More on homelessness and violence as a public health problem...

 

This is further analysis of the homelessness and violence issue.  As I look back on the title of the White House Executive Disorder as a guy with an interest in rhetoric – I cannot help to notice those elements.  What does the title “Ending Crime and Disorder on America’s Streets” suggest?  First off – a definitive solution.  In other words, if you follow what is in this order that solves the problem – period.  Secondly, it suggests that there is crime and disorder that is widely agreed upon.  The problem is widespread.  Third and implicitly – that the problem was ignored until this administration came along to solve it.   Fourth as elaborated in the subsequent text – if you magically eliminate the problems of mental illness, substance use, and homelessness – the problem is solved.  Let’s look at the reality versus this rhetoric.

The definitive solution: Per my previous analysis this order conflates “crime and disorder” with homelessness, mental illness, and substance use.  It further conflates homelessness with mental illness and substance use.  None of the other features of homelessness noted by the OECD namely youth, the elderly, families, and immigrant status are mentioned. None of the features noted by the United States Interagency Council on Homelessness namely non-white minority status, homeless workers that cannot afford housing, and the fact that housing first options are effective is mentioned. The only solutions presented are law enforcement and forced mental health and substance use treatment.

Crime and Disorder are widely agreed upon:  Looking at the real crime rates in the top 100 cities by population in the US shows some interesting trends.  Some cities with very low crime rates (like New York City) are often held up as examples of crime being rampant in the US.  Other considerably smaller cities with much higher crime rates are never mentioned.  This selective attention from the news media and politicians illustrates that the rampant crime problem is pretty much what somebody decides to say it is - whether there are facts to back it up or not.  That is especially true because current violent crime rates using the same measure are down by 75% since 1993. Crime in cities is like crime in the homeless populations – it is localized and most people have no contact with it. Apart from occasional mass protests – I am not aware of any consistent widespread disorder in American cities that needs to be addressed.  I don’t think it is too much to consider that hyperbole.

The problem was ignored until this administration came along:  More hyperbole considering the obvious examples of lawlessness exhibited at the highest levels of government by this administration.  The January 6^th Insurrection was not as result of homelessness, mental illness, or substance use.  Neither was the pardon of all of those who were convicted.  The strong message in this executive order is that the homeless, mentally ill, and substance using populations are not above the law and need both the criminal laws and civil commitment laws enforced against them.  That is hypocritical considering the numerous incidents in this administration giving the strong message that certain people with many resources are above the law.  The message that nobody in the US is above the law falls apart under that scrutiny and this administration has no higher moral ground on enforcing the law than any other.  Further – it can be argued that consistent changes since 1993 have resulted in a major drop in violent crime in the US and stating otherwise is not historically accurate.  

The magic elimination of the problems: At this point – I hope that I have illustrated why the title of the executive order is grossly exaggerated.  On that basis alone eliminating the states problems of homelessness, mental illness and substance use would be expected to have no impact.  In the previous post, I also examine why the proposed solutions will not put a dent in a non-system of care that has been rationed for profit by the same politicians charged with improving it.  Massive cuts in health care spending and research by this administration can only make things much worse rather than better.  President Trump seems to think that if he orders something and does not provide resources people with either scramble to provide them for free or law enforcement will solve the problem by mass incarceration.

That is the rhetoric associated with the current executive order, but what is the reality.  Rhetoric flows both ways and for a long-time advocates for the mentally ill took the extreme that there was no violence risk or that it was not any greater than violence from people with no mental illnesses.  As an acute care psychiatrist, one of the commonest reasons people are admitted to acute care units is violent or aggressive behavior. I have assessed and treated thousands of those admissions and know the underlying causes, but have no good data on what it looks like in the community.  As can be imagined that real world data is difficult to come by because it involves access to information in a number of databases and a major effort to synthesize all of it.

That brings me to a recent study that I think was very well done and could probably not be done in the US (1).  The study was registry based and done in Denmark by a group of researchers with expertise in this problem. The study cohort was 1,786,433 Danish residents between the ages of 15-42 living in Denmark at some point during the ten year between January 1, 2001 and December 31, 2021.  The primary outcome was any violent offense leading to conviction as noted in the table below: 

 The authors used data on multiple registries in Denmark including the Danish Civil Registration System, the Central Criminal Register, the Danish Homeless Register, the Psychiatric Central research Register, the National Patient Register, National Register of Drug Abusers, and the National Register on Treatment with Heroin and Methadone.  The substance use registers were available only for a 10-year period and were used as a quality check on the other data.  This methodology is also why this kind of study cannot be done in the US. In the US all this data is siloed with respective insurers, managed care companies, pharmacy benefit managers, and pharmacies.  It is considered proprietary data that is typically out of the reach of most researchers.  The privatization of healthcare in the US has made this kind of research nearly impossible to do.  I consider this to be a conflict of interest because the same healthcare companies that profit from rationing healthcare control all the data needed to assess whether they are doing an adequate job.  

The main aggregation of data is illustrated in the first two tables.  During the study period a total of 55,624 experienced no homelessness and were convicted of their first violent offense or 55,624/1,771,879 = 3.13% of the sample.   1,460/14,555 = 0.08% of the sample experienced homelessness and were convicted of their first violent offense.  Without considering cultural or geographic factors that means if you were walking through Denmark about 3.2% of the non-homeless population over the time course of this study has first time violent offenses.  At the same time, 0.08% of the total population over this same period are violent first-time offenders who have also experienced homelessness (1,460/1,771,879).  In other words, all things being equal you are 38 times more likely to encounter a violent offender who has not been homeless than one who has.  That hardly seems like an argument for ending “crime and disorder” by ending homelessness.   

A Bayesian (based on prior probabilities) or cultural argument could be made that the first violent offense rate in the homeless is three times higher in that population than the general population and therefore caution should be used in homeless encampments. An extreme argument could be made that this is a reason for removing these camps.  But the fact is 90% of those people would not have violent offenses and there are certainly subcultures across any major city where the prevalence of violent crime is as high if not higher.  Is it rational policy to excise those neighborhoods from any city?  The heat map below is a graphic county by county representation of annual average violent crime rates.  The gray areas are unreported.  There are clearly high crime areas in the absence of significant homeless populations.  The heatmap below plots the number of reported offenses per 100,000 of population.  Data is from the FBI’s Uniform Crime Reporting (UCR) Program and violent crime is defined as four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. 

