March/ April 2013 Reality-Based Mental Health Reform

Preventing mass killings like the one in Newtown may be impossible. But there’s plenty we can do to reduce violence by the mentally ill in general. And the tools are right there in Obamacare.

By Harold Pollack

In the aftermath of the massacre in Newtown, Connecticut, America is having a long-overdue national conversation about guns, mental health, and avoidable violence. The slaughter of elementary schoolchildren has a way of clarifying things.

Much of the conversation thus far has focused, quite rightly, on the guns. President Barack Obama has presented a package of valuable measures that closely match the recommendations of the nation’s leading gun violence experts. If enacted into public policy and American law, the president’s proposals, especially closing loopholes on background checks, have the potential to save many lives.

But there’s a certain irony in the timing of this national conversation, and the way in which we are conducting it. High-profile mass shootings are relatively rare, resulting on average in a few dozen deaths a year; ordinary, day-in, day-out gun crimes, on the other hand, wipe out more than 10,000 lives a year. Mass shootings are also quite difficult to prevent. I hope the sheer horror of Newtown catalyzes passage of a strong assault weapons ban, but the number of lives we will save through such a measure is likely to be modest. That’s because the overwhelming majority of gun-related murders and injuries, whether by angry spouses or by professional criminals, aren’t committed with assault weapons (defined, loosely, as semiautomatic firearms with military-style characteristics). Rifles and shotguns of all types, assault versions and not, together account for less than 12 percent of murders for which the type of gun is recorded; handguns account for the rest. The flow of ordinary crimes committed with ordinary weapons doesn’t command the same attention, but it accounts for many more gun deaths.

A similar irony applies in the area of mental health. The Newtown massacre has elicited serious calls to do something to stop the violently prone mentally ill. Yet the fact is that very little of the violence perpetrated by people with mental illnesses takes the form of mass shootings. Much more common are cases in which deranged individuals commit assaults, muggings, and robberies, or cases in which individuals with mental illnesses commit crimes connected with the misuse of alcohol or illicit drugs. In many cases, the primary victims are not strangers, but the perpetrator’s own loved ones and friends.

Just like those ordinary crimes committed with ordinary weapons, these individual acts of violence seldom make headlines. And of all the mentally ill likely to commit violence, mass shooters may be the hardest to identify in advance—in part because of the unusual, often idiosyncratic nature of such atrocities.

To be sure, in rare cases—often the cases that make headlines—mental health systems have failed to stop specific individuals who were already known to be dangerous. Seung-Hui Cho, the twenty-three-year-old who killed thirty-two people at Virginia Tech, had previously been found by a judge to be “an imminent danger to himself as a result of mental illness” and forced into outpatient mental health care. But things are usually far murkier. After an atrocity happens, one can often spot some ominous warning sign, some missed opportunity to intervene. Jared Loughner displayed strange and scary tendencies before he shot Gabrielle Giffords and eighteen others. James Holmes saw three mental health professionals before he shot dozens of Aurora theatergoers. Such red flags generally appear brighter in retrospect, the dots easier to connect, than they do in real time. One rarely sees the equally red flags waved by tens of thousands of others who have struggled with mental illness or who have sought help for personal challenges who never subsequently hurt anyone. There is little in the biography of Adam Lanza that should have led law enforcement authorities to specifically identify him as a threat to public safety before the events in Newtown.

In a New York Times op-ed last December by Richard A. Friedman, Columbia University clinical psychiatrist Michael Stone noted that “most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.” They are damaged, but not disabled, by whatever impels them to hurt others. Indeed, they remain sufficiently lucid to plan and execute horrific crimes. Except perhaps to the people closest to them, shooters’ signs of possible violence are rarely sufficiently obvious or precise to provide the basis for effective clinical or law enforcement intervention.

That doesn’t mean we should abandon the effort to identify and stop potential mass killers. Rather, as with gun policy, we need to be realistic about where the bigger problems lie, and what is likely to be accomplished. We must use the political energy of this moment to take actions that can reduce far more prevalent kinds of violence perpetrated by the mentally ill.

Fortunately—and unlike the situation with guns—Congress doesn’t need to pass major legislation to deal with mental illness-related violence. We might begin by doing a better job implementing programs we’ve already put in place. In Illinois, a 2011 report indicated that the state police should have reported an estimated 120,000 mental health records to the FBI National Instant Criminal Background Check System, which is used to keep guns out of the hands of the dangerously mentally ill. Only about 5,000 of these records had been provided. Illinois law enforcement also struggles to effectively retrieve weapons when people who bought guns legally in the past are found to have serious mental health problems. Boring nuts-and-bolts issues, funding challenges, and bureaucratic wrangling thwart such efforts. Obama has proposed federal money to support such state and local efforts. We should make sure that happens.

