Skip to main content

Both NRA types and gun-control advocates have called for greater emphasis on screening for, and treatment of, potential mass murderers by the mental health system.  There is no question that the public mental health system in this country has been shredded by decades of ever-intensifying fiscal starvation, as I well know from having worked in that system for 20 years.  Likewise, there is no question that a MUCH more robust and effective public mental health system might prevent some small portion of the seemingly ever-more-frequent mass murders by gun in this country.  But the idea that the mental health professions, even if lavishly supported, could stem this epidemic of extreme violence in the absence of effective gun control measures, is not just an obvious attempt at distraction and diversion by the NRA but even a fallacious assumption by the best intentioned advocates of mental health services.  In brief, you don't treat stop epidemics with targeted medical treatment of individuals but rather with public health measures, ESPECIALLY when it's so difficult to identify the individuals who are actually at high risk of manifesting the "disease.". To see what I mean, follow me below the stylized orange Kama Sutra illustration.

There are many reasons that even an effective public mental health system can only incidentally affect the epidemic of mass murders by gun, but most of them can be subsumed under two general facts.

1.  It is close to impossible to identify individuals who are actually likely to commit mass violence because it is such a LOW BASE-RATE behavior -- I.e., it is so rare.  It may seem horribly common;  but in a population of 330 million or so, the chances of any single person committing such an act are vanishingly small.  Even if you restrict your population to people with a diagnosis of schizophrenia, bipolar disorder, or one of the personality disorders with a high incidence of violence, you're still talking about a population of at least 10 million people.  Even if you then further restrict your population to those in your 10 million diagnosed people who have characteristics that we know are associated with violent acting-out (e.g., paranoid ideation and violent fantasies), you restrict your "at-risk" population to, at best, 500,000 to 1,000,000.  So if even 500 of these people commit murders in a year, your odds against identifying an actual murderer in any year, much less the much rarer MASS murderer ala Aurora or Newton,  are 1,000-2,000 to 1.  

There's also the problem that a good portion of murderers and even mass murderers don't have an easily diagnosed or obvious psychiatric disorder that would have led them to be labelled "at risk" -- e.g., some portion of those people who "go postal" when fired.  

Any therapist who deals with people with severe psychopathology is familiar with this problem.  I was director of a community mental health center for five years, staff psychologist on the psychiatric unit of a community hospital for 10 years, and for 20 years had a private practice with an unusually high proportion of patients with severe pathology.  I can't make even a ball-park estimate of the times that I dealt directly or as a supervisor with threats of violence by patients, much less heard about patients' violent fantasies.  And there certainly were instances in which I was genuinely concerned that certain patients were going to act out those threats or fantasies.  Yet there were only two instances in which such acting-out occurred to the point of murder, and in neither instance was the patient presently considered at "high risk" because in neither case had the patient informed his therapist about a definite high-risk indicator -- namely, that the patient had stopped taking his anti-psychotic medication.

These cases illustrate the second reason that the mental health system cannot serve as a public health measure for the prevention of mass murders.

2.  Its effectiveness is dependent on the voluntary involvement, truthfulness, and cooperation of its clients.  

Take Adam Lanza.  There have been reports that Nanzy Lanza had told friends that she had gotten psychiatric help for Adam.  But she reportedly had also told friends that Adam was burning himself repeatedly with a lighter.  Now if Adam really had seen a psychiatrist AND if either he or Nancy had been truthful and open about Adam's self-injurious behavior and also about the guns in the house, there is no way that any competent mental health professional would have continued to see Adam unless the guns had been removed from the house.  So either Adam actually had not been seeing anyone or the person he was seeing was not being given the complete picture relevant to Adam's potential for violence.

Finally, what if a fully informed professional had given Nancy and Adam an ultimatum about the guns -- get them out of the house or I don't see Adam -- and they had refused.  What can the professional -- or for that matter society -- do at that point?  Assuming that Adam had not in the recent past done any significant violent acting-out toward others, we're back to the LOW BASE-RATE problem again:  Adam may be at a much greater risk than the average person of doing something very violent in the near future but the odds are still some thousands to one against it.

Then, of course, there's always the possibility that people in the place of Adam and Nancy agree to get the weapons out of the house but never do so and the therapist is never the wiser -- just as patients often discontinue their medication without telling their therapists.  (Most people with mental health problems see a non-medical professional for therapy and a psychiatrist for medication checks only very occasionally.)

