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We spend $140 billion on public mental health services in this country, but at any given time, approximately half of all seriously mentally ill people receive no treatment at all. Lack of public understanding is part of the problem: many still believe severe mental illness is psychological rather than biological. Federal programs conceived half a century ago to replace much maligned state institutions were poorly conceived, never adequately coordinated and, by all accounts, woefully inadequate. Today, family members, police officers and the courts find themselves on the front lines of this crisis. Diane and her guests discuss the challenges of getting help for people with severe mental illness.
- Dr. Liza Gold clinical professor of psychiatry, Georgetown University Medical Center and vice president, American Academy of Psychiatry & The Law.
- Rep. Tim Murphy congressman, (R-Penn, 18th).
- Michael Biasotti police chief, New Windsor, N.Y. and past president, New York State Association of Chiefs of Police
- Dr. E. Fuller Torrey president, Treatment Advocacy Center.
Read An Excerpt
Reprinted from “American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System” by E. Fuller Torrey, M.D. with permission from Oxford University Press. Copyright © E. Fuller Torrey 2014
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. One in 17 adults suffers from severe mental illness. But options for treatment are limited. When large state mental hospitals were closed, starting nearly 50 years ago, community-based care was supposed to fill in, but it hasn't. Families in crisis, homelessness, crowded prisons, and sometimes violence are the results. Joining me to talk about why our mental illness treatment system is such a disaster and what we can do about it, Dr. E. Fuller Torrey of the Treatment Advocacy Center.
MS. DIANE REHMHe's the author of a new book titled "American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System." And Dr. Liza Gold, clinical professor of psychiatry at the Georgetown University Medical Center. I do invite you to be part of the program. Give us a call, 800-433-8850. Send us an email to firstname.lastname@example.org. Follow us on Facebook or send us a tweet. Welcome to both of you.
DR. E. FULLER TORREYThank you very much, Diane. Nice to be here.
DR. LIZA GOLDThank you. Thank you for having us.
REHMGood to have you both. Dr. Torrey, you write in your new book that what we have now is a chaotic, unplanned mental health system that's not only dysfunctional. It's also expensive. How did we get here?
TORREYWell, that's what the book's all about, Diane, is really the 50-year history of the mistakes we've made. And my feeling is that, unless we can understand how we got here, it's going to be difficult to figure out how to get out of here because we're really -- as you say, we have a very, very dysfunctional system.
TORREYThe jails and prisons are filling up by the day with the seriously mentally ill. The homeless, as we've seen now for 30 years on the street, untreated, and of course, we're seeing an increasing number of not only homicides but of mass killings of which about half of the mass killings are being caused by severely mentally ill people who are not being treated.
REHMMm. You take us all the way back to John F. Kennedy. Why?
TORREYWell, because, in fact, this all came -- one of the things that's remarkable is it all came from a series of mistakes from well-meaning people. And John Kennedy was as well-meaning as anyone. His sister had developed mental retardation, as some of us know. But then she developed psychosis on top of that, Rosemary Kennedy.
TORREYSo the father, Joe Kennedy, had a lobotomy on her in 1941. At that time, of course, there was no other treatment for severe mental illness. But the lobotomy was a disaster. So when John Kennedy then became president, the family felt very strongly they want to do something for mental retardation and mental illness.
TORREYAnd out of that came the federal program, the Community Mental Health Center program, which was the beginning of what has been a disaster. As the federal government assumed more and more responsibility, took the responsibility away from the states, the states actually were in the process of doing a reasonably good job and improving. But once we gave it to the federal government, it's all been downhill.
REHMBut at the same time, you had some pretty huge disasters in state mental institutions.
TORREYWell, yeah. No one will say the mental institutions were great. In fact, there was no treatment that -- we had 550,000 people in the state hospitals. None of us are saying we need to go back to that. But by the time Kennedy came in, we already were starting to empty the hospitals. And the states, in fact, were starting to put programs to treat people in the community. What the federal government said is, no, you don't really need to bother. We're going to do this under the Community Mental Health Center program. And that's where it all started downhill.
REHME. Fuller Torrey, he's president of the Treatment Advocacy Center and author of a new book titled "American Psychosis." Do join us, 800-433-8850. Dr. Gold, how do you encounter people today who have mental illness, and what options are available?
