Ornstein, Leifman, Insel discuss depth of mental health crisis in U.S., ways forward


From left, Insel, Leifman and Ornstein join in conversation on mental health and the health care and justice systems in the Amp. DAVE MUNCH / PHOTO EDITOR

Norman Ornstein had some questions for his Amphitheater audience: How many of them know someone who has a mental illness, and how many know someone with a very serious mental illness? Then he asked the people who did not raise their hands: Why were they lying? 

“The fact is that mental illness touches virtually every family in this society,” said Ornstein, an emeritus scholar at the American Enterprise Institute and the vice president of the Matthew Harris Ornstein Memorial Foundation, named in memory of his son Matthew. 

And just like every family, Ornstein said, his own has been touched by mental illness.

“I’ll try and keep my composure as much as I can,” Ornstein said, “but our son, Matthew, was a brilliant, funny, warm and compassionate person who was a national champion high school debater, went to Princeton and excelled, was out in Hollywood having success when, at age 24, he had a psychotic break.”

Ornstein said his son and family went through 10 years of pain because of a broken system, from health care to court systems, that are not fit to support people with mental illness. His son was one of them, and “had no insight into the fact that he had an illness,” which is called anosognosia.

“He believed that for some reason, which he could not fathom, God had come for him and had taken his soul, but left his body behind inadvertently, and it was a struggle to recapture God’s grace and get back his soul,” Ornstein said. “The idea of taking medicine or getting treatment was anathema to him, because it would be taking the easy way out, and God would not approve.”

Ornstein was naive, he said, and thought medication would be a magic bullet. But in reality, it was one of many steps. 

“Now, for the rest of us, as we tried, we got no help from a system that did not provide any avenue for family members to intervene, but also left him on his own, because of the assumption that he was a person with freedom and agency,” Ornstein said. 

Ornstein said his son suffered from a “double whammy” of mental illness and cigarette addiction.

“He died in a hotel room of carbon monoxide poisoning. An accidental death, but a death that was not preordained, that did not have to happen,” Ornstein said. “And as my wife has said many times, he died with his civil liberties intact.”

His family and he had two options, he said: “Curl up in a ball into the corner and just grieve,” or, as President Joe Biden said, “Turn our grief into purpose.”

The fact is that mental illness touches virtually every family in this society.

—Norman Ornstein
Emeritus Scholar,
American Enterprise Institute

At 10:30 a.m. on Aug. 17 in the Amp, Ornstein joined Steven Leifman and Thomas Insel in a panel discussion about the state of mental health in the U.S. and ways forward through reforms in health care and criminal justice. Leifman is an associate administrative judge of the Eleventh Judicial Circuit Court of Florida, and Insel is the former director of the National Institute of Mental Health. The three spoke as part of Week Eight’s theme of “The Human Brain: Our Greatest Mystery.”

Leifman said most judges received no training on how to approach working with people with mental illness.

“The criminal justice system in America is the repository for many failed public policies, and there is no greater failed public policy than our treatment toward people with serious mental illnesses,” Leifman said. “But none of that was taught to me before I started.”

Early in Leifman’s career on the bench, he handled low-level charges for people who were still in custody. Most commonly, the people he saw in his court were defendants who had serious mental illnesses who did not know how to get out of jail.

As a young judge right before a trial, Insel was approached by the parents of the defendant. The mom was crying and the dad was shaking and begged him to do whatever he could to help their son. Their son was a nationally ranked debater in high school, a Harvard graduate and had been cycling through the criminal justice system. 

As a relatively new judge, Leifman thought he had more power than he actually did. 

“I deal in logic, and I knew if you got arrested and had a heart attack, there was an amazing health care system you would go to and you would get really good care, and I said, ‘Well, it must be the same for people with mental illnesses,’” Leifman said. “So I promised them that I would get their son help. The worst mistake I ever made as a judge.”

As Leifman started to go back to the courtroom, the mother stopped him, and said, “With all due respect, I think my son knows more about mental health than you do.” 

“Excuse me?” Leifman said. 

