So You Think Someone Might Be Mentally Ill

In the wake of mass shootings, some blame a failure to spot the signs of mental illness. But myriad obstacles stand in the way of getting someone good mental-health treatment.

A mug shot of Nikolas Cruz
Nikolas Cruz was charged with 17 counts of premeditated murder following a school shooting in Parkland, Florida. (Broward County Sheriff / Reuters)

In the years before 19-year-old Nikolas Cruz allegedly killed 17 people in a Florida high school on Wednesday, his behavior was strange, but not necessarily criminal. And not necessarily suggestive of a specific mental illness, either. He seemed fixated on guns and on killing animals, and his mother would sometimes call the police on him in an effort to manage his behavior. Some news reports have also said that Cruz has been “in and out of mental-health treatment,” though his diagnosis is not clear.

After mass shootings, opponents of gun control are often quick to suggest more mental-health treatment as a way to prevent further carnage. Yesterday morning, President Trump tweeted as much:

As I’ve written, most mentally ill people are not violent, and curing all mental illnesses would only prevent a small fraction—about 4 percent—of all violence. However, mentally ill people are more likely to carry out acts of violence if they aren’t being treated—hospitalized or medicated—for their mental illness. In other words, if we do want to prevent the small percentage of mentally ill people who might be violent from being violent, we should try to get them into treatment.

But mental-health advocates say there are many outdated laws and funding gaps that explain why reporting someone who’s acting strangely “to authorities” doesn’t always work to get them treatment. To understand exactly how that breakdown occurs, I spoke with John Snook, the director of the Treatment Advocacy Center, which pushes for more robust mental-health treatment. An edited transcript of our conversation follows.

Olga Khazan: The suspect in this shooting seemed to have strange things he did that did not qualify as criminal, but were nevertheless concerning. What can people do if their loved one is, say, talking a lot about guns, or acting strangely, but not necessarily in a criminal way, and they want to get them into some sort of psychiatric treatment?

John Snook: The law is actually different in every state. The system for getting someone [exhibiting signs of a potential mental illness] into care, especially if someone doesn’t want to go themselves, can be very different state to state. It’s called an “emergency evaluation.” In a state like Florida, the focus ends up being on whether the person is dangerous to themselves or someone else. That, unfortunately, becomes something of a barrier [to] getting care. The common story you hear from families is, “Obviously something is going on with my son, but every time I tried to do something, they said, ‘Well but he’s not dangerous yet.’”

Florida has done an inexcusably poor job at funding mental health. They are [44th in the nation], so it’s hard to get someone engaged in care unless they’re at a point where it’s obvious to everyone that they are sick and really dangerous. The examples you hear is if a person is convinced the CIA is after them and running around and yelling, that’s the level of sickness you need to have in Florida to get engaged in the system. That’s why in Florida, you so often see law enforcement being the means by which someone gets into care in the first place.

Khazan: Who is the person saying, “he’s not dangerous yet?” Is it the ER doctor?

Snook: In most states, you’ll have two basic doorways: going into an emergency room or a psychiatric facility. In Virgina, it’s a community-service board—it’s a mental-health system that’s set up to engage when a person seems like they need mental-health care.

In Florida, the system is so starved that you really are only getting care through law enforcement. Law enforcement needs to sign off on those situations. When it comes to mental health, every single part of the system is broken. In Florida, [as in much of the United States], you don’t have enough hospital beds. That is obviously a simple place to start. There also aren’t enough community services, there aren’t enough psychiatrists. Basically, every angle that you can think of for looking at the system for getting someone care for mental illness is essentially broken in Florida.

Khazan: How would it work in a state that does fund mental-health care more generously?

Snook: In many states, there’s a continuum of care, and it’s treated like any other illness. There are options for providing care to a person in the community. There are programs designed to engage them depending on their age, if you’re having your first psychotic break, or if you’ve been in the system a number of times. Arizona [is an example of a state that] has started to do a good job of coordinating that continuum of care.

Khazan: If you’re a parent, and you think your child is losing touch with reality, what are your options?

Snook: Typically, a family member will be able to bring a person for an examination if they’re under 18. Some states complicate that by saying the decisions will be the child’s after 14 [or another age younger than 18].

Khazan: What if it’s an adult child?

Snook: That’s the worst-case scenario. The family will say, once they turned 18, I lost them. They were too sick to understand they needed care, and the system completely shut us out. It’s complicated by HIPaA confidentiality laws.

Khazan: What about involuntary commitment?

Snook: Each state has its own requirement. What we have seen across the country is a move to ensure that these standards don’t just focus on dangerousness. Our organization focuses on making it a much more medical model, and instead of focusing on immediate harm, let’s look at their medical history and their ability to make informed decisions. That’s what we do for every other illness. If they’re having a stroke, you don’t say, “They’re having a stroke, but they aren’t dangerous to anyone yet.” In mental illness, we lose that too often.

About half the states have updated their standards to move to something more like a medical determination. But in Pennsylvania, for example, the standard is, are you a clear and present danger? Most people with mental illness aren’t going to be actively dangerous. A standard like “clear and present danger” leaves a huge amount of people without treatment for no reason. A homeless person on the street talking to themselves needs help, but they aren’t dangerous.

Khazan: What if you’re not the person’s relative, but you’re their neighbor? Let’s say I’m a neighbor and I notice someone talking to themselves or setting, say, ants on fire.

Snook: It is more difficult in those situations. You want to try to engage the family if you can. If it seems like an emergency, call 911 or your local mental-health professionals. The local mental-health agency will almost always have an emergency number you can call.

Khazan: In some of these cases of mass shooters, they either didn’t have a mental-health history, or the mental-health history just seems strange, like “an obsession with guns.” Are there diagnostic criteria we’re missing? Are there diagnoses other than schizophrenia and bipolar disorder that could potentially lead to violence?

Snook: In some of these incidents, the man who shot up the Fort Lauderdale airport, for example, that was an obvious case regarding serious mental illness. The FBI had taken him to a mental-health facility, and they still didn’t do anything. But then you have cases where there’s not a serious mental-health connection, there’s just a problem with the person. Those are the cases where people struggle to figure out answers.

There are risk factors for violence that are pretty well-researched at this point, like prior episodes of violence, prior domestic-violence incidents. There are two sides to this. [One is] the people who have a serious mental illness who aren’t getting the care they need. And there’s another side, that’s different, which is: What’s going on with this population that has an increased risk of violence? And we’re talking about two different populations.

Khazan: What happens if you just call the cops on someone who’s behaving in a disturbing way?

Snook: I think what law enforcement would tell you is that they have been forced into a role they don’t want and aren’t trained for, and that’s to be mental-health providers. The evidence is very clear, there’s a huge percentage of people with mental illness in our jails and prisons.

In a state like Florida, sheriffs are able to initiate the commitment process. Because the system is so broken there, you will have sheriffs doing far more involuntary commitments than they do arrests for drunk driving or assault and battery. Sheriffs didn’t sign up to be mental-health professionals. None of them want to be spending their day [doing this].

Khazan: What are the main things that need to be done to improve this situation?

Snook: The simplest thing is we need to take mental illness seriously. We need to get rid of outdated federal laws that say Medicaid can’t be used to reimburse for hospital stays if it’s because you’re there for a mental illness. We have to invest. We’re not saving any money if we’re letting these issues get this bad.