Problems with Protection and Advocacy (PAIMI/P&A) Program  


The Protection and Advocacy Program was founded with the noble purpose of preventing neglect and abuse of persons with serious mental illness in institutions. The mandate was later expanded. Today PAIMI has morphed.  It construes it’s mandate to be protecting people with mental illness from having to receive treatment, rather than insuring those who need it gain access. For example, PAIMI “freed” Willie Bruce from a psychiatric hospital over the objections of his parents. After release, Willie killed his mom, Amy. The 2011 SAMHSA evaluation of PAIMI confirmed PAIMI taking the opposite side of legal guardians.Problems may arise from a genuine legal issue, such as when a guardian or other individual with legal authority opposes PAIMI having access to a person’s records.”
Instead of protecting patients from abuse and neglect, PAIMI lobbies government to bend to it’s will. For example, as members of the Energy and Commerce Committee well know, PAIMI and their trade association (National Disability Rights Network, NDRN) are aggressively lobbying to prevent HR-2646 from passing. PAIMI’s easy access to federal funds enables them to drown out the voice of concerned families who will be negatively affected if NDRN/PAIMI succeed. For more on prohibited lobbying by PAIMI read, “Lawyers Who Break the Law: What Congress Can Do to Prevent Mental Health Patient Advocates from Violating Federal Legislation” published in the Oregon Law Review.

SAMHSA’s 2011 Evaluation of PAIMI shows problems PAIMI  

An analysis of the SAMHSA 2011 evaluation of PAIMI reveals numerous problems.

  • PAIMII does almost nothing to ensure those who need access to hospitalization or treatment get it.  The focus is almost exclusively on getting people free of treatment, rather than into it.
  • Extensive PAIMI resources are going to fight AOT. There is nothing in PAIMI mandate that allows that. AOT is not ‘neglect’, ‘abuse’, or—according to courts—a violation of civil liberties.
  •  Extensive PAIMI resources are going to force states to close psychiatric hospitals in spite of the fact there are not enough beds for the seriously mentally ill who need them.
  • PAIMI can do this because SAMHSA is failing to provide proper oversight of PAIMI as legislatively required.

PAIMII is required to help minorities, but not meeting it’s responsibilities  

SAMHSA’s evaluation of PAIMI found that “PAIMI is required to “address the special problems and cultural barriers faced by minorities.” The report notes PAIMI fails.  “It appears that two of every three PAIMI clients assisted in individual (not systemic reform) matters are White, and that very few people of Asian and Native American backgrounds are provided PAIMI assistance. While the Hispanic segment of the U.S. population has substantially grown during the PAIMI Program’s tenure, the percent of Hispanics represented has declined.“ Elsewhere the evaluators questioned, “why information on such topics as cultural competency …is kept private on a website supported by public funds.”

PAIMI supposed to focus on abuse and neglect, but fails to do so.

The SAMHSA evaluation of PAIMI found, “The 1997 to 2004 PPR data reveal a slow, but steady decline in cases related to abuse and neglect.” The report also found PAIMI is becoming less successful.  “In 1999, 75 percent of cases were resolved in favor of the client; the comparable figure in 2004 was 64 percent.”

PAIMI fails to provide adequate consumer/family representation on Advisory Boards

The SAMHSA evaluators stated the “federally required standard” for the Advisory boards is “60 percent representation by individuals who had either received mental health services or were family members of those who received mental health services.” They found SAMHSA fails. “A decline began in the late 1990s and reached a low in 2003. After 2003, compliance with this standard began to improve. In 2004, 37 of the 57 grantees met the requirement of 60 percent recipient or family membership, although individual grantees varied widely in the extent to which they met this requirement (14 percent to 89 percent).”

PAIMI Fails to focus on institutionalized

The SAMHSA evaluation of PAIMI correctly states, “P&As must still prioritize services to persons in institutional settings.” The report notes SAMHSA fails. “Between 1997 and 2004, the proportion of PAIMI clients residing in institutions at intake fell from over 70 percent to 58 percent.“ “Although most PAIMI clients live in institutional settings, the 1997 to 2004 data show a significant shift towards serving clients in the community.”

PAIMI Required to focus on seriously mentally ill (SMI) but fails to do so.

