not defined by 

both the National Institute of Mental Health and SAMHSA as examples of SMI, serious mental illnesses? 

Ms. HYDE. As I said earlier, the Leading Change document 

doesn’t have any diagnoses in it. It is not the purpose of that document. The definition of serious mental illness is different in different places. Congress has given us a definition in one place that 

is different with the NIMH in another place. We have—each State 

46 

makes their own definition of it for purposes of the block grant, so 

there is lots of different definitions, and certainly, people with 

schizophrenia and people with bipolar disorder are some of the diagnostic categories that could be a person with serious mental illness. In many cases, it also includes a function or a history that 

makes the individual in need of intensive treatment. 

Mr. GINGREY. Well, there is a lot of controversy. I read an article 

this weekend in the Wall Street Journal that expanded there was 

a lot of coverage of mental illness. Those of you may be here on 

the panel or members of the subcommittee may have read these articles about DSM–V and the concern, you know, about how in the 

world, you know, psychiatrists and psychologists getting away from 

really the cause of some of these serious things and just throwing 

medication at it. Maybe that is another subject, maybe not. 

But according to the National Institute of Health, schizophrenia 

affects around 2.5 million Americans while bipolar disorder affects 

5.7 million Americans in this country. And I am discouraged that 

it seems to me, Madam Administrator, it just seems to me that 

your action plan fails to address both of these populations of people. In the time remaining, can you please explain to this committee what if anything SAMHSA has done in the last 5 years 

which has impacted treatment for a patient with one of these diseases if they walk into a typical community mental health center 

in an average State, Georgia, mine; what is it, Missouri? Yours and 

my friend Mr. Long in front of me. What happens if a person walks 

into these community mental health centers in the average State 

in this country, Missouri or Georgia? 

Ms. HYDE. We know health centers across the country frequently 

are funded by the Mental Health Block Grant, which SAMHSA administers. They frequently are recipients of SAMHSA grants. Almost all of them now get Medicaid dollars and Medicare dollars. 

Most of them now get private insurance dollars as well. So as we 

indicated earlier, 2⁄3 of the money to fund those services come from 

Medicaid, Medicare, and private insurance. 

The SAMHSA grant that we provide help those community mental health centers to provide those things that a typical insurance 

benefit would not necessarily provide. We provide it for both a different kind of set of services, evidence-based practices that are over 

and above those, and we also provide it for those individuals who 

were not covered the moment. 

So there is a lot of ways in which if you walk into a community 

mental health center, you can bet they are touched by SAMHSA 

funding and they certainly may very well be touched as well by 

SAMHSA technical assistance, by their training, by our public education and outreach and awareness. They may use our data. There 

is a number of ways in which those community health centers are 

touched by us. 

Mr. GINGREY. Madam Administrator, that is helpful. Thank you 

and I yield back. 

Mr. MURPHY. Thank you. I now recognize the gentleman from 

Iowa, Mr. Braley, for 5 minutes. 

Mr. BRALEY. I want to talk about the Garrett Lee Smith Suicide 

Prevention Program, a program that is very personal to me because 

I lost my niece to suicide her senior year of high school, and I am 

47 

concerned about the proliferation of social media sites and the 

amount of information available to teenagers who are contemplating suicide and who have some of their concerns reinforced 

about information provided by those sites. What are we doing to 

monitor the traffic on Facebook and Twitter and other social media 

sites to be more aggressive in intervening with young people to prevent them from taking this most drastic step to end their problems? 

Ms. HYDE. It is a great question. We have a relationship with 

Google, who actually has allowed us to have our National Suicide 

Prevention Hotline be the first thing that comes up. You know, normally, Google will just do a—it will come up different every time, 

but if you Google suicide, it will come up our lifeline number first. 

We also have relationships with Facebook who worked with us 

over the release last year of the National Strategy for Suicide Prevention, which was the Surgeon General’s report that was developed by a public-private partnership that we participated heavily 

in. Facebook is one of the partners there and they have actually— 

now are monitoring some of the language and some of the materials or some of the chatter that is going on and trying then to intervene and allow that individual to know that there is a way that 

can reach out. So we have good public-private partnerships working with entities like that to try to address some of the issues you 

have raised. 

Mr. BRALEY. What are we doing to affirmatively promote information through those platforms to try to counter some of the misinformation and encouragement that takes place over those platforms 

and educate young people to the alternatives that are available to 

seek help when they are in such a time of crisis in their lives? 

Ms. HYDE. Again, I think there is a couple of ways. We have a 

Garrett Lee Smith, as you know, program that is campus-based. 

That is one of the age groups that has a high proportion of death 

by suicide and a high proportion of individuals who either seriously 

consider or act on those issues. Those grants help to raise awareness. They help to provide support groups. They help to provide actually information to faculty and students. So we have a fairly extensive—again, limited by the dollars that we have, we have a fairly extensive effort around that. 

We also do a significant amount of public awareness and support 

with materials, posters, things to hand out to people. I have got 

them in my backpack. I carry them around, signs of suicide prevention that you can give to anyone who appears to be talking about 

that kind of thing. We have also tried to provide some training for 

parents and survivors of actual attempts as well as parents of—or 

family members of those who have experienced this. So we do a fair 

amount of work in that and we do it with partners. It is not just 

SAMHSA. It is some of our stakeholder partners who work on this 

issue extensively. 

Mr. BRALEY. Thank you. That is all I have. 

Mr. GRIFFITH [presiding]. I now recognize the gentlelady from 

North Carolina, Mrs. Ellmers. 

Mrs. ELLMERS. Sorry. Thank you, Mr. Chairman. Thank you, Ms. 

Hyde, for being with us today. You know, mental health in this 

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sight and Investigation is taking on with a great passion. We know 

that the health care system in this country needs to be reformed. 

We know that the mental health system in this country needs to 

be improved upon. 

And that brings me to my concerns about the way that your organization is moving forward with hard-earned taxpayer dollars. I 

am concerned that there seems to be a lack of physicians and 

nurses and social workers that are a part of your organization, and 

I have reviewed all of the information here, and I would like to hit 

on a couple of very specific issues, especially with healthcare professionals. I read the brochure on the Alternatives Conference that 

you are a part of, and I don’t see anywhere where they discuss continuing education credits for psychiatrists, for psychologists, for 

nurses, for social workers. Is this correct? I mean is there no program that you are associated with with at least education and 

training for these healthcare professionals? 

Ms. HYDE. No, that is not correct. Alternatives is just one thing 

that we do. We also work with—I gave a keynote at the American 

psychiatric nurses Association as well. So there is lots of different 

efforts that we do with psychology groups, social work groups, 

nursing groups and others to try to—— 

Mrs. ELLMERS. But not for this particular conference that you do 

like, again, providing accredited hours of education training for 

these individuals? 

Ms. HYDE. Not at—I don’t believe that is—— 

Mrs. ELLMERS. Through federal dollars? 

Ms. HYDE. I would have to check that for you. 

Mrs. ELLMERS. OK. And if you could provide to our committee 

those keynote points that you made at that particular conference, 

that would be helpful as well. 

Also, some of the other issues, and there again we are looking 

at federal dollars that are being spent here. We discussed the sequester cuts that you have identified as problematic, and I can certainly understand that as well. However, I think there are dollars 

that are being spent here that aren’t necessarily getting to the root 

of the mental health issues that we are faced with in this country, 

especially with young people. 

But also in the document that you have, Leading Change, you do 

make very specific reference to suicide, substance abuse, which obviously definitely falls under your jurisdiction, depression, PTSD, 

so you are able to name specific diagnoses. So this is something 

that you do not have any difficulty talking about specific diagnoses, 

is that correct? 

Ms. HYDE. In the right context, absolutely not. We don’t have 

any problem with that in the—— 

Mrs. ELLMERS. OK. So that is a yes. In your document Leading 

Change again, you do not specifically mention schizophrenia, bipolar disorder. So is that something that you do not regard as serious 

mental illness? 

Ms. HYDE. Of course we consider those serious mental illness diagnoses. That document was not a clinically-based document. It 

laid out our eight strategic initiatives ranging from prevention to 

military families to trauma issues to quality issues to public awareness and support and to electronic health records. 

49 

Mrs. ELLMERS. OK, well—— 

Ms. HYDE. The nature of that document—— 

Mrs. ELLMERS [continuing]. I would like to hit on one specific 

area, though, in relation to those with my 1 minute that I have 

left. One of the areas there again getting back to that document, 

getting back to schizophrenia and bipolar, do you believe medication is a proven evidence-based treatment for these diagnoses? 

Ms. HYDE. Absolutely. For most people. There are, however, a 

number of people who have those diagnoses for which medication 

is still not effective. 

Mrs. ELLMERS. Well, see, that is one of those curious areas there 

because you also are providing funding to organizations that support and promote taking away medical treatment. Do you acknowledge that? 

Ms. HYDE. We provide funding for entities to do the grants that 

we give them to do. Whether or not they espouse other—— 

Mrs. ELLMERS. Well, then, what are the criteria that you would 

give a grant if it isn’t a treatment that you would support for mental illness—— 

Ms. HYDE. The—— 

Mrs. ELLMERS. Ten seconds. 

Ms. HYDE. It depends on what the grant is. There is a lot of different grants that we give for a lot of different purposes. I would 

be glad to talk to you offline about that some more. 

Mrs. ELLMERS. Well, I would like to see that criteria of how you 

qualify an organization that you are giving hard-earned taxpayer 

dollars when it is something as serious as mental health. And if 

you could provide the criteria or the application process that would 

be wonderful so that we can see who gets this money and how you 

qualify them. Thank you very much. I went over and I apologize, 

Mr. Chairman. 

Mr. GRIFFITH. I now recognize the gentleman from California, 

Mr. Waxman, for 5 minutes. 

Mr. WAXMAN. Thank you, Mr. Chairman. 

I understand there has been a good deal of discussion regarding 

the role of Protection and Advocacy Program, and I am very familiar with this program having worked on the authorizing statute 

when I was chairman of the Health and Environment Subcommittee. The Protection and Advocacy for Individuals with Mental Illness Act authorized Protection and Advocacy organizations to, 

one, protect and advocate for the rights of people with mental illness; and two, investigate reports of abuse and neglect in facilities 

that provide care or treat people with mental illness. 

I know we have heard criticisms about efforts of these entities 

in specific cases, but I want to underscore two points: First, Protection and Advocacy organizations are designed by their respective 

States and are acting within the scope of congressionally mandated 

activities; and second, absent their efforts, thousands of individuals 

would continue to experience abuse, neglect, and violation of their 

civil rights. 

For example, in 2011 the PAIMI program supported casework for 

approximately 4,000 children and adolescents, nearly 13,000 adults 

and elderly individuals, and entities receiving funding resolved 

over 11,000 complaints. Now, Administrator Hyde, you also noted 

50 

that SAMHSA is developing a framework to guide behavioral 

health services and programs throughout the country and to provide a consistent set of measures for use by various stakeholders. 

Can you tell us how you expect this framework to improve accountability for your stakeholders? 

Ms. HYDE. Thank you. Yes, we are developing a National Behavioral Health Quality Framework. It is modeled on the National 

Quality Strategy that was required by Congress so we have been 

working with the organizations to develop that. It has six goals, 

things like safe care, evidence-based care, effective care, patientcentered care, et cetera. And we are developing rules and measures 

with the National Quality Forum and others to populate what that 

quality framework might look like. 

Mr. WAXMAN. Is there anything else you would like to add with 

regard to SAMHSA’s ongoing accountability efforts? 

Ms. HYDE. Yes, thanks for the question. We—every one of our 

programs—our grant programs we evaluate. We have evaluation 

data. We have one of the highest number of the GPRA, what we 

call GPRA or government accountability measures of any of the 

agencies. We report that data. We make it available. All of our 

grantees are doing that. We also work hard—we are in the process 

of revising our data reporting and data collection activities both for 

our discretionary grants, as well as for our block grants to assure 

that we have the best data possible available for you all, as well 

as for the public. So we do a lot of work in this area. We also do 

oversight of each of our grants and then we respond to complaints 

and investigations and investigate those when they are brought to 

our attention. 

Mr. WAXMAN. And even as you are requesting more information 

from your grantees, I understand there are instances in which you 

lack the authority to require States and other grantees to report 

on certain measures, for example, within the Community Mental 

Health Services Block Grant. Is that correct? 

Ms. HYDE. Well, the block grant is meant to be a flexible funding 

stream, so for States—they make different choices about that. They 

do provide us information about how they use those dollars and we 

do report those back. We also—but we—so we have limited authority in some ways but I think it was designed to be a flexible funding stream for each State. 

Mr. WAXMAN. Well, it is a flexible funding stream for each State 

but when you try to get information from them and you are asking 

them to report on certain measures, are you able to get the information you need? 

Ms. HYDE. To an extent we are and we have just begun a new 

effort with the States to try to see how we can collectively report 

data better. We all want to improve that so we have data now. We 

have information about what the States use the dollars for—— 

Mr. WAXMAN. Yes. 

Ms. HYDE [continuing]. But we do want to improve those data. 

We are always looking for ways to improve that accountability for 

Congress and the public. 

Mr. WAXMAN. I think we can agree that it is important to make 

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ures in place so that we can track progress over time. I hope that 

we can work together to support SAMHSA’s efforts on this issue. 

And I thank the chair for recognizing me. I yield back the balance of my time. 

Mr. MURPHY. I thank the gentleman. I now recognize the gentleman from Ohio, Mr. Johnson, for 5 minutes. 

Mr. JOHNSON. Thank you, Mr. Chairman. And I appreciate the 

opportunity. Thank you, Ms. Hyde, for being here today. 

I do have one comment I want to make, though, before I get into 

the questions because I was struck by what my colleague from Missouri mentioned about the idea of sequestration because that seems 

to be a hot topic today. We consistently have administration officials come before our committees to talk about sequestration and 

the fact that it is hurting their ability to do the job that they are 

assigned to do. However, we know and it has even been admitted 

that the idea of sequestration came from the White House. 

I came from the floor just a little bit earlier where our minority 

whip talked about or tried to make the case that once again this 

was a Republican House idea, which it was not, and that we have 

abdicated our leadership because we haven’t worked across the 

aisle to try and replace the sequestration when in fact we passed 

two pieces of legislation in the last Congress that would replace sequestration, give the Administration the flexibility that it needed 

by making more responsible spending cuts. 

So I am a little frustrated with the disingenuousness that continues to come from the Administration and the agencies that try 

to blame sequestration on their inability to do their jobs. I wonder 

where that backlash was when the Administration was putting 

forth this idea. That is just a comment. 

Let me ask you, Ms. Hyde, how our review criteria for 

SAMHSA’s formula and competitive grant programs developed? 

Ms. HYDE. Review criteria come from the RFAs, which is request 

for applications. So when we developed the RFAs based on congressional input and the program design, then we develop criteria from 

that about what the applicants have to meet. There is a checklist 

that the reviewers have to go through. They actually have to put 

the page number of the application of where the different criteria 

are in the application. They are scored and then that scoring drives 

the decisions about development. Now, that is sort of the discretionary grants. The formula grants like block grant and the PME 

program and others, those are done by application from the States 

because each State is entitled to those dollars so long as their application—— 

Mr. JOHNSON. How do you ensure that SAMHSA grant reviewers 

follow the criteria consistently? 

Ms. HYDE. As I said, there is a checklist and they have to identify the page number in the application where they actually saw 

the criteria that they are looking for in the grant review. So there 

is an extensive documentation about how they reviewed the criteria 

and how they—the scoring occurs. 

Mr. JOHNSON. What kind of oversight does SAMHSA perform 

over its grantees after the grant is awarded? 

Ms. HYDE. Each grantee has a grant project officer. Those grant 

project officers provide oversight by visits, by audits of papers, by 

52 

technical assistance, and by looking at the materials that are provided for reporting and overseeing whether or not those are up to 

snuff and what they are required for meeting their grant performance. 

Mr. JOHNSON. How often is this type of oversight performed? 

Ms. HYDE. It depends on the situation and depends on how many 

grantees there are, what kind they are, whether or not they are 

sort of usual grants or new grants. So new grantees may get additional attention or more oversight than grantees who have been 

going for a while, et cetera. 

Mr. JOHNSON. OK. Ms. Hyde, some have called the annual Alternatives Conference that is funded by SAMHSA to be the largest 

anti-psychiatry, anti-treatment meeting in the U.S. In your view, 

what is the value that has been obtained for the American people 

and more specifically the mentally ill from these conferences? 

Ms. HYDE. Again, this is one event of many that we have worked 

with—— 

Mr. JOHNSON. But it is paid for by the taxpayers, correct? 

Ms. HYDE. It is one event that SAMHSA funds. 

Mr. JOHNSON. But it is paid for by the taxpayers, correct? 

Ms. HYDE. Well, SAMHSA uses taxpayer dollars—— 

Mr. JOHNSON. There you go. 

Ms. HYDE [continuing]. That is correct. 

Mr. JOHNSON. OK. 

Ms. HYDE. But it is only one. We have many others. The effort 

is to provide information and to provide assistance, for example, 

trying to provide help and information about how people can enroll 

in coverage to get access to treatment and services. We provide information there on different types of treatments and approaches 

that will help individuals. We try to develop workforce efforts 

there. There is a number of opportunities that we do at that conference, as with many of the other conferences that we support. 

Mr. JOHNSON. Mr. Chairman, I yield back. 

Mr. MURPHY. Thank you. I now recognize Mr. Tonko for 5 minutes. 

Ms. DEGETTE. Will the gentleman yield to me just for one question? 

Mr. TONKO. I would. 

Ms. DEGETTE. Thank you. I just want to ask you quickly, Administrator Hyde, irrespective of whose fault the sequester was—and 

I don’t think it was my fault because I voted no—but irrespective 

if it is the White House or the Congress’ fault, the fact is that the 

cuts have gone into effect and your agency still has to administer 

those cuts, correct? 

Ms. HYDE. Correct. 

Ms. DEGETTE. Thank you. Thank you, Mr. Tonko. 

Mr. TONKO. Thank you, Ranking Member DeGette. And thank 

you, Mr. Chair. Thank you as well to Administrator Hyde for your 

testimony here today on the sequestration rundown. I think one 

piece was left out that the Democrats in this House proposed an 

alternative to sequestration. It was blocked by the majority in the 

House. 

Like many of my colleagues, I, too, am concerned over allegations 

of wasteful spending and the questionable activities of some 

53 

SAMHSA grantees. These incidents should and will continue to receive the utmost scrutiny from this committee and I applaud the 

chair’s initiative to conduct this important oversight hearing. 

However, I also have significant concerns that the instincts of 

some of my colleagues in investigating these allegations would be 

to throw the proverbial baby out with the bathwater resulting in 

further damage to our Nation’s already reeling mental health system. This is not the right approach. 

And according to the National Association of State Mental Health Program Directors, States have cut at least $4.35 billion in 

public mental health spending from 2009 to 2012. In these tough 

times, federal funding from sources like SAMHSA’s Community 

Mental Health Sources Block Grant is more important than ever 

to ensure that even more individuals do not fall through the cracks 

of our fragmented mental health systems. 

Administrator Hyde, that being said, I think the two biggest 

criticisms lobbied against SAMHSA are its funding of the Consumer and Consumer-Supporter Technical Assistance Centers and 

the Protection and Advocacy for Individuals with Mental Illness 

program. Can you tell us what proportion of SAMHSA’s mental 

health budget in 2013 was spent on these very programs respectively? 

Ms. HYDE. Congressman, I don’t have that number off the top of 

my head but I can tell you it was miniscule compared to the overall 

expenditures. We can get that. 

Mr. TONKO. Sure. 

Ms. HYDE. We can do the math and get you that information. 

Mr. TONKO. Well, according to my information, SAMHSA’s 2014 

budget request document, the Consumer Technical Assistance Centers program was funded at a level of 1.9 million and the Protection and Advocacy for Individuals with Mental Illness program was 

funded at 36 million. Together, these programs would comprise a 

little more than 3 percent of SAMHSA’s $954 million mental health 

budget in 2013. If you could check on those numbers, please, Administrator Hyde—— 

Ms. HYDE. Will do. 

Mr. TONKO [continuing]. I would appreciate it and get back to 

the Committee. And by contrast, what percentages of SAMHSA’s 

mental health funding went directly to States to support mental 

health treatment services in 2013? 

Ms. HYDE. About 48 percent of our mental health dollars went 

to States through the block grant program. There are additional 

discretionary grant programs that States have dollars from. Again, 

we could add up how much of that is States. Most of our dollars 

do go towards States. 

Mr. TONKO. So when you say most, like a rough percentage 

would be? 

Ms. HYDE. Again, I don’t know how many of our grantees are 

States versus communities sitting here, but we can certainly get 

you that information. 

Mr. TONKO. It appears as though a vast majority of the dollars 

are going toward assistance for treatment. Regardless of how much 

money is spent on programs such as the Consumer and ConsumerSupporter Technical Assistance Centers and the Protection and AdVerDate Nov 24 2008 14:18 Nov 22, 2013 Jkt 037690 PO 00000 Frm 00059 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-47 CHRIS
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vocacy for Individuals with Mental Illness, these programs should 

be accountable for spending taxpayer money wisely. I share the 

opinions of many on this committee that grantees should not be 

able to use federal funds to lobby against duly enacted state laws. 

Can you describe what type of internal safeguards SAMHSA has 

in place to ensure that these monies are spent appropriately? 

Ms. HYDE. We review the grantee expenditures to assure that 

they are being spent on the issues that were identified in their applications and that the funding allows. If we are—if someone 

brings to us an allegation that those dollars are being spent inappropriately, we investigate that and act accordingly. 

Mr. TONKO. Thank you, Administrator Hyde. 

In closing, I would just like to point out that many of the programs that we are scrutinizing here today such as the Protection 

and Advocacy for Individuals with Mental Illness program saw 

their congressional authorizations expire at the end of 2003. Simply put, as a Congress, we have been derelict in our duty to provide 

proper and continuous oversight to this agency, and as such, this 

agency shares in the responsibility for any failures at SAMHSA. 

I would strongly urge my colleagues on both sides of the aisle to 

continue this dialogue and to work to enact meaningful legislation 

that will provide SAMHSA with the appropriate congressional 

guidance it needs to find out what works and what doesn’t and to 

ensure it is meeting its core mission of serving individuals with serious mental illness. I stand more than ready to work on this goal 

with anyone who will join. And with that, Mr. Chair, I yield back. 

Mr. MURPHY. The gentleman yields back. I now recognize the 

gentleman from Louisiana, Mr. Cassidy, for 5 minutes. 

Mr. CASSIDY. Hello, Administrator Hyde. 

Ms. HYDE. Hi. 

Mr. CASSIDY. A couple things. Clearly, we are in a time of budgetary constraints. You referred to it multiple times, but on the 

other hand, that is the new reality. That said, it seems a luxury 

to be unfocused in how we are implementing programs. I had to 

step out several times, I apologize, but I gathered one of the things 

I heard you say is that there are many working definitions of severe mental illness. Now, truly, this seems like an area that you, 

your agency could give guidance as to what severe mental illness 

is about. 

One example, one of the witnesses on the next panel speaks 

about how there is an unbalance in your compendium of care. She 

formerly worked with yours, says that of 288 programs listed, only 

four would address things pertaining to schizophrenia or bipolar 

disease. Now, first, knowing that our money is tight, why out of 

288 programs will we only have four that seem to directly pertain 

to what we could all agree would be severe mental illness? 

Ms. HYDE. I don’t agree with those numbers. I don’t know exactly 

where that comes from. 

Mr. CASSIDY. She is a psychiatrist formerly with SAMHSA. You 

can read her testimony but she ballparked it. She goes, listen, 

maybe there is a couple I missed. Let’s say that there is 8, there 

is 12, but out of 288 it seems like 286 should be related to something that we could all agree was severe mental illness. Is something wrong with that logic? 

55 

Ms. HYDE. The issue of serious mental illness is different for different purposes. So there is literally congressional definitions. 

There is definitions—— 

Mr. CASSIDY. So I am coming back to the fact that knowing in 

a time of budgetary constraint, when, by the way, in the shadow 

of Sandy Hook I think we are compelled not to accept that there 

are a lot of different definitions but to try and hone down at least 

in programmatic funding upon something that if there was a psychiatrist at the Agency in a position of authority, she would say, 

wow, this is how we prevent another Sandy Hook, put our resources there as opposed to a lot of other things which are more 

diffuse. 

Ms. HYDE. I am not aware of any of SAMHSA’s programs that 

are targeted to serious mental illness that doesn’t include schizophrenia. It is not just—— 

Mr. CASSIDY. OK. But our point is that there is—— 

Ms. HYDE [continuing]. Schizophrenia, however—— 

Mr. CASSIDY [continuing]. A maladjustment of the compendium 

of care that there is only four programs—let’s say for the sake of 

argument it is 12 out of 288 that are specifically focused upon what 

we could all agree would be serious mental illness. 

Ms. HYDE. I am sorry. I just don’t agree with the numbers. As 

I told you earlier—— 

Mr. CASSIDY. So if she comes up with that, would you agree in 

concept—because her testimony is next—in concept would you 

agree that if that is true that that would be an unbalanced compendium of care? 

Ms. HYDE. I don’t agree that that is true. 

Mr. CASSIDY. But if it were true, would you accept that, just a 

hypothetical if you can go with me that there really should be a 

focus of these programs—in fact, your answer implies that you 

think it should be. There should be a focus of these programs upon 

those that we can agree would be severe mental illness? 

Ms. HYDE. I think I have said several times there is a priority 

on serious mental illness. 

Mr. CASSIDY. And how do you define priority? 

Ms. HYDE. Seventy-five to eighty percent of our funding for mental health goes to people with serious mental illness or serious 

emotional disturbance, which is—— 

Mr. CASSIDY. OK. 

Ms. HYDE [continuing]. The name for our children’s programs. 

Mr. CASSIDY. OK. Now, that said, severely mental ill patients, I 

see a lot of these grants go for prevention, but you can’t really prevent paranoid schizophrenia. I mean we don’t know the biologic 

basis in terms of a prevention activity. 

Ms. HYDE. Actually, there is increasing evidence that we can prevent the disability related to those psychotic illnesses, and the earlier we intervene, the more we can have a positive impact—— 

Mr. CASSIDY. So when you say prevention, you don’t technically 

mean prevention of the illness; you mean prevention of the untoward effects of having mental illness. 

Ms. HYDE. Prevention has a range of issues in it. From—the Institute of Medicine has a whole range from primary prevention all 

the way up to intervention. 

56 

Mr. CASSIDY. Is there primary prevention of paranoid schizophrenia? 

Ms. HYDE. No, I don’t think we have the ability to do that at this 

point. 

Mr. CASSIDY. So my problem again, in an era of budgetary constraints, should we be focusing our dollars on that which actually 

would prevent another Sandy Hook or should we be more diffuse? 

And let me ask you that. Do you agree with that question? 

Ms. HYDE. I think we should do everything we can to prevent incidents like Sandy Hook. 

Mr. CASSIDY. So does that mean again yes or no that we should 

focus our limited dollars upon those activities not exclusively but 

would primarily focus our limited dollars on those activities that 

would definitely have the potential to prevent such an incident like 

that? 

Ms. HYDE. I think that is why the President has proposed the 

2014 budget, several programs that we believe will help identify 

that and help—— 

Mr. CASSIDY. And so you do agree that we should focus our dollars because that is actually not a yes or no answer. And I don’t 

mean to be confrontational, but that is—— 

Ms. HYDE. We have no choice as public administrators but to 

focus our dollars and we do that every day. 

Mr. CASSIDY. OK. Great. I am almost out. I yield back. 

Mr. MURPHY. I thank the gentleman. I just want to point out, I 

am looking at a document that SAMHSA put out called Mental 

Health: United States 2010. And in that on page 11 SAMHSA does 

define serious mental illness. Among adults, it is defined as ‘‘persons 18 or older who currently or at any time in the past year had 

a diagnosable mental, behavioral, or emotional disorder and resulting in substantial impairment in carrying out major life activities.’’ 

So I am assuming diagnosable. So you do have a definition. I know 

we have been going back-and-forth on that but that is helpful and 

I should focus on that. 

We have finished our questions but I do want to ask a favor of 

you if I can. I know one of the things that you have said frequently 

is you are not aware about some of the programs you fund and you 

asked for some of our feedback on those. So I have a personal request. On the next panel a man named Joe Bruce is going to testify 

and I know you are very busy, but Mr. Bruce’s testimony, he said 

he is going through something that no parent or husband should 

ever have to experience. 

His son William, after being discharged from a mental health 

treatment center with the assistance of a representative from the 

SAMHSA-funded Protection and Advocacy for Individuals with 

Mental Illness program murdered his mother. And it is also Mr. 

Bruce’s wife, and he murdered her with a hatchet. I believe his 

story is very powerful and important and I think it is important 

for you to hear what one of the agencies you funded has done in 

this instance. So if you can stay just to hear his 5 minutes of testimony, I would be grateful if you could do that. 

And with that, we end this panel and we will prepare the second 

panel to come up. Thank you. 

Ms. HYDE. Thank you. 

57 

Mr. MURPHY. I will start to introduce our witnesses as they are 

taking their seats. I will introduce the witnesses of the second 

panel. 

Our first witness is Joseph Bruce, the father of a son who suffers 

from severe mental illness. Our second witness is Dr. E. Fuller 

Torrey. He is a research psychiatrist specializing in schizophrenia 

and bipolar disorder and founded the Treatment Advocacy Center 

and executive director of the Stanley Medical Research Institute, 

which supports research on schizophrenia and bipolar disorder. He 

is also a professor of psychiatry at the Uniform Services University 

of the Health Sciences. 

Our third witness is Dr. Sally Satel, a psychiatrist trained at 

Yale University School of Medicine. Since 2001 she has been a resident scholar at the American Enterprise Institute and also continues part-time clinical work in drug treatment clinics in Washington, D.C. 

And our fourth witness is Dr. Joseph Parks. He is the chief clinical officer at the Missouri Department of Mental Health. There, he 

is responsible for clinical standards and quality of care for persons 

with mental illness, mental retardation, and developmental disabilities and alcohol and drug dependence. In this capacity, he has substantial experience working on SAMHSA-funded grants. 

I will now swear in the witnesses. And you are aware the Committee is holding an investigative hearing. When doing so, we have 

the practice of taking testimony under oath. Do any of you have 

any objections to testifying under oath? 

All have responded no. 

The chair then advises you that under the rules of the House and 

the rules of the Committee, you are entitled to be advised by counsel. Do you desire to be advised by counsel during your testimony 

today? 

All have said negative. 

In that case, if you would please rise, raise your right hand, I 

will swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. Let the record show all witnesses have answered 

in the affirmative. 

You are now under oath and subject to the penalties set forth in 

Title XVIII, Section 1001 of the United States Code. You may now 

each give a 5-minute summary of your written statement. I will 

call upon you first, Mr. Bruce, for your statement. Thank you for 

being here. 

TESTIMONY OF JOSEPH BRUCE, FATHER OF A SON WITH SEVERE MENTAL ILLNESS; E. FULLER TORREY, FOUNDER, 

TREATMENT ADVOCACY CENTER; SALLY SATEL, RESIDENT 

SCHOLAR, AMERICAN ENTERPRISE INSTITUTE; AND JOSEPH 

PARKS, III, CHIEF CLINICAL OFFICER, MISSOURI DEPARTMENT OF MENTAL HEALTH 

TESTIMONY OF JOSEPH BRUCE 

Mr. BRUCE. My name is Joe Bruce. I live in Caratunk, Maine. 

On February 6—— 

58 

Mr. MURPHY. Pull the microphone real close to you, please. 

Thank you. 

Mr. BRUCE. On February 6, 2006, my son William Bruce, age 24, 

was involuntarily committed to Riverview Psychiatric Center in 

Augusta, Maine. On April 20, 2006, with help from federally funded patient rights advocates from the Disability Rights Center of 

Maine, Will was discharged early from Riverview without the benefit of any medication. 

As is most often the case with severely and persistently mentally 

ill persons across the country, Will returned home. Fears his mother and I had voiced to his doctors that Will would hurt or kill someone came true. On June 20, 2006, I returned home to find the body 

of my wife Amy. Will, in a state of deep psychosis, had killed her 

with a hatchet. 

Will was advised that without his consent, his parents had no 

right to participate in his treatment or have access to his medical 

records. Will believed there was nothing wrong with him and that 

he was not mentally ill, a condition characteristic of many persons 

with severe bipolar disorder or paranoid schizophrenia, particularly 

of younger ages such as Will’s. He would not consent to our involvement with his treatment, and because he was an adult, his 

mother and I were barred from all access to his treatment. The 

doctor’s decision to release him, which resulted in such a tragic 

outcome, was made without the benefit of all of Will’s history or 

any input from Amy and me. 

After his commitment to Riverview by the criminal court, I applied to become his guardian. Will was agreeable to this until, incredibly, a patient advocate told him the guardianship is a bad 

idea. It would give your father complete power over you. 

The attending physician, a new doctor, undoubtedly at the urging 

of DRCM, refused to provide the evaluation required in the guardianship application. He told me, I could never participate in anything that would cause your son to be considered an incapacitated 

person. Bear in mind that at this point in time, Will had been 

placed in the hospital after being found incompetent to even stand 

trial. 

Suffice it to say, I finally did become guardian, and I was able 

to participate in Will’s treatment and to obtain the medical records 

of his prior treatments. Until then, I had not known the role that 

patient advocates had played in Will’s premature and unmedicated 

release. 

The medical records revealed exactly what the patient advocates 

had recklessly done and said to encourage Will to avoid the treatment he so desperately needed. His doctor had recorded verbatim 

what the patient advocates said to Will in the meetings from which 

Amy and I had been excluded. The patient advocate, a Trish Callahan, told the treating doctor that DRCM regarded Amy and me 

as a ‘‘negative force in Will’s life.’’ Amy and I had never met any 

of these people or even heard of Disability Rights of Maine. 

In the treatment meetings, she acted like a criminal defense lawyer. She openly coached Will on how to answer the doctor’s questions so as to get Will the least treatment and the earliest release. 

She did this in the face of strongly contrary evidence of Will’s 

unsuitability for unmedicated release. She repeatedly pressed for 

59 

his early release despite knowing or recklessly disregarding that he 

was unsuited for it. 

DRCM willfully neglected Will’s need for treatment, and their 

pressure on the doctor to release Will led directly to Amy’s death. 

But neither the patient advocates nor the DRCM has ever acknowledged they did anything wrong. They have not changed their procedures, and Trish Callahan, the advocate who helped fuel Will’s 

paranoid hostility towards his mother and contributed to her death, 

continued to work on the same unit at Riverview for years afterwards. 

Lest anyone believe this is a local, isolated occurrence, the National Disability Rights Network, responding to the Wall Street 

Journal’s page 1 article concerning Will’s case, defended the actions 

of DRCM, and even prepared talking points to deflect criticism. 

The patient advocates can do this with impunity because they are 

literally accountable to no one. But my experience with the patient 

advocates did not end here. I have come to know the stories of 

many families, and their experience with the advocates’ surprising 

approach to these issues. 

Beginning in 2007, I joined with other family members of some 

of the most severely mentally ill individuals in the State of Maine 

to seek legislative change to laws that had prevented our loved 

ones from receiving treatment. We took our concerns to the lawmakers in the Maine legislature. To the shock of all of us, we met 

with fierce lobbying opposition from Disability Rights Center of 

Maine. Nonetheless, we were successful in obtaining helpful legislation in 2007 providing for medication over objection in appropriate cases. Having failed in the legislature, the lawyers at DRCM 

filed a legal action challenging the law, which thankfully was unsuccessful. 

At the time of Amy’s death, the courts in Maine only had two options at a commitment hearing: to place someone in the hospital or 

to release them unconditionally. In 2008 and 2009 I and other family members worked to give the court a third option, that of releasing an individual into the community on the condition that he remain on medication. These types of laws are known as Assisted 

Outpatient Treatment laws and they have been opposed across the 

Nation by PAIMI organizations. Maine was no exception. 

DRCM mounted a well-orchestrated attack on the proposed AOT 

law. It was joined in this effort by the Advocacy Initiative Network 

of Maine, another SAMHSA-funded organization. Their campaign 

included proffering 20 or so consumer witnesses in opposition to 

the law, but these consumers were completely aware of their mental illness, stable on medication and successfully living in the community, the very goals that the proposed law was designed to 

achieve for our loved ones. DRCM had persuaded them to oppose 

the law by misrepresenting its essential provisions. This cynical opposition to the AOT law—which failed, because the law was ultimately enacted—shocked me and the families. The incident illustrates the national policy of the PAIMI program to oppose any form 

of involuntary treatment. 

The PAIMIs, like DRCM, are so concerned that one person may 

be inappropriately treated involuntarily that they seek to prevent 

60 

anyone from being medicated. In Will’s case, once I became his 

guardian, medication over his objection was his route to recovery. 

As another example of DRCM’s lobbying influence in this area, 

while the Maine families and I were busy working on the AOT law, 

DRCM was successful in getting a bill through the Maine legislature to make it more difficult for families to become guardians. Becoming a guardian is the only way families of adult patients can 

be involved in the treatment of their loved ones where the patients 

are unwilling or unable to consent. Why do PAIMIs want guardianship to be more difficult? Because guardianship lifts HIPAA secrecy 

and allows the guardians into the treatment meetings. 

Will is still in Riverview, to which he was committed by the 

criminal court. Once he was committed, he got the care he should 

have gotten before. Ironically and horribly, Will was only able to 

get treatment by killing his mother. We have found a medication 

that works. He leaves the hospital frequently on supervised release 

with staff or family members. He is being successfully treated and 

he is doing extremely well. He now recognizes that if he had been 

treated, his mother would still be alive today. He stated to the Wall 

Street Journal, ‘‘the advocates didn’t protect me from myself. None 

of this would have happened if I had been medicated.’’ 

Tragedy visits families every day. That is a sad fact of life. But 

an unbearable aspect of Amy’s death is that my own tax dollars 

helped make it possible. A retired nurse from Riverview may have 

summed it up best. She wrote: ‘‘Mr. Bruce, your losses didn’t happen for reasons other than your family’s misfortune to become involved with the mental health system, when politics now overrides 

sound medical decisions.’’ 

Thank you for hearing my testimony. I would be happy to answer 

any questions. 

[The prepared statement of Mr. Bruce follows:] 

61 


85437.013

HOUSE COMMITTEE ON ENERGY AND COMMERCE 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

Examining SAMHSA 's Role in Delivering Services to the Severely Mentally III 

Statement of Robert "Joe" Bruce and Exhibits 

10:00 a.m. 

May 22, 2013 

My name is Joe Bruce. I live in Caratunk, Maine. 

On February 6, 2006, my son William Bruce, age 24, was involuntarily committed to 

Riverview Psychiatric Center in Augusta, Maine. On April 20, 2006, with help from federally 

funded patient rights advocates from the Disability Rights Center of Maine (DRCM), Will was 

discharged early from Riverview without the benefit of any medication. 

As is most often the case with severely and persistently mentally ill persons across the 

country, Will returned home. Fears his mother and I had voiced to his doctors that Will would 

hurt or kill someone came true. On June 20, 2006 I returned home to find the body of my wife 

Amy.! Will, in a state of deep psychosis, had killed her with a hatchet.2 

Will was advised that without his consent, his parents had no right to participate in his 

treatment, or have access to his medical records. Will believed there was nothing wrong with 

him. that he was not mentally ill, a condition characteristic of many persons with severe bipolar 

disorder or paranoid schizophrenia, particularly of younger ages such as Will's. He would not 

consent to our involvement with his treatment, and because he was an adult, his mother and I 

were barred from all access to his treatment. The doctor's decision to release him, which 

resulted in such a tragic outcome, was made without the benefit of all of Will's history or any 

input from Amy and me. 

1 Pictures of Amy and Will appear behind Tab 1. 

2 A transcript of my call to tbe 911 operator is annexed behind Tab 2. 

- I -
62 


85437.014

After his commitment to Riverview by the criminal court, I applied to become his 

guardian. Will was agreeable to this until, incredibly, a patient advocate told him, "The 

guardianship is a bad idea. It would give your father complete power over you." 

The attending physician (a new doctor), undoubtedly at the urging ofDRCM, refused to 

provide the evaluation required in the guardianship application. He told me, "1 could never 

participate in anything that would cause your son to be considered an incapacitated person." 

Bear in mind that at this point in time, Will had been placed in the hospital after being found 

incompetent to even stand trial! 

Suffice it to say, I finally did become guardian, and I was able to participate in Will's 

treatment and to obtain the medical records of his prior treatments. Until then, 1 had not known 

the role the patient advocates had played in Will's premature and unmedicated release. 

The medical records revealed exactly what the patient advocates had recklessly done and 

said to encourage Will to avoid the treatment he so desperately needed. His doctor had recorded 

verbatim what the patient advocates said to Will in the meetings from which Amy and [ had been 

excluded. 

- The patient advocate, a Trish Callahan, told the treating doctor that DRCM 

regarded Amy and me as a "negative force in Will's life." Amy and I had never met any 

of these people or even heard of Disability Rights Center of Maine. 

- In the treatment meetings, she acted like a criminal defense lawyer. She openly 

coached Will on how to answer the doctor's questions so as to get Will the least treatment 

and the earliest release. She did this in the face of strongly contrary evidence of Will's 

unsuitability for unmedicated release. 

-2-
63 


85437.015

She repeatedly pressed for his early release despite knowing or recklessly 

disregarding that he was unsuited for it.3 

DRCM willfully neglected Will's need for treatment, and their pressure on the doctor to 

release Will led directly to Amy's death. But neither the patient advocates nor the DRCM has 

ever acknowledged they did anything wrong. They have not changed their procedures and Trish 

Callahan, the advocate who helped fuel Will's paranoid hostility towards his mother and 

contributed to her death, continued to work on the same unit at Riverview for years afterwards. 

Lest anyone believe this is a local, isolated occurrence, the National Disability Rights 

Network, responding to the Wall Street Journal's page one article4 concerning Will's case, 

defended the actions ofDRCM, 5 and even prepared talking points to deflect criticism.6 The 

patient advocates can do this with impunity because they are literally accountable to no one. But 

my experience with the patient advocates did not end here. 

I have come to know the stories of many other families, and their experiences with the 

advocates' surprising approach to these issues. 

Beginning in 2007, I joined with other family members of some of the most severely 

mentally ill individuals in the State of Maine to seek legislative change to laws that had 

prevented our loved ones from receiving treatment. We took our concerns to the lawmakers in 

the Maine legislature. 

To the shock of all of us we met with fierce lobbying opposition from Disability Rights 

Center of Maine. Nonetheless, we were successful in obtaining helpful legislation in 2007 

3 A summary ofthe patient advocate's statements and actions appears behind Tab 4, and a more detailed chronology 

of Will's medical records appears behind Tab 5. 

4 A copy of the Wall Street Journal's August 16,2008 article, "A Death in the Family, is annexed behind Tab 7. 

5 A copy ofthe NDRN response to the Wall Street Journal's article is annexed behind Tab 8. 

6 A copy of the NDRN's talking points is annexed behind Tab 9. 

- 3-
64 


85437.016

providing for medication over objection in appropriate cases. Having failed in the legislature, 

the lawyers at DRCM filed a legal action challenging the law, which thankfully was 

unsuccessful. 

At the time of Amy's death, the courts in Maine only had two options at a commitment 

hearing: to place someone in the hospital or to release them unconditionally. In 2008 and 2009 I 

and other Maine families worked to give the court a third option, that of releasing an individual 

into the community on the condition that he remain on medication. These types of laws are 

known as Assisted Outpatient Treatment laws and they have been opposed across the Nation by 

PAlMI organizations. Maine was no exception. 

DRCM mounted a well-orchestrated lobbying attack on the proposed AOT law. It was 

joined in this effort by the Advocacy Initiative Network of Maine, another SAMHSA funded 

organization. Their campaign included proffering 20 or so consumer witnesses in opposition to 

the law, but these consumers were completely aware of their mental illness, stable on medication 

and successfully living in the community - the very goals that the proposed law was designed to 

achieve for our loved ones. DRCM had persuaded them to oppose the law by misrepresenting its 

essential provisions. This cynical opposition to the AOT law (which failed, because the law 

ultimately enacted) shocked me and the families. The incident illustrates the national policy of 

the PAlMI program to oppose any form of involuntary treatment. 

