Transcripts For CSPAN2 Key Capitol Hill Hearings 20140423

Even if i learned about some of his strong arm tactics, some things about him that i did not necessarily like very much on a personal level, i actually came away republicking the man more, and ill tell you why because this man was not just groomed for the presidency at all, but he met with fdr, Something Like, i dont know, six or eight times, and these were just inform mall meetings. Fdr shared nothing with truman. He was a running mate because he was a consensus candidate, got ratify at the convention, and they figure, well, trumans popular in the senate, and when i was to ratify the peace treaty to end it, truman does it for me. Guess what, harry, youre on the ticket. That was it. He did not let truman into the tent on anything. You have a man who had to crash learn the most difficult office in the world in two weeks, which he did, and then amid that, hes president at the birth of the cold war at the claches of europe as they grabbed all the Eastern States and took them over to installing puppet governments and all that, and despite the enormous pressure, the man, roughly as old as fdr, put in 18hour days, and when he got home, he cared about what was going on with the white house. He was interest the. He wanted to see the report,mented to pick out the paint color. They painted the state dining room this green, you know, a moss green. They took the paint off. There was a huge, you know, process, with guys running across pennsylvania avenue with paint samples, and i thought, well, what keep of guy has time for that. Truman had time for it, cared without it, and so he might have been ham handed in term the of what we got, but, you know, perhaps somebody from a slightly more i dont want to say cultured background, he was extraordinarily wellread, but, you know, we might have got a more refined house, but i dont know if we would have got a better one, and structurally, i think hes the reason why we have not had to worry about the place since then, and we havent. The us the answers that frequencyrn that we on to the new jersey of other sensors. [ jzorcd . 1 i remember the first conversation i had at the table was not where are you from or what is school like that about ukraine. Politics. Our beliefs, education, religion and after that moment i thought this week would be intense. But it has spent cool to see the evolution of our friendships and bond to talk about politics or our experience is what we have learned and what we have met. This is an experience i will never forget. I always thought i can never go that far with politics is such a caustic environment but slowly throat though we quizzed people we have met chipped away at the opinion did has been so ingrained in my head maybe i do want to make a difference to run for something local because like the president said yesterday he said dont get cynical because the nation doesnt need any more cynical people that will run hopeless relieve the problems we have some things that are brought up is social media were ebert able to express opinions easily in send the tweet about what we think a and i think that starts the conversation and we like to talk a lot didnt we like to get our opinions out there. I think this whole week has been about morning. I come from a small town where it is very politically of a genetic. There is not much chance for people who dont think the same to get their opinions out without being ridiculed the and being here with the other delegates has given me an opportunity to see another few pan viewpoints and without being shunned or for thinking differently. [inaudible conversations] i am a resident saw scholars here at day e i and our discussion is on the role of Mental Health the role of federal government in Mental Health policy. We typically think of that as a state responsibility and to a large extent it is but the federal government can have a very influential role to Shape Services and policies for the mentally ill patients. Unfortunately over the last few decades we have not use that influence effectively. We have a chaotic patchwork of services with huge gaps through which mentally ill patients fall into the street here and end up in jail. It is completely unacceptable and a heartbreaking situation. Today we have representative tim murphy a and our panel will discuss his proposed legislation and called helping families and a Mental Health crisis to address persistent problems in Mental Health care system in the month of the shortage of psychiatric beds. There is a hearing today is the golan that and inadequate at implementation of treatment denis small problem of violence and outdated involuntary commitment laws a. M. To the questionable prior days of the of the Agency Within hhs that is responsible for funding the services for the nations mentally ill. Everyone on the panel who will respond to mr. Murphys comments are deeply dedicated to the patients in and to the families who love them. For several introduce representative murphy you have a full biography at your desk so i will be brief. Then be will begin. Representative murphy is currently in his sixth term in congress representing the 18th district of pennsylvania. A former psychologist actually he is a psychologist. [laughter] he always has his degree. The chairman of the oversight investigation subcommittee and cochair of the Mental Health caucus and Founding Member of the g. O. P. Doctors caucus. He authored seniors access to Mental Health act that in discharging copayments to seniors on medicare in introduced the of Mental Health security act for roerichs families in education which was mr. Mandel to get College Students who were suffering from depression the help they need before tragedy strikes. Next is dr. Lieberman to the chairman of psychiatry at Columbia University college of physicians and surgeons. Director of the New York State Psychiatric Institute and his expertise is in schizophrenia and this year the president of the American Psychiatric association. Next is dr. Kennedy the cofounder of one mind for research serving 16 years in the house and the author and lead sponsor of the Mental Health parity and addiction equity act of 2008. Authored a cosponsored other bills to increase mentalhealth a and treatment to reduce. In final via a professor of psychiatry at the university in Research Psychiatrist specializing in schizophrenia and policy in the Infectious Diseases in schizophrenia which is an interesting syria. Brodeur of the Treatment Advocacy Center and of the stalemate medical Research Institute and has coauthored numerous Institute Papers and that is our distinguished panel. Mr. Murphy. Spee mcfadyen is convenient. I dont know how to get the slides working . What can we do . We will move to 20 for second century technology. Good morning. To have so many distinguished colleagues in the audience today i wish i could say you were getting continuing Education Credits but we will move forward. But i want to talk about is h. R. 3717 the bill we introduced last december for the important reason that i committed to the parents from the Sandy Hook Elementary School that we would have this bill before the anniversary of the tragedy. Our nation has been rocked and although those with Mental Illness are not of the vast majority likely to be violent nonetheless it is an area of grave concern that there has been committed by an treated Mental Illness. And we need to deal with these things. Someone has to figure a how to make it work. I have no idea. It does look the nancy. [laughter] i will just keep talking. I will give you numbers. There are about 68 million americans that some degree of Mental Illness with the mild acute problem of anxiety or sadness to severe Mental Illness. In 3. 6 million are without treatment. Extremely important to a understand what happens when someone is without because they can be more likely to exhibit violent tendencies but there is a 15 fold decrease that they could become involved with the violence. It is also important to know that they have three or four times more likelihood they are victims of violence rape, assault, robbery for someone is imprisoned on the streets or at home, whenever that might be and children to are mentally ill are three times more likely to be victims of sexual abuse that alone should move us toward action but the problem is the action that has been taken very much are graceful, misdirected and not giving the cerebus to the people that we needed. The government already spends 125 billion for Mental Illness most of that is for payments for disability, the medicaid, a very biddle is for research or for early treatment assets. What saves to happen is if you look at the next slide with king in the 50s 1860s where we had 550,000 beds for a population of 150 million. As the beds closed down rigo have 40,000 but where have the patients bone . Sadly we have filled our prisons so while the state budget burst at the seams we pay for growth in the expansion and overpopulation. It is no wonder why it is not the crime that is so vast but we have traded down hospital bet for the prison cell. We have also traded the hospital bet for a mattress and a flophouse in a homeless shelter with blankets over a subway grate. It is inhumane in the immoral and it is of a third world status even when we do take action which is say a typical situation with seriously mentally ill that is threatening the police are called the taken to the Emergency Department and the ill equipped a and ill staffed emergency room that is not designed to deal with mentally