Their questions didn't surprise me, but they sure did break my heart. Did he shoot them because he was adopted? Can this happen at my school if a kid forgets to take his medication? Is it best not to give consequences to students who seem irritable?
I had just delivered the keynote address for the Texas Classroom Teachers Association conference in Austin (my topic: stress management and resilience for teachers), and I followed with the Q&A. The question they seemed to be asking without actually asking was "How afraid should I be?"
I assured them that events like the ones to which they referred rarely happen out of nowhere, as sometimes portrayed in the media, and that the vast majority of individuals with mental illness are not violent. The repeated association of violence with mental illness only further stigmatizes public perception of mental illness. Yet, although many mental health agencies demonstrate valiant efforts to utilize limited resources to maximize treatment, the state of our nation's mental health services has not grown at a rate to adequately meet the increasing demand for services.
As I write this, I'm thinking of one of my patients, whom I'll call David.
David is a 13-year-old male from a generational history of extreme physical, emotional and sexual abuse and interaction with both the legal system and Child Protective Services. Part of what amazed me about David is that precisely because of the trauma he had experienced as a child, he was brilliant in his interaction with younger children. He was something of the ideal big brother -- protector and mentor -- and younger kids absolutely adored him. Our goal in September 2012 was to nurture and develop that healthy part of his core identity while David, for the first time in his life, unpacked the realities of his traumatic past.
Predictably, as David began to face the trauma, his functioning began to deteriorate. Between early September and late October, David was expelled from three schools for physical aggression toward staff and peers and noncompliance with adult directives. I consulted with his psychiatrist, and his medications were changed. We increased the frequency of outpatient therapy to twice weekly. We knew that we would soon reach the limit of his allowed number of therapy sessions, and I knew that David soon would occupy one of the precious few pro-bono slots afforded by the economics of my private practice.
By November, David was facing a felony offense for assaulting a teacher (while the teacher was trying to break up a fight between David and another student), and he was transferred to the district's Disciplinary Alternative Education Program. A referral for evaluation by school district staff was initiated to determine whether David was eligible for special education services as a student with an emotional disturbance. In a classroom with a lower student-to-teacher ratio, it was hoped, David could be more academic and behaviorally successful. That process would take up to 60 days. David's medications were tweaked, and we continued with therapy twice weekly.
On Dec. 21, David told his father that he was going to murder the family with kitchen knives and then kill himself. Later that day, David went into a rage, destroyed his room, put his hand through a window, and ran away. Police found him roaming the streets later that night; he was transported to the emergency room and admitted for inpatient treatment. David's behavior on the inpatient unit was so volatile that staff had to use physical and chemical restraints to maintain his safety. After 10 days of inpatient treatment, David's clinical presentation still was so fragile that the attending physician did not feel that David was safe enough to be discharged. Only at the urging of the attending physician did David's insurance company reluctantly agree to one week of residential treatment; subsequent treatment would be authorized only on a week-to-week basis.
On Jan. 1, David was transferred to a highly-structured residential treatment facility. After three weeks of intensive treatment in the residential facility, David's therapist had finally developed enough rapport with David to begin to talk about root of the emotions that were driving his behavior -- his past trauma. His behavior on the unit became more consistently stable, and the frequency, intensity and duration of his outbursts at the facility's school were decreasing. There was hope.
On Jan. 26, David was triggered by seemingly-benign verbal interaction with the staff, and he became increasingly emotionally volatile and hostile. During a moment when another patient on the unit was in crisis, David propped open an otherwise secure door when staff were not looking, and he ran. Police found him within minutes, attempting to cross a major interstate on foot on a weekend night. Even though David was beginning to show signs of favorable response to treatment, his judgment was clearly still impaired, and he was a threat to himself. Two days later, the following Monday, hospital staff requested an additional week of treatment. The insurance company approved one additional day.
On Jan. 29 -- three days after attempting to flee residential treatment and nearly running onto highway traffic -- David was discharged. I met with David twice weekly for his hour-long therapy session starting Jan. 30. We talked about the events that led to his hospitalization. We dug as deeply as he could tolerate, and then we problem-solved, rehearsing all the possible if-then scenarios he might encounter as he returned to school. We reviewed coping strategies. We reviewed what he would do differently next time he experiences overwhelming feelings. He gave me all the right answers.
On Feb. 8, back at the Disciplinary Alternative Education Program from which he was suspended and still facing a felony charge for the assault that occurred in November, David took a bottle of psychotropic medication to school with the intent to distribute. One of the five students who took the medication at school was taken to the emergency room. David was transported to and detained at the juvenile detention facility, where he is now facing two felony charges.
David had mental health benefits from a major insurance provider that most mental health providers would consider to be on the better end of the spectrum. Even with that, though, his inpatient treatment was grossly inadequate, and his parents' portion of the treatment cost was $3,500. In the insurance company's failure to authorize the additional needed treatment, the residential treatment facility offered to reduce to $450 per day the out-of-pocket treatment cost for David's family. They could not afford it.
David's history of abuse is extreme, as are his treatment needs. David's core identity is fundamentally loving, empathetic, and protective; it is also smothered by the complications of his traumatic past. I imagine David's future in three scenarios. In the first, he has access to guns. In the second, he does not. In the third, he has access to effective mental health services. In only one of those three scenarios does David have even the slightest long-run hope of not posing a threat to himself or others. Until we fix the mental health care system and meet these issues head on, the problem will persist, and the results may be deeply painful.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
For more by Adam Saenz, Ph.D., click here.
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