The PAIMIs, like DRCM, are so concerned that one person may be inappropriately 

treated involuntarily that they seek to prevent anyone from being medicated. In Will's case, 

once I became his guardian, medication over his objection was his route to recovery. 

As another example ofDRCM's lobbying influence in this area, while the Maine families 

and I were busy working on the AOT law, DRCM was successful in getting a bill through the 

4 
65 


85437.017

Maine legislature to make it more difficult for families to become guardians. Becoming a 

guardian is the only way families of adult patients can be involved in the treatment of their loved 

ones where the patients are unwilling or unable to consent. Why do PAIMls want guardianship 

to be more difficult? Because a guardianship lifts H1PAA secrecy and allows the guardians into 

the treatment meetings. 

* * * 

Will is still in Riverview, to which he was committed by the criminal court. Once he was 

committed, he got the care he should have gotten before. Ironically and horribly, Will was only 

able to get treatment by killing his mother. We have found a medication that works. He leaves 

the hospital frequently on supervised release with staff or family members. He is being 

successfully treated and he is doing extremely well.7 He now recognizes that ifhe had been 

treated his mother would still be alive today. He stated to the Wall Street Journal, "The 

advocates didn't protect me from myself. None of this would have happened if! had been 

medicated." 

Tragedy visits families every day. That is a sad fact of life. But an unbearable aspect of 

Amy's death is that my own tax dollars helped make it possible. A retired nurse from Riverview 

may have summed it up best. She wrote: "Mr. Bruce ... Your losses didn't happen for reasons 

other than your family's misfortune to become involved with the mental health system, when 

politics (now) override sound medical decisions."g 

Thank you for hearing my testimony. I would be happy to answer any questions you 

might have. 

7 Behind Tab 3 is a transcript ofthe hearing that resulted in Will's commitment to Riverview, in which a psychiatrist 

testified to the "remarkable change" that occurred in Will's condition once he was given antipsychotic medications. 

At page 51. 

8 A copy of the nurse's letter is annexed behind Tab 10. She has given me permission to use it publicly. 

- 5-
66 


85437.018

Exhibits to the Testimony of Joe Bruce 

I. Pictures of Amy and Will. 

2. Transcript of Joe Bruce's call to 911 operator, June 20, 2006. 

3. Transcript of hearing in State of Maine v. William Bruce, March 27, 2007. 

(Once Will started antipsychotic medication in December 2006, it brought 

about "'remarkable change" in his insight into his need for treatment. At 

51.) 

4. The Role of the Patient Advocates, A Summary of the Medical Records of 

William Bruce, prepared by Robert D. Owen, counsel to Joe Bruce. 

5. William Bruce: Chronology of His Medical Records and Treatment, 

prepared by Robert D. Owen, counsel to Joe Bruce. 

6. Preliminary Appointment as Guardian, In Re: William H Bruce, 

Piscataquis County (Me.) Probate Court, Feb. 8,2007. 

7. "A Death in the Family: Aided by advocates for the mentally ill, William 

Bruce left the hospital -- only to kill his mother," WALL ST. J., August 16, 

2008. 

8. National Disability Rights Network "Summary in Response to WSJ 

Article." 

9. National Disability Rights Network talking points memo. 

10. Letter dated Dec. 16, 2006 to Joe Bruce from Maria Champine, a 

registered nurse who worked at Riverview. 

- 6-
67 

Mr. MURPHY. Thank you, Mr. Bruce. And our hearts are with you 

and your family. I know you made references to a number of documents. You ask that these be submitted in the record and the minority has no objection. We will include these in the record then. 

Thank you. 

Dr. Torrey, you are recognized next for 5 minutes. 

TESTIMONY OF E. FULLER TORREY 

Dr. TORREY. Thank you very much. 

Mr. MURPHY. Microphone on and close to your mouth, please. 

Dr. TORREY. Thank you very much, Chairman Murphy, Ms. 

DeGette. Very, very important what you are doing. It is not as sexy 

as the IRS hearings but it is just as important. 

I am here to describe why I think SAMHSA is not only a failed 

federal agency but it has been so for 30 years. That is one of the 

qualifications I don’t like. This is not a new issue. This is not just 

something that falls on Ms. Hyde. This is something that has been 

going on for 30 years really unlooked at by Congress in any serious—and so I strongly commend you for doing what you are doing. 

I also want to emphasize that is not a Democratic or Republican 

issue. The—SAMHSA has been a failed agency. It was originally 

put together under the Bush Administration. It was a failed agency 

under the Clinton Administration, under the George Bush Administration, and it is continuing to be a failed agency under the 

Obama Administration. I would like to illustrate that by six points. 

Point number one—and I am emphasizing what they should be 

doing compared to what they really are doing. Mass killings are increasing. We have heard that today. About half of the mass killers 

have serious mental illness, mostly schizophrenia, Seung-Hui Cho, 

Jared Loughner, James Holmes being only examples of them. 

There is no question they are increasing. SAMHSA does not seem 

to see this is a—this is not a priority for them at all. 

We have talked about the fact that their 3-year plan has nothing 

about these problems but talks completely about behavioral health 

problems. A 4-year-old with tantrums having behavioral health 

problem, I understand that. A 12-year-old skipping school has problems. Somebody who goes down and kills 30 first-graders doesn’t 

have a behavioral health problem; he has a severe mental illness 

and that should be recognized as such. 

We now know that these are severe mental illnesses. I have a 

tremor of my left hand that is an early Parkinson’s disease. This 

is not a behavioral health problem; this is a brain disease, just as 

schizophrenia, bipolar are brain diseases. These are twins that we 

looked at many years ago, now showing the one on the right who 

has schizophrenia, identical twins, has larger ventricles. There are 

now literally hundreds of studies showing that severe mental illnesses like this are brain diseases on it. Severe mental illness has 

been defined for Congress. It was defined by the mental health 

NIMH Advisory Council at the request of Congress in 1994 on it. 

SAMHSA does not understand. It has no expertise on severe 

mental illness. Its last psychiatrist who had any expertise, Ken 

Thompson, left 3 years ago. The one psychiatrist was retained as 

an expert only on substance abuse, and the psychiatrist they just 

68 

hired only has expertise on substance abuse, a very good woman 

but has no expertise on severe mental illness. 

When SAMHSA was asked to bring a psychiatrist to testify before the Vice President Biden’s committee, they brought in Dr. 

Daniel Fisher, who doesn’t believe schizophrenia exists. He thinks 

it is a severe emotional distress, a spiritual experience. Mr. Cho 

and Loughner and Holmes were not having a spiritual experience. 

They were having a brain disease that needs treatment. 

We have effective treatments. We have medication, we have assisted outpatient treatment. We know that assisted outpatient 

treatment will decrease hospitalizations in several different studies, decrease homelessness in one study, decreased victimization, 

decrease arrests in four studies, decrease violent behavior in three 

studies, and saves money in two studies. We have all kinds of evidence that this is a very effective treatment for people, especially 

who don’t recognize that they are sick. 

There is no evidence of that at all in SAMHSA, and in fact, 

SAMHSA has funded, as you have already heard today, programs, 

in my count, 14 States protection and advocacy consumer groups 

that have actively opposed the use of outpatient—assisted outpatient treatment and other effective treatments, including the 

States of many members of this committee on it. 

Three, there is the issue of the unawareness of illness, and we 

know now there is about 20 studies showing the people who are not 

aware of their illness have differences in their brain, those people 

with schizophrenia on it. We need to pay attention to that. Instead, 

what they do is they find Alternatives Conference, as you have 

heard. I will answer the question from the Congressman of Tennessee. We estimate the cost of a single Alternatives Conference is 

about $500,000, and although SAMHSA appears to be feeling that 

they are short of money, 2 weeks ago they funded and approved for 

funding the conference for this year on it. 

Another issue is the shortness of psychiatric beds. SAMHSA 

doesn’t pay any attention to that but does have an international office and has an interest in psychiatric beds in Iraq and held conferences in Cairo and Amman on that. 

Severe mental illness in jails and prisons is about 400,000. This 

is not a priority for SAMHSA. SAMHSA instead is concerned with 

putting out reading books, ‘‘Wally Bear and Friends,’’ sticker books, 

et cetera. 

Finally, last but not least, federal money to support severe mental illnesses are among the fastest-growing items in the federal 

budget, including federal funds for psychoses. That was the most 

expensive of all the nine chronic diseases, three times more expensive than the cost of diabetes on it. SAMHSA, this is not a priority. 

In 2010 I asked about several questions about, for example, why 

do some States have three times more patients on severe mental 

illnesses on SSI and SSDI? SAMHSA had no answers to any of 

these questions and did not answer, and the reason why I know 

they didn’t have any is because they were very busy. Number one, 

they were—— 

Mr. MURPHY. The gentleman’s time is expired. Can you wrap up 

with a final moment? Are you ready to wrap up? 

Dr. TORREY. Sorry. 

69 

Mr. MURPHY. So your time expired. Can you wrap up with whatever final statements you are going to make on this? 

Dr. TORREY. Ten seconds of a video? 

Mr. MURPHY. Yes. 

[Video shown.] 

Dr. TORREY. This is what they were spending $80,000 on, which 

is their annual songfest that they have in early December on it. 

This cost about $80,000 and involved all the members and was 

their attempt to bring attention to substance abuse. And my argument is that people who have $109,000 as an average salary don’t 

need to be told that substance abuse is a big issue on it. 

Thank you very much. I just want to again emphasize how important what you are doing is. And if Congress doesn’t act at this 

point, then we are going to have additional problems under the 

next Clinton or the next Bush or the next Obama Administration. 

Mr. MURPHY. Thank you. 

Dr. TORREY. Thank you. 

[The prepared statement of Dr. Torrey follows:] 

70 


85437.019

"Examining SAMHSA's Role in Delivering Services to the Severely Mentally III" 

Summary of testimony ofE. Fuller Torrey, M.D. to the House Subcommittee on Oversight and 

Investigation, May 22, 2013 

I. SAMHSA is a $3.5 billion federal agency with 574 employees. It defines its core mission as 

reducing "the impact of substance abuse and mental illness on America's communities." Severe 

mental illnesses include conditions such as schizophrenia and bipolar disorder, as defined in J 992 

by the National Advisory Mental Health Council in response to a request from Congress. One 

would expect SAMHSA to be concerned about severe mental illnesses since SAMHSA 

acknowledges that 9.8 million adult Americans have such illnesses. 

2. Among the major mental illness problems in the U.S. are increasing mass killings; the 

underutilization of treatments known to be effective in such cases; a shortage of psychiatric beds; 

increasing number of mentally ill inmates injails and prisons; and rapidly increasing federal 

costs. Except for a brief mention ofthe problems of jails and prisons, none of these problems are 

priorities for SAMHSA. 

3. In contrast to the above, SAMHSA spends millions of dollars supporting programs which actively 

oppose effective treatments; funds an annual anti-treatment national conference; is more 

concerned about psychiatric bed availability in Iraq than in the U.S.; produces picture books for 

children; commissions paintings ($22,500); and holds an annual staff musical ($80,000). 

4. Thus, SAMHSA priorities have virtually no relationship to national needs. 

5. SAMHSA has been a failed federal agency for 30 years, spanning two Democrat and two 

Republican administrations. It is not a partisan problem but rather a national problem. 

Page 1 of 12 
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85437.020

U.S House of Representatives Committee on Energy and Commerce 

Subcommittee on Oversight and Investigations 

Hearings on the Substance Abuse and Mental Health Services Administration (SAMHSA): 

"Examining SAMHSA's Role in Delivering Services to the Severely Mentally Ill" 

May 22. 2013 

Testimony of E. Fuller Torrey. M.D. 

Chairman Murphy and Ms. DeGette, thank you for inviting me to testify on this important issue. I am a 

psychiatrist specializing in the treatment of individuals with severe mental illnesses, especially 

schizophrenia and bipolar disorder. I am a retired career officer in the U.S. Public Health Service and 

currently the Executive Director of the Stanley Medical Research Institute, which spends $40 million 

each year in private funds for research on schizophrenia and bipolar disorder. I am also the founder of the 

Treatment Advocacy Center, a non-profit group which advocates for better treatment for individuals with 

severe mental illness. 

I am here to testify regarding SAMHSA's role in delivering services to the severely mentally ill. 

SAMHSA is a $3.5 billion agency which has been designated by the Dept. of Health and Human Services 

(DHHS) as the lead federal agency for services to individuals with mental illness and/or substance abuse 

problems. 

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When the federal govemment receives inquiries regarding mental illness issues, such as occurred 

following the tragedies in Tucson, Aurora, and Newtown, these inquiries are usually referred to 

SAMHSA for response. SAMHSA defines its core mission as reducing "the impact of substance abuse 

and mental illness on America's communities." This is an important mission. 

I will illustrate today how SAMHSA is failing badly in fulfilling that mission. SAMHSA is, in fact, a very 

troubled federal agency. But let me clearly state at the outset that this failure is not a Democrat or 

Republican failure. The failure ofSAMHSA is a politically equal opportunity failure. SAMHSA was put 

together in 1992 from the remnants of existing failed programs from other agencies by President George 

H. Bush. It continued to be a failed agency under Presidents Bill Clinton and George W. Bush, and is now 

continuing this tradition offailure under President Baraek Obama. I wrote critically of SAMHSA's failed 

programs during the first Bush administration ("Hippie Healthcare Policy," Washington Monthly. April 

2002) and have also done so during the Obama administration ("Bureaucratic Insanity," National Review, 

June 20, 2011). To politicize SAMHSA and blame its failure on one party or the other is to miss the point. 

I will summarize the failures of SAMHSA by contrasting six types of activities SAMHSA should be 

doing with six types of activities SAMHSA actually is doing. 

(\) SAMHSA should be concerned with the fact that mass killings associated with untreated severe 

mental illnesses are increasing in the United States. This has now been demonstrated by three 

studies.1.2.3 The most extensive of the studies was done by the New York Times and showed a dramatic 

rise in mass killings between 1949 and 1999. 

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70 

60 

50 

Number of mass killings, 1949-1999 

1949-1959 1979·1989 1989·1999 

All three studies concluded that a majority of the perpetrators were mentally ill, e.g. Seung-Hui Cho, 

Jared Loughner, and James Holmes. all of whom had schizophrenia. 

Schizophrenia is one form of severe mental illness as defined by the National Advisory Mental Health 

Council in 1992, in response to a request from Congress. In addition to schizophrenia, severe mental 

illnesses were said to include schizo-affective disorder, bipolar disorder, autism, and severe forms of 

depression, obsessive-compulsive disorder. and panic disorder. SAMHSA acknowledges that 9.8 million 

American adults suffer from these illnesses. 

What is SAMHSA actually doing? Severe mental illnesses appear to have a very low priority at 

SAMHSA. In its current three-year plan defining its priorities ("Leading Change: A Plan for SAMHSA's 

Roles and Actions, 2011-2014"), a 41,804 word document, there is no mention whatsoever of 

schizophrenia, schizo-affective disorder, bipolar disorder. severe depression, or obsessive-compulsive 

disorder, and a single mention of panic disorder. 

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SAMHSA's failure to focus on severe mental illnesses was also illustrated by its response to the 

Newtown mass killings. A Task Force under Vice-President Joseph Biden was convened to make 

recommendations regarding how such tragedies could be averted in the future. Pamela Hyde, 

Administrator ofSAMHSA and a member of the Task Force, recommended that insurance coverage for 

mental illness treatment should be improved and that the early identification of individuals with mental 

illness should also be improved. In fact. insurance coverage and early identification were not problems for 

Seung-Hui Cho, Jared Loughner. James Holmes, Adam Lanza, or most other perpetrators of these 

tragedies. The SAMHSA response therefore completely missed the core problem, which is how to 

guarantee treatment for such severely mentally ill individuals once they are identified. 

To support the SAMHSA position it invited a psychiatrist, Dr. Daniel Fisher, to testifY before the Biden 

Task Force. SAMHSA had to invite an outside psychiatrist because it has nobody among its 574 staff 

who has expertise on severe mental illness. For the past 3 years, it has employed only one psychiatrist but 

his expertise is exclusively substance abuse treatment. Dr. Fisher stated categorically to the Task Force 

that mental illness and violence are not linked, an assertion that is contradicted by more than 20 studies.' 

Dr. Fisher, whose organization receives $330.000 each year from SAMHSA, is unusual in his belief that 

schizophrenia is not a disease of the brain. an assertion that is contradicted by literally hundreds of 

studies. This picture of identical twins. one of whom has schizophrenia. is illustrative. 

Page 5 ofl2 
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Rather Dr. Fisher describes the condition called schizophrenia as "severe emotional distress" or "a 

spiritual experience." This is apparently consistent with SAMHSA's position. 

(2) SAMHSA should be promoting treatment programs which have been proven to decrease violent 

behavior in individuals with severe mental illnesses. An example of such a program is conditional 

release which, in a study in New Hampshire, was shown to reduce violent episodes by half. 5 Assisted 

outpatient treatment (AOT) has also been shown to be highly effective in reducing hospitalizations, 

incarcerations, and episodes of violence. In North Carolina AOT reduced violent behavior from 42 to 27 

percent.6 ln New York AOT reduced the number of individuals who "physically harmed others" from 15 

to 8 percent in one study.7ln another study, AOT reduced by 88 percent the chances of the mentally ill 

individual being arrested for a violent crime: 

What is SAMHSA actually doing? SAMHSA's three-year plan includes no mention whatsoever of 

these effective treatment programs. Ignoring such programs is bad enough, but it gets worse. SAMHSA 

actually funds many programs which lobby to block the implementation of these effective programs in the 

states. An example is the California Network of Mental Health Clients which has been funded by 

SAMHSA for almost two decades with as much as $200,000 per year. This organization has actively 

lobbied to prevent the implementation of AOT, called "Laura's Law", in California. The California 

Network of Mental Health Clients lost much of its state money in 2012 when it was publicly revealed that 

its acting director had used the organization's credit card to bail himself out of jail after being charged 

with drunken driving. 9 SAMHSA has funded similar organizations under its consumer grant program and 

its Protection and Advocacy grant program that have actively impeded the implementation of improved 

treatment laws in many other states, including Connecticut, Florida, Maine, Maryland, Michigan, Nevada, 

New Jersey, New Mexico, New York, Pennsylvania, Utah, Vermont and Wisconsin. 

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(3) SAMHSA should be concerned about the fact that many individuals with severe mental 

illnesses-including Cho, Loughner, Holmes and Lanza-are unaware of their own mental illness 

and thus are very unlikely to seek treatment voluntarily. This unawareness is a result of their brain 

Brain scans of two individuals 

with schizophrenia 

disease and is referred to as anosognosia. At least 18 studies of 

schizophrenia have reported differences in the brains of individuals 

with and without awareness of their illness. This poses major 

problems for treatment; the need to treat such individuals before they 

commit an act of violence must be weighed against the protection of 

that individual's civil liberties. 

What is SAMHSA actually doing? SAMHSA does not acknowledge 

that some individuals with severe mental illnesses must be treated 

involuntarily because they lack awareness and are potentially 

dangerous to others as a result of their illness. Instead, SA MHSA sponsors an annual conference for 

individuals with severe mental illnesses at which individuals are encouraged to not take their medication. 

This federally-sponsored conference, called "Alternatives," is the largest anti-psychiatry, anti-treatment 

meeting in the United States. Speakers at this conference make claims such as the following: "What is 

called schizophrenia in young people appears to be a healthy transformational process that should be 

facilitated instead of treated." At the 2010 conference, at which the SAMHSA administrator gave the 

opening talk, one speaker claimed that schizophrenia is caused by the antipsychotic drugs used to treat it. 

Another speaker called severe mental illnesses "extreme states of consciousness that are mad gifts to be 

nurtured and cultivated." Workshops such as "Coming off medications: A harm-reduction approach," 

were widely available. 

The annual "Alternatives" conference costs at least $500,000 in federal dollars each year; SAMHSA pays 

the conference sponsor $127,000 for administrative costs and many of the approximately 1,000 attendees 

Page 70f12 
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use SAMHSA funds to pay for transportation and hotels. Early this month SAMHSA approved funds for 

a similar conference this year. 

(4) SAMHSA should be concerned about the severe shortage in hospital beds for individuals with 

severe mental illness. Over the past half century 96 percent of state mental hospital beds for treating 

mentally ill individuals have been closed. The United States now has the same number of such beds. per 

population. as were available in 1850. According to experts in these fields. we now have less than onethird the number of beds which are needed for adequate psychiatric care.'o 

What is SAMHSA actually doing? SAMHSA has publicly expressed virtually no concern about the 

severe shortage of psychiatric hospital beds in the United States. SAMHSA appears to be too busy with 

concerns about mental illness issues in other countries. SAMHSA has an International Office and in 2005 

and 2006 "sponsored two Action Plarming Conferences on Iraq Mental Health ... in Amman. Jordan and 

Cairo, Egypt." SAMHSA also sponsored 11 teams of "Iraqi behavioral health providers" who were 

brought to the U.S. in 2008 and 2010 to visit "trauma services. substance abuse services, and children's 

mental health services." One of the outcomes of the SAMHSA-sponsored meetings on Iraq mental health 

was a decision to close the AI-Rashad Mental Hospital in Baghdad, despite the already severe shortage of 

beds in that city. SAMHSA has also been involved in helping Afghanistan "build its mental health 

programs and capacity." 

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(5) SAMHSA should be concerned that there are now more 

than three times more persons with severe mental illnesses in 

jails and prisons than in hospitals. 

In the 1970s the percent of jail and prison inmates with severe 

mental illnesses was said to be 5 percent. In the J 980s it was 10 

percent; in the 1990s 15 percent; and from 2000 to 2010 it was 

20 percent.ll It is not unusual now to see estimates of 25 percent 

or more. 

What is SAMHSA actually doing? The incarceration of mentally ill persons in jails and prisons is not a 

priority for SAMHSA. It appears to be too busy with what it apparently regards as more important 

problems. For example, it produces and distributes free of charge reading books for children such as "Play 

Day in the Park" and "Wally Bear and Friends." It also produces 

online children's games such as "The Great Weather Race" and 

"Boogie Band Studio" as well as children's sticker sets with 

stickers saying "My Smile is Beautiful" and "( love you." 

SAMHSA also makes available hundreds of brochures on a wide 

variety oftopics, e.g. "Hurricane Recovery Guides Preparedness 

Planning", "Oil Spill Response: Making Behavioral Health a Top 

Priority." Almost none oflhe SAMHSA brochures include 

anything about severe mental illnesses. 

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85437.028

(6) SAMHSA should be concerned that federal expenses for the care of individuals with severe 

mental illnesses are among the fastest growing federal budget items. Federal Medicaid, Medicare, 

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) associated with 

mental illness have risen sharply over the last three decades. "The total increase in these four programs 

between 1986-87 and 1997-98 was $2.6 billion per year, making them among the most rapidly growing 

programs in the federal budget."I' Over the past decade these programs have continue to rapidly increase. 

Even allowing for inflation, the United States is now spending 12 times more per capita on mental illness 

than it was a half century ago. 

What is SAMHSA actually doing? In 2010 I asked SAMHSA for information on why federal costs for 

mental illness were increasing so rapidly, including the following questions: 

• Why do some states have more than three times more mentally ill individuals, per 

population, on SSI and SSDI than other states do? 

• What is the percentage of mentally ill individuals on SSI and SSDI who are not receiving 

treatment? 

What is the percentage of Americans with serious mental illnesses who are receiving SSI 

and/or SSDI? 

The answers SAMHSA provided on November 19,2010 were as follows: "We have no data"; "there is no 

source of this data to our knowledge"; and "SAMSHA does not have access to this information."I} 

SAMHSA could collect such data if it wished to do so; its data collection branch is one of its few 

effective components. As the lead federal agency for mental health services, one might have expected 

SAMHSA to be interested in these questions, and to collect such infonnation if it did not exist. 

SAMHSA apparently had no interest in such questions since at that time it was focused on other projects 

which it apparently deemed to be more important." One of these was the commissioning in 2010 of a 

Page 10 of 12 
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85437.029

painting for $22,500 by New Mexico artist Sam English. 

This painting, which was officially unveiled on March 8, 

2011, shows a group of Native Americans. According to 

the press release put out by SAMHSA at the time of the 

painting's unveiling, it "was commissioned to help raise 

awareness about the roles of families and the community 

in mental and substance use disorder prevention." I 

believe everyone is aware that families are important, but 

how this painting was supposed to "raise awareness", and 

whose awareness was supposed to be raised, is unclear. 

To try and answer these questions I went to the SAMHSA 

headquarter to see the painting. However the guard at the door would not let me in and told me that I 

would need to call ahead and get a special appointment to see the painting. 

The other project that SAMHSA was preoccupied with in November 2010, was final preparations for the 

SAMHSA annual staff musical. This took place on Dec. 1-3, 2010, with three perfonnances attended by 

most ofSAMHSA's 574 staff members. According to the SAMHSA news release, the musical depicted 

characters who use drugs and "experience 

consequences of their behavior, including 

addiction and HIV I AIDS," and finally "recognize 

the need to seek help." The cost of the musical 

was over $80,000, including staff time. It is 

unclear what the musical was supposed to 

accomplish. Since the average salary of 

SAMHSA's 574 employees is $109,000, it can be 

Page 11 of 12 
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85437.030

presumed that they all were aware that alcohol and drug use may have adverse consequences, and they 

should not need a musical to tell them that. 

In summary, SAMHSA is, and has been since its creation 30 years ago, a failed federal agency. It is not a 

Democrat or Republican failure but rather a joint political failure. What I wish to emphasize most 

strongly is that this failure has consequences that affect us all. The issue is not merely what SAMHSA is 

doing-the waste of taxpayer money on projects like anti psychiatry conferences, the commissioning of 

paintings, or staff musicals. Many federal agencies waste money. The important issue is what SAMHSA 

is not doing to improve the broken mental illness and substance abuse treatment system in the United 

States. Because people with severe mental illnesses are not receiving treatment, tragedies occur every day 

of which Tucson, Aurora and Newtown are merely the most prominent. And unless Congress acts to 

improve this situation, such tragedies will continue to occur. 

Thank you for your attention. 

1 Hempel AG, Meloy JR, Richards TC. Offenders and offense characteristics of a nonrandom sample of mass 

murders. Journal of the American Academy of Psychiatry and Law 1999,27:213-225. 

2 Fessenden F. They threaten, seethe and unhinge, then kill in quantity. New York Times, April 9, 2000. 

J Follman M, Aronsen G, Pan D. A guide to mass shootings in America. Mother Jones, December 15,2012. 

4 Torrey EF. The Insanity Offense: How America's Failure to Treat the Seriously Menta/(v 1lI Endangers Its 

Citi::ens. New York: W.W. Norton, 2008. Pp. 140-148,229-234. 

50 'Keefe C, Potenza DP, Mueser KR. Treatment outcomes for severely mentally ill patients on conditional 

discharge to community-based treatment. Journal of Nervous and Mental Diseases 1997, 185:409-411. 

6 Swanson J\\l, Borum R, Swartz MS. et a1. Can involuntary outpatient commitment reduce arrests among persons 

with severe mental illness? Criminal Justice and Behavior 2001, 28: 156-189. 

7 Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment (New York State Office of Mental 

Health, March 2005). 

8 Link BG, Epperson MW, Perron BE, el al. Arrest outcomes associated with outpatient commitment in Ncw York 

state. Psychiatric Services 2011, 62:504-508. 

9 Branan B. $3 million in state contracts yanked from Sacramento mental health group. Sacramento Bee, November 

11,2012. 

10 Torrey EF, Entsminger K, Geller J, et al. No room at the inn: trends and consequences of closing public 

psychiatric hospitals 2005-2010 (Treatment Advocacy Center, July 2012). 

11 Torrey EF, Kennard AD, Eslinger D, et al. More mentally ill persons are in jails and prisons than hospitals: a 

s~rvcy of the states (Treatment Advocacy Center. May 2010). 

1, Torrey EF, The Insanity Offense, pp. 168-169. 

13 Letter from Frances M. Harding, Director of the Center for Mental Health Services, SAMHSA, Nov. 19,2010. 

Page 12 of 12 
82 

Mr. MURPHY. Dr. Satel, you are recognized for 5 minutes. 

TESTIMONY OF SALLY SATEL 

Dr. SATEL. Thank you, Representatives Murphy, DeGette, 

and—— 

Mr. MURPHY. Microphone, and pull it close. Thank you. Press the 

button so it is green. 

Dr. SATEL. Thank you for inviting me to be here today. 

Mr. MURPHY. It is not on yet. Do you have a green button? It is 

lit up? 

Dr. SATEL. I apologize. 

Mr. MURPHY. Thank you. 

Dr. SATEL. Thank you for inviting me to be here today. I am a 

resident scholar at the American Enterprise Institute, and as a 

psychiatrist, I do some work at a local methadone clinic. And from 

2002 to 2006 I was a member of the National Advisory Council of 

the Center for Mental Health Services. 

My point today is that SAMHSA does not adequately serve the 

sickest individuals despite its statutory mission to do so. To start 

with, the Agency has adopted an idiosyncratic interpretation of its 

very mission. I am referring to something called the Recovery 

Model. The Recovery Model, according to SAMHSA’s definition as 

its guiding philosophy, is ‘‘a process of changes through which individuals improve their health and wellness, live a self-directed life, 

and strive to reach their full potential.’’ Well, living a self-directed 

life and reaching one’s full potential is an excellent aspiration and 

I try to accomplish that with my patients as well, so I am not here 

to criticize the spirit of that model. 

What I am here to do is to underscore how inappropriate it is 

for the sickest patients. We are talking about individuals here who 

are too psychotic to participate in their own self-directed life, too 

paranoid, too terrorized by hallucinations, too lost in delusional 

thoughts. Fifty percent of them, as Dr. Torrey just alluded to, don’t 

even recognize they have an illness, and if they don’t have insight 

into the problem, there is no way they are going to be able to ‘‘collaborate in creating a detailed life plan,’’ which is part of 

SAMHSA’s agenda for the mentally ill, or ‘‘determined their own 

unique path.’’ 

They are the most vulnerable of CMHS’s constituency. They are 

the sickest silent minority who languish in back bedrooms and jail 

cells and homeless shelters. And CMHS does not hear from them. 

Instead, they hear from consumers, which is the word—politically 

correct word for patient—consumers who are able to be directed. 

They don’t hear from the folks who are most impaired, nor do they 

hear from their caregivers, the clinicians who get their hands dirty 

in the trenches with these most desperate patients, or even from 

some of those patients themselves who, once they are improved, 

can acknowledge that mainstream psychiatry has been helpful for 

them and medications as well. They don’t hear from them. They 

hear from consumer survivors who claim to speak for all patients, 

but obviously don’t do that. 

This imbalance has concerned me for years. When I was on the 

Advisory Council from 2002 to 2006, we repeatedly were trying to 

have some input into the decisions regarding the grants that were 

83 

approved but it was clear that we were pretty much there to 

rubberstamp those grants. They had already been approved. We 

asked repeatedly if we could see them prior to approval or if we 

could review them after approval and then have our assessment be 

reconsidered, and we were turned away every time. My colleague— 

I mentioned a colleague—actually, his name should appear in my 

testimony. It is Dr. Jeffrey Geller, who is a professor at University 

of Massachusetts, but he followed me or we overlapped a bit on the 

Council, and what he told me was he and fellow members during 

those years just gave up at attempts for meaningful input and left 

in disgust. 

Finally, I will turn to the kinds of programs that serve as a 

model for the kinds of programs that SAMHSA hopes, states will 

enact. This is through—it is a national registry of evidence-based 

programs and practices. And here, there is a striking imbalance. 

What I mentioned in my testimony was of the 228 programs, four 

specifically mentioned severe mental illness in their description. 

Now, that doesn’t mean only four attend to severe mental illness, 

but it is striking that even some of the others who did not mention 

severe mental illness talked about patients who were—I will give 

you one example here—designed for patients motivated to manage 

their mental health issues. Again, these are patients whose psychotic symptoms are in check. They are not the most disturbed. 

And what is also very striking about this registry of programs is 

the fact that it pointedly omits AOT, assisted outpatient treatment. 

As Dr. Torrey described what those are, I won’t go into it. 

Briefly, a word about prevention. No, we cannot enact primary 

prevention in the mentally ill, severely mentally ill. We don’t understand the brain mechanisms yet that cause it. 

I will end with two recommendations. One would be really to Administrator Hyde, which is to abandon the Recovery Model that is 

the umbrella philosophy and take advice as well from parents, clinicians, and the sickest but improved patients who have something 

constructive to offer. Don’t fund groups that are anti-psychiatry in 

their agenda. It is like the CDC funding activists who would tell 

people with HIV not to take their antiretrovirals or not to have 

protected sex. And consider directing the Secretary to commission 

an independent review of the scientific soundness of the studies 

listed on that registry about which ones are there and which ones 

are missing and should be included. 

Thank you very much for your time. 

[The prepared statement of Dr. Satel follows:] 

84 


85437.031

U.S. House of Representatives Committee on Energy and Commerce 

Subcommittee on Oversight and Investigations 

Hearings on the Substance Abuse and Mental health Services Administration 

Examining SAAIHSA 's Role in Delivering Services to the Sel'erezy Alenlally III 

Testimony of Sally Satel, MD 

May 22, 2013 

Representatives Murphy, DeGette, and other members of the Subcommittee: 

Thank you for inviting me to testify today. I am a psychiatrist trained at Yale 

University School of Medicine. I served on the faculty until 1993. Since leaving 

Yale I have continued clinical work, part time, in drug treatment clinics in 

Washington D.C., and, since 2001, I have been a resident scholar at the 

American Enterprise Institute. 

From 2002 to 2006 I was a member of the National Advisory Council of the 

Center for Mental Health Services (CMHS), the agency within SAMHSA 

charged with funding services for individuals who are mentally ill. 1 At that 

time, I expressed concerns privately to the head of SAMHSA, and publicly in 

published articles, that CMHS was failing to provide adequate federal 

leadership in the care of people with severe psychiatric disorders. By this term 

I refer to individuals afflicted by schizophrenia, bipolar disorder, severe 

depression (often with psychotic features), and related psychotic conditions. 

In the time I have today, I first wish to describe what I believe are two major 

sources of SAMSHA's dereliction in attending to the sickest individuals. These 

are (1) its idiosyncratic interpretation of its very mission - one that fosters 

models of care that many chronically psychotic people are not capable of 

using, and (2) a dearth of psychiatrists in leadership position. These two 

dynamics have played a significant role in shaping the agency's overall 

orientation towards the severely mentally ill. Next, I will outline the 

I To Fight Stigmas, Start With Treatment, New York Times, April 29, 2009 at 

http://www.nytimes.coml2009/04/21/heaIthl2Imind.html 

Sane Mental Health Laws? Don't Hold Your Breath The Weekly Standard May 28, 2006 at 

http://www.sallysatelmd.comlhtml/a-ws8.html 

Commission's Omission - The President's Mental-health Commission in Denial. National 

Review July 9,2003 at http://mentalillnesspolicy.orgimentaIhealthinew-freedomcommission.html 

1 
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manifestation ofSAMSHA's vision in the kinds of the programs it advances as 

models of care under its National Registry of Evidence-based Programs and 

Practices. 

SAMHSA's Understanding of its Mission 

The Recovery Model- SAMHSA's guiding philosophy of care for all mental 

disorders, no matter the severity, is the "recovery model." In 2004, the agency 

convened a conference at which the recovery model was fonnalized: "By 

definition, the recovery process must be self-directed by the individual, who 

defines his or her own life goals and designs a unique path toward those goals." 

A 2012 SAMHSA newsletter framed recovery as "A process of change through 

which individuals improve their health and wellness, live a self-directed life, 

and strive to reach their full potential.,,2 

Many can benefit from the Recovery Model. But so many cannot, as I will 

discuss in a moment. 

The recovery emphasis reflects a chief recommendation of the 2003 New 

Freedom Commission on Mental Illness in a report commissioned by 

President George Bush. The commission focused on people who are 

willing and able to make use of treatments, programs, and opportunities. 

Notably, the commission even prided itself on soliciting testimony from 

constituents, stating, "Nearly every consumer ... expressed the need to 

fully participate in his or her plan for recovery." The commission 

suggested that sufficient therapy, housing options, and employment 

programs will enable people with schizophrenia or manic-depressive 

illness to take charge oftheir lives. 

Now, I recognize that many patients who have been diagnosed with these 

disorders can lead lives that are much more fulfilling and productive than 

some clinicians ever imagined and that some clinicians don't pay enough 

attention to what a particular patient wants and to what he values in his or 

her life. 

The problem is that some patients are too sick to take advantage of 

treatment, to collaborate in creating a detailed life plan, or to detennine 

their own "unique path." I am referring here to the fact that over half of 

all untreated people with a psychotic illness do not acknowledge there is 

anything wrong with them, a condition technically called anosognosia. 

This is a neurological problem caused by disruption of the mechanisms 

within the brain that mediate our capacity to reflect upon ourselves. They 

are the most vulnerable ofCMHS' constituency, yet the agency invests 

not nearly enough in their wellbeing. 

2 http://www .samhsa.gov/samhsanewsletterN olume _ 20_ Number _3/Fa1l20 12-volume-20-

number-3.pdf 

2 
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85437.033

Indeed, during its hearings, the Commission did not hear from the sickest 

silent minority that is languishing in back bedrooms, jail cells, and 

homeless shelters. They are too paranoid, oblivious, or lost in psychosis 

to attend hearings, let alone testify at one. 

This is a good place to point out that SAMSHA, too, receives much of its 

input - intentionally and selectively so in my view -- from so-called 

"consumer-survivors" to claim to speak for all patients. This creates 

significant distortion: the agency asserts that it is responsive to its 

constituents when, in fact, its most impaired constituents cannot advocate 

for themselves. What's more, the views of other patients who would 

indeed able to participate more fully in their care, but also recognize the 

value of mainstream psychiatry and readily say they benefit from it, are 

not routinely, if at all, solicited. 3 

The problem with the recovery vision is that it is a dangerously partial 

vision. The emphasis on recovery as a goal steers policy away from the 

needs ofthe most severely disabled. SAMHSA forthrightly 

acknowledges that it sees the "consumer" who can "fully participate in 

his plan for recovery" is its primary constituent, not the dependent 

patients who need quality psychiatric care.4 This imbalance needs to be 

corrected. 

Dearth of Professional Psychiatric Input at CMHS 

SAMHSA makes an inadequate contribution to the treatment of individuals 

with severe psychiatric disorders because it is under-populated by staff 

with expertise in the nature of their treatment needs. 

During my tenure on the CMHS National Advisory Council, I attempted to 

have some input into the CMHS decisions regarding what projects should be 

funded. Despite the fact that we were called an "advisory council," it was 

clear that CMHS did not want our advice. Rather than being able to see 

proposals ahead of time, we were presented with the approved proposals as a 

fait accompli at the time of the meeting. Thus SAMHSA not only had little 

3 http://phcnomcnologyofmadness.wordpress.coml20 13/0511110n-problcms-inside-themovementl See also, http://www.treatmentadvocacycenter.org/resourcesibriefing-papers-andfact-sheets! 15 9/46 7 

4 Interview with Kathryn Power, CMHS Director circa 2003 - 2008 

http://vvww.accessmylibrarv.com/coms2/summary 0286-35121827 ITM. Power is the 

Regional Administrator, Region One for the Substance Abuse and Mental Health Services 

Administration, where she continues to promote that philosophy. 

3 
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in-house expertise on serious psychiatric disorders (I recall a single public 

mental health psychiatrist) it also failed to take advantage of the expertise on 

its own advisory council. 

My colleague, Jeffrey Geller MD, Director of Public Sector Psychiatry at the 

University of Massachusetts Medical School, who served on the CMHS 

Advisory Council from 2004-2008, had a similar experience. "Most 

members who served during the years I served, gave up attempts 

for meaningful input and left in disgust," he notes. They had repeatedly asked 

then-CMHS director, Kathryn Power, that the grant proposals "be provided 

to Council members in advance of the meetings, [that we have] time and 

opportunity for meaningful exchange on the merits of a proposal at the 

meeting, and/or revisions and re-review ofthe proposals ... We were rebuffed 

each and every time."s 

Unbalanced Compendium of Care 

SAMHSA's National Registry of Evidence-based Programs and Practices 

(NREPP) is an online "registry of mental health and substance abuse 

interventions that have been reviewed and rated by independent reviewers. 

The purpose of this registry is to assist the public in identifying scientifically 

based approaches to preventing and treating mental and/or substance use 

disorders that can be readily disseminated to the field.,,6 When a program is 

certified as evidence-based by SAMHSA, state mental health departments are 

encouraged to use block grant money for them. 

On its website, http://www.nrepp.samhsa.gov/viewAll.aspx, SAMHSA lists 

288 separate evidence based programs (ideally understood to mean 

demonstrated in clinical trials, subjected to peer review and successful 

replication). Among the almost 300 studies, are many sound programs to 

treat substance abusers and drug offenders (e.g., Motivational Enhancement 

Therapy; Moral Reconation Therapy, Oxford House), enhance parenting 

skills, support caregivers, prevent HIV, etc. Broad-focus programs such as 

"Enhance Wellness" (an exercise and education program for adults with 

physical illnesses) and "Coping Cat" (to help children recognizes symptoms 

or anxiety) may well be useful if well executed, but, crucially, like the vast 

majority of programs listed in the Registry, these are not intended for the 

sickest of individuals. 

The striking nature of the NREPP repertoire of programs is its imbalance. 

Programs for the Mentally III -- Of the 288 programs listed, four by my 

count, specifically designated people with severe illness as their recipients 

(Compeer, Critical Time Intervention, Housing First, and Psychiatric 

5 Personal communication, May 12, 2013 

6 http://v,ww,nrepp.samhsa,goyIViewAll.aspx 

4 
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Rehabilitation Process Model). Among those, the Rehab Process Model is 

"client" centered and aimed at "encouraging self-determination," again the 

recovery agenda with its intrinsic limitations, while Compeer is aimed at 

reducing isolation (a most noble aim, but, by design, not about treatment 

itself). Housing First is an excellent program for people who need minimal 

supervision and can comply with rules. Critical Time Intervention 

provides time-limited case management, under supervision of a 

psychiatrist or psychologist, to prevent homelessness and other adverse 

outcomes in people with serious mental illness following discharge from 

hospitals, shelters, prisons and other institutions. This program is notable 

as is it most narrowly aimed at a highly vulnerable subpopulation. 

A handful of other programs (Modified Therapeutic Community, and 

International Center for Club House Development, Wellness Recovery 

Action Planning, WRAP) do not specifically mention severe mental illness 

in their description, but presumably serve those patients as welL WRAP, 

in particular, is only eight weeks long. It is "designed to create a safe, 

non judgmental autonomy supportive environment in which people feel 

motivated to manage their mental health issues.,,7 Again, it is a program 

aimed at patients whose psychotic symptoms are in check. Worth noting 

as well, a recent assessment contains no measures of re-hospitalization, 

incarceration, or homelessness. 8 

Even if I missed some programs in my review of the synopses of all 288 

programs listed, it is abundantly clear that services aimed specifically at 

the most desperately ill- or, more precisely, those in the most intense 

phase oftheir psychotic illness - represent only a small minority of the 

NREPP programs. 

Furthermore - and remarkably -- NREPP neglects one of the most 

effective and best-studied programs for individuals with severe mental 

illnesses: Assisted Outpatient Therapy (AOT). AOT is a form of civil 

court-ordered community treatment, which is often necessary for those 

who have a reliable pattern of falling into a spiral of self-destruction or 

dangerousness when off medication. To date, studies have shown that it 

reduces hospitalizations; homelessness; both arrest and victimization of 

mentally ill people, and violent behavior. 9 Two studies document that 

AOT saves money. IOThe Department of Justice has certified AOT as an 

effective crime prevention program II Despite numerous attempts by 

7 http://www.mentalhealthrecovery.com!wrap/documents/SchizophrBull-20 11-Cook-schbul_sbrO 12.pdf 

8 ibid. 

