ON WEDNESDAY, November 20, 1996, my son Tim brought a gun to school. He thought he had a good reason—he was angry with another student. He was eleven years old and in the sixth grade. He had been diagnosed with a mental illness earlier in the year.
That morning, as he waited for the school bus, he pulled the gun from the bush in which he had hidden it the night before. As the bus pulled up, he put the gun in a brown paper bag inside his book bag. When he arrived at school, he went straight to his locker and put the gun inside.
Tim forgot about the gun as he went about his school routine. At the end of the day, he went back to his locker and grabbed his jacket, leaving the gun behind.
As he stood in line for the bus, he noticed the student with whom he was angry and remembered the gun. He quietly stepped out of line and bolted toward the school, ignoring the calls of the bus monitors to come back. Tim’s special education teacher chased after him. Tim ignored him, removed the paper bag with the gun, and ran in the opposite direction. He exited the school through a side door, coming out beside a Dumpster. He had to think quickly. Students and teachers were standing around one corner of the building, and parents were gathering in the parking lot around the other. With no easy escape, he stopped in his tracks and threw the bag into the Dumpster just as his teacher emerged from the school.
His teacher looked at Tim, then peered over the top of the Dumpster, reached in, and retrieved the bag. He pulled out the gun. “Is this yours?” he asked. “Sort of,” Tim replied. Then he explained. It was a BB gun. He was mad at the other boy because the gun was broken. “He sold it to me for twenty dollars yesterday and it doesn’t work, so I want to make him take it back and give me back my money.”
The teacher relaxed a bit and said, “You know it’s against the rules to have guns at school, don’t you?” Tim nodded. “For now,” his teacher added, “this will be between you and me. Go back to your bus line. I’ll see you tomorrow.”
Tim went through his normal routine the rest of the day. When he came home, he did not tell me about the other student, the gun, or the encounter with his teacher. He played outside for a while, Rollerblading down our long driveway in the cool November dusk. He watched television and played video games with his younger brother, Ben, as I prepared dinner. He laughed and joked with Ben and his sisters, Lizzie and Larissa, over a supper of spaghetti with spicy calamari sauce. After dinner, he played with our dog, Peggy, and then worked grudgingly on his homework after failing to convince me that he had none. At bedtime, he relaxed with one of his favorite Calvin and Hobbes books until I came by to kiss him goodnight.
The next morning, Tim lay in bed for a while listening to rock music. It was a typical morning—I had to nag him twice to get up and get dressed so that he wouldn’t miss his bus. When he finally came downstairs, he was too late to eat breakfast; he happily settled for a breakfast bar and milk. I checked his book bag for his homework, packed him a snack and lunch, and sent him out the door as the bus pulled up.
I had no idea how this day would change our lives.
The principal was waiting for Tim when he arrived at school. “Did you bring this to school yesterday?” the principal asked, holding up the BB gun. Tim nodded. The principal told Tim that he had broken the law and that the police were on their way. He also planned to suspend Tim from school for ten days.
Then the principal called me. He had left a phone message for me the previous day but had been unavailable when I called back. I assumed that he was calling about Tim’s special-education-mandated Individualized Education Program (IEP), in which we had been negotiating changes for months.
I could not have been more surprised when he told me about the gun. I was momentarily stunned when he added that the police were on their way and that he was suspending Tim from school. Then I felt a rush of adrenaline. “You can’t suspend him,” I blurted out. Tim’s IEP explicitly forbade Tim from being suspended from school for any reason. It was the principal’s turn to be surprised.
This wasn’t the first time he and I had battled over Tim’s IEP. In fact, there were already armies of educators, administrators, clinicians, lawyers, family members, and advocates involved in Tim’s life. Tim’s gun-toting incident was just the spark that turned our cold war hot.
November 21, 1996—the day after Tim brought his gun to school—would be the day that changed the trajectory of his life. It was the day he was first suspended from school, the day the justice system first became involved in his life, and the day he first went sliding down the steep slope to failure.
It was not as if things had gone smoothly for Tim up until then. When he entered the sixth grade, he had already been diagnosed with language-based learning disabilities, attention deficit disorder, and clinical depression. He was receiving special education services in school, therapy from a well-qualified psychologist, and treatment from his pediatrician and a psychiatrist. He had a loving family and involved, well-educated parents. But none of this mattered on the day he brought his gun to school.
