After months of quiescence, the gears of legislative action on mental health have swung into action. Next week, the House Energy and Commerce Committee will mark up the Helping Families in Mental Health Crisis Act of 2016, an important bill crafted by Rep Tim Murphy (R-PA) and Eddie Bernice Johnson (D-Tex). If the full House approves the bill and the Senate follows suit, a solid groundwork for improving the nation’s mental health system will be laid.

The odyssey of the bill, which was first introduced in 2013 and has gone through several revisions in response to critics, is worth examining. The controversy it has generated sheds light on pre-existing tensions surrounding ideas about the nature of the forces (psychological, biological, and social) that lead to psychopathology – and, in turn, the most appropriate forms of treatment and intervention. This clash of cultures explains much of why our federal mental health system is so troubled in the first place.

Some background. Our federal mental health system has suffered for decades under poor leadership. One major manifestation is that we now have a system geared more toward mental health than severe mental illness. What is the difference?

According to government statistics, only about 17% of adults are considered to be in a state of optimal mental health — the rest, apparently, need some kind of professional assistance to achieve optimal “wellness.” At the opposite extreme, severe mental illness afflicts 4% of the population. Mainly diagnosed with schizophrenia, bipolar (manic-depressive illness), or major depression, such individuals are chronically or periodically unable to care for themselves or are suicidal. At times, they may be dangerous to the public.

Sandwiched between mental health and severe mental illness is a clinical category called mental illness. One recent national survey estimates that nearly 18% of those individuals older than 18, or about 43.7 million people annually, are mentally ill — meaning they fulfill diagnostic criteria for any condition listed in psychiatry’s official diagnostic handbook, ranging from attention deficit disorder to panic attacks to anorexia. The severity and chronicity of these conditions varies dramatically, with most conditions resolving on their own, while others are best served with time-limited psychiatric care; some may require hospitalization and long-term medication and therapy.
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The distinction between mental health, mental illness, and severe mental illness is crucial, because it leads us to different clinical and policy prescriptions.

A key problem is that the federal government’s lead agency on mental health, the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services, is geared toward the mildly to moderately ill at the expense of the more seriously debilitated. The agency downplays the need for medication in the care of people in the latter group and traffics in the dubious notion that external influences, such as stress, social problems, traumatic experiences, and even coercive psychiatric care itself are the primary causes of severe mental illness. Thus, rather than focusing on combating homelessness, the crying need for more hospital beds, or reducing incarceration among people with serious mental illness, it concentrates federal and state efforts on delivering amorphous “behavioral health” to everyone else.
This is profoundly misguided. Too many sick people are now caught in a pernicious cycle, rotating in and out of emergency rooms, crisis hospitalization, incarceration, homelessness, and back again. It’s no wonder some of the strongest supporters of mental-health reform are police, district attorneys, corrections officials, and emergency-room physicians. We need a mental-illness system in which care for the sickest of the sick is a priority.

Reps. Murphy and Johnson recognized this more acutely than most lawmakers. Their initial bill (HR 3717), introduced in 2013 was a hard hitting attempt to bring clinically-informed leadership to SAMHSA. It included provisions that oriented the institution more fully to the care of the sickest; sought to provide more bed capacity and bring humane surveillance mechanisms to bear on patients who reliably descend into self-destructive psychosis or violence when they stop taking medication.

The original bill did this in several key ways. First, it created in the Department of Health and Human Services an Assistant Secretary for Mental Health and Substance Use Disorders to supervise and direct SAMHSA. The act required that the secretary possess a PhD or MD in psychology or psychiatry with research and clinical experience in practicing integrated care models.

Second, to increase bed capacity, it amended Medicaid to cover medical assistance for inpatient psychiatric hospital services and psychiatric residential treatment facility services for individuals age 21-65 absent the existing 16-bed limit.

Third, the proposed law would have allowed a physician to use his or her best judgment when determining that sharing critical information related to the health, safety, and well-being of the family and severely mentally ill patient is in the best interest of the severely mentally ill patient and his or her family. Currently, physicians are stymied by overly tight privacy rules and cannot tell concerned family members about the clinical status of their seriously ill loved ones.

Fourth, provisions would allow courts to order certain mentally ill individuals with a history of arrest, hospitalization, and whose condition will worsen without medical care, to comply with treatment while living in the community. This arrangement is called Assisted Outpatient Treatment, or AOT. A section required a state to have an assisted outpatient treatment law in order to be eligible to receive funds through the Community Mental Health Services Block Grant. (In the rewritten bill of June 2015 this was changed from a mandate to an incentive: a two percent addition to the states’ block grants for implementing AOT).
Fifth, the bill prohibited SAMHSA-funded legal advocates from counseling an individual with a serious mental illness or serious emotional disturbance who lacks insight into their condition on refusing medical treatment or acting against the wishes of such individual’s caregiver.

Reaction from Democrats, SAMHSA, and some mental health groups was swift. They deplored the curtailment of the power of SAMHSA, of bed capacity (out of fear that it would signal a return to the dismal days of the mental asylum), and any perceived intrusion on patient civil rights. In June 2015, Murphy softened the bill, HR 2646, in various ways and revised it again in June 2016, almost a year to the day later.

Meanwhile, in the Senate, a companion bill was introduced, co-sponsored by Senators Chris Murphy and Bill Cassidy in 2015. Senate Democrats voiced strong opposition which was fueled by the already simmering tension between political parties as to whether such violence is more aptly attributable to the availability of high-powered guns or to the broken mental-health system, whose many fault lines allow ill people who are armed to slip into classrooms, movie theaters, and college campuses.

This gave rise to an impasse. Democrats refused to move on mental-health legislation because Republicans refused to pass gun-control legislation. The standoff lifted last March when Senator Patty Murray (D-WA) and Lamar Alexander (R-Tenn) proposed a tepid Mental Health Reform Act of 2016. This act, in essence, eviscerated the parts of the Murphy-Johnson that were specifically aimed at people with severe mental illnesses such as schizophrenia and bipolar illness. And now, the very short Senate calendar this year may doom this proposal.

This brings us to the final version of The Murphy-Johnson Helping Families in Mental Health Crisis Act released last week. In the end, negotiations resulted in some loss of its original force. For example, it does not give the new Assistant Secretary as much control over SAMHSA as did earlier versions (though there is now new independent audit capacity of the agency). It is less aggressive in contesting the overly rigid privacy provision; it does not authorize specific sums to the establishment of AOT; and creates less new bed capacity than is needed. The bill does not mandate that Protection and Advocacy refrain from advocating for the “right” of deeply psychotic patients to refuse treatment (it does, however, introduce a new accountability mechanism).

Nonetheless, the latest Murphy-Johnson remains an achievement that fosters the needs of severely mentally ill patients and is far superior to the Senate version. It brings greater oversight and accountability to an agency within HHS whose misdirected power has long been ignored. And it increases treatment services and research capacity. Given the ideological struggles that beset the field of mental health/illness and the hyper-partisan climate of Congress, the current version is most likely the best compromise available. It is an excellent and hard won reform.