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Safety Nets

Profiles of Leading Funders

Hogg Foundation

Any compendium of mental-health funders would be incomplete without a profile of the Hogg Foundation, established in 1940 as the first philanthropy in the nation devoted solely to mental health. Throughout the 1950s and 1960s, this foundation was the most influential donor in the field. It helped fuel the movement for deinstitutionalization that led to the closing of many state-operated psychiatric hospitals, and today Hogg remains an influential voice in mental-health philanthropy.

The Hogg Foundation’s founder “Miss Ima” Hogg grew up in the center of Texas political life. Her father served as the state’s attorney general, leader of the Texas Democratic Party, and governor from 1891 to 1895. He was a social reformer, and the Hogg children were taught to “nurture the communities that nurtured them.” With her father, Hogg sometimes visited state hospitals for adults and children with mental illness, and this had an effect on her.

By the time Hogg was 23 years old, she had lost both her father and her mother, after nursing them through debilitating illnesses. She fell into a five-year depression marked by severe insomnia. In search of a cure, she relocated to the Berkshire mountains of Massachusetts, where she met a psychiatrist who helped her recover.

 

Shutting down psychiatric institutions

Hogg’s psychiatrist connected her to the fast-growing mental hygiene movement. Its messengers argued that asylums imprison people and fail to mend conditions that are often eminently curable.

The organizer of the movement, the National Committee for Mental Hygiene, was founded in 1909 by Clifford Beers, a Wall Street financier who had been hospitalized after an episode of bipolar disorder and a subsequent suicide attempt. He spent three years in private and state mental institutions. His autobiography A Mind That Found Itself gave disturbing accounts of how mentally ill people fare in asylums. The National Committee was ultimately renamed Mental Health America, which is still today a leading mental-health advocacy organization. It focuses on promoting mental health as a critical part of community wellness.

NCMH insisted that mental illness stems from adverse psychological experiences, which can be prevented by creating positive social environments. It sped the creation of a hundred child-guidance clinics in the U.S. to offer prevention and early intervention with children at risk. The group conducted surveys of mental hospitals and agitated for uniform standards of treatment at psychiatric institutions. And it pushed for laws making it harder to commit someone to an asylum. The NCMH had a chapter in every state by 1920.

While an estimated 18 percent of the population copes with some form of mental-health condition, only three to four percent—roughly 10 million Americans—have a serious mental illness.

At around this time, the prospecting company built up by Hogg’s father, later known as Texaco, struck oil, and she became wealthy. With this infusion of funds, she launched the crusade for “positive mental health” that her foundation waged for decades, right up to the current day.

Through the Rockefeller Foundation’s Commonwealth Fund, which was opening child-guidance clinics across America, Hogg opened a clinic for children in Houston. She joined with Rockefeller and other philanthropists in efforts to “influence social policy and government spending by identifying a need, financing and organizing pilot programs, garnering public enthusiasm, and then turning to government agencies for funding and maintenance,” as historian Kate Kirkland has summarized.

The mental-hygiene movement sparked many battles. Whether insanity was curable. Whether it was even a brain disease at all. How best to protect the lives and civil rights of the seriously mentally ill. Differing philosophies on fundamental questions like these still divide mental-health advocates today.

The Hogg Foundation, however, unambiguously won its argument in favor of shutting down state-operated psychiatric hospitals. It was the most influential philanthropic force behind this cause, and due in no small part to its efforts, the number of beds in psychiatric hospitals fell from 340 per 100,000 Americans in 1955 to just 12 per 100,000 today.

Congress fueled the effort to move psychiatric patients out into everyday life by passing the Community Mental Health Act of 1963. The advent of the Medicaid program in 1965 and discoveries of the first antipsychotic compounds further sped the transfer of mentally ill individuals into neighborhoods. Hogg Foundation advocacy thus helped drive seismic changes in the structure of our society and the operation of our public safety net, setting the stage for many of the challenges we grapple with today.