The main data analysis in this project involves calculating incidence (defined as cases/10,000) and incidence rate ratios or IRR defined as the incidence in the homeless population/incidence in the non-homeless population.  The example below is from Supplementary Table 7a.  Association of homelessness and specific violent offences leading to conviction in men (10,623,486 person-years), 2001-2021. For the category “homicide and attempted homicide”.   

Raw Data	Incidence	Incidence Rate Ratio (IRR)
Homeless cohort: 36 cases/74,706 person-yrs x 10,000	4.8	4.8/0.4 = 12.2
Non-homeless cohort: 446 cases/11,144092 person-yrs x 10,000	0.4

 Calculating the IRRs across the board, the authors illustrate that the risk in the homeless cohort is generally many times greater for first violent offenses than in the non-homeless cohort. An additional substance use problem increases the IRRs further. Homelessness alone increased the risk of first violent offense by 5-6 times.  The degree of homelessness by the number of repeat contacts with homeless facilities increases the risk higher suggesting there is a duration factor (see supplementary table 4). In looking for explanation they consider that the best defense may be offense (violence perpetration explained as self-protection), adverse childhood experiences, the breakdown of social norms in homeless environments, and using drugs particularly methamphetamine as a coping strategy. 

There are also obvious environmental and ecological factors in homelessness that may be associated with violence.  Relative to any typical living environment there is limited privacy and security.  There are far fewer locked doors, security cameras, and alarm systems. Crowding is a problem that in general is associated with more conflict and violence.  Noise is an additional problem.  Poverty is a complicating factor that can make things worse if there are people getting retirement or disability checks at specified times or who are known to be carrying food or money. 

The neuropsychiatric and psychiatric disability aspects of homelessness were not explored to any degree in this paper.  Many homeless people come to the attention of law enforcement and end up in jail or transported to local emergency departments.  In both settings significant psychiatric disorders are noted and may or may not be treated. Severe psychiatric disorders can lead to many impairments associated with violence including delusional thoughts, impaired insight and judgement, and overt agitation and aggression. All of that behavior is worsened by alcohol and substance use which are also independent risk factors.   

The authors conclude for all the problems noted in their paper that homelessness is a significant public health problem that needs to be addressed.  They have made that assessment in a Scandinavian country with less income disparity and a more robust safety and medical network than the US.  In the US we have no definitive research – only a political statement in the form of an Executive Order that mischaracterizes the problem.  That Order also has clear parallels with previous action by the administration against immigrants because of their purportedly higher crimes rates, rates of mental illnesses, and substance use.  In that case it was shown that native born use citizens have higher rates of violent crimes, property crimes, and drug crimes than either legal immigrants or native born citizens (2).

The Executive Order in question has no scientific, rational, or moral basis.  Further – the party that supports it is long on a states’ rights approach that allows politicians to not provide needed medical and housing assistance to people in their own states.  At a national level – they have severely cut budgets that will result in the closure of hundreds of facilities (hospitals and substance use treatment facilities).  The idea that a public health problem can be addressed by removing resources and adding more law enforcement is pure fantasy - or politics. 

George Dawson, MD, DFAPA

References:

1:  Nilsson SF, Laursen TM, Andersen LH, Nordentoft M, Fazel S. Homelessness, psychiatric disorders, and violence in Denmark: a population-based cohort study. Lancet Public Health. 2024 Jun;9(6):e376-e385. doi: 10.1016/S2468-2667(24)00096-3. PMID: 38821684.

2:  Light MT, He J, Robey JP. Comparing crime rates between undocumented immigrants, legal immigrants, and native-born US citizens in Texas. Proc Natl Acad Sci U S A. 2020 Dec 22;117(51):32340-32347. doi: 10.1073/pnas.2014704117. Epub 2020 Dec 7. PMID: 33288713; PMCID: PMC7768760.

Graphics Credit:

Both graphics at the top of the post are from the Department of Justice Bureau of Justice Statistics dashboard at:  https://ncvs.bjs.ojp.gov/multi-year-trends/crimeType

The heatmap USA graphic was produced by me using the Datawrapper interface and FBI data. 

The Autocratic Approach to Homelessness

 

President Trump issued another poorly thought out Executive Order yesterday entitled ENDING CRIME AND DISORDER ON AMERICA’S STREETS. It contains many myths about homelessness as well as an unrealistic approach.  As a psychiatrist who focused on this issue in the population I treated for decades, I consider myself qualified to comment on this executive order and why it will fail.  Many of the central points have already been covered on this blog and I will connect to them when relevant.  Here is a section by section look.

“The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both.  Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes”

There is the common conflation with homelessness and drug addiction and mental illness.  While these conditions are overrepresented in homeless populations – the idea that the overwhelming majority of the homeless are drug addicted or mentally ill is a myth per the government agency that directly monitors the problem (3). According to that agency the majority of the homeless do not have mental health or substance use problems and the majority of people with those problems are not homeless.

Further violent crime rates are about ¼ of what they were in 1993.  It follows if homelessness is higher in the context of dropping violent crime rates it is not likely a causative factor.

The order conflates mental illness with violent crime and suggests that it puts the public at risk for violent crime.  It suggests that the solution is to get them off the street and into institutions to protect the public.  Based on the lack of connection to crime that is a doubtful solution.  Further there has been a decades long initiative by federal and state governments to shut down long term bed capacity.  The US currently ranks 30 of 35 OECD countries in terms of psychiatric bed capacity.  That current minimalist bed capacity does not meet suggested standards to keep emergency department waits at an acceptable range and there is no evidence that the trend is changing.

