It has been more than a month since the
tragic shooting in Newtown Connecticut. I have been listening to the
pundits and newsies talk about what could have possibly prevented the tragic
murders. One huge faction is arguing
that better gun control will prevent tragedies and one strong rebuttal to that
argument has been that more attention to metal health issues will save us. I hear
the arguments that gun control isn’t going to prevent any tragedies, and it is
not my intention to prove or disprove that notion. As
a psychiatrist currently working in community mental health, I just
want to mention you might not want to put all your eggs in the mental health
basket either. Let me explain:
Today at a community mental health
facility I had two patients. One patient is a charming good looking young man,
who on the surface doesn’t look like anything is bothering him, but he has
auditory hallucinations that torment him and tell him not to trust his family
and to kill them before they kill him. Today I spoke to his mother who told me her
and her kids and grandchildren sleep in locked rooms afraid of what he may do
on a whim. When medicated he is pleasant cheerful, and very funny; but he
isn’t taking his medication and today in this state he is anything but, and
quite scary.
The second patient I had only one brief
encounter and didn’t know very well. The report I got was he had been reportedly
discharging a firearm in his neighborhood 2 days ago. I was told that he had
been refusing his medication for weeks, and was held up in his apartment
talking to the walls and yelling out the windows. The field agents who are
charged with visiting his home and making sure he is ok were able to get him to
come to the clinic by telling him they were taking him grocery shopping. Through
a lot of hard work the community agents were able to bring these two men into
the clinic for evaluation. Given the report of how these men were acting in the
community I decided it would be safer if they were admitted to the hospital to
have their medications adjusted. They both demonstrated demonstrable danger to
others and potentially themselves. Sounds simple enough. Wrong.
It is usually the job of the sheriff's
office to pick up involuntary commitments in the community, so I filled out the
paperwork for involuntary commitment and called the sheriff's office. My call
was answered by a less than courteous dispatcher who told me they were in
middle of shift change and they would not be able to send someone out until 7pm.
It was 4:30 pm.
I explained that I had a staff of mostly
females and that the patients were potentially dangerous when
agitated. I let her know they were only here begrudgingly and it was
only a matter of time before they became agitated. The dispatcher
then transferred me to a shift manager whose disposition made the
first person's curtness seem pleasant by comparison.
I again explained the situation
and asked if someone could please transfer the patients to the nearest
hospital. She rudely told me that shift change wasn’t until seven and even then
I would have to demonstrate the patients had been given medication to calm them
30mins prior to their arrival. I attempted to explain that as a private
clinic I have no medication to give the patients. We are not a hospital or ER
with shots to give agitated patients. She said then she would not send anyone.
"So, you want me to send my deputies into danger with a violent 'crazy. person?"
,she asked. I explained these people with mental illnesses (not crazy people)
were in need of medical help. The people who went into the community to get
them were not trained, nor armed. Yet they went into the community to retrieve
them, even with the knowledge that one may have been potentially armed. But she
was telling me trained police officers with weapons and restraints could not
handle two unarmed men?
As she was refusing to help one of the
patients turned to the other and said "It's a trap, they're trying to lock
us up". At which point both men began to get irate. I explained this to
the person on the phone who heard this but still wasn’t moved one inch towards
caring.
I then hung up with her and called 911.
The 911 dispatcher, who at least was pleasant, explained that it was the
sheriff's department's responsibility to
transport involuntary commitments and that by law they could not. She
said she would at least send a patrol car over to assess the situation.
The patrol officer did arrive promptly,
and he too was at least polite. By this time one of the two men saw the police,
thus confirming his suspicion that he had been duped. He began cursing and pacing
angrily. He was now visibly agitated, but thanks to the great community worker
was able to be calmed. The officer who witnessed this suggested that now that
the patient was calm and one of my workers should transport him to the
hospital. When asked if he could at least follow them to the hospital he, again
politely, said no.
