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resident Trump’s pick to run federal mental health services has called for a bold reordering of priorities — shifting money away from education and support services and toward a more aggressive treatment of patients with severe psychiatric disorders.

The proposal has some psychiatrists — a generally liberal bunch — cheering despite their distrust of the Trump administration.

But it’s also sparked concern among other health professionals, who worry that the administration will put too much emphasis on medicating and hospitalizing patients, and remove supports that might help them integrate successfully into society.

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If confirmed by the Senate, Dr. Elinore McCance-Katz will take the helm of the Substance Abuse and Mental Health Services Administration, a federal agency with a budget of about $3.6 billion a year, most of it dispensed in grants to help states pay for mental health and addiction treatment.

She will be the first to assume the title of assistant secretary for mental health and substance abuse — a near-cabinet position which reports directly to Health and Human Services Secretary Tom Price. Congress created the post to bring order to a scattered system; this is the first time mental health and substance abuse have received such a weighty emphasis in D.C.

“We’ve never had someone coordinating the fragmented mental health services in this country,” said clinical psychologist Xavier Amador, who has written several books for patients with mental illness. “There are huge cracks that people get pushed through. They don’t fall through — they literally get pushed, because the right supports aren’t in place.”

McCance-Katz, a psychiatrist who specializes in opioid abuse, hasn’t spoken publicly since her nomination, and declined to talk to STAT. But she has had a long career in mental health, and her writings — as well as a fact sheet put out by the Department of Health and Human Services — give insight into her priorities. Among them:

  • Increase the number of inpatient beds for patients experiencing serious psychiatric symptoms.
  • Reconfigure health privacy laws to give families access to information about patients who are severely mentally ill.
  • Reevaluate federal funding for suicide hotlines and programs that train patients with psychiatric disorders to help their peers.

About 4 percent of Americans live with serious mental illness, but about one-third of them receive no treatment — and McCance-Katz firmly believes that they are the people most in need of federal support. She calls the current gap in care for severely ill patients, such as those suffering from schizophrenia or bipolar disorder, a “fixable problem.”

A ‘change agent’ poised to make big changes

Generally speaking, there are two schools of thought in approaching mental illness. The “medical model” emphasizes intervention with drugs and other medical treatments. The “recovery model” focuses more on providing peer support.

“There’s a tension in our field between two models — and it’s sad,” said Ron Honberg, senior policy director for the National Alliance on Mental Illness. “I think both the medical model and recovery model apply — and it’s not an either/or proposition.”

Indeed, most health providers advocate a balance of both approaches — but SAMHSA has long been criticized for focusing too much on softer, “recovery” programs rather than medication and medical treatment. McCance-Katz is expected to shift that emphasis.

And even some liberals say they’d welcome it.

“The mental health industry is mainly full of liberals — and I’m to the left of Bernie [Sanders],” said DJ Jaffe, founder of the think tank Mental Illness Policy Org. “But they don’t want to admit the unpleasant truths involved in treating the seriously mentally ill.”

Liberals “don’t want to admit the unpleasant truths involved in treating the seriously mentally ill.”

DJ Jaffe, Mental Illness Policy Org

McCance-Katz, he said, has “been a change agent” over the course of her career. He said he’s “astounded and elated” about her nomination.

“My only concern about Dr. Katz: I hope that she does not alienate the peer recovery movement,” Amador said. “I hope she realizes that the pendulum shouldn’t swing in the opposite direction: It needs to be right in the middle.”

Searing words for federal mental health policy

McCance-Katz first became interested in caring for people with mental and substance disorders as a third-year medical student. She treated a woman in the midst of a severe episode of depression and psychosis — but saw that as her patient received medical treatment and emotional support, she was able to move forward successfully with her life.

In the ensuing decades, McCance-Katz, 60, has built a lengthy résumé, treating both mental illness and substance abuse. She served as state medical director of the California Department of Alcohol and Drugs Programs for eight years, before a two-year stint as chief medical officer of SAMHSA. Since then, she’s led the Rhode Island department in charge of behavioral health care. She’s also a professor of psychiatry at Brown University.

