In the wake of the horror that was the Sandy Hook tragedy, much has been written and discussed about guns, violence and mental health. Americans say they're worried about what kind of discrimination mentally ill people face, but just 29 percent said they'd be willing to work closely with someone who has a serious mental illness, according to a new survey published in the New England Journal of Medicine. Yep, there is a new stigma in town - guns + mental illness = violence, and it should break the hearts of advocates nationwide.
As Americans are prone to do, we love the sound bite. We know from the NEJ article that people are afraid, but afraid of what? Of someone working through a difficult issue? Of someone in therapy? Of someone with a diagnosis? Therein lies the rub. The popular press is doing a wonderful job of lumping it all together so that suddenly anyone with a mental health challenge is a suspect for violence.
Yes, Sandy Hook was horrible. Yes, we need to do something about the easy access to weapons with large-capacity magazines, yes we need to increase mental health services, but NO we do not need to pair the need for improved mental health services with the blind statement "so that a tragedy like Sandy Hook will never happen again." You know what I fear most? A lot of bluster about improving mental health services which will result in increased psychiatric hospital beds and residential programs - not that those services don't have their place - they do. But we have learned so much over the past twenty years about a community approach to serving youth with mental health challenges and their families. Why are we not hearing more about those approaches in the popular press?
Some of the answers can be found in the recent New England Journal of Medicine opinion piece. Consider these excerpts from the NEJ article:
- The horrific loss of life at Sandy Hook Elementary School in Newtown, Connecticut, in December 2012 has prompted a national conversation about guns and mental illness in the United States. This tragedy occurred less than 6 months after 70 people were shot in a movie theater in Colorado and after highly publicized mass shootings in Arizona and at Virginia Tech. These four events share two common characteristics: all four shooters were apparently mentally ill, and all four used guns with large-capacity magazines, allowing them to fire multiple rounds of ammunition without reloading. As policymakers consider options to reduce gun violence, they should understand public attitudes about various violence-prevention proposals, including policies affecting persons with mental illness; past research findings on Americans' attitudes about policies for curbing gun violence need to be updated. In the aftermath of Sandy Hook, it's also important to understand how Americans view mental illness...
Almost half of respondents believed that people with serious mental illness are more dangerous than members of the general population, but less than a third believed that locating a group residence for people with mental illness in a residential neighborhood would endanger area residents. Most said they were unwilling to have a person with a serious mental illness as a coworker or a neighbor. However, 69% favored requiring insurance companies to offer benefits for mental health and drug and alcohol abuse services that are equivalent to benefits for other medical services. Such equity was the core idea behind a federal parity law that took effect in 2010...
Fifty-nine percent of respondents supported increased government spending on mental health care, and 61% favored greater spending on such care as a strategy for reducing gun violence. (Support was substantially lower for spending on treatment for drug and alcohol abuse.) Finally, 58% viewed discrimination against people with mental illness as a serious problem, while 56% believed that, with treatment, these people could get well and return to productive lives. In most cases, respondents who had direct experience with mental illness personally or through a close relationship had more positive views about mental illness than those without direct experience...
Findings from these surveys indicate high support among Americans — including gun-owners, in many cases — for a range of policies aimed at reducing gun violence. Gun policies with the highest support included those related to persons with mental illness. The majority of Americans apparently also support increasing government spending on mental health treatment as a strategy for reducing gun violence. Given the data on public attitudes about persons with mental illness, it is worth thinking carefully about how to implement effective gun-violence–prevention measures without exacerbating stigma or discouraging people from seeking treatment.
- You can read the complete article here.
And then there is the new analysis conducted by the Bazelon Center for Mental Health Law that looked at the relationships between states' rates of murder by firearms, incarceration, and the availability of psychiatric hospital beds. Probably no surprise to Network readers, their analysis found that the correlation among these factors is dramatically low. The analysis suggests that the public policy answers should not be directed toward increasing the number of psychiatric hospital beds, but should be directed elsewhere.
As well, let us not forget President Obama's strong words - “We are going to need to work on making access to mental health care as easy as access to a gun.” Today, less than half of children and adults with diagnosable mental health problems receive the treatment they need. While the vast majority of Americans with a mental illness are not violent, several recent mass shootings have highlighted how some cases of mental illness can develop into crisis situations if individuals do not receive proper treatment. We need to do more than just keep guns out of the hands of people with serious mental illness; we need to identify mental health issues early and help individuals get the treatment they need before these dangerous situations develop."
- Training teachers and other adults who regularly interact with students to recognize young people who need help and ensure they are referred to mental health;
- Implementing Project AWARE (Advancing Wellness and Resilience in Education), to provide this training and set up systems to provide these referrals. This initiative, which would reach 750,000 young people;
- Providing "Mental Health First Aid" training for teachers;
- Making sure students with signs of mental illness get referred to treatment;
- Improving state-base strategies supporting young people ages 16 to 25 with mental health or substance abuse issues;
- Offering students mental health services for trauma or anxiety, conflict resolution programs, and other school-based violence prevention strategies;
- Training social workers, counselors, psychologists, and other mental health professionals; and
- Launching a national conversation to increase the understanding about mental health
- The Administration issuing final regulations governing how existing group health plans that offer mental health services must cover them at parity under the Mental Health Parity and Addiction Equity Act of 2008, and
- The Administration issuing a letter to state health officials making clear that Medicaid plans must comply with mental health parity requirements.
And then I try to coalesce in my simple brain all of these really good ideas with a tremendous concern that they will lead to targeting and profiling high risk youth with the unfortunately convenient and easy answer of increasing residential and psychiatric hospital bed space without an equal or greater focus on providing effective community-based services.