GOLDWell, it's very unfortunate that there are so few options actually available for the people who are in most need of treatment. Often people with serious mental illnesses, which involve -- often involve psychosis, one of the aspects of the illness frequently is lack of insight. So these are not people who themselves often are coming and asking for treatment.
GOLDWhat you find are family members coming, begging -- I mean, they are trying to turn heaven and Earth in order to get treatment for their son, their daughter, their spouse, whoever, and...
REHMWhat -- tell me, what was supposed to happen when people were deinstitutionalized?
GOLDThere was supposed to be a continuum of care where they would be living in the community and supported by community-based services of all kinds, mental health, vocational rehabilitation, all kinds of services for folks, which never materialized in the way that they were supposed to. There are community service boards.
GOLDThere is public mental health treatment available. It's woefully underfunded, often understaffed. The waiting list to get an appointment for someone who is not in urgent, urgent crisis -- you know, if you're in urgent crisis, you can go to an emergency room. However, you will not -- that's separate from the community service boards.
GOLDYou can go to the emergency room of any hospital if you're in a crisis. If you meet the very stringent criteria for commitment, you will perhaps get a temporary -- what's called a temporary detention order or TDO -- it's called different things in different states -- which allows people to be held for 48, 72 hours and then have a commitment hearing. But the criteria for being committed are so stringent that many people are not going to meet those criteria, even though they're in desperate need of treatment.
REHMDr. Liza Gold, she's clinical professor of psychiatry at the Georgetown -- pardon me -- Georgetown University Medical Center. She's vice president of the American Academy of Psychiatry & the Law. Do join us, 800-433-8850. Send us your email to email@example.com. Dr. Torrey, Medicaid has now become the largest payer of mental health treatment services.
REHMWe have an email here -- sorry, a tweet from Anne, who says, "Hospitalization of the mentally ill is not profitable. Our hospital got rid of its inpatient psychiatry beds. There's nowhere for people to go." How did that happen?
TORREYWell, it happened because we basically emptied out the public mental hospitals, which basically the states did it because it shifted the cost from the states to the federal government. At one time we had about 550,000 beds in the public sector. We've now got less than 40,000 beds in the public sector. And most of those are being taken up by forensic cases and court cases. So if you are severely mentally ill today and you need a public psychiatric bed, there's almost nowhere where you can go.
REHMExcept to jail.
TORREYExcept to jail and/or to prison, and that's where of the severely mentally ill are now.
REHMDr. Liza Gold.
GOLDYes. It's true. And in fact the only population in the United States that has a right to treatment are prison populations, jail populations. There is no right to treatment for anyone else in the United States.
REHMSo if you're acting out in ways that concern those around you and if you are looking for help, the only way you're going to get it almost is if you commit some form of crime?
GOLDWell, unfortunately, what happens -- it's not as well-thought out even as you put it. These are individuals who -- many of the "crimes" that they commit are misdemeanor type -- relatively little violence is associated with the seriously mentally ill. It's about three to 5 percent of serious violence is associated with people with serious mental illness.
GOLDIt's a complex question because substance abuse is a big issue relative to violence with or without mental illness. But most of the crime that we talk about are misdemeanor things, trespassing, shoplifting -- they're not felony type crimes. These are not people who often are organized enough to commit a well-thought out type of crime like a bank robbery.
REHMAnd yet, on the other hand, quite recently we've heard about people who have mental illness who've been associated with violent crime. Dr. Torrey.
TORREYAnd I think it's very important, Diane, to emphasize to everybody that most people with severe mental illnesses are not violent. It's a small number, and they are almost always the ones not being treated. But we are seeing it. We are seeing an increasing number, and we're going to continue to see it until we do something about fixing the mental illness treatment system.
REHMSo what you're getting is a focus on people who are committing horrific crimes...
REHM...who do have mental illness and who have managed to not only not get but actually to avoid treatment.
TORREYWe're seeing this increasingly. We saw it most recently in the Navy Yard shootings here. It goes back to the Jared Loughner in Tucson and James Holmes in Aurora. This is what we're seeing. We're seeing increasingly -- if these people were being treated -- and they should have been treated -- we would not have had these disasters.
REHMBut -- go ahead, Dr. Gold.
