In a letter that could’ve been written in virtually any state by any National Alliance on Mental Illness (NAMI) representative, NAMI Delaware executive director Matthew Stehl and president Mary Berger recently wrote an op-ed for Delaware’s leading newspaper, The News Journal.
In the opinion piece, Stehl and Berger decry the lack of adequate funding for mental illness treatment in the state. In a period of economic recession, state-funded health and human services are usually the first to undergo cuts. But it’s an especially relevant issue in Delaware, because the U.S. Department of Justice struck an agreement with the state to ensure it improves its mental health services for its indigent and poor residents who need mental health services.
All of which is good. I’m all for states and their legislatures to stop looking at the short-term costs of things like mental health treatment and start looking at the longer-term costs of failing to fund adequate mental health care in their state (in terms of increased burdens on the courts, police, emergency rooms, etc.).
What I object to is trotting out a straw man in the form of tragic and violent shootings, and suggest that the lack of access to mental health care was the reason for the shootings at Virginia Tech and Tucson, Arizona. How ashamed I am, as a native Delawarean, when mental health advocates make such irrational appeals to emotion.
Regular readers know this is a sore point for me — connecting people with mental illness and violence. As I wrote 4 years ago, the relationship between violence and mental illness is very complex. It is ridiculous to make a simplistic claim that people with mental illness are more prone to violence (that’s not what the research data show). It is even more ridiculous to use data outliers — such as the Virginia Tech shooting — to advocate for broad, sweeping general policy changes.
I quoted Paul S. Appelbaum back then, and his words are especially true today:
No single approach to reducing the risk is likely to be completely effective. And given the relatively modest contribution to the overall risk of violence by persons with mental disorders, the likelihood and magnitude of adverse effects from any intervention must be carefully considered before it is embodied in law.
But that didn’t stop NAMI Delaware from making the opposite claim in their op-ed:
Although statistics verify that people with mental illness are far more often the victims of crime rather than the perpetrators, we cannot dismiss the result of untreated mental illness that occasionally manifests itself in horrifying events such as those at Virginia Tech and in Tucson, Ariz. These men were known to have a history of mental illness. Had they been receiving effective treatment, these events would most probably never have occurred.
So on one hand, the authors suggest that people with mental health concerns are more often the victims of violence, than the perpetrators of it. Then on the other hand, they go ahead and say, well, yeah, but we still need to watch out for the mentally ill, because look what they can do!
It’s like saying, “Hey, it’s true that flying is about 26 times more safe than driving around in your car. But still, what about those 251 passengers that died when American Airlines Flight 587 crashed into a Queens neighborhood on November 12, 2001?”
We don’t know what caused Jared Lee Loughner to allegedly open fire on January 8, 2011 at a political demonstration, killing six people and seriously injuring many others (including U.S. Representative Gabrielle Giffords). While he has been so far found incompetent to stand trial on these charges, we don’t have enough information to conclude that Mr. Loughner shot others because of his alleged mental illness (or in the argument NAMI Delaware is suggestively making, because of his lack of ability to attain timely and affordable care to treat his mental illness — whether voluntary or not isn’t clear, since we don’t know Mr. Loughner’s specific treatment or mental health history [contrary to NAMI Delaware’s claims]).
In the case of Virginia Tech, Seung-Hui Cho killed 32 people and wounded 25 others. In the Virginia Tech Review Panel report about the shooting, it noted that failures by Virginia Tech’s counseling center, flaws in Virginia’s mental health laws, and inadequate state mental health services contributed to the problem. But the report concluded that “Cho himself was the biggest impediment to stabilizing his mental health” in college. Cho was also the apparent recipient of a fair amount of psychotherapy and counseling before he entered college. All of it was apparently for naught in terms of helping him with his demons, however, as he still carried out his attack on his fellow students.
Can we really play Monday morning quarterback and try and say that a fully-funded mental health system would’ve prevented these kinds of tragedies?
Of course not. It’s an unreasonable and fairly ridiculous argument to make. Violence will always occur in any society, and all you can do is to make reasonable efforts to reduce the likelihood of it occurring. There’s no research (that I’m aware of) to indicate that getting better access to mental health services in mainstream society is associated with a reduction in the crime rate in one’s community. While it’s the right thing for a society to do, it’s not justified by promoting fear and ignorance about the likelihood of violence by people with a mental illness.
So while I commend NAMI Delaware for speaking out on behalf of people in Delaware who have a mental health concern, I’m ashamed they used two violent tragedies to try and make their case. It turns my stomach when I read things like this, similar to the disrespectful and dishonorable strategies of the Treatment Advocacy Center.
Let’s stand up and advocate for better care and funding of people with mental disorders. But let’s not do so on the backs of tragedies that represent significant outliers — ones that can never be adequately or wholly explained by a lack of services. All the treatment in the world may not have made a damned bit of difference in those two cases. Appealing to emotion is a common tactical ploy in op-eds such as these, but it doesn’t make it a good strategy for others to use. Instead, it turns me off of their cause.
Read the full article: State’s flawed mental health system desperate for overhaul
37 comments
“Regular readers know this is a sore point for me —connecting people with mental illness and violence.”