The United States already uses jails as the largest psychiatric institutions.  Roughly 70,000 of the 350,000 incarcerated have a significant mental illness and receive various levels of inadequate care.  So where exactly are the “long-term institutional settings for humane treatment” supposed to come from? 

“seek, in appropriate cases, the reversal of Federal or State judicial precedents and the termination of consent decrees that impede the United States’ policy of encouraging civil commitment of individuals with mental illness who pose risks to themselves or the public or are living on the streets and cannot care for themselves in appropriate facilities for appropriate periods of time.”

I have written about civil commitment may times on this blog.  I have personally initiated and testified in hundreds if not thousands of civil commitment, guardianship, and conservatorship proceedings over a period of 35 years in the states of Wisconsin and Minnesota.  As far as I know there is no US policy to encourage commitment.  All civil commitment comes down to a county decision by a judge in that county.  Further – that commitment decision is affected by real world circumstances on the ground at the time including the financial state of the county, the number of commitments done per year, the ideological biases of the attorneys and judges, and the known outcomes of the court proceedings.  As an example of the latter, if a judge releases a patient from a hospital without commitment and that person kills or injures someone or themselves – it is less likely that court will take a similar risk in the future.

Inability to care for self is the third standard for commitment after danger to self (aggression directed at self as self-injurious behavior or suicidal behavior) and danger to others (outward directed violence and aggression).  It is the least likely standard to result in civil commitment and the most likely to result in a patient being discharged back into a homeless situation.

On a social media forum, a link was posted to me about 18 U.S. Code § 4248 Civil commitment of a sexually dangerous person. Although it was not explained it seemed to be a rebuttal to my statement that all commitments are local.  Sexually dangerous person is not a psychiatric diagnosis and it is not likely to be a significant factor in homelessness.  Additionally, the federal government does not track this diagnosis in terms of the total number of people incarcerated because of it. 

“provide assistance to State and local governments, through technical guidance, grants, or other legally available means, for the identification, adoption, and implementation of maximally flexible civil commitment, institutional treatment, and “step-down” treatment standards that allow for the appropriate commitment and treatment of individuals with mental illness who pose a danger to others or are living on the streets and cannot care for themselves.”    

This is an ironic statement considering the massive cuts to Medicaid and long history of federal cuts to any programs that fund long term care of the mentally ill.  Medicaid is a major funder of both health care for homeless populations and people with serious and persistent mental illness.  The idea that there will be funds available to massively convert the current rationed, stripped down services to a cornucopia of outpatient, inpatient, and residential services is more than a little unrealistic. 

A realistic goal would be to fund Assertive Community Treatment (ACT) and Forensic Assertive Community Treatment (FACT) teams across every county in the US. This approach to supportive treatment has been known since 1975 – but rarely encountered due to rationing at various levels.  The goal of this treatment is to support people with severe mental illnesses living housed and independently in the community and assisting them every step of the way with access to medical and psychiatric care.  There is no more humane approach. 

“Fighting Vagrancy on America’s Streets.  (a)  The Attorney General, the Secretary of Health and Human Services, the Secretary of Housing and Urban Development, and the Secretary of Transportation shall take immediate steps to assess their discretionary grant programs and determine whether priority for those grants may be given to grantees in States and municipalities that actively meet the below criteria, to the maximum extent permitted by law: (i) enforce prohibitions on open illicit drug use; (ii)  enforce prohibitions on urban camping and loitering; (iii)  enforce prohibitions on urban squatting”

Are there grants for enforcing existing laws?  With the draconian cuts already made by this administration exactly how much is available to enforce existing laws and would it be used with more effect in other areas. Trump has already cut $27 billion in funding for affordable housing and that has been estimated to affect 23 million households.  Homelessness assisted grants have been cut by $532 million or 12%.  These proposals have been described as “devastating” by housing advocates.  That is hardly a serious effort to address homelessness.

Instead, this appears to be an attempt to villainize the homeless and blame them for their predicament.  The wording in this section about monitoring unregistered sex offenders and suggesting that all arrested homeless are screened as sex offenders seems like the approach taken with undocumented immigrants.  Suggest a group of people are guilty until proven innocent and further suggest that law enforcement can make any problem go away.

“..ensure that discretionary grants issued by the Substance Abuse and Mental Health Services Administration for substance use disorder prevention, treatment, and recovery fund evidence-based programs and do not fund programs that fail to achieve adequate outcomes, including so-called “harm reduction” or “safe consumption” efforts that only facilitate illegal drug use and its attendant harm”

This is an overtly dangerous section of the order.  What is the administration calling “harm reduction”, “safe consumption”, and “illegal drug use”.  Would medications for opioid use disorder treatment (MOUD) fall under this category?  Would clinics prescribing methadone maintenance and buprenorphine maintenance be under even tighter scrutiny that they currently are? The wording suggests a level of accountability to an administration that clearly has none itself.     

This executive order is a good if not perfect example of an authoritarian approach to the problem.  Experts in the areas of homelessness, civil commitment, mental illness, and substance use have not been consulted.  Rather than expertise we see and overriding theme that law enforcement will be used to crackdown on the homeless. It suggests that there are systems of care that do not exist and cannot exist due to previous rationing and the more draconian measures from this administration.  In all of the rhetoric about the homeless problem in the US, the average American is led to be believe that this is a crisis unique to this country.  Real data (1) suggests otherwise.  The US has had a roughly 0.2% of the population homeless over the past 13 years and this is comparable to many OECD countries in Europe. Further – this is higher than the social democracies in Scandinavian countries and homelessness does correlate with economic disparity – another factor poorly addressed by this administration.

For all the above reasons – I don’t see any reason why this order will have much of an effect on the homelessness problem.  It probably will present many photo-ops of law enforcement disrupting homeless camps and arresting people.  The unfortunate outcome here is that there is ample opportunity for doing good across many problems – but apparently little interest in that.      

