by Art Levine
The drive for involuntary commitment has been led by Dr. E. Fuller Torrey of the Treatment Advocacy Center. His approach has garnered uncritical attention from most media outlets, including 60 Minutes. “You’re going to have to accept Tucson and Aurora. You’re going to have to accept Cho at Virginia Tech,” Torrey said in 2013 after the Washington Navy Yard shootings. “These are the consequences when we allow people who need to be treated to go untreated.”
But Torrey’s claims of mandated treatment’s magical powers to stop mass shootings aren’t accepted even by those who believe that AOT combined with intensive services can have a beneficial impact. Dr. Marvin Swartz, the head of Duke University Medical School’s division of Social and Community Psychiatry, says bluntly after years of studying such programs, “I don’t think it makes sense to view AOT as a solution to gun violence.” The state laws aim to force treatment on chronically mentally ill people who have repeatedly been hospitalized or found homeless over the years, so they don’t even apply to mass shooters such as Elliot Rodger. On top of that, there are no well-accepted studies showing that mandating treatment works any better than voluntarily offering the same services. As the respected research organization, the Cochrane Collaboration, concluded in its review of mandated treatment: “It is no more likely to result in better service use, social functioning, mental state or quality of life compared with standard voluntary care.” While mandated treatment won’t prevent violent attacks, today’s narrow, ideologically-driven debates offer few other alternatives.
With gun control dead for the foreseeable future, can the nation really have only two choices: either force meds on the untreated, chronically mentally ill who seem dangerous, or do nothing while some crazed young men plan mass slaughter? Even strong supporters of forced treatment, such as D. J. Jaffe of the Mental Illness Policy Center, quietly concede that AOT usually wouldn’t be able to identify or help those young people, such as the Newtown killer, Adam Lanza, or the Aurora cinema shooter, James Holmes, who don’t have long histories of hospitalizations.
But in LA County, Linda Boyd, an affable, seasoned psychiatric nurse, and the law enforcement–linked outreach teams she leads in the county’s $2 billion Department of Mental Health, can’t afford to wait for congressional fixes that aren’t likely to prevent violent attacks. Instead, in the days after the 2014 Santa Barbara shooting, working out of her cramped tenth-floor DMH office, she and her associates reached out to the seventy-five potentially dangerous young people—along with their families and the professionals treating them—who they’re regularly tracking in the nation’s most sophisticated, collaborative program involving law enforcement, school officials and mental health staff. The School Threat Assessment Response Team Program (START), launched in 2007 after the Virginia Tech massacre, has already halted well over fifty planned school and campus attacks and screened more than 5,000 people, mostly students.
As Boyd explained, “We realized we needed to do something about the threats people are making, and we do whatever intervention is needed.” The START team coordinates multi-agency threat assessments that include a scanning of social media, interviews with the potentially dangerous person and the key people who know him and have treated him. That’s followed by usually arranging voluntary intensive services with regular at-home visits, although involuntary psychiatric “holds” are sometimes invoked initially as well.
Could all that have prevented Elliott Rodger from going on his shooting spree? “Absolutely,” said J. Kevin Cameron, a leading international pioneer of multi-agency, data-based threat investigations at the Canadian Center for Threat Assessment and Trauma Response and a consultant to LA County. He was particularly appalled at the way the Santa Barbara Sheriff’s deputies showed up at Rodger’s home and, based on a one-time, superficial talk with him at his front door, concluded that he was “perfectly polite” and posed no danger.
“They relied on their friggin’ ‘feelings,’” Cameron said, “instead of relying on the data.”
Based on information available from a START-style investigation, mental health workers or police would doubtlessly have had more than enough evidence to place Rodger on a “probable cause” temporary psychiatric hold. That, in turn, would have allowed police to bar him from owning weapons for five years under California law. The ability to seize weapons is a little-used power under most state laws involving seriously mentally ill people who have been committed. Some states, such as California, Connecticut and Indiana have the authority to seize weapons for between a year and five years—without requiring a formal court-ordered commitment—if people are deemed dangerous by authorities.
