Serious Mental Illness and Gun Violence

by Tony Salvatore, MA

mhfirearmsAs an adult mental health crisis center serving southeastern Pennsylvania for almost forty years, Montgomery County Emergency Service is closely following the public discussion regarding violence and serious mental illness.  We deal daily with many of the concerns that have been raised.  Our input was sought by the Commonwealth of Virginia in the wake of the Virginia Tech situation.

As has been noted, such violent events cannot be foreseen and there is often very little opportunity to prevent their occurrence.  Sadly, such events can happen anywhere with no forewarning.  We agree that much more can be done to reduce the risk of such behavior in our communities.  Here we want to share some of the measures in place to do just that in Montgomery County.

First, our work is premised on the evidenced-based reality that the overwhelming majority of people struggling with serious mental illness do not engage in violent acts of any nature.  A very few do and we are prepared to deal with such cases.  However, shootings involving individuals with psychiatric histories in Phoenix, Aurora, and, closer to home, at Western Psychiatric Institute in Pittsburgh, are very rare, but well-publicized.

It is important to understand that as devastating as these events are, they involve only a very small fraction of those with serious mental illness.  Our experience, as supported by NAMI and other mental health advocacy groups, is that individuals with mental illness are far more likely to be victims of violence than perpetrators.  Many of those we serve come to us with severe emotional and physical trauma as a result of exposure to violence and abuse.

Second, because many of those with serious mental illness are very likely to have contact with emergency responders as a consequence of their illness, we have engaged local police and other law enforcement agencies as our partners in creating an early warning system for identifying and getting help as appropriate for those experiencing mental health crises.  We provide ongoing training to all criminal justice personnel in recognizing the signs of mental illness and the basics of crisis intervention.

We provide much more than knowledge and skills.  We back-up what we teach with 24/7 availability to officers in the field to answer questions, and give referrals and advice on resolving a situation in a manner that assures the safety of all parties and leads to the provision of emergency services by our facility or by community resources when the need is less urgent.  Police, in turn, keep us apprised of contacts with individuals at-risk that may warrant follow-up by our Outreach Program.

Third, we facilitate the ability of concerned individuals, including friends and family members, hospital emergency departments, and behavioral health providers, to arrange involuntary emergency psychiatric evaluations for individuals felt to be a danger to themselves or others because of mental illness.  Through the Montgomery County Department of Behavioral Health and Developmental Disabilities, we administer the emergency psychiatric provisions of the state mental health statutes.

We agree that our state and national mental health policies and spending should fit emerging needs and that existing behavioral health resources must be enhanced.  However, we also feel that every effort must be made to make full use of what is on hand to do everything possible to deter possible harm and meet needs as they arise.  To this end, our staff maintain currency on applicable mental health law and community resources so that we can aid those bringing potential emergency situations to our attention in understanding options, making a decision, and mobilizing the optimal intervention.

Fourth, as part of our responsibility to meet the emergency mental health needs of those who are unwilling or unable to do so we also fulfill the requirements of PA Act 77 that restricts purchase or ownership of firearms in Pennsylvania to anyone who is involuntarily admitted to a psychiatric hospital.  Information on all such admissions in Montgomery County is submitted to the PA State Police for entry in a state-wide data base.

Fifth, people with behavioral health problems may get involved with the criminal justice system apart from any crisis situation.  On their behalf, our assistance is sought by District Attorneys, Public Defenders, private defense attorneys, District Justices, Common Pleas Judges, Probation Officers, family members, and the police in clarifying the mental health status and needs of particular individuals.  This happens because our staff is seen as understanding mental illness, being able to assess an individual’s crisis level, and having a strong understanding of mental health laws and regulations. This capability represents a further layer of risk reduction.

Lastly, we fulfill our duties with an acute awareness that our actions have significant consequences for community safety, the welfare of at-risk individuals, and for their personal rights and liberties also.  Accordingly, we feel very strongly that the current prevailing interest in public safety at all costs be tempered by a concern for the rights and privacy of vulnerable individuals who present no threat to the community’s welfare.

The Crisis Continuum

By Tony Salvatore, MA

Mental health consumers and providers, and often family members and others, often use the term “crisis” to encompass a wide range of personal, interpersonal, and environmental situations with current or anticipated negative consequences. This “one size fits all” concept of a crisis is overly simplistic, obscures or minimizes the complexity of the situation, and impedes effective intervention and resolution.

Mental illness-related crises vary in scale and in terms of how they affect the individual. They also seem to follow trajectories and may move to higher levels of risk. All may be triggered by life events (or an individual’s anticipation of an adverse life event) that produces emotional discomfort or even the recurrence of psychiatric symptoms. Continue reading

Do 90% of Suicide Victims Really Have Serious Mental Illness? (Part 1)

By Tony Salvatore, MA

Anyone who turns to the print or electronic sources for insight on the topic of suicide and mental illness will encounter this statement in some form: Ninety percent of suicide victims had a psychiatric disorder.(1)  The implication of this contention is almost causal in nature, and it has taken on the trappings of a veritable “truth” of suicide prevention that is rarely questioned.  Mental illness has been shown to be a factor in suicide, but “the relative importance of mental disorders compared to social strains is not fully clear.”(2)

Here we will look into the origins of this assertion and consider some issues with its underlying methodology.  In Part 2, we will look at some actual data on the incidence of mental illness in suicide victims, examine mental illness and suicide from the perspective of current theories of suicide, and show mental illness in its proper role as a suicide risk factor. Continue reading

Do 90% of Suicide Victims Really have Serious Mental Illness? (Part 2)

By Tony Salvatore, MA

In our previous blog, we looked at the use of the psychological autopsy method in suicide research and questioned this approach and its results.  Here we will consider some “hard” data on the incidence of psychiatric diagnoses in suicide victims at the time of death, look at how the role mental illness plays in two current theories of suicide, and argue that mental illness is a serious suicide risk factor but not necessarily the key independent variable in the onset of suicidality in at-risk persons.

Some Countervailing Data

The Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS), has collected data on suicide from death certificates and other sources from sixteen states.[1]  In 2008, of 9276 suicides, approximately 45.4% had a diagnosed mental illness at death.  The NVDRS has found that “mental health problems were the most common circumstances among suicide decedents” in the US.  However, the incidence in a very large population of victims is half that reported by psychological autopsy studies.  Continue reading


Behavioral Health’s “Elephant in the Room”

By Tony Salvatore, MA

Among the many unwieldy problems in behavioral health, one looms especially large. This pachyderm-sized concern is “chronic suicidality.” This is repetitive parasuicidal behavior involving suicide threats and acts without any intent to die. It may arise at any time and convert low-risk situations into what appears to be a potential life-threatening psychiatric emergency.

Chronic suicidality seems to co-occur with a desperate “need” for shelter, inpatient care, or residential rehabilitation. Dramatic and emphatic suicide threats are voiced with an effect that comes from much practice. Immediately, urgent attention is forthcoming, doors open, and then the suicidal crisis usually subsides.

Curiously and incongruously such “suicidal” individuals who project themselves to be at imminent risk of self-destruction may still feel the need for a smoke break or a sandwich. Equally surprising is that despite the depth of their despair they have often managed to pack for what they hope will be a long stay in a hospital or rehab. Continue reading