George Dawson, MD, DFAPA

 

References:

1:  OECD - Social Policy Division - Directorate of Employment, Labour and Social Affairs OECD Affordable Housing Database, 2023. – http://oe.cd/ahd

2:  ASAM Statement on Executive Order to Increase the Use of Involuntary Civil Commitment of Unhoused People with SUD.  https://downloads.asam.org/sitefinity-production-blobs/docs/default-source/advocacy/press-releases/asam-statement-exec-order-final_7-25-25.pdf

3:  United States Interagency Council on Homelessness.  Data and Trends.  (accessed 07/25/2025):  https://usich.gov/guidance-reports-data/data-trends

Gun Extremism Not Mental Illness

With the most recent school shooting in Uvalde, Texas the familiar repetition persists. There is public outcry to do something.  Many commentators make the comparison to the Sandy Hook Elementary School shooting a decade ago that produced public outcry but no effective response.  In fact, since Sandy Hook there have been 266 additional incidents of school shootings. Member of the pro-gun party have already spoken out and it is clear that their position of supporting gun ownership at all costs is essentially unchanged. That includes access to military grade weapons and high capacity weapons, with minimum and in many cases no regulations.  We keep hearing about all of the polls of “responsible gun owners” who support more reasonable regulation of firearms and more reasonable firearms – but they are generally drowned out by the aggressive tactics of the gun extremism faction.

Before going any further, I will provide my assessment of gun extremism. It is based on my personal observation about how guns have essentially been radicalized over the past 50 years.  When I was in middle school in the early 1960s living in a small town in northern Wisconsin, gun ownership by adults was common.  That gun ownership was focused on hunting seasons – primarily water fowl and deer hunting.  Middle schoolers took the NRA Hunter safety course in order to be able to handle firearms and hunt. Gun safety was taught primarily with the use of lectures and pamphlets. I can still recall some of the passages in the pamphlet with captions like “alcohol and gunpowder don’t mix” and a page with suggestions about what a safe target was. There was no explanation about why a crow is a safe target. The practical side of the training was with BB guns and then a .22 caliber rifle. Even though the common deer hunting rifles at the time were larger calibers like 30.06 there was no training with those guns. There was a competition series based on accuracy and most people in the class were eventually awarded Distinguished Marksman if they practiced and submitted enough targets. Memberships in the NRA was required and for $18.00/year – you got the National Rifleman magazine sent to your home every month.  The centerfold of that magazine was an array of inexpensive rifles, often “sporterized” surplus rifles from WWII.  They typically held 5 cartridges and could be used for hunting.

But like most kids taking the course. I never went hunting or acquired any additional firearms. My family was not a family of hunters and we did not have a typical cabin in the woods where everybody gathered during hunting season. The course was taught by an instructor who had been doing it for years. His overriding message was that guns had to be taken very seriously. In fact, one of the prerequisites for taking the course was that students had to vow never to “play” at guns again. That involved never pointing a gun at a person, even accidentally on the gun range. He described a number of incidents where people were accidentally shot by relatives to emphasize that point.  We all took it very seriously and there were no close calls in the class. There was no emphasis on “gun rights”, the need for self-protection, or the Second Amendment.  Handguns were not discussed because they were not used for hunting and you had to be 21 years of age to own one.  Gun rights was not an issue in any political campaign.

I don’t want to create the impression that the firearm situation was idyllic during my childhood.  Two classmates died by firearm suicide and one was killed in a hunting accident. I knew all three of them.

That is the backdrop against which gun extremism has evolved and it contains several elements.  First of all, politics. There are obvious contradictions when politicians say it is not a time for politics in the wake of the next mass shooting after they have passed laws that allow people to avoid background checks, carry military grade weapons with high capacity magazines, allow large purchased of ammunition, carry guns without permits, carry guns openly, and not have to “stand down” in confrontations – even when their opponent is not armed. That is all politics and if you are trying to deal with the aftermath pf a shooting – you are dealing with the aftermath of that politics especially if your politics facilitated that.

At a broader political level what has to be considered is how most polls show that Americans favor “common sense” gun laws – but the gun extremists continue to have their way.  In the decade following the Sandy Hook Elementary School Shooting, nothing has been done at the federal level.  Even the most basic fix of eliminating loopholes in the background checks laws has been avoided. Even when a law has been passed in the House (HR8) that makes a few changes – to the background check law there is practically no chance that it will pass in the Senate, even though the Republicans in the Senate represent 44 million fewer people. This situation has been referred to as the tyranny of the minority or a highly motivated smaller group of people dictating in this case the laws of the nation. That tyranny is even more complicated by Republican appointed Supreme Court making decisions on both gun laws and probably abortion consistent with what the minority party wants. Demographically that comes down to white, rural, less college educated voters making the laws that in the case of guns carry out an extremist agenda.

What do I mean about gun extremism?  Basically, all of the interventions over the past two generations that have allowed lax background checks and registration, lowered minimum age to purchase handguns and high-capacity military grade weapons, the increased carrying of weapons (both concealed and open) in many cases without permits, and stand your ground laws that say there is no obligation to retreat in a confrontation – even in the case where one of the parties is unarmed. There is an associated lack of gun safety and that has clearly been a factor in accidental death of adolescents and teenagers, suicides, carrying firearms into schools, and even arming mass shooters. That lack of basic gun safety is a likely contributing factor to firearm deaths being the leading cause of death in children and adolescents (1). And finally, there is a constant stream of pro-gun rhetoric that routinely distorts those facts about gun availability and usefulness.   There is good evidence that this gun extremism began in the 1970 and 1980s and has been unabated since then. 

Since the school shooting in Uvalde, gun extremists jumped to the defense of permissive to non-existent gun laws.  They offered alternate explanations for the school shooting. Governor Abbot of Texas suggested the shooter had a “mental health challenge” since anyone who shoots someone does.  That is clearly not true.  Recent evidence from high profile media cases where a homicide occurred during a fight over a firearm are cases in point. The vast majority of homicides by firearms does not involve mental illness of any kind.  In carefully selected samples – probably biased because they are selected based on forensic criteria – only 10-25% of the sample is described as having a mental illness diagnosis (2,3).

