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The President's New Freedom Commission on Mental Health met on March
5, 2003 at the Crystal Gateway Marriott, 1700 Jefferson Davis Highway
in Arlington, Virginia. In accordance with the provisions of Public
Law 92-463, the meeting was open to the public on March 5th from 10:45
a.m. to 5:30 p.m.
Commissioners present:
Michael F. Hogan, Chair
Ginger Lerner-Wren
Jane Adams
Stephen W. Mayberg
Rodolfo Arredondo, Jr.
Joan Mele-McCarthy
Patricia Carlile
Frances M. Murphy
Charles G. Curie
Richard Nakamura
Wayne Fenton
Robert Pasternack
Daniel B. Fisher
Robert N. Postlethwait
Anil G. Godbole
Waltraud E. Prechter
Henry T. Harbin
Dennis Smith
Larke N. Huang
Nancy C. Speck
Gail P. Hutchings
Glenn Stanton
Thomas R. Insel
Deanna F. Yates
Norwood W. Knight-Richardson
Staff members present:
Claire Heffernan, Executive Director
H. Stanley Eichenauer, Deputy Executive Director
Dawn Foti Levinson
Ann Jacob Smith
Patty DiToto
Elaine Viccora
March 5, 2003
Work Session
Chair Hogan opened the Commission's work session at 10:45 a.m. He
commented that, while the Commission had formed Subcommittees to discuss
a number of critical mental health topics, several crosscutting issues
(e.g., work force and acute care) had not been the primary focus of
any one Subcommittee. Thus, the Commission decided to create a working
group to examine and discuss the status of acute care. Commissioner
Knight-Richardson would provide a report of the Subcommittee on Acute
Care's deliberations and findings.
Report of the Subcommittee on Acute Care
Commissioner Knight-Richardson highlighted the importance of the
acute care system for Commissioners and gave an overview of the Subcommittee's
findings. There is widespread agreement that acute care is an essential
component of a comprehensive system of mental health services in a
community. Acute care refers to short-term (with a median length of
stay of approximately thirty days or fewer) inpatient care and emergency
services provided in hospitals, short-term 24-hour care in residential
treatment facilities for children, and other crisis and urgent care
service settings. This definition also includes non-traditional approaches
to 24-hour acute care, such as crisis residential programs for adults,
and crisis family care and treatment foster care for children, which
may be more normalized and less costly alternatives to inpatient care.
An important role for acute care is to provide a safe setting to address
crises and to evaluate and assess the adult or child who is in crisis.
In a fully developed system it is generally thought that inpatient
settings are most appropriate for those situations where personal
safety is a significant consideration.
The problem addressed by the Subcommittee on Acute Care is the lack
of short-term acute care of all types: acute care and treatment in
some communities, alternative forms of acute care in others, and both
forms in many communities. Another concern of the Subcommittee is
the excessive use of hospital emergency rooms often associated with
the unavailability of more appropriate inpatient and other acute care
settings. The appropriate management of acute care needs requires
a comprehensive community mental health system with a full range of
effectively coordinated components appropriate for people across the
life span.
Solutions to the problem of acute care are complicated by the limited
availability of relevant data and the lack of consensus standards
on the number of beds and the types of acute care settings that are
most appropriate. There are outstanding models for every type of acute
care. However, fully developed and integrated model community systems
are lacking. Numerous news stories and testimony before the Commission
described communities that are experiencing severe problems with access
to short-term inpatient care and other forms of acute care. In some
of these communities, the shortage of acute care beds has risen to
crisis proportions. Too often budget shortfalls have led to reductions
in funding for other essential community mental health services, consequently
increasing the demand for already limited inpatient care as an alternative.
The Commission has heard accounts of communities where emergency departments
are overwhelmed with patients in extreme psychiatric distress who
have nowhere else to go.
The total number of inpatient psychiatric beds per capita has declined
dramatically (62%) since 1970. Over this same period, state and county
psychiatric hospital beds per capita have decreased even more precipitously
(89%). It is noteworthy that no national data are yet available on
non-traditional acute care settings, such as crisis residential programs
for adults or crisis family care or treatment foster care for children.
