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Scott Gibson: The myth of a mental health solution

Once again, our country has been traumatized by a mass shooting, this time  a synagogue in Pittsburgh. And once again, we have heard calls for America to fix its “broken mental health care system.”

But in spite of all the killings, the debate on mental health always stops at the We-Gotta-Fix-It stage. Nothing more ever gets done.

Why?

In the U.S. today, we already have excellent tools for helping the mentally ill. With the right medication and therapy, patients can experience tremendous, even life-changing, improvement.

In spite of this, there are good reasons why improving mental health care on a large scale is difficult. And there are real limits to how much we can achieve.

In the interest of kick-starting the debate about mental health and mass killings, I would like to discuss some roadblocks that limit treatment of the mentally ill as a means of ending the mass murders.

1) Identifying the mentally ill can be hard. In fact, it may be the weakest link in the system.

According to the National Academy of Science, about two-thirds of people with a diagnosable mental illness do not receive treatment. And stigma is one big reason.

Guest Writer

Dr. Scott Gibson s a board-certified internist who has established a local practice almost 30 years ago. He maintains an affiliation with the Willamette Valley Medical Center in addition to operating the Yamhill Valley Surgical Center, specializing in colonoscopies and endoscopies. He served several years on the McMinnville School Board before moving to Amity to open a bed and breakfast inn with his wife, Melody. He is also an accomplished landscape photographer.

It doesn’t help when people like Wayne LaPierre of the National Rifle Association call for a national registry of mentally ill persons. If getting a prescription for Prozac or confessing to PTSD can put you on a registry, still fewer people will seek treatment.  

Even homicidal people can be hard to detect in advance. Take the bump-stock shooter in Las Vegas, who killed scores of concert-goers in 2017. He had shown no sign of serious mental illness before he committed mass murder.

Determining who is and is not mentally ill will remain a daunting challenge regardless.

2) The mentally ill sometimes resist treatment. This is especially true in the case of certain severe illnesses, like schizophrenia, where people lose touch with reality and do not comprehend the disorder in their thinking.

Schizophrenics are also paranoid, making them suspicious of the very people seeking to aid them. A 2005 study found 74 percent of schizophrenics discontinued their medications, and a study of bipolar patients found 40 percent were non-compliant.

The mentally ill have the right to refuse therapy, and often do. At what point are we willing as a society to coerce treatment, especially for those who have broken no laws? 

3) Separating the dangerously mentally ill from the harmlessly mentally ill is nearly impossible.

Here is a vital point rarely mentioned — no psychiatrist, psychologist or social worker can reliably predict the future behavior of mentally ill persons. Short of a person stating an intention to do harm, we do not have tools to predict violent behavior in any individual.

Studies confirm this. Researcher Jeffrey Swanson of Duke University states, “Psychiatrists using clinical judgment are not much better than chance at predicting which individual patients will do something violent and which will not.”

Human behavior is simply too complex. And chance events can push previously docile individuals past a tipping point into violence.

Current law limits involuntary detention to those deemed to pose an “imminent risk” to themselves or others. That reflects the reality that we are very poor at predicting behavior beyond the immediate future.

In fact, the great majority of mentally ill persons are nonviolent. Picking out the few who will commit horrific crimes is just a futuristic dream.

4) Distinguishing anger from mental illness is a tricky affair.

Many people in America are angry with our politics now. But how do we define the transition from anger to mental illness?

Cesar Sayoc, the man who sent pipe bombs to prominent Democrats and Trump critics, drove a van plastered with anti-Democrat bumper stickers, including one depicting Hillary Clinton in rifle cross-hairs. And the man who killed the Jews in the Pittsburgh synagogue posted deplorable anti-Jewish messages on social media.

At what point does exercising free speech get you a mandated mental health exam? Do we have a bumper sticker limit? Ten or more and you see the forensic psychologist? Will depicting cross-hairs on people get you a Rorschach test? 

There are hosts of people in America who have opinions others find inconceivable, irrational, hateful and even dangerous. Those opinions are, however, protected by our right to freedom of speech, guaranteed in the First Amendment. And that is a very tall fence to get over.

5) Last, mass treatment of the mentally ill could be incredibly expensive. How much it would cost would depend on how aggressively we wanted to expand the system. If we are going to make a big difference on a national scale, we have to be prepared for some sticker shock.

Improving our mental health system is vitally important, as it is badly underfunded and understaffed. There is no doubt we can make our country a better place by aiding those suffering from a mental illness.

But expanded mental health care will not eliminate hatred and anger. It will not make people decide to be treated. It will not distinguish the dangerous from the harmless. And it will not be cheap.

We may have to rethink how civil liberties like freedom of speech and the right to refuse treatment intersect with the mentally ill. 

Too often, in the debate over mass shootings, “fixing” mental health care is used to end the discussion. But even if we untie the Gordian knot of our mental health system, mass killings will continue.

We need to consider all possible ways to stem the carnage. The mentally ill will always be with us, and a few will always prove dangerous.

We should not delude ourselves into thinking we can medicate our way to safety.

