How America’s Mental Health Establishment Empowered the Navy Yard Shooter
The security breaches are already being well covered in the public media on the tragic D.C. Navy Yard massacre. So is the absurd U.S. tolerance and obsession with violence. And, hopefully, the gun culture debate is firing up again. But what I’d like my readers to focus on is the total failure of our mental health system, if you can call it that. The dozen innocent victims of the shooter’s crazed act and their families can look to the numerous red flags apparent in his long history of schizophrenic behavior ignored or overlooked by mental health professionals and Aaron Alexis associates alike. And no, it was not within his capability to recognize the illness in his own behavior. The responsibility sits squarely with the so called professionals. They own it as do they own the stunning inadequacy of our country’s mental health care. Here’s what we must address as a society, holding these professionals accountable for joining we the people in fixing this travesty of a system.
The Law Empowers Irrationality
The patchwork of 50 State laws prescribes that even in an impaired, delusional, irrational state, mentally ill persons should make their own decisions unless declared incompetent by a court, irrespective of the consequences for society, the patient, their caregivers or family. The law actually supports irrational, self-destructive decisions even in the face of a patient having been declared incompetent by probate and criminal courts. Let me illustrate this absurdity: Patients are allowed to decide, in spite of not having complete rational faculties, to refuse or abandon medication which can give them a reasonably predictable life and freedom from haunting paranoid fantasies. And the medication-free state enables patients to physically endanger or harm family, caregivers, the public or law enforcement persons. This legal right allows them to wander the streets and violate the rights of society, friends, neighbors, co-workers and family. Not to mention the cost use of the jail to house them until authorities can figure out what can be done for them. How does this allowed irrationality make any sense for a society? Intervention should have been done years prior with this shooter as well as those across the country in other recent mass slaughters.
Why Aren’t Society’s Rights At Parity With Patient’s?
Further the law as well as the mental health establishment, both social workers and medical professionals, prescribe that limitations can only be placed on a patient should they be a “danger to themselves or others”. The word “danger” is subject to broad and varied interpretation. Somehow, “danger” is only interpreted to be imminent threats to life, the patient or someone else. Usually this stands to mean only that they might commit suicide or homicide. Damage is never interpreted to mean creating physical, psychological and mental pain for society or impossible physical, psychological or financial demands on caregivers and family members. This law needs elaboration to include the physical psychological damage resulting from the patient’s behavior in not taking medications prescribed.
The laws governing forced medication must be reformed to enable humane and manageable care for both the patient and caregiver, clarifying and simplifying due process for both the patient and caregiver.
The vision of the reformers when the asylums were emptied in the 60’s and 70’s was for community based centers with outpatient services. This vision was never realized anywhere that I know of in the U.S. medical system. Taxpayers apparently are unwilling to fund such enterprises nor have such facilities in their backyards. So, realistically, rejuvenating and modernizing centralized care facilities seem to be the only humane (for all involved) alternative.
Reform Won’t Be From Clinicians. Care Givers Must Rise Up.
Clinical training of psychiatrists and therapists seems not to include equipping caregivers with proven methods to achieve more successful interactions with the patient. Nor does there seem to be training to secure and listen to the feedback of the caregiver or associate regarding patient behavior and ideation. These clinicians, more often than not, in my experience, would rather blindly stab at information gathering on their own, securing often wrong information from an irrational and delusional patient, relying on them, not more rational sources of information. I attribute this to professional arrogance as well as privacy law. This is why there is no medical/law enforcement database to document behavioral/ideation history as appears to be the case with the shooter.
My own experience is that the primary role of psychiatrists, at least in the public sector of mental health care is to write prescriptions. Is this what their many years of training intended; to by hyper-pharmacists? The public and family are in desperate need for education on recognizing the symptoms of serious mental illness. And we need guidelines on how to get us all help when the symptoms are apparent. Why not require such community service of all psychiatrists and therapists to retain their license to practice?
The privacy laws protecting the patient in these cases actually deny their clinical providers both information and contact that can assist the patient and them in preparing treatment plans which are sustainable. Lawmakers must reengage on privacy issues and craft better methods of protecting the privacy of patients while not handicapping diagnostics and treatment and putting the public at risk.
Likewise, clinical providers, courts and legal guardians must be properly trained in both privacy and rights protecting policy so as to not undermine the rights of society and caregivers, thus also undermining proper care giving. Clearly, currently this is seldom the case. HIPPA laws are often used to enhance the power of clinical caregivers, not enhance the ability of family members or society to cope with mentally ill persons.