ill patients, they tie them by their wrist and their vegas to often leave them in the hallway or in a room surrounded by a sheet if they get at of controlled they sedate them. What could be more if you read them putting someone in jail or leave them on the streets or chemically and physically handcuffing them to a bet to call that treatment . It is wrong in our nation needs to wake up that pitcher whale that the families feel has got to change. In pursuit of over the last year i have held a series of hearings with oversight investigations subcommittee. There is inadequate Treatment Options quite frankly inadequate outpatient also. The patient is far away from helping to get better with independent housing the treatment is out there. A number of Supportive Services commuted the Wraparound Services but unfortunately there is not enough. There is a huge shortage overall particularly those to treat serious Mental Illness. With 7,000 child psychiatrist with 30,000 that is the serious problem. People cannot get help when there is no health care there is no hope and then people feel a stigma of going from place to place from Police Squad Car to car the wonder they have the stigma because it ignores those with Mental Illness. Another problem is the hipaa laws and in and Family Education rights are subject to a great deal of confusion there is supposed to be there to protect confidentiality records. I legree to make sure that the privacy act is there to make sure people are not Getting School records but it is another barrier because as a feeder often do nothing at all many times parents were in a hospital and try to convince someone else i need to tell you about the history of my son or daughter we cannot give you permission for someone who does not know where they are with psychosis and they dont know who they are but yet they tell people we cannot tell you anything. Its is wrong in the misinterpretation of the law. If you are in the auto accident and unconscious or if you have a stroke or incoherent no one says you have to get better. Why is it someone with deep depression or deep bipolar disorder . We need to refine those are you cannot get a history you cannot give the history you can not diagnose or treat it is like telling a surgery what you do diagnosis they have fractures and their phone but we have to stop that. With confidentiality with the other rules quite frankly this has existed with the standard that says if they have to be in imminent danger then without their authority with that patient care against there will. Basically have to be slitting their wrists overdosing and drugs before we believe they need help. Do we do that with any other medical illness . Did somebody say your cancer cannot be treated until stage four or your chest pains until your unconscious or your cardiovascular problems until you have a stroke . No. But somehow we have the things with the psychiatric illness to wait until the person is completely deteriorated because that is the more optimistic and better product one prague prognosis. There are treatments that are out there. Several but it goes more along the of lions of lets just find it and put it away because nobody wants to deal with the problem. Americas big secret so lets just fund the programs nobody asks a question it does not work. In some cases they dont work they spend on silly things that would make your blood boil. Why is it federal dollars paid where the topics are interpreted of dancing . Stopped taking medication getting in touch . If you want to a weekend workshop pay for god of your own pocket the when millions of dollars go to those sayings then tell people we dont have enough people to provide help . That is wrong and we will not put up with that anymore. It goes to the point of federal dollars. First of all, we empower parents and caregivers to make it clear definition to refine the hipaa select providers in Family Members clearly no it does not mean someone that has no relationship for a the Family Member that is disjointed from the patient can come in to get information. No. This is very important. We want them to have access to history when they need it. Also takes the shortage of the impatient to bet. Right now it is a 16 bad rule. How to read not reimburse you if you have 19 . When most states have a critical bet shortage so we have a boost the beds for medicaid payments. Also will alternatives to the institutionalize why is the only jail or homeless or longterm patient facility . No patient treated is the street extremely effective 44 states have been on the books but very few do it. York is an example to do a rights where they have found instead of putting people with the involuntary commitment with the Family Members or the District Attorney to stay on your medication what they found is the cost fell 46 overall but it is quite high quite frankly. Encourages states to adopt a treatment standard. Looking at it before treatment the next item reaches beyond the emergency room. The cms kim up with the ruling they would limit the of medication is available in three had a rather emotional packed hearing where a representative told us they would limit the drugs available. We had them read out loud from the American Psychiatric association that said you cannot have certain psychiatric drugs and with that i said can you tell me what is the ss are right . The responses of was a brief time that if you dont know we were talking about it is pretty clear you will draw conclusions that have nothing to do with reality and a and understanding my concern for the decision and i pointed out if you are not three hospitalized for seven days it is okay to change it. But limiting the type of drugs that would greatly impaired of physicians ability adding to this overage 65 and receive the diagnosis your twice as likely to double your Health Care Cost for lots of Different Reasons of exacerbation or less likely to comply with other treatments. I reminded him when seniors commit suicide 20 to with the day of their doctor visit 40 one week seven within one month so to recognize many of these antidepressant drugs take between to do six weeks that you cannot use this drug . That was the patients life bad risk. A few days later they reversed the decision but we will not be but up to those decision the chair the same day billing issue is important you cannot get to a doctor bills in the same day. A person is more likely to go to a pediatrician to seek assistance when they exhibit at severe Mental Illness in the averages 112 weeks before the person has their first visit to treat Mental Illness . As a mother brings her teenage son to a doctor and he says i am very concerned about the things that your son says into weedy to see a psychiatrist now you were on medicaid can you come back tomorrow . Headed city main. We will say in these cases there days to be allowances for same day billing. Also chosen territory Access Program where they can call a number it is a very effective mechanism and those barriers. With of rain initiative in with their research on the brain the response after the schizophrenic episode is the Effective Program for these problems. We also want to integrate primary health care for the reason i said before the part of this is the bill puts into the bill that was passed yesterday tuned also put in funding the was approved yesterday a and then another 60 million for the l pasted treatment programs. Medical records are moving into the 21st century where they are Electronic Medical record but not for behavioral medicine. Why would that be . We need the care model not something you put in jail or a kick out of the office but what the brain does this is the Behavior Health records need to be in there so they can be obtained. Another part is to the Community Health center to allow mentalhealth professionals to volunteer. If you work in the Community Health center this is a marvelous place you are covered by the federal tort claims act they could provide the integrated care because those senators practitioners all Work Together that is what you want but unfortunately if you are employed there you are covered if youre at a free clinic indue volunteer you are covered but if you read a Community Health center in volunteer you are not covered were free clinic you are not covered for a good number of studies has said people will give their time to work one afternoon of the his very valuable so they take away that barrier to be the Good Samaritan and quite frankly will be about 1 billion of free care every year at least. So what i described before unfortunately a lot of those estimates we still dont know a lot of what happens we want to know what happens with serious Mental Illness with the disjointed model that may have the different kind of care we want to make sure we track that. It is extremely important to help educators center stated that a serious Mental Illness what the symptoms are so they are not afraid and Evidence Based care. This is extremely important of all the money the federal government spends nobody looks over what happens department of defense, Veterans Affairs affairs, to private education hhs the be the department of labour or transportation as i said a lot of it is Evidence Base care dod has done some marvelous things at walter reed and to throw out the military a number of initiatives to create more care for active duty guardsmen serving our nation. But there is a disjointed thank someone did the fda sought to that 20 percent get appropriate help. Say get as a group for their date there be it is not a treatment