I was getting ready for work yesterday morning and watching The Today Show in the background as usual. Suddenly there was the story of a young woman trying to ram the security barriers at the White House and then being pursued in a high speed chase down Pennsylvania Avenue. It eventually showed a direct confrontation with law enforcement and them opening fire on her through the window of her vehicle. There was an initial report saying that she had fired shots but she was unarmed. The police discovered her one year old daughter in the car and removed her. The acute reaction captured on film was surreal. There were descriptions of some of her recent behavior and thoughts. A police official commented that the security barriers "worked" as though this was an assault by a terrorist. A different official commented how her daughter was "rescued" by the police. People were talking as though this was an actual assault by a terrorist. The last person I heard was a politician who made the quote at the top of this post and finally suggested the real problem.
Confrontation between people with severe mental illnesses and law enforcement are very common. During my years of acute inpatient work I have talked with many people who have been injured in every imaginable way during these confrontations. In some cases they were themselves engaged in very dangerous and aggressive behavior as the direct result of a mood disorder or a psychosis. In other cases law enforcement just misinterpreted their behavior. That happened most commonly when the person refused to comply with what the officer wanted them to do. These confrontations are always high risk situations because most people in society know that it is in their best interest to be law abiding and comply with the police. The people who don't are criminals or people with impaired judgment due to mental illness or intoxication states. Even if the police can make that distinction rapidly that does not mean they can easily use a different approach to the person with mental illness. Police officers have been injured or killed in these situations.
There seems to be a great deal of misunderstanding and continued bias about how these situations can occur. It can happen as rapidly as waking up one morning finding out that your entire state of consciousness has changed. That gas company truck across the street is there to monitor you and direct microwaves at you. The phones and your computer are bugged. Going to work that morning you decide you need to take evasive action because it seems like you are being followed. Your anxiety levels build all day and that night at home you can't sleep. You decide you need to move the refrigerator in front of the door because you had the thought that it would be too easy for government agents to kick the door down and grab you. You do a Google search on microwaves and decide these people are trying to do a lot more than harass you - they are trying to kill you. You start to make plans on that basis.
That is how paranoid delusions evolve and how they change your behavior. You are no longer making rational assessments of the environment. Your brain has come up with a theory and you are now interpreting all of the environmental information according to that theory. When I approach the problem psychotherapeutically, I generally explain that delusional thoughts are very low probability explanations or interpretations of an event in the environment. I illustrate this by asking the question: "If we had 100 people in the room right now - how many of them would agree with what you just told me?" Many people know that hardly anyone would agree with them, but that doesn't stop them from continuing to misinterpret the data or trying to cast me with everyone else who either doesn't believe them or is just saying that they are "crazy".
Before I outline an approach to the problem of people experiencing episodes of psychosis or mania and running into problems with law enforcement consider what gets in the way of any of early intervention? Keeping with my cardiology comparison from a previous post - most people know that chest pain is a warning sign for a possible heart attack. With continued public health interventions most people know cardiac risk factors. Public health intervention has been so effective that the current campaign is focused on decreasing the denial in women and decreasing cardiac sudden death in women. Two generations of public health intervention are associated with a decreasing rate of cardiac mortality.
How does that compare with psychosis and mania? I have never seen a public service ad advising about the warning signs of psychosis or mania. There are countless euphemisms for acute changes in a persons mental status. The public treats it like a mystery. When a tragedy occurs there is often no explanation or an inadequate one like "some sort of mental illness." The cultural approach is an obstacle to a rational approach to helping affected individuals. Stigma is considered to be a factor, but it could as easily be an artifact of the process. What would be a better approach?
I have been advocating a public health approach to the problem for a long time now. At a political level there is a lot of confusion about whether this is a firearms issue. Firearms are just a subset of the problem. The overriding public health goal is to get people the help that they need as soon as possible. Our current system of care is set up to provide minimal care to people with severe mental illnesses. The level of care and condition of the facilities where the care occurs is widely known in communities and most people do not want to access these facilities for help. I hear a lot about the concern that someone is going to be stigmatized by treatment at a psychiatric facility. I think it is as likely that many facilities are substandard physical plants that are poorly managed. Based on the length of stay policies alone, nobody wants to bring their relative to a facility that has a reputation for discharging partially stabilized people back into the community. The long term goal needs to be improving the quality of psychiatric facilities in addition to changing the culture about severe mental illness.
I thought of a public service announcement that would potentially have the same advertising power as some of the more popular health spots like the "7 warning signs of cancer". I call it the 4 warning signs of severe mental illness. A concerted effort to focus on severe mental illnesses that can potentially lead to errors in judgment is a logical way to approach this problem. Based on my previous paragraph it takes a much more enlightened approach to treating the problem. Health care systems in general are not friendly to people with severe mental illnesses. There are no specialty centers designed to cater to their needs like the high margin businesses get. Many of these health care organizations sponsor walks for mental illness and other programs like National Depression Screening day. But none of them say - if you have these symptoms we want to see you and treat you in a hospitable environment.
That attitude has to change to prevent the loss of innocent lives as the direct result of severe mental illness.
George Dawson, MD, DFAPA