Morning Zen

SAMHSA Watch

December 13, 2019

Beginning this week, we are publishing our very own SAMHSA Watch – a recurring feature that will focus on SAMHSA, the small but ever-so-important federal agency that has a large footprint on the delivery of children’s mental health in America. Let’s face it; the agency needs our help. Recent news accounts about employee lawsuits, sinking morale, tales of spooky oversight of employee actions leading to banishments, and the rampant exiting of brilliant people; I could go on, but you get the idea.

21st Century Cures Act Is the Foundation on Which We Advocate for a Better SAMHSA
In order for us to help SAMHSA find its way, we need to do some homework first.
The foundation of our advocacy efforts on behalf of SAMHSA operating at a high level of excellence is the 21st Century Cures Act. Yep, that long and essential piece of legislation is your bible moving forward. Why? Because tucked into the Cures Act is none other than the Helping Families in Mental Health Crisis Reform Act of 2016, which we have devoted much discussion over the past six years. No need to read the entire Cures Act, but you will need to study up on Division B, the section that includes the Helping Families in Mental Health Crisis Reform Act and focuses specifically on  SAMHSA. When you open the Cures Act pdf, type in “1202” in the search box. Read from page 1202 to page 1315 and you will know what the law says SAMHSA should be doing. Then, type the words “Mental Health Crisis Reform Act” into the CMHNetwork website search box, and you can spend a long afternoon reading articles discussing the pros and cons of the Act. I told you there was homework!

Are you dizzy yet? Good. Read on.

The Cliff’s Notes version of understanding the importance of the Helping Families in Mental Health Crisis Reform Act (which is part of the 21st Century Cures Bill) is this.

I wrote my first analysis of the Helping Families Act after then-Congressman Tim Murphy introduced it back in 2013. Take some time to read that Morning Zen post, as it will give you a good feel of the pros and cons of the draft bill at that time.

Three of the more controversial proposals in that early draft of legislation lived on to become pillars of the SAMHSA reform effort that were incorporated into the 21s Century Cures Act. You must know the back story of how and why they came to be, as that foundation knowledge will help you better understand what we are seeing taking place at SAMHSA today.

Creation of the Assistant Secretary for Mental Health and Substance Use Disorders
The first pillar of SAMHSA reform called for in the 21st Century Cures Act is the creation of the position of Assistant Secretary for Mental Health and Substance Use Disorders. Here’s the back story. Some of you faithful readers will remember that in 2013, we had a Democrat in charge of the Executive Branch and Republicans in charge of the House of Representatives. A year earlier, the horrific shootings at Sandy Hook Elementary School took place, and Congressman Tim Murphy (the only psychologist in the House), made it his mission to shed light on and reform if need be, mental health efforts at the federal level. His bright light was directly focused on then SAMHSA Administrator Pamela Hyde. The friction between the two, and then between Administrator Hyde and the Subcommittee on Oversight and Investigations, Energy and Commerce Committee, where hearings on the proposed bill took place, was quite palpable. There was no love lost on either side. Which begs the question – “How do you manage an Administrator in the Executive Branch if you are in the Legislative Branch of government? Easy, create a position in your new bill that supervises the Administrator. In fact, and if this weren’t so serious, would be laughable, the early versions of the bill copied the duties of the SAMHSA Administrator almost word for word and made them the responsibilities of the proposed Assistant Secretary position. If the bill passes, creating the position of Assistant Secretary, there is no longer a need for a SAMHSA Administrator. Problem solved. And yes, this came to pass, and we no longer have a SAMHSA Administrator, but instead, now have an Assistant Secretary for Mental Health and Substance Use Disorders. But what is different? How has the creation of this position benefited the work of SAMHSA? Over the next year, we will be exploring the role of the Assistant Secretary position to better assess how in sync it is with the requirements laid out in the 21st Century Cures Act.

There is so much to focus on regarding the Assistant Secretary position, and focus we will. But first, do your homework and read what is required of the Assistant Secretary for Mental Health and Substance Use Disorders as written in the legislation. Go to page 1202 to begin reading.