Tim fit a certain profile that was just beginning to emerge in the mid-1990s—that of an unbalanced young man who might do harm to innocent children. This was before Columbine, before Virginia Tech, and long before Sandy Hook, yet the public already connected mental illness with a propensity to violence. In “Violence and Mental Illness: The Facts,” the Federal Substance Abuse and Mental Health Services Administration quoted a study that noted that between 1950 and the mid-1990s, the proportion of Americans who associated people who have mental illnesses with violent acts nearly doubled (SAMHSA 2011).
This perception has always been more wrong than right. The Institute of Medicine has noted that “the magnitude of the relationship is greatly exaggerated in the minds of the general population” (National Research Council 2006, 103). Others concluded that “severe mental illness did not independently predict future violent behavior” (Elbogen and Johnson 2009). In fact, people with mental illness are more likely to be the victims of violence than its perpetrators (SAMHSA 2011).
On the day he first tried to suspend Tim, the principal already knew that there was no chance Tim would have used the gun in school. By then—the day after the incident—the principal knew that the gun was broken and that Tim had no ammunition. And had he taken the time to check, he could have found good research to show that Tim’s mental illness was not a significant risk factor, either.
So what risk factors are associated with violence and would have warranted a call to the police? A history of violence, substance abuse, and environmental stressors such as job loss, divorce, and becoming the victim of a crime are some (Elbogen and Johnson 2009). The Institute of Medicine (IOM) also singles out abuse, neglect, and living with parents who have been incarcerated (O’Connell, Boat, and Warner 2009). Tim had none of these risks; he was the child of a stable and loving family.
When the principal decided to call the police he was just following protocol. But when he treated what Tim did as a criminal act, he changed the conditions under which Tim was both treated and educated. And he fed the perception that Tim was dangerous—a perception that attaches itself to Tim and to so many others like him even more so today.
For years, both SAMHSA and the National Institute of Mental Health (NIMH) have worked to dispel the myth that more than a small minority of people with mental illness are potentially violent. In the aftermath of the Tucson shootings in early 2011, Dr. Thomas Insel, the director of NIMH, reminded us that “those with serious mental illness are eleven times more likely to be victims of violent crime than the general population” (Insel 2011). But every time a mass killing occurs, media coverage of the event tends to further cement the relationship in peoples’ minds. In the wake of the Tucson shooting, the mental illness of the gunman, Jared Lee Loughner, was immediately identified as a factor in his actions, and a mental disorder was automatically presumed to be a factor in the actions of Adam Lanza, the Sandy Hook shooter. So, we begin to think, the association must always be there, especially in children like Tim, even though the experts reiterate that “the vast majority of people who are violent do not suffer from mental illnesses” (quoted in SAMHSA 2011).
But there is a clear connection between violence and mental illness, and it is the opposite of what many of us think. Exposure to violence can cause mental illness. The most vivid example? Exposure to violence can cause post–traumatic stress disorder (PTSD), a common mental illness in America. According to the National Center for PTSD (2014) of the U.S. Department of Veterans Affairs, 7 to 8 percent of us will have PTSD at some point in our lives. And we know that all violence—not just the violence of war—can cause PTSD and can contribute to depression, anxiety, and other mental illnesses. We also know that children are especially susceptible to its effects.
The Adverse Childhood Experiences (ACE) Study, an ongoing collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, demonstrates the connection between abuse and neglect during childhood and adult dysfunction and depression. The ACE-affiliated authors Felitti and Anda (2010) noted that 54 percent of adult depression could be linked to adverse childhood experiences. ACE Study researchers have also argued that the more violence to which children are exposed, the more likely they are to experience depression, suicide attempts, obesity, alcohol abuse, and a variety of other adverse conditions.
Tim was diagnosed with PTSD three months after he brought his gun to school, and for a time it seemed that this diagnosis would explain many of his symptoms. But it would turn out that Tim did not just have PTSD, and the truth is that if the only thing ailing Tim had been PTSD, then with a proper response we might have been able to turn his life around in sixth grade.
