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.