The Case for Involuntary Commitment

Writing in The American Conservative John Hirschauer makes the case for involuntary psychiatric commitment. As longtime readers of this blog know, I have recommended this solution-- however stopgap it may seem-- to the problem of school shootings and other act of mass murder and mayhem.

In many of the cases, the shooter was flagged by psychiatric authorities or at least by family members. Whether in Aurora, CO or Sandy Hook, CT or Parkland, FL or Buffalo, NY civil authorities knew about the dangers the shooters presented, and did nothing.

Of course, it is easier to blame guns than it is to hold the psychiatric establishment to account. And it is certainly easier than to accuse the civil libertarians who promoted the daffy idea that we should empty psychiatric hospitals, the better to liberate the mentally ill from the chains of medical oppression.

Considering the extremely small number of mass killers out there and considering the extremely large number of guns, you would think that it would be more effective to commit dangerous people involuntarily, and to get over the notion that these people can exercise free will.

Now, Hirschauer reports on the American attitude toward involuntary commitment by advancing a tale of two states, Connecticut and Texas. Whereas Adam Lanza, the Sandy Hook shooter, and Payton Gendron, the Buffalo murderer were referred for psychiatric evaluation and were not seen to be dangerous, Salvador Ramos was ignored. Unfortunately, it is also far easier to commit someone in Texas than it is in Connecticut. 

In Connecticut the problem was the lack of psychiatric beds. In Texas it was the blindness of family and community. The mother of Salvador Ramos explained that she saw no signs of mental illness or emotional distress. Perhaps the reason was that she was a drug addict. And she did not mention that she had abandoned her son and had thrown him out of her house.

So, begin with Connecticut, a test case for the civil libertarian attitude toward mental illness, and a place where psychiatric hospitals were shut down many years ago.

Hirschauer explains:

Connecticut, like most states, was winding down its inpatient population. State and federal law had made it more difficult to commit someone who was not imminently dangerous to himself or others to an inpatient facility. By 1995, the average patient who remained at the hospitals was generally sicker and more expensive to treat than the average patient had been 40 years prior. By the time Rowland announced the closures, no one in Connecticut was being institutionalized for “hysteria” or “burnout.”

Naturally, liberal litigators came to defend those who had been committed involuntarily:

Civil-rights litigators also pressured the state to reduce its institutional population. In 1990, a group of non-profits brought a class-action lawsuit against the state on behalf of people with traumatic brain injuries and intellectual disabilities in each of the three state hospitals. Attorneys for the plaintiffs argued their clients were placed in inappropriately restrictive settings in violation of federal law. They kept the class-action suit going for more than four years. By the time the case was settled, Connecticut had already announced it was closing the hospitals in Preston and Newtown.

The result could have been predicted, assuming that anyone had cared:

In the decades since two of its three mental hospitals closed, Connecticut, like most states, has suffered an acute shortage of psychiatric beds. The statewide inpatient-utilization rate, which measures the number of psychiatric patients treated in inpatient settings versus the number of beds allocated by the state and private providers, is upwards of 120 percent. In other words, there were more psychiatric inpatients in Connecticut than there were beds allocated to treat them.

What are the direct consequences:

This is presents several problems. For one, it forces suicidal, homicidal, and otherwise acutely ill patients to wait in emergency rooms for days or weeks on end for a vacant hospital bed. As of this writing, there are no vacant beds in the civil section of Connecticut’s large state hospital in Middletown. For another, it discourages people with acute conditions from coming forward to seek inpatient care in the first place. Finally, by effectively reserving the beds at the large state institutions for the most difficult cases—those immediately dangerous to themselves or others, and those with treatment-resistant psychosis—individuals with mental illness living in the community who need more intensive services than the community can provide are left to devolve until they become so ill that they either make an attempt on their own lives or, in rare cases, the lives of others.

As it happened Adam Lanza, the Sandy Hook shooter, lived just a few miles from an abandoned psychiatric hospital:

You cannot draw a straight line between the closure of a hospital and an act of mass violence by a person with mental illness, but there is at least a chilling irony in the fact that an 18-year-old man with untreated serious mental illness killed 19 children at Sandy Hook Elementary School less than five miles from the grounds of the abandoned Fairfield Hills Hospital.

Things are different in Texas, where inpatient psychiatric treatment is more readily available and where involuntary commitment is easier to obtain:

Texas operates ten state hospitals and funds more than 2,200 public psychiatric beds. Its inpatient-utilization rate is less than 100 percent, reducing the chance that a psychiatric patient will be stranded in an emergency room.

State law also allows prosecutors and family members to initiate commitment proceedings when a person is unable to care for himself or is otherwise so disabled as to require hospital care, allowing families and communities to intervene before a person with serious mental illness deteriorates to the point of violence.

Yet the tragic events of Uvalde demonstrate that robust commitment laws and a well-funded network of state hospitals are of little use if the family and community surrounding a dangerous individual fail to intervene.

The last point deserves emphasis. People around Ramos had seen the signs of his distress and derangement. They did nothing. Was it not obvious, even to a non-professional?

The Texas shooter reportedly tortured small animals and made regular threats against his classmates. His peers reported that he showed up to school with self-inflicted face wounds. He may simply have been an evil person who did an evil thing. We tend to medicalize evil, and should not assume that the shooter was “mentally ill” without evidence. But in a sane society, his behavior would be grounds for intervention regardless of its clinical significance. A half-century ago, it would have landed him in a state hospital.

Whatever his behavior constituted under law—whether the threats were criminal in nature or the self-harm sufficient evidence to initiate a commitment hearing—it was clearly worthy of examination. What is more, it demanded a period of retreat—”asylum”—from his social milieu.

So, in Texas, even with far better psychiatric treatment, someone like Salvador Ramos fell through the cracks-- because no one in the family, the community or the school system was sufficiently alert to the danger.