The mass shooting at Marjory Stoneman Douglas High School in Parkland, Fla., has drawn attention to the nation’s mental-health system. In a televised speech, President Trump said his administration wants to “tackle the difficult issue of mental health.” At a town hall hosted by CNN, Dana Loesch, a spokeswoman for the National Rifle Association, announced, “None of us support people who are crazy, who are a danger to themselves, who are a danger to others getting their hands on a firearm.”
Many such conversations about mental health and guns tend not only to stigmatize mental illness but also to ignore the realities of mental-health care. Psychiatric care is filled with uncertainty. Predicting whether individuals will hurt themselves or others can be a difficult and inexact science, even for the most skilled mental-health providers.
While making these kinds of predictions is guided by clinical judgment, deciding what to do next often is governed by laws. And the legal frameworks around mental-health care in the United States give primacy to personal liberty.
In reaction to the historical abuses of psychiatry, such as widespread neglect of patients in dilapidated asylums, and to preserve patients’ freedoms, laws across the country have introduced checks and balances at nearly every step in psychiatric treatment.
Elyn Saks, a mental-health expert and law professor at the University of Southern California, once wrote, “Law is based on a theory of personhood; that is, the concept of someone who can make choices and suffer consequences, and who understands the threat of sanction. The doctrine of informed consent (indeed, most of American political theory) presumes that we are not just subjects to be directed, but rather autonomous beings capable of making independent decisions.”
The problem is that mental illness raises challenging questions about that very autonomy, along with uncertainties about the kinds of decisions that unwell people should be able to make. Does a patient with fixed delusions about her medications have a right to refuse them? Is it ethical to allow a patient with an eating disorder to starve to death?
Should someone suffering from mental illness own a gun?
From the start of residency training, psychiatrists must learn to navigate this interface between deciding what is the best care for patients and following mental-health laws that are based on principles of patient autonomy.
For example, if a patient threatening to hurt himself or others comes into the hospital, psychiatrists often have to decide if the patient appears to be truly dangerous and needs to be placed on a temporary legal hold. When patients cannot take care of themselves because of debilitating hallucinations, paranoia or other symptoms of severe mental illness, we are supposed to stabilize them and determine whether legal action such as conservatorship is necessary to get them back on their feet.
As psychiatrists, we have to interpret the nuances of mental-health laws on matters including homicidal threats, medication refusals, suicide risk assessments and conservatorships. We learn how to fill out legal documents, work with law enforcement officials, and testify in legal hearings. It’s not unusual for psychiatrists, especially those working in inpatient settings, to find themselves sitting in conference rooms or courtrooms with lawyers present.
On the other side of those rooms sit our patients, their lives often in turmoil as a result of mental-health issues. For the sickest patients, mental illness can still carry stark legal implications, including separation from family and friends, loss of certain rights and even court-mandated supervision.
Overriding a patient’s wishes is never desirable or straightforward in medicine, and especially not in mental-health care. Take involuntary commitment for mental-health treatment, one of the more controversial aspects of psychiatric care.
Standards for involuntary commitment vary by state; California, where I’m training in psychiatry, passed landmark legislation in 1967 called the Lanterman-Petris-Short Act, which went on to influence mental-health practices across the nation. The law limits psychiatric holds to specific time frames, such as 72 hours for an initial evaluation, and establishes criteria for involuntary commitment, including appearing to be a danger to self, a danger to others or gravely disabled (unable to care for self) as a result of mental illness.
These criteria seem black and white, yet mental-health care is rarely that clear-cut in the real world. Patients may threaten to kill themselves and then suddenly take it back. Families may try to hospitalize patients, such as those suffering from mania or delusions, but patients can refuse care and may not be ill enough to meet the law’s criteria. There are diseases, including dementia and alcoholism, that aren’t universally considered to be mental illness and sometimes fall outside the bounds of such laws.
Amid the unsettled science of medicine, mental-health care in the United States emphasizes freedom over treatment, liberty over well-being. Critics have long denounced psychiatry for being able to force treatment on patients and for having too much legal power. It’s partly why protesters often gather outside meetings of the American Psychiatric Association. (There’s a Wikipedia page extensively detailing political abuses of psychiatry.)
Yet has the pendulum swung too far?
During my medical training, I’ve seen psychiatric patients living in their own feces or wandering naked in the streets, permitted to do so in the name of independence. My colleagues and I have hospitalized patients who we felt posed a danger to themselves or others, but review hearings have overruled our clinical judgment on legal technicalities, and the patients walked out. I’ve been spit on, threatened and called a monster for placing patients on legal holds for safety purposes. And too many patients have owned guns that we can’t do anything about.
In response to the Parkland shooting, a number of advocacy groups and politicians are calling for stricter regulations surrounding people with mental illness; proposals include shoring up background check systems to deny firearms to people deemed dangerous by mental-health professionals and expanding the scope of civil commitment laws. During a White House meeting, President Trump said, “We’re going to be talking seriously about opening mental-health institutions again.”
It’s sad that the country seems to focus so much on mental health in the wake of mass shootings. Evidence suggests that gun availability is a far better explanation for mass shootings than mental illness and that gun regulations targeted exclusively toward people with mental health issues will have minimal impact on the American epidemic of gun homicides. And when it comes to the link between guns and mental illness, gun-related suicides are an overlooked issue that takes more than 20,000 lives each year.
We need to rethink the nation’s mental-health laws, but mass shootings aren’t the reason.
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.