When Vester Lee Flanagan II fatally shot a television reporter and a cameraman in the midst of a live interview in Moneta, Virginia, it was a scene that has become all too familiar to us.
In all these scenarios, we learn after the fact that the perpetrator has had a troubled past in which he exhibited bizarre and disruptive behavior, and frequently a history of diagnosed but untreated mental illness. The media and public erupt in outrage, but after the chest thumping and soul searching, nothing is ever done.
As a psychiatrist, I’ve treated thousands of patients with serious mental illness over my 30-year career and consulted on too many such criminal cases. I find it lamentable that we still cannot connect the dots and take effective action, as a vast majority of these tragedies are preventable.
A 2007 case that I was asked to review illustrates the problem. It involved an 18-year-old man, an athlete and a good student, who began college with high hopes.
However, at the start of sophomore year, he quit the football team, left school and went home. At home he was withdrawn, disheveled, talked to himself and was suspicious of his friends and family. His parents knew something was wrong and sought treatment. When a mobile crisis team was called to the house, he refused to engage. Although he clearly was ill, he was not aggressive, so they told his parents to continue monitoring their son’s behavior and to call if he became a threat to himself or others. The next day he stabbed his twin half-brothers with a kitchen knife, killing one of them and severely injuring the other.
Incidents like this are part of the glaring array of social pathologies that emanate from our country’s failed mental health care system. We need to identify mental illness early and intervene before a person’s symptoms disrupt their lives and society. One way to do this is to embed mental health professionals in emergency rooms and general medical clinics. Another, since many mental disorders begin in adolescence, is to train school personnel and guidance counselors and provide them with screening instruments and referral sources for mental health care.
The New York State Office of Mental Health was an early adopter of an innovative program called OnTrackNY. Similar programs are now spreading across the country and being supported by the federal government.
This model of mental health care targets adolescents and young adults in the incipient stages of psychotic disorders and establishes specialized clinics that provide “wraparound” services with pharmacological, psychological, educational and social-support treatments to engage patients and promote recovery.
For patients already at advanced stages and disabled by their mental illness, it is imperative that we make comprehensive services available to them. This includes medical management, psychotherapy, rehabilitation services and supervised residential facilities.
In many instances mentally disturbed people lack awareness of their illness and are unwilling to accept treatment. Almost every mentally ill perpetrator of mass violence had been symptomatic and untreated for lengthy periods of time before their crimes, because they (or their families) did not seek treatment or they refused it.
Statutory mechanisms like assisted outpatient treatment have been enacted in 45 states. They enable doctors to obtain a court order that requires severely mentally ill patients who meet certain legal criteria – if they are unable to care for themselves or are unwilling to take medication – to adhere to treatment. However, these legal mechanisms are controversial and infrequently used despite their effectiveness in reducing violent incidents and hospital readmissions.
We are reluctant to infringe on people’s civil rights by forcing them to accept treatment, even though we do just that for communicable infectious diseases such as tuberculosis and various sexually transmitted diseases. But we must start using this law to treat patients in need, over their objections if necessary. This strategy would apply to a small number of people who have psychotic disorders and known risk factors for violence, such as drug abuse and a history of violence.
The good news is that these strategies have proved highly effective and really work. They simply have not been widely applied.
The New York Times
Jeffrey A. Lieberman is chairman of psychiatry at Columbia University Medical Center of the New York-Presbyterian Hospital.