GOLDI would make one exception -- take one exception to that, and I agree with Dr. Torrey wholeheartedly about the need for more treatment, et cetera. But I do have to put in that it's not just the serious untreated or -- some of these folks were actually being treated. The Aurora shooter had been in -- I believe the Aurora shooter had been in treatment, the University of Colorado. But I think you actually also have to put in here access to firearms is part of what the problem is for these very serious violent acts.
REHMDr. Liza Gold, she's clinical professor of psychiatry at Georgetown University Medical Center. We'll take a short break here. When we come back, we'll hear firsthand from a police chief.
REHMAnd welcome back. We are joined now as we talk about the mental health system in this country by Michael Biasotti. I think I've got it right. Do I, sir?
CHIEF MICHAEL BIASOTTIYes, you do. You have it right.
REHMThank you. Go ahead, say it.
REHMBiasotti. Got it. All right. He is police chief in New Windsor, N.Y. and past president of the New York State Association of Chiefs of Police. So give us a sense of just what police are dealing with when it comes to confronting problems of untreated mental illness.
BIASOTTIWell, Diane, I conducted a survey as part of my masters' degree at the Center of Homeland Defense and Security at the Naval Post Graduate School and surveyed this issue through the International Association of Chiefs of Police and was surprised to see 2400 responses in a couple weeks, which to me meant it was a huge issue in law enforcement nationwide. Every state was represented.
BIASOTTIAnd it has just been growing and growing out of control, as far as law enforcement is concerned, with dealing with an issue that historically was dealt with by the medical community. And now more and more is dealt with by the first responders, and most importantly law enforcement. And it's causing huge issues nationwide that need to be addressed, which is why I'm glad to be here speaking this morning with you.
REHMIs it true that some people actually hope to be arrested?
BIASOTTII haven't seen that myself, but I know that we are -- the police themselves really do not wish to arrest people who are committing crimes or nuisance acts due to being untreated for their mental illness. I mean, it's a horrible path to go, but it also, as your earlier speakers have said, is sometimes the pathway to treatment although we don't believe it to be the best treatment. You know, the push today is obviously for less restrictive housing and less restrictive care for people. However, jail is certainly not that place. And being arrested doesn't meet that criteria.
REHMTell me what kind of training police officer getting about how best to deal with people they suspect may have untreated mental illness?
BIASOTTIWell, there are several programs out because it usually becomes an issue when police respond to mental -- someone who's severely mentally ill and untreated who is acting out and they don't know the person's mental status when they get there. And many times it escalates to a condition where either the police officer is injured or the mentally ill person is injured due basically to lack of care in the mental illness -- person with the mental illness' issues.
BIASOTTISo, I mean, it -- the training we're aiming for now is we're trying to increase training to respond to seriously mentally ill. But also, you know, today, funding is an issue with police training nationwide. The economy the way it is, there's not a lot of money for training. However, it is an extremely serious issue both for severely mentally ill people being killed by police and police being killed by seriously mentally ill people.
REHMSo what would you -- if you had a magic wand, what would you like to see happen to the problem of access to mental health care?
BIASOTTIOne of the main problems that the law enforcement or police have when they respond to, take for instance, you know, a homeowner calls to say that their son is -- their teenage son 18, 19 years old is in the bedroom and FBI put a bug in his brain according to him. And the law officer gets there and, you know, you take this job because you want to help people. And you get there and this child or the 18-, 19-year-old, you ask him, do you want to hurt yourself? No. Do you want to hurt anybody else? No, I don't want to hurt anybody else.
BIASOTTIAnd then the officer's forced to turn to the family and say, listen, there's really nothing I can do for you. He's not clearly dangerous to himself or others although he is surely in need of psychiatric care. And the standard in most states is that for that initial 72-hour evaluation period they need to be dangerous to themselves or others before they can be taken to an emergency room. And it's the only law I can think of that requires the dangerousness before you act. Instead of preventing it, it requires it.
BIASOTTISo, I mean, what I would like to see, I would like to see that initial 72-hour evaluation or to get them to the hospital to be able to be evaluated, I'd like to see that dangerous level reduced nationwide to a need for care -- an obvious need for care. I mean -- and, you know, it's very stressful on the police officers. You take this job because you want to help people.
BIASOTTIAnd you get there, and you're leaving a family in total, you know, disarray because they don't know what to do with their child. And no one will give them help when he obviously is in a serious problem here -- having a serious issue when you walk away and leave it.
