How fixing America’s mental health system might catch future mass shooters

This week, two shooters opened fire on a workplace holiday party in San Bernardino, California, killing 14 people and wounding at least 21. Not much is known about the shooters yet, other than the fact that all four of their weapons were legally purchased, according to the New York Times.

What we do know is that the events in San Bernardino are far from unique: Statistics show that there’s a mass shooting, defined as one in in which at least four people died, almost every day in America. To most people watching, this frequency suggests that, with Congress gridlocked, mass shootings have become the new normal. In a succinct encapsulation of the public’s disillusionment, the writer Dan Hodges tweeted in January, "In retrospect Sandy Hook marked the end of the US gun control debate. Once America decided killing children was bearable, it was over."

But that’s not quite true. More restrictions around who can purchase and possess a gun may be a nonstarter in Congress, but restricting access to weapons is just one of numerous policy approaches the government can take to address the underlying problem. Although authorities are pointing to radicalism as a more likely motive than mental illness in the San Bernardino shooting, so many other mass shooters have exhibited signs of instability that it bears mentioning. According to Mother Jones’s ongoing tracker, 43 of the 99 mass shooters they’ve tracked definitely have a history of mental illness, and nine more potentially did as well. If we want to tackle one potential solution to stopping more mass shootings in the United States, it makes sense to look at how to increase access to treatment for mental illness.

A bill proposed by Rep. Tim Murphy (R-PA), the only clinical psychologist in Congress, wants to close many of the fissures in the country’s mental health system that have allowed those shooters to slip through.

The bill, first proposed in 2013 and reintroduced in June, is a transparent effort by Murphy — who maintains an A rating from the NRA — to divert the conversation away from limiting potential shooters’ access to guns. But politics aside, the bill is chock full of proposals that are as likely as any to catch and treat mass shooters before they snap.

"We have to keep in mind that gun violence is not a simple problem amenable to a single solution. Like cancer, there are multiple causes," said Dewey Cornell, a forensic psychologist at the University of Virginia. "And it will require more than one response." So far, Murphy’s response – unlike the numerous congressional attempts to amend gun laws before it — stands a solid chance of becoming law.

Three major ways the bill could transform the mental health system

Though Murphy pitches his legislation as an effort to stem the flow of gun violence, at its heart the bill is a substantive revamp of America’s mental health system. Much of it focuses on improving and expanding existing community mental health resources to cover many more Americans in need of care — very few of whom will likely ever commit any sort of violence. Laying the bedrock for a system that catches individuals with severe mental illness sooner, ideally while they’re still in school, would drastically bring down the numbers of people with undiagnosed mental illness crowding jails and living on streets. It’s harder to predict whether a strengthened system would be able to catch mass shooters before they act. But four mental health experts I spoke to said they tend to view mass shootings as a symptom of the system’s complete breakdown, a state of disarray that the bill does try to address.

But even in the best of conditions, there will always be individuals who experience crises, whether they feel suicidal, grow violent, or otherwise fall too ill to take care of themselves. This is the point many mass shooters reach when they carry out what appear to be seemingly random acts of violence. Those are the individuals that Murphy’s bill, through a patchwork of small fixes, hopes it can protect — both from themselves and from others.

1) Increase access to inpatient mental health treatment

First, and perhaps most significant, the bill proposes to scale back the ban on allocating federal dollars toward psychiatric hospital beds. Put in place during the Lyndon B. Johnson administration, the ban was intended to discourage clinicians from institutionalizing patients for long periods of time, in favor of allowing patients to live at home during treatment. But in the years since, adequate community-based treatment never materialized, sending too many individuals with mental illness seeking treatment in states of crisis. The ban has forced states to adopt the burden of paying for acute inpatient mental health care, a proposition so expensive that the number of psychiatric beds across the country has fallen below the number available in 1850, according to the Treatment Advocacy Center. The shortage has ensured that when a patient begins to deteriorate, doctors often must turn them away unless they’re unmistakably and immediately dangerous, a standard that amounts to little more than guesswork. Even so, patients in extreme states of distress are still sometimes turned away for the lack of space — as in the highly publicized case of a Virginia state senator’s son who stabbed his father and killed himself after being denied a hospital bed. Eliminating the exclusion would help expand the number of beds available to patients, a cost the bill is weighing against what the government currently pays when a person with mental illness visits the ER or goes to jail.