The SAMHSA evaluation of PAIMI correctly states, the “PAIMI Program was established to extend… protections to persons with significant psychiatric disability “ The report found SAMHSA fails.  “35 percent of state NAMI directors surveyed said that PAIMI efforts to make themselves known to individuals with psychiatric disabilities were “mostly ineffective.” Six of 16 NAMI directors stated they knew little about their state P&A or PAIMI Program.”

PAIMI engages in anti Assisted Outpatient Treatment lobbying

PAIMI is supposed to address ‘civil rights’ issues. But it is courts, not PAIMI that decides what ‘violates civil rights’. Courts have held that AOT is an appropriate use of the states police powers and parens patraie powers. However, ignoring that, PAIMI raises “civil rights concerns’ to justify spending public dollars to fight programs they don’t like and support those they do. By way of background.  AOT is proven to reduce hospitalization, suicide, homelessness, arrest, violence, incarceration of the most seriously ill. The SAMHSA evaluation of PAIMI found

  • PAIMI “collaborate(s) with…a consumer advocacy organization to block passage of a proposed expansion of an outpatient commitment law.“
  • “PAIMIs reported joining other advocates in …Ad hoc partnerships focused on …opposing outpatient commitment”
  •  “A number of PAIMIs worked to prevent the enactment of state laws creating outpatient commitment systems”

PAIMI works to close psychiatric hospitals in spite of a nationwide shortage of 93,000 beds and won’t work to insure care in hospitals

SAMHSA’s evaluation of PAIMI correctly and clearly states: “As public psychiatric institutions close, more individuals with psychiatric disability are found in nursing homes and jails.” They went on to state, “In the evaluation team’s opinion, such settings constitute the new institutions.” SAMHSA evaluators found PAIMI fails to focus on people in those institutions. “Given that the Federal regulations still emphasize [PAIMI engage in] institution-based over community advocacy, more PAIMI attention should be directed to work in these facilities.”

  • “In one state, a PAIMI worked with stakeholders to ensure what advocates described as the “responsible closings of state hospitals.” In another state, PAIMI efforts were a major factor in “the closure of a state hospital”
  • “The [State MH] directors cited the significant influence of PAIMI advocacy on their agencies’ activities, including… Planning for closure of state hospitals and large personal care homes”
  •  “More emphasis could be placed on providing advocacy to individuals with psychiatric disability residing in nursing homes and criminal justice settings where these individuals are particularly vulnerable and isolated.”

PAIMIs are inadequately staffed in spite of funds being provided for staffing:

The SAMHSA evaluation of PAIMI found in spite of receiving federal funds, “Currently, few P&As retain staff dedicated solely to PAIMI activities. Although several grantees in the sample reported their P&As have three or more dedicated PAIMI staff, 62 percent reported no dedicated PAIMI staff. “  (i.e., staff do lots of things)

PAIMI expanded definition of neglect and rights that need protecting to enable them to do whatever they please

The SAMHSA evaluation found PAIMI adopted an exceedingly expansive definition of ‘neglect’ that they can use to justify doing whatever they want. PAIMIs made claims to SAMHSA evaluators:

  • “While (these) extensive rights are not enumerated in the PAIMII legislation, their protection is within the jurisdiction of the PAIMII program”.
  • ”As mental health services mature and evidence-based practices are identified, neglect may occur when organizations fail to provide services that reflect readily available knowledge.“ (We agree with that, but PAIMII does opposite. To kill HR2646, PAIMI now argues SAMHSA funding should NOT be limited to programs with evidence. )

PAIMI engages in anti-treatment advocacy and funds free trips to Alternatives
The SAMHSA evaluation of PAIMIs found

  • They “increasingly work with consumer groups on activities like …jointly developing legislative testimony and public comments, sponsoring state and local conferences, and paying for individuals with psychiatric disabilities to attend national meetings such as the annual Alternatives Conference funded by the CMHS.”
  •  “The [State Mental Health Authority] directors cited the significant influence of PAIMI advocacy on their agencies’ activities

