We sweep it under the rug at our own peril

iVillage Member
Registered: 07-11-2006
We sweep it under the rug at our own peril
Sun, 08-12-2012 - 1:59pm

How Do We Stop the Next Aurora? We need a mental health system that helps men like James Holmes—and Jared Loughner, and Seung-Hui Cho—before it’s too late.


By Emily Bazelon Aug. 10, 2012


James Holmes is mentally ill, lawyers for the accused Aurora, Colo., movie theater shooter say. They asked the judge on Thursday for more time to “assess the nature and depth” of his illness.


Here’s what will happen next: Holmes will be diagnosed with a form of delusional psychosis like schizophrenia, or perhaps with suicidal depression. He will be medicated until he comes out of the weird daze he’s been in during court appearances. Eventually, after the medication takes effect, he will be found competent to stand trial: The hurdle is low, so he just has to be able to understand the charges against him and be able to consult rationally with his lawyer. If the drugs have in fact made Holmes saner, he may plead guilty to avoid the death penalty. He’ll go away for life. And we’ll be no closer than we were before to fixing the holes in the mental health care system that he fell through—taking his victims with him.


Here’s what we know about Holmes, who is 24: He was a promising neuroscience Ph.D. student at the University of Colorado and one of six students with a prestigious training grant from the National Institutes of Health. He had no criminal record. But he failed his oral exams in the spring, and he was seeing a psychiatrist, Lynne Fenton, who in June was concerned enough about something she saw in him—we don’t yet know what—to call the campus police and to alert the university’s threat assessment team.


Before the team met, however, Holmes dropped out of school. And that looks like the end of the line for his psychiatric care. The university assessment team never met. Holmes surely stopped seeing Fenton once he lost his student status. It’s not clear whether she tried to refer him to another therapist outside the university. We do know that he mailed Fenton a package detailing his murderous plans, which arrived at the university the Monday after the shootings—too late. (The package did not sit in the mailroom for a week, as Fox originally reported, according to university officials.)


In sum, Holmes sent signals that he was on the edge—but once he left school, he was on his own. That is the fact at the center of this tragedy and others like it. James Holmes has far too much in common with Jared Loughner, who pleaded guilty this week to killing six people and wounding 13 more in the Arizona shooting that seriously injured Rep. Gabrielle Giffords. Loughner also dropped out before the shootings, after he was suspended from Pima Community College for erratic outbursts. “No one in that class would even sit next to him,” one of the students in his poetry course said. Pima required Loughner to get a mental health consultation before he could come back to school. He didn’t. And so, like Holmes, he was left to his own distress and delusions. It wasn’t until after the killings that Loughner was diagnosed as schizophrenic by a court-appointed psychologist. At that point he got medication, so he could be deemed competent to stand trial. And he started showing “some understanding of his actions,” according to the psychologist. He told her he wished he’d taken medication earlier. And he expressed remorse to her, saying, "I especially cried about the child," in reference to the 9-year-old girl he killed.


This is so incredibly sad, from every vantage point—the killers’ as well as the victims’. As Dave Cullen writes in a superb analysis of the Aurora shootings, a mentally ill person who becomes violent often unravels slowly. As this frightening process unfolds, he is “typically perplexed and then distraught by the alarming thoughts ricocheting around his brain.” Seung-Hui Cho, who killed 32 people and wounded 25 at Virginia Tech in 2007, requested a psych evaluation as he felt himself falling into his mind’s abyss.


As far as we know, Holmes, too, voluntarily sought help from Fenton. What’s particularly terrible about the bare minimum of the facts we know—the judge in this case has imposed a blanket seal and gag order that he should soon lift—is how tantalizingly close he came to getting sustained care and to being flagged as dangerous. Closer than Loughner. Closer than Cho.


Of course, it’s only easy to say in retrospect that Fenton and the university assessment team she alerted should have acted with urgency. Surely, she and they would have done anything in their power to stop Holmes if they’d known he would soon kill 12 people and wound 58 more. The larger and crucial point about mentally ill people who become violent is this, as Benedict Carey wrote in the New York Times after Loughner’s shooting spree: “Even after the 2007 massacre by a student at Virginia Tech, institutions and employers are seldom set up to handle such potential threats, experts say — even when the warning signs are blatant and numerous.” There’s often no single person or office tracking students who behave strangely. Worse, if a student leaves school or an employee loses a job, he loses his access to university or employer-based health services—with no follow-up and no clear alternative.


I have to point out that it’s very rare for mentally ill people to become deranged killers. According to the Bazelon Center for Mental Health Law (disclosure: It’s named in memory of my grandfather), studies show that having a mental illness in itself doesn’t increase the likelihood of becoming seriously violent. Untreated mental illness, however, is a risk factor. And so it is terribly scary, as well as terribly sad, that “America’s mental health care system is horribly broken and horribly underfunded,” as Robert Bernstein, director of the Bazelon Center, underscored after the Arizona shootings.


Serious mental illness can be incredibly hard to live with and to deal with. But these shootings keep telling us that we sweep it under the rug at our own peril. After a massacre like Aurora, it’s very hard to see the killer as worthy of any sort of sympathy. "They keep talking about fairness for him," a man whose sister died in the Aurora shootings told the Associated Press at Holmes’ court appearance this week. "It's like they're babying this dude." It’s an understandable reaction, but if Holmes’ lawyers are right and he is seriously ill, he won’t be coddled by the legal system. He’ll get the treatment he needed, but far too late.