2) Compel patients to accept early treatment — before they reach a crisis point

The bill also contains language to compel treatment for a person with severe mental illness before he or she reaches a point of crisis. It does so by incentivizing states to adopt court-ordered outpatient treatment programs, known in the mental health community as Assisted Outpatient Treatment, by offering additional federal funds to states that have them in place. These programs, which already exist to varying degrees in 45 states, allow courts to order patients to comply with their treatment plans, which can include therapy and medication. If a patient does not comply, the court order allows her to then be reassessed for inpatient care. It’s easiest to understand the utility of AOT in a context where it doesn’t exist: If a patient can’t be compelled to stick with her treatment, clinicians are simply left to wait until she becomes suicidal or violent to get her care.

3) Allow families to know what’s going on with relatives receiving treatment

Another major provision wants to specify what sort of communication is permissible between clinicians and family members when an adult with mental illness is being treated. Right now, HIPAA, the federal patient privacy law, states that doctors under limited circumstances may communicate essential information with caretakers of adult patients (often their family members). But the law provides no guidance on when it’s legal to utilize this exception. As a result, most doctors, buoyed by lawsuit-weary insurance companies, err on the side of privacy. Families routinely complain that because of HIPAA, doctors won’t reveal whether a loved one has even checked into a hospital, let alone what sort of treatment he or she is receiving. Many doctors refuse to even listen to family members, eager to share their concerns. This sort of behavior betrays a level of caution far beyond current HIPAA requirements, which the Department of Health and Human Services clarified last year. The Murphy bill proposes several explicit conditions under which clinicians are permitted to share vital details about a patient’s treatment without violating patient privacy. Advocates hope that if the bill is passed, families or caretakers can use the law to better demand that a patient receive adequate treatment before spiraling into crisis.

What the bill doesn’t do

From the perspective of preventing mass shootings, one major hole in the bill is a provision preventing individuals with serious mental illness from obtaining guns. Murphy likely omits such a provision because many mental health advocates vehemently oppose it, saying it unfairly discriminates against individuals with mental illness and potentially prevents them from seeking treatment. (To Murphy's credit, the omission likely has little to do with his desire to appease the gun lobby, since the National Rifle Association is actually on record supporting such a proposal.) That’s a shame – since numerous studies have recently affirmed the effectiveness of keeping guns out of the hands of the mentally ill, mostly in preventing them from taking their own lives.

But the larger issue with Murphy’s bill is not its contents, but rather its premise: that by improving the nation’s mental health resources, Murphy can eradicate the underlying motivation to commit mass atrocities. That belief ignores the reality that many mass public shooters are not mentally ill; they’re angry, disgruntled, bitter, sure. But an individual can’t be medically treated for his or her state of mind.

It’s much more difficult to propose catchall policy solutions to prevent these people from acting, especially as new potential shooters draw inspirations from the atrocities that come before them, so the profile of a shooter is becoming more muddled. Still, it isn’t impossible. Policy experts are increasingly looking to a model of prevention known as "threat assessment," which typically involves preassembled teams of professionals who can provide wraparound services to a person suspected of plotting to harm others. In Virginia, where threat assessment teams have been implemented in colleges across the state, a recent study found that 96 percent of planned crimes, identified by threat assessment teams, were averted.

Gun control is politically untenable. But mental health might not be.

Murphy’s mental health bill has garnered the rare distinction of looking politically viable. It has broad bipartisan support in the House, a bipartisan companion bill in the Senate, and broad backing from mental health advocacy organizations, including several that did not lend the bill their support in its last iteration. In November, the bill cleared a House subcommittee – albeit with some partisan infighting – and is now pending before the full House Energy and Commerce Committee. In light of the San Bernardino shooting, Murphy’s bill has received the full backing of House Speaker Paul Ryan (R-WI), who said mental illness is a "common theme" of mass shootings.

It’s taken Murphy several years to get to this point. In 2013, when he first introduced his bill, many of its provisions came with much sharper edges. The previous bill, for example, made court-ordered outpatient treatment a requirement for federal funding, rather than an incentive for additional grants. The new bill also softens its stance on HIPAA, easing the apprehensions of many advocates with legitimate privacy concerns. Murphy has clearly engineered the legislation to draw support from as broad a coalition as possible – an effort that, so far this session, seems to be paying off. The companion Senate bill, co-sponsored by Sens. Chris Murphy (D-CT) and Bill Cassidy (R-LA), contains language on federal funds for inpatient stays, court-ordered outpatient treatment, and HIPAA, all of which were duds with many Democrats and mental health advocates last year.

One of the remaining political hurtles the bill must clear, congressional process aside, is to shed its reputation as an alternative to gun control. Though the bill does little to assuage the desires of many Democrats to see Congress take another stab at tightening gun restrictions, it does them a disservice not to recognize this bill’s many benefits in fighting the same national scourge. As Sen. Murphy put it in a speech on the Senate floor in October: "We are not going to get a background checks bill this year. I hope we could, but we won't. What we can get is a mental health reform bill." And that’s a none-too-shabby consolation prize.