Creation of the Mental Health and Substance Use Policy Laboratory
The second pillar of SAMHSA reform called for in the 21st Century Cures Act was the creation of the Mental Health and Substance Use Policy Laboratory. The public stance of many politicians and some advocates at the time was that SAMHSA was not directing enough resources to the seriously mentally ill and that there was too much emphasis on “softer” approaches like peer support and peer-led services. The idea behind the laboratory was that there would be a structure in place that would ensure that only the most robust evidence-based practices would be encouraged. Ah, but who defines what evidence-based practice is? The repository of evidence-based programs and practices in place back in 2014 was the National Registry of Evidence-Based Programs and Practices (NREPP). This repository took a lot of heat from Representative Tim Murphy, some members of the committee he chaired, and influential advocates who were concerned that NREPP was promoting approaches that relied more on peer-to-peer support rather than hospital-based approaches to treating the adult seriously mentally ill.

Not too long after the Cures Act passed, SAMHSA abruptly abolished NREPP and replaced it with the Evidence-Based Practices Resource Center. Was this the work of the Mental Health Policy Lab? It’s hard to know, as there actually isn’t a functioning policy lab, even though the Cures Act calls for one to be in place. I encourage you to read Sharon Green- Hennessy’s Morning Zen Post on the impact of the dissolution of NREPP.

Since the passage of the Cures Act, there have been two different people in the position of “Director” of the Policy Lab. Other than that, there does not appear to be a functioning unit that we can identify. I would love to be wrong about this! 

There is so much to focus on regarding the Mental Health and Substance Use Policy Laboratory, and focus we will. But first, do your homework and read what is required of the Policy Lab as written in the legislation. Go to page 1220 to begin reading.

Creation of the Interdepartmental Serious Mental Illness Coordinating Committee
The third pillar of SAMHSA reform called for in the 21st Century Cures Act was the creation of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). For the framers of the Helping Families in Mental Health Crisis Act, having in place a group of individuals across departments in federal government as well as an array of external experts (hopefully individuals that aligned ideologically) who could provide oversight over the work of the SAMHSA Administrator and equally important, the work of the Mental Health and Substance Use Policy Laboratory, was critical. And thus, the ISMICC was conceived. And better yet, not only would the ISMICC provide oversight to SAMHSA, but they would also be required to report their findings to Congress. Here is a quote from the first report from the ISMICC:

A central charge of this committee is to submit two reports to Congress, the first no later than 1 year and the second 5 years after the enactment of the Act. The reports are directed to include: 

    • A summary of advances in research on SMI and SED related to prevention, diagnosis, intervention, treatment and recovery, and access to services and supports;
    • An evaluation of the effect that federal programs related to SMI and SED have on public health, including outcomes across a number of important dimensions; and,
    • Specific recommendations for actions that federal departments can take to better coordinate the administration of mental health services for adults with SMI or children any youth with SED.

Like the other two pillars of SAMHSA reform called for in the Cures Act, there is so much to focus on regarding the work of the ISMICC, and focus we will. But first, do your homework and read what is required of the ISMICC, as written in the legislation. Go to page 1217 to begin reading.

The Delicious Irony of it All
Remember, in 2014, when this reform effort was being conceived, the Republicans controlled the House of Representatives. Now, don’t get caught up in “Republican” “Democrat” when reading this. A more accurate description would be that the Party in control of the House of Representatives put in place three pillars of a SAMHSA reform effort that would ensure they would have a more significant stake in the game of controlling an agency in the Executive Branch. I know, kind of makes your head swim, doesn’t it?

And now, here we are in 2019, soon to be 2020, and the Party in control of the House has changed, as has the Party in control of the Executive Branch. With the law firmly in place, why is the Party in control of the House not pursuing oversight of SAMHSA as vigorously as the opposite Party did when writing the legislation that became part of the Cures Act?

Oh yea, I guess they have been busy with a few other things going on in Congress… like impeachment… or keeping up with the latest tweets…

This is where we come in. Advocates need to do a much better job of filtering out the noise and focusing on what the law is requiring of federal agencies responsible for promoting excellence in children’s mental health. And I put myself at the top of the “guilty” list of not focusing on what is most important. But, as you know, advocates are perennially optimistic, and this is no exception. We start today. Will you join me?

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About the Author

Scott Bryant-Comstock

My passion is helping to shape policy and practice in children’s mental health. For the past 40 years, my journey as a mental health advocate has traveled from volunteering at a suicide and crisis center, professional roles as a therapist in an outpatient clinic, in-home family therapist, state mental health official, Board Chair for a county mental health program, and national reviewer of children’s mental health systems reform efforts. As the founder of the Children’s Mental Health Network (2009), I lead the Network’s efforts to grow a national online forum for the exchange of ideas on how to continually improve children’s mental health research, policy and practice.

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