Can mental health treatment help halt gun violence?

A few years ago, Washington State University Vancouver launched AWARE, an anonymous and secure Web-based reporting system that gets immediate word to a team of administrators, safety specialists and at least one psychologist when a student appears to be despondent or disturbed. From there, the group can decide how to intervene.

“Each case is very different,” said Nancy Youlden, vice chancellor for student affairs. The group can do an “intelligence check” around campus or call in the subject for a frank conversation, she said. “We don’t want to jeopardize anyone or assume anyone’s guilty of anything. We don’t get ahead of ourselves.” The AWARE system is used about a dozen times a year, she said.

Posted on the school’s website is the following list of pointers for identifying someone who may be in crisis. “Changes in a student’s style and level of functioning are often indicators of distress,” the site says. “The suddenness and extent of change may reflect the severity of the difficulty.”

Faculty and staff are advised to be aware of:

o Assignments not being turned in, or turned in late.

o A change in frequency of absences from class.

o Disinterest, apathy, and hopelessness.

o Disruptiveness in class (e.g. angry outbursts, acting out).

o Excessive emotional content in discussing or writing class materials.

o Mention of suicide or homicide in the content of coursework.

o Significant decline or deficit in self-care behaviors (e.g. personal hygiene, extreme weight loss).

o Noticeable changes in personality or behavior

o Change in perception of reality.

o Significant paranoia regarding government, law enforcement, administration, etc.

Fellow students should be aware of:

o Communicating threats against self, others or the campus

o Fantasizing about harm to self, others or the campus.

o Aggressive behavior or speech.

o Frequent mentioning of or discussion about death.

o Noticeable changes in personality or behavior.

o Increase in substance use/abuse.

o Disinterest, apathy, and hopelessness.

o Social withdrawal.

Signs of an immediate mental health emergency and potential danger to self or others:

o Direct suicidal or homicidal statements.

o Bizarre speech.

o Loss of contact with reality.

o Extreme anxiety; panic.

— Scott Hewitt

Fewer than half of all Americans with diagnosable mental health problems receive treatment, says the White House plan to reduce gun violence, released Jan. 16. The vast majority of people with mental illness never are violent, but a tiny fraction have caused terrible tragedies. The president’s five-area plan emphasizes improving mental health services:

o Train teachers and other adults to recognize and refer young people who need help to mental health services, and make sure the connection with services is made.

o Train 5,000 new mental health professionals to serve students and young adults.

o Provide increased trauma and anxiety treatment, as well as conflict resolution, anti-bullying programs and other school-based violence prevention.

o Ensure that private health insurance and Medicaid coverage of mental health and substance abuse issues is “at parity” with medical and surgical benefits.

o Launch a national conversation about mental health that reduces stigma and encourages people to seek help.

Other measures in the plan emphasize gun control and research:

o Require background checks for all gun sales. (Nearly 40 percent of all gun sales are via private seller).) Update prohibitions on who may buy a gun. Share information more fully.

o Ban military-style assault weapons and high-capacity ammunition magazines. Numerous recent mass shooters involved magazines holding more than 10 rounds.

o Trace guns as they move from owner to owner; stiffen punishments for traffickers; analyze data on lost and stolen guns.

o End the “freeze” on gun violence research. In 1996, the Centers for Disease Control and other scientific agencies were barred by Congress from using funds to “advocate or promote gun control”; the real outcome of this has been no CDC research on causes of gun violence — including media influence.

o Encourage medical professionals to talk to patients about gun safety, and clarify that no federal law prohibits medical professionals from reporting credible threats of violence to authorities.

o Put 1,000 more school resource officers and mental health professionals in schools. Make sure every school has a comprehensive emergency plan that’s rehearsed by staff and students.

o Train 14,000 police, first responders and school officials to be ready for an active shooter.

— Scott Hewitt

Evan Griffis of Vancouver, a graduate of Union High School and a sophomore at Whitman College, recently won an Abshire Award, which funds joint undergraduate-faculty research projects. Griffis, who is double-majoring in anthropology and gender studies, will work with Prof. Jason Pribilsky to study gun use and the spectrum of attitudes about guns in the United States. Griffis’ first target is the Pink Pistols, a national organization of gay gun-rights activists.

The U.S. Dept of Justice announced on Feb. 1 that it will grant up to $1.5 million, total, for research projects “on firearms and violence such as, but not limited to, the effects of criminal justice interventions on reducing gun violence, improving data systems for studying gun violence, illicit gun markets, and the effects of firearm policies and legislation on public safety.”

Crisis? Call your doctor or therapist, or Southwest Washington Behavioral Heath. For emergency situations that require immediate response, dial 911.

Clark County Crisis Line: 360-696-9560 or 800-626-8137 or TTY: #711.

Cowlitz County Crisis Line: 360-425-6064 or 800-803-8833.

Skamania County Crisis Line: 509-427-3850.

Professional counselors will answer 24 hours per day to evaluate and refer callers to appropriate resources, including inpatient, outpatient or peer support services. A designated mental health professional may initiate a 72-hour involuntary hold on a person who is determined to be dangerous to self or others.

