As a forensic psychiatrist and psychotherapist who has also served as medical director of a community mental health center serving 10,000 patients and medical director of a psychiatric hospital (as well as having worked as a psychiatrist at a state psychiatric hospital and on a locked psychiatric unit at a VA hospital), I believe it could be helpful to disclose the reasons why the “next Jared Lee Loughner” might fall through the cracks and kill people, too.
Here’s the basic problem: The cracks in the mental health care system in America are not fissures; they are canyons.
First, we do almost nothing to effectively educate the public about mental illness. If the next Jared Lee Loughner should stare blankly at people logically explaining why the number “6” is not the number “18” (which apparently did not compute for him), or speak of dreaming for a dozen or more hours a day, or appear too confused to follow simple instructions as a volunteer at an animal care center, or stare back at college police officers as if in a trance, it is very possible no one will identify mental illness as the possible reason. If the idea of mental illness fueling such behavior is considered as a reason for that person’s bizarre conduct, the continuing stigma and fear connected with it might well result in shunning him or laughing at him.
How much time in “health” class in grade school and beyond is spent on education about mental illness—including how to get those afflicted some help? Almost none.
Think about the difference, after all, in how people responded to Jared Loughner’s obvious and severe psychiatric symptoms and how they would respond to a person passing out repeatedly from the hyperglycemia caused by diabetes, or seizing from epilepsy or reporting migraine headaches. Can you imagine people simply turning away or rolling their eyes or chuckling?
Second, if the next Jared Lee Loughner should appear on one of the nation’s college campuses, he is likely to be met with a student health system in utter disarray, as regards dealing with psychological/psychiatric issues. Again and again, I have been consulted about and actually treated students who literally have had to be at the point of contemplating killing themselves (or others) in order to trigger attention from student health services, with the result being that the most severe cases are sent home, with no follow-up.
Sound familiar? Can you imagine a doctor treating a young person with severe hypertension by simply saying, “Go home and don’t come back here?” That would be called malpractice—and rightfully so.
Third, most folks have no idea what to do even if they are aware of mental illness and are concerned enough to want to do something to help a person struggling with severe symptoms. We don’t get the word out that emergency rooms have on-call
mental health counselors and psychiatrists and that nearly every community in America has a community mental health center attached to it, with 24-hour crisis teams associated with them—crisis teams charged with evaluating the Jared Lee Loughners of this world and making sure they get the treatment they need.
Fourth, in most states, the mental health care delivery systems have been gutted by disproportionate cuts that leave them reeling, understaffed and unreliable.
Fifth, even if the next Jared Lee Loughner finds his way to an emergency room or crisis team, he is unlikely to get help. Too many mental health care workers have become pawns of reprehensible mental health insurers and their “reviewers” who routinely deny comprehensive services (like hospitalization) to people, even if they are psychotic and drug addicted and even if they have expressed very serious thoughts of violence. I have battled with insurance company reviewers dozens of times to get very ill patients even short stays in locked psychiatric units after they have shared suicidal and homicidal thoughts. Far too often, even after reporting plans for violence, such patients are encouraged by emergency room personnel (doing the bidding of insurers) to “contract for safety” (promise they won’t do it), and are sent home. Too many emergency room and crisis team workers don’t know that they still have to do the right thing clinically even when insurance companies strong arm them. In other words: The payor must not be the final word on who gets treatment and who does not; the clinician must render an independent judgment and fight for compensation later.
Sixth, if the next Jared Lee Loughner gets helped to an emergency room and actually gets admitted to a locked psychiatric unit, a good deal of the effort on that unit will be spent trying to get him out of there very, very quickly, whether he is stabilized on his medication or not. In fact, suicidal and homicidal patients are routinely discharged just a few days after admission, even though psychiatric medications can take weeks to work.
Seventh, families do not have the knowledge of their rights and the judicial clout to get attorneys, get court dates and seek “substituted judgment” to deliver treatment even to desperately ill loved ones who clearly cannot care for themselves. Many states have no provision to deliver enforced medication to severely psychiatrically ill individuals against their will in the community, even if they pose a clear danger to others. And, keep in mind, #5 and #6 (above). The system to which the most fortunate Jared Lee Loughners would ultimately be handed over is shoddy and shattered.
We have real work to do to repair the mental health care system in America. That’s why it is so very dispiriting when politicians try to make points by suggesting that this Jared Lee Loughner (or the next Jared Lee Loughner) was expressing an extreme political point of view with his violence. He seems to have been expressing nothing other than the chaotic thought product of a catastrophically severe mental illness, while speaking volumes about how ill-prepared we were to deal with it.
Dr. Keith Ablow is a psychiatrist and member of the Fox News Medical A-Team. He is a New York Times best-selling author, and co-author, with Glenn Beck, of the book "The 7: Seven Wonders That Will Change Your Life". Dr. Ablow can be reached at firstname.lastname@example.org.