specifically designed how clinical psychologists say this persons job with the Evidence Based care in this city is great expanded. With that mentalhealth parity bill is a part of what they can do to move forward. This is what the bill does it is very comprehensive the state from a thumbnail sketch but but its what theyve done to change the result that the changeup president kennedy made just to stop warehousing people. The virtues that the former congressman did to make sure that we had a Mental Health parity but these are the reforms that the two have been. Then they stood up to make reforms to stage the barriers. None of us want to see these headlines of victimization more of violence committed. Lets treat the issue of the shadows to make changes to help our country before word. [applause] faq. In conclusion i would like to thank that i have spent most of my career bba pointy headed scientist on neurobiology as schizophrenia but also over the past decade as a chair the largest Mental Health care provider have been drawn into the legislative political dimension. It is a an interesting experience when sally called free to participate i know that it was smack in the middle of the vacation that i take every year to keep this gained to watch the ted is open. Hearing who would be here and particularly with the momentum of the legislative issues i will come. I missed larger playing yesterday. [laughter] and it was for good reason because this is for the time that can really become i know it is a cliche a Tipping Point or a turning point. Help a with decades many people have been talking about it included my good friend in to colleague. But it did the resonate s. Foley but we are here today because the individual lead congressman for free has stepped forward not just to assume the leadership role but double that is doing something important a and a meaningful. He is not alone there has been champions for mentalhealth previously. Accordance with. John porter. But as time goes on day buffon and to we are not sure who will follow in their place in congressman murphy has stepped forward to do so for those who are working in this way such as senators stabbed know and your cochair. In the narrow science caucus. Sochi really have a chance to do something with the individual who has the vision is the platform stepping forward to doing so. Says a researcher you cannot talk for too long without having slides. [laughter] here so you can follow along. It will not be easy because our system of care which ended the is fragmented is trying to address a least three distinct populations defined by. The one that we hear the most about and the most urgent are the serious with schizophrenia, but polar, a major psychotic depression isnt they are treated virtually in Mental Health care facilities. Then the people that are receiving medical and Surgical Services at one dash services. This proportion of the health care population is one of the biggest cost drivers of the overall cost of care. A third group is individuals who have of milder form of Mental Illness fact so we have three distinct groups human to be be a different emphasis and it is also where we received care. We have opportunities to you and there is an obvious need to do several things one is the new buzzword with collaborative and integrated care. Simply that psychiatry and Mental Health care needs to be embedded into the primary care system. Embedded just like journalists go to war and mentalhealth care providers need to be embedded. Similarly psychiatrists dont take on general medical care because of their responsibility by primary care professionals need to be embedded in the clinics treating cup population. If we really want to get serious this is the next thing we will try to push congressman murphy is a Public Health Initiative Just like hypertension and screening cover diabetes, yet what me as easy but their deeds to be mentalhealth efforts moving data of clinical settings and to the Community Whether primarycare, educational system faith based organizations that is where Health Care Needs to move also. Until health care and psychiatry is a stepchild for health care. There is reasons for that but it is something that the cover brentwood step been because it would have then worth taken care of. Now largely it has fallen to the local and state mentalhealth system nobody is providing mentalhealth care. The federal initiative i dont know if you talk about it brilliantly depicts the trajectory of the federal government to take on Mental Health care but when it began post world war ii it failed miserably now were struggling to recover but the recognition that mentalhealth was somewhat different for special attention a and that is still the case. Edition the challenges are obvious everyone is well aware of the of fragmentation the failed mentalhealth policy the violent incident gets the most attention but the homeless, the jailed, the cost of care that drives up the percentage that is driven by this. But we have opportunities here. This is a convergence and the truth be told one of the reasons they have Mental Illness is because it could be discrimination on one hand or distrust of the other. They have reasons. We did not have that much to offer but now we do. That there are Evidence Based treatments that it is the new science if it has given mentalhealth traction it never had before combined with the legislative initiative. In even though not perfect the increased social awareness so historically has not occurred to take full of vintage. Finally as we move i think as we move on and patrick is passionate, people who are involved in Mental Health care as a provider side or the policy side as the consumer advocacy side tea to put aside the parochial interest. Were not competing for market share. And the other plan doesnt. List is the optimal model . What are the rules different people play . What is in the context of services and how do we fight news . Fight or reimburse . We dont have to do an experiment or have a breakthrough drug to have a huge impact. This is the way it can be orchestrated. I usually do not have the rosy glasses but the challenges have a historic opportunity to matter how much we know that it will only work if we can orchestrate the political process. Think you. Representative committee . Representative kennedy i have gotten a very not have to turn on microphones for the last three years. I am rusty. [laughter] i am honored to be here that you are amassing that kind of energy that needs to be placed in this area to get the federal government to Pay Attention how do we move forward . I just want to say i am honored to be here with all of you it is a. E. I. And i am a liberal democrat but mentalhealth knows no partisanship as has been stated before my dad and i were in the principal sponsors in it could not have been done with many others. So in this town of bir polarize by ideology but this is one area that we put ideology aside that there will be those that the large majority can Work Together to find common ground. So i will use say before to explain what we tried to explain with the academic and medical leave go. He talked about the tip of the iceberg. We have see the titanic and we are taking on water to see how do we avoid hitting the ice berg again . We could build more lifeboats to take care of those that will be displaced because of the disastrous was supply dash system or steer clear. What a thought. In other words, the you answer in my view is not only to prevent people from becoming severe or consisted but to like in it to diabetes we are about discussing more imputations as opposed to getting people of the primary care that will catch them early for candidates for diabetes to treat aggressively early so they never have to develop the symptoms that necessitate such a cody responses. So i appreciate the fact that so many people who asked with the president s correct vision. He talked about doing more research to come up with better therapies. A and communitybased care because the people want to live with their family in their community. Not to institution but to get there that famous term follow the money . Had never went from the institution to provide the needed care in the community. Look at the most successful experiment in the country country, what makes it so successful is there are the funding mechanisms to support people in their community. There is no quick fix. Brady a comprehensive approach but ultimately to tell the American People what we talk about. Not Mental Health but treating every american in the way we will treat them if they have cardiovascular disease, or any other illness. If we truly change our mind set in to think about this the same way of any other health care a lot of these problems go away. Why . Because we start paying for them. I have 15 years. Are you kidding me . Why do they worry about be having a stroke in my 60s . I was in my thirties i was first put on this.  widely take that same mentality with Mental Health . Looked at my face i will have skin cancer. I already had it. When have you been to the dermatologist recently . You got me. Thiokol lit it check up for the neck up. By dow we have every physician visit include the czech up from the neck up . Talk about changing perceptions mentalhealth is not calling down bohol to drink from the colored water fountain because nobody wants that separate but not equal system of care. That is Little Health care separate but not equal we want michelle help as part of Overall Health care. The way to achieve this to put together this bill is