Transcripts For CSPAN Manhattan Institute - Mental Health 20180107

Good morning, i am Vice President for research and publications at the manhattan institute. Welcome to todays symposium on the state of treatment of americas mentally ill. Were pleased and honored to have with us to distinguished authors. Their current books on Mental Illness are shaping public discussion. Also, the assistant secretary for Mental Health and Substance Abuse its. She is playing a key role in shaping public policy. The is worth pointing out that the question of the right role for government into supporting the care and treatment of the mentally ill is one that has long vexed us as a nation. Consider the case of the educator who in the 1930s began to visit residents presence prisons. Sadly and tragically, the same can be said about the situation today. Even as the population of the Rikers Island jail here in new york city as declined, the percentage of the population that is mentally ill there has increased. She would be distressed to know that the atlantic referred to Cook County Jail and chicago as the nations largest Mental Health hospital. Americans who suffer from conditions such as schizophrenia have no access to help. Many can be found on sidewalks not far from the building in which we are meeting this morning. How did this situation come to be . What is it like for the families of the mentally ill when they seek help . What steps should government take . What policies should rethink . These questions will be at the heart of our discussion. Will hear first from authors dj jaffe and peter earle their discussion will be moderated byy. Erin billups. She also hosts the weekly city help beat program. For those unfamiliar with new york one, it is the most serious news cast here. First, to introduce dj jaffe, peter earley, and erin billups. I am here to introduce to authors whose own personal family circumstances have opened their eyes and their passion to advocate for those with Mental Health illnesses. Your book was a 2007 Pulitzer Prize finalist. He is currently a member of the National Alliance on Mental Illness. Dj jaffe is the executive director of a think tank. He has also served on the board and is a regular contributor to the huffington post. Gentlemen, if you can, i would love for you to share your personal experience that has propelled you into your advocacy work. Thank you so much. It is nice to see so many familiar faces. My story begins, my son was a College Student here in new york. I found out that he was having a psychotic breakdown. I raced to new york from fairfax county, virginia. I discovered that he had been wandering around for five days. He had barely slept and had hardly eaten. I took him to fairfax. On that for our ride, he would cry when minute, then left the next. I begged him to take medication. He had been diagnosed as bipolar one year earlier. He asked me how i would feel if he killed himself. I took him to the emergency room. We did not have a psychiatrist. We sat there for hours. He finally said he had enough. I literally grabbed a doctor, tracked him into the room, he came in with his hands up and said, im sorry i cannot help you. You have been in this room for four hours. Your son has told us that he does not want medication. Bring him back after he tries to kill you or somebody else. I took him home. 48 hours later, he slipped out of my house. He broke into a strangers house to take a bubble bath. He was charged with two felonies , breaking and entering, and destruction of property. He became one of the thousands of people with serious mental onus that part sitting in our it jails and prisons. Because of that, i spent 10 months in the miami jail following people with Mental Illnesses through the system. I went to miami because Rikers Island said no. Cook county said no. Los angeles twin towers said no, they would not let me in. The judge down there let me in. That is why i got involved in the system. I cannot get my son help. After i wrote my book, five hospitalizations later, i called up the mental crisis team. I said come look at my son. They ask him is he dangerous . One night he became violent and i called. They asked, is he dangerous or violence violence . The police came and shot my son twice with eight taser a taser. They hauled him away. And the 80s, my wife and i became guardian for her sister. We thought that if she came to new york and lived with us, that would solve all of her problems. At night, during the day, we would sit around the dinner table and she would spew out this barrage of uncontrollable gibberish. Ive never heard Something Like that from someone i loved. We hear her screaming at night. They were voices only she could hear. Which right to get her into treatment, but she did not think she was sick. She thought she was the messiah. She thought everybody else had a problem. Eventually we were able to get her into treatment, but they would not tell us what was wrong with her, or what her next appointment was, because they wanted to protect her privacy. Because the system wanted to protect her privacy, we did not know when her next doctor appointment was. We didnt know what prescription she needed. We cannot assist in monitoring her treatment. We kept going through this cycle. That kind of led me to realize how horrific the system was. Ive been involved in a love nonprofits a lot of nonprofits. I came to learn that a lot of what we are told about Mental Health is simply not true. That is what i wrote a book on. Can you talk about what you see as a possible solution to end this constant stream of those with serious Mental Illness and turned the criminal Justice System . Yes. First i want to say that the outcome is, my son is ok and doing well. When you are talking about Mental Health you have to divide the groups. Housing first, giving them a place to live is the first cornerstone. You cant get better if youre living under a bridge. The Community Treatment team kenexa person with people that care about them. We know from the left logic in los angeles that they have an 80 recovery rate. They did people jobs get people jobs. People with Mental Health what what we all want. Mental health what what we all want. They want a safe place to live, a purpose in their life, and somebody to love them. It is that simple. We create all these barriers to keep people from getting these services. I think that supervised housing and not necessarily permanent housing first. My sister and a lot lived in a group home. For many years, that is what taught her the skills to live independently. They put her in an dependent living one time, and she failed. The thesis of my book is that we have to understand that 100 of the population can have their wellness improved. There are 4 who are seriously and persistently mentally ill. We tend to focus the bulk of our resources on the least symptomatic. As a result, criminal justice is running a shadow Mental Health system for those who refuse