What seems clear from the national data is that there has been a decline
in the supply of most types of beds for short-term inpatient psychiatric
care with the most severe drops in publicly operated services. It
is widely known that the share of health care expenditures allocated
to mental health and substance abuse treatment declined from 1987
to 1997. Recent analysis on a sample of the employer-based private
insurance market found a decrease in the mental health and substance
abuse spending trends that they attribute to a lower probability of
admission to inpatient care and shorter lengths of inpatient stay.
The trends in the national data are suggestive of an emerging widespread
problem that already has caused serious disruption of the service
delivery system in a substantial number of communities. In the most
troubled communities, the lack of acute inpatient care is compounded
by a simultaneous shortage of other effective alternative community
services. Each community has a different experience, however, with
the various forces that account for the changes in the patterns of
care. Changes in payment mechanisms (such as prospective payment),
the emergence of managed care, and newer utilization guidelines that
limit lengths of inpatient stays are some of the factors that account
for these changes. Some communities also have been successful at building
and maintaining robust outpatient treatment systems and community-based
acute and longer-term services that may reduce the need for short-term
inpatient care and the misuse of emergency rooms.
This is a complex problem resulting from a combination of national,
state and local factors. The solution must balance integration in
the community with the need for safety and acute care at times of
crisis. It also must reflect a consensus on the role of acute inpatient
care and emergency services in an array of community mental health
services. Problems exist with access and availability of acute care,
coordinating care between short-term and other community-based services,
and outcomes and quality of care throughout the service system. It
is difficult to solve these problems when there is a lack of standards
for assessing the number of beds needed for acute and crisis care,
or the balance and mix of settings and services that constitute an
ideal community-based system of care. Also, there is no agreement
on the best approach to paying for acute inpatient care. The method
of payment and the payment rates are a matter of current study and
much controversy. Clearly, payment methodologies have a powerful determining
role in structuring the array of community services. It is equally
clear that existing payment systems are not fully aligned with the
goals of the system of care-another indicator of the pervasive fragmentation
of the national mental health system.
Given the current circumstances of regional variation, absence of
a consistent vision and standards, and limited availability of critical
data, the Subcommittee on Acute Care recommends that a National Working
Group on Acute and Crisis Care be formed. The Subcommittee envisions
a work group started and initially funded by the federal government
with full participation by all stakeholder groups. The mission of
the work group will be to synthesize existing knowledge, review the
many outstanding model programs already in existence, develop new
knowledge as necessary, and attempt to develop a consensus on and
policy option relevant to the following issues:
· The role of acute care in an array of community mental
health services, including the proper connections among services
· The range and types of longer-term care and supportive
services needed to complement acute care in a comprehensive community
system, with particular attention to evidence-based services and
the need for consumer involvement
· The forces that shape the role of acute care and the relationships
in the service system
· Methods for assessing the need for short-term 24-hour care,
including a psychiatric bed needs analysis. The methods should recognize
that it is essential to tailor these assessments to local conditions
and regional variations
· Methods of payment for acute and crisis care that support
the vision for a comprehensive system of care
· Standards for coordinating care between short-term 24-hour
services and non 24-hour community services. These standards must
consider the "functional interface" between these settings
that takes into account different forms in different communities
on the basis of existing resources and policies in other human services.
Examples of these services include housing, homelessness services
and criminal justice for adult populations, and child welfare, school,
and juvenile justice for child populations
· Standards for determining the appropriate content of care
and what constitutes effective short-term 24-hour care and treatment
As a member of the Subcommittee on Acute Care, Commissioner Godbole
added that many of the topics identified by the Subcommittee arose
previously during Commission discussions. Unfortunately, the Subcommittee
on Acute Care only had psychiatric inpatient data to review. Commissioner
Godbole asserted that, despite the limited availability of data, the
trends were quite clear. He stated that acute care beds must be available
to serve as a safety net for the mental health system, yet, in many
areas in the country, the number of available beds has fallen below
the safety net threshold. The lack of acute care availability affects
the entire mental health system, creating backlogs in emergency rooms
and ultimately resulting in people being deflected to the criminal
justice system. Commissioner Godbole urged the Commission to offer
a recommendation that addresses the developing acute care crisis.
