In light of the recent Parkland school shooting tragedy, I began to reflect on my 38 years of experience in the provision of mental health services and the struggles I and my colleges confronted in order to obtain the correct level of treatment for the most severely disturbed. Many of these people fall between the cracks of an extremely flawed mental health system, which is predicated on the belief that persons with mental illness should live in the least restrictive environment. The result, in many instances, is that many of them live in jails, under bridges, in cardboard boxes in subway tunnels, in shelters or marginally with friends or relatives — all of which offers little supervision or support. In these circumstances, crime, violence and death are commonplace outcomes.
How did we get here? Over the past 45 years, all of the states combined have closed hundreds of thousands of their long-term psychiatric beds, even as the U.S. population has grown by at least 33 percent.
In 2016, the National Association of State Mental Health Program Directors (NASMHPD) reported that the availability of a safety net of services for individuals experiencing a psychiatric crisis is a critical need in every state. After a half-century of downsizing of state and other psychiatric hospitals, there is widespread concern that too much of the capacity has been eliminated. Further, many states no longer provide long-term care for persons under 18. A variety of sources report waiting time for admission. Non-criminal related admissions for long-term care can be as long as months or even years.
Where are we now? Over the past 50 years, the federal government and the courts have established a variety of laws and rules that strongly direct states to minimize institutional care for the mentally ill. For example, the Medicaid institutions for mental disease limit the use of federal Medicaid payments in hospitals. Federal mental health block grant funds cannot be used for inpatient services. Federal disability laws such as the Civil Rights of Institutionalized Persons Act of 1980 and regulations implementing the Supreme Court’s Olmstead decision continue to emphasize the development of community-based alternatives to inpatient care.
All of this has translated to persons with mental illness in many cases living in the least restrictive environment.
States like to blame the feds, but state funding for long-term beds has almost disappeared, with most states choosing to rely on matching federal dollars to fund in many cases inadequate community based care systems in an effort to save state dollars. The number of state psychiatric beds has fallen by 93 percent since a heyday in the early 1970s. No one planned this decrease, but it happened.
Some of the reasoning behind the closures is based on legislation and court cases that hold people with mental illness have rights not to be held against their will unless they are an eminent danger to self or others, and the availability of psychiatric medications to maintain them in the community and control their symptoms.
The public is led to believe is that everything is fine, mental health care works well and — except for doing a better job with a few homeless people off their medication and getting guns off the street — all future shootings will end. This narrative is clearly a false one. Let’s look at some of the real issues and where these people have actually gone? Because they have not just gone away.
On any given day, 385,000 persons with mental illness are in jails in the United States. Some of them may be incarcerated for a few days or weeks, others for a few years. While in jail, they are treated after they are released most receive no follow-up. Another 38,000 reside in state mental facilities; a majority of these are forensic commitments. For example, the three largest mental hospitals by bed capacity in the United States are the Los Angeles County Jail, the Cook County Jail (Chicago) and Riker’s Island (New York City).
A significant subset of people with severe untreated mental illness are walking around. Rather than finding a solution to this problem, we continue to hear that it’s time to ban guns or shut down the National Rifle Association. Those are patently absurd solutions to the problem.
What one can deduce is that there are hundreds of thousands of people who are walking around that are severally mentally ill. Many are frequently in and out jail. Their symptoms are not controlled by medication, either because they do not take it, have access to it, or they abuse drugs and alcohol. Currently, they cannot be held against their will until they commit a major felony and are determined to be not guilty by reason of insanity or incompetent to stand trial, at which time they can be retained for long-term care in a state psychiatric facility. Others are just arrested for a variety of crimes after the fact, held and released again until they either die on the street, commit another crime or kill someone or themselves.
It may be time to recognize that some persons may need long-term care before they kill or maim people. And it is safer for society in general and clearly more humane for these persons themselves to have them placed and treated and released at such time when they can receive humane community care. Clearly, banning guns does nothing to affect the root of the problem: realistic care for persons with severe mental illness.
Thomas Patitucci is a licensed clinical social worker and master addictions counselor. He is also a retired mental health administrator and former visiting instructor at the Rutgers Graduate School of Social Work.
The views and opinions expressed in this commentary are those of the author and do not reflect the official position of The Daily Caller.