If mental illness is not an explanation for a mass shooter or mass school shooter behavior what is more likely? Given the fact that this behavior has been going on for at least 2-3 generations at this point it likely represents a subcultural phenomenon.  Subcultures are cultural groups within a larger culture that hold beliefs at variance with the larger culture.  American culture in general is steeped in violence and crime largely through entertainment and news media outlets. There are well known violent subcultures in the United States including organized crime, gangs, domestic terrorists, and various hate groups that perpetrate violence against specific people.  These other crimes are frequently seen in the news. It is easy to ascribe some of the behaviors of these groups to individual psychopathology. You can see these efforts in many true crime television shows. Crime dramas are likely to emphasize profiling as a way that the crimes are solved. Practically all of these cases lack features that are typically seen with individual psychopathology. Instead, we hear about a profile of social factors and circumstances that are cited as motivations for the violence and aggression. Those factors are also not uniform explanations for all of the violence and aggression seen across all categories and typically are collected long after the commission of the crime and by people who seemingly have unlimited time to do that task.  A good example was a forensic psychiatrist giving a profile of the Uvalde, Texas shooter describing him as a marginalized loner who had been bullied in the past and pointing out that many shooters have this profile but only a small number of people with the profile ever engage in firearm violence.

I think it is highly likely that the mass shooter and mass school shooter have become a meme that is passed in this subculture of primarily men or boys who feel that they have been victimized and they begin to see this as acceptable payback for their perceived victimization.  It is subculturally acceptable even though it produces outrage and is completely unacceptable in the larger culture and that is why the questions about “motivation” always go unanswered. Firearms and secrecy are obviously a big part of this meme and the way it is typically enacted. Gun extremism makes it much easier to enact.  In analyzing these situations, the usual starting point is where the individual perpetrator has gone wrong.  From the perspective of an alienated subculture these people and those who identify with them consider what they are doing to be correct for various reasons and more importantly widely accepted in that subculture (7). There are many reports that these subcultures are reinforced and more accessible through social media sites where manifestos, threats, time lines, and in some cases photos and recordings of the violence are posted.

In addition to the subcultural effects, important developmental effects are seldom considered.  In the past 20 years development and brain maturation has been the object of increasing neuroscience scrutiny and in addition to structural brain changes – correlations with culture, socioeconomic class, and social network/peer environment have also been investigated. In an excellent review of this topic Foulkes and Blakemore (3) point out that averaging of large samples has been used so far to get to statistical significance – but they discuss the benefits of looking beyond the averages at the total variation of normal brain development. They illustrate significant variation in the brain volume of subcortical grey matter structures over the course of ages 7 to 23.3.  I think it is generally accepted that brain maturation by these indices is not complete until mid-20s for most people, but the graphs also suggest that there may be quite a lot of variation even at that point. Beyond that they discuss several aspects of cognition and social cognition that develop in the transition from adolescence to adulthood including reasoning, risk perception, risk taking, the varied effects of social exclusion, and the use of others’ perceptions in decision making. They demonstrate what appear to be specific cultural, socioeconomic and peer effects and discuss the neuroscience correlates where they are known.  An analysis of mass shooters at this level of detail may provide better answers in terms of prevention.

What can be done to interrupt this cycle of school and mass shooter violence? Plenty can be done.  A basic time-tested public health intervention is to remove the means for perpetrating the violence and injury. This has worked in the case of suicide prevention by specific methods as well as preventing gun violence.  In a previous post, I pointed out that Tombstone had an ordinance in 1881 forbidding the carrying of deadly weapons within the city. This was a time commonly referred to as the Wild West (1865-1895).  This period is typically idealized by movies like Gunfight at the OK Corral. That was a 30 second gunfight between three Earp brothers and Doc Holiday and 5 cowboys that occurred in 1881.  One of the precipitants of that gunfight was violation of the city ordinance about carrying deadly weapons. Contrary to most accounts – both Wyatt Earp and Doc Holliday were arrested and charged with murder.  They were released after a three-day probable cause hearing. Even during America’s Wild West days, people knew that removing deadly weapons would lead to less violence.

In many ways American streets are less protected from gun violence than they were in Tombstone in 1881.  All 50 states allow people to carry handguns.  Twenty-four states require no permit to carry a firearm.  Federal law requires a handgun holder to be 18 years of age and 21 years of age to purchase a handgun. There are currently 21 million concealed carry permit holders in the US.   There is no minimum age for possessing a rifle or a shotgun.  There was a ten-year ban on assault rifles at the federal level from 1994-2004.  The ban grandfathered in all assault weapons before 1994 and there were also many other qualifications that decreased the overall impact of the bill.  Despite these limitations the ban may have decreased the frequency of mass shootings when it was in effect. (6).  Considering that there are 258.3 million Americans over the age of 18, the manufacture and importation of firearms is brisk to say the least as well as the concentration of handguns. (Click to expand the graphic)

Concluding this post, the most clearcut path to reducing gun violence of all kinds is to improve gun regulation.  The evidence is clearly there in terms of reductions in suicides, homicides and accidental deaths. The idea that gun regulation has no effect on gun deaths or that the Second Amendment is a sacred clause that mandates gun extremism is pure misinformation.  Even as I typed this post today, the Prime Minister of Canada announced stricter handgun regulations in the interest of safety.  There is absolutely no reason that high-capacity military grade weapons are necessary in society and there are many groups of responsible gun owners who openly acknowledge that fact.

Gun extremists’ additional rhetoric about how mental illness is the real problem rather than gun access is also incorrect.  Mental illness is not defined by homicide, but by constellations of findings and associated disability. There are general developmental, socioeconomic, cultural and subcultural trends associated with violence and aggression – but none are precise enough to allow for predictions of who will likely perpetrate mass homicide.  It will take continued large longitudinal studies to examine all of these factors close enough to produce an effective population wide intervention. One of my suggestions since I started writing this blog is explicit homicide prevention.  You won’t be able to find that is a book or research paper – it is based on my experience in acute care psychiatry. In that context, I encountered many people with acute homicidal thinking who ended up on my inpatient unit.  Irrespective of any psychiatric diagnosis, we were able to help them resolve that crisis.  Before the rationed mental health system takes on another significant task, it has to be adequately funded.  And beyond the mental health system – social services are required to address many of the factors associated with violence and aggression.

