December 18, 2012 at 7:15 pm #174920
Borrowed from a fellow GovLooper, David Grinberg, who is hosting a similar discussion on gun control in the wake of the Newtown tragedy, "It should be obvious by now that something is seriously wrong in America regarding..."(I'll modify from here) the identification and care of our mentally ill.
Gun rampages tend to have two things in common 1. a gun 2. someone with a mental illness.
In the Newtown shootings, the shooter showed early signs that he was mentally ill.
In the Columbine shootings, the two shooters posted a Blog showing "...ever-growing anger against society." two years before the shooting. The mother of a friend "...filed numerous complaints with the Jefferson County Sheriff's office concerning Harris, as she thought he was dangerous." These two boys were ignored until they made headlines.
In the shooting of Congresswoman Gabrielle Giffords and eighteen others, the shooter was found incompetent to stand trial. He left messages in a safe, on MySpace, and argued with his Dad during the day of the shooting. He was forcibly medicated following his diagnosis of schizophrenia. Ironically, the shooter was stopped by a 74 yr old retired US Army Colonel (presumably intimately familiar with guns), and two bystanders - one with a weapon and a concealed carry permit (though he did not draw his weapon).
Of the 62 mass murders in this country since 1982, at least 62% of the shooters had signs of mental illness prior to the mass murder events. At least 35 of the killers (56%) committed suicide on or near the scene. The statistics suggest that mental illness is definitely a factor in these events. Since 1982, .000119230769230769% of US gun owners have gone on shooting sprees. Considering the overwhelming number of gun owners in the US (52 milion) who do not go on shooting sprees or commit mass murder, it's possible that mental illness is a dominant factor worth looking into. See below from CNN:
What should we be doing about the identification and appropriate treatment of people with mental disorders in this country?
December 18, 2012 at 8:43 pm #174963
The fundamental challenge in the intervention in ANY health issue, whether physical or mental, whether with the full agreement of the individual or against their will, is one of the detection of a signal in the midst of all that noise.
You're in the shower, because the baby is finally asleep and you've needed one desperately since yesterday. But, but....was that the baby crying...or the phone? Can't tell, over the noise of the shower. Wait, I thought I heard it again....turn off the water for a sec, and....nah, just my imagination. Finally come out of the shower and the baby is screaming its lungs out and hoarse.
We regularly miss things because they occur against a backdrop of events, and states, and distractions that obscure easy and reliable detection; all hits, no misses, no false positives or false negatives. Thirteen years ago, I had a heart attack. I had actually been experiencing angina for several years before, but never knew it. Trouble was that, as a highly sedentary person, I had only experienced it when running for the bus in February on sub-zero days. My chest would hurt like a sunuvabitch for 15 minutes, but once I got warm on the bus, it would go away...so I thought it was just freezing air irritating my lungs. The heart attack didn't feel like anything I had ever been led to believe one would feel, and it took a few hours of my wife pestering me before I went to the hospital. I drove myself, thinking I'd be blowing $10 in parking just to be told "It's nothing. Go home."
A close friend died at 33 from a cancer he didn't even know was there, two weeks after discovering it, because he chalked it up to mere lower back pain. A former student of mine became hospitalized for depression and took his own life on a day pass from hospital, jumping into traffic from an overpass. As a psychologist, I should have known, but I thought he was simply shy and introverted, like so many other students. A grad student in the lab I was working in would come into the lab regularly saying "Oh man, I went to the pub and got so smashed the other night". When I visited the lab a year or two later, after starting a grad program elsewhere, I asked the prof how everyone was doing, and when I got to this guy, she replied "He left because he had a drinking problem". He did, and I knew he did, but chalked it up to "grad student life". A former co-worker was gradually becoming more and more dishevelled and "over-committed" to things outside of work, to the point where no one would work with him or assign any work to him. He ended up being put on long-term diability, and although we were never given a formal report (at least that was shared with us underlings), it was clear he met all clinical criteria for mania. It had been years in the making, but nothing was ever done, and since the guy didn't have a partner of any sort, there was no one close to him to recommend he seek help.
Much like the proverbial frog in the pot of water that gradually comes to a boil, we constantly find ourselves facing assorted health challenges in ourselves or others, and we wonder where the dickens THAT came from, because we were so immersed in it on a daily basis that we simply couldn't see it. You see, or maybe you even live in, a highly dysfunctional family, and you just get used to it. You put on 30lbs, a tiny bit at a time, and before you know it, all your clothes still fit you...because you keep buying new ones.