ON THE WEB

Southwest Washington Behavioral Health

National Association on Mental Illness, Clark County branch

Build a better, tighter, more diligent mental health system and it likely will catch troubled people who otherwise might have gone ballistic — literally.

But it won’t put an end to gun violence. That’s what mental health professionals working the front lines of crisis intervention and prevention in Clark County say.

Local experts are trying to piece together a better mental health system against a constantly shifting background of agency mergers, tightened budgets and evolving laws and public attitudes. Early intervention is key, all agree, so local K-12 school districts have developed procedures for identifying and assessing troubled students and the danger they may present to themselves or others; mental health agencies are patching holes in their networks and trying for “radical engagement” with deeply disturbed, hard-to-treat individuals; and, as the last line of defense, local police are regularly trained in crisis intervention techniques.

All of which likely won’t take more than a nibble out of the shootings and mayhem that grab headlines with shocking regularity these days, experts say.

“It’s not a predictive science we’re working with,” said Barb Laurenzo, the threat assessment coordinator for Educational Service District 112. “It’s a very complicated picture.”

“A person with a mental diagnosis is not always dangerous, and a person who is dangerous does not always have a mental diagnosis,” said Stephen Maynard, network manager at Southwest Washington Behavioral Health, which operates a public crisis hotline and contracts with local providers for mental health services. “Substance abuse and previous violence, including domestic violence, are the strongest indicators of potential violence.”

People in crisis are not the same as people with mental illness. People with mental illness are not the same as people who do violence. Many mental health professionals have underlined this nuanced point for years: automatically judging people who behave violently as simply “crazy” does society a serious disservice — in continuing to stigmatize mental problems so that suffering people don’t seek out help.

“Because we don’t understand, we assume (people with mental illness) are dangerous,” said SWBH executive director Connie Mom-Chhing. “This is very sad.”

Small numbers

There’s been a flurry of calls for better mental health screening and treatment as the best way to “catch” disturbed people before they become violent. After the Dec. 14 massacre at at Sandy Hook Elementary School in Newtown, Conn., and after President Obama called for stricter gun control, National Rifle Association spokesman Wayne LaPierre responded with a call for a national database of the mentally ill. NRA legislative director Chris Cox added: “American gun owners and Second Amendment supporters are ready for Washington to put politics aside and come together to fix our broken mental health system.”

There may be no better contemporary example of strange political bedfellows: generally conservative gun-rights supporters joining with generally progressive public health advocates in supporting what you might call a big-government solution.

Vigorous attention to mental health issues is welcome, experts say. According to the grass-roots National Association on Mental Illness, one in four adults experience a mental health disorder in a given year, and one in 17 lives with a serious mental illness such as schizophrenia, major depression or bipolar disorder. The number of children living with a serious mental or emotional disorder is approximately one in 10. In all, almost half of all Americans will experience mental health or substance abuse disorders in their lifetime.

But study after study has found that mental illness contributes little to violence in America. In 1999, the U.S. Surgeon General reported that “the overall contribution of mental disorders to the total level of violence in society is exceptionally small.” More often, people living with mental illness are the victims of violence, the report said.

“(T)here is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts,” wrote Richard A. Friedman, professor of clinical psychiatry and director of the psychopharmacology clinic at Weill Cornell Medical College in New York, in The New York Times on Dec. 17. “Only about 4 percent of violence in the United States can be attributed to people with mental illness.”

An earlier study cited by the U.S. Department of Justice put the number closer to 3 percent; a 2005 Institute of Medicine study put the number at 5 percent.

“All the focus on the small number of people with mental illness who are violent serves to make us feel safer,” Friedman concluded. “But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.”

SWBH’s Maynard said suicide, not homicide, is the most common violence committed by people with mental illness, he said.

Meanwhile, the National Association of State Mental Health Program Directors reported to Congress last year that states cut at least $4.35 billion in funding for mental health agencies over the previous four fiscal years. In 2010, the Washington Legislature voted to make it easier to detain and involuntarily “commit” potentially dangerous mental health patients — but never funded the necessary hospital beds to take up the resulting flood of commitments.

Jails are taking up much of the slack. And the state Legislature is grappling with a nearly $1 billion budget shortfall.

Illness vs. crisis

Perhaps the question of diagnosable mental illness versus explosive distress is academic, since the systems and safety nets aimed at catching troubled people and preventing problems are more or less the same?

Gun violence “is a very complicated question and I think there are multiple layers of solutions,” said ESD 112’s Laurenzo. “Mental health is certainly one of them.”

“If money was put into the mental health community, could it stop this violence? We think it can help,” said Janice McKenzie, executive director of the local branch of National Alliance on Mental Illness.

McKenzie’s opinions on some of these questions are different than many of her peers — “because I actually talk to the families, who are desperate to get help for their loved ones,” she said. McKenzie is in favor of forced medication and even institutionalization for severely mentally ill people — the ones who are hearing voices, seeing visions, suffering paranoid schizophrenia and otherwise “living inside their own fantasies,” she said. “We are talking about the small percentage of folks who don’t know how sick they are.”

Recovery is possible for many of them, she said — but not without medication and a secure place to stay.