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So McCance-Katz easily would be the most qualified leader of SAMHSA in recent years. Her predecessor, Pamela Hyde, was an attorney by training — yet led the mental health unit of federal government from 2009 to 2015. She stepped down amid swirling criticism of the direction she’d taken SAMHSA.

One of the leading critics? McCance-Katz, who served under Hyde for two years. After leaving the agency, McCance-Katz penned a scathing critique in Psychiatric Times, saying she was “greatly disappointed” with the unit:

“SAMHSA’s approach includes a focus on activities that don’t directly assist those who have serious mental illness,” she wrote.

The federal government “has lost its way and largely ignored the needs of people with psychotic disorders such as schizophrenia and bipolar illness.”

Dr. Elinore McCance-Katz, Trump nominee

McCance-Katz doubled down on the indictment in a 2016 article in the National Review, a conservative news outlet. She opened the piece by asserting: “The election of Donald Trump is an exciting turn of events for people afflicted with mental illness.” She went on to explain that she hoped he would be able to expand access to treatment and reform SAMHSA.

Under President Obama, she wrote, the agency “has lost its way and largely ignored the needs of people with psychotic disorders such as schizophrenia and bipolar illness.”

She added: “There is within SAMHSA a perceptible hostility toward psychiatric medicine” that she blamed for a failure to serve patients with serious disorders.

Representative Tim Murphy (R-Penn.) agrees with that perspective. He’s no fan of McCance-Katz; he’s argued that she was ineffective during her years at SAMHSA and failed to exercise proper oversight over grant recipients.

But he’s also eager to see the agency shift gears. Murphy, who has consistently pushed for mental health reform, has accused the federal mental health bureaucracy of being “anti-psychiatry” and operating from a “feel-good space” rather than focusing on evidence-backed treatments. “Right now, there is no science at SAMHSA,” he told Clinical Psychiatry News in 2015.

If confirmed, McCance-Katz will be in a position to change that.

Health care providers just hope she doesn’t go too far. Psychiatric medication, after all, just isn’t always effective — and hospitalization is just a temporary solution for what’s often a lifelong disorder. Statistics vary, but about 30 percent of people with schizophrenia don’t respond to any medication whatsoever. Another third only respond partially.

“I think the reality is, medical treatment — particularly for the more serious mental illnesses — is part of the equation, but there’s much more that is needed,” said Honberg, the policy director at NAMI. Patients also need help with employment, housing, case management, and navigating day-to-day life.

McCance-Katz will get a chance to explain her priorities — and her plans for federal spending — at her confirmation hearing. It hasn’t yet been scheduled, but already she has lined up some high-powered support.

“President Trump has nominated a qualified and experienced leader who will make mental health reform a reality,” said Republican Senator Bill Cassidy, a physician who worked for decades with low-income patients in Louisiana’s public hospital system. He added: “We look forward to her swift approval in the Senate and working closely with her to bring about needed change.”

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  • Sounds like big pharma already owns this jewess and her hypocritical concern for “severely” mentally ill people to be chemically lobotomized is touching. Valid statistical proof shows people placed on psych drugs have a lower recovery rate then those given placebos. Read Robert Whitaker’s book, Mad in America, and get real you psychiatrist fraud.

    • I agree with your comments about psych drugs and lower recovery rates 100%. I don’t know how her religion/cultural heritage is relevant, because lots of non-Jewish people support this and lots of Jewish people are against drugging everyone who has a thought or emotion that’s uncomfortable. You’d add to your credibility by dropping the Jewish comment, which I say because I want folks like you and me to be taken seriously, since you’re actually talking about scientific facts instead of the manipulative propaganda coming from Big Pharma and their psychiatric and government allies.

      Thanks for commenting!

  • In my opinion, almost everyone in our society has some sort of mental unease or “dis-ease”, even dis-order. Even if it’s mild OCD or ADD, depression or anxiety. That’s all and well to focus on the small minority of severely mentally ill, but increasing inpatient hospital beds is nothing revolutionary or new. Most people with severe mental illnesses can stay out of the hospital when they have services available which are recovery oriented. All I have to say is, she’d better not take it too far! And seclusion and restraints are NOT therapeutic and should be used as a last resort only.

