Sunday, December 16, 2012

Please Don't Make Assumptions

Like many, I have been drenched in sadness this weekend.  In honor of ClinkShrink's wisdom that media coverage of  tragedies leads to more such atrocities, I will talk in generalities.

When a public tragedy happens, it gives us reason to relate it to the issues we naturally advocate for.  I am no exception, and I've been posting articles on my own Facebook page in support of gun control.  I especially like this article by Nicholas Kristof, "Do We Have The Courage to Change This?"

Mass shootings bring up the issues of gun control, adequate treatment of the mentally ill, and the combination of the two, as President Obama has put it, oh so in-eloquently, “Enforce the laws we’ve already got.  Make sure we are keeping the guns out of the hands of criminals… Those who are mentally ill."  And finally, there are what I'll call the Out-in-Left Field assumptions.

Let me take it systematically:

The Out in Left Field Assumptions:
It seems to me that sometimes people are quick to make assumptions, to fill in the blanks using their own stories.  On Friday, someone I follow on Twitter posted that the perpetrator's mother (at that point, thought to be a school teacher), was probably bullied at school and the son was doing her "dirty work."  I was floored at the assumptions that were made there, with no evidence whatsoever, and I no longer follow that person's tweets.

The Problem is The Mentally Ill People and the Care They Are or Are Not Getting:

On a blog called The Anarchist Soccer Mom, a woman posted about her own son's problems. Her 13-year-old is violent, unpredictable, and sometimes dangerous.  He has been hospitalized and she's had to hide sharp objects and call the police.  Treatment with many medications has not helped, and she's been told by a social worker that unless he gets into the legal system -- presumably by her pressing charges--  little more can be done (note that this is a child who is in treatment, not an adult refusing care) and she finds that answer inadequate (it is).  I don't know enough to comment on the quality of her son's care and whether or not there is more that could be done if only the resources were available --she does say she has health insurance.  But what troubled me is that the Huffington Post reprinted it with a title asserting that she is the shooter's mom, naming the gunman in the most recent tragedy.  I understand that she worries terribly that her child could do something awful and that she is frustrated by the inadequacy of a system that has been unable to help her child, but so far, we don't know that the shooter in question was anything like her son.  We've heard he was smart, quiet, withdrawn, and may have had a diagnosis on the autism spectrum.  So far, we've heard nothing about violence or hospitalizations.  And since I'm asking people not to make assumptions, I will tell you that I am making the assumption that the Huffington Post renamed her piece with a provocative title.

As of this writing, we know little about the mental health history, or care, that the most recent gunman requested or received, and we have reason to believe that his family may have had resources to obtain care for him.  In other instances, shooters have been in active treatment, or have had a history of a single, or a few, visits to student mental health centers, sometimes in the remote past.  In retrospect, on any case with a mass shooting of strangers, it's obvious that the mental health care rendered was insufficient, but whether there is something that can learned to prevent future such events remains unclear.  These shooters tend to be male and isolated -- that would be a lot of people to round up in preventative measures.  While I certainly believe that our mental health services are inadequate, we aren't hearing that shooters were people trying desperately to access care but were unable to do so. Sometimes they are people that a mental health professional or an educational institution was concerned about.  And while some gunmen have sought treatment at some point and then fallen through the cracks, it's not always clear that having laws that would make it easier to commit someone would make a difference, or that we want to become a society where people can be forced into treatment because they fit a profile.    Nevertheless, Newser linked to the Huffington Post anarchist soccer mom's Huffington Post title with the statement,"It's time for a meaningful, nation-wide conversation about mental health. That's the only way our nation can ever truly heal."

Yes, we need better mental health care.  And I do think that if we had a kinder and gentler system of involuntary treatment that didn't upset and traumatize people, then there might be a lower threshold to getting help for people, but I'm not sure that would prevent all these tragedies. It's one way we can begin the process of healing, but it's not the only way.  Do we ever really heal from something like this?

Keep the Guns Away from the Mentally Ill

On Pete Earley's website, he talks about how troubling it is when a mentally ill person commits a heinous crime because it further stigmatizes his son who is not violent, but has suffered from a psychiatric condition.  I'll let you read his post, because I'm not sure I'll do it justice.