Involuntary observation and hospitalization must be more readily available to family members and/or associates of a diagnosed mental health patient. The process of involving family members or associates in the assessment of an undiagnosed person must be simplified. Inadequate, typically two week length of stays for treatment, which appears to be the current practice for chronically ill patients, is completely unrealistic. It does not allow for adequate medication administration and adjustment, not to mention adequate counseling to find individualized treatment plans. This includes an efficient forced medication policy which also assures due process. Lengths of stays must be increased and caregivers and patients alike need for schools of psychiatry and psych nursing to step up and be heard and listened to by those who control state/local budgets for such public care.
HIPPA laws and clinical practices must be modified from the current status of requiring the non-rational patient to sign a release in order that information about their diagnosis, treatment plan and medication regime be shared with family members and caregivers. The result? Patients discharged with the only hope of their staying on their medical regime lies with the irrational patient themselves. This, in the case of suicidal or patients with violent histories, potentially endangers family and caregivers, or at the very least, denies the patient support around them to sustain their care program. This is so obvious to those of us who have lived with such situations, why not the clinicians and lawmakers?
How are these reforms to be implemented? One would hope they could come from within the educational and clinical mental health community. But, they likely will not come from within the mental health profession. Mental health professionals, your fellow citizens must rebuild your broken system since you seem unable/unwilling to do so, evidenced by the story I read about The Navy Yard shooter.
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Excellent first post. Welcome again PP!
I think I will count to 10 before I respond. PP and I will clearly cross swords on this one of where to place an undeniable culpability in the mental health fiasco we are all tasked to live with for now.
How long of a “grace” period do new DL contributors get before gloves come off? You know I don’t want to be rude to my host :). And there is that gathering tonite…..
But wait…how timely…..pirate behavior yes?????
Imma side with Joanne on this. Some of these suggestions are just flat-out crazy (may be time for an involuntary hospitalization).
Sigh.
My solution to this problem is actually to create a single-payer mental healthcare system. Anyone who needs mental health services, would get them. It would be a great way to ensure that people aren’t locked out of the services that they need or locked in to an institution waiting on Geraldo to rescue them.
Welcome!
Intentionally taking the cynical message from this, It seems like you are suggesting that we go back to a system where people can be locked away if their family or doctor says so. They break no laws, but because of a condition they cannot control and did not create, their freedom is forfeit for “the greater good”.
We used to do this to people with cognitive disabilities, communication challenges, head injury victims, people with PTSD, homosexuals, reluctant Christians, women who didn’t smother their sex drive………. you get the idea.
Now that the “devil’s advocate” slippery slope crap has been said…. how do you think these steps would be implemented? Do we first define “danger” so when it becomes legal to commit someone to an institution, there are already clear legal guidelines? If mental health professionals are, as you say and I personally know, are indeed writing RX’s left and right as a way of “dealing with the problem”, how long before people start getting sent to these institutions who really dont need to be? At the very least we should
I’ve never seen your thoughts on government spying, the NSA, or Bush’s “preemptive war”, but “locking people up” (to put it blithely) or taking away freedom in the form of forced medication from someone based on what they “might” do is a very dangerous suggestion…. were that what you are suggesting.
Im interested in how this would be different from all the things i mentioned that are probably not at all what you’re talking about.
Clearly im not as polite as JC 🙂
LG, jumping over the fence here….
What is to be done with people who aren’t able to recognize their own needs? Psychiatric medication that exists today is rough stuff. For weeks after starting treatment, the side effects can be a worse experience than the mental illness.
In the end, I don’t think you can always trust people to “do what’s best for society”, which is what we are asking of the (I’m sorry, i know it’s not the correct vernacular) mentally ill. Self-regulation… that sounds familiar.
No, they arent the CEO of a company focused on getting more money…. but they are an individual trying to find comfort and happiness, and WAY too often, medicine and treatment, no matter how readily available just doesn’t provide that.
I have mixed feelings. A good friend of mine’s husband was horribly depressed and suicidal. There were moments where he was unreachable and moments he asked for help. Unfortunately, during one of his unreachable times he killed himself. She had called and called for help for him… but to no avail. Surely, there’s something in-between.
Nice first post!
No time right now to go where I want to go with this. But just putting it out there…pandora cites a worst case scenario–of which I have plenty. But here’s a typical one, FAMILIES deal w/ all the time…….