What might this response look like? As a matter of public policy, we should address these causes of violence because addressing them will also address many of the risk factors associated with mental illness. In 2001, the U.S. surgeon general linked youth violence to poverty, weak social ties, antisocial parents, and peer conflict (Office of the Surgeon General et al. 2001, chap. 4). The 2009 IOM report linked mental illness to many of the same factors (O’Connell, Boat, and Warner). What we should not do is act out of fear or ignorance. We should not be so quick to blame violence on mental illness. And we should not blame children and their families for a disease a child can’t help having. I was often put on the defensive about Tim by school principals and other parents, even though I had three younger children who did not have any of Tim’s problems. “If he were mine, I’d keep him under control,” was a comment I heard more than once. It is a comment to which all parents of children with mental illness can relate. And when I heard it, I was often both angered and bemused. I always wondered just how long the person making the comment would have lasted if they had had to deal with the symptoms of serious mental illness twenty-four hours a day, seven days a week while people told them what to do!
The day Tim brought his gun to school, I could understand why his principal didn’t want to risk underreacting; he was afraid Tim might use it someday. But that fear was unfounded, and when the principal made Tim’s illness a matter for the police instead of Tim’s mental health providers, fear trumped reason.
I blamed him for this. When Tim was in the sixth grade, I still believed that we were just one good principal, one good teacher, and one good therapist away from forging a successful path in life for him. I was naive about that.
In fact, it was already too late. The deck had been stacked against Tim from the start. The people making the rules, not the people following them, were to blame. And I had been one of those rule makers just a few years earlier.
When my home state of Connecticut eliminated most of its state psychiatric hospital beds in the latter part of the twentieth century, we did not replace them with a well-conceived or adequately funded system of community educational, social, or behavioral health services and supports. I know this because I was part of this effort as a member of the Connecticut state legislature for eleven years.
Our goal in Connecticut—and throughout the country—was to move people needing treatment for chronic mental health problems from large psychiatric institutions into community mental health centers, halfway houses, schools, and supported workplaces. We also intended to provide supports to families so that family members with mental illness could live at home.
But we fell far short of the mark in building a coherent system of care and treatment. Part of the reason was budgetary. The recession of the early 1980s limited our tax resources just as we needed them for new community programs. Another part of the reason was political. It is always difficult to redirect funds away from existing services with strong lobbying efforts toward groups with little political clout.
But mainly, we fell short out of pure ignorance because we made two critical mistakes. The first was not noticing that while older adults were often the ones exiting the institutions, they had been children and younger adults when they first entered them. We paid too little attention to building the community-based special education system on which we would depend to provide the educational services these children and young adults needed in order to thrive. The second was believing that community-based services would always be better than institution-based care, whether or not we coordinated these services properly and funded them adequately. In both instances, our failure to integrate behavioral health care with health, educational, social, judicial, and correctional services was a policy blunder that magnified the effects of our mistakes.
We did not know better at the time because we had so little experience with deinstitutionalized populations. So instead of fixing the problems that were so apparent in our institutions, we unintentionally created a chain of neglect in which many people, like my son Tim, have been tangled for more than a generation.
A brilliant state legislator with whom I once served said that she came to politics believing that good ideas, good information, and good arguments would result in good public policy. She discovered she was wrong when her ideas, information, and arguments were beaten back by emotions, gut feeling, and rigid beliefs.
Like her, we are all disappointed when political leaders fall short of our expectations. We usually blame lobbyists and moneyed special interests, but we forget that the people we elect typically represent the thinking of the people in their districts. These elected officials do not have to be policy experts. In fact, we often idealize inexperience, electing “outsiders” with little knowledge of public policy in the hope that they will bring about whatever change we desire. The result is often the opposite of what we want. Outsiders too often build imperfect government systems and structures, and, where health and mental health are concerned, imperfect systems of care.
When I entered the Connecticut state legislature in 1978, I was an outsider who knew very little about health or mental health policy. I majored in philosophy at Wesleyan University. After graduating in 1975, I spent time as a community activist working on clean energy and energy-conservation policy. Then I joined the federal VISTA program, working with Connecticut Legal Services.
In the meantime, I took an active interest in local politics. Inspired by the Xaverian Brothers who taught at my high school to serve those in need as best I could and by the community activism encouraged at both colleges I attended—Middlebury College and Wesleyan University—I ran in a Democratic primary for the Middletown, Connecticut, city council in 1975, when I was just twenty-two. I lost that election, finishing last in a field of eleven. However, I was appointed shortly after that to the Democratic Town Committee and was given a seat on Middletown’s Human Relations Commission.
In 1976, I helped organize the local campaign for Morris Udall for President. Relying heavily on Wesleyan students and faculty, a few progressive local Democrats, family members, and friends of my parents, our cobbled-together political organization won a surprise victory on primary day when Udall took Middletown. I had my first political victory and new clout in the neighborhoods that would become my legislative district.
