The Newtown, Conn., shooting in which 26 students and educators were killed at Sandy Hook Elementary led to an increased focus on the role of mental health care in preventing such tragedies. One year later, it is clear that the more that mental health systems have focused on dangerousness, the less safe we have become.
In most states, mentally ill individuals can only be required to undergo a psychiatric assessment if they meet certain criteria, such as a subjective inability to provide for one’s basic needs, or dangerousness to themselves and others. With mental health systems chronically strained for resources, the threshold for hospitalizing people with psychiatric conditions is only increasing, making it more and more difficult for them to receive care.
Recently, a patient was brought into the psychiatric emergency room by his concerned parents because he believed that aliens were tracking his movements and had implanted chips in his brain to read his mind and ultimately kill him. However, the nature of his condition prevented him from realizing that he needed help for a mental illness and he instead requested to leave the hospital so he could seek protection from authorities.
Based on laws governing emergency treatment of the mentally ill, since he did not express any overt threats of harming himself or others and because his parents provided for his basic needs at home, he didn’t satisfy the legal criteria for involuntary treatment and was subsequently discharged.
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Trained or untrained, it was clear that this person was in serious distress and in need of urgent care to prevent further deterioration. Similar cases arrive on the doorsteps of hospitals across the United States every day, and represent the challenges confronting gatekeepers of a system that is seemingly more designed to block care than to encourage it.
Rather than being based on the need for treatment, the foundation of acute psychiatric care today largely rests on determinations of dangerousness. However, given that violence is notoriously difficult to predict, basing treatment decisions on dangerousness criteria is fundamentally flawed.
This approach is also reactive as opposed to proactive because treatment is a critical variable that generally precedes violent acts committed by those with serious mental illnesses such as schizophrenia or bipolar disorder. When individuals with these conditions receive treatment, studies have shown that their likelihood for violence significantly decreases. Thus, if care were based more on clinical need as opposed to the downstream risk for violence, mental health professionals would be better able to intervene earlier and more effectively.
While there will always be an element of unpredictability in human behavior, recent high-profile tragedies involving those with untreated mental illness have necessitated a re-evaluation of how we approach these complex cases. Unlike in other fields of medicine where the provision of care rests on the doctor, in mental health that decision has largely been relegated to lawmakers. It is problematic when psychiatric care can only be provided when legally allowable, as opposed to when clinically necessary.
The reason for this diversion of responsibility dates back to prior abuses of power and trust during an unfortunate period in the history of psychiatry when vulnerable patients were inappropriately housed in dilapidated mental asylums for years or even decades. Laws were subsequently enacted to prevent a repeat of this social injustice.
Yet, in order to learn from the past, we must move forward and start trusting our mental health providers to make sound clinical decisions about providing necessary treatment. Times have changed, as have training, treatment approaches and the field as a whole. The laws governing the provision of mental health care need to reflect this evolution as well.
It is unacceptable for someone with heart disease to have to wait until they have a heart attack before receiving services, or for the cardiologist treating the heart attack to be prevented from providing care by outdated laws disconnected from appropriate clinical interventions. Conditions of the brain are no different. As the son of a mother with schizophrenia and an emergency psychiatrist who constantly struggles to practice compassionate care in an eroding mental health system, I think that we can and should do better.