I'll Think of a Catchy Title Later

Over the past two months, I have been working with my friend Anne Rosenberg to address the proposed “national registry of persons with mental illnesses” proposed by the National Rifle Association.  Our completed article is below. 

–Anne Rosenberg is a Licensed Clinical Social Worker who specializes in working with children, adolescent and adult survivors of trauma.  She has experience working in outpatient mental health clinics and with adults struggling with chronic mental illness.  Anne currently works in a New York City outpatient mental health clinic for clients diagnosed with both a mental health disorder as well as intellectual and/or developmental disabilities

By Anne Rosenberg and Andrew Grossman

In American politics, it often takes a tragedy to prompt preventative action.  This was true after the attempted Reagan assassination (see the Brady Bill), after the financial collapse (see Dodd-Frank), and by all indications, it will be true after last month’s shootings at Sandy Hook Elementary School.  There is broad general consensus that something needs to be done in the wake of our most recent tragedy; the debate is focused on what actions are appropriate.

In an attempt to deflect efforts to pass gun control legislation, the National Rifle Association and other conservative groups have taken aim at persons with mental illnesses.  The most dramatic of these proposals is to create a national registry of people with diagnosed mental illness.  This registry, proponents claim, would help enforce existing restrictions on firearm purchases by those deemed “mentally defective” (thank you, Illinois legislature, for your compassionate terminology), and will thus reduce the risk of gun violence.

In this article, we discuss several reasons we believe the NRA’s proposal is unwarranted, and would harm efforts to treat and interdict potentially dangerous mental disorders.  In addition, we explain that a constructive approach must focus on accessibility, education, and early treatment of those with mental disorders, in order to  lessen the likelihood of a recurrence of Sandy Hook.

The National Rifle Association’s proposal to establish a national list of persons with mental disorders is overbroad, and would result in government monitoring of a large portion of the US population.  

The approach proposed by NRA Executive Vice-President Wayne LaPierre is consistent with the NRA’s long-held mantra that the responsibility for gun violence lies not with the weapon, but with its wielder.  To an extent, they have a point; federal and state laws already prohibit gun purchases by convicted criminals, those adjudicated to be a danger to themselves or others, and children.  That said, their broad-stroke proposal to have the government register all individuals diagnosed with mental illnesses is misguided and offensive enough to make mental health professionals cringe.

One of the first threshold concerns this raises is what group, exactly, is the NRA’s intended target.  The term “mental disorder” is incredibly broad.  Mental Health Professionals use a system known as the Diagnostic and Statistical Manual of Mental Disorders- currently the Fourth Edition with Text Revisions. The DSM-IV-TR covers everything related to mental health, including Intellectual and Developmental Disabilities; Learning Disorders; Developmental Coordination Disorder; Communication Disorders; Attention Deficit/ Hyperactivity Disorder; Oppositional Defiant Disorder; Feeding and Eating Disorders; Dementia; Alcohol Dependence and other Substance Related Disorders; Schizophrenia and other Psychotic Disorders; Depression; Anxiety; Post Traumatic Stress; Pain Disorder; Insomnia and other Sleep Disorders; Gender Identity; Kleptomania; Adjustment Disorders; Personality Disorders; and Erectile Dysfunction, to name a few.

Which of these diagnoses is dangerous? Who needs to be monitored?

What about someone with insomnia? What about the CEO of a major corporation who is unable to get an erection because his job is stressful? No diagnosis represents a threat in and of itself.  It is the combination of a diagnosis that leaves the individual vulnerable, and the complex family and environmental factors that contribute to a situation where there is a higher risk of violence for that individual. It is not the mental illness that creates violence; mental illness leaves that individual vulnerable, with possibly unpredictable reactions to high-stress situations. Rather than keeping a list of everyone with a mental illness, investing in quality care and available resources for those who are vulnerable would be much more effective.

Of all the above diagnoses indicated, the one most positively correlated with acts of violence is substance abuse- drinking and using drugs. With this, it would be more effective to establish a list of people who consume and abuse drugs and alcohol, but we suspect no one would feel comfortable with the government monitoring our drinking habits.  However, the same right to privacy from government intrusion that renders such monitoring unappetizing applies to the mentally ill.

In the Newton Connecticut shootings, the shooter, Adam Lanza, was not, as far as we know, diagnosed with Schizophrenia or any other mental illness.  While initial reports suggested that he may have been diagnosed with Asperger’s Disorder, that disorder is not typically associated with violent tendencies.  More recent reports cast doubt on whether Mr. Lanza was diagnosed with any mental illness at all.  It is more likely that he suffered from an undiagnosed condition; the events of that terrible day are a clear indication that he was not mentally well-adjusted.  However, suffering from a mental disorder- even an undiagnosed one- is not a good predictor of violent tendencies.

In fact, over one quarter of all American adults are estimated to have a mental disorder in any given year.  These can range from anxiety disorders to acute depression or schizophrenia.  While this number may seem staggeringly high, most mental disorders can be managed or treated, and patients can continue to live healthy, productive lives.

Creating a national database of persons diagnosed with mental disorders could discourage people from seeking treatment, exacerbating the problem.  