But why should that be a sore point? Obviously there is a connection according to the studies. If you want to say that the factor is overly-exaggerated, then that is a different point (and a correct one).
Sorry if I took your words too literally, but I am a placid guy that when the illness took control…yes violence that never would have otherwise been there was in the picture.
I still shudder remembering that time.
Increasing access for the chronically ill probably cannot prevent future events like the above tragedies from happening, but, limiting access still further will not lessen the odds either. I have worked in Delaware in the past, and let me say their current set up for managing the chronically ill is less than adequate, basically expecting private practitioners to handle all patients in an office setting that is not equipped to manage patients with the treatment needs required for said population. And, this is a state that per my last interaction with their correctional facilities, albeit 10 years ago, puts as many people to death per population comparison as that of Texas, irregardless of mental health status to the crime commmitted.
As I suspect you well know, Dr Grohol, the mentally ill are still highly discriminated against, and thanks to the efforts of managed care starting back in the late 1980’s, they don’t even earn the title of third class citizens. Just look at the way they handle formularies and limit what diagnoses can be reimbursed for treatment. Does any other specialty in this country have the level of micromanagement that goes on in mental health care as of 2011?
And don’t look to PPACA, ie ObamaCare, to improve things for better mental health care. In fact, watch psychiatry basically wiped out as a general specialty by 2014 to 2016. Hey, as a prior post already has pointed out, anyone who has prescribing privileges can write psychotropic prescriptions, because, mental health is just a biochemical imbalance. And watch the likes of NAMI just advocate for everyone who is “chemically imbalanced” be medicated, whether they agree or not.
The slope has already been greased, so where does one walk to avoid the fall?
Simple!take away the poison (Zyprexa) that causes violence in the victim being force poisoned for a starter,and shoot the sick see-errs. Then replace the poison with proper caring psychologists and rehabs for the emotionally and psychologically damaged or concerned (mostly) vulnerable, easy to manipulate teens and young adults, people who look for the good, the well part of a persons psyche, and build from there,no good building on sick, adding sick, seeing sick, wheres that going, only down im afraid.
I agree with you that “the relationship between violence and mental illness is very complex” and so was surprised to see you fault the authors for pointing out victimization stats and going on to point out that “untreated” mental illness is a causative factor of violence. (I would have added untreated “serious” mental illness.) If media reports are true (and they are supported by his current status) then Mr. Loughner lacked capacity, had serious mental illness, and was untreated. Those are some of the most important factors in determining if someone with serious mental illness is likely to become violent. (The other two factors would be a past history of danger, and substance abuse). As Dr. Thomas Insel wrote violence is more common in people with Serious Mental Illness (SMI) and during an episode of psychosis, especially one associated with paranoia, it can be increased..
Or as Monahan wrote, “The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social or demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.
Like many, your issue seems to be you don’t want anyone connecting the reality of violence to real people. Perhaps you fear it causes ‘stigma’. But the failure of mental health advocates to acknowledge an increased incident of violence, and the desire to hide consumers who do become involved in acts of violence doesn’t help the public understand the reality of serious mental illness. It prevents it.
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DJ — I try not to diagnose people from afar based upon “media reports.” That’s why I find such use by well-meaning people to promote their own cause appalling. And even if we were to allow that Loughner had a mental illness (what’s with all this “serious mental illness” crap? All mental illness is serious), what about Cho? He spent years in therapy, in and out of treatment as a teenager. If none of that seemed to help (given that he still committed the crimes), that seems to argue just the opposite — that even if we do get some people treatment, that is no guarantee or argument that they aren’t going to commit a violent crime.
Which is why using the violent crime angle as a rational argument for greater mental health treatment is a shaky one.
Of course there should be better treatment options available for those who can’t otherwise afford treatment. JFK’s vision of community mental health care never materialized in the comprehensive manner he wanted in most communities here in the U.S. We can do a better job for people who can’t afford to pay and have a mental health concern.
But we shouldn’t make the argument that we need better funding in this area because it’ll reduce violent crime. Fear is not a good motivator for improving public policy, and it plays to our worst instincts and prejudices.
Re, your comment: “What’s with all this “serious mental illness†crap? All mental illness is serious.” I think that explains our difference in perspective. We’ll have to agree to disagree. I would only ask that while you try to “do no harm”.
I think you set up a straw man. No one I know is “using the violent crime angle as a rational argument for greater mental “health” treatment”. Some do use the ‘violent crime’ angle as one reason it is important to get mental “illness” treatment to people with serious mental “illness”. JFK’s vision was fundamentally flawed. It was premised on the belief (which still gets massive funding today) that we can “prevent” mental illness, in spite of the fact we don’t know what ’causes” it. If you know what causes schizophrenia, I hope you will share. Kennedy’s vision also failed to recognize that (while some, like you, believe all illnesses are equal), mental “health” providers (who ran CMHCs) wanted no connections with the ‘seriously” ill coming out of state hospitals. Those who run programs today also know who is seriously ill and who is not, and they won’t let the seriously ill in. Sorry for responding.
