BY JEFF DEENEY In the days since Gabrielle Gifford was shot, the media conversation surrounding the event has shifted focus away from whether or not the ambient atmosphere of bigotry and political extremism in Arizona, along with the toxic political rhetoric espoused by Tea Party figures like Sarah Palin and Sharron Angle, drove Jared Lee Loughner’s actions. Details have emerged painting a portrait of an unhinged young man with obvious mental health problems, and the conversation is now focusing on whether the mental health system did enough to help Loughner and protect the community. Whenever a high profile violent crime is committed by someone with a history of mental illness there is a public outpouring of frustration with the mental health system for not taking necessary steps to treat the sick individual before they lashed out. In the case of Loughner’s crime, the cry is now loud and clear and coming from all corners of the media spectrum.
Did the mental health system fail to protect Tucson from Jared Loughner? And if the system failed, who is to blame? The answer to those questions isn’t as clear as many have made it seem.
The easiest place to seek culpability, and where is does most clearly exist, is with Pima County Community College. News accounts of Loughner’s interactions with his professors don’t portray an institution experienced and knowledgeable in handling mentally ill students. This is especially unfortunate as many commentators have pointed out that the college years span the common age of onset of many severe mental health disorders. Colleges need to know exactly what to do when students exhibit mental health symptoms. They should know what symptoms look like, know how to engage students in mental health services, and have those services abundantly available. Pima County Community College did not; instead, they called police, a whopping five times according to a Slate story that ran today.
The police in multiple encounters with Loughner likely raised the issue of his eroding mental health status, but cops are not typically the best messengers to convey the benefits of mental health treatment to someone experiencing paranoid delusions about state control. The college, after professors were menaced by Loughner’s increasingly bizarre behavior, did nothing to steer him into mental health treatment. Then PCCC covered its liability after cutting him loose by demanding a psychiatric evaluation before letting Loughner re-enroll. Thus, the college, after its ham-fisted handling of a student with major mental problems, shifted the burden for engaging Loughner in mental health treatment to the community. That’s a good way to keep the school from getting sued, but it clearly wasn’t the best way to get Loughner mental health treatment.
Note that by then Loughner had no contact with what professionals understand “the mental health system” to be. Adjunct humanities professors are not mental health professionals, nor are police. The college definitely failed to make an appropriate referral it should have known how to make, and as a result when Loughner left PCCC he remained unknown to the treatment system. Loughner had no history of contacts with mental health treatment providers and so we can’t point to instances where mental health professionals didn’t adequately do their jobs in treating him. The mental health system hadn’t failed anyone at that point, though the college certainly did.
How does the mental health system work for a severely mentally ill young man like Loughner? Once no longer in school, Loughner had recourse to resources in what is called “the community mental health system” regardless of whether or not he had health insurance. The community mental health system is the typically Medicaid-funded network of outpatient treatment providers serving the uninsured poor. Community mental health is one of our social safety nets for the disadvantaged, which the severely and chronically mentally ill tend to be.
Progressive bloggers seized the opportunity to point out that Arizona’s funding cuts for mental health have been severe, leaving safety nets threadbare. That’s true, though true for many states other than Arizona. State, federal and municipal budgets that fund such services have cratered in the past couple years. But the presumption that these funding cuts left Loughner with no options does not necessarily follow if you know how the community mental health system operates.
A Google search turns up a number of community mental health centers in Tucson (COPE, CODAC, and La Froontera, Southern Arizona Mental Health among others). I can’t testify as to the quality of these agencies, but options were available to Loughner should he have sought them out. I cannot say that Loughner certainly would have been eligible for funding in the community mental health system without knowing some details that aren’t publicly available. But based on what I know about how these services are meted out, I suspect that he would have been.
Medicaid funding for community mental health services are controlled by regional oversight agencies that decide which consumers get funded for different types of services. In Tucson’s case, Community Partnership of Southern Arizona is that agency. Such agencies make funding decisions case-by-case, directing money where they think the dollars are best spent, because the pool of dollars is very limited.
Using the Medicaid funding oversight model, Loughner was attractive from a treatment funding perspective. He is young, at the age of initial symptom onset, and didn’t have a long history of failures at recovery. If a consumer needing treatment has a long trail of expensive emergency hospitalizations and no outpatient follow up in the community, he starts to look like a drain on limited resources. Think an older, mentally ill chronic alcoholic or substance abuser with a long history of resisting treatment. To a funding oversight agency he’s an increasingly bad money risk each time he doesn’t get his act together, and the scant services he’s eligible for will reflect this.
But, in the case of Loughner, a young man with no history, who is unemployed and uninsured, with no significant assets or resources, who is severely mentally ill and clearly in need of treatment, I think the funding could have been procured for at least an initial attempt at treatment with minimal advocacy.