    • I agree 100%. I am very worried that this bill is regressive, moving away from providing services and back toward locking people up and forcing them to accept “treatment” they don’t want or that doesn’t work for them. Thanks for making your strong statement!

  • Treating mental illness with drugs only, will never help the patients to cope with reality or society. inpatient is the only way to try to keep the patient on their medication, and that’s if there monitored very closely. We patiently gain the individuals trust, then monitor their medication intake. The next step is to work with the individuals to understand their place in society and how to help others to do better as well. This takes time and patience, but is so rewarding when the progress is made. The patients or members smile and enjoy the company of others whom are receiving help as well. Thanks!

  • There should be more emphasis on protecting the rights of people labeled with “severe mental illnesses”. The process of “diagnosing” people is more subjective than the mainstream media reveals. Thomas Szasz(www.szasz.com), a dissident psychiatrist, wrote that psychiatry is used for social control and political repression. Not just authoritarian governments, but some repressive families use psychiatry to control and suppress their members. There should be more emphasis on protecting people’s rights and less on pushing people into authoritarian systems.

    • McCance-Katz, Please make reclassifying schizophrenia spectrum disorders as a neurological illness, one of your very first priorities!! This complex brain illness greatly exceeds the scope of care/practice known to SAMHSA.

  • They wanna help people with mental illness. providers who treat people with mental illness like garbage should be fined or have some sort of punishment. People with mental illness such as ptsd shouldn’t be punished for getting help or be lied about in reports because professionals have a stigma against people with mental illness. It’s rapid and s to stop.

    • Agreed. There is zero accountability for psychiatrists or psychologists today, and it is too easy to blame the client when something goes wrong. Any real attempt to help should start with respecting the client and his/her views and needs rather than telling him/her what to think and how to act and how to feel. It is sad that so many so-called professionals are unable to understand the negative impact they have on those they are supposedly trying to help!

    • The problem with psychiatry is that it relies on coercion more than any other profession to obtain “clients”. That is why it is harder to hold psychiatrists accountable. This coercion is what makes psychiatry likelier to attract people with authoritarian personalities.

  • Interesting article.As an LCSW Social Worker and Director of a S/ A and MH clinic in Ct . I am optimistic about Dr. Katz proposed appointment.Having an atty. run SAMSA has not been effective /at all.

  • Interesting article.As an LCSW Social Worker and Director of a S/ A and MH clinic in Ct . I am optimistic about Dr. Katz proposed appointment.Having an atty. run SAMSA has not been effective /at all.

  • So, instead of being proactive and focusing on preventative services that will help with decreasing the cycle of abuse like education and social services, the plan is to take away from providing a better education and EBP with implementing aggressive tx or more medications that do not work without behavioral modification? Are you all serious?

    • She sounds like the kind of arrogant prig who wants to revert to blaming the victims, locking them up and forcing drugs down their throats. News flash: we tried that and it DOESN’T WORK! Did y’all know that being psychiatrically hospitalized dramatically INCREASES the odds that you’ll kill yourself?

      It’s fair to say that anything psychiatrists are excited about can’t be a good thing. This will be great for their profession’s bottom line – more forced “clients” who have no choice but to use their blunt and generally ineffective “services” – and it will be a boon to the drug industry, but as for the actual clients – watch out! It will soon be “drugs for everyone who objects to the status quo!”

    • You seem to have missed the entire point of the article. Preventative services don’t exist when it comes to serious illnesses. What does that look like for a schizophrenic? Or for someone with serious bipolar illness? A good diet? A support group?

    • Actually, they do. Mainly around prevention of trauma, but also including providing housing and creating increased social interactions – the more social connections, the less likely a person becomes psychotic. But look up “Housing First” and you will see that not only does mental illness cause homelessness, often homelessness causes or exacerbates mental illness, and providing food and shelter without insisting on “services” or “treatment” is a very viable method to reduce symptoms and increase functioning.

      Also, support groups for voice hearers do exist, and have been shown to be as or more effective than “treatment as usual.” They are usually called “hearing voices” groups. I am not surprised if you haven’t heard of them, as the psychiatric mainstream likes to belittle or disguise the effectiveness of any kind of psychosocial interventions, but they do have a very positive effect.