Noting that the Subcommittee's emphasis was on short-term, 24-hour
crisis, Commissioner Yates questioned whether the Subcommittee discussed
longer-term residential treatment. Commissioner Knight-Richardson
responded that the Subcommittee defined the scope of acute care as
24-hour to 30-day treatment, and therefore did not address residential
treatment.
Chair Hogan added that while there is agreement on the need for acute
care beds, there is less consensus on the need for long-term beds.
Thus, the Subcommittee focused its attention on the area of agreement.
Commissioner Fisher suggested that Alternate Commissioner Fenton's
input would be helpful given his work on alternatives to hospital
care. Commissioner Fisher requested that the Subcommittee's report
reflect the existence of alternatives to hospitalization, which keep
a person connected to the community (e.g., respite care, crisis hostels,
and emergency foster care).
Commissioner Knight-Richardson agreed that acute care can occur in
many settings, as indicated by the Subcommittee's broad definition
of acute care.
Commissioner Godbole added that if people had good access to treatment
and supports there would be fewer acute situations.
Alternate Commissioner Nakamura commented that the Subcommittee's
report did lay out the full range of possible acute care settings.
He also said he will ask Alternate Commissioner Fenton to review the
Subcommittee's report.
Chair Hogan stated that a comprehensive, community-wide approach
is necessary to address the shortage of acute care beds. A community-wide
approach identifies people approaching a crisis and selects the least
restrictive and most appropriate intervention from an array of different
settings. He suggested that the Subcommittee might want to consider
a community-wide approach that offers a broader range of interventions
for people requiring acute care.
Commissioner Huang was pleased with the Subcommittee's broad definition
of acute care. When there is not an array of services available, both
acute care and community-services can experience a back up. She also
cautioned that it is easier for policy makers to understand the need
for acute services and not appreciate the broader need for an array
of available services. As acute services traditionally have been better
funded, the Commission should be careful that an emphasis on acute
care does not result in a lessened focus on the need for least restrictive
community settings.
Chair Hogan believed that the Subcommittee's framing of the acute
care issue accommodated Commissioner Huang's concern. He lamented
the lack of available data on acute care and the necessary reliance
on old data from state hospitals. The Chair suggested that the system
needed data that would serve as a "thermometer" to determine
the adequacy of acute care access, particularly given the wide variability
of access among communities.
For people who speak languages other than English, Commissioner Fisher
suggested that rapid access to interpreters may have as much impact
on crisis situations as the setting of services. Appropriate acute
care is
not just dependent upon the setting, but also how the care is delivered
and by whom. For example, police need immediate access to mental health
professionals to diffuse crisis situations.
Commissioner Knight-Richardson noted that general hospitals operating
inpatient psychiatric units face financial hurdles that jeopardize
the financial viability and continued existence of psychiatric units.
Commissioner Godbole expressed the sentiment of the Subcommittee
that inpatient care was viewed as the provider of last resort. However,
inpatient care is a necessary safety net which cannot be weakened
further.
Alternate Commissioner Hutchings moved to accept the Subcommittee
on Acute Care's report and the ensuing discussion. Commissioner Postlethwait
seconded the motion. The Commission voted unanimously to accept the
Subcommittee's report.
Commissioner Speck announced that she had a videotape produced by
the Mental Health Corporation of America which depicted the 40-year
history of community mental health services, including the system's
problems and accomplishments. Commissioners and members of the public
were invited to view the videotape at the conclusion of the day's
meeting.
A copy of the summary provided by the Subcommittee on Acute Care
is on the web site, www.MentalHealthCommission.gov.
