In response to the mass shooting that took the lives of 17 people at Marjory Stoneman Douglas High School in Florida, President Trump suggested reopening mental health hospitals as a way of addressing gun violence.
“Part of the problem is we used to have mental institutions... where you take a sicko like this guy,” Trump said to state and local officials. “We’re going to be talking seriously about opening mental health institutions again.”
The president’s sentiment raises many questions about psychiatric hospitals and the mental healthcare system in the United States, beginning with why many of them closed to begin with.
In the 1960s, laws were changed to limit the ability of state and local officials to admit people into mental health hospitals. This lead to budget cuts in both state and federal funding for mental health programs.
As a result, states across the country began closing and downsizing their psychiatric hospitals. More continued to do so over the following decades, into the 1980s.
“As a person who was a state elected official in Connecticut 40 years ago, I toured state psychiatric facilities at that time, and I can tell you that they not only look identical to our prisons today, but the prisons are often in the same exact buildings that were once the state mental hospitals,” Paul Gionfriddo, president and CEO of Mental Health America, told Healthline.
Gionfriddo’s point is that the country already has plenty of space for those who are violent and, in fact, already uses that space.
“The problem isn’t that we don’t have enough beds and custodial care institutions. The problem is that when we closed our state psychiatric hospitals, we effectively reopened them as county jails, and so those beds are currently there already,” he said.
Dominic A. Sisti, PhD, director of the Scattergood Program for Applied Ethics of Behavioral Health Care at the University of Pennsylvania, agrees.
He said shutting down state mental health hospitals over the years was a global phenomenon.
“Our bed ratio is about the same as Canada’s and European Union countries, but they have different healthcare systems that allow more access to mental health treatment, and they have more robust community psychiatry,” Sisti told Healthline.
“The fact is they don’t have easy access to firearms. To me it’s so obvious, a rhetorical solution to a complex problem that involves mental health and gun policy. Putting people in mental institutions as if it’s going to change anything is very sophomoric,” he said.
Predicting who will be violent
Trump’s notion of opening more mental health institutions implies that authorities would easily be able to identify who’s inclined to act out mass violence and that those people indeed have mental illnesses.
However, Gionfriddo notes that there are millions of people with serious mental illnesses who have never had a violent thought in their lives.
“One study I saw indicated about 8 percent of the general population harbors a violent thought at some point in their lives, while about 15 percent of people with serious mental illness might,” says Gionfriddo. “It’s a small minority of both populations.”
For the general population, risk factors include those who have been exposed to repeated domestic violence as well as living with people who have been in prison, having a substance use disorder, and living in neighborhoods that are unsafe.
According to the MacArthur Violence Risk Assessment Study, people with mental illnesses who also have substance use disorders are at increased risk for violence.
Gionfriddo adds that people with mental illness who experience active psychosis increases their risk for being violent.
“You can say there is a very small number of people upon having an episode of active psychosis who could be readily identified as being potentially violent,” he said. “The hard part is the vast majority of people who may be violent in the general population give very little clue in advance.”
Sisti added that if all mental illness was cured, mass violence wouldn’t end.
“It’d diminish by about 5 percent, which is good,” said Sisti. “But there are hundreds of syndromes under the umbrella of mental illness, just like there are many kinds of cancer. About 90 percent of people with mental illness do just fine with medication and therapy. We’d really have to focus on the people who have psychosis or who are angry or isolated.”
Should it be easier to commit people?
Some mass shooters do show signs of psychosis or serious mental illness leading up to the incident.
These include the Florida school shooter and James Holmes, who killed 12 people at a Colorado movie theater in 2012. How come they weren’t stopped?
While almost all but a handful of states allow for involuntary civil commitment into a mental health unit for a mentally ill person who’s dangerous, the process seems flawed.
“I would say this Florida individual was missed and someone could have petitioned for involuntarily commitment, and possibly got it if they tried, but maybe that did happen, and nothing was done,” noted Sisti. “But, having more hospitals wouldn’t matter, because we can involuntarily commit people already. The process needs revising.”
What about making it easier for family members or authorities to admit a person?
“It would be good to make it easier for family members to get someone quickly into treatment without going through a whole process of proving that the person is at high risk or having to pinpoint where or how they might act out violence. It is right now a bit onerous,” said Sisti.
The concern is families who may wrongly accuse a family member or abandon them.
“That’s what happened in the olden days and what we don’t want to happen again. It’s tricky, because some family members you don’t want involved and others you do. But I do think HIPAA and confidentiality laws can be fixed to make this easier,” said Sisti.
Gionfriddo adds that society as a whole has a responsibility to understand and acknowledge the need for mental healthcare reform.
“The answer isn’t that it’s always hard to get people into treatment. The answer is it’s harder to get people into treatment if you’ve ignored them for years and years, told them what they had wasn’t serious, told them they weren’t sick, or that they should pull themselves up by the bootstraps,” said Gionfriddo.