We then had to call off duty male staff in
to ride with the female staff and patient to the hospital. Meanwhile the other
patient, who introduced the idea of a mass conspiracy, began to rock in his
chair, mumbling how he’d be damned if he was going to the hospital. The police officer and I were sat and berated
the sheriff’s department for not doing their job. The officer agreed that it
was a shame that mental health services were in shambles. He talked about the
time he spent as a community support officer. He went on to say that the
sheriff’s office should have sent someone urgently despite being in the middle
of shift change. It was in the midst of this conversation that the empathetic
officer who just spent five minutes talking about his understanding of the
broken mental health system informed me that he was leaving. He told me he had to get back to his patrol.
I asked him what I was supposed to do if these patients became violent while we
waited the still whole hour left until 7pm. He responded that if they did
become violent we could then call 911 and THEN someone would come.
Around this time some of our male staff
arrived and the calmer patient was able to be taken to the hospital leaving me,
two female staff members, and the patient who 2 days ago was reportedly
shooting in his neighborhood. Some more
male staff came and I had to leave them untrained, unarmed civilians with the
patient to wait for the trained armed sheriff’s office. Time 7:05
I wish that I was just venting about one
bad experience with one bad county with one bad system, but I can’t. In my
short career I have worked in two states three cities and numerous different
counties and it is sad but I have had the same experience with the relationship
between law enforcement in mental health in each of those settings.
I don’t want to touch the gun control
debate that has come up since the last mass shooting, but I do notice that each
time one of these tragedies comes up people mention mental health as the failed
barrier that should have protected society from these tragedies. And I only
mention the gun control debate in the same breath as mental health because I
feel it is futile to say the current status of mental health care in this
country will offer any help in the same way that it is viewed the status quo
with regards to gun control will offer any addition safety to society at large.
The major similarity between both discussions is that as soon as a great tragedy
occurs we get really amped up to change the world. We posture and talk really
grand for a moment and then nothing happens.
Why nothing really happens is because the
problem is very complex and difficult to solve. In this story better
communication between law enforcement and mental health services needs to
happen. It can’t be just one department that is responsible to responding to a
crisis if that department can’t be responsive 24 hours a day, and then an
emergency department who is trained to handle potentially violent situations abdicates
that responsibility to civilians when the situation is inconvenient for
scheduling.
Coordination is one small facet of the
problem but it is deeper still. Even when law enforcement agencies are
cooperating there is no place to take acutely agitated patients. Mental health
institutions have gradually been decreased over the last three decades. There
are fewer and fewer long term treatment facilities. As a result, most acute
inpatient hospitalizations are for less than a week and then patients are sent
back into a community that is ill equipped to support them. Because they are poorly supported with poor
outpatient care they bounce back very frequently which creates a jam in ER’s
across the country. Because ER’s are overflowing, there is more pressure to
discharge patients quickly (not to mention the financial pressure to discharge
quickly, but a separate conversation). Poorly stabilized patients decompensate
quickly and end up back in the ER which starts the cycle all over again—
leaving mental health providers very frustrated.
The legal system is equally frustrated
because the patient who aren’t in the revolving door of
ER->hospital->community->ER often make detours in the justice center. Jails
aren’t equipped to handle serious mental illness so they try without success to
access the above mental health system and find it just as jammed as described.
I really started this article to vent
about a horrible incident I had, but my frustration wasn’t because of the time
I lost that day or necessarily with the rudeness of some of the people I
encountered. My main frustration was that as I sat and reflected the day’s
event I came up with more problems than I had solutions for. Ultimately all of
the solutions I could come up with involved the expenditure of monies. Most of
this country considers things that improve living conditions for poor and indigent
(which most of the severely mentally ill population falls under) entitlement
spending. But I cant help to see it differently. Money spent to decrease social stressors
(assisted living, vocational training, community support staff etc, and access
to medical care, etc) is not philanthropic, it is self preservation. Poor
social support and substance abuse more than triples the likelihood of violence
in mentally ill population. Yet if I
suggested spending money on the above no bills or referendums would pass, no
media outrage would occupy the 24 hour news cycle, nobody would care—until the
next Newtown. That’s what frustrates me.