The big loophole, though, as a New York Times survey found in 2013, was that deranged people not currently acting dangerously could petition to get their guns back—and often do. The result can be tragic. Even though limited gun control laws restrict this loophole in most states, they usually aren’t used.
If START-style assessment practices were in place in Santa Barbara, Cameron said, “There’s no question that this particular case would have had a different trajectory.” In other words, those seven young people in Isla Vista near the Santa Barbara campus would still be alive today.
Now, in the days after the Isla Vista shootings, the Los Angeles START team had to prevent potential copycat attacks and respond to new threats. (The copycat threat is no myth: A Mother Jones investigation found that the 1999 Columbine massacre inspired at least seventy-four plots or attacks across thirty states by November 2015.) On the first Tuesday after the murders, the LA County team learned that a high school student who was assigned a personal essay stood up in his suburban school to recite a rant about his desire to kill people in the school. School officials summoned two specially trained social workers from the START program to evaluate him. After a targeted school violence assessment, he was taken involuntarily to a local hospital for a seventy-two-hour observation period that could be extended if needed.
More typically, the START teams made sure to check up on the young people they were aiding. During a remarkable three-hour weekly meeting of the START team I attended, they reviewed the pitfalls facing four young clients they were following. (Note: The word “patient” is widely considered a pejorative.) One such client they discussed, a nearly eighteen-year-old Hispanic youth who had violent, hallucinatory fantasies about killing himself and his schoolmates, was contacted after the Isla Vista shooting and was still potentially dangerous: His psychiatrist had reported the threats to police under a “duty to warn” law that led to him being placed on an observational hold in a hospital. He also violated a restraining order barring him from any school in his town after showing up for a Halloween event on campus with a bandolier packed with real bullets. Placed on probation, he was eventually referred to intensive social work and psychiatric care from the county’s “Full Service Partnership” team for youth and young adults.
The student had made considerable progress. But now he was living with a relative who doesn’t believe in professional therapy, so she recently stopped taking him to sessions, Boyd learned when she contacted a DMH team clinician. “He’s going to need a new home visit,” Boyd said at the meeting. “He wants to engage with us, and we can help him with whatever he needs.”
START’s success is a challenge to the conventional thinking and political debates about mental illness and violence. In these ideologically-freighted statistical battles, it’s commonly argued by academic researchers that violence by people with mental illness is extremely rare: only 4 percent of all violent acts are committed by those with a mental disorder and they’re eleven times more likely to be victims than perpetrators. But those figures on violence, although understandably cited to challenge the myth that most gun violence is caused by the mentally ill, don’t tell the full story. They’re based on recollections culled from large surveys of mentally ill people compared with those from an annual Justice Department crime victimization survey of nearly 160,000 people.
Recent
assessments of severely mentally ill people studied over time have found that they disproportionately—although rarely—commit violent acts, especially if they’re not receiving any treatment. A comprehensive meta-analysis of twenty studies by Oxford psychiatry professor Seena Fazel, for instance, found that males with schizophrenia were three to five times more likely to commit violence and for women, the risk was four to thirteen times higher when compared with the general population—but most of the violence could be accounted for by the attacker’s substance abuse.
Fazel joined with other leading researchers in a 2015 Annals of Epidemiology article that critiqued the media for promoting the stigmatizing myth that mental illness often results in violent attacks on others. In fact, the far greater risk is actually posed by suicides, which account for over half of all gun fatalities. Citing the best available epidemiological (or prevalence) reports from NIMH, they also took aim at the polarized spin on these hot-button issues: “[The data] debunked claims on both extremes of the debate about violence and mental illness—from the stigma-busting advocates on the one side who insisted that mental illness had no intrinsic significant connection to violence at all, and from the fearmongers on the other side who asserted that the mentally ill are a dangerous menace and should be locked up; both views were wrong.”