George Dawson, MD, DFAPA

 

 

References:

 

1:  Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022 May 19;386(20):1955-1956. doi: 10.1056/NEJMc2201761. Epub 2022 Apr 20. PMID: 35443104.

2:  Stone MH. Mass murder, mental illness, and men. Violence and Gender. 2015 Mar 1;2(1): 51-86.

3:  Hall RCW, Friedman SH, Sorrentino R, Lapchenko M, Marcus A, Ellis R. The myth of school shooters and psychotropic medications. Behav Sci Law. 2019 Sep;37(5):540-558. doi: 10.1002/bsl.2429. Epub 2019 Sep 12. PMID: 31513302.

4:  Firearms Commerce Report in the United States: Accessed 05.29.2022:  https://www.atf.gov/firearms/docs/report/2021-firearms-commerce-report/download

5:  Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nature Neuroscience. 2018 Mar;21(3):315-23.

6:   DiMaggio C, Avraham J, Berry C, Bukur M, Feldman J, Klein M, Shah N, Tandon M, Frangos S. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019 Jan;86(1):11-19. doi: 10.1097/TA.0000000000002060. PMID: 30188421.

7: Simon Cottee (2021) Incel (E)motives: Resentment, Shame and Revenge, Studies in Conflict & Terrorism, 44:2, 93-114, DOI: 10.1080/1057610X.2020.1822589

8: Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450. PMID: 29874513; PMCID: PMC5993413

9:  Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med. 1991 Dec 5;325(23):1615-20. doi: 10.1056/NEJM199112053252305. PMID: 1669841.

Graphics Credit:

Photo by Ed Colon, MD

.

Unsane - It Sure Is

I watch TV while working out - usually Amazon, Netflix, or HBO.  It is all on the Amazon Fire interface.  Today I saw Unsane advertised and despite my aversion to the ongoing One Flew Over The Cuckoo's Nest portrayals of psychiatry - I decided to watch it on the strength of Claire Foy as the leading actor.  Could the actor save the predictable portrayal?  I was skeptical but forged ahead anyway.  The film was a Steven Soderbergh film and I later learned that he shot it on an iPhone 7 Plus.

In the introductory section we learn that the main character Sawyer Valentini (Claire Foy) has moved from Boston to Pennsylvania.  She is a financial analyst in a bank and does financial analysis and reports.  We see her in a contentious phone call with a client in the opening scene.  He coworker expresses some concern and another coworker looks and rolls his eyes.  She meets with her boss and the conversation has overtones of sexual harassment.  Later there is a computer dating scenario where she ends up at her apartment with the date and starts to react like he is assaulting her.  She ends up taking some medication out of a medicine cabinet.  Later we see her Google "Support groups for stalking victims".  She drives out to a psychiatric facility for an initial appointment and that is where the drama begins.  I am going to list the problems point-by-point.

1.  She meets with the intake staff person and describes her concerns about being stalked as well as the residual "neurosis" (her term) of being in an new city and having a tendency to see her stalker everywhere. At one point she alludes to feeling depressed at times and thinking about whether there is any point in going on.  The staff person asks her if she has ever had suicidal ideation and she goes into a detailed discussion of Therapeutic Index and how she would be experimenting with that if she was going to attempt suicide (translation - overdosing).  The therapist leaves and has her complete routine paperwork.

2.  She completes the "routine paperwork" that is also described as "boilerplate" and learns that in doing so she has voluntarily committed herself for 24 hours.  In other words she was tricked into being hospitalized and that trick was apparently irreversible.

3.  While voicing strong objections she is asked by a nurse to disrobe, be searched, and change into hospital clothing.  The nurse's tone is threatening and she complies.

4.  She is taken to a psychiatric ward of about 10 people.  It is a combination of men and women and they are all locked into a room with no supervision all night long.  She is threatened by the other patients, gets into a physical confrontation with two of them and is eventually sedated in the same 10 bed ward in full view of the other patients with no safety monitoring.  She is subsequently restrained in the same manner in full view of all of the male and female patients and not protected.

5.  She finally sees the psychiatrist the next day.  He does the world's most cursory evaluation - largely reading chart notes in between phone calls.  It lasts about 5 minutes. She makes a compelling argument to be released. He informs her that she needs to stay another 7 days based on her assaults on another patient and staff. At no point in the interview does he ask her any direct questions about depression, suicidal thinking, or the details of the incidents of aggression.

6.  She befriends another patient who has smuggled in a cell phone and convinces him to let her use it.  We learn that the patient with the cell phone is really an undercover reporter investigating the hospital.  She calls her mother who comes to the facility and demands that they release Sawyer. The psychiatrist refers her to an administrator. The administrator gives her an irrelevant sales pitch on all of the good work that is done there and passive-aggressively acknowledges that it is her mother's prerogative to contact an attorney in order to get her daughter freed. 

From a creative and artistic standpoint - it was apparent to me from the outset that Sawyer's reality testing was not impaired.  Hypervigilance is not psychosis. So when she recognized her stalker on the nursing staff passing out medications it was not a surprise.

Spoiler alert right here - if you really wanted to be surprised see another film.  If you don't want to know the ending to this predictable one stop reading right here.

A series of implausible scenes unfold that depend both on the stalker as nursing staff and Sawyer's transformation to homicidality bent on killing the stalker/staff person. The stalker gives Sawyer a "megadose" of methylphenidate a stimulant a - controlled substance. Special effects at that moment seem to indicate she has some kind of psychedelic experience from the drug.  The stalker is warned by the nurse that he has to be more cautious of "we could lose our jobs." The stalker ends up killing two patients and torturing one of them with cardioversion paddles - right out of the old action series 24.  Some reviews of the film think this was an electroconvulsive therapy device - more proof that old Hollywood stereotypes about psychiatry don't ever go away.

