Violence and Mental Illness

January 19, 2015 | By Neil Howe

This editorial originally appeared in Forbes.

Last month’s murder of two NYPD police officers has been widely discussed as an outcome of anti-police sentiment or inadequate gun control. But there’s a deeper and more complex story here: that of rampant untreated mental illness in America. This incident was just one of many recent atrocities—including Virginia Tech, Sandy Hook, Aurora, Tucson, Fort Hood, and the Navy Yard—in which the perpetrator was mentally troubled.

As the public calls for action in an effort to prevent future tragedies, states are implementing various policies aimed at keeping mental health crises from turning destructive. A new generation of leaders is poised to take a more active role in both protecting the public and caring for the mentally ill—and thus move beyond the “deinstitutionalizing” wave that began sweeping across America a half-century ago.

Some are advocating for more spending across the board. In 2014, 27 states increased mental health funding. Virginia led the charge, allocating an additional $54.9 million to crisis services, community-based therapies, and hospitals. This money will undoubtedly assist the one in four adults—approximately 61.5 million Americans—who experience mental illness in a given year. However, given the sheer number of those who need treatment, it’s unlikely that spending more public money on mental illness in general will do much to prevent violence—since the vast majority of mentally ill people show no propensity for it.

A more effective approach might focus on those suffering from serious mental illnesses. These parameters narrow the field to the 2.4 and 6.1 million Americans living with schizophrenia and bipolar disorder, respectively. On the one hand, these cases are more highly correlated with violent behavior. On the other, they’re far more difficult to treat. Some states have already implemented laws that compel individuals with serious mental illnesses into treatmentunder court order—and assigns health care workers to monitor their movements if they refuse help.

Still others argue for a narrower approach that addresses the mentally ill living on the outskirts of society—namely, the imprisoned and the homeless. Nearly ten times as many mentally ill individuals are in prison than are in mental health treatment facilities. The situation is so dire that the Los Angeles County Jail has been described as “the largest mental health provider in the country.” Although the criminal justice system provides treatment to inmates, that care is minimal and ends once the person is released—creating a revolving door of patients whose conditions deteriorate over time. If states spent more on mental health treatment for those who are either in jail or who could easily be released from jail, they might save moneyin the long run in lower correctional costs and lower rates of recidivism.

A similar approach could also be effective for the 26% of homeless persons who suffer from a serious mental illness. Two types of responses are gaining favor among state and local governments. The first establishes housing first, and then administers treatment. Houston’s Housing First initiative has reduced the homeless population by 57%. The second, permanent-supportive housing, includes housing, counseling, and access to medication. Madison’s Assertive Community Treatment program, for example, includes round-the-clock services in a community setting.

Perhaps the most compelling argument points to monitoring mentally ill individuals with a history of violence or threats of violence.The 2007 report from the Virginia Tech shootings review panel outlined several policy recommendations requiring that “incidents of aberrant, dangerous, or threatening behavior” be immediately documented and acted upon by a threat assessment team. And after repeated incidents, troubled students must attend counseling as a condition of class enrollment.

All of these strategies are attempts to reform a system that has largely shaped—and been shaped by—generational attitudes. To a great extent, the widespread neglect of mental health treatment for seriously ill individuals is the result of decades of deinstitutionalization. Since the 1960s, the population in mental hospitals has fallen drastically—at the same time that the mentally ill population in prisons has skyrocketed. Although Silent and Boomers grew up in an era characterized by a protective system for the mentally ill, many came to view state hospitals as just another repressive institution. Popular intellectuals of the day (like Michel Foucault) suggested that everyone was mentally ill and that those inside the hospitals might even be saner than the rest. Seminal works like One Flew Over the Cuckoo’s Nest only reaffirmed these beliefs—which ultimately translated into the emptying of the mentally ill from hospitals in hopes that they could be reintegrated into the community.

Generation X, which is today taking charge of hospitals and public agencies, is spearheading a very different approach. While younger policymakers aren’t advocating a return to the old era of institutionalization, they’re making more hard-nosed decisions about how to care for seriously ill individuals. Xers are less likely to believe that allowing people to make their own decisions without supervision—regardless of their capacity for sound judgment—is necessarily the best policy. And rather than spend thousands of dollars on open-ended hospital stays, Xers favor treatments with proven results at a lower cost, such as behavioral treatments or prescription medications.

Longer-term, Millennials can be expected to follow Xers’ lead. Millennials have grown up with a much more hands-on approach to mental health, with parents, teachers, and doctors paying close attention to their well-being. Millennials are also opting into technologies that monitor their physical and social lives 24/7. Already, interest is growing in using Big Data to enhance this process. By using “language signals,” cell phones may be able to continuously monitor an individual’s mental health status outside formal treatments. Researchers at Johns Hopkins have already figured out how to parse people’s Twitter feeds and identify whether they’ve been diagnosed with specific conditions. Soon, algorithms could introduce a new era of psychometric screening.

When Millennials are fully in control, one can imagine a society in which everyone’s mental health will be tracked for the good of the community—ensuring that no one will fall through the cracks.