Public Comment
Chair Hogan welcomed members of the audience who had signed up to
offer public comments. Individuals who provided brief oral remarks
and written statements included:
John Greden, University of Michigan, Depression Center
Nancy Vineburgh, Screening for Mental Health
Randal Bosin, Consumer
Carol, Jim, and Justin Otremba, family members and consumer from Minnesota
Margie Heldring, President, America's Health Together
Charles Swenson, Behavioral Tech LLC
Helen Best, Behavioral Tech LLC
Eloise Newell, Restoration Project
Susan Goren, National Association of School Psychologists
Stephen Spector, CHADD
Nuala Moore, American Academy of Child and Adolescent Psychiatry
Laurel Stein, American Academy of Child and Adolescent Psychiatry
Bob Egnew, National Association of County Behavioral Health Directors
Bob Lieberman, President, American Association of Children's Residential
Centers
Work Session
Report by the Subcommittee on Consumer Issues
As Chair of the Subcommittee on Consumer Issues, Commissioner Fisher
provided the report to the full Commission. He observed that mental
health research shows that people can and do fully recover, even from
the most severe forms of mental illness. Fundamentally, recovery means
having hope for the future, living a self-determined life, maintaining
self-esteem, and achieving meaningful roles in society. Most consumers
report they want the same things as others want: a sense of belonging,
an adequate income, a way to get around and a decent place to live.
They aspire to build an acceptable identity for themselves and in
the community at large. These are the essential ingredients of recovery
from mental illness.
An emerging literature on the success of the recovery approach comes
from the self-help movement, testimony of consumers, the psychiatric
rehabilitation community, and research. Public and private sectors
of the mental health community are initiating recovery-based programs,
services and self-help technologies to overcome the barriers faced
by people living with a mental illness in America. Recovery is an
organizing principle for mental health services, programs, and supports,
based on consumer values of choice, self-determination, acceptance,
and healing.
For recovery to take place, the culture of mental health care must
shift to a culture based on self-determination, empowering relationships,
and full participation of mental health consumers in the work and
community life of society. To build a recovery-based system, the mental
health community must draw upon the resources of people with a mental
illness in their communities.
It is widely recognized that changing the mental health system to
be more responsive to consumer needs requires the participation of
consumers at all levels of policy planning and program development,
implementation, and evaluation. Meaningful involvement of consumers
in the mental health system can ensure they lead a self-determined
life in the community, rather than remaining dependent on the mental
health system for a lifetime.
A recovery-oriented mental health system embraces the following values:
· Self-Determination
· Empowering Relationships
· Meaningful Roles in Society
· Eliminating Stigma and Discrimination
In order to facilitate recovery from mental illness, the Subcommittee
urges Federal, state and local governments to develop a National
Recovery Initiative that promotes consumers' self-determination
at both the collective and individual levels of recovery. The policy
options that follow comprise the key components of the proposed
National Recovery Initiative.
Policy Option 1. Promote Collective Self-Determination
The Subcommittee recommends increasing collective consumer self-determination
by ensuring consumers' significant participation in the development
of a National Recovery Initiative. This initiative would inform policy,
evaluation, research, training, and service delivery at local, state
and national levels in all systems integral to recovery from mental
illness.
1.1 Employ Consumer Leadership in a National Recovery Initiative
The Subcommittee urges Federal, state and local governments to employ
consumers in leadership roles in the development of a National Recovery
Initiative, including the following:
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All boards, panels, and committees where mental health policy
and research decisions are considered should include significant
consumer representation. Developing consumer representation guidelines
and providing incentives for consumer inclusion might accomplish
this.
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Where major barriers to recovery exist, such as a lack of housing,
education, or employment, ad hoc committees with meaningful consumer
involvement should be convened to develop policy options.
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The government at all levels is urged to organize stakeholder
panels to (1) explore ways to create more flexible funding streams
for housing supports, TANF programs, community-based waivers and
housing set asides; and (2) develop more integrated and voluntary
approaches to treatment, housing, employment services, and other
supports.
