By Michael B. Friedman, L.M.S.W.
From time to time, a person with a severe mental illness (or assumed to have a mental illness) commits a murder that makes headlines. As the tragic slaughter of children and teachers in Newtown, Conn. illustrates, the reactive call to address "the mental health issue" is entirely predictable. Sometimes the call to improve mental health policy and practice comes from people trying to distract us from issues such as gun control. But often it comes from politicians, journalists, and social advocates (even mental health advocates) who sincerely believe that addressing the so-called mental health issue could reduce mass murders in the United States. Are they right? Are there interventions that would reduce the incidence of mass murders?
Those who call for addressing the mental health issue in criminal violence have disparate and often unclear views of what can be done to help. But, despite their differences, they appear to share three highly questionable assumptions.
ASSUMPTION 1: Mass murders like that in Newtown are generally committed by people who are severely mentally ill.
This assumption ignores the fact that people with mental illness are not likely to be violent. It also ignores the fact that mass murders include acts of terrorism, mob and gang violence, and acts of revenge. Yes, some mass murders are committed by people with serious mental illness, but it is likely that most are committed by people who are not. Unfortunately, there is a dearth of research about multiple or single murders of strangers by people with psychotic conditions in the United States, but research elsewhere suggests that such events take place at a rate of 1 per 14 million population. In contrast, stranger homicide in the United States takes place at a rate of 140 per 14 million population. Obviously, stranger homicide by people with psychotic conditions is both rare and a small proportion of all such murders.
ASSUMPTION 2: These events reflect widespread inadequacies in the mental health system.
This assumption ignores the progress that has been made in mental health care over the past 50 years. Frank and Glied's Better But Not Well documents the fact that more people are getting better mental health care now than ever before. Of course, there continue to be significant inadequacies in America's mental health system, but our nation has come a long way since the beginning of the community mental health movement in the 1950s. There do appear to have been some cuts in public mental health services in recent years that may have reduced access to mental health services, but America's mental health system is simply not as terrible as it is frequently portrayed. And it is likely to improve further through health care reform and the growing emphasis on "recovery" and "person-centered care."
ASSUMPTION 3: There are specific changes in mental health policy and practice that could reduce the incidence of mass murders committed by people with serious mental illness.
- Increased coercive interventions including both involuntary inpatient and involuntary outpatient commitment
- Easier admission to inpatient treatment and longer lengths of stay
- Requirements that mental health professionals report dangerous patients to criminal justice authorities
- Outreach to, and voluntary engagement of, people known to be seriously mentally ill who have dropped out of treatment
- More housing for people with serious mental illness
- More community mental health services generally so as to increase access to treatment
- Increased support for families with frightening mentally ill family members
- More screening for mental disorders in primary health care, schools, and social services
- Earlier intervention
- More primary prevention interventions
- Expansion of the mental health workforce.
The belief that coercive interventions with people who have serious mental disorders should be used more frequently is highly controversial. There are critical questions about:
- The rights of Americans who have psychiatric disabilities to live freely in the community if they have not committed a crime or manifested danger to self or others
- The long-term impact of involuntary incarceration of people with mental disorders
- The effectiveness of court mandated treatment in contrast to outreach and voluntary engagement programs
- The assumption that increased coercion will reduce the incidence of criminal violence by people with serious mental illness.
The belief that admission to psychiatric inpatient treatment should be easier and that lengths of stay should be longer is also highly controversial. Do people generally benefit more from longer or shorter inpatient treatment? Would more admissions and longer length of stay really result in reduced incidence of murders by people with severe mental illness? This is highly questionable, as a recent report by the Bazelon Center documents. And if our nation decides to put more resources into mental health care, should they be invested in more inpatient treatment, or in expansion of the kinds of community mental health services that might reach people with mental disorders before they become acutely psychotic?
The suggestion that mental health professionals be required to report patients they believe to be dangerous to criminal justice authorities, which is a cornerstone of New York State's new gun control law, has stirred tremendous reaction in the mental health community. One question is whether this violation of confidentiality will drive people away from treatment. Equally important is the fact that people who commit mass murders, even those who are mentally ill, are exceedingly unlikely to be in treatment. In addition, this provision assumes that mental health clinicians do not now take protective action when they have a clearly dangerous patient, which is simply not the case. New York's approach is sharing information between the mental health and criminal justice systems is not the only possible way to go. But all raise reasonable questions.
The other suggestions for improved mental health policy and practice are far less controversial, but not because they clearly would reduce the incidence of murders by people with serious mental disorders. These proposed changes in policy and practice are important—most agree—because they would improve the overall mental health of all Americans.
Is there anything that can be done by the field of mental health to reduce the rare incidence of murders by people with serious mental illness? There is some reason to believe that more efforts to engage people in treatment in the year after their first psychotic break and reaching out to those who have dropped out of treatment would help.
But we don't really know what changes in mental health policy and practice would reduce the incidence of murders by people with serious mental illness because research regarding this question is so undeveloped.
The most critical need at the moment is a comprehensive epidemiological study to clarify the incidence of mass murders by people with severe mental illness, to track it over time, to identify the characteristics of the perpetrators and of the situations in which they commit murder, to identify possible points of intervention, and then to explore the viability of mounting preventive programs that could be effective without casting such a broad net that they would inevitably violate the rights of the vast majority of people with mental illness, who will never commit a crime, let alone a mass murder.
This article originally appeared on January 17, 2013, in the Huffington Post, where Michael B. Friedman is a regular contributor, under Healthy Living.
Michael B. Friedman has worked in the field of mental health for over 40 years as a direct service provider, an administrator, a government official and as an educator. He is an adjunct associate professor at the Columbia University School of Social Work and at the Mailman School of Public Health.