I do not know what will come forth from the recent tragedy but I am
certain that if no change takes place, then this will be followed by
an even more spectacular outcome. This article is excellent and
clearly shows us our real options.
To start with, mental health management and therapies are all far
less than any hoped for ideal. The trend lines are positive in terms
of developing protocols, but management of the victims has been
thrown back on the families who are generally overwhelmed and
naturally inept at working with the problem if only because they lack
distance. In fact it surely worsens the risk.
Effective gun control protocols are necessary. The correct way is to
insist on a high level of weapons training oriented to the weapon
been licensed and ongoing refresher training in order to maintain the
license. This is tough, but it satisfies the personal need to pack
with societies need to have the weapon handled by highly trained
individuals. It says nowhere in the constitution that the price of
carrying a weapon will be free of responsibility. It is the
responsibility that we enforce.
In the recent case, the training program by experienced third parties
who would be expected to vouch for the trainee is quite capable to
slap a hold on such a kid. Even better, the mother needed a serious
independent perspective in her life. If you do not understand what
is flowing through a person's mind, then it must be simple sense to
secure the weapons. That did not happen here.
A turn down by an experienced third party could have led directly to
mandatory supervision of the weapons at a secure site.
My core point is that weapons use like car use is a jealously
protected privilege and not a right.
How to Prevent Mass
Shootings
Wednesday, 19 December
2012 00:00By James L Knoll IV, Truthout
Psychiatry alone
cannot solve the tragic problem of mass murder. Careful reflection on
gun control laws, responsible media reporting and heroic reporting by
intimates of potential perpetrators could help.
"Thankfully we
had a responsible family member or we might have had a different
outcome."
- Bolivar, Missouri
Police Chief
Each time another mass
shooting happens in the US, the response is entirely predictable.
After the media coverage subsides a bit, a familiar sequence
unfolds:Who is this person? How did the "mental health system"
fail him? How did he get his hands on such a powerful arsenal? If
only the actual tragedy was so predictable beforehand.
Mass murder
predictable? Not likely. Preventable? Well, here is where I believe
we have a bit of a chance. But it depends. How much do we really want
to prevent mass murder? And by "how much" I mean: How much
responsibility are we willing to take on in an effort to make a
meaningful difference? We can talk about it for a few more decades,
and in the meantime we will likely have a few more Sandy Hooks,
Auroras, Virginia Techs or Columbines. I cannot mount an argument
against those who proclaim these tragedies are impossible to predict
or prevent solely with psychiatric efforts. I can't and I won't,
because I agree with them. But I do believe there are other ways that
are far more effective, and ultimately, far more beneficial for
society.
It turns out that
recently, Bolivar, Missouri narrowly avoided becoming the next
Aurora. How? The mother of a potential mass murderer contacted police
because she was worried that her son, Blaec Lammers, had intentions
of shooting people during the opening of the final film in the
popular Twilight vampire movie series. Predictably, the
mother was right to be concerned. When Tricia Lammers' son was
questioned by police, he said he had already bought tickets and
"planned to shoot people inside the theater." Upon
investigation, police found that Lammers "did have the weapons;
he did have the ammunition ... and then he made the statements to the
officer about what his plans were."
This leads me to one
of my first suggestions on how to prevent mass murder. The mayor of
Bolivar, or better yet the governor of Missouri, should give Tricia
Lammers a medal. In fact, if neither party will do this, I will
personally have one made and sent to her. The medal will be engraved
with the words: "For Brave, Humane and Lifesaving Action."
How many can say that
they saved potentially dozens of lives, while also saving the life
and mental health of a family member? Tricia Lammers - I applaud you,
and others should as well. Am I making too big a deal out of this
mother's actions? I do not believe so. I think her act represents one
of the strongest methods of prevention available. Third parties,
particularly family members, are the most likely to
have pre-offense knowledge or significant concerns.2 In
other words, potential mass murderers often "leak their
intent"3 to third parties who, in turn, remain
quiet for various reasons.4 But it is important for family
members to know that help and resources exist. Tricia Lammers was
able to rely on some of these resources, most notably
the National Alliance for Mental Illness, which has offices all
over the country.
In contrast to Ms.
Lammers, the silence of third parties seals the fate of both their
loved one and scores of innocent people. Need another example? They
are not difficult to find. Take the relatively recent case of Anders
Behring Breivik who, on July 22, 2011, obliterated more than
70 innocent people in Oslo.7 Breivik's sister had been
concerned enough to warn her mother at least two years
prior to the tragedy.
