Serious illness is painful and heart-wrenching for patients, family, and friends, be it physical or mental. Since most medical conditions rarely result in severe behavioral changes that prompt violence, mental illness carries a stigma that does not accompany congestive heart failures, ectopic pregnancies, or psoriasis. It is easy to conflate mental illnesses with evil because the end result — shooting innocent people in a theater or planting a bomb in a day-care center — can have similarly horrific outcomes. Such misunderstandings in the public sphere leave the erroneous impression that most people suffering from mental illness are prone to violence, which is not the case. It would be inappropriate here to prematurely assert a specific diagnosis of the attacker in the Connecticut massacre, but we can certainly examine the role of mental illness in a past attack.
John Warnock Hinckley Jr. suffers from mental illness, which spurred him to stalk President Jimmy Carter in 1980. In his mind — a mind untreated for a mental illness that would be diagnosed only later — he would win the affection of the actress Jodie Foster by murdering the president. With the inauguration of Ronald Reagan, Hinckley’s target shifted seamlessly from one president to another, culminating in a 1981 attack when he fired shots on a crowded street, seriously wounding a police officer and a Secret Service agent, permanently disabling White House press secretary James Brady, and nearly killing President Reagan.
Since then, as if trying to prove a point about the condition of the government mental-health system, Hinckley has slowly but surely attempted to dig his way toward freedom from the mental institution where he resides. (He was found not guilty by reason of insanity and transferred out of prison custody.) Typically, violent mental-health patients operate under the radar until a crime happens that can trigger a paper trail, but after a patient commits a violent act, the fight to keep him in care becomes necessary and never ends. Incredibly, Hinckley was awarded frequent furloughs to his family residence in Virginia several years ago.
From November 2011 to February 2012, a long, expensive, and tension-filled evidentiary hearing in the U.S. District Court for the District of Columbia was held to determine whether Hinckley should be released from St. Elizabeths Mental Hospital. While any release would not be a complete, unconditional parole, it would allow Hinckley to be released into the custody of his octogenarian mother in Virginia, even though the Secret Service currently follows him when away from the hospital because he is considered a threat to the president.
The Hinckley case shows where America is on handling mentally ill patients who are violent threats: A man who shoots four people on a crowded street is considered for release from the mental hospital, with no guarantees or assurances that he will continue taking the proper medication when living among the general public. Hinckley’s petition is thwarted for the time being only because the mental facility near Hinckley’s mother has withdrawn its offer to provide treatment to him after his release from St. Elizabeths. If this mental-health system is so close to releasing an attempted presidential assassin, what are the odds that other systems will allow the next potential attacker to leave, untreated and unmonitored, to commit another massacre?
And if state mental-health hospitals are this ill equipped, imagine the treatment of mentally ill patients in our prisons. Consider that on any given day the jail in Harris County, Texas, handles a population of 2,400 mentally ill patients, far more than do any of our state-run mental hospitals. Patrol officers and jailers are not psychiatrists, even if they do receive training on how to handle mentally ill individuals. Across the nation, people in need of mental-health care are encountering dangerous situations with police and others. A significant portion of drug and alcohol addicts may suffer from undiagnosed or untreated mental illness. A survey of the chronically homeless in downtown Houston would, I suspect, lead to a similar conclusion.
In sworn testimony earlier this year in the Hinckley hearing, a psychiatrist confirmed a fundamental problem with treating the mentally ill who are prone to violence: An enormous challenge in treating outpatients is the medication regime. Typically, outpatients feel better when they are taking their medication, leading them to the conclusion that they can go without it. This of course puts them on the path to suffer the very symptoms the psychiatrist-ordered medication is intended to prevent. It is a vicious cycle, only compounded by the powerful side effects of the same medications, which further incentivizes patients to cease adhering to physician instructions.
One solution would be for states to institutionalize mentally ill individuals, against their will if necessary, if there is enough evidence that they pose a danger to themselves or others. Such a process, transparent and carried out with due process, must be available if we are to prevent the mentally ill from stealing weapons and committing attacks on others when they are not being treated.
This proposal may raise the civil-liberty alarm for many. A balance must be struck between the rights of those diagnosed with mental illness and the rights of others to be free from the threat of violence. This means answering the key question: Is the patient mentally able to make decisions for himself? Clearly a patient suffering from a manic episode or hearing voices is not able to make a decision on whether to receive treatment from a mental hospital. Likewise, patients under medication may mistakenly conclude that they can function independent of hospital custody. Finally, there are those mentally ill who never seek treatment because they feel perfectly fine despite their condition.
Although those opposed to such authority voice general opposition to policies that restrict individual freedom, I have yet to hear specific alternatives that would plausibly enable a state to prevent such violence at issue here. I am sympathetic to their concern — certainly no one wants himself or a loved one to be involuntarily committed without cause. However, the state has a compelling interest to ensure that violent individuals receive the proper treatment. Such a government effort to prevent violence should be restricted to that very small percentage of patients who pose a threat. The world would be better off if the attackers of both the Aurora movie-theater and the Virginia Tech incidents had been involuntarily committed to state mental hospitals before having a chance to murder so many innocents.
My plea is to focus on what we can realistically do quickly in the mental-health arena to help prevent these tragic attacks in the future while helping patients and their families in the present.
— Michael James Barton is a director at ARTIS Research and has served in a variety of leadership roles on Capitol Hill, the White House, and the Pentagon.