services by the Mental Health system. What are your feelings on the push for more. Mentors peer mentors . The question is, would someone two somebody providing support . What that same support provided by a professional, a Family Member, a member of the community, be as effective as that provided be a. There has been zero research on that. On some cases it works really well. Within the leadership, there is an antimedication and antitreatment bias. The leaders of the peers support community and new york have worked to close more hospitals, oppose something we have called kendras law, they have supported making it easier for the seriously mentally ill to get guns. It has had a negative affect on the system. There is no doubt that being a peers supporter is very helpful. You have a sense of wellness. You are getting a paycheck. Peers support is clearly beneficial. Try joining that having someone who has been there is extremely helpful. I also found that it is a dual street. You have ap or that has social connectivity with someone. One of the biggest ways to help people get engaged in their own treatment is to have them help someone else. My son was really five hospitalizations. We get into this argument all the time where we say, if we just give People Services then they will get better. My son had a house, he had people who cared about him. It was not enough. You need all of this, in my opinion. The question is, how do you get that individual to want to engage in his own treatment . One of the things that encourages me is that the test comes from the addiction world. This is probably a much larger problem there than it is with mental i asked my son. The things that got him to want to change for fear change were fear, punishment, his brother said that he cannot see his niece. But also, acceptance of being sick. That is very hard and our society for somebody to admit that they have a Mental Illness. I believe you need all of these tools. There is just no one single answer. Do you agree with the direction that mr. Jaffe says . That all of the resources are being taken away from the mentally ill . When you go down to miami, youll discover that pete earley went to a clinic today. One person could have 52 records. There is no continuity. There is no personal relationship. You are already isolated. We focus on the frequent utilizers. They eat up all of the services, they are stuck in the revolving door. What dj is a saying is sure. We have broadened Mental Health. These people are easier to help. We tend to go, lets have this program, and this program, and that program. Nobody wants to help these people, and that is why they are in jail. It is obvious we are not helping people. If you look at the numbers, community programs, they only accept voluntary patients. There is a chart in my book where i document the number of hospitals circa 1960. I forgot what the number was, 500,000. And then the number incarcerated, and then i compare that number two today. The totals are the exact same. We just moved the mentally ill out of the institutions and into the jails. In the Mental Health system, we tend to the reports on, how are the people in the Mental Health system doing . The majority of the most seriously mentally ill are not in that system. They are in the corrections system. The statistics are undeniable, that we not focusing on the most seriously ill. What shocked me was that these people knew the programs better than i did. They knew what to say. They knew all of that stuff, but we still were not engaging them. Youve got to get them engaged in their own treatment. 25 of people with schizophrenia cannot be helped no matter what we do. What do you do with those folks . Where do they end up . They end up in jails and prisons. There is also the issue of the shortage of Mental Health professionals to support this community. There is a need for a. Workforce there is a need for a peer workforce. People would say that there are benefits for peer support. It is clear that those who are providing, everyone who provides peer support gives the statistics showing how great the programs are working. I reviewed all the literature. There is no literature that compares the delivery of peer support with the delivery of service with something else. What needs to be done to create more support within Mental Health professionals to address the needs of the seriously mentally ill . All of my working out is focused on criminal justice. There somebody from the Citys Department of Public Safety here. It is because the Mental Health system has offloaded the most seriously ill to the criminal Justice System, it is the criminal Justice System that is running a shadow Mental Health system. They are the ones interested in solving this problem. If you ask somebody in corrections what do we need to solve the problem . They will instantly say more hospitals, we have to keep the people in a longer until they are stabilized, we need to be able to put them into mandated and monitored treatment in the community. Asked that same question to somebody in the Mental Health industry. They will say that we have to educate the public, and the stigma. They are going to propose things that are totally irrelevant to the elephant in the room. There are 90,000 seriously mentally people in new york city who received zero treatment and the past year in the past year. This is who we are not focusing on and that is the issue. If you want to improve the delivery of Psychiatric Services to people who are seriously mentally ill, then you need to start paying for those services. Parity has been turned into almost a joke, when it comes to actually a look, my son had seven psychiatrists. Only two bothered to learn more than his name and symptoms. Treating the mind also requires treating the heart. You cannot do it that way. Sorry, it is also important to understand that throwing more money at Mental Health is not the same as treating the seriously ill. When i was growing up, blinged was not bulltying was not a part of Mental Health. Every social Service Problem is been wrapped in a Mental Health narrative. Mental health funds are diverted to it. Until we focus on the most seriously mentally ill, more money is not necessarily the answer. It certainly has not been so far. I will agree with you on that. The funds are not being focused on those who can deliver those services. I would love to hear from you guys about the current opioid crisis. People with bipolar disorder have drug and alcohol problems, some of them. Im not an expert on the open your crisis. I know that 99 of the people in the miami jail had problems. That does not necessarily address the opioid crisis. I will let dj jumping on that one. We have finally figured out that Mental Health mental and addictions are combined. People with both disorders are the least likely to get into care. If somebody needs marriage counseling and the other is a mentally ill, opioid user, the person with marriage counseling