Unfortunately,  Mr. Obama, I'm not sure how one goes about keeping arms away from the mentally ill.  I'm not even sure who those mentally ill are, given that a gazillion people take psychotropic medications and door-to-door surveys show that over half of all people suffer from a psychiatric disorder at some point in their lives.  It seems that disturbed people sometimes obtain guns legally because they aren't ill enough to be identified by the system (for example, if they haven't been hospitalized or criminally charged), or they are related to someone who has legal guns and they use those.  And people who are well can buy guns and then later become mentally ill, if you think it's an issue of "those people," think again.

It sounds good -- obviously suicidal or homicidal people shouldn't have guns -- but I don't know how it translates into something useful in terms of legislation.

Gun Control

Okay, you can fly a plane into a building, knife multiple people in China, blow up a federal building with fertilizer, or jump off a bridge.  We are never going to prevent all murders and suicides, but gun possession allows for a level of lethality that isn't seen in such numbers when people have impulsive violent moments, have had a little too much to drink, or leave their guns where children can play with them, or disturbed people can take them.  We probably can't round up every young man who is isolated and distressed, but we probably can question everyone who purchases large amounts of ammunition, or make it illegal to own high-velocity weapons. 

 Dr. Erik Roskes, a forensic psychiatrist, notes about the astounding number of gun deaths,"Those victims far outnumber the victims in Connecticut, Colorado, etc on an annual basis, and many would not be dead were it not for easy access to handguns. Many more people die due to impulsive shootings than due to the planned acts of the perpetrators of the mass tragedies - yet because they happen one at a time, there are no headlines.  It is not too soon - it is never too soon - to rethink our antisocial national approach to weaponry."  

I don't know if we'll find out what happened last week, whether this tragedy was planned or impulsive, the result of anger or psychosis, illness or evil, or whether this, or other similar tragedies,  are preventable in a society that values the right to bear arms and the right to refuse psychiatric treatment in the absence of stated imminent dangerousness.  Making assumptions is not helpful.


~Yes, we need better access to mental health care, whether or not such care helps prevent tragic, senseless acts that effect many people or one person.
~Perhaps we want to re-think our threshold for involuntary treatments, but that certainly will not capture every potential mass murderer.  If we do so, we want a system where accessing treatment is fast, easy, non-stigmatizing, humane, and respectful.
~We need to re-evaluate our gun laws, now. 

I'll go back to my sadness now.



Anonymous said...
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Anonymous said...

Yes!! someone posed the question to me : why dont these things happen in europe and other places as they do here?
because european citizens do not keep semi-automatic weapons in their homes and cars!It really is (pretty much)that simple...

cherry said...

It does seem that the men who are spree shooters tend to be isolated, and in this case it was probably much harder to detect that. This man had Asperger's Syndrome, and being a loner is normal for people with that condition (at least normally). It is not a sign of severe mental illness.

I also have Asperger's, and I am very much a lone wolf (probably much like the spree shooter was). I don't know what drove him to commit such an awful crime. But if I had met him before the crime, I hope that I would have taken the time to ask him what was going on in his head. That doesn't happen often enough for Aspies, and maybe in this case it neeeded to happen more.

L said...

I am the shooters mom is a line taken from the end of the soccer mom's article. And having worked extensively with that population at the 10-15 year old range, I can wholeheartedly agree. We as a country do not have adequate (any) effective treatment for kids like those. And yes, they do grow up to be shooters. So while I get your offense (at huff post, at soccer mom, at everyone in the world who's ever wronged anything you even remotely are professionalyl involved with)...get your facts straight. You come off sounding foolish in addition to just irate.

Anonymous said...

there were so many things hinted at. Mentally ill and gun control. Then there is the blaring " THE PARENTS WERE DIVORCED!" I keep hearing over and over and over again. Yet another side street that they keep trying to see as a contributing factor... who knows. But as a recently divorced mom that has full custody of two girls and makes all of their decisions, you can still be a great parent! I have one with a developmental disability. I have gotten her all the help she needs and will continue to do so.

However, I realize that as they get older, you know it is virtually impossible to make someone take their pills all the time. You can drag them to therapy, but only they can determine to use what is being provided for them. Only they decide to change their behavior,thought process. change takes a long time to implement and it is not easily done. How bad do you have to be to get long term hospitalization? How about that person that seems like a loner and is quiet. How do you determine between them just being shy or serial killer.

