From time-to-time, a person with a severe mental illness (or assumed to have a mental illness) commits a heinous act that makes headlines. The reactive call for better mental health services is entirely predictable, not only on the part of those who are trying to distract us from issues such as gun control but also by mental health advocates who see these events as opportunities to get public support for improvements in mental health policy. It is true, of course, that these are moments when the public will pay attention, but should those of us who care about the well-being of people with serious mental illness take advantage of these opportunities or resist the temptation?
Throughout my career—over 30 years of mental health advocacy—I have refused to use public fear of people with mental illness as an opportunity to seek a better mental health system.
I am not surprised when advocates who believe that deinstitutionalization was a mistake and that we need a more coercive mental health system use these events to advocate for their point of view. But I am always surprised and a bit distressed when colleagues who support community-based mental health policy, who fight stigma and especially the myth that people with mental illness are violent, see this as an opportunity to ask for more money for community mental health generally or for specific needs such as housing, assertive community treatment, family support, screening, early intervention, preventive interventions, and more.
Some of the people who do this really believe that increased funding for more and better community mental health services will result in reduced incidence of killings by people who are mentally ill. But most, I think, know that these events are so rare and that we know so little about them there’s little reason to believe that any of the recommended changes—which may be valuable for other reasons—will affect the rare incidence of murder by people with serious mental illness.
But they know that powerful people listen when they are barraged by headlines crying for them to do something to prevent dreadful events. When President Obama says in response to the murders of children and teachers in Newtown, CT. that there should be “as much access to mental health services as to guns,” something extraordinary has happened. A President is thinking about mental health policy.
Sometimes getting this kind of attention makes a positive difference. For example, when Kendra Webdale was pushed to her death in front of a subway by a psychotic man, Governor Pataki, who previously had opposed any growth of mental health funding, added $200 million or so to the mental health budget in New York State. In theory, the additional funding was to pay for services for people who were subject to New York’s new involuntary outpatient commitment law; but in fact, most of the funding went for housing, assertive community treatment, and other critical community-based services. Public fear had resulted in a significant gain for mental health.
So maybe I’m wrong. Maybe we should take advantage of public fear to draw attention to the inadequacies of the mental health system. Let me explain why I am not convinced.
First, playing on public fear is tantamount to confirming the myth that people with mental illness are dangerous. We should instead provide data about how rare murder by people with severe mental illness is. For example, a meta-analysis Nielson, et al published in the Schizophrenia Bulletin in 2011 estimated that there is one murder of a stranger(s) by a psychotic person per 14 million population per year.1 That is a murder rate of between .3 and .7 per 100,000 people with a psychotic disorder. Each event, of course, is awful, but statistically there are far too few to warrant fear of the entire population of people with even the most severe mental disorders.
Second, public fear fuels a demand that the mental health system somehow prevent these very rare acts of homicide and invites increased coercive interventions—especially easier involuntary inpatient and outpatient commitment. There are arguments to be made for re-examining criteria for coercive interventions; but they have little to do with murder, and there are very important questions to be raised about how big a net should be spread over the population of people with serious mental illness in the hope of preventing exceedingly rare acts of homicide. Let’s not forget how much abuse there used to be of the governmental power to commit people to psychiatric hospitals. More generally, let’s not forget that fear generates a willingness to erode civil liberties. Democracy can only be preserved if we tolerate the hazards of freedom.
Third, saying that the American mental health system is terribly inadequate ignores all the progress that has been made. Those of us who have been mental health advocates over the past 30-50 years have contributed to vast improvements in the mental health system. Everyone should read Better But Not Well, a wonderful book by Richard Frank and Sherry Glied (who is now Assistant Secretary of HHW), which documents the fact that more people are getting more effective mental health treatment now than ever before.2 Of course, as the book’s title implies, more improvements are needed, but when we overstate the flaws of the current system, we discourage any rational policy maker from putting more money into the system. If increased spending has not resulted in a better mental health system, why spend even more?
Fourth, headlines—and the fears they generate—fade quickly. Determination to improve the mental health system turns to disinterest in the blink of the next political scandal, fiscal cliff, or threat of terrorism. Effective advocacy over time takes persistence and needs reasons for change that go far beyond fear of rare heinous acts.
Fifth, these are dangerous times for health and human services in the United States. Conservatives are determined to force cuts in federal discretionary spending and entitlements. That means cuts to Medicaid—the major source of public funding for mental health—and to Medicare, which will become a more important source of funding as America ages. Is threatening the American public with murders by people with severe mental illness the way to fend off these cuts? I don’t think so.
For all these reasons, I personally am opposed to playing on irrational fear to gain ground for mental health services. Of course, as I’ve said, sometimes it works. So, I could be wrong, and over the years I’ve become a bit less moralistic about going this way. But I still hope that community mental health advocates will ask seriously whether occasional, horrible acts by people with serious mental illness should be seen as an opportunity to trumpet the need for more and better mental health services or as a temptation to be resisted.
Michael B. Friedman, MSW retired as Director of the Center for Mental Health Policy and Advocacy of MHA of NYC in 2010. He still teaches health and mental health policy at Columbia University. His writings can be found at www.michaelbfriedman.com. He can be reached at firstname.lastname@example.org.
- Niellssen, O. et al. “Homicide of Strangers by People With A Psychotic Condition,” Schizophrenia Bulletin, 2011.
- Frank R. and Glied S., “Better But Not Well: Mental Health Policy In The United States Since 1950,” JHU Press. 2006