Rethink Mental Illness

Rethink Mental Illness (Photo credit: Wikipedia)


That’s the title of the tweet from the New York Times that caught my eye.


From an article published yesterday, Warning Signs of Violent Acts Often Unclear:


No one but a deeply disturbed individual marches into an elementary school or a movie theater and guns down random, innocent people.

That hard fact drives the public longing for a mental health system that produces clear warning signals and can somehow stop the violence.


But is the public putting its faith and longing in the wrong place when they believe that a sound mental healthcare system alone will supply those clear warning signs everyone so desperately desires?

Assuming every killer is mentally ill and identifying killers before they have a chance to kill is extremely complex and most of the time idealistic at best.

As some of you have undoubtedly heard, New York State has already passed the most stringent gun laws in the nation, including a requirement that doctors and mental healthcare workers  report to a mental healthcare director anyone whom they believe has made a credible threat to use a firearm “to engage in conduct that would result in serious harm to self or others.”  The mental health director would then  report serious threats to the state Department of Criminal Justice Services, who will presumably keep a database of all individuals reported.  A patient’s gun could then be taken from him or her.

Not surprisingly, there’s been a backlash, citing both the obvious intrusion into the doctor-patient relationship and the likelihood people who need help will be discouraged from reaching out.

This new law also goes further in its criteria for who belongs in the database.

“The way I read the new law, it means I have to report voluntary as well as involuntary hospitalizations, as well as many people being treated for suicidal thinking, for instance, as outpatients,” said Dr. Paul S. Appelbaum, director of the Division of Law, Ethics, and Psychiatry at Columbia University’s medical school. “That is a much larger group of people than before, and most of whom will never be a serious threat to anyone.”

[Underline is mine.]

The article then goes on to state, “while more likely to commit aggressive acts than the average person, [people with serious mental disorders] account for only about 4 percent of violent crimes over all.”

[Again, underline is mine.]

After all of the carefully thought out policy and procedural changes around the mental illness component of revamped NY gun control laws, the reasonable person would assume there is a universally accepted definition of what constitutes a “major mental illness,” thereby giving all mental healthcare workers and doctors a standard set of criteria to work with.  Alas, this is not the case.  At least not when  I sat down to write this post.  The only mention of specific mental illness I could find while reading current articles was in the NYT piece.  A forensic psychiatrist who has a database of 200 mass and serial killers cited,  “likely to have had paranoid schizophrenia or severe depression or were psychopathic, meaning they were impulsive and remorseless,” as common threads.

What the New York law leaves us with is no clear definition of “severe mental illness,” a largely subjective definition of what constitutes a credible threat, the near-invasion of doctor-patient confidentiality and the forced documentation of those who were institutionalized by force along with those who voluntarily sought help.  (By the way, God help the patients who have a risk-adverse doctor or MH professional handling their treatment.  This new law will have those wishing to cover their proverbial butts reporting everything from serious suicide / homicide threats to shooting rubber bands across the room.)

Since a quick-fix to the mental illness / gun control issue is clearly what everyone wants, is there any existing diagnostic tool within our broken mental healthcare system that can be used as a stop-gap?  There must be something that’s useful to us in the short term.

The sort of young, troubled males who seem to psychiatrists most likely to commit school shootings — identified because they have made credible threats — often do not qualify for any diagnosis, experts said. They might have elements of paranoia, of deep resentment, or of narcissism, a grandiose self-regard, that are noticeable but do not add up to any specific “disorder” according to strict criteria.

(Underlines are mine.)

This is where the nice, neat, and very convenient link of violence and mental illness is broken.   The mental healthcare system in the US is sorely inadequate, but there is no credible way to unfailingly identify killers before they strike by using the currently accepted, standard set of mental health criteria.

In the end, is this new set of laws in NY helping identify would-be killers or is it merely throwing mental healthcare back to the stone age?  Experts agree that those who have perpetrated the latest wave of mass killings would not have been identified because they do not fit into the categorizations of DSM mental disorders.  Experts also agree, as previously stated, that these laws make voluntarily getting help much less appealing for those who need it.

What happens when laws surrounding mental health like those in New York are instituted nationally and those of us who voluntarily admitted to get the help we needed are now forever branded at the Federal level?  (Of course that’s assuming the Feds can get their act together and implement a national database of the mentally ill.)

I am a strong advocate for gun control, make no mistake.   I am also a strong advocate against mental illness stigma and persecution.  Overreacting in the form of puncturing the sacred space of doctor-patient confidentiality and keeping track of people who voluntarily seek inpatient help no matter what their form of mental illness is nothing more than a passive-aggressive form of persecution.

I’d love to refine this post further , but President Obama is due to speak on his gun violence proposals within the next hour, and I’m out of time.  CNN is reporting one of the proposed solutions surrounds funding for mental healthcare.  I am hoping our President and Vice President were briefed  at some time during the policy making process that  branding all mentally ill individuals will not supply those clear warning signs everyone so desperately desires.