In a recent article in the New York Times, author Deborah Sontag details a tragic sequence of events in Massachusetts in which the primary players are a seriously mentally ill man and the minimally trained mental health worker whom he kills.
In previous blogs, I have discussed the problem of people having to be charged with crimes in order to obtain treatment, and of responding to extreme examples with extreme, if misguided, responses.
How do we respond to horrific incidents of the type described by Ms. Sontag?
If history is any guide, we respond by:
- Altering criteria for the affirmative defense of insanity (cf. John Hinckley)
- Devising coercive paradigms that would have done little to alter the events that prompted the legislation that followed (cf. Kendra's Law), or
- Develop well informed approaches to community-based care for people with serious mental illness (cf. Crisis Intervention Teams)
While this is not an exhaustive list, it outlines three potential ways in which our society responds to these horrific events.
We limit the availability of exculpatory approaches to the criminal case. We provide for increased coercion in the civil mental health system. Or we create innovative, outside-the-box responses to societal problems.
Unfortunately, the two former approaches often seem easier to implement – they do not require any type of paradigm shift – whereas the latter requires a creative approach to a problem that often seems insoluble until the right person comes along.
The problems discussed in Ms. Sontag's recent article are not new.
This is not the first time we have read about a person with serious mental illness who could not access care and who then progressed to commit a very serious and tragic crime that, perhaps, could have been prevented with better care.
But it is important to recognize that even in the most secure environments, tragedies happen. We have read recently of the murder of an employee at Napa State Hospital in California, and of a patient at Clifton T. Perkins Hospital in Maryland.
So clearly, any answer that stops at “why can't these people get hospitalized?” will not address the problem.
As I wrote in response to the tragedy in Tucson, it is imperative that we avoid simplistic answers that start with “if only….”
All such statements may be a part of the solution, but none alone will constitute the entire solution to the problem of violence stemming from untreated or unmanaged mental illness. There is no system in our society that could not benefit from better funding?be it mental health care, public safety, transportation, or education.
But crying for money that does not exist is useless.
What holds the promise for our future is when someone comes along with fresh eyes who can look at a problem from a new perspective, and who then says “what if we tried this?”
In 1988, in Memphis, Tennessee, just such a person came along. Responding to a series of bad outcomes involving police use of force against people with serious mental illness, then Lt. Sam Cochran developed a new approach, partnering with mental health colleagues to develop the first Crisis Intervention Team (CIT).
Rather than focusing on blaming someone or something for the bad outcome, Lt. Cochran decided to develop a novel approach to policing that has spread across the country. Now, less than 25 years later, nearly every state has at least one CIT, and there are international conferences focused on this unique approach.
In many jurisdictions, the introduction of a CIT has led to reduced police injuries and reduced arrests of people with mental illness.
So, rather than falling prey to reactive, vengeance-based urges, or to the bad law that is often the result of bad cases, I believe we should constantly be considering novel approaches to individuals with serious mental illness at risk for criminal justice involvement.
Whether these are police-based, or court-based, or jail-based, or probation-based, it is imperative that we use the rational parts of our brains and not the emotional parts.
While an emotional reaction may be more satisfying in the short-term, it does little to improve the lives of those we serve. Would readier access to hospitalization have prevented the tragedy in Massachusetts? The cases in California and Maryland suggest not.
While it is important to remember that people with serious mental illness usually do not commit serious crimes, we cannot forget that, at times, they do.
Our job, whether on the justice side or the mental health side, is to try to develop better ways to identify those at risk and to intervene appropriately when the risk is high. But at the same time, we must take care not to respond inappropriately to those who are not at risk for violence.
Striking this balance is difficult. Perhaps impossible. But this should not keep us from continually questioning our response and attempting to craft rational?not reactive?responses to adverse outcomes.
Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. He welcomes readers comments. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes.