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06/02/14

Facilitating Pathways to Mental Health Treatment for Those in Crisis

By Joel E. Miller,
AMHCA Executive Director & CEO

The terrible tragedy on May 23 in Isla Vista, Calif., that left six people dead, 13 injured, and the shooter dead from a self-inflicted gunshot has the behavioral health field and society at large wondering what could have been done to avert this horrific event. 

From a classroom at Virginia Tech to a strip mall in Tucson, to a movie theater in Colorado, to a grammar school in Connecticut, to a military complex in DC, and now in a college town in California, a common thread runs through many of the nation's tragic mass murders: severe and untreated mental illness.

The imperative from UC Santa Barbara, the Navy Yard, Sandy Hook Elementary, and the earlier spree killings—to keep the most destructive weapons out of the hands of people with severe mental illnesses—requires addressing both ends of the equation. Our nation’s fragmented and underfunded mental health system might prove even harder to grapple with than guns.

The solutions are complex. Some require major infusions of taxpayer dollars at a time when most of the talk is of cutting the federal and state budgets (but there are recent Congressional initiatives to try to reverse course). Many advocates for people with mental illnesses fear, not without reason, that the response to the UC Santa Barbara shooting could further stigmatize everyone who suffers from a mental illness. That, too, would be tragic. Only the tiniest fraction of people with mental health conditions ever become violent, and then, usually when they fail to get treatment.

So one focus, properly, should be trying to track and treat those with the highest potential to harm themselves and others.

However, recent calls to make it easier to commit people against their will for outpatient mental health treatment will do little or nothing to prevent violent acts. It is more likely to scare people away from seeking help voluntarily. It could also compromise the confidentiality around treatment for mental health issues, a deeply held value—not only for those seeking treatment, but for their families, and clinical mental health counselors, too.

Several experts in the field have already pointed out that no one is able to reliably predict or prevent violent acts. Even in the case of severe mental illnesses, mental health professionals possess no special knowledge or ability to predict future behavior.

Actually, people with mental health conditions are no more likely to be violent than is the general population. In fact, the mentally ill are more likely to be victims of violence than perpetrators, and continuing to link violence and mental illness only stigmatizes people and deters them from seeking care.

Paradoxically, making it easier to commit people to treatment will not lead to more commitments or more people getting care. A chronically underfunded mental health system, which experienced $4.6 billion in state budget cuts between 2009 and 2012, does not have the capacity to meet those needs, according to the National Association of State Mental Health Program Directors (NASMHPD). 

For example:

  • The number of people who meet existing commitment standards in every state already exceeds the beds available for them. And it highly unlikely we will increase the number of psychiatric beds.
  • When Illinois lowered its standard to allow the commitment of virtually every person with schizophrenia and bipolar disorder, commitments decreased because of the continued reduction in public and private inpatient beds.
  • In Washington, a study of the state's lowered commitment standard revealed fewer voluntary admissions and a rapid increase in the revolving door of discharges and re-admissions.

Rather than forcing more people into treatment, we should dedicate adequate resources toward prevention and early identification of emotional disturbances in children and young adults, and fund cost-effective community-based interventions that work.

Only 40 percent of individuals with a mental illness receive appropriate services. When care is provided, there is a gap of up to 10 years between their first symptoms and first treatment, according to statistics from the Substance Abuse and Mental Health Services Administration (SAMHSA).

So Where Do We Begin?

First, we must begin a national conversation that decouples mental illness from the tendency to be violent. The two are not equated. And we know that it will likely take years to get to a better understanding by all stakeholders.  But we must start now with that conversation!

There are several actions we can take right now to reduce the chances of more tragic events like we just witnessed in Isla Vista:

  • End Discrimination:

Our priority must be to facilitate the pathways for people to access appropriate treatment and supports without fear of shame, marginalization, and discrimination. 