Nonetheless, these and many other experts have their own blind spot: they insist, incorrectly, that it’s basically impossible to predict or prevent violence beforehand. Jeffrey Swanson, a Duke University psychiatry professor who was the lead author of the paper, has argued that looking for a likely mass killer is like looking for a needle in a haystack. “You would have to detain the haystack,” he told Behavioral.net.
As Linda Boyd scrolled through a shocking PowerPoint presentation on the warning signs the START program uses, illustrated with pictures of such notorious deranged killers as Tucson’s Jared Loughner, she might have cause to disagree with those shibboleths. “What did they have in common?” she asked of the mass murderers she reviewed. “They all intersected with law enforcement, mental health and schools beforehand, but nobody ever connected the dots.” After displaying the weapons stash of Adam Lanza from the Newtown massacre, she showed some of the frightening writings and drawings found in the backpacks and lockers of Los Angeles County students. Particularly troubling was the vivid calligraphy and drawings of a teenager who created a booklet called “1,000 ways to kill yourself,” declaring “I just want the pain to end,” with drawings of a boy hanging from a noose and a girl being cut in half with a chainsaw. Yet Boyd noted, “He’s really talented, and we got him help. Now he’s in an art college and he sees a future now”—one augmented by psychiatric care.
Yet despite LA County’s successful approach to preventing more than fifty attacks, no national mental health organization champions START. That’s apparently because the program doesn’t fit neatly into either side of the intensely ideological debate over mandated outpatient commitment involving rights, safety and effective programs. If widely implemented nationwide, START would undercut Rep. Murphy’s political arguments that long-term forced medication is the best deterrent to prevent the rare instances of mass violence by people with dangerously untreated mental illnesses. On the other hand, one noted advocacy group critic of Murphy’s bill said she couldn’t champion START because it would risk further stigmatizing people with mental illness as disproportionately violent. “We can’t afford to give out a mixed message,” she told me, regardless of the lives that could be saved.
At the same time, the success of the START program also challenges by example the ill-informed claims by the Santa Barbara County Sheriff’s Department that there was little that they could do. And, confounding all sides of the political debate, it shows that more can be done to prevent violence beyond such oft-touted long-term solutions as more hospital beds, more medications and more outpatient clinics.
• • •
THE START TEAM, IN FACT, IS PART OF A BROAD ARRAY OF DEPARTMENT outreach services including mobile crisis teams and roughly ninety joint pairings of DMH clinicians with cops in patrol cars deployed in Los Angeles and across LA County each day. All told, the various teams help over 26,000 people a year, usually summoned through 911 and hotline calls.
Their empathetic approach to psychiatric crises generally doesn’t inflict needless trauma and avoids the deadly violence that too often accompanies such encounters in other localities. But the local police departments are hardly perfect on that score. In August 2014, two apparently ill-trained, hard-line Los Angeles Police Department city policemen with the gang squad shot at close range Ezell Ford, an unarmed twenty-five-year-old man with schizophrenia. Ford died just two days after a white police officer shot and killed Michael Brown in Ferguson, Missouri. The family has filed at least $75 million in wrongful death and civil rights lawsuits against the LAPD and the city of Los Angeles. All charges of wrongdoing and racism have been denied by city officials and the two policemen, who weren’t charged. Yet the city settled the lawsuit for $1.5 million in February 2017. Both the county and city police departments have paired clinician-cop patrol teams that could make such needless killings far less likely. Indeed, many local policemen have been exposed to at least some general training about people with mental illness. That doesn’t mean that all policemen buy into a sensitive approach or know how to defuse a crisis.
Los Angeles County offers more than just improved crisis intervention training for police officers alone. Its unique approach to policing on this issue has sparked interest from other communities in the wake of the furor surrounding the ruthless beating death in 2011 of Kelly Thomas, a homeless man with schizophrenia, by six Fullerton, California, policemen. The acquittal in 2014 of two officers charged in his death sparked new outrage, concerns essentially confirmed by the $4.9 million settlement Fullerton paid to the dead man’s father days before the opening of a 2015 civil trial against the city.
