On February 11th, the House Energy and Commerce Subcommittee on Oversight and Investigations, chaired by Rep. Tim Murphy (R-PA), held a hearing to learn more about the results of a recent GAO report entitled “Mental Health: HHS Leadership Needed to Coordinate Federal Efforts Related to Serious Mental Illness.”

Why a hearing? 
In 2013, Congressman Murphy introduced the Helping Families in Mental Health Crisis Act, designed to focus on programs and resources on psychiatric care for patients and families in most need of services. One of the key components of the bill focused on how the federal government coordinates efforts to provide services and supports for individuals with serious mental illness.

The sub-committee requested the GAO to conduct a survey and write a report of findings so they could get a better idea of how mental health programming efforts were coordinated across eight federal agencies. SAMHSA’s role in promoting coordination of programs focused on mental illness across the federal government was of particular interest to members of this sub-committee.

What did the GAO report recommend? 
There were two primary recommendations from the report. 

• GAO recommends that HHS establish a mechanism to facilitate interagency coordination across programs that support individuals with serious mental illness. 
  The recommendation to increase interagency coordination at the federal leadership level is a no-brainer in our book. For those of you who have been involved in federally funded SAMHSA grants focused on improving services and supports for youth with serious emotional disturbances and their families, you know that a key grant requirement for receiving these funds has always been to establish strong interagency collaboration and coordination both at the programmatic and upper leadership levels. At the federal level, this recommendation asks nothing different from HHS leadership than is asked of states and local communities receiving SAMHSA funds.
• GAO also recommends that DOD, HHS, DOJ, and VA document which programs targeting individuals with serious mental illness should be evaluated and how often such evaluations should be completed. 
  The recommendation to clarify and prioritize evaluation efforts would provide a welcome opportunity to devote evaluation focus to programs that historically may not have had much in the way of funding for evaluation but may be producing promising results. I have heard on many occasions the “chicken and egg” conundrum of “How are we supposed to prove the effectiveness of our program if you don’t give us adequate funding to evaluate it?”  

How did SAMHSA respond to the recommendations in the GAO report? 
Unfortunately, and for me, quite stunning, the official SAMHSA response from Administrator Pamela Hyde was to disagree with both recommendations. If you watch the video of the hearing (included at the end of this post), three things become evident:

• Sub-committee members were looking for concise, direct answers to their questions about the coordination and evaluation of federal efforts focused on individuals with severe mental illness.
• Administrator Hyde was responding to sub-committee member questions with answers that focused on the complexities inherent in coordinating and evaluating federal efforts focused on severe mental illness. She repeatedly emphasized the need for multiple strategies in answering their questions, often elaborating with multi-layered explanations, and more often than not, concluding with a response of “I will have to get back to you on that.”
• As the hearing went on, massive frustration built up on both sides. A few congressional committee members started behaving badly, and one used badgering tactics in a line of questioning with Administrator Hyde. The display of disturbing etiquette resulted in the admonishment from the Co-chair and recognition from the Chair on the importance of civility when questioning witnesses. 

There were many examples of a sort of cognitive disconnect between the questions being asked by members of the committee and the responses given by Administrator Hyde. Here is one example:

• During an interchange with Congressman Kennedy, who was asking what should be done to improve coordination among agency partners, Administrator Hyde said, “We need to push our grants to require coordination at the state and local level.” She went on to say that the GAO recommendation (for interagency coordination) was “about a specific infrastructure piece that wasn’t relevant to people on the ground – more of a bureaucratic recommendation.”

  Linda Cohn of the GAO, lead author of the report, clarified that the GAO wasn’t suggesting an “either or.” She said “lack of coordination at the federal level inhibits our understanding of the federal footprint in this area. What are the programs in place? We started from programs; populations served, etc. People don’t fall into tidy categories, which is why this coordination becomes so important. Are there gaps? Are there complementary programs that are not linked? If there are gaps, how are we identifying them if we are not coordinated? The coordination we are talking about is not either or, it is in addition to.”

This kind of back and forth continued throughout the hearing. Sitting in the audience, I was getting as frustrated as I am sure both the witnesses and committee members were. And looking around the room, frustration seemed to be running high in the audience, both for supporters and detractors of SAMHSA.

