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After Newtown Shooting: Make the Right Call (for Action)

By Dr. Julia Frank
. 4 Comment(s)

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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  1. Scott Poppen

    Great points. Hard to see, however, how laws for involuntary commitment could ever be expanded in light of modern court interpretations of the Fourteenth Amendment's civil liberty protections. Just like with the Second Amendment's right to bear arms, the Constitution's civil liberties protections, a bit unique in the entire world, are our great blessing and our great curse.
  2. Julia Frank

    I don't think older, broader commitment laws were overturned on constitutional grounds. There are legal categories for people whose conditions compromise their autonomous decision making capacity--children, people with intellectual disabilities and so on. Many mental illnesses compromise people only intermittently, which makes things more complicated, but in medicine we do allow substitute decision making for treatments of other sorts, when people are temporarily not competent. Probate Courts can do that freely--when doctors do, the grounds are rightly much more strict, but it is still constitutional. Expanded and better services would also, presumably, reduce the need for involuntary treatment, though that would still be needed for some.
    The problem with the shooter case is that reports suggest he was probably competent to refuse treatment.

    Another problem is that a risk that is only potential or probablistic, eg. the risk of violence,is different from the risk run by patients unwilling to accept, say, emergency cardiac care. Conditions which spare intellectual and allow normal daily functioning are harder to address legally. Still, there are precedents. Many substance abusers are intact when not intoxicated. For them, mental health courts, rather than the decisions of a physician, are an appropriate avenue of coercing treatment as an alternative to incarceration. Treatment under those circumstances actually works for many people. While neither expanded commitment laws or mental health courts for complex cases would have stopped the man who committed the Newtown atrocity, they would prevent many other crimes and acts of violence.
    Mental health reform is a complement to gun control,not a substitute. One without the other will not substantially reduce the amount of violence in our society.
  3. Scott Poppen

    "I don't think older, broader commitment laws were overturned on constitutional grounds." On what other basis could they have been overturned?

    Mental health courts...intriguing idea.
  4. Julia Frank

    Thanks for correcting me. I was basing my comment on the fact that commitment statutes were/are all state laws, not federal. However, there was a major Supreme court ruling in 1975 that did invoke the 14th amendment to reduce the scope of commitment laws. Nevertheless, there is still considerable variation among states, in particular whether "grave disability" can be considered as grounds for commitment. The supreme court ruling also limited the length of involuntary commitment without review.

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