Earlier this month a mentally ill man named Alexander Bonds killed New York City police officer Misosotis Familia with a bullet to the head while she sat parked in a police truck. The assassination should be a wake-up call. As I discovered while researching Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, the government’s mental-health policies are in urgent need of reform. President Trump, HHS Secretary Price, and state officials must work together to
- fix Medicaid so the hospitalized mentally ill are not discharged while still psychotic,
- implement programs that require the dangerous mentally ill to accept treatment when they are in the community, and
- encourage all levels of government to focus their existing mental-health funds on treating the most serious cases of mental illness rather than improving “mental wellness” (whatever that is) more broadly.
Alexander Bonds was a poster-child for what’s wrong with our society’s approach to mental illness. According to the New York Times,
Mr. Bonds had been given diagnoses of schizophrenia and bipolar disorder and had been hospitalized on and off for years. When he was taking his medications, [his aunt said], he could be serene and almost never exhibited violent tendencies. But if he stopped taking them or, worse, had a few drinks, he could go wild.”
Despite having active mental illness and a criminal record, Bonds was discharged from a psychiatric hospital just a week before the shooting.
None of this is atypical. Prematurely releasing unstable mentally ill patients from psychiatric hospitals is now standard procedure, due to the nation’s being short at least 100,000 psychiatric beds. The average length of stay for the psychotic is now down to seven days, which is not enough time to stabilize them and properly titrate their medications. State governors exacerbate the trend by closing even more hospitals, apparently oblivious to the fact that fewer psychiatric beds lead to more mentally ill prisoners incarcerated. An obscure provision in Medicaid called the “Institutes for Mental Disease (IMD) Exclusion” encourages hospital closings by preventing states from being reimbursed for many mentally ill patients. To compensate, governors simply lock the front door and open the back. Representative Eddie Bernice Johnson has attempted to fix the IMD Exclusion, recent regulations from the Centers for Medicare and Medicaid Services (CMS) slightly ameliorated the provision’s damage, and several senators would like to further chip away at it in the Republican health-care plan. But much more needs to be done.
Familia’s tragic death might also have been avoided if the hospital that released Bonds had petitioned the court to put him in Assisted Outpatient Treatment (AOT) under what is known as “Kendra’s Law” in New York. The law allows courts to order those with serious mental illness and a history of violence kept in treatment, which almost always includes medication, as a condition of living in the community. AOT has been proven to reduce hospitalization, incarceration, arrests, and violence by around 70 percent. It could have kept Bonds in his “serene” state rather than his “wild” one.
Assisted Outpatient Treatment laws exist in 46 states, but are rarely used because state officials have sided with mental-health trade associations that believe psychosis is a right to be protected, rather than an illness to be treated. Last month New York considered a bill that would have required mandatory evaluation of patients who were being released from involuntary commitment, but Governor Andrew Cuomo and Assistant Assembly Speaker Felix Ortiz caved in to the mental-health industry and scrapped the idea. Massachusetts is considering an AOT bill. The state Department of Mental Health is funding Western Mass Recovery Learning Community, which is not only lobbying against it, they are running classes to teach the mentally ill how to stop taking their medications. In California, government mental-health funds intended to help those with serious mental illness are regularly diverted to groups that oppose the state’s AOT law.
To overcome the resistance to AOT in the mental-health community, Senator Cornyn inserted a provision in the 21st Century Cures Act that allows Department of Justice funds to be used for the treatment. Representative Tim Murphy also created funds for AOT pilot programs in his bill. More states must make use of AOT and police departments, which are so profoundly affected by the failure to use the treatment, must start to speak up for it.
Finally, government should stop focusing its mental-health spending on pop-psychology programs that fail to make a whit of difference to the seriously ill. Today, you can simply claim you have trauma, bad grades, are getting divorced, are sad, or were bullied, and you’ll gain access to mental-health funds. This leaves fewer dollars to treat the seriously ill. Mayor Bill de Blasio’s ThriveNYC plan, which his wife Chirlane McCray is trying to expand to other states, is the most brazen example of this eye-off-the-prize strategy, but California’s Mental Health Services Act is an even worse offender.
To fix this problem, President Trump announced that he will appoint Dr. Elinore McCance-Katz as first assistant secretary of mental health and substance use disorders. As she wrote late last year in National Review, McCance-Katz is a strong champion of focusing resources on the elephant in the room: treatment of the most seriously ill patients. Her confirmation hearing, like many of this administration’s, appears to be on the back burner, and it needs to be moved to the front. We must change direction now before someone else dies.
I have someone with serious mental illness in my family. I don’t want her to become a poster-child like Alexander Bonds. It is the seriously ill like her who need help the most. By spending money on serious mental illness rather than diverting it elsewhere, we can avoid more tragic deaths and grieving families in the future.
— DJ Jaffe is the author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill and the executive director of Mental Illness Policy Org.
A version of this originally appeared in National Review on July 12, 2017.