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National leadership is encouraged to organize a Policy and Research
Task Force for Consumer Affairs composed of consumer members of
the various boards, panels, and committees. The Task Force would
meet regularly and develop integrated mental health policy recommendations
from a mental health consumer perspective.
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The Subcommittee recommends establishing a panel with significant
consumer representation to address streamlining the process for
accessing disability benefits, educating people with psychiatric
disabilities about disability benefits and services, and encouraging
states to adopt the Medicaid Buy-In option, which allows recipients
to retain Medicaid coverage after returning to work.
1.2 Involve Consumers and Promote Recovery in All Aspects of Research
Design, Conduct, and Evaluation
The Subcommittee urges policy makers and researchers in this arena
to talk with people diagnosed with a mental illness to learn about
the challenges to recovery that they face. For many consumers, current
research methods and standards, which are intended to advance our
understanding of mental illnesses and effective services, pose challenges
to their values and hopes for recovery.
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Providers and administrators who are also consumers have a unique
perspective to offer when developing research designs and evaluations
involving persons diagnosed with a mental illness. As such, funds
should be made available to support a summer training institute
for these mental health professionals in order to enhance their
research and evaluation skills.
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NIMH is urged to create special research initiatives to study
emerging evidence-based practices such as peer support programs.
Other research initiatives might include the development and measurement
of service satisfaction and outcomes that reflect recovery principles
and other service outcomes important to mental health consumers
(e.g., healing, personhood, well-being, or effects of coercion).
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The Subcommittee recommends that NIMH offer incentives to researchers
that will encourage research on recovery from mental illness.
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The Subcommittee recommends that CMHS continue to support the
development of a core set of system level indicators that measure
critical elements and processes of recovery. CMHS will be
responsible for integrating these items into a multi-state "report
card" of mental health performance measures.
1.3 Campaign to Increase Awareness of Recovery and Reduce Stigma
and Discrimination
The Subcommittee recommends a broad campaign to reduce stigma and
discrimination, increase awareness that people can and do recover
from mental illness and to dispel the myth that people with mental
illnesses are more violent than the general population. The campaign
will target all levels of the mental health system, including providers
and administrators, as well as families and the general public.
Policy Option 2. Promote Individual Self-Determination
The Subcommittee urges the mental health system at the Federal, state
and local levels to increase individual consumer self-determination
by helping people with a mental illness to acquire the self-management
skills needed to manage their own lives. To accomplish this, the Subcommittee
urges a shift from traditional services to recovery planning services,
such as peer support services and services provided by independent
living centers.
The Subcommittee encourages state mental health authorities to include
recovery competencies as part of their licensing and professional
certification programs for mental health professionals. Furthermore,
professional training programs are urged to include recovery competencies
and consumer participation in their curricula and program design.
2.1 Integrate Peer Support Services into the Continuum of Community
Care
The Subcommittee recommends that peer support services be integrated
into the continuum of community care and that public and private funding
mechanisms be made sufficiently flexible to allow access to these
effective support services.
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The Subcommittee proposes that a carve-out from the Federal Community
Mental Health Block Grant funding be established to support the
integration of community-based peer support services within the
continuum of community care.
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Billable peer services should be included under the Medicaid
Rehabilitation Option.
2.2 Promote Inter-Agency Collaboration to Better Inform Consumer
Choice
The Subcommittee urges CMS, SAMHSA and RSA (Rehabilitation Services
Administration) to collaborate on an initiative that would enable
individuals with psychiatric disabilities to manage their Medicaid
benefits and obtain needed private and public services. This assistance
would be analogous to that offered to people with other disabilities
through Independent Living Centers.
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HHS, CMS and the VA are urged to ensure that any programs receiving
Federal funding provide evidence that consumers play a primary
role in the design, implementation, and evaluation of their individual
recovery plans and that these plans are based on the consumers'
goals.
- Agencies should ensure that consumers are fully informed of and
have voluntarily chosen any services they receive that are government-funded
or provided in a government facility.
