Firearms account for nearly two-thirds of Idaho’s completed suicides, one of the highest and fastest growing rates in the entire nation. Low frequency incidents such as the rampage shootings at Sandy Hook Elementary School in Newtown, Conn., which also ended in a suicide, easily over-shadow chronic rates of rates of suicide and other firearm deaths, which correlate more directly with poverty, alcohol abuse and domestic violence. The search for underlying causes to rampage homicides often involves some sort of psychiatric diagnosis, especially since the vast majority of such events culminate in the shooter killing himself. Both sides of the political spectrum appear to agree on this point, with liberal New York State and the conservative National Rifle Association calling for comprehensive databases of people with histories of mental illness treatment.

The heated debates—when they do rise to the level of actual debates—frequently ignore larger public policy questions regarding the politics of mental illness. Idaho’s suicide rate went from 11th to 6th in the nation between 2009 and 2010, the latest date for which data is available.Idaho is a case in point. While Idaho Code denies a concealed weapons permit to people defined as mentally ill, the state’s last attempt at a comprehensive definition of “biologically based mental illness” is now 15 years old. The definition includes “schizophrenia and other psychotic disorders, bipolar disorders, major depressive disorders, pervasive developmental disorders, obsessive-compulsive disorders or panic disorders.” Mental conditions due to “chronic alcoholism or drug abuse” or geriatric dementia are specifically excluded, “unless these are associated with the other disorders” (18-41-1843). Also missing are the so-called personality disorders, binge alcohol or substance use, identity disorders, eating disorders, attention-deficit/hyperactivity disorders and sexual dysfunction disorders. And stress-related or situational conditions ranging from PTSD to temporary depression to surviving rape, incest or domestic violence remain unmentioned as well. People in these higher risk categories are allowed to own firearms.

Several other states define mental illness for purposes of firearms restriction in terms of histories of treatment by inpatient psychiatric facilities. Idaho instead relies quite specifically on the diagnostic nomenclature and criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), currently in its fourth and revised edition, and scheduled to be updated this month. Aside from access to guns, DSM definitions shape all statutes governing involuntary mental holds, insurance reimbursement, Workman’s Compensation settlements and licensure requirements for mental health practitioners.

PSYCHIATRY’S INFLUENCE ON POLICY

While it appears premature to enter into the controversies surrounding the final edition of the DSM-5, it’s useful to briefly trace the intersection between psychiatric theory and other public policy decisions. Some of the major intellectual spadework in this area was suggested by the work of Michel Foucault. In his Madness and Civilization (1961), Foucault traced the positioning of mental illness within the philosophical framework of the Age of Reason, as fundamentally deviant and therefore in need of correction and rehabilitation. As Foucault pointed out, government-sponsored asylums were filled with criminals, prostitutes and the insane, all housed together on the basis of the shared inability to engage in economic productivity.

Such strong distinctions between sanity and its opposites were clearly challenged by the Romantic Movement, of which Freud was the most scientifically ambitious spokesman. The concept of universal intra-psychic conflicts and the infantile roots of unconscious adult behavior had already been articulated by Nietzsche, Wagner, Schelling, Wordsworth and the Symbolists, all leading to a reframing of mental illness as a matter of degree, rather than kind, from so-called “normal” social behavior. In terms of treatment modalities, psychoanalysis was the first that moved treatment sites out of the large institutions and into small scale private practice. Psychotherapy was now a humanistic endeavor, one that emphasized self-knowledge, interpretative insights and a studied stoicism in the face of the irrationality that client and therapist share with the rest of humanity. Its major enclaves now included academic departments of fine art, art history, religious studies, English, film studies and comparative literature.

But the exercise of empiricism and the application of the medical model continued apace here in America, especially given the increasingly large number of mental conditions that appeared to disqualify enlistees from service in the two world wars and the Korean conflict. Insulin shock, electroshock, prefrontal lobotomy and other intrusive brain surgeries, and the use of psychotropic medications were all highly specialized technologies that could best be applied within centralized institutional settings. These were conceived of as sites for advanced research as well as protective asylums that could secure both patient and public safety. Idaho established its first state-run mental facility in Blackfoot in 1886, followed by State Hospital North in Orifino in 1905; both facilities are still in active operation.

POLITICS AND MENTAL HEALTH TREATMENT

Criticisms of the “warehousing” of mental patients began to swell in the post-World War II period, energized by the 1962 film One Flew Over the Cuckoo’s Nest with a graphic scene of electroconvulsive shock therapy as its centerpiece. During the year prior to this film’s release, a federal Joint Commission on Mental Illness had issued its recommendations in the “Action for Mental Health” report, which called for deinstitutionalization and community integration of mental patients via local community mental health centers. The centers were to offer medications, a range of psychological and occupational therapies, social contacts and case management. While legislated into existence in 1963, a large number of these failed by the end of the decade due to underfunding. Mental patients continued to be discharged from hospitals but, lacking transitional facilities, most became homeless or wound up being arrested for petty crimes such as vagrancy and shoplifting. President Jimmy Carter attempted to restructure and re-fund the centers under his Mental Health Systems Act of 1980. One of Ronald Reagan’s first acts in office was to rescind this legislation.