9 http://mentalillnesspolicy.orglkendras-law/researchlkendras-law-studies.html; 

http://www . treatmentadvocacycenter .org/about -usl our-reports-and-studies/4 71 

10 http://www.treatmentadvocacycenter.org/storage/documents/aot_saves _ money.pdf 

11 hrtp:llwww.crimesolutions.gov/ProgramDetails.aspx?ID=228 

5 
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85437.036

families of people with mental illness to raise the profile of AOT at the 

agency, such programs remain unrecognized by NREPP. 12 

Primary Prevention Agenda of Block Grant Not Relevant to Severe Mental 

Illness 

SAMHSA focuses heavily on the prevention of mental illness and substance 

abuse. 

Prevention and severe mental illness is a puzzling concept because we know 

little about the biological causes of conditions such as schizophrenia and bipolar 

disorder. These are primarily diseases of the brain but our understanding of the 

underlying brain mechanisms is still in the early stages. Absent this knowledge, 

prevention is not possible. Therefore, SAMHSA's focus on prevention has 

virtually nothing to contribute to the well-being of individuals with severe 

mental illnesses. 

Clearly, SAMSHA's net is wide: In its instructions to the states on how the 

federal block grant funds should be spent, SAMHSA instructs them to "make 

general prevention and primary prevention priorities." States are also told that: 

"The focus is about everyone, not just those illness or disease, but whole 

population. The focus is on prevention and wellness activities." 13rnclusive as it 

is mission is, the agency makes relatively minimal room for the most needy. 

Conclusion and Recommendations 

In summary, SAMHSA is the federal agency created by Congress in 1992 to provide 

leadership on severe illness (among other aspects of mental health), yet little 

leadership is to be found within its walls. That CMHS does not have any psychiatrists 

in a leadership position is, frankly, astounding. Imagine the National Institute of 

Mental Health employing no neuroscientists in key roles. "Home, health, purpose, and 

community;' SAMHSA's stated priorities, are supremely laudable goals but onlyand this is a critical point only for people who are motivated to to attain them and 

able to make use of help. 

Unfortunately, the Center for Mental Health Services has a skewed understanding of 

its constituency-no surprise, really, as its mission is refracted through the lens of the 

"recovery model." The agency's guiding ideology leads it to overlook millions of 

people with long-term psychotic disorders. Very few SAMHSA programs help reduce 

the impact of mental illness on the communities - that is, on rates of incarceration, 

J2 http://feedback.samhsa. gov/forumsl 148531-closed-help-samhsa-highlight-advances-of-thebeh/suggestionsI2580341-implementation-of-assisted-outpatient-treatment and 

http://feedback.samhsa. govlforumsl 148531-closed-help-samhsa-highlight -advances-of-thebehl suggestions/25 86918-court -ordered-outpatient -treatment: 

http://fccdback.samhsa. govlforumsl77283-closed-samhsa-s-strategic-initiatives/suggestions/1155179-

increase-use-of-assisted-outpatient-treatment 

J3 http://www.samhsa.gov/grants/blockgrant/docs/BGapplication-l 003 12.pdf P 39 

6 
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85437.037

homelessness, and dangerousness. 

The agency's relative neglect of those with severe mental illness is only part of the 

problem. As the testimony of other panelists will make clear, the agency also supports 

activities that actively sabotage their welfare. This is strong language, I am aware. I 

refer here to CMHS's seemingly uncritical support of both "consumer" groups and 

legal aide workers (though its Protection and Advocacy, PAlMI, program) who either 

condemn the use medications or are hostile to formal psychiatric care. The efforts of 

these advocates have been decidedly harmful to patients with schizophrenia and other 

psychotic illnesses. 

I respectfully recommend that: 

Consider directing the Secretary ofHSS to commission demonstration projects of 

Assisted Outpatient Treatment (e.g. Kendra's Law in New York, Laura's Law in 

California) throughout the country. 

Consider directing the Secretary to commission an independent review ofthe scientific 

soundness ofNREPP programs, paying particular attention to effective programs for 

severe mental illness that should be included in the NREPP. 

Consider directing the Secretary to review personnel hiring policies at SAMHSA with 

the goal of introducing more psychiatrists and psychologists who have direct clinical 

expertise in delivering publicly funded care to people with severe psychiatric 

disorders. 

Consider redefining the goals of PAlMI by limiting its role to protection and 

disallowing lobbying of state legislatures on commitment laws 

It is my hope that today that this Congressional Subcommittee can begin to address 

these shortcomings I've outlined in my remarks. 

Thank you for your attention. 

7 
91 

Mr. MURPHY. Thank you, Dr. Satel. 

Dr. Parks, you are recognized for 5 minutes. 

TESTIMONY OF JOSEPH PARKS 

Dr. PARKS. Good morning. I am Joseph Parks. I want to thank 

the chairman and Congresswoman DeGette for the opportunity to 

testify today. I am testifying today in my individual capacity and 

not on behalf of any organization. 

I am a board-certified psychiatrist with specialty training in 

emergency psychiatry. I have served as the medical director for the 

Missouri Department of Mental Health for 20 years. For 3 years, 

I was the director of its overall mental health operation. Throughout my career, I have continued to see patients and I still see patients on a weekly basis. I have provided psychiatric service to 

harmlessly mentally ill persons in shelters and through assertive 

community treatment teams. 

For the past 12 years I have been the president of the Medical 

Director Council of the National Association of State Mental Health 

Program Directors, and for the past 3 years, I have served as director of the Missouri Institute of Mental Health and professor at the 

University of Missouri St. Louis. 

Through my various roles, I am very familiar with the SAMHSA 

Mental Health Block Grant and the Discretionary Grant programs. 

These programs are an important contribution to improving the 

lives of people with serious mental illness. I have been a principal 

investigator for SAMHSA Discretionary Grants, I have independently evaluated grants through my role at MIMH, and as Missouri 

Mental Health Division director, I was responsible for the execution of the block grant plan. 

Although the amounts are modest and inadequate to meet the 

overall needs, the SAMHSA Mental Health Block Grant plays an 

important role in funding services for uninsured persons and services that are not payable through Medicaid, particularly in young 

adults who are not usually insured when they first become ill. 

Block grant funding has been especially critical to keep in place the 

full range of activities and services that a comprehensive state 

mental health system wants to have, including early identification 

and early intervention. 

I specifically want to mention to the Committee that SAMHSA 

requires us when using the block grant if we are funding individual 

activities to spend them on persons with serious mental illness or 

children with SED. That is a requirement of how we use those 

funds. 

Now, SAMHSA discretionary grants play an important role in 

implementing new evidence-based practices and improving the 

quality of care to people with serious mental illness. A good example is SAMHSA’s Co-Occurring State Incentive Grants—they were 

called COSIG—which helped us improve the ability of community 

mental health centers and substance abuse treatment agencies to 

promptly and effectively serve people who have both mental illness 

and substance abuse conditions simultaneously. This is particularly 

important with respect to reducing violence by people with serious 

mental illness. The discretionary grants also fund technical assistance. In Missouri we got technical assistance to reduce the use of 

92 

seclusion and restraint in our state hospitals, which reduced both 

patient and staff injuries. 

Before I turn to policy recommendations, I would like to acknowledge in light of Oklahoma’s tornadoes that SAMHSA gave significant support when we had tornadoes in Joplin in 2011 in Representative Long’s district. They were instrumental in us getting 

care out to those people rapidly. 

I want to make the following recommendations for improving 

treatment for people with serious mental illness and reducing violence: first, there is a growing shortage of psychiatrists. We need 

a national approach to increase the psychiatric workforce. Demand 

for psychiatric services is far outstripping the ability of the available workforce to supply timely needed care. Aging psychiatrists 

are retiring out faster than new graduates are taking their place. 

The current estimated gap by the EPA is about 45,000 psychiatrists short. Patients are not being seen for months and clinic and 

hospital psychiatric units are closing because they can’t get the 

staff. There needs to be attention here. 

Second, I would like to make recommendation for two specific 

discretionary grant directions. There should be grants available to 

implement mental health first aid training. This is an early identification, early intervention for mental illness that is a training with 

the general public similar to regular first aid. It is a national—it 

is being implemented nationally but it needs more support to roll 

it out to get people engaged before they become suicidal or violent. 

Third, there needs to be a new round of the COSIG grants. Substance abuse increases the likelihood that somebody will be mentally ill significantly. Over half of people with mental illness have 

substance abuse problems. We need new grants in this area. 

Regarding mandatory treatment, I would actually recommend 

greater support for mental health courts. I have been involved in 

providing mandatory treatment through different legal modalities, 

including inpatient and outpatient civil commitment, guardianship 

in mental health courts in three different States. In all three States 

the outpatient—had outpatient commitment laws and in all three 

States they were difficult to implement and used rarely primarily 

because local law enforcement doesn’t have the resources and 

doesn’t want to use their officers to follow up on people that are 

violating the commitment orders. Also, it is—mental health courts 

are more agreeable—are more acceptable to the courts, to law enforcement, and to the people with mental illness. I think they 

would be the best strategy. 

Finally, to end my comments, there is an epidemic of premature 

death among people with serious mental illness. Research shows 

that people in the public mental health system, most of whom are 

seriously mentally ill, die an average of 25 years younger—in their 

mid-50s—than the general population. This is shorter than the life 

expectancy of someone with HIV and on a pier with sub-Saharan 

Africa. It is an unaddressed national tragedy. 

People with serious mental illness should be federally designated 

as a health disparities population and their rates and causes of 

death should be monitored annually. HHS and SAMHSA should 

develop a national strategy that Congress should fund specifically 

for reducing these premature deaths, most of which are due to 

93 

chronic medical conditions due to poor care. We need to promote 

the integration of behavioral health and general medical care and 

promote integrated preventive measures on both the healthcare 

side and the mental health side. Nobody recovers from their mental 

illness once they are dead of a heart attack, and that is what is 

killing our people with serious mental illness. 

Thank you for the opportunity to present my views on these critical issues. I would be happy to assist the Committee in my various 

roles to help you implement solutions and address the needs of people with mental illness. This deserves national attention and leadership at all levels. It is greatly appreciated you holding this hearing. 

[The prepared statement of Dr. Parks follows:] 

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85437.038

Statement of Joseph Parks, M.D. 

before the 

Oversight and Investigations Subcommittee of the House 

Committee on Energy and Commerce 

on the 

"Examination ofSAMHSA's Role in Delivering Services to the 

Severely-Mentally Ill." 

May 22, 2013 
95 


85437.039

"The health of the people is really the foundation upon which all their happiness and all 

their powers as a state depend. " 

Benjamin Disraeli, British Prime Minister, 1877 

A. CREDENTIALS 

My name is Joseph Parks, M.D. 

I want to thank Chairman Murphy and Congressman DeGette for the opportunity to testify 

today at this hearing on the "Examination ofSAMHSA's Role in Delivering Services to he 

Severely-Mentally III. " 

I am a board certified psychiatrist and was the first psychiatrist nationally to complete a 

fellowship in emergency psychiatry. I've served as Medical Director for the Missouri 

Department of Mental Health for 20 years. For three years I was the Director of its mental 

health operation. 

For the past three years I have also served as Director of the Missouri Institute for Mental 

Health (MIMH) that is part of the University of Missouri St. Louis with the academic title of 

Distinguished Professor of Science. For the past 12 years I have been president of the 

Medical Directors Council of the National Association of State Mental Health Program 

Directors - also known as NASMHPD. 

Throughout my career I have continued to provide direct patient care and I currently see 

patients at a federally qualified health center in Columbia, Missouri. I have previously been 

medical director of state hospitals in Chicago, Illinois, in Cincinnati, Ohio, and I have 

provided psychiatric services to homeless mentally ill patients in shelters and through 

assertive community treatment teams. 

I have previously been part of the faculty of Department of Psychiatry at the University of 

Cincinnati, University of Chicago, and University of Missouri at Columbia. I'm testifying 

today in my individual capacity, and not on behalf of any organization. 

B. Experience with SAMHSA 

Through my role with the Missouri Department of Mental Health, I have been familiar with 

the SAMHSA Mental Health Bock Grant (MHBG) Program. In 2013, Missouri received 

MHBG funding in the amount of$7,495,01O. Missouri's MHBG funds have only increased 

by 7.7 percent over its funding level in 2010, a rate of increase far below the rate ofinflation 

in the cost of providing services. The Substance Abuse Block Grant is far larger-

$25,895,523 in 2013 - but has actually gone down by 1.3 percent since 2010. 

2 
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IN 2013, Missouri will use 93 percent of its MHBG funds for purchasing mental health 

treatment services for uninsured persons or purchasing services that cannot be covered by 

Medicaid, 2 percent will be spent on suicide prevention, and nearly 5 percent will be spent on 

administrative costs. 

SAMHSA requires that 95 percent ofMHBG funds must be spent on services and only 5 

percent can be spent on administrative costs. 

Through my role at Missouri's Department of Mental Health, I have also been familiar with 

SAMHSA's discretionary grants. I have been the principal investigator for suicide prevention 

grants and SBIRT (brief screening assessment and intervention for excessive drinking and 

risky drug use) grants. 

In 2013, the Missouri Department of Mental Health received $4,395,873 in funding for six 

different discretionary grants from the Center for Mental Health Services (CMHS) at 

SAMHSA, and $7,679,234 in funding for three discretionary grants from the Center for 

Substance Abuse and Treatment (CSAT). 

The six CMHS grants include: 

• Improving the organization and delivery of mental health services across 

communities; 

• Transitioning young adults from child mental health services to adult mental health 

services; 

• Serving homeless mentally ill persons, 

• Identifying very young children at risk for mental health problems and intervening 

early; 

• A data reporting grant; and 

• A youth suicide prevention grant. 

The first three grants primarily target persons with serious mental illness and account for 63 

percent of the total funding. The youth suicide prevention grant emanates from funds that are 

Congressionally designated and are to be used for that purpose. 

Through my role as Director ofMIMH, I am familiar with the evaluation ofSAMHSA grants. 

The goals of the SAMHSA grants goals usually include a required evaluation component to 

determine how effectively they are implemented and what the outcome and results of the 

interventions. MIMH is currently evaluating 14 separate SAMHSA grants totaling $4,350,095 

to nine different organizations. Only one of these grants is for consumer advocacy and it 

amounts to less than 1 percent of the total funding. 

C. Role of SAMHSA in Serving Persons with SMI 

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85437.041

Although the amounts are modest and inadequate to meet overall needs, the SAMHSA block 

grant funds play an important role in funding services for uninsured persons. Most people 

develop serious mental illness (SMI) in their late teens or 20s before they have established 

employment and prior to coverage under employment-based insurance. MHBG funds have 

been extremely helpful in covering the mental health needs for this population. 

SAMHSA discretionary grants play an important role in implementing new evidence-based 

practices and improving the quality of care to persons with serious mental illness. Grant 

programs that have been particularly successful in Missouri in improving the quality of 

services to persons with mental illness include Co-Occurring State Incentive Grants 

(COSIG), which improve the ability of both community mental health centers and substance 

abuse provider agencies to serve persons that have both mental illness and substance abuse 

conditions concurrently. Prior to these grants it would be common for a person who had both 

serious mental illness and addiction to be told by the community mental health center that 

they could not be treated for their serious mental illness until their addiction was treated. 

Substance abuse treatment agencies would not treat them until their serious mental illness 

was stable. 

With the COSIG grants, there is truly a "no wrong door" approach by community mental 

health centers and substance abuse treatment provider agencies in welcoming the person who 

needs treatment and engage those individuals immediately. This is a particularly important 

improvement with respect to reducing violence by persons with mental illness. The presence 

or absence of a substance use disorder is the major predictive factor of whether or not a 

person with mental illness will be more violent than a person without mental illness. The 

SAMHSA grants for reduction of seclusion and restraint have markedly reduced episodes of 

violence in our state hospitals. 

SAMHSA discretionary grants also fund technical assistance to states. Missouri has received 

technical assistance in reducing seclusion or restraint from NASMHPD that was funded by 

SAMHSA. The landmark study by the NASMHPD Research Institute (NRI) that found that 

persons in public mental health systems died 25 years younger than the general population 

was implemented with SAMHSA funding. 

The NASMHPD study was instrumental in creating a public dialogue about the need for 

integration of behavioral health in general medical care, and the role that serious mental 

illness plays in increasing the cost of general medical care in the Medicaid and Medicare 

programs. SAMHSA has responded nationally to this epidemic of death among persons with 

SMI by funding over 90 CMHCs nationally to provide integrated behavioral health and 

medical care. 

SAMHSA has also emphasized that a modem mental health and addiction system in the 

states should have prevention, treatment and recovery support services available both on a 

4 
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stand-alone and integrated basis with primary care, and should be provided by appropriate 

organizations and in other relevant community settings. SAMHSA's proposed continuum 

comprises of nine domains, including: 

• Health Homes 

• Prevention and Wellness Services 

• Engagement Services 

• Outpatient and Medication Assisted Treatment 

• Community Supports and Recovery Services 

• Intensive Support Services 

• Other Living Supports 

• Out of Home Residential Services 

• Acute Intensive Services 

Block grant funding has especially critical for the full range of activities and services that a 

comprehensive state system should include such as early identification and intervention, 

supported housing, crisis services, all the way to inpatient services. 

Moreover, these services are not only for individuals with a mental or substance use disorder, but 

also support their families who are critical to achieving recovery and resiliency. 

Briefly, before I tum to specific policy recommendations, I also would like to 

acknowledge SAMHSA's substantial support during various state and regional natural disasters 

over the last few years. Due to the SAMHSA' s leadership and the tools they have provided on a 

prospective basis, it has allowed state mental health agencies to be on the ground to lend 

assistance on many levels to residents devastated by recent hurricanes, tornados and flash floods 

in several states. 

D. Recommendations for Improving Treatment of 8MI and Reducing Violence 

1) Increase the Resources Available through Both the 8AMH8A Mental Health Block 

Grant and Discretionary Grauts 

SAMHSA resources have not kept pace with either the general rate of inflation in the cost 

of care or with the markedly increased demand for mental health services that has 

5 
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occurred in the last 10 years. It is critically important that Congress provide SAMHSA 

with appropriate funding so the agency can disseminate important tools to states and 

communities for improving the treatment of serious mental illness, and providing the 

early interventions that will be the most effective means of reducing violence that involve 

persons with serious mental illness. 

2) Develop a National Approach for Increasing Psychiatric Workforce 

The demand for psychiatric services is far outstripping the ability of the available 

workforce to supply timely, needed care. Severe workforce gaps are increasing and 

significantly restricting access to essential treatment services for persons with serious 

mental illness. 

According to a University of North Carolina (UNC) 2008 study commissioned by the 

Health Resources and Services Administration (HRSA), the United States has a 

significant shortage of mental health professionals, especially "prescribers". The current 

supply of psychiatrists is at least 30,000 short of what is needed. 

The projected demand for all physicians continues to rise outstripping the projected 

increase in physicians. For psychiatry, the anticipated demand has risen dramatically. 

The number of people seeking psychiatric services has increased because of the growing 

and aging population, mental health parity and anti-stigma efforts. The number of 

psychiatric problems has increased because of the economic downturn and the 

psychological toll of two wars. Other factors increasing the demand for psychiatrists are 

direct marketing of psychiatric medications to the public and an increase in the number of 

FDA black box warnings causing primary care clinicians to be reluctant to prescribe 

psychotropics. This is occurring at the same time that the projected supply of 

psychiatrists is flat. 

Psychiatrists are not increasing in number because retirements are outnumbering those 

entering the workforce through training. Currently 55 percent of psychiatrists are older 

than age 55. In a recent projection using a similar methodology to the UNC study, the 

deficit has increased to 45,000. Patients often have to wait months to see a psychiatrist 

because clinics cannot find enough psychiatrists to hire to provide service. Hospitals have 

closed their psychiatric units due to difficulties in recruiting psychiatrists to staff those 

operations. Current national shortages in mental health professionals, specifically 

psychiatrists, will continue to exacerbate. All projections estimate the gap between 

unruet need and supply will widen substantially over the next 20 years. 

3) Specific Discretionary Grant Recommendations 

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a. Grants Funding Mental Health First Aid - Early identification and treatment 

can prevent a mental illness from developing into a disability or leading to suicide 

or violence against others. 

Mental Health First Aid (MHFA) is a groundbreaking public education program 

that helps the public identify, understand, and respond to signs of mental illnesses 

and substance use disorders. The idea behind MHF A is no different than that of 

traditional first aid: to create an environment where people know how to help 

someone in emergency situations. But instead ofleaming how to give CPR or 

how to treat a broken bone, the 8-hour course teaches people how to recognize the 

signs and symptoms of mental health problems and how to provide initial aid 

before guiding a person toward appropriate professional help. 

The interactive 8-hour course is presented by instructors who have been certified 

through an intensive 5-day training. The course presents an overview of mental 

illness and substance use disorders in the U.S. and introduces participants to risk 

factors and warning signs of mental health problems, builds understanding of their 

impact, and overviews common treatments. Those who take the course to certify 

as Mental Health First Aiders, learn a 5-step action plan encompassing the skills, 

resources and knowledge to help an individual in crisis connect with appropriate 

professional, peer, social, and self-help care. Since its introduction in the u.S. 

four years ago, more than 50,000 people have been trained in 47 states and the 

District of Columbia. Mental Health First Aid can create community 

environments more alert to, and prepared to intervene in, the psychiatric distress, 

that leads to suicide and violence against others. 

b. Grants to Implement and Improve the Integrated Treatment of Substance 

Abuse Disorders and Mental Health Disorders in Persons with SMI - The 

presence of substance abuse is the strongest predictor that persons with SMI will 

commit violence. We can do much better addressing substance abuse disorders in 

people with SMl. 

c. Grants Supporting Effective Early Treatment of Psychotic Illness - Our 

nation's approach to helping people with psychotic illnesses like schizophrenia is 

shameful. 

Usually, young people slip into psychotic illnesses for several years while theyor their families - get no help. When they have a "first psychotic break," they 

usually are briefly hospitalized. Almost always, medications take the worst of the 

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symptoms away within days or weeks. So then they are discharged with a 

referral to care and maybe a recommendation of a support group. This is 

woefully, stupidly deficient! Having symptoms reduced is not a cure. When 

people feel better, and especially since the drugs have significant side effects, they 

often stop taking the medications. Relapse is likely. Usually the second psychotic 

break is worse. And then the revolving door begins. 

Often after decades people figure out how to manage their illness, but by then 

they are often on permanent disability status, unemployed, and in terrible health. 

Some have suggested that the solution to this problem is going backward - not 

forward - to the days when stays for individuals in psychiatric hospitals were 

measured in months and years. This is simply idiotic. 

There is no research to suggest it is effective. It is terribly expensive. Hospitals 

cannot be run (as the old asylums were) on unpaid patient labor. And a civilized 

society cannot detain people on a vague hope they will get better. So we should 

not tum the clock back on mental health care. But we do need a modem approach 

to care for people with psychotic disorders, one that replaces both the asylum and 

the revolving door with continuous team treatment like that we provide for people 

with chronic medical problems. Teams delivering First Episode Psychosis (FEP) 

care have figured out how to do this work. It is person-centered, family driven. 

collaborative and recovery oriented. Staying in school or work is encouraged -

though adaptations may be needed. It is time to implement this approach, as both 

Australia and Great Britain have done. We need not lag behind other nations in 

this area. 

Our country needs to make modest investments now to develop FEP teams so that 

families anywhere in the state struggling with a young adult who is slipping away 

from sanity can get good care reasonably close to home. The Committee's 

attention to this issue could have an enormous positive effect. 

4) Make HIPAA Work as it Was Originally Intended 

Although HIPAA explicitly allows health care providers and providers of health care 

related services to share protected health information absent patient consent for the 

purposes of treatment, which includes care coordination, many health care providers 

continue to insist that they can only share protected health information with the patient's 

consent. 

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Adding additional groups with whom health care providers are allowed to share 

information, such as family members who are directly supporting the persons 

coordination of care, is unlikely to be successful when health care providers routinely 

interpret HIPAA as prohibiting sharing protected health information absent patient 

consent, even between other health care providers, when in fact that is what HIPAA 

explicitly allows. 

These health care providers are taking an inappropriately restrictive interpretation of 

HIPAA in an attempt to reduce their personal and organizational liability, as opposed to 

taking an interpretation that maximizes the patient's best interests in receiving 

coordinated care. In short, their primary goal is not what is best for the patient but rather 

how best to limit their own liability risks. This is both clinically dangerous for patients 

because it results in information not being shared that would improve care decisions, and 

at the same time economically wasteful for the health care system in that it results in 

unnecessary repetition of assessments, tests, and hospitalizations. 

There is a need for a national initiative to retrain health care providers to error on the side 

of sharing protected health information when it would benefit the individual receiving 

treatments. There is a need for a national strategy to make the perceived liability risk of 

not sharing information, when it could have been shared and the lack of sharing 

information results in patient harm, as great as or greater than the perceived risk of 

sharing information absent patient consent. 

5) Increase Federal Support for Mental Health Courts 

I have been involved in providing mandatory treatment through different modalitiesincluding inpatient and outpatient civil commitment - guardianship, not guilty by reason 

of insanity processes, probate court orders and in mental health and drug courts in Ohio, 

III inois, and Missouri. 

All three states have outpatient commitment laws and in all three states they are difficult 

to implement and only used rarely. The major barrier has been the unwillingness of 

police and sheriff departments to commit resources to enforcing violations of 

commitment orders. Local law enforcement almost uniformly indicate that they do not 

have the resources in terms of officers available to assist with mental health treatment in 

this manner and that crimes the have been committed, or are being committed, are a 

higher priority for community safety. Police departments are usually quite effective in 

persuading the local judges to make orders for outpatient commitment rarely if at all. 

There has been much more success nationally in implementing mental health courts were 

a person is required to accept treatment for their mental illness as a condition of probation 

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or parole. This is more acceptable to local law enforcement because it helps keep 

mentally ill people out of their jails, more acceptable to the courts because it provides 

them with an additional option or disposition of the case, and more acceptable to the 

mentally ill person who is usually more ready to admit they have committed a crime then 

they are so to admit that they must have treatment is a civil probate requirement because 

they might do something dangerous in the future. 

Regarding research outcomes for outpatient commitment, the most recent systematic 

review of outpatient commitment published up until November 2009 by the Cochrane 

Collaboration suggests that compulsory community treatment may not be an effective 

alternative to standard care. This research is on the effectiveness of compulsory 

community treatment for people with severe mental illness through a systematic review 

of all relevant randomized controlled clinical trials. Only two relevant trials were found 

and these provided little evidence of efficacy on any outcomes such as health service use, 

social functioning, mental state, quality of life or satisfaction with care. No data were 

available for cost and unclear presentation of data made it impossible to assess the effect 

on mental health state, and most aspects of satisfaction with care. In terms of numbers 

needed to treat, it would take 85 outpatient commitment orders to prevent one 

readmission, 27 to prevent one episode of homeless ness, and 238 to prevent one arrest. 

The reviewers concluded that Compulsory community treatment results in no significant 

difference in service use, social functioning or quality oflife compared with standard 

care. People receiving compulsory community treatment were, however, less likely to be 

victims of violent or non-violent crime. 

It is unclear whether this benefit is due to the intensity of treatment or its compulsory 

nature. There have been five new research studies made available since November 2009 

awaiting inclusion in the review may alter the conclusions of the review once assessed. 

There is no Cochrane review available regarding mental health courts available at this 

time, however, the Cochrane review of drug courts is somewhat more hopeful concluding 

that they promising results for the reduction of drug use and criminal activity in drug 

using offenders. 

The Cochrane Collaboration is an international network of evidence based practice 

reviewers. They are an independent, not-for-profit organization, funded by a variety of 

sources including governments, universities, hospital trusts, charities and personal 

donations. A systematic review is a high-level overview of primary research on a 

particular research question that tries to identifY, select, synthesize and appraise all high 

quality research evidence relevant to that question in order to answer the question. There 

has been much more federal support available for implementing drug courts than there 

has been for mental health courts. 

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In view of the lack of compelling evidence for the effectiveness of mandated outpatient 

commitment and the reluctance of local law enforcement agencies to be involved, the 

best current strategy for increasing the availability of mandatory treatment for persons 

with serious mental illness would be to increase federal support for mental health courts -

- which are easier to implement and more acceptable to both local law enforcement and 

the persons being mandated into treatment. 

6) We need additional block grant funds directed at reducing the devastating impacts 

of various forms of trauma (e.g., impact on individuals of natural disasters, child 

abuse, violence) that lead to mental health disorders in our society. 

Over 90 percent of public behavioral health clients have been exposed to trauma, and 

most have multiple experiences of trauma. 

Millions of Americans suffer traumatic events due to range of incidents - rare or 

consistently over time. Over 90 percent of public behavioral health clients have been 

exposed to trauma, and most have multiple experiences of trauma. 

SAMHSA has tried through limited funds to address the behavioral health impact of 

trauma by developing public health approaches to trauma that strengthens surveillance, 

screening, and treatment that better responds to the needs of those affected. Reducing the 

impact early is possible and cost-effective, and SAMHSA should receive increased 

funding to address the needs of people affected by traumatic episodes. 

7) Treat the Appalling Rate of Premature Death Among Persons with Serious Mental 

Illness in the Public Mental Health System like the National Epidemic It IsIt is been over 10 years now since research showed that persons in the public mental 

health system, most of whom have serious mental illness, are dying on average 25 years 

younger than the general population. This is a higher death rate than experienced 

currently by persons with HIV and on a par with sub-Saharan Africa. But what is 

overlooked is that over 80 percent of the premature deaths and years of life lost are due to 

co-occurring chronic medical conditions such as diabetes and heart ailments, not suicide 

or accidents. There is no federal agency that is routinely and systematically tracking this 

epidemic, let alone addressing it. 

Key recommendations in this area include: 

a. Persons with serious mental illness should be federally designated as a "distinct at 

risk health disparities" population; 

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b. The CDC and SAMHSA should develop, implement, and fund national annual 

surveillance of the mortality rates and causes of death in persons with serious 

mental illness; and 

c. HHS and SAMHSA should develop, implement, and fund a national strategy 

specifically for reducing premature death among persons with serious mental 

illness by promoting and accelerating the integration of behavioral health care and 

general medical care - and integration of preventive measures on the health care 

side and mental health side. 

Thank you again for the opportunity to present my views on these critically important issues that 

the Committee is tackling. I would be happy to assist the Committee in my various roles, to help 

you implement solutions to addressing the needs of people with serious mental illness. 

They deserve national attention and leadership at all levels. 

12 
106 

Mr. MURPHY. Thank you. I just recognize myself for 5 minutes. 

Dr. Parks, you are opposed to assisted outpatient treatment; you 

say so in your written and oral testimony? Yes or no? 

Dr. PARKS. I think—no, I don’t think I can make a yes/no answer. What I am advising the Committee of is if you wish to increase access using mandatory methods, I think you will be more 

successful and get better implementation if you focus on mental 

health courts. 

Mr. MURPHY. I understand, but with regard to getting treatment, 

courts don’t provide treatment. Assisted outpatient treatment is an 

alternative that has been—we have heard testimony, read things 

that have been fought by some of these advocacy groups funded by 

SAMHSA. 

Dr. Torrey, do you think assisted outpatient treatment, mandatory assisted outpatient treatment has a value and is there evidence to prove that? 

Dr. TORREY. Obviously, assisted outpatient treatment is a proven 

entity at this point. Mental health courts are also good but it is important to recognize that mental health courts are merely being 

used because of the failure of the mental health treatment system 

as such. The other problem with mental health courts is you can’t 

get treatment until you have broken a law, so if I said to you today 

we have a very good treatment for people with diabetes or hypertension but you have to break a law to get it, you would probably 

say that I deserve some treatment. 

This is the problem of where we are now that we don’t have any 

real treatment system out there and we are having to use the mental health courts. That is a sign of the failure of the system, not 

the good part of the system. But they work. 

Mr. MURPHY. And Mr. Bruce, in your testimony, do you believe 

that if your son had been court-ordered to receive other treatment, 

inpatient or outpatient, that an outcome could have been different 

for him? 

Mr. BRUCE. There is no question about it. He—— 

Mr. MURPHY. It is on. Just pull it closer. It was on. There you 

go. Now, it is off. The green light needs to be on. There should be 

a green light on there. Thank you. 

Mr. BRUCE. My son responded to medication immediately. The 

testimony of Dr. Schottky at—a forensic psychiatrist who evaluated 

him for his trial talked about the difference between Will before— 

when she met him the first time unmedicated and then when she 

spoke to him again later after he had started taking Seroquel, and 

I knew immediately that he was on medication because he called 

me for the first time in 4 months or so and he was in tears and 

he said, Dad, I am sick. 

And he is—Seroquel was not the right medication for him. He 

later began taking Abilify. But I take Will out to lunch in Augustine, Maine. We go shopping together. He—if you were to talk to 

him now, you wouldn’t—there is no sign of delusions. He is able 

to plan and think. He has problems because of the length of time 

that he remained psychotic, but he is—if he had been on medication in 2006 and had been released from the hospital on a court 

order that said he had to remain on his treatment plan, that would 

have given him an opportunity for the medication to work and with 

107 

the supporting treatment that is necessary in these kind of programs, I think that he would be living in a community somewhere 

probably with a job, and life would be a lot different for the Bruce 

family. 

Mr. MURPHY. Thank you. Real quickly from each of the doctors 

I want to ask you a question. In the SAMHSA administrator’s testimony she talked about the 5,000 additional mental health professionals also requested by the President, and listed in there to train 

social workers, counselors, psychologists, behavioral health professionals, marriage and family therapists, nurses, and other mental 

health professionals. Dr. Torrey, yes or no, do you think this should 

also include psychiatrists? 

Dr. TORREY. Absolutely. I worked at the National Institute of 

Mental Health for many years. I can’t conceive of a federally administered program for people with mental illnesses that does not 

include psychiatric input on it. 

Mr. MURPHY. Dr. Satel, do you think funding should also increase to get more psychiatrists? 

Dr. SATEL. Of course. 

Mr. MURPHY. And Dr. Parks, you already said so? 

Dr. PARKS. The shortage is more severe for psychiatrists than the 

other categories. 

Mr. MURPHY. Particularly child psychiatrists, I believe. 

Dr. PARKS. Particularly child psychiatrists, horrible shortage. 

Mr. MURPHY. I would just like to conclude with one other comment. When it comes to court-ordered inpatient or outpatient treatment, it is extremely important to note that unless a legal procedure takes place for inpatient or outpatient treatment by a court 

proceeding, that person’s name does not go on the National Instant 

Background Check. Quite frankly, we don’t know how many people 

should be on that list and the NICS list is what is used to determine if someone should be permitted to buy a gun. And while people are advocating whether or not we should expand registration, 

my concern is that we may not be putting people on that list who 

are at risk of abusing a weapon for an attack. 

I yield now to Ms. DeGette for 5 minutes. 

Ms. DEGETTE. Thank you, Mr. Chairman. 

And Mr. Bruce, your experience is heartbreaking and as a mom, 

you know, I want to give my deepest condolences to you and all the 

issues that you continue to work through to this day. And I also 

want to say I think this assisted outpatient treatment should be a 

tool that psychiatrists and mental institutions are allowed to have. 

Forty-four States allow that right now. 

And, Dr. Parks, maybe you can answer this. I think that in the 

block grants that SAMHSA gives to the States, they would be able 

to use that money for the assisted outpatient treatment if they decide to do that, correct? 

Dr. PARKS. That is correct. 

Ms. DEGETTE. Thank you. 

Dr. PARKS. And to answer the chairman’s question, I do not oppose assisted outpatient treatment—— 

Ms. DEGETTE. You don’t oppose it either but—— 

Dr. PARKS. It is difficult. 

108 

Ms. DEGETTE. So in my previous life before I came to Congress 

I was a practicing lawyer, and I think everybody kind of alluded 

to this, including you, Mr. Bruce, which is if you are going to get 

in order for assisted outpatient treatment, that is going to have to 

be in order that is given by somebody. And I think maybe, Dr. 

Parks, that is what you are talking about when you talk about 

these mental health courts. Is that part of it? 

Dr. PARKS. Assisted outpatient treatment is a civil court order 

and a mental health court is a criminal court order. 

Ms. DEGETTE. OK. So this would be a—— 

Dr. PARKS. But either is a court order in either case. 

Ms. DEGETTE. OK. But it is a court order. And so one thing I 

think—and this goes to our whole discussion we are having today— 

is that we have just woefully underfunded our entire mental health 

system in this country because if you are going to do a court order, 

which is appropriate in many cases, then you have to have the resources to enforce that. 

And I have constituents coming in with very similar stories, Mr. 

Bruce, to yours. And, you know, one of the things we have learned 

in these hearings that we have been doing is that schizophrenia 

tends to manifest itself in young men between the ages of 19 and 

25. So that is just the age that these young men are going off on 

their own. They are in college or whatever and they are above 18. 

And so, you know, the care providers of the colleges are not required to tell the parents. So this is the kind of tragedy we are 

hearing about and we don’t have enough resources in our mental 

health system to target people like that and to help them. 

Dr. Parks, you are nodding your head. Do you want to—— 

Dr. PARKS. Usually when I go to court to get either a civil order 

or to get a criminal condition of probation, it takes half a day. That 

means that there is 12 to 16 people I did not see in clinic because 

I was taking the time in court. Psychiatrists’ time gets shorter and 

shorter and this is a choice agencies face. You know, I only have 

three—— 

Ms. DEGETTE. Right. 

Dr. PARKS [continuing]. Psychiatrists. Do I do some more assisted outpatient treatment and tie up their time in testimony or 

do I try and just stay away from that? 

Ms. DEGETTE. And there are not enough resources to process 

those cases and there is not enough resources to treat the patients. 

I had a lady in Denver who said to me that her son, he became 

psychotic. He was committed. Then, he was on a 72-hour hold. He 

was released and then he came home and he said, Mom, I think 

I am going to kill you or myself. And she couldn’t get him the help 

he needed. And everybody has stories like this. 

I just want to ask you a couple of questions, Dr. Parks, about the 

SAMHSA block grant program because a lot of people have been 

saying that a lot of SAMHSA’s funding is not reaching people living with serious mental illness issues, and frankly, that is Congress’ fault because of the way we budget it. But for the money 

that is used for mental illness as opposed to drug abuse, you have 

seen on the ground in Missouri funding from the SAMHSA Mental 

Health Block Grant. How much does Missouri get every year in 

that block grant? 

109 

Dr. PARKS. For the block grant we get approximately $7.5 million, a very moderate—— 

Ms. DEGETTE. And what percentage of the 7 1⁄2 million that Missouri gets is used to treat people that don’t have health insurance? 

Dr. PARKS. About 65 percent goes to people that are uninsured. 

Ms. DEGETTE. So if they didn’t have that money from that block 

grant for mental health treatment, where would they be able to get 

mental health treatment dollars for your State? 

Dr. PARKS. Where people usually go, the emergency room. 

Ms. DEGETTE. OK. And how much of SAMHSA’s Mental Health 

Block Grant is used to treat patients diagnosed with a serious mental illness? 

Dr. PARKS. Essentially all of it. There is a small amount used for 

suicide prevention that was approved and there is about 4.5 percent we are allowed to spend on administrative overhead, much 

lower than the 20 percent administrative overhead that commercial 

insurance is allowed. 

Ms. DEGETTE. So most of it is for serious mental illness? OK. 

Thank you very much, Mr. Chairman. 

Mr. MURPHY. Thank you. I now recognize the gentleman from 

Texas, Mr. Olson, for 5 minutes. 

Mr. OLSON. I thank the chair and welcome to our witnesses. A 

very special warm welcome to you, Mr. Bruce. I have seen a tragedy similar to yours. Two weeks before Christmas in 2003 a family 

of four from my church came home from dinner. A mass gunman 

was waiting for them. The wife was killed, the younger son was 

killed, the husband was severely wounded, and the oldest son was 

shot in the arm. The investigation took a course no one saw coming. Because of an irrational hate, the oldest son had hired a 

hitman to kill his family. 

I know your situation is different from that situation, but having 

talked to the father, I know the courage it takes to come here and 

testify. So I thank you for your courage and your strength to be 

here today. You will be in my family’s thoughts and prayers. 

My question is for Mr. Torrey. Mr. Torrey, your first witness, you 

mentioned your 2010 request to SAMHSA for information, data on 

why federal costs in mental illness were increasing so rapidly and 

their response that there was no data. Have you received any information to your knowledge that SAMHSA has begun collecting this 

type of data? For example, in your testimony you said what if some 

States have more than three times more mentally ill individuals 

per population on SSI, supplemental security income, or on Social 

Security disability insurance than our States do? What is the percentage of mentally ill individuals on SSI, SSDI who are not receiving treatment? What is the percentage of Americans with serious 

mental illnesses who are receiving SSI and/or SSDI? And the answer you got? We have no data. Is that true? 

Dr. TORREY. Yes, it is. 

Mr. OLSON. There is no data? 

Dr. TORREY. Yes, that is absolutely correct. And it is important to realize that we have $140 billion in the mental health treatment 

system right now. Everyone says we need more money. In fact, we 

have 12 times more, corrected for population, than we had 60 years 

ago. I am one of the few people in Washington who probably says 

110 

we don’t need more money; what we need to do is spend the money 

the way we should be spending it and focus on the seriously mentally ill. Then, we would have a system that worked. 

Mr. OLSON. Can you identify any federal barriers as to why they 

are not collecting this data? 

Dr. TORREY. I would say they are not collecting the data because 

they have no interest in these questions. And one of the things you 

will learn early in government is you don’t ask questions that you 

don’t want the answers to. 

Mr. OLSON. This question is one for you again, Dr. Torrey, and 

Dr. Satel, if you would please answer this question as well. How 

can SAMHSA maximize their resources for those with severe mental illnesses? Just blanket. I mean how can they do this because 

they are missing the target completely? How can they maximize 

the resources right here, right now, today? Dr. Torrey? 

Dr. TORREY. Well, there is a whole series of things they could do. 

First of all, you could look at the rate that Ms. Hyde talked about. 

Seventy percent goes to substance abuse, thirty percent to seriously 

mentally ill. I don’t know why that ratio is as it is. It certainly 

should be at least 50/50 on it. Secondly, you can specify that 

SAMHSA must focus its resources on severe mental illness and report back on a regular basis. Third, I think a GAO investigation 

of the discretionary grants, things like the P and A program and 

other things is way overdue. 

I have looked at a few of these grants under Freedom of Information. They really look like they need some light of day looking at 

them, and I think that is one of the important things the Committee could do. 

Mr. OLSON. Thank you, Dr. Torrey. Dr. Satel? 

Dr. SATEL. Yes. I would like to mention, though, that when we 

are all saying severe mental illness as a large category, and, yes, 

it typically refers to bipolar, schizophrenia, the chronic psychoses, 

but what we are specifically talking about is the subset of the severely mentally ill who are so psychotic that they don’t know they 

are ill and can’t cooperate. So even if a program says it is dedicated 

for the severely mentally ill, that doesn’t really answer the whole 

question. It has to also respond to those who are so sick and so debilitated that they cannot cooperate with that program. That is an 

important difference. 

But the more direct answer to your question, what I worry about 

in addition to what Dr. Torrey said is the active sabotage of the 

best interests of the mentally ill that SAMHSA underwrites. And 

again, the PAIMI, maybe if you kept the protection, I know they 

do some good things. I know there is certainly abuse in these institutions and someone needs to be a watchdog. The advocacy element 

has become very, very destructive. 

Also, even though there is not much money, as Administrator 

Hyde had mentioned that may go to Alternatives Conferences or 

consumer survivor groups, that money is leveraged so efficiently, 

these folks go out and they lobby state legislatures and they interfere with the passage of these AOT laws. I mean they are very efficient. So even if it is a small amount of money, it can have a much 

broader effect than many might expect. 

111 

Mr. OLSON. Thank you, ma’am. I am out of time. I will remember 

the term ‘‘active sabotage.’’ Thank you. 

Mr. MURPHY. Thank you. I now recognize Mr. Griffith from Virginia for 5 minutes. 

Mr. GRIFFITH. Thank you, Mr. Chairman. I appreciate all of you 

being here with your testimony and everything that you all have 

said. Great concerns about where we are spending our money and 

if we are spending it in the right places. I appreciate that, Dr. 

Torrey. 