Adult supposedly on meds, has not taken meds because “doesn’t need them anymore, I feel better, I don’t like them……” Calls a taxi–has the cabby drive person all around the county…..long story short—a 4am wake-up call to a relative by a taxi-cab driver w/ a $428 fare….that needs to be paid NOW!!!!! And an adult relative who still needs a ride home. Didn’t hurt anybody, so no grounds for involutary etc.. But, you now have a stiffed and PO’d cabby, a family member once again answering the middle of the night crisis phone call to get this fare, and cover the fare…..a sick relative obviously needing a med check, but thinks and CAN walk right away from all the chaos, that just unfolded. Oh, and you now have another relative on meds to deal w/ all this. It’s Ground Hog’s Day for the families and caregivers of this conundrum our laws have created.
SB – In my perfect world, people get help earlier because it isn’t as costly to get in to see someone.
Just like single-payer for everything else, it isn’t a panacea. It makes fewer people seek help only when the issue is acute. It won’t fix everything. People that don’t like to go to the doctor still die of diseases that can be cured if caught early even when they are insured. People that have a psychotic incident will still do bad things.
But what I see proposed here is the stripping of rights from a person due to a medical diagnosis. It is a very fine line that we have to walk to balance the rights of different people in society (patient v. potential victim) but the suggestions are out of proportion with the real scope of the problem.
I’m disappointed in the lack of respect shown for the rights of the mentally ill, who are generally at greater danger from themselves or others than others are from them. Community treatment when appropriately funded works wonders. Psychiatry is poorly reimbursed by insurance and so many practitioners remain financially out of reach for people who need them. If you’re uninsured or poorly insured, you can’t get enough talk therapy because of costs, but meds will be comparatively pennies. Mental health stigma also keeps people from seeking help, a stigma not helped when media only addresses the issue when discussing violence, as though the needs of sick people for their own sake isn’t a story. As for educating people on mental illness, NAMI is an invaluable resource to the community, and here in Delaware they have housing as well to keep people in the community. I’m proud to call them neighbors.
PP, thank you for the post. There is a lot to respond to, but I just want to focus on a couple of points:
“Involuntary observation and hospitalization must be more readily available to family members and/or associates of a diagnosed mental health patient.” This assertion falsely assumes 1) every family has members wishing the best for each other 2) the ‘family’ will always agree upon one plan of action and 3) hospitalization is the optimal place for treatment
1) Not every family member makes the decision making for that patient’s “best interest.” When people abuse their spouses and an argument erupts between the two, the husband/wife wants to get rid of the other spouse via any means possible. Involuntary confinement is actually a preferred way for many abusers because it allows the abuser to save face and place the blame of the violence on the person being confined (due to being “crazy”).
2) There is a reason why health care professionals don’t provide health care for their direct family members. Emotions do get in the way of making an objective assessment of the patient’s illness. And the different family members don’t always agree on the plan. Recall Terri Schiavo.
3) Studies show that familial involvement in the patient with schizophrenia’s life reduces his/her hallucinations by about 50%. Many psychiatrists actually refuse to treat schizophrenia unless the family is involved. Much of this is because the patient remembers the family and his/her home before the hallucinations start (typically in the 18-30 year old range). Therefore, the patient can recognize what is real and what is not real (not a part of that home environment). Placing a patient with schizophrenia into a unfamiliar mental health institute like Rockford and/or Delaware behavioral health center does not allow him/her to recognize what is real and what is a hallucination.
The larger point you’re missing is patient autonomy, which is a cardinal medical principle. There is a reason why patients put under involuntary confinement have a right to appear in court within a certain period of time of whether confinement is necessary. Others have hit at that a little bit, so I’ll leave that to them.
“Patients are allowed to decide, in spite of not having complete rational faculties, to refuse or abandon medication which can give them a reasonably predictable life and freedom from haunting paranoid fantasies.”
What. The. Fuck. Isthis?
Did you guys get this dope from the Texas We Know What’s Better For You So Shut Up And Take Your Medicine You Crazy Person Party?
As someone who has suffered from mental illness, who has been on medication, and who has had family members suffer from the same, allow me to jut in here just a bit.
What’s needed is NOT the ability to lock up Crazy Aunt Jane for a while if she won’t take her meds. There exists a process for involuntary commitment already, and it works. What IS needed are more counselors, less expensive drugs, and less expensive counseling sessions. Lower the cost, make it as accessible as pediatric care, and more people will get the help they need.
In the meantime, somebody please muzzle this reactionary sonofabitch who’s writing this shit.
That’s SussexWatcher’s way of saying “Welcome”
Whoa! Take it down a notch. There’s a lot of grey area here, and I doubt that anyone reading about the Navy Yard shooter was stunned. Talk about cries for help.