to monitor the federal government implementation of the equity act that centers of medicare in and medicaid will have more say on rare that dollars of Mental Health will go. I would like to see them follow the federal law of the agenda government following their own laws. Never to come if the department of labor will oversee the erisa plan, why not have a monitoring or clarity to ensure they treat invisible wounds of war the same way we treat their visible wounds . Because both were killing them and quite frankly invisible ones will cost more lives they and the visible ones. My view is, it is all about free being the issue you but its as you have pointed out it is important time in history to get their right. There is a lot on blind john the line not to mention an average ebros so not only of our employees all across this country. We better get their right. Not only for those of us that have the Mental Illness or and addiction but for our returning heroes. I am glad to be here youd look forward to the discussion. Thanks to a. E. I. For sponsoring this. It is an honor to support representative murphy. I have been following him for over 40 years entering that time they have gotten progressively worse. Is an equal opportunity disaster since 1963 and we have had five republican in five democratic president s none has understood the problem that day are brain diseases. So nothing has been done. To president ial commissions and nothing important cape route between 50 to 25 members of congress who had severely mentally ill people in their family, and the insurance parity representative kennedy mentioned. That did a lot for a lot of people but varied little for those with severe Mental Illness. Representative murphy is the first member of congress to take on a serious Mental Illness to propose Serious Solutions and we all very obligated. But is it a difficult problem . You bet. 3. 5 millionton treated people today. That is the save as the population of San Francisco and oakland put together or minneapolis and st. Paul. These are not just numbers but people. There is an acute shortage of psychiatric beds we dont need to go back to 1958 with 340 beds for every 100,000 that we now have aca. We have effectively closed 1 million public State Hospital beds. If you project to the save population 1 Million People who claim saree half a century ago would have been in psychiatric hospitals but where are they now . One week from tuesday we will release a report on a number of mentally ill people in prisons and jails and and the number of the best is about 350,000. What we have left is 35,000 in the State Hospital so 10 times more people with severe Mental Illness in prison and jail the of the mental hospital. At least two to thousand homeless and that is a conservative member. 350,000 taels, 200,000 homeless cover representative murphy had very good hearings on wednesday where have the people . There is 600,000 right there in and that is where they are. These are not just numbers but people who have mothers and fathers and sisters and brothers and i get a printout every day from around the United States what is going on. Last week of College Graduates a homeless refuse to take his medicine and is unaware of his illness and said sometimes he was sleeping in the trash bin and was found dead contacted. These are tragedies that happen every day. We have 10 percent of the 13,000 homicides per year that are committed with severe and treated Mental Illness about 50 are committed by severe Mental Illness and treated for court and Emergency Rooms are overrun with those other 400,000. Is the huge problem and it is getting worse. Last year of man with severe Mental Illness was stuck in the emergency room 36 days waiting for a bet. Until recently we thought 36 hours now 36 days . Thirtysix months . At what point will we turn this around . Please ensure for over roads with a number of severely mentally ill increase of justifiable homicides the suggested just the data about half of the People Better killed by police are savvier mental ill. This is getting worse. Individuals have taken over many of the public spaces. 28 have a psychiatric diagnosis. They are the largest and Fastest Growing group of ssdi beneficiaries on it. The problem is huge. Its costly both in terms of human live and dollars. Its a good start. It is a good start, hitting many areas on it, the need for treatment standards, demonstration funds for aot, those of us who dont know what aot is, assisted outpatient treatment, meaning you live in the community as long as you take medicine because, number one, we know you have it, you dont know youre sick, true of 50 of those with bipolar features, and, two, we know you have been dangerous. Only a small number of people need to be on aot, only 1 . Those who need to be on it really need to be on it, and it is marvelously functioning and effective. Five states show a decrease in hospital admissions, studies in new york and North Carolina shows it decreases arrests and theres a study this month in florida showing that when you keep people on medication, you decrease the costs on it. Again, were not talking about a large number of people who need it, but its one of the things in the bill, demonstration projects for aot, and i think its going to become very clear how important this has been on it. Refocusing samsa, the least functional Government Agency in washington. Thats saying a lot. Ive been around for 40 years, and im constantly amazed how dysfunctional some of the federal agencies are, and i think it is in a class all by itself. This bill attempts to bring them into the 21st century. They are one of the few people moo understand the problem, put the best leadership on it to date, and anything we can do to get involved, thank him for taking it on, obligated to him, and what hes doing is doing subpoena important and deserves support, thank you. [applause] we have a microphone, and one thing ill mention, you may have mr. Murphy just went through a tour de fourth of his bill, but whats important is also this the provision that works this that works with the criminal Justice System to educate law enforcement, sheriffs about Mental Illness and how to manage these folks into the treatment system and not into the criminal Justice System. Too often, these are the front lines professionals, and in the case of that navy the Washington Navy yard shooting, may have in retrospect, everything is 20 20 of course, but may have made the fatal difference in this case, may 5th, the hotel room, and did not quite manage it as well as they might have. Anyway, its a very important aspect of the bill. Im sorry. There were hands. Okay. Gentleman in the red tie. Mr. Kennedy, i share your illness. I, too, am a democrat. [laughter] say your name and affiliation. Im c. J. With mental policy work, and im a hard core democrat, but found on the issues of the seriously mentally ill, and it is a lot better and mr. Murphy in particular. Throwing money at Mental Health, but unwilling to admit the politically incorrect things that need to be done to help the most seriously ill, and in your presentation, for instance, you talked about prevention. There is no way to prevent schizophrenia or bipolarment we dont know how to do that. You talked about early intervention. We dont know how to identify someone with schizophrenia before they come up with a symptom. Working on it, but we dont know how. You talked about arisa, i can count on one hand the number of people with schizophrenia can nonsubsidized employment outside the field. What is it about serious Mental Illness that my own party wont address . Well, again, not to get polarizing here because the one thing we cannot afford toot in our field to do in our field is to not Work Together when we have more in common than we have that separates us here. I think we absolutely need to do more, and thats why ive been talking to tim on the legislation. I think identifying the real elephant in the room, and im not talking about my republican colleagues, but the fact that there is a problem of reinstitutionalization as tim pointed out in our Emergency Rooms and in our prisons, but i think for us to retreat from the notion that the race program, which i salute tim for highlights in the legislation, i think as fuller talked about the work on the naples project, the notion that we cant do early intervention, if you intervene on first instance of psychosis, you can dramatically reduce the pathology of that illness if you intervene early. Everybody knows that. To say that were not going to put in place a system of care that responds to you with Mental Illness the same way we would, like i pointed out with diabetes, because the way we treat Mental Health today is we wait until you have to get the amputation. We do not pay. We say if you have cancer, we wouldnt imagine saying to somebody, come back when you have stage 4 cancer. Thats how we reimburse Mental Illness today. Im saying if you were in a historic time of as they say, reincentivizing the payment. If we start paying for these primary and secondary levels of care, my con tension is youre not going to have as many tour industry levels of care. What i want to say politically is i dont think were ire reconcile l here today. We have to deal with the mentally ill, but reorient the system so we dont create so many of them. I think in this day and age, were in a moment in time to change the system so that while were treating those who are sick, were off of preventing others from ending up in that situation, and i agree with you. Is there a vacuum