In response to the school shootings, especially Parkland Florida, our consultant Tom Croke wrote an essay about the matter and placed it online at Linked In shortly after that event. We also created this page for our readers to see it. It is now October, 2018, and we have entered a few revisions. What you see below is the revised version. To see the original on the Linked In site become a member of Linked In, sign in, and then enter the following in the search panel: "Mental Health and Mass Shootings" Croke) We welcome feedback from our readers -- note comment box at bottom of this page. What you see here is revision of what is posted at Linked In.
We usually put this kind of commentary in the Member/ Subscriber section of our website so payment is required to access the page. With this topic that restriction does not apply. It is too important an issue to place this restriction. This is page is accessible to the public and will remain so.
INTRODUCTION
We at FamilyLight support the Second Amendment. We also support some gun restrictions that the Supreme Court says are constitutional, including and not limited to universal background checks. Almost all recommendations for Mental Health improvements that we have heard in the immediate aftermath of each shooting not only have appeared to be a distraction to take attention away from gun regulation but also a distraction from serious proposals about Mental Health services. Since writing that, we became aware of the cultures and legal framework for gun ownership in Iceland and Switzerland. In both of these countries, widespread ownership of firearms is deeply embedded in the culture, with any kind of gun violence being extremely rare. Both countries have elaborate requirements for gun ownership, which do not prevent almost universal firearm ownership in each of these countries. We like the Iceland approach a bit better than Switzerland although either is a radical improvement over what we do in this country.
The recent school shootings, especially the attack in Parkland Florida has, not surprisingly, prompted further discussion of gun laws, mental health and preventative identification of people who have potential to engage in such actions. Most of what I hear regarding improvement to funding and delivery of mental health services is not only distracting from the gun debate, but is also distracting from the real issues surrounding mental health service delivery that could help to prevent mass shootings.
Much of the rhetoric that suggests that the problem of mass shootings would best be solved by fixing the Mental Health Services delivery system comes from the gun lobby. As I will explain in what follows, some of the changes in the Mental Health System that would actually make a difference would be vigorously opposed by the gun lobby and very likely most advocacy groups for improved mental health services. For this reason, we see advocacy for improvements in mental health services coming from the gun lobby as a complete red herring distracting from constructive discussion about saving lives. We do support improved resources for mental health mental health services, but that alone will not prevent mass shootings.
Therefore, my hope is also to draw the energy and attention of our best experts into a serious discussion of how improvements in delivery of mental health prevention and treatment services could make a positive difference and then motivate the general public to support those improvements. It is also to expose the hypocritical mental health proposals coming from the gun lobby for what they are. Here I am referring to lawyers, mental health clinicians and researchers.
My own situation is that I have worked a half century in capacities that require some knowledge of mental health issues, including directing clinical facilities, advising judges on matters related to addiction and mental health, marketing for addiction and mental health services, and consulting with families seeking mental health services. I hope to point this conversation in the right direction, although the input of others with specific areas of expertise which I lack will be needed to get all of the details right.
WHY SIMPLY OFFERING IMPROVED MENTAL HEALTH SERVICES IS NOT GOOD ENOUGH
Too often I have had client families who well understood that a family member had serious mental illness AND had reason to fear that this family member might well be the next mass shooter. At issue here are families with financial resources to pay out of pocket for the best care available anywhere. And we could do NOTHING about it. This has arisen most frequently among my client families where the person of concern showed evidence of a thought disorder, but denied any problem. In each case we made certain that local law enforcement was aware of the situation. We could do no more. In several of these situations, after we spent many hours engaged in coaching the family and many months went by, the young man accepted treatment. Diagnoses ranged from schizophrenia and bipolar I to drug induced psychosis. In one such case we, we never did get a firm diagnosis, because the young man refused to be evaluated. He currently lives in a small city where the local police remain very alert to his presence.
For all the talk about improving background checks and improving access to mental health services, no one seems to be talking about either the most serious obstacles to having effective mental health intervention for people at risk or the real obstacles to identification of people who should not have guns due to mental health issues. Simply throwing more money at mental health resources will not solve this problem. I certainly would not mind seeing additional resources for mental health. We need funding for more and better resources, wisely applied. But getting results calls for a more careful look than just trying to throw money at the problem.