is going to go in. Wed like to take a few questions from the audience. The thesis that is put out there is only someone compared to the addition of the same Services Provided by anyone and then i want to see, does it improve a meaningful metric. Everything in the world that makes you smile. Show somebody a picture of a cat and theyll smile so that is now evidence baseed to improve Mental Health it made you smile but what we should look at is what programs are improving meaningful metrics. Metrics are homelessness, arrest and incarceration and victimization. I would like to see research on all programs that do that. I can tell you this. The 21st century security act created an interdepartment mental agency and were drafting a report right now and everything is about this. Creating sidewalks and studies of what separates the chatter from what really is working so hopefully that will report. Everything you said is true, from my practice. The problem here is that with some things. Whether its Global Warming or als. You know nothing is going to happen until theres greater acknowledgement or understanding. People talk about access or capacity. Theres not providers. But the how do we get traction to influence whole policy wholesale vamping not just to provide it but to actually then ensure quality. Irs i want to stymie this flood. We look at outcomes for those quality. Talk about at improving the quality of the system when 10 times the amount of people are being incarcerated. When you look at problems with the Mental Health system, you look at outcomes within the system and we are blind to the fact that the majority of mentally ill are in prison and have not been looked at. As the commission reported, you are talking about a fractured system that is not much of a system. If you take your kid to the emergency room, they can be chained to a gurney and waiting three or four days before they see anyone. Even ifis broken you want help, trying to get into it is nearly impossible. This goes to one of my ideas about dangerousness and we have to implement a system to help people before they get to stage four that leads them to jails or prisons. Thank you so much. We have time for one more question. This gentleman. I am a retired police chief. 40 years of Law Enforcement and current chairman of the committee on severe Mental Illness for new york city. For new york state. I have a daughter so heres the daughter with severe schizophrenia who has been hospitalized. About peers but even in that 4 percent, there is a wide spectrum. Peopleseeing the same come into our emergency rooms. The same person is in and out. If there is a time to stabilize them theyre never going to get , the housing or to any of that. Until we do something with that small percentage cycling in and out and it takes an aggressive approach to have something to break that cycle but its not going to happen with a 72hour commitment. It takes more time than that for the medication to become effective. We need to break it at that point before we can talk about peers and what we can talk about. More of a statement. As Law Enforcement, we triage. We go to the most dangerous and then work backwards. Thank you so much and we have one more. Corporation for supportive housing. Im wondering you can speak to the effectiveness of Mental Health court . I have been in Mental Health court. Matthew is here and he runs the brooklyn Mental Health court and i get a little choked up because i went to his court and he let me sit in the witness box. If someone is arrested and they have to a certain level of crime and the dna and prosecutor and defendant phil they are mentally ill. They can take them to his court and he can order them to stay in treatment for x amount of time and if they do that the charges are dropped. He brings them in every week and gets report from brilliant social workers as to whether they have been complying with treatment. And he graduates and gives them a thing that says they graduate and its terrific. Heres the problem. He does after a crime is committed what we should be doing before the crime is committed. So for instance we have a law in new york that is identical to mental ending around the country , called assisted outpatient treatment. This allows judges to order a person with a history of violence and incarceration duing to stay on treatment while they live in the community. Its brilliant. This one of the things that the Peer Community is Work Together see we dont get more of yet they will have demonstrations saying well we got to train the police to do better. We have to recognize violence. The reality is, fact acted psychiatric units are locked. Were training officers to go on Mental Illness calls. The Mental Health Community Wants to deny violence is an issue a. What happens is a tragedy so we have to train the police. We have problemsolving courts everywhere but virginia, which is so backwards that we think people are thinking we are giving them a break if we take into problemsolving court. Lemppy the prob goes back that you have to enter the criminal Justice System to get that kind of treatment. Disagree parley with you is thatparley with you all these things are great if you have nowhere to send anybody, it does not work. You have to have housing, treatment and services. That will end the conversation. Gentlemen, thank you for listening. [applause] book is insane consequences. On at the an expert litigation. We have someone who is in a position to move the system. In a situation to improve she is the first person to ever hold the position for Mental Health and Substance Abuse. Services areealth administered on the state and local level but the agency she leads provide evidencebased programs to find out what really does work and it provides guidance for systems around the country. It is the leading edge of improving our national Mental Illness stream and regiment. The a graduate of shes a distinguished fellow with the American Academy of addiction. She spent over 25 years as a clinician and medical researcher. Her work has focused closely on opioid addiction, which is so much of our national conversation. Please join me in welcoming dr. Eleanor mccaskey. Subjecttart with the that and filled said was that aps phillips said was perh a side issue and perhaps not. President trump said the opioid addiction is a Public Health emergency. Addiction and Substance Abuse is housed under the same umbrella at your agency has Substance Abuse. The Substance Abuse and Mental Health Services Administration addresses issues related to behavior health. ,he president recognized through the declaration of a Public Health, which was signed leader, ity our is important to say that our administration has been working hard on the Opioid Epidemic since the election. And since the president got into office. What i mean is, a couple of things came together very nicely. Made a lot of Resources Available but it was our administration that put those resources into