Columbine, Colo.; Fort Hood, Texas; Virginia Tech; Tucson, Ariz.; and now Aurora, Colo. -- and too many other sites of horror -- are often seen as random acts of violence. Perhaps we arrive at this view because these acts and actors are not tied to conspiracies, or to systematic terrorist plans. Instead, they generally are the actions of a severely disturbed person, typically acting alone, but not spontaneously or without careful planning. In other words, they are not random. In fact, the perpetrators of these acts of murder and mayhem generally build their catastrophic scenario slowly, over months or longer; their progressive behavioral deterioration is often evident to others or sometimes the plan is even broadcast by the perpetrator himself. Analyses after the fact from families, friends, neighbors and personal journals painfully demonstrate their angst, rage, loathing of self and others, and intensifying and monocular attention to their day of reckoning.
Many of us will react with horror and think we need to lock these people up, maybe throw away the key. If we let them out, some advocate for the involuntary use of psychotropic medications. But, in fact, the trajectory to these disastrous events calls for more complex actions. These individuals herald their problems by dropping out (of school, work, treatment) or by overuse of hospital services (especially emergency rooms) or by police confrontations. Functioning deteriorates, and their behaviors communicate distress. Most people are responsive to help when it is offered and provided with dignity and quality. Rare yet unthinkably awful cases go on to violence -- and that is when inattention has allowed their conditions to reach an extreme. The mental health system, including substance abuse services, has been too ineffective for too long in detecting and delivering what is needed, despite the dedicated people who work in these settings.
One "solution" (for those already determined to have a serious and persistent mental illness) is called "involuntary outpatient commitment" -- IOC -- (or "assisted outpatient treatment," "mandatory outpatient treatment"); it has been legally adopted in many (but not all) states, though the requirements of this law vary substantially from state to state. As a rule, the law permits courts to mandate outpatient psychiatric treatment for people with severe mental illness who are at risk of clinical relapse or deterioration that may place themselves or others in danger, and who have demonstrated by past behavior that on their own they are not apt to voluntarily comply (laws for inpatient commitment exist in all states and emergency intervention requires imminent dangerousness). What IOC can provide, when effectively organized and delivered, is clear accountability for, and coordination and monitoring of, a person's condition by community service providers; it also places IOC patients at the front of a long queue for limited mental health resources (including case management, clinic and psychiatric visits, medication, even housing). The fact that a court weighs in adds an unparalleled dimension to the accountability of community service agencies.
But the number of people with serious mental (and addictive) disorders who could benefit from accountable, coordinated and accessible care far outnumbers the capacities of any IOC program, which is always time-limited by a court anyway. My colleagues in many states recognize the considerable limits of IOC, and its dependence on undaunted leadership in clinical and legal services as well as adequate and sustained funding to ensure that the involuntary services demanded of the patient are in place and accessible. What this amounts to is that despite the evidence of success of IOC (and its necessity for some people who may not for years come to appreciate that they are ill), it sounds better than it is.
A special commission by a group of experts and government officials was created in 2008 in New York State by Mayor Bloomberg and then Governor Paterson in the wake of a series of violent incidents in New York City that involved people with mental illnesses, including their use of drugs and alcohol.[1],[2] The report emphasizes two key findings: namely, that violence by people with mental illness is generally the result of their not being engaged in treatments (that can be highly effective), and their use of drugs and alcohol. The implication is that for citizens and police to have their risk of harm reduced, people with mental and addictive disorders need better early engagement and retention in proven (so called evidence-based) treatments.
Acute conditions (whether a broken arm, a heart attack, a delirium, a raging psychosis) benefit from doctors stepping in and taking control. But most conditions are chronic (like diabetes, heart disease, asthma, PTSD, schizophrenia, depression and bipolar disorder) where early detection, accessible and patient-centered care (not in slogan but in reality), the involvement of families and significant others, and the provision of proven treatments are basic to their management. The same approach applies for both physical and mental disorders. With chronic disorders, unless those who are ill learn to take responsibility for and manage their illnesses, the disease (not recovery) triumphs -- and everyone loses.
True clinical accountability means that service providers have designated populations of patients (specified caseloads, registries of patients) for whom they are held continuously responsible (not by involuntary outpatient commitment but by contractual and medical standards); this was one idea advanced but not achieved by the Community Mental Health Act of 1963 (!) that was the foundation for the community-based mental health services we have today. We also need better ways to encourage people with mental disorders to come to and participate in treatment. To achieve this latter goal will mean far more responsiveness to what patients want (again, patient-centered care), peers (other patients advanced in their recovery) as community workers, and creating the experience that it is safe to seek treatment (that the result will not be activating police and locked hospital settings). I wish our provision of these effective elements of care was greater and faster than it has been to date. The need is surely there, with 1 in 5 Americans annually suffering from a mental disorder that adversely affects their life and functioning.
