08 November 2018

Yet Another Mass Shooting; What Can We Do?

There was yet another mass shooting yesterday, this time at a bar in California, last night by an ex-Marine with PTSD and a history of minor run-ins with police. Eleven patrons of the bar, a sheriff's deputy, and the shooter are dead.

Something like 98%-99% of mass shootings result in a perpetrator who dies or is apprehended and never walks free again. Whether or not they are killed, the perpetrators are predominantly indifferent to their own lives at the time.

No new criminal laws can do anything to deter perpetrators from committing these kinds of crimes, and at roughly one mass shooting a day in the United States over the last year, it is a problem that shouldn't be ignored. And, it takes pro-active solutions that go beyond imposing harsh criminal punishments upon people who commit these crimes in an effort to deter them.

What can we do?

Gun Control

One is to institute better regulation of guns in our society, which make mass murders much easier to commit and make them far more common. Some examples include the following ideas.

* Actively disarm people who show "red flags" (don't just prohibit them from buying new arms). This threshold shouldn't be too high. But, it needs to be defined in a way that doesn't discourage people from seeking mental health treatment.

* A license should be required to own any firearm, that license should require renewal every few years, and the renewal should involve a background check each time that could catch mental health incidents, run-ins with police, early signs of dementia, and other "yellow flags."

* Hold people who provide guns to people who aren't allowed to have them without doing due diligence to confirm that they are allowed to have guns both criminally and civilly liable for the harm that they cause.

* Establish clear civil liability for people whose guns are stolen or lost because they failed to take reasonable care to secure their guns and maintain control of their guns.

* Require guns owners, collectively, to finance compensation for those harmed by gun crimes of people who lawfully possess guns, perhaps through mandatory insurance or an excise tax going into a compensation fund.

* Make "smart guns" that can only be used by the owner who has, for example, an RFID key to it, the norm. Perhaps mandatory insurance rates could be much lower for smart gun owners than for others, for example.

* There is some cause for minor regulation of the types of firearms that may be legally owned such as the assault rifles used in so many mass shooting and the extended magazines used in this shooting.

* The default position ought to be that ex-service members should not have guns until affirmative cleared with a psychological evaluation (indeed, a psychological evaluation not just immediately following discharge but also a year or two after discharge really ought to be standard operating procedure for every single discharged service member whether the discharge is honorable, a bad conduct discharge, a dishonorable discharge or otherwise). While veterans all have training in the use and care of guns, in a situation that while they are in service is much more tightly regulated than it is in private life, the rate of PTSD in veterans is high due to what they encounter in their service. This is often undiagnosed because military culture often treats a PTSD or other mental health diagnosis as a sign of weakness. 

Mental Health Care Reform

The Problem

The current deinstitutionalization approach and physical disease/injury model of health care used for mental health has led to many, many negative side effects, even though it addressed genuine problems with the previous regime and even though the physical health-mental health parity movement has increased the availability of mental health treatment resources that are sorely needed. These include:

* high levels of the subset of homelessness involving vagrancy among people who have mental health conditions (particularly notable are the large number of veterans who have mental health issues often related to their service that cause issues);

* ill treatment in jails and prisons that are full of people whose main problems are mental health or substance abuse issues that also don't protect the public well;

* the status quo has led to the widespread closing in inpatient mental health and substance abuse treatment facilities in recent years;

* many of the people least able to access health care in the current system are people who are most in need of mental health care;

* mental health care for those who need it benefits the general public in myriad ways in addition to being a community obligation;

* poverty and suffering for individuals with mental health and substance abuse conditions who can't get treatment;

* the massive numbers of deaths from the opiate epidemic that we aren't equipped to treat, 

* many tragic incidents of mismanaged interactions between police and people with mental health conditions, and

* crimes such as mass shootings and killings of people in the families of people with mental health issues by a certain distinct and narrow subset of people with mental health conditions.

One important subset of mental health/behavioral health conditions that are often associated with both vagrancy and criminal activity is a history of traumatic brain injury, a very serious condition with very serious consequences that very frequently goes undiagnosed. TBI is pervasive among people with many rule violations while incarcerated, people with high recidivism rates and vagrants (a term I prefer to describe a subset of the much larger class of people called "homeless" that isn't all euphemistic techno-babble; homelessness overall is largely an economic problem, but persistent vagrancy is mostly a mental health and substance abuse problem).

Even when TBI is diagnosed, people who suffer from it very often receive inadequate treatment and support.

Reforms To Address The Problems

A whole sale overhaul of how we treat mental health is in order.  What kind of reforms make sense?

* The mental health care sector needs to have a component that is not organized on the patient self-advocacy, isolated curable disease or injury model. 

* Instead of setting up the system to discourage excessive use, it needs to be designed to minimize underuse of mental health resources. 

* It needs to be pro-active. 

* It needs to get people who have mental health issues out of default criminal justice system regulation that doesn't address the problem when possible, and when not, needs to provide treatment to people in the criminal justice system.

* It needs to be universal and not dependent upon patient ability to pay and hence probably not private insurance based at all. 

* It needs to finance far more outpatient facilities and inpatient mental health beds than our existing system does. 

* It needs to recognize that an M.D. with a residency in psychiatry should not be necessary for the vast majority of mental health treatment including mental health treatment involving prescription drugs. 

* It needs to be the primary means that our society deals with substance abuse issues of all kinds, which should generally be decriminalized, at least at the level of the user of substances who is often addicted to those substances.

Also note that comprehensive, universal mental health care is much, much less expensive than comprehensive universal health care generally (also a good idea, but mostly with different institutional needs).

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