 

Comments

Jim

Scott I think you wrote a great piece on mental illness in our country. You had many great points and I couldn’t agree with them more. It’s a tough situation for individuals,family’s,law enforcement and the general public. I don’t have any magic to offer but I hope as a Nation of people we can eventually offer better help and guidance to this group of humans.

Scott Gibson

Jim, I agree that it would be good if we could find and intervene positively with the mentally disturbed. But I also feel we should spend more time working on solutions that have been shown to decrease shooting deaths that don't depend on somehow unlocking the human psyche. That goal is a long way off, and it is time we admitted that.

Joel

Thanks Dr Gibson for a very thought provoking essay.
In my view, many,if not most, of our problems as humans are amendable to prevention and treatment utilizing interventions that are underpinned with scientific studies. Polio? Thanks Mr Salk for utilizing the scientific method to find a cure. Desire to fly like the birds? Thanks Wright brothers for utilizing the science of physics to make it a reality.
However, their are some aspects of human nature and behavior that seem beyond the reach of science. These acts of violence that Dr Gibson speaks of are one example (and by the way, despite Dr Gibson's lopsided use of far right examples, extremists on BOTH sides of the political spectrum, as well as non or apolitical individuals, engage in these kind of violent acts).
At some point we have to acknowledge that the scientific method has limitations. So when it comes to preventing mass shooting and the mental illness that precipitates them, if not science, what? Well, this isn't going to go over very well in our society that currently worships at the alter of secularism, (and at this point many may stop reading and just write me off as a kook, and I'm okay with that) but here goes anyway...the cure is a return to God. Not in a black and white "my God is better than your God" way. But in returning to God as you know him (or her).
Alcoholics and drug addicts will tell you that scientific treatments from Psychiatrists are for the most part impotent in curing their affliction. Why? It's another example of an aspect of our human behavior that is beyond the reach of science. What works best to help the addict? AA. What is the central tenet of AA? turning ones life over to a higher power.
So again, in my view, we as a nation need to return to God. We have cast Him out and in so doing we sowed the eastwind. Is it any wonder we are now reaping the whirlwind?

Mudstump

Joel - I respect your "return to God" belief, but I think we also need a return to mental health funding and it may be necessary to return to involuntary hospitalization. In the early 1980s president Reagan ended involuntary hospitalization and evaluation and he failed to renew funding for mental health. He also released half of the mental patients into the general population to roam the streets of California. So, God...yes (if it works for you)....funding yes...and a closer look at returning to involuntary hospitalization may be needed to get the problem under control. Right now many of the mentally ill are incarcerated when they need to be mandated to mental hospitals instead where they can get treatment for a possible healthy return to society....jmo.

Joel

I completely agree, Mudstump. Along with a return to God I believe we should try everything we can think of... and what you have proposed makes good sense.

Lulu

Hosea 8:7: "For they have sown the wind, and they shall reap the whirlwind." I don't know where the east wind figures in with this warning.
Mudstump is absolutely right about the emptying of mental institutions, dumping sick, psychotic people on the streets in the idealistic quest for the least-restrictive environment. That practice is also popular in schools and, while a swell idea on paper to sociologists, it simply doesn't work. God's involvement means nothing, either; it's used as a carrot-and-stick, or rod and staff, motivator. There may be many mansions in the Promised Land, but we need physical places here on earth that lock.

Mudstump

Joel - I grew up in Kansas City. Just north of KC is a town called St. Joseph where the state mental hospital is located. I have to chuckle when I think about my mother and how she used to say..."Do you want them to come get you and take you to St. Joe?"....when I was misbehaving of course. It was real then....the state could mandate that you be evaluated and if necessary they put you in the hospital until you were well enough to return to society. No one likes the idea that one could be committed to the hospital for treatment against their will, but right now these people are free to cause harm to others. We see the consequences when we hear that another mass shooting has occurred.

Joel

Sounds like you have a cool mom, Mudstump. I think it would be great if our state would commit people to a mental hospital. I feel bad for anyone that has to go through that, but I feel a lot worse when I see mentally ill people committing these mass shootings.
I don't think more gun control is the answer...we have the second amendment. I don't think banning violent video games is the answer...we have the first amendment.
I think you're on to something, Mudstump. Identify who the mentally ill people are, lock them up in a hospital and treat them until they are safe to be in society. It's not a perfect fix, nothing is, but it would make a difference.

Scott Gibson

I appreciate the discussion that I see here. I was hoping I might be able to stimulate an exchange of ideas. Joel, I would agree that if we could get people to live by the "love thy neighbor as thyself" admonition of Jesus, we would not need to have this discussion. But as Ghandi said when he was asked what he thought of Western Civilization, he answered, "It would be a very good idea." As Lulu and Mudstump point out, we may need to consider re-examining involuntary treatment of mental illness. And as Joel says, it might make a difference. I do have to diverge on the issue of gun control. Even within the Second Amendment, there is room for regulation. Hence the proscription of machine gun ownership. I think we should look for gun regulations that will pass Constitutional muster and may help decrease the risk of mass murder. I would start with bump stocks.

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