Alternate Commissioner Nakamura indicated that the Subcommittee's
report provided an overall positive vision. However, he believed that
the report reflected two different definitions of recovery: (1) recovery
meaning a person no longer has an illness and (2) recovery implying
a person can lead a self-determined life while ill. He suggested that
the second definition of recovery was relevant for people with serious
mental illness and should be used by the Commission. He also expressed
discomfort with the report's use of the term "self esteem"
as it is a construct that is difficult to define and measure.
Commissioner Fisher referred to Courtney Harding's study results
indicating that over 60 percent of people with schizophrenia recovered
completely and remained a-symptomatic. Alternate Commissioner Nakamura
stated that he would like to see that study replicated before the
Commission concludes that complete recovery is possible.
Chair Hogan commented that the Commission is not ready to think of
recovery as remission or adopt the view that there is no longer an
illness. While this level of recovery may be true for some subset
of persons with a mental illness, the size of that subset is not yet
clear. He suggested that the Commission adopt a definition from the
current professional literature that is positive and optimistic and
also reflects that recovery is a process.
Alternate Commissioner Nakamura suggested that the report's statement
that, "meaningful involvement of consumers in the mental health
system 'can ensure' they lead a self-determined life in the community"
is an overstatement. He suggested using different language, such as
inserting that meaningful involvement 'can help' to ensure they lead
a self-determined life."
Alternate Commissioner Nakamura also requested that the section detailing
recovery's values include "the right to treatment" as the
first of those values.
Finally, Alternate Commissioner Nakamura asked for further explanation
around the concept of "collective self determination." Commissioner
Fisher responded that, when a group of individual's experiences discrimination
and stigma, there is strong motivation to change the circumstances
for the whole group. Alternate Commissioner Nakamura suggested that
different wording might better communicate this idea.
Commissioner Lerner-Wren indicated that the Commission heard from
many people who felt undervalued and dehumanized by the mental health
system. In her experience, people can transcend the label and effects
of stigma.
Alternate Commissioner Nakamura acknowledged Commissioner Lerner-Wren's
point. He added his concern was that those who are skeptical about
the reality of mental illnesses might read the Subcommittee's report
and think that people with sufficient willpower can recover.
Chair Hogan suggested that the final report's headlines may be: (1)
people with the most serious of mental illnesses can and do get better,
(2) that possibility exists for everybody and (3) 'better' may mean
different things for different people.
Commissioner Fisher stated the Subcommittee's intention was to shift
the framework of understanding mental illness to incorporate hope
and a positive sense of the future. The field needs to move away from
an overemphasis on etiology and whether an illness is 'recoverable.'
People with a mental illness do not want to think of themselves as
having a permanent defect that prevents reintegration back into society.
This framework is not a "biological versus non-biological"
debate.
Commissioner Adams requested that the Subcommittee broaden its focus
to reflect the lifespan and address the consumer issues of children
and families. While families may not resonate with the term recovery,
they are interested in expressing their collective voice. She suggested
it was possible to expand the focus without losing the concept of
recovery.
Commissioner Fisher expressed concern that the issues expressed in
the summary might be watered down if the language was broadened to
include families. He wanted to address the specific and slightly different
needs of adults who have faced the system on their own and are trying
to recover from the effects of treatment.
Commissioner Harbin indicated his support of the sub-goals contained
in the Subcommittee's report, specifically (1) fact-based optimism
that people will get better, (2) people want choices, and (3) the
treatment system needs to change its attitudes and practices to view
primary consumers as partners. He suggested that whatever term is
used, it is important to not obscure those goals. He also agreed with
Alternate Commissioner Nakamura that some of the report's assertions
were overstated.
Commissioner Harbin also posed several questions. He asked whether
the National Recovery Initiative and other references to consumer
boards promoted separate consumer-only advisory boards, consumer representation
on advisory boards, or both. He noted that both seemed duplicative.
Commissioner Fisher responded that having both sets of boards would
not be duplicative as a consumer-only board would have a very different
and important dynamic.