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DJ — That’s because some people have setup an artificial duality that isn’t supported in any research to suggest there are two kinds of mental disorders — “serious” mental disorders and everything else in the DSM. Of course, the DSM doesn’t reference this duality. The research hasn’t come to any firm conclusions to support this duality.
Instead, apparently some policymakers in a room got together and decided to create this marketing phrase to try and distinguish what they’re fighting for, versus everything else. In the meantime, they’ve marginalized and minimized very serious disorders that they simply have deemed as such.
I think that too is a tragedy, but one I’ll save for a future blog entry.
Do you consider drug and alcohol addiction to be a mental illness? If so, expanding treatment options could dramatically reduce crime, and have a somewhat lesser but still real impact on violent crime.
What are the rates of mental illness and addiction in the prison population? Would treating the underlying illness or addiction have prevented those individuals from committing the crimes for which they were imprisoned? Many of those are property crimes, of course. But how many people imprisoned for vehicular homicide or manslaughter were intoxicated or on drugs when they committed their offenses? Of course, someone can be drunk/high and not actually be an addict, and many addicts still won’t seek treatment even with expanded availability. Still, completely ignoring the ouliers, I believe improving access and UTILIZATION of mental health services, including addiction treatment services, could reduce crime against both property and people.
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Angela — We probably shouldn’t cloud the argument further without differentiating between “crime” and “violent crime.” Many people become criminals in seeking out money to pay for drugs to support their illegal drug habit. So yes, I agree that the prisons are increasingly filling up with people who have mental health concerns — often substance and alcohol abuse issues.
In a recent study of an LA jail (Lamb et al., 2007), the researchers looked at a random sample of 104 males. Of those, they concluded 75 percent had a mental illness, and of those 75 percent, 76 percent had a history of substance abuse.
Obviously if we did a better job with our ability to treat people with substance abuse issues, we could reduce these numbers. But as long as we look at drug problems as crimes first, and as a mental health issue second, we’re not going to make much inroads in treatment of these concerns. Substance abusers are difficult to treat even in the best of conditions. When receiving treatment in the criminal justice system, you can expect that results are going to be less than ideal.
Most people with a mental health diagnosis don’t have a substance abuse issue. Most people with a mental health diagnosis don’t have an issue with violent behavior or violent crime. Making an argument to help the majority of these people based upon a very small minority of them is an argument based upon a logical fallacy called an appeal to emotion (in this case, the negative emotion that violence stirs in many).
It’s no way for mental health advocates to be arguing for policy.
75% of people in that survey met true criteria for mental illness? What, 75% of them were anxious, because, they were incarcerated? 75% of them were antisocial, because that personality disorder is listed in the DSM yet over 75% with that diagnosis do not respond to reasonable and fair interventions for mental health care? 75% had substance abuse issues, but per my opinion, substance abuse is not uniquely under the umbrella of mental health care alone for treatment?Snapshots of population characteristics are just that, moments in time that is fluid. Yes, there is a large percentage of people who are jailed who have mental health problems/issues, but, to say that 3/4 of them have serious mental health disorders only clouds the reasons for their arrest.Is it me, or has forensic psychiatry just basically created the premise that anyone who commits a crime must be mentally ill? Or, perhaps, maybe there are people out there who have little if any regard for other’s possessions and welfare and even if impaired by substance abuse or dependence, they are still culpable for the consequences of using substances and committing acts that are felonies in this society?Coddling and enabling are not defenses, just poor excuses for those who are cunning to grab them to justify unjustifible choices and actions. On a case by case basis, we need to assess who is impaired and in need and likely to respond to such interventions, and, who is just a criminal.And, as unfortunate to have to say this, some people are not amenable to mental health care as providers were trained to offer.That is why we have jails. And, graveyards.
Hi John,
I agree that the premise of this advocacy is inaccurate. Of course, treating those violent offenders with underlying mental illness could certainly reduce their likelihood to recommit. But just having more availability and more terrific practitioners in the community doesn’t mean people with those issues will automatically use those services. It’s so much more complex than that.
The authors you speak of are trying to draw a straight line between availability and prevention. We have good quality counseling offices and a psychiatric hospital in my community. One of them has a sliding fee scale and the hospital works with all kinds of funding sources and is open to anyone 24 hours a day.
Could mental health treatment have a larger presence in my small city? Possibly, but it’s not like we lack services. And even then, we’ve had bomb threats at our school, an attempted abduction recently, a senseless kidnapping/shooting incident, a bank hostage situation, a few high profile child deaths at the hands of the adults who cared for them, and other violent acts.
Did any of these people get services? I have no idea. Would building a second psychiatric hospital and doubling the amount of counseling offices, all with sliding fee scales and free transportation keep any or all of these problems from happening? There’s no way to know, but I doubt it that would be enough.
Courts need to be more willing to sentence people to treatment. Families need to be willing to recognize that they need help and to take committed action at the earliest stages (and before tragedies occur). Individuals need to be willing to make significant changes in their life and to follow through with good self care.
Those things will have a much greater impact on whether someone would take the leap to commit a violent crime. Simply having an undiagnosed or untreated mental illness (yes, all mental illness is serious!) and some underfunded programs isn’t enough to claim cause and effect.
