Speaking Ill of the Dead

I'm moving this discussion to its own post since it has little to do with mandatory employee health screening and I think it deserves its own section.

Jesse put up a link to a PBS news interview with Drs. E. Fuller Torrey and Elspeth Ritchie regarding Aaron Alexis, the alleged Navy yard shooter. This has spurred discussion about what, if anything, psychiatrists should be saying in the media about specific individuals with rumored mental illness.

I've gotten on a soapbox about this a number of times before and I don't want to be repetitive, so if you feel inclined you can search the blog for the labels "shooter psychology" and "spree killing." You can also read my Clinical Psychiatry News column about a similar situation, "Use of Psychological Profile to Infer Ivins' Guilt is Prolematic". (Titles are not my strong suit.) I wrote a followup column about this just last month when the president of the APA tweeted out a statement regarding the legal sanity of the Fort Hood shooter.

Honestly, at this point I feel like a broken record. (Oh dear, some of our readers have probably never played a record!)

In my opinion, no mental health professional should be making public statements about the legal sanity or mental state of a living criminal defendant prior to trial. Presently our APA ethical guidelines do not expressly forbid this, unfortunately. The guidelines make a generic caution against public statements regarding people we haven't personally examined in a principle known as the Goldwater rule. This has been interpreted to mean that public statements are OK as long as the professional makes an initial disclaimer that they have not personally examined the individual they're talking about.

This guideline was written and adopted before the Internet was invented, even before there were personal computers (back when people knew what 'records' were and what happened when they cracked).

I felt the time was ripe to bring this so-called Goldwater rule into the modern age, and I also felt strongly that we should include a specific caution or prohibition against public statements regarding criminal defendants. I drafted proposed language in an action paper which was later adopted by the APA. To my knowledge, the Goldwater rule is being revisited (and hopefully revised) right now.

But back to Aaron Alexis and the PBS interview. This is where it gets tricky. In contrast to the Fort Hood shooter, Jared Loughner and the Aurora theater shooter, this is a situation where people are making statements about a dead suspect rather than a living defendant. The impact on a dead person is, well, moot.

Nevertheless, there are ramifications to consider. Media statements may reinforce the notion of guilt in the public mind when the deceased was never actually tried or convicted, or any of the evidence put to the test. This was the case in the situation of the late Bruce Ivins, the anthrax mailing suspect. In that case the only physical evidence linking him to the crime was the genotype of the anthrax bacillus. This evidence was weak enough that FBI investigators were concerned it might not be admissible. He might have been innocent. The situation is slightly different for Aaron Alexis given that he was definitely at the scene of the crime and presumably the evidence of guilt might be stronger than in the Ivins case. But does that change our professional obligation to maintain respect for persons? At what point do we need to balance the real need for public education about mental illness, violence risk assessment and the pro's and con's of involuntary treatment against the distress of a surviving loved one? While public opinions about won't impact a dead suspect, they will impact the suspect's wife, children and siblings. Just ask the mother of the Columbine shooter.

This post is getting a bit long and I have other things to do, but I thought I'd spew out an initial reaction. There are also state laws about medical confidentiality which address the maintenance of confidentiality after death, but that's a topic for another post. Some confidential information might have become available to investigators when the suspect was still alive, in the heat of the incident when danger was imminent. Given that there will be no trial, we likely will never know. But these situations are bound to come up again so we should be prepared for these discussions.

The News is So Depressing Lately

Usually ClinkShrink posts about shooters.  It's really not my area of expertise, but lately I've been struck by how many shootings there have been.  I'm wondering if this is a more common occurrence lately, if it's more publicized, or if I'm just paying more attention.

In the last few weeks, it feels like there is a constant flow of tragedies in the news:
There was the teenager who killed 3 students and wounded two others at a school in Ohio.
A Florida teacher killed the head of his ex-school after being fired .
A gunman walked into a psychiatric hospital in Pittsburgh and killed one person and wounded 6 others.
A U.S. soldier in Afghanistan killed 16 civilians in their homes, including young children.

I suppose the story of the teacher is different in that it was a murder-suicide where the shooter knew the victim and had a motive-- such tragedies do happen often and their news coverage is often limited to local news-- while the other shootings sound to have random, multiple victims, and no obvious motive.  I've actually never heard of a mass shooting in a psychiatric hospital. 

Any thoughts?  Maybe ClinkShrink has some insights.  

Committed!

There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

• The psychiatrist doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a psychiatrist to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
• There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the psychiatrist/ER staff to give them each enough attention.
• There are other risk factors which leave the psychiatrist feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
• The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
• The psychiatrist has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
• The psychiatrist has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
• A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
• The patient refuses to commit to a safety plan.
• The psychiatrist is evil and loves power.  (I had to throw that in here)

This is our 1,500th post.  Thank you for helping me procrastinate.

Shooter Psychology, Part II

Here's an aspect of shooter psychology you don't often hear about. It's from an article written by the mother of Dylan Klebold, one of the Columbine killers. It's hard to imagine how one's child could do something so horrific, harder still to imagine that a shooter could keep his plans so well hidden even from those who knew him best. He was a bright child with few previous problems. Certainly fewer problems than the Tucson shooter and less evidence of mental illness. How did things go wrong?

