Why solutions to mental health continue to evade us

Another tragedy, another tragic series of errors, another avalanche of debriefings and politicization, and in Washington, DC, there are 12 more dead.  What can we say about this?  It seems that the standard commentary fails.  Aaron Alexis was not an angry white man, nor a conservative.  He carried no assault rifle and he had a secret security clearance. He doesn’t seem to have been motivated by race.  He was a educated consultant.  He certainly wasn’t a radical Islamist.  In fact, he was allegedly a Buddhist.  (A demographic not known for violent outbursts these days.)

We can talk about effective security and we can write about background checks and all the rest. All of these are relevant points.  But the other relevant issue is that the shooter was a man who seemed to have mental illness.  We now know that he had a history of violent outbursts.  It is also alleged that he “heard voices.”  In the coming weeks experts on mental illness will hold forth in every conceivable venue.  Thanks to the inconvenient absence of the shooter, who was killed by police, the analysis will be largely speculative.  That won’t stop anyone.  We will hear impassioned please for better mental health coverage and we will hear bold declarations that “something has to be done” to improve access to mental health.  And when the grass begins to grow over the graves of the deceased, not much will have happened.

I know this because I see the mentally ill all the time.  Why do I see them? If you read me with any regularity you’ll know that I’m not a psychiatrist.  I practice emergency medicine. And I see the mentally ill because emergency departments are where many of society’s mentally ill find themselves, if they interact with “the system” at all.

Indeed, we have a system of mental health hospitals and clinics, in this state and in others.  And bless their hearts (as we say here), those state mental health workers, nurses, counselors, psychologists and psychiatrists alike, are a dedicated lot.  They spend their days and nights trying to sort through the thoughts and behaviors of untold men, women, boys and girls who are confused, broken, hallucinating, homicidal, suicidal, anxious, depressed, addicted and everything in between.

They take the story they are told, by family, friends, police or other physicians, and find the best treatment, then make the best predictions about what might (or might not) happen when the patient is released.  Furthermore, they are woefully underfunded and understaffed.  And they are crushed (overwhelmed is too soft a word) by rules, regulations and forms built to protect individual’s rights, but which sometimes make intervention a thing of legal peril.

Furthermore, and I tread lightly here, the mental health system is also stretched a bit thin by patients who are not, in fact, mentally ill.  A small but significant subset use “mental illness” to achieve the requisite incapacity necessary for disability claims or to avoid accountability for their actions.  They create a lot of hay through which the mental health system must sift to find the needles, as it were.

But I doubt if anyone will mention what makes mental health care the most difficult.  We all know that the workers are understaffed and underpaid and the patients typically uninsured.  But there’s something else.  You see, if a patient has chest pain, a fever or a broken arm, they aren’t generally afraid to acknowledge it and their loved ones know exactly what to do … and feel no shame about it.

This is not the case with mental illness.  Many self-aware patients acknowledge their problem.  But a significant number of those with the most dangerous and difficult conditions don’t.  Or can’t.  They aren’t hallucinating, they’re just seeing things more clearly than everyone else.  And they aren’t delusional; it’s just that the CIA and the aliens actually are after them … if only we could understand!

When the mind is impaired, the very tool we use to make decisions about our health and welfare, then it becomes remarkably difficult for even the best system to make a difference. And when patients (and many of their loved ones) see mental illness as a moral failure, not a disease, then all the money and staff in the world won’t solve the problems posed by men like Aaron Alexis.

I have more questions than answers. But the pundit’s cry, “we have to address mental health in America” is just so much window-dressing.  In the real world, the solutions continue to evade us all.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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