of leadership . You bet. Thats what were here to discuss is what to do about putting that Leadership Back in washington, d. C. On these issues. Let me come at it first, and thank you so much for the support of the bill. Ronald reagan, i dont know what he was reporting to at the time, but if i can imply the quote here, a question to the left or right, question of do we move forward or back . Thats what it comes down to. Ive not seen any division among my colleagues on either side of the aisle on dealing with these issues, and i think whats together is a common desire to do something here, but there is a divide op a couple issues, and you probably know this history better than i, but back in the 60s, reagan was the governor of california in the 70s, and there was a movement at that time in california, and so you had two groups, one group saying, well, we cant have the hospitals there because thats like the russian goulash putting people we dont want to talk, hide them, and so that was coming from one fringe, and another fringe was saying were putting people there against their will, not allowing them to have their rights, ect. , and so here you had this imperfect storm in california that shut the Hospital Systems down, and still what remains are groups that talk about the rights of patients. I think patients and people have a right to get well. This is where this often gets grossly misinterpreted from people who say, well, this person should have the ability to refuse treatment. Look, i understand that sometimes people are there with late, late stage cancer and say, look, its time, but when someone is not even well, and they cant even make a decision, they dont even know what planet they are on or who they are. How do you say if theyre going to make a decision . Former psychiatrist says, they die with their rights on. During the hearing this week, we had really em passioned comments from the georgetown Homeless Center in washington, d. C. Saying most of the homeless they deal with have no idea theres a Mental Illness r which dr. Torre referred to. We have to talk about lets have the people on the right to get better and right to treatment rather than arguing they can refuse treatment if they want. Let them get better and have the option to feel healthy. The stigma that comes from Mental Illness is the idea they cant be streeted. They think that, you know, we show them inkblots, give them drugs, and sit on the couch and talk about their relationship with the mother. That does not happen. What we do is really get them real treatment and make them better. Thats where then we can have people talk about the rights to go back to work, the right to live independently, the right to say hello to the policeman rather than hearing him say youre under arrest. We can do this early rather than wait for the crisis occur. To that point, if you treat early, you dont have to use as much medication, which is the thing, really, for people who are consumers really up nevers them, the level of the side effects. You treat this early, youre not going to have the need to same levels because youre not going to wait for the illness to pathology, and then the point is, there might be greater compliance. Youre not going to have to tell them through court order you have to take this. They will be able to live and understand this is well within their ability to integrate into their livelihoods, and if we got them on our side, believe me, youre going to have much better results in the long term than if we try to have this government micromanage people with Mental Illness. Yes, this gentleman. [inaudible] thank you to the panel. Question, dr. Murphy, as a Naval Medical officer, with our armed forces, including massive numbers of guard and reserve units standing down after 13 years of continuous deployments, can you address, please, the necessity for more varied and out of the box effective treatments, but also a cultural imperative to e eliminate stigma associated with posttraumatic stress disorder, they need to decompress and reintegrate in society to do the point. Congressman kennedy says treat it early and effectively so they do not go fullblown into the system, and, you know, helped the economy and everybody. Thank you, sir. Thank you, yes, sir. Putting my navy hat on. Im not authorized to make payments on behalf of the department of defense, but ill describe what i see as Lieutenant Commander and what i do with the work of ptsd and traumatic drain injuries. Theres treatment seen as something led to loss of rank, loss of opportunity to grow in the military, sometimes discharged, ect. They were afraid to talk. They thought their noncommission and Commission Officers would not put them into battle or would give them bad write ups. What we have found is with ptsd, posttraumatic stress disorder and posttraumatic stress, another one related, it is diagnoseable and you can treat it. We have to remove the interim stigma. No, generals have done a lot of work on this helping people understand they can get help. A lot needs to go to the level of the noncommission office and the chiefs. The best thing i heard from a patient i was seeing at walter reid hospital, a marine was i was asking him about some of the symptoms after he had been in the hospital, we have a number of wounds, but dealing with some of the mental aspects of this too, and this is the fascinating thing, he sent his gunny sergeant off, would tell him almost every day, look, if you have a twisted aping l, and you go to war with us, and you dont tell us and slow us down, youll get us killed, speak up. You have a twisted brain that day, get somebody killed, speak up, we get you fixed and back out there back in the saddle and moving forward. That is the kind of attitude we need. Now r what happens is i dont think theres enough providers within the department of defense. I dont think we have enough providers to have more experience, and very often theres folks in medical school, residencies, psychological programs, great providers, incredibly dedicated people led by great officers too, but theres not enough years of experience behind them. One seal told me i want to work with those with more gray hair. Okay, ill take that. What it comes down to is making more of those and making the transition between when they leave the service and when they get into the va system or in other parts of the, the campus of guardsman, within the unit and active duty, they go back to the force, and when they come back, the continental United States, they have groups to work with them, a lot of base, and when they go back to the reserve basis, the unit is dispersed, and they dont have that. Theres a quite of bit more work, more to do with training military ptsd, and one of the things i tell them, people have a choice with this. I think its important for people with a problem to understand they have a choice. This is a choice. A person who experienced severe combat, now, i cant imagine, i have not been in that. I cant even imagine, but they have a choice. They can be a victim the rest of their life because they are always under the bullet that holds them back from doing anything. Sad to see them living in their mothers basement, playing video games, numbing themselves with vodka. They can be a victim and not move anywhere. Second choice, they can be a survivor, say, you know, despite what happened to me, im moving forward. I have thats sometimes, but i need to work, get moving forward, and do what i can despite what happened. The third choice is they can become a thriver. They can turn the simplist work of strength because they have been through what they have been through, stronger, faster, better, smarter than most people. They can teach other people how to handle it saying this is a source to make me a better person. Now, over the years, theres been millions of people in our wars traumatized by combat, shell shock, whatever it is, but it is only within the last decade or so that weve begun to address that, and this is part of what i see our secretary working with all the grouping to ensure that dod does not reinvent the wheel as the va gets up to snuff where it needs to be and dhs does what they are to do dealing with care, and not everybody has to do it on their own, but say, just like everything else, i mean, every branch the service and hhs and every community does not treat diabetes differently or cancer differently or Heart Disease or deliver babies differently, why not do the same thing as Mental Health . Thats what it is for me, thanks. I just want to make two followup comments, one to the gentlemans question and murphys comments, a response, and then coming back to patrick and c. J. s question on prevention. First thing is that, you know, the military has taken world war i, warld war ii korea, vietnam, iraq, afghanistan, taken a few wars to sort of realize, you know, theres psychological consequences to war, not just physical consequences, and everything said is true. We also need to be, i think, honest candidly. Our understanding of ptsd and how stress affects the brain how could some of the relatively normal, and then in the span of ied explosions or repeated tours of duty, be changed . Thats what happens, but we dont know the pathology or what all the as a vulnerabilities are. Truth be told, treatments are effective, better than thoag, but they are far from optimal. A lot more has to go into understanding this, and its also something that general peter corelli, who knew nothing about Mental Health and got religion as a result of his war in iraq, said, i want