Mental Illness and Violence

In the past couple of years we have witnessed an alarming number high profile mass murders perpetuated by those with histories of serious mental illness. From Sandy Hook, New Jersey to Aurora, Colorado, and more recently to Oregon those with apparently severe mental illness have been able to obtain high powered rifles and astounding amounts of ammunition enabling them to act out their delusions and/or homicidal and suicidal thoughts in a public place on innocent people. (Adam Lanza's mother bought the guns used not only to kill her, but also the children and their teachers at Sandy Hook.)

As a nation we are horrified and wring our hands about what can be done. First of all let us acknowledge that the vast number of seriously mental ill people are not violent. Indeed, they are more likely to be victims of crime that to perpetrate crimes. Second, any mental health professional, including forensic psychiatrists, will acknowledge the difficulty in determining that a particular individual is dangerous and might commit such crimes. Although when a mental health worker believes that someone is a danger to self and/or others, that person can be committed to a mental health facility, usually 72 hours, for an evaluation. However, given the state of mental health care even those who come to the attention of mental health professionals may slip through the cracks and fail to receive a competent evaluation.

Persons who have been in and out of mental health facilities and have long histories of serious illness coupled with non-compliance with prescribed medication and failure to maintain a relationship with out-patient clinics should not have access to fire arms of any kind. While their names might appear on the government "no sale" list and they may be denied access to guns from a legitimate dealer, anyone, no matter how ill, can obtain military style weapons from gun shows, estate sales, and individuals. No questions asked, except perhaps age, and a seriously mentally ill, often delusional (believing things that are not real), perhaps hallucinating (seeing things that are not real) can obtain weapons and rounds of ammunition. They typically gain entry to a public place, like a movie theater or small town elementary school, and commit mass murder.

The madness of allowing anyone with a few hundred dollars to purchase guns will have to be addressed before such horrific incidences will stop! Without adequate mental health care and improved gun regulation, each one of us will continue to be in danger!

He Did the Unthinkable

The world was shocked and horrified by the actions of severely depressed pilot, Andreas Lubitz, who committed suicide by slamming an airplane filled with passengers into a mountain. As the investigation continues, we learn of his history with mental illness and the note in Lubitz's trash can from his psychiatrist stating he was unfit for work due to his severe depression. Lubitz did the unthinkable, even his doctor must have felt incredulous horror at his actions.

Only a tiny fraction of those with mental illness carry out violent acts. However, approximately 1 in 4 persons in the United States has a diagnosable mental illness in any one given year. This statistic is remarkably consistent across the world. Yet we continue to either ignore mental illness, push it to the back burner of health care, or stigmatize the sufferer, wringing our collective hands when the seriously ill commit the unthinkable, like Lubitz or mass murderer Adam Lanza in Sandy Hook, New Jersey.

As a society, we behave as though we cannot afford to treat mental illness, do not know how to treat it, make it a civil rights or privacy issue, or ignore the problem, hoping it will simply go away. All of these attitudes led to the current state of mental health care - which in too many cases is no care or grossly inadequate care.

In reality, we cannot afford not to treat mental illness.  Most mental illness are chronic diseases, once it develops one is seldom cured, but rather the disease is managed, much like diabetes. We now know that most mental illnesses are diseases of the brain - the brain is mal-functioning, much like many chronic illnesses effecting other organs of the body. Mental illness can be treated and successfully managed. Advances in treatment, especially medications, allow those who suffer with many mental illnesses to live and work successfully - if they continue with  treatment. Lack of compliance with extended treatment is a major issue leading often to the return of symptoms.

Treatment costs money - just as any other chronic illness management requires the expenditure of resources. Research is costly, but research into the causes and effective treatments of complex diseases of the brain is desperately needed.

Fortunately, we are beginning to come out of denial and deal with this pandemic - we have a very long way to go and if we scurry back into our denial, we not only increase the suffering of those afflicted with mental illness and their families, we guarantee yet another mass murder.

Why Does She Stay?

                                                       Why Does She Stay?

                                           It is Not Just About The Beatings!

When NFL player Ray Rice punched his then fiancé and mother of his child, Jaylan, knocking her unconscious and dragging her (though he could have quite easily carried her) out of an elevator, many who viewed the tape asked the question "Why did she stay with him?" Not only did she stay, but she married him several days later!

I do not know about the personal lives of  Mr. and Mrs. Rice, but the circumstances are not uncommon and the question "Why did she (or he) stay?" is one often asked by those not familiar with the circumstances surrounding domestic abuse. The reasons are many and most have to do with the complex nature of intimate partner abuse. In other words, it is not just about the beatings.

Of the 2 million injuries and 1,300 deaths each year in the United States resulting from domestic abuse, the most dangerous time is when the victim attempts to leave. Domestic abuse is about control, control of the victim and when the perpetrator feels the loss of control they will often increase the violence and the threats. The perpetrator may threaten to kill not only the victim, but their children, parents, other family members, and even pets. The victim, terrified the perpetrator will act on these threats, feels they must stay in order to save their own life as well as others. The perpetrator may also threaten to kill themselves. The victim often feels they cannot live with themselves should the suicide threat be carried out.

