Confusing Mental-Health Intervention and Violence Prevention

By Jeff Deeney

In the wake of this weekend’s mass murder at the University of California Santa Barbra, people are again asking—as they have after each of the nation’s recent mass shootings—what could we have done to prevent this. There were obvious indications that Elliot Rodger was planning something terrible, a spectacular crime against women that he outlined in YouTube videos and a lengthy manifesto that would bring him infamy.  His family was concerned enough to contact the local Sheriff’s office and ask them to perform a mental health check on their son. Sheriffs arrived to find Rodger lucid, denying intentions of violence, and described him as articulate and shy.

What they didn’t know was that he was hiding an arsenal of handguns and ammunition and a document that would later prove that he was lying about not intending violence, that in fact he had spent a year devising plan to attack a sorority house that symbolized his suffering at the hands of women who rejected him and refused him the sexual gratification he felt entitled to. After murdering seven people, injuring many others and then committing suicide the investigation immediately turned to the question of whether the Sheriffs who visited him hadn’t made a mistake in not detaining him for psychiatric observation.

The question of whether law enforcement and mental health professionals hadn’t failed in their duty to their communities by failing to forcibly detain those who would go on to commit mass shootings has been raised after most recent episodes of such violence.

“If only the police had put him in a 5150 hold.....” one Twitter user lamented.  Even Santa Barbara Sheriff Bill Brown was second guessing himself on CBS’s Face the Nation, saying he wished "we could turn the clock back and maybe change some things,” implying that given a second chance his men would have detained Rodger for a mental health evaluation.

Adam Lanza had therapeutic contact with mental health professionals before he went on to shoot up Sandy Hook Elementary School. James Holmes was seeing a psychiatrist before he went on a killing spree at an Aurora, Colorado movie theater in July of 2012. Before Jared Loughner shot Gabbie Giffords near Tucson, Arizona he had raised red flags at school, where teachers reported that he had become increasingly bizarre, delusional, and threatening in class.

So why didn’t law enforcement detain Elliot Roger, or any of the other recent mass shooters who had some contact or had some concern raised about their wellbeing before they went on to kill? It seems obvious after the fact that such an intervention could have prevented unfathomable tragedy. Why do we fail to intervene?

In the case of Elliot Rodger, based on the description given by the Sheriff Bill Brown at Saturday night’s press conference, it’s hard to argue that they should have done anything more than they did. Trained in mental-health response calls, the officers arrived to find Rodgers not fitting the criteria they would normally use to take someone involuntarily into custody for a mental health evaluation. Officers said that they found him lucid and articulate, saying that he had no intention of hurting anyone. They said that he was shy, but shyness isn’t indicative of unstable mental health. They probed enough to find out that he was lonely and having problems in his social life. But being a loner is no more an indication of unstable mental health than shyness. And the criterion for involuntarily holding someone, while they may differ some from state-to-state, are usually very clearly defined: Does the person pose an immediate threat to themselves or the community (As in, do they actually verbalize, “I am going to kill somebody or myself and here is my plan for how to do that”?) If not, the right thing to do, which the Sheriffs in this case did, is to not detain someone.

This fact has begun to frustrate a public grown weary of mass shootings where mental illness may be a contributing factor. After previous mass shootings, there have been calls to ease the strict standards guiding involuntary mental health treatment to give authorities greater ability to detain and compel the treatment of mentally ill people they fear could become a risk to the community, even if they aren’t imminently one at the time of their interaction with the person. In The National Review, David Gratzer wrote after Jared Loughner’s 2011 Arizona rampage, “Before the 1960s, psychiatry was largely unrestricted by patient rights. In the past four decades, the pendulum has swung to the other extreme … Arizona is a tragedy. But perhaps it will inspire us to reconsider the rights of the severely mentally ill, and our responsibility to them.”