BIASOTTIAnd that's how disasters happen. And, you know, you say to the parent, well, did he break any plates in the kitchen? If he did, he can be arrested for criminal mischief, and then we can get him psychiatric evaluation through the jail process. So is that what we want? Do we want to criminalize this act or do we want to get it help? And that's very frustrating for law enforcement nationwide.
REHMMichael Biasotti, he's police chief in New Windsor, N.Y. He's past president of the New York State Association of Chiefs of Police. Thank you so much for joining us.
BIASOTTIOh, thanks for having me.
REHMAnd, Dr. Gold, your reaction.
GOLDWell, I think that the police chief is telling what we see all the time -- is describing what we see all the time where if someone doesn't meet these very stringent criteria for being detained temporarily, then there's really very little that anybody can do.
GOLDOne of the programs that has happened since the deinstitutionalization, in response to the fact that so many police are involved now and law enforcement are involved now, is the increasing number of diversion programs and training for law enforcement done by mental health personnel so that they can take someone who might get otherwise placed into jail or under arrest and divert them, pre-booking, to a hospital situation.
REHMI see. I see.
GOLDBut, unfortunately, then you still run into the same system. Now, some communities have been very, very welcoming of the kind of training for their law enforcement personnel because it helps them avoid some of these very desperate situations and gives them a way to intervene that might potentially be helpful. However, other communities have not been so accepting of it. It varies widely. The places that are accepting of it, and have done a good job with it, report really good results with the diversion programs.
REHMHere's a tweet from Cal: "Has the pharmaceutical industry played a part in shaping or influencing the current state of mental health programs/institutions?" Dr. Torrey?
TORREYI'd say the pharmaceutical industry has done a lot of things wrong, but they haven't ruined the treatment program. They have oversold the drugs, especially for children. And so that has not been helpful, but you can't really blame them for the deterioration of the mental health program. I'd like to also add in terms of Chief Biasotti, he's really hit one of the issues is the laws.
TORREYAnd that's why 15 years ago we started the Treatment Advocacy Center, which is the only organization that has tried to change the laws to make it easier. The website of the Treatment Advocacy Center is www.treatmentadvocacycenter -- all one word -- .org.
REHMAll right. I want to open the phones -- we have many callers -- first to Megan here in Washington, D.C. You're on the air.
MEGANHi. Thanks so much for taking my call. I'm a huge fan of the show.
MEGANMy father is a retired combat veteran, and he was institutionalized in the VA for several years for being psychotic and schizophrenic. My dad's a very smart man. He's a graduate of West Point, and he was able to get a lawyer through the VA system and be released. However, now he's really unable to care for himself.
MEGANAnd he's going back and forth between being homeless and being in a hotel. My question for your panel is, what options are available to families and to people who suffer from severe mental illness who are not so dangerous that they will hurt themselves or others but cannot function in society, per se, support themselves, et cetera? And I'll take my question off the air.
REHMAll right. Dr. Torrey.
TORREYMegan, you've got thousands of others like yourself out there that are trying to solve that. These are state laws, so it varies from state to state. The Treatment Advocacy Center website has the state laws for each state. So the first thing to find out where he's living and what the laws are in terms of commitment there.
TORREYBeyond that, then you have to either try and bribe him or encourage him in whatever way you can. It would be very nice to be able to get hold of the VA money so that you can control that, which also may help you get a handle on getting him into a better living situation, better housing and treatment.
REHMHere's an email from Matthew about his own experiences in Raleigh, N.C. He says, "I was diagnosed with MDD..." -- what is that, Dr. Gold?
GOLDMajor depressive disorder.
REHMAll right. "...and put on medication. All that was paid for by the state. Unfortunately, that's where the good news ends. About a year-and-a-half ago the local facility I was going to was closed due to budget cuts by the state. I've had no interaction with the doctor, no medication since then. I did have some hope with the new Affordable Health Care law but then realized I fall into the hole where my governor, Pat McCrory, did not expand Medicaid in our state, so I'm at a loss there also. What can I do?" Dr. Gold.
GOLDYou know, again, as Dr. Torrey said, this is one young man among thousands and thousands of people who have very similar stories. It's really unfortunate, I think, that 26 governors opted out of the Affordable Care Act because the Affordable Care Act -- and, again, you know, we don't know how it's all going to come out.