I will tell you that the court system is very concerned about this. 

I spent 27 years before I came to Congress 2 1⁄2 years ago as a 

street lawyer as a lot of folks would say, dealt with families that 

were dealing with these issues, dealt with clients who were dealing 

with these issues. It is seen on a regular basis in every court across 

this country. 

And I will do a little shout-out for my hometown. They don’t call 

it a mental health court because that isn’t authorized at this point, 

but one of our judges has set up a therapeutic docket specifically 

because we had sufficient numbers even in our area of people who 

are in the criminal court system who need help. And it may not 

be that they are completely out of touch like that subset you are 

talking about, Dr. Satel, the severe mental illness, but they have 

got significant issues that the court needs to make sure somebody 

is dealing with it. If our mental health system isn’t going to do it, 

the court system has got to try to figure out how to do it in a just 

manner. And so I commend Judge Talevi for setting that up. 

Mr. Bruce, in those regards, I would ask you what your son’s 

condition was like before April 2006 and specifically if you could 

tell me, prior to killing his mother, had he had any contact with 

the criminal justice system? 

Mr. BRUCE [continuing]. With the criminal justice system, but he 

had been brought to a hospital for evaluation in 2005 after pointing 

a loaded weapon at two people and coming within a hair of killing 

both of them. He was in a state of deep psychosis. At that time 

they decided not to send him to a commitment hearing after he had 

been on some Thorazine and a little bit of lithium and had calmed 

down because they said that he felt that he didn’t meet the standard for involuntary commitment. 

Mr. GRIFFITH. Who said that? 

Mr. BRUCE. My wife and I waited in the psychiatrist’s office for 

this commitment hearing to start. She got a call, said that was the 

hospital’s lawyer and he felt that they didn’t have a case so they 

weren’t sending him to the commitment hearing. And I said what 

do you mean, no case? And she said, well, the standard is imminent danger, which actually is not the standard in Maine. It poses 

a likelihood of serious harm. But anyway, this is what happens 

when mental health people are forced to interpret law. I said, well, 

a couple weeks ago he almost killed two people. And she said, well, 

that was then and this is now. And I said, well, but you told me 

that in all likelihood the minute he leaves the hospital he is going 

to stop taking these medications which you yourself said are not 

even adequate for his disease. She said, how could I go before a 

judge and truthfully say that he was in imminent danger? Just 

look at him. I mean he was calm. He wasn’t threatening anybody. 

112 

Mr. GRIFFITH. Well, what a tragedy and I am sorry for all the 

pain and the loss of your wife that you have had to go through over 

this. 

Mr. BRUCE. Thank you. 

Mr. GRIFFITH. Do you think at that time he was able to make 

decisions for himself that were rational? 

Mr. BRUCE. No. No. 

Mr. GRIFFITH. And you did obtain the guardianship in February 

2007 and he was, I believe you said, found not guilty by reason of 

insanity, is that correct—— 

Mr. BRUCE. Yes, sir. 

Mr. GRIFFITH [continuing]. At the time of the offense? 

Mr. BRUCE. Yes. 

Mr. GRIFFITH. OK. Well, I hope that we can find some answers 

and I appreciate all of you all testifying today. 

I do think it is important that we have input at the court level 

because us street lawyers see a lot of mental illness in a lot of our 

clients and the family members know what is going on, so they 

need to be involved. And I have had many cases where the families 

kept folks from doing things that they might otherwise have done 

that could have caused problems. So I do appreciate it and appreciate all of your testimony today. Thank you. 

I yield back, Mr. Chairman. 

Mr. MURPHY. Thank you. The gentleman’s time is expired. I now 

recognize that Dr. Cassidy of Louisiana for 5 minutes. 

Mr. CASSIDY. Dr. Parks, for the record, obviously one of my concerns—I am a doc, too, not a psychiatrist—but one of my concerns 

is that some of the SAMHSA money is going for folks who advocate 

doing without medications. And yet I have read from your testimony it seems as if you would reject that. You firmly seem to believe that medications have a role in the treatment of serious mental illness. 

Dr. PARKS. Absolutely. That is correct, Representative. 

Mr. CASSIDY. Yes. I am told that you are a primary investigator 

or a principal investigator on a number of SAMHSA-type studies? 

Dr. PARKS. That is correct. 

Mr. CASSIDY. May I ask what type of studies just quickly? 

Dr. PARKS. The two that I am currently principal investigator on, 

one is suicide prevention on the mental health side. This has been 

a 10-year series of grants, many of them are direct congressional 

funding. They said spend this on suicide prevention, particularly 

with youth, the Garrett Smith Act. 

The second one is out of the CSA, the substance abuse side. And 

that is for a brief—that is for screening for excessive drinking and 

risky drug use with brief interventions following an assessment. It 

is a primary care intervention. 

Mr. CASSIDY. I have just limited time so I get the—— 

Dr. PARKS. Sorry. 

Mr. CASSIDY. Do you feel as if your participation in those grants 

presents a conflict of interest in your testimony today? Just asking. 

Dr. PARKS. I agree it could have the appearance of that. I am 

here as an expert. 

Mr. CASSIDY. I accept that. I mean I can make do. Do you agree 

with Dr. Satel and Dr. Satel’s statement that it is not the actual 

113 

severe, severe mental illness; it is the people with severe mental 

illness which is beyond the current reach of society that seems to 

be ignored by the funding priorities of SAMHSA? 

Dr. PARKS. No, I would not agree by that. That is who we are 

spending the block grant money on and that is certainly who we 

were treating with the COSIG grants that have now ended. These 

are the grants that serve people that have substance abuse problems and serious mental illness, greatly increasing their risk of violence. So I would not agree. 

Mr. CASSIDY. Dr. Satel, how would you—— 

Dr. SATEL. Yes, I would say that I have no question that Dr. 

Parks is treating people who have the diagnosis of schizophrenia 

and bipolar, and correctly so, but that they are not in that active 

phase where they are, again, so profoundly ill that they cannot 

even cooperate with your care. 

So—but that is the point I am making, again, distinguishing between—the question isn’t does SAMHSA have programs that serve 

people with these illnesses; it is, do they serve them also in the 

most debilitated phase of that condition? 

Mr. CASSIDY. So I gather it was your testimony or Dr. Torrey’s 

regarding now the efforts seem to be those patients who actually 

can participate in their care but the issue is how do we reach those 

who cannot participate in their care? 

Dr. SATEL. Yes, exactly. 

Mr. CASSIDY. OK. I got that. And you stand by your statement— 

you heard me quote your testimony earlier speaking to Administrator Hyde that there is a—I forget your term, but there is a relative imbalance in terms of the compendium of care? 

Dr. SATEL. Oh, I definitely stand by that. I did clarify it when 

you, I think, were out of the room that I mentioned that there were 

only four studies that explicitly mentioned severe mental illness in 

their description, but, as you also alluded to, that there were more 

programs that probably did—or definitely did attend to them. But 

again, we are back to that distinction between those who can cooperate and those who can’t. 

Mr. CASSIDY. So, Dr. Parks, I respect that you are frontline. I 

mean I have worked in a safety net hospital so I always figure 

frontline folks have a little bit of street cred. My impression, 

though, is that SAMHSA has somewhat lack of focus. You heard 

my questioning of the administrator. Would you disagree with that 

or do you feel like everything is working great, no problem, or 

would you accept what Dr. Torrey says, what in the heck are we 

spending $20,000 on an oil painting for? 

Dr. PARKS. I have not yet found a governmental agency that 

couldn’t improve its performance. 

Mr. CASSIDY. Were you at Charity, by the way, Charity Hospital? 

Dr. PARKS. I was at a daughter of Charity. 

Mr. CASSIDY. OK. 

Dr. PARKS. I am a Charity alum. 

Mr. CASSIDY. Yes. 

Dr. PARKS. That is where I did my internship—— 

Mr. CASSIDY. Yes. 

Dr. PARKS [continuing]. Wonderful experience. I think the major 

problem we have with SAMHSA is they are funding short. They 

114 

cannot fund all their priorities adequately. In terms of the $20,000 

painting, I can’t support having funded that. That is $20,000 is 

very small dollars in the big picture of things. It is not an excuse 

to waste it but I think the proper policy focuses on the big picture 

dollars. 

Mr. CASSIDY. And Dr. Torrey, I am sorry, I was out of the room 

with other responsibilities but is there anything that you would— 

you heard Administrator Hyde kind of contradict some of your assertions. Just now that I am back in the room, is there anything 

you would say to me as regards to her testimony? 

Dr. TORREY. Yes, can you repeat that, Dr. Cassidy? 

Mr. CASSIDY. Yes, her response to my questions in which I suggested that there was a lack of focus, she seemed to feel as if there 

is not. I take it you stand by your assertions that that indeed there 

is a lack of focus and even a frivolity as to some of their spending? 

Dr. TORREY. Yes, it is not that there is no worthwhile programs. 

In SAMHSA there are some worthwhile programs but they are relatively few and far between. And I certainly stand by my statement 

that not only is severe mental illness not a priority; it is almost 

nonexistent. 

Mr. CASSIDY. OK. I yield back. Thank you. 

Mr. MURPHY. I thank the gentleman. 

And I want to thank all the panelists today and all the members, 

both sides of the aisle. It is clear we are all dedicated to coming 

up with some answers, a solution. Unfortunately, it was pointed 

out this may not have the publicity of the IRS hearings or 

Benghazi, but given that 20 percent of people have diagnosable 

mental illnesses in any given year and 38,000 people commit suicide I think last year, 750,000 suicide attempts, we all are very 

concerned. And I appreciate the dedication of all the members of 

this committee in trying to find some answers. 

I also want to restate my commitment and everyone’s commitment to science-based evidence for real solutions. Good intentions 

do not guarantee good results, and as we move forward to come up 

with some solutions, I am pretty sure I speak for both sides of the 

aisle when I say that is what we are going to be looking for, good, 

effective results will do this. 

Again, I thank everybody and I want to then mention that in 

conclusion I remind members they have 10 business days to submit 

questions for the record. I ask the witnesses to please respond 

promptly to any of the questions. Again, Mr. Bruce, our prayers 

and our thoughts are with you and your family and I thank all the 

other panelists for this very important hearing today 

And with that, I adjourn. 

[Whereupon, at 1:10 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

115 


85437.050

Index to Hearing Binder 

1. 911 Transcript 

2. Transcript of Hearing 

3. Role of Patient Advocates 

4. Chronology of Medical Records and Treatment for William Bruce 

5. Preliminary Report as Guardian 

6. Wall Street Journal Article 

7. National Disability Rights Response to Wall Street Journal Article 1 

8. National Disability Rights Response to Wall Street Journal Article 2 

9. Letter from Nurse to Joe Bruce 

10. Letter from William Bruce to Maine Legislature 
116 


85437.051

A Father's Call for Help - WSJ.com 

:)ow Jones Repr·f'!S This C0PY:S tor YOLir oers-onal non-COfTlrnercla: !lseo',ly 

erda' Repnnts \:)0' at tie bottom of any article or v s't wwwdJrepnnts com 

See a sample repnnt In PDF format Qrdera reprint of this article new 

AUGUST 16. 2008, 12 21 El 

A Father's Call for Help 

My Son Has Killed My Wife' 

Page I of7 

citents or custol11e,s lise the 

Late one afternoon in June 2006, Joe Bruce of Caratunk, Maine, came home from work to find his wife dead. He called 

911 and told the dispatcherthat his 24-year-old schizophrenic son, William, had killed her, that he couldn't find the 

son, and that he was arming himself for self-defense. Below are excerpts from the transcript of that call made available 

to The Wall Street Journal. (See related article.) 

Caratunk, Maine, June 20,2006, at 4:49 p.m. 

Dispatcher: 911. What is the address of the emergency? 

Mr, Bruce: My name is [ ... J I live at [ ... J in Caratunk. Urn, my son has killed my wife, he is schizo -- completely out of 

his mind. 

Dispatcher: Where is your wife now? 

Mr. Bruce: She is in the bathtub, she is dead. I just came home from work, her car is gone. [ ... J I don't believe anyone 

has been here, there is no sign the neighbors are aware of anything going on. His name [ ... J. He is 24 years old. 

Dispatcher: Howald is she? 

Mr. Bruce: She's 48 years old. Please, please don't put this out over the scanner. Just send someone up somehow. 

Would you please just do me that favor? 

Dispatcher: Hold on just one second sir, OK? 

Mr. Bruce: Yes. 

Dispatcher: OK, we are going to send them out over the phone that way .... 

Mr. Bruce: Yes, please. I will be right here. There's uh .... 

Dispatcher: Do you have any idea where your son may be going? 

Mr. Bruce: I have have, he is completely out of his mind. 

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Dispatcher: OK, what is your phone number there? 

Mr. Bruce: [Number]. 1 don't know where the phone went from up at the house, I'm down in her shop. 

Dispatcher: OK Stay right there, sir, 1 will be in touch with you shortly. 1 am going to make some calls and get 

everyone started that way, OK? Don't go anywhere. 

Mr. Bruce: OK, yes. 1 will not. 

Dispatcher: I'll call you back in a few minutes. 

Mr. Bruce: Yes. Sir, 1 am going to arm myself. Please, 1 will only have a weapon nearby. 1 don't intend to kill him or 

anything, but ifhe shows up 1 do want to be able to defend myself. 1 don't want the officers to feel threatened when 

they get here. I won't be standing out there with a gun. Ijust wanted you to know that, OK? 

Dispatcher: If you see a deputy or officer, just make sure you keep your hands where they can see them. I will inform 

them of that. 

Mr. Bruce: OK 

Dispatcher: Just make sure if you see them you keep your hands wbere tbey can see them. 

Mr. Bruce: OK 

Dispatcher: Somebody will be in touch witb you sbortly, sir. 

Mr. Bruce: OK 

Dispatcher: Thank you. 

[The 911 Center called back.) 

Dispatcher: Did he have any access to weapons? 

Mr. Bruce: I have ... everything has been locked up for a long time. 

Dispatcher: Do all of your firearms are locked up? 

Mr. Bruce: Yes, 1 have a federal firearms license. Everytbing has been locked in a bnilding in a safe with an alarm 

system. 1 bave cbecked tbat. 

Dispatcher: When was the last time you spoke to your wife? 

Mr. Bruce: About 7 a.m. this morning. 

Dispatcher: Was your son tbere at that time? 

Mr. Bruce: My son was here -- he was asleep. We tried to get hold of tbe case manager. There's a guy they have, this, 

oh, this f--ing system. Tbey let these people out. They won't give them medications and they let them out, and they put 

them with a case manager, I have called this guy. We said, "Jeez he is getting worse." 1 said, "I can't go on like this 

having him here, until be killed somebody." 

Dispatcher: He has had some longer issues that go back? 

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A Father's Call for Help - WSJ.com Page 3 of7 

Mr. Bruce: He got out of Riverview, they committed him and let him out, said there was nothing they could do for 

him, he won't take medication and they won't give it to him underthis these f--ing nuts are the ones making these 

friggin, she was one of the most beautiful people in the world. [Inaudible 1 

Dispatcher: You have to stay with me. 

Mr. Bruce: I know, I'm OK. 

Dispatcher: We need to make sure we get everybody up there for you to make sure .... 

Dispatcher: I'm alright. 

Dispatcher: OK. You are doing great. 

Mr. Bruce: I'm alright. I'm, my other kids, the rest of the family, the lives that afe going to be ruined because of the 

lunatic God D---laws. We told them he's going to kill somebody. They say, "Well he seems OK now so there is nothing 

that we can do, you know." 

Dispatcher: You're the one there correct, sir? 

Mr. Bruce: As far as I know. I don't know where he is. 

Dispatcher: OK. 

Mr. Bruce: But the car is gone. 

Dispatcher: And that is your wife's car, correct? 

Mr. Bruce: That is my wife's car. 

Dispatcher: OK. There's a description showing on the Department of Motor Vehicles. We got the plate number and 

everything. 

Dispatcher: Does he have any friends? Any idea at all where he might have gone? 

Mr. Bruce: No clue. He has been completely out of his mind. He's been home here with us ... I'm going to say three 

weeks, and he'll bave periods where he'll calm down, but most of the time you talk to him and you can't even carryon a 

conversation with him. He talks about, way gone, way gone. Well, obviously. 

Dispatcher: OK. I'm going to explain to you what we are doing on this end. Just so you know real quickly. I have an 

ambulance coming that way, but they are not going to be able to come there until the police secure that scene. OK? 

Mr. Bruce: Yes. 

Dispatcher: For their protection and your protection. 

Mr. Bruce: Yes. I understand. 

Dispatcher: OK. Police will come first. I've already told them you have a firearm to protect yourself. It's close to you 

and you don't have it on you. OK, when you see them .... 

Mr. Bruce: I know what to do. I will come out. They will know its me and not him. 

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A Father's Call for Help - WSJ.com Page 4 of7 

Dispatcher: Right. They're going to go inside, probably just one of them. 

Mr. Bruce: Which officers are coming up? 

Dispatcher: I have numerous deputies coming. 

Mr. Bruce: Alright. I know some of them. 

Dispatcher: OK. [Name] is on his way. There's a list of them. Probably just one of them will go into the house and 

secure the scene. 

Mr. Bruce: OK. 

Dispatcher: And then the ambulance will go in, OK? 

Mr. Bruce: I've been upstairs. The only place I haven't been down into the basement. I left my ... I had no weapon, so 

I grabbed my flashlight when I went down to check the gun room, I grabbed my flashlight, that was the only light, but 

I'll .... 

Dispatcher: Do you have power there? There was a hig stann going through. 

Mr. Bruce: We lost power. I hit the worst of it in Solon, Bingham. It's just rain and a little lighter up here. 

Dispatcher: OK. 

Mr. Bruce: Oh God. 

Dispatcher: You haven't called anyone to come down, have you? 

Mr. Bruce: I haven't called anybody but you. 

Dispatcher: OK. If you could refrain from doing that for right now. 

Mr. Bruce: [Inaudible] Yes ... just, I don't need all the, kinds of people getting wound up. We knew there was no plan 

and within a week he was back up here and we ... My wife wouldn't just leave him out. I said, "Ifhe comes here 

something bad is going to happen." I knew it. I felt it. 

Dispatcher: OK. They are actually coming towards you. I just want to make sure that they are going to get there. OK, 

as soon as they get there we can hang up. 

Mr. Bruce: Yup. 

Dispatcher: You're on the front porch now? 

Mr. Bruce: I am on the front porch now. 

Dispatcher: OK. Just so they can identifY you sir, what are you wearing? 

Mr. Bruce: Blue jeans, black and white checked shirt, sleeves rolled up, blne baseball cap on. 

Dispatcher: OK. 

Mr. Bruce: I'm 54 years old [ ... J I have the shot gun sitting on the kitchen table. I don't know where he is. 

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A Father's Call for Help - WSJ.com Page 5 of7 

Dispatcher: OK. 

Mr. Bruce: When they come, I'm watching, I'll go out the door. There's nothing to worry about. I understand how it 

works. 

Dispatcher: OK. 

Mr. Bruce: There's not going to be a problem. You don't have to worry about it. I'm not going to do anything stupid. 

Dispatcher: Please, don't walk around much sir. 

Mr. Bruce: I am sure you have already put out an APB, or whatever you guys call it. I just want to let them know they 

want to be God D--- careful approaching him because he is completely out of his mind. 

Dispatcher: OK. 

Mr. Bruce: And he was in the army and he does know how to kill. 

Dispatcher: He does, OK. So he would be considered armed and dangerous. 

Mr. Bruce: He must be. I don't know what he is armed with. I don't know what he is armed with. I've got to say it's a 

knife of some sort. 

Dispatcher: So, is it still raining up there? 

Mr. Bruce: Yeah, but not hard. 

Dispatcher: Does your wife work, sir? 

Mr. Bruce: Yeah, home business. 

Dispatcher: And your son, does he work? 

Mr, Bruce: My son does not do anything. He is totally incapable of functioning. 

Dispatcher: OK. Was he on any medications, I know you said he refused? 

Mr. Bruce: No. 

Dispatcher: OK. Does he have a diagnosis? 

Mr. Bruce: Yes. 

Dispatcher: Do you know what that is? 

Mr, Bruce: Yes, schizophrenia. [Inaudible] 

Dispatcher: What was that? 

Mr. Bruce: I haven't checked out the barn yet. 

Dispatcher: OK. Don't go in there then. 

Mr. Bruce: OK. 

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A Father's Call for Help - WSJ.com Page 6 of7 

Dispatcher: Hang on a second. I am going to ask them how long it is before they get there. 

Mr. Bruce: OK. 

Dispatcher: They are about four minutes out. 

Mr. Bruce: Yup. 

Dispatcher: Think you can take talking to me for another four minutes. 

Mr. Bruce: Still hanging in there. 

Dispatcher: Alright. Good deal. When you called me today, sir, you had just arrived home from work? 

Mr. Bruce: Yes. I work for [ ... J. Ijust left the Fairfield office, stopped at Dr. ------ office to pick up a prescription and 

didn't stop for gas ..... 

Dispatcher: Is there something else? 

Mr. Bruce: No. 

Dispatcher: Just trying to see if you knew what he was wearing when you left for work or was he still sleeping so you 

wouldn't know that. 

Mr. Bruce: I have no idea what he was wearing. 

Dispatcher: OK. 

Mr. Bruce: He's got... I believe it's ... [InaudibleJ 

Dispatcher: Have you heen fighting lately? I'm sure it is hard to live with someone with that diagnosis. Do you know 

if they were fighting? 

Mr. Bruce: No. 

Dispatcher: OK. 

Mr. Bruce: No, he was really whacked out the last couple of days. We talked about it last night. I said, "He's getting 

worse, more aggressive." I called this guy named [NameJ who is the case manager three times trying to get hold of him. 

Dispatcher: Are you south of the Pleasant Pond turnoff, sir? 

Mr. Bruce: [DirectionsJ. As soon as I see a cruiser I'll be right out the door. 

Dispatcher: OK. He is on the road now, just looking for your place. 

Mr. Bruce: Yup, I'll stand out on the porch. 

Dispatcher: OK. You can see the porch from the road? 

Mr. Bruce: Yup. 

Dispatcher: They're there sir? 

Mr. Bruce: No. 

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A Father's Call for Help - WSJ.com Page 7 of7 

Dispatcher: He's asking if you are north of the Village. 

Mr. Bruce: I'm in the Village, [Directions]. I'll be standing out in the driveway. 

Dispatcher: OK. 

Mr. Bruce: I see him right now. 

Dispatcher: Is he there with you? 

Mr. Bruce: He is coming, they're pulling in now, two of them. 

Dispatcher: You got them? 

Mr. Bruce: Yes. 

Dispatcher: OK. Thank you, sir. 

Mr. Bruce: Good bye. 

Police arrested William at his grandparents' house, 120 miles away in Portland, Maine, and charged him with his 

mother's murder. William was eventually found not criminally responsible by reason of insanity for the crime and 

was sentfor treatment at Riverview Psychiatric Center, in Augusta, Maine, the same hospital that had released him 

shortly before the murder. He will be there indefinitely. 

Copyright 2008 Dow Jones & Company, Inc. All Rights Reserved 

This copy is for your personal, non-commercial use only. Distribution and use of this material are governed by our Subscriber Agreement and by copyright 

law. For non-personal use or to order multiple copies, please contact Dow Jones Reprints at 1-800·843-0008 or visit 

www.djreprints com 

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85437.058

1 

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3 

STATE OF MAINE 

PENOBSCOT, ss. 

SUPERIOR COURT 

Criminal Action 

Somerset Docket No. CR-06-298 

4 STATE OF MAINE 

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v. 

WILLAM BRUCE, 

Defendant. 

ARRAIGNMENT & HEARING 

BEFORE: HONORABLE JOSEPH M. JABAR, 

JUSTICE OF THE SUPERIOR COURT 

Penobscot County Courthouse 

97 Hammond Street 

Bangor, Maine 

March 27, 2007 

21 APPEARANCES: 

22 

23 

24 

25 

For the State: ANDREW B. BENSON, ESQ. 

For the Defendant: PHILIP G. MOHLAR, ESQ. 

Maureen A. Bradford 

Official Court Reporter 

1 
124 


85437.059

1 INDEX OF TESTIMONY 

2 JEFFREY LOVE 

3 Direct Examination by Mr. Benson 

4 

ANDREW WISCH 

5 

Direct Examination by Mr. Benson 

6 

7 DIANE SCHETKY 

8 Direct Examination by Mr. Benson 

9 

* * * * * 

10 

11 INDEX OF EXHIBITS 

12 State's 

Exhibit No. Description Offered 

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1 

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Report 

Report 

Report 

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43 

Admitted 

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i 
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TRANSCRIPT OF PROCEEDINGS 

(This case came on for hearing before 

Honorable Joseph M. Jabar, Justice, at ~he 

Penobscot County Courthouse, Bangor, Maine, on 

March 27, 2007, commencing at 9:10 a.m.) 

* ~ * * * 

THE COURT: You may be seated. Good morning 

everybody. 

Okay. We're on the record. First of all, I 

want to thank you for coming here. We couldn't 

find a courtroom in Somerset County, so I 

appreciate your traveling up here to take care of 

this. This is State of Maine versus William Bruce, 

Docket No. CR-06-298. 

Are you William Bruce? 

THE DEFENDANT: Yes, Your Honor. 

THE COURT: Okay. Mr. Bruce is in the 

courtroom with his attorney, Mr. Mohlar. I 

understand that Mr. Bruce has not entered a plea 

yet -- has not been arraigned on the charges, is 

that correct, gentlemen? 

MR. MOHLAR: That is correct, Your Honor. 

There's issues of competency, and so he has not yet 

been arraigned. 

THE COURT: Okay. So one of the first issues 
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85437.061

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(The witness left the witness stand.) 

MR. BENSON: I call Dr. Diane Schetky. 

43 

THE CLERK: Please raise your right hand and 

state your name for the record. 

or 

now 

and 

THE WITNESS: Diane Schetky. S-c-h-e-t-k-y. 

THE CLERK: Thank you. Do you solemnly swear 

affirm the testimony you will give in the cause 

in hearing will be the truth, the whole truth, 

nothing but the truth, so help you God. 

THE WITNESS: I do. 

THE CLERK: Please be seated. 

12 DIANE SCHETKY, having been duly sworn, was examined and 

13 testified as follows: 

14 DIRECT EXAMINATION 

15 BY MR. BENSON: 

16 

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Q. 

A. 

Q. 

A. 

Q. 

A. 

Q. 

A. 

Good morning, Dr. Schetky. 

Good morning, Mr. Benson. 

Your name is Diane Schetky? 

It is. 

And you're a physician licensed to practice in the 

state of Maine? 

I am. 

And in addition to being a physician, you're a 

psychiatrist? 

That's correct. 
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A. 

Q. 

A. 

Q. 

A. 

Q. 

A. 

Q. 

A. 

44 

And, sadly, you are about to retire from consulting 

for the State Forensic Service; is that right? 

That's true. 

Formerly, or at least currently up until a few 

months from now, you did the bulk of the 

psychiatric work for the State Forensic Service; is 

that fair to say? 

I guess so. I don't know the actual numbers. 

I can't think of anybody else. 

But there are many more psychologists working for 

the service than there are psychiatrists, and I 

guess I've kind of specialized in the northern part 

of the state, which I'm told starts in Falmouth. 

Augusta. Dr. Schetky, prior to your retirement, 

the last couple of years, did you limit your 

practice almost solely to the area of forensic 

psychiatry? 

That is true, since 2000. And, then, about a year 

and a half ago, I eliminated the private practice, 

and I've only been working part-time for the State 

Forensic Service. 

And could you describe briefly what forensic 

psychiatry is? It's probably largely similar to 

forensic psychology, I assume. 

It is, very similar. It's the application of 
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45 

psychiatric expertise to legal issues. Our role is 

not to help the examinee but, rather, to help the 

Court weigh the mental health issues as they might 

impact on the legal questions. 

And, briefly, Dr. Schetky, can you describe your 

educational background? 

Yes. I graduated from Sarah Lawrence College. I 

then went on to Case Western Reserve University 

School of Medicine in Cleveland. I graduated from 

there in 1966. I did a year of an internship in 

pediatrics. I then did a residency in adult 

psychiatry and another residency in child 

psychiatry. 

And could you describe just generally in a 

post-education sense your experience in the field 

of clinical psychiatry? 

Yes. Until 2000, I maintained a private practice, 

which consisted of both children and adults and 

adolescents. 

And clinical psychiatry is what as opposed to 

forensic psychiatry? 

The diagnosis and treatment of mental illnesses, 

as well as providing consultation to physicians and 

other mental health personnel. But throughout that 

time, I also did forensic psychiatry, initially in 
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the arena of child and adolescent forensic 

psychiatry. Then branched out into doing civil 

cases involving adults and children, and, then, 

since '98, was seeing criminal defendants for the 

State Forensic Service, as well as doing civil 

cases. 

46 

And you've done forensic psychiatry not just in the 

state of Maine; is that fair to say? 

Oh, I got started way back in Oregon in the 1970s 

writing about child sexual abuse. 

Now, can you also describe, Dr. Schetky, the 

experience that you've had in terms of identifying 

major mental illness? 

Well, certainly that was a major part of my 

psychiatric education, my residency training, and 

I've continued to focus on that area throughout my 

years of private practice. 

And could you describe, again, for purposes of the 

record, what major mental illness is? 

Yes. Generally, as Dr. Wisch said, it consists of 

psychiatric disorders that are often accompanied by 

impaired reality testing such as mania or the 

spectrum of schizophrenic disorders. Major mental 

illness can also be a result of severe traumatic 

brain injury. But, generally, there's a high 
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degree of impairment there, and, for legal 

purposes, that impairment would impact on their 

ability to appreciate the wrongfulness of their 

behavior. 

And I know you've touched on this briefly in your 

answer, but does major mental illness also 

frequently involve psychosis? 

Yes. 

And could you describe what psychosis is? 

47 

Yes. As Dr. Wisch said, it's impairment of reality 

testing involving both cognition and perception. 

And throughout your career, how many times, 

approximately, if you know, have you had occasion 

to testify as an expert witness on forensic matters 

in court? 

Probably over 200. 

Now, I'd like to call your attention to late last 

summer, early last fall. Did you have occasion to 

receive a Title 15 order to evaluate Mr. Bruce, the 

defendant in this case? 

Yes, I did. 

And did you begin, as Dr. Wisch said he began, in 

terms of sort of dealing with the issues 

surrounding the issue of competence? 

Well, I -- I usually begin with getting informed 
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48 

consent to proceed. 

Probably a good way to start. 

So Mr. Bruce was clear about my role and who I was 

or was not working for. 

So 

And the implications of following through with the 

investigation. 

You weren't there to treat him --

Exactly. 

-- but to provide information to the Court? 

Exactly, and that I could be called upon to 

testify. 

Now, in preparing for your evaluation of Mr. Bruce, 

did you have occasion to read the police reports in 

connection with this case? 

I did. 

And did you also read the Acadia records and the 

Riverview records in connection with the case? 

I did. I think there was about 600 pages of 

discovery. 

And there was also another forensic psychologist, a 

University of Maine professor, Jeffrey Hecker, who 

also did an initial evaluation of Mr. Bruce; is 

that correct? 

Yes, he did, yes. 
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49 

And did you have occasion -- did you have access to 

Dr. Hecker's report? 

I did review that. 

And would it be fair to say, Dr. Schetky, that when 

you dealt with Mr. Bruce initially, it became clear 

to you right from the outset that there were 

concerns concerning whether he had the skills 

associated with competence? 

Yes, particularly in the area of his ability to 

work with his attorney. His thoughts were so 

scattered and fragmented and delusional, I thought 

he would have trouble tracking procedures. I 

thought he would have trouble probably retaining 

new information because there was so much going on 

on his radar screen, clutter in his mind. 

When you say there's so much going on there, you're 

referring to psychotic delusions and 

hallucinations? 

A lot of paranoid thoughts, as well as grandiose 

thoughts, that impaired his reasoning. If I could 

give an example, he had this fantasy that somehow 

he was going to defect to Russia and the KGB wanted 

him to work for them. And in my initial 

evaluation, I had a resident sitting in with me who 

happened to be Russian, and he was so pleased when 
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50 

he figured out that she was from Russia, and he 

assumed that she had come over there -- come over 

here just to meet with him and that she was going 

to assure his safe passage -- passage somehow back 

to Russia, and we had to spend a lot of time 

clarifying that was not her role. So, as you can 

see, he was perceiving a lot of things through that 

very paranoid lens, attaching special meaning to 

things. 

And sometime toward the end of summer or early 

fall, you wrote an initial report to the Court 

concerning Mr. Bruce; is that correct? 

I did, yes. 

And in that report, do you essentially say that you 

had concerns concerning competence and that you 

really couldn't reach the other issues because you 

couldn't get beyond competence? 

That's true. 

And as a result of that report, there was an 

initial finding that Mr. Bruce lacked the skills 

associated with competence? 

Correct. 

Is that your understanding? Now, Mr. Bruce, after 

that, went back to Riverview; is that correct? 

He was at Riverview when I saw him. 
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51 

All right. So he was treated at Riverview during 

the fall and early winter of last year, going into 

this year? 

Well, it was ~ore custodial care initially because 

he was refusing antipsychotic medication, which 

would have been the first line of treatment. 

Now, at some point, did Mr. Bruce begin to agree to 

take the antipsychotic medication? 

He did, in December. 

And did that cause a change in terms of his having 

the skills associated with competence? 

Indeed it did. 

And could you describe that? 

Yes. His -- his thoughts were much more organized. 

I found he still had some residual -- residual 

paranoid thoughts. 

Mm-h~~. 

The other remarkable change was he was starting to 

have some insight into the fact that he had a 

mental illness and perhaps he really did need to be 

on medication. That was totally lacking when I 

first saw him. So he was -- his reality testing 

was much improved. He appreciated the severity of 

this crime, even evidenced some remorse, and I felt 

at this point he was capable of working with 
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Mr. Moh1ar. 

You 

But I put in the proviso there that it was very 

important that he stay on his antipsychotic 

medication. 

52 

And would it be fair to say that you still believe 

that in spite of some of this paranoid thinking, 

that by and large he has the skills associated with 

competence? 

I believe he does. 

Now, when Mr. Bruce began taking the antipsychotic 

medication that you referred to, were you able to 

go back to him and then look into the issues of 

criminal responsibility? 

Yes, I was. 

And did you take a history from Mr. Bruce at that 

point about the events of June 20th? 

I did. 

And could you briefly relate to the Court the 

history that you took from Mr. Bruce? 

Yes. He told me how he had left Riverview 

Psychiatric Center the end of April. He was not 

taking any medication because he didn't like the 

side effects. He realized that his condition was 

getting worse, although he was not conflicted 
136 


85437.071

The Role of the Patient Advocates: 

A Summary of the Medical Records of William Bruce 

By March 2006, William Bruce had a well documented history of dangerousness, 

paranoid thinking, and refusal to take medication. Despite this, and despite his family's oftvoiced fears for his and their safety and their pleas that he remain in an environment where he 

would be compelled to take the medications that were so effective in ameliorating his condition, 

the patient advocates from the Disability Rights Center ("DRC") persistently lobbied William's 

doctors to allow William to leave Riverview. William was discharged from Riverview 

Psychiatric Center on April 20, 2006. He murdered his mother on June 20, 2006. The following 

is a brief summary of events leading up to his discharge, with an emphasis on the role that the 

patient advocates played in this tragedy. 

On March 23, 2006, William met with his treatment team, including his psychiatrist Dr. 

Fliesser. The "patient advocates" Helen Bailey and Trish Callahan from the DRC were also 

present at this meeting. Members of William's family were excluded and were not present. Dr. 

Fliesser's notes indicate that during the meeting "repeatedly emphasized to the disability rights 

advocate my clinical opinion that the patient's paranoid psychosis is not likely to improve 

without pharmacotherapy" and "the patient continues to refuse pharmacotherapy." Fliesser's 

notes make clear that the patient advocates disregarded his cautions. The notes reveal that the 

advocates instead asked for clarification of specific treatment goals for him so he could be 

released from the hospital. Ms. Bailey, not a doctor herself, even asked if a second opinion from 

another psychiatrist could be obtained. (Tab 151: Note by Jeffrey M. Fliesser MD, dated 

3/23/06). 

Helen Bailey stated that she had reviewed the medical record (!) and saw no 

documentation to support William's having to remain at Riverview. (Tab 16: Progress Note 

from the Treatment team meeting, dated 3/23/06). Patient advocate Callahan suggested that 

William may actually be getting worse by remaining at Riverview. (Tab 16: Progress Note from 

the Treatment team meeting, dated 3/23/06). On March 27, 2006, Dr. Fliesser's notes again 

indicate that he "emphasized" to both William and William's "advocates" that William requires 

pharmacotherapy to treat these paranoid symptoms and be able to be safely discharged to the 

community and William continues to refuse medication. (Tab 19: Progress Note by Jeffrey M. 

Fliesser, MD, dated 3/27/06). His views mirrored that of the people who knew William best, his 

family. 

After Dr. Fliesser stopped seeing William on March 30, 2006, the patient advocates 

began to urge William's new psychiatrist, Dr. Filene, to discharge William. At a treatment team 

meeting on April 6, 2006, social worker Andy Davis and patient advocate Trish Callahan were 

present. During the meeting, the notes reveal that Callahan actually instructed William how to 

answer, as if she were his lawyer at a deposition or trial, and repeatedly interjected on his behalf, 

as Dr. Filene was attempting to examine him. William deferred to Callahan and was much less 

interactive than in a meeting with Dr. Filene on the previous day, when, notably, the patient 

l References to "Tab _" are to the medical records found behind the referenced tab in an accompanying notebook. 

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advocates were not present. Callahan redirected the discussion away from exploring William's 

history, mental status and treatment, and focused the discussion instead on attempting to define a 

date of discharge and her own assertions that William's well-being was being harmed by 

ongoing hospitalization. She stated the prospects of his summer employment would be impaired 

the longer he stays. The meeting had a tone of "legal antagonism" according to Dr. Filene's 

contemporaneous notes. (Tab 23: Progress Note by Daniel R. Filene, MD, dated 4/6/06). 

When Dr. Filene asked William about his activity level being increased so he could 

access the community he hesitated. Again according to Dr. Filene's contemporaneous notes: 

"Ms. Callahan then stated, 'They want to see that you can play nicely in the community. Just say 

ru: after which William Bruce stated 'Yes. '" The doctor asked William whether there was any 

risk he'd refuse to return to the hospital from a community trip; according to the medical records, 

"Ms. Callahan told him' Just say no,' after which William stated 'No.''' (Tab 23: Progress Note 

by Daniel R. Filene, MD, dated 4/6/06) 

When Dr. Filene asked William about speaking with outpatient providers, Ms. Callahan 

responded that there would be no benefit in obtaining their opinions and William declined 

consent. When Dr. Filene asked if he could speak with William's mother, Ms. Callahan 

responded that his parents are a negative influence in his life (!) and William declined consent. 

William said he would not undertake psychological testing with a Dr. Gregor. When Dr. Filene 

inquired about his misgivings, "Ms. Callahan responded 'He said no, he doesn't have to answer 

anything else.''' William was innately guarded about his mental state, and was "further urged in 

this direction by his advocate who urges him to avoid revealing personal information." "The 

opinions of those who know him best in the community [referring to William's family and 

others] are not available to me, again with the advocate's concurrence." (Tab 23: Progress Note 

by Daniel R. Filene, MD, dated 4/6/06) 

On April 11,2006, William told Dr. Filene that his advocates are stating "he is not ill, not 

a danger and should be released." (Tab 24: Progress Note by Daniel R. Filene, MD, dated 

4/11106). On April 20, 2006, Dr. Filene noted that "Mr. Bruce and Patient Advocates continue to 

push for his release" in advance of the expiration of his court commitment. The Client, social 

worker, and Advocate continued to reiterate that William had a secure discharge plan including 

housing with his friend Jesse. Dr. Filene then began discussing a plan of discharging William on 

April 24 but this date did not work for social worker Andy Davis for his own personal reasons, 

who requested it be moved to April 20. Dr. Filene agreed to the advancement. (Tab 26: 

Progress Note by Daniel R. Filene, MD, dated 4/20/06). 

After discussing this plan with William, Dr. Filene was informed that Jesse was out of 

state until early May but Andy Davis arranged for William to stay at a hotel by himself until 

Jesse returned. Dr. Filene noted that "he weighed the potential increased risk of social isolation 

while using a hotel, against the importance of promoting the patient's trust in the mental health 

system by not reversing my agreement to discharge." At the team meeting Dr. Filene discussed 

the plan with social worker Davis who was comfortable with it and indicated he was nearby and 

could check on William frequently. (Tab 26: Progress Note by Daniel R. Filene, MD, dated 

4/20/06). William was discharged on April 20, 2006 . 

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The patient advocates repeatedly encouraged Dr. Filene to discharge William. Even 

though Dr. FiJene's progress notes on April 6 and April II stated that Dr. Filene felt "Mr. Bruce 

presents an intermediate level of safety concern," the patient was discharged on April 20. (Tabs 

23 and 24: Progress notes by Daniel R. Filene, MD, dated 4/6/06 and 4/11106 2006). 

70501 Summary DOC ·3-
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85437.074

William Bruce: 

Chronology of His Diagnosis and Treatment 

2/06/06 - William Bruce is admitted to Riverview Psychiatric Center; initial nursing assessment 

states "poor impulse control", "delusions", "agitation", "noncompliance with meds", "isolative", 

"guarded", "assaultive." (Tab I· Initial Nursing Assessment signed by RN Cecelia Garrett, see 

page 10, pages 1·5 are missing from our folders) 

2/06/06 - "Pt has paranoid ideations wI delusional thought process. Pt is on an involuntary 90 

day court commitment." "Patient lacks ability to control impulses." "Patient is threatening and 

assaultive." (Tab 2 • Admission Note signed by RN Cecelia Garrett) 

2/10/2006 - "Due to recent violence associated with current hospitalization, Mr. Bruce continues 

to meet medical necessity criteria." He is refusing to take medication. "Observation in a secure 

setting is crucial at this time" for this patient who has a history of violent potential. 

"Schizoaffective disorder, bipolar-type, alcohol and polysubstance abuse (marijuana and 

cocaine)." No overt threatening behavior. (Tab 3· Progress Note signed by Jeffrey M. Fliesser, 

MD, the patient's psychiatrist) 

2/14/06 - "[D]angerous to others if discharged to a less restrictive setting at this time." William 

has a history of recent violence and "he continues to have some evidence of paranoid thinking on 

mental status examination." Not a management problem so far but his mental status examination 

notes show he has "ongoing paranoid thinking." William insisted people made things up about 

his history, including the treatment team at the hospital from which he was transferred to 

Riverview. This in conjunction with his recent history of violence against his father "continues 

to make him dangerous to others." He has no insight into his illness and refuses medication. 

(Tab 4 - Progress Note signed by Jeffrey M. Fliesser, MD) 

2/23/06 - "Due to ongoing paranoid symptoms, and the patient's recent history of violence 

towards his father, he is dangerous to others without additional observation, and active attempts 

to treat him." William suffers from paranoid schizophrenia and remains guarded, often hostile 

and has no insight into his mental illness. When Dr. Fliesser tried to supportively confront him 

with the symptoms he called him an "Asshole." "Although he has not had behavioral problems 

on the unit so far, he has a serious history of violence and ongoing paranoid symptoms and 

marked guardedness." (Tab 5 - Progress note by Jeffrey M. Fliesser, MD) 

3/01106 - William continues to have no insight into his illness, resists taking any medication, but 

is observed with paranoid symptoms and some threatening behavior at times. For example, he 

was observed whispering to another patient "What would happen ifI punched you in the head." 

