Health Care

Yes, the U.S. Has a Mental-Health Problem

Candles burn as part of a memorial at the scene of Sunday morning’s mass shooting in Dayton, Ohio, August 5, 2019. (Bryan Woolston/Reuters)
What Congress can do to fix our broken treatment system

The Dayton killer, according to his ex-girlfriend’s interview in the Washington Post, heard voices, suffered troubling hallucinations, and battled psychosis from his youth.

But there is no connection between violence and mental illness. Say it over and again if you must, at least until you disabuse your lying eyes. The experts have spoken. CNN distilled the media’s recitation of this creed in their headline Monday: “Blaming mass shootings on mental illness is ‘inaccurate’ and ‘stigmatizing,’ experts say.”

“Experts say,” as employed here, means what it usually does: a handful of ideologues get to pawn off their ideology as fact under the pretense of “expertise” to those in the media eager to toe a particular line. Whatever the “experts say,” the fact remains that the untreated, seriously mentally ill (those with schizophrenia and bipolar disorder, most often) are significantly more likely to engage in violence. Individuals with schizophrenia, most of whom are non-violent, still commit homicide at a rate 20 times that of the population at large. The prevailing social science on the matter suggests that at least 33 percent of mass shootings are committed by someone with a serious mental illness (even when this is narrowly defined).

What are we to do about it?

Congress might start by repealing the Johnson administration’s so-called “IMD (Institutions for Mental Disease) exclusion” in the Medicaid statutes, which prevents individuals from using Medicaid funds at a facility with more than 16 psychiatric beds. The measure was included to forward the vision of Johnson’s late predecessor, John F. Kennedy, whose final legislative act was the signing of the Community Mental Health Act (CMHA) of 1963. CHMA usurped state control of mental-illness treatment and anointed the federal government architect of an entirely new method of care.

CMHA called for the federally guided construction of nascent hospital alternatives called “community mental health centers,” which became hotbeds of radical political activity forwarded under the guise of “preventing” mental illness. Even the name of the program betrayed the shift in priorities — while state hospitals were ostensibly in the “hospital” business (i.e., curing illnesses), a “community mental health center” is more of a euphemism subject to ever-expanding mission creep. The federal government would initially fund these facilities and pay the staff, before eventually petering out and delegating responsibility back to the states. Johnson felt that the IMD exclusion would disincentivize the creation of “institutions” meant to care for the most severely mentally ill and hollow out the populations of state hospitals. The mass deinstitutionalization that came in its wake was the goal of the policy.

It is no accident then that states have consolidated their state hospital networks to an embarrassing shell of themselves, impotent in the face of exploding homelessness and the mass incarceration of the mentally ill that have inevitably followed their downsizing. Several hospitals from the past sit abandoned, with ivy-covered buildings resting like headstones on a brick-laden graveyard both real and imagined. But not all of these facilities closed: John Kennedy’s sister Rosemary had profound mental illness and developmental disabilities, and, after undergoing a frontal lobotomy, lived in a private institution in Wisconsin until the day she died in 2005.

Even before Kennedy’s federal legislation, “community-based” alternatives for the less severely mentally ill were already developing organically on a state level, as the advent of psychotropic medication allowed for large numbers of patients to be released from state hospitals. CHMA and, later, the IMD exclusion created an antagonistic rather than a complementary relationship between community providers and the state hospital network. This antagonism, too, was by design; Mike Gorman, a former member of the Communist party and booster of the community-mental-health-center movement, later revealed that his “hidden agenda was to break the back of the state mental hospital.” Alas, he succeeded.

While every state still has psychiatric hospitals, it’s almost impossible to be admitted to one unless an individual is an immediate danger to himself or others, a standard which is often met only after it is too late. Repealing the IMD exclusion (a move which the administration has shown itself open to) would allow both states and private providers to expand existing institutions or even create new residential services as institutions without running into the blatant discrimination against the most severely ill that is baked into the Medicaid cake. This, combined with more proactive commitment policies for the incapacitated in these hospitals, is an evidence-based means to reduce state homicide rates: A 2011 study from the University of California at Berkeley found a statistically significant association between looser involuntary commitment standards and declines in statewide homicide rates.

Next, the president should direct the Department of Justice to stop its obstreperous Olmstead litigation. Olmstead v. L.C. was a 1999 Supreme Court case which held that the Americans With Disabilities Act (ADA) granted persons with mental illness and intellectual and developmental disabilities the right to treatment in a community-based setting, provided 1) that the “community-based” care, as opposed to institutional services, is medically appropriate; 2) the individual does not oppose a transfer from an institution to a community setting; and 3) it can be reasonably accommodated by the state without a fundamental alteration to their delivery of services.

The Obama DOJ made a point of ravaging the existing care networks of some of the states that were most reliant on state hospitals and institutional services. While there are legitimate Olmstead violations to be fought — an individual, for instance, who is medically capable of living in the community, and whose transfer from an institution would not force a fundamental alteration to state services, represents the ideal candidate for such action — the DOJ has gone far beyond these individual remedies, preferring class-action suits that indict statewide paradigms of care. The Department’s discordant and often-abrasive actions leave one with little alternative but to presume that their Civil Rights division would, if made king, close every last public psychiatric hospital in this country. DOJ, as I write this, is going after Mississippi (a state that, despite its poverty, has the single lowest statewide rate of homelessness) for its supposedly disproportionate reliance on state hospitals. A better approach would be to expand community services for those qualified, while leaving open the hospitals that are providing care to the most vulnerable citizens in Mississippi.

To quote the warning of Justice Kennedy in his concurring Olmstead opinion:

It would be unreasonable, it would be a tragic event, then, were the Americans with Disabilities Act of 1990 (ADA) to be interpreted so that States had some incentive, for fear of litigation, to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.

Litigious activists at DOJ are making states reluctant to make use of institutional services, even for those who need it, for precisely that “fear of litigation” of which Justice Kennedy so presciently forewarned. The president could stop it tomorrow by shifting the Department’s focus toward individual abuses and away from class-action suits, which often conscript unwitting and unwilling parties and are explicitly designed to change entire systems of care.

It is, finally, important not to stop citing mental illness as a causal factor in mass shootings, even as advocates breathlessly hector about “stigma.” Untreated mental illness is a factor in mass violence, despite coordinated efforts from mental-health nonprofits and their allies in the media to make claims to the contrary. The American Psychological Association, no doubt among the anonymous “experts” invoked by CNN, insisted on Monday that “blaming mass shootings on mental illness is unfounded and stigmatizing. Research has shown that only a very small percentage of violent acts are committed by people . . . [with] mental illness.”

Contra the APA, it is, as noted, well-founded to tie mass shootings to mental illness. As Dr. E. Fuller Torrey recently noted in the Wall Street Journal, in a report from the U.S. Secret Service examining mass shootings in 2018 “investigators found that 67% of the suspects displayed symptoms of mental illness or emotional disturbance,” while “in 93% of the incidents, the authorities found that the suspects had a history of threats or other troubling communications.” This is in line with the literature and a fair reading of the voluminous data on the subject. The clearest distillation of this point comes from this reluctant concession by University of Virginia law professor John Monahan:

The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are randomly selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social or demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.

It does neither society nor the seriously mentally ill any good to deny the link between violence and serious, untreated mental illness.

There are measures Congress and the president can take to reduce what is at least a part of our national problem with mass violence: a system of treating the mentally ill that tacitly ignores the plight of its most severely affected constituents.

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