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 Congress Refuses To Give States Flexibility In Providing Integrated Treatment For Persons With Co-Occurring Mental Illness And Addictive Disorders

Letter To Commerce Chair Representative Tom Bliley And Representative Michael Bilirakis From Nami Executive Director Laurie Flynn

For Immediate Release, September 26, 2000
Contact: Chris Marshall

The House of Representatives is expected to pass H.R. 4365, the "Children's Health Act of 2000," later today. This legislation has 36 detailed legislative titles, including reauthorization of the Substance Abuse and Mental Health Services Administration (SAMHSA). The bill passed the Senate on September 22, and after the vote in the House later this evening, the bill will move on to the White House where President Clinton is expected to sign it into law. Attached below is a copy of NAMI's letter to leaders of the House Commerce Committee expressing both support and concern regarding key provisions in HR 4365 affecting children and adults with severe mental illnesses.

The previous E-News summarized the creation of a national restraint standard in the legislation. A subsequent E-News will summarize other important provisions contained in the legislation, including a number of key provisions contained in the Mental Health Early Intervention, Treatment and Prevention Act (S 2639/HR 5091), introduced earlier this year by Senators Pete Domenici (R-NM) and Edward M. Kennedy (D-MA) and Representatives Ted Strickland (D-OH) and Heather Wilson (R-NM). Among these are a new authorizations for SAMHSA programs on jail diversion, emergency mental health centers, suicide prevention and mental illness screening for at-risk children. This E-News details provisions related to treatment programs for persons with co-occurring mental illness and substance abuse disorder.


Despite efforts by NAMI and allied national organizations, the final version of HR 4365 does not contain a proposal to grant states flexibility in providing integrated treatment for persons with co-occurring mental illness and addictive disorders. Instead, the bill creates a modest federal discretionary grant program targeted to this population. As is often the case, Congress required a study to be issued within 2 years.

NAMI and other mental health advocates sought to clarify that SAMHSA reporting requirements should not be so burdensome that states can't finance integrated treatment through the mental health and substance abuse block grants. NAMI and other advocates pushed to have the following phrase inserted in the legislation: "In administering this section, the Secretary shall ensure that federal reporting requirements do not unduly hinder the States in their ability to use combined funds from sections 1911 and 1921 for integrated treatment for persons with co-occurring mental illness and substance use disorder."

The mental health advocates had previously proposed more substantial legislation including blended block grant funding, phase-in of blended funding, hold-harmless with phase-in of blended funding, and a limit of 20% of block grants which a state could allocate to integrated treatment. All of these proposals were intended to give the states the discretion - the option - to finance integrated treatment programs. The mental health advocates had also proposed the state mental health planning requirement related to persons with co-occurring disorders should equally apply to the state substance abuse planning requirement.

Unfortunately, key members of the Senate Health Education, Labor and Pensions Committee and the House Commerce Committee, at the urging of both SAMHSA and the state substance abuse directors (as well as their provider clients), rejected this proposal. Section 3407 of H.R. 4365 declares: "States may use funds (mental health and substance abuse block grants) to treat persons with co-occurring substance abuse and mental 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." In effect, few, if any integrated treatment programs will be financed with block grant dollars.

Public mental health authorities - including members of the National Association of State Mental Health Program Directors and National Association of County Behavioral Health Directors - and community providers - including members of the National Council for Community Behavioral Health and International Association of Psychosocial Rehabilitation - tell us that they do not have the sophisticated management information systems (MIS) required to track increments of minutes in mental health and substance abuse services within integrated programs.

A coalition of mental health advocates joined NAMI in pushing for this state flexibility. These groups included:

Bazelon Center for Mental Health Law
Federation of Families for Children's Mental Health
International Association of Psychosocial Rehabilitation Services
National Association of County Behavioral Health Directors
National Council for Community Behavioral Healthcare
National Mental Health Association

Interestingly, the state mental health directors (NASMHPD) did not advocate such flexibility. In the summer of 1999 the state mental health and state substance abuse directors cut a deal to maintain the status quo so that each block grant would only serve the primary population (mental illness and addictive disorder) and not allow integrated treatment. Senate leaders opposed to state flexibility cited this state agency administrators' agreement for the status quo as the reason to oppose what the mental health advocates desired.


Section 3213 of H.R. 4365 includes a provision originally included in S 2639/HR 5091 establishing a discretionary grant program targeted exclusively to integrated treatment for persons with co-occurring disorders. While this Domenici-Kennedy proposal would have authorized $50 million a year for such a program, H.R. 4365 cut this "authorization level" to $40 million.

The purpose of this new grant program is to provide fully integrated services rather than serial or parallel services, employ staff that are cross-trained, and provide services at the same location. Priority would be given to persons who have a history of interventions with law enforcement or the criminal justice system; have recently been released from incarceration; have a history of unsuccessful treatment; have never followed through with outpatient services despite repeated referrals, or are homeless.

Another Study

Section 3406 of H.R. 4365 requires a study within 2 years of enactment. Such a study will report in the manner in which individuals with co-occurring disorders are receiving treatment, a summary of improvements necessary, and a summary of evidence-based practices.

The Evidence-Based Practice Already Exists

NAMI and the other mental health advocates have consistently argued in recent years that the existing evidence base of scientific research already strongly supports the efficacy of integrated treatment.