Having more mental health practitioners in your city doesn’t prevent a kid from taking a gun to school. Reallocating funds in the legislature doesn’t prevent an adult from beating someone up. Heck, even getting someone inside a counseling office with an scheduled appointment doesn’t guarantee ANYthing except a warm body in the room!
Not to dismiss at all the important of treatment where underlying mental illness is significant. But yes, the connections these authors make are unrealistic and misrepresentative. It would certainly be more credible if they had based their advocacy on a broader foundation of outcomes.
Surely the world of mental health is not so disrespected that we have to resort to slight of hand and sensationalism to get any real attention?
Dr. Grohol:
Thanks. I look forward to reading your blog equating the severity of “caffeine withdrawal symptom” with schizophrenia. It will be a wonderful addition to the literature. Another blog I might suggest is “Avoiding discussing schizophrenia to reduce stigma”. I think you could add a lot to that literature as well. Best.
dj
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Since DJ Jaffe has so graciously responded in this thread, I’d also note he failed to disclose his conflicts of interest, namely that he is a co-founder of the “Treatment Advocacy Center” (TAC), an organization that appears to be for more forced-treatment laws in states (which more often than not equates to simply forced-medication).
The logic, if I follow it correctly, is that by turning back time to when citizens could be forcefully medicated against their will (ala One Flew Over the Cuckoo’s Nest), we would have less problems with people who don’t fit society’s mold of what a citizen should be.
As an example of how easily the state can take away your rights because of these laws, here’s all that’s needed to force you into outpatient treatment in Alabama:
(i) the respondent is mentally ill;
(ii) as a result of the mental illness the respondent will, if not treated, continue to suffer mental distress and will continue to experience deterioration of the ability to function independently; and
(iii) the respondent is unable to make a rational and informed decision as to whether or not treatment for mental illness would be desirable.
That’s it. A court can force you into treatment simply because you have a mental disorder (anything in the DSM will do), they find that you may — in the future — not be able to function independently, and they believe that whatever your opinion about treatment is is different and “irrational” than their own.
In other words, once diagnosed with a mental disorder, the option for whether and how you will be treated may be taken out of your hands in the future — especially if you disagree with whether you even want treatment in the first place.
It used to be that you were allowed to be as crazy as you wanted to be, as long as it didn’t interfere with other people or cause yourself or them harm or potential harm. It wasn’t against the law to be crazy and not be in treatment. Now, in most states, you can only be as crazy as the government allows.
All thanks to TAC.
I have no problem with the way NAMI advocated for increased mental health funding by pointing out violent crime and the need for preventative services. In fact, i think it’s fairly smart. How else will mental health advocates appeal to republicans and others who want to cut social services? By stating ‘it is the humane thing to do’? Creative.
This statement:
“Making an argument to help the majority of these people based upon a very small minority of them is an argument based upon a logical fallacy called an appeal to emotion (in this case, the negative emotion that violence stirs in many).”
..does not adhere to policy making logic either. It’s not a matter of ‘head counts’ (“very small minority of them”) but a matter of social cost, positive externalities, and other costs that economists can measure, but which psychologists may/may not be aware of. That small minority has an exponential impact on others (crime victims, children of the offender, spouses, etc).
Policy makers who center policies around ‘head counts’ without measuring all the other costs would likely be incompetent.
At any rate, the idea of a multifaceted approach does make sense to me.
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Sarah — I think my concern is one of promoting prejudice and misinformation among the general public, since this was an op-ed that appeared in the daily newspaper in Delaware.
My (perhaps irrational) fear is that policymakers look at fully funding mental health services in their locale out of fear rather than out of an understanding of how it makes good public policy across the board. It likely reduces general healthcare costs by keeping folks out of the ER. It may also help reduce homelessness and petty crimes. It helps people in the greatest need in their community, who have the fewest resources and often no families on which to rely on.
These things were mentioned in a single sentence, while the connection to two violent, shooting tragedies (one of which does little to help make the authors’ point) took up a whole paragraph. Few policymakers are going to moved by such tragedies because they are so rare, and because they didn’t happen in their communities (which we irrationally believe to be different than communities where tragedy does strike).
When you want to use emotion to strike a chord in an argument, use a positive story — and a positive emotion — to give policymakers and citizens the sense that these things can change people’s lives for the better.
Arguing from fear is the lowest common denominator, and is used to justify some of the worst government interventions into our lives.
Dr. Grohol, from a patient perspective thank you for standing up for our rights. I don’t hurt people, and I am too afraid to see a psychiatrist because of people like Torrey and Jaffe. A couple of weeks ago my therapist encouraged me to see a psychiatrist in conjunction with the therapy because she thought medication might be helpful, and I told her that I don’t want to end up like some the patients I read about on MindFreedom who are having to go into hiding to escape being forcibly medicated or dragged out of their homes to have ECT – I will not put myself in that position and I don’t know if the psychiatrist I would get thinks like Torrey or is more reasonable like Dr. Hassman seems to be. It’s scary to me as a patient to wonder if I’m going to have my rights taken away if I don’t agree with the psychiatrist. So, Jaffe you may think forced treatment saves lives, but I wonder how many avoid treatment altogether because of what your organization is doing. If I recall, I remember reading I believe it was your suggestion (or it was someone affiliated with TAC) who told parents to turn over the furniture and lie to the cops so the person will be taken in against their will, the patient’s rights be damned.
