Why can't America care for the mentally ill?

Adam Lanza, 20, who killed 20 children and 6 adults on Friday, has brought incalculable grief to dozens of families and stunned our nation.

Now, the debate begins about what to do in the wake of his carnage in Newtown, Connecticut and the multiple murders in Aurora, Colorado and at Columbine High School, the Red Lake Indian Reservation in Minnesota and the West Nickel Mines School in Pennsylvania, Virginia Tech and Chardon High School in Ohio.

Some will say that gun control is the answer, but that ignores the obvious:  Too many guns isn’t the issue; too little mental health care is.


Focusing on gun control does more than squander the time and effort of our public officials and state resources and town police forces, it distracts us dangerously from the real work that must be done.

America’s mental health care system is shattered and on its knees.

After decades of deconstructing our inpatient psychiatric hospitals and community mental health centers and after decades of insurance companies demanding that they pay only for  social workers and nurses to treat even the most extremely mentally ill and potentially violent individuals (rather than including psychologists and psychiatrists) we now have a mental health care system that simply ignores those among us who suffer with incapacitating symptoms of psychiatric illness and whose suffering can—only in a very, very small percentage of cases, thankfully—lead to terrible violence.

What is wrong, exactly?

Here is the truth:  Today, even a mentally ill young man with a known propensity for violence, or even a history of serious violence, is likely to receive just an hour a week of counseling (if that) by a social worker.

He is likely have an unclear diagnosis of his condition and to be on a list of constantly changing, very powerful psychoactive medications prescribed by a nurse.

He is also likely to be turned away -- repeatedly --by emergency room social workers who act as gatekeepers for insurance companies to restrict access to inpatient psychiatric treatment.
If admitted to a psychiatric hospital, he will likely be triaged quickly through an often-incompetent “tune up” of medications that might accomplish nothing and then be sent back home as soon as he “contracts for safety”—simply promising a social worker that he won’t kill anyone.

That young man’s good parents might well pray that he be arrested for another violent crime so that the terms of his probation might (but probably still wouldn’t) include mandatory visits to a mental health professional (though not always the right one for their child’s needs) and mandatory drug testing.  At least then he can be jailed if he refuses all treatment or gets hold of some heroin that could worsen his hallucinations.

Imagine the sort of anemic services made available to someone who clearly needs help, and might well be dwelling on very dark thoughts, but has yet to act out violently.

How could this be?  What has happened to render such a great nation so incapable or unwilling -- or both -- of caring for the mentally ill?

The following list is not exhaustive, but, though short, it will give you an important window into just how bad our mental health care system has become and why I can only call it a national disgrace:

1) The essential art of helping understand the roots of psychiatric illness in emotion is not available to the vast majority most families, now being reserved for people who can find the small number of professionals who are expert in that skill set, many of whom would never be paid by insurance companies at all, or given only three or six or a dozen hours to treat a very disturbed patient.

Not only have insurance companies demanded that empathy be dispensed in tiny doses, in favor of ten minute medication appointments, but many, many American training programs for psychiatric residents have responded by curtailing  education in that healing art such that most new psychiatrists have never even been in therapy themselves and have limited ability to perform it.

The mental health care system is now itself dangerously devoid of the ability to understand patients’ lives, empathize with their suffering and help them beyond their depression and rage.

The constantly changing, partly insurance-company driven, "Diagnostic and Statistical Manual of Mental Disorders"—which pretends to accurately describe the range of psychiatric suffering through the use of 300 sterile diagnostic labels (conveniently ready for matching up to medications), is part of the problem, too.

2) The demands of insurance companies, including Medicare and Medicaid and every public insurance program, has been to cram down the educational level of clinicians more and more and more. 

People with complex histories of abuse and neglect and extremely toxic interpersonal dynamics are now routinely in the case loads of mental health counselors with little more than college degrees (if that) and social workers and nurses, many of whom are very talented and extremely dedicated people, but many of whom simply do not have the ability or training to do what psychiatrists trained for at least 8 years in medical school and residency could do for them.