      You might also want to look into the Open Dialog approach in Finland. Totally scientifically supported and in use for decades, but again, the psychiatric profession doesn’t want word getting around that they have an 80% functional recovery rate with minimal use of drugs.

      There’s a lot of propaganda out there saying that drugs are the only answer for schizophrenia/bipolar. This propaganda is simply false.

    • Yes, Steve, you offer up some impressive examples of successful traditions I am also aware of to maybe broaden Suzanne’s awareness that there are effective alternatives to psychiatric medication, many times more effective, for making a big difference during a crisis state of experiencing extreme states of consciousness. I can think of a lot more great examples also for anyone reading this that may also be open to take the time to expand their minds to the possibilities, though, to make this short I would only add “Emotional CPR” to the list of best practices here. We are seeing growing interest in many regions of the country for blending the human inclusion potential of empathy connection that E-CPR represents into a region’s traditionally modeled service array. Because, well that seems to be the big difference between the models: peer support and the recovery model emphasizes inclusion and connection, being real and human together whereas practitioners of the medical model won’t let down the walls created by roles or privilege of expert status from schooling to get real, vulnerable, and connect authentically together. This does make it hard to feel that inclusion piece that Steve pointed out that can really make a big difference in a crisis state. Many times it is that inability to connect and be understood and accepted by others, learned from family dynamics, that sets in motion the experience of these extreme mental states. Speaking of the Hearing Voices Network, Eleanor Longden’s story makes that point very well I think. Her TED Talks page is a good place to learn about the successes she has had recovering from hearing voices that were preventing her from living a happy, successful life; and what a success story her’s is. Wow! She is one of the greatest of Greats in my book: https://www.ted.com/speakers/eleanor_longden

      Housing First is also very powerful piece, I agree, and I would like to point out that I find it intriguing the Soteria Houses, residential environments that were supportive of alternatives to medication, when first introduced in America, were proven to be so much more successful than the predominant medical model approaches of institutional settings that they discontinued operations here in the U.S. for many years, continuing with their success over in Europe. Only recently have Soteria Houses started making a comeback in America, I heard of one in New England recently, to my great pleasure. I have wanted to open one so I could also live in the nurturing and empowering environment and experience a successful alternative to the institutions and help to establish successes to build solid grounds there are other options that really, really do work “well.”

    • Yes, Steve, you offer up some impressive examples of successful traditions I am also aware of to maybe broaden Suzanne’s awareness that there are effective alternatives to psychiatric medication, many times more effective, for making a big difference during a crisis state of experiencing extreme states of consciousness. I can think of a lot more great examples also for anyone reading this that may also be open to take the time to expand their minds to the possibilities, though, to make this short I would only add “Emotional CPR” to the list of best practices here. We are seeing growing interest in many regions of the country for blending the human inclusion potential of empathy connection that E-CPR represents into a region’s traditionally modeled service array. Because, well that seems to be the big difference between the models: peer support and the recovery model emphasizes inclusion and connection, being real and human together whereas practitioners of the medical model won’t let down the walls created by roles or privilege of expert status from schooling to get real, vulnerable, and connect authentically together. This does make it hard to feel that inclusion piece that Steve pointed out that can really make a big difference in a crisis state. Many times it is that inability to connect and be understood and accepted by others, learned from family dynamics, that sets in motion the experience of these extreme mental states. Speaking of the Hearing Voices Network, Eleanor Longden’s story makes that point very well I think. Her TED Talks page is a good place to learn about the successes she has had recovering from hearing voices that were preventing her from living a happy, successful life; and what a success story it is. Wow! Hers is one of the greatest of Greats in my humble opinion.

      “Eleanor Longden overcame her diagnosis of schizophrenia to earn a master’s in psychology and demonstrate that the voices in her head were ‘a sane reaction to insane circumstances.’”

      Housing First is also very powerful piece, I agree, and I would like to point out that I find it intriguing the Soteria Houses, residential environments that were supportive of alternatives to medication, when first introduced in America, were proven to be so much more successful than the predominant medical model approaches of institutional settings that they discontinued operations here in the U.S. for many years, continuing with their success over in Europe. Only recently have Soteria Houses started making a comeback in America, I heard of one in New England recently, to my great pleasure. I have wanted to open one so I could also live in the nurturing and empowering environment and experience a successful alternative to the institutions and help to establish successes to build solid grounds there are other options that really, really do work “well.”

