Violence and Mental Illness

In a thoughtful piece in the New York Times on June 16, Deborah Sontag reported on the tragic murder in Boston this past January of a 25-year-old mental health counselor in a state-funded group home. The suspect accused of the murder was a resident of the home, a seriously troubled young man with schizophrenia whose history included a mix of stability when on antipsychotic medication, laced with periods of psychosis and violence when not taking medication.

Dr. Ken Duckworth, a former medical director of the Massachusetts Department of Mental Health, is quoted questioning if this case "will signal that we've gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?"

What follows in this balanced piece of reporting is a reasoned discussion of the merits and drawbacks of community-based care, what the proper balance should be between community-based and hospital-based care, and the state-by-state nationwide trend of reduction in funding for programs that care for those with severe and persistent mental illness.

My own experience relevant to these enormous challenges involved the almost 15 years during which I served as chief medical officer for the New York State Office of Mental Health (OMH). When I assumed this role, in 1988, there were almost 25,000 psychiatric state hospital beds operated by OMH, and when I left New York in 2002, there were about 4,500 (and there are even fewer now). This massive transformation of the public mental health system in New York might be viewed as "planned deinstitutionalization," shifting from hospital-based care to community-based care, consistent with a rehabilitation and recovery-oriented treatment philosophy. The success of this restructuring—and in many ways it was successful—reflected a wise action by the New York legislature to override a gubernatorial veto, to pass "reinvestment legislation," so that every dollar saved by closing a state hospital bed was required, by law, to be reinvested into community-based alternative programs, such as community mental health centers, ACT teams, supported housing, mobile outreach, and other components of treatment. Even so, New York was not immune to the rough waters that almost inevitably accompany such extensive change, including transinstitutionalization into nursing homes and into the correctional system, overloading of emergency rooms, and additions to the ranks of the psychiatrically disabled homeless. I would often muse about our conceptual framework, the "biopsychosocial" model of care, worrying that a "one-size-fits-all" attitude could be risky, particularly when it came to the "social" part of the model. For example, some communities in which to locate care for very needy patients are much better than others—some provide strong support, while others may have high levels of poverty and crime, making them far less safe and supportive than at least the better-run state hospitals of the past.

Unlike the careful and balanced New York Times article, media coverage regularly sensationalizes tragic events, giving the impression that catastrophes are far more prevalent than they really are. Nonetheless, when an almost unimaginable tragedy strikes, such as the tragedy at Virginia Tech in 2007, all of us are deeply affected. How could this happen? How safe is my college-age child, grandchild, sibling, family member?

In psychiatry, we are in the business of trying to understand human behavior, provide advice, prescribe treatment, and suggest prevention strategies, yet we are humbled by an eruption of violent behavior of this magnitude. Those of us in the behavioral health field, with ferocious intensity and curiosity, devour every emerging detail about the alleged perpetrator. We anticipate that there might be a history of abuse or neglect, severe trauma, a fragmented and unstable family, or a pattern of substance abuse. In the Virginia Tech case, what unfolded was a story of a painfully isolated young man who walled himself off from his family and the world, despite efforts by many to reach out and try to bring him out of his shell.

Monday-morning quarterbacks, those ubiquitous experts suddenly filled with wisdom who appeared on all the major networks, sent up the usual flags—shouldn't someone have seen this sooner, surely it was obvious that this man was a powder keg about to blow, shouldn't he have been involuntarily hospitalized, aren't people who are mentally ill dangerous? And of course these are all crucial issues, riddled with a mix of known facts and remarkable fears, prejudices, and misinformation.

We in the field must do what we can to underscore what we do know and where we are falling short. We know more and more about risk factors, gene-environment interactions, and warning signs of dangerous behavior. We won't be able to predict every outcome, no more than medicine can predict the future for an individual patient whose family history shows high risk of cancer. But we need to ask more questions, screen more college students, and intervene more definitively when danger seems a real possibility. A tall order for us all, but one we must embrace. In cases like that of the young man in Massachusetts, we must work harder not to allow discontinuities in treatment, and we must be proactive so that treatment that does lead to remission and stability can be sustained. In our fragmented system of care, patients can fall through the cracks all too often, and tragic consequences, though thankfully rare, can occur. Meanwhile, society must increase its efforts to curb violence unrelated to mental illness, to make our world a safer place.