to see a diagnosis. I want to see a way of diagnosing this because there is a suspicion that people do malinger. Thats an unkind thing to say, but it is reality of this. There needs to be a better understanding of the conditions as well as addressing whats obviously the manifest. In terms of c. J. s prevention, think about the point, prevention comes in many forms, not just primary prevention, like, we know that somebodys at risk for Heart Disease and treat you so it never becomes a possibility. Theres intervention, serious and professionally mentally ill, you know, like tuberculosis, there was no sanitary anymore, no iron lungs anymore. Were not going to have these needs for these programs for people who have progressed that far in the illness if we do things like we can. Now, the other side of that coin is interdicting people with respect to the checkup from the neck up when they are getting their primary care or nonpsychiatric care, and for that, we have to have an integrated distributed care model. Psychiatry, Mental Health needs to rejoin medicine. Next friday, next friday, by happenstance, were meeting the ata, holding a forum at the National Press club on integrated care where a very comprehensive report on the model of care, the economic consequences, the effects on outcomes would occur with an integrated care model implemented. As i was saying before, theres different populations that need menial health care, and they are seen at different places and different sort of clinical venues, and we need to be thinking or something approaches to deal with them in all these republics, and the military is another one, which is a specialized sort of venue and population, the same body of knowledge and forums that require slightly adopted set of services. Thank you. Other questions . The gentleman in the corner. Im with the safe foundation. Question for the congressman. Now you have, in the new law, those people who run to our socalled Justice System and when judge orders business checkup and put to that test in the prisons, when they are under arrest, that can turn them crazy too, and i dont know as a doctor, you may know the procedure, and it seems our Justice System is turning a lot of people crazy. Given that, is there any way you can address that . Let me talk about a couple things there. I think by the time a person is involved with a major crime, such as a felony assault or murder, its too late to do something. What happens in some states with the Justice System changes what they do, this week, we have the sheriff in the cooke county jail . Chicago, the second largest psychiatric facility in the nation is a jail. The first largest is a jail and it goes down the line. What happens, some of the states too, lets say some is picked up for shoplifting in a big box store, stealing 29 worth of sheets, a schizophrenic man, department know where he was, grabbed them, and ran out. They prosecuted him, put him in jail, running up a cost of 16,000 before it came before a judge, he said, time served, case dismissed. He was back on the street without any treatment provided for him. This happens all the time. The case of the Navy Yard Shooter talked about before, several times he came before the police, the apartments, made noise, said, oh, no, discharged my weapon, shot someone. Shot a woman on the airplane, harassing him, and thought his microwave was talking to him. Now, i dont know this, but i guess the policemen didnt know whatted to do and thought, oh, this is kind of a guy who talks to the microwave. Twice, at least with the va hospital, complaining he could not sleep, and they gave him sleeping pills and go see your primary care physician. I dont know if he ever saw a psychologist there, i dont know. Probablifuls not the case. What i see here is its a long list of failures of a system, and then i was disappointed when the only thing the department of the defense concluded could be prevented if they were doing security background checks. Wrong. They should have done a better job of identifying in the navy and they needed treatment. Dont give Honorable Discharge with these problems. Work at it, treat these issues. What happened in some areas, theres a Mental Health court where a judge is aware what to do, work with the system to get the person in treatment, new york has assisted treatment, heard from the chief of police, we dont want the people to go to jail. A case of a gentleman who was found standing, wanted to press charges, again, severely mentally ill, just wander into a home thinking it was his. He needs to be in treatment, get medication, see therapist, follow by people, wrap around services, better off than jail where he learns other problems, and what happens in some jails, this is where he gets really third world, is patients are victims of assaults, prisoners, more combative and aggressive, and they deal with it giving more sedation, putting them in isolation, and they have not committed the crime, but thats what happens to them, making it worse. Now, so were trying to address these by ramping up awareness more of police and how to handle that and getting early treatment. I dome want to say this, though, for the audience, chairman joe pitts of the Health Subcommittee of energy and commerce announced a hearing on this bill, 3717, helping families, Mental Health crisis act, this thursday at 10 30 in the morning, very, very important, come, be there, hope america is watching and people write their congressmen and become a cosponsor. Along with the republicans and democrats, its a bipartisan bill, but, yeah, im saying that because thats a major issue. You have a hearing on a bill to help it move forward, a markup looking at amendments, thats perfecting a bill, part of the process, thats moving forward. Thats a start. Time for one last question. Okay, one last question, sir . Peter carson, curious how you feel with the increase in medicaid coverage for individuals, a positive impact it has on treatments for severely mentally ill. Let me hand that one to exploratory. It dpeps its not enough to say were going to cover more peoples medicaid. Will there be parody in the states . A lot vary by states. Are there people to see someone . You cant say you have Insurance Coverage if theres not social worker to see them. If a hospital does not have beds, emergency room for a hundred days . 150 days. Weve heard of children tied to a bed for several days or so, medicaid is not the answer. You have to make sure theres treatments, make sure theres a lot of support services available, and many places, a Jewish Health system, amazed how many volunteers there that work with people, and provide assistance. Many places found it effective with using a recovery model of peer support, recovered from their Mental Illness and doing quite well can be in great support for someone, help assist them through or going through the system. Those are fendmental changes to make. Medicaid will not be enough. We have to tear down other barriers to provide services. I would just echo that comment that its a step, but its far from being adequate, i mean, for one reason, medicaid reimbursement, certainly at the lower level at the reimbursement spectrum in terms of third party payments. In addition, made cad is really medicaid is really managed through the states, and each state determines how its going to, you know Medicare Medicaid had been a new york state largely at least for Mental Health care, feeforservice, but its now being converted to managed care process, so each state is going through a way as they try to deal with how to control their own medicaid costs, how to administer programs, and then the third thing, and congressman murphy said, even if you have a Payment System viable for the states and provides, you know, at least minimally adequate level of reimbursement whether its inpatient, ambulance, emergency, it depends on the services being in place that are going to accept the vehicles and the number of beds, number of providers thats been eroded systematically over the last two to three decades. The infrastructure is not really adequate. There needs to be a more its not just the financing process, though thats the lever of change. It needs to be a reconfiguration of the Health Care Delivery system when it comes to Mental Health care. I want to add concluding comments. I thank all the people out there providing help. They are underpaid and under valued in what they do. It is the people in the military who are phenomenal in what they give as providers, and its the people in the civilian sector, Veterans Administration and volunteers out there, i want more ways to allow this, but what stands out are the people suffering as Family Members and as they pace themselves, who are looking for a way out of this, looking for a way for hope. That can be done. Its going to take courage in us, and we can do that, thank you. If i could, quickly, i have four of the expansion of the imd exclusion in the legislation going back to where we can find commonground. Now, hes the thing, its all because its a violation of parody. Medicare medicaid aeromedicare do not have parody. What. I i want to find is the nexus point to take it to the next level, and the parody becomes common law. We dont have common law in what constitutes Mental Health. I think we need to have a process that shares best practices mongs the states amongst the states so that people will pay for something that can be demonstrated to the effective. Wondering why republicans dont get its deliverable make sure they are standardized forms of care, and you