When Richard Martinez, the father of a young man killed in the Isla Vista, CA attacks, came to Washington last week to bring his gun control message of "Not One More" raised by the recent spate of mass shootings, it was actually a sad reminder of how little the polarized federal government is willing to do about either guns or our failed mental health system. In fact, a few hours after that May shooting rampage by Elliot Rodger that left seven people dead, Rep. Tim Murphy (R-PA) drew attention to his controversial mental health reform bill that has now stalled in Congress, due in part to its emphasis on involuntary treatment. He declared, "How many more people must lose their lives before we take action on addressing cases of serious mental illness?"
But in Los Angeles County, psychiatric nurse Linda Boyd and the law enforcement-linked outreach teams she leads aren't waiting for Congress. Instead, she worked out of her cramped Department of Mental Health (DMH) office in the days after the shooting coordinating the department's efforts to reach out to nearly 100 possibly dangerous young people who've made threats in the last several years that they've been monitoring. The department also reaches out to the young people's families and the professionals treating them.
It is the nation's most sophisticated, collaborative program involving law enforcement, school and mental health staff. The School Threat Assessment Response Team Program (START), launched in 2007 after the Virginia Tech massacre, is believed to haveprevented more than 50 imminent school and campus attacks and screened more than 5,000 people, mostly students.
Boyd explained, "We realized we needed to do something about the threats people are making, and we do whatever intervention is needed." The START team coordinates multi-agency threat assessments that include a scanning of social media; a weapons ownership check; and interviews with the potentially dangerous person andthe key people who know the individual and have treated him or her. For those deemed ill or dangerous, that is generally followed by voluntary services that can be intensive, including regular at-home visits. Short-term involuntary psychiatric "holds" are initially invoked about 40 percent of the time for those assessed as dangerous. They then typically enroll in the voluntary services in part because they know that their progress and behaviors are now being tracked.
Could this approach have prevented Elliott Rodger from his shooting spree, given that local police were contacted by his alarmed therapist a month before the tragedy? Police had even interrogated him after he was attacked trying to push women off a ledge.
"Absolutely," says J. Kevin Cameron, a pioneer of multi-agency, data-based threat investigations at the Canadian Center for Threat Assessment and Trauma Response. Cameron has served as a consultant to LA County's mental health department and school district. He's appalled that Santa Barbara sheriff's deputies showed up at Rodger's home and, based on a short talk with him at his front door, concluded that he was "perfectly polite" and posed no danger.
"They relied on their friggin' 'feelings,'" he said, "instead of relying on the data." Based on the information available through a START-style investigation, he believes mental health workers or police would have had enough evidence to place Rodger under a "probable cause" temporary psychiatric hold. That, in turn, would have allowed police to bar him from owning weapons for five years.If those assessment practices were in place in Santa Barbara, Cameron says, "there's no question that this particular case would have had a different trajectory."
Based on emerging news accounts on the suspects, those strategies might also have spotted warning signs from the killers in the recent Oregon and Seattle shootings that could have arranged for effective treatment and potentially seized their weapons -- a little-used power under many state laws involving seriously mentally ill people who have been committed. For example, years before Aaron Ybarra's June 5th spree in Seattle that killed one person, the threat he posed wasn't fully assessed or responded to after a counselor reported that he heard the voices of a Columbine killer telling him to hurt people and he was involuntarily hospitalized twice , starting as a college student in 2010.
After the Isla Vista shootings, for instance, the Los Angeles START team acted to prevent potential copycat attacks and to respond to new threats. On the first Tuesday after the shootings, a high-school student, assigned a personal essay, stood up in a suburban Los Angeles school and read a rant about his desire to kill people in the school. School officials summoned two specially trained social workers from the START program to evaluate him. After a targeted school violence assessment, he was taken involuntarily to a local hospital for a 72-hour observation.
