Amy Barnhorst MD

In Crisis

Fixing Our Broken Mental Health System

It's a great idea, but it's not a way to stop mass shootings.

Posted Aug 07, 2019

After three mass shootings in the past week left 29 people dead, politicians resurrected a familiar narrative: The perpetrators were mentally ill, and the solution to the problem is to shore up our nation’s mental health system. We could then rely on professionals like myself to identify these young men, intercept them before they act, and cure them of their violent impulses.

Let’s stop for a moment and consider what that would look like.

First, this will take hundreds of millions of dollars and decades of reform. The United States currently has only about a fifth of the number of inpatient psychiatric beds that health policy experts say we need, ranking us 29th out of the 34 OECD member nations. There also is a serious provider shortage: By 2025, we are projected to have a deficit of 15,600 psychiatrists. That’s about 25 percent of the national pool. Sixty percent of psychiatrists in practice are above the age of 55, so we are losing them from the workforce at an alarming rate. And in 2015, 44 states were rated as having a “severe shortage” of child and adolescent psychiatrists, the experts in treating the population we’re concerned about.

We will have to open more slots in medical schools and psychiatric residency programs across the country, and incentivize aspiring doctors to choose a specialty with poor reimbursement, high rates of burnout, and challenging patients. There are only 141 medical schools in the U.S., so each would need to admit about 20 extra students per year for the next five years, then convince them all to become psychiatrists. After we create and fund those extra slots, it will take eight years of training before the influx of newly minted psychiatrists is ready to practice. This would still leave us needing to address the shortages of nurses, psychologists, and other therapists that will be crucial parts of their treatment teams.

And then they need a place to practice. But building more facilities should be easy; who doesn’t want an acute psychiatric hospital going up in their neighborhood?

Once the clinics, hospitals, and providers are all in place, the next step is identifying who will commit a mass shooting. We haven’t quite figured out how to do that yet, so we’ll select a group of people at elevated risk, people who have all those red flags we talk about with the false certainty of hindsight. They’ll be young males who have experienced some kind of loss in their life, like a parental death or divorce. They will have seen a therapist for anger issues or depression. They will spend time on the internet reading about other mass shootings. They will enjoy violent video games.

This will be a large group. There are roughly 20 million men age 15 to 25 in the United States, many of whom struggle with their emotions and play Fortnite. Not everyone who checks all our boxes will go on to become a mass shooter, so we could narrow down the list a bit to leave more innocent people out of it. But the smaller and more selective our criteria, the bigger the chance we will miss someone dangerous. Mass shooters are rare, so we need to cast a wide net.

Once we have whittled our high-risk group down to a mere million or two, let’s get them into care in our new system. Unfortunately, there’s no medication that will cure these young men of their hatred, entitlement, and vengeful fantasies, but intensive psychotherapy might have some effect. We can enroll them two or three hours a week, and after a few years, we might see some improvement. Of course, this assumes that every person can find a great therapist with multiple hour-long slots open each week, and that the $3000-$4000 monthly costs of those sessions were somehow covered.

Therapy only works for people who are motivated for personal growth and want to do the hard emotional work required. That description doesn’t fit many teenage boys, and probably fewer in the subset who display the narcissism, entitlement, and external blaming we see in mass shooters. For those who can’t or won’t do therapy, we’ll have to treat them against their will.

Involuntary commitment criteria would need to be loosened. Currently, to be psychiatrically hospitalized in most states, someone has to be dangerous due to a specific mental illness. Even after a mental-health provider decides to admit them, due process requires that each patient have the chance to be heard in court. A judge weighs both sides of the story and makes the final decision as to whether the person truly meets the threshold of dangerousness and mental illness. Because few of our group have an official psychiatric diagnosis as the cause of their violent tendencies, many of these potential mass shooters wouldn’t qualify.

 Image by Лечение Наркомании from Pixabay
The system can't take care of the people who depend on it now, let alone thousands of others
Source: Image by Лечение Наркомании from Pixabay

This judicial process is crucial to prevent the abuse of people’s civil liberties, but if we wanted to detain all potentially dangerous people, it would have to be suspended. Instead, we would put all the power in the hands of a single authority, unchecked by the courts and able to justify a heavy-handed and conservative approach. Hundreds of thousands of young people would be locked in the hospital indefinitely, as the customary time limits on commitment will also have to be lifted.

When would they be released? No current treatments are available and psychotherapy can’t be done involuntarily, so they would stay until they outgrew their violent fantasies, likely months to years. Every day spent in the hospital is a day not spent living independently, attending school, spending time with family, or working: It’s time spent not growing up. This total loss of freedom seems a reasonable price for a mass shooter to pay. But many of the people caught in the net of our selection criteria were never going to go on to be violent, and won’t benefit from being there at all. What of their lives?

Mental health professionals agree that the majority of mass shooters don’t meet the criteria for an official diagnosis, but any layperson can see that they are not well. Whether or not these people are mentally ill is something of a useless exercise in semantics. Our mental health system can’t fix them; it can’t even meet the needs of the sick people who desperately rely on it now. We probably can’t design it to effectively target potential mass shooters, and given the negative impact that would have on our patients and the protection of our civil liberties, we shouldn’t try. If we are going to fix it, and we should, let's make sure it serves the people it was intended to serve—those with mental illness.

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