There’s a fierce debate brewing on Capitol Hill over two competing bills that seek to overhaul our nation’s mental health system. Rep. Ron Barber (D-AZ), a survivor of Jared Loughner’s 2011 mass shooting, has proposed the Strengthening Mental Health in Our Communities Act of 2014, a bill that would provide additional funding for the Substance Abuse and Mental Health Administration (SAMHSA). Barber’s legislation specifically targets at-risk populations who may be underserved − young people, seniors, veterans, and Native American communities − and seeks to provide patient-driven treatment before the illness becomes unmanageable.
Rep. Tim Murphy (R-PA) has offered the Helping Families in Mental Health Crisis Act, the final result of a yearlong investigation that began after Adam Lanza’s 2012 attack on the Sandy Hook Elementary School left 28 dead, including Lanza. The Helping Families in Mental Health Crisis Act seeks to reallocate the $460 million in block grants currently distributed to community mental-health centers by SAMHSA, and replace that with a top-down system of federal control. It’s already garnered impressive bipartisan support − a full one-third of its co-sponsors are Democrats − by seeking to disperse $60 million in federal funds to states willing to collect data on key outcomes (such as emergency room visits and mortality rates of persons with serious mental illness) and institute evidence-based programs of medical-model practices.
However, buried under Title VII, Section 704 of the 134-page bill, there’s a catch − to be eligible to receive federal grant money, states must change their standards for involuntary treatment of the mentally ill from posing an imminent danger to oneself or others, to the far more vague “disabled and in need of treatment.”
Disabled is defined in this way: “[T]his impairment causes the individual to be incapable of understanding the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages, and alternatives are explained to the individual.” In other words, refusing treatment would become sufficient grounds to legally compel treatment.
This is the standard that currently exists in most states. A person may have the right to refuse treatment, as long as he or she is competent, but the very refusal to accept treatment is regularly seen as evidence of incompetence. In essence, it becomes very difficult, if not impossible, for a person seen to be mentally ill to refuse treatment. Diagnosis leads to an almost automatic claim by the state that it can now force treatment.
The Helping Families in Mental Health Crisis Act would expand outpatient commitment laws, curbing the civil rights of millions of Americans. That expansion is predicated on the assumptions that the mentally ill are more likely to engage in violence than the general population, and that forced medication will reduce this violence. Yet, looking at the clinical research may question these assumptions.
Are Persons with Mental Illness More Likely to be Violent?
Are persons with mental illness more likely to be violent than the general population? The New York Times offered a roundtable discussion entitled “Can Therapists Prevent Violence?” where two of the six pieces explicitly endorsed Rep. Murphy’s Helping Families in Mental Health Crisis Act, and none of the six questioned the premise of the discussion. American Enterprise Institute scholar Sally Satel wrote a piece entitled “Loosen Restrictions for Therapists to Report Danger.” However, 2012 study of violent risk assessment by psychiatric residents found that the young doctors were “no better than chance” at predicting violence in patients.
There is a simple explanation for this ineptness − mental illness has nothing to do with violence. Studies show that the mentally ill are no more likely to be violent than their sane cohort. The MacArthur Community Violence Survey found that persons with mental illness have no higher risk for violence than the others from the same neighborhood. A 2000 study on violence and delusions using the MacArthur data found that “[n]either delusions in general nor threat/control override delusions in particular were associated with a higher risk of violent behavior.” Seena Fazel, a psychiatrist at the University at Oxford, studied violence in people diagnosed with schizophrenia in 2009 and in people with bipolar disorder in 2010. He found that the increased risk for violence is caused by substance abuse. Fazel concluded that for people diagnosed with schizophrenia, “most of the excess risk appears to be mediated by substance abuse comorbidity” and for persons with bipolar disorder, “[t]he risk increase was minimal in patients without substance abuse comorbidity.”
