As a psychiatrist, I have frequently seen psychotic patients brought into the emergency room by police, only to be released into the night because of a toxic combination of restrictive commitment laws and a desperate shortage of psychiatric beds. For the most part, such sad stories affect only the patients themselves and their families. On a few horrific occasions, they are a missed opportunity to prevent a larger, bloodier tragedy.
We will never know his precise motivations, yet it is becoming increasingly clear how Aaron Alexis, who police say shot and killed 12 people at the Navy Yard in Washington this week, fell through some cracks in our mental health system.
On Aug. 7, police in Newport, Rhode Island, responded to a call from Alexis, who was staying at a Marriott hotel. According to the police, Alexis said he had an argument at the airport with a stranger who had sent three people to follow him and who were keeping him awake by talking to him through the walls and by sending vibrations to his body from a microwave machine. He said he had already switched hotels twice to escape them.
Although he was clearly delusional, Alexis denied having psychiatric trouble. When he told the police he was afraid the strangers whose voices he heard were going to hurt him, one officer, rather curiously, “advised him to stay away from the individuals that are following him and to make contact with the NPD if they attempt to make contact with him.”
Here was the first problem: The responding officers either didn’t have the training to realize they were dealing with a very psychotic man or, if they did, didn’t know how to handle the situation. That wouldn’t be unusual; many officers find themselves at sea when responding to a “mental disturbance” call.
Worse, even if the Newport police officers had realized they were dealing with a person who was severely mentally ill, they might not have been able to bring Alexis to a hospital for emergency evaluation. “He’s just hearing voices,” Lieutenant William Fitzgerald, a spokesman for the Newport Police Department, told the New York Times. “We can’t arrest someone for that.”
Arrest? The issue here isn’t crime-fighting. It is aiding a sick person -- and the law in Rhode Island authorizes police to do so only if they deem the person in need of “immediate care and treatment” to avert “imminent likelihood of serious harm.” Alexis clearly needed treatment, but the judgment call of whether he needed immediate care was left to the officers, who would have had to deem him a danger to himself or others.
Even if Alexis had been brought to a hospital where the doctors found him psychotic, it’s quite possible that he couldn’t have been admitted against his will.
That’s because many states have restrictive civil commitment laws. In Rhode Island, for example, an individual with mental illness must exhibit a “grave, clear and present risk to physical health and safety” before a court can intervene and order treatment. These criteria might not have applied to Alexis: He wasn’t violent, didn’t display any intent to harm himself or others, and appeared capable of meeting his basic survival needs.
Many lapses and missed opportunities along Alexis’s journey to the Navy Yard were preventable. First, police need training in handling mental disturbances. According to the Treatment Advocacy Center in Arlington, Virginia, only 49 percent of the public is served by law enforcement personnel who have received such instruction.
Most states offer crisis intervention training to law enforcement (Rhode Island is one of five that don’t). One popular program, a 40-hour curriculum known as the Memphis model, teaches police how to respond safely to a person in crisis. It includes information about how to recognize mental illness and about the local mental health system and laws, as well as guidelines for interacting with disturbed people who are extremely agitated or aggressive.
A second response should be to expand commitment laws. The majority of states -- again, Rhode Island is an exception -- have a “grave disability” standard, an explicit and broad designation that focuses on a person’s ability to feed, clothe and protect themselves.
For instance, people who are so paranoid that they refuse to eat for fear of being poisoned would meet the criteria for a grave disability, yet more restrictive rules such as Rhode Island’s might not allow authorities to act.
States shouldn’t stop there. More should adopt an even more progressive type of commitment statute: the “need for treatment” standard. This provision, which is in effect in about half the states, allows a court to intervene in a mental health crisis. These standards are particularly relevant for individuals who lack insight into their illness (a syndrome known as anosognosia).
The most important component of reform, however, is to ensure that these legal tools are used. Arizona, where Jared Lee Loughner shot Representative Gabrielle Giffords and 17 others in 2011, has a need for treatment standard. If Loughner had been found “persistently and acutely disabled” by severe mental illness and “likely to benefit from treatment,” an emergency evaluation and subsequent care could have been mandated by the court.
Admittedly, vivid patterns jump out in hindsight. Before his shooting spree, Loughner had accumulated a troubling record: Concerned staff of Pima Community College had called campus police about him, a teacher and students had voiced safety concerns, and the college wouldn’t readmit him after a suspension without psychiatric clearance. Those events could have justified involuntary assessment, if not treatment.
The Navy Yard shootings, like so many recent disasters, had roots in deficiencies in the U.S. mental health system. We need better training for law enforcement, more responsive statutes that put therapeutic need on a par with protection of the patient and the public, awareness of good laws that are already in place, and the will to use them.
(Sally Satel is a doctor and a resident scholar at the American Enterprise Institute.)
To contact the writer of this article: Sally Satel at http://www.sallysatelmd.com/.
To contact the editor responsible for this article: Max Berley at firstname.lastname@example.org.