At this point in time,
most authorities agree that preventing mass murder requires measures
well above and beyond the "mental health system."9 For
example, after Jared Loughner perpetrated the tragic mass shooting in
Tucson, mental health experts concurred that "homicides
perpetrated with firearms against strangers by individuals with
mental disorders occur far too infrequently" to predict or
prevent with mental health efforts alone.10 Yet after the Tucson
tragedy, there was still the familiar media refrain: "Did
the system fail Jared Lee Loughner?"[emphasis added]
The "Mental
Health System?"
When the inevitable
human tragedy recurs, point not at the system - for you
will be pointing at nothing at all. An apparition. A fiction created
some 50 years ago, which only returns as a ghost in the night. And so
it goes - American society seems comfortable to periodically point at
and condemn the ghost every now and then whenever a serious haunting
takes place. But many are not likely in a position to see the cycles
psychiatrists see due to their permanent residence near the
graveyard. We see the perpetual tragedies, followed by the haunting
incantations: "The system ... the system failed him...."
It is my contention
that there exists no legitimate "system" in the US when it
comes to mental health treatment. Despite this, we most certainly
want to believe in one, particularly so that when tragedies occur, we
will have something to cast our outrage upon. For example, when asked
in a poll where they placed blame for the Tucson shooting, a majority
of Americans said in a USA Today/Gallup Poll that they placed a
"great deal of blame on mental health system failures."
Since it is possible that the term "mental health system"
may be thrown about loose and fast, let us consider it with a bit
more precision.
From a literal
perspective, one might define a system as: an organized, regularly
interacting set of principles forming a network - especially for
distributing something or serving a common purpose. Even more
germane, the Surgeon General's report on mental health14 gives
us the following definition: "[D]iverse, relatively independent,
and loosely coordinated facilities and services - both public and
private - that researchers refer to, collectively, as the de
facto mental health service system" (emphasis not added). Since
a particular legal term has been invoked, let us examine the
definition of de facto. Here we discover both a lay and a legal
definition respectively:
1. Exercising power or
serving a function without being legally or officially
established;
2. Used to characterize... a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate.16
2. Used to characterize... a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate.16
Thus, per the Surgeon
General's own definition, the "system" is at best,
unofficial and at worst illegitimate. Why might it be that in 2012,
we have no "legal or legitimate" mental health system?
Returning to the Surgeon General's report, we are told that:
"Effective functioning of the mental health service system
requires connections and coordination among many sectors.... Without
coordination, it can readily become organizationally fragmented,
creating barriers to access. Adding to the system's complexity is its
dependence on many streams of funding, with their sometimes competing
incentives."
So it appears that
both lack of coordination and funding inconsistencies confound the
system. But as it turns out, these are problems that have never been
adequately addressed since the time of their inception -
deinstitutionalization. Deinstitutionalization was the term used to
describe the rapid emptying out of state mental hospitals beginning
in the 60s and 70s due to a number of factors, including: the
patients' rights movement, financial reasons, early hopes for a
"magic bullet" in the form of antipsychotic medications and
the never-realized hopes for adequate community mental health
services. Thus, deinstitutionalization became
"trans-institutionalization" - also referred to as the
"criminalization" of mentally ill persons.17, 18 Extremely
laudable efforts have been made to divert persons with serious mental
illness away from corrections (e.g., jail diversion and mental health
courts).19, 20,21 But the fact remains that there are large
numbers of persons with serious mental illness in the correctional
system, and the trend shows no signs of reversing itself.
In Virginia, jails now
house more persons with SMI than do Virginia psychiatric
hospitals.22 The Los Angeles correctional system has been
referred to as America's largest psychiatric facility.23 It
is now jails that serve as the "predominant settings for
providing acute psychiatric inpatient treatment."24 During
this era of retribution, corrections facilities earned their
designation as "the new asylums." Correctional
administrators readily concede that their facilities are being used
as "dumping grounds for many individuals who could be better
served through early intervention in noncustodial environments
because other options are just not available."26 But alas,
"interventions in noncustodial environments" are in short
supply in 2012.
Couldn't this have
been foreseen? Quite unlikely I believe, for a variety of reasons,
including: "The fact that most deinstitutionalized people
suffer from various forms of brain dysfunction [which] was not as
well understood when the policy ofdeinstitutionalization got under
way." Indeed, it was poorly planned deinstitutionalization
that created our present illusion of a system "by discharging
people from public psychiatric hospitals without ensuring that they
received the medication and rehabilitation services necessary for
them to live successfully in the community."30 The mental health
system has failed no one, simply because there is no system to speak
of. Thus, we must look elsewhere for solutions to violent outbursts
by mass murderers, most of whom have never accessed mental health
care to begin with.