Oh, and lastly, whatever the failures of society to deal with Adam Lanza's mental health problems, it obviously had very little if anything to do directly with the financial starvation of the public mental health system over the last 30 years.  Nancy Lanza's yearly income was north of $250,000.  Assuming that Adam was covered by excellent private insurance,  his mother and father could have afforded the finest mental health care available.  Perhaps the still powerful stigma attached to psychiatric disorders played a role in Adam's never receiving treatment that prevented his eventually perpetrating the Newtown atrocity, but certainly lack of resources never did.  

So, while I'm the last person who would discourage more resources being devoted to the country's mental health system, I'd strongly advise against any claims that such an influx of resources will have any appreciable effect on the national mass murder rate or any claim that the mental health professions have some special ability to identify ahead of time those who are very likely to perpetrate such atrocities -- especially not when it's easier to buy a semi-automatic assault rifle with huge clips than it is to get a driver's license.  

Not to mention the contribution of the aggression and violence endemic to our national culture, with its foundation on genocide, slavery, and imperialism.  But Michael Moore already covered that today, even if most comments in response to him seemed to avoid assiduously that part of his diary.  

EMAIL TO A FRIEND X
Your Email has been sent.
You must add at least one tag to this diary before publishing it.

Add keywords that describe this diary. Separate multiple keywords with commas.
Tagging tips - Search For Tags - Browse For Tags

?

More Tagging tips:

A tag is a way to search for this diary. If someone is searching for "Barack Obama," is this a diary they'd be trying to find?

Use a person's full name, without any title. Senator Obama may become President Obama, and Michelle Obama might run for office.

If your diary covers an election or elected official, use election tags, which are generally the state abbreviation followed by the office. CA-01 is the first district House seat. CA-Sen covers both senate races. NY-GOV covers the New York governor's race.

Tags do not compound: that is, "education reform" is a completely different tag from "education". A tag like "reform" alone is probably not meaningful.

Consider if one or more of these tags fits your diary: Civil Rights, Community, Congress, Culture, Economy, Education, Elections, Energy, Environment, Health Care, International, Labor, Law, Media, Meta, National Security, Science, Transportation, or White House. If your diary is specific to a state, consider adding the state (California, Texas, etc). Keep in mind, though, that there are many wonderful and important diaries that don't fit in any of these tags. Don't worry if yours doesn't.

You can add a private note to this diary when hotlisting it:
Are you sure you want to remove this diary from your hotlist?
Are you sure you want to remove your recommendation? You can only recommend a diary once, so you will not be able to re-recommend it afterwards.
Rescue this diary, and add a note:
Are you sure you want to remove this diary from Rescue?
Choose where to republish this diary. The diary will be added to the queue for that group. Publish it from the queue to make it appear.

You must be a member of a group to use this feature.

Add a quick update to your diary without changing the diary itself:
Are you sure you want to remove this diary?
(The diary will be removed from the site and returned to your drafts for further editing.)
(The diary will be removed.)
Are you sure you want to save these changes to the published diary?

Comment Preferences

  •  Not to mention people who seem fine and then break (6+ / 0-)

    quickly. You are right it is a red herring. Stop the huge number of weapons that can be used in mass murders. No way we will ever get sane enough to take em all away... And now that I think of it doesn't that backfire on the fetishers because isn't fetishism a mental health issue. Haven't seen the latest Mental Health code book.... hear there are lots of changes... adding stuff .... taking away stufff... wonder how often they alter it.

    Fear is the Mind Killer...

    by boophus on Mon Dec 24, 2012 at 03:18:09 PM PST

  •  Thanks for this! I had heard a doc from BU... (5+ / 0-)

    who studies mass murder say about the same thing. There are roughly twenty mass murders per year in the US and they kill about 150 people total. There are 10 to 12 thousand killings with guns and another 15,000 suicides annually...these are the numbers I find most troubling.

  •  Also, (1+ / 0-)
    Recommended by:
    Duckmg

    People with mental illnesses have the same right to privacy for their health records as everyone else.  Government databases of people under treatment are NOT the answer.

    "We *can* go back to the Dark Ages! The crust of learning and good manners and tolerance is so thin!" -- Sinclair Lewis

    by Nespolo on Mon Dec 24, 2012 at 03:39:58 PM PST

  •  Tipped, recommended, and questioned (0+ / 0-)

    If all of those numerous people got as much treatment as they were willing to take, wouldn't that also help the tiny fraction who would otherwise have become public safety problems?

    Isn't there an opportunity, and indeed a need, for research to overcome our current inability to predict violent behavior? Has anyone even tried fMRI or autopsy of people who are capable of shooting up a school?

    Exceptionally good diary, in any case.