play. We work closely with the state and help them to provide medicated assisted treatment, which is a standard of care for the opioid abuse treatment. Widespread see the distribution of the opioid abuse antidote. On recoveryed services, including health steps Health Care Recovery services for people recovering from various serious opioid addictions. Announcement, we will continue to expand what we are work and it allows a to collaboratively with congress to bring these forces to bear. That is the direction that the president has taken. Let me ask you a slightly more blunt question that draws on your own experience in psychiatry. Can people recover from opioid addiction and does it happen . Yes, people can recover. Ofave seen many hundreds thousands of people recover. Be of the things that can difficult is that people often of the worst part disease before it is treated. See if theey do not kind of evidencebased practices that are available to help people get their lives back. We have three fda approved medications which have shown to be quite useful in helping people to get into recovery and get on with productive lives. Shown,roducts have been in the context of getting proper services, it has helped people to break the cycle of addiction and to move on with their lives. Having seen this for so many years, you are not pessimistic . I am not pessimistic. This is a very serious problem. We fully recognize this. We have seen the heroin supply contaminated with sentinel fentynal, which is increasing the number of overdoses. Someonee hard to revive who has taken care of and heroine handed contaminated with the strong opioid. The issue is if we can expand treatment and expand evidencebased treatment, people get tocountry too often services that do not provide all of the evidencebased interventions that we know work. And when that happens, they do not get the recovery that they could otherwise obtain. Administration, the work of our agency would be to help better established nationally these evidencebased practices. We do think that people can recover if they get the services and that is how you get the demand. Help people to get on with their lives. That is going to take time. But we know how no do it. Let me pivot then to the questions about the treatment of the seriously mentally ill who of course can include opioid addicts. That is the nature of your administration that you discussed. Within of a few blocks of where we are in manhattan you can find lots of People Living on the streets with all of their belongings. Let me ask another naive question. How the heck about that happen . Happen . Eck did that i think that unfortunately for many years theres been an emphasis on reducing State Hospital beds and resources that previously were available to the very seriously mentally ill. That was concurrent with the advent of new medications, and im talking back to the 1960s, 1950s and 1960s when we first started to see antipsychotic medications that i presume i was very young back then but i presume looked like miracle drugs. Coincident with the development of those types of medications and the acknowledgment that State Hospitals have really deteriorated in quality to the point where they really were not places that anyone should be, there was a push to put people into communities. Unfortunately, the treatment didnt follow the release of all of these folks into communities and that has continued. We havent made the kinds of investments that need to be made in community Mental Health services to help people get the care and treatment they need to live in their communities. So, what would a system d. J. Javie referenced we need places to take people. What would that system look like if we were able to go out on the street and right somebody into a world of engaged treatment what would that system look like that is absent now . Theres a lot of work to be done, and i will try to cover as much as i can. So, the way things work right now, some of this was just discussed in terms of the criminalization of the seriously mentally ill. There is a need to really reshape how we provide services in the Community Related to the treatment of mental disorders. What i mean by that is, right now, as d. J. Said, it is very easy to treat the people that are not as seriously ill in favor of knowing and in fairness two Community Providers these , folks often present problems of such gravity that they dont have the resources in their Community Health centers and behavioral Health Centers to provide the care needed and they know there will be compulsory treatment that occurs when they legally when they enter the legal system. Im not saying that is the right way to do things but that is the reality of the system we live in. How do we think about that differently . We need to develop models that can accommodate people with Mental Illness and focus on the most seriously ill. We have a model that has just been funded that we call the Certified Community Behavioral Health center. What these do is they bring together all of the types of Psychosocial Services and medication that people with serious Mental Illness will need to get their own recoveries in place. They also include Addiction Services and i also think we should have physical Health Services available there as well. And we will be trying to work on that as we move those models forward. But the idea would be that a person could come to one place we have a fragmented system. If you have an addiction problem you go to one part of , town. If you have a Mental Health problem, you go to another part of town and maybe you dont go to any part of town because you cant figure it out when your brain is not working right. These would be places that would have outreach. For example they might have , mobile outreach and teams associated with them and treatments associated with as well as on site providers. The other thing that needs to happen and i have talked to mr. Rosenthal about this, the other thing that doesnt happen and i hope we can get to happen is there is a dichotomy between the medical treatment of serious Mental Illness and recovery. These are not separate things. This is a continuum. An individual who give all of these resources who gets all of these resources would be best. Where im going with the ccblc is if the payment for services there is a bundled payment we bundled payment. We know that works for our Community Health centers, so the model on the physical health side is to have a bundled payment. Bundle is the money from washington that pays for the services . Correct. By bundled payment, a per person and any service they need would be compensated. You get paid for making People Better as opposed to getting streams of different funds. Exactly. So we are using this model and we are going to follow it for a few years and we hope that we will be able to establish this kind of model permanently because we know from the Community Health center side this has worked very