We all want to make sense of this one. I don't think you can. My heart aches for those adults and small children that are now gone. For their families that are feeling the profound loss. I hurt for the family of the shooter. They too are trying to make sense of it while getting scrutinized by the media as to what kind of father/mother/sibling/grandparent etc. they were and how they contributed to the problem.

Too much to speculate about.

Anonymous said...

What is their idea of better mental health treatment for people like him? Involuntary treatment for all people who seem a little odd and who don't have many friends? Shall we lock up and forcibly medicate all the nerdy science types just in case they become spree killers at some point?

As a patient, it makes me want to distance myself from mental health care because i've read the hateful comments online about the mentally ill. I do not want to be lumped in with people like him.

Sunny CA said...

I agree with anonymous above.

As someone who has been hospitalized, I assume I am unable to buy a gun. Even that generalization, that all people who have ever been in a psychiatric hospital should not be able to buy a gun is flawed, in my opinion. I am quite sane and calm and nonviolent, even though I had a single hospitalization.

Anonymous said...

Anderson Cooper is on right now asking if we have gone too far in favor of patient's rights. He says parents cannot get their adult children help. He doesn't know that this was even an issue with the shooter and his family, but hey, who cares about facts.

Instead of wondering about this, maybe he should wonder why the shooter's mom felt ok with having guns available to her son if he was so clearly disturbed. Maybe he should wonder why the mom and the shooter went to the shooting range together (per the news reports) if he was so clearly disturbed. Maybe instead of talking about how parents don't have access to good mental health care for their children, he might look at the fact that the parents were wealthy and could have afforded quality psychiatric treatment for their child had they felt he needed it before he became an adult. And, perhaps they did.

Or maybe, heaven forbid, we hold the person who did this accountable for his actions. No, apparently the media and the tv mental health professionals would rather the rest of the "mentally ill" give up more of their rights so these folks can pat themselves on the back and believe they did something helpful.

The more the media and tv mental health professionals link every high profile violent crime to mental illness without knowing the facts, the more they make people diagnosed with a mental illness who would never hurt a flea want to stay in hiding. It's beyond nauseating what he did. I am not Adam Lanza, and I never will be.

Simple Citizen said...

Some things can't be prevented.

However - These horrific tragedies can happen less often.

The answer is the same for guns as it is for drugs and also for mental illness.

It's about Access and Availability. If mental health treatment is more easily accessible - it will be used more.
If guns are less accessible, they'll be used less.

Until the whole of society changes and hate, envy, stigma, and revenge are eliminated - we need to work on access and availability.

Anonymous said...

Not sure that increasing accessibility to psychiatric treatment would prevent this sort of thing. My understanding is that many involved in these types of shootings had either received or were taking psychiatric medication, at least that's what is being reported. Also, is the type of person who would murder kindergarteners the type of person who would voluntarily sign up for psychiatric treatment, even if it's more accessible?

Should we round up anyone who looks or acts a little odd but has not been violent in case they might become a potential shooter one day? Or maybe we could require all males in their teens and twenties get mental health treatment as males in that age range are statistically more violent?

Of course, I am not being serious about forcing all men in their teens and twenties to get mental health treatment, regardless of the statistics. That would be unfair to make most men who are not violent pay for those who are. It's of course equally ludicrous and unfair to take away more rights of those with mental illness who have done nothing wrong because one person who may or may not have a mental illness does something evil.

Since the shooter had apparently not been in any legal trouble or been violent (that we know of) then how would we be able to require treatment for people like him if their only crime thus far is being a weirdo? There are plenty of weirdos who don't go around killing people.

The stigma around mental illness worsens every time the media, the tv mental health professionals, and "advocacy" organizations like TAC automatically attribute violent crimes to mental illness without bothering to wait for the facts. I read the comments on multiple articles, and they are almost universally negative about people with mental illness. I have organizations like TAC and the media to thank for making it more difficult for people like me who are diagnosed with a mental illness but who would hurt no one. If they continue to reinforce the stigma with their fear mongering, who is going to voluntarily seek psychiatric treatment? Not sure too many people want to be lumped in with that guy. I know I don't.

Anonymous said...

To the anonymous who posted right before me, great post.

I fear people with an "MI" label and or all oddball loners who have done nothing wrong are going to be treated like the Muslims were after 9-11. Actually, this has been occurring after high profile shootings and is getting worse in my opinion.