GOLDBut theoretically the Affordable Care Act should increase coverage for millions of people. And parity is written into the act -- mental health parity so that people should now have access to mental health benefits. But if the governor's opted out of Medicaid, then the poorest people are not going to be able to access that.
TORREYYeah, I think the most important thing is to get access to the medication that you need to stay stable. And there's a variety of ways to do that. But I think also you need some kind of supporting psychotherapy or whatever. That's now become very, very difficult to get in most states on it.
GOLDI would also add that this young man and other people can contact NAMI, the National Alliance for the Mentally Ill, and they will often have suggestions, provide advocates and help people access treatment.
REHMDr. Liza Gold of Georgetown University Medical Center, and you're listening to "The Diane Rehm Show." And joining us now is Congressman Tim Murphy. He represents Pennsylvania's 18th congressional district. Good morning, Sir.
REP. TIM MURPHYGood morning, Diane. Great to be with you today.
REHMThank you. I know you worked as a psychologist before serving in Congress and you're writing legislation on this issue. What are your priorities in terms of what needs to be addressed?
MURPHYWell, ideally, this mental health system as it currently exists needs to be turned around so that there is really steps of prevention, early detection, getting people engaged in treatment and to following them up. And so far some of the discussion you've had has been extremely important.
MURPHYThat is, those who first have contact with someone who is showing early signs of mental illness, parents and family, and may at first go to someone who is a primary care physician, such as a pediatrician, a family physician, one of our goals is to get them more training, perhaps in certification and some higher levels of information.
MURPHYI know when I taught at the University of Pittsburgh School of Medicine, sometimes the only training someone would have would be a couple weeks during their residency rotation. They need more of that so they can learn to identify, screen, and make some initial self-referrals. When we look at some of those who have been involved in acts of violence, they've been involved perhaps with the medical system tangentially but not directly with those who have more training in mental health.
MURPHYSecond thing is those who are involved with first responders, police, EMS, paramedics, more training, so they know how to identify because very often when I read police reports or they've come into contact with someone from mental illness, they have not had the background to know what is correct. They may hear that someone has some paranoia, the hallucinations or delusions.
MURPHYAnd I suspect they are trying to think of how do we get this person away from it as opposed to how do we get this person care. And when they are trying to get them care, they may bring them to a hospital, an emergency department who themselves is staffed with people who have little or no training in psychiatry.
MURPHYAnd we've got to ramp that up. Then there is the issues of follow-through treatment. And the treatment cannot be the way we've been doing it for the last half-century. The community mental health systems had their time in terms of providing some care within the community. But it's been isolated like the patients that they see. The patients themselves, oftentimes they're losing their support network.
MURPHYThey do not get involved in primary care -- medical care, yet they have a higher rate of other chronic disorders. We have to make sure that we integrate the care of the medical to psychiatric to psychological and get it involved in the systems. And that's going to be part of what I'm looking at how states are handling this now, and having incentives for integrating that mental and physical health.
REHMAnd, Congressman Murphy, what changes would you like to see in terms of privacy laws?
MURPHYWell, the privacy laws are very important because what's called the HIPAA law, the insurance laws and FERPA, which is the Family Educational Rights and Privacy, is right now -- there still are some real or even perceived barriers for when a professional can talk with the family.
MURPHYIn the hearings that I have held in my chairmanship of oversight and investigation, time and time again, we've had heart-wrenching stories of parents or loved ones saying, if only I had known the problems my son or daughter was having, we could've stepped in. Or if only the doctors would've let me tell them the problems my child was having, they could've done more.
MURPHYAnd we need to make sure that this communication is there. It's extremely important that we take down those barriers, too.
REHMTell me how your bill would differ from what was passed in the Senate earlier this year.
MURPHYWell, the Senate looks at integrating some of the care at community mental health centers, and that is important. We're looking at taking that as part of a wider package of block grants to states with setting some higher standards and also making sure that they are using evidence-based care. Right now the states are doing things, but I would like to tie them in more -- some sound research. So you collect the data, show that what you're doing is effective, including also looking at what is done at the two largest areas of mental health care. And that's our prisons, and that's our homeless programs.
MURPHYThose are terrible places to provide treatment. But I want states to gather that data and show what they're doing to be effective, and also doing more with community health centers and expanding more of NIMH's research into the areas of how severe mental illness and persistent mental illness has its roots and how we can prevent and orchestrate...
REHMAnd considering what's going on in Congress, how optimistic are you that the two bodies can work together on this?