nicely. Model is the key word. That is what your agency does. Set up a model that we hope will eventually change the situation around the country. Should that model include, it used to be that we had a very large system of locked mental asylums across the country. Families who were at their wits end because they had relatives who they considered to be dangerous could have them committed. That whole system is wiped away. Should we in part reinvent that to have the asylum be part of our retinue of possible services . Yes, so what im trying to talk about here is the spectrum of services that are needed starting with the heart of services, which i see as Community Based services. I believe that people have the right to live in communities. I believe that communities can best meet the needs of their people and that we need to build around that to make it, to remake our current Mental Health system. We should not be relying on jails and prisons to provide what is minimal if any treatment to the seriously mentally ill. So, to answer your question, i see this as a whole spectrum of services. So, do we need State Hospital beds . Absolutely we need State Hospital beds. In is a minority but a definite there is a minority but a definite significant number of people who simply have such severe illness that they can not live independently. I ran the State Hospital system in rhode island for two years before coming to my present position, and i can tell you that there are people that, regardless of our current approaches, cannot benefit and they need to be cared for and protected. So, i see the State Hospital system as that kind of a respite. On the other side of that though, we need to develop more in the way of Crisis Intervention Services. I dont think hospital Emergency Departments are the place for the seriously mentally ill. They are not equipped to take care of these folks. When we talk about people not agreeing to treatment or having the ability to consent for treatment, part of that has to do with the lack of engagement. If you see a patient in the Emergency Department you know what i mean it is not a place where somebody is having problems thinking and is frightened to get the help. But weve models for Crisis Intervention Services where we can bring people that are experiencing exacerbation of their symptoms, where weve people that know how to work with folks that are experience that. That is what they do for a living. Where we have peers and other types of healthcare support that can often help people to avoid hospitalization. Now, there will be people who need hospitalization and need acute careumber of beds. But in cases where we cannot get People Better, we need to make use of State Hospital beds. Right now in many states, maybe all states, acute Care Hospitals are often compelled to keep people who they are no longer being paid for, the insurance has stopped because we have these odd definitions of what constitutes the need of hospitalization. And that is based on acute dangerousness and as soon as that ends they are going to stop paying for services. My own view is it has to be what has been a persons history and what services do they need and we must have time to get in place before we release them. Now, people who dont get better are stuck often in acute Care Hospitals with those hospitals not getting any compensation because we dont have enough State Hospitals. They have to make room for more that do need services. So, on the State Hospitals, i can tell you in my own hospital in rhode island we had people who were ready to go back to communities and the only reason they were in the hospital is because we couldnt find a Community Bed for them. A place for them to be. As pete said you have to have housing. You cant put people on the street. So we had people that the only reason they were there is because we couldnt find a group home bed. Im talking about crisis service, Community Behavioral Health Centers, acute care beds, State Hospital beds. But you also have to have other levels of care. So stepdown units, group homes. Supervised apartments. So that people can fully recover and get on with their lives. Great to see that the federal administration can spit out an organizational chart just like that. That is very reassuring. You said we need to protect the seriously mentally ill, some of whom would have to be in State Hospital beds. Do we need to be protected from them . People who get treatment for their serious Mental Illness can recover. They can go on and be productive citizens, hold jobs, who you may not know are getting mental treatment. We have to be protected from somebody that has an out of control Mental Illness. That can be dangerous. But if people get access to the care and treatment they need ,absolutely not. Let me rephrase it. Do the untreated pose a threat to themselves and others . The dialogue that ensues after the horrible Mass Shootings we have seen. Gun control on the one hand, Mental Health services on the other. Without asking you to wade into the swamp of gun control thank you. Is it appropriate to the think about some of those who have been engaged in those situations as indicators of our failure to provide member Health Services . Of course. Of course, that is a failure. Because we can the vast majority of these folks we can treat and get back into productive lives. Just to put a clear espn on it, then it is possible Virginia Tech could have been prevented and newtown could have been prevented . You believe that . I think it is possible to have a supportive set of Community Services to help us to identify. Will we ever be able to intervene 100 of time before there is a tragedy, of course just to put a clear espn on not. But i do think, without speaking to a specific case, i do think that we know how to identify the symptoms of developing Mental Illness. We have studies going on that samhsa is involved in as well as n. I. H. We know some of genetic vulnerabilities for some of these disorder looking at family history. So, we could know who to focus on. That is what we need to do. We need to be able to focus on people who we can identify as high risk. So, it is interesting to hear how optimistic you are that if the services are provided things can get better. I absolutely believe that. And but i will say one other thing and i want to be able to speak about this before we end our discussion. That is, while we can discuss a way of providing care, we cant do it without providers. And we have very severe shortages in our workforce. Psychiatry is one of the oldest of the medical professions and i dont mean in terms of how long it has been around. Unfortunately people like me and some of my colleagues back there, we are getting older and they only turn out about 1,200 residents from psychiatry each year. We need more psychiatrists and addiction specialists. One of the things that im going to be working on my time in federal service would be to talk about how we can bring incentives