Many details of James’ story are still unknown, but the portrait that has emerged from some of his videos is that of a man who seemed isolated, deeply frustrated by his treatment by society and often filled with rage, misogyny and animus toward people of all races, including African Americans. His thoughts in the videos were often disjointed and difficult to follow. But he made his threats in plain view for anyone who clicked, stating in one recent video that he had “been through a lot of sh*t, where I can say I wanted to kill people” and wanted to “watch people die.” He explicitly referenced his own “crisis of mental health back in the ’90s, ’80s and ’70s” and his interactions with health workers as he scoffed at New York City Mayor Eric Adams’ plan to address safety and homelessness on the subway by involving more mental health professionals — predicting the mayor’s effort was “doomed to fail.” In the midst of his journey from Wisconsin to the East Coast, he warned his viewers in a video uploaded March 20 that he believed he was “heading back into the danger zone,” asserting that he had a “severe case of post-traumatic stress.”
Even to the untrained person, those all would have been red flags that suggested James could have benefited, at the very least, from a psychiatric evaluation. The New York City mayor expressed his frustration during an appearance this week on CNN’s “New Day,” saying, “We are watching signs around us of those who are leaning toward violent actions, and we are ignoring them.” But criminologists have also pointed out that James shared his violent thoughts within an ocean of social media — an enormous challenge for law enforcement — and he may just been one of the millions of Americans who could have benefited from help or an intervention that he didn’t get.
At a court hearing Thursday, Assistant US Attorney Sara Winik described the attack as “premeditated and carefully planned.” James has been charged with violating a law that prohibits terrorist and violent attacks against mass transportation; he did not enter a plea and was denied bail.
Still as New Yorkers question whether the attack could have been prevented, James’ case is reinvigorating the debate over the number of Americans who are falling through the cracks as the US faces an acute shortage of mental health providers, a woefully inadequate number of inpatient psychiatric beds and too few community crisis centers where people can seek help outside of emergency room settings.
There are continuing gaps in health insurance coverage for psychological issues and major barriers even at the entry point of finding a provider, worsened by the low reimbursement levels for mental health professionals willing to treat patients on government insurance. Those issues barely scratch the surface of the problem, and they have all been aggravated by the strain that the Covid-19 pandemic has placed on the health care system.
Even before the pandemic, studies showed that one in five Americans lived with a mental illness and about 5.6% of adults were experiencing severe mental illness, including diagnoses like severe depression, bipolar disorder or schizophrenia. The mental health crisis among youth in particular has accelerated. For both adolescents and adults, mental illness can often become intertwined with substance abuse disorders as the nation grapples with a record high number of drug overdose deaths. One of the more stunning findings in last year’s “National Healthcare Quality and Disparities Report” is that more than half of people who need mental health care in this country don’t get it. The report noted that the “unmet need” is much higher among people of color: About 63% of African Americans who experience those mental health issues did not get treatment, along with 65% of Hispanics and nearly 80% of Asian and Pacific Islanders.
Suddenly, the public is paying more attention, not only because of the pandemic, the opioid crisis and the increase in overdose deaths, but also because they are encountering increasing numbers of people who have mental illness as homelessness has become more visible in their neighborhoods. President Joe Biden mentioned the nation’s problems with mental health in his “State of the Union” address, calling for “full parity between physical and mental health care.”
But the wheels of Congress are grinding slowly and the reality is that there is very little room in that body’s schedule this year to move major legislation still in the works, even though recent hearings suggest there is actually bipartisan consensus that something needs to be done.
Oregon Sen. Ron Wyden, a Democrat who heads the Senate Finance Committee, has joined forces with the panel’s ranking Republican member, Sen. Mike Crapo of Idaho, to put together what he called a “major bipartisan effort to bring behavioral health care to the forefront of the U.S. health system.”
They have tasked 10 members, five from each party, to develop legislative solutions in five key areas that include bolstering the behavioral health workforce and improving care for children and young people. Wyden’s goal is to draft legislation by the summer, and several other Senate and House committees are working on parallel tracks.
The motivation stems from the fact that members of Congress are getting an earful about the need to address mental health from constituents. That is in part because of concern about rising crime and also how mental health, housing instability and homelessness can become inextricably intertwined, sometimes with disastrous outcomes.
The shooting in Brooklyn followed several other high-profile incidents that have refocused attention on massive gaps in the mental health system. After a January incident in New York where a homeless man shoved a woman in front an oncoming subway train, Adams warned that fears are rising as people see “homeless individuals with mental health issues not being attended to.” That same month in Los Angeles, a longtime nurse died after being struck in the face and falling to the ground while waiting for the bus in an attack by a man police described as homeless. The act, police said, was “without provocation and for no reason.”
Mitch Prinstein, chief science officer of the American Psychological Association, said it was important for the public to remember that the vast majority of people who have psychological symptoms are not violent, and that “while these exceptions make headlines, for every violent person experiencing psychological symptoms, there are hundreds of thousands of people who are suffering silently.”
While there has been more attention to mental health because of the pandemic and other reasons, he said he is worried that what he’s seen coming out of DC so far “suggests incremental change.”
“It’s topping up the current systems that we have, to provide enough of a benefit to create the appearance that something meaningful was done,” said Prinstein, who recently testified about what should be done at a mental health hearing before the US Senate Committee on Health, Education, Labor & Pensions.
Prinstein told members of the committee in written testimony that they should focus on expanding the ranks of the mental health workforce and making it more diverse. In addition to investing in more programs that fund the education and training of mental health professionals, he said Congress should help reduce the student loan burdens that doctoral psychologists carry after graduate school, including through legislation that would authorize a student loan repayment program for mental health professionals who agree to work in the many areas that lack accessible care.
To address the growing needs among children and youth, he also advocated for greater access to “school-based mental health services.” And he emphasized the need for better integration of primary care and behavioral health services, as well as the need for more robust enforcement of laws aimed at ending insurance discrimination against those with mental health and substance abuse disorders.
“What I really wish that people would recognize is that the system that we have right now is so woefully inadequate — not only because we don’t have the number of health care providers that we need to address mental health — but we’re ignoring decades of science that could help us prevent so many people from suffering symptoms in the first place,” he said.
As an example, he noted that the federal government invests $15 billion a year to train medical health providers and less than 1% is directed toward training mental health care providers.
Dr. Michelle P. Durham, who is vice chair of education in the Department of Psychiatry at Boston Medical Center, said she hopes both lawmakers and everyday Americans will recognize that it’s “a system that’s really never been invested in.”
“We’re now in this point in time where the pandemic has affected lots of folks, and there’s been an increase in demand for services with a lack of infrastructure at community levels across the country. … There’s just not enough resources,” Durham said. “We have to invest in the infrastructure, we have to invest in our workforce and then we have to invest in community supports, period, so that people can get treatment when they need it.”
She pointed to some of the ideas that Congress should explore like greater investment in walk-in clinics at the community level and mobile crisis teams that can send out clinicians to evaluate and treat those who are experiencing a crisis, as well as successful programs like the Children’s Behavioral Health Initiative in Massachusetts that has made more therapists, case managers and peer support systems available to families within their communities.
Durham said she was encouraged that the pandemic had shined a light on some of those urgent needs. “I think many of us in the field, we’re feeling hopeful, actually, that people are starting to listen; people are starting to understand more about the difficulties of the mental health care system in the US,” she said.
The question now is whether members of Congress will show the political will to follow through.