Let’s Talk “Mental Health Reforms” (eye-roll)

I’ve worked in mental health formally since March 2013. I’ve worked as a nurse, and in an emergency department for seven years prior to that.

It disturbs and angers me when I read or hear ignorant people make ignorant statements such as:

“We must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence,” Trump said in an address to the nation from the White House on Monday. “Mental illness and hatred pulls the trigger, not the gun.”

Back in 2015 I did a research project and presentation to incoming resident psychiatrists regarding mass murders. I specifically reviewed data and research related to school shootings and looked deeply into fourteen perpetrators. They were all high school shootings except for one college perpetrator- Virginia Tech.

I also looked at more recent cases (not schools) that didn’t have data in studies yet- Aurora, Giffords in Tucson, and naval base shooting: all three had mental health professionals report the perpetrators PRIOR to the shootings. All three times nothing happened. Specifically in Tucson the person refused treatment and state laws protected his choice to refuse treatment.

I also explored the Tarasoff case. That is the case in 1969 that the duty to warn law came out of. A psychologist reported the patient as a threat. Nothing was done. A month later the patient killed the person they threatened the month before. Out of that the Duty to Warn law came: a mental health professional can break privacy laws in order to warn a named target. To be clear- the psychologist did provide a warning. Nothing was done about it.

Here’s why.

Those pesky state laws and HIPPAA interfere with legal and mental health intervention when something is threatened but not actually carried out. A person who is threatened can get a restraining order or protective order. But as we see in every single dramatic movie about domestic violence; what the hell does a piece of paper do when a person shows up and breaks the protective order with a bullet?

Let’s start at the beginning. I have a patient in my office. They are homicidal. They don’t have an intended target. They just have images of killing people when they are sitting in class or walking down the street. They watch ISIS videos of beheadings. They find these thrilling. All of this is disturbing to me. If they are under 18 I will tell their parents my concerns and encourage a higher level of care. If they are over 18 I may talk to their therapist as I am likely just doing medication management. We may chew over what we can do.

It’s usually a whole lot of nothing. Without a specific intended target we as mental health professionals can do nothing. I can threaten to discharge them if they don’t complete an IOP or go inpatient. But usually they leave and don’t come back.

If there is an intended target I can hospitalize them. Rather I can send them to the emergency department. There they will be evaluated. If there are no inpatient beds the emergency room doctor or APRN will likely try and lead them into stating they are not actually going to kill any one, get them to agree to go to an intensive outpatient program (IOP) and then discharge them.

If on the off chance they are admitted…well I’ve worked there too. Insurance companies will be breathing down our necks to discharge them. We will likely not be able to medicate them because they will refuse and we won’t have enough evidence to win an involuntary medication hearing. Even if we do win a hearing, medicate them, and discharge them they can stop taking the medication as soon as they are back home. We set them up with an IOP or back to their primary therapist and prescriber. And then we start back at square one.

I’ve had patients who are homicidal. They generally stop coming to see me as I relentlessly try and medicate them and push them into higher levels of care when the homicidal ideation does not stabilize.

“Mental health reforms” would have to include: private and public insurance companies being told to back off, pay out the nose for treatment for every single person who has an inkling of homicidal ideation, and never question the length or intensity of treatment.

It would have to include training every single mental health professional in the country to better assess and predict violent behavior. Good luck with that. It’s not something that can be predicted.

It would have to include sweeping federal legislation and the states to give up their individual laws and be okay with ceding power to the federal government (which right now is made of dipshits who I wouldn’t trust to baby-sit my children let alone create standardized mental health laws)…this legislation would have to include the ability to involuntarily mandate individuals to higher levels of care who have homicidal ideation and not all together as I don’t think group treatment of a room full of homicidal individuals would be a smart thing.

It would have to expand duty to warn to include any one who has contact with children/schools/public spaces: student teachers who make generalized statements about killing a room full of children. Currently we can’t report that. Daycare workers. Students. For all ages there should be some sort of mandate regarding medication compliance if some one is actively homicidal. For under 18: there should be regulations for parents about following the recommendations of a mental health professional if their child is homicidal. Etc. Etc. Etc.