While there have been no overt acts of aggression observed on the unit so far, these threatening 

statements "in the context of some paranoid symptoms and his recent history of violence prior to 

admission, make him dangerous to others without additional observation and treatment." (Tab 6 

- Progress Note by Jeffrey M. Fliesser, MD) 

3/07/06 - Dr. Fliesser "strongly encourages" William to consider taking medication to feel more 

comfortable around others and diminish his paranoid thinking. "It is my clinical opinion that 

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without such treatment, he would remain dangerous to others if released to the community 

without treatment." "Mr. Bruce continues to have paranoid symptoms evident, and is refusing 

pharmacotherapy at this time." He continues to be "markedly guarded." He denies having 

pointed a loaded AK47 at two of his friends when target practicing even though there is 

documentation this incident did occur. William misattributes hostile intentions to doctors, his 

parents and anyone who has reported he had symptoms of mental illness. This is consistent with 

paranoid schizophrenia. (Tab 7 - Progress Note by Jeffrey M. Fliesser, MD) 

3/13/06 - William was caught smoking in the bathroom today and he apologized. William is 

pleasant on approach. (Tab 8 - RN Note signed by RN Cecelia Garrett) 

3/14/06 - William said "he'd like to get out ofhere but somebody has it in for me." He was 

assured by a MHW that ifhe kept up his good behavior he would be able to leave soon. (Tab 9 -

MHW Note signed by MHW whose name appears to be Judy Ferris and a RN whose name is 

illegible) 

3/14/06 - "Due to ongoing paranoid symptoms, evident on recent mental status examinations 

coupled with the patient's poor insight into his mental illness and with a history of 

dangerousness in the context of his mental illness, the patient remains dangerous to others 

without treatment." William declined to speak to Fliesser on this day. Another patient told Dr. 

Fliesser that William made an obscene gesture towards him as Dr. Fliesser was talking with that 

patient. (Tab 10 - Progress report by Jeffrey M. Fliesser, MD) 

3117/06 - William is quiet and visible on the unit, and is sociable with select peers. He said that 

he has yet to get free time "because he refuses to take meds," and he says "There's a law that 

says I don't have to take meds." (Tab 11 - RN Note, appears to be signed by Valerie Files) 

3/18/06 - William continues to harass clients for cigarettes. William denies taking a cigarette 

but he was observed doing so by two MHWS and when approached to return the cigarette he 

said "whatever and gave the middle finger repeatedly." (Tab 12 - Progress Note, note type is 

labeled nursing but signature is illegible) 

3/19/06 Mood is okay but his "delusional material comes out." William said he is of Scottish 

descent and his great ancestors were royalty and he wants to be called' Wilhelm'. (Tab 13 - RN 

Note, signature illegible) 

3/20/06 - "Due to ongoing paranoid symptoms, history of dangerousness in the context of 

symptoms of his mental illness, the patient's lack of insight into his illness and unwillingness to 

take any medication treatment for it, he remains dangerous to others if released without 

additional treatment and stabilization from the hospital." William has ongoing paranoid 

symptoms of hostility, making obscene gestures, cursing at Fliesser and displaying hostility and 

other paranoid symptoms to the staff. Pharmacotherapy is crucial to ameliorate paranoid 

symptoms. William is "dangerous indeed for release to the community without 

pharmacotherapy and decrease in paranoid symptoms." (Tab 14 - Progress Report by Jeffrey M. 

Fliesser, MD, pages 1-2) 

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William hid silverware and was seen speaking to another patient who has a history of self injury 

and secreting dangerous items on the unit just before this missing silverware incident. William 

said he innocently placed them in his pocket and forget they were there. Dr. Fliesser was of the 

impression that William was attempting to conceal the utensils but not attempting to use them as 

a weapon. (Tab 14 - Progress Report by Jeffrey M. Fliesser. MD, pages 2-3) 

3/23/06 - William was seen today by Dr. Fliesser along with his advocate Helen Bailey and his 

disability rights advocate Trish, his community case manager, and the regular treatment team. 

Dr. William Nelson, the medical director, was also present. Fliesser's note states "I repeatedly 

emphasized to the disability rights advocate my clinical opinion that the patient's paranoid 

psychosis is not likely to improve without pharmacotherapy. Nonetheless, William continues to 

refuse phannacotherapy and, in my clinical opinion, at this time remains competent to give or 

refuse informed consent." (Tab 15 - Incidental Note by Jeffrey M. Fliesser, MD) 

William has an emergence of paranoid symptoms including hostility, cursing at staff, accusing 

staff of stealing from him, accusing Dr. Fliesser of being jealous of him and reportedly harassing 

clients for cigarettes. Advocates asked for explanation of his treatment program to secure his 

release. Ms. Bailey asked if a second opinion from another psychiatrist could be obtained. Dr. 

Nelson is considering this but pointed out the patient will get a second opinion because Dr. 

Fliesser is leaving and Dr. Daniel Filene will take over. (Tab 15 - Incidental Note by Jeffrey M. 

Fliesser, MD) 

3/23/06 - Helen Bailey verbalized concern that she reviewed the record and saw no 

documentation to support William having to remain at Riverview. Patient advocate Callahan 

suggested that William may actually be getting worse by remaining at Riverview. (Tab 16 -

Progress Note from the Treatment Team Meeting, note type is nursing, appears to be signed by 

Co[leen Cutler) 

3/24/06 - When asked ifhe would like lunch William stuck up his middle finger. William 

looked at a MHW and said "I've got your number." (Tab 17 - Progress Notes signed by MHWs, 

signatures are illegible) 

3/25/06 - William said "I'm just going to do my time here, until my commitment is up, not 

taking meds." He states he "only has a few more weeks before his discharge." (Tab 18 - RN 

Note, appears to be signed by Valerie Files) 

3/27/06 - Dr. Nelson examined William at Dr. Fliesser's request in order to "ensure continuity of 

care" when Dr. Daniel Filene takes over. William refused evaluation by Dr. Fliesser but agreed 

to speak with Dr. Nelson on an individual basis. According to Fliesser's progress note, the 

treatment team reports "that the patient has continued to exhibit paranoid and hostile behaviors," 

including sticking up his middle finger at a mental health worker and telling another staff 

member "I got your number." (Tab 19 - Progress Note by Jeffrey M. Fliesser, MD, page 1) 

Fliesser's progress note states that in light of ongoing paranoid symptoms, which include 

suspiciousness, guardedness and evasiveness on questioning, hostility towards the staff (as 

evidenced by making obscene gestures, telling the staff, for example, "I got your number"), and 

delusional beliefs that Dr. Fliesser and a number of other people are lying, "I believe he remains 

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dangerous if released to the community without pharmacological treatment of these paranoid 

symptoms." (Tab 19 - Progress Note by Jeffrey M. Fliesser, MD, page 2) 

Dr. Fliesser stated in his notes that he "emphasized" to both William and William's advocates 

that William requires pharmacotherapy to treat these paranoid symptoms and be able to be safely 

discharged to the community. William continues to refuse to take medication. William's 

worrisome violent history (pointing a loaded AK47 at two of his friends as well as a physical 

altercation with his father) in conjunction with paranoid symptoms, "makes him a serious risk to 

harm himself if released to the community." (Tab 19 - Progress Note by Jeffrey M. Fliesser, 

MD, page 2) 

3/30/06 - Psychologist notes that "William remains guarded and suspicious." She spoke to him 

about how suspiciousness/lack oftrust hinders self-disclosure and mentioned her understanding 

of his eagerness to leave and reluctance to disclose information he believes may interfere with 

getting out of the hospital. William said he viewed the therapist client relationship as predatorprey. (Tab 20 - Progress Note by psychologist, appears to be signed by Janie, last name 

illegible) 

3/30/06 - Dr. reviewed William's prior records from Acadia Hospital related to the patient's 

admission there on March 27, 2005 and summarizes certain sections in this incidental note. The 

Dr. noted that when he reviewed the records he saw "striking similarities in the patient's 

presentation then as well as the attending psychiatrist's great concern about the patient's 

dangerousness." Dr. said "1 am in clear concurrence" with the other psychiatrists who treated the 

patient at Acadia Hospital "in that the patient is presenting now with very similar symptoms, and 

I agree that he is at high risk of being released to the community ifhe does not receive 

pharmacotherapy to ameliorate his paranoid and other psychotic symptoms." (Apparent typo 

here Dr. must mean to say he is at high risk if released to the community) (Tab 21 - Incidental 

Note Signed by "William Nelson, MD for Jeffrey M. Fliesser, MD" ) 

Dr. Fliesser stops seeing William on March 30th 2006 

4/5/06 - William told his psychologist he is a distant relative of President Bush and the 

psychologist noted that when he mentions subjects typically kept concealed he becomes guarded 

about discussing the topic further. (Tab 22 - Progress Note by psychologist, appears to be signed 

by Janie, last name illegible) 

4/6/06 - Dr. Filene's notes begin. William's "case currently is in a high state of contention." 

William will not allow contact with his parents or others in the community who might know him 

well. William says he will decline appointments to see a psychiatrist in the community. While 

at Riverview, William has reportedly had no serious, overt acts of aggression but there have been 

a variety of instances which, taken together, may be worrisome. For example, instances 

documented in the record include frightening staffby putting his arm around them; attempting to 

bring contraband metal objects back to the unit; making threatening statements toward peers (on 

4/3 he was reported to have told a peer he would put a pillow over his face). (Tab 23 - Progress 

Note by Daniel R. Filene, MD, page I) 

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Dr. Filene's progress note mentions that Dr. Fliesser's notes indicate patient "has a serious but 

subtle, psychotic disorder, which he often effectively masks" and Fliesser made repeated 

notation that he believes William "poses a serious danger of violence to himself and others." Dr. 

Filene states that Dr. Nelson believed William has a "significant psychotic illness and may be at 

some risk for adverse event if discharged" but "he feels the risk is somewhat lower than Dr. 

Fliesser's assessment." Dr. Filene states that Dr. Gregor, unit psychologist, reports that William 

has "notable paranoid and disorganized features, but was uncertain whether these represented 

short-term dangerousness." Many of the nursing staff think he should be discharged. Review of 

past records in the chart shows assessment by two psychiatrists at Acadia both of whom felt that 

"Mr. B represented a serious, though subtle, danger if symptoms remain untreated." Disability 

Rights Center is assisting patient. (Tab 23 - Progress Note by Daniel R. Filene, MD, pages 1-2) 

At Treatment Team Meeting on 4/6 patient was joined by his ICM, Andy Davis and Patient 

Advocate, Trish Callahan. Callahan instructed William in the meeting and repeatedly interjected 

on behalf of him. William deferred to Callahan and was much less interactive than on the 

previous day. Callahan focused on attempting to define a date of discharge. She redirected the 

discussion away from exploring William's mental status and treatment. She stated the prospects 

of his summer employment would be impaired the longer he stays. Meeting had a tone of "legal 

antagonism." When Dr. Filene asked William about his activity level being increased so he 

could access the community he hesitated, "Ms. Callahan then stated, 'They want to see that you 

can play nicely in the community. Just say yes,' after which Mr. B stated 'Yes.'" The Dr. asked 

William whether there was any risk he'd refuse to return to the hospital from a community trip; 

"Ms. Callahan told him' Just say no,' after which Mr. B stated 'No.'" (Tab 23 - Progress Note 

by Daniel R. Filene, MD, pages 3-4) 

Dr. Filene asked William about speaking with outpatient providers, Ms. Callahan responded that 

there would be no benefit in obtaining their opinions and William declined consent. When Dr. 

Filene asked ifhe could speak with William's mother, Ms. Callahan responded that his parents 

are a negative influence in his life and William decline consent. William said he would not 

undertake psychological testing with Dr. Gregor. When the Dr. inquired about his misgivings, 

"Ms. Callahan responded 'He said no, he doesn't have to answer anything else.'" "William is 

innately guarded about his mental state, and is further urged in this direction by his advocate who 

urges him to avoid revealing personal information. The opinions of those who know him best in 

the community are not available to me, again with the advocate's concurrence." Dr. Filene said 

he believed patient "most likely does have a psychotic illness" and would benefit from 

medication but will not take it. (Tab 23 - Progress Note by Daniel R. Filene, MD, pages 3-4) 

Objective risk assessment elements: "Mr. B has psychotic thought patterns, which are not 

noticeably improved since admission and not currently treated with medication; Mr. B makes 

efforts to minimize these patterns and avoid their assessment/treatment; two hospitalizations in a 

year have been precipitated by reported violence or threatening behavior; a variety of incidents 

on the unit while not individually dramatic, suggest that Mr. B has underlying tendencies 

towards aggression and violation of societal norms." "Overall, as a best estimate, I currently feel 

Mr. Bruce represents an intermediate level of safety concern." (Tab 23 - Progress Note by 

Daniel R. Filene, MD, pages 4-5) 

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4/11/06 - Dr. Filene meets with William and says that he "continues to make a variety of 

grandiose, disorganized and likely delusional statements." For example, he states he is from a 

close-knit family, but he has over 200 relatives he's close to and then later he states he wants no 

contact with anyone in his family except possibly one uncle. (Tab 24 - Progress Note by Daniel 

R. Filene, MD, page I) 

William states his advocates are stating "he is not ill, not a danger and should be released." Dr. 

Filene notes that William feels these opinions have the same or more weight than that of mental 

health professionals. William continues to refuse medication. Dr. Filene informed William that 

the plan of his previous psychiatrist was, ifhis mental status remained the same, to reinitiate 

Emergency Involuntary proceedings at the end of his commitment, but that Filene would not do 

this assuming William's behavior did not worsen. (Tab 24 - Progress Note by Daniel R. Filene, 

MD, page 2) 

Filene observed that William had no insight that he might have a mental illness. During the 

interview William appeared distracted by internal stimuli. Filene noted that Dr. Fliesser felt the 

patient was a serious risk, but this opinion was not held by most other staff. "Overall, as a best 

estimate, I currently feel Mr. Bruce presents an intermediate level of safety concern, and, given 

another week without incident, slightly lower than my initial assessment." (Tab 24 - Progress 

Note by Daniel R. Filene. MD, pages 2-3) 

4/20/06 - "No recent threats/declined medication." "Since last review; in your clinical opinion 

does this patient pose any danger to self/or others? No." He will be discharged on 4120 to a 

motel in Bingham. coverage will be with Andy Davis and will have a referral to Capitol 

Community Clinic for psych coverage. (Tab 25 - Service Plan Review signed by Treatment 

Team Members which include the client William Bruce, continuity of care manager whose name 

appears to be Kathryn (last name illegible), peer specialist whose name appears to be Heidi 

Smith, RN whose name is illegible, psychiatrist whose name is Daniel Filene, recreation 

therapist whose name appears to be Dan (last name illegible), Community support worker whose 

name is illegible, Treatment team coordinator whose name appears to be Larry Hayward, family 

member whose name is illegible and the patient advocate Patricia Callahan added a place for her 

name and signed her name) 

4/20/06 Meets criteria for acute hospitalization. "In ongoing review of Mr. Bruce's case with 

other staff, there were no particular concerns about his immediate safety." William and Patient 

Advocates continue to push for his release in advance of the expiration of his court commitment. 

Client, ICM, social worker, and Advocate continued to reiterate that patient had a secure 

discharge plan including housing with his friend Jesse. Dr. Filene said that "Although I 

continued to feel that Mr. B would benefit from additional treatment, specifically antipsychotic 

medication, it had become very clear to me that he would not accept this recommendation." 

"Mr. B appeared very unlikely to meet criteria for re-initiation of Emergency Involuntary status 

at the end of his court commitment on 4/30. Also it seemed extremely unlikely that any material 

change in his mental status or social situation would occur in the remaining time on his court 

commitment." Dr. Filene discusses plan of discharging patient on 4/24 but this date did not work 

for ICM Andy Davis who requested it be moved to 4/20 and Filene agreed to the advancement. 

(Tab 26 - Progress Note by Daniel R. Filene, MD) 

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After discussing this plan with William, Filene was infonned Jesse was out of state until early 

May but Andy Davis arranged for William to stay at a hotel. Filene noted that "he weighed the 

potential increased risk of social isolation while using a hotel, against the importance of 

promoting the patient's trust in the mental health system by not reversing my agreement to 

discharge." At the team meeting Dr. Filene discussed the plan with ICM Davis who was 

comfortable with it and indicated he was nearby and could check on William frequently. Dr. 

Filene also discussed the situation with Dr. Nelson who felt it was reasonable under the 

circumstances to continue with discharge. Plan is for social work to schedule follow up with 

psychiatrist at Capitol Community Clinic. (Tab 26 - Progress Note by Daniel R. Filene, MD) 

Amy Bruce killed on 6/20/06 

7131/06 - Transferred from the Somerset County Jail today for a Stage 3 evaluation. William is 

charged with his mother's murder. A significant portion of this Psychiatric admission 

assessment "is gleaned from his January 2006 Acadia hospital record and the subsequent transfer 

to RPC in February 2006." (Tab 27 - Psychiatric Admission Assessment by psychiatrist Carolyn 

Criss, page 1) 

The admission assessment discusses William's past psychiatric history (left a suicide note as a 

late adolescent; last summer shot 30 rounds from an AK47 into the trees and then pointed it at 

his two friends and asked them if they knew anything about boys being sexually molested; 

admitted to Acadia hospital last January after an altercation with his father; had his mother in a 

judo type headlock to demonstrate he could break her neck, etc.) and discusses his past 

problems/diagnoses. (Tab 27 - Psychiatric Admission Assessment by psychiatrist Carolyn Criss, 

page I) 

William has delusions about his role as a CIA operative and is focused on the world problems. 

He mentioned it was not a coincidence his mother's death was the day before the current Israel 

war with Lebanon (actually those dates are 3 wks apart). Lacks capacity for insight and 

judgment is impaired. Appears to be able to understand risks and benefits of treatment. Criteria 

for discharge is no evidence of danger to self or others and demonstrated ability to care for self 

sufficient to meet daily basic needs, estimated time 30-60 days. "Medical necessity for Hospital 

Admission: Meets on basis of significant risk to seriously hann others." (Tab 27 - Psychiatric 

Admission Assessment by psychiatrist Carolyn Criss, pages 2-3) 

8/07/06 - Upon admission the individual is not a danger to selfbut is a danger to others, meets 

medical necessity criteria for inpatient hospitalization. (Tab 28 - Individual Treatment and 

Discharge Plan signed by William Bruce, Carolyn Criss, continuity of care manager whose name 

appears to be Kate Leonard, nurses whose names appear to be Kim (last name illegible) and 

Patrick (last name illegible), community support worker whose name is illegible, peer support 

specialist whose name appears to be Eric (last name illegible), and a patient advocate whose 

name is illegible) 

8/07/06 - William spoke about "delusions about being an undercover operative and expressing 

his desire to 'defect' to Russia. He believes his desire to defect will take precedence over any 

legal issues he may be facing at present." Staff observed him scanning the fence, there are real 

concerns about elopement risk. Psychological testing is needed to examine his symptoms 

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objectively. He is refusing scheduled medications and maintains good control on the ward so he 

does not meet criteria for a psychiatric emergency. (Tab 29 - Progress note by Dr. Criss) 

8/17/06 - "He denies psychotic symptoms but is easily distracted." He reports joining the army 

but could not give the rank he achieved and he said his father was in the military and his father is 

like "Joseph Stalin," which Dr. Criss found interesting given his motivation to defect to Russia 

and his report that his relationship with his father is not repairable. Psychological testing is 

needed and he continues to be considered an elopement risk and is restricted to the ward. He had 

his first session with State Forensics Service this week and another scheduled for next week. 

(Tab 30 - Progress note by Dr. Criss) 

8/22/06 - William is discharged back to Somerset County Jail. He states that his mother was 

"assassinated" due to her connection with Hamas which started the current IsraelilLebanese 

conflict. He was seen by the state forensic service and the psychiatric center was advised he was 

to be released to the Somerset County Jail. "He declined medications and treatment for the 

duration of his admission and never met criteria for a psychiatric emergency." (Tab 31 -

Inpatient Discharge Summary by Dr. Criss) 

10/4/06 - Court determined defendant is currently incompetent to stand trial and committed 

William to be placed in a mental institution. (Tab 32 Order and Finding ofIncompetence) 

10/11/06 - 25 year old William was transferred to Riverview from Waldo County Jail after he 

was found to be incompetent to stand trial. "He is charged with the murder of his mother last 

June and was at Riverview this past August for a Stage III evaluation to determine his 

competency to stand trial. At that time he did not want treatment and did not believe he had a 

psychiatric illness. His focus was primarily invested in delusions that he is involved in 

espionage as an agent for Russia and voicing his plan to defect. He returns today complaining of 

feeling depressed for the past week and is willing to discuss medications. He is resolved to being 

here for a year." Medical Necessity for Hospital Admission: "Meets on basis of psychotic 

delusions which make him a significant risk to seriously harm others." (Tab 33 - Psychiatric 

Admission Assessment by Dr. Criss) 

10/13/06 - "He has delusions of working with the KGB and is planning to ask for asylum from 

the Russian Embassy." (Tab 34 - Progress note by Dr. Criss) 

70501 Chronology (2).doc -8-
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In Re: WUti~m H. Bruee 

UK l006~lJ6 
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Given the circumstances of this matter and the 

Court this court believes that a for a of 90 This 

""in allow J\1r. Bruce both the such reports so as to allow tbis 

court to consider the entry 
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A Death in the Family - WSJ.com Page I of6 

See a s.ample repnnt In PDF format Order a rspnr>l otlhtsarhcle now 

TIlE WAll STREET JOUR'i.Y.. 

LEADER (U.S.) August 1 G. 2008 

A Death in the Family Aided by adL'ocates for the mentally ill, l1lilliam Bruce left the hospital-- only to kill his mother 

By ELIZABETH BERNSTEIN and NATHAN KOPPEL 

On June 20, 2006, William Bruce approached his mother as she worked at her desk at home and 

struck killing blows to her head with a hatchet. 

Two months earlier, William, a 24-year-old schizophrenic, had been released from Riverview 

Psychiatric Center in Augusta, Maine, against the recommendations of his doctors. "Very dangerous 

indeed for release to the community," wrote one in William's record. 

But the doctor's notes also show that William's release 

was backed by government-funded patient advocates. 

According to medical records, the advocates -- none of 

them physicians -- appear to have fought for his right to 

refuse treatment, to have coached him on how to answer 

doctors' questions and to have resisted the medical staffs 

efforts to contact his parents. As one doctor wrote, 

William told him his advocates believed he is "not a 

danger, and should be released." 

William's father, Joe Bruce, obtained his son's medical 

records from Riverview eight months after the killing. "I 

read through the records and I just remember crying all 

the way through," Joe Bruce says. "My God, these people 

knew exactly what they were sending home to us." 

Helen Bailey, one of William's advocates, declined to discuss the details of his case but says the 

handling of it was consistent with her professional duties. "My job is to get the patient's voice into 

the mix where decisions are made," says Ms. Bailey, an attoruey with Maine's Disability Rights 

Center in Augusta. "No matter how psychotic, that voice is still worthy of being heard. I have not 

had the person who is so out of it that they can't communicate what they want." She added that the 

records reflect the doctors' perception of what happened. 

The story of William Bruce -- based on medical records made available to The Wall Street Journal--

as well as interviews with relatives, doctors, advocates and hospital administrators brings into 

sharp focus the impact of a little-known government-funded advocacy program for psychiatric 

patients. 

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A Death in the Family - WSJ.com 

Attempt to Curb Abuses 

More 

A Father's Call for Help: Excerpts from 

911 call. 

AmyBruce.org 

Page 2 of6 

Congress created the national Protection and Advocacy 

for Individuals with Mental Illness program, or PAlMI, 

in 1986 to curb abuse and neglect of the mentally ill, 

primarily in institutions. In the 1960s and 1970S, many 

abuses were uncovered at hospitals, where patients were 

physically restrained, neglected or overmedicated. 

The PAlMI program, operated by the Substance Abuse 

and Mental Health Services Administration with a 2008 

budget of $34.8 million a year, funds protection-andadvocacy agencies in each state. Typically nonprofits, 

these groups sometimes receive supplemental funding 

from states. According to a 2007 SAMHSA report, the 

agencies served 19,000 people in 2006. 

Some doctors, hospital administrators and mental-health veterans argue that advocates are 

endangering the mentally ill and the public by too often fighting for patients' right to refuse 

treatment. Many advocates "have a strong bias," says Robert Liberman, a director of a psychiatric 

rehabilitation program at the University of California, Los Angeles. 

"I don't know if they are doing people a service when they assert the right of mentally-ill individuals 

to remain psychotic," says Ron Honberg, director of policy and legal affairs for the National Alliance 

on Mental Illness, an education, support and advocacy group. 

Proponents of patient advocates say they're essential to protecting the rights of the mentally ill. The 

National Disability Rights Network, which provides lobbying and other services for the patientadvocacy system, says advocates playa critical oversight role. 

They cite the 2006 sentencing of the owners of a Kansas 

treatment facility on charges that they subjected patients to forced labor and involuntary servitude, 

and a class-action lawsuit alleging that female patients of the Lincoln Regional Center in Nebraska 

were raped and assaulted by a male staff member. The latter case was settled in 2007 with the 

hospital, which denied liability, agreeing to more thoroughly investigate assault complaints. 

The mentally ill are "very ,,,Inerable," says Curt Decker, executive director of the National 

Disability Rights Network. "There needs to be an external, independent, legally based advocacy 

system to make sure they are being treated fairly, equitably and safely." 

John Morrow, senior public health advisor at SAMHSA, declined to discuss the Bruce case. But he 

says advocates serve a very important function, and that the organization has resolved thousands of 

cases of abuse and neglect. 

In recent years, there has been a wave of legislative efforts, many inspired by violent crimes, to 

make it easier to mandate treatment for the mentally ill. Advocates have blunted those efforts in 

California, New Mexico and Michigan. 

In Michigan, advocates successfully pushed for limits to a 200slaw -- proposed after a 

schizophrenic killed a young man -- mandating outpatient treatment. "They have a left-wing, 

individual-rights-at-all-costs agenda," says Virg Bernero, mayor of Lansing, Mich., who helped pass 

the law when he was a state legislator. 

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A Death in the Family - WSJ.com Page 3 of6 

"Our legal mandate is to protect the rights of individuals," says Elmer Cerano, executive director of 

Michigan's P AIM! chapter. But, he says, "rights are limited when it comes to safety." 

Despite advocates' objections, Joe Bruce -- with the help of his pro-bono attorney, Robert Owen of 

Fulbright & Jaworski LLP in New York -- successfully lobbied the Maine legislature to pass three 

bills. One gives mental-health professionals greater leeway to disclose patient information to those 

who may be affected by that person's conduct. Another makes it easier to medicate involuntarily 

committed patients. 

William Bruce, who kHled his mother in 2006 

after he was released from Riverview 

Psychiatric Center In Augusta, Maine. He was 

found not criminally responSible by reason of 

insanity for the crime and was recommitted 

indefinitely. He takes classes online through 

Colorado Technical University 

William Bruce grew up in Caratunk, Maine, a picturesque 

town of about 110 residents nestled in the state's northern 

hills. His father, a rugged, talkative man, worked as a 

senior technician for the Maine Department of 

Transportation. His mother, Amy, served as the town's 

treasurer. The oldest of three boys, William grew up in a 

lOo-year-old farmhouse that sits on the banks of the 

winding, rock-strewn Pleasant Pond Stream. 

Even when Willy -- as he was known as a boy -- was 

young, "there was just something different about him," 

his father says. Although cute and energetic, William was 

hyperactive and deeply self-centered, his father says. And 

he could tum suddenly violent: When he was four, he 

pushed his younger brother down the stairs. At five, he 

broke the same brother's leg, his father says. 

As an adolescent, William was handsome, popular with girls and deeply troubled, attempting 

suicide at 14. He would sometimes see therapists, but would quit and stop taking any prescribed 

medication, Joe says. 

William's behavior particularly pained his mother. Tanned and athletic, Amy loved kids, often 

hugging her own and opening her home to neighborhood children. But Joe says she was seldom 

able to emotionally connect with her eldest son, and repeatedly blamed herself for his problems. 

After dropping out of high school, getting his equivalency degree and serving in the Army, William 

bounced among low-level jobs and had a few minor brushes with the law. On Christmas Eve, 2003, 

Joe says William had his first psychotic episode in a Target store, telling his father that the security 

cameras were monitoring him. 

But he refused to seek treatment, and his family couldn't insist. Maine, like many states, requires 

that the mentally ill pose a substantial risk of harm to themselves or others, based on recent 

evidence, to be involuntarily committed. 

In March 2005, after William threatened two men with a loaded AK-47 assault rifle -- his father is a 

licensed gun dealer -- William went to a psychiatric facility in Bangor. He was eventually released 

but stopped taking his medicine. 

William deteriorated. Sometimes he walked into neighbors' homes unannounced. Once he put his 

mother in a headlock. In January 2006, William punched his father in the face, screaming, "You 

have disobeyed direct orders from a superior officer in the CIA." He was sent on Feb. 6, to 

Riverview, an extended-care psychiatric facility. 

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A Death in the Family - WSJ.com Page 40f6 

~n Awful, Awful Feeling' 

"We were certain he would be released," Joe Bruce says. Waiting for that day "was an awful, awful 

feeling." 

A few weeks after William Bruce's admission, psychiatrist Jeffrey Fliesser wrote that William was 

hostile, paranoid and "dangerous to others without additional observation and active attempts to 

treat him," an opinion he reiterated over the next five weeks. The doctor also wrote that he urged 

William, now diagnosed with paranoid schizophrenia, to take medication, but William refused. Dr. 

F1iesser declined to comment about the case for this story. 

William began working with advocates employed by the Maine Disability Rights Center, which 

receives funding from the federal P AIMI program as well as state and private sources. 

According to a nurse's treatment record dated March 23, Ms. Bailey, the advocate, told Riverview 

administrators she saw no documentation showing that William should remain hospitalized. Trish 

Callahan, another advocate, suggested that William "may actually be getting worse by remaining 

here," the nurse's record says. 

"I repeatedly explained to the patient, his advocates and other team members, his paranoid 

psychosis will not likely improve without medication therapy," Dr. Fliesser wrote in his notes. Ms. 

Bailey says she gives legal opinions, not clinical ones, and notes that her job is to represent the 

client's wishes. 

By the beginning of April, William Bruce's case was "in a high state of contention," wrote Daniel 

Filene, a psychiatrist who had taken over the case. On April 6, Trish Callahan, another advocate, 

attended a meeting with William's treatment team. She stressed that William should be discharged 

and that his summer job prospects were being harmed by his continued hospitalization, Dr. Filene's 

notes say. 

According to these notes, Dr. Filene suggested to William that he take trips outside the hospital. 

When William voiced reluctance to venture out, Ms. Callahan told William, "They want to see that 

you can play nicely in the community. Just say 'Yes.''' He did. Dr. Filene asked William if there was 

a risk he would refuse to return to the hospital from a community trip. "Ms. Callahan told him, 'Just 

say no,' and Mr. B. replied, 'No,' "the doctor wrote in his notes. 

Dr. Filene wrote that he asked William for permission to speak to his mother and his previous 

mental-health providers. Ms. Callahan said there would be no benefit and that William's parents 

were "a negative force in his life." William refused to give consent, Dr. Filene's notes say. On April 

11, Dr. Filene wrote that William said his advocates were telling him that he is "not a danger and 

should be released." 

Ms. Callahan didn't respond to requests seeking comment. Dr. Filene declined to comment about 

the case for this story. 

"I think the advocates overstepped their bounds," says Riverview Superintendent David Proffitt. 

William "was relying on the people whose purpose it was to ensure his civil rights were being 

exercised, and unfortunately that interfered with his other right, which was to get medical care." 

Ms. Bailey, Ms. Callahan's superior, doesn't believe the advocates prevented William from getting 

medical care. "There is nothing in the William Bruce case that is contrary to the way we do 

business," she says, adding that it is the hospital's responsibility to try to have a patient committed 

or forcibly medicated. 

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A Death in the Family - WSJ.com Page 5 of6 

William Gets Released 

More generally, Ms. Bailey says it isn't a given that families of the mentally ill should be involved in 

decisions involving their care. "There are some God damn nasty families out there," she says. 

SAMHSA declined to comment on the case, as did the Maine Department of Health & Human 

Services. 

In the end, Dr. Filene wrote that while he recommended William stay at Riverview, William 

appeared very unlikely to meet Maine's legal criteria for further involuntary hospitalization beyond 

his court-ordered commitment term, which expired at the end of April. On April 20, 2006, William 

was discharged. 

William was soon back home. He hid steak and hutcher knives in his hedroom and spent hours 

pacing in the driveway, giggling and babbling unintelligibly to himself. Joe began calling to check 

on his wife several times a day. "It was the worst we'd ever seen him," he says. 

On June 20, two months after his son's release, Joe Bruce returned home from his office to find his 

wife's battered, bloodied body. William was gone. 

"My son has killed my wife," Joe told the 911 dispatcher, later adding that he was arming himself in 

self-defense. 

According to the medica! examiner's report, Amy died of multiple blunt-force trauma and chop 

injuries to her head. She was 47 years old. 

Police arrested William Bruce at his grandparents' house and later charged him with killing his 

mother. He told a psychologist that the Pope told him to kill his mother because she was involved 

with a! Qaeda and Saddam Hussein. Joe Bruce became William's legal guardian and gained access 

to his medical records. 

When police returned Amy Bruce's purse to Joe, he found an unsent letter she had written to her 

eldest son. 

'Tve always had this horrible feeling that I've let you down in some way," she wrote. "The only wish 

I have is that someday we can look each other straight in the eyes and say I'm sorry and I love you 

more than life itself." She added: "I will not give up on you ever." 

In March 2007, William was found not criminally responsible by reason of insanity and was 

committed to Riverview again, this time indefinitely. At the end of 2007, faced with the possibility 

of being restrained and medicated against his will, William agreed to take Abilify, an antipsychotic 

drug. Within weeks, his mental status improved. 

'J Blame Myself 

William Bruce, now 26, is strikingly handsome, his dark hair slicked back. Sitting in a Riverview 

conference room on July 23, he spoke courteously but deliberately. It was the first time he has been 

interviewed about his case. 

"I blame the illness, and I blame myself," William said of his mother's death. "The guilt is ... ," he 

paused, struggling to find a word" ... tough." 

William said the first time he came to Riverview, he refused to believe he was mentally ill and 

approached the advocates because he wanted out. 

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A Death in the Family - WSJ.com Page 60f6 

"They helped me immensely with getting out of the hospital, so I was very happy," he said. He later 

added, "The advocates didn't protect me from myself, unfortunately." 

These days, William is taking criminal-justice classes online through Colorado Technical University. 

He points proudly to his 3.94 grade-point average and says he hopes to attend law school to learn 

more about mental-health laws. William and his father talk on the phone almost every day. "He 

stood by me the whole time despite the horrible tragedy ... despite what I did," William said. "I am 

the man I am today because of my dad." 

While William believes patients deserve some protection, he said he understands his father's fight 

to strengthen commitment and treatment laws. That fight took another tum last month, when Ms. 

Bailey and another attorney filed a lawsuit that could undermine portions of a law Joe supported. 

The suit, filed in U.S. District Court in Maine, is directed at the law which makes it easier for 

hospitals to compel patients to take medication. 

"There are times when people should be committed," William said. "Institutions can really help. 

Medicine can help." 

"None ofthis would have happened ifI had been medicated." 

Write to Elizabeth Bernstein at elizabeth.bernstein@wsj.com and Nathan Koppel at 

nathan.koppel@wsj.c01l1 

Copyright 2012 Dow Jones & Company, Inc< All Rights Reserved 

This copy is for your personal, non-commercial use only. Distribution and use of this material are governed by our Subscriber Agreement and by 

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wwwdjrepnnts com 

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NATIONAL 

DISABILITY RIGHTS 

SUMMARY IN RESPONSE TO WSJ ARTICLE 

ORe staff attended a treatment and discharge planning meeting for William Bruce on 

March 23, 2006. As of that date William Bruce already had been a patient at RPC for 

more than 6 weeks. Throughout that period he had declined medication and the 

hospital had taken no action to initiate forced medication procedures. 

The treating doctor entered a note on March 23 stating that William Bruce "remains 

competent to give or refuse informed consent." 

A pre-condition for the non-emergency involuntary administration of medication under 

the Maine regulations as they applied at that time was that an individual must be found 

to lack capacity to give informed consent. Lacking capacity to give informed consent 

remains a requirement in Maine law even now. 

As of March 23, William Bruce was within a few days time when a petition for 

recommitment would need to be filed. Under Maine Law at the time, the hospital was 

required to file an application for recommitment 30 days prior to expiration of the then 

current commitment. 

A ORe attorney reviewed the documentation and expressed concern at a team meeting 

that the documentary evidence in the record would not support the legal standard for 

Mr. Bruce's recommitment. ORe staff also asked if the hospital would be amenable to 

obtaining an independent evaluation. ORe believes this is an appropriate request when 

a patient either is not engaging in or is not responding to the treatment the hospital is 

offering. 

When a hospital has taken no action to recommit, a patient may leave at the end of a 

commitment with no plans for community services. Because of this, ORe consistently 

advocates with hospital social workers to assure adequate discharge planning. This 

includes issues such as housing, employment, income, psychological and psychiatric 

services, case management and other supports. ORe also provides information 

regarding services available in the community directly to the patient. 

In early April, a new treating physician was aSSigned to Mr. Bruce. The new treating 

psychiatrist assessed Mr. Bruce as "not likely to meet criteria for re-initiation of 

emergency involuntary status" and arranged for discharge to occur. 
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85437.091

The decision to apply for recommitment is a hospital decision. The hospital took no 

action to recommit Mr. Bruce. The hospital's Medical Director was actively involved with 

Mr. Bruce's care and could have directed that an application be initiated if he felt it was 

needed. 

When Mr. Bruce was discharged on April 20, 2006, the doctor developed a plan which 

included an intake appointment with a therapist the following week and direction to the 

social work department to schedule a follow-up appointment with a psychiatrist at the 

clinic located in the hospital. Mr. Bruce had been encouraged to attend even though he 

was not taking medication. 

Mr. Bruce also had an Intensive Case Manager (ICM) whom he had met with while still 

a patient at RPC, and who had been in contact with the hospital social worker and 

psychiatrist. An ICM is a state employee charged with responsibility for, among several 

other responsibilities, assessing client needs, arranging for and monitoring delivery of 

services and for ensuring the delivery of necessary crisis intervention services. 

OTHER ACTIVITY: 

Helen Bailey participated, along with William Bruce's father, on a "think tank" organized 

by NAMI ME to come up with strategies for addressing barriers to access to mental 

health services. Along with NAMI and provider representatives, Helen Bailey actively 

supported recommending increased development of low-barrier services, such as peer 

run social clubs, targeted to engaging individuals otherwise not engaged with mental 

health services. Helen Bailey also supported expansion of the "Portland Identification 

and Early Referral Program (PIER)" at Maine Medical Center to other areas of the state. 

When the state experienced serious budget shortfalls, this group disbanded. 

DRC had opposed enactment of the Progressive Treatment Program (a type of 

outpatient treatment program). Helen Bailey sat on a committee charged with making 

recommendations to the legislature on the issue of outpatient commitment. Members of 

the group recommended amending the inpatient commitment law by shortening the time 

frames between an emergency admission and a court commitment so that should 

involuntary medication procedures need to be initiated, they could be resorted to 

sooner. DRC supported this amendment. 

DRC participated on the committee to consider jail diversion and development of a 

mental health court. A mental health court was developed for the Kennebec County 

area following the recommendations of this committee. 

DRC did oppose LD 1033, a bill designed to amend provisions governing involuntary 

administration of medications. Helen Bailey participated with other interested 

individuals to consider amendments to the bill, and proposed and drafted several 

options that combined early access to procedures along with due process protections. 

2 
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85437.092

ORe sat on a committee to examine the needs of individuals in nursing homes and 

worked with other interested individuals to amend the preadmission screening and 

resident review process to better assure that the mental health needs of such 

individuals were being properly assessed. 

ORe worked with departmental staff and legislators to develop final language of a bill 

that created a forensic review panel to review deaths and other incidents involving 

individuals with mental illness. It addresses instances where individuals with mental 

illness are victims or the individuals charged with the crimes. 

ORe supported amendments to the commitment statute that revised that portion of the 

law that mandated dismissal of a commitment application if the two independent 

examiners found that an individual did not meet commitment standards, and permitted a 

hospital to proceed if it disagreed with this assessment. In connection with this bill, 

ORe recommended that the time within which a hospital need apply for recommitment 

be reduced from 30 days to 21 days in light of the fact that commitments can be as 

short as 30 to 45 days. 

Helen Bailey has been counsel for the plaintiffs in the case now captioned Bates v. 

Department of Health and Humans Services, since the case was first initiated in 1989. 

In accordance with the terms of the settlement agreement in this case, the state has 

developed significant resources to address the housing, vocational, treatment and other 

needs of individuals with mental illness. 

3 
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85437.093

NATIONAL 

DISABIUTY RIGHTS 

About Bruce Case - If you receive media queries on this topic, we want you have talking 

points about the case. If you don't feel comfortable, please forward any media calls to 

Curt Decker at NDRN or Kim Moody at the Disability Rights Center of Maine. 

• Mrs. Bruce's death was a terrible tragedy. 

• The WSJ article suggested that the Disability Rights Center (DRC) of Maine caused Mr. 

Bruce's release. However, because the hospital had taken no action to legally recommit 

him, he was due to be discharged anyway. 

• DRC reviewed the medical record and alerted the facility that it appeared they did not 

have adequate legal documentation to hold Mr. Bruce beyond his already scheduled 

discharge date. 

• When a psychiatric facility takes no such action to recommit, or when there does not 

seem to be sufficient evidence to support recommitment, as the DRC pointed out to the 

facility in this case, DRC advocates with hospital social work staff to develop and 

implement a quality discharge plan including housing, employment, case management, 

counseling and other support services. 

• Since its inception in 1986, the DRC's PAlMI program has worked hand-in-hand with the 

State Department of Health and Human Services, the Maine Legislature, provider & 

consumer organizations and the Maine chapter of the National Alliance on Mental Illness 

(NAMI) to enhance and improve community supports and services for people with 

mental illnesses. 

• Over the past five years, the program has provided direct representation to 1,791 

people, among them were 360 cases involving abuse and 127 relating to neglect. The 

program has provided training and group advocacy to countless others. 

About PAlMI I Advocacy Work 

• Founded in 1986, the Protection & Advocacy for Individuals with Mental Illness (PAlMI) 

program has been a very successful program both in Maine and throughout the United 

States. In 2007 alone the program closed 16,000 cases, of which 4,200 were related to 

abuse, 3,300 to neglect, and 8,500 to a violation of individual rights. 

• PAlMI uses a broad range of strategies to resolve issues including short-term technical 

assistance, investigations of incidents and administrative remedies. Less than 3 percent 

of cases result in legal action being taken. 

• The Program Assessment Rating Tool (PART) program provides real data on the impact 

of the program. The HHS Office of Inspector General report states that P&A advocacy 

efforts have had a major impact on how states and facilities protect the rights of persons 

with disabilities. 
159 


85437.094

Dear Mr. 5ruce, 

12/16/06 

Gardiner, ME.. 

J am writing to 'you as a stranger, I know, but J have 

followed the traged'y of 'your son's illness and 

subse'iuent death of 'your wife for man'y weeks, 

thru the media. Flease accept m'y deepest s'ympath'y 

for what 'you are enduring. 

It's not as if I am totall'y unaware of tbe mechanics of 

Riverview. After working there as a nurse for 22 'yrs 

(and loving the work J did with the patients) I was 

exposed to a new group of administrators, who were 

chosen to expedite closure of AMHI and to build a 

small hospital (and hopefull'y release the state from 

the Consent Decree). 

Therefd~e, th·~ Kecover'y Model was introduced, 

allowing pts to make their own treatment declsionseven when this included med refusal. 
160 


85437.095

Those of us who had worked with brain diseased 

patients for gears, knew, that their were times when a 

patient's decision to opt out of medication therap9 

could be the re~ult of pS9chotic thinking, and that 

decision had to be over ridden b9 dearer thinking 

caretakers. Generall9' we had seen med compliant 

patients, whose s9mptoms would remit 

5ECAUSE of the medication. We all believed 

the analogy of mental illness being like diabetestreatable with positive results, IF MED 

COMFLIANCE OCCURReD. 5ut, 

90ung people are often in denial and the meds are 

far less than perfect, and, sometimes, caused some 

nast9 side effects, so doctors alwa9s tried to 

minimize the dosage against resumption of 

s'ymptoms. 5ut, between the administrators and 

advocatC4 a . ~.Recover'y" theor9 became the rule, 

encouragIng patients to make their own treatment 

decisions. 
161 


85437.096

r erhaps this is wh'y there is not one permanent staff 

ph'ysician @ Riverview, and "rent-a-docs" provide 

t~ein-patient care. 1. 

