This is a current (6:30pm Pacific Time, December 6, 2007) headline on CNN:
“State official: Shooter placed in mental health facility 5 years ago“.
Yahoo! news reports “Omaha gunman freed from centers, homes“. MSNBC leaves it at “Mourners light candles for Omaha mall victims” and the New York Times states “Details of Omaha Shooting Emerge”.
We cannot contest the truth within CNN’s headline: Yes, the public record indicates that the young man received (both in the past and recently) mental health treatment. Placing this information within the headline, however, overemphasizes this fact. Though not explicitly stated, the implicit message is “the reason why this young man shot all of those people is because he was mentally ill”. This information can be further distorted such that people then think “mentally ill people are violent”. The media communicated similar messages earlier this year following the Virginia Tech shootings and thus, one might then suppose “all mentally ill people are violent”.
Stigma increases.
So? Is it really true that people with psychiatric diagnoses are “all” violent? How about just “more likely” to be violent? By how much?
Is all of this media attention on “mental health” warranted?
What evidence is available?
One paper (”Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods“) compared people who were recently discharged from psychiatric facilities (the study group) and people who lived in the same neighborhoods as the study group. The study followed everyone for one year. For those who did not use any illicit substances, the rate of violence did not differ significantly between the two groups. For those people who did use illicit substances, the rate of violence increased in both groups and was higher in those with a psychiatric diagnosis. Most of the violence was directed towards family and friends. Of note, most of the violence from the study group occurred within the first ten weeks following discharge from the hospital (though it is also true that people “disappeared” from the study as it progressed…). There was also something suboptimal about the statistics (a field which is definitely not my forte)… though that is often said about many, many studies.
So one might conclude from this study that substance abuse/dependence increases the risk of violence in all people, though a bit more in people with a psychiatric diagnosis, particularly in the period immediately following discharge from hospitalization.
Another paper reviewed data from the National Comorbidity Survey (a mental health survey that involved thousands of people—this is the document that came up with the statistic that nearly 50% of people experience a mental disorder in their lifetime…). This data relied upon self-report. The paper concluded that
People with 12-month diagnoses of anxiety disorders, dysthymia and major depression were three to four times more likely to admit violent behaviors than those with no disorders. People with bipolar disorder or drug and alcohol abuse were eight times more likely to report violent behaviors. People with co-occurring non-substance and substance abuse disorders were more likely to report violence than those with only non-abuse disorders.
The authors also state in the abstract (I do not have access to the paper myself) that ethnicity and gender are better predictors of violence than psychiatric diagnoses (which opens up another can of worms…).
What does this information mean? That people with psychiatric diagnoses are more likely to share this information? Are we to assume that everyone was telling the truth? Was there any collateral information available?
Another paper appeared in the New England Journal of Medicine (by Richard Friedman, who I referred to a couple entries back) that also asked the question I write of now. He, too, reviews a few studies, including another large, epidemiological study (it looks like from a book?), which concluded that people with diagnoses of schizophrenia, major depression, and bipolar disorder were twice to three times as likely to assault someone as compared to those who do not have a psychiatric diagnosis. (He also comments about the increased likelihood of violence in those individuals using illicit substances.) However, he then states that the prevalence of mental disorders is very low in the population and thus contributes very little to the absolute amount of violence in a population. He pithily finishes the article with “most people who are violent are not mentally ill, and most people who are mentally ill are not violent.”
I don’t know just how much “strength” we can attribute to what data is available. There seem to be some associations, but there certainly is insufficient evidence to support the idea that all people with psychiatric diagnoses are dangerously violent.
It is both unfair and unfortunate that some major media insist on advertising in bold, large-point font that perpetrators of violence are mentally ill. Such disproportionate attention suggests causation when none exists. Do headlines ever read “SHOOTER DID NOT HAVE A MENTAL ILLNESS”? Or “GUNMAN NEVER RECEIVED MENTAL HEALTH SERVICES”?
Why not?
I do not mean to minimize the sorrow of the citizens of Omaha. We all wish for a reason for this violence—we want to assign responsibility to someone or something. A psychiatric diagnosis or history, however, is not always—and, in fact, is very rarely—to blame.
6 Dec 2007 |
Ok, so you are saying that people who are completely mentally well, who Maslow would classify as self-actualised, who are eu-whatever on all DSM axes, are just as likely as, say, someone with paranoid delusions to accumulate a weapons store and kill a bunch of strangers and then kill themselves? Because that’s really counter-intuitive.
In my lay worldview, this kind of killing is by definition a sign of mental illness. Killing is part of the range of human behaviour, but normal killing is more purposeful or directed or has a group component.
