The dramatic and horrific events at Sandy Hook elementary school have spawned a wave of useful discussion (in addition to speculation and pontification) about the causes of such actions. The effectiveness of current gun control regulations, treatment of mental illness, violence in our culture, and excessive media coverage have all been targeted. We will likely never be able to unravel the peculiar mixture of thoughts, feelings, personal and cultural factors that lead to the brutal murder of 26 people, mostly young children, but perhaps we can stand back and ask bigger questions about our society.
Of the issues above, I want to focus in this article about our current attitudes and treatment of those with mental disorders. In doing so I am not making any statement about the relevance of this factor in the Sandy Hook tragedy - I am simply using public attention after this event to ask the bigger question: how are we doing as a society in providing treatment and services to those with mental illness or disorders?
There have been a few trends in the last four decades that are worth pointing out. Back in the "dark ages" of psychiatry people who were deemed a threat to themselves or others, or simply who were unable to live independently due to mental illness or cognitive impairment, were often institutionalized. They had little rights or say in their fate. The principle of paternalism held sway - doing what one thinks is best for others as a parent would a child, without consent or even explanation.
This state of affairs spawned an anti-psychiatry movement, whose most notable figure was Thomas Szasz. He rightly criticized the excesses of psychiatry as it was practiced in the 1960s and earlier. He also, in my opinion, went way too far and denied the very reality of mental illness or the need for any mental health treatment.
In the 1960s, 70s, and 80s this largely changed. A series of legal precedents and a new ethical approach to medicine in general ceded increasing rights to the mentally ill. Paternalism was out, and the age of informed consent was here. This is a good thing, and we are all better off for it.
The mentally ill gained greater respect and personal freedom. Health care professionals now had a much greater burden of proof that an individual was an immediate risk to themselves or others to commit them against their will, and only for brief hospital stays. Providers had to avoid restraining patients, and use the least restrictive option available. And patients earned the right to refuse any treatment they did not want.
In essence, Thomas Szasz won his battle for freedom and respect for the mentally ill. He refused to accept this, however, and continued until his recent death to rail against psychiatry as if he were still living in the 1960s. He essentially became a denier of mental illness. He also found common cause with Scientology, who deny the modern concept of mental illness and treatment for their bizarre ideological reasons.
During the 1970s there was also a move to deinstitutionalize as many people with mental illness or cognitive limitations as possible. The idea was to close the "warehouses" and shift to community-based halfway houses and other facilities where those who need services and supervision can get the support they need while maintaining whatever independence and freedom they wanted and were capable of having.
This was actually a reasonable plan, but it was poorly executed. It was much easier for lawmakers to close institutions than to provide the funding for community-based services, which were never adequate. Further, after an initial push for such services, financial support slowly waned over the years and now we have woefully insufficient services available.
The result of this massive shift toward individual freedom, as ethically sound and well-motivated as it was, was to leave millions of people who need mental health services with inadequate help and supervision. The formerly institutionalized population (meeting criteria for serious mental illness) now comprises 20-25% of the homeless population, with 40% reporting some mental illness.
By some estimates 16% of prison inmates have a serious mental illness (with up to 70% reporting some mental illness). The severely mentally ill are now 3.2 times more likely to be in prison than in a hospital.
In short - over the last half century many people with severe mental illness who were previously institutionalized are now largely homeless or in prison. In fact prison has become in many ways our de facto institution for the seriously mentally ill. That is the freedom we have given to this population.
I am not suggesting we return to the days of large institutions to house the mentally ill. This is an area, however, where policy changes and funding can have a huge impact. We should, at the very least, complete the second half of the original plan - to follow the closing of institutions with the establishment of community-based services. This will require funding, which is currently in short supply. However, many experts argue this will be cost effective, even possibly cost saving. We are already paying for many of the mentally ill to be institutionalized - in prisons. Proper treatment could reduce imprisonment and homelessness and the net cost is likely something we can afford.
Whatever form mental health services take, they need to become more available and easy to obtain.
Further, I think we need to continue the trend of destigmatizing mental illness. The brain is just another organ, albeit a very complex and important one. The brain, however, can suffer disease and dysfunction just like any other part of the body. We should not confuse the rights and freedoms of the mentally ill with the notion that mental illness does not exist.
The more challenging task is to reconsider the balance between the need to properly assess, treat, and provide services to those with mental illness and the rights and freedoms of all individuals. Perhaps we have not currently struck the optimal balance.
Steven Novella, M.D. is the JREF's Senior Fellow and Director of the JREF’s Science-Based Medicine project.