. . . 

M~m'yof us have left Riverview -after 'years of hard, 

but fulfilling work~because it has all become more 

p~litical than ·~Ii~ical. An'yone who loves the mentall'y 

ill, and understands their struggles and the pain, 

which the'y and their families endure, have not been 

able to work in a s'ystems which NO longer focuses 

on the best interest of the patient. 

50, Mr. I)ruce, I hope 'you procee.d with 'your 

litigation against the state, because 'yC?ur losses 

didn't happen for reasons other than 'yourfamil'y's 

misfortune to become involved with the mental health 

s'ystem, when politics (now) override sound medical 

decisions. 

With sorrow for 'your losses, 
162 


85437.097

From: William H. Bruce II 

Riverview Psychiatric Center 

250 Arsenal St. 

Augusta, Me 04330 

To: Members of Health and Human Services Committee, Sen. Joseph C. Brannigan, Sen. Lisa T. 

Marrache, Sen. Peter Mills, Rep. Anne C. Perry, Rep. Patricia Jones, Rep. Mark Eves, Rep. 

Matthew J. Peterson, Rep. Linda F. Sanborn, Rep. Peter C. Stuckey, Rep. Sarah O. Lewin, Rep. 

James J. Campbell, Sr., Rep. Henry L. Joy, Rep. Meredith N. Strang Burgess, Rep. Donald O. 

Soctomah 

April 27, 2009 

Dear Committee, 

I'm writing you in support ofLD1360. My name is William Bruce and I'm a patient at 

Riverview. I have been committed here for almost three years. I was committed because on June 20th of 

2006 I killed my mother. I have been living in sorrow since. 

Life has been very difficult for me at times but with the hospitals help and medication 1 get by.l 

would like to talk about the importance of medication in my life. Before the crime happened I was 

hospitalized but I refused medication. If! had been on medication and in an outpatient treatment program 

I would not be writing you this letter today. I struggle with this on a daily basis. At the time everything 

seemed clear to me. I was a clandestine operative and I believed my mother was an Al Qaeda operative 

and I was being ordered to kill her. I did not realize how distorted my mind was and how much the 

delusions had taken over. My dad tells me everyone could see there was something wrong with me but I 

couldn't. This is when I should have been treated. 
163 


85437.098

After I arrived back at the hospital I was still refusing medication, this is when my father stepped 

in and became my guardian. The hospital told me I would have to start taking medication or they would 

force me to. So in late 2006 I started a medicine regime. I don't really know how to describe the change; 

all I can tell you is that the medicine worked well for me. It actually took a medicine change before I 

found one that worked the best for me. I'm currently on ability. Waking up and realizing what I did, had a 

major effect on me at first and still does today. 

Today I have a better grip on things thanks to Dr. Fischer and hours of treatment. Treatment is 

another important part of the medicine, without it you are running blind. The education you receive at the 

hospital is designed to work with the medication and help you understand your own illness. I'm not going 

to tell you I have had it easy because it hasn't been. It has actually been very difficult. It took me a long 

time to accept that I even had a mental illness but the longer I was on the medication the clearer things 

became. I know I will most likely have to take medication for the rest of my life. I have resigned myself 

to that fact but others haven't others who need the medication. It took a lot to get to this point today but 

I'm here and I will continue to go forward. 

At the current point in time I'm allowed to go into the community a couple times a week with 

supervision. I also work grounds maintenance five days out of the week for two hours. 1 just recently got 

an associate degree after two years of hard work. You could say I keep myself very busy. 

I'm writing you in support ofLD1360 because I see firsthand what the benefits of medication are 

and what would happen if someone who is diagnosed with a mental illness and prescribed medication 

goes off ofthem. It is not healthy for the person taking them or the people around them. LD1360 will help 

keep people on their medication. 

Sincerely, 
164 


85437.099

William H. Bruce II 
165 


85437.178

The Honorable Pamela S. Hyde 

Administrator 

June 6. 2013 

The Substance Abuse and "'!ental Health Services Administration 

1 Choke Cherry Road 

Rockville. MD 20857 

Dear Administrator Hyde: 

Thank you i'L)r appearing betore the Subcommittee on Oversight and Investigations on 

Wednesday. May 22. 2013, to testify at the hearing entitled "Examining SAMlISA's Role in Delivering 

Services to the Severely Mentally Ill:' 

Pursuant lolhc Rulcs of the Committee on Energy and Commerce. the hearing record remains 

0rt'n for ten business days to permit Members to submit additional questions for the record, which are 

auached, The format of your responses to these questions should be as follows: (1) the name of the 

Member whose question you arc addressing. (2) the complete text of the question you are addressing in 

bold. and (3) Y"UI' answer to that question in plain text. 

To HlCilitatc the printing of the hearing record. please respond to these questions by the close of 

business on Thursday. June 20, 2013. Your responses should be e-mailcd to the Legislative Clerk in 

Word formal at brit\,lIlv,havcns@lt1ai1.hollse.goy and mailed to Brittany Havens, Legislative Clerk, 

Committee on Energy and Commerce, 2125 Rayburn House Officc Building, Washington, D.C. 20SIS. 

Thank you again for your timc and effort preparing and deliyering testimony before the 

Subcol1ll11iucc. 

Sincerely. 

Tim Murphy 

Chairman 

Subcommittee on Oversight and Investigations 

cc: Diana DcGel'tc. Ranking Member, Subcommil'tee on Oversight and Investigations 

Atmcilmcnt 
166 


85437.179

The Honorable Tim Murnhy 

Responses 

Questions for the Record 

House Committee on Energy and Commerce 

Oversight Hearing 

May 22,2013 

1. I appreciate your agreeing to stay for the testimony of Joe Bruce, who appeared on 

our second panel at the May 22 hearing. The role played by advocates from the 

Disability Rights Center, the designated agency for administering the Protection and 

Advocacy for Individuals with Mental Illness (PAlM!) program in Maine, in 

obtaining the premature release of Mr. Bruce's son, William, from Riverview 

Psychiatric Center, is very troubling to me. 

a. Aside from audits, what kind of regular oversight does SAMHSA perform over 

recipients of PAlMI formula grants? 

Response: SAMHSA provides rigorous oversight of the grants it awards. Grantees must 

fulfill their role in regard to the stewardship of Federal funds, and as such, SAMHSA 

grants management and project officers work collaboratively to identify potential 

problems and areas where technical assistance might be necessary. This active 

monitoring is accomplished through review of reports and correspondence from the 

grantee, audit reports, site visits, and other information available to SAMHSA. As a 

condition of award, grantees must provide specific information to SAMHSA on the 

management, performance, and accountability of the SAMHSA grant they run. 

Reporting requirements include a Federal Financial Report on an annual basis and must 

be submitted to SAMHSA for each budget period as stated, either a quarterly, semiannually, or an annual progress report. OMB Circular A-133 now requires that all 

grantees receiving over $500,000 in Federal funding submit a data collection form in 

addition to the audit report, due by the earlier of 30 days after receiving the report or nine 

months after the end of the fiscal year. Quarterly financial reports that provide an 

overview of cash status are required by the Department of Health and Human 

Services (HHS) Division of Payment Management. The Federal Financial Report is the 

mechanism for reporting disbursements. Failure to submit reports by the specified due 

dates can result in fund access restrictions. Programmatically, SAMHSA project officers 

monitor the conduct and progress of grants, and collaborate with grantees in planning, 

implementation, and evaluation activities. Project officers' interactions with grantees 

might include answering questions about specific policies, advising grantees on 

programmatic issues, providing technical assistance, and requesting clarification about 

required documents as necessary. 

b. What mechanisms has SAMHSA put in place, if any, to enable individuals, like 

Mr. Bruce, with concerns about the practices of SAMHSA's state-by-state 

designated PAlMI organizations, to communicate these concerns to SAMHSA? 

1 
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85437.180

Response: Individuals may exercise their right to file a grievance with the Protection and 

Advocacy (P&A) system under the Protection and Advocacy for Individuals with Mental 

Illness Act (PAlMI Act) (42 U.S.C. § I0805(a)(9» and regulations (42 CFR 51.25). 

Complaints that allege fiscal mismanagement, discrimination, etc. may be reported 

directly to SAMHSA, for review and further action. Individuals may also submit 

complaints to the HHS Office ofthe Inspector General (OIG). Likewise, individuals may 

also submit concerns to their governors' offices, since, by statute, the governor of each 

state designates, with HHS approval, the entity to which SAMHSA provides the PAlMI 

funds. If the issue of concern has to do with actions of the P&A entity conducted with 

other than SAMHSA funding, state action may be the most appropriate venue. 

Anyone is welcome to express a concern to SAMHSA, and the appropriate staff person 

will address the concern or make a referral to the appropriate body that can do so. 

c. Does SAMHSA have criteria, or an established standard, against which to judge 

the appropriateness of a PAlMI grant recipient's advocacy efforts? 

Response: PAlMI project officers and grants management staff provide routine fiscal, 

programmatic, and monitoring oversight of all aspects of PAlMI formula grants within 

states. In this capacity, the project officer and grants management specialist monitor 

work to ensure that Federal PAlMI funds are being used consistent with the statutory 

authority and in compliance with PAlMI application requirements and annual program 

priorities established by the respective PAlMI Advisory Councils. 

i. What would SAMHSA do, if anything, if it had reason to question whether a 

PAlMI grant recipient, such as the Disability Rights Center, is in fact acting in 

the long-term best interests of a patient such as William Bruce? 

Response: SAMHSA receives allegations and complaints relating to health and 

safety concerns both from the OIG Hotline and directly from individuals. Upon 

receipt, SAMHSA's point-of-contact convenes a meeting with appropriate program 

officials. The most common and first response to health and safety allegations is 

normally to issue a letter to the grantee requiring it to specifically respond to each 

allegation. A follow-up conference call would be held with grantee officials to go 

over any related concerns. If these steps do not dispel the health and safety 

allegations, or if the allegations were considered severe in the first place, program 

officials would conduct a site visit, develop a corrective action plan (CAP) addressing 

the confirmed issues, and issue the CAP to the grantee with a deadline for 

completion. Classifying a grantee as high-risk, which involves imposing restrictions 

on the grantee's ability to drawdown grant funds, would not alone remedy health and 

safety issues, but may be utilized to encourage the grantee to implement the CAP. 

d. Do you believe that all of the activities performed by the Disability Rights 

Center, as set out in Mr. Bruce's testimony, were consistent with his son's best 

interests? 

2 
168 


85437.181

Response: SAMHSA is unable to confinn that all ofthe activities perfonned by the 

Disability Rights Center were done as set out in Mr. Bruce's testimony. SAMHSA does 

not have statutory authority to intervene in individual cases to detennine the best interests 

of each individual served by the PAlMI system. Rather, SAMHSA's role is to assure the 

entity designated to receive these Federal funds is complying with the requirements of the 

Federal funding. Concerns about these issues would be explored by SAMHSA staff. If 

concerns are brought to SAMHSA's attention regarding the actions of an individual 

attorney or advocate in an individual situation, SAMHSA would direct the individual 

concerned to the governor's office, to the state bar association responsible for oversight 

of attorneys licensed by that state, or in some cases to the state mental health authority if 

broader treatment or services issues are identified. 

e. Do you believe that the Disability Rights Center may have been better advised not to 

advocate for Mr. and Mrs. Bruce to be completely shut out of their son's treatment 

at Riverview? 

Response: SAMHSA's Guiding Principles of Recovery include numerous mentions 

of the importance that family members play in the recovery process and explicitly 

states that "[i]ndividuals, families, and communities have strengths and resources that 

serve as a foundation for recovery." 

f. Since the establishment of PAlMI in 1986, has there ever been an instance where 

a SAMHSA-funded PAlMI organization has engaged in advocacy for or against 

pending legislation either on the Federal or State level? 

Response: SAMHSA is not aware of any instance of a PAlMI organization using 

Federal funds to engage in advocacy for or against pending legislation at either the state 

or Federal level. Entities designated to receive these Federal funds may have other 

sources of funding in addition to PAlMI funding and may have additional responsibilities 

in addition to PAlMI responsibilities. 

2. In 1986, Congress established PAlMI to help families and individuals with 

psychiatric illnesses or developmental disa bilities who were being abused or 

neglected. In its 2011 "Evaluation of the PAlMI Program, Phase III: Evaluation 

Report," SAMHSA states that Congress had a~ "expectation that PAIMIs [would] 

address both individnal abuse and neglect cases and systemic deficiencies." This 

report suggests that SAMHSA can identify "more realistic performance 

indicators ... when estimating the impact of systemic advocacy and policy work" by 

PAlMI grant recipients. 

a. Please identify the specific statutory language authorizing recipients of PAlMI 

grants to engage in systemic advocacy or policy work. 

Response: 42 U.S.C. § 10805(a)(I) authorizes P&A systems to: (I) investigate incidents 

of abuse and neglect of individuals with mental illness if the incidents are reported to the 

system or if there is probable cause to believe that the incidents occurred; (2) pursue 

3 
169 


85437.182

administrative, legal, and other appropriate remedies to ensure the protection of 

individuals with mental illness who are receiving care or treatment in the state; and 

(3) pursue administrative, legal, and other remedies on behalf of an individual with 

mental illness. The legislative history of the Act indicates that the Congress (S. Rep. No. 

100-454, at 7 (1988» intended that PAlMI authorize activities of protection and 

advocacy systems which address systemic deficiencies that could lead to abuse and 

neglect: 

During the reauthorization hearing on the Act, several witnesses spoke 

of systemic conditions that negatively impact the working environment 

encountered by direct care workers. These adverse conditions include 

inadequate staffing levels and inadequate staff training ... The 

Committee recognizes that in some facilities efforts of even the most 

dedicated care staff to provide quality treatment continue to be 

frustrated by such systemic conditions, which can foster abuse and 

neglect. The Committee believes that the protection and advocacy 

activities authorized in this legislation will have a positive impact upon 

the working environment. 

Consistent with congressional intent, PAlMI's implementing regulations direct protection 

and advocacy systems to carry out systemic advocacy, i.e .. "those efforts to implement 

changes in policies and practices of systems that impact persons with mental 

illness" (42 CFR 51.31(f). 

b. Describe how SAMHSA collects and evaluates data of individual cases versus 

systemic cases closed under PAlMI in order to measure performance. 

Response: The annual Program Performance Report (PPR) mandated by the 

PAlMI Act (42 U.S.C. § 10805(a)(7» includes outcome statements that describe or relate 

to the initial complaints of abuse, neglect, rights violations, and group (systemic) 

activities used on behalf of the clients served. The PPR from each P&A provides data on 

the number and types of individual cases of alleged abuse, neglect, and rights 

violations. The PPR also includes an outcome measure for each closed case that 

indicates if the case was resolved in the client's favor and resulted in positive change for 

the client in herlhis environment, community, or facility. These data allow for review of 

the positive percentage rates for each ofthese three areas as well as a combined measure 

for longitudinal change over time for the individual PAlMI programs. The data also 

allow for comparison among the other P&As in the system and can be used to track 

improvement and to target areas that may need some corrective action. 

3. After hearing Mr. Bruce's testimony, do you plan to follow-up with the Disability 

Rights Center in any way about their use of SAMHSA funding under the PAlMI 

program going forward? 

Response: The SAMHSA project officer is in continual contact with this and other 

PAlMI grantees regarding the appropriate use of Federal funding. 

4 
170 


85437.183

4. Mr. Bruce mentioned in his testimony that when he approached the Maine 

legislature to press for an improved Assisted Outpatient Treatment law, he was 

shocked to encounter public opposition from the Disability Rights Center. What 

affirmative steps, if any, does SAMHSA take to ensure that its grant recipients, 

including recipients of formula grants under the PAlMI program, do not use any 

federal dollars to lobby for or against proposed legislation at the local, State, or 

Federal level? 

Response: SAMHSA's Request for Applications (RFA) includes the following language: 

Disclosure of Lobbying Activities - Federal law prohibits the use of appropriated 

funds for publicity or propaganda purposes or for the preparation, distribution, or 

use of the infonnation designed to support or defeat legislation pending before the 

Congress or state legislatures. This includes "grass roots" lobbying, which 

consists of appeals to members of the public suggesting that they contact their 

elected representatives to indicate their support for or opposition to pending 

legislation or to urge those representatives to vote in a particular way. You must 

sign and submit this fonn, if applicable. 

All applicants must complete the Disclosure of Lobbying Activities, if applicable. All grant 

applications must include a signed face page by the authorized representative which states 

that he/she agrees that the statements contained in the list of certifications are true, complete 

and accurate and agree to comply with any resulting tenns if the Notice of Award. 

All Notices of Award include a Standard Tenn and Condition that prohibits grant funds from 

being used for lobbying. Section 503 of the Labor, HHS, and Education Appropriations Act 

language is also included in all LlHHS-funded RFAs and standard tenns & conditions. 

In addition, SAMHSA has offered courses to staff that incorporate the prohibition on using 

Federal funds for lobbying. These courses include Appropriations Law for Business 

Operations in Government and The Legislative Process: Working with Congress. 

Specific to the PAlMI program, the Fiscal Year (FY) 2013 RFA included the following 

PAlMI Grant Award Terms and Conditions: 

1) That each PAlMI grantee submit a Disclosure of Lobbying Activities fonn 

[OMB approved 0348-0046, Standard Fonn LLL (rev. 7-97)]. 

2) Breach ofTenns and Conditions: A State P&A system will be considered 

in breach of the tenns and conditions of this grant award for failure to 

satisfY any other requirements under the Act, CFR, or any other requisites, 

e.g., compliance with SAMHSA audit, on-site monitoring and/or technical 

assistance recommendations within specified time frames. 

A breach of the tenns and conditions will require remedial action, which 

5 
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85437.184

may include the following SAMHSA actions: recommendation for 

suspension or termination of the PAlMI Program grant; conversion to a 

reimbursement method of payment; and/or agency retention of grant 

payments. [PAlMI RFA FY 2013]. 

3) Lobbying Prohibitions: No part of any appropriated funds contained in this 

Act may be used other than for normal and recognized executive-legislative 

relationships, for publicity or propaganda purposes, for the preparation, 

distribution, or use of any information kit, pamphlet, booklet, publication, 

radio, television, or video presentation designed to support or defeat 

legislation pending before the Congress, except in presentation to the 

Congress itself or any State legislature. This includes "grass roots" lobbying, 

which consists of appeals to the public suggesting that they contact their 

elected officials to indicate their support for or opposition to pending 

legislation, or to urge those representatives to vote a particular way, 

(Emphasis added) 

No part of any appropriation made under this Act may be used to pay the 

salary or expenses of any grant or contract recipient, or agent acting for such 

recipient, related to any direct lobbying activity designed to influence 

legislation or appropriations pending before the Congress or any State 

legislature. (Emphasis added) 

PAlMI grantees are also made aware that lobbying with Federal funds is prohibited by 

applicable regulations (42 CFR S1.6(b), which state that "[Federal a]llotments may not be 

used to support lobbying activities to influence proposed or pending Federal legislation or 

appropriations. This restriction does not affect the right of any P&A system, organization, or 

individual to petition Congress or any other government body or official using other 

resources. " 

As a reminder, on June 12,2013, Paolo del Vecchio, Director ofSAMHSA's Center for 

Mental Health Services (CMHS), sent a letter to each PAlMI grantee reiterating this 

information. 

5. Are the majority of reviewers of SAMHSA competitive grants individnals who have 

specific advanced training and academic and professional credentials in the mental 

health fields rather than just experience, yes or no? 

Response: Yes, a majority of peer reviewers have advanced training and academic and 

professional credentials relevant to the behavioral health and other fields appropriate to the 

program under review. In the selection of peer reviewers, staff adheres to SAMHSA 

Extramural Policy Statement 11-02. This guidance outlines six key factors in the selection of 

an appropriate committee of reviewers, including "experts from various areas of 

specialization within relevant professional, technical and scientific fields." 

6 
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85437.185

6. Your name is listed in tbe credits for a SAMHSA staff musical beld December 1-3, 

2010, and titled "A Place for Us." Wbat role did you bave in tbe planning and 

execution of tbis play? 

Response: The Administrator had no role in the planning and execution of the musical, 

which was about HIV I AIDS and substance abuse and mental health issues. At the request of 

the staff, the Administrator along with three other SAMHSA staff recorded a short song, 

which was played during the musical. The recording was done without professional help and 

without cost to the agency and was done on a break from work lasting only a few minutes. 

7. Is SAMHSA planning a staff musical for 2013? 

Response: No, SAMHSA is not planning a staff musical for 2013. 

8. On Marcb 9, 2009, President Obama released a memorandum committing tbat 

"science and tbe scientific process must inform and guide decisions of my 

Administration on a wide range of issues, including improvement of public bealtb." 

Tbis memo instructed tbe Director of tbe Office of Science and Technology Policy to 

guarantee scientific integrity, noting tbat "the selection and retention of candidates 

for science and tecbnology positions in tbe executive brancb sbould be based on tbe 

candidate's knowledge, credentials, experience, and integrity." 

a. Are recipients of SAMHSA competitive grants, in eacb and every case prior to 

awarding of tbe grant, subjected to rigorons, blind peer review? 

Response: Yes, all competitive grant applications are subject to an identical and rigorous 

peer review process. 

b. Wbat steps does SAMHSA take to ensure tbat grant reviewers for a particular 

competitive grant do not stand to financially benefit from approval of tbat 

grant? Wbat conflict of interest policies does SAMHSA bave in place for its grant 

reviewers? 

Response: SAMHSA performs due diligence with regard to peer reviewer conflict of 

interest. In considering potential reviewers, SAMHSA will not allow individuals to 

review applications iftheir organization applied for that grant of ifthey have a general 

appearance of a conflict of interest, such as being a technical assistance provider to 

potential applicants. In addition, upon receiving assigned applications to evaluate, the 

first action a reviewer must take is to sign a form attesting that they do not have a conflict 

of interest with any of the applications under review. 

c. Does SAMHSA require tbat tbose wbo evaluate grant applications for science 

quality and integrity hold advanced degrees in social work, psychology, and 

psychiatry? 

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Response: SAMHSA grant reviewers are individuals who possess the specific 

knowledge and skill sets necessary to implement and therefore review for a specific 

program. When an RFA is published, the Review Administrator in the Division of Grant 

Review (DGR), a unit within SAMHSA's Office of Financial Resources, identifies three 

to five specific areas of expertise that are necessary. The Review Administrator then 

searches DGR's Peer Reviewer Database for individuals with these areas of expertise and 

seeks recommendations from program staff. The Review Administrator makes an initial 

selection of a large pool of reviewers and sends an e-mail to determine potential interest 

and availability to participate in the review of applications to the program. If an 

individual is interested, slhe must submit a Reviewer Contact Information form which 

updates their areas of expertise, resume or CV, and a paragraph outlining how their 

expertise and knowledge is relevant to the program. Once the Review Administrator 

collects information from all interested reviewers, they develop the Reviewer Matrix, a 

document that includes the specific and general expertise of all potential reviewers. This 

document is submitted to the Director of Grant Review for approval. Reviewers often 

have advanced degrees related to the mental health/prevention/treatment fields and 

decades of experience working in these fields with various populations in various 

settings. Many reviewers are affiliated with community-based organizations, 

universities, or state and local government public health authorities. 

9. Individuals with a serious mental illness often lack awareness of the existence of 

their illness. This serves as a common barrier to these individuals taking their 

medications or following their doctors' orders. 

a. What would you suggest be done if the patient in question refuses his or her 

doctor-prescribed medication? 

Response: SAMHSA does not interfere in doctor/patient relationships and believes the 

patient's treatment team is in the best position to determine the appropriate treatment 

protocol. SAMHSA believes and supports the use of medications as one important 

approach to symptom management and to recovery. Therefore, SAMHSA has worked 

with physicians, other HHS operating divisions, and persons in recovery (often made 

possible with medications) to develop shared decision-making tools and practices as well 

as practice improvement toolkits (see also answers below to questions 1 and 2 from 

Representative Gingrey) to assist physicians and their patients work together to determine 

the best medication approaches for mental health conditions. Shared decision-making 

helps to assure understanding about the value of medications and medication compliance 

just as it does for other health conditions. Additionally, SAMHSA supports peer support 

and other approaches which often assist individuals to understand the role of medications 

in treatment and the importance of medication compliance. For those individuals with 

serious mental illness for whom medications are not effective or who do not choose to 

take medications (and are not legally required to do so), SAMHSA recommends assertive 

outreach and engagement efforts and practices that have shown promise in building 

relationships so that eventually individuals may be able to participate in treatment or 

services beneficial to them and their recovery. 

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b. In such instances, do you think there is a role to be played by court-ordered 

outpatient treatment? 

Response: SAMHSA supports the treatment and recovery of persons with mental illness 

in the least restrictive environments and at the earliest possible opportunity. Waiting 

until someone is so sick they must be relieved of their rights and freedoms is the most 

costly and least effective practice. Focusing on early intervention and prevention of 

mental illness and/or the disabling effects of such illnesses can save millions of dollars in 

incarceration costs, allow people to work and earn a living and reduce the burden on 

families. Lowering the threshold to forced treatment may discourage Americans from 

seeking treatment. Therefore, SAMHSA supports treatment options that engage 

individuals with mental illness or mental health conditions to understand their health 

condition as much as possible and choose treatment and service options that will be 

acceptable to them. When a person cannot be engaged and will not participate in 

necessary treatment and meets criteria for involuntary treatment, SAMHSA agrees that 

such approaches may be necessary. Involuntary treatment criteria and laws are governed 

by states and state legislation. 

10. Prior to joining SAMHSA, and while serving as Cabinet Secretary for Human 

Services Department in New Mexico, you were already on the record opposing the 

introduction of AOT, along the lines of New York's Kendra's Law, in your state. 

You expressed this in a November 29, 2005 letter to the mayor of Albuquerque that 

you co-signed with Michelle Lujan Grisham, currently a Member of Congress from 

New Mexico's IstDistrict. 

a. Among your representations at the time were that "seeking an AOT law at this 

time would seriously divide our behavioral health community ••• Any discussion 

offorced treatment will create division and controversy." How do you reconcile 

your position with respect to New Mexico with the very favorable view of AOT 

expressed to then-Secretary Grisham at about the same time by the 

Commissioner of the New York State Office of Mental Health? For example, the 

Commissioner reported to your office that as a result of AOT, rates tor 

hospitalizations, homelessness, arrests and incarcerations declined dramatically 

in New York. 

Response: I expressed concern about the timing and impact of the proposed New 

Mexico legislation, as indicated in the quoted statement. The proposed law had not been 

discussed with New Mexico behavioral health stakeholders before it was initially 

introduced, including the judges that would have to implement the law. 

Involuntary treatment is governed by states and state legislation. As indicated at the 

hearing, AOT can be an effective model when accompanied by sufficient financial 

resources to ensure that appropriate treatment services are available to individuals that are 

court-ordered to receive outpatient treatment. The AOT law in New York was in a state 

with one of the highest per capita spending for mental health services and in addition was 

accompanied by a significant increase in state funding for mental health treatment 

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services, and later funding was provided to do an extensive evaluation of New York's 

law. No such funding was included in the proposed New Mexico AOT legislation, even 

though New Mexico at the time had one of the lowest per capita spending rates in the 

country. 

11. In December 2011, SAMHSA announced a new working definition of "recovery" 

from mental and substance use disorders. Recovery is defined as "a process of 

change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential." 

a. Is "Recovery," defined as such, an appropriate course of treatment for the 

11 million Americans SAMHSA counts as having a serious mental illness? Is a 

self-directed life possible or indeed optimal for everyone, if it means individuals 

will go off their doctor-prescribed medications? 

Response: SAMHSA does not define "Recovery" as a course of treatment but as a 

process and an outcome of better health, which can be accomplished through a number of 

clinical interventions and recovery supports, tailored to a person's individual needs. 

Medication is an important part of managing symptoms and hence the path to recovery 

for many persons with mental illness. Recovery can be viewed as a process by which an 

individual learns to manage hislher condition and lead a productive life and is facilitated 

by working with providers via medications, counseling, rehabilitative services, stress and 

relapse management, and other services and supports. The concept of recovery is for all 

individuals who are in process of improving their health care condition - including mental 

illnesses - at any stage of that condition. It does not negate the fact that a mental illness 

or an addiction can be a chronic or life-long condition. For too long, we have assumed as 

a society that persons with mental illness have a limited future and little to contribute. 

SAMHSA believes in recovery, with the key factor of hope that people can overcome 

their illnesses and live healthy, full and productive lives. Just as with other health 

conditions, medication is often a key part of that positive outcome, but it is unfortunately 

not effective for everyone or for every mental health condition. 

SAMHSA's role is not limited to certain mental illnesses or a small number of mental 

health conditions. Rather, SAMHSA's mission is to reduce the impact of substance 

abuse and mental illness on America's communities. Thus, SAMHSA is concerned about 

all Americans, whether they are in need of prevention or whether they are facing mild, 

moderate, or serious and persistent mental health issues. SAMHSA does not support 

only one approach to treatment for persons with mental health and addiction issues. 

SAMHSA supports individuals with mental illness and persons with addiction receiving 

the best available medication as well as other treatments and services they need to help 

them on the path to recovery. SAMHSA also supports additional research to improve the 

availability of effective medications and other treatments and services for all mental 

health conditions. 

Recovery is a process, not a treatment or an end state. Recovery is the goal of improved 

health and a productive life without addiction and without the disabling impacts of 

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mental illness and is important to anyone with a health care problem at any stage. 

12. What is the basis for SAMHSA's strong commitment to "peer mentoring" and 

"peer support" approaches to "Recovery"? 

a. Is SAMHSA operating on the basis of any specific study which shows that peer 

support is more effective than the support of licensed mental health 

professionals? 

Response: SAMHSA is not operating from a position that peer support is more effective 

than the support of licensed mental health professionals. SAMHSA's inclusion of peer 

support as an evidence-based practice is based on the demonstrated outcomes of 

numerous studies.! Peer support services usually operate in conjunction with other 

clinical services which amplifY the benefit of treatment by offering ongoing support and 

psychosocial rehabilitation. Many peer support services require that they be part of a 

treatment plan authorized by a "licensed practitioner of the healing arts" such as a 

psychiatrist, psychologist, or physician in order to be reimbursed by Medicaid under 

Centers for Medicare & Medicaid Services (CMS) rules. Peer support services are a 

valuable adjunct to traditional care that are known to contribute to improved outcomes in 

employment, education, housing stability, satisfaction, self-esteem, medication adherence 

and decrease the need for more costly services, such as hospitalizations. 

The Department of Veterans Affairs (VA) has also recognized the value of peer supports 

and has a goal of hiring 800 peer support specialists representing people who are 

Veterans and who have successfully recovered from mental health conditions. 

b. How much money, in the form of grants - either formula (including block 

grants) or competitive does SAMHSA provide on an annual basis for programs 

whose primary treatment model is based around peer mentoring or peer 

support? 

Response: SAMHSA does not directly fund any program operations whose primary 

treatment model is based around peer mentoring or peer support. SAMHSA promotes 

peer support services in behavioral health as effective, evidence-based practices mostly 

by providing technical assistance. As directed by Congress through appropriations 

legislation, SAMHSA funds the Consumer and Family State Network Grants (FY 2013 at 

$6.1 million for approximately 44 new grants, 17 grant continuations, and a technical 

assistance center) that promote peer-to-peer support and family-to-family support, and 

the Consumer and Consumer Supporter Technical Assistance Centers (FY 2013 at 

$1.9 million for five grants) that also provide information about peer support. SAMHSA 

also supports the Recovery Community Services Program for peers with addiction issues 

to prevent relapse and promote long-term recovery (FY 2013 at $2.4 million for five 

grants and two supporting contracts). 

1 See a review of the evidence at http://store.samhsa.gov/shin/contcnt!!SMAII·4633CD-DVDffheEvidence-COSP.pdf. 

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The President's FY 2014 Budget includes $50 million for workforce activities to help 

train more than 5,000 additional professionals to work with students and young adults 

with mental illnesses and other behavioral health problems. The proposal includes 

$35 million for ajointly-administered activity with HRSA to expand the Mental and 

Behavioral Health Education and Training (MBHET) Grant Program, $10 million for 

SAMHSA's Peer Professionals training program, and $5 million to expand SAMHSA's 

Minority Fellowship Program as described below. The Peer Professionals Workforce 

Development program would strengthen the behavioral workforce by increasing the 

number of trained peers, recovery coaches, mental health/addiction specialists, prevention 

specialists, and pre-Master's level addiction counselors working with an emphasis on 

youth ages 16-25. 

13. What is the vetting process that SAMHSA nses before a given mental health 

intervention qnalifies for inclusion in the Natioual Registry of Evidence-based 

Programs and Practices (NREPP)? What are NREPP's minimum requirements for 

review? Who performs these reviews? How does NREPP defiue "evidence-based"? 

Response: The National Registry of Evidence-based Programs and Practices (NREPP) is a 

voluntary, self-nominating system in which intervention developers elect to participate. 

There will always be some interventions that are not submitted to NREPP, and not all that are 

submitted are reviewed. 

As outlined in "Announcement for the National Registry of Evidence-Based Programs 

and Practices; Open Submission Period for Fiscal Year 2014" (78 Fed. Reg. 33,854) for an 

intervention to be eligible for review, the submitter must provide written documentation that 

demonstrates the following minimum requirements have been met; 

I) The intervention has produced one or more positive behavioral outcomes (pS.05) in 

mental health or substance abuse among individuals, communities, or populations. 

Significant differences between groups over time must be demonstrated for each 

outcome. 

2) Evidence of the positive behavioral outcome(s) has been demonstrated in at least one 

study using an experimental or quasi-experimental design. Experimental designs 

include random assignment of participants, a control or comparison group in addition 

to the intervention group, and pre- and post-test assessments. Quasi-experimental 

designs include a control or comparison group and pre-and post-test assessments but 

do not use random assignment. Studies with single-group, pre-test/post-test designs 

do not meet this requirement. 

3) The results of these studies have been published in a peer-reviewed journal or other 

professional publication (e.g.. a book volume) or documented in a comprehensive 

evaluation report. Comprehensive evaluation reports must include the following 

sections or their equivalent: a review of the literature, theoretical framework, 

purpose, methodology, findings/results (with statistical analysis and p values for 

significant outcomes), discussion, and conclusions. Information must be included to 

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enable rating of the six Quality of Research criteria: (1) reliability of measures, 

(2) validity of measures, (3) intervention fidelity, (4) missing data and attrition, 

(5) potential confounding variables, and (6) appropriateness of analysis. 

4) Implementation materials, training and support resources, and quality assurance 

procedures have been developed and are ready for use by the public. 

The documentation demonstrating these minimum requirements must be provided at the time 

of submission. 

Once an intervention has been accepted for review, the developer and NREPP stafIwork 

together to identify the outcomes and materials to be used in the review. A review generally 

takes several months to complete, from the initial scheduling of the kick-off call to the 

completion of an NREPP intervention summary. NREPP staff identifies the reviewers who 

will participate in the review. 

NREPP staff sends review packets to two pairs of reviewers. One pair of reviewers 

focuses on Quality of Research, while the other pair looks at Readiness for 

Dissemination. 

Each of the reviewers independently reviews the materials provided and calculates 

ratings using the predefined Quality of Research and Readiness for Dissemination 

rev iew criteria. 

The reviewers submit their ratings to NREPP. 

If their ratings differ by a significant margin, NREPP staff may hold a consensus 

conference to discuss and resolve the differences. 

With respect to Quality of Research, each reviewer independently evaluates the Quality of 

Research for an intervention's reported results using the following six criteria (links below 

are to the NREPP website which will provide additional information): 

I) Reliability ofmeasuresl 

2) Validity of measuresd 

3) Intervention fidelity" 

4) Missing data and attrition2 

5) Potential confounding variables§ 

6) Appropriateness of analysis1 

Reviewers use a scale of 0.0 to 4.0, with 4.0 being the highest rating given. 

With respect to criteria for rating Readiness for Dissemination, each reviewer independently 

2 http://www.nrepp.samhsa.gov/ReviewQOR.aspx#ROM. 

3 http://www.nrepp.samhsa.gov/ReviewQOR.aspx#VOM. 

4 http://www.nrepp.samhsa.gov/ReviewQOR.aspx#FID. 

5 http://www.nrepp.samhsa.gov/ReviewQOR.aspx#MDA. 

6 http://www.nrepp.samhsa.gov/ReviewQOR.aspxffPCV. 

7 http://www.nrepp.samhsa.gov/ReviewQOR.aspx#ANA. 

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evaluates the intervention's Readiness for Dissemination using the following three criteria 

(with links to the NREPP website for each): 

I. Availability of implementation materialsli 

2. Availability of training and support resources:!' 

3. Availability of quality assurance procedureslQ 

Reviewers use a scale of 0.0 to 4.0, with 4.0 being the highest rating given. 

All NREPP reviewers are recruited, selected, and approved by SAMHSA based on their 

experience and areas of expertise. The reviewer qualifications required for Quality of 

Research and Readiness for Dissemination differ because of the different kinds of expertise 

needed for these two areas. Once approved by SAMHSA, reviewers participate in at least 2 

hours of training on the procedures and criteria they will use to rate interventions. Reviewers 

arc paid for their participation in the training as well as any preparation time. Training is 

typically done via web conferencing. Reviewers are required to sign a Conflict ofInterest 

disclosure statement for each intervention they review, to ensure they have no professional 

ties or financial or other interests in the intervention that could prevent an objective review. 

SAMHSA does not assign reviewers to specific interventions. Instead, assignments are made 

by NREPP contract staff. Interventions are matched with reviewers having appropriate 

qualifications and the most relevant experience and content knowledge. The identity of 

reviewers assigned to reviews is kept confidential from both SAMHSA and the applicant. 

Quality of Research reviewers must possess: 

A doctoral-level degree; and 

A strong background and understanding of current methods of evaluating prevention 

and treatment interventions. 

In addition, candidates who have direct experience providing prevention and/or treatment 

services are preferred. 

Readiness for Dissemination reviewers are selected from two categories: direct service 

experts (including both providers and consumers of services), or experts in the field of 

implementation. 

For direct service experts, the minimum qualifications include: 

Previous experience evaluating prevention or treatment interventions; and 

Knowledge of mental health or substance abuse prevention or treatment content areas. 

• http://www.nrepp.samhsa.gov/ReviewRFD.aspx#Materials. 

9 http://www.nrepp.samhsa.gov/Rev;ewRFD.aspxffTraining. 

10 http://www.nrepp.samhsa.gov/ReviewRFD.aspx#QA. 

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For implementation experts, the minimum qualifications include: 

Previous experience implementing interventions, doing evaluation work in service 

settings, and/or conducting research across interventions; and 

Knowledge of mental health or substance abuse prevention or treatment content areas. 

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The Honorable Marsha Blackburn 

1. Please submit to the Committee your complete remarks, as delivered at the 2012 

Alternatives Conference. If not transcribed, please provide the Committee with a 

videotape of your remarks. 

Response: The remarks were not transcribed or videotaped. 

2. When did SAMHSA begin sponsoring the Alternatives Conferences? 

Response: SAMHSA began sponsoring the conference when the Agency was formed in 

1992. 

3. How much money have you spent on Alternatives Conferences in 2012, and in all 

prior years? 

Response: SAMHSA spent a total of$165,373 FY 2012 funds for the Alternatives 

Conference. This cost includes grant supplement, consumer scholarships, speaker fees, and 

Federal travel. 

SAMHSA provided the following dollar amounts via grants to facilitate the planning of the 

Alternatives conference in previous years. These amounts do not include the amount of 

consumer scholarship support which in general averages around $30,000 each year to ensure 

that approximately 30 people with mental illnesses can attend the conference. 

FY 2012: $127,000 

FY2011: $127,000 

FY 2010: $127,000 

FY 2009: $126,000 

FY 2008: $124,000 

4. How much money has SAMHSA spent on conferences in general? 

Response: As reported in the HHS report on FY 2012 conference spending, which is 

required by Office of Management and Budget Memorandum M-12-12, SAMHSA held 17 

conferences over $100,000 each between February and September 2012, for an aggregate 

cost of$6,666,696. 11 FY 2012 was the first year that this information was collected and 

reported, and not all conferences and their costs were able to be included. SAMHSA expects 

the reporting in FY 2013 and beyond will be more complete due to the ongoing 

implementation of the reporting requirements of M-12-12, and now section 3003 of the 

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Consolidated and Further Continuing Appropriations Act, 2013. Please note that the 2012 

Alternatives conference was held in October 2012, and was therefore not included in the 

FY 2012 report. 

In the first three quarters ofFY 2013, SAMHSA estimates it will spend $5 million on 

conferences, a 40 percent savings of$3.5 million below the previously projected conference 

costs of $8,478, 132. 

5. What is the breakdown of money that you have spent on speakers you have had at 

these conferences and the scholarships that you have given? 

Response: In FY 2012, $29,848 was paid for travel, lodging and registration for 28 

consumers to attend the Alternatives Conference. The only scholarships provided by 

SAMHSA in FY 2012 were for the Alternatives Conference. For the 17 conferences that 

SAMHSA held from February to September 2012 that cost over $1 00,000, $51,743 was 

spent on speaker costs. 

6. How much did SAMHSA pay for the painting it commissioned of Sam English. as 

referenced in SAM HSA's newsletter from March/April 2011? 

Response: SAMHSA paid Mr. English $8,500 for the painting. 

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The Honorable Phil Gingrey 

1. The Director of the National Institute of Mental Health, Thomas Inse~M.D., testified 

before this Subcommittee on March 5, 2013, "that effective treatments, which 

include medication adherence and evidence-based psychosocial therapy, can rednce 

the risk of violent behavior fifteen-fold in persons with serious mental illness." We 

also heard at the Hearing multiple testimonies on the importance of medication 

adherence and the tragic consequences that can follow when a person with a serious 

mental illness stops taking his or her prescribed anti- psychotic medications. Given 

the importnce of medication adherence, please provide a report on what materials 

and information, for patients, families and treatment professionals, SAMHSA has 

created and disseminated, that address the importance of medication adherence for 

serious mental illness. 

Response: SAMHSA has I I Evidence-Based Practices (EBP) Knowledge Infonning 

Transfonnation (KIT) products which address various aspects of providing behavioral health 

evaluation and treatment for children, adults with serious mental illness and older adults. All 

SAMHSA's EBP KITs support adherence to medication regimes along with patient-centered 

treatment approaches. Implicit in this approach is for psychiatrists or other physicians who 

prescribe medications for patients with mental or substance use disorders to work with the 

patient to determine the best type and schedule of medication which will enable the person to 

function at the highest level. The KITs describe various types of psychosocial treatment 

modalities in detail which complement medication management. 

The Medication, Treatment, Evaluation, and Management (MedTEAM) EBP KIT!2 is a 

specific KIT for psychiatrists and other prescribing physicians that provide guidance on 

EBPs related to medication management for clients/consumers with mental disorders. 

MedTEAM offers agencies, and the systems in which they participate, guidance on 

developing a systematic approach to medication management. The approach includes 

developing a plan to keep up with the evidence about medications, including using treatment 

guidelines or algorithms to inform medication decisions. 

The Illness Management and Recovery EBP KIT13 promotes using medications more 

consistently. The KIT provides practical handouts and class session descriptions which 

include training on how to use medications as prescribed by the psychiatrist. 

Other EBP KITs in the series are: 

• Family Psychoeducation; 

• Integrated Treatment for Co-Occurring Disorders; 

• Assertive Community Treatment; 

• Intervention for Disruptive Behavior Disorders; 

12 http://store.samhsa,govjproductJMedTEAM~Mcdication~ Treat111ent~Evaluation-and-Management-Evidencc-Based-Prac ticesESP-KIT/SMA 10-4549 

13 hllilJ/store.samhsa.gov/productlIllness-Management-and-Recoverv-Evidence-Based-Practices-EBP-KIT!SMA09-4463 

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• Consumer Operated Services; 

• Permanent Supportive Housing; 

• Evidence-Based Treatment for Depression in Older Adults; and 

• Supported Employment; 

• Supported Education: A Promising Practice.14 

2. In our own effort to find materials that SAMHSA has producOO and made available 

to the public and professionals on the topic of anti-psychotic medications, we were 

able to find only two pnblication s 15 160f these two publications, neither of them 

made mention of the medications that are specifically formulated to address the 

problem of non-adherence-that is, long-acting injectable antipsychotic medications. 