Yet plenty of improvements are also needed in the Los Angeles area as well, especially with trigger-happy LAPD officers. Between 2011 and 2015, the Los Angeles police admitted in a 2016 report, its officers shot thirty-eight people—killing twenty-one of them—and more than a third of them had an indication of mental illness.
Unfortunately for those victims and Kelly Thomas, they never got a chance to interact with caring professionals like the two Los Angeles County Sheriff’s Department Mental Evaluation Team (MET) members with whom I rode along in an unmarked police car during a daytime shift. The pair—we’ll call the nurse Marjorie and the deputy Gail because of their confidentiality concerns—are usually called in as mental health backup for the first police on the scene. They’re also trained in START evaluations, and wouldn’t have been fooled by a polite, shy Elliot Rodger. On the day of my ride-along, they’re summoned when a distraught mother called 911 after her eighteen-year-old daughter with bipolar disorder exploded in a dangerous rage after her mother said she couldn’t afford to buy her Proactiv acne cream. The girl had thrown her skateboard through the window. “She went nuclear,” the mother tells Marjorie. “I felt scared and called the police.”
Outside, Gail is gently maneuvering the handcuffed girl into the backseat of the car as they went to the hospital for a seventy-two-hour psychiatric hold. Still covered by her family’s insurance, the girl, whom we’ll call Maria, complains, “I’m going to have to pay for medication. It’s too expensive!” Yet something remarkable occurs—Gail quietly chats with the girl about her life and learns secrets she hadn’t even told her mother: the teen wasn’t taking her medications because she was trying to get pregnant with her schizophrenic boyfriend. Marjorie advises her: “You have an illness, like diabetes, and you need to take your medication.”
By the time they arrive at the emergency room, waiting for intake, Gail stands next to the girl in handcuffs and begins schmoozing and joking with her about makeup and styling, and eventually removes her handcuffs. As the MET team gets ready to leave while the hospital arranges for a psychi
atric exam, Marjorie tells her, “Don’t worry about the money, worry about feeling better. That’s why you’re here.”
Despite such compassionate outreach, far too many policemen in California and other states simply haven’t been trained properly in how to respond in a safe, responsible manner to mentally ill people who are acting in a bizarre or potentially dangerous manner. That was made clear in Los Angeles when city police in March 2015 shot a homeless, mentally ill man nicknamed “Africa”—real name Charley Kuenang, forty-three—five times during a scuffle caught on a video that went viral. Despite differing police and eyewitness versions of the tragic encounter, it appears that “Africa” was shot by police who were following up on a robbery he reportedly committed. A campaign for police reform linked this new shooting with a fatal Skid Row police tasering a few months earlier that led its victim to plunge to his death from a rooftop while fleeing arrest; they were now part of the “Black Lives Matter” movement.
The LAPD has System-wide Mental Assessment Response Teams (SMART) that operate along the lines of the county MET team run by Gail and Marjorie—but in the city, they’re largely staffed by police who are assigned the jobs even if they don’t want them; in the county, the positions only go to those who ask for the work. Moreover, critics say the city inexplicably won’t deploy them in the neighborhood with the highest concentration of severely mentally ill people in the metropolitan area: Skid Row. The Los Angeles City police chief, Charles Beck, insists the SMART teams shouldn’t get involved in such incidents, although their central mission is precisely that: to reduce the potential for violence during police encounters with people with mental illness.
Yet if you or a loved one has a serious mental illness, you don’t have to be a denizen of Skid Row to be killed by police. A detailed look by The Washington Post at the scope of 426 deadly nationwide police shootings in the first six months of 2015 showed that a stunning quarter of all fatal shootings by police involved mentally unstable people. Some involved disputes that got out of hand, others were deliberate attempts to provoke “suicide-by-cop.” On average, police shot and killed someone who was in a mental crisis every thirty-six hours in the first half of 2015, the Post noted.