In my lay worldview, the statement that these mass killers had received psychiatric services in the past is a comment on the services. The people who knew them could see that something was wrong; other people had tried to help; the help wasn’t enough. This is very sad.
I’ve known a number of mentally ill people socially over the years. The only murderers I have known personally were mentally ill. That doesn’t mean that I think all mentally ill people are murderers, but it does mean that I think the problem of getting treatment for the mentally ill is a real one. If a schizophrenic I know is aggressive, swearing or threatening someone with a knife, it’s a sign to me that they have either stopped taking their meds or are taking street drugs or both. It doesn’t make me think that they are well.
Most mentally ill people I have known are not violent or aggressive, on or off meds. But paranoia worries me, and paranoia is not a sign of wellness.
Comment by Alison Cummins | 7 Dec 2007 @ 11:19am
Alison- I think there are several factors here that need to be addressed. First, a paranoid person may commit violence, or they may barricade themselves in their home. Paranoia in and of itself doesn’t mean schizophrenia, and very few paranoid schizophrenics are actually violent. Second, just how many people out there are “mentally well” in a Maslow sense? Just because you don’t fit a DSM diagnosis doesn’t mean you are a fully actualized, mentally healthy human being. While I think it is true that such a healthy person would only rarely commit a violent act, look at the people who do commit violence to obtain drugs, money, etc–these people don’t usually meet criteria for a psychiatric diagnosis, but I doubt most of us would think they are really “healthy”.
I think the drug abuse angle is probably the most telling. The Omaha shooter had a documented history of drug abuse, in addition to possible depression (per his friends). Did the mental illness precede the drugs, or did the drugs cause the mental illness? It’s a question we often can’t answer. It appears that this particular person was released with everyone’s blessing–his father’s, the court’s, the doctor’s, etc. As he was an adult, he was released to no one’s custody. While I wonder what kind of life skill training he was given in all those group treatment settings, the fact remains that when he was released, he’d served time for his drug charges and received far more treatment than most people (when the average inpatient stay is 5-7 days), and could not legally be committed any longer. Unless you are proposing that we lock up the mentally ill indefinitely just because they are mentally ill, we’ll continue to release people like him (just as violent offenders are released from prison when they have completed their sentence). Could the services he received have been better? I have no idea, but they probably could have been. Was this person a ticking time bomb, waiting to “snap” (his word)? Possibly; if those responsible for his release had any idea, they would not have let him go. At some point, he was responsible for his own action, and he chose to commit a terrible crime. Was he actively psychotic at the time of his crime? That I don’t know, but his note actually sounds fairly logical, which would argue against psychosis. Unless a person with major depression is psychotic, they can still see reality albeit through a dark lens, and they are still responsible for their actions.
Comment by Tiny Shrink | 8 Dec 2007 @ 7:07am
Here’s an odd twist I haven’t heard anyone comment on. Sorry to take you off point, but that’s my diagnosis….
Our small town had a tragic shooting. 35 YO male with semi-auto kills his wife, the opens up 250 rounds on the Sherriff’s office, kills deputy and a nearby all night church janitor, then self. Maybe you read about in the Northwest news, even national news. Guy had received court ordered counselling as part of domestic violence issues and divorce procedings previously. He refused to continue in counselling. He was scheduled to appear before the judge the coming Monday as to why he wouldn’t go to counselling and the threat of jail was out there.
But it seemed like this guy, (I believe he was mentally ill, but dx??) seems to have been set off by the THREAT of counselling (or jail, the judge had tried to make the choice clear)….I’m sure there were other issues, but as I studied the local news reports that came out. The guy had been out drinking beer with his buddies just 30 minutes before he locked and loaded.
I have seen counselling in family discussions used as an insult(”She’s so wacked out, she needs counselling!”) as a threat ( I’ll send you to counselling if you don’t shape up!”) and of course the usual avoidance stategy, but I had never heard of a homicidal rage triggered by the threat having to go to counselling.
Multiple homicide tragedies make news, and the perception is they are more frequent….As to the ’sense’ of them, and their relationship to Mental health treatment, I’m not sure the discussion is fruitful. It reminds me of the forensic pathologist(Byard) from Australia who studied the details and prognostic factors for maternal multiple infanticide( Moms killing their kids). His presentation was so dry, his examples(6?) so horrific…the contrast he even, in his reserved, clipped way apologized for a couple times. There’s something to say about the ability to turn the light of analysis on that which we abhor. But it makes you wonder…
In the last comment(tiny shrink) I believe the issue of responsibility arises. In this country, (see “The Diseasing of America”) it seems if you have a dx you can escape responsibility for your actions. In that sense, we physicians contribute to the general unhealthiness of society. We are the “excusers”.