Her son was the former head of psychiatry at Jackson Memorial Hospital, until one day he had his first psychotic breakdown. He did not show up to work, thought he needed to be closer to God ­— which is called religious ideation — cashed in his life insurance policy, flew to Israel, was later deported for running around naked in the Orthodox sections of Jerusalem, and was now homeless.

In the trial, Leifman could see nothing wrong with the defendant; he was thoughtful and more respectful than the lawyers, to the point where Leifman thought that it might be the parents who were the problem. So Leifman asked him how, if there was nothing wrong with him, a Harvard-educated doctor ended up in his position. He triggered a psychotic breakdown in the defendant.

“It took me a long time to understand that I caused his psychotic episode. He never told me that he was a Harvard-educated psychiatrist, and as soon as I said those words to him, his brilliant, fast mind made the assumption that I must have been part of the CIA conspiracy, because how else would I know?” Leifman said. “And the one person he thought he could trust in the courtroom, the judge, had let him down.”

Leifman later did what his predecessor told him to do and ordered psychological evaluations, and all three came back that the defendant was incompetent to stand trial and met the criteria for involuntary hospitalization. Leifman was about to order he be put in a mental hospital and put on medication, when a lawyer informed him that, as a local judge, he did not have the authority to do so. 

Leifman’s only option was to send him back into society.

“This is the state of our mental health system in America. Not only did I not fulfill the promise I had made to his parents, I put him at risk, I put the community at risk, I probably put my job at risk, God forbid, (if) he went out and did something terrible, or something terrible happened to him,” Leifman said. “But I followed the law that day.”

The criminal justice system in America is the repository for many failed public policies, and there is no greater failed public policy than our treatment toward people with serious mental illnesses. But none of that was taught to me before I started.

—Steven Leifman
Associate Administrative Judge,
Eleventh Judicial Circuit Court of Florida

Insel said stories like this are not the exception. For people in mental health crises, they are far more likely, he said, to go into the criminal justice system than into the health care system. 

But he said this wasn’t inevitable, and there are plenty of good treatments throughout the world and in the U.S. — and though a lot of the focus is put onto medications, they are only a small part of treatment. 

Fifty years ago, he said, people with mental illness were not funneled into the criminal justice system.

“We didn’t send people to jail,” Insel said. “We didn’t assume that this was the job of a judge or a warden or a prison. We actually had health care for them. We had a community mental health system — wasn’t perfect, lots of problems there, too little of it actually dealt with the people who had the greatest needs.”

In the 1850s, he said society moved people with mental illness from the prisons into hospitals. He said people were at least safe in these hospitals, but were not well treated in many places, though sometimes they were. Public support for these systems decayed into the 1900s, and in 1963, President John F. Kennedy said people with mental illness and people in these hospitals should no longer “be alien to our affections.”

“All of that changed in about 1980, when the Reagan Administration basically demolished the community mental health system, which wasn’t working all that great anyway,” Insel said. “By that time, it needed to be rebuilt, and they decided to simply gut it.”

Since then, Insel said, in the U.S., beds in hospitals dedicated for people with mental illness dropped from 600,000 to 39,000, while the amount of people has only gone up, especially within unhoused and formerly incarcerated populations. 

Insel said everyone sees pieces of this “extraordinary injustice,” from people who are homeless to overcrowded jails. 

“What we don’t understand is that much of the root cause of those social ills, and sometimes the extreme poverty that we hear about, is untreated mental illness,” Insel said. “Yet, this is entirely treatable. I shouldn’t say entirely, but it’s mostly treatable. We can do so much better if we care about it and if we know about it.”

In 2000, Leifman had meetings in Miami with police, health care workers and politicians who recognized the need for reforms around how institutions treated people with mental illness. Leifman worked to educate police officers on how to work with people in crisis through a 40-hour training program.

“Over the last 10 years, we kept data on the two largest agencies, Miami and Miami-Dade. Those two agencies alone handled 105,268 cases, and out of the 105,000-plus mental health cases, they only made 198 arrests,” Leifman said. “The number of arrests in Miami-Dade went from 118,000 arrests per year before our program to just 53,000. After we did all of our training,  the program saved the county 300 years of jail-bed days.”

