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 House SAMHSA Legislation Silent On Integrated Treatment For Persons With Co-Occurring Disorders

Restraint Protections Included But Have
Unintended Negative Consequences

For Immediate Release, July 13, 2000
Contact: Chris Marshall

Democratic members of the House Committee on Commerce, in an effort to stimulate attention and action by the U.S. House of Representatives, have introduced legislation (H.R. 4867) to reauthorize the Substance Abuse and Mental Health Services Administration (SAMHSA). H.R. 4867 is sponsored by Representative Lois Capps (D-CA) and the first co-sponsor is Commerce Committee ranking minority member Representative John Dingell (D-MI).

Unfortunately, despite the advocacy efforts of many national mental health associations, including NAMI, H.R. 4867 fails to even mention integrated treatment approaches for persons with co-occurring mental illness and addictive disorders. Amendments are needed to allow such integrated treatment. H.R. 4867 includes Senate passed minimum national standards for the use of restraints and seclusion. However, several serious unintended consequences of these restraint provisions have recently been predicted. Amendments are needed to prevent these negative consequences.

H.R. 4867 is a 117 page legislative bill which reauthorizes SAMHSA and proposes a variety of positive program initiatives. Unfortunately, the legislation fails to address NAMI's two major priorities - integrated treatment for persons with co-occurring mental illness and addictive disorders and meaningful program and financial accountability through the Community Mental Health Services Block Grant (MHBG). And unintended consequences in the restraints provisions could do great harm. This E-News focuses on two NAMI legislative priorities - integrated treatment and restraints.

Members of the House Commerce Committee need to IMMEDIATELY hear your concerns. The roster of Commerce Committee members is listed at the end of this E-News.


Roughly 10-to-12 million Americans experience a co-occurring mental illness and addictive disorder. Frequently their clinical treatment fails, because only one disorder is treated, the two disorders are treated one at a time (known as sequential treatment), or the two disorders are treated at the same time but by two different agencies usually not communicating with each other and usually using different clinical philosophies (known as parallel treatment). Clinical failure frequently results in homelessness and involvement with the criminal justice system. Research, financed by the National Institute of Mental Health and National Institute of Drug Abuse, amassed over the last decade have clearly demonstrated that "integrated treatment," treatment directed simultaneously at the same program site, ideally using crossed-trained staff, is more effective than the failed sequential or parallel treatment. The recent Surgeon General's Report on Mental Health refers to integrated treatment as "combined" treatment. Further information and citations of this research are available from NAMI's "Where We Stand" paper on co-occurring disorders, posted on the NAMI web site (

In December 1999, the Senate passed a SAMHSA reauthorization bill (S. 976). This bill failed to allow integrated treatment for persons with co-occurring disorders. The substance abuse providers and state agencies, supported by SAMHSA and the National Association of State Mental Health Program Directors, oppose federal legislation granting states the immediate ability, at their discretion, to finance integrated treatment programs.

In April 2000, six national mental health associations - Bazelon Center for Mental Health Law, International Association of Psychosocial Rehabilitation Services, NAMI, National Association of County Behavioral Health Directors, National Council of Community Behavioral Health, and National Mental Health Association - approached key members of the House Commerce Committee asking for a modest package of amendments to the Senate passed SAMHSA bill to allow integrated treatment. Specifically, the mental health advocates proposed:

1. Allowing states, at their discretion, next year, to use up to 20% of their substance abuse and mental health block grants, to finance integrated treatment.

2. In allowing integrated treatment, SAMHSA shall ensure that federal reporting requirements do not unduly hinder the States in their ability to combine or commingle funds in order to provide an integrated program of services.

3. State annual plans for substance abuse, just like the state annual plans for mental health are required to do, must address the needs of persons with co-occurring disorders.

The sponsors of H.R. 4867 refused to adopt these modest provisions.

