Rethinking approach to mental illness
In a recent column, I asked readers to share their experiences with warning signs that someone could become a mass shooter, and their thoughts about why this hideous phenomenon seems to have started in the 1980s. We may have uncovered the answer. “You struck a nerve,” one reader wrote. “I am 92, and have lived through a time when the mentally ill were routinely committed to what I recall as sanitariums where they could be kept in custody. These sanitariums were in lovely parklike but protected settings away from the normal world of the day. My mother in her later years suffered from senile dementia and although not a danger to anyone else, was a danger to herself. This establishment was in Ventura County as I recall, and I visited her weekly. There was a cost per month which I was able to meet. She always seemed well cared for and I was kept up to date. Eventually, the psychiatrists were able to treat her with new drugs then coming on the market in the 1970s to help. The end came to the sanitariums with the new political attitude that containing these people was denying them their freedom, and both the Republican and Democratic parties embraced the change for their own reasons to save the costs. Those costs they sought to save are now being paid for on the streets of California cities as I write.”
This reader’s memory of the sequence of events is accurate. At one time, people who were a danger to themselves or others could be confined against their will in a psychiatric hospital. With the development of drugs to treat mental illnesses, public opinion began to turn away from the idea of involuntary confinement, particularly for people who could live independently with the help of treatment provided at a community mental health facility.
In 1955, the number of patients confined in public mental health hospitals was 558,000, the highest it has ever been. Around that time, the Food and Drug Administration gave its approval to Thorazine for the treatment of psychotic episodes. Previously, the only available treatments were electroshock therapy and lobotomies.
That year, Congress passed the Mental Health Study Act, setting up a commission that reported in 1961 that community health centers should be set up to treat patients with less severe mental illness.
In 1962, author Ken Kesey’s “One Flew Over the Cuckoo’s Nest” was published. It was a fictional story about abuses in a mental hospital, based on the author’s experiences working in one.
In 1963, President John F. Kennedy signed the Community Mental Health Centers Construction Act to provide federal funding to build community-based facilities. In 1965, President Lyndon Johnson signed the legislation that created Medicaid, the health insurance program for low-income Americans that’s called Medi-cal in California.
But Medicaid did not pay for care in mental hospitals. As a result, states transferred low-income mental health patients into conventional hospitals or nursing homes so the cost would be covered. These facilities were ill-equipped to handle patients with severe mental illnesses.
Funding considerations converged with public pressure for deinstitutionalization. In 1967, California Gov. Ronald Reagan signed the Lanterman-petris-short Act, which limited involuntary commitment and further drove the movement away from psychiatric hospitals and toward community-based treatment. Other states followed California’s lead. These changes appeared to save money in state budgets. However, more and more mentally ill people fell into the criminal justice system.
Even if fully funded, community-based care on a voluntary, outpatient basis will not be adequate for some people with serious mental illnesses. People who are a danger to themselves or others require more.
One reader wrote, “I was a psychiatric nurse in New York City in the 1970s. I administered the medications to young men; heavy psychotropic medications that the patients didn’t like, but they had no choice. They were forced to take them and the combination of medication and hospital confinement prevented these young men from harming themselves or others.”
In 1975, the film version of “One Flew Over the Cuckoo’s Nest” was released.
That movie probably sealed the fate of state-funded psychiatric hospitals. The laws, the courts and public opinion saw to it that even patients with severe mental illnesses could not be committed involuntarily, and the number of psychiatric hospital beds declined to the point that there often was no place to put them anyway.
Homelessness and mass shootings reached crisis-level proportions in the 1980s and haven’t gotten any better since. Coincidence? Or unintended consequence?
It’s a tragic fact that we haven’t given up the use of involuntary commitment of people who are a danger to themselves or others, but now we wait until there are victims and we do it through the criminal justice system. Many people with severe mental illness are treated inside our county jails and state prisons. And they’re released, as anyone else would be after they’ve served their sentence.
A number of readers shared frightening stories about people they’ve encountered who appear to have the potential to become a mass shooter, and the equally frightening fact that nothing that can be done about it until it’s too late.
The “estranged son of my best friend” has made “multiple deadly threats against his mother, his father and me,” wrote one reader. “This fellow’s father has, on numerous occasions, referred his son to the appropriate authorities, and cannot obtain any longlasting help from any of them.”
Some mass shootings happen in the workplace. One reader wrote of fearing that an employee who was fired for physically assaulting a co-worker “would return with a weapon,” but was told by an investigator that it would open the company to litigation if an effort was made to find out if the individual owned guns. “Laws also prevent me from alerting a new employer about mental health concerns,” the reader wrote.
“I have a fellow employee who has threatened to kill me seven times, who takes opioids at work,” wrote another reader. “I feel that if I report him for these issues I will lose my job. There is no credible way to ‘tip’ authorities, so I come to work every day wondering if I’ll be going home.”
It would be useful to look at the policies in other countries as they relate to involuntary confinement for serious mental illnesses. There’s no shortage of commentary about the laws regarding gun ownership, but comparative studies of mental health care might be more relevant in explaining varying rates of gun violence.
It may be that two of the most intractable and troubling problems in our society, homelessness and mass shootings, can be successfully addressed with cautious changes to the law and full funding of new, carefully managed, state-of-the-art psychiatric hospitals in every state.
Let’s try that.