And that poses a huge dilema. The state can't treat everyone like children and straight-arm their way into intervening; both because no one would stand for it, and because it would cost a bloody fortune. At the same time, if you left it up to people to self-refer or otherwise seek help for themselves or someone else, you're creating a HUGE crack for people to fall through. That crack is narrowed a tiny bit by removing stigma about seeking help, but that tiny bit pales in comparison to how much is neglected because nobody realized that help was even warranted.
It's also the case that, like my manic former co-worker, a lot of people do live lives that permit them to go unobserved by others, or at least not be in a position where others get to see the full extent of their lives. Parents see some of their 16 year-olds' behaviour, but not all of it. Singles with their own apartment may mingle at work, but what are they like outside of work? The declining person is able to witness the full scope of their own behaviour but thinks of it as increasingly normal. The person who is removed enough to be able to say "Um, that's just not right", doesn't get to see enough behaviour to be convinced they have the right take on things.
Treatment is easy. Detection IS the fundamental challenge.
December 18, 2012 at 11:56 pm #174961
This is a clever and informative post, David.
FYI -- I totally agree that the issue of people with mental illness and access to guns, in general, is of utmost importance and needs to be addressed ASAP. In my follow up post this morning, Guns & Gov: Banning Assault Weapons (12/18/12, 8:30 a.m.), I specifically state:
"It is important to note there is no easy or quick solution to solving the epidemic of mass gun violence in America. A comprehensive multi-pronged approach is needed by the public sector and private sector alike to address a broad range of issues related to firearms, including...
Studying the relation between mental health, age and gun violence.
Leveraging Big Data to improve background checks and gun tracking systems.
Increasing citizen engagement through enhanced public education and awareness campaigns."
All of these suggested approaches encompass the critically important issue of limiting access to guns for people with mental illness. Thanks for keeping this in mind.
December 19, 2012 at 12:07 am #174959
I like your comment and can relate to it. There always did seem to be a misunderstanding about mental health and mental health professionals. And sometimes I wonder if people's fear of the subject encourages them to not see what is going on around them.
Maybe because I wanted to be a psychologist before discovering engineering and because I became involved in the field in a voluntary capacity, I have no hesitation seeking out help from someone in mental health. The people in this profession are there to help anyone - not just people who have a "mental condition." The first time I went was when I was in college - I was having some family problems and wanted an objective observation of what was happening so I could appropriately respond without making the problem worse. It was so helpful to have someone who is trained to guide you to a reasonable solution. The whole thing worked out perfectly because that person helped me assess the situation and correctly respond avoiding any contribution to what might have been a huge family fight.
The other time I went was when I wasn't feeling good and the physician I went to said I was crazy and imagining the symptoms and should see a psychiatrist. Again because I view people in mental health more as "life guides" I figured I would follow up with one to get his assessment and advice. We had a great talk - he told me there was nothing wrong with me on an emotional or mental level and that I really did need a physician which is what I had suspected. Soon after with the help of some co-workers and a different physician I discovered a collection of physical problems that were eventually taken care of.
Perhaps we need to rebrand the mental health profession, look at partnerships with religious counselors if that is appropriate for some, and encourage and support everyone to seek out help whether it is for just some general life counseling or for more serious and personal challenges. We always give our heroes in stories a Master or guide to help them through life - why do we deny them for ourselves?
December 19, 2012 at 2:14 am #174957
The mere fact that someone shoots or kills individuals with whom they have no personal connection, who pose no immediate danger to them or are not simply in the line of fire, and who may fulfill some sort of arcane symbolic function for them, is a clear clinical sign that something is simply not "right" with the individual. The legal question then turns to one of whether a non compos mentis defense can be legitimately applied (as in the case of a severe psychotic episode), or whether you have someone like Anders Breivik, whose actions stem from a "normal" mind that has woven a seamless set of outrageously anti-social beliefs that justify (for him) heinous actions.
But here's the thing. Maybe more than half of those who become shooters were "off the charts" clinically, but they comprise a teeny tiny share of all those with the exact same observed, and measurable symptomotology. For every Anders Breivik that goes and kills 70 people to "stop the Muslims overrunning his country", there are literally thousands more who have the same bizarre seamless belief system, but sit in a donut shop cursing under their breath instead, or spending their days writing hostile xenophobic posts on newspaper sites. I remember one summer, I was working in a youth ward at a psychiatric hospital, and one of the kids would keep rolling out the plasticine into crude figures, and muttering something angrily about "ripping his head off". To the best of my knowledge, he never went on to do anythingparticularly criminal.