CatLover said...

I haven't commented on this blog for a year, but I will this time.

I have struggled with depression for many years, and been in the hospital several times. In hindsight, the hospitalizations were needed due to reactions to psychiatric drugs (akathisia, I suppose). I got off those drugs and after a couple years, I'm doing better, albeit still depressed. I still see a psychiatrist just in case, and have a therapist.

I would just as soon drop out of mental health treatment due to the public rage against mental patients in recent years. It's just isn't safe to be a mental patient. I am "the other." I don't dare get close to anyone for fear they will find out I am a mental patient. I already went thru the "she must be an axe murderer" thing when I made a mistake and disclosed that I have bipolar disorder to others.

I live in a rural area, and I'm a deer hunter, as are most people I know. I don't own any sort of semiautomatic and don't keep loaded guns around for home defense. I have discussed my family's firearms ownership with my psychiatrist, and they are secured, and he asks about it when I am severely depressed. I don't think I deserve to be rounded up and institutionalized or have my family's guns taken away because some teenage and 20 something men go on rampages. Just leave me alone and stop persecuting others like me (nerdy science types)! But many in the public don't hear that message, due to TAC style messages.

Why doesn't anyone advocate for more research to better determine who will become violent? As was mentioned, many people get depressed later in life, then they go on a rampage. It's not all young men and boys.

As for legality of owning firearms if you are a mental patient, in most states, a court must involuntarily commit you. Just being in a hospital voluntarily or even on a 72 hour hold will not make it illegal to possess a firearm in most states.

CatLover said...

One more comment. If getting a diagnosis of a mental illness is going to become the standard to deny gun ownership or other civil freedoms, as many people are hysterically proposing, then nobody is going to voluntarily get treatment unless they are a martyr. Of course, most people who read this blog already know that.

Joel Hassman, MD said...

As far as I am concerned, mental health care providers better watch out, we will be forced to take on patients that are not amenable to care. If politicians set policy by themselves, it will not work out well for mental health care, that I can almost guarantee.

It is time for providers to start publicly discussing what we can do to help people who can be helped. Society is looking for scapegoats and easy targets for blame. The past shooter profiles I have read long after the facts are in, we as psychiatrists can't stop these people as psychiatrists. If we stay silent and give the illusion this is a psychiatric matter alone, well, say goodbye to the profession!

Anonymous said...

Just found this article which is the ultimate irony in light of commitment concerns

Anyway, so much for the theory that the mother didn't do anything about seeking help for her son.


jesse said...

Thanks for posting that, AA. It is quite interesting. But I feel that whatever is learned there is no explanation that will be found as to why Adam did what he did, and in any event the efforts to understand him shift us away from the central point:

Regardless of his problems or what care was or was not available, if he had not access to guns the outcome would have been far different.

The Second Amendment has been distorted far beyond its original intention. Ideally it should be repealed. Gun ownership needs to be severely restricted.

Dinah said...

The Fox story does not make sense. In Maryland, certainly, guardianship does not allow you to commit someone to a hospital, the initial decision comes from 2 physicians and is soon heard in court. A family member can't make a decision to sign you in (accept in the case of a child), but it's still not the parent's call, it's the doctor's decision whether admission is indicated, and for how long. I checked with a Connecticut shrink and she said the article makes no sense.

Zoe Brain said...

Re : The Catastrophe in CT - as with all politically charged issues in the USA today, I distrust MSM reports.

There are too many vested interests, eager to put their spin on things, as witnessed by the numerous contradictory and factually challenged stories.

The truth will out, maybe not the whole truth, but enough, eventually. It might take years though. In the meantime, the waters have been muddied far too much for me to make any constructive comment on the particulars of this case.

Personally, I have difficulty believing that anyone can shoot preschoolers without being insane in some sense. The nature of that insanity is another matter, and yes, it makes a difference.

Someone who does it "for fun" and without thought of the consequences has one type.

Someone who sincerely believes these are invading creatures from the dark side of the moon who drink the blood of innocent victims has another.

In the latter case, they may not just be acting out of a sense of self-defence, but even out of a highly moral ideal of self-sacrifice. They can see the problem, even if no-one else can, and are willing to sacrifice their lives to save the world.