Very few abusive relationships are violent on a daily basis, instead there is often a cycle of abuse. The cycle begins with an abusive episode, after which the victim may threaten to leave and the remorseful abuser responds with pleas for forgiveness, promises to change, and demonstrations of gifts and affection. This is called the "honeymoon period." Jaylan Rice has probably enjoyed quite a honeymoon. They were quickly married, likely something she has wanted for a long time since they had been together since high school and have a child. He praises and thanks her publicly and is probably acting like the man she always wanted. Since he is wealthy the gifts are likely plentiful and expensive.

The "honey moon period" gives way to mounting tension between the couple. Most victims sense the coming abuse and attempt to modify their own behavior to prevent or they may provoke it, just to end the tension and get it over with. Inevitability the abuse will occur, bringing the cycle full circle.

Abuse is not only physical, it is psychological. Perpetrators often tell the victim if they leave no one will ever want them, they will be alone for the rest their lives, or you are too stupid to care for themselves. Even the most attractive and capable person will eventually come to believe such negative programing especially, if it comes from someone who has said they love them. Low self-esteem and doubt generates an absolute terror of being alone. A former client once told me about what would happen to her if she ended an abusive relationship, "I disappear." She believed this despite exceptional attractiveness and a college education.

Other reasons for staying include believing that abuse means love, "If you will get mad enough to hit me, you love me, just don't ignore me." Or "If you are jealous enough to hit me, then you most love me." This dynamic often occurs when the victim has witnessed or has been the victim of  abuse and neglect as a child.

Those with children may believe living in an a home with an abusive, violent relationship is better than being in a single parent home. In reality, witnessing abuse between parents is terribly damaging to children, teaching them to enter into their own abusive relationships.

Even in this day of more egalitarian marriages and information about the effects of abusive relationships, women are often told by male religious figures or family members, including their mothers, that it is her responsibility to keep the marriage together and she must be doing something to provoke the abuser. It is her duty to change her behavior.

Small wonder most abuse victims find it so difficult to leave or to press charges against the abuser. Men find it particularly difficult to admit to themselves and to others they are being abused by their female spouse. Gay or lesbian couple's may also find themselves caught in an abusive relationship. When a victim does find the motivation and the courage to leave the relationship, it is imperative that she or he find compassion, community support, and the resources to make this dangerous, total life change.

Current State of Mental Health Care:Finding Help

If you believe physical health care is in a state of disrepair, then you have not attempted to enter the mental health care system. It is in a far more chaotic and dysfunctional state than any portion of the medical health care system.

In my community, a moderately sized city, if one requires mental health services for a serious mental health crisis, for instance, severe depression, worsening of a bi-polar condition, or schizophrenia, there are several choices.

First, if one is insured, there are two private psychiatric hospitals. They can admit patients who are in crisis, that is, one is "a danger to self or others."  If one is not suicidal or homicidal, getting an out-patient appointment with a psychiatrist may take more than six weeks, especially if one does not have a previous relationship with the physician. A psychiatrist may admit a patient who does not meet the criteria for a crisis admission, but insurance companies may deny the admission in favor of out-patient treatment. If the insurer does permit admission, the length of stay will likely be limited to less than ten days.

Second, there is a state psychiatric hospital. The admission criteria is the same as the private hospitals, with one important exception. The state hospital must admit and evaluate anyone arrested for a violent or serious property crime, if a judge suspects they are mentally ill. Most such persons will eventually stand trial and, if found guilty, will be incarcerated.

If one requires out-patient services, there are non-profit mental health clinics where one might see a counselor or clinical social worker. A psychiatrist will supervise the care and will schedule a brief appointment if medications or substantial changes in medications are needed. Fees are generally on a sliding scale. Such non-profit clinics are extremely busy and wait times for an appointment may be several weeks.

There are also a number of counselors and therapists in private practice. Their credentials range from Clinical Psychologist, Licensed Professional Counselor, Clinical Social Worker, Nurse Practioner, Licensed Substance Abuse Counselor, or  Pastoral Counselor. All of these persons have training and legitimate credentials, but since any one may call themselves a counselor in Tennessee, it pays to ask questions. Many well creditaled therapists (counselor and therapist are often used interchangbly) may file for insurance reimbursement, but insured visits are limited, even if one is referred by their employer's Employee Assistance Program. Reimbursement may not cover the over $100 an hour fees of many therapists. However, most private practice therapists can see clients in less than two weeks.

There you have it. Not many good options. My community is probably not substantially worse or better than most communities, with the exception of a state hospital which gives one additional option. Small wonder so many people are not getting appropriate care and continue to suffer, as do their families. Suffering may be a part of life, but much of it is optional and as a nation we have chosen not to invest the resources to relieve the suffering of those we call mentally ill.