H.R. 4867 has three sections dealing with the treatment problems of persons with co-occurring mental illness and addictive disorders. These provisions would:

1. Create a new federal grant program to provide comprehensive treatment services to persons with co-occurring disorders. Such programs are to develop innovative models and validate and replicate evidence based practices.

2. Allow state substance abuse and mental health block grant funds to serve persons with co-occurring disorders "as long as funds available under such sections are used for the purposes for which they were authorized by law and can be tracked for accounting purposes." This means that every dollar of the mental health block grant must be spent for mental health services only. This means that every dollar of substance abuse block grant dollars must be spent for substance abuse services. This language, insisted on by SAMHSA, means that a state may not finance integrated treatment programs for persons with co-occurring disorders.

3. Require SAMHSA, after two years, to submit a report to Congress on promising and evidence-based practices for serving persons with co-occurring disorders. This requirement does not require SAMHSA to rely upon or coordinate with NIMH and NIDA research. This study puts off the issue for integrated treatment for years - 2 years for the study, then whatever years it will take Congress to propose legislation.

When the mental health advocates learned that Reps Capps, Dingell, and others were going to propose a new federal grant program for persons with co-occurring disorders, we recommended that the House language use the language proposed in the Senate mental health reform legislation (S. 2639), sponsored by Senators Pete Domenici (R-NM), Ted Kennedy (D-MA), Paul Wellstone (D-MN), and others. For information on S. 2639 refer to NAMI E-News, May 26, 2000, Vol.00-138 entitled "Senators Domenici and Kennedy Introduce Mental Health Early Intervention, Treatment and Prevention Act". S. 2639 specifically would authorize "grants for integrated treatment of serious mental illness and co-occurring substance abuse." Representatives Capps and Dingell refused to use the Domenici-Kennedy-Wellstone bill.

H.R. 4867 never mentions the phrase "integrated treatment."

The mental health advocates have now proposed two very modest additions to H.R. 4867:

1. Include the phrase "including, integrated treatment models" in the new federal grant authority, Section 506 (b) (2) (b) of H.R. 4867.

2. Include a flexibility provision in dealing with use of the substance abuse and mental health block grant for co-occurring disorders with the sentence, "The Secretary shall ensure that federal reporting requirements do not unduly hinder States in their ability to use combined funds from sections 1911 and 1921 for this purpose."

ACTION REQUESTED: Please write your members of the House Committee on Commerce, stress your disappointment that H.R. 4867 refuses to even mention "integrated" treatment and ask that the Section 506 grant authority expressly allow integrated treatment and that SAMHSA in administering its block grants does not unduly hinder states from using their funds for integrated treatment. All members of Congress can be reached by calling the Capitol Switchboard at 202-224-3121 or addresses and other contact information can be obtained by going to the policy page of the NAMI Web site at and click on "Write to Congress."


H.R. 4867 contains Senate passed legislation which would create a national patient protection to ensure the appropriate use of restraint and seclusion in psychiatric treatment programs. The Senate passed this legislation, sponsored by Senator Chris Dodd (D-CT), twice - as part of the SAMHSA reauthorization legislation (S. 976) and as part of the Health and Human Services Appropriations legislation (H.R. 4577). Though far less comprehensive than NAMI's ideal public policy objectives, NAMI has supported the Dodd amendment as a modest good first step in creating a national standard. Recently, however, two unintended consequences of the Dodd provision have become known. These consequences could undermine the protections we are pursuing. To see NAMI's ideal public policy objectives as they relate to restraint and seclusion use, go to the NAMI web site (, go to the NAMI public policy platform, and examine section 7.8.

The Dodd provisions would declare that residents of psychiatric treatment programs are entitled to the right to be free from mental and physical abuse, corporal punishment, and any restraint and involuntary seclusion imposed for discipline or staff convenience. The amendment would require that restraint be imposed only on the written order of a physician. The Dodd amendment requires that all deaths associated with restraint or seclusion be reported to a governmental agency. [H.R. 4867 requires the reporting to the state Protection and Advocacy Agency while the Senate passed provision requires reporting to agencies designated by the Secretary of Health and Human Services.] The legislation would also require adequate staffing and training of staff.

