David Ignatius

Helping the mentally ill

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David Ignatius
Thursday, January 20, 2011

But what should we do about the mentally ill who walk among us, stumbling toward what may be violent confrontations with authority? That question was asked by dozens of readers after a column last week about our inability to stop an obviously unstable Jared Lee Loughner on his way to the rampage just outside Tucson.

The anguished e-mails were a reminder that milder versions of the Tucson tragedy happen every day. Mentally ill people frighten their parents, neighbors and friends - but people don't know where to get help. They fear that the law protects the individual rights of the unstable person at the risk of the community's safety.

The tales were harrowing: One woman wrote about a brother whose severe bipolar disorder first surfaced as her mother "cowered behind a locked door while he pounded it and tried to knock it down." When the police arrived, they said there was nothing they could do, "as he hadn't hurt anyone."

A father described his mentally ill daughter: "Since she is an adult, no agency would do anything until she proved she was a danger to herself and others. Well they waited until she attempted suicide (twice)!"

A mother in Ohio described how she tried to get her son into a treatment facility and was told to keep him on medication at home. When he was old enough, the young man "hits the streets without meds (his right) and on several occasions is hospitalized due to being unsafe to himself and others." He ends up back on the streets because insurance will only pay for six days of inpatient care.

"We are still in the dark ages about mental illness in many ways," writes this woman.

Many of my correspondents blame fear of lawsuits for our passivity. "Nobody wants to be a Good Samaritan anymore. It just isn't worth it in today's litigious world," writes one man.

Prompted by these questions, I did a little research. What I found was reassuring. Experts say there are good ways for communities to reach out to the mentally ill without depriving them of their legal rights. These programs require two things in limited supply - concern and money.

"We have an ethic of leaving people alone, but people should be able to call on the mental health system to come and get engaged," says Ira Burnim, the legal director of the Bazelon Center for Mental Health Law in Washington.

What unites such practical remedies is that they connect the community with isolated and unstable people, rather than leaving them alone as ticking time bombs. Psychiatrists have an obligation, for example, to warn potential victims if a patient threatens violence. Lawyers and health professionals are often required to notify the police if they see signs of child abuse.

In the aftermath of the 2007 Virginia Tech massacre, many colleges have added mental health counseling. Virginia, for example, now requires all colleges to have a "threat assessment team" to intervene if a student acts erratically. If such a program had existed at Tucson's Pima Community College, Loughner might now be in a treatment center, and his victims might be alive.

What might have made a difference in Tucson is an approach known as "assertive community treatment," or ACT, where teams of mental health professionals can be summoned for help, rather than the police. Studies show that these ACT teams are very effective. They're also expensive, but perhaps less costly than the alternatives of hospitals or prisons.

Another interesting approach is known as "mandated community treatment." A study concluded in December by John Monahan at the University of Virginia found that people with mental illness are more likely to seek treatment if it's a condition for receiving housing or money, or avoiding jail. This "leverage," as Monahan calls it, helps communities deal with homeless people who would otherwise wander the streets, dazed and often drugged. Just giving them housing can decrease their symptoms, according to a study by New York psychologist Sam Tsemberis, who runs a program called Pathways to Housing.

Though the Tucson shooting has focused attention on disturbed people who commit violent acts, I should note that research by Monahan and others shows that mentally ill people who don't use drugs or alcohol are no more likely to commit violence than the average person.

And finally, there are volunteer programs in every city and town that reach out to the Jared Loughners before they become violent. A woman in Tucson who helps run a program there called One-on-One Mentoring implored me in an e-mail: "People need to be rallied to the cause. Told they have something to offer. Encouraged to step up. Tell people what they should and can do and wake them the hell up."


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