to bring more behavioral experts in the field so more residency slots for psychiatry and addiction. I see prosecute practice itsers as extremely important to get people the care and treatment they need. I think psychologists are extraordinarily important to being able to help to focus the appropriate therapy and Psychosocial Services. Social workers, peers, i do think we should develop a peer professional workforce. I hope that will happen during my time. I hope that we can bring those peers and others who provide Community Support closer to those of us who are working in the behavioral Health Centers so there is better communication and seamless sets of services we can get to people in need. The people with the most serious illnesses have a lot of needs. But our systems are so fragmented and we have had this argument about medical treatment versus recovery. Recovery is including medical treatment. Most people with severe Mental Illnesses cant get to recovery without medical treatment. On the other hand they cant be successful if the medical treatment if they dont get medical services. Treatment if they dont get medical services. I will call that for young people to consider the field much psychiatry, psychology, social work and related. I really hope that we can bring more young people in because i think they are the key. One last question. We heard pete talk about the difficulty he had and d. J. Javie mentioned the difficulty in tracking the needs, penetrating the veil of appointments of privacy laws, not being able to shepherd your son or daughter or Family Member through the system because you are not supposed to be involved. Does that privacy veil need to be changed, amended, adjusted . This is something that the president spoke about before he was elected. This has been an issue for his Administration Since the time he became president. I only started here a couple of months ago bun of the first one of the first things i was involved in is is the whole expiration of current privacy laws both hipaa, Health Insurance could you repeat that . Privacy and patient affordability act. Look it up on google. It means our privacy laws. We also have even tighter confidentiality requirements for people in Substance Abuse treatment. We call that 42 c. F. R. That is the statute. The administration has been looking at this and there will be guidance out very soon. I think there is some misunderstanding of the current laws. There is the ability under hipaa to communicate with families when a person is when there is an emergency situation and they are incapacitated there is the ability to speak with families and that is not well known. And families my own view of the world is that families are probably the most important part of a persons recovery. They are who the person grew up with and will be with growing forward in some way, shape or forward in some way, shape or family. Those are the people that love and care for these folks. [applause] thank you. And what the federal government does dropping the bucket, really, it is very important that we put as many dollars as we can into these evidence based treatments. But the fact is that treatments provide the care and that is the value of of that is incalculable so families must be involved in the care of their loved ones who have these serious disorders. And there are ways to do this under hipaa while also respecting the persons rights when they did become able to tell us what they want and how they want it done. Similarly, we are looking at issues around the confidentiality statutes for Substance Abuse disorders. But this is a high priority for our administration to make it possible for families to be able to tell clinicians what is going on, what they have observed and to get information back. When you think about it, if you have someone who comes in to an acaught care set acute care setting and their Treatment Team has provided treatment and they are ready to discharge them and you cant talk to a family about what are the treatments that are being given, what the continuing risk might be, how they should address those risks. That makes no sense. So, we have to do things differently. This has been a priority since the time the president came into office. I guess from that applause you got this is an audience that is very engaged and may have questions so we will turn to the audience. Wow please wait for the microphone and tell us who you are if you dont mind and i will start with this gentleman on the right at the front table. Thank you. Quick comment and question. Access is not enough, engagement, i think, is vital. I heard you say that in so many words. I heard pete say that. To get to my question i want to thank you for your comment about the peer providers and medical approaching on a spectrum rather than always in conflict. That has been my experience as a Family Member and clinician and clinical researcher since the 1980s. Here is my question. You talked about the need to reshape how we provide services to the seriously mentally ill, reshape the models of how we provide services. Im wondering, would that include models that educate all include models that educate all Service Providers . I will broaden that term based on your discussion. Here is my question. You talked about the need to Family Members, clinicians of all kinds, peers, people in the Justice System, Law Enforcement. Educate them both about the very common problem, pete used that some people dont understand they are ill and research is clear 50 of all patients with schizophrenia do not understand their ill. It is typically brain based. Top predictor of nonadherence. Are we going to educate these people about that problem and most importantly evidence based models that help those providers engage people like d. J. s sisterinlaw, petes son and i have a son who i cant get his medical record and he is 17. If you dont mind my winding this up if i can interpret this anybody who might interact with somebody who is mentally ill should have some sense of what that Mental Illness is perhaps expanding familiarity in medical schools, in police academy. Is that practical and does it make sense . I think it is practical and i certainly think it makes sense. We do have to prioritize what we should have some sense of what do in terms of education and training for everyone from School Children to Health Professionals to Law Enforcement, to anyone. So, you will always see that there will be a conflict between how much time can you spend on the various requirements. But when we look at the prevalence of mental disorders in our society i dont see how at this point anyone could say that we should not prioritize providing education and information to all of these groups that will interact with folks. Going to the health stop we want to make sure they know actually you should not be here, you should be here . Correct. And one of the other big initiatives of samhsa and other federal agencies that are involved