The list could literally go on and on. All of it will impede patient rights. All of it would put mental health professionals in a position of power that is not deserved. We should not be making these decisions for other people. It strips people of their ability to choose.

Guess what would be easier. Banning freaking guns. But it’s cool. Just keep throwing this back on mental health as our funding is cut and we have less people going into the field because it pays crap and it’s dangerous in many different ways, and oh yeah, there has yet to be ANY reform to our mental health system.

In all the cases I examined they all had one thing in common. EASY and OPEN access to guns NONE of them were registered to the perpetrator. They were all registered to family members. The Jonesboro murders: by the way they are alive and well, and one tried to register for a conceal and carry license under an assumed name…but I digress. The boy who’s guns they used…the parents had locked them up so they changed their plans the day of and just drove a mile to his grandparents because the grandparents had plenty of guns laying around. And those boys used them to kill children.

THREE shootings mental health professionals made the call to report a concern. NOTHING happened. They still had access to guns. Guess which shootings were not reported by mental health professionals? The one’s perpetrated by children. Because it’s very hard to access a child’s homicidal ideation. Trust me on this one. It’s then even harder to convince the parent that little Johnny the apple of their eyes is actually homicidal. Trust me on that one also. Been there.

Mental health is broken for sure. But “reform” of the system will not stop mass murder. Banning guns will. And “reform” of mental health will require an administration who understands the mental health system. The barriers to treatment. The barriers to mandating treatment, and the lack of training we receive in predicting violence. Because yeah that’s not a thing.

I only pull this out occasionally…I attended an ivy league school and worked with some of the top psychiatrists in our country. They write the research papers. Not one time was I taught how to predict violence. In fact I was told that is not our role at all and it’s virtually impossible to do anyway. This was from the best of the best.

I’ll leave you with this:

  • Stated by the US Supreme Court (1980’s) and the American Psychiatric Association in the 1980’s and then after El Paso 2019:

    • “Neither petitioner nor the APA suggests that psychiatrists are always wrong with respect to future dangerousness, only most of the time.”

    • “Routinely 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 who are diagnosed with, or in treatment for, mental illness. The rates of mental illness are roughly the same around the world, yet other countries are not experiencing these traumatic events as often as we face them. One critical factor is access to, and the lethality of, the weapons that are being used in these crimes. Adding racism, intolerance and bigotry to the mix is a recipe for disaster. 

    • “If we want to address the gun violence that is tearing our country apart, we must keep our focus on finding evidence-based solutions. This includes restricting access to guns for people who are at risk for violence and working with psychologists and other experts to find solutions to the intolerance that is infecting our nation and the public dialogue.”

“In 2017 the NRA spent over 5.1 million dollars in lobbying.”

Guess how much the combined families of all the parents of all the children killed by guns contributed. Not 5.1 million. But yeah it’s totally a mental health problem.

Next time someone makes the statement “We need mental health reform not control,” please ask then to expand on exactly what mental health reform means to them. How will it be accomplished? What would the goals be? Where will funding come from?

Because make no mistake it needs to be reformed. But no amount of laws and reform and funding will help humans predict which humans will commit murder.

  • Campbell, Messing, Kub, Agnew, Sheridan, Workplace violence prevalence and risk factors in the Safe at Work Study, JOEM, 2011
  • Chaloner, R., Hall, W., Friedman, S., Guns, Schools, and Mental Illness: Potential Concerns for Physicians and Mental Health Professionals. Mayo Clinic Proceedings, 2013
  • Czaja, Moss, Mealer, Symptoms of PTSD among pediatric acute care nurses, Journal of Pediatric Nursing, 2012
  • Gates, Gillespie, Succop, Violence against nurses and its impact on stress and productivity, Nursing Economics, 2011
  • Hawkins, McIntosh, Silver, Holman, Early Responses to school violence: A qualitative analysis of students’ and parents’ immediate reactions to the shootings at Columbine High School, Journal of Emotional Abuse, 2004
  • Shulz, Muschert, Dingwall, Cohen, The Sandy Hook Elementary school shooting as tipping point, Disaster Health, 2013.
  • Daniels, Bradley, Hays, The impact of school violence on school personnel: Implications for psychologists, Professional Psychology, 2007
  • Book- Deadly Lessons-Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, 2003, IOM