Since long-acting antipsychotic medications have been available for more than 10 

years, and provide a reliable way of certifying that patients with serious mental 

illness are receiving their medication, what plans does SAMHSA have for helping 

the public and professionals learn about these antipsychotic medications? 

Response: As described above, the MedTEAM EBP Kit equips treatment teams at mental 

health agencies with a systematic plan to ensure they use the latest scientific evidence 

coupled with patient input in making medication management decisions for people with 

mental illnesses. The KIT recognizes that the key to a client's adherence to medication 

therapy is their active participation and involvement in shared decision making. When 

clients understand and participate in their treatment regimen, they are more likely to adhere 

to the plan and take medication as prescribed. 

SAMHSA has created an interactive decision aid on the use of antipsychotic medications that 

helps providers and patients choose which antipsychotic medications work best for the 

individual. Although the decision aid does not specifically mention long-acting injectable 

delivery systems for antipsychotic medications, the intent of the decision aid is for the 

provider and patient to review what works best when taking antipsychotic medications and 

how they are delivered would be a component of that conversation. The decision aid also 

helps them consider services and a variety of well ness activities as part of an overall recovery 

plan. Also available are a series of one-page, downloadable tools that include worksheets, a 

medication side effect checklist, questions to ask about recommended medications, and 

conversation starters. A companion workbook titled, Supporting Choice: Helping Someone 

Make an Important Decision, is designed to help a supporter guide a person through the 

process of making decisions about antipsychotic medications. 

14 See http://store,samhsa.gov/lisUscrics?name=Eyidencc-Bascd-Practices-KITs. 

15 Substance Abuse and Mental Health Services Administration. Interventions for Disruptive Behavior Disorders: Afedication 

Management. HIlS Pub. No. SMA-I 1-4634. Rock'Ville. MD: Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration, U.S. Department of Health and Human Services, 201 L 

16 Substance Abuse and Ment::J11I e a 1 t h Servkes Administration. 57u(rcd Decision .Haking in Mental flcalth Decision 

Aid ('nl1.<,;idl?rillg the Rolet~r AlIlIjJsycholic ,\ledfealions ill YOllr Recon:ry Plan April 2012. 

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The following list is a sample of publications distributed by SAMHSA that discuss the use of 

antipsychotic medications in the treatment of behavioral health conditions: 

• Community Conversations About Mental Health: Information Brief;!7 

• Illness Management and Recovery: Practitioner Guides and Handouts;!8 

• Integrated Treatment for Co-Occurring Disorders: Training Frontline Staff;J9 

• Interventions for Disruptive Behavior Disorders: Medication Management;20 

• Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs 

In-service Training;2! 

• MedTEAM: Training Frontline Stafe2 

• Substance Abuse Treatment for Persons With Co-Occurring Disorders;23 

• SAMHSA's Wellness Initiative: Information for General Health Care Providers;24 and 

• What is Right for Me? Considering the Role of Antipsychotic Medications in My 

Recovery Plan.25 

3. When an individual suffers from both schizophrenia and alcohol dependence, 

research has shown that they are at much greater risk for violent behavior. Over 

one-third of patients with schizophrenia also have a drinking problem, and the 

prevaleuce of alcohol dependence among individuals with schizophrenia is several 

times greater compared to the general population. Even without the added 

challenges of serious mental illness, alcohol dependence is strongly associated with 

violence and crime. In an analysis conducted by the Department of Justice, a third 

of all criminal offenses were alcohol-related and nearly 40% of all violent offenses 

were alcohol-related. As with antipsychotic medications, the problem of nonadherence is a major issue for alcohol dependent individuals. The negative impact 

of non-adherence on the orally-dosed alcohol dependence treatment medications is 

notorious and extensively well-documented in general (also see: oral naltrexoue, 

acamprosate and disulfiram), and is correlated with increased healthcare costs. 

Quite simply, medications do not work if they are not taken. Given the role that 

excessive alcohol use plays in violent crime, and crime in general,as well as its 

impact on people with serious mental illness and on health, please describe what 

initiatives SAMHSA is fnnding to encourage the use of FDA-approved medications 

in the treatment of alcohol dependence and whether and how the issue of nonadherence with these medications is being addressed. 

Response: SAMHSA has produced and disseminated a Treatment Improvement 

Protocol (TIP), "Incorporating Alcohol Pharmacotherapies into Medical Practice,,,26 along 

17 http://store.samhsa.gov/shinicontenUISMA J3-4763/SMA 13-4763.pdf. 

J8 hltp:llstore.samhsa.gov/shin!contentiSMA09-4463!PractitionerGuidesandHandouts.pdf 

19 http://store.samhsa.gov/shin/contentiSMA08-4367ITrainin£FrontjineStaff-ITC.pdf 

20 hltp:!!store.samhsa.gov/shin/eontentiSMA I 1-4634('0-0 VD/Medieation Management(,hild-I OBO .pdf 

21 http://store.samhsa.gov/shin1contentiISMA09-4341/SMA09-4341.pdf 

22 htip:llstore.samhsa.gov/shin/content! IS MA I 0-4549/T rainingFrontlineSta ff-MT .pd f 

23 http://m''' .ncbi.nlm.nih.gov /booksNBK64197 /pdfrrOC .pd f 

24 http://store.samhsa.gov/shin/contenti!SMA 12-4566/SMA 12-4566.pdf 

25 hlllJ:!Il62.99.3.211/scimIDA files/index.html 

26 http://162.99.3.213Iproducts!manualsltips!DdffTIP49.pdf. 

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with a series of related publications.17 The TIP covers each of the FDA-approved 

medications for treating alcohol use disorders and addresses pretreatment indicators, 

including risk factors for poor medication adherence. SAMHSA has also released a 

Substance Abuse Treatment Advisory, "Naltrexone for Extended-Release Injectable 

Suspension for Treatment of Alcohol Dependence.,,28 

Research evidence supports that pharmacotherapy combined with psychotherapy is more 

effective than deploying either intervention alone. SAMHSA's NREPP features one such 

intervention for alcohol treatment. Broad Spectrum Treatment (BST) and Naltrexone for 

Alcohol Dependence is a three-to-six-month program that uses manual-guided cognitive 

behavioral therapy in combination with naltrexone pharmacotherapy (50mg daily) to treat 

adults with alcohol dependence. BST therapists deliver eight to 14 individual sessions 

incorporating components of motivational enhancement therapy community reinforcement, 

and 12-step approaches 

SAMHSA's Addiction Technology and Transfer Centers communicate considerable 

information to the field about alcoholism and the medications used to combat this problem. 

They conduct training and provide resources regarding medication management and 

adherence, including a training PowerPoint on medication management and adherence.29 

4. In your testimony before us on May 22, 2013 you stated that much of SAMHSA's 

funding goes to the block grants, which are passed on to States to fund substance 

abuse treatment - which is well over $1 billion. We understand that a significant 

portion of addicted individuals relapse to drug use. Further, we understand that, 

for the treatment of opioid depeudence, SAMHSA dedicates a great deal of funding, 

time and effort on the development and delivery of education and training activities 

with respect to substitution, or replacement therapies -medicines which can be 

diverted, traded, sold, smuggled and/or abused. Is it within the authority of 

SAMHSA to provide stronger guidance to States to use some percent of their block 

grant funds on FDA-approved non-addictive medications? 

Response: The authorizing statute for the Substance Abuse Prevention and Treatment 

Block Grant (SABG) does not provide SAMHSA the authority to direct states to dedicate a 

percentage oftbeir SABG funds to the use of specific types of medications. However, 

states have the flexibility to implement evidence-based practices that meet the needs of their 

respective jurisdictions and the use of interventions such as naltrexone combined with 

psychotherapy to treat opioid dependence have been highlighted in SAMHSA's 

consultations with state authorities as promising practices. As indicated above, SAMHSA 

also provides guidance through the Addiction Technology and Transfer Centers, 

Z7 See Quick Guide for Physicians Based on TIP 49 at http://store.samhsa.gov/shin/contentJ/SMAJ 0-4543/SMA 1O-4543.pdf: 

Quick Guide for Counselors Based on TIP 49 at http://store.samhsa.gov/shin/contentJISMAJ 0-4542/SMA JO-4542.pdf; and KAP 

Keys for Clinicians Based on TIP 49 at hltp:!lstore.samhsa.gov/shin/contenUiSMA J Q-4544/SMA J Q.4544.pdf. 

28 http://162. 99.3.213/products/manuaJs/pdfs/naltrcxonc.pdf. 

29 See illiQ.:/ /\\'Ww.attcnetwork.orgjfind!n_~ws!attcnews!epubs!addmsg/august20 12article .asp and 

http://w\llrw.attcnetwork.org/leam/topics!alcoho!lsm/treatment medications.asp. 

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publications, and training activities. 

5. Since the inception of the Medicaid program in 1965, inpatient psychiatric services 

provided in an IMD (Institution for Mental Disease) have been excluded from 

federal matching funds. This policy has been maintained over time in order to 

prevent federal Medicaid funds from financing long-term state psychiatric hospitals. 

However, in many States, this Medicaid IMD exclusion still serves as a hnge barrier 

to the availability of acnte inpatient treatment. In many commnnities across 

Georgia and the nation, the acnte inpatient psychiatric bed capacity has reached 

dangeronsly low levels, creating a genuine access crisis for emergency mental health 

services. 

a. Has SAMHSA compiled any data on the lack of acute in pat i e n t bed capacity 

and its consequences in terms of the burden placed on hospital emergency 

rooms, law enforcement and homeless services that you can share with the 

Subcommittee? 

Response: SAMHSA routinely reports the number of state psychiatric hospital beds 

available in its publication series Mental Health, United States. For more than 25 years, 

the Mental Health, United States series has presented nationwide measures of mental 

health. Published biannually by SAMHSA, the volume serves as the Nation's most 

comprehensive resource for mental health statistics. The data provide timely insights into 

the population's mental health status, the provision of mental health treatment, and 

funding for that treatment in the United States.3D 

In addition, Mental Health, United States, 2010 (Table 46) reported that the number of 

mental health organizations with 24-hour hospital/residential treatment 

settings (including all types of organizations) decreased from 3,039 in 1986 to 2,891 in 

2004. The number of beds per 100,000 civilian population in these organizations went 

from 111.7 in 1986 to 71.2 in 2004.31 

SAMHSA reported in Mental Health United States 2010 (Tables 113, 114, and 115) that 

in 2007 there were 232,636 psychiatric beds in state and local hospitals, beds in other 

state and local hospitals, private psychiatric hospital beds, and in all General Hospital 

psychiatric beds. 

In addition to the number of psychiatric hospital beds, SAMHSA has highlighted 

approaches to comprehensive crisis services in order to help prevent the need for 

emergency room visits and/or psychiatric inpatient services. These include: the 

development of crisis service delivery system guide to establish services or expand on 

existing services and make them more effective; support and knowledge dissemination of 

effective crisis respite services to alleviate pressure on emergency rooms; and suicide 

response crisis services. 

30 hnp:l/www.samhsa.gov/dataf2kI2IMHUS2010iMHUS-2010.pdf. 

)1 h!.\Jl:/i"ww.samhsa.gov/dataf2k 12/MHl)S20 1 O/MII..US-20 I O.pdf. 

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In addition, SAMHSA is aware of the CMS demonstration project that is testing whether 

Medicaid programs can support higher quality care at a lower total cost by reimbursing 

private psychiatric hospitals for certain services for which Medicaid reimbursement has 

historically been available. The demonstration project was authorized by section 2707 of 

the Affordable Care Act. The demonstration provides states with Federal Medicaid 

matching funds to reimburse private psychiatric hospitals for emergency inpatient 

psychiatric care provided to Medicaid recipients aged 21 to 64 who are experiencing a 

psychiatric emergency. 

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The Honorable Morgan Griffith 

1. What is the total amount of money that SAMHSA has spent on tobacco programs 

annually over the last five fiscal years? How does this compare with the total 

funding for mental health programs, including treatment, during that same tim e 

period? 

Response: SAMHSA has spent the following on tobacco programs over the last five fiscal 

years: 

FY 2008: 

FY 2009: 

FY 2010: 

FY 2011: 

FY 2012: 

$36 million 

$37 million 

$38 million 

$38 million 

$38 million 

In comparison, SAMHSA has spent the following on mental health programs in CMHS over 

the last five fiscal years: 

FY 2008: 

FY 2009: 

FY 2010: 

FY 2011: 

FY 2012: 

$911 million 

$969 million 

$1,019 million 

$1,022 million 

$994 million 

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The Honorable Renee EImers 

1. Is SAMHSA providing funding to organizations that support and promote taking 

away medical treatment for the mentally ill? 

Response: None ofSAMHSA's grants, cooperative agreements or contracts is for the 

purpose of supporting or promoting the denial of medical or other treatment for individuals 

with mental illness. SAMHSA only provides funding to organizations for the specific 

purposes of its grant, cooperative agreement and contract specifications, regardless of the 

views of the organization. Thus, no organizations are allowed to use SAMHSA funding for 

the purpose of supporting or promoting the denial of medical or other treatment for 

individuals with mental illness. 

2. What criteria do organizations have to meet before you would give them a grant, if 

they are supporting a treatment that is not something you would maintain is 

beneficial for treating mental illness? 

Response: SAMHSA does not give grants for treatments or services that are not beneficial 

for treating mental illness or substance use disorders. However, most grantees have state or 

Federal grants or other non-governmental resources in addition to the funds provided by 

SAMHSA. In general, SAMHSA grants may be awarded to domestic public or private, nonprofit or for-profit organizations. Some funds are designated by the Congress for certain 

entities (e.g., states and territories, governor-designated entities such as PAlMI programs, or 

non-profits only in some cases). For example, 67 percent of SAMHSA grants are formula 

grants provided directly to States under SAMHSA's authorizing legislation. Other than these 

state formula grants, eligible organizations may include state, local, and tribal governments; 

institutions of higher education; other non-profit organizations (including faith-based, 

community-based, and tribal organizations); and hospitals. Eligibility for a particular 

funding opportunity announcement is specified in the Grants.gov FIND synopsis, with more 

detailed eligibility information found in the funding opportunity announcement. On the basis 

of a statute, regulation or a limitation, with appropriate justification, described in a funding 

opportunity announcement, SAMHSA may limit eligibility to, or exclude from eligibility, 

classes or types of entities. Examples are limitations on the participation of foreign entities, 

and programs under which only small businesses are eligible applicants. 

An example of linking formulary grant eligibility or acceptance criteria to outcomes can be 

found in the Community Mental Health Services Block Grant (MHBG). This key source of 

funding for community-based services for adults with serious mental illness and children 

with serious emotional disturbance is used by states, territories and one tribe (hereinafter, 

states) to provide a range of mental health services and system infrastructure and capacity 

support described in their Block Grant application plans. Prior to grant award, states must 

demonstrate capacity and ability to report on performance and outcome data. SAMHSA's 

reporting systems collect and report state performance data on MHBG service recipients. 

SAMHSA provides monitoring and technical assistance to ensure successful grantee 

performance and improved outcomes for adults with serious mental illness and 

children/youth with serious emotional disturbance. 

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On the discretionary grant side, SAMHSA's Primary and Behavioral Health Care Integration 

program links discretionary grant eligibility or acceptance criteria to outcomes by requiring 

grantees improve the physical health status of adults with serious mental illness. Grantees 

must work as integrated clinical service communities to coordinate and integrate primary 

care services into publicly funded community mental health and other community-based 

behavioral health settings. Prior to grant award, applicants must demonstrate capacity and 

ability to report on performance and outcome data. SAMHSA's reporting systems collect 

and report grantee performance data on discretionary grant requirements. 

3. What are the details of the application process for organizations tbat want to receive 

grants from SAMHSA? 

Response: In order to maintain objectivity in the grant review process, all peer reviews for 

applications to programs supported by CMHS are performed by DGR. The peer review 

process is identical for all discretionary grant applications, regardless of the size or subject of 

award. Prior to submission to a peer review committee, every application is screened to 

ensure that basic eligibility requirements and program specific requirements as published in 

the RF A are met. Any applications that do not adhere to the administrative and 

programmatic eligibility screening requirements are screened out and not reviewed further. 

SAMHSA employs a rigorous process that treats all applications in a fair and equitable 

manner. Once an application clears the preliminary screening it is sent forward to a peer 

review committee. Each application is reviewed by three external reviewers who have been 

chosen because their expertise and education align with those identified as required to 

successfully implement the specific program. In addition to expertise, a concerted effort is 

made to include diversity in reviewer pools, therefore factors such as gender, ethnicity, and 

geographic location are considered but do not outweigh expertise. 

To ensure that all applications are reviewed in the same manner, peer reviewers are 

instructed to use the detailed assessment form created by DGR when scoring applications. 

The assessment form includes the detailed breakdown of all scored criteria from the specific 

program announcement. To ensure that reviewers are thorough and complete, reviewers 

must, for example, indicate the page number of the application where the response is found 

for each contributing factor. Reviewers must also write detailed comments for any criteria 

that they deem "Marginal" or "Unacceptable." Lastly, reviewers are asked to provide 

comments on the budget and participant protection elements of each application. While these 

two items are not scored, it still provides critical feedback for the applicants. 

Applications are then ranked in score order. In making funding decisions, SAMHSA utilizes 

this order ranking to determine a fundable range. Frequently SAMHSA receives more 

applications than it can fund. However, staff may consider other factors such as population 

focus andlor geographic distribution when determining awards and these factors are specified 

in the funding announcement. When this occurs, the justification for skipping applications is 

provided in the funding plan that is submitted to the Administrator. 

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The Honorable Henry A. Waxman 

I. Does SAMHSA use evidence-based approaches to identify how to prioritize its 

resources? Can you provide examples to the Committee? 

Response: Both SAMHSA's discretionary and formula grant portfolios place significant 

importance on the use of evidence-based practices. Discretionary grant RF As routinely 

include application criteria in which applicants must describe selecting, implementing, 

evaluating, and sustaining evidence-based practices as a requirement of the grant. 

Evidence-based programs form the basis of most key initiatives; a few examples include, but 

are not limited to, the National Children Traumatic Stress Initiative, Children's Mental 

Health Initiative, Homeless Prevention and Treatment for Homeless programs, Strategic 

Prevention Framework including the related Partnership for Success, Safe SchoolslHealthy 

Students, and the Screening, Brief Intervention, and Referral to Treatment program. In 

addition, SAMHSA supports the advancement of evidence-based practices by disseminating 

key evidence based behavioral health resources such as TIPs, Technical Assistance 

Publications (TAPs), the NREPPs, and evidence-based toolkits to the mental health and 

substance abuse delivery system further facilitating practice improvement. 

For formula grants, the MHBG application encourages state grantees to purchase evidencebased practices. This focus and subsequent reporting to SAMHSA through the performance 

measurement system, has contributed to more effective treatment through evidence-based 

practices for adults with serious mental illness and children with serious emotional 

disturbance. Data indicate a continual growth in both the number of children receiving 

evidence-based practices and the number of evidence-based practices established, and the 

number of adults reported to receive evidence-based practices increased. 

The President's FY 2014 Budget proposes to work with states to use at least five percent of 

their MHBG funds to award competitive grants to implement the most effective evidencebased prevention and treatment approaches, focusing on promotion, prevention and early 

intervention. This new set-aside and focus would be used by states to demonstrate how both 

MHBG and other funding streams can be utilized in the changing funding and service 

delivery environment to have the most positive impact on the health and well-being of the 

persons and communities served through these set-aside awards. 

2. Dr. Fuller Torrey, a witness on the second panel, stated in his testimony to the 

Committee that mass killings conducted by people with serious mental illness is 

"nota priority for them SAMHSA at all." Istbisaccurate? Whatsteps istbe 

agency taking to combat this problem? 

Res pOD se: This statement is not accurate. The Administration understands sometimes, 

particularly when untreated, mental illness can lead to suicide or a large-scale tragedy. Even 

for individuals with no likelihood of violence, untreated mental illnesses too often cause 

immense distress and can prevent people from living healthy, fulfilling lives. That's why the 

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85437.206

President's gun-violence-reduction plan includes a new $130 million initiative at SAMHSA 

to address several barriers that sometimes prevent people from accessing help. This initiative 

proposes to help teachers and others interacting with young people recognize signs of mental 

illness in students and refer them to mental health services if needed, support innovative 

state-based programs to improve mental health outcomes for young people ages 16-25, and 

train 5,000 more mental health professionals to serve students and young adults. SAMHSA 

looks forward to congressional support for those initiatives. 

At the same time, it is important to note that behavioral health research and practice over the 

last 20 years reveal that most people who are violent do not have a mental disorder, and most 

people with a mental disorder are not violent.32 Studies indicate that people with mental 

illnesses are more likely to be the victims of violent attacks than the general population.33 In 

fact, demographic variables such as age, gender and socioeconomic status are more reliable 

predictors of violence than mental illness.34 These facts are important because 

misconceptions about mental illness can cause discrimination and unfairly hamper the 

treatment and recovery of the nearly 20 percent of all adult Americans who experience a 

mental illness each year. 

In FY 2013, approximately 29 percent ($961.3 million) ofSAMHSA's funding was 

appropriated to support mental health programs and activities, with the remainder directed to 

substance abuse programs and activities. As directed by Congress, of the SAMHSA mental 

health funding, most ($915.3 million) supports prevention, treatment and recovery support 

programs and activities within CMHS. Approximately 48 percent ($436.81 million) of 

CMHS funding is directed toward the Community Mental Health Services Block Grant, 

which provides services and supports for adults with serious mental illness and children with 

serious emotional disturbance. The balance of the CMHS budget (52 percent) provides 

support for a range of mental health prevention, treatment and recovery support services, also 

as directed by Congress. In FY 2013, approximately 81 percent of the CMHS budget will 

support adults with and at risk for serious mental illness andlor children with serious 

emotional disturbance. Within the CMHS budget over the last five years, 75-80 percent of 

appropriated funding has been used for mental health programs in support of adults with 

serious mental illness and children with serious emotional disturbance. 

SAMHSA is extremely concerned about the violence perpetrated by and on persons with 

mental health conditions, and on the trauma that results from violent and mass casualty 

events, whether due to a weather related event, a man-made event, or the act of a person with 

mental illness or more often of persons with hate, terrorism, domestic violence, or other 

criminal intent. SAMHSA plays a critical role in the response to mass casualty events 

through its Disaster Technical Assistance Center, its Disaster Distress Helpline, its first 

responder training and disaster preparedness and response materials. SAMHSA also plays a 

32 Monahan J, Steadman H, Silver E, et al: Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. 

New York, Oxford University Press, 2001 and Swanson, 1994. 

33 Appleby, L., Mortensen, P. B., Dunn, G .. & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in 

r,eoplc with mental illness: a population-based study. The Lancet, 358, 2110-2112. 

4 Elbogen EB, Johnson sc. Arch Gen Psychiatry. 2009 Feb:66(2):152-61. doi: 10.IOOI/arehgenpsyehiatry.2008.537. 

~e intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related 

Conditions. 

28 
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85437.207

leadership role in addressing the primary violence that occurs by and against persons with 

mental health conditions, which are self-inflicted suicide attempts or death by suicide. In 

addition, SAMHSA staff members are active participants in the Nation Forum on Youth 

Violence Prevention. 

SAMHSA also plays a critical role in helping states and communities address the impact of 

trauma through its National Child Traumatic Stress Initiative. SAMHSA is also working 

closely with the White House, with other operating divisions within HHS, and with other 

Federal agencies such as VA and the Departments of Education, Justice, and Defense (DOD), 

to identifY ways to identify individuals with untreated behavioral health needs and build the 

capacity in communities, families and primary care settings to recognize and refer to 

treatment such individuals earlier in order to prevent negative outcomes for individuals and 

their families. The President's FY 2014 Budget proposes additional approaches in which 

SAMHSA will be able to reduce negative attitudes and increase mental health literacy so 

individuals with mental health needs and their families do not go unnoticed or become 

isolated without adequate treatment and support. For example, Project AWARE (Advancing 

Well ness and Resilience in Education) would increase awareness of mental health issues and 

connect young people with behavioral health issues and their families with needed services. 

Project AWARE State Grants ($40 million) would build on the Safe Schools/Healthy 

Students State Planning and Community Pilot Program, which is intended to create safe and 

supportive schools and communities. The second component, Mental Health First 

Aid (MHFA) ($15 million), proposes widespread dissemination of the MHFA curriculum 

and supports training to reach 750,000 students to identify mental illness early and refer them 

to treatment. In addition, the President's FY 2014 Budget includes $25 million for a new 

Healthy Transitions Program, to assist 16 to 25 year-olds with mental illnesses and their 

families to access and navigate behavioral health treatment systems. SAMHSA looks 

forward to congressional support for those initiatives. 

3. Dr. Fuller Torrey posited in his written testimony that "SAMHSA spends millions 

of dollars supporting programs which actively oppose effective treatments; funds an 

annual anti-treatment national conference; is more concerned about psychiatric bed 

availability in Iraq than in the U.S.; produces picture books for children; 

commission's paintings ($22,500); and holds an annual staff musical ($80,000)." 

Are these statements accurate? Can you provide context on the allegations made by 

Dr. Torrey? 

Response: These statements are not accurate. SAMHSA does not fund programs that 

actively oppose effective treatment for mental illnesses. SAMHSA does not fund an annual 

anti-treatment national conference. SAMHSA is not more concerned about psychiatric beds 

in Iraq than in the United States. 

Dr. Torrey has inaccurately referred to the Alternatives Conference as an anti-treatment 

annual conference. The purpose of the Alternatives Conference since first funded in 1985, 

seven years before SAMHSA's establishment, is to provide a forum for individuals with 

serious mental illnesses from all over the nation to meet, to exchange information and ideas, 

and to provide and receive technical assistance through hands-on skill-building, knowledge 

29 
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85437.208

development and knowledge application on topics such as effective treatments and supports 

(including medications, and evidence-based practices) and complementary services such as 

recovery supports and peer-support services reimbursed by Medicaid. SAMHSA's grant 

funding would not imply endorsement of an organization's policy positions in any case, but 

neither would SAMHSA provide funding to support any meeting or conference that is 

against treatment for mental or substance use disorders. 

With regard to the allegations about Iraq, SAMHSA began providing technical assistance in 

2004 to Iraq's Ministry of Health in its efforts to rebuild Iraq's mental health services sector. 

Such support included two conferences, one in 2005 and one in 2006 and two visits to 

various United States host sites by teams oflraqi behavioral health professionals in 2008 and 

2010. Discussions about availability of psychiatric beds in Iraq took place at the two 

conferences, at which SAMHSA provided input on a variety of behavioral health system 

issues ranging from the development of community-based services to institutional care. 

SAMHSA has produced a handful of picture books for very young children because 

according to scientific evidence it is more effective to communicate with very young children 

via picture books and visuals to help them understand mental health and help them recover 

from traumatic experiences. Age-appropriate intervention tools explain the importance of 

mental health and demonstrate ways to appropriately express feelings relevant to the age 

group (the coloring books are a good example of how a young child can learn about mental 

health and emotions). 

American Indian/Alaska Native (AllAN) populations have indicated a desire for materials 

and information produced by AI/AN individuals and sensitive to AllAN values and 

traditions. In 2010, SAMHSA engaged a Native American artist who is a person in recovery 

from alcoholism and depression and who has created images and posters for Native 

American substance abuse and other health and human services programs throughout the 

country. This individual, just as any graphic artist assisting with materials development, 

produced an original image in the form of a painting from which he printed posters including 

SAMHSA's phone number and website for information about behavioral health and ways to 

find treatment, as well as positive behavioral health messages. Mr. English also helped 

launch the public awareness effort at a small event at the SAMHSA building involving 

SAMHSA employees and representatives from the Indian Health Service as well as other 

HHS agencies. The posters were ultimately disseminated to tribal leaders throughout the 

country to post in their facilities and use in their programs and to individuals requesting the 

posters through SAMHSA's online store. 

SAMHSA staff is comprised of dedicated, creative and passionate professionals who care 

deeply about the issues they work on each day. To provide information about SAMHSA's 

programs, services, and issues and keep staff up to date on issues in the field, staff members 

sometimes conduct in-service trainings for their colleagues using experts in SAMHSA or 

other agencies. This process helps provide information for SAMHSA staff and for interested 

stakeholders and individuals in the field. SAMHSA's direct costs for this production were 

approximately $7,000 for set support and sound. 

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85437.209

Was the artwork painted by Sam English used as the basis for outreach materials? 

If so, how many tribes received the outreach materials on the topic of mental health? 

What value did these outreach materials play with regard to achieving a successful 

outcome for this program? 

Response: Yes, as outlined above, the artwork was used as the basis for outreach materials 

to the AI/AN community. SAMHSA has provided the posters, which include the image of 

an AI/AN community, ways to obtain information on behavioral health issues by listing 

SAMHSA's phone number and website, as well as positive behavioral health messages, to 

representatives of Federally-recognized tribes and tribal organizations who have requested 

the posters or who attended various tribal consultation events. The value added by the 

outreach materials is that culturally-appropriate public awareness materials were made 

available to reach the AIl AN population which responds best to materials and infonnation 

produced by AI/AN individuals and sensitive to AlAN values and traditions. Data from 

SAMHSA's National Survey on Drug Use and Health show that AI/AN individuals were 

more likely than persons from other racial/ethnic groups to have needed treatment for alcohol 

or illicit drugs in the past year and that the percentage of adults aged 18 or older having 

serious thoughts of suicide in the past year was 13.1 percent. These data show the 

importance of reaching the AIIAN popUlation in order to ensure that they receive treatment 

for behavioral health issues. 

4. Dr. Torrey's statement referred to the Vice President's Task Force on Gun Violence. 

He stated: 

To support the SAMHSA position it invited a psychiatrist, Dr. Daniel 

Fisher, to testity before the Biden Task Force. SAMHSA had to invite an 

outside psychiatrist because it has nobody among its 574 staff who has 

expertise on severe mental illness •... Dr. Fisher stated categorically to the 

Task Force that mental illness and violence are not linked, an assertion 

that is contradicted by more than 20 studies. Dr. Fisher, whose 

organization receives $330,000 each year from SAMHSA, is unusual in his 

belief that schizophrenia is not a disease of the brain, an assertion that is 

contradicted by literally hundreds of studies .... Rather Dr. Fisher 

describes the condition called schizophrenia as "severe emotiooal 

distress"or "a spiritual experience." This is apparently consistent with 

SAMHSA's position. 

Please comment on the role of SAMHSA 00 the Vice President's Task Force, and ou 

the accuracy of the statements above. 

Response: Dr. Torrey's statements related to the expertise ofSAMHSA staff on the topics 

of adults with serious mental illness and children with serious emotional disturbance are 

inaccurate. Dr. H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, is an expert in serious 

mental illness and has previously served as an associate clinical professor, Department of 

Psychiatry, University of Cali fomi a at San Francisco. In addition, SAMHSA's National 

Advisory Council includes experts in serious mental illness and serious emotional 

31 
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85437.210

disturbance including Dr. Stephanie Le Melle, Dr. Donald E. Rosen, and Dr. Benjamin F. 

Springgate. 

SAMHSA of course recognizes that schizophrenia is one of many diagnoses listed in the 

DSM-S, and is a serious mental illness. However, SAMHSA's statutory authority and 

mission do not permit the agency to limit its focus to only those individuals who experience 

specific diagnoses in the DSM-S. 

SAMHSA's role in the Vice President's Task Force on Gun Violence was to provide 

expertise on the issues of mental health promotion and early intervention, as well as on the 

state of the mental health workforce. Proposals related to reducing the impact of mental 

illness on America's communities were included in the President's Now is the Time plan. 

SAMHSA recommended potential meeting participants but did not decide which individuals 

or organizations from the mental health community would have an opportunity to meet with 

the Vice President's Task Force, but is aware that a wide range of behavioral health 

professionals representing psychology, social work, counseling, state mental health 

authorities, county behavioral health authorities, community mental health and substance 

abuse providers, along with advocates representing children and families who have 

experienced behavioral health issues, participated. No one testified for the Task Forcethese mental health experts and advocates were invited to a meeting with Secretary Sebelius 

and other Administration officials. 

5. Dr. Fuller Torrey asserted that SAMHSA did not collect data on people living with 

mental illness who receive social security benefits because agency officials "have no 

interest in these questions." Is this statement accurate? What barriers exist for 

SAMHSA to collect information on social security recipients? 

Response: The Social Security Administration is the Federal agency responsible for 

collecting data on individuals receiving Social Security Disability Insurance. The 

information that Dr. Torrey may be seeking can be found in the publication, Annual 

Statistical Report on the Social Security Disability Insurance Program, 2011, at Table 6 

(Distribution, by sex and diagnostic group, December 2011).35 SAMHSA uses this and other 

data for surveillance, program planning and policy purposes. 

6. Dr. Sally Satel, a witness on the second panel, testified: 

When I was on the Advisory Council from 2002 to 2006, we repeatedly were 

trying to have some input into the decisions regarding the grants that were 

approved but it was clear that we were pretty much there to rubberstamp 

those grants. They had already been approved. We asked repeatedly if we 

could see them prior to approval or if we could review them after approval 

and then have our assessment be reconsidered, and we were turned away 

J5 http://w\vw,ssa.e.ov!policy/docs/statcomps/di asr!20 11!sectO 1 b.pdf. 

32 
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every time. 

Can you explain the role of a mem ber of the Advisory Council? Do participants 

select the recipients of grants? 

Response: The Federal Advisory Committee Act defines an advisory committee as "any 

committee, board, commission, council, conference, panel, task force, or other similar group" 

that is "established or utilized" by the President or an agency "in the interest of obtaining 

advice or recommendations" for the President or one or more agencies or officers of the 

Federal Government." (5 U.S.c. App. 2 § 3(2» 

A member of an Advisory Council serves as a source of independent expertise and advicenot decision-making - on policy and program activities carried out by the committee. A 

member of an Advisory Council may make recommendations but does not make decisions on 

technical evaluation reports/summary statements for contract proposals, grants, and 

cooperative agreements. (Federal Advisory Committee Management Handbook, revised 

edition January 2003, Part I(E). 

The function of advisory committees is advisory only, unless specifically provided by statue 

or Presidential directive. [41 CFR 102-3.30(e)] 

Advisory committees are advisory only and do not select the recipients of grants. All 

SAMHSA councils and committees perfonn a policy and program advisory role and the three 

Center councils have an additional, legally required grant "second-level" review 

role. (SAMHSA Policy and Guidance Handbook for Advisory Committee Members, 

Section 2, revised May 2011) 

SAMHSA's peer review system, required by law (Section 504 of the Public Health Service 

Act) and known as a two-level review process, is used to ensure that knowledgeable, 

objective review of the technical merit and quality of grant and cooperative agreement 

applications is conducted before funding decisions are made by the officials in SAMHSA. 

Section 412 of the Health Professional Partnerships Act of 1998 (P.L. 105-392) amended 

section 504 of the Public Health Service Act by eliminating the requirement for council 

review of contracts. Thus, councils perfonn second-level review only for grant and 

cooperative agreement applications. 

The two-level review system involves: (1) peer review by an Initial Review Group; and 

(2) second-level review by a Center national advisory council. Although all competing grant 

and cooperative agreement applications are subject to peer review, generally only grant and 

cooperative agreement applications where the direct costs exceed $150,000 are subject to the 

second-level council review. The purpose of this second-level council review is primarily to 

assure the process used by SAMHSA to make decisions on grants using the peer review 

process is adhered to and is sufficient to assure objectivity, and is not intended to allow 

advisory council members to select grantees. 

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85437.212

The Honorable Paul Tonko 

1. What proportion of SAMHSA's mental health budget in 2013 funded the Consumer 

and Consumer-Supporter Technical Assistance and the Centers and the Protection 

and Advocacy for Individuals with Mental Illness program? 

Response: The National Consumer and Consumer Supporter Technical Assistance Centers 

consists of five grantees, three of whom are Consumer Technical Assistance Centers and two 

are Consumer Supporter Technical Assistance Centers. Each is funded at $330,000 annually 

for a subtotal of$I,650,000. The Consumer and Consumer-Supporter Technical Assistance 

Centers total funding for FY 2013 is $1,875,102 and represents 0.2 percent of the SAMHSA 

Mental Health appropriation of$915 million. 

The PAlMI program is 3.75 percent ofSAMHSA's FY 2013 mental health budget. 

2. What important services do these two programs provide to people living with serious 

mental illness? 

Response: The Technical Assistance Centers assist in the transformation of the mental 

health system by promoting services for adults with serious mental illnesses. They promote 

skill development for individuals with mental illnesses (sometimes called consumers) with an 

emphasis on business and management; strengthening consumer organizations and leadership 

in communities; collaboration with other consumers, families, advocates, providers, and 

administrators; coalition building; self-management/self-help approaches to symptom and 

illness management; evaluation and policy formation; and building opportunities for 

meaningful paid employment. 

Most of the requests received by the Technical Assistance Centers are for materials; referrals 

to self-help groups and clinical and non-clinical services; and for trainings. The Technical 

Assistance Centers have available 169 English-language materials and 23 English-language 

written training curriculums. The majority of the written training curriculums focus on 

Assertive Community Treatment teams, recovery, and self-help or organizational skills. The 

Technical Assistance Centers also have 29 written training curriculums or materials in nonEnglish languages: 17 in Spanish, ten in Japanese, and two in French. 

As mentioned in response to previous questions, the purpose of the PAlMI program is to: 

(l) ensure that the rights of individuals with mental illness are protected; (2) assist states to 

establish and operate a protection and advocacy system for individuals with mental illness, 

which will protect and advocate the rights of such individuals through activities to ensure the 

enforcement of the Constitution and Federal and state statutes; and (3) investigate incidents 

of abuse and neglect of individuals with mental illness if the incidents are reported to the 

system or if there is probable cause to believe that the incidents occurred. 

3. In contrast, what percentages of SAMHSA's mental health funding went directly to 

States to support mental health treatment services in 2013? 

34 
200 


85437.213

Response: Over half(54.8 percent) ofCMHS funding will go directly to states to support 

mental health treatment services for people with serious mental illness in FY 2013. 

Approximately 81 percent ofSAMHSA's total CMHS budget for FY 2013 will support 

adults with and at risk for serious mental illness and/or children with serious emotional 

disturbance, with grants to states, communities, and other entities. Within the CMHS budget 

over the last five years, 75-80 percent of all appropriated funding has been used for mental 

health programs in support of adults with serious mental illness and children with serious 

emotional disturbance. 

4. What efforts has SAMHSA undertaken to specifically address the issue of mental 

health stigma and what type of investment do you think is necessary to truly change 

public opinion on this issue? Are there specific statistics or metrics used by 

SAMHSA to quantify the impact that mental health stigma has on the rate of 

untreated mental illness? 

Response: SAMHSA has been working on the issue of negative attitudes associated with 

mental illnesses since its formation in 1992. SAMHSA has invested in many grants and 

programs not only to help individuals with mental illnesses find the help thcy need, but also 

to change the external prejudice and discrimination associated with mental illnesses and the 

internal shame and embarrassment that often prevents people from seeking help. SAMHSA 

has done this through a multitude of programs including the What a Difference a Friend 

Makes Campaign; the SAMHSA Voice Awards program; the Resource Center to Promote 

Acceptance, Dignity, and Social Inclusion; National Children's Mental Health Awareness 

Day; suicide prevention awareness campaigns; and many more. Although these programs 

have shown to be effective based on evaluations, much more can be done to bring mental 

illness out of the shadows and be considered by the American public as an acceptable 

condition for which to seek help. SAMHSA does track survey data in SAMHSA's NSDUH 

that shows that negative attitudes and prejudice associated with mental illnesses are one of 

the top reasons individuals avoid seeking treatment and services, and also the fear of 

disclosing a mental illness to an employer inhibits individuals from seeking treatment. Many 

national surveys show that the fear of social rejection, prejudice, and discrimination has a 

chilling effect on help seeking. SAMHSA will continue working to educate people about the 

importance of behavioral health issues as public health issues; to help reduce negative 

attitudes, prejudice and misinformation about behavioral health, mental illness, and 

addictions; and to encourage individuals and families to seek services when they experience 

mental health and/or substance abuse conditions. 

In addition, SAMHSA is participating in the coordination and planning process for the White 

House's National Conference on Mental Health scheduled for this summer. The purpose of 

the event will be to discuss how we can all work together to reduce negative attitudes and 

perceptions about mental illnesses, encourage people experiencing mental health problems to 

reach out for help, and encourage friends and family members to support their loved ones and 

connect them with help. 

35 
201 


85437.214

5. Can you briefly describe the work that SAMHSA does in the area of suicide 

prevention and discuss what programs like the National Suicide Prevention Hotline 

are having on reducing the rate of suicide in the United States? 

Response: SAMHSA provides grants to states, tribes and colleges for youth suicide 

prevention, as authorized by the Garrett Lee Smith Memorial Act. Since the start of the 

program in 2005, 49 states, 44 tribes, one territory, and 146 college campuses have received 

funding for their youth suicide prevention efforts. SAMHSA also funds the National Suicide 

Prevention Lifeline, a network of 161 crisis centers across the United States which answers 

calls through the toll free number 1-800-273-TALK (8255). The Lifeline currently answers 

over 80,000 calls per month. SAMHSA-funded evaluations have found that approximately 

25 percent of callers to the Lifeline are suicidal at the time they make the call, approximately 

20,000 callers per month. The crisis centers 2417 live trained responders provide crisis 

intervention, emergency rescue when needed, referral to mental health treatment providers, 

and other services as well as follow up for suicidal callers. The Lifeline also provides a crisis 

chat service, and works in collaboration with V A and DOD to route the more than 17,500 

callers every month who press" I" to the Veterans Crisis Line. 

SAMHSA also funds the Suicide Prevention Resource Center and participates in and helps 

support the National Action Alliance for Suicide Prevention, a public-private partnership cochaired by former Senator Gordon Smith and Secretary ofthe Army John McHugh. Last 

year, the Action Alliance, working together with the Surgeon General of the United States, 

released a revised National Strategy for Suicide Prevention. While it is not possible to say 

what the rate of suicide in the United States would he without these programs, SAMHSA 

believes that its suicide prevention programs are saving lives. The effort has a goal of 

reducing the number of deaths hy suicide over the next five years. 

36 
202 


85437.215

Mr. Joe Bruee 

198 ;vlain Street 

Caratunk. IVI E 04925 

D~ar :VII'. Bruce: 

June 6, 1013 

Thank you for appearing before the Suhcf>l11mittee 011 Oversight and Investigations on 

Wednesday. May 22. :::013, to testil) at the hearing entitled "Examining SA:VIIISA's Role in Delivering 

Services to the Severely Ylcntally III." 

Pursuant to the Rules "fthe Committee on Ener(!v and Commerce, the hearing record remains 

open for ten business days to permit Members to submit';;dditional questions for the I';;cord, which arc 

attached. The fonnat of your responses to these questions should be as follows: (I) the name of the 

IVlember whose question you arc addressing, (2) the complete text of the question you are addressing in 

bold. and (3) your answer to that question in plain text. 

Tc) facilitate the printing of the hearing record, please respond to these questions by the close of 

business on ThursdllY, June 20, 2013. Your responses should be c-ll1ailcd to the Legislative Clork in 

\Vord format at bril1anv.havens0)mail.housc.gov and mailed to Brittany Ilavons, Legislative Clerk, 

Committee on Energ~ and ComJ11erce, 2125 Rayburn House omce Building, Washington, D.C. 20SIS. 

Thank you again for your time and efrort preparing and delivering testimony before the 

Subcommittec_ 

Sincerely. 