“And then when they’re in crisis, suddenly you want them to acknowledge the opposite of what everybody’s told them for the last 10 years, because we as a society didn’t want to deal with it,” he said.
The benefits of more institutions
Sisti said more reputable mental health hospitals are needed for people who want psychiatric treatment.
“A lot of issues related to mass violence are related to easy access to firearms that are military weapons. While we do need more inpatient psychiatric capacity, it’s not to prevent violence. It’s because sick people need help. Oftentimes, people are voluntarily looking for help, but are not provided adequate treatment,” said Sisti.
The reason people may not have access to treatment is because they don’t have insurance or it isn’t provided in their community.
While Sisti doesn’t suggest opening the old mental health hospitals or using them as a model, he said we should allow more people more access to good psychiatric hospitals that already exist, noting that most are privately paid and cost around $35,000 per month.
“I’m saying return to the original idea of what an asylum was meant to be — a place of safety and sanctuary for vulnerable people. I’m saying create more spaces that are ethically administered and well run, and give people access to them,” he said.
Hospitals don’t have to be the only option, either. Services can be provided in farmsteads or recovery centers or in other forms.
Follow the money
In the end, it all comes down to money, noted Gionfriddo.
He said many laws already exist that can help with costs, but the mandates aren’t fully funded.
For one, he points to the Individuals with Disabilities Education Act (IDEA) that has been in place for 40 years and in its current form for 25 years.
The law was designed to help all children with disabilities, including those with mental health conditions, get access to services. However, Gionfriddo says only one child in every 28 who has a serious mental health condition is identified as having that condition for purposes of special education.
He points to lack of funding, stating that the federal government doesn’t fully fund that mandate and pushes it off to the states. Then, the states don’t fully fund it either, and push it off to the local school boards and communities, who also don’t fund it.
“If we had full funding for special education services, then we’d identify kids much earlier in the disease process because half of all mental illnesses emerge by the age of 14,” Gionfriddo said.
“Instead of ignoring kids or suspending or expelling them, we’d actually be able to identify them and treat them and keep them in an educational setting early on, and frequently in their own classrooms or in alternative settings as they get older if needed,” he said.
Funding could pay for more resources, such as in-class services, as well as school psychologists, social workers, and counselors.
Gionfriddo suggests that a way to fund the IDEA is to permit private or public insurers to cover health-related costs.
“The current law says that if a school puts services into an individualized education program, the school has to pay 100 percent of those costs. The law should include that if an insurer would pay for it, then it should be allowed to,” he explained. “This would lower the expense to the education system.”
He also points to Medicaid revisions that could help alleviate costs and provide preventive measures.
For instance, the U.S. Preventive Services Task Force recommends that every person have a mental health screening from the age of 11 and up. For adults, adding this to annual physicals makes sense. Gionfriddo says for children, this could easily be done when schools perform vision and hearing screenings.
Since 2015, schools have been able to get reimbursed for annual vision and screening tests for kids who are eligible for Medicaid.
“All the states have to do is change their state plans to permit that to also happen with mental health screenings for kids who are eligible for Medicaid,” said Gionfriddo. “With the Medicaid dollars that are brought in, schools could use that money for mental health resources.”
He also says continuing to fund Medicaid is crucial.
“The Medicaid expansion has covered a lot of people with mental illness, so if we cut it back, they won’t be covered anymore,” he says. “Lack of funding makes us all pay the price when we have more people in prison and on the streets.”
Wouldn’t more institutions help the homeless?
When psychiatric hospitals were closed rapidly in late 1970s and early 1980s, Gionfriddo says it was widely acknowledged that an increase in the number of homeless people was a direct consequence.
In fact, the Treatment Advocacy Center reports that about one-third of the homeless population are individuals with serious, untreated mental illnesses.
“The problem was we didn’t have community-based care, so the real reason wasn’t just that we eliminated the hospitals. It was that we eliminated them and had no community-based care to offer the mentally ill,” said Gionfriddo.
If more rooms became available through mental health hospitals, he says it wouldn’t solve the issue of homelessness.
“You’d still have a rotation of people in and out of hospitals. The difference would be that today’s revolving door would be between infrequent hospitalization, frequent incarnation, and chronic homelessness. If you make hospitalization more frequent, you’d go back to the old revolving door between hospitalization and homelessness, and bypass incarnation,” he explained.
Throwing the homeless and mentally ill into psychiatric hospitals like we did in the past would be cruel and incompatible with modern American and international society, notes Gionfriddo.
“We’re not cruel to people anymore, to lock them up and throw away the key,” he said.
Sisti points out that people with serious mental illness often circle through emergency rooms and don’t get long-term psychiatric care that’s needed to become stable and create a foundation for recovery.
“They need full-on treatment, not just 72 hours of stabilization,” Sisti said. “I wouldn’t want to see people living in institutions for the rest of their lives unless they really needed to, but I would like to see these places be available for people to get weeks, months, or even longer treatment so they can begin their recovery.”