COMMENTARY

Mass Shootings and the Ethic of the Open Heart

James Knoll IV, MD

Disclosures

December 20, 2012

In This Article

The "Mental Health System"

Friends, Romans, countrymen, lend me your ears; I come to bury the system, not to praise it. When the inevitable human tragedy recurs, point not at the system, for you will be pointing at nothing at all. An apparition. A fiction created some 50 years ago which only returns as a ghost in the night. And so it goes. American society seems comfortable to periodically point at and condemn the ghost every now and then whenever a serious haunting takes place. But many are not likely in a position to see the cycles that psychiatrists see due to their permanent residence near the graveyard. We see the perpetual tragedies, followed by the haunting incantations: "The system... the system failed him..."

After one tragedy in Massachusetts, the phantom apparition was summoned yet again: "Many people wondered aloud whether the system had failed both the suspect and the victim. How had [the victim] ended up alone in a home with a psychotic man who had a history of violence and was off his medication?... Did he need the tighter supervision of a hospital?"[14] To his great credit, the state's former mental health director responded, "Will this case be the canary in the coal mine? Will it signal that we've gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?" Alas, would that it were so. So many canaries have succumbed by now that our consciences have become ghostly aviaries.

It is my contention that there exists no legitimate "system" in the United States when it comes to mental health treatment. Despite this, we most certainly want to believe in one, particularly so that when tragedies occur, we will have something to cast our outrage upon. For example, when asked where they placed blame for the Tucson shooting, a majority of Americans said in a USA TODAY/Gallup Poll that they placed a "great deal of blame on mental health system failures."[15] Because it is possible that the term "mental health system" may be thrown about loose and fast, let us consider it with a bit more precision.

From a literal perspective, one might define a system as an organized, regularly interacting set of principles forming a network -- especially for distributing something or serving a common purpose.[16] Even more germane, the Surgeon General's report on Mental Health[17] gives us the following definition: "[D]iverse, relatively independent, and loosely coordinated facilities and services -- both public and private -- that researchers refer to, collectively, as the de facto mental health service system" [emphasis not added].[18] Because a particular legal term has been invoked, let us examine the definition of de facto. Here we discover both a lay and a legal definition, respectively:

  • Exercising power or serving a function without being legally or officially established;

  • Used to characterize...a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate.[19]

Thus, per the Surgeon General's own definition, the "system" is at best unofficial and at worst illegitimate. Why might it be that in 2012 we have no "legal or legitimate" mental health system? Returning to the Surgeon General's report, we are told that: "Effective functioning of the mental health service system requires connections and coordination among many sectors...Without coordination, it can readily become organizationally fragmented, creating barriers to access. Adding to the system's complexity is its dependence on many streams of funding, with their sometimes competing incentives."[14]

So, it appears that both lack of coordination and funding inconsistencies confound the system. But as it turns out, these are problems that have never been addressed adequately since the time of their inception -- deinstitutionalization. Deinstitutionalization was the term used to describe the rapid emptying out of state mental hospitals beginning in the 1960s and '70s due to a number of factors, including the patients' rights movement, financial reasons, early hopes for a "magic bullet" in the form of antipsychotic medications, and the never-realized hopes for adequate community mental health services. Thus, deinstitutionalization became "trans-institutionalization," also referred to as the "criminalization" of mentally ill persons.[20,21] Extremely laudable efforts have been made to divert persons with serious mental illness away from corrections (eg, jail diversion and mental health courts).[22,23,24] But the fact remains that there are large numbers of persons with serious mental illness in the correctional system, and the trend shows no signs of reversing itself.

In Virginia, jails now house more persons with serious mental illness than do Virginia psychiatric hospitals.[25] The Los Angeles correctional system has been referred to as America's largest psychiatric facility.[26] It is now the jails that serve as the "predominant settings for providing acute psychiatric inpatient treatment."[27] During this era of retribution, correctional facilities have now earned the designation "the new asylums."[28] Correctional administrators readily concede that their facilities are being used as "dumping grounds for many individuals who could be better served through early intervention in noncustodial environments because other options are just not available."[29] But alas, "interventions in noncustodial environments" are in short supply in 2012.

Couldn't this have been foreseen? Quite unlikely, I believe, for a variety of reasons, including: "The fact that most deinstitutionalized people suffer from various forms of brain dysfunction [which] was not as well understood when the policy of deinstitutionalization got under way."[30] Indeed, it was poorly planned deinstitutionalization that created our present illusion of a system "by discharging people from public psychiatric hospitals without ensuring that they received the medication and rehabilitation services necessary for them to live successfully in the community."[30] The mental health system has failed no one, simply because there is no system to speak of. Thus, we must look elsewhere for solutions to violent outbursts by mass murderers, most of whom have never accessed mental health care to begin with.

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