with Community Health centers is integration of care. So, bringing Behavioral Healthcare into primary care and bringing primary care into Behavioral Health programs and cross training. If the guy on the street goes in for a flu shot maybe they will offer him more services, right . Behavioral Health Programs and well, you know, that is pretty quick interaction. We have a lot of questions. She has a hard stop at 10 30 because she is part of the cabinet officials fan being out and out to announce the approach the administration is taking on opioid addiction. For 10 years i have run a Child Welfare organization in new york city and i have been looking for addiction models for biological parents whose kids have been removed. I recently met with n. Y. U. And college of nursing because im looking at Nurse Practitioners and they said that the most effective recovery is for people who are using opioids because there is naloxone and it is harder to treat alcoholism, et cetera. How do you deal with the stigma of going back to someone saying there is a substitute drug when as a society we think people should be off everything . Because i have been encountering that. This is a matter, again, of making people aware that giving people medication and you are talking about medication for opioid addiction, and i presume you are talking about medication like methadone and so people need to understand that taking an opioid therapy for addiction is not addiction. Here is what addiction is. When you get physically dependent on a short acting opioid your life is controlled, controlled by getting it, using it, being intoxicated briefly, feeling the withdrawal systems and getting that symptoms and getting the next dose and doing whatever you have to do in order to avoid. When you give that medication that is a once a day drug that helps to stable size you so that you can get on with your life and you can take care of your family and have a job. I would challenge anyone to identify those folks who are well stabilized and getting on with their lives. So this is a big issue we need to educate the public about. The woman in white in the back. Im from new jersey a social service organization. I wonder how you propose we are going to pay for the increase in psychiatrists and social workers and all of the Additional Services that are needed when medicaid is being cut, insurance reimbursement is lacking to say the least and most people are not even covered. Well, what i would say is that those negotiations go on between the congress and the president. We dont know what that is going to look like. But i would advocate for putting the resources we need into insurance resources that will provide care and treatment for Behavioral Health and i dont mean just medical treatment but the Psychosocial Services. And i will keep saying that as long as i have the ability to do that from this position. So, i hope that thats going to be addressed. When i was going through the process of confirmation i was able to meet with lots of senators. I can tell you that they said they are very committed to this and very interested in this in a way that i have never heard of in my time as an adult and working in the field of Behavioral Healthcare. So this is a different time. And we do now have, to me, all the tools we need because we have a president and an administration that also supports Behavioral Healthcare. So, im hoping that that will be addressed in a positive way. Now, i will also tell you that we have parity laws. We have had them for a long time. Parity laws. That means that if you have insurance that provides for services that are related to mental and Substance Abuse they need to be provided on par with physical healthcare services. Thats been in place a number of years. Our administration is really focusing on trying to get attention to the enforcement of parity laws. So, we have a website where consumers who have had problems can be shepherded to the appropriate agency that can address complaint. Aside from that, we will be looking to really enforce those laws. Let me briefly make that question harder for you if you dont mind. Are there things that we should stop doing so we can divert dont mind. Resources, repurpose resources . We need to take a hard look at what is being funded now and if they are not evidence based practices i would argue that there is a question of why we should be paying for them. We know what works for example for opioid addiction. We know how to treat serious Mental Illness. But that also is inclusive of services that are not paid for. So, it is going to go both ways. I dont know what the Additional Resources are that are needed. I think we need to take a look at what is being paid for now and if we could become more efficient and make sure people get these services that we know are effective, how many more folks could away provide care and treatment to . Sounds like you will take a hard look at your own administration. We are. Im antoine crepa, im with an organization focused on Mental Health for black men . Congratulations on your appointment. It is a threepart question. Make it a quick three. What is the federal government doing to address Mental Health for lgbt people and, by extension, lgbt people of color . Second, we know that in medical schools around the country about 4 of the curriculum is spent on cultural competency training including psychologists and psychiatrists. What is the federal government going to address increasing cultural competency training in medical institutions . The third question, which is kind of a holdover from the previous panel, what can the federal government do to ensure that Police Departments around the country are culturally sensitized to the cause for Mental Health crisis especially when it affects people of color . The issue of sensitivity it cultural differences is one that is important. At my agency we have the office of Behavioral Health equity. That office works across agencies to try to better make sure that individuals and organizations have access to the kinds of tools that are needed to instill cultural competency. The issue of sensitivity it that is an ongoing role at our agency. As far as care and treatment of people of color with mental and substance because disorder, this is part of every Funding Initiative that we have. We actually ask for plans from our grantees as to how they will assure that culturally sensitive care is being provided and we review that. So, we are aware of it. We try to be sensitive to it. Our office of Behavioral Health equity will continue to work on those issues going forward. And, as i say, fanning out across other agencies to assist them as needed. Who would be a grantee such as that . And what might they need to do that they are not doing to reach people in communities of color, lgbt, or the people on the sidewalks they are not doing now lgbt, or the people on the sidewalks they are not doing now to culturally competent, as you put