Last I checked per my training, treatment was a choice, not a demand, and even if impaired in judgment, not a quick determination by a psychiatrist in a 10 min visit to satisfy a judge, or ethics panel at a hospital to assess a critical care need.
As I said in an earlier post here, forensic psychiatry has done as much as disservice as any real progressive role in administering legal determinations into care needs. Hey, guess what colleagues, patients do have a choice if they refuse care and are in the judicial system: agree to be in treatment or go to jail if the issue is a felony that has incarceration as a consequence.
When we get that pill that improves insight and judgment, let me know so I can retire, as this medication will basically put me out of work anyway!!! Good pick up on that commenter by the way, Dr Grohol.
And, really it’s not just about worrying if my rights are going to be violated. What’s also bothersome is that I would be assumed to be a more violent person or that people would look at me as a potential Cho or Loughner sinply for having a certain diagnosis. That’s offensive. THat’s like looking at all men as potential perpetrators, just because a small percentage abuse people. I have nothing in common with Cho or Loughner, and neither do most other patients. I don’t think it’s right to make the rest pay for what they did. Yet, that’s exactly what TAC is doing. I do feel some relief that even in the states that use AOT, they’re having a difficult time funding it. I hope that problem continues.
Naturally, the Treatment Advocacy Center was disappointed to see our activities characterized as “disrespectful and dishonorable.†We are the only national nonprofit that exclusively focuses on the treatment needs of the estimated 3.3 million Americans who suffer untreated mental illnesses with psychotic features. We conduct a variety of activities that, for example, recently included developing a Psychiatric Crisis Resources Kit to help families and caregivers with a loved one in crisis, providing a centralized source of up-to-date information about relevant laws such as state standards for emergency hospitalization, and researching and publicizing trends in imprisoning rather than treating people with severe mental illness.
We also advocate changes in state laws to make treatment available even to those too ill to seek it themselves – through court-ordered treatment in a very few severe cases. We have yet to see evidence that “in most states, you can only be as crazy as the government allows.†Nationwide, only 10% of the state hospital beds that existed in 1960 still exist, and the vast majority of those in more and more states are dedicated to forensic patients, not the general public. The typical state hospital stay today is 5-6 days, Delaware being the flagrant and intolerable outlier. As millions of families can attest, the barriers to getting involuntary treatment – even for a loved one who is actively threatening suicide or homicide – are now so excruciatingly high that the prospect of Hollywood’s 1975 version of psychiatric hospitalization becoming a real and present threat to freedom today is laughable, if not outright fear-mongering.
We, too, agree that the relationship between violence and mental illness is complex, but we respectfully disagree that talking about the link between them is “ridiculous†or “simplistic†and that doing so is “trotting out a straw man.†In just a single one of our many briefing papers, we cite more than 50 international studies and U.S. government reports containing findings that individuals with UNtreated severe mental illness (typically, those with psychotic features) are more likely to commit acts of violence than the general public or than individuals with mental illness who take medication.
The consensus among researchers is that 10% of the homicides in the western world occur as a result of untreated severe mental illness, a rate vastly out of proportion to the sliver of the population in this demographic. In the U.S., the rate translates to about 1,600 men, women and children, many of them family members who loved or were caring for the person who killed them. Just because far more people survive untreated mental illness than die or are injured or go to prison or to the death chamber as a result of it is no reason to ignore the ones who do.
The public associated violence with severe mental illness long before the Treatment Advocacy Center was founded and would continue to do so if we disappeared. That association, in fact, has long been recognized as the leading cause of mental illness stigma. What we’ve injected into the equation is advocacy based on the conviction that if there was more treatment, there would be fewer consequences of non-treatment – including violence and stigma. No, every life lost in some way as a consequence of not treating mental illness wouldn’t be saved. But ignoring, dismissing or otherwise pretending the consequences – not just homicide but suicide, arrest, incarceration, homelessness, victimization and all the rest – will save none.
Debating the Treatment Advocacy Center’s goals and our strategies is a natural byproduct of disagreement, and reasonable minds will always find grounds for disagreement. Characterizing them as “disrespectful and dishonorable†devalues the lives of the individuals and families that already have or someday may benefit from them.
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Doris — Respectfully, neither TAC nor the laws you’ve helped pass in most states distinguish between people who have a mental illness with psychotic features, and those people who have any mental disorder diagnosis. I quoted to readers the Alabama law, for instance, to demonstrate how extraordinarily far-reaching the legislation that TAC helped make possible is.
I think it’s all fine and good to say, “Oh, we’re only doing this for the worse of the worst,” but the reality of TAC’s past actions are contradicting your reasoned and respectful reply here.
I am all for getting treatment to people most in need, and especially help ensuring legislators in states understand the perspective and need of people with mental illness.
But nobody — including TAC — needs to trot out extreme examples of violence and possible mental illness to try to make the argument. It’s sickening and completely disrespectful of the millions of Americans who suffer from a mental illness who have no greater likelihood of committing violence than a bunny rabbit does.