After Loughner’s guilty plea, one of the survivors of his shooting spree had the compassion to point out the lack of mental health services for people like him. "We really have to be our brother's keeper here and reach out and get them help," victim Randy Gardner said. Real reform of mental health care, so that dropping out of school doesn’t mean being dropped by your therapist, would be arduous. It would offer no throb of vengeance. But it would make us safer.

iVillage Member
Registered: 05-25-2004
Sun, 08-12-2012 - 3:06pm

I understand what you're saying here and I think it's tragic people don't receive the mental health care they need. I agree that being able to treat people sooner could stop some of the tragedies. Did his therapist actually drop him or did he stop seeing her? One of the problems with mental illness is that people who need care often don't seek it or don't stay in treatment. The assessment team not meeting is a huge error. I realize it says he had dropped out of school, but I would hope the team would do something besides just drop the issue--as if "Okay, he's not our problem any  more so we can forget about him." And mental illness is a hard thing for the average person to diagnose. I've known a number of people throughout my life that I believe need professional help, but that's just a guess on my part. And getting someone who has a mental illness to see a professional isn't easy; there's such a stigma about mental illness that many needing help avoid it. And according to law, even if experts know someone has a mental illness, they can't force the person to attend therapy (unless court-ordered) or take meds. It's a difficult area and I know I don't have any answers. I wish someone had the answer. I don't think the author, Emily Bazelon, has any answers either. We all have lots of questions, know it should be different, but how do we change things and how do get people the treatment they need?

iVillage Member
Registered: 07-11-2006
Sun, 08-12-2012 - 3:28pm

My prediction is that Obamacare will be viewed as a step in the right direction. Here's a suggestion:

The data are emerging; more work needs to be done to evaluate comprehensively the connection between incidence of severe mental illness and lack of appropriate, coordinated medical care.  Whatever exact relationship is revealed, the situation is clearly dire: the fragmentation of our health care system causes particularly severe problems for people with serious mental illness.  The Association noted that emerging chronic care management techniques offer a way out of this unconscionable mess.  It advocates the adoption and application of patient-centered medical home programs that bring together primary care, mental health care, and care for chronic medical conditions in a patient- and community-centered environment.


iVillage Member
Registered: 07-11-2006
Sun, 08-12-2012 - 3:35pm


Xavier Amador has been a very vocal advocate for people who have a loved one with serious mental illness who are to impaired to know that they need help.

He has proposed a communication model called LEAP,  Listen-Empathize-Agree-Partner

iVillage Member
Registered: 07-11-2006
Sun, 08-12-2012 - 3:50pm

The go-to source for information on treating people with severe mental illness is the Treatment Advocacy Center. They advocate for "Assisted Treatment Laws"

Here is a quote from their Assistant Treatment Model Law webpage:

The consequence of requiring treatment to be withheld until a person becomes a danger to themselves is predictable. By that time, they are likely to be either one of the 19 percent who attempts suicide or one of the 10% – 15% who eventually succeed. Suicide is the leading cause of death in jails and 95% of those who commit suicide in jails have psychiatric illnesses. Withholding treatment also puts people in jeopardy of victimization. Persons with severe mental illnesses are nearly three times more likely to be victims of violent crimes than the general population.

Clearly, a new wave of reform is needed. Enacting and utilizing standards based on the need for treatment will allow for intervention before it is too late. Abandoning dangerousness as the sole standard for assisted treatment will not require re-opening hospital wards. While counter-intuitive, it is logical that hospital usage will decrease by substituting a need for treatment standard for one based on dangerousness. The change will facilitate needed intervention sooner rather than later. For the most part, the same people who would be hospitalized when they become dangerous will simply helped sooner. Because intervention occurs sooner, it will take less time to stabilize patients and they will spend less time in the hospital. At least five states that have adopted standards based on the need-for-treatment experienced decreased hospital admissions after the law changed (i.e., North Carolina, Alaska, Kansas, Texas and Colorado).

Perhaps the single most important reform needed to prevent the need for repeated hospitalization and to prevent the consequences of non-treatment is to encourage the use of assisted outpatient treatment. When appropriate, assisted outpatient treatment fosters treatment compliance in the community through a court-ordered treatment plan. Moreover, not only does the court commit the patient to the treatment system, it also commits the treatment system to the patient. In the most comprehensive study to date, long-term assisted outpatient treatment was shown to reduce hospital admissions by 57 percent. The results were even more dramatic for individuals with schizophrenia and other psychotic disorders whose hospital admissions were reduced by 72 percent. Additionally, the same study showed that long-term assisted treatment combined with routine outpatient services reduced the predicted probability of violence by 50 percent.

Progressive assisted treatment laws must be crafted to reflect the significant advances that have been made in the last decade in our understanding and ability to treat severe mental illnesses. We now know that these conditions are treatable biological brain diseases and not lifestyle choices, as was the prevailing thought three decades ago. Research shows that at least 40 percent of those diagnosed with schizophrenia and manic-depressive illness lack insight into their illness because of a biologically based symptom known as anosognosia. A person suffering from this symptom does not believe he or she is ill and is likely to refuse treatment reasoning, "Why should I take medication if there is nothing wrong with me?" For those who previously refused treatment because of unpleasant or dangerous side-effects of medication, a much broader array of medications is now available so that possible adverse effects of treatment can be more effectively mitigated.

The Treatment Advocacy Center was established in 1998 to eliminate barriers to treatment caused by outdated treatment laws. In drafting a Model Law that would meet those goals, the Center solicited advice and assistance from individuals who are diagnosed with severe mental illnesses, their families, and medical and legal professionals. The Model Law was carefully drafted to withstand constitutional challenge. 



The Treatment Advocacy Center is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illness. The organization promotes laws, policies and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder.

The Stanley Medical Research Institute (SMRI) is a supporting organization of The Treatment Advocacy Center.