THE REAL ISSUES
We can see a pattern here. Several mass shootings have been perpetrated by people who had been offered mental health services and refused them. If we research all of the news coverage of the shooting at the Mother Emanuel AME Church in Charleston SC, we find multiple reports that the convicted shooter repeatedly denied that he was mentally ill and refused services offered to him. According to multiple press reports, the alleged shooter's efforts at trial appeared to be focused on proving that he was not mentally ill, rather than defending himself against the actual charges or seeking consideration for his illness at sentencing. Inability to see oneself as having a mental illness is frequently a manifestation of the illness itself, especially in cases of episodic psychosis.
Currently, an adult (18 and up) who is mentally ill has complete freedom to choose whether he or she will receive mental health services except when he or she is found to present an IMMEDIATE threat of harm to self or others. Interpretation and implementation of this standard does vary somewhat from jurisdiction to jurisdiction. The fact that the person is known to be at risk for perpetrating a massacre of several hundred people next week is not likely to be a factor in determining “immediate harm to others” in most in most jurisdictions. It would likely lead to an involuntary civil commitment in most jurisdictions if the massacre were likely to occur in the next hour or so.
In addition, the people who assessed this person for this kind of risk are usually legally prohibited from passing the information to law enforcement to enter the name on the “no firearms” database. Even if the person is subject to involuntary commitment to a psychiatric hospital due to risk of immediate harm, in most cases confidentiality laws that have been in place for a long time prevent putting that information into a data base of people who may not purchase firearms. The hospital records would be confidential; the court action ordering the commitment might be accessible, and therefore deliverable to the data bases. Would the fact of an involuntary commitment without any additional clinical information warrant loss of gun privileges?
EXPECTED REBUTTAL
The clinical and legal folk who actually make judgments about what I am writing here will likely object to my over-simplification of the issues. Good. I want them to do that – and to fill in with greater precision and detail what is actually at issue here. But I am quite certain that knowledgeable folks who might call me out for oversimplification will not tell you I am barking up the wrong tree. I am not and I will not be contradicted for how I describe the “big picture” by the people making these judgments in the trenches. The details they can add are important. Let the discussion and/ or debate begin.
The law must be changed if we are to maximize impact on gun tragedies by impacting mental health services. At issue are confidentiality laws, reporting requirements (or absence thereof), and involuntary treatment laws. Changing the law will not be easy. Several decades ago, thousands of mental health patients were being warehoused in the back wards of state mental hospitals. These actually operated more like prisons than hospitals. One Flew Over the Cuckoo’s Nest was not too far off in its depiction of what these places were really like. Advocates for the mentally ill succeeded in getting those places closed and sparked the transition to what was called “deinstitutionalization.”
They also succeeded in getting privacy laws passed that specifically blocked disclosure of information without patient consent, no matter how mentally disabled the patient was. Even immediate family of a person with an ongoing psychosis cannot get information without the person’s consent. Conservatorships and guardianships provided some easing of that, but they became harder to obtain and in some jurisdictions (New York City, for example) the legal expense became prohibitive except for the most affluent. I have been advised by legal counsel that in Pennsylvania that courts do not have the authority to access records of a private therapist treating a teenager even when presented with compelling evidence that not to do so could cause severe harm to the teenager or others. This includes when it is a parent seeking the information.
HIPPA – FACTS AND MYTHS
All of the above is apart from the “HIPPA” law. The original purpose of the HIPPA law was to facilitate the necessary flow of information between health care providers and insurers. That law does that well. However to open up that form of communication without denying people a right of privacy, “safeguards” had to be built in to prevent information from falling into the wrong hands. These “safeguards” which also serve a very useful purpose for most people receiving care, also block some kinds of common sense communication, including notifying the agencies that keep lists of people who should not pass a background check for a would-be gun purchaser.
(Note: The HIPPA law by itself does not block any communication. Each provider sets its own standards for communication and disclosure and requires patients to sign a document annually accepting those standards. The arcane requirements for disclosure that many consider bothersome are all about communication and disclosures that were not part of what is authorized in the document the patient signed accepting those standards. We know one mental health facility, that ducks the whole issue by giving legal notice they do not observe confidentiality.)