Last, I would love to see you back up your assertion that the “consensus among researchers is that 10% of the homicides in the western world occur as a result of untreated severe mental illness” with an actual research citation.
I’m also reminded of the NESARC (2009) study that showed if a person with mental illness had no substance abuse or history of violence, their risk of violence was no different than any other person in the population. To me, that once again clearly shows there is no link between mental illness and violence.
The slippery slope of adding antisocial personality disorder and addiction to psychiatric disorders inferring that mental health alone can manage these problems. I still go on record that:
1. Antisocial personality disorder is NOT amenable to any real impact of intervention by mental health providers. It is a personality disorder, but, in my opinion a majority of these individuals are contraindicated to be in psychotherapy with the general mental health provider population, and,
2. Addiction is not limited to psychiatric services for treatment alone. In fact, again, in my opinion, the subspecialty of addiction medicine in psychiatry has just inappropriately marginalized the treatment process as a biological intervention, per a prior post here so well documented. Add to the fact that what, 70% of people with dependency issues have at least antisocial traits (note I am NOT saying antisocial personality as a diagnosis) and again, is that really a legitimate psychiatric population that gives that 10% figure a substantial claim?
Or, has forensic psychiatry and addiction psychiatry just sucked the profession into a morass of false hope and less than effective treatment modalities?
We need to address the rising incidence of murder-suicides that are occurring in this culture, but not just simplify it as mentally ill people who need to be coerced into care that comes across as punitive, not therapeutic.
That’s true, Dr. Grohol. In my state, it doesn’t require the patient be psychotic nor do you have to be violent to qualify for AOT. That scares me, because I realize I could be forced to do something I don’t agree with. This is the criteria in my state (according to TAC) for forced outpatient treatment:
For “temporary†(90-day) outpatient commitment, a person must be ALL of the following:
(1) severely and persistently mentally ill;
(2) if untreated, destined to continue to suffer BOTH:
(i) severe and abnormal mental, emotional, or physical distress; AND
(ii) deterioration of the ability to function independently, leading to an inability to live
safely in community;
(3) unable to voluntarily and effectively participate in outpatient treatment.
I don’t want to be afraid to see a psychiatrist, but this law makes me afraid.
Having been diagnosed as paranoid schizophrenic in 1964, I would like to offer a (hopefully) brief personal history and put forth my opinions on some of the issues being discussed here.
At seventeen I experienced a psychotic episode during which I went into my grandmother’s bedroom one night with a loaded shotgun intending to kill her believing her to be the devil. Fortunately I did not follow through with my intent but was hospitalized in a nearby state mental institution. There I was treated by professionals trained to deal with psychosis. They used electric shock therapy which was, and in some circles still is, believed to effect physical or biochemical changes in the brain which often allow a psychotic individual to become lucid. In my case, after a series of treatments, I recovered. Maybe I would have recoverd anyway, but it seems reasonable to think the shock therapy may have helped. It was the best they knew how to do in those days. A few years later, I had another episode and got arrested. After determining that I wasn’t high on drugs, I was taken before a judge who determined that I had a mental health issue and I was taken to the same state institution as before. This time the professionals treated me with an antipsychotic medication-Thorazine. Again in about the same period of time, I recovered. I was fine for many years after that, but in 1979, I again became psychotic. My wife quickly became aware of this and sought help. She was told that no one could help her unless I committed a crime and got arrested. Eventually this happened and I found myself in Pima County Jail where at various times I was strip searched, body cavity searched, put in pshyical restraints and put in solatary confinement. I was also put on Thorazine and spent brief periods of time in a local psych ward. Because my wife advocated fiercely on my behalf from outside, charges were eventually dropped, I was released and allowed to resume my life. The reality is that were it not for my wife, I probably would have been convicted of arson, given a lengthy sentence in which I would have been locked away in solitary somewhere and forgotten about for an indefinite time period. I have now been pretty much symptom free for nearly thirty years. I continue to take small doses of antipsychotic medication and intend to do so until death. I relate my story to illustrate the points I wish to make. First I want to say that when one refers to serious mental illness they should be referring to people experiencing psychosis. That being the case, the choices someone with serious mental illness has have nothing to do with personal liberty and freedom-it is between being treated by trained professionals with training and experience in dealing with mental illness, or a life where one spends some time homeless on the streets and the rest of his time in the prison system where, if anyone cares, they are not trained to treat such people. Since “One Flew Over the Cuckoo’s Nest” in 1975, society’s understanding of mental illness and the availability of often effective treatment and medication has increased greatly, yet the prospects for the average psychotic individual are arguably much worse. Should I become psychotic again, I don’t want someone defending my rights and freedom. I want someone in the position my wife was in in 1979 to be able to get help. I want her to be able to compel me to get treatment should I not seek it on my own.
My apologies if this goes through twice, something screwy going on with my laptop.
