People With Mental Problems

As the nation expresses its shock and grief over another school shooting, another group of people, although terribly saddened, will tell you that they are not surprised. Actually they are relieved that this sort of thing does not happen more often.

The people that I am referring to are the country’s psychotherapists. Therapists are acutely aware that a part of society is walking around, an invisible ticking time bomb, waiting to explode. The therapeutic community is the front line in dealing with the problem and they know the level of care for troubled people in America today is simply awful. They have pleaded for years with politicians to make changes in the level of public support for the mentally troubled, and they have been repeatedly rebuffed.

Every therapist will tell you about shaking their head after a session with a certain client, knowing there is no other help and praying that this person wouldn’t hurt someone or themselves before their next session. Until the client picks up a gun and becomes an identifiable threat, there are few resources available to deal with a potentially explosive situation. Waiting to intervene with the police until a threat is identifiable, as we saw at Virginia Tech, is simply way too late. And it is the wrong kind of intervention, anyway. And for every potentially violent person we see, there are many more out there walking the streets who refuse treatment. And for every potentially violent person, there are 1,000 more who pose no particular threat, but are greatly in need of care. We are not providing that care.

The issue presents a number of difficult challenges; I will try and shed some light on some of the problems:

The perennial issue is funding. In 1963 during the Kennedy administration, the nation moved from the tradition of custodial hospital care to a system of community based care. The idea was to get people out of expensive physician-run hospitals and manage their care on an outpatient basis. The hospitals weren’t producing results and many chronically mentally ill people could exist in the world with the right kind of support and supervision. It’s a good and workable system, when properly funded. But the government has never properly funded the concept. It did what it often does, pass a grandstanding idea and then hold back the funding. Can you say “Medicare?” Can you say “No Child Left Behind?” Can you say “body armor?”

Care for mental illness is also one of the first places that axe-wielding politicians look during budget crises. If you cut subsidies for drug companies, farmers or military contractors, their special interest groups raise a ruckus. The mentally ill have no constituency. They are easy targets. In 1970 there were 200 in-patient mental health beds per 100,000 population in the country. Today that number is less than 25. Yet the population of mentally ill people grows daily. The result is that we have a woefully inadequate, fragmented, ad hoc system that puts mentally ill people through incredible hurdles to receive at best a marginal level of care, if any at all.

In any given year, 5% to 7% of the adult population experiences a serious mental illness. If you want to find them, go to a freeway underpass. Thirty to fifty percent of the homeless in the country are mental patients. Funding for mental health care comprises 8 percent of all health care spending, without counting the cost of freeway overpasses and alleyways for housing. A former Surgeon General estimates that 20 percent of the U.S. population has a diagnosable mental disorder.We are not helping these people; we are just turning them out into the street. I could give you a lot of statistics, but the bottom line is that we are doing an abysmal job. A country that can spend $25 billion on a Navy aircraft carrier attack group and $3 billion on a single Air Force bomber and spent $2 billion a week on a war in Iraq, should be able to provide adequate care for its mentally ill.

Most of the private agencies that help troubled people would collapse without the support of the volunteers that carry the system on their backs. And these groups would disappear without donations from the public. A professionally trained mental health staff is a rare commodity in their world.

Public resources are pitiful. There simply is little there. Social Services Caseworkers manage hundreds and hundreds of cases, under incredible stress and get paid maybe $25,000 a year. The position has an annual turnover rate of 40% in some states. A Psychiatric Social Worker with a master’s degree, who does individual and group counseling, will make between $35,000 and $50,000 a year. Business MBA’s start out today at $92,360.

Most mentally troubled people have little money. Their lives are difficult and they cannot hold down jobs. They have no insurance. There is little publicly funded therapy. The therapeutic profession provides many thousands of hours of gratis consultation to troubled people every year. Many of these patients wait until their problems become critical and then go to the hospital emergency room where they know they will not be refused help. They will then stiff the doctors and the hospital for the cost of their care. It’s a lousy system and it makes physicians angry with poor people.

I write about troubled people as a group, but “they” are not easily identifiable. We start out with the great mass of people in the center and then as we move toward the fringes, we find people who do not conform to the norm. Some of these people we describe as “mentally ill.” The few who are way out on the fringe are identifiable, but what about all the many others who exist in the gray areas? Where you draw the line is a difficult judgment call, even for experienced professionals.

Complicating the assessment is that it is very difficult to know what a mentally troubled person will do. The extreme cases are obvious, but they are the minority. You can take two similarly troubled people and it will extremely difficult to predict how each is going to respond. If therapists had accurate predictors, they would have solved the problem long ago.

For various reasons many of these people will resist voluntarily seeking help. Some are delusional, most of them disconnect from reality in some way or other. Many of them are incapable of assessing their own situation or the risk they pose to themselves or to others. Many of them do not see themselves as a threat or simply do not care. Some of these people are decidedly anti-social and are angry at the world. They react violently even to the idea that they are troubled. If you tried to incarcerate every potentially troublesome person, the task would be monumental. Psychotropic drugs have terrible side effects and many troubled people resist taking drugs for a host of other reasons. And I haven’t even mentioned the related drug and alcohol addiction problems. But, we can help these people, and we can certainly do a much better job than we are today.

Adding complications to an already difficult situation, there are important legal concerns.  Even though they are troubled, these people have rights. Our society bends over backward to be certain that a person is not deprived of their rights through error or malice. There is important precedent here. If you consider the abuses of civil rights by the Nazis, the former Soviet Union and today’s Communist China, you have vivid examples of how individual rights need to be carefully protected, lest they be abused for political ends. And if you consider the surveillance of civil rights leaders and liberals by the FBI during J. Edgar Hoover’s tenure, (and heaven only knows what’s going on today under the guise of homeland security!) you begin to realize how fragile these freedoms can be.

