There has been a lot of public debate recently about the public safety risk posed when mental health challenges go untreated by conventional medicine. For the most part, this debate has been framed as an either-or discussion: Public officials either “do something” and pass laws that require a mandatory medical response, or they “ignore the problem” and provide no response at all. In this context, it’s not at all surprising that people tend to think of legally-mandated medication (forced treatment) as the only viable solution. It’s a matter of self-protection really. There’s so much violence out there, and every one of us is at risk.
At the same time, I’m concerned that we don’t understand how dangerous force is as an approach to human distress. Widely-accepted government research suggests that some 90% of us in the public mental health system are trauma survivors. Much of the trauma that leads to mental health system involvement has to do with violence, force and coercion. We have been invaded, violated and treated like objects or problems to be managed on physical, sexual, emotional, social and spiritual levels. We are dealing with life – like everyone else – the best way we know how.
Moreover, like everyone else, we respond to feeling afraid or threatened with the normal human survival reflexes of fight, flight or freeze. The implications in polite modern society are critical to understand. Because it promotes species survival, we can reliably predict that some human beings will default under stress to “fight” – instead of “flight” or “freeze.” This kind of stress reflex can happen even when there is no ill intention. People are simply upset and sincerely want safety. For some of us mortals – especially when confused, distressed or closed in – it just doesn’t seem to register that this is the exact wrong thing to do, e.g., with a public safety officer carrying a gun.
So what can be done instead? Clearly, as a community, we still need to respond. We need to do so early and often. We need to do so safely and effectively. But more than anything else, we need to understand that force – and sometimes even hospitals, medications or people in uniform – are not our best resource.
To those of us who have been there, it is no mystery why Antoinette Tuff and everyone else at the McNair Discovery Learning Center are still alive today. You can listen to the 911 recording of her conversation with Michael Hill, who was at one point armed and shooting, here.
There’s a lot to learn from her example.
Ms. Tuff was respectful, responsive and kind. She showed interest and concern. She worked to create and negotiate solutions. She shared her own difficulties and offered her own humanity.
In giving these things, she made the human space for Michael Hill to slow down and take a deep breath. He was able to stop and think. She offered connection and helped him reconnect with himself. She gave him the best of her humanity and, to his credit, he took the risk of responding in kind. Thanks to Ms. Tuff, everyone, including Mr. Hill, left the scene in safety in half an hour.
Now, at this point you may be thinking, “Yes, that is good and well for people like Michael Hill. He seems pretty mild compared to most. But, what about the really dangerous people – the ones with the ‘real mental illness’?”
This is where the discussion gets really interesting. On the one hand, the issues are far too complex for a simple “one size fits all” answer. There is some violence that no one can predict or stop – no matter what – at least at our current level of understanding. Moreover, there are some people with serious mental health challenges (current research suggests about 20%) who will do better with a medication-oriented psychiatric approach. (For research & analysis, see Anatomy of an Epidemic & Mad in America).
At the same time, for those of us who have been there, there is much truth in the maxim: “What you see is what you get.” No matter how disturbed or distressed, we all want to be seen as human. In fact, for many of us, our challenges have stemmed in no small part from the trauma of being treated as less than human by important others. As is increasingly recognized in an era of trauma-informed care, much of the behavior that gets diagnosed as “mental illness” is simply an attempt to cope with effects of pre-existing life trauma. Traumatic distress gets further compounded when coping attempts are seen as strange or unacceptable and then result in social judgment or exclusion.
A poignant example of the way outsider experience can escalate distress is the suicide of Josh Marks, finalist on MasterChef, a Fox Network reality show. Josh sought professional mental health treatment for anxiety following the stressful production schedule and ensuing notoriety when the show aired. He got worse instead of better. A year later, despite taking prescribed medications, the 7’2” ‘gentle giant’ shot himself in the head. It was just 24 hours after being told he was “schizophrenic.” According to his mother, Josh “was just coming to accept the diagnosis of bipolar” and “couldn’t bear the thought of another diagnosis.” (“Suicide Begs Question: Time to Retire a Diagnosis?”)
What happens when extreme actions, like violence to self or others, stem from this kind of injury – the open wound of social disconnection or outright exclusion? In these circumstances, for many of us, unwelcome attempts to treat, control or manage often backfire. Such responses torturously highlight the fact that we do not belong. The result is a vicious cycle: The resort to authority, while clearly understandable, stands in stark contrast to the normal social courtesy of appeal to shared humanity. It painfully activates our raw sense of being “other.” This, in turn, escalates distress. Behavioral reactivity surges accordingly.
This is why, from experience, I would venture that Ms. Tuff’s approach is the far safer one. It still involves risk. Not more risk – but definitely real risk. However, it is risk of a different kind. Real people still put their lives on the line. But not to manage, control or subdue. Rather, they risk in order to attempt connection. They reach out across vast expanses of human confusion and distress. They offer a lifeline back to humanity.
This kind of risk-taking is human service of the highest level. It reflects the greatest potential and the most sacred aspirations of our species. These are the healers and public servants of our future world community.
To be sure, this “Tuff” kind of public safety work is not for everyone. However, many exist who are doing it today. Indeed, across the country and around the world, this work is occurring every day in countless unofficial and unacknowledged ways. There are untold mental health and public safety workers who quietly manage to avert violence, again and again, in situations that would rapidly deteriorate if routine use of force protocols were initiated. Homeless shelters, soup kitchens, churches and other public service programs all have unsung local heroes who are exceptionally skilled in averting conflict or crisis. They lead with a friendly greeting, negotiate workable solutions and set everyone at ease.
More formally, peer and community health initiatives are often intentionally designed to support people experiencing significant mental distress or intensity. These programs intuitively grasp the importance of meeting each other on a human level. They seek to understand and work with the challenging, unsettling ways that human anguish and alienation are sometimes expressed. Many also offer the potential to develop real-life relationships based on respect, dignity, and authentic human connection.
Many such initiatives are operated by lay staff or volunteers with relevant or similar life experiences. They are trained in innovative practices like Intentional Peer Support, Accepting/ Hearing Voices, Emotional CPR, Alternatives to Suicide, Non-Violent Communication, Wellness Recovery Action Planning, Community Mediation, crisis respite and telephone/ internet support.
Other initiatives are sponsored by professional or public mental health providers. They span diverse modalities including person-centered therapy, trauma-informed care, the Sanctuary Model, Risking Connection, Finland’s Open Dialogue and many, many others. Such programs profoundly alter the experiences of both service recipients and staff.
As a case in point, from 2000 to 2009, the Pennsylvania state hospital system reduced seclusion and restraint by more than 99 percent using a trauma-informed, hope-based, “people-first” approach. In 2005, they eliminated chemical restraints (involuntary PRN medications). Remarkably, these outcomes were achieved for detainees under involuntary civil or forensic commitment – and without increasing staff injuries or program spending. What is more, post-hospitalization, more than 60% of service recipients go on to complete the community support plans they started as inpatients.
The advances represented by these cutting-edge initiatives are necessary components of a considered, modern public safety response. They provide us with responsible, affordable, effective alternatives. They pave the way for the vibrant, inclusive, respectful communities we want to live in. They offer us a practical, sensible, principled course to heal the violence we fear instead of perpetuating or becoming it.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.