Mass Murder - What
is it?
Mass murder is no
recent phenomenon. It has occurred since well before the Charles
Whitman shooting in 1966 at my alma mater, the University of Texas at
Austin. However, access to powerful, automatic firearms, media
attention and a possible glorification of the phenomenon among
certain vulnerable, disaffected individuals are factors making
present day mass murders unique.
Mass murder, strictly
defined, is the killing of four or more victims at one location
within one event.28 It is both a rare and catastrophic event that is
usually carried out by a single individual. Mass murder is
distinguished from both spree and serial murder. In the case of
serial murder: There have been at least two victims, the victims are
killed in a non-continuous fashion (i.e., there is an emotional
"cooling off" period between murders), and the murders
usually involve a sexual component.29 In contrast, a spree murder
involves killings at two or more locations with very little time in
between murders and no cooling off period.31 The type of
mass murder discussed here involves those carried out by a single,
heavily armed individual who is very likely to expect to die as a
result of the event. This further distinguishes it from gang-related
mass murder, in which the perpetrators do not typically expect to
die, and their motive involves various forms of profit, drug trade or
territorial disputes.33
At the present time,
it is typically the high-profile cases that are most heavily covered
by the media; yet these are the least representative. In many cases,
the precise number of victims may be arbitrary. Research has been
slow in the area of mass murder, and there is not yet an officially
accepted typology. However, it is clear that not all mass murderers
are alike in their motivations and psychology. Some may be driven by
strong feelings of revenge born of social alienation or a perceived
injustice. Others may also suffer from severe depression or, rarely,
psychosis. Still others may resemble terrorists with idiosyncratic
political beliefs. Such was the case with a Polish chemistry
professor who was recently arrested before he could blow up a
parliament building. Dr. Brunon Kwiecien openly supported Breivik,
and wished to carry out a similar attack, but on a larger
scale. His wife alerted authorities after he asked her how he could
make a biological "dirty bomb." When he was apprehended, he
was found to be in possession of high-powered, military-grade
explosives, bomb-making equipment, several hundred rounds of
ammunition, a bulletproof vest and a pistol.
The majority of
research indicates that there are factors common to mass murderers
such as: extreme feelings of anger and revenge, the lack of an
accomplice (in adult mass murder), feelings of social alienation and
planning/organizing the offense. In a detailed case study of five
mass murderers who were caught before they were killed, a number of
common traits and historical factors were found.35 The subjects
had all been bullied or isolated as children, turning into loners who
felt despair over being socially excluded. They were described as
suspicious, resentful, grudge-holders who demonstrated obsessive and
inflexible thinking.
Not surprisingly, they
were also narcissistic and coped with personal problems by blaming
others. Their worldview was characterized by seeing most others as
rejecting and uncaring. As a result, they spent a great deal of time
nurturing their resentment and ruminating on past humiliations. The
ruminations evolved into fantasies of violent revenge. They did not
see their own violent death as a deterrent, particularly because they
perceived it as bringing them fame with an aura of power. Careful
study of individual cases of mass murder often reveals that the
offender felt compelled to leave some type of final
message.36,37 These messages may be written, videotaped or
posted on the internet or social media networks.38
In sum, the factors
associated with, and contributing to, mass murder are complex and
multi-determined. Biological factors may include possible
brain pathology, as well as psychiatric
illnesses. Psychological factors include a negative or
fragile self-image, a strong sense of entitlement, and vulnerability
to humiliation. Social factors include social
isolation/alienation, being bullied and marital or financial loss.
Mass Murder - Can
it be Prevented?
Mass murder is quite
rare, and depends on the fluid vicissitudes of an extremely
distraught and nihilistic individual who has access to firearms and
ammunition. This must be kept firmly in mind when attempting to
formulate preventive solutions. The reality is that mass murder
cannot be "predicted" as such, particularly by persons
outside the perpetrator's social circle.39 Any hopes of
prevention must rely on various approaches acting together to provide
a widely-cast safety net.40
How much does society
truly wish to tackle this problem? Yes, it's rare, but the fallout is
profound, devastating and long-lasting. I conclude that it is society
that must first decide if it cares enough to take meaningful action.