Joseph, I don’t think anyone here is arguing that people waving around guns at people shouldn’t lose some of their freedom. By all means please detain people who are behaving violently. What I am arguing is that it’s not right to use the actions of someone who has been violent to generalize to the rest of the population with that diagnosis. The majority of people diagnosed with a serious mental illness are not aiming guns at people. So, I don’t support the laws (like AOT) which make it easier to force treatment on people with mental illnesses who aren’t being violent. It makes some people afraid to seek treatment.
Much of DJ Jaffe’s single-minded pursuit has seized upon the outrageous to pose loaded questions, often based on erroneous information, and designed to inflame. The Treatment Advocacy Center which he co-founded (and is no longer on the board) relied on overstated estimates, with concocted data about violence, and then used that to lobby to change laws promoting outpatient commitment after a crisis. The single-most important predictor of gun violence is gender (male); that couples with gun ownership. Scapegoating a class of people with mental illness, or “untreated mental illness,” has failed to control the violence, most of which is committed by people without a psychiatric diagnosis. Jaffe, with a background in public relations, knows this and he also knows how to market. “You have to take the debate out of the mental health arena and put it in the criminal justice/public safety arena,” he said in the mid 1990’s. To do this “It may be necessary to capitalize on the fear of violence.” I wrote about this for EXTRA! See “Mindless and Deadly: Media hype on mental illness and violence” http://www.fair.org
/index.php?page=1064.
Phyllis Vine
Editor
MIWatch.org
Scared: I want to repeat that when referring to someone with a serious mental illness, I am referring to someone experiencing psychosis. Nevertheless, it is absolutely true that the vast majority of these people (even paranoid schizophrenics) will never commit a violent act toward another human being. That being said, the incidence of suicide is much higher among psychotics than the general population; and most psychotics could benefit from treatment. Studies indicate that maybe as many as half of psychotics are unaware that there is anything wrong and therefore will not seek nor often voluntarily accept treatment. For these reasons and out of consideration for the loved ones of psychotics who are desperately seeking help in many cases, I support the efforts of the TAC and involuntary assisted treatment.
I want to point out also that most people in the mental health profession are not ghouls looking to exercise power over helpless individuals. They are mostly sincere, caring individuals seriously trying to help.
But here is the inherent problem in applying a black and white solution to a gray problem: the psychiatric patient gets arrested, goes in front of judge who concludes the defendant has a mental illness and orders, not suggests mind you, the person has to be in mental health care and then sends said defendant on his/her way to find the provider to provide these enforced services.
Has a judge ever called me to ask my opinion how to handle a case to encourage the patient access and stay in treatment? NO. Has a judge ever called me to ask how to maintain compliance with therapeutic interventions that were presented as punitive initially? NO. Has a judge ever considered that telling a person to do whatever is told by a physician and/or therapist only weakens any effort to maintain a therapeutic alliance? NO.
I would like to watch the reactions to the likes of those who run TAC to see if someone apart from a physician opinion determines that if you get diagnosed with Diabetes and have to take insulin shots, and that person with diabetes is a TAC advocate, how agreeable they would be to get those shots up to 4 times a day.
How fascinating those who champion for such intrusive and invasive actions are those who scream loudest, “but not me!” But then again, it isn’t those at the front lines who come up with these solutions in the first place.
Hmmm, depressed people can get psychotic, yet are they in the same patient population of psychotic individuals who should be deemed mandatory treatment patients? Is every psychosis a diagnostic impression to allow for such determinations?
Hey, the slope ain’t slippery anymore. It is a cliff!
Joseph, I don’t doubt that those supporting forced treatment are sincere in their desire to help. However, with the exception of those who are being violent, I don’t agree with forcing treatment on people. I cannot put myself under the care of anyone who supports TAC’s philosophy, because I don’t think it’s right to do that. I know that not all psychiatrists support forcing treatment on people who are not and have not been violent. The problem for me is trying to determine who does and who does not support it. I don’t want to end up like the woman in Minnesota who had hurt no one yet was being dragged from her home to have ECT against her will. That’s not right, and I wouldn’t want to be put in a position where I was having to flee my state to avoid psych treatment. I don’t think being put in that position would support my mental health.
I talked more with my therapist yesterday, and she has assured me that the psychiatrist she recommended would not force treatment on me or threaten me if I decided against his treatment recommendations. Her exact words were, “That’s not his style.”
I don’t think using threats to gain compliance and making people worry about being forced into something is going to lead people to seek treatment. I think it makes many people run away from it.
Scared: You make some good points. Obviously it’s wrong to physcially force ECTs on a non-violent individual against her will. All I am saying is that being delusional, hearing voices, seeing hallucinations or being emotionally overwrought either depressed, manic or back and forth is not being the best you can be or being the real you. People experiencing these things should, for their own good, seek and accept treatment. Many will not do so voluntarily.
Dr. Hassman, I have really appreciated reading your comments. It helps to be reminded that not all psychiatrists support TAC’s philosophy. I think intuitively I know that, but it still helps to read it. Particularly when I already lean toward the paranoid as it is.
I cringe every time I hear the so called “experts” on tv following violent acts by someone who is considered mentally ill, because they often talk about restricting the rights of the rest of us who had nada to do with what those people did. I definitely have my issues, but being violent is not one of them. In fact, it’s pretty much the opposite – I withdraw from society and hide. Even at my most cuckoo nut moments, I’ve never been violent or at risk of hurting anyone.