    • Eleanor is an amazing woman and everyone dealing with people suffering from extreme states MUST see her talk! It is absolutely the best counter to the medical model I know.

      Thanks for your kind words!

  • Many, many of us across this country who have experienced severe mental un-wellness, including the often traumatic treatment processes offered in this country, have lived to find mental health and a balanced life again. I, for one, take exception to this promoted concept that those who are REALLY ill are not sufficiently the focus of SAMHSA’s effort.

    Our leadership would be wise to look at the treatment and support paradigm offered in many other countries which result in lower costs to taxpayers AND to individuals being served. (I reference Australia, New Zealand, Great Britain and Scandinavia, for example.) Additionally, leadership needs to review the numbers of individuals hospitalized in some of these countries–how, proportionally, there is less forced care, far more INVITING services offered, and more recovery of higher quality of life. In some of these countries, psychiatric medications are used when people are experiencing certain specific crises effects, but they are not used as maintenance medications—they are tapered off as they stabilize! Clinicians in those countries marvel at the United States and our dependency on pharmaceuticals—acknowledging that the medications are very often effective, but that they are not sufficient to support actual longer-term recovery!

    It is too simple and too dishonest to state we just need to do more clinical, pharmaceutically centered treatment, often at the expense of the rights of individuals. I think this is the approach taken by people who really do not value the potential of even very sick individuals who can actually discover their own roles in recovery and work their way through the ill-being to hope and wellness again. I see it happen continually at our local peer support center.

    It is the re-humanizing of the relationship between individuals and systems and engaging them in the practical process (holistic or clinical or both) that we will see more people living well instead of having illness. This re-humanization would result in systems that cost less to taxpayers and to clients and we would see more accountability for the value of the dollar spent in terms of real results in people’s lives .

    • From insight gained into the recipe of services that work best, in my humble opinion, a perspective gained through lived experience in the “institutional rock-crusher” and witnessed firsthand, in a majority of cases, a medical model heavy approach aggravates conditions of un-wellness more so in people, I agree with you in all your points, Laurie. Especially where you offered the recommendation to learn from what is working so much better for other countries. I speak with confidence representing the nationwide Consumer/Survivor/Ex-patient Movement that we had high hopes an Assistant Secretary would be chosen who could not only bring to the helm many years of expertise but also represent a balanced perspective, well able to address the needs of both sides of the equation (medical & recovery) for effective solutions in SAMHSA’s responsibility of authority. I am not confident that Dr. McCance-Katz is that especially qualified leader. Which probably explains why she only served 2 years at SAMHSA. I myself and many others that speak through me are concerned for a system coming with primary focus on coercive care tactics in general, and I was glad you mentioned “maintenance medication” which seems to be the preferred solution for our nation’s emphasis on “preemptive risk mitigation” and ensures people don’t have high chances to live long lives, in the constitutionally granted pursuit of (sustainable) happiness, not to mention the concerning trial and error process of trying out multiple medication cocktails until finding a med that seems to work somewhat, experimentation which is popularly relied upon in institutions and turns people into zombies, it doesn’t support the re-humanizing efforts we all claim to support…all of US. As an avid peace worker, I will keep the hope we can find common ground eventually. Thank you, Laurie, for speaking up. We, in the recovery and wellness community, HAVE experienced great successes in the realizing (recovering) of quality of life, despite Rep. Murphy and other figures challenging the worth in SAMHSA funding education and peer support programs. I hope you inspire others to share, as you have done me, viewpoints on what has worked best from our lived experience as witness…supportive to strengthen SAMHSA’s priorities.

  • “President Trump’s pick to run federal mental health services has called for a bold reordering of priorities — shifting money away from education and support services and toward a more aggressive treatment of patients with severe psychiatric disorders.” So does this mean all the federal mental health money will be spent on the President?

    • But he is convinced that he has no mental health problems. So how can any treatment be given to him, after using the 25th Amendment to ease him from office??

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