More typically, the team made sure to check on the young people they were already aiding. One of its clients is an over-18-year-old student with autism and a mood disorder. He had been expelled from a local community college after threatening an administrator and talking in detail about famous school violence incidents. Later, he flouted a restraining order against visiting the campus. But these days he is doing well, thanks to treatment over the last year and regular at-home social work visits. Best of all, the same college that expelled him was now willing to take him back in a technology certificate program. But family pressures -- led by a relative determined to see him get a four-year college degree - have kept him unsettled.
He was one of four clients discussed during a recent three-hour weekly meeting of the START team and other outreach workers attended by this reporter. The team learned during a social worker's home visit that the former college student had angrily pushed his relative, a sign of new threatening behavior against his family. A therapist advising the START team responded to this news: "In a perfect storm if all the bad elements line up, he's liable to attack [her] or choke her, with all that rage." The therapist viewed the college administrator as another potential high-risk target.
Another client discussed at the meeting was contacted after the Isla Vista shooting -- "patient" is widely considered a stigmatizing slur -- because he was potentially truly dangerous. He is a teenager who had violent hallucinatory fantasies about killing himself and his schoolmates. His actual behavior hadn't originally set off alarm bells even after he showed up at an event on campus with a bandolier packed with real bullets. But after telling his disturbing hallucinations to his psychiatrist, the doctor reported the threats to police under a "duty to warn" law. This led to the student being placed on an observational hold in a hospital. He also violated a restraining order barring him from any school in his town. Placed on probation, he eventually was referred to intensive social work and psychiatric care from the county's "Full Service Partnership" team for youth and young adults.
The probation ruling provided an added incentive for getting him involved in treatment, staff psychologist Pietro Diengello noted. "The beauty of this combo of law enforcement and mental health is you can prioritize the mental health care," he said. "It's not punitive, it's help-based."
The student has made considerable progress. But he's living with a relative who doesn't believe in professional therapy. She's recently stopped taking him to sessions, Boyd learned when she contacted a DMH team clinician. "He's going to need a new home visit," Boyd observed. "He wants to engage with us, and we can help him with whatever he needs."
START's success is a challenge to the conventional thinking and political debates about mental illness and violence. It's commonly argued by academic researchers that violence by people with mental illness is extremely rare: only four percent of all violent acts are committed by those with a mental disorder. People with mental illness are 11 times more likely to be victims than perpetrators.
Many experts also insist it's virtually impossible to predict or prevent violence beforehand. As one psychiatry professor, Olav Niellsen of the University of Sydney, concluded, "The extreme rarity of these events means that identification of individual patients who might kill a stranger is not possible."
As nurse Boyd scrolled through a Power-Point presentation on the warning signs the START program uses, she might have cause to disagree. She pulls up the disturbing photos of some of the country's most notorious mass murderers, including Jared Loughner of the Tucson shootings and Seung-Hui Cho, who killed 32 people at Virginia Tech. "So what do they have in common?" she asked. "They all intersected with law enforcement, mental health and schools beforehand, but nobody ever connected the dots."
After displaying the weapons stash of Adam Lanza from the Newtown, CT. massacre, she shows some of the frightening writings and drawings the team has seen in student backpacks and lockers. Particularly troubling was the vivid calligraphy and drawings of a teenager who created a booklet called, "1,000 ways to kill yourself," noting, "I just want the pain to end." His drawings included a boy hanging from a noose and a girl being cut in half with a chain saw. Yet Boyd noted, "He's really talented, and we got him help. Now he's in an art college and he sees a future now," augmented by psychiatric care.
The START presentation shows the weapons caches they've found -- sawed-off shotguns, knives, a hatchet, even explosives. "There's a pathway to violence," she said. "They're stacking up grievances." The START team's job is to discover, disrupt and offer help to those who are going down that road.
Despite the team's successful approach, no national mental health organization champions it. That's because the program doesn't fit into either side of the intensely ideological debate over the efficacy of mandated outpatient commitments. The program's generally voluntary providing of services, for example, undercuts the way mandated "Assisted Outpatient Treatment" is being sold politically as the best mental health solution to violent rampages. But a prominent researcher who has studied the cost-effectiveness of such involuntary treatment,Duke University psychiatry professor, Dr. Marvin Swartz, has declared, "Outpatient commitment isn't going to prevent mass shootings." The approach also challenges the claims by the Santa Barbara County Sheriff's Department that there was little that they could do to prevent Rodger's rampage.