MURPHYI think we can work together. Been building over several months bipartisan support for this and helping people understand, what is the assisted outpatient treatment? Why is that important? How the folks who have been involved in these tragic incidences are folks who peripherally at best have been involved in the mental health system. There's a lot of treatment that can be engaged. But a system whereby one is just around other people with problems, we have to do more in getting them involved with effective treatment.
REHMCongressman Tim Murphy of Pennsylvania's 18th congressional district, thank you for joining us.
REHMAnd, thus far, a great discussion on the state of mental illness treatment in this country. You've heard from E. Fuller Torrey. You've heard from Liza Gold, Chief of Police Michael Biasotti, Congressman Tim Murphy. And now an email from Bernadette, in Laconia, N.H. "Please ask your panel to discuss the very real truth that the Reagan administration closed hospitals which treated the mentally ill and turned many thousands of these individuals out on the street. They became the homeless population."
REHMShe says, "This was a horrific travesty. I was a parent/child advocate for the handicapped, mentally ill and dyslexic children in New York State at that very moment." Dr. Torrey?
TORREYDiane, it would be very nice and very easy if we could simply blame this on President Reagan or any other single person. This is really politically an equal opportunity disaster. Over the 50 years, we've had five Republican and five Democrat presidents. Not a single one of them has understood the issue.
TORREYAnd not a single one of them has really taken leadership on this issue. I commend Rep. Murphy. That's the kind of leadership we need in Congress now. This has not been a politically popular thing to do. And I think we're very happy, and we really need people like Rep. Murphy to take leadership on this.
GOLDAnd I would like to add that the American Psychiatric Association has a position that has called for the organization of a presidential commission with the specific goal of looking at the resources that are already available and integrating care, buffing up those resources, and then integrating care. We know how to treat people. That's not the mystery. The mystery is why we can't. And part of the reason is because there's no longer any form of integrated care model in the treatment of people with mental illness.
REHMWell, it all began, as you said, Dr. Torrey, more than 30 years ago, indeed, more than 40, 45 years ago. Are we reaching a point where, as you said, Dr. Gold, the pendulum is finally swinging?
TORREYI think we are. And I think it's because we're increasingly seeing the disasters. I mean, it really has gone on for 50 years. First we saw the homeless mentally ill. Then in the '90s we saw the increasing number in jails and prisons. And now, in the last decade, we're seeing the increasing number of episodes of violence on it. It really has gone on for too long, and I think the American public generally realizes now that what we've been doing for the last 50 years has not worked. We need to try something different.
REHMAll right. Let's go to Kirk in Pensacola, Fla. You're on the air.
KIRKThank you, guys. I have a neighbor that is currently in a facility. The last thing that happened in her home was, after her daughter had expired, she waited many days. And finally she asked another neighbor to come in and change a light bulb, and she asked the hospital to show up to try to cure her daughter.
KIRKBut prior to this, what she did, I mean, resulted in, I believe, 357 calls to the local authorities because she would threaten children and harm dogs, not to mention she was always yelling at the neighbors to get out of her yard, and she would wield a baseball bat. But the neighbors could be a block away when she would yell at them to stay out of her yard. Her yard is posted with innumerable posted keep out signs.
KIRKAnd she has put barbed wire everywhere.
KIRKShe would even put it around her car.
REHMSo what can be done in a situation like this, Dr. Torrey?
TORREYYou know, this is not rare. We're seeing this all over the country. And, again, it goes back to one of the commitment laws. Florida has a fairly strict law. But they have Baker Act, so that under certain circumstances the person can be involuntarily hospitalized and treated on. Again, I would suggest, you need to check the laws to see what can be done. Treatment Advocacy Center has those laws state by state, and also consulting with a local NAMI group and consulting with a local police department in terms of what you can actually do.
REHMOK. So say you're the parent of a young person. Say you're the wife of someone who is behaving in these ways, and you are scared. But that person has neither broken a dish nor attacked you personally. What options do you have? What are the civil rights objectives here and obligations?
TORREYAnd, of course, we have to honor people's civil rights as well. The issue comes as, does the person who's very disturbed and probably mentally ill, do they have an awareness of their illness? If they don't have any awareness of their illness, than they are not voluntarily going to seek help. So then it comes down to the state laws, as Dr. Gold very clearly said. And the laws in most states are quite strict in terms of what you can do. I think that's why we need to look at the laws, and that's why we need to make amendments to them to make sure that we're current in terms of what we can actually do.