I began to think seriously about running for the state legislature, and I got my chance two years later, in 1978. I won a contested primary for an open legislative seat and then took the general election with 70 percent of the vote.
I was sworn in as a member of the state House of Representatives in January 1979. At twenty-five, I was one of the youngest state legislators. My district included about half the population of Middletown. Wesleyan was geographically at the center of my district, as was Long Lane School, a state-run juvenile-justice facility. I also represented Middle-town’s downtown business district, some lower- and middle-class neighborhoods surrounding the city’s center, and the wealthier, more rural Westfield section of the city.
Connecticut Valley Hospital, one of the state’s three large state psychiatric hospitals, was in another part of Middletown, represented by an out-of-town legislator. I could see it off in the distance from the Wesleyan campus, and when I was sworn in I never expected to be heavily involved with what went on there.
My expectations changed during my first month as a legislator. I was assigned to the prestigious Joint Appropriations Committee through the intervention of a colleague and mentor. I was the low person on the totem pole when I was invited to meet with the committee chairs to discuss my subcommittee assignments. I requested Education, Regulated Activities, and Human Services, all areas in which I felt I had either some background or interest. “You’re going to do Health and Hospitals,” they said. “I don’t want to do Health and Hospitals,” I responded. “Neither does anyone else,” they replied, ending the conversation.
A few weeks into my legislative career, with no background or training, I was the reluctant new “expert” on health, mental health, developmental services, substance abuse, and veterans services. I remained on the Appropriations Committee for ten of my eleven years in the state legislature and helped to fund every major health and mental health initiative that came before us in the 1980s. I also chaired the Public Health Committee for four of those years and managed the entirety of the state’s health and mental health policy agenda as well.
There was a clear consensus about what to do with the state psychiatric hospitals back then. We believed that they were often no better than prisons for people with mental illness and that it was time to empty them. I helped close down a state psychiatric hospital in New-town, start closing a second in Norwich, and reduce the size of the third one, in Middletown.
The same thing was happening everywhere; after decades of relying on institutional care, many people believed there were better ways to treat people with mental illness. According to the 1935 Statistical Abstract of the United States, in the depths of the Great Depression more than 300,000 people received mental health treatment in institutional settings (U.S. Census Bureau 1935). In those days, institutionalization was the primary strategy for treating mental illness. While the institutions housed people with serious mental illnesses like schizophrenia, depression, and what we now recognize as PTSD among World War I veterans and survivors of the Great Depression, without modern medications these institutions offered little more than custodial care.
Many of these institutions were like cities unto themselves. Both patients and staff lived and worked on the campus. Patients who were able to work were assigned jobs like farming and light manufacturing. Patients often stayed for years or even decades, and many died and were buried there. The institutional burial grounds at Connecticut Valley Hospital, for example, are a sad and moving reminder of those times.
The care and treatment of people with mental illness changed dramatically during the last fifty years of the twentieth century as new medications became available and the state hospitals were closed. Between 1970 and 2002, the number of psychiatric beds throughout the United States was reduced from 525,000 to 212,000. In 1970, 80 percent of the beds were in state or county hospitals; in 2002, only 27 percent were (Sharfstein and Dickerson 2009). This trend continued during the beginning of the current century. As a result, there were only 43,318 public psychiatric hospital beds left by 2010 (Torrey et al. 2012).
There was less of a consensus about what we should do to replace the psychiatric hospitals. I favored community health and mental health programming, including the establishment of supported living arrangements and supported work programs for people with developmental disabilities or mental illness, and respite services for caregivers. I also worked on passing an amendment to Connecticut’s constitution giving equal rights to people with disabilities. But it was always much easier to cut funding from state hospitals than to add dollars to community programs. In 1981, the federal government repealed the Community Mental Health Centers Act of 1963, which ended the dedicated flow of federal dollars to the new community mental health centers that were supposed to help replace the hospital beds that were disappearing.
At the time, there were no loud voices in our communities clamoring for more mental health services. The families affected by serious mental illness often kept this information to themselves. I recall the time a successful Middletown attorney who served with me on our Democratic Town Committee quietly approached me after a meeting to express his sincere appreciation for my efforts in funding mental health services. His daughter had a serious mental illness, he explained. I had known him for years and had no idea that he even had a daughter. Now I know how he felt. Parents—too often unfairly shouldering blame or shame for the mental illness of their child—are often just as reluctant to speak up today.