I do believe Administrator Hyde was trying to address the complexities involved in understanding the role of SAMHSA with other federal agencies, attempting to illustrate how those with serious mental illness dip in and out of the programmatic touch of federally funded efforts across myriad agencies. Unfortunately, to my ears, her tone came across as both arrogant and dismissive, particularly to committee members who were more challenging in their tone, and in two particular cases, downright offensive and rude to her. I do not believe the Administrator came into the hearing with the intent of being off-putting, but she, like some of the committee members, appeared to get caught up in the moment. Regardless, getting involved in a wrestling match was not helping anyone.

The elephant in the room 
I have no tangible evidence, just a gut level feeling, that SAMHSA leadership may be a bit concerned that agreeing with the recommendations in the GAO report might open the door for increased support for the creation of the additional layer of oversight over SAMHSA called for in the Murphy mental health reform bill. 

 It is no secret that a core component of Congressman Murphy’s Helping All Families in Mental Health Crisis Act includes the creation of a new HHS assistant secretary for mental health and substance-abuse disorders who, in addition to interagency coordination efforts, would, among other things, supervise the Administrator of SAMHSA.

Let’s be clear, I think there are huge challenges with the way the language was written in HR 3717 regarding the creation of an HHS assistant secretary position. Much of what was written looked like tasks that should already be in place as responsibilities of the SAMHSA Administrator. It seems that before adding on an additional layer of bureaucracy, all possibilities should be explored for how coordination and collaboration can be improved within the current structure.

That being said, I think anything remotely resembling a practice that would fit neatly into legislative language calling for an HHS Assistant Secretary (which these recommendations potentially pave the way for), is a frightening prospect for SAMHSA leadership.

• I could be completely wrong, but I don’t think so.

In closing, here are a few respectfully submitted recommendations for Administrator Hyde and one big old recommendation for the rest of us:

Recommendations for Administrator Hyde and members of her leadership team 
Show through action, that the type of leadership and accountability called for in the GAO report can be achieved without adding additional layers of bureaucracy.

• Accept the GAO recommendations
  Administrator Hyde would be better served to accept the GAO recommendations and work toward building trust with Congress by demonstrating the facilitation of cooperation and collaboration on the needs of individuals with severe mental illness across federal agencies. 
• Facilitate a more constructive dialogue with members of Congress 
  Now is the time for collaborative leadership on the part of Administrator Hyde. I would hope that Administrator Hyde would welcome the opportunity to bring together her peers in leadership across federal agencies to help identify federal efforts to improve services and supports for individuals with severe mental illness. Congress is asking for some specific action steps. Even if you think you are doing them already, doing them better, or find them at face value to not be worth the effort, do them anyway. If you don’t, guess what? We are likely to end up with the type of restructuring described in last years HR 3717. And that, in and of itself, is not the answer to meeting the needs of individuals with serious mental illness across the spectrum of severity. 
• Facilitate a more comprehensive understanding of the value of SAMHSA programs across the continuum of services and supports for individuals with severe mental illness 
  The widening gulf in public understanding of the interconnectedness between services for individuals with severe mental illness at both ends of the continuum, from most restrictive to least restrictive, is frankly, frightening. Administrator Hyde needs to step up to the plate and aggressively help Congress, and the nation, see how treatment and recovery can have a productive and healthy interrelationship.

  One does not need to look any further than the work being done in partnership between SAMHSA and NIMH on the First Episode Psychosis (FEP) 5% setaside initiative for potentially innovative examples. While the FEP initiative is in its early stages of development, the opportunity to show how science and recovery can work side by side is exciting. 

A simple recommendation for the rest of us 

• Be relentless in your efforts to share healthy examples of the interconnectedness between high-intensity services and recovery support for youth with serious emotional disturbance or young adults (and older) with severe mental illness 
  The current tendency to speak in terms of “either-or” when discussing treatment options for individuals with severe mental illness is not healthy for the overall conversation about mental health reform and definitely not healthy for those who are counting on us to help shape the most appropriate array of services and supports for those with serious mental illness, regardless of where they are in their journey to recovery.

  Send us your examples of community-based efforts that “connect the dots” between the most intensive services and supports to the most individually directed services and supports. Get busy Network faithful, we got work to do! 

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Scott Bryant-Comstock
President & CEO
Children’s Mental Health Network