Commissioner Harbin requested clarification about the policy options
aimed at training professionals. He expressed concern about the references
to licensing and establishing competency in recovery, due to the variety
of viewpoints around recovery and the lack of an agreed-upon knowledge
base supported by data. Commissioner Fisher responded that the Massachusetts
Department of Mental Health incorporated recovery into its training
and cited this growing body of information on recovery. The Subcommittee's
consultant, Dr. Jean Campbell, is gathering the existing literature
and data to include in the appendix of the Subcommittee's report.
Alternate Commissioner Nakamura also encouraged language changes to
emphasize training in recovery instead of referencing licensing and
certification. While the evidence about a recovery-orientation is
improving, more research is needed before the field can demonstrate
'competency' in recovery.
Commissioner Arredondo suggested that the Commission may want to
borrow the recovery definition from the substance abuse field: a person
recovers physically, emotionally, mentally, and spiritually from their
illness.
Commissioner Godbole spoke about his experience at a Chicago health
fair where, in his view, representatives from other illness and disability
groups were trying to legitimize their illnesses, rather than denying
their illnesses. He wondered about the tension and debate within the
mental illness community regarding the legitimacy of mental illness.
Commissioner Fisher stated that the tension exists because no other
illness faces the prospect of forcible treatment.
Chair Hogan suggested that the health care system's approach to physical
and mental illnesses is vastly different. As the Commission has heard
from witnesses, obtaining information and appropriate treatment options
for a child with bipolar disorder can take many years. However, a
treatment team is likely to relay information, identify resources,
and lay out evidenced-based treatment options immediately for a child
with
cancer. He reiterated his suggestion that the Commission's main point
be that mental illness is an illness - but getting better is possible.
Commissioner Fisher expressed his interest in finding the middle
ground where Commissioners could agree, noting that members of the
mental health community are greatly concerned about coercive treatment.
He did not want the Commission to view consumer issues exclusively
through a medical lens, particularly as consumers cite support services
(e.g., housing and vocational rehabilitation) as being more important
to their recovery than medication.
Commissioner Mayberg suggested that Commissioners all agree upon
the values contained in the Subcommittee's report; the disagreement
is around the phrasing to endorse those values. It would not be helpful
to enter into a debate around coercive treatment. The Commission should
phrase these important issues in an empirical way that is not politicized.
For example, in the discussion about stigma, the report states that
persons with a mental illness are no more violent than the general
population. However, the research indicates that people with co-occurring
disorders are much more violent. The real issue may be that persons
with a mental illness are inappropriately portrayed as being violent
in the media. It is important to phrase these issues empirically so
as to not confuse or lose important points.
Commissioner Knight-Richardson commented that mental illness is not
the only illness that may result in forced treatment. People who have
behavioral disturbances due to any physiological disorder (e.g., delirium)
and who are at risk to self or others may face involuntary treatment.
Thus, involuntary treatment is not unique to people with mental illnesses.
Alternate Commissioner Stanton discussed the term "self-determination"
used in the report, noting that self-determination extends beyond
peer-delivered services to include consumer control of resources and
consumer choice among options. He offered to assist the Subcommittee
with framing self-determination in order to promote better informed
consumer choice and control of resources (e.g., helping individuals
better manage their Medicaid benefits).
Chair Hogan commented that the concept of consumer control and choice
should not be limited to the Medicaid system, but should apply to
state mental health systems, as well.
Alternate Commissioner Stanton suggested that the Subcommittee examine
its recommendation which encourages reimbursement of peer services
through the Medicaid Rehab Option. Currently, this option already
exists and a few states are exercising this option. The Commission
should avoid recommending a strategy which is already permissible
under current Medicaid policy.
Chair Hogan observed that this recommendation might be added to a
growing list of areas where CMS could provide guidance and clarification
to the states about how it is possible to obtain Medicaid reimbursement
for certain services.
