Mental health advocates were delighted to read recent media reports stating that the Trump administration is researching several initiatives designed to improve treatment of the seriously mentally ill. These initiatives include researching the ability of personal technology to help people with mental illness, moving the homeless in California to government housing, and keeping guns from a small group of people with serious mental illness who are potentially violent.
But there are two much more important initiatives that should be on the table — and very well may be, if comments President Trump made in August are any indication. Those are increasing the number of psychiatric hospitals and reforming procedures for involuntary commitment (known as “civil commitment”).
According to the Treatment Advocacy Center, there is a nationwide shortage of at least 95,000 psychiatric hospital beds — and the shortage grows worse every year. President Trump proposed the right solution on Aug. 15: “I think we have to start building institutions again. … So many of these institutions were closed, and the people were just allowed to go onto the streets. And that was a terrible thing for our country,” he told reporters in New Jersey. He was also right in calling for civil commitment reform on Aug. 5; referring to people with serious mental illness who are potentially dangerous, he told reporters that we have to “make sure those people not only get treatment but, when necessary, involuntary confinement.”
To achieve his objective of increasing the number of hospital beds, President Trump should work with Congress to eliminate the Institutes for Mental Disease (IMD) Exclusion embedded in Medicaid. The IMD Exclusion prevents states from receiving Medicaid funds for seriously mentally ill adults when they reside in a state psychiatric hospital. The only way states can get Medicaid funds for hospitalized mentally ill adults is to kick them out of the psychiatric hospitals, at which point Medicaid will reimburse them for their care. Homelessness, arrest and incarceration are the inevitable results of evicting people from hospitals who need hospital care. It’s not fair and it’s not compassionate.
Those who claim that allowing Medicaid to fund psychiatric hospitalization will return us to the days of “snake-pit” hospitals are wrong. It was the lack of money that created the snake pits. Giving hospitals more money will enable them to deliver care that is truly therapeutic.
There are Democrats who agree with the president and should work with him. Rep. Eddie Bernice Johnson (D-Texas) is a former psychiatric nurse who worked on the front lines of the deinstitutionalization tragedy. She has proposed a bill to eliminate the IMD Exclusion. Democratic presidential candidates Sen. Amy Klobuchar (D-Minn.) and South Bend, Ind., Mayor Pete Buttigieg also have called for more beds and hopefully are willing to work with the Trump administration to achieve that.
When it comes to civil commitment, the most important change that President Trump can propose is increasing the use of assisted outpatient treatment (AOT), a procedure that allows judges — after full due process — to commit the few seriously mentally ill who are historically and potentially dangerous to stay in up to one year of outpatient treatment, often including medications, while they continue to live uninstitutionalized in the community. Outpatient commitment is less expensive and less restrictive than inpatient commitment.
Extensive research in multiple localities shows AOT decreases homelessness, arrest, incarceration and hospitalization in the 70-percent range. Mass violence, which has been in the headlines recently, is so rare that no one knows if AOT would reduce it — but AOT clearly can help reduce violence in general. One important study found individuals in AOT were four times less likely to commit violence than similar individuals who were not in AOT. That explains why expansion of AOT is supported by advocates for the seriously mentally ill, the National Sheriffs’ Association, the International Association of Chiefs of Police, the U.S. Conference of Catholic Bishops, the Department of Justice, the Agency for Healthcare Research and Quality (AHRQ), and many in the public and in urban business groups.
It is true that some mental health program directors oppose AOT laws. But that’s likely because AOT laws could require their programs to accept the most seriously ill, thus threatening their ability to cherry-pick the highest-functioning individuals to serve. But when it comes to homelessness, arrest and violence, refusing to serve the seriously ill is part of the problem. And AOT can help solve it.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a report that shows the AOT pilot programs it funds are effective, but it has not released that report. President Trump should order the report to be released. Next, the president and Congress should robustly fund AOT by setting aside 10 percent of the $722 million mental health block grant to fund AOT programs. That could increase the use of AOT at no additional cost to the government.
Both Democrats and Republicans agree that something has to be done to reduce violence and help the 140,000 seriously mentally ill who are homeless and the 400,000 who are incarcerated. By calling for more psychiatric hospitals and civil-commitment reform, President Trump has given both parties a road map for how to do it.
DJ Jaffe is the author of “Insane Consequences: How the Mental Health Industry Fails the Mentally Ill,” an adjunct fellow at the Manhattan Institute, and executive director of Mental Illness Policy Org. Follow him on Twitter @MetnalIllPolicy.