If You’re Going To Blame Mental Health
Shooter after mass shooter has been a domestic abuser who should not have had access to a gun. But Trump and our politicians do not want to talk about guns. They want to talk about mental health.
As a mental health advocate, I would love to talk about the nation’s mental health system. So let’s go ahead and have that conversation since you insist.
This Mental Health Problem Is Old
Knowing what to do with people who have serious mental health problems has puzzled Americans since the country began. The Quakers became aware of what was considered an innovative treatment in the 1700s and 1800s — the asylum.
The word asylum predates any association with a building for insane people. It once just meant a peaceful, calm retreat. Just like the word bedlam comes from an old 1300s to 1600s Bethleham hospital in London for “lunatics,” words linked with the mentally ill soon take on a negative connotation.
Therefore, the asylum which started as a relatively effective treatment for serious mental illness was abused. How? Asylums worked because they did provide structured, calm environments with supportive, caring staff who in that day and age used work therapy and prayer as treatment. They were small enough that the patients who lived at the asylum were more like community members who assisted in running the “farms.”
It was fairly amazing these Quakers were effectively treating people who no doubt had schizophrenia, bipolar disorder, and other psychotic disorders without benefit of medications. However, numerous writings from the time describe how people recovered from their psychosis in asylums.
So again, what went wrong? How did the word asylum become associated with nearly every word the opposite of peaceful retreat? The snide response is human nature. We found out something that worked so we flooded it with people but never gave the tool any resources. It turns out that putting 700 people into a large building where they are just warehoused, it is understaffed, and it starts to look like a jail — well, that is not a place of wellness.
That’s what we did. Retreats that should have had 100 people and at least 25 staff became institutions with a 1000 people and 50 staff. We did not treat people with mental illness. We put them in jail. Our European forefathers had jailed the mentally ill instead of treating them, too. Back in the days of bedlam.
They chained them to the walls in Europe, and a man named Phillipe Pinel is said to have liberated the mentally ill from their chains in Europe. In the United States, our liberator is Dorothea Dix. She went around the United States in the 1840s making note of the conditions people with mental illness were living in.
Dix actually advocated for the building of more asylums because at her time the problem was that people were chaining their relatives to the wall in their barn when they became psychotic. Or we were just throwing people with mental illnesses in jails and prisons.
It Worked. We Reformed For a While
We built the asylums more and more starting in the 1850s. They worked. People got better.
But by the 1900s, we had spoiled our cure. We built bigger and bigger. Losing completely the concept of retreat. Losing completely the concept of work therapy. Losing completely the concept of treatment.
Almost right away we overcrowded them. We underfunded them. We tried experimental treatments from lobotomies to ice baths. They became the nightmares of Batman scenarios and cuckoo’s nests.
Open the Doors Without a Plan
Since asylums became cruel places, people wanted them closed. The cruelty was a good excuse to close them quickly without much care for what would happen to people with serious mental illness.
All along, mental health researchers have been trying to figure out what works best to treat serious mental illness. People in the field of psychiatric rehabilitation have developed a whole body of evidence-based treatment methods.
But this process unfolded slowly over time. There have been fits and starts. Mistakes have been made along the way.
First but not necessarily in this order, the researchers developed medications that helped people to reduce their symptoms. There have been fights over whether some people should have to be court-ordered to take psychiatric medications, and those arguments have been resolved by the courts over time.
If people show a pattern of violence or self-harm, we have decided as a society, we feel comfortable requiring people to take medications, even if those medications might have potentially harmful side effects.
This is a trade-off we have navigated as a country. In exchange, we emptied out our institutions. Some people would say, “Hey, you get to be free, if you take your meds.” But in this country where we are all about freedom, people don’t think they should have to take meds to be free, so there have been problems getting some people to buy this argument.
Ronald Reagan opened the doors of the “insane asylums” in the 1980s and flooded the streets with homeless people. He said they wanted to be homeless. Psychotic people often do want to do things that are not healthy for them. So we didn’t empty out our institutions in a thoughtful or well-planned way.
Ronald Reagan closed all of our institutions to save money. Nowadays, most mental health professionals agree there are some people with mental illness who do need to be inside a hospital setting full-time. This forensic population is dangerous to others primarily, but sometimes a danger to themselves.
This group is frequently not getting the services it needs so they end up in jails or prisons instead of hospitals. This often happens because the individual is not treated in a preventive fashion. The harm is already done. This is when we all turn to each other and ask why. The answer is always to save money.
John F. Kennedy watched his sister sent off to an institution because she was mentally retarded, and he didn’t like it. He became one of the sponsors of a movement that was spreading in the mental health community-as-a-whole — community-based services.
Community-based services were in their infancy in JFK’s era, but nowadays they have been research-tested and improved. There are models like Assertive Community Treatment and the Clubhouse Model that serve people with serious mental illness in the community so well that you have been living next door to people with schizophrenia, bipolar disorder, and other psychoses for years without incident.
The Assertive Community Treatment model operates like a mobile hospital team with a social worker, a psychiatrist, a nurse, a case manager, a substance abuse specialist, and a couple of other specialists who go out into the community to serve people with serious mental illnesses. They get to live at home and have relatively normal lives. It costs much less than a hospital. And people with serious mental illness who are treated are no more likely to be dangerous than any other person.
The Clubhouse Model is a large home that operates a small non-profit business. That small business employs the people with serious mental illness. They may just be making food for the community or providing IT services for a local business. The people with serious mental illness who work there are usually taking medications in addition to their work therapy and the staff who work at the clubhouse help the people with SMI to stay healthy in multiple aspects of their lives aside from work.
Guns or Mental Health or Both?
As a matter of fact, having the President call these gun incidents a mental health problem is a statement of ignorance. Researchers with the National Comorbidity Study, which is an annual, national mental health and substance abuse research study, actually put this question of guns and mental health to the test.
The NCS study has been going on for over two decades. The researchers found that people with serious mental illnesses were not committing these mass spree crimes. People with anger issues — such as demonstrated through a domestic violence incidence — and who owned more than six guns were the ones who showed up as at risk for these crimes.
People with these anger and violence issues could benefit from mental health treatment. They could benefit from community-based services that might have served a preventative role if they were more available, or they may need inpatient services that are currently just not available in our system.
In the end, the United States has a weak mental health system because we barely make community-based services available to people who need them. We have some inpatient services available to some people who need them. The whole system is unaffordable to most people with serious mental illness.
We fund our public mental health system with but a pittance. We keep it separate from our health system as if our mental health could ever really be separate from our health.
Our private mental health system is only available to people with good health insurance. Typically, this means if people fall from their employment as their mental health declines, they go from the private to the public mental health systems.
In a way, this can be a blessing or a curse for a person with a serious mental illness. Depending on your state, you could either end up with progressive psychiatric rehabilitation or you could end up with regressive prison warehousing. Will Utah or Massachusetts help you find a clubhouse, while Mississippi puts you in prison?
It shouldn’t be this kind of lottery. We do need a better mental health system. If we’re going to keep using it as the scapegoat for gun violence, could we at least put the resources into improving it? Unfortunately, that does mean spending money on poor, sick, and disabled people. This is not something Americans have shown an inclination to do.