WELL MEANING OPPOSITION FROM MENTAL HEALTH ADVOCATES
The point here is that the opposition to any relaxation of the “immediate harm to self and others” standard and/or relaxation of privacy protections for mental health patients will be vigorously opposed by the same mental health advocates that brought about reforms several decades ago. In most situations we agree with these advocates and would not want relaxation of the current standards and legal protections without extreme caution and careful work on wording laws passed so as not to promote unintended negative consequences. Unfortunately, SOME of those advocates will simply oppose any change on the theory that any relaxation will start a trend toward return to the conditions exemplified by One Flew Over the Cuckoo’s Nest.
I understand that changes in law regarding information sharing can be effected by legislation. However getting such legislation passed would meet very strong and well organized opposition and would, in any case, be difficult to craft without creating some very problematic unintended consequences. We do need the input from the advocates to ensure that these changes, if enacted, do not lead to serious abuses. I expect those advocates to be highly skilled at spotting unintended negative consequences.
CONSTITUTIONAL ROADBLOCKS AND POSSIBLE SOLUTIONS
The larger problem is the standard of “immediate harm to self or others.” The problem, stated in the most general terms, is that in addition to opposition from advocates for the mentally ill, relaxation of this standard would almost certainly run afoul of prior interpretations of the Fourth and Fourteenth Amendments to the United States Constitution by the Supreme Court (SCOTUS). Passing a constitutional amendment that would actually impact roadblocks to getting mental health treatment to the treatment resistant, or to relax the Second Amendment is simply not going to happen any time soon. We leave any more detailed explanation of the legal basis for this problem in the hands of our friends in the legal profession.
I had initially expected to find and cite a SCOTUS decision that set the current standard in place. When pursuing that research I found that I could not narrow this down to a single decision. I could find no single decision which, by itself, established the criterion of “IMMEDIATE harm to self or others” as currently interpreted by clinicians and legal experts. Several related decisions, when combined, appear to be responsible for that standard. For readers who are willing to be “armchair lawyers,” this article (ostensibly on the topic of deinstitutionalization and homelessness) addresses legal decisions that create this situation.
Here is a key question: Could states pass laws that would challenge the interpretation of the word “immediate” in the “immediate danger to self or others?” I note that SCOTUS is now much more conservative than it was during the period when the relevant past decisions were issued. As such, the current Supreme Court might be a bit less protective of the civil rights of the mentally ill, and authorize disclosure and mandatory treatment in cases where risk of a mass killing is well documented but perhaps not quite so immediate. Here is where we really need help from the professionals, legal and clinical, actually in the trenches on this. With serious discussion on these issues, in greater detail than I can provide, perhaps we could get a proposal of state legislation that broadens authority to disclose.
One other possible approach that would be to require any person who owns or wishes to acquire a firearm be required to apply for a license to do so. The licensing process suggested here would include a requirement that the applicant authorize the licensing agency to acquire mental health records. This proposal would run into vigorous political opposition. Would it be seen by the courts as unconstitutional? This would mean that in order for a person exercise his/ her Second Amendment rights, he/ she must submit to a very invasive personal inquiry. Would SCOTUS allow that? We would expect very strong opposition from the same gun lobby that says the solution to mass shootings is a mental health issue.
My proposal is that well qualified experts investigate ways of intervening in situations that have the known potential for this kind of tragedy that do not run afoul of the United States Constitution. We would need some modification to the definition of “risk of immediate harm to self or others.” Must “immediate” be part of that? Can we alter the past understanding of “immediate?” Might SCOTUS approve an exception for people whose pathology prevents them from understanding their own mental illness? Clearly that particular disability creates a danger for that person and in some cases others. It just is not an illness that predicts that the danger will present itself in acute form immediately – or at any other particular, definable time. Where medically appropriate, and as a specific treatment for this particular disability, could the court also approve requiring people to accept long acting injectable antipsychotic medication?
Movement in this direction would surely run into opposition from from mental health advocates, fearing return to abuses of the past.