And yeah, I’ve been there for the aftermath. I was with my friend 10 minutes after she found her husband’s body. I was there as the paramedics removed the body, and I was there as the police questioned her. Did she help him commit suicide? Did she kill him? Awful questions. Know when I wasn’t there? A month before he killed himself. I feel guilty about that, but dealing with mental illness was too much for me – he was exhausting to be around, and I do have my own family – but not a day goes by when I don’t wonder if I could have done more. I probably could have, but it was too much for me at the time. Yeah, I feel like sh*t about that.
Know who else could have done more? The mental health professionals. The stigma attached to mental health issues is horrific. But there needs to be more intervention. Despite what is said, most people don’t use commitment as a form of payback. Most families in this situation are desperate for help.
Grandstanding aside k–you may be proud to call them “neighbors”–but I’m personally talking about, and dealing with relatives, friends, and acquaintances. Nobody is disrespecting anybody’s rights when being mentally ill. But those rights can tend to distance greatly; and hurriedly; the very folks who care about them, are trying to navigate the care in crisis or daily living, and end up being the “emergency contact” or ride home when it all blows up. Sorry–but the “exclusivity” clause aligned w/ mental illness has worn it’s way thin on the backs of family, caregivers, police, clergy, employers etc..It’s time to reboot.
Heck, we have durable power of attorney, health care power of attorney, why not a mental health power of attorney when a person knows their history, routine, red flags, etc.. This isn’t their first rodeo, when intervention is needed–and the mental health POA is executed. But it’s real hard going from being held hostage, to being a compassionate caregiver all in 72hrs—because “you’re the only one he/she will listen to….” and the social worker is on the line to do discharge planning. Geez, we just found temporary, emergency, shelter for the 7 cats brought home in the last 2 weeks…..when we tried to tell you….things are ramping up………. But yea, 7 cats aren’t dangerous, and adults are allowed to have cats, and under the “law”……..oh please.
Oh, yeah. Welcome.
Before you come down too hard on us mental health professionals, recognize we are facing quite a few limitations in trying to get help for our clients. I can’t tell you how many times I’ve thought a client needed to be hospitalized, but, they “contracted for safety” so nothing could be done. When I call mobile crisis I get a whole list of reasons why they can’t respond to a situation. And, believe it or not, when I call 911 it can take hours for police or an ambulance to arrive once they hear its a mental health issue. I could have been treating Mr. Alexis right here in DE and probably would not have been able to hospitalize him. Incidentally, thanks to the cowardice of our senate, I’m also less likely to be able to assure he does not have any guns either!
I’m in your corner AQC. PP is delusional w/ who is in control involving mental health.
Process: I think PP just found out that no good rant goes unpunished in the DE blogosphere.
Content: Legislative remedies (even if I agreed with PP’s list) are inadequate and will do nothing to change the situation without (a) capacity building for mental health care [both in-patient and out-patient] on a state and national basis, and (b) a cultural change in how we perceive mental illness.
On the capacity building issue, this State’s record is laughable. Millions for casinos but not even pennies for mental health.
“Patients are allowed to decide, in spite of not having complete rational faculties, to refuse or abandon medication which can give them a reasonably predictable life and freedom from haunting paranoid fantasies.”
Patients are also allowed to refuse to take medication that ISN’T working and causing side effects worse than the original problem. ProgressivePopulist – who is neither of those – would have locked me up for insisting that my original regimen of antidepressants didn’t work. Newsflash: They don’t always work. AstraZeneca can’t craft a one-size-fits-all magic bullet.
“Involuntary observation and hospitalization must be more readily available to family members and/or associates of a diagnosed mental health patient.”
I have had to coax a family member into inpatient treatment. It was not fun, but I did it. If the family member had refused, there was an existing process I was prepared to use for involuntary commitment. That process works. What would PP do to change it, exactly? Saying it must be “more readily available” means jack. Would you broaden it to cover more conditions? What would those be? Where do you draw the line? How do you protect the elderly person from greedy relatives who want the family home faster and have decided to all swear that Uncle James is out of his gourd?
I still think you’re dumb as hell, but I’m willing to listen to your specifics.
Sorry for the delayed response, but family visiting so was off line. It is my intention on Monday, probably late day, to offer some responses and exchange views with some very thoughtful comments. This will not include responses to the few uncivil, ad hominem attacks which don’t merit, IMO, a response.
This will not include responses to the few uncivil, ad hominem attacks which don’t merit, IMO, a response.
Apparently they didn’t tell you a lot about this community when they signed you up, huh?
No problem for me, Steve. Confrontation is my middle name ! In the Texas progressive community we called it The Circular Firing Squad. Known to be an executioner myself from time to time.