dont need a million conferences before you nail down whats the sweet spot in terms of therapy. We can accelerate this with cms, human oversight in delivery as well as through back to plans overseen by department of of labor because the private sector shunted everyone off in the medicare system. We can show them its a valueadded for services early, you get more cost sharing and savings sharing, which i like, and will resinate here at aei. Thank you, aei thanks all of you for coming, and for an excellent panel, and, i dont know, im optimistic with all this passion and this group and the growing interest on the hill that things may get better for the mentally ill. Thank you so much. [applause] [inaudible conversations] for more than a year, theres allegations, insinuations, that i knew about the planning of the watergate breakin, and that involved in an extensive plot to cover it up. The House Judiciary Committee is now invest gaiting these charges. On march 6th, i ordered all materials that i had previously furnished to the special prosecutor turn over to the cadet. These included tape recordings of 19 president ial conversations and more than 700 documents in private white house files. On april 11, the Judiciary Committee issued a subpoena for 42 additional taped conversations which it contended necessary for its investigation. I agreed to respond to the subpoena by tomorrow. Forty years ago on april 29, president nixon respond to a subpoena for additional water gate tapes. His response, plus reflections from former Washington Post journalist sunday night at eight eastern, part of american historytv this weekend on cspan 33. The Vermont Senate passed a bill making it the first state to enact mandatory laboring of foods meet with gmos or genetically modified organisms. Tonight, a debate on gmos with consumer advocate Jeffrey Smith and biotech entrepreneur gregly scott. See it wednesday at 8 p. M. On cspan. Of all the scientists in 40 countries, they all agree, whether they are against or for gmos, does not matter, they agree it was released long before the science was ready based on economic interests and political interests, and the process itself, i dont agree, is irrelevant because the process of engineering causes massive collateral damage, hundreds of thousands mew tigses up and down the dna, far more than conventional breeding, and they dont evaluate it. Some independent scientists looked at the corn after it was on the market and found what was silent was switched on, and that gene produces an allergen. You may have an areaction from eating corn genetically engineered unlabeled as containing an allergen, but the process of genetic engineering created a switch on of the dormant gene and change of 43 other genes. As for gmos, you know, heres the organizations, world health organization, National Academy of sciences, world food safety authority, mental association, no problems with gmos, are all of these part of the conspiracy that a person with no scientific training just uncovered . Telling us all about . If thats not enough for you, heres a bunch of other organizations. These are not organizations with some scientific sounding name, but real medical and protective organizations. In europe, which is very antigmo. In australia, all over the world, theres the epa, which we Pay Attention to when it comes to Global Warming or Something Like that, they say, would not pose on unreasonable risk to human health and the environment. I could come up with dozens of these. The the australian and new zeal land food safety groups, weve identified no safety concerns for any of the foods assessed. Is this reasonable . Something that is extraordinarily of poisen here, this is just fear mongering, and all these organizations ignore it . See the debate on gmos in its entirety wednesday night at eight eastern on cspan. Now, biographer diane jacobs discusses dear abigail, from the Adams National historic Park Visitors Center in massachusetts, this is 45 minutes. [applause] can you hear me now . Oh, good. Well, im so flattered that i have this overflowing audience. Im sorry anyone who was uncomfortable, soon youll be getting chairs. Thats what i hear. Well, as was said, this is my book dear abigail, the story of three 18th century women. I know that everybody in this room will no doubt know who Abigail Adams is. In fact, i feel like probably living in this environment, you could tell me a lot about abigail that i still dont know. Why is it that abigail is the one name that we all know . It really is because of her man, because she married john adams. I must say being here today, i feel sort of like ive come home because ive come to john and abigails home and also home of all Three Sisters spent a lot of time in, but the other two sisters that i think know less about, i argue in my book, are even though they did not marry president s, theyre equally important and remarkable women. First theres the older sister, mary, and she was the uncrowned queen of the family because in the puritan family, hierarchy was very important, and she was born first, so she was the first born. She was very important, and especially after her brother was disinherited by their father, she was really the one who inherited the the first sons role because there was no brother. When she grew up, she taught herself to be a wonderful administrator. Although she was a woman and could not be elected to any position, she was the de facto mayor of quincy, and her husband would be appointed to positions, but, really, everyone would know mary would take care of everything. Theres elizabeth peabody, the youngest sister, and always thought that neither of her older sisters gave her enough attention, and she was constantly clam moriing, listen to me, listen to me, and she was also the most literate and best educated of the three of them. She had the ambition when she was young to grow up and become a published writer, a published letter writer, the golden age of letter writing, and shemented her letters to be published like others, and ill let you read the book to find out whether or not that actually happened, but she did become with her husband, the founder of the coeducational school in america, that, itself, was impressive. The working title of the book, and somehow i think of the book as threefold cord because it speaks to the interwovenness of the Three Sisters and intensity of their bond. A threefold cord, Social Security a reference to e close yays tees and its a cord wound over three times and its hard to break a cord wound over three times, and this is referred to three ford cords, and they worked on something particularly moving when in a letter to her son, john quincy. She said never was there a stronger connection, affection, than that in a threefold cord, your mama and her two sisters. After i wrote the book, i wanted the idea of sisterhood to resinate. I wanted the readers to know while im speaking very specifically about three bilogical sisters living 250 years ago that what is true for them can also be true for women today who are not bilogically related or perhaps best friends. I thought before i went into more detail, i think a little bit about how i came to write this book in the tiers place. I finish the book on the great radical feminist, and i have loved living in the late 18th century. I loved all the drama. I love the guillotine, the revolution [laughter] particularly, i love the ideas. I love what was sewn and lym, and what was all said, and i love the characters i was writing about had read all of these people. I thought, okay, let me find some other man or woman and follow them through the same period, and im in the file as in i more Close Friends can temperature you, and i thought, wow, if i can think of a french person, i can just do paris and the french revolution all over again, but i just have a lot of thinking of the french first, fit into the category, and one day, a colleague said to me, what do you have against americans . [laughter] i dont have anything against americans. I love americans. I am one. About a week later, i was in the shower, and all the sudden, and this is not a tale, this is true, i remember the book that i had reviewed for the village boys 15 years earlier called the adams women, and which i had in the library there, and mostly it was about Abigail Adams and her double married to john quincy, but there was very tantalizing sections about abigails sister, and as i was standing there in the shower, soap coming down by back, i always the sudden had a image flash before me of one of the last lines in the epilogue, and it said someday they will write a boying of the Three Sisters, and i thought, ha, thats me. After that moment, there was a lot of work to be done. [laughter] that moment is always so great, and then afterwords, the grown, oh, no, do i have the material to write this book . I knew i had the wonderful massachusetts historical society. I knew that i had this wonderful ad. S type, and i knew they would have a lot oven abigail, but then my question was, what about mary . What about elizabeth . Are there letters from them . What did abigail say to them . What did they say to abigail . What did they say to each other . At first i heard, theres a nice collection of Elizabeth Shaw peabodys, the youngest sisters correspondence in the library of congress. I went down to the library of congress, and i was delighted. I found letters from the time she was a teenager, and she was writing her cousin, issac, off at harvard, and he would give her suggestions about books to read