A Conversation With Political Scientist Norm Ornstein

COVID-19, Police Reform, and Fixing a Broken Mental Health System

Lloyd I. Sederer, MD


July 16, 2020

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This transcript has been edited for clarity.

Lloyd I. Sederer, MD: Welcome to Medscape, in partnership with Columbia Psychiatry Media. I'm Dr Lloyd Sederer, your host. Our program today is going to focus on politics, policies, and social change related to mental health in this country.

I'm particularly pleased to have as our guest a dear friend, and a considerable expert on these matters, Norm Ornstein. Norm is a resident scholar at the American Enterprise Institute, an author, and a great social commentator. Welcome, and thank you for doing this interview.

Norman J. Ornstein, PhD: It's so good to be with you, Lloyd.

Sederer: We're going to focus on two areas. The first is the broken mental health system in this country. We've noted that it's broken for many years, and it still is. The second area is how mental health and addiction problems in the US have moved away from experts and toward the police or correctional services, courts, jails, and prisons.

Let's start with the broken mental health system. We know that it's fragmented. One entity doesn't talk to another. Quality is uneven and it can be unaccountable. These problems have been around for a long time. And now the mental health system is enveloped in a collection of disasters: COVID-19, the opioid epidemic, the economic fallout from all of this, and social unrest.

This is an incredible collection of troubles. Is this a good and opportune moment for change or not?

Ornstein: The first chief of staff to Barack Obama, Rahm Emanuel, said that every crisis poses an opportunity. And clearly we have the crisis and we have the opportunity now. The mental health system, as you said, is broken in so many ways. It's a particular challenge for those with serious mental illness, and even more for those with anosognosia, the lack of insight into the fact that they have an illness.

We know that we have large numbers of homeless on the streets, and the lion's share are people with mental illness. We know that our jails are filled with people with mental illness; and with the opioid crisis, very large numbers of them have a dual diagnosis. Often these people are picked up on a minor drug charge.

All of this — the lack of funding where we need it, the misapplication of funds — is happening alongside the crisis we're having now with police and the FBI and people of color.

During the COVID epidemic, we see that a person on the street has no hygiene, no opportunity to wash hands or maintain any kind of cleanliness, and they're in close proximity to others. If you're dealing with people who don't even understand that they have an illness, then the idea that if they were infected with COVID they would quarantine, or take care of themselves, is a fool's errand. At the same time, we've had these terrible COVID crises in jails and prisons.

I would add one other element to this, which is the community mental health centers. These were designed when John F. Kennedy transformed — he thought — the mental health system to get people out of institutions and have them treated in these community mental health centers. But these facilities have not been funded.

For people who have tried to deal with serious mental illness during the COVID crisis, their centers have often been shuttered, or if not shuttered, then the personnel have been afraid to go in and they haven't had the protective equipment. There's no place to go for large numbers of people in crisis. That's true even for people who are complying, who are going to their community mental health centers for their medications. All of this — the lack of funding where we need it, the misapplication of funds — is happening alongside the crisis we're having now with police and the FBI and people of color.

Sederer: It's a perfect storm. I want to return to this broken system. All change, particularly substantive change, is fiercely resisted by those who continue to benefit from having things remain the same. How do we get around that? How do we get through that mental health industrial complex, the homeless industrial complex? What can we do?

Our healthcare system was built by accident. Nobody came up with an architecture for it.

Ornstein: This is not easy, and I've been around efforts to change the political process for many decades now. It's always hard. One of the challenges we have now, of course, is that we have an economy that's not likely to get better for a very long period of time. And we've had the federal government pour in trillions of dollars, with no end in sight. We're going to need at least one more, if not many more, stimulus injections. We have state governments, almost all of which have in their state constitutions balanced budget amendments, and they're deeply in the hole. So getting new resources may be impossible and reallocating resources is going to be very difficult. And as you say, these establishments like things the way they are now because they're doing fine.

But because of all this, people are feeling a significant jolt, an understanding that this is just not working. I see that when I talk to members of Congress. I see it when I talk to people who are associated with the Biden campaign. Jill Biden, the wife of Joe Biden, has said that if she becomes First Lady, she wants to make mental health one of her major focal points. All of that gives me a slight amount of optimism.

What you and I know is that it's not about just finding new money. It's moving money to places where you can have a better outcome, and that better outcome can save money even as it saves lives. Overcoming our inertia is, as much as anything, our greatest challenge.

I just hope we can take advantage of this moment, because if we don't, we know from past epidemics and pandemics that we'll see a sizable increase in issues of mental illness and mental health in the aftermath — people with depression or posttraumatic stress disorder. We're seeing it in health professionals, some of whom are having suicidal ideation or even dying by suicide. We're seeing it with many other populations. We also know from the past that there's often an increase in serious mental illness following a pandemic — schizophrenia, for example. We're going to have our hands full and society is going to have to cope with this. Even those who don't want to.

