Target help to the seriously mentally ill, not 'mental health' in general

Target help to the seriously mentally ill, not 'mental health' in general
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Mass murder by the mentally ill is thankfully rare and accounts for a small portion of overall murders and violence by people with mental illness. While the mass murders by mentally ill are difficult to prevent through mental health interventions, the larger numbers of non-mass murders by mentally ill can be prevented. If we are going to limit our violence-prevention efforts to those incidents perpetrated by the mentally ill, non-mass violence is where we should focus our attention.

It appears that at least one third of mass killings are carried out by those with untreated serious mental illness. Applying that rate to the 475 people who were killed in a mass murder in 2015 means 156 individuals lost their lives in mass shootings involving the untreated seriously mentally ill. But multiple studies suggest that at least 1,000 individual homicides are committed by people with untreated severe mental illness. So non-mass murders by untreated seriously mentally ill are six times more common than mass murders.

Incidents of non-mass violence by mentally ill can be reduced by reforms in the mental health system. 

To avoid stigmatizing those with mental illness, the mental health industry is too reluctant to admit serious mental illness is a factor and instead, hide behind the the platitude that “the mentally ill are no more violent than others.”

Studies to support that claim use the broadest definition of mental illness, 18 percent of the population. They are often of the treated. They show treatment works, not that the mentally ill are no more violent. And they include everyone with any mental health condition, not just the seriously ill. And most of the studies explicitly exclude the violent including those who are involuntarily committed, hospitalized, in jails and in prisons.

Once it is accepted that the untreated seriously mentally are more violent, the key fact is that 35 percent of them go entirely untreated. To reduce violence, government should focus it’s mental health policy on delivering treatment to the untreated seriously mentally ill rather than improving mental wellness in all others.

We have to stop giving community mental health programs mental health funds free of any obligation to help the seriously mentally ill. For example, many programs declare the seriously ill “high-needs” patients and claim they are not set up to serve them. Or they get money to fight stigma which often takes the form of misleading the public about violence with the claim the mentally ill are no more violent than others. This makes it less likely that solutions will be adopted.

Assisted Outpatient Treatment (AOT) is perhaps the most effective way to reduce violence by the untreated seriously mentally ill. If a seriously mentally ill individual fails to stay in treatment and has a history of deteriorating as a result, AOT allows judges to order them to stay in mandated and monitored treatment — including medications, while they continue to live in the community.

Nikolas Cruz had been prescribed medications, but was allowed to go off them. AOT might have kept him in treatment.

According to some studies, it has reduced violence by between 36 and 88 percent, depending on the time scale, and had greater reductions in homelessness, arrest, incarceration and hospitalization. In another study, it saved taxpayers 50 percent of the cost of care by reducing the use of jails, prisons and hospitals. Assistant Secretary of Mental Health and Substance Use Disorders, Dr. Elinore McCance-Katz has made expanding the program a priority, but Congress and states must allocate much more funding to it. The funding could come from programs that don’t help the seriously ill.

Adopting easier-to-meet civil commitment standards would also reduce violence. A 2011 report notes state homicide rates may be correlated to the state’s civil commitment laws, i.e, states that make it easier to treat people with mental illness have lower homicide rates. State laws, like those in Florida, generally require persons to become danger to self or others before they can be treated over objection. That’s ludicrous. Laws should prevent violence, not require it. States should adopt “need for treatment,” “grave-disability,” and “lack of capacity” standards to supplement their “danger to self or others” standards. Mental health officials determined Cruz did not meet Florida’s dangerousness standard. Perhaps these other standards would have helped.

More psychiatric hospital beds would also reduce violence. According to 2005 data, we are short at least 95,000 beds nationwide, due in part to a horrific provision in Medicaid — the IMD Exclusion — that prevents states from receiving reimbursement for many mentally ill patients who need long-term hospital care. From 2010 to 2016, for instance, Florida alone closed 673 beds.

I know of no mental illness-centric intervention that would have absolutely prevented Nikolas Cruz from allegedly killing 17 in Parkland, Fla.

Even though he cut himself, and although there were several police visits to his home, those factors alone are not serious enough to trigger a mental health intervention over objection. As far as we know so far, he was not ill enough to put him in a special class to allow gun removal based on his mental illness alone. Therefore, laws to stop mentally ill from having guns and reform of our treatment system might not have helped in this particular case.

Removing guns from everyone would have helped, since he is an “everyone.” But the Second Amendment, in general, guarantees a right to firearms. Gun violence restraining orders allow families to petition for guns to be removed from threatening and dangerous family members and may be a useful tool for reducing gun violence by the mentally ill and non-mentally ill. There is no such law in Florida. Removing fast acting assault weapons, large clips or fast acting gun stocks from the market may be doable, and is what many police departments endorse. That might have lessened the carnage.

Everyone wants a soundbite solution to mass carnage created by people with mental illness. But even if one doesn’t exist, by focusing our resources on the mentally ill who are most likely to become violent, we can reduce far more deaths than those caused by mass murders.  

DJ Jaffe is the the executive director of Mental Illness Policy Org a non-partisan think-tank on serious mental illness. And the and author of "Insane Consequences: How the Mental Health Industry Fails the Mentally Ill." Follow him on Twitter @MentalIllPolicy.