3) The holistic view of the patient—essential to understanding his view of himself and others and assessing whether dangerous behavior could result—has all but disappeared, having yielded to simplifying and splitting the patient into someone with some emotional problems who should talk to a counselor about his feelings once a week (or less) and someone who needs medicine to think clearly or stop hallucinating or stop being paranoid who should visit a doctor or nurse ten minutes a month for prescriptions.  These two professionals often never speak to one another and never even compare notes via email.

Thus, the crucial subtleties of how medicines are impacting the psyche are ignored and the possibilities for bad results are exponentially increased.

4) The use of inpatient psychiatry units as healing environments in which more sophisticated assessments of psychiatric patients are performed is now mostly relegated to rare hospitals that can cost as much as $20,000 or $40,000 or $80,000 a month, which people must pay for themselves, since insurance companies will not.

Insurance companies will only pay for overcrowded psychiatric units, often in disrepair, in which the violent mentally ill are often lumped into one space (and share rooms) with depressed young adults, drug addicted homeless folks and the elderly suffering with dementia.

Most of these units are revolving doors where someone can assault his mother or threaten to kill her on a Friday and be discharged with a new prescription on Monday.

5) There is no system in place—at all—that routes very sick mentally ill individuals, especially those at risk for violence, to forensic psychiatry professions truly skilled to evaluate them.  In any case, the numbers of such professionals are extremely low and their use largely limited to evaluating and treating those who have already committed sex crimes or very violent acts, including murder.

Clinicians in ERs and in clinics, whose resources are already stretched dangerously thin—are loathe to file the paperwork that would force hospitalization on the unwilling or force medications on individuals who need them and refuse them, if they are lucky enough to get hospital care.

6) There is no effective, ongoing line of communication between law enforcement  
officials and psychiatry professionals about the status of dangerous patients
, even those who have broken the law, already, in very significant ways.  The expectation of most probation officers for sex offenders or those mentally ill people charged with violent crimes including guns is a letter faxed to them once a month stating that visits are ongoing—if that.  And if the letter were not to arrive, many probation officials would not take notice or take action.

7) In most communities, there are no real psychological/psychiatric resources available within the schools, nor any established and effective line of communication between the schools and outside mental health professionals or agencies.

When I was medical director of the Tri-City Community Mental Health Centers in Massachusetts, I appointed a clinician to act as a liaison to every school we could afford to reach out to.  But that was too thin a safety net and a very rare one at that.  And centers like Tri-City (where we had 10,000 clients) are so poorly funded that it is an embarrassment.

8) In most states there is no way to arrange court-ordered, involuntary outpatient use of medications (including antipsychotic medications) even if someone is very violent or has reported extremely violent thoughts in the hospital, even if that person is psychotic and also addicted to cocaine or heroin, and even if that person is court-ordered to take such antipsychotic medications in the hospital.

Once that person hits the streets he or she is too often free to never visit a psychiatrist, again, to never take another medication and to never be drug-tested.

That is where we are.  And that defines what poses as a mental health care system, but does not merit that label.

It is a cruel ruse to suggest to American families struggling with mentally ill loved ones that they can receive effective and healing psychiatric care without spending tens of thousands or, more likely, hundreds of thousands of dollars to do it.

With the dehumanizing forces of media, entertainment and, especially, technology gathering steam every day, we can expect more and more horrific violence, until we come up with a real strategy and a real system to prevent it.

You might think that the system is so far gone that it cannot be rebuilt and built better than ever.  But that is not true.  All that stands in the way is a clear plan and clear resolve.  
Psychiatry and psychology are amazingly effective disciplines, when properly harnessed and deployed.  And it doesn’t even have to cost billions of dollars to do that.  Within the week, I will post the rough framework of such a plan here on FoxNews.com.

Until then, when you hear well-meaning politicians or community leaders talk about gun control as a solution to school shootings, remember that Adam Lanza was mentally ill (in a way that I would label as “violently ill”) in a nation that has no real mental health care system at all, that he used firearms that were legally obtained by his mother and that he could just as easily have used other means to inflict horrible casualties.

We have no time for misplaced efforts. Our will to heal, not bluster, will define how much senseless, horrific, preventable violence we are yet to see in our schools.