The call to scale back protections against the civil liberties of the mentally ill has found many advocates in the gun-rights movement, who feel that the bad press surrounding mass shootings threatens the Second-Amendment rights of responsible gun owners. After Adam Lanza’s killing spree at Sandy Hook Elementary School in Connecticut, there were calls for Three Strike mental health laws, where all protections against involuntary commitment to mental health facilities would be forfeited by the chronically mentally ill.

The question of using the civil mental health system to involuntarily detain someone who hasn’t committed a crime, but who we fear may commit one at some point in the future is fundamentally one of human rights. The civil mental health system is set up the way it is now, with strict rules guiding how it can be used to treat someone without their consent and tight checks and balances against abuse including repeated hearings in front of a judge every few days to prevent someone from being unnecessarily detained, to protect citizens from others using the system against them for abusive reasons. Other nations use psychiatric systems to penalize political dissidents. Our history of abuse-ridden mental hospitals where people were indefinitely detained demonstrates how such institutions can operate without strict oversight.

Most people have never participated in an involuntary mental health commitment. As a social worker, I have, a number of times. When you’ve participated in one, especially one that has gone awry, you see with crystal clarity the reasons for so many layers of protections for the detainee. When a civil commitment is authorized in the state of Pennsylvania, it becomes a warrant to take them into custody. People who go to psychiatric units against their will don’t go in ambulances, they go in paddy wagons. The responding officers may be well trained professionals who treat your client with respect, and I have had many mental health interactions with the police where they acted with tenderness and empathy.

However, every involuntary commitment is a dice roll. Maybe you get a good cop; maybe you don’t. Maybe you get a good cop who’s having a bad day and antagonizes your client. Maybe your client, once the police arrive, resists or even goes on the attack. In such cases I’ve seen police restrain and gag a client, roughly dragging her from her home mewling, unable to scream through the restraints they jammed in her mouth. The effect is traumatizing, and every social worker knows that their relationship with their client is almost assuredly ruined after such an intervention. After every involuntary commitment I’ve weighed whether I could ever participate in such an act again, or if I should pursue a different line of work, because I’m always haunted by the question of whether I did the right thing. I think I’d be a bad social worker if I took the civil liberties of the people I serve any less seriously than to ever consider subjecting them to this unless I knew with certainty that they or someone else would imminently die if I didn’t.

Involuntary commitments are not the silver bullet some want them to be in dealing with mass shooters. People who are involuntarily committed frequently leave psychiatric institutions little more stable than when they arrived. Some in the public assume that one can’t refuse medication in a psychiatric unit, when in fact forcibly medicating requires two doctors’ orders submitted to review by a judge, so many patients aren’t stabilized on medication because they resist taking it, even in a hospital setting. The public assumes that there is some life-changing intervention that happens inside psychiatric units after someone is committed, that leaves them permanently fixed after 72 hours. In fact, it’s more typical receive little more than observation to make sure one doesn’t harm oneself while on the unit. A social worker will refer you to an outpatient mental health program when you’re discharged, but if you don’t want to go to one you don’t have to. If you choose, like so many do, to return to the community with a small supply of medication you don’t intend to use let alone refill, that’s your prerogative.

This is why Elliot Rodger likely would have still committed murder even if the Sheriffs had detained him on the day they visited him. A 72-hour stay on a psych unit might have done little more than but make him more determined. And there’s no evidence suggesting that changing our mental health policies to make involuntarily committing people with mental illness easier to do won’t wind up netting more Elliot Rodger types in the nick of time before they kill. It will more likely wind up hurting our friends, family and community members with mental illness who are not violent, that make up the vast majority of all people with mental health disorders. It risks making it easier to commit the terrible injustice of unnecessarily taking away the freedom of mentally ill people who pose no real risk to public safety. There are many ways to prevent mass murder that we should be discussing, including the quality of mental health treatment we provide, but calling for more involuntary mental health commitments isn’t one of them.

 

This article available online at:

http://www.theatlantic.com/health/archive/2014/05/confusing-mental-health-intervention-and-violence-prevention/371577/