Sederer: I agree that this is not going to be about additional money; so much money is wasted right now. The financing of healthcare, including mental health care, is really out of control in this country, and primarily that financing is by volume. The more you do, the more patients you see, the more you get. What are your thoughts about that?

Ornstein: It's a crazy way to run a healthcare system. Our healthcare system was built by accident. Nobody came up with an architecture for it. The first kind of architecture we've had in a while has been the Affordable Care Act, which is now undergoing evisceration, or at least very serious change. But another problem on the mental health front is that we have never thought through a better way to allocate resources to mental health professionals or to provide the kind of treatment that's necessary for those with serious mental illness. We have not allocated our research funds appropriately on this front, either.

My family went through a terrible tragedy, as you know. Our son was a brilliant young man who, at 24, had a psychotic break and went through 10 years of struggle with serious mental illness. He did not recognize that he had an illness. We had an enormously difficult time finding any professional who was willing to treat him. As you know, most psychiatrists in private practice like to have patients who come in on time, stay for 45 or 50 minutes, leave after talking about their problems at work or with their spouses or their kids, and then pay. My son could not have been on time to an appointment if his life depended on it, and sometimes it did. Many people in the field don't have an understanding of some of these deeper problems. You are an exception to this, Lloyd — a shining exception to it.

But until we train people better and compensate them appropriately, we're going to have a problem on that front. Until we do a fundamental overhaul of our entire healthcare system, so that instead of having a country where we pay twice as much for healthcare as any other country and get worse outcomes — not only in mental health but in almost every area — and until we also confront some of the social realities and bottom-line issues of what we do with people with serious mental illnesses, we're going to continue to flounder and throw money basically down the toilet.

Sederer: Some years ago, you and your wife, Judy Harris, established the Matthew Ornstein Foundation, which recently underwrote a PBS documentary called The Definition of Insanity . This documentary tells the story of how Miami-Dade County and its police department went about changing the way it approached people with serious mental illness. Tell us about that.

Ornstein: We had encountered this remarkable judge in Miami-Dade County named Steve Leifman, who is in many ways a miracle worker. Over almost 20 years, he has transformed the way this huge county, the seventh most populous in America, deals with people with mental illness.

There are two components to it. One is to transform the courts and create a jail diversion program that requires buy-in from everyone. It's not like mental health courts, which are often staffed by judges who don't have any real understanding and there's no backup. Instead, it has comprehensive wraparound services and an understanding on the part of judges, prosecutors, jailers, public defenders, and others that everyone must work together for a better outcome.

The second component is the critical element, especially as we face this larger crisis following George Floyd's death and some of the other tragedies. Leifman has trained roughly 7500 police officers in this county through a week-long program developed in Memphis in Crisis Intervention Team (CIT) policing. It teaches sensitivity and how to de-escalate conflict instead of what police typically do, which is to escalate conflict.

This program led to several outcomes. They used to have an average of two shootings a month in this county, in encounters between police and people with a serious mental illness. Many of those shootings were subsequent to calls from family or neighbors because someone was going through a crisis. But instead of helping, police would end up escalating the crisis and shooting. As you know, if somebody shouts at a person with a serious mental illness, or gives them a command, they're going to get the worst kind of response — certainly not compliance.

By treating this in a different way and sensitizing people on how to deescalate a situation, they've gone from two shootings a month to five or six in the past 8-10 years. As a result, the city of Miami improved its bond rating, saving hundreds of millions of dollars, because of the drop in wrongful death and wrongful assault suits. Before, if they didn't shoot someone, they would tase them or arrest them for resisting arrest. After CIT, they've cut the number of arrests in half, which meant that they could close one of their three main jails. Over 7 years they've saved $84 million. And they're getting 150 calls a month into their mental health hotline from police officers dealing with their own mental health issues. I would be the last to say that this is a panacea for all of these issues surrounding Black Lives Matter; so many of these people who are encountered in this fashion are people of color. But this is a giant first step to take to de-escalate that conflict and save lives and money at the same time.

Sederer: Norm, thank you for your wise counsel and thoughts. It's been a great pleasure. On behalf of Medscape and Columbia Psychiatry Media, thanks to our audience for joining us. I'm Dr Lloyd Sederer. I hope you'll continue to follow our program.

Lloyd I. Sederer, MD, is the former chief medical officer for the New York State Office of Mental Health and an adjunct professor in the Department of Epidemiology at the Columbia University School of Public Health. His latest book is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs.

Norman J. Ornstein, PhD, is a political scientist and resident scholar at the American Enterprise Institute. He writes regularly for The Atlantic and National Journal, and is a co-author of several books, including It's Even Worse Than It Looks: How the American Constitutional System Collided With the New Politics of Extremism, and One Nation After Trump: A Guide for the Perplexed, the Disillusioned, the Desperate, and the Not-Yet Deported.

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