Saturday, December 22, 2012

The post-Sandy Hook conversation we should be having

How long after release of the news of the tragedy in Newtown did it take the Usual Suspects to start arguing about gun control?  Was it more than thirty-six hours?  Had the names of any of the children been released?

It’s the same bloody non-conversation we’ve been having since I wrote my first “letter to the editor” thirty years ago, the same tug-o’-war between those who want to give teachers permits to carry Uzis and those who want to register anyone who buys so much as a Super Soaker.  [Case in point: this loony screed on The Slate.  But then, this equally nutty proposal from the NRA's Wayne LaPierre didn't help either.]  A Boise writer named Liza Long did write a thought-provoking piece for The Blue Review; outlets like HuffPo, TIME, MSN and Yahoo all reprinted it, paused for a breath … and resumed the non-conversation.  (Although HuffPo for some reason wasted two or three posts on Asperger’s syndrome, an autism spectrum disorder which they finally admitted has no causal connection to violent behavior.  Typical — shoot first, do the research later.  If necessary.)

On the liberal side, the major failing is that the tragedy in se hasn’t inspired any policy suggestions that really, specifically address such mass murders … except for reinstating the ban on assault rifles.  On the conservative side, the major failing is the tendency to engage in amateur psychology: the Adam Lanzas all hit soft targets, like schools and malls, because no one is likely to shoot back at them and they can get their fifteen minutes of fame with no real risk, don’cha know. 

(Hitting vulnerable, low-risk targets for the sake of fame may be a motive for a certain kind of serial killer … but for a mass murderer who ends his rampage by blowing his brains out?  Bah-loney.)

Keith Ablow, FOXNews’ resident psychiatrist, is one of the few MSM talking heads to really pick up where Liza Long left off: “Focusing on gun control does more than squander the time and effort of our public officials and state resources and town police forces, it distracts us dangerously from the real work that must be done.  America’s mental health care system is shattered and on its knees.”

Here is the truth:  Today, even a mentally ill young man with a known propensity for violence, or even a history of serious violence, is likely to receive just an hour a week of counseling (if that) by a social worker.
He is likely have an unclear diagnosis of his condition and to be on a list of constantly changing, very powerful psychoactive medications prescribed by a nurse.
He is also likely to be turned away — repeatedly — by emergency room social workers who act as gatekeepers for insurance companies to restrict access to inpatient psychiatric treatment.
If admitted to a psychiatric hospital, he will likely be triaged quickly through an often-incompetent “tune up” of medications that might accomplish nothing and then be sent back home as soon as he “contracts for safety” — simply promising a social worker that he won’t kill anyone.
That young man’s good parents might well pray that he be arrested for another violent crime so that the terms of his probation might (but probably still wouldn’t) include mandatory visits to a mental health professional (though not always the right one for their child’s needs) and mandatory drug testing.  At least then he can be jailed if he refuses all treatment or gets hold of some heroin that could worsen his hallucinations.

Moreover, Dr. Ablow mourns, since insurance companies drive down their costs by pushing treatment to the least-trained clinicians possible, training programs for psychiatric residents have responded by curtailing education in “the essential art of helping [to] understand the roots of psychiatric illness in emotion”, a problem exacerbated by “[the] constantly changing, partly insurance-company driven” Diagnostic and Statistical Manual of Mental Disorders, which describes treatment mostly in terms of medications.

And even when the insurance companies are willing to pay for inpatient treatment, it’s for overcrowded psychiatric units where the psychotic are “lumped into one space (and share rooms) with depressed young adults, drug addicted homeless folks and the elderly suffering from dementia.”  The stays are too often too short, and simply result in another prescription for a different psychoactive medication that may or may not work — if the patient takes it.

By the way, nothing in the Obamacare Act fixes any of this.  President Obama has supposedly put mental health on the table of items for the new task force VP Biden is heading to look at.  White House press secretary Jay Carney said, in speaking of gun violence, “It’s a complex problem that requires more than one solution. … It calls for not only re-examining our gun laws and how well we enforce them, but also for engaging mental health professionals, law-enforcement officials, educators, parents and communities to find those solutions.” However, the best opportunity for the Administration to look at mental health care passed with the end of the PPACA fight, which sapped a lot of Obama’s political capital.

At least in Connecticut they’re talking about mental health.  Barnini Chakraborty of FOXNews notes, “Ironically, a Connecticut mental health bill calling for changes that could have taken someone like shooter Adam Lanza off the streets was defeated earlier this year in the state legislature. The bill would have allowed the state to commit someone if there was a reason to think that would prevent them from harming others.”  Virginia tightened its mandatory outpatient treatment procedures and increased funding for mental health services in the wake of the 2007 Virginia Tech massacre.  But in other states, mental health care budgets have been cut and facilities closed, nominally as misguided responses to problems of corruption and brutality … but more to save money.

Mental health care is just part of a hot mess of a national health care system that, in the words of the Institute of Medicine’s September report, “lags in its ability to adapt, affordably meet patients’ needs, and consistently achieve better outcomes.”  In large part, the market has failed to drive down health care costs because health care as an industry is still too fragmentary.  With the exceptions of pharmaceutical companies, equipment manufacturers and some hospitals, health-care provision is at the same point that ironworking was prior to the Industrial Revolution — small, community-based and individually-owned shops without effective centralized organization, incapable of taking advantage of the economies of scale.  Maggie Fox of NBC reports:

If banking were like health care, it would take days to get money out of an ATM because the records would be lost.  If airlines were like health care, pilots would decide on their own which safety checks to make, if any.  If shopping were like health care … “Product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment,” the [IOM] report says.

It’s past time for us to make meaningful, systemic changes to our health care system that do more than just socialize the costs and entrench the insurance companies more firmly in control of treatment.  As part of those changes, we need to find better prevention and treatment protocols for mental illness, protocols that aren’t driven solely by the desire to save money and boost profits.

This is the conversation we should be having.  It’s the conversation we won’t have, however, so long as we focus on the gun and not on the person pulling the trigger.