To help communities cope with new problems, the Hogg Foundation funded what it called “circuit riders for mental health,” modeled after eighteenth- and nineteenth-century preachers on horseback, to lecture and distribute pamphlets promoting “positive mental health” in towns across Texas. These advocates addressed 2,000 audiences in 152 communities, reaching roughly 400,000 people at colleges, schools, churches, and Rotary Clubs. The aim was to bring hope to communities who were struggling with interrelated social issues still very familiar to us today.

Today, the Hogg Foundation grants about $9 million per year. Promoting the integration of primary health care with behavioral treatments by counselors is a primary interest. One signature project is the Hogg Policy Fellows program, which trains individuals to lead and influence mental-health policy. Another is trying to build up the mental-health workforce by training more than 500 peer counselors with lived experience in mental-health problems. This is now run by a separate 501c3 organization spun out from the foundation called Via Hope.

Other efforts to build mental-health capacity in communities are in the works. Rural areas are a special focus. One $400,000 grant aims to design rural wellness plans that help localities map their mental-health assets and then plan new initiatives. These will be implemented across Texas over the next decade.

 

The Achelis & Bodman Foundation

For several years, The Achelis & Bodman Foundation has supported groups that serve people with mental illness, and projects that address the confluence of untreated mental disorders, substance abuse, and violence. The foundation draws important distinctions between serious mental illness and commoner mental-health conditions. A serious mental illness is defined as a behavioral, emotional, or psychiatric disorder that substantially interferes with major life activities. While an estimated 18 percent of the population copes with some form of mental-health condition, only three to four percent—roughly 10 million Americans—have a serious mental illness.7

Achelis & Bodman focuses on these people coping with problems like schizophrenia, major depression, or bipolar disorder. Antipsychotic medicines, antidepressants, and lithium for bipolar disorder are currently able to reduce symptoms in about two thirds of such patients (or even more if treatment begins early). These medications are not cures, but they allow many mentally afflicted individuals to live comparatively normal lives, and their efficacy rates compare well with many other branches of medicine.8

However: several million individuals with schizophrenia, bipolar disorder, or dangerous depression are untreated today. In many cases this is simply because patients refuse to take their medications. Sometimes resistance is sparked by fear of side effects like weight gain, loss of libido, or mental flatness. Other severely mentally ill individuals don’t even know they have a problem—something specialists call anosognosia, meaning lack of insight. Just as an Alzheimer’s patient may not be aware of his deficits, perhaps 40 percent of people with schizophrenia are anosognosic.

Off their medications, or never treated, mentally ill patients can pose a danger to themselves or others. This reality has led to sharp disagreements about whether the mentally ill patient or a family member has better insight into the right course of treatment. For instance, headquarters staff of the National Alliance on Mental Illness, one of the nation’s leading mental-health advocacy organizations, generally hold that the civil rights of patients forbid letting anyone else make decisions about their treatment. Most local chapters of the same organization, however, support efforts to make it easier for family members to initiate treatment of disturbed individuals. The Achelis & Bodman Foundation exclusively supports groups that champion this family point of view.

One of its grantees is the Mental Illness Policy Organization, founded in 2011 by advocate D. J. Jaffe. Jaffe’s 2018 book, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill argues that the U.S. spends too much on psychological issues but not enough on the seriously ill. His organization and others supported by Achelis & Bodman promote a loosening of civil commitment laws so families can commence treatment for the 40 percent of seriously mentally ill persons who are so sick—often in the throes of psychosis—they don’t realize they need help.9

Jaffe also blames perverse reimbursement incentives in the federal Medicaid program for some of the problems in getting treatment for people with serious mental illness. Before Medicaid started paying most health costs for the indigent, state and county governments covered mental treatments. But once Medicaid started to gush states began discharging patients from state hospitals before they were well, trying to shift costs onto the federal program.

That is because the federal government instituted an “IMD exclusion” in the original Medicaid legislation in 1965, banning care for mental health or substance abuse in institutions with more than 16 beds. In late 2018, the Department of Health and Human Services announced states can seek waivers from the exclusion. This marked an advocacy win for Achelis & Bodman’s grantees.