In her own words:

"Those of us who cared for Dylan felt responsible for his death. We thought, "If I had been a better (mother, father, brother, friend, aunt, uncle, cousin), I would have known this was coming." We perceived his actions to be our failure. I tried to identify a pivotal event in his upbringing that could account for his anger. Had I been too strict? Not strict enough? Had I pushed too hard, or not hard enough? In the days before he died, I had hugged him and told him how much I loved him. I held his scratchy face between my palms and told him that he was a wonderful person and that I was proud of him. Had he felt pressured by this? Did he feel that he could not live up to my expectations?"

It's hard enough being a parent, wondering if you're doing things 'right' or 'good enough', even you're kid isn't a spree killer. The parents of the Tucson shooter are probably asking the same questions.

What I Want From ClinkShrink, by Dinah

Dear ClinkShrink,

Thank you for writing your post yesterday in response to requests for your input on the tragedy in Arizona. I liked reading about The Killers I've Known (or rather the killers you've known) and certainly I enjoyed revisiting your article on Shooter Psychology. And it does seem to be true that we all pester you every time there is a mass shooting.

I know you can't really comment on the motives of a mass murderer whom you've never examined.

Here is what I think it would be interesting for you to write about, if you want to. Or maybe if our readers bother you because they seem to have more influence than I do.

I'd like to read about the process of what will happen to the man who committed this heinous act. The descriptions in the news paint a picture of a man who may have been mentally ill or under the influence of drugs, or both. So what happens from here? Does he go to jail or to a psychiatric facility? How is it determined if he was mentally ill? What sorts of documents are examined and what sorts of people (if any) are interviewed? If he's found to be unable to stand trial, how does that work? Will he be treated with medicines? If he's very psychotic, might the medicines make him much better, and how would play out? Could he then stand trial? I'm going to assume that there's no chance (I hope) that he will be released back into free society, at least not now. What factors influence whether he is found not guilty by reason of insanity (does that designation even exist anymore?) And where does he go if he's found to be a) mentally ill and unable to understand the consequences of his actions, b) mentally ill but able to understand that what he did was wrong, c) that drugs were part of the picture or d) not mentally ill and fully able to understand what he did. How much difference does it make as to which state someone lives in who does something like this in terms of where he might end up? And in death penalty cases, does his mental state matter at the time of the crime? At the time of the trial? At the time of execution?

So perhaps I want you to give us a full forensic fellowship in a blog post. You are a good sport. It seems we're going to hear a lot about gun control and tea party's and political agendas and obstacles to treatment of the mentally ill and what obligation society has to prevent such atrocities. You have something different and important to add.

Cheers,
Dinah

The Killers I've Known

Some blog readers have been asking for a post about the Arizona shooting incident. The issue of spree killing has come up on the blog before, after the Amish killings in Pennsylvania, after Virginia Tech and the Fort Hood incidents. This will officially be my third poster about shooter psychology and it's getting hard to find something new to say.

First of all, most murderers don't have multiple victims. According to the Uniform Crime Reports, the number of multiple-victim killings has remained pretty stable over the last five or so years, at about 350 per year. Almost all multiple victim killings are committed using guns, although in 1987 there was an anomaly in which 24 people were killed by poison. More about that later.

In most cases, the killer knows the victim and that's true both for single and multiple victim offenses. The nature of the relationship varies with the setting and type of killing: spree shooters most often kill co-workers or other students, while single victim killers murder their partners or drug acquaintances. Psychotic killers will usually murder a caretaker, a mother or wife, but only if the killer is a young male. Female psychotic killers tend to kill their children. It's rare for a psychotic killer to murder multiple strangers. Locally I can recall only one case like this over the last twenty years. In this case the killer suffered from a grandiose delusion, and the victims were killed in a car crash. Psychotic people can stalk or threaten political or other high profile figures, but this usually doesn't result in violence. Typically what motivates psychotic political stalkers is a delusion of some type, for example the belief that a political (or other stranger victim) is threatening them in some way. For example, one political stalker I examined believed that a U.S. Senator was a devil worshiper, and that he was destined to kill all devil worshippers. Another psychotic letter writer had a delusion about the president, although he was so thought disordered it was a little hard to sort out the "logic" behind the delusional motivation.

Multiple victim killers could be spree killers or serial killers. That 1987 anomaly with the poison deaths was partly due to Donald Harvey, a serial killer in Ohio who poisoned patients at the hospital where he worked.

Non-psychotic spree killers have the same motivations as "regular" single victim murderers: frustration over the loss of a job, the loss of a relationship, loss of a living situation, lack of money or friends, alienation from family and substance abuse. Killing is an act of desperation whether you're killing one person or many. Political motivations may come into play, but without the "nothing left to lose" factor political motivation isn't enough.

So why did the Tucson shooter act? Ya got me, I haven't examined him so we can only speculate based on what's in the news. All I can tell you about is the usual characteristics of the killers I've known.