Among the core components of President Obama’s plan to stem an “epidemic of gun violence” announced yesterday at a high profile White House press conference are steps to expand access to mental health care. In the weeks since the murder of 20 children at Connecticut’s Sandy Hook elementary school in December, liberals and conservatives alike have raised concerns about mental illness and its relationship to mass gun violence. But while mental health seems to make its way to the top of the list of concerns after every mass shooting, it’s not at all clear what psychiatric diagnoses, mental health care and gun violence have to do with each other.
Advocates for people with mental illness find themselves in a bind: on the one hand attempting to fend off the blind conflation of people with mental illness and a propensity toward mass slaughter and on the other, recognizing that moments like this present the rare opportunity for expanding the mental health safety-net.
To the relief of mental health advocates, President Obama seemed to understand this tension well. When the president did talk about mental health, he was cautious not to suggest that clinical insanity kills children, while carefully calling for more support for widely accessible psychiatric care. “We are going to need to work on making access to mental health care as easy as access to a gun,” he said.
With this as a starting place, the president’s opening gambit on guns proposes some expansion of mental health care access while allaying fears among the mental health professionals that the overwhelmingly non-violent population they work with will become the scapegoats of a larger problem. Advocates say they are hopeful this moment will provide an opportunity for expanding an underfunded mental health system.
The President’s Plans For Mental Health
Four of the 23 executive actions the president plans to enact to fight gun violence target mental health explicitly. They aim primarily to use the president’s healthcare reform law to compel private insurers and Medicaid to provide coverage for mental health just as medical and surgical needs are covered.
The Affordable Care Act is expected to provide healthcare coverage to tens millions of people previously living without insurance, many of whom struggle with mental illness. But existing healthcare guidelines often leave insurers and state Medicaid officials without certainty about which mental health issues must be covered. The president yesterday vowed to finalize rules requiring that health insurance companies provide equal coverage for mental illness. Similarly, the president will issue a letter to state health officials to clarify that mental health parity rules apply also to Medicaid.
“This is going to provide an additional opportunity and impetus for the federal government to educate states about the scope of mental health services that they can and need to provide,” said Jennifer Mathis, program director of the Bazelon Center for Mental Health Law. “We knew healthcare reform would expand coverage but exactly how wasn’t clear. Now we’re hopeful it will include broad coverage.”
Mathis says she hopes the administration’s guidance will require states to provide Medicaid recipients with “a core set of services that are necessary for well functioning mental health system to enable people to live the same kinds of lives as others: to live in their own homes, in their own communities and get the support they need.”
Mental health advocates note that ensuring parity between mental health and medical issues will not be enough if Medicaid spending is cut or fails to grow along with increased need. Nearly half of all public mental health care coverage is provided through Medicaid and while federal officials largely determine the types of medical issues the program is required to cover, the Supreme Court decision on the healthcare bill gave states the power to decide whether to expand Medicaid.
Mental health care providers warn that the current trend in the states has been to chop mental health spending to makeup for other budget shortfalls and that this puts vulnerable mentally ill people at risk. States cut over $4 billion in public mental health dollars between 2009 to 2012, according to the National Association of State Mental Health Program Directors. It’s the largest reduction since widespread deinstitutionalization of people with mental illness 40 years ago.
Beyond healthcare coverage, the president promised to “launch a national dialogue” on mental health led by the Department of Health and Human Services and Department of Education and to provide additional resources for school mental health services, including training for teachers. The administration wants more than $150 million in additional mental health care spending, mostly for teenagers and young adults. Some education advocates and civil libertarians warn that Obama’s plans for schools also include more police officers, whose presence rarely make schools safer, and instead drive more youth into the criminal justice system.
What’s Mental Illness Have to Do With Gun Violence?
Mental health professionals are quick to note that they can’t predict who will become violent, and that even a fully funded and robust community mental health system would not end gun violence. Research tends to show that the past acts of violence, the availability of weapons and substance abuse are far better indicators of propensity for harming others than mental illness.
A study by Columbia University psychiatry professor Paul Appelbaum found that only about 4 percent of violence can be attributed solely to a perpetrator’s mental illness and the percentage is less for gun violence. While other research finds greater overlap between psychiatric issues and violence, most agree that to the extent that mental illness does lead to violence, it’s usually in combination with other factors like alcohol use or the stress of being out of work.
Yet gun rights groups point to psychiatric issues as the only site of legitimate action to reduce gun violence. On Tuesday, the president of the National Rifle Association said on talk radio that the only issue “we can get together on” with the White House would be in barring “people who are within the group among the mentally ill who are potentially violent—schizophrenics and others who are not on their meds who haven’t been treated or dealt with” from buying firearms.
The NRA’s stance is not far from broadly held ideas about mental illness.
“There’s a common belief among ordinary people that individuals with mental illness are dangerous, particularly likely to be violent, the kinds of people who if possible should be put away somewhere or if not, at the very least, avoided,” said Appelbaum. “This is not reflected in the research.”
So mental health professionals are conflicted about using moments like the current one to call attention to mental health issues for fear that they’ll add fodder to an existing belief that mental illness and violence equate.
“This is a terribly unfortunate time and context to improve our mental health services and programs,” said Mathis. “Though the data doesn’t draw a deep connection, and the responses can be reactive, we do need to fix the mental health system and this an opportunity we can’t miss.”
Advocates and care providers were relieved yesterday when the president made a bold effort to back against violent portrayals of people with mental illness.
“Someone with a mental illness is far more likely”—by about 2.5 times research shows—“to be the victim of a violent crime than the perpetrator,” the president said.
The consequences for the mentally ill of the gun control push are not yet fully clear, as the full content of the president’s executive actions have yet to be released. And advocates will watch closely as congressional deliberations unfold over the vast parts of gun control that the president can’t do alone. But for now, it appears things are moving forward with some distance between proactive plans to improve mental health care and those to prevent mass murder.