Nearly every mental-health advocate believes that the optimal solution for most mental patients is local community treatment. Jaffe celebrates the “clubhouse” model used by New York City’s renowned Fountain House as one of the best approaches. This combines supported employment or other work with strong communal peer support, close management of care, and housing when needed. The Fountain House model has been replicated in 300 locations and now serves 100,000 people with mental illness.

Unfortunately, “not in my backyard” pressures make it hard in many cities to create as many group “clubhouses” as are needed. Plus, Medicaid has not historically covered the social supports that keep seriously mentally ill people complying with treatment. More flexibility may be possible with waivers and other regulations that allow some flexibility with the Medicaid program. Government incentives are hurting in other ways as well. Payer cost-shifting because of Medicaid caps often forces patients to move from psychiatric units to ill-equipped general hospitals and nursing homes. Or seriously mentally ill patients are just released and end up at homeless shelters or jails.

Something called “assisted outpatient treatment” is favored by many Achelis & Bodman grantees. AOT is mandatory court-supervised treatment within the community, with local mental-health systems playing important roles in helping participants adhere to their medical plans. If someone has a history of arrest, incarceration, homelessness, or needless hospitalization because of noncompliance with treatment, AOT provides a way to take them to court, under due process, and gain supervised community-based care. Assisted outpatient treatment has been endorsed by prominent mental-health advocacy groups, and by the International Association of Chiefs of Police, the National Sheriff’s Association, and the U.S. Department of Justice.

Because a court is ordering the intervention, there is a case manager responsible for monitoring the person and keeping him or her in treatment. This has reduced homelessness, arrest, and incarceration by 70 percent in places where it is put into place—cities, rural areas, Southern regions, Northern regions. Although nearly all states now have AOT laws, these programs aren’t enforced or funded consistently, even though AOT is less expensive and less restrictive than alternatives like in-patient hospitalization or involuntary commitment.

One Achelis & Bodman grantee pressing government officials for fuller implementation of assisted outpatient treatment is the Treatment Advocacy Center. TAC develops briefs, research, and policy advice to assist states in changing their civil-commitment laws. It provides technical assistance and resources that help counties, cities, and courts put their AOT programs into effect.

Another element of education and advocacy supported by the Achelis & Bodman Foundation is its funding for a documentary film detailing the work of Judge Steve Leifman in Miami-Dade County. In 2000, Judge Leifman created a Mental Health Project in his Eleventh Judicial Circuit. This diverts from incarceration into community-based care people with mental illnesses who have committed low-level offenses. Individuals accepted into the diversion program receive case management, housing, and other services. Judge Leifman’s program has been particularly successful in scooping up “super-utilizers” who consume large public resources as they bounce from emergency room to emergency room, from homeless shelter to jail.

Some individuals have such severe mental illness they are unable to live in the community. For these individuals, Jaffe argues, a psychiatric hospital is the most humane option. But with the closure of most such hospitals over the last generation, it is tremendously difficult for any but the criminally mentally ill (who occupy nearly half of the remaining beds) to find a spot. That’s why advocates supported by Achelis & Bodman—like the Mental Illness Policy Organization and the Treatment Advocacy Center—believe that the number of psychiatric hospital beds needs to be increased from the current level of 12 per 100,000 population to more like 40-50 beds per 100,000. At a minimum, Jaffe argues, mental-health advocates should oppose further closures of state-run psychiatric centers.10

By carefully zeroing in on a small number of grantees who are tightly focused on securing treatment for persons with serious mental illnesses, Achelis & Bodman executive director John Krieger and his trustees are having effects on a field where many funders get lost in tangles of complexity and fuzzy targeting.

This is bringing crisp life improvements to individual patients. And, more broadly, the foundation aims to alter perspectives among mental-health advocates. What is most lacking today when it comes to solving serious mental illness, Achelis & Bodman believes, is not good intentions or even richer resources, but more realistic understanding of the roots of today’s problems, followed by pragmatic responses.