The U.S. Surgeon General's Report on Mental Health observes: "Substance abuse is a major co-occurring problem for adults with mental disorders. Evidence supports combined treatment, although there are substantial gaps between what research recommends and what typically is available in communities." (pages 18-19)

Further, the Surgeon General's report states: "Research amassed over the past 10 years supports a shift to treatment that combines interventions directed simultaneously to both conditions - that is, severe mental illness and substance abuse - by the same group of providers (Kosten and Ziedonis, 1997; for an example, see Mowbray et. Al. 1995), but access to such treatment remains limited....Combined treatment is effective at engaging people with both diagnoses in outpatient services, maintaining continuity and consistency of care, reducing hospitalization, and decreasing substance abuse, while at the same time improving social functioning (Miner et. al., 1997; Mueser et. al., 1997 a)." (page 288)

And lastly, the Surgeon General further observes: "Most of the treatment services for mental illness and for substance abuse are separate (and use different kinds of providers), as are virtually all of the public funds for these services. This separation causes problems for treating the substantial proportion of individuals with co-morbid mental illness and substance abuse disorders, who benefit from treating both disorders together (Drake et al, 1998)."

In the coming months, NAMI will be monitoring implementation of both the new CMHS integrated treatment program and the SAMHSA demonstration and report on co-occurring disorders to ensure that the new Administration taking office in January 2001 takes every opportunity to pursue greater state flexibility investing in integrated treatment programs.

September 26, 2000

The Honorable Tom Bliley
Chairman, Committee on Commerce
U.S. House of Representatives
2125 Rayburn Office Building
Washington, DC 20515

The Honorable Michael Bilirakis
Chairman, Subcommittee on Health
Committee on Commerce
U.S. House of Representatives
2125 Rayburn Office Building
Washington, DC 20515

Dear Chairman Bliley and Chairman Bilirakis:

On behalf of the 220,000 members and 1,200 affiliates of the National Alliance for the Mentally Ill (NAMI), I am writing to express our support for final passage of HR 4365, the Children's Health Act of 2000, and its provisions reauthorizing the Substance Abuse and Mental Health Services Administration (SAMHSA). As the nation's largest organization representing children and adults with severe mental illnesses, NAMI is hopeful that this legislation will improve federal leadership in the delivery of services for individuals and families in need.

NAMI is particularly pleased that HR 4365 contains provisions from the Mental Health Early Intervention, Treatment and Prevention Act (S 2639/HR 5091) authored by your colleagues Senators Pete Domenici and Edward M. Kennedy and Representatives Ted Strickland and Heather Wilson. Inclusion of new authorization provisions at SAMHSA and the Center for Mental Health Services (CMHS) on grants for jail diversion, grants for homeless persons, emergency mental health centers and new training programs for teachers and emergency personnel are major steps forward.

Further, NAMI feels that provisions which include evidenced-based suicide prevention will help in reducing the alarming suicide rate in young people that has increased over the last several decades. The funding of projects to identify and analyze unique profiles of children and youth, ages 13 and under and ages 13-to-21, who have attempted or completed suicide will be able to provide better assessment, treatment and preventative measures. Collectively, these new programs will help CMHS assist states and communities in building the capacity of systems serving individuals with the most severe mental illnesses.

NAMI is especially supportive of the new program authorized at CMHS on integrated treatment for persons with co-occurring mental illness and addictive disorders. As you know, this provision was originally included in S 2639/HR 5091 and will allow grants to communities to invest in evidence-based approaches that have already demonstrated that programs that integrate treatment are more effective than parallel and sequential treatment.

However, NAMI is troubled that because this new program is placed solely within the jurisdiction of CMHS, state alcohol and drug abuse agencies will continue to view funding for integrated treatment as the exclusive responsibility of the mental health system. NAMI believes that more needs to be done to allow state flexibility in providing integrated treatment for persons with co-occurring mental illness and addictive disorders and to break down barriers in embedded policies at SAMHSA that prevent states from blending federal substance abuse and mental health block grant dollars. Federal reporting requirements and inflexible bureaucracies should not get in the way of access to evidence-based approaches that have been proven effective in serving the most severely impaired, treatment resistant population. NAMI is concerned that this legislation has been a missed opportunity to break down those barriers and promote state flexibility.

NAMI would also like to express its backing for provisions in HR 4365 establishing new federal standards for the use of restraint and seclusion in facilities receiving federal funds and "non-medical community-based facilities for children and youth." These new standards will ensure that residents in these facilities will be free from restraints and involuntary seclusion imposed for the purpose of discipline or convenience. In NAMI's view, use of restraint and seclusion should only be used in emergency safety situations. Provisions in HR 4365 that restrict the imposition of restraint and seclusion to written orders of physicians and other licensed practitioners are a major step forward in federal policy. Likewise, requirements for mandatory reporting of deaths occurring immediately after imposition of restraint and seclusion will help ensure that serious abuses are properly investigated.

NAMI is appreciative of the bipartisan effort to move HR 4365 to final passage. Our consumer and family membership looks forward to working with you and your colleagues on the Commerce Committee to continue the process of promoting federal policies that focus on expanding access to evidence-based programs that place the highest value on serving children and adults diagnosed with severe mental illness.


Laurie M. Flynn
Executive Director


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