We know what strategies work to increase access to treatment—including the policy tools to implement those practices, and there are ways to fight the stigma that keeps people from seeking treatment, the real fear of discrimination if they do, and the barriers to accessing treatment and supports without full insurance parity. 

We must invest in mental health and addiction services that promote hope, recovery, and community inclusion.

We must work together to end discrimination and educate the public on the prevalence of mental health and addiction challenges and recovery through the use of media, advertising, and community dialogues.


  • Eliminate Access Barriers:

We need to fully implement the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Expanding access to care under the Affordable Care Act and mental health parity law will serve people better than changing commitment laws that will change very little.

To ensure enough mental health professionals are available to treat the increased number of people who will seek mental health treatment under the ACA and the Parity Act, Medicare and Medicaid must provide direct reimbursement to licensed clinical mental health counselors (CMHCs) and licensed marriage and family therapists. (See AMHCA’s congressional testimony in March.) 

In addition, we need to establish coordination between youth and adult service systems to ensure continuity of care, especially during times of transition.  

Moreover, we need to provide incentives—to employers, the military, schools, and universities—to foster environments where individuals are encouraged to seek help and are not afraid to do so.


  • Invest in Communities:

Several existing initiatives support recovery-focused initiatives, such as:


  • Funding early childhood development supports;
  • Using a public health approach to end gun violence; and
  • Utilizing the Prevention and Public Health Fund for mental illness and addiction prevention and mental health promotion initiatives.
  • Create More Crisis Services

Creating and promoting crisis services and partnerships between mental health professionals should be part of an urgent “to-do” list going forward.

We need to require Medicaid, private insurance, and community funding to cover services for crisis support and prevention, and more funds for training key professionals, including Crisis Intervention Teams (CITs), and to work with law enforcement agencies. CITs know how to deescalate a crisis, but intervening in a crisis to provide care is different situation, and that is where CMHCs come in.

Partnerships between CMHCs and law enforcement personnel are vital to the outcome for individuals who are in crisis and struggling. Only a mental health crisis team member such as a CMHC can determine whether a person qualifies for an intervention.

Since the huge mental health budget cuts made since the recession began, most communities now have only have a fraying patchwork of crisis mental health services at best. We need an array of assessment, crisis stabilization services, and hotlines available.
 


Just Get On With It

We as a nation—and mainly policymakers at all levels—must acknowledge once and for all that one in five Americans every year are affected by mental health conditions, many of which can be devastating, according to SAMHSA. 

Then we must embrace the millions of people affected by mental health conditions, who include family members, friends, co-workers, and neighbors.

If more people knew how to help people with mental illnesses, fewer tragedies like the Isla Vista might occur. One way is through the Mental Health First Aid and Emotional CPR Program, which helps train people to learn to recognize the need for help and provide assistance to individuals with mental illness in their community. CMHCs can help promote the program in a general way within their communities. (Read more about mental health first aid.)

To make the country safer for all of us, including those with mental health conditions among us, we need to:

  • Provide financial incentives to providers to administer routine mental health checkups for children, adolescents, and adults.
  • Ensure that providers utilize the U.S. Preventive Services Task Force recommendations for depression, alcohol, and illicit drug screenings.
  • Understand the impact of drug and alcohol abuse. Most Americans don’t know that these serious conditions are much more powerful risk factors for violence than other mental health conditions. 
  • Accelerate initiatives that integrate mental health services and primary health care, since many individuals with mental illness have serious medical problems such as diabetes, high blood pressure and other cardiovascular ailments.  We need to treat the whole person.
  • Be honest about how best to minimize the risk of future mass shootings. Regarding guns and mental illness, Richard Friedman said in a recent New York Times op-ed, “We have had—and always will have—Adam Lanzas and Elliot Rodgers. The sobering fact is that there is little we can do to predict or change human behavior, particularly violence; it is a lot easier to control its expression, and to limit deadly means of self-expression.”

To start a conversation here at AMHCA, please contact me with your thoughts and ideas at jmiller@amhca.org.  

We can make a difference.

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