CITY JOURNAL, March 30, 2018
Culture of Denial
DJ Jaffe’s harrowing account of the half-century-long breakdown of America’s treatment of the mentally ill. A review of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill (Prometheus Books, 363 pp., $25)
“We heard it after Sandy Hook. You heard it after Aurora. You heard it after Arizona. You heard it after Parkland. That these mass shootings are the result of somebody suffering with mental illness and the only thing we can do is address this as a mental illness problem. So let’s get the facts straight right away.” So begins a video spot by Congressman Joe Kennedy III, produced by “NowThis” for Facebook and watched by millions of viewers, that discounts the relationship between mental illness and mass violence. The voices of American liberalism have long refused to acknowledge the slightest connection between the two.
“The attempt to turn the question of gun violence into a question of mental health is obscene,” writes Adam Gopnik in The New Yorker. Yet in his next sentence, Gopnik concedes: “Of course, people who kill children en masse are crazy. That’s the given.”
Such atrocities should warrant an examination of root causes and their implications. And, yes, such shooters are often crazy. Kennedy states that “only 22 percent” of mass shootings were “conducted by somebody suffering from mental illness.” The actual numbers may be much higher. The shooters in at least three of the four examples that Kennedy cites displayed symptoms of mental illness. But shouldn’t even a rate of 22 percent suggest further review? And shouldn’t the call for further gun control go hand-in-hand with a reevaluation of our treatment of the mentally ill?
But, in fact, a culture of denial has long surrounded the half-century-long breakdown of America’s treatment of its mentally ill. As it happens, the Kennedys themselves have long been at the center of this rollback in care for those suffering from extreme mental illness due. In 1941, 23-year-old Rosemary Kennedy, Congressman Kennedy’s great aunt, underwent what was then a widely used treatment—the transorbital, or “ice-pick,” lobotomy. Rosemary’s father, Joseph Kennedy, Sr., the autocratic family scion, believed that the procedure would calm her mood swings, which had become a family embarrassment. Unfortunately, the botched procedure left Rosemary severely mentally disabled. Partly as a consequence, the Kennedy family has embarked on a multi-generational crusade against institutionalization and invasive treatment. In 1963, President John F. Kennedy proposed replacing dedicated institutions for the mentally ill with decentralized Community Mental Health Centers (CMHCs). As I described for City Journal in “A New Moral Treatment,” the result not only led to the shuttering of the asylums but also to a near-ban on committing patients for treatment against their will and to prevent them from harming themselves and others.
The madness of this present system of care is the subject of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, DJ Jaffe’s harrowing, personal, and all-too-timely account of how a system that now prioritizes “mental health” does little to treat true mental illness. Like many advocates for the severely mentally ill, Jaffe, a self-described “aging hippie” and the founder of the Mental Illness Policy Org, came to his cause through personal experience. In the 1980s, his wife’s sister, Lynn, developed schizophrenia. The diagnosis was bad enough, but the mental health system’s inability to help her, and to help her family help her, proved disastrous. Doctors refused to share findings about her condition. “Lynn returned home to us,” writes Jaffe, “and stopped taking the antipsychotic medications we didn’t even know she’d been prescribed.” Jaffe (an adjunct fellow at the Manhattan Institute) came to realize that the law “prevents parents from helping psychotic or delusional loved ones who refuse treatment until after they become a danger. As ludicrous as it sounds, rather than preventing violence, the law requires it. That realization led me on a thirty-year journey to try to find out what is wrong with the mental health system and what can be done to fix it.”
As Jaffe makes clear, the headline-making cases involving gun violence and mass murder are only the most atrocious symptoms of a much greater systemic failure, one that leads to the expense of billions a year on mental health yet leaves hundreds of thousands of mentally ill Americans to the cruelties of the streets, the “trans-institutionalization” of the prisons, and the life-threatening dangers of their own diseases.
One problem is “anosognosia,” the clinical term for the lack of understanding of one’s own mental fitness. Anosognosia is “present in up to 50 percent of those with untreated schizophrenia and 40 percent of those with untreated bipolar disorder,” writes Jaffe. In a system that relies on patients serving as their own health-care agents and that no longer permits consultation on treatment with parents or loved ones, the consequences of anosognosia mean that the severely mentally ill often go untreated or undertreated. The result: “there are ten times more people with mental illness incarcerated as hospitalized.” Those are just the ones who make it to jail. Thousands die each year by their own hand or are shot by police committing crimes that shouldn’t have happened.
“We should move away from a system that requires tragedy before treatment to one that offers treatment before tragedy,” writes Jaffe. Insane Consequences details the “catch and release attitude” of today’s mental health system and the Kafkaesque trials that concerned family members often endure to protect their loved ones from themselves.
The implications extend far beyond gun violence, to harm of any kind. Consider the subway pusher Andrew Goldstein, whose lack of treatment for schizophrenia led to the death of Kendra Webdale in 1999; a law written in her name now permits at least limited involuntary treatment of the mentally ill. Or Richard Rojas, a driver high on PCP with known psychological issues who rammed his car into pedestrians in Times Square in 2017, injuring 20 and killing 18-year-old Alyssa Elsman.
Jaffe could go further in advancing the argument for new institutions for those mentally ill who pose such a danger to themselves or others that they should not be integrated into society—a measure with real relevance to the gun debate, for example. Federal law already bans the sale of firearms to people who have been involuntarily committed. Written into existing policy, institutionalization therefore remains a proven path to reducing gun deaths, if only such intervention were still readily available to the severely mentally ill.
“A lot of kids threw jokes around like that, saying that he’s the one to shoot up the school,” said Eddie Bonilla, a former classmate of Nikolas Cruz, the Parkland shooter. “But it turns out everyone predicted it. It’s crazy.”
Crazy, it is.