The stalker traps Sawyer in an isolated seclusion room and in an excruciatingly long exchange, she tricks him and ends up stabbing him in the neck.  Like most films of this genre, he survives and recaptures her outside of the hospital and kidnaps her.  During the kidnap sequence we learn that he killed her mother and the hospital staff person who he has been impersonating.  Sawyer gets another chance to kill him and apparently does in the most gruesome manner  possible.

We flash forward 6 months and see Sawyer eating at a restaurant with a friend.  She looks out into the room and see the profile of a man who appears to be the stalker. She hears him saying things the stalker would say.  She grabs a steak knife and approaches him from behind.............. 

All of the points above are what a psychiatrist would consider to be highly problematic.  By that I mean they would all merit investigation by the appropriate authorities,  legal penalties, and disciplinary action against licensed health professionals. If I was prone to discuss malpractice - the incidents could also lead to that type of civil litigation.  Anyone experiencing a fraction of what Sawyer experienced in this psychiatric hospital should contact the responsible officials or an attorney about what could be done.  In my experience health officials are quite eager to do exhaustive investigations of these complaints both in the case of licensed health care professionals and institutions.  In the film it took a dead body on the premises to get any action from the police.  In real life, a call from Sawyer's mother would be enough to get action in any state that I have practiced in.

The commitment law in Pennsylvania did not seem to be adequately portrayed.  The statute says that any interested party can initiate commitment based on an imminent dangerousness standard.  That was certainly not present in the film.  At no point was Sawyer suicidal and the brief scraps that she was in would not have required physical restraint or forced medication in any setting that I ever worked in.  The maximum period of confinement in the state of Pennsylvania without a court order is 5 days and in this case Sawyer was detained 1 day initially and then another week.  That is a violation of the law.  In the state where I work, the longest period of time that a person can be help without a court order signed by a judge is 72 hours. In cases where it appeared a high risk person would be released, attorneys have always advised me that the person needs to be released according to the law - no matter what the possible adverse outcome.   

There are some continuity problems with the film.  How is it that her stalker would happen to know that she would be inappropriately admitted to a psychiatric hospital and be able to identify and kill a prospective employee in order to work there?  Wouldn't it be much easier to get close to her in real life rather than inside an institution?  And what about Sawyer?  She has insight into the fact that she is hypervigilant and needs to avoid the stalker. Is there a better film just exploring that theme and what happens to people in these situations plus or minus the real stalker?

In the past, my standard for films has been recognizing that they are entertainment and not really about psychiatry.  This film fails at both levels.  I suppose at some point all actors might be interested in doing a horror movie - but the psychiatric hospital as horror genre is as tiresome as it gets.  How many times can you show a gun toting Dr. Sam Loomis battling evil incarnate as a former asylum patient?   How many times can you show hospital staff that are sadistic, abusive, or grossly incompetent? Apparently there is no limit. The idea that a film like this should just be brushed off as fiction minimizes the fact that One Flew Over the Cuckoo's Nest seems to have stigmatized the most effective treatment in psychiatry for two generations.

The psychiatric hospital that Soderberg is reaching for is the spooky old asylum of the late 19th and early 20th century.  What made that asylum spooky was that people were freaked out about severe mental illness.  They did not know what it was and they did not have a name for the symptoms or disorders. They knew that some of their relatives went to these places and never came back. They lived the rest of their lives there.  They were warehoused and never got better.  That was the real scary part.  Most if not all of those places are shut down and have been for a long time.

The real horror story these days is trying to get into a mental hospital when it is needed.  Contrary to Sawyer's experience in the film, nobody is trying to recruit people into hospitals.  They are rationing the beds and turning people away.  All of the beds are typically full.  The emergency department psychiatric staff will do whatever they can to discharge.  A lot of people end up waiting a day or two and just give up and go home.  In some cases if people with mental problems are brought in by the police, the choice is admission to the hospital or jail.  Jail is the most likely outcome.

Jail is the real scary place these days and it has been for at least 20 years.  That is where a diverted patient needs to worry about incompetent or nonexistent treatment, physical assaults, and encounters with the evil people that Hollywood typically, uses to populate psychiatric hospitals.

The real evil out there today - is the system of non care that exists.  That is what people feared - developing a mental illness for which there was no treatment and being sent away for a lifetime. 

That is what Hollywood needs to understand.

That and a ton about modern psychiatric treatment.


George Dawson,  MD, DFAPA





Graphic Credit:  Inked Pixels.  A ghostly figure casts a long shadow down the middle of a dimly lit passage of a dilapidated mental asylum.  Downloaded from Shutterstock per their standard licensing agreement on 11/12/2018.

The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.

 

Stigma and Addiction

The basic position that I take on this blog is that stigma is an overblown concept.  Certainly no professional should ever be in the position of treating a person with a mental illness or addiction in any way that conforms to stereotypes.  I have been in many situations where that occurred during my training.  In those days a lot of alcoholics were admitted to medicine services because they needed detoxification by people who knew what they were doing .  They also needed close monitoring by nursing staff.  That did not mean that they were treated like all of the other medical patients.  There was usually a sense of hopelessness on the part of the house staff who could see several of these men admitted repeatedly during a 3 month rotation.  Men with hepatic encephalopathy, recurrent pancreatitis, alcoholic hepatitis, and upper GI bleeding from varices.  During one of the rotations, I encountered the term "incorrigible alcoholic" right there in the PGY3 note countersigning my intern note.  I had never seen a term in a medical chart like that before.  I had to look it up to make sure I knew what it meant and sure enough the first definition was bad beyond reform.

These reactions extended far beyond alcohol use problems.  Young addicts using various street and prescriptions drugs would present confused and aggressive.  At times paranoia and aggressive behavior were also prominent problems.  Nursing staff and house staff were frequently injured and in these emotionally charged encounters, the word "dirtball" was frequently uttered.  It was clear that at least some professionals viewed the confusion or aggressive behavior as volitional on the part of the patient and classified them as people who were intentionally trying to injure the staff.  The only way that you can make it in psychiatry is if you realize that aggressive behavior is a component of the illness.  It needs to be contained, but it does not need to be seen as a conscious "choice" of the patient involved.  Neither does their hygiene, cognitive problems, general lack of self care, inability to follow through with discharge instructions or stay away from drugs or alcohol.  That is not "excusing" them because you don't think they have a legitimate illness or can't prove that their behavior  is biologically based.  It is treating them like a human being and recognizing that you might be bringing too much emotion into the equation yourself.  There is nobody who needs a doctor with a cool head more than an addict or an alcoholic.