The START team is part of an array of department outreach services including mobile crisis teams and nearly 40 joint police-clinician patrol teams deployed in Los Angeles and across the county each day. Ten more will be added soon. All told, the various teams reach more than 21,000 people a year, usually summoned through 911 and hotline calls.
Their empathetic approach to psychiatric crises generally doesn't inflict trauma and avoids the deadly violence that too often accompanies encounters in other locales. More than just improved crisis intervention training for police, Los Angeles County's pioneering policing approach to this issue, launched in 1993, has sparked interest from other communities in the wake of the ruthless beating death in 2011 of a homeless man with schizophrenia by two Fullerton, California policemen. Their acquittal this year sparked new outrage.
Unfortunately that victim, Kelly Thomas, never got a chance to interact with professionals like the Los Angeles County Sheriff's Department Mental Evaluation Team (MET) members. I rode with two of them in an unmarked police car during a recent daytime shift. The pair -- -- we'll call the nurse Marjorie and the deputy Gail because of confidentiality concerns -- usually are called as mental health backup for the police first responders. They're also trained in START evaluations and aren't swayed by deceptively polite encounters.
Today, they're summoned when a distraught mother called 911 after her teenage daughter with bipolar disorder exploded in a dangerous rage. The girl erupted in anger when her mother said she couldn't afford to buy the teenager Pro-Active acne cream that day. The girl threw her skateboard through the window. "She went nuclear," the mother tells Marjorie. "I felt scared and called the police."
The nurse, reviewing the medications the girl stopped taking regularly after she turned 18, did more than triage. She also offered reassurance and useful information, including a National Alliance on Mental Illness brochure on family support programs.
Outside, Gail gently maneuvered the handcuffed girl into the car to go to a hospital for a 72-hour psychiatric hold. Still on her family's insurance, the girl complained, "I'm going to have pay for medication. It's too expensive!" Something remarkable occurred inside the black patrol car: the easygoing Gail quietly chatted with the girl and learned secrets the teen hadn't even told her mother. Winning the teen's consent, Gail disclosed that the girl wasn't taking her medication because she was trying to get pregnant by her boyfriend, who has schizophrenia. Marjorie advised her: "You have an illness, like diabetes, and you need to take your medication."
By the time they arrived at the emergency room, waiting for intake, Gail began schmoozing with the girl about make-up. "How do you get your eyebrows like that?" the cop asked. Soon they were joking together and the deputy took off the handcuffs. As the MET team prepared to leave while the hospital arranged for a psychiatric exam, Marjorie told her, "Don't worry about the money, worry about feeling better. That's why you're here."
But by the end of their shift, the pair wondered aloud about the long-term value of their work. "I've made them safer for a day or two," Marjorie mused, "but we see the same people over and over again."
There is no guarantee that the teen, for instance, will follow any of the treatment plan arranged for her when she's released. Ironically, privately insured individual treatment for serious mental illness -- as Elliot Rodger received -- often doesn't produce the results that public mental health programs can at their best. In part that's because those in Los Angeles County have developed a way to engage people voluntarily in in-depth services that go well beyond therapy alone. The approach has cut hospitalization rates, incarceration and homelessness by up to 80 percent or more for those lucky enough to receive them.
The reform-minded director of the county mental health department, Marvin Southard, proclaims, "We have a 'whatever it takes' philosophy." But the department still grapples with the reality that at least half of seriously mentally ill people receive no treatment at all, a situation of possible danger to the entire community and, far more often, to themselves.
Art Levine, a Contributing Editor of The Washington Monthly in Washington, D.C., is researching the treatment of mental illness in America under an Alicia Patterson Foundation fellowship. This article has been adapted from one originally published on the foundation's website.