By: Adalia WoodburyDec. 20th, 2012more from Adalia Woodbury

Discussion about mental illness and its treatment remains a challenge in our society.  If we are going to take meaningful action to prevent another incident like Sandy Hook, we need a frank discussion about our broken mental health system.

We also need to dispel the stigmatization of mental illness.  Some people with mental illness are at greater risk of being violent – more so without treatment. While there is an increased risk that people with some mental illnesses will be violent; mental illness is not synonymous with violence.

The stigma that goes with mental illness makes it more difficult to seek treatment.  Stigma means facing discrimination in the work place and in social situations.  In the case of mental illness, stigma is reflected in the absence of coverage for mental health treatment in many health care insurance policies.  Other policies fail to provide sufficient coverage.

Then we wonder why people who have mental illness may be reluctant to acknowledge their illness and get treatment.  We wonder why some parents don’t seek help for children who have mental illness. In some cases it may be a matter of choice.  In many cases, it is a matter of lacking the resources.

We need a better understanding of the relationship between mental illness and violence.  Part of the problem is how little we know about this relationship.  What little we do know suggests that with different types of mental illness, there are also different relationships between the illness and violence.

As noted in I am Adam Lanze’s Psychiatrist: A Response from the Mental Health Trenches to “I am Adam Lanza’s Mother”

In terms of the relationship between mental illness and violence, here is the little we do know. According to APA Council on Law and Psychiatry (Access to Firearms by People With Mental Illness: Resource Document, Arlington, Va., American Psychiatric Association, 2009), “The ‘absolute risk’ message is that the vast majority of people with mental illness in the community are not violent. The ‘relative risk’ message is that people with serious mental illness are, indeed, somewhat more likely to commit violent acts than people who are not mentally ill. And the ‘attributable risk’ message is that violence is a societal problem caused largely by other things besides mental illness (ready availability of guns, for example).

We also need to understand the consequences of cuts to mental health funding, Medicare and Medicaid.  Cuts reduce the resources available to provide treatment and reduce access to treatment.

On a pragmatic level, we can whine about personal responsibility.  Alternatively, we can face the fact that reducing resources and access to mental health care comes with a heavy price.  Innocent people who were not in a position to enact responsible policies will pay that price.

Budget cuts over the decades mean people working in social services have seen their pay cut or frozen for years.  For years, the people charged with assessing treatment and finding the means to provide it have had to resort to food stamps because of pay cuts and freezes.

When we talk about ‘”good jobs” we are talking about jobs that provide enough income for families to live on.  Most occupations make dressage horses and car elevators way out of reach. However, who would realistically invest in an education and the training required to care for the mentally ill when there is a certainty they will not earn enough money to live on? Cuts in mental health spending already less access and a lower quality of care.  More cuts will only produce greater shortages of resources and a further reduction in the quality of care.

Never mind the reality that for treatment to happen, caseworkers need consent from someone who they assess to be dangerous.  Yet, people who need help most are also most likely to deny that they need it. For some people it is so tempting to reduce this to a question about liberty.

Even if we accept that some people should be compelled to have treatment, making that assessment is far from simple, as noted in I am Adam Lanze’s Psychiatrist: A Response from the Mental Health Trenches to “I am Adam Lanza’s Mother”

I have had patients who have believed they were “chosen” to carry out a mission or who started to speak of the devil being present in the form of human beings. But are they violent? Do they need to be locked up? At what point do I inform the authorities when no specific plans to commit violence are mentioned to me, but the words start to become more terror-inducing. “Enemies” are mentioned. “Hate” punctuates every other word. Conscience can appear strikingly absent or little, if at all. Behavior is erratic — but does not pose a technical threat.

Even if we have enough qualified people to make these assessments, a shortage of resources means hospitals turn people away unless there is proof they are dangerous.  That’s a high bar to meet. As a result, we are warehousing the mentally ill in already overcrowded jails.  This is all too real for parents and loved ones across the country. As told in  “I am Adam Lanze’s Mother”

When I asked my son’s social worker about my options, he said that the only thing I could do was to get Michael charged with a crime. “If he’s back in the system, they’ll create a paper trail,” he said. “That’s the only way you’re ever going to get anything done. No one will pay attention to you unless you’ve got charges.”

I don’t believe my son belongs in jail. The chaotic environment exacerbates Michael’s sensitivity to sensory stimuli and doesn’t deal with the underlying pathology. But it seems like the United States is using prison as the solution of choice for mentally ill people… With state-run treatment centers and hospitals shuttered, prison is now the last resort for the mentally ill—Rikers Island, the LA County Jail and Cook County Jail in Illinois housed the nation’s largest treatment centers in 2011.

In short, jail is not a solution.  It’s more like a place to warehouse people with mental illness thereby making it all the easier to pretend they and their illnesses don’t exist.

Yet, the possibility of having an illness that alters our behavior can happen at any time, and comes from a variety of factors.

In The Brain on Trial, David Eagleman makes the following observation.

When your biology changes, so can your decision-making and your desires. The drives you take for granted (“I’m a heterosexual/homosexual,” “I’m attracted to children/adults,” “I’m aggressive/not aggressive,” and so on) depend on the intricate details of your neural machinery. Although acting on such drives is popularly thought to be a free choice, the most cursory examination of the evidence demonstrates the limits of that assumption.

I don’t have all the questions – let alone all the answers. When it comes to our broken mental health care system, there are a few things that I know with certainty.

It’s easy to dismiss mental illness by warehousing people.   It’s easy to pass flawed judgments on people who have mental illnesses.  It’s easy to cast blame, especially in hindsight.  It is easy to criticize the health care professionals for lacking a crystal ball.

It is more difficult to accept that failed policy also plays a role.

Image from Community Counseling Centers of Chicago