McKenzie believes most of the worst mass shootings in recent memory, she said — from Virginia Tech to Newtown and the movie theater in Aurora, Colo., to the parking lot in Arizona where U.S. Rep. Gabby Giffords was meeting constituents — were undeniably the result of untreated mental illness. “In each case, they were not living in reality,” she said.

Forced treatment is not popular in her field, she said. “I know it is an invasion of rights and it plays into the stigma,” she said. “But is it right for someone who is living in fantasy to be walking the streets?”

Early identification

After something terrible happens, noted chief clinical officer Marc Bollinger of SWBH, there’s usually lots of rear-window gazing at an obvious trail of red flags — “but you don’t see enough people trying to look ahead,” he said.

That changed after the 1998 mass shooting by 15-year-old Kip Kinkel, a student at Thurston High School in Springfield, Ore., that left two students and Kinkel’s parents dead and many more wounded. “It was a marker in a lot of our minds,” said Laurenzo, who manages the threat assessment program that’s coming online in many Clark County K-12 school buildings.

Vancouver Public Schools has instituted a couple of overlapping, early “universal screening” processes at several — but not all — of its elementary and middle schools, said special services coordinator Bill Link. One is academic and the other is behavioral, he said. Both aim for early identification and help for children who appear headed for trouble.

The academic screen focuses on students who aren’t performing in class. The thinking is, a child who falls far behind may be headed for bigger trouble later on, while a child who is helped to succeed will feel better about school and self, life and the future. “We find that if we do not intervene, those children continue to be at risk and the academic problems can lead to behavior problems,” Link said.

There are also a couple of behavioral screening tools, Link said, that are now being road-tested in various district buildings. One is a brief (15-item) checklist that teachers can use to record behavior problems and incidents for each student; the other is a computer program that crunches student discipline data.

“You run your data monthly or so, and you look for trends and patterns,” said Link. “You might notice this one guy had six office referrals in two weeks. The larger the school, the more difficult it may be to keep track of those trends and intervene when appropriate.” But comb the computer data during weekly meetings of key players — school counselor or psychologist, literacy specialist, principal, security officer, teachers and others — and you get a pretty accurate picture of which individuals regularly display what sorts of problems, Link said.

“We’re getting pretty good at designing interventions,” he said. Like an adult mentoring approach — assigning a troubled kid a dedicated adult buddy who is there at the building each day.

“Rather than a punitive approach,” Link said, “this person is on hand to visit and help and be a positive influence. ‘How’s your day going today? Did you have breakfast? What are your goals? How did it go?’ We’re seeing a pretty good effect with this — lower incidents of discipline in terms of suspension. More support in school means we don’t have to send kids home. We don’t end up with fighting.”

That’s the good news, he said. The bad news is that public budget cuts are having a direct impact on Link’s ability to institute these positive, preventive measures throughout the school district, he said. A staffer at nonprofit Columbia River Mental Health was working with Link on a grant to do just that — provide broader mental health services to all Vancouver School District buildings — until he was laid off.

“I called back and found out the guy got cut,” said Link. “I was hoping our recession was over.”

Budget reaction

“When budgets get reduced, what’s left is reactive,” said Bollingerof SWBH. “We do our best when our work is preventive. If you are able to intervene earlier, symptoms may not fully manifest themselves.” But, he said, “in tough economic times, prevention is what gets cut first.”

Why? Maybe because it’s hard to cheer (let alone pay for) a negative — or, as SWBH’s Maynard put it, to “demonstrate success based on what didn’t happen.”

Southwest Washington Behavioral Health is a relatively recent regional merger of budget-reduced mental health agencies in Clark, Cowlitz and Skamania counties. All three, and their community partners — private and public clinics, hospitals, jails and other service providers — have their individual budget constraints and missions, Bollinger said, but SWBH is trying to assemble them all into a seamless system by acting as “a convener. It’s relatively inexpensive to bring all the partners together” to make sure policies cooperate and communication is flowing.

Danger to self or others trumps any medical privacy laws, Maynard said. “Every mental health professional has a duty to notify the person threatened and to notify relevant officials,” he said.

SWBH also is stressing what Bollinger called “radical engagement” with deeply disturbed people who may be hard to find, distrusting and difficult to deal with — and are in dire need of mental health treatment. Reaching out to them “is a lot of work on everybody’s part, and may take some clinicians out of their comfort zone,” he said. “But we want to make sure everyone is getting what they need.” For mentally ill people emerging from jail, there are transition caseworkers who make sure services and medications are in place, Maynard said.

“We are always improving upon (our system),” said Maynard. “We can always do better. But if you look at these tragic situations, these outbreaks of violence all across the country … the impact of an improved system is going to be fractional.”

Experts agree: The first line of defense is you. Nobody notices faster than a family member or friend when somebody’s behavior changes. A friend or family member expressing care and concern — or calling the crisis line or police, or providing a ride to the emergency room — is the earliest intervention possible.

“Families see these things first,” said Mom-Chhing. “Families know your behavior and know when something is not right.”

Scott Hewitt: 360-735-4525; scott.hewitt@columbian.com; facebook.com/reporterhewitt; twitter.com/col_nonprofits.