The unintended consequences have recently been identified by NAMI founding member Max Schneier, also a former member of the first SAMHSA national advisory panel and a former member of the Joint Commission on Accreditation of Health Care Organizations (JCAHO) professional and technical advisory committee on behavioral health (PATC).

NAMI is now seeking two technical amendments, consistent with the Dodd amendment, to deflect these unintended consequences.

Section 591 (b) (1) specifies that restraints and seclusion are only allowed upon the written order of a physician or licensed independent practitioner.

1.This does not prohibit standing physician or licensed independent practitioner orders, which both HCFA and JCAHO currently prohibit. Standing orders are known as PRNs - pro re nata - meaning on a as needed basis.

Needed - a technical amendment which prohibits PRNs.
In implementing the written order requirement of this section, standing orders or as needed basis orders, referred to as PRNs (pro re nata), are prohibited.

2. Concern is expressed that the physician or LIP order language, by itself, would negate additional protections currently required in both the HCFA and JCAHO standards, such as the face-to-face evaluation requirement.

Needed - a technical amendment which expressly allows these additional patient protections.

Nothing in this section prohibits the Secretary and the Health Care Financing Administration and their deemed status agent, the Joint Commission on Accreditation of Health Care Organizations (JCAHO), from requiring additional patient protections, such as face-to-face evaluations when restraints and seclusion are used.

ACTION REQUESTED: write your member of the House Commerce Committee, support enactment of the restraint protections contained in H.R. 4867, but insist that without technical amendments to avoid unintended consequences the restraint provisions could actually cause great harm. All members of Congress can be reached by calling the Capitol Switchboard at 202-224-3121 or addresses and other contact information can be obtained by going to the policy page of the NAMI Web site at and click on "Write to Congress."

Republicans (29)

Thomas J. Bliley Jr., Va. - chairman
W.J. "Billy" Tauzin, La.
Michael G. Oxley, Ohio
Michael Bilirakis, Fla.
Joe L. Barton, Texas
Fred Upton, Mich.
Cliff Stearns, Fla.
Paul E. Gillmor, Ohio
James C. Greenwood, Pa.
Christopher Cox, Calif.
Nathan Deal, Ga.
Steve Largent, Okla.
Richard M. Burr, N.C.
Brian P. Bilbray, Calif.
Edward Whitfield, Ky.
Greg Ganske, Iowa
Charlie Norwood, Ga.
Tom Coburn, Okla.
Rick A. Lazio, N.Y.
Barbara Cubin, Wyo.
James E. Rogan, Calif.
John Shimkus, Ill.
Heather A. Wilson, N.M.
John Shadegg, Ariz.
Charles W. "Chip" Pickering Jr., Miss.
Vito J. Fossella, N.Y.
Roy Blunt, Mo.
Ed Bryant, Tenn.
Robert L. Ehrlich Jr., Md.

Democrats (24)

John D. Dingell, Mich. - ranking member
Henry A. Waxman, Calif.
Edward J. Markey, Mass.
Ralph M. Hall, Texas
Rick Boucher, Va.
Edolphus Towns, N.Y.
Frank Pallone Jr., N.J.
Sherrod Brown, Ohio
Bart Gordon, Tenn.
Peter Deutsch, Fla.
Bobby L. Rush, Ill.
Anna G. Eshoo, Calif.
Ron Klink, Pa.
Bart Stupak, Mich.
Eliot L. Engel, N.Y.
Tom Sawyer, Ohio
Albert R. Wynn, Md.
Gene Green, Texas
Karen McCarthy, Mo.
Ted Strickland, Ohio
Diana DeGette, Colo.
Thomas M. Barrett, Wis.
Bill Luther, Minn.
Lois Capps, Calif.