Consider this recent plea from Cheryl Des Montaignes, MSW, LCSW, LMSW, one of many Network faithful who have sent emails to us, and try to juxtapose her concerns with the wonderful plans outlined above:
- There has been much talk of restricting availability of assault style weapons, some talk of changing mental health services reporting requirements but I have not heard any discussion of the challenges in the field of mental health services and diminishment of mental health services. In the state of Michigan funding and services have been drastically cut, many psychiatric facilities closed to the point that only very limited services are available in some areas. And the services available continue to be diminished by increased pressure to provide services to more people with less cost. Individual practitioners are under increased pressure to fill more and more roles and to complete more and more documentation or paperwork much of which seems to be orientated towards covering possible liability of agencies or funders such as community mental health rather than quality of services. Therapists' time and energy is increasingly distracted by case management and administrative and other functions outside of their area of training. The pressures are increasing in the mental health field to complete more documentation with less time, focus, and energy to provide therapeutic services. The concern of supervisors and agencies is orientated around documentation and paperwork and timing of reports not the quality of therapy or services, the competency of the therapist. The priority too often is the appearance of the documentation and filling requirements of the state or funder and not providing good mental health services, not providing services that assist and heal people, services that keep people safe. This too must be addressed if we are to address the issue of violence in this country.
Or the comments by Patricia Rehmer, Commissioner of the Department of Mental Health and Addiction Services in Connecticut, in a recent interview with the Washington Post, who lamented that there are limits on the number of services that can be used annually, which can create a problem for a family, and said:
“I am often called, especially by parents of young adults who are now keeping their children — young adults — on their insurance until they’re 26, who need the services that we provide,” Rehmer said of her agency, which serves only people without private insurance. “They need case management. They need supportive housing. They need interactions with their peers,” she said. “Those are things that private insurance companies do not pay for.”
Or the comments of another Network follower, reacting to a recent episode of Dr. Phil:
- I am delighted to see the increased attention to mental health in general and children's mental health in particular, although I am certainly not happy about the reasons for it. I am concerned now that it might lead to more kids rather than less being shipped away to residential programs, and money being spent to try to identify high-risk kids rather than to provide effective services. It just seems to me that the timing is good for a major public education program, and part of that perhaps could be a TV series, maybe on PBS, that talks about positive developments in supporting children, youth, and families. We hear so much about the failures and yet there have been great gains that the public is unaware of (and that many professionals are unaware of as well).
As you may know, earlier this week Dr. Phil had a show with young adults who had been in abusive residential programs as teens. There was absolutely no mention of non-residential alternatives. Dr. Phil acknowledged that the programs the youth had been in were in fact abusive (which is progress) but left the audience with the impression (at least I believe he did) that the alternative is to find better residential programs. And of course he reached an enormous audience. How can we get a more positive message out there to a large audience?
Or these shocking statistics regarding mental health funding from our friends at NAMI:
- About 30 states have reduced mental health spending since 2008, when revenues were in steep decline, according to the National Alliance on Mental Illness.
- The steepest drop by percentage was in South Carolina, where spending fell by nearly 40 percent over four years — an amount that Republican Gov. Nikki Haley has called "absolutely immoral." South Carolina eliminated 600 full0time caseworkers and closed five treatment centers. That led to an increase in the number of people with mental illness in jail in Columbia — so much that it now exceeds the patient total at the city's public psychiatric hospital.
If there is good news in the wake of this tragedy, it is that many states are rethinking planned mental health cuts. In an AP article, Shelley Chandler, executive director of the Iowa Alliance of Community Providers notes that that in many states, lawmakers have begun to recognize that their cuts "may have gone too deep. People start talking when there's a crisis." Read the full article here.
And in an ironic twist, quite possibly the easiest path to funding appropriate mental health services may lie with Medicaid Expansion - the very thing that many governors are fighting. In an article in Stateline it is noted that if states opt in, "For the first three years that additional coverage would cost the states nothing: Under terms of the Affordable Care Act, the federal government will cover 100 percent of the costs of new Medicaid enrollees for the first three years and 90 percent after 2020... If all states opted into the expansion, an estimated 13 million more Americans would receive mental health benefits through Medicaid next year, according to a report by the Congressional Budget Office. The number would rise to 17 million in 2022.
- “This is a golden opportunity to shore up the state public mental health systems where they have seen these major cuts in the last ten years,” says Joel Miller, senior director of policy and health care reform at the National Association of State Mental Health Program Directors (NASMHPD)... And from Mike Fitzpatrick, Executive Director, NAMI, "As states take up this legislation, mental health advocates and some state officials express wariness about aggravating the uneasiness many people already feel toward those with mental illness. “People begin to equate mental illness with violence or evil,” says NAMI’s Fitzpatrick, “but there are very few people with mental illness who become violent.” Read the full article here.
So what's the moral of this particular story?
Go slow, beware the stereotype, and do your homework. Learn about what works and what doesn't. And finally, recognize that we as mental health professionals need to take some responsibility for the holes in the mental health safety net. This is a challenge that we all must assume responsibility for and address. No bystanders on this one.
Next week we will be reviewing an article by Garland, et al that shines a very bright light on the effectiveness (or lack thereof) of traditional mental health care. What would be most egregious would be to throw money at programs and initiatives to just to say we did it. Over the next few months we will be working on appropriate education vehicles to educate and inform about mental health services that work - both for those with the most serious issues all the way down to those who are just beginning this amazing journey known as life. If you would like to be a part of the discussion and action, please let us know. All are welcome. Click here to get involved.
Scott Bryant-Comstock, President & CEO
Children's Mental Health Network