What Leifman and others did not expect from their work was for the rate of post-traumatic stress disorder within police officers to go down. He said police officers often do not want to seek mental health treatment within their own department for fear of ridicule, so part of their reforms was creating a better pipeline for officers to seek treatment in other departments.

What we don’t understand is that much of the root cause of those social ills … is untreated mental illness. Yet, this is entirely treatable. I shouldn’t say entirely, but it’s mostly treatable. We can do so much better if we care about it and if we know about it.

—Thomas Insel
Former Director,
National Institute of Mental Health

Another reform making its way through on the federal level is the mental health crisis line, 988. Insel said that across the country, as soon as states enact it, people can call this number to receive mental health support from a nurse, a social worker and a peer, who Leifman called the “secret sauce of the program.”

“The first thing we have to do is not to convince someone to take medication. We have to convince somebody that they want to live,” Leifman said. “By the time they end up in jail with these illnesses, they’ve given up on life. They don’t really want to breathe. They’ve lost all hope. They have no dreams. They’ve been treated like garbage by all of us, and the systems that we send them to whether it’s civil or criminal,” Leifman said.

While 988 responders will have a direct line to the police, they will not have a police officer with them when they first arrive on the scene. 

“We know that about 6% of calls will require police involvement. But that means 94% of the time, we’re going to handle this in a different way,” Insel said. 

Leifman said the next reform which might be added is more virtual crisis response. He said people in rural areas may not have access to a quick response from 988, so adding a way of treatment through phone could increase accessibility. 

Then Leifman talked about a project in the works with the University of South Florida. Leifman’s team asked them to identify a smaller group of repeat offenders with mental illness. He expected a group of 1,000 people, but USF narrowed the group down to 97 people who, over five years, were arrested 2,200 times, spent 27,000 days in Dade County Jail and cost taxpayers $14.7 million.

“Whether you’re a compassionate, empathetic person who just is horrified by this — which we all should be — or you’re really concerned about your taxes, we are all on the same page on this, because we are wasting it,” Leifman said. “Do you know what it costs in America for this problem? Over a trillion dollars a year to incarcerate this population in direct and indirect costs. Seventy percent of the people in jail have a mental illness, or substance use disorder, or both.”

Leifman said the work has been so successful that one of the jails in the area was closed because fewer people with mental illness were funneled into the system and more formerly incarcerated people received the help they needed. This is saving Miami-Dade County $12 million a year.

From left, Leifman, Insel and Ornstein discuss health care and justice systems in the Amp. DAVE MUNCH / PHOTO EDITOR

And because the work was so successful, Leifman and his group were approved funding for a new short-term mental health service. It is a seven-story building with 200 beds, with every service needed, from a crisis stabilization unit to a short-term residential facility, primary, dental and eye clinic, a tattoo remover, a courtroom, and programs run by people with mental illnesses to teach self-sufficiency.

“Instead of just kicking people to the curb once we’ve adjudicated their case, we will gently reintegrate them back into the community with the support that they need to maintain their recovery,” Leifman said. “People can recover. This is not a death sentence.”

The three panelists want more people to get involved in this work.

“We just have to start thinking about these like other illnesses,” Leifman said. “You wouldn’t let someone with cancer or heart disease lay out on the street and walk by them. And I don’t know why we’re not madder about it. I don’t want to be the angriest man in the room. It is so offensive because we, as judges and the police, we see this every single day.”

Tags : mental healthmorning lecturemorning lecture recapNorman OrnsteinSteven Leifmanthe human brain: our greatest mysteryThomas InselWeek Eight

The author Nick Danlag

This is Nick Danlag’s second season at the Daily reporting the morning lecture recap. He worked remotely last year but loved waking up each day in Las Vegas to learn more about Chautauqua through his reporting. From Mount Laurel, New Jersey, Nick earned a creative writing degree from Eckerd College in St. Petersburg, Florida. As editor-in-chief of his student newspaper, The Current, he loved helping the staff develop their voices.