CONFIDENTIALITY
Both the Icelandic gun laws and the Swiss gun laws appear, based upon what I have seen in published articles, to require universal background checks prior to any person being permitted to own firearms, and allowing those background checks to include access to mental health records that would indicate the person should not have firearms. To create a similar system in the USA, we would need to require those obtaining firearms to sign a release authorizing government access to mental health records. That would be necessary, but not sufficient. Mental health records are generally in the hands of treatment providers and payers (such as insurance companies and state Medicaid programs). Signing a release alone will not connect the people doing the background check to the concerning record. Replication of the mandatory reporting statutes in place where suspicion of child abuse is at issue could solve that -- and lead to strenuous opposition from both gun lobby and mental health advocacy groups.
We would also need a loosening of the restrictions on involuntary civil commitments of mentally ill people. This would also lead to serious opposition from the mental health advocates. Quite possibly it could not be done without a constitutional amendment. That simply will not happen. But perhaps our more conservative supreme court would allow civil commitment processes to go forward where we have medical certification that this is a case where inability to understand ones own illness warrants a means to go forward with involuntary commitment to effective treatment. Clearly this would bring opposition from the usual suspects.
ONE FOUNDATION SEEKS SOME VERY SPECIFIC CHANGES
One very serious effort to provide for residential treatment for people who might otherwise refuse treatment is currently underway in New York City. Real Estate Developer Francis Greenburger has created the Greenburger Center for Social and Criminal Justice. This particular effort targets people with mental health problems who are also in the criminal justice system. I have had the privilege of speaking with Mr. Greenburger about this. He is interested in creating a treatment center that people can only enter voluntarily, but when they do they sign a consent to be held at that program until they have accomplished what they were there to accomplish. Once signed in by their own choice, they would have no option to leave until the clinical staff determined that was a safe and appropriate choice. We are unaware of any state that would currently license such a facility, but it is an interesting concept. Could we change state laws to allow such facilities? Would those changes in state law be constitutional? This is where we need the legal experts to weigh in.
CONCLUSION
I strongly suspect that if what I have written here gains serious traction, both mental health advocates and gun rights activists will challenge my thinking. Good. We need their input here. Especially if we were to introduce a reporting requirement, similar to the requirement that mental health (and other) professionals report suspicion of child abuse, we need those professionals to define precisely the criteria for those reports to occur. We can expect opposition from mental health advocates, but without it, we have no way of having relevant mental health information turning up on a gun purchase background check. Iceland has very exhaustive universal background checks in order to apply for a license to own a gun, along with extensive safety training. (Switzerland's regulations are similar, but we are not including all detail here) Icelanders have a license in hand prior to the gun purchase. The gun lobby, which opposes requiring background checks on private sales would certainly oppose comparable license requirements in this country, especially if obtaining such a license would be required of a person who already owns one or more firearms if they are to keep that firearm.
I am not interested in going back to the mental health practices of the 1950s and before. However, major changes would need to occur in involuntary treatment, patient confidentiality, and reporting if improved mental health services is to have any measurable impact on mass shootings. We can reasonably expect vigorous opposition from both mental health advocates and the gun lobby if these changes are proposed. In particular, the same people in the gun lobby who propose that improvements in mental health services would vigorously oppose the very changes in mental health services that would be needed before improvements in mental health service delivery could accomplish any measurable results in suppression of mass shootings.
If for no other reason we need participation of historic advocates for both mental health services and gun rights to keep this system accountable and not leading to exploitation. But serious discussion must include a recognition that for the gun lobby to suggest that prevention of mass shootings is simply a consequence of poor mental health services is nothing more than a distraction and a red herring. Any effective resolution to this problem will need to involve correlation between sensible gun safety legislation and carefully designed changes in our mental health system. Effective change will involve changes that both the gun lobby and mental health activists would be expected to oppose.
Let the serious discussion begin!!
Note on "Our best experts:" I am neither a licensed clinician nor a lawyer. We need both to enter this discussion in order to get the best outcome. Return to link to this note.
Thanks to Phil DeBoard, Helen Croke, David Altshuler, Lee Croke for editorial suggestions.
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Last Update October 25, 2018