The majority of those with serious psychological problems will never do any more harm in their lives than ruin a relationship or three, lose a few jobs, and dash a parent's fondest hopes, as their own life crumbles. So, considering large-scale intervention as a way to prevent tragedies like Newtown is like trying to bail out the tide with a bucket. I mean, it's wonderful that we do take some more extensive action on behavioural and mental problems, but don't delude yourself into thinking you'd be able to reliably flag every single person who ought not to be able to walk into a gun shop and make a purchase and then stick their name on a national list.
And yes, there probably ARE some reliable indicators we can identify post hoc, that differentiate people who carry out such terrible acts from those who simply have equivalently difficult emotional issues, but these are things we can only know post-hoc to establish a statistically predictive relationship once such individuals are identified, and are rarely, if ever, fully visible/available to the family member, partner, teacher, sibling, neighbour, supervisor, or co-worker before things go terribly wrong. All those folks will ever be able to tell you is something like "He was a quiet guy. Pretty much kept to himself." Yep, there's the clinical picture that should compell people to spring into action.
Again, reliable detection is the big wall to climb over, not just in helping people, but in developing workable and effective public policy too.
December 19, 2012 at 12:29 pm #174955
All good comments here. Forgive me if someone said this already. But sick groups produce sick people. For example stigmatizing depression causes men in particular to fear and avoid help. Another example would be parents working multiple jobs to support kids, leaving them to raise themselves under the influence of peers. A third is insufficient integration of our veterans who return from duty having to cope with so much. A fourth is the glorification of violence in movies - physical strength and weapons equal power. A fifth is sexism - we call emotional people "weak." And on and on. There is too much focus on psychology and not enough on sociology. (Plug for the major!!!)
December 19, 2012 at 2:34 pm #174953
I used to be a psych major and spent a good deal of time working in group homes, homeless shelters and other organizations that serve a predominately mentally ill population. Assumptions that produce the stigma around mental illness that make it hard to address:
1) "those people" are dangerous
2) let's just institutionalize them
3) send 'em to a shrink
4) I don't want to hurt my neighbor / friend / fellow parishioner's feelings by sharing a concern about their son / husband / nephew
5) I don't know what to do about people with mental illness (I'm confused by / scared of them)
6) I'm not sure psychotherapy works
7) Pharmaceuticals seem to have questionable / inconsistent impact
8) I don't know how to report someone that is making me nervous
9) I don't know what can be done about them under the law anyway
10) 1 in 5 Americans is medicated for some form of mental illness - I don't know where to start!
This is very complicated...
December 19, 2012 at 3:59 pm #174951
Not sure that I have the answer but I know what is NOT working...
The fine govenor of Texas spent several minutes bragging on how the state of Texas spends considerably less on the detection/management of mental illness than any other state.
Then I watch a news story on how Harris County deals with the issue of the mentally ill who have little money or no insurance. Lock them up in the Mental health "branch" of the county jail, determine what thier problem might be and then release them when the "medication" takes affect or they are determined to not be a danger to others. That is only for those who have NOT committed a crime, those will go thru the "normal" criminal justice system where with the exception of homicide cases there is no such thing as an insanity plea.
December 19, 2012 at 4:08 pm #174949
One of the basic principles of security is that it is a very natural tendency - indeed, a basic need - to want to trust, and a rather unnatural tendency to sustain mistrust. It's also a basic principle of human attention, that when exposed to the repetitive, human attention wanders. That's why, if your work building has several access points and a security guard working each one, the guards are rotated often, such that they don't simply treat everyone coming through as familiar and trustworthy, and don't get automatic about nodding to every ID card flashed their way. Something has to reset their attention and capacity to have at least a modicum of mistrust so that they feel the need to ask for, and actually look at, your ID.
Your place of work can probably afford to have a dozen security guards rotating during the day, but your average elementary, middle, or high school, can not. Whomever is tasked with monitoring the mental health of employees in your organization also probably gets somewhat automatized in how they do their job, no matter how sincere they are about the mission.
I should add, rather cynically, that it is also a principle that the more people you have to throw at a problem, in order to tackle it, the less well-compensated they tend to be, and the less qualified they tend to be, as a result of that modest compensation. You get some saints who are dedicated enough to stick around, but you also tend to get more turnover as a consequence of that modest compensation.