There is a myth that a well-run government is like a well-run business and that the skill sets needed are the same for both. This isn’t true. What I learned on the job about policy making was that well-run governments provide services that address the needs of their constituents, while well-run businesses provide products that respond to the demands of consumers. These are very different missions.
In the case of mental health treatment, we usually deal with a reluctant consumer. Just because people need services doesn’t mean they are lining up to get them. If anything, the opposite is true. A 2005 study calculated that nearly half of us will have a behavioral health disorder at some point in our lives (Kessler et al. 2005). “Behavioral health disorders” is a term for which I don’t care because it often implies to laypeople that bad behavior is the only problem. But these are all real diseases of the brain and include addiction disorders as well as all mental illnesses, including the so-called Big Three—depression, bipolar disorder, and schizophrenia—as well as PTSD, personality disorder, and others. Other surveys suggest that only 36 percent of those with a mental illness in any given year receive treatment (NIMH n.d.a).
Like many of my colleagues, I learned about mental health policy as I listened to advocates and made decisions about what to fund based on their presentations. Their perspectives were usually provider-focused. Connecticut’s mental health commissioners explained the reasons for the department’s budget requests. The unions representing mental health workers wanted better working conditions at hospitals and an expanded role for state employees in community treatment programs. Community mental health providers advocated for more funding for the services they provided. And the Vietnam veterans taught me about one of the greatest ironies in our mental health system at the time—our primary “treatment” program for addicted veterans at our state Veterans Home and Hospital was a basement bar called the Foxhole. The idea was to confine residents’ drinking to the hospital grounds so that they wouldn’t be getting drunk in nearby Rocky Hill. Only after this became public were more active forms of treatment added.
In building my policy expertise, I had an advantage over other citizen-legislators. I was content enough with the low pay to make the state legislature my full-time job. I used the time to attend as many educational forums as I could, becoming a regular at policy workshops offered by the National Center for Health Services Research (NCHSR), which is now the Agency for Healthcare Research and Quality (AHRQ). At those workshops, government officials from around the country gathered with health services researchers to explore health policy topics in depth.
I learned in these workshops that many of my out-of-state peers struggled just as much as I did with policy expertise. After listening to one research presentation, a colleague requested, “You need to make this simpler and clearer; I’ve got to be able to explain this to a plumber.” “I get it,” the researcher responded, “you mean you have to explain your actions to people who aren’t well versed in health policy.” “No,” my colleague replied, “I mean that the chair of my Health Committee is a plumber!” At least we had some time to get up to speed; there were no term limits in those days.
The one area with which NCHSR couldn’t help us was mental health, which was under the purview of NIMH. Many states also split the responsibility for health and mental health services into different agencies, promoting a nonintegrated approach to the delivery of health and mental health services. This approach is changing slowly. In 2010 the Milbank Memorial Fund reported on two decades of efforts around the country to integrate health and mental health services (Collins et al. 2010). These efforts and others resulted in some language in the Patient Protection and Affordable Care Act of 2010 promoting services integration. But the concept remains an elusive one for many policy leaders.
During my time as a legislator, we never fully integrated mental health services at the policy level with other health or educational services. At least I learned to make some connections. For example, I learned about the relationship between mental illness and substance abuse: people with mental illness sometimes use drugs to self-medicate. By doing so, they may ease the symptoms of their mental illness, in some unfortunate cases at the cost of addiction.
When I was making policy, our mental health and substance abuse services systems had recently been administratively separated. While they were reconnected in Connecticut later on (and are commonly found within a single agency in most states today), community service providers still often specialize in either mental health or addiction services. And that’s not all. Despite clear connections between mental illness and other chronic diseases, we have made little progress administratively connecting health and mental health services delivery in our states. And with the notable exception of school-based health centers, there is next to no connection among educational, health, and behavioral health services to school-aged children—which is what my son Tim so desperately needed.
When Tim was diagnosed with mental illness, he entered this fragmented world I helped to create.
Tim’s clinical services would be managed under one set of rules; his educational services under another. Correctional services would have a third set of rules; social services yet another. For Tim, as for many people with serious mental illness, following all these rules was often overwhelming. He was never quite able to bend to them. And too often, the well-meaning adults who tried to educate, support, and serve him could not bend from them. Rules could not be broken. As a result, his young life was.