Comment by Dan J Schmidt | 8 Dec 2007 @ 7:48am
TinyShrink,
I never said anyone should be locked up; I never said violence was the only possible outcome of paranoia (though paranoia is something to worry about); and I never said all schizophrenics were paranoid. What I said was, mass undirected, apparently purposeless shootings are not a sign of mental health. Paranoia and unprovoked aggression are not signs of mental health. What I said was, it’s very sad when we try to get help for people and that help is not effective. And I still don’t understand why anyone would try to maintain that mass shooters are at least as sane as the average person walking down the street; that the only difference between a mass shooter and, say, you is that a mass shooter sat down one day, made a grocery list and then rationally developed a plan for improving his life (rational people do not plan to make their lives worse) that included killing innocent people and committing suicide. And that your plan for improving your life was an equally rational decision to mow the lawn.
Actually, perhaps the answer is that you guys are American? That if someone can establish “disease,” (or is it “mental defect”?) then they can escape all consequences for their actions? Thus the urgent rush to declare all kinds of perpetrators of irrational acts “rational” and “free of disease,” in other words “mentally healthy.” Because otherwise they could not even be charged in court. (If I understand American law correctly.)
The problem can be rephrased as a legal one. If the law were changed then people would not to have to be free of disease to face consequences to their acts, and we would not have to go around pretending that these people are in full possession of all their faculties. Because we secretly do not think they are. Even you, Tiny Shrink, admit that if people had known of the shooter’s plans that he would have been retained in psychiatric care against his will. We don’t do that to people if we consider them fully responsible for their own actions.
There can be degrees of responsibility, even if someone has a mental illness. If I understand correctly, there is (was?) a big push to diagnose FAS so that a certain class of impulsive people wit IQs of less than 100 will be able to claim mental defect and thus escape legal consequences of their actions. Which is just silly. Criminals are quite commonly impulsive people with IQs of less than 100, whether or not it’s a consequence of FAS. Even if someone has FAS, if they are spared consequences how are they supposed to learn?
We know that something isn’t right with mass shooters. Just like we know that something isn’t right with mothers who kill their children. We don’t have to investigate their individual psychiatric histories; sane people do not do these things, by definition.
(Sane people do other things, of course. But they do not do these things.)
Comment by Alison Cummins | 8 Dec 2007 @ 5:59pm
Alison-
Sorry if I took what you said out of context or misunderstood you. It actually sounds like we are in part saying the same thing: many of the people who commit violent acts are still responsible for their actions, whether we’ve labeled them with a psych disorder or not. I am amused that “even [I] admit that if people had known of the shooter’s plans that he would have been retained in psychiatric care against his will.”–I was apparently mistaken as to the bent of your original comment. Of course they let him out, and I think rightfully so. In America, though, after something like this happens, people often blame the psych services that released the violent, mentally ill criminal, as in how could we? We should have known! They were crazy!
It is true, in America, that because of M’Naghten a person who commits a crime may attempt to claim “mental illness” as a reason why they are not responsible. Whether the law in its current application is fair or just, who knows, but there is a stringent test which must be applied, that the defendant could not appreciate right from wrong (worded in different ways by different states). Therefore, simply saying that this kid had a mental illness would not necessarily have exonerated him by American law had he not killed himself but instead gone to trial.
I think what I wanted to get across was that I don’t think this particular person in Omaha would have qualified to be “not guilty by reason of mental disease or defect”, even with a history of depression or drug abuse or whatever it was. If his writing is a good clue as to his mental state, it sounds like he knew exactly what he was doing, had no remorse toward the people he was going to kill at random, and was not psychotic. However, I do believe there are people who are truly so psychotic as to not be able to appreciate right from wrong, or believe they are so persecuted that killing becomes their defense; these people I think should not be prosecuted in the same fashion as someone in full possession of their mental faculties. DSM covers psychoses pretty well, but there’s no real category (aside from antisocial personality) that covers what lay or religious folk might call simply “evil” (and as a medical student, I do still believe in a person’s ability to choose to be evil. Label it antisocial or whatever.)
Mr. (Dr.?) Schmidt–I think you’re right, we physicians are enablers in many ways. Hypertensive, diabetic, overweight? I’ll give you medicines, it must be your genetics. Kid can’t behave in school? Must be AD/HD, I’ll give him stimulants. I do think we lose sight of people’s choices by diagnosing everything.
Comment by Tiny Shrink | 11 Dec 2007 @ 2:42pm