As for more sweeping mental health efforts, much of what’s needed is already on the books, in the form of the Affordable Care Act. The trick will be making sure that the new law gets translated into regulations and on-the-ground policies that actually address the problems we face.

Millions of Americans suffer from some form of severe mental illness, or SMI. It’s important to remember that the vast majority of these men and women have never committed a violent crime and never will commit one. (Indeed, the mentally ill are often victims of violent crime, a social problem that has not received sufficient attention.) The most careful studies in several wealthy democracies suggest that the severely mentally ill account for perhaps 5 percent of violent crimes.

Despite these rather low numbers, violence perpetrated by a subset of disturbed individuals is a genuine public safety concern. These are certainly familiar issues for law enforcement. As one influential report notes, “Officers spend more time managing incidents related to severely mentally-ill persons than they do responding to traffic accidents, burglaries, or assaults.”

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.


  • Jonathan Sanchez on March 04, 2013 12:40 PM:

    There's something wrong with the link to the third page of this article--it's looping back to the first page.

  • bigtuna on March 04, 2013 5:04 PM:

    Two thoughts

    1. Perhaps ACA will help with some aspects of mental health and violence. However, you omit another source of death and debilitation regarding weapons and the mental health system - suicides and attempts to prevent suicides. Here, the access to guns is a very big issue, as is the fact that many people who attempt suicide are likely battling depression or other mental health issues.

    2. In this regard, AND in regard the mental health and violence towards others, I wonder about how well ACA will help. Yes, more people will be insured. However, I think many elements of ACA that will govern reimbursements to health care provides will rely on evidence-based care - that is, covreing more people, and we hope at lower costs, will mean a tight control on the nature of care given, the amount of drugs, tests., etc. So if a heart med is 85% likely to reduce hearth attacks in patients, it will be paid for. Bone marrow transplants for various cancers? Various radiological scans for certain conditions that have a 30% rate of showing something? Probably not so much. There is nothing wrong with this sort of system - it injects a level of evidence based medicine to our system, and has to be done if we are going to offer basic care to people w/o insurance.

    However, When it comes to mental health, I bet the stats are much harder to come by; while some treatments will be pretty verifible, others are not. THis is going to be pretty tricky territory for the system as it is reformed.

  • Rich on March 11, 2013 11:49 AM:

    What about services funded by CSAT and CMHS? What is Illinois doing with this money? What about locally raised funds? In many places, much of teh funding is raised locally.

    ACA-related insurance, including Medicaid expansion will require the same things that make it difficult to maintain entitlements. Marginal mentally ill people may lack a permanaent address or ways to remain in touch with whatever system manages these benefits.

  • Dana on March 16, 2013 10:21 PM:

    However accessible or effective we make mental health care, it is useless against violence as long as the mental health system refuses to define violence as pathological. For all the controversy surrounding DSM-V, there was not one peep suggesting that - just as one example - domestic abusers should have a diagnostic code. Half of the mass killings in the United States are honor killings. But as defined by our mental health system, most of the perpetrators are perfectly sane.

  • Ron Wagner RN, MA on April 03, 2013 12:37 PM:

    An interesting article. It really doesn't offer anything valuable in the way of solutions however. It seems to be a plea to support Obamacare. Dual diagnosis of substance abuse and mental illness does offer some indication of mental illness, but just substance abuse alone is the primary indicator. Behavior period, is the key indicator. Diagnosis is over rated. Past behavior is the best indicator of future behavior. Past behavior may not be violence itself, but preparations for it. That is not illegal, unless it involves illegal weapons.

    The best solution is actually for individuals to learn to avoid, and defend against dangerous people. For schools, that means being able to keep them out. Mass murderers are attracted to places where people are known to be defenseless.
    Police must keep records on those who are dangerous, for whatever reason. They should request mental evaluations, and treatment should be considered. Anyone can be committed if a trained medical provider can be convinced that a person is a danger to himself or others. There is a danger to civil liberties inherent in the abuse of the ability to commit, and it is difficult to keep someone for more than a few days. Society cannot afford to, and should not commit many people. Once committed guns can be taken from the patient, but they can always obtain them on the black market, along with other weapons.

  • Cary on July 15, 2013 11:09 PM:

    The comment that the reason the mentally ill don't get help is they don't have access to Medicaid is ridiculous. Definitely plugging obamacare. I have a brother who is bipolar, ptsd and alcoholic. He is a vet so has been in and out of va many, many times. They can't legally hold him long enough to stabilize him. I've been told so many times that he has the right to be crazy--in other words, unless he's pointing a gun at himself or someone else, that's just fine. Very frustrating that its impossible to get a mentally ill person help with or without insurance. Obamacare won't change that. Sickening to even suggest it.