In the same Times roundtable, Associate Professor of Psychology Kevin Nadel suggested that mental health professionals work in crisis teams with police to prevent violence: “These qualified professionals are much more competent in assessing mental illness than police officers.” Nadel omits the main reason mental health professionals should work with the police − to train law enforcement not to kill persons with mental illness. The recent acquittal of two officers who beat to death Kelly Thomas, a homeless man living with mental illness, as well as the regular killings by police of persons with mental illness underscore the vulnerability of this population and the need for protection. In fact, those with mental illness are much more likely to be a victim than an attacker. The National Crime Victimization Survey reports that persons with severe mental illness are 16 times more likely to be raped, and 10 times more likely to be violently victimized than the general population.
Does Outpatient Commitment Work?
This focus, not on treating persons with mental illness, but on the ostensible danger posed to rest of the society was echoed throughout the roundtable. D.J. Jaffe, Executive Director of the Mental Illness Policy Org, touted the Helping Families in Mental Health Crisis Act as “a smart limited exception to confidentiality law that could help improve care and reduce violence.” But does the forced treatment of Rep. Murphy’s bill actually improve care and reduce violence?
The studies on forced treatment are decidedly mixed. Even those that have found a reduction in violence are unwilling to ascribe the drop to coercive treatment, and recommend against the expansion of outpatient commitment. A 2010 study of New York’s outpatient commitment program found that patients in the outpatient group acknowledged that “assisted outpatient treatment clients also received other enhanced services, such as priority for housing and vocational services. We cannot conclude which of these elements of the package deal contributed most to the generally positive outcomes for participants. We therefore caution against using our results to justify an expansion of coercion in psychiatric treatment.”
A 2001 study of outpatient commitment in North Carolina found that patients assigned to the forced treatment group did not experience a reduction in violence, but that frequency of service contacts (three or more per month) did reduce violence in the studied population. It also found that the outpatient commitment group reported greater feelings of perceived coercion, which often leads to self-reported low medication adherence, higher feelings of devaluation and discrimination, and lower quality of life in discharged patients. The North Carolina study ultimately recommended against the expansion of coercive treatment, concluding: “A court order alone cannot substitute for effective treatment in improving outcomes.” Indeed, these legislative measures may be preventing people with mental illness from seeking help. A 2003 survey of people diagnosed with schizophrenia indicated that 36% of people resisted seeking help for fear of coerced treatment.
Judicial Intervention, Not Preventative Care
A recurring theme in media coverage attacked the focus on preventative care of Rep. Barber’s bill, favoring the more forceful approach of Rep. Murphy’s proposed legislation. In a blog post on mental health reform, the Washington Post gave just 37 words of the 600-word report to Rep. Barber’s legislation: ”Democrats have also called for changes in mental health programs in a similar bill, authored by Rep. Ron Barber (D-Ariz.) that offers broader reforms to mental health programs instead of focusing solely on the most severely ill patients.” D.J. Jaffe in the New York Times wrote that Rep. Murphy’s bill “requires the government to start focusing it’s [sic] vast spending on getting treatment to the most seriously ill rather than all others.” However, Barber’s bill is designed to focus on vulnerable populations to ensure that treatment is provided before the illness becomes so debilitating that the patient cannot actively participate in his/her own recovery.
In an editorial endorsing Rep. Murphy’s bill, the Washington Post seemed to misunderstand exactly what the legislation proposes: “It makes obvious sense for the government to back community-based clinics that promise to prevent individuals’ mental illnesses from spiraling out of control, when possible.” However, cutting funding to community-based clinics and replacing them with a federally controlled system of medical-model care is exactly what the bill seeks to do.
Both the Chicago Tribune and the Wall Street Journal issued editorials supporting Rep. Murphy’s legislation and attacking the patient-driven approach currently used by SAMHSA. The Tribune referred to patient-driven care as “dubious” and the Journal deployed selective quotation in its attack on SAMHSA: “The agency is a fan of ‘patient driven recovery,’ which allows the mentally ill to craft their own treatments and stresses ‘hope’ and ‘empowerment.’”
Yet, the preventative, patient-driven care ignored by Rep. Murphy’s bill has been shown to be hugely clinically effective in treating persons with mental illness. “A recovery-oriented and patient-directed approach to care was associated with greater satisfaction with mental health medications, leading to fewer mental health symptoms and to better quality of life and recovery. Recovery-oriented care was also directly associated with improved recovery outcomes, and indirectly through clinician satisfaction, with quality of life. The total effect of patient-directed recovery-oriented approach to care on recovery was 0.57, and on quality of life 0.37.” concluded a 2008 study.
