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In the recent past there have been multiple cases of mentally and emotionally unstable men who have gone into a theater or school and gunned down unarmed, innocent people for no apparent reason.  How to combat this trend has brought much debate to the airwaves and news outlets.  Some people say we need to arm teachers and allow them to carry guns to school.  Others say we should put armed security guards or policemen in every school.  There are inevitably those who say we should outlaw all guns so that this can’t happen.  What we don’t hear much about is what the actual problem is and how to fix it.

Saying that the cause with all these shootings is the availability of guns is like saying that the cause of obesity is the availability of spoons.  A gun is just a tool and if a gun is not available, knives, baseball bats, chain saws and gasoline are alternatives.  So as you see, it is illogical in the extreme to blame the shootings on guns.  Guns don’t kill people, people kill people.  It doesn’t take much reading about history’s serial killers to find that most of them didn’t use a gun to finish off their victims.

There is no doubt that we cannot just sit idly by and allow these sick individuals to waltz into our schools, theaters and malls, mow everyone down with whatever their firearm of choice may be and go their merry way off to life in prison.  The real problem here is that the problem itself has not been clearly defined.  The problem is not the tool – the guns; nor is it the lack of security — the guard or police.  The problem is that we have thousands of mentally ill people running loose in our communities without proper supervision.

In the 1950’s this country began a process of what is referred to as “deinstitutionalization”.  This happened shortly after the advent of psychotropic medications that alleviated many of the most difficult and dangerous symptoms of many psychiatric patients.  Many of these patients had lived decades within the confines of institutions and were not too keen on being put back out into the community.  In that day and time there was not much understanding and tolerance of any sort of deviant behavior.  So over a period of several decades most of the people were medicated, stabilized and moved out into the communities to live amongst us.  As long as they kept to their medication and had some family members to keep tabs on them, they were pretty much going to be okay — or so it was thought.

Flash forward about 50 years and now there are few mental institutions left.  Those that do exist are primarily for taking in acute cases of psychosis or depression, getting them to the point that they are on medication that appears to be working and then turning them out to be treated by their family physician or local community mental health cooperative.  Unfortunately, they are not getting the help they need.

With the advent of this “community based outpatient care” model, many if not most of those patients who need to be in an institution, under constant psychiatric supervision, are not.  They go off their medications, may not have family who are able or willing to care for them, often end up homeless, on other drugs or alcohol that aggravates their underlying psychosis, or in prisons where they must be segregated from the general prison population.  Much of their behavior, having been criminalized, rather than hospitalized, is out of anyone’s control.  These people have rights too.  As any mother of one of these mentally ill people will tell you, once they turn 18 years of age, they have the right to go off their medication, the right to say and do whatever they please, the right to use drugs, the right to look at pornography, the right to drive around the community, the right to drink and even the right to buy firearms — if they have not yet been incarcerated as a criminal.

Now we have defined the problem.  How shall we fix it?  Should we bring back the institutions where people lived from time of diagnosis until they died?  I don’t think that is the answer.  Unfortunately, when our government gets involved it seems to be all or nothing.  Either there is a one-size fits all solution or it can’t be solved.  In this case we need a measure of discretion on the part of healthcare providers and family members.  We need to provide caregivers with the tools they need to make sure these people are properly supervised, medicated and accountable.

Insurance providers need to allow for hospitalization in mental institutions of up to six weeks or more for patients to begin to get the proper medication in their systems and make sure it is being well tolerated and is the proper dosage.  This can’t be done in less than two weeks.  They need to be allowed to be stabilized, begin a program of psychotherapy that can be continued on an outpatient basis and have a case worker make sure they are being properly cared for at home.  You wouldn’t set a cardiac patient out on the sidewalk with nobody to care for them a day after open heart surgery would you?

If they are going to have community based outpatient care, the healthcare system, whether through private insurance or public medicare/Medicaid, needs to provide proper care when they exit into the community.  In cases of people who are no longer living with family members, that is probably going to look like live-in or around the clock, in-home supervision and staffing.  They need to be in an institution.  If that institution has to be their  second floor apartment, so be it, but they need to be cared for properly.  Proper caregiver support will mean that their medication is tracked, side effects noted, medication adjusted, behavior documented and the necessary actions taken to make sure they are not a threat to themselves or the community at large.  Those living with family need to have their family given the ability to make them take their medication and be hospitalized if their behavior or symptoms get out of hand.

Until these safeguards are put in place, you will see more tragedies like the school shooting in Connecticut, the theater shooting in Colorado and the schizophrenic locked up in prison or living under a bridge in a community near you.

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