Those experiences led me to pay close attention to an opinion piece in JAMA about stigma and addiction.  One of the authors was from the White House Office of National Dug Control Policy.  The other was from Harvard T.H. Chan School of Public Health.  I looked even closer when it became apparent that their arguments were focused on the stigma arguments that were used for mental illness.  The authors use mental illness and the early days of the HIV epidemic as examples of how the language used to describe these patients implied moral deficiencies and led to discrimination.  They go on to cite studies of how differences in words can affect how treatment decision made by professionals can be similarly biased depending  on how loaded the stigmatizing term is.  They describe how the fear of stigma keeps people out of treatment.  Finally they outline the government's approach to changing the language about addiction and how that will help.  The White House Office of National Drug Control Policy is releasing Changing the Language of Addiction for guidance on these issues.  Common examples include changing "substance abuser" or person with a drug "habit" to a "person with a substance use disorder."  Near the end of the essay they acknowledge language changes are not enough.

Their initiative will not have any impact for the same the same reason that the anti-stigma campaigns for mental illness don't have any impact and here is why:


1.  The real bias occurs at the level of the insurance industry -  Coverage for addictive disorders varies widely and the only unifying theme seems to be rationing of treatment resources.  That rationing has been going on for 30 years and has led to inadequate treatment capacity.  The best time to provide treatment is right at the point that the affected person needs help.  Setting them up for an appointment 2 - 4 weeks later does not make any sense and can be dangerous if they are using dangerous levels of addictive compounds.  It makes absolutely no sense at all to deny care to a person who is using dangerous levels of addictive drugs simply because they have not yet tried outpatient treatment.

2.  Clinicians don't resist evidence based treatment  - there is nobody around to deliver it -  It is well known that psychiatric and addiction services are understaffed and have been for decades and the situation will probably get worse.  The number of addiction psychiatrists and addictionologists is even lower on population based metrics.  Policy makers seem to have the idea that primary care physicians will start actively treating addiction because treatment is currently described as being contained in a medication.  A recent study showed the underutilization of buprenorphine by these physicians.  They expressed in that same survey that they wished that they had someone who they could refer their patient to.  It is very difficult to go from prescribing opioids for a pain diagnosis to diagnosing and treating addiction in the  same setting.  It is also very difficult to provide treatment without adequate cross coverage.  There need to be adequate numbers of clinicians in any primary care clinic who are interested and competent to treat addictions.  In the case of buprenorphine maintenance. they need to be licensed to prescribe it.  Even then they need referrals sources to physicians who specialize in treating addictions and have some access to more resources.

3.  Community factors are prominent -  Insurance companies still discriminate against anyone with a substance use disorder.  I had a recent conversation with a person who needed some form of treatment. but was concerned about what would happen once the medical records got out to a long term insurance carrier.  Previous experience suggests that company takes 5 years to reconsider any application from a person with an alcohol or drug use disorder.  He  declined any form of treatment that would become part of the medical record that could be accessed by the insurance carrier.

4.  The Mental Health Parity and Addiction Equity Act of 2008 is a bust - time to stop pretending that it means much -    This is the highly acclaimed parity act started by Senators Paul Wellstone and Pete Domenici.  Discrimination and unfair treatment are widespread and contrary to what was expected there has been no boom in treatment for addictions.  Addiction and mental illnesses are still subjected to the same rationing policies and lack of infrastructure as they were before this act.

5.  It all starts and ends with the government -  This essay has that familiar ring to it:  "We are from the government and we are here to help you."  Let's not forget who started the system of discrimination against people with mental illness and addiction in the first place - the government at all levels.  The government invented the managed care industry as its surrogate in the first place.  If they were really interested in solving the problem - they could use the same top down approach that they used to create it in the first place.  They could provide medical detoxification in hospitals and coordinate the development of those guidelines.  They could provide access to Addiction Psychiatrists and  Addiction medicine practitioners.  They could open up bed capacity for residential and sober house care.  They could fund clinics where medication assisted treatments for opioid use and alcohol use are conducted.  They could fund addiction centers of excellence.  They could fund research on treatment for court ordered offenders and whether it is effective.  This is all evidence-based care, but the article suggests that primary care physicians who are currently overworked by government mismanagement are going to suddenly see hundreds or thousands of new patients with addictions.  Suggesting that this is a language based problem put the blames directly on clinicians.  It is clear to me that there are no psychiatrists blaming people for mental illness or addiction.  Who are these people and how extensive is the problem?  The idea that everyone needs to be reformed or reeducated is a familiar tactic used by politicians and policy makers.  It was the rationale for managed care rationing in the first place.

6.  Prevention is a priority - The prevention of drug use is the surest way to prevent increasing number of people from experiencing morbidity and mortality due to drug and alcohol use.  Prevention of drug use at this point in time is historically difficult as the country swings into another era of permissive attitudes toward drug use.  Individuals not abusing their first opioids will have a much greater impact on the prevalence of addiction than all of treatments after an addiction has started.

All of these factors are what clinicians like me see as everyday interference with helping patients who have a substance use disorder.  Semantics may help some.  Training and recruiting physicians who know that it is only luck that separates them from people with addictions and mental illnesses will help more.  Ending insurance company dominance over clinicians will help the most.

In the end - words don't keep people with addictions from lifesaving treatment.

The government and health insurance companies do.             

  



George Dawson, MD, DFAPA


Reference:   

1: Botticelli MP, Koh HK. Changing the Language of Addiction. JAMA. 2016 Oct 4;316(13):1361-1362. doi: 10.1001/jama.2016.11874. PubMed PMID: 27701667. (free full text).