REHMWhat does that mean?
TORREYIn terms of when you can actually involuntarily hospitalize someone, when you can actually seek treatment for them, that's what varies by state.
GOLDWell, and again, these are -- in speaking of the pendulum, you know, we're talking about 50 years since anyone's taken a good hard look at all of this. And as part of an integrated care commission, I would very much hope that the commitment laws would be part of that. Again, they are on a state-by-state basis.
GOLDBut you also have to understand that we're talking about the change in those laws came as a result of people being more concerned about individual's civil rights. There was a time when a husband who wanted a divorce from a wife could ask for her to be hospitalized indefinitely, and the woman could be indefinitely hospitalized with no way to get out because the husband wouldn't sign her out.
GOLDThere was a time when there were no criteria for commitment, and people were being held involuntarily without any concern for their civil rights. And a lot of that resulted in a lot of the problems with institutionalization and asylums, which led to the commission 50 years ago -- it's been 50 years since anyone's taken a really good, hard look at this, with some teeth, with…
GOLDHow many things have changed in the last 50 years?
GOLDNever mind, you know, just medications, but our understanding, our knowledge has grown so much. It's time to take a look at the whole package.
REHMAll right. To Jemma, in Raleigh, N.C. You're on the air.
JEMMAThank you for taking my call.
JEMMAI just wanted to ask about the idea of associating mentally ill people with violence and the idea of registry for mentally ill people versus a gun registry. I feel like every time people talk about gun rights on TV these days, they mention mental health. And I don't think that the two things have anything to do with another.
GOLDI couldn't agree with you more. I think that if you look at the statistics, although it is true that half of the mass killings, as Dr. Torrey has pointed out -- the amount of violence perpetrated by individuals with mental illness is, again, 3 to 5 percent of the incidents of violence in this country and not all of them involve firearms -- when it comes to talking about access to firearms and dangerousness, I believe that mental health has to be taken into the equation as one factor potentially in assessing whether someone is dangerous or not.
GOLDMost people who commit firearm violence are not mentally ill. And most people who are mentally ill do not commit firearm violence. And…
GOLD…it unfortunately stigmatizes, as this caller points out, the bulk of the people with mental illness.
TORREYYeah, I agree. Jemma, you're correct. It's a small number of people that we're talking about who are causing most of the problems. And I think we need to focus on that small number. And it may be keeping track of them, where the list is necessary, but it's very important to emphasize that most people with severe mental illnesses aren't violent. But the small number that are are ruining it for everybody else and causing a great deal of stigma.
REHMAll right. To Jackson, Miss. Kaja, you're on the air.
KAJAHi. I'm an in-home clinician, and I also work in a psychiatric department. So thank you, panel, for being here. And you guys have really made some good points, and they resonate with me. Our system is greatly flawed. It's almost like we're going into homes, and we're Band-Aiding. We can safety plan, but safety plan only goes as far as insight.
KAJASo we see our psych units, they don't have enough beds. Our CMH is out of funding. So I wonder, where do we go from here? And I hate to be skeptical and maybe a bit jaded by saying that laws and amendments can be changed. I just have a feeling that that isn't going to be sufficient.
KAJAAnd then we have the risk of -- sorry -- stigmatizing our very vulnerable population.
TORREYI think we really need to go back and look at what we're doing. At this point in time, the funding for the mental health system is coming largely from the federal government, but the federal government doesn't take responsibility for it. I know this is incorrect to do and politically incorrect in Washington, but I don't think that Washington does a very good job of mental health services.
TORREYI think we do a good job of research, FDA, CDC, things like that. But I would give the responsibility back to the states, and I would hold them responsible. Ultimately, I'd hold a governor and the state legislature responsible for what happens in the state. I think that would be true in Mississippi, in North Carolina, and every other state.
REHMNorman says, "I'd like to hear some discussion on the difficulty with the standard of being dangerous to oneself or to others. It seems in many cases, you can see there's a clear path to dangerousness. If you wait until that danger occurs, it's too late to undo the harm. I understand the need to protect an individual's rights, but when there's a clear trajectory headed toward danger, that should be enough for involuntary commitment." How do you feel about that, Dr. Gold?
