[Originally published May 2014.] Last week in Isla Vista, California, Elliot Rodger killed six people before taking his own life. His family says he was seeing multiple therapists. Meanwhile, in the California legislature, discussion of a bill that would mandate additional suicide prevention training for therapists has focused on research showing that more than 30% of those who commit suicide had seen a mental health professional within the past year. Why can’t therapists do more to stop violence among our own clients?
First, let’s be clear: Psychotherapists can and do intervene to prevent hundreds if not thousands of acts of violence every day. We talk clients down from fits of rage, we help suicidal clients to find hope (or at least to understand what hurting themselves would do to their loved ones), we coordinate care with physicians to make sure those who need to be on medication stay on it, and when we assess imminent danger, we hospitalize or coordinate with law enforcement. The violence we prevent doesn’t make the news, but it saves many, many lives.
Ed. note: This post was originally published in May 2014 and republished in December 2015. We’re publishing it again, in October 2017, in the wake of the Las Vegas shooting. There is, at present, no evidence that the shooter had mental illness or was under the care of a mental health professional. Still, some of the discussion in the wake of the shooting has returned to the topic of mental health care in the US, and therapists’ responsibility to protect the public from dangerous clients.
Critics are right, however, to point out that in spite of these successes, therapists often fail to prevent violent acts. Two factors prevent therapists from stopping a client intent on hurting themselves or others. One is simple to explain, the other a bit more complicated.
Let’s start with the simple one: Access to proper care. While the deinstitutionalization movement has unquestionably led to higher quality of life for many of those who struggle with mental illness, it also has meant that when someone experiences a mental health crisis that reasonably requires inpatient care — like presenting a risk of suicide or homicide that a therapist accurately assesses — there often is simply no place to put them. Nationally, some 95% of public inpatient psychiatric beds have been lost since 1955 (you can read “public” there as “non-jail”). California lost 30% of its public inpatient mental health beds in just 15 years, and now almost half the counties in the state have no inpatient mental health beds whatsoever. In those counties that do still have them, only the most dangerous among the most dangerous are kept there; others are often simply sent home. (Some places, like San Diego, have a network of crisis houses that are a short step down from hospitalization; even there, beds are often unavailable.)
The situation is similar in most of the rest of the country: Clients sent to a hospital for evaluation are often sent home not because they are risk-free but because there is no room for them. The nonprofit Treatment Advocacy Center estimates that across the country, an additional 95,000 beds are needed to provide an adequate supply. On a per capita basis, the number of public psychiatric beds in the US is roughly equal to what it was in 1850.
This is unconscionable. It is also the first place governments should look when wondering where to put money to reduce suicide and homicide rates among the mentally ill: Simple access to appropriate care.
The second factor preventing therapists from successfully intervening to stop violence is more nuanced, but equally important to understand. The principle of client autonomy was a cornerstone of the deinstitutionalization movement and remains a core ethical principle for every major mental health professional group today. In simple terms, it means that clients are free to make their own decisions and direct their own lives. Therapists (and physicians, when considering hospitalization) only interfere in a client’s autonomy as a last resort to prevent imminent danger to the client or to others.
Of course, there is no lab test or brain scan for suicidality or homicidality, so the decision of whether to hospitalize someone against their will comes down to an assessment of risk factors, including how the client presents themselves. Someone who is planning violence often can convince therapists and doctors (and, in Rodger’s case, police), that their threatening statements were simply “blowing off steam” and that they are not, in fact, about to hurt anyone. Since the overwhelming majority of people who make this case are telling the truth — clients do often talk about how much they would like to hurt someone, without intent to actually do so — we can’t just hospitalize everyone who makes such statements. (Even if enough beds were available to do so, there would be billions of dollars wasted on hospitalizations that weren’t truly necessary, and the shift would eliminate the very trust between client and therapist that allows them to freely discuss their rage or hopelessness so that they can be properly assessed and treated.)
The trend in mental health policy for the past 10 years has been to more carefully whittle away at the concept of autonomy for clients perceived to be high-risk. Many states have adopted laws authorizing mandatory outpatient care in limited circumstances. While these policies have been deemed a success, they are still not in use everywhere, partly due to concerns over their impact on autonomy and civil liberties. Data seems to show these laws as effective in reducing arrests and hospitalizations, and it stands to reason that they are preventing at least some acts of violence, though it is unknown how many.
As therapists, we deeply empathize with the pain experienced by the families of Rodger’s victims, and with the families of those who have lost a loved one to suicide. It is a level of pain I would not wish on my worst enemy. Unfortunately, the pendulum has swung so far away from institutionalization, and toward even the severely mentally ill living independently and with autonomy, that today higher levels of care simply are not available for many of those who need it most. (It says something awful about us that the country’s largest inpatient psychiatric facilities are the county jails in Los Angeles, Chicago, and New York.)
Therapists do share some of the blame for this. While there is no evidence so far that Rodger’s therapist should have or even could have done more to prevent violence in his specific case, we have failed as professionals to raise the alarm about inadequate crisis care among the public and policymakers. Every mass shooting seems to be followed by non-specific calls to improve mental health care, with little long-term follow-through.
The problem is clear: Suicidal and homicidal clients, even when properly assessed, often have no place to go for adequate care. We are so reluctant to restrict patient autonomy that we have created a system where we can’t restrict such freedom even when there is a desperate need to do so. There isn’t room. Whether there is now the political will to truly do something about that remains to be seen.
Update (5/31/14): The New York Times has a well-done discussion on this same topic, with leaders from the legal and mental health communities. It’s worth the read.
Update (12/3/15): The Washington Post has a been tracking mass shootings, with a number of articles on the topic.