it . We have training that we provide at samhsa around issues of being sensitive it is more an issue of being sensitive to differences. Who would you be training . Our agency is a services agency, and we award discretionary grants that provide services. Those services will involve individuals who will provide services, be they behavioral Health Services, peers and others who might be involved like the young woman from the new jersey agency. Im sure they would like to. Exactly. So, we have a lot of information and training available to help people to it is really a major issue of being aware of differences and how to acknowledge we are different from each other and how can i best help you. One more and two of your quick. Yes, the woman right there. Im jody silver and i direct an agency called collaborative support programs of new jersey. Elena kravits is part of your community and we appreciate the opportunity. My agency, we, like many other colleagues, we focus on that 4 of people coming directly out of State Hospitals that nobody wants to serve along with people coming out of jails and prisons. I really appreciate what you were saying about the hole continuum whole continuum were all of these supports from every aspect that you outlined. The question that i have that we have not been able to focus on is the poverty and homelessness. It is hard to get to recover going from Mental Health issues all the things we are talking about if you dont have a roof over your head and the ability to get out of poverty through going from Mental Health issues education and employment. I was just wondering what your plans are or how your focus is on that component . If you return to a life of poverty and no job. What is the best way to help . I think we all agree that housing is absolutely essential and secretary carson has talked housing is absolutely essential about his review of what goes on at housing and urban development and trying to make changes that will make it easier to provide will make it easier to provide housing for people in needs and people with Behavioral Health issues. One of the roles that i have as a new assistant secretary is to work across agencies, so this will require us to really do an inventory of what is being done at a federal level right now and what could we be doing better. The 21st century cures act requires that we put together something that the interdepartmental seriousness illness coordinating committee. A partnership of individuals from the communities nationally, many stakeholders and federal partners. And we are in the process right now of undertaking a review of federal programs and getting recommendations about how we can better serve americans with serious Mental Illness and looking at all of the kinds of issues, not just treatment issues but also what are the other kinds of resources that are needed and what could we be doing better at a federal level. I cant give you a full answer but i can tell you that we are working on it. That the people that are helping us nationally are very dedicated and they take this to their Stakeholder Group so we are getting volumes of feedback and we hope to bring that together and be able to focus that on federal services and improve them. Sounds like an important body. What does housing look like . They are homeless. Do they get their own apartment or ranch house . You said group home. Housing with services. That can take a number of forms. But we dont have that many of them in this country right now. It is very difficult to get people we need group homes that focus, for example, on certain types of disorders are where you can bring people into a Community Setting and there are people available that have Behavioral Health skills that focus on particular types of issues. We need group homes that can aid our transitional one thing that concerns me greatly are transitional age youth 18 to 25 often age being out of the foster care system with Mental Health problems and substance problems and we dont have the resources in place, i have personal experience, we dont have the resources in place to make sure that these young people get the care and treatment they need. And we are seeing it on our National Survey on drug use and health we are seeing increases in 18 to 25yearolds with serious depression, suicidity. Increase in alcohol and other abuse. So these group homes and other Community Living services need to be a focus and we need to expand access. We will be working on that at samhsa. One thing i have done is put together a special emphasis group on transitional age youth to look at their needs and address them. Im very concerned about what i term a triple diagnosis of seriousness Mental Illness, Substance Abuse disorder and intellectual limited ability. We have people with very serious cooccurring conditions and they will get into the State Hospital and that is not the place for them. Serious Mental Illness, Substance Use disorder, and intellectual disability. We have so many people that have these very serious recurring conditions, and we do not have the services in place to help maintain them in their communities. Sometimes they will get into the State Hospital. It is not the place for them, but there is no other place. We need to do better, so that is another focus i will be having with my agency, and we will be trying to bring in experts so we can get a handle on this. This has not been the traditional focus of Substance Abuse and Mental Health, but it will be. [applause] we will let dr. Mccants get up to New Hampshire to spread the message about the Public Health emergency, but thank you for your service. Thank you. [applause] [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] tonight on cspans q and a. Of proposed action now. [applause] [captions Copyright National i propose it for the sake of a better world and i say again and again and again that ive refroz propose it for our own american selfinterest. Arthur vandenberg, the man in the middle of the american century. Vandenberg finds himself in electedon when fdr is and the democrats in the early 1930s take majority of the senate, he is in opposition for the next dozen years. That means that to get anything done, which often meant resisting some of Franklin Roosevelt initiatives, there needed to be a coalition. He had to reach across the aisle. Q a tonight at 8 00 eastern on cspan. Reidler, acting assistant attorney general for the civil division, the justice discusses, immigration and sanctuary cities. It is about 40 minutes. It is about 40 minutes. Good afternoon, everyone. Good afternoon and welcome to the ashland center. As you all know we were to celebrate constitution day. This sunday, september 17 marks the 230th anniversary of the date when the delegates in philadelphia concluded the work of the constitutional convention. They sent the constitution to the people beginning one of the greatest tenmonth debates in American History over the ratification of the constitution