Civil Rights Coverage
Joe Nocera’s New York Times op-ed in the wake of Elliot Rodger’s shooting was one of the few to acknowledge that Rodger was “an outlier” and that “you can’t go around committing them all because a tiny handful might turn out to be killers.” (However, this position represents a reversal of the one Nocera outlined shortly after the December 2012 school shooting in Newtown, Connecticut: “[L]iberals need to acknowledge that untreated mental illness is also an important part of the reason mass killings take place . . . The state and federal rules around mental illness are built upon a delusion: that the sickest among us should always be in control of their own treatment, and that deinstitutionalization is the more humane route.”)
The New York Times was also one of the few media outlets to cover the civil rights aspect of the Helping Families in Mental Health Crisis Act in an even-handed way, quoting Gina Nikkel of the Foundation for Excellence in Mental Health Care and Robert Bernstein of the Bazelon Center for Mental Health Law– both strong critics of the bill– along with Keris Myrick of the National Alliance on Mental Illness, and E. Fuller Torrey of the Treatment Advocacy Center, both supporters of the bill. However, the article failed to mention Torrey’s involvement with the legislation, which is so large that journalist Pete Earley was moved to note on his blog that “Torrey’s fingerprints can be found all over Rep. Murphy’s bill” and that the bill is informally called “Torrey’s revenge.”
The Times article also misunderstood the scope of the proposed legislation. “But the bill’s backing for involuntary treatment is highly contentious. It would provide state grants for so-called assisted outpatient treatment programs under which certain mentally ill people with a history of legal or other problems get court-ordered therapy, which in most cases means trying to ensure they take their medication.” The bill would provide grants solely to states that change their outpatient commitment laws, lowering the standard for judicial intervention to “in need of treatment.” This standard encompasses not only persons with a history of legal problems, but also people deemed “in need of treatment,” which could affect millions of Americans who suffer from mental illness, not merely those who pose a danger to society.
The Root Causes of Violence
But has the media been too focused on mental illness to examine the true causes of violence? By focusing on mental illness as the cause of violence, the media has missed not only the rollback in civil rights that Rep. Murphy’s Helping Families in Mental Health Crisis would entail, but also as the connection between drugs and violence. As Saleen Fazel notes in his studies of violence in persons diagnosed with schizophrenia and bipolar disorder, substance abuse, not mental illness, appears to be the mediator of violence. A 1994 report by the Bureau of Justice Statistics notes that in 64.4% of homicides, the perpetrators had been drinking alcohol. A separate 2011 study found that “57% of the homicides would be attributable to alcohol” in the United States.
Additionally, there is some evidence that prescription drugs commonly prescribed to treat mental illness may spur violence. A 2010 study by Thomas Moore, Joseph Glenmullen, and Curt Furberg concluded: “Acts of violence towards others are a genuine and serious adverse drug event associated with a relatively small group of drugs. Varenicline, which increases the availability of dopamine, and antidepressants with serotonergic effects were the most strongly and consistently implicated drugs.” Not knowing this connection led the media to cover Newtown shooter Adam Lanza’s autism rather than his celexa prescription. Likewise, coverage of Tuscon shooter Jared Loughner focused on his diagnosis as a paranoid schizophrenic rather than the drug use that got him rejected from the army. And in the case of Elliot Rodger, the Santa Barbara shooter, the story was possible mental illness, ignoring his risperdone prescription and possible Xanax dependency.
If the Helping Families in Mental Health Crisis bill passes, boosted by editorial support in the media, millions of Americans will potentially face the forced medication of outpatient commitment, which could potentially spark a new wave of violence across the country. But one thing is certain. If we are going to have a sensible discussion about mental health in the United States, the media needs to stop equating mental illness with violence and start considering the civil rights issue of forced treatment. Only then will we be able to have a real conversation about the underlying causes of mass violence in America.
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.