GOLDWell, I think that hits the nail on the head in terms of what the problem with the commitment laws are. And you can't detain -- I mean, when you talk about depriving people of civil rights, when you talk about depriving people of their freedom, I mean, that's basically what you're talking about, about involuntary commitment. And the law is very clear in how it defines acts that allow you to do that.
REHMDr. Liza Gold of Georgetown University Medical Center. Dr. E. Fuller Torrey, he's author of the new book titled, "American Psychosis." And you're listening to "The Diane Rehm Show." All right. Let's go now to Colleen in Tampa, Fla. You're on the air.
COLLEENHi, Diane. I'm a longtime listener. And…
REHMColleen, I'm sorry, you're breaking up on us. And I cannot quite hear you. Can you call us back on a landline?
COLLEENI will. Thank you.
REHMAll right. Thank you. And to John in Lorton, Va. Your turn.
JOHNI'd like to have an idea of exactly what percentage of veterans comprise this group of mentally ill patients. And does that percentage of those flare out as far back as perhaps when we were tracking it 50 years ago from WWII, Korea, Vietnam?
REHMDr. Torrey, any idea?
TORREYYou know, there's no sign and no evidence that the incidents of severe mental illness, schizophrenia, bipolar disorder has changed very much over the last 50 years. There is some evidence earlier that it changed, that it increased during the 19th century. But since we started deinstitutionalizing people, studies both here, and especially from Europe, have suggested it's about the same. It's just that it looks much greater now because they used to be in the hospital. And now they're on the streets, and now we see them much more visible.
REHMAnd here's another email from Barbara in San Antonio. "How do you reconcile the patients who are in need of treatment but not a danger to themselves or others with patient advocacy groups who fight commitments? Those of us who have family members with serious illness understand both sides. What do your panel members say?" Dr. Gold.
GOLDWell, it absolutely is a balance. You have to have laws that somewhere find a sweet spot or at least a sweeter spot than we have right now, where the pendulum swung from no criteria and all kinds of abuses to now people who desperately need treatment but who don't meet commitment criteria. There are so few psychiatric beds available that, unless you meet commitment criteria, the likelihood that you're going to get one of those in-patient beds is minimal, almost non-existent.
GOLDAnd I've been involved in commitment hearings where the staff are on the phone for hours and hours after someone actually has been adjudicated, in need of involuntary commitment, where staff has been on the phone for hours and hours just trying to find a bed to send this person to. It's really a horrific state of affairs.
REHMAnd one final question. A problem families face is when their loved one stops taking medication because "everything is OK now." What can be done, Dr. Torrey?
TORREYYou do everything you can. And when they stop taking medication, it's often because they're not aware that they're sick, which is a huge problem. They're not aware that they're sick because that's the effect of the disease on the brain. Again, you have to look at your state laws. If the person is dangerous in the past, then you have a reasonable chance of getting them on to what we call assisted out-patient treatment.
TORREYAssisted out-patient treatment says, yes, you can live in the community as long as you take your medication. That is very effective. It exists in all except five states now and can be used -- again, the rules for using it are on the Treatment Advocacy Center website.
REHMTell me what you believe a good mental health treatment system would look like, Dr. Torrey.
TORREYYou know, the sad thing is, Diane, we know exactly what to do. We know that we would put people who are dangerous and don't know they're sick, we'd put them on assisted out-patient treatment. Most of them would do fine. They need rehabilitation, like clubhouses. They need jobs. We know exactly what to do. It's just that we don't have the will to do it. We don't have the political will. And it's not just a question of money. We've got a lot of money in the system. It's a question of getting a system organized and actually using the money that's in the system to help the people who need it most.
GOLDYeah, I agree. And I think that leadership for doing that has to come -- although I agree with Dr. Torrey, the responsibility ultimately will devolve on states. I think leadership has to come from a central location, from Washington, from Congressmen, like Congressman Murphy, who can put together a commission of mental health professionals who know what an integrated spectrum of care looks like.
REHMIt's time. After all these years of turning people out of institutions, it's time to find a way. Dr. Liza Gold, she's clinical professor of psychiatry at Georgetown University Medical Center. Dr. E. Fuller Torrey is author of a new book. It's titled, "American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System." Thank you both.
GOLDThank you, Diane.
TORREYThank you, Diane.
REHMAnd thanks for listening, all. I'm Diane Rehm.
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