and she would write him back her opinions of the book, and she was very contrary, no matter what he said, she said the opposite. I thought, well, this is sweet, you know, i have this really fiesty character to deal with, and it was particularly funny because you can see how issac was sort of baiting her. At one point, he writes her, oh, you must really love this collection because youre just like her, and she didnt think much of marriage and neither do you. Well, not only was elizabeth thinking of marriage, but she was thinking of marrying issac. [laughter] she was really, very strong in her reply to that. I had a list of it, and i had e elizabeth when she grew older, and there were tragedies in her life, and you can read the book to find them out. Theres mary, what do we have op mary . Shes the eldest, abigail looked up to her, but what else is there about her . Did she have any ideas . I went to the Albany Institute of history and art, and there is a wonderful selection there, and among the letters that they have, its a letter where she says to abigail, dont you think its silly that men think that we dont have the same intelligence that they have . Now, today, like remember the ladies, that may seem very obvious to us, but at the time, it was anything but obvious, and, in fact, everyone presumed this is in europe as well, but particularly in the colonies, that a woman was given two things, intelligence and a uterus, and if she used her mind, well, no wonder she couldnt have children, and if she bore children, well, then, no wonder she was silly and could only think about shopping and things like that because shed already used her one instrument. So they are saying this, and saying about the ungenderred mind, meant a lot to me, and i realized i was doing a lot more about her book on the powers of women, and the rights of women was craft, but the capacity of woman they all had, that feeling, feeling there was a capacity of woman, and all of them also tutored daughters in the same they they treated their sons, and so i had a lot of resource material, i saw, and i was going to have to pick and choose because the society as well as the two other libraries have so much information i was going to have to decide what to write about, but i hope i managed to do that. After i came out with the three character, and i thought, okay, i have enough research material, then i had the problem of how i was going to structure the book, and ive written two other biographies, and with one character, and it was easy, the structure, that is, not the writing, the biography, never easy, but structure was because i wrote from one persons point of view. Now, all of the sudden, i had three people, and so i had to be seeing the world through three different perspectives. I thought id read you a little bit from the first chapter of the book, and give you an idea of how they approached the sisters, and also who the sisters were. It would have been of to anyone who met them that abigail, mary, and betsy were sister. Mary was darker and taller and betsy the slimmest, all were small and slender with oval faces, narrow decisive mouths, smooth noses, shining brown hair, and clear skin. Their dark eyes conveyeded authority and an intelligence, and they all shared their mothers energy selfcompetent air and passionate for doing good and surprisingly elizabeth gaunt. The the first and last to recover when she was very young, abigail had been parol lidsed for two weeks with the fever, and her birth was far more tresh rows of marys. A battle of death to produce a child. Betsy was so weak after one childhood illness r, doctor ordered her not to read, write, work, or even think. [laughter] it was lucky she atashinged her body rather than mood or would be impossible to live with, abigail observed. Mary with pleasing ways was like her mother and wanting in our studies and no one to point us to it. She reminded abigail when they were out of the parsonage. Our parents felt necessity of keeping ourselves from scenes of volty and left the rest to nature much mary was a beautiful first born and able was rebellious and wild. Make a very bad or good woman, a family friend told her. Obviously, suspecting the first. In her teens, they committed on proposing the society and thought she made clear resented how her person denied her innocent request. Abigail was sent away for long visits to her grandmothers quip sighs, who she sometimes thought loved more than her own mother because she was not compared to mary or more than once for a crime. Then there was betsy, just as high spirited as abigail and left to express herself. She could not run off to her grandmothers because she was the youngest, and unlike her also, unmarried, far less industrial brother, billy, always had duties to perform at home. Billy wasted his chances to learn, she grasped every free moment to read, and not just enthusiastically, but with a cultivated pace that would arrange wider if one duty or another was not always pulling her from her fathers book. Thats my approach to to the Three Sisters. I know it just gives you a little taste, and i hope you have a little feeling of who they are, visavis each other. They are the characters, but not just the main characters. As i wrote the book, theres two other very important characters in this book, and one of them is the one i was most determined to keep out of the book, john adams, and i thought so much is said, theres the most wonderful book about john adams, who needs me to add anything . Well, what i realized was i needed me because and so many of the great events that happened, not only in abigails life, but in the lives of the other two sisters reinvolve around what john adams was doing. Okay, im going to take them on, and i hope hes not overwhelmed the book, i dont think he has, but i feel hes a very important part of it, and i hope that i have added something fresh to what we already know about john adams because we know what a wonderful husband he was, how devoted he was to his children, but i hope that im giving you a feeling for what he was like as a brotherinlaw, particularly to marys husband, richard, who was a very, very close friend of his. He knew, actually, richard before he knew abigail, and best friends said, can you get me some kind of little job in government . No. Even his soninlaw, im not helping until the very end. However, for some reason, he felt so warmly towards his nephew that when one of them, and this was the one who had so many oddities he will not do anything in public life, just stay home and read, but adams said no, hes my nephew, and he got him a job as his secretary, probably the only job he could have gotten, but he performed so well in that job, and he went on to have a fruitful life, and his other did a lot for was marys son, william, who was one of the midnight judges that was appointed by adams. John adams is one character. My book begins in 1765 when britain imposes the first of its punishing acts op the colonies, the stamp act, and it ends 35 years later when adams loses a bid for second term as president of the United States to thomas jefferson, and abigail goes home to her sisters at last. Now, the times are the character because they are important to all the sisters. Of course, abigail who is frequently in the limelight with john, but no less during the revolution certainly to mary and elizabeth. They were equally exited, terrified, by the battle of boston, and they were equally astonished and overjoyed when the french navy arrived last minute at york town and won the revolution at last. These times are very important to the book. They are the times they live through, and, also, what was important for me was that they lived through the times, through the ideas of the times. Because of what was happen in america, we were getting the opportunity to start a nation anew. They had. S on what it was like to live under a monarch and they had ideas on what the ideal nation state should be. I soon found there was two very large impacts on their vision, on all of their visions. One was the enlightenment they all read the books of the enlightment, read the views on equality and views on the general will, and that it had a very, very big impact, and they felt strongly about the qualities between the races. Abigail had, at one point, said to john, i really dont understand how someone in virginia can have the same passion we have for a revolution for the rights of man and women because they take place. They had very, very strong ideas about equalitity. For puritans, the most important thing in the world was order. Order for government was particularly necessary. In order to be order, they believe there had to be io ark kyes, and thats why the oldest child was the most important, and one man had to bow to another man, and one family had a better pew in charge than another. They were competing with each other in views of what the idea of nation state should be. I have my characters nowing and i wanted to be an equal opportunity biographer. I wanted to give each of them equal space, and if anything, push abigail to the side and say, okay, you had a turn. Lets hear about the others. What i wanted to do within each chapter, i wanted to divide it in three and do onethird on abigail, onethird on elizabeth, onethird on mary. Well, i tried that for four chapters, and it was a fiasco. Fiasco. I said there is no way. We are getting no narrative from this and this isnt working. What i decided to do was let the story pull me along. You will find in one chapter it is abigail and she is going off