All of this is to say, yet one more annoying time, that treating "detection" of psychological problems the way we would treat detection of intruders, requires the sort of substantial investment that we are collectively unwilling to make. So don't put all your chips on it.
December 19, 2012 at 7:28 pm #174947
Is it as simple as identifying/isolating "them" (the "mentally ill") so that they can't go on shooting sprees?
Who is "crazy"? The bullied kid who lets loose on his peers and then commits suicide? Maybe it is the bullies themselves who require an intervention?
Many people who appear functional in public are completely dysfunctional in private.
So mental illness is a continuum that begins with being aware of and adjusted to reality - and ends with total disconnection.
In between is ordinary life and some cops better, some worse.
If statistics I hear are correct, one in six adults suffer from some form of mental illness. Clinical depression is included in that mix.
The reason we can't cope with the issue is that we want to run away from its symptoms in ourselves.
Unfortunately nobody gets through life unscarred. So the solution is to have EAP counseling, coaching, mentoring, time-out rooms, available freely. For parents to ask kids what's doing. For managers to manage. To be a mensch and if you see someone sad, say how are you?
It's like those Steamfresh vegetables. If you poke holes in the bag and microwave the steam comes out a little at a time. If you don't let the steam out it explodes.
My mom used to be the camp nurse and many of the so called cuts and scrapes were kids escaping their crappy counselors, taunting friends, dealing with boyfriend/girlfriend issues, or homesick.
If you mistreat people emotionally, ignore or misdiagnose a chemical imbalance, shame them into silence, etc....what do you expect but these mini explosions?
We are lucky there are not more. And they would happen with or without guns.
On the other hand well trained and well armed guards could minimize their impact if they do occur.
December 20, 2012 at 1:08 am #174945
Pam - your post made me think of a college project my daughter did on faith-based rehabilitation. Prisoners are a stigmatized population just as people with a diagnosed mental illness are. Because of their privileged position, a religious practitioner is uniquely situated to remove that stigma and bring the person back to the community. There is also a trend toward more clergy joining the ranks of therapists. A natural fit there although it can also be exploitive and manipulative, so extra oversight is required. (For example therapy refrains from value judgments whereas religion imposes them.)
I also like your use of the word "rebranding." You hit it right on the head. Even the word "mental" has a bad sound to it. How about "psychological?"
December 20, 2012 at 4:27 pm #174943
I work in perforamnce management, employee and labor relations. There are suppposed to be people monitoring mental health in my organizaton? Or if someone is acting strangely, who are we supposed to call? Under what circumstances?
December 20, 2012 at 6:45 pm #174941
It's like that in universities, too. It's not clear who is tasked with keeping tabs on people such that they stay clear of the cliff. It's a huge challenge.
There are also legitimate privacy concerns that get raised, since "keeping tabs" can very easily cross the boundary.
We had a case here in town in the last few years where a young woman living in the dorm in her first year at university became depressed. Some guy in Minnesota, posing as a woman in some on-line chat room "counselled" depressed people to commit suicide. And tragically, she did. When the investigation was complete,and the case went to court, it appeared he had done so on several occasions. Her parents had no clue she was that close to the edge, and if anyone at school knew, it wasn't their "job" to report it or do anything else about it, except perhaps worry.
I mention this not to go off on some tangent about on-line predators, but rather to illustrate that the task of being our brothers' and sisters' keepers is a complex one, that extends well beyond simply preventing violence, and well beyond the events that resulted in this thread.
I think a lot of this is hampered by people lacking both "scripts" and a sense of permission. Where am I allowed to intervene? How should I do it? What do I say and who do I say it to? What sort of questions do I ask so that I can find out things are actually okay, before rushing to a more grave judgment? How do I present what I know to those who ARE tasked with taking more formal steps, such that the degree of intervention is properly titrated/calibrated to the degree of problem I think might exist?
These are things people regularly ponder, and in the absence of clear and rehearsed answers to those questions, it can pose an obstacle to folks doing the right thing with the best of intentions at the right time. All of which makes this good conversations to have with staff, and if you're at a university or high school, with students.
December 20, 2012 at 9:58 pm #174939
Nothing. Have a look at the list of 200 top selling pharmaceuticals - you will find 2 anti-psychotics and 1 antidepressant in top 10 brands. The situation with generics looks very similar.