This addresses the question about whether the system failed due to funding cuts, but what about the question of intervention? Why did the mental health system sit around waiting for Loughner to come to them? Why didn’t the mental health system intervene and treat Loughner before he attempted to assassinate a U.S. Congresswoman? This lack of involuntary involvement in Loughner’s life by mental health professionals is the biggest thing people perceive, incorrectly, as a failure on behalf of the mental health system.
The mental health system didn’t intervene in Loughner’s life because the mental health system intervenes only if somebody is an immediate danger to themselves or to others. The bar for determining when the mental health system can step into your life unwanted is set very high because such high standards protect people from the state abusing its power to commit and detain. Psychiatrists can’t barge into people’s homes, accusing them of being potentially dangerous, declaring them incompetent and use the power of the state to institutionalize them. Thank God for that; such limitations on the detaining powers of mental health professionals are necessary and good.
Recall that these power limitations arose after years of human rights abuses within the mental institution system that used to exist here in America. Recall how mental hospitals in other countries (and, some would argue, also in America) have been and are still subject to abuses of state power, places where the government can railroad its political enemies. Perhaps unfortunately, in extreme cases like Loughner’s where a severely mentally ill person is ticking bomb walking the streets, with no interest in seeking treatment, these restraints do also prevent him from being preemptively committed, the same way one cannot be preemptively arrested for having the potential to commit a crime.
Each time police intervened at Pima County Community College they found someone who was acting bizarre, even aggressive, but not violently. As such, Loughner was not, nor likely could have been, held for observation on a psychiatric unit against his will. Again, the standard for involuntary commitment is being homicidal or suicidal, not acting bizarrely and being angry.
Note that I said “held for observation against his will,” not “treated against his will,” as effective treatment is not what usually goes on in locked county psych units. Such involuntary commitments, where a person is detained on a locked ward, are to observe him during a crisis to make sure no one is harmed. Civil mental health commitments are effective as instruments of behavioral control more than behavioral modification. Often, the person is released after a period too brief to have lasting impact — 72 hours is standard. Civil mental health courts make it very difficult to detain a person longer than this, precisely to protect individuals from being unnecessarily detained.
Had Loughner been committed by police at school he likely would have been released back into the community after a brief inpatient observation stay. Upon release, social workers would have provided him with an intake appointment at an outpatient treatment center in the community and a psychiatrist would have written 30 day prescription for psychiatric medication. But what if the Loughner didn’t want to go to outpatient treatment? What if he didn’t want to take the medication? He wouldn’t have to do either.
This is frustrating for readers trying to grasp how Jared Loughner wasn’t permanently committed a psych ward before things got so out of control. In many cases it takes multiple cycles through crisis centers and commitments to psych units before a person with a chronic, severe mental health disorder willingly engages in recovery. Often, in the case of involuntary treatment stays, the person emerges traumatized, with a resentment towards the system itself, and withdraws even further from the professionals who can help him.
Persistent outreach to severely mentally ill individuals in the community who are resistant to treatment is an important part of what social workers do. Many people eventually get tired of suffering the consequences accompanying severe mental health disorders like homelessness and jail stays and after long periods of resisting they seek treatment and recover. Had the mental health system in Tucson known about Loughner, had previous contact with him, and not followed up with attempts to have him voluntarily engage in treatment, the system could be said to be at fault. However, that wasn’t the case.
As a mental health professional who has walked with many clients through this often long, painful process of failed attempts at recovery, I can sympathize with the frustrations readers feel towards the mental health treatment system when someone with a severe mental illness commits a horrible crime. Why didn’t anyone stop him? Why didn’t the system intervene? Unfortunately, what the system offers works best when someone wants treatment, voluntarily engages in services, and maintains their participation across time, thereby maximizing their potential in the community, and reducing the likelihood that they’ll have to resort to traumatizing crisis care to keep from hurting someone. Based on what we know about Loughner’s paranoid suspicions of state power, his lack of family support and his aggressive behavior, it’s highly doubtful he would have voluntarily engaged in mental health recovery even if it was offered to him by skilled and caring professionals.
Did the mental health system fail us in letting Jared Loughner fall further into psychosis, delusion and ultimately violence? Unfortunately, based on reports of his college’s failure to get him treatment and his own unwillingness to seek it in the community once he left school, we’ll never know. The fact is that the mental health system never got much of a chance to try to help.
ABOUT THE AUTHOR: Jeff Deeney is a freelance writer whose work has appeared in PW, City Paper and the Inquirer. He focuses on issues of urban poverty and drug culture. He is currently working on a book about life in the crossfire of poverty, drugs, guns, and the bureaucracies designed to remedy them, all of which informed his experiences as social workers in some of the city’s most dire and depleted neighborhoods.