What if the decision to incarcerate someone, is wrong? As I said, in many cases it is a very difficult call to make in the first place. And, some mentally ill people are very angry and delusional and have pursued health care professionals physically as well as through the courts. It’s a way to get back at the world they are violently angry at. When there is little legal protection for professionals, they are pressured to not expose themselves to physical harm or to lawsuits. Another problem is that psychiatrists – the people that the courts rely on for diagnoses – are in well trained in medicine, but generally not well trained in psychology.

As a result of the legal and economic considerations, public agencies have adopted the “imminent threat” standard. The imminent threat policy means that only when an individual has expressed a specific intention to harm themselves or others that public agencies can intervene – if someone is available. The policy frankly is both a cop-out and a legitimate response to the lack of funding. It limits the public system’s legal exposure and saves a great deal of taxpayer money.

Once in custody, a person who has been identified as a threat can be detained, usually for no longer than 72 hours. Then, if a psychiatrist determines that incarceration should continue, a hearing is held and a judge can then decide to give control of the person over to the state. It’s a big hammer. Arrested for violent behavior, once a person in the justice system a few states do provide good mental health care.

If a troubled person has fallen off the edge and desperately needs care, unless he or she poses an imminent threat, they get sent to the freeway underpass or back to their room to live in hell. There is no reward in the system for taking a risk on a patient (some do anyway) and there is legal risk. The publicly employed people I know would run the legal risks if they had resources to address the problem. They don’t. If a troubled person gets help it will be either from someone bending the rules, the generosity of an individual therapist or some privately funded organization. This person may be able to get a free bed and a meal, but they will not likely to get the care they need.

The tragic thing is if the patient freezes and dies in some alley or takes their own life, no one will notice, almost no one will care. These people are our lost and silent 51st state. Los Angeles hospitals dumped their indigent patients on skid row for years until it was exposed.

Young people present a special set of mental health issues. Primary care providers report seeing an increasing number of children and youth with mental health problems, 9% is a commonly used figure. That is higher than the average population. And, there is great difficulty in finding available clinicians to take these cases. We just do not have enough people trained in dealing with adolescent issues. And, frankly for the pittance they are paid, I don’t blame them. Studies consistently show that children with untreated mental disorders are at a higher risk for dropping out of school, committing violence and criminal acts, drug abuse, and suicide.

Just to give you an idea of how bad the situation is, some therapists, undoubtedly in contravention of everything they believe in, have recommended to parents with abusive schizophrenic or bipolar children, that they literally kick the kids out of the house (make them homeless) so that the kids will get arrested, become a part of the criminal justice system, and thereby receive the care that they cannot presently get from social services. It’s that bad out there. How would you fell as a parent, faced with that kind of choice?

School shootings are terrible and painful events. We have had far more school shootings than we should have. And every day young men a gunned down in inner-city drug gang wars.

An additional dynamic we are beginning to recognize is that with adolescent boys, a synergy can occur from their relationship that gives rise to a “third,” extremely destructive, combined persona. Neither of the boys in the Columbine shootings for example, fit the profile of a school shooter. But together they formed a grotesque, two-headed killing machine that did.

What should we do? Here are a few ideas.

A. Provide a middle step to incarceration. Provide the level of community-based mental health care funding that was originally conceived in community based mental health care (and has never been funded). Set up properly funded mental health centers with real counseling support and a trained professional staff in every community in the country. In addition to voluntary services, require that people referred to the centers (see below) participate. Pay public therapists and staff people a decent wage so that you get first-rate professionals dealing with society’s most troubled citizens.

B. Expand and properly fund the concept of supervised community housing for troubled people.

C. Pay private therapists to provide help for people who need it. Do not bury them in paperwork for doing so. Give therapists the power to refer people to community mental health facilities (“A” above). Require that referred patients attend. Remove the legal onus from therapists for errors of judgment regarding these referrals. Give licensed therapists permission to prescribe medications.

D. Fund non-church related organizations to provide beds for homeless people and counseling assistance.

E. Recertify therapists every three years by boards of their peers.

F. Put some real teeth into gun control laws – especially as it applies to mentally troubled people. Create a national registry of felons, drug dealers and the potentially violent mentally ill who would be prohibited from purchasing or owning guns.

G. Establish T.A.T. (Threat Assessment Teams) in every school and college in the country to identify and funnel help to troubled students. Give teachers and college professors the right to refer students to the mental health centers (“A” above). Provide legal protection for them from lawsuits for such referrals. Return to teachers the right to discipline students for dysfunctional behavior without the fear of being sued by parents.

H. Provide meaningful training for first responders to help them better deal with mentally troubled people.

Will this solve all of the problems identified above? In a word, no, but we can definitely reduce the number of them.  I do not believe that it is possible to completely eliminate outbreaks of violence. But, both his teachers and fellow students had repeatedly identified Cho Seung-Hui as a potential problem. Sadly, there was no mechanism to both help him and to protect the community. The system failed miserably to do anything meaningful about a clearly troubled young man, and I will guarantee you that his behavior was identifiable long before recent events. Someone could have caught him, if we had a net. We can most certainly do a great deal better than we have. It would also be a big step towards becoming the kind of compassionate society that we say we would like to have. It is going to cost a lot of money, but I wonder, what is it costing us today in ways that we do not realize?

The question my friends is, what are we willing to do about it?

copyright©Blue Lotus Press 2016

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