Many anti-psychotics originally approved for i.e. schizophrenia (typically risperidone) are prescribed off label for all sorts of fancy pseudo-diagnoses such as "bouncy teenager" or "how-can-I-keep-this-monkey-sitting-still" type of "diseases" (meaning ADHD and Autism). Medication does not necessarily mean diagnosis for which the drug is approved.
Many people have "early signs of mental illness" and do not shoot their neighbors. The idea that it is somehow possible or even sensible to label as mentally ill everyone who was ever treated for mental health problem is scary. Most people would end up with "mental health record" even after an episode of depression. What do you want to do? Label all grieving relatives, women with baby blues, victims of abuse, or people who get into pub fights as mentally ill? It would soon look like in Russia – no offense.
December 20, 2012 at 11:30 pm #174937
FYI: Today's letter from the federal National Council on Disability to President Obama regarding Newtown shooting and mental health. Read it here. According to the letter:
"While a disability diagnosis of the perpetrator of the violence in Newtown remains unconfirmed, media coverage and national dialogue has increasingly focused on issues related to mental health, often portraying, intentionally or not, a correlation between certain mental or developmental disabilities and violence. On the contrary, research consistently documents that people with disabilities are much more likely to be victims of violence than the perpetrators of it."
December 21, 2012 at 2:55 am #174935
The "baseline problem" is an all-too-common sort of inferential error people make. Not just lay-folk, but professionals, too.
I recall the famous "Lexington study", from the 1930's or maybe earlier, in which patients/inmates at a facility for addicts in Kentucky were surveyed as to whether they had ever used marijuana. The overwhelming majority indicated that, yes, they had used marijuana prior to eventually becoming heroin addicts. This was part of what resulted in marijuana becoming labelled as a "gateway drug". Of course, the baseline for comparison was inappropriately chosen. The more appropriate question to ask would have been "Out of all those who have ever smoked marijuana, what percentage eventually went on to become heroin addicts, and out of all those who have never used marijuana, what proportion went on to become addicts?".
Fundamentally, it is a miscalculated sense of relative risk.
We will always see strong representation from those with deep psychological problems among those who have commited grave offenses. But, like our misdirected pot-leads-to-smack example, that ignores the true baseline to compare against, which is "Of all those folks who could rightly be classified as having serious problems in living (to use the late Thomas Szasz' phrase), what proportion go on to commit grave offenses, and how does that percentage stack up against the proportion of people without such problems who commit offenses of equal gravity?".
In each instance, we may see that the calculated risk is actually quite small, compared to the estimated risk when you start off with a conspicuously selected sample and work backwards. And as the NCD so correctly points out, it is important to do the reverse calculation and ask about rate of victimization.
December 21, 2012 at 6:03 am #174933
It is strange that some media automatically assume that "mental illness" equals "disability". Very few people of those who are clinically treated for a mental health problem (including major depressive disorder or reactive depression) are disabled. They can be temporarily incapacitated just like by any other illness but this has nothing to do with disability. As other people mentioned in this discussion, 1 in 5 Americans is treated for a psychiatric condition. This does not say how many Americans have a history of being treated for a psychiatric condition over their lifetime!
I am rather worried by this quest for the feebleminded in order to prevent "grave harm to society". A little bit of history is rarely harmful:
The search for causes of crime:
Buck vs. Bell
statistics of forcibly sterilized people affected by some mental illnesses in Nazi Germany
Galton's Hereditary genius:
and most importantly... The Jukes:
The link between mental illness and violence is pathetic. It sounds like a link between sorrel and solstice.
December 21, 2012 at 6:54 am #174930
What should we be doing about the identification and appropriate treatment of people with mental disorders in this country?
First of all stop recklessly sharing sensitive medical files across the globe.
December 21, 2012 at 4:24 pm #174928
In what ways are veterans not "fully integrated?' Specifically what are you referring to?
December 21, 2012 at 4:26 pm #174926
Define "acting strangely."
December 21, 2012 at 10:40 pm #174924
June 11, 2013 at 11:47 pm #174922
1) Everyone needs to understand that jails are not the answer. State and local governments need to collaborate to set in place alternatives to jail, supported by public health/public mental health agencies. See discussion of the principles involved at http://bit.ly/JailsAndMH, and see an example of how a solution was developed at http://bit.ly/Washoe-MH
2) We need better (and/or better-working) options for reporting a person who we perceive may pose a danger to self or others, and better systems for follow-up by public safety agencies - perhaps with a new kind of mental health screening court to approve probable cause to investigate a person's well being.
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