Reagan’s actions, while driven by an ideology of fiscal conservatism and “The New Federalism,” coincided with the development of a biopsychosocial or ecological model of mental functioning promoted by patient advocacy groups such as the National Alliance for Mental Illness (NAMI), founded in 1979. This agenda also decried psychiatric abuses and favored individual autonomy and choice in treatment. The appeal of community psychiatry and outpatient clinics, along with sheltered housing and workplaces, seemed a good fit with demands for economic efficiency in the mental health care system. Many NAMI members felt that states would prove far more sympathetic and responsive to patient needs than the federal government. The creation of state mental health councils—Idaho’s wasn’t established until 1990—brought along the hope that recipients (now “consumers”) of public mental health services would finally enjoy a place at the table in terms of formulating local policies. This optimism was underscored by the development of so-called “second generation” or “atypical” antipsychotics and antidepressants including less expensive, time-release and injectable formats. Funding was to be guaranteed by the federal transfer payments to state Medicaid programs under Lyndon Johnson’s plans for “The Great Society.” These had been set up in 1967 and ratified by Idaho in 1969.

Medicaid also opened the door to the lucrative privatization of mental health and substance abuse treatment programs. For example Intermountain Hospital, Boise’s only private mental health facility, has changed ownership at least four times since the 1970s. Ironically, its last three owners have been large corporations that recreate, in their own way, the type of centralized financial decision-making that Reagan-era policy makers and mental health advocates found so objectionable. The state health care insurance exchange appears headed in an identical direction.

The current care structure has clearly demonstrated its vulnerability to constrained economic conditions and state government funding priorities. NAMI Idaho’s 2012 legislative report noted that Idaho led the nation in overall and per capita cuts to funding for mental health services. While Health and Welfare regional offices do offer diagnostic, assessment and pharmaceutical services for the most indigent suffering from severe and persistent mental illnesses, counseling supports remain a low priority. State clinicians devote more of their energies to emergency competence examinations and involuntary commitment court proceedings. And with Medicaid reimbursement rates in steep decline, many private practitioners now refuse to admit these sorts of clients. Increasingly discouraged by the inaccessibility of services, mental health clients become overrepresented among those who “never come in but always show up” through homelessness, arrest and incarceration.

Idaho Governor C.L. Butch Otter’s 2013 State of the State speech called for a $70 million bond issue to build “a 579-bed secure mental facility at the prison complex south of Boise.” The announcement came as no surprise. Otter chose to frame mental health issues in terms of incarceration rather than treatment and recovery. As Otter, a fierce defender of gun ownership rights, put it to the Legislature, “We all saw just a few weeks ago the terrible impact on a community and a nation when mental illness leads to tragedy.” Yet the $70 million, to be spent under the auspices of the Department of Corrections rather than Health and Welfare, dwarfs the $41.1 million that Idaho spent on mental health services in 2011.

The 2013 Legislature killed the facility proposal for financial reasons, along with efforts to establish permanent school counselor funding based on student population densities. But Otter and other politicians may find it difficult to avoid increasing pressures to reframe a public health system into a public safety surveillance apparatus. The major legacy of the rampage shootings in Idaho is the plus ca change framing of mental illness issues in terms of criminality and control, rather than treatment, recovery and hope.

The views and opinions expressed here are those of the writer and do not necessarily reflect the views and opinions of Boise State University or the College of Social Sciences and Public Affairs.

In the meantime, it’s still far easier for someone to purchase an assault rifle in Idaho than to access a psychiatrist, psychiatric nurse or mental health counselor.

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The views and opinions expressed here are those of the writer and do not necessarily reflect those of Boise State University or the School of Public Service.

  • Clayton Cramer

    There are so many things wrong with this column factually. The deinstutitionalization movement was well under way among psychiatrists by the late 1950s, and the legal pressure towards deinstitutionalization starts with John Kennedy in 1963.

    Governor Reagan was actually a pretty minor player in California steps towards deinstitutionalization (a well-intentioned policy that created massive homelessness, and dramatic expansions of deaths by exposure — hypothermia death rates more than doubled 1974 to 1984 nationally). The Lanterman-Petris-Short Act of 1967 that started California down this road was the result of well-intentioned efforts, but took a model that the authors had successfully pursued to improve conditions for the mentally retarded, and applied to a population with very different problems.

    Foucalt Madness and Civilization may make you all warm and soft, but as an explanation, it fails badly. E. Fuller Torrey and Judy Miller’s The Invisible Plague: The Rise of Mental Illness from 1750 to the Present makes a persuasive case that schizophrenia rates roughly octupled from the 17th century until the 1980s (for reasons that remain highly speculative: urbanization and toxoplasmosis are among the more plausible explanations). This better explains the Age of Reason’s expansion of mental hospital systems than this fantasy of the capitalists locking up those who weren’t productive. Would it not make more sense to just let them starve to death, if that was the reason?

    There are multiple reasons for the failure of the community mental health care centers,but “underfunding” is something of a cheap and misleading explanation. CMHCs failed for multiple reasons: failure to fully appreciate that only in a few areas would those in need of these services be sufficiently dense for an outpatient strategy to work; the fact that many of the most severely mentally ill were so ill that they saw no reason for help; mission creep, whereby CMHCs found it more interesting to do psychoanalysis on middle class patients with relatively minor emotional problems instead of helping the sometimes scary psychotics for whom psychoanalysis does not work.

    For anyone who needs a scholarly perspective on what happened (and it is a complicated and tragic story), let me recommend my book My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill (2012). http://www.amazon.com/My-Brother-Ron-Personal-Deinstitutionalization/dp/1477667539/ref=sr_1_1?ie=UTF8&qid=1377637021&sr=8-1&keywords=My+Brother+ron