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President's New Freedom
Commission on Mental Health


Meeting Minutes
March 5, 2003

Crystal Gateway Marriott
Arlington, Virginia

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,

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:

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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).

  • The Subcommittee recommends that NIMH offer incentives to researchers that will encourage research on recovery from mental illness.

  • 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.

  • 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.

  • 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.

  • 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,

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,

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.
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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