    •  A huge influx of resources into the public (2+ / 0-)
      Recommended by:
      gramofsam1, Dogs are fuzzy

      mental health system would undoubtedly lead to some decrease in violence.  But remember that Adam Lanza's parents could have afforded the finest mental health care available -- Adam comes from the type of background you typically see in the patients at McClean or other Harvard-affiliated hospitals or at the best-staffed independent private hospitals.  And the Aurora shooter was in therapy with someone -- at the college health center ? -- not long before the shooting.

      A massive investment in community mental health might be considered analogous to the development and widespread prescription of anti-viral drugs for AIDS, which obviously had some beneficial effect regarding the spread of HIV.  But the truly effective methods of controlling its spread have been the public health ones.

      As for better methods of predicting dangerousness, the problem is that a person's suddenly acting out in a massively violent way is seldom a function of solely internal factors -- it's almost always set off by some external stressor(s) interacting with some personal vulnerability.  So when I did psychological eveluations with people -- and I did literally hundreds with both psychiatric inpatients and at-risk adolescents, my prognoses would always be in the form of "if-then" predictions.  And, of course, you can't always anticipate all the "if's." In one particular case, for example, I never would have said, "If he meets a particularly sadistic and abusive staff member at his residential placement after he leaves the detention center, he'll become extremely violent." But that's what happened.

      Finally, a major problem with predicting "low base-rate" behaviors is that you have to set your "signal detection sensitivity" pretty high to capture as many "true positives" as possible; and that, by necessity,  gooses up your false positive rate.  In other words, even with a prediction system that identifies most of your targets of interest, you're going to have a lot of people identified as dangerous who ultimately don't act out.  This is less a function of very  imperfect predictors and more a function of the mathematics of prediction of low base-rate behaviors when you have anything much less than PERFECT predictors of the behavior, something that doesn't exist in the real world.

      Speaking of the real world, it's dangerous for practioners to set their sensitivity to signs of dangerousness too high and thus become prone to overpredict dangerousness, because they will then ultimately develop a reputation of professional "boys who cry wolf," which can have disastrous consequences for all concerned when the wolf really is at the door and no authorities will heed the warnings of the professional who, for once, actually is right that someone being evaluated IS very dangerous.  And this isn't just a theoretical concern. I've sen it happen more than once; and in one time of these cases, the psychologist's being ignored because of a previous history of cring wolf too often eventually ruined many, many lives and cost various individuals and institutions many millions of dollars.  So when a psychologist or psychiatrist is circumspect about when he or she predicts significant dangerousness in particular cases, it's not simply a matter of CYA.  

      •  It is such a pleasure (0+ / 0-)

        To "meet" someone who understands the base rate fallacy. Surveys show that even a lot of medical professionals don't.

        Absolutely right, none of the health-related proposals would have prevented Newtown, but the goal is to prevent as many as possible of the next ones.

        Is the willingness to murder young children, just the sort of people we are usually genetically influenced to cherish and protect, something distinguishable from the background of people attacking sources of grievances?

  •  I agree (2+ / 0-)
    Recommended by:
    gramofsam1, jessical

    When people say that the mental health issues are complex, they are right. I'm no expert, but I think it's possible for perfectly healthy people to find themselves in a "state", triggered by life events, where they might become either suicidal or homicidal. Also, if Lanza was only diagnosed with Asperger's, there would have been no reason to suspect he might become violent - it's a disability, not an illness. We know too little about what makes people do these things.

    The civil rights, gay rights and women's movements, designed to allow others to reach for power previously grasped only by white men, have made a real difference, and the outlines of 21st century America have emerged. -- Paul West of LA Times

    by LiberalLady on Mon Dec 24, 2012 at 10:17:57 PM PST

  •  I agree, (0+ / 0-)

    And so the only solution is a ban.

    Also, if only the mentally ill were banned from owning Gus, wouldn't this discourage treatment?

  •  These news "professionals"... (0+ / 0-)

    Why do these news "professionals" allow the NRA and gun politicians to lead the country away from gun control to this impossible task of identifying all would-be mass murderers? How can people like David Gregory and Chuck Todd and others be so easily led astray? These "newsmen" are no match for the likes of Wayne LaPierre or Gun Politicians- who seem to hypnotize them into going off in any direction they want them to go, except guns and the fact that there is no purpose for them except to kill or one day be in a position to kill.

    Is America Stupid?: Legitimate Rape, an Illegitimate President, and the Politics of Nonsense- www.isamericastupid.com

    by sfreeman614 on Mon Dec 24, 2012 at 11:27:31 PM PST

Subscribe or Donate to support Daily Kos.

Click here for the mobile view of the site