While I support without reservation the call to reduce or eliminate firearms in the civilian population, I am uneasy about making this tragedy a call for mental health law reform. Over the past decades, mental health laws have focused more and more narrowly on reducing dangerousness as the main justification for treatment and the only legitimate grounds for involuntary treatment. Our hospital beds are now largely reserved for people who seem dangerous (many aren't but have to claim to be to gain access.) Quite often, as soon as someone says he or she is no longer on the verge of suicide or targeted aggression, the person is released far sooner than is reasonable to experience a true treatment response. As a consequence, too many inpatient wards are little more than holding pens, where vulnerable and aggressive people are confined together for brief, ineffectual interactions with professionals.
Many dangerous people do not merit verifiable psychiatric diagnoses. The vast majority of people who are mentally ill are not dangerous. Indeed, they are more likely to be the victims than the perpetrators of violence. They do, however, suffer in ways large and small, and many are severely disabled. The emphasis on control of dangerousness, if anything, limits rather than expands access to mental health care for the majority of people who would benefit. Expanded access to treatment in general and expanded grounds for brief commitment are both needed. This requires both legal reform and funding.
More people would accept care voluntarily if hospitals were more therapeutic and the intensive outpatient care more available and affordable. The grounds for involuntary treatment for brief periods-- subject to early court review-- should encompass people with illnesses in which hopelessness, lack of insight, internalized stigma, or fear of what hospitals have become makes them reluctant to request voluntary admission. Even now, many patients quickly change their minds and would stay longer if they could.
Focusing our reform efforts, psychiatric treatments, institutions, and resources so narrowly on people who might commit terrible acts of mass violence causes us to neglect the much, much larger population of people who need and would benefit from a much broader range of mental health services.
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