We have no perfect treatments for a host of chronic conditions, including cardiovascular disorders, cancer, Parkinson's disease, dementias, schizophrenia and bipolar disorder. But we have learned a lot about chronic disease management. Our challenge is to turn what we know into better delivery of the right treatments that patients receive from doctors and enabling patients to learn to manage their diseases; some call this closing the science-to-practice gap. The challenge is as great in physical medicine as it is in psychiatric medicine. In mental health, we need to be wary of short-term, reactive "fixes" stimulated by agonizing events that may have emotional appeal but are no substitute for an ongoing resolve to apply proven means of systematically improving care and accountability, which are our best chance to reduce risks to the safety of individuals and communities.
"Random" is not so random. We have not adequately implemented prevention, screening, early intervention and ongoing engagement in good treatment that would better recognize patterns, detect disorders and assure accountable ways to respond. We can close this gap, we know how. When we do, and I believe we can, our communities will be able to meet the complex goals of public safety, personal liberty and high-quality clinical care.
References:
1. Smith,TE, Sederer,LI. "Changing the Landscape of an Urban Public Mental Health System: The 2008 New York State/New York City Mental Health-Criminal Justice Review Panel." Journal of Urban Health, Bulletin of the NY Academy of Medicine. No. 87, Vol. 1, January 2010, pp 129-135. [Link]
2. Smith TE, Appel A, Donahue SA, Essock SM, Jackson CT, Karpati A, Marsik T, Myers RW, Tom L, Sederer LI: "Using Medicaid claims data to identify service gaps for high-need clients: The NYC Mental Health Care Monitoring Initiative." Psychiatric Services. Vol. 62, No. 1, January 2011; pp 9-11
Lloyd I. Sederer, MD
www.askdrlloyd.com
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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What happens when 90% of these people fall off the map after their first treatment? You think states have the resources to track them down? In Chicago the police are so overwhelmed an armed robbery call takes an hour to get a police officer. You think they would have police tracking down the mentally ill? Oh and let's not get into the gutting of the state's mental health budget.
Again, criminally utopian. Having worked with the MI population, it is not callous to state many of these people are a serious danger to a population. These people are mentally ill and anything they do voluntarily is subject to inconsistencies and lack of fidelity with treatment. You really want to take that chance? Really..
I don't think you have the necessary experience with these populations. If you did, you would realize how absolutely ridiculous are your ideas of "involuntary outpatient commitment".
I too have worked for years in state mental health services. IOC can be very effective and I have personally worked with many patients who have benefited from IOC. However, I agree with Sederer's description of IOC's limitations. I also agree with JMilton1976 that IOC cannot be an effective treatment without the availability of law enforcement services.
I would be thrilled if my state had administrators like Dr Sederer. Administrators in my state become administrators because they're willing to be political pawns. While my state administrators spend their time towing the party line, Dr Sederer takes the time to write about complicated medical and societal issues. Bravo Dr Sederer!
Talk therapy is a Freudican hangover which we continued because we had no idea of how to manage the suffering of the SMI--other than phrenology or a plunge into cold water..
Solutions must come from medical research. Surely, it's time we use scientific brain research to find the infectious agents of transmission from generation to generation to find a cure. Let's confess to society's foolish errors as we held out false hope by continuing to use old time unscientific practices, which cost lots of money but have never succeeded in eliminating these no fault chronic brain diseases.
Brain diseases are in need of world-wide cooperative scientific dedicated brain research to find the etiologies of all brain diseases, and despatch them as we have other physical scourges. This would mean salvation for millions.
There is no proof that "chemical imbalances" cause mental illness but there is evidence that psychiatric drugs cause chemical imbalances and brain damage . Autopsies of the mentally are no different than the non mentally ill except where psych drugs were used.
Even if it is correct, there is not necessarily a causal relationship.
Finally, I would point out that none of these 'nutcases' who have perpetrated these horendous acts were in any form of treatment, and certainly were never 'locked up', so the problem isn't that they were 'turned loose' on us.
If one positive thing emerges from this latest shooting, I hope that it's more resources allocated (from wars, perhaps?) toward counseling services.
Prevention, treatment, diagnosis, all of these things imply a duty of care to the person who commits these kinds of acts and far too many people would rather just treat them as evil and dispose of them in the way that least troubles their society.
And then everyone acts all shocked when it happens again.
Most of these horrendous acts of violence could have been averted. Many people saw (or should have seen) in advance that the individual was showing signs and symptoms of deteriorating mentally, but they did nothing to intervene.For example, officials at the college where Jared Loughner was a student knew that he was seriously mentally ill, and should have offered to help him get the psychiatric help he needed. But instead, they isolated him with his mental illness by expelling him and telling him he could not return until he had looked after his mental illness by himself. If they really expected him to be able to help himself, they were ignorant of the nature of florid psychosis. If they realized that he was too far gone mentally to get help for himself, then they were just plain irresponsible.