Finally, Alternate Commissioner Stanton requested that several Subcommittees
reconsider recommendations, which imply that federal agencies should
mandate consumer participation, as this creates new 'conditions of
participation' for states to receive funds. Proposing such requirements
has significant implications and may not be realistic.
Chair Hogan shared the definition of recovery contained in the Surgeon
General's report on mental health. He suggested that this might be
a starting point for the Commission's discussions to reach a common
definition of recovery for the final report.
Commissioner Harbin stated that the Subcommittee may want to rewrite
its last comment on page 3 about choosing services. In its current
form, the statement seems to imply that the mental health system should
only pay for voluntary services and not involuntary treatment.
Chair Hogan observed that the idea of recovery is bigger and more
powerful than any specific policy option advanced by the Commission.
The Commission's main message should be that the entire mental health
system needs to be reoriented to a perspective focused on recovery.
In conclusion, Chair Hogan suggested that the Subcommittee not use
the term "initiative" when describing the National Recovery
Initiative, as it may connote a small, "boutique" effort.
The Commission is more interested in a sweeping change that will realign
the entire mental health system around recovery and the President's
goal of meaningful participation in the community.
Commissioner Godbole moved to accept the Subcommittee on Consumer
Issues report and the ensuing Commission discussion. Commissioner
Arredondo seconded the motion. The full Commission unanimously approved
the motion.
A copy of the summary provided by the Subcommittee on Consumer Issues
is on the web site, www.MentalHealthCommission.gov.
Report by the Subcommittee on Rights and Engagement
Chair Hogan announced that the Commission was revisiting the report
provided by the Subcommittee on Rights and Engagement. After the Commission's
comprehensive discussion at the January 2003
meeting, the Subcommittee was asked to continue its work and address
some of the concerns expressed by Commissioners.
Commissioner Lerner-Wren indicated that Commission staff effectively
incorporated the issues raised during the previous meeting to create
a more acceptable, and even stronger, report.
Commissioner Fisher echoed his agreement. He thanked Alternate Commissioner
Stanton for providing information about HHS initiatives, which address
the Supreme Court's Olmstead decision. The Subcommittee used this
information to set forth a series of steps, which lessen the likelihood
of litigation.
Commissioner Harbin added that the essence of the policy options
remain, although they are now framed in a better and clearer context.
Commissioner Huang asked whether the Subcommittee addressed the issue
of linguistic access. Commissioner Fisher responded that linguistic
access would be addressed in the preamble or another policy option.
Commissioner Mayberg complimented the Subcommittee on Rights and
Engagement and the writers on how they addressed previous concerns.
The current report emphasizes collaboration and partnerships, yet
does not minimize the importance of rights and dignity. Chair Hogan
echoed his appreciation of Dr. Susan Azrin for her excellent revisions
of the report.
Commissioner Huang moved that the Commission accept the report offered
by the Subcommittee on Rights and Engagement. Commissioner Arredondo
seconded the motion. The Commission unanimously approved the motion
and accepted the report.
A copy of the revised summary provided by the Subcommittee on Rights
and Engagement is on the web site, www.MentalHealthCommission.gov.
Approval of February Meeting Minutes
Chair Hogan requested that Commissioners approve the draft minutes
from the February 4-6, 2003 meeting. Commissioner Knight-Richardson
offered a motion to accept the minutes, which Commissioner Speck seconded.
The minutes were adopted by a unanimous vote.
Adjournment and Next Meeting Announcement
Chair Hogan adjourned the meeting at 4:30 p.m. Commissioners and
members of the public watched the video, You Can't Not Do That, provided
by the Mental Health Corporation of America. The final Commission
meeting will occur April 3, 2003 in Washington, D.C.
I hereby certify that, to the best of my knowledge, the foregoing
minutes are accurate and complete.
Claire Heffernan
Executive Director
President's New Freedom Commission on Mental Health
Michael Hogan, Ph.D.
Chair
President's New Freedom Commission on Mental Health
These minutes were considered and approved by the Commission at its
April 3, 2003 meeting and any corrections or annotations incorporated
into the text.
Last Modified 4/9/03
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