In order to manage or recover, however, the patient must first seek treatment.  One of the toughest challenges faced by health service providers is the reluctance of many to speak to a psychiatrist, psychologist, social workers, or other mental health professional about their symptoms and challenges.

The reasons for this reluctance to seek treatment are complex, and it is perilous to generalize for a population that includes tens of millions of us.  However, the societal stigma placed on mental illness is certainly a factor in a large percentage of cases in which the mentally ill do not seek treatment.  This stigma will only be exacerbated if the government begins requiring individuals diagnosed with mental illness to participate in a national registry.
Mental health diagnosis is not an exact science.  Unlike diseases which can be cultured and confirmed, mental health treatment and management decisions are typically made by using the DSM-IV-TR system to classify symptoms and make differential diagnoses based on symptom clusters.  While not all mental health disorders can be cured, the vast majority can be managed and treated with both pharmacological and therapy-based approaches.

By setting up a system in which a loss of rights and loss of privacy results from a mental health disorder diagnosis, the government would be creating a substantial disincentive for people to seek treatment.  Ironically, the most dangerous subset of those suffering from mental disorders- those who do not seek treatment- would be the only group excluded from the list.

Moreover, the significance of registration on this national database has not been fully thought-through.  Would new laws aim to deprive any person with a diagnosed mental illness from gun ownership?  While this may seem sensible for persons with severe, dangerous disorders, it is an inappropriately broad restriction for the vast majority of those whose mental illnesses present without any tendency or proclivity towards violent behavior.  It is also inconsistent with the 2nd Amendment rights so loudly trumpeted by some of its proponents.

While the intention may be simply to change the topic from gun control to mental illness, this proposal smacks of scapegoating a vulnerable population.  While the mentally ill have advocates looking out for their interests, they are nowhere near as well-organized and well-funded as the pro-gun lobby.  This makes them an easier target than proposals to regulate gun violence through the regulation of firearms.

The best way to prevent violence by those suffering from mental illness is to increase access to care, reduce patient costs, and reinforce the resources available to patients.

We do support a spotlight being placed on mental health services, not because those with mental health issues are a threat, but because we are creating a system where mental health services are difficult to get and high quality care can only be obtained by the wealthy. We all know about the recent and impending cuts to Medicaid and Medicare, and one of the primary consequences is that mental health services are becoming grossly more expensive and less-widely available.

Two years ago, New York’s Office of Mental Health underwent a huge Medicaid reimbursement restructuring for its mental health clinics.  This resulted, among many other changes, in clinics being reimbursed less for the same services. Since then numerous clinics have closed due to lack of financial viability, and those that remain open have long waiting lists, particularly those serving children. Most of the workforce is now made up of what are known as “fee-for-service” contractors, who are paid $18-35 average per clinical session. In this situation, they are typically paid only to do their 30-45 minute clinical hour. Not for paperwork, not for outreach, not for supervision or consultation with more experienced workers. This austere system replaces one in which full time staff members were provided with salary, benefits, and one hour of supervision a week- ideally with a more experienced clinician.

Because there is less money coming in, the fee-for-service workers are needed to make the clinic cost-efficient, and the full time staff are expected to carry draining caseloads of 35-60+ clients a week in order to justify their salaries. Because of this, good clinicians burn out, change jobs frequently, or leave for private practice as soon as they are ready, so they can make significantly more money with a smaller caseload. This means that clinics are ill-equipped to handle the demands of the population, and people fall through the cracks. This is not to say that there isn’t excellent care being provided in these clinics- some clinics go above and beyond to provide the best care for their clients- but this is at the expense of very dedicated workers. This also creates situations in which someone receiving services at an outpatient mental health clinic for a total of 3 years may have as many as 4-5 therapists. There isn’t the ability to provided consistent, comprehensive care when clinics are struggling to keep the doors open and lights on.  After the 2nd or 3rd therapist leaves, many clients say “why bother.”

We are hopeful that instead of imposing an unhelpful system of monitoring useless information that stigmatizes and inhibits people from seeking services, the policy changes to come from the Connecticut shooting will be to provide better funding for and more access to mental health services. This way, people are able to locate local clinics and obtain services with better quality care.

We need to encourage, rather than discourage, individuals in need of mental health treatment to seek help.  Setting up a national registry of the mentally ill would cast too wide a net, and give people an additional reason to put off seeking treatment.  Crimes of this magnitude appropriately focus our attention on the risks of letting mental illness remain undiagnosed and untreated, and of presenting  those with dangerous, untreated illnesses with the opportunity to cause spectacular harm.  The best response will encourage diagnosis, treatment, and management of mental illness, without making a large part of the US population yet another victim of the Sandy Hook tragedy.

We are not expressing an opinion in favor of gun control legislation in this article.  While there is a general assumption that something must be done to avert future school violence of this magnitude, any either/or discussion is misplaced, and each proposal should be scrutinized on its own merits, not in contrast to other competing proposals on unrelated topics.  Over the coming months, gun control will certainly be debated and discussed, and so will our treatment of the mentally ill.  It is our sincere hope that the focus remain on making treatment available, affordable, and free from unnecessary stigma.

~Anne and Andrew