Tim \1urphy 

Chairman 

Subcommittee on Oversight and Investigations 

cc: Diana DeGette, Ranking \,lember, Subcommittee on O\-er,ignt and Investigations 

Attachment 
203 


85437.216

The Honorable Tim Murphy 

1. You have said that the mental health system, as it is currently constituted, 

seems designed to handicap families in their efforts to obtain the best 

treatment and long-term outcomes for their loved ones. In his book, Out of 

the Shadows, E. Fuller Torrey discnsses the different ways of ensuring 

accountability for and measuring performance of mental health services. He 

gives the example of the Riverside County Department of Mental Health in 

California that employs a full-time Family Advocate whose job is to solicit 

information from families about problems in the county meutal health 

treatment system. 

a. Could a Family Advocate, or someone like it, have been helpful to 

you while your son was committed to Riverview? Why or why not? 

I have read Dr. E. Fuller Torrey's comments that any organization funded by the 

government or by the pharmaceutical industry will find it difficult to criticize either. It is 

an excellent point that I have to agree with. 

Rather than set up separate family advocacy systems, a more immediate and effective 

remedy is to rewrite HIP AA and PAlMI to remove barriers to family participation in the 

care of adult patients. In my opinion, three changes should be made to these statutes and 

regulations. 

FIRST, as Peter Mills of Maine has suggested, "Mental health workers should have 

greater latitude in communicating with caregivers who are providing daily care for 

someone outside an institution. A limited sacrifice in privacy is the price that a patient 

should reasonably pay to receive effective care in the least restrictive setting." 

I agree and respectfully suggest the following provisions (courtesy of Peter Mills) be 

added to HIP AA: 

"Caregiver" is a person including a family member who shares responsibility for 

the day-to-day care or protection of an individual with mental illness. 

If an individual with mental illness withholds consent for disclosure because of 

compromised insight into the nature and extent of the illness, a provider may, 

without the consent of the individual, disclose to caregivers such protected health 

information as the provider reasonably believes is necessary either for the health, 

safety. or welfare of the individual or for the safety of others. 

A provider is not liable for failing to make a disclosure in those instances where a 

threat is not serious and imminent and the disclosure would. in the provider's 

good faith judgment, interfere with rendering effective care. 

SECOND, I urge that Congress enact an amendment to PAlMI to prevent the Patient 

Advocates from supporting the rejection of treatment by severely mentally ill patients 

who lack insight into their illness. Peter Mills wrote the following on this subject: 
204 


85437.217

"Approximately half the people with schizophrenia and 40% of those with bipolar 

disorder go through periods of 'anosognosia', a deficit of awareness or lack of 

insight into the nature and extent of the illness. 

"In 1986, Congress passed the 'PAlMI' law (for Protection and Advocacy for 

Individuals with Mental Illness) to create P&A ('Protection and Advocacy') 

systems in aliSO states to prevent abuse and neglect of people with mental illness. 

It was modeled on an earlier statute to protect those with developmental 

disabilities. 

"While the statute might have been written to focus on effective care, protection 

and treatment, it is worded instead to speak of ' rights.' In fact, there is a bill of 

rights appended to the law. 

"The right to treatment has often been interpreted to include the right to reject 

treatment even if rejection makes the illness worse, causes permanent harm and 

leads to loss of liberty, incarceration or death. 

"Does a patient with anosognosia have the right to a publicly paid advocate whose 

mission is to block the delivery of effective care? Does the right to reject 

treatment translate into the right to remain psychotic? What is an advocate to do 

when a delusional rejection of treatment conflicts with the right to receive 

treatment? 

"PAlMI should define the advocate's role to resolve this common and difficult 

conflict. It might be done either by prohibiting the advocate from interfering with 

necessary treatment or, at the very least, by granting the advocate discretion not to 

interfere even when the patient insists. 

"In 42 USC 10802 add the following definition as a new paragraph 6: 

"(6) The term 'rights of individuals with mental illness' includes a right to 

suitable care, protection and treatment. An advocate may not support an 

individual's rejection of necessary treatment ifthe rejection arises from lack of 

awareness of a mental illness or lack of insight concerning the nature or extent of 

a mental illness. 

"or 

"(6) The term 'rights of individuals with mental illness' includes a right to 

suitable care, protection and treatment. An advocate may refuse to support an 

individual's rejection of necessary treatment if the rejection arises from lack of 

awareness of a mental illness or lack of insight concerning the nature and extent 

of a mental illness." 

Personally, having seen the philosophical inclinations of the patient advocates first hand, 

I prefer the first suggested alternative because it removes discretion from the advocates to 

support a refusal of treatment. 
205 


85437.218

THIRD, the Patient Advocates should be prohibited from lobbying. As Peter Mills wrote: 

"Protection and Advocacy (P&A) groups have often ignored prohibitions against 

lobbying. In Maine, they intervened to make it more difficult for a parent to 

become the guardian of an adult disabled child. Throughout the U.S. they have 

vigorously opposed passage of outpatient treatment laws even though these laws 

have been successful in providing "least restrictive alternatives" for treatment. 

"Although these laws enhance freedom and opportunity for the mentally ill, 

advocates on SAMHSA's payroll have often shown up to oppose such measures 

in state legislatures. 

"To the extent that lobbying has been justified by the fact that P&A groups 

receive some oftheir funding from non-federal sources, the law should perhaps be 

changed to prohibit lobbying by a P&A group that receives any funding under 

PAlMI. 

"Law Professor Amanda Peters concluded: 

'The only effective way of preventing lobbying is to do as Congress has 

done with the Legal Services Corporation: consider passing additional 

laws that prevent patient advocates from using any funds to lobby, set up 

an agency to closely monitor their spending and lobbying efforts, and 

come up with a plan to unfund or otherwise punish advocates who 

nevertheless engage in such activity.' 89 Oregon Law Rev. 133, 156." 

* * * 

In conclusion, I believe that these three changes would not only have helped the Bruce 

family, but would help families with severely mentally ill loved ones across the country 

and be in the best interests of the severely mentally ill themselves. Like the mothers of 

severely mentally ill individuals I have met from across the country, Amy Bruce was the 

greatest advocate our son could ever have had. Opening the iron curtain of HIPAA to 

allow family members to be involved in their adult loved ones' treatment would 

simultaneously increase the efficacy of that treatment and provide costless oversightwhich is currently lacking - of the activities of the individual patient advocates and of the 

entire system. In the case ofthe Bruce family it would likely have saved Amy's life. 

Thank you for giving me this opportunity to give you my thoughts on this important 

subject. 

Sincerely, 

Robert (Joe) Bruce 

Caratunk, Maine 
206 


85437.219

Dr, E. Fuller Torrey 

Founder 

Treatment Advocacy Cemer 

6204 Ridge Drivc 

Bethesda. MD 208 16 

Dear Dr. Tnrrey: 

June 6, 2013 

Thank you for app<:'aring before the Subcommittee 011 Ove-I'sight and Investigations on 

Wednesday. \1ay 22. 2013. to kstify at Ihe hearing entitled "Examining SAMHSi\'s Role in Delivering 

Services to (he Severely \1enlally III." 

Pursuant to the Rules of the COlllllliuce 011 Energy and Commerce, the hearing record remains 

open ftlr len husiness days (0 permit Members to submit additional questions for the record. which arc 

attached. The format of your responses to these questions should be as foll,'''"s: (I) the name oflhe 

:Vlclllbcr whose question you are addressing. (2) the complete teAt onhe question you arc addressing in 

bold. and (3) your answer to that question in plain text 

To facilil<lte the printing of the hearing record, please respond to these questions by the close of 

business on Thursday, June 20, 2013. Your responses should be ,,-mailed to the Legislative Clerk in 

Word format at brittanv.havens@n.mil.house.gov and mailed to Brittany Havens, Legislative Clerk. 

Committee on Energy and Commerce. 2125 Rayburn House Office Building. Washington. D.C. 20515. 

Thank you again for your time and effort preparing and delivering teslimony before the 

Subcommittee. 

Sincerely, 

Subcommittee on Oversight and Investigations 

cc: Diana DeGette, Ranking Member. Sl1bcommittee on Oversight and Investigations 

i\tl3\:hll1~l1t 
207 


85437.220

The Honorable Tim Murphy 

1. Patients and health providers have their advocates. What about the families of the mentally 

ill? What about people like Joe Bruce? 

a. In your book, Out of the Shadows, you discuss the different ways of ensuring 

accountability for and measuring the performance of mental health services. You 

give the example of the Riverside County Department of Mental Health in 

California that employs a full-time Family Advocate whose job is to solicit 

information from families about problems in the county mental health treatment 

system. As far as you know, has the practice expanded since your book came out? 

Would it help? Why or why not? 

I described the Riverside County family advocate program as it existed in the mid-1990s. 

At that time, the county had an excellent Director of Mental Health who was very 

interested in improving the county's services for individuals with serious mental 

illnesses. The family advocate program has continued in Riverside County and has spread 

to approximately six other counties in California. However, its usefulness depends 

largely on the interests ofthe county Director of Mental Health. In Riverside County, for 

example, the person who replaced the man who started the program has had less interest 

in using the information. 

Do such programs help to improve services? They certainly can do so by providing 

ongoing input from patients and families to county officials regarding what is and is not 

working and weaknesses in their programs. This assumes, of course, that the county 

officials want such information, which is currently not true except in unusual instances. 

County officials will want such information only if they are being evaluated on how well 

they are doing their job and are being held responsible for patient outcomes. Presently, 

because ofthe thought-disordered way we are funding mental illness services, county 

officials are largely judged on a single criteria, and that is how successful they are in 

shifting the cost of services from the county and state to federal sources, especially 

Medicaid and Medicare. If the primary funding for mental illness services was shifted 

from the federal government back to the states, as existed prior to 1963 when the federal 

Community Mental Health Centers Act was passed, and the states were held fully 

responsible for mental illness services, then the use offamily advocates would become 

wi despread. 

b. Is SAMHSA presently funding programs that promote the spread of Family 

Advocates? Should they be? 

SAMHSA has funded, and currently is funding as far as I know, Mental Health America 

(MHA) and NAMI, the two largest associations of family advocates. I do not believe that 

SAMHSA or any other government agency, federal or state, should be funding such 

advocacy groups, since it renders them completely ineffective as advocates. For family or 

patient mental illness advocacy groups to be effective, they must be able to publicly 
208 


85437.221

criticize government agencies which are failing to do an adequate job on services and/or 

research. Without this ability such advocacy groups are effectively emasculated, and 

operate merely with the appearance of being an advocacy group but without any ability to 

do so. 

Government agencies, of course, know this and that is why they fund the advocacy 

groups. Thus when SAMHSA was recently being criticized, Mental Health America 

publicly sprang to SAMHSA's defense and suddenly decided to give SAMHSA 

Administrator Pamela Hyde a public award. Similarly, the majority of state NAMI offices 

now receive the majority of their funding from the state departments of mental health 

(e.g., in New York State it is 92 percent), and are thus unable to criticize the departments. 

As state mental illness services have deteriorated progressively over the past two 

decades, it is remarkable how quiet most state and national NAMI and MHA groups have 

been. For advocacy groups to be effective, they must be completely financially 

independent from the government agencies which are the objects oftheir advocacy. This 

is why the Treatment Advocacy Center, which I founded, has never accepted any funds 

from government agencies or from pharmaceutical companies. 
209 


85437.222

The Honorable Panl Tonko 

1. Dr. Torrey, you have been an outspoken critic ofSAMHSA for quite some time and have 

repeatedly called for its abolishment. You acknowledge, however, that some programs at 

SAMHSA have merit and value. In your opinion, what are the "good programs" at 

SAMHSA that you would like to keep and potentially expand? 

I have indeed called for the abolishment ofSAMHSA for more than a decade but have never said 

that SAMHSA did not have some programs of merit and value. Such programs would be much 

more valuable, however, if transferred to other agencies, such as was proposed by Senator Tom 

Coburn in his analysis ofSAMHSA in his 2011 report, "Back in Black." Examples ofSAMHSA 

programs which I believe have some merit include: 

• The data collection branch: This branch has competent staff but is badly underutilized 

because they are not asked to collect the most relevant data. For example, they collect 

data on the decreasing number of public psychiatric beds available but do not collect data 

on the logical corollary: where to such patients go ifthe beds are no longer available? 

The answer is to jails, prisons, and the streets. 

• Integrated "wraparound" services for adolescents with mental illness and substance abuse 

disorders: Some of these programs are excellent. However, SAMHSA should fund such 

programs as demonstration projects, not pennanent funding. They should carefully 

evaluate what works and what does not work. and demonstrate how these programs 

ultimately save money. 

• Programs for homeless individuals with serious mental illness: Some of these programs 

have been very useful. Like the "wraparound" services, however, they should be funded 

as demonstration programs with careful cost-benefit evaluations, not as permanent 

federal funding as is now the case. Another shortcoming of this program is SAMHSA's 

requirement that the mentally ill homeless persons being served by the program must 

agree to the services. This assumes that the mentally ill individual is aware oftheir own 

illness and need for treatment. I personally volunteered for 16 years in free clinics for 

homeless individuals in Washington, D.C. and can testity that no more than one-quarter 

of homeless mentally ill individuals are aware of their illness and need for treatment. The 

other three-quarters have a lack of awareness of their illness caused by damage to the 

brain by their mental illness, a condition we call anosognosia. Thus this SAMHSA 

program, which is one of the agency's best programs, is ineffective for three-quarters of 

its target population. 

• Mental Health Block Grant: In theory, this should be one of SAMHSA's best programs 

and in fact it does some good, not because of SAMHSA but despite SAMHSA. The 

purpose of these Block Grants, as described in federal statutes (section 300, formula 

grants to states, under Title 42, The Public Health and Welfare) is to improve 

"community mental health services to individuals who are either adults with a serious 
210 


85437.223

mental illness or children with a serious emotional disturbance." The target population 

for these Block Grants is thus clearly prescribed by law. However, SAMHSA has its own 

priorities for the mental health Block Grants, as detailed on its website: "SAMHSA 

strongly recommends that Block Grant funds be directed ... to fund ... prevention activities 

and services for individuals not identified as needing treatment." Since we have no 

knowledge of how to prevent serious mental illnesses, to order the funds for this program 

to be used for prevention and for individuals "not identified as needing treatment" is 

absurd and probably illegal. 

• Specifically regarding your Congressional district (21" New York) I would like to point 

out one other important shortcoming of SAMHSA. In 1977, a study was done in Albany 

County in which the number of homicides committed by mentally ill individuals for the 

period before wholesale discharges from psychiatric hospitals (1963-69) was compared 

with the number of homicides after discharges were underway (1970-75). A lthough the 

number of homicides by non-mentally ill individuals did not change between the two 

periods, the number of homicides by seriously mentally ill individuals increased from one 

(an eighty-two-year-old man with dementia) to eight, all of whom were diagnosed with 

schizophrenia. These eight individuals were responsible for 29 percent of all homicides in 

the county during the six-year period. The authors of the study recommended that 

additional studies be done and concluded that "closer follow-ups of psychotic patients, 

especially schizophrenics, could do a lot to improve the welfare of the patient and the 

community."; Such additional studies, which should have been done by SAMHSA, were 

never done and "closer follow-ups of psychotic patients" never took place. That is why 

your Congressional district and every other Congressional district, has continued to see a 

minimum of 10 percent of all homicides committed by seriously mentally ill individuals 

who are not being treated. This issue has been completely ignored by SAMHSA. 

Please let me know if you have additional questions. 

E. Fuller Torrey MD 

Founder, Treatment Advocacy Center 

'F. Grunberg, B.I. Klinger, and B. Grumet, "Homicide and deinstitutionalization ofthe mentally ill," American 

Journal afPsychiatry 134 (1977): 685-87; F. Grunberg, B. I. Klinger, and B. R. Grumet, "Homicide and 

community-based psychiatry," Journal afNervous and Menial Disease 166 (1978): 868-74. 
211 


85437.224

Dr. Sally Satcl 

Resident Scholar 

American Enterprise Institute 

1150 17th Street, N.W. 

Washington. D.C. 20036 

Dear Dr. Satel: 

June 6. 201 3 

Thank you for appearing bej()re the Subcommittee on Oversight and Investigations on 

Wednesday. :V1ay 22. 2013. to (cstilYat the hearing entitled "Examining SAMHSA's Role in Delivering 

Services to the Severely :Vlentally Ill." 

Pursuant to the Rules of the Committee on Energy and Com111erce, the hearing record remains 

open j\)I' tcn busincss days to permit [V!cmbers to submit additional questions for the record. which arc 

attached. The format of your responses to these questions should be as follows: (I) the name of the 

Member "hose question you are addressing. (2) the complete text of the question you are addressing in 

bold. and (3) your answer to that question in plain text. 

To facilitate the printing of the hearing record. please respond to these questions by the close of 

business on Thursday, .hme ~O. 2013. Your responses should be e-mailed to the Legislative Clerk in 

Word format at hrilt[\Ill'.havens'(/)mai!.house.gov and mailed to Brittany Havens. Legislative Clerk, 

Committee on Energy and Commerce. 2125 Raybul"tl Ilouse Office Building, Washington. D.C. 20515. 

Thank you again 1<)1' your time and effort preparing and delivering testimony hefore the 

Subcommiuec. 

Sincerely. 

Tim Murphy 

Chairman 

Subcommittee on Oversight and Investigations 

cc: Diana Denette, Ranking Member. Subcommittee on Over,ight and Investigations 

Attachment 
212 


85437.225

The Honorable Tim Murphy 

Attn. Brittany Havens 

Legislative Clerk, Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, D.C. 20515 

Dear Congressman Murphy 

Thank you for your dedication to this issue. You ask: 

June 10, 2013 

Do you see any benefit in de-monopolizing the Protection & Advocacy system altogether? That 

is, allowing states to select attorneys for individual representation on a competitive basis, rather 

than contracting these representations out to a designated organization in each state, like the 

Disability Rights Center of Maine in Mr. Bruce's Case? 

As a rule, SAMHSA should not enter into contracts with or endorse any clinical or legal entity 

that is averse to or dismissive of the practices mainstream psychiatry. I am referring here, 

specifically, to the appropriate use of psychiatric medication, involuntary hospitalization or 

mandated outpatient care. 

I see potential benefit in allowing states to select attorneys to represent severely mentally ill 

patients in commitment proceedings, but there must be a mechanism of some sort for HHS to 

override a state's choice if the attorney chosen rejects the practices of mainstream psychiatry. 

Given the popularity ofthe "recovery model" at the level of state mental health departments 

(granted, far more pronounced in some states than others), simply allowing states latitude is not a 

guarantee of reasonable representation. 

Thank you for your attention 

Sally Satel MD 

1150 Seventeenth Street, NoW" Washington, D.C. 20036 202.862.5800 www.aeLorg 
213 


85437.226

Dr. Joseph Parks. III 

ChicrClinicalOfficer 

"'lissom; Dcpal1l11cl1t of:vlenral Health 

1706 East Elm Strc('t, 1',0. Box 687 

Jefferson City. :,,10 651 02~0687 

DcaI' Dr. Parks: 

June 6. 20 1J 

Thank you Ii)!' appearing hefore the Subcommittee on Oversight and Imcstigatio!1s on 

Wednesday. May 2~. 2013. to testify at the hearing entitled "Examining SAMHSA'5 Role in Delivering 

Services to the 5e,erely \'1cntaily III." 

Pursuant to the Rules of the Committee on Encru:\' and Commerce. the hearing record remains 

open fm ten businc" days to permit Members to submit~;dditional questidns for the r~cord, which are 

attached, The format ofyollr responses to these questions should be as follows: (I) the name ofthc 

Member whose qnestion you arc addressing, (2) the complete text orthe question you arc addressing in 

bold, and (3) your answer to that question in plain text, 

To facilitate the printing ofthc hearing record, please respond to these questions by the close of 

business 011 Thursday, JUlle 20,2013. Your respollses should be e-l11ailed to the Legislative Clerk in 

Word format at brittal1\',havens'@mail.housc,govand mailed to Brittan\' Havens, Legislative Clerk. 

Committee on Energy and Commerce, 2125 l{ayburn ! louse omce Building, Washi~gt(}n. D,C. 20515. 

Thank you again for your time and elTol1 preparing and delivering testimony bet()re the 

Subcommittee, 

Sincerely, 

Tim Murphy 

Chairman 

Subcommittee on Oversight and Investigations 

cc: Diana DcGene. Ranking Member. Subcommittee on Oversight and Investigations 

Attachment 
214 


85437.227

June 24, 2013 

Brittany Havens 

Legislative Clerk 

Committee on Energy and Commerce 

2125 Rayburn House Office Building 

Washington, DC 20515 

Dear Ms. Havens: 

As a follow up to the questions from Rep. Waxman in regard to the Subcommittee on 

Oversight and Investigations Hearing on "Examining SAMHSA's Role in Delivering 

Services to the Severely Mentally Ill," please find attached my responses to each 

question for Rep. Waxman's consideration. 

I appreciate the opportunity very much to respond to these critically important 

questions, as it helps to further expand on my written and oral testimony provided 

at the May 22 Oversight Sub-committee hearing on SAMHSA's initiatives. 

I would be pleased to respond to any follow up questions based on the enclosed 

additional remarks, or additional questions that may arise during your 

deliberations. 

Thank you again for inviting me to testify at the May 22 Oversight Hearing, and the 

opportunity to address further queries through this written submission. 

o eph Parks, M.D. 

40 E Highway 163 

Columbia, MO 65201 
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Responses to Rep. Waxman's Follow-Up Questions 

Can you explain how SAMHSA's Co-Occurring State Incentive Grants (COSIG) 

helped your state improve the ability of community mental health centers and 

substance abuse treatment agencies to promptly and effectively serve people who have 

both mental illness and substance abuse conditions simultaneously? Is this program 

still in effect? What steps can Congress take? 

The COSIO grants improved the ability of both community mental health centers and substance abuse 

provider agencies, to serve persons that had both mental illness and substance abuse concurrently. 

Prior to these grants it would be common for a person who had both serious mental illness and 

addiction to be told by the community mental health center that they could not be treated for their 

serious mental illness until their addiction was treated and substance abuse treatment agencies would 

not treat them until their serious mental illness was stable. COSIO provided training and technical 

assistance so that both Community Mental Health Centers and Substance Abuse Treatment Agencies 

became competent and comfortable working with patients who have co-occurring Mental illness and 

addiction. 

Since the COSIO grants have been in place, there is truly "a no wrong door" approach by community 

mental health centers and substance abuse treatment provider agencies in both welcoming the person 

needing treatment and engaging them immediately. This is a particularly important improvement with 

respect to reducing violence by persons with mental illness. The presence or absence of a substance 

use disorder is the major predictive factor of whether or not a person with mental illness will be more 

violent than a person without mental illness. In addition, integrated treatment of substance abuse and 

mental illness is more effective than treating only one condition and more efficient than treating the 

conditions simultaneously through using two different clinics or programs. 

The COSIO grant program has ended, but further progress is needed. Congress should provide 

funding to SAMHSA for a new round of COSIO grants. 

How do you anticipate the Affordable Care Act will impact services for people living 

with mental illness in your state? 

Much of the impact ofthe ACA in Missouri hinges on whether or not Missouri expands Medicaid. 

If Missouri chooses to expand Medicaid to 138% of poverty, THE Department of Mental Health 

(DMH) prevalence estimates and utilization trends tell us that nearly 50,000 of the 300,000 newly 

eligible Missourians will obtain treatment annually through DMH: 65% for substance abuse 35% 

for serious mental illness. Most will not be new to DMH. About 34,000 of those individuals - now 

indigent who would qualify under Medicaid expansion would seek DMH services annually anyway, 

whether or not the state expands Medicaid coverage. Services for these indigent clients are now 

covered fully by state or block grant funds, or through charity care delivered by DMH's contracted 

community behavioral health providers. Without insurance or Medicaid coverage, indigent care 

services are limited and crisis focused. Today, the average annual cost for individuals receiving DMH 

behavioral health services is about $2,800. The cost of adding 50,000 consumers is about $140 

million. The 10% state match ultimately required by Medicaid expansion is $14 million and can be 

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fully funded from cost offsets in DMH's core budget as indigent our consumers become Medicaid 

eligible. Missouri's mental health system is now largely focused on Medicaid eligible individuals to 

maximize limited funding. Most of its community program dollars serve people who are categorically 

Medicaid eligible by disability determination, and for their ancillary services that Medicaid doesn't 

cover. Unfortunately, only a small percentage of Missourians with substance use disorders now 

qualifY for Medicaid. And young adults, in early stages of serious mental illness, only become 

Medicaid-eligible after being determined disabled, usually through a lengthy federal eligibility 

process that is extremely difficult to navigate for people with mental illnesses. 

DMH's behavioral health system turns away 100,000 Missourians annually. What this means, in realworld terms, is that most young adults, beginning to experience mental illnesses, like Schizophrenia 

or Bipolar Disorder, will go for years with inadequate treatment, or none at all. As their illnesses 

progress, they move from crisis to crisis, appearing frequently in hospital ERs. Some are involuntarily 

committed by courts to short-term, episodic inpatient treatment. Some commit law violations, mostly 

minor nuisance violations, but that ultimately ensnares them in the criminal justice system. 

Many, if not most of these individuals, initially fight outpatient mental health treatment and fail to 

take their medications, either because they don't think they need treatment, or because of the 

detrimental side effects of the powerful psychotropic medications they are prescribed, or because they 

feel stigmatized by the their mental illness. And their desperate families don't know where to turn for 

help. The sad outcome of all this is that thousands of confused, vulnerable young people 

decompensate and become long-term victims of poverty, poor health care, crime and abuse long 

before they ever enter DMH's services continuum. When they do enter our system, they are older and 

their conditions have deteriorated to the point that they require more expensive services. Most 

develop serious, chronic medical conditions, like hypertension, diabetes, heart disease, and COPD. 

On average, they will die between the ages of 50-60 years old. Eight of ten will die from their chronic 

medical condition. 

Although people with mental illness are far more likely to be victims of crime than perpetrators, a 

small number strike out at society. We hear about them in local, state and national news, and we 

mourn their actions. The ACA Medicaid expansion can change this. New services can be tailored to 

young people in earlier stages of mental illness without the need for stigmatizing disability labels. 

This would be of immeasurable value to vulnerable consumers and their exhausted families, and 

would represent a long overdue "sea change" toward early intervention for mental health. There is 

also a major Missouri mental health system downside to not accepting Medicaid expansion. 

Under ACA, Missouri's community hospitals, some of whom now do all oftbe acute psychiatric 

inpatient care in our state, will lose about $250 million in federal disproportionate share (DSH) 

funding for the indigent patients they serve because it is assumed that hospitals will receive Medicaid 

reimbursement for these patients once the Medicaid expansion occurs. It is critical to understand that 

the percentage of indigent care patients is much higher on psychiatric units than on general medical 

units in these hospitals. For example, Cox Medical Center in Springfield has an overall patient mix of 

only 7% indigent patients, but 22% of its psychiatric patients are indigent When hospitals incur the 

DSH cuts, they will first be forced to close psychiatric units serving indigent adult patients under age 

65. 

Currently, there are only 1,170 acute psychiatric beds for adult, non-geriatric patients left in Missouri. 

We have lost 1,400 psychiatric beds in this state since 1990. We now have one acute psychiatric bed 

for every 2,800 Missourians. In comparison, we have one medical hospital bed for every 300 

Missourians. This has placed an incredible strain on the system, and it has affected county and city 

law enforcement units, who must transport these patients longer distances and remain with them as 

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they are processed by community hospital emergency rooms and ultimately transferred to a 

psychiatric bed, if available. If not, the individual often winds up in a county jail. Not expanding 

Medicaid guarantees the further elimination of adult psychiatric beds in Missouri and will ultimately 

put pressure on the state to reopen acute psychiatric beds. 

We closed our acute care beds in Kansas City, St. Louis, Columbia and Farmington in FY 2010-201 I 

due to budget cuts. A state-operated acute inpatient psychiatric bed will cost roughly $900 per day, or 

about $33 million per year for each 100 beds, not counting capital costs. The state will receive no 

Medicaid reimbursement because the federal government prohibits it, and will receive dramatically 

reduced DSH funding. County and city jails, already stressed with untreated mentally ill individuals, 

will initially feel the brunt of the loss of more beds. Corrections will also feel it. Now, over 16% of all 

inmates incarcerated in DOC are treated for a serious mental illness. That number and percentage will 

grow. For mental health services in Missouri, the decision to expand or not to expand Medicaid will 

create a sea change for Missouri, either way it goes. If it is not accepted, I believe that the resulting 

sea change downward is even more threatening than the sea change up if expansion occurs. 

Aside from Medicaid expansion the ACA will provide life changing and life saving benefits to people 

in Missouri with mental illness. The combination of requiring community rating, parity with medical 

benefits, and prohibiting the exclusion of pre-existing conditions from coverage will give people with 

mental illness access to decent affordable health insurance. The numerous programs and incentives to 

integrate mental health care and medical care in the ACA, particularly the Medicaid Health Homes 

for Persons with Chronic Conditions (Section 2703) are bringing transformative improvements to 

care that are saving both lives and money. 

In 2008, the Mental Health Parity Addiction and Equity Act was enacted. Many of the 

Committee members co-sponsored and voted for this legislation. How does the mental 

health parity law impact people living with mental illness in your state? 

The Mental Health Parity Addiction Equity Act has significantly improved access to mental health 

treatment particularly in the area of quantitative limits. Persons with mental illness are no longer 

faced with arbitrary limitations on the number of treatment visits they can have with their mental 

health clinician and no longer have to pay higher co-pays and deductibles that are paid for the 

treatment of medical illnesses. There has not been as much progress in achieving the parity goals of 

the act in the area of qualitative limits. For instance many plans that allow for a period of several 

weeks of more intensive rehabilitation services following a stroke or a heart attack are still not 

providing the same period of intensive rehabilitation services following a hospital admission for a 

psychotic episode or suicide attempt. Congress should make funding available to assist patients work 

through the administratively complicated appeals process laid out in the legislation. Persons with 

mental illness commonly have impairments of concentration, memory, attention, and difficulties with 

organization and persistence, all of which are required to successfully avail themselves of their appeal 

rights. Providing funding to assist mentally ill persons with the appeal process and including such 

assistance as one of the functions of existing funded advocacy and rights programs is necessary to 

achieve full implementation of the Mental Health Parity Addiction and Equity Act. 

Dr. Parks, what next steps can Congress take to provide the best treatment for those 

living with mental health issues? 

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My Recommendations are: 

1) Increase the Resources Available through SAMHSA MENTAL HEALTH Block Grant 

(MHBG) and Discretionary Grants. 

SAMHSA resources have not kept pace with either the general rate of inflation in the cost of care or 

with the markedly increased demand for mental health services that has occurred in the last 10 years. 

THE MHBG and discretionary provide important tools to states and communities for improving the 

treatment of serious mental illness and providing the early interventions that will be the most effective 

means of reducing violence involving persons with serious mental illness. 

2) Develop a National Approach for Increasing the Psychiatric Workforce 

The demand for psychiatric services is far outstripping the ability of the available workforce to supply 

them this is increasingly severely restricting access to essential treatment services for persons with 

serious mental illness. According to a University of North Carolina (UNC) 2008 study commissioned 

by Health Resources and Services Administration (HRSA) the United States have a significant 

shortage of mental health professionals, especially "prescribers". The current supply of psychiatrists 

is at least 30,000 short of what is needed. 

The projected demand for all physicians continues to rise outstripping the projected increase in 

physicians. For psychiatry, the anticipated demand has risen dramatically. The number of people 

seeking psychiatric services has increased because of the growing and aging population, mental 

health parity and anti-stigma efforts. 

The number of psychiatric problems has increased because of the economic downturn and the 

psychological toll of two wars. Other factors increasing the demand for psychiatrists are direct 

marketing of psychiatric medications to the public and an increase in the number of black box 

warnings causing primary care clinicians to be reluctant to prescribe psychotropic medications. This 

is occurring at the same time that the projected supply of psychiatrists is flat. 

Psychiatrists are not increasing in number because retirements are outnumbering those entering the 

workforce through training. Currently 55% of psychiatrists are older than age 55. In a recent 

projection using a similar methodology to the UNC study, the deficit has increased to 45,000. Patients 

often have to wait months to see a psychiatrist because clinics cannot find enough psychiatrists to hire 

to provide service. Hospitals have closed their psychiatric units due to difficulties recruiting 

psychiatrists to staff them. Current national shortages in mental health professionals specifically 

psychiatrists will continue to exacerbate. All projections estimate the gap between unmet need and 

supply will widen substantially over the next 20 years. 

3) Specific Discretionary Grant Recommendations 

a. Grants Funding Mental Health First Aid (MHFA) - Early identification and treatment can 

prevent a mental illness from developing into a disability or leading to suicide or violence against 

others. Mental Health First Aid is a groundbreaking public education program that helps the public 

identify, understand, and respond to signs of mental illnesses and substance use disorders. 

The idea behind MHFA is no different than that of traditional first aid: to create an enviromnent 

where people know how to help someone in emergency situations. But instead of learning how to 

give CPR or how to treat a broken bone, the program teaches people how to recognize the signs and 

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symptoms of mental health problems and how to provide initial aid before guiding a person toward 

appropriate professional help. 

Mental Health First Aid is offered in the form of an interactive 8-hour course that is presented by 

instructors who have been certified through intensive 5-day training. The course presents an overview 

of mental illness and substance use disorders in the U.S. and introduces participants to risk factors 

and warning signs of mental health problems, builds understanding of their impact, and overviews 

common treatments. Those who take the course to certifY as Mental Health First Aiders learn an 

action plan encompassing the skills, resources and knowledge to help an individual in crisis connect 

with appropriate professional, peer, social, and self-help care. Since its introduction in the U.S. four 

years ago, more than 50,000 people have been trained in 47 states and the District of Columbia. 

Mental Health First Aid can create community environments more alert, and prepared, to intervene in 

the mental distress that leads to suicide and violence against others. 

b. Grants to Implement and Improve the Integrated Treatment of Substance Abuse 

Disorders and Mental Disorders in Persons with SMI 

The presence of substance abuse is the strongest protector that persons with SMI will commit 

violence. We can do better addressing substance abuse disorders in people with SMI. 

c. Grants Supporting Effective Early Treatment of Psychotic IIIness.-

Our nation's approach to helping people with psychotic illnesses like schizophrenia is shameful. 

Usually, yOUllg people slip into psychotic illnesses for several years while these individuals-or their 

families--get no help. When they have a "first psychotic break," they usually are briefly hospitalized. 

Almost always, medications take the worst of the symptoms away-within days or weeks. So then 

they are discharged with a referral to care and maybe a recommendation of a support group. This is 

woefully deficient. 

Having symptoms reduced is not a cure. When people feel better, and especially since the drugs have 

significant side effects, they often stop taking them. Relapse is likely. Usually the second break is 

worse. And then the revolving door begins. Often after decades people figure out how to manage their 

illness, but by then they are often on permanent disability status, unemployed, and in terrible health. 

Some have suggested that the solution to this problem is in going backward-not forward-to days 

when stays in mental hospitals were measured in months and years. This is not the approach I would 

advocate. There is no research to suggest it is effective. It is terribly expensive. Hospitals cannot be 

run (as the old asylums were) on unpaid patient labor. And a civilized society cannot detain people on 

a vague hope they will get better. 

So we should not tum the clock back on mental health care. But we do need a modem approach to 

care for people with psychotic disorders, one that replaces both the asylum and the revolving door 

with continuous team treatment like that we provide for people with chronic medical problems. 

Teams delivering First Episode Psychosis (FEP) care have figured out how to do this work. It is 

person-centered, family driven, collaborative and recovery oriented. Staying in school or work is 

encouraged-though adaptations may be needed. It is time to implement this approach, as both 

Australia and Great Britain have done. We need not lag behind other nations in this area. Our country 

needs to make modest investments now to develop FEP tearns so that families anywhere in the state 

struggling with a young adult who is slipping away from sanity can get good care reasonably close to 

home. The Committee's attention to this issue could have an enormous positive effect. 

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4) Make HIPAA Work as it was Originally Intended 

Although HIP AA explicitly allows health care providers and providers of healthcare related services 

to share protected health infonnation absent patient consent for the purposes of treatment, which 

includes care coordination, many health care providers continue to insist that they can only share 

protected health infonnation with patient consent. Adding additional groups with whom health care 

providers are allowed to share infonnation, such as family members who are directly supporting the 

persons coordination of care, is unlikely to be successful when health care providers routinely 

interpret HIPAA as prohibiting sharing protected health information absent patient consent even 

between other health care providers when in fact that is what HIP AA explicitly allows. These health 

care providers are taking an inappropriately restrictive interpretation of HIPAA in an attempt to 

reduce their personal and organizational liability as opposed to taking an interpretation that 

maximizes the patient's best interests in receiving coordinated care. In short their primary goal is not 

what is best for the patient but rather how best to limit their own liability risks. This is both clinically 

dangerous for patients because it results in infonnation not being shared that would improve care 

decisions and economically wasteful for the health care system in that it results in unnecessary 

repetition of assessments, tests, and hospitalizations. 

There is a need for a national initiative to retrain health care providers to error on the side of sharing 

protected health infonnation when it would benefit the individual receiving treatment. There is a need 

for a national strategy to make the perceived liability risk of not sharing infonnation when it could 

have been shared, and the lack of sharing infonnation, results in patient hann as great as or greater 

than the perceived risk of sharing infonnation absent patient consent. 

5) Increase Federal Support for Mental Health Courts 

I have been involved in providing mandatory treatment through different modalities including 

inpatient and outpatient civil commitment, guardianship, not guilty by reason of insanity processes, 

probate court order and both mental health and drug courts in Ohio, Illinois, and Missouri. All three 

states have outpatient commitment laws and in all three states they are difficult to implement and only 

used rarely. The major barrier has been the unwillingness of police and sheriff departments to commit 

resources to enforcing violations of commitment orders. Local law enforcement almost unifonnly 

state that they do not have the resources in terms of officers available to assist with mental health 

treatment in this manner and that crimes the have been committed or are being committed are a higher 

priority for community safety. 

Please ensure departments are usually effective in persuading the local judges to make orders for 

outpatient commitment rarely if at all. There has been much more success nationally in implementing 

mental health courts were a person is required to accept treatment for their mental illness as a 

condition of probation or parole. This is more acceptable local law enforcement because it helps keep 

mentally ill people out of their jails, more acceptable to the courts because it provides them with an 

additional option or disposition ofthe case, and more acceptable to mentally ill person who is usually 

more ready to admit they have committed a crime then they are so sick that they must have treatment 

is a civil probate requirement because they might do something dangerous in the future. There is been 

much more federal support available for implementing drug courts and there has been for mental 

health courts. 

The best current strategy for increasing the in availability of mandatory treatment for persons with 

serious mental illness would be to increase federal support for mental health courts which are easier 

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to implement and more acceptable to both local law enforcement and the persons being mandated in 

to treatment. 

6) Treat the Appalling Rate of Premature Death Among Persons with Serious Mental 

Illness in the Public Mental Health System like the National Epidemic It Is 

It has been over 10 years now since research showed that persons in the public mental health system 

most of whom have serious mental illness are dying on average 25 years younger than the general 

population. This is a higher death rate than experienced currently by persons with HIV and on a par 

with sub-Saharan Africa. Over 80% of the premature deaths and years of life lost are due to chronic 

medical conditions, not suicide or accidents. There is no federal agency that is routinely and 

systematically tracking this epidemic let alone addressing it. 

a. Persons with serious mental illness should be federally designated as a distinct at risk health 

disparities population 

b. The CDC and SAMHSA should develop, implement, and fund national annual surveillance of the 

mortality rates and causes of death in persons with serious mental illness. 

c. HHS and SAMHSA should develop, implement, and fund a national strategy specifically for 

reducing premature death among persons with serious mental illness by promoting the integration of 

behavioral health care and general medical care. 

What is the value of the HIP AA law? Why is patient privacy important with regard to 

treating those with mental illnesses? 

HIPAA as written in statute provides both reasonable protections to patient privacy and reasonable 

access to health information when it is necessary for individual treatment and efficient healthcare 

delivery. 

Can you explain how HlP AA is impacting the coordination of care among mental 

health care providers? 

Persons with serious mental illness are much more likely than the general population to have multiple 

chronic medical problems in addition to their mental illness. It is common for persons with serious 

mental illness to see 20 or more different health care providers in a single year and take 20 or more 

different medications prescribed by mUltiple physicians. HIP AA as written in statute allows health 

care providers to communicate to coordinate care even without patient consent. This is essential since 

it is not possible to anticipate what providers an individual will see in the future, and it is not 

reasonable to expect anyone and especially persons with mental illness to remember all every 

provider they have seen in all the details of their care. 

Patients cannot provide consent unless they remember all the providers that they have seen. In my 

career, I have seen many more patients harmed when information was not appropriately shared, 

compared to patients harmed when information was inappropriately released. When health care 

organizations implement HIP AA as written there is administratively efficient sharing of critical 

individual clinical information that is life saving and health enhancing. 

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HIPAA allows disclosures to share and discuss medical information with family, 

friends, and individuals involved with a patient's care in appropriate circumstances. 

Have you encountered health care providers taking an inappropriately restrictive 

interpretation of HIPAA privacy rules? 

Unfortunately it is quite common for health care organizations to impose many more restrictions on 

sharing individual health information for treatment and coordination of care is required under 

HIP AA. I commonly encounter health care organization privacy officers, risk managers, and general 

counsels who have not actually read HIP AA or advise their organizations to be more restrictive 'just 

to be safe". They appear to believe that this will somehow reduce their organization's legalliabiJity 

and believe that that is more important to reduce their organizations potential liability from sharing 

information than it is to prevent harm from occurring due to information not being appropriately 

shared. 

There is another inappropriate and burdensome restriction to sharing patient information for 

coordination of care and treatment in the case of persons receiving treatment for alcoholism and drug 

addiction. A separate federal statute and regulation commonly referred to as 42CFR puts much 

greater restriction on any information related to the treatment of alcoholism and substance abuse 

disorders that occur under HIPAA. This impacts persons with mental illness since many of them also 

suffer from alcoholism and addictions. Since co-occurring substance abuse and alcoholism is the 

major factor associated with violence by persons with mental illness 42CFR actually prevents 

clinicians treating persons with mental illness from accurately assessing risk of violence and 

intervening to reduce the risk of violence. 

Under 42CFR, information cannot be shared without explicit and specific patient consent and that 

consent must be time-limited with an automatic expiration date. Persons with alcoholism and 

addictions commonly have multiple chronic medical problems and are frequently prescribed more 

medications than persons without these disorders. Mental health clinicians need the restricted 

information to accurately diagnose, assess risk of violence and treat persons with co-occurring 

substance abuse and alcoholism. Persons with alcoholism and addiction need the support and 

encouragement of all their healthcare providers in achieving and maintaining sobriety not just their 

substance abuse treatment programs. 42CFR actually discriminates against persons with alcoholism 

and addictions because they cannot get the same level of coordination of care for all their health care 

conditions that are available to patients with other conditions. Treating alcoholism and addictions 

differently from other conditions under the privacy laws promotes and keeps alive the stigma that 

these conditions are somehow intrinsically different and less worthy of good clinical care than other 

healthcare conditions. Separate is never equal. Congress should repeal 42CFR. 

Do you have any suggestions on how we can address the problems with the mistaken 

way HIPAA is often applied? 

Congress should mandate and fund a substantial HlPAA re-education initiative targeted at health 

organization's privacy officers, risk managers, general counsels, and CEOs. In particular HHS should 

assert and require that health organization's privacy officers, risk managers, general counsels, and 

CEOs acknowledge that they understand that: 

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HIPAA allows sharing healthcare infonnation between providers directly involved in treatment 

absent patient consent. 

a) HIPAA allows sharing health care information between providers directly involved in treatment 

even when the patient requests infonnation not be shared. 

b) Neglect has occurred if a patient comes to harm due to health care infonnation not being shared 

when it could have been and should have been shared in order to coordinate care and provide the 

best possible treatment outcomes. 

c) The failure to appropriately share health care infonnation for coordination of care and to provide 

the best possible treatment outcomes is substandard care and outside of the acceptable community 

standard of treatment. 

d) A simple and clear statement that the appropriate sharing of health care information for 

coordination of care and to provide the best possible treatment outcomes - is a requirement for 

adequate care on a par with having infection control procedures - will go a very long way to 

ending the inappropriate and self-serving restrictions on the flow of information necessary for 

good clinical care. 

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