30% of PAIMIs use the funds for programs that have nothing to do with their mandate
The SAMHSA evaluation of PAIMI found, “Less prevalent, though still representing significant resource allocations, were… reducing stigma (30 percent).” Evaluators found “PAIMI works with a survivor group on a project to “honor the thousands of people who died in state institutions, many of them buried on state hospital grounds.” These activities leave fewer funds to help the living.
There is a lack of transparency in PAMI programs
The SAMHSA evaluators found that “CMHS intends that site monitoring reports be distributed to each PAIMI’s governing board president, the PAC chair, and the P&A executive director. These reports are so carefully guarded they are not shared with other PAIMI GPOs or other grantees, a practice that impedes systemic learning and improvement. Since the PAIMI programs are public programs funded with Federal monies, monitoring reports should be publicly available.” “P&As are expected to offer the public opportunity to comment on the priorities and activities of the P&A every year. …(M)ore than two-thirds of legal counsels to SMHA (State Mental Health Authority) directors were unaware of comment opportunities.
SAMHSA evaluators found

  • “CMHS allows PAIMIs to select their own goals and objectives. This is unusual as the Federal Government directs the structure of other grant program goals and objectives. CMHS views grantees’ performance in setting goals and objectives as in need of improvement.”
  • “ CMHS GPOs (evaluators) are perceived as insufficiently trained in PAIMI or fiscal issues and do not always know what to look for on a site visit. “
  • “Communication between the SAMHSA fiscal oversight office and the CMHS branch that oversees PAIMI is neither routine nor standardized, which is seen as a problem.”
  • “No attention is paid to outcomes for clients, the impact of grantee activity, or level of grantee effort to move a system toward Federal goals. Systemic work is not as thoroughly reviewed as individual representation.“
  • “Reports show a grantee can be found to operate “in compliance overall,” even when there are areas of noncompliance. In the evaluation team’s opinion, a program out of compliance on even a single criterion is still out of compliance in that performance area”
  • “Fifty percent of (PAIMI) directors who had site monitoring visits since 2002 reported CMHS did not provide site review reports according to the established time lines. CMHS site monitors also stressed that the time lines for delivery of reports are not followed. GPOs concur with directors that the delay in delivering reports is problematic and that it can take up to 16 months before grantees receive written reports.”
  • “Over the 22-year history of the program, not all grantees have received the scrutiny of a site visit. CMHS rarely recommends TA, even when grantees are found “out of compliance” with Federal regulations”

Summary: An analysis of the SAMHSA 2011 Evaluation of PAIMI reveals PAIMI ignores the institutionalized, minorities, and people with SMI. Rather than focus on abuse and neglect they use the rubric of ‘civil rights concerns’ to allow them to focus on whatever they find ideologically palatable. They engage in activities harmful to the seriously ill (threatening states that implement AOT and working to close hospitals).  SAMHSA has looked the other way and implemented little oversight.
Oregon Law Review article available at

Evaluation of the Protection and Advocacy for Individuals With Mental Illness (PAIMI) Program Phase III: Evaluation Report, SAMHSA, 2011. It was conducted by among others, Judi Chamberlin, a founder of antipsychiatry. The advisory board for the SAMHSA evaluation of PAIMII also consisted of the head of Bazelon (Bernstein), the head of National Disability Rights Network (Decker) and others who lacked independence and/or identified as antipsychiatrists. Therefore much of the ‘evaluation’ is a call for PAIMI to continue down the wrong path that at times reeks of self-promotion. No critics were interviewed. However, while the info in the report came from PAIMI supporters, an evaluation of what they found still allows problems to be exposed.

Brennan, K. J. (2009). Kendra’s Law: Assisted Outpatient Treatment in New York. Unpublished revision of Brennan, K. J. (2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment Appendix 2)
DJ Jaffe is Executive Director of the non-partisan Mental Illness Policy Org., and author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is a critic of the mental health industry for ignoring the seriously ill, and has been advocating for better treatment for individuals with serious mental illness for over 30 years. He has written op-eds on the intersection of mental health and criminal justice policy for the New York Times, Wall St. Journal and the Washington Post. New York Magazine has credited him with being the driving force behind the passage of New York’s Kendra’s Law and Congress incorporated ideas proposed by DJ in the Helping Families in Mental Health Crisis Act.