Pragmatically, it makes no difference in terms of preventing them from doing further harm, but I think that in the latter case, a cure may be possible, and punishment isn't appropriate.

In the former, I'm not sure the concept of "punishment" works either, even as an aid to "cure". Perpetual removal from society is essential, but beyond that I don't know. I have difficulty caring about what happens to them, even though I think I should.

Lest I become too much like them myself.

Joel Hassman, MD said...

Wait for it folks. State and Federal responses to this shooting will be to basically incarcerate anyone who is even remotely seen as a threat to society. Oh, putting them in psychiatric facilities are basically going to be the same as jail.

Where is Clink Shrink in this dialogue as of December 20?

ClinkShrink said...

Where am I? The same place I was after the Amish shootings, after Virginia Tech, after Fort Hood and the Tucson shootings. After each incident I get asked exactly the same questions and have to trot out exactly the same answers for the same discussions I'm reading now. Dinah summarized it nicely in her recent post (she knew better than to nudge me to write about this again). I quit writing about spree shooters after the third post. Too much is being written and said, too much media attention given, too much of a spotlight created for the next person who wants to go down in a blaze of celebrity. So, I don't talk about specific shooters.

Where else was I? I was on WSBA radio talking about why we shouldn't be harassing and singling out psychiatric patients because of this, why we should be spending more money on substance abuse treatment (the single factor that increases a risk of violence ten-fold), and what health care systems and professional organizations are doing to better coordinate care and make it easier to identify and offer treatment to people who need it.

As my Twitter profile states, I'm the quiet Shrink Rapper. But don't mistake quietness for apathy or inactivity. I think we need less talk, more action.

Anonymous said...

ClinkShrink, I wish I had heard your interview instead of Torrey's. I might feel a little less like a pariah

ClinkShrink said...

Anon: I wish you had seen Peter Earley's appearance, with his mentally ill son, on the late night NBC news last night. It was refreshing to see a major media outlet talking about the importance of addressing stigma and about how hard it is for people without insurance to get care.

Plain Anon said...

I'm glad that people like Clink and others are talking about the consequences of stigma, because it is a bad time to be a crazy person right now. I read this and I thought to myself, "the government will ban that drug before they do anything else of real consequence". Even tho no one knows if he was really on that drug, but it's now out there as a possibility.

I mean Congress quickly did this because the gods forbid the do something that matters.

I keep thinking about a couple months ago when I had a manic episode and my psychiatrist asked if I felt like harming other people. I have never harmed anyone ever and was pretty offended. And it was weird because in the 5 years she's been treating me, she's never asked that (that I can remember and the meds do make my memory wonky). But then on the other hand when I'm manic, she always asks me if I've taken any drugs and I'm pretty anti-drugs so I find the question ridiculous. Just something she has to ask. Anyway, my long ramble boils down to, by virtue of being manic, and not by anything I say, is it more likely I'm going to be hospitalized, "just in case"? I have a high level of trust with my psychiatrist, but still...

Anonymous said...

ClinkShrink, thanks for the link. I appreciate what you said about not singling out psychiatric patients because of this, i hope people listen to that. The media, especially, needs to hear that.

I'm afraid the stigma of mental illness has significantly worsened due to the media's repeated attempts to attribute high profile violent acts to mental illness without bothering to consider whether or not the actual person involved knew right from wrong. It's depressing.

On Point with Tom Ashbrook did a show called "Mental Health and Murder: Mass shootings, Sandy Hook, and how we care for troubled minds." Then, he said we don't know the whole story about Adam Lanza and that we should just "wait and learn." But, the problem is he (and the rest of media) didn't just "wait and learn." The title of the show said it all. The answer, of course, forced treatment. (I was grateful to Patricia Rehmer who offered a calm, more reasonable viewpoint).

i listen to some of the mental health professionals on tv, on the radio, etc and I can't help but wonder if the reason these guys see anosognosia everywhere they look is because they are not good at creating a therapeutic alliance with their patients. I see a psychiatrist, but I wouldn't stay for even 5 minutes, if he was anything like some of those guys. i listen to them and want to run the other direction.

i am going to try and remember that my psychiatrist is not like the reactionary psychiatrists on tv. He is calm, thoughtful, and kind. He tends to see the good in people not the bad.

I wish the media would stop giving most of the press to reactionary mental health professionals. Let calmer heads prevail.