Joseph, please read Dr. Hassman’s comments on Sept 1. We’re not all the same, and we don’t all need the same approach.
Responsible clinicians do not buy into cookie cutter approaches to treatment, nor do they agree to black and white approaches to interventions when offered by the legal system. I am at a point in my life that I am not worried about insulting or annoying those who are lazy, careless, or just focused on income streams first in accepting patient care opportunites. You agree to take on patients referred by the courts, then you are inherently compromising on the treament experience for the patient being referred. I agree to treat people who are at least somewhat interested in what I can offer to aid them in returning to functional, healthy, productive lives. If they are only coming to avoid jail time or other legal consequences, then this is all I have to say to said individuals: go back to the judge and figure out your future, I was never consulted nor asked how to assist in the situation at hand.
If people want help, they need to find some way to ask, even if not fully able to do so completely.
Again, otherwise that is why we have jails, and graveyards. I have no interest in dealing with seasoned criminals and those who have no desire for therapeutic interventions. Treatment is and alway will be voluntary. If anyone really believes you can dictate care, good luck with that expectation!
Dear Dr Hassman,
I fully agree with your wise yet compassionate comment that “If people want help, they need to find some way to ask, even if not fully able to do so completely.” I was reading Dr Samuel Lopez’s postings on Narcissism when I saw your post as one of the related links. The reason I say this is because I have my narcissist ex continually sending me Emails using false names as a way to connect with me because I have told him in Messenger Posts that I still care deeply for him and want to help him. There is nothing threatening in the content – it’s just to make the connection – to tell me HE IS THERE HEARING WHAT I HAVE SAID. For example I said I’ve lost weight so he sent me a weight loss ad. I have been so DEEPLY HURT AND FRUSTRATED by this indirect approach – why DOESN’T HE JUST SHOW HIMSELF – HIS REAL NAME AND ASK FOR HELP I say to myself ??? Then I realise that HE IS CIRCLING THE WAGONS – HE IS FIGHTING THE BAD DEMONS VS THE GOOD ONES THAT LET HIM REACH OUT, AND IS NOT STRONG ENOUGH AT PRESENT TO REACH OUT – NOT “fully able to do so completely” in the same way as the people you refer to – those who have committed crimes, sometimes cannot. But if they kept coming by your office say once a week and smoking a cigarette outside while pacing and looking up at your office – YOU COULD CERTAINLY SMILE OUT OF THE WINDOW AND KNOW THAT THERE IS A CHANCE FOR THAT PERSON – THAT ONE DAY HE WILL LIKELY SUMMON THE COURAGE TO COME UPSTAIRS AND KNOCK ON YOUR DOOR. There is a chance BECAUSE HE IS STILL THERE CIRCLING – HE IS NOT GONE. Life is not black and white – it is GREY. Thank you for your kind supportive words – that one quote in particular about recognising how HARD IT IS TO FULLY AND COMPLETELY ASK FOR HELP really helped me in my life with what I’m struggling with re an extreme narcissist who committed a crime against me and HAS NOT YET ASKED FOR HELP, but I BELIEVE WANTS TO, after reading your wisdom. So thank-you – when we are sincere like you are and we express that in a post we help people in ways we may not ever fully know or understand. A quote containing empathy and wisdom in a world of despair can save a life. THANK YOU.
“If people want help, they need to find some way to ask, even if not fully able to do so completely.
Again, otherwise that is why we have jails, and graveyards.”
WOW….just WOW. If you have a heart attack that leaves you writhing in the street without the capacity for speach should we just watch you die on the pavement?
My guess is that you have never been psychotic, otherwise you might have at least some semblance of compassion for those that are.
Maybe I’m missing something from Sammy’s post but it seems to me that someone who has narcissistic personality is still responsible for their actions. What that guy did sounds more evil than mentally disordered, but what do I know.
I’m probably beating a dead horse here…while I realize TAC’s intended audience is not the patient, what they don’t seem to realize is that the patients (or potential patients) are listening, too. Many are reluctant as it is to see a psychiatrist, because who wants to admit they need to see a psychiatrist. It doesn’t exactly encourage people who might benefit from psychiatric treatment to hear TAC go on and on about forced treatment and people being violent. I wonder if those affiliated with TAC just haven’t been very good at building a therapeutic alliance with their patients, so force is all they have left. I do know that even if I were forced into treatment, I would keep much of what was going on in my head to myself. It was only because I trusted the therapist that I was able to finally admit to some of my cuckoo thoughts (which were not violent thoughts, by the way, just cuckoo). If I had thought she was going to use that against me to force meds on me, I wouldn’t have told her.
“It used to be that you were allowed to be as crazy as you wanted to be, as long as it didn’t interfere with other people or cause yourself or them harm or potential harm. It wasn’t against the law to be crazy and not be in treatment. Now, in most states, you can only be as crazy as the government allows.”
I’m aghast at that comment from Grohol.
Sorry, but if I ever again lose the ability of rational thought to my illness the right to be crazy is the last thing I will worry about. Being psychotic ain’t the best way to go through life.
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