I will forever advocate for better mental health services and
improved access to care. However, at the present time, measures such
as screening for prior psychiatric treatment (often in the distant
past) among individuals who want to legally purchase
firearms represents no meaningful intervention.41, 42, 43 Here
I refer to the Brady Act and relevant portions of the National
Instant Criminal Background Check System (NICS). Not only does the
present patchwork of inconsistent NICS procedures across the country
do nothing to solve the problem, but it is also wasteful of precious
resources.
Experience has shown
us that, at this point in time, the higher yield interventions
are:
1. Third-party
reporting of concerns or leaked intent
2. Sensible gun
control laws
3. Media
responsibility
Having already
addressed the issue of third-party reporting with the example of
Lammers' mother, I now turn to the perennial and contentious subject
of gun control in the US. It turns out that countries with less
stringent gun control laws have been observed to have a higher risk
of mass murder than countries with stricter laws.44 In contrast,
consider an Australian observational study done in the wake of a
highly publicized 1996 mass shooting in Tasmania.45 The study
compared mass murders before and after Australia enacted gun law
reforms that included removing semiautomatic firearms, pump-action
shotguns and rifles from civilian possession. In the 18 years
before the gun laws, there were 13 mass shootings in Australia. In
the 10-and-a-half years after the gun law reforms, there were none.
Dr. Allen Frances,
chairman of the DSM-IV, has framed the situation a bit more bluntly.
He believes we have only two choices: "Accept mass murder as a
part of the American way of life ... [or] get in line with the rest
of the civilized world and adopt sane gun control
policies."46 But Dr. Frances' latter option seems difficult
for many to consider, let alone accept. Others, such as Michael
Moore, have speculated that it is our deep seated,
long-standing fear that keeps us clutching at our guns. 48 I
will not lay out here all of the debate, but would only point out
that there is "no other democracy on the face of earth that
experiences this type of gun violence. We are the only free society
that has yet to address this problem."49
Our rates of gun
violence far exceed that of other countries. In a piece on gun
violence in the US, Fareed Zakaria noted that: "The gun-homicide
rate per capita in the US is 30 times that of Britain and Australia,
10 times that of India and four times that of Switzerland. When
confronted with such a large deviation, a scholar would ask, 'Does
America have some potential cause for this that is also off the
chart?' I doubt that anyone seriously thinks we have 30 times as many
crazy people as Britain or Australia. But we do have many, many
more guns."
Given these
associations, and the fact that at the present time, psychiatry is
largely impotent to "stop" or "predict" mass
murder, what can be done? Perhaps confronting gun-related
violence as a serious public health issue is a start. For example,
adopting sensible restrictions "such as eliminating the
sale of semi-automatic weapons."51This is an approach that has
already been advocated by both the American Psychiatric Association
and the International Association of Chiefs of Police. But of course,
it must ultimately be society that decides to take this path. If and
when it does, it will be critical for the regulations to be applied
nationally, or otherwise be doomed to failure: "A piecemeal
approach to firearms regulation that affects only some cities or
states cannot be expected to produce a robust effect on gun-homicides
or mass shootings."
The issue of media
responsibility in helping to prevent mass murder has been highlighted
since the Columbine and Virginia Tech tragedies. It became clear
after these events, that some perpetrators were, in part, motivated
by the infamy they saw past mass murderers receive via news coverage.
Although some news media may be disinclined to admit it, they may
often be in the business of searching for "the right sort of
madness" to capture the public's imagination.52 This may
involve exploiting violent and tragic acts carried out by mentally or
emotionally disturbed individuals. In reality, it is a difficult task
to report the occurrence of a mass murder in such a way that the
public is adequately informed, yet certain details (e.g., numbers of
victims, whether the offender was killed, etc.) are not reported.
Efforts to develop a universal reporting code have been recommended
that would appropriately cover the tragedy and reduce the impact of
the copycat effect.53 Most recommendations involve ensuring that
the perpetrator is neither glorified nor demonized. In fact, avoiding
much emphasis on the perpetrator seems to be a good general rule.
Rather, media should emphasize victim and community recovery efforts.
As a psychiatrist, I
desperately wish that improved psychiatric care and access to
treatment could save the day. I have little doubt that over the
years, unsung mental health heroes have averted possible mass murder
tragedies. Yet it seems all too clear to me that this is simply
not a problem that psychiatry can solve on its own. No one should
expect psychiatry to do the impossible - it already has its hands
full with the possible. Therefore, I am suggesting three
additional methods of prevention that should be seriously considered
if we wish to confront the tragic phenomenon of mass murder: careful
reflection on gun control laws, responsible media reporting, and
finally - acknowledging the heroism of Tricia Lammers in the hopes
that more will follow her example.
No comments:
Post a Comment