Thoughts and opinions on conceptions and misconceptions in the media and popular culture regarding psychotherapy, psychiatric diagnoses, mental illness, and happiness.
Whenever there is a tragedy involving a mass shooting, as with the tragedy in Connecticut last week, the shooting outside of Portland the week before, and the shooting in Aurora, Colorado this summer, there are two predictable responses. One is to call for more stringent gun control, and the other is a call for "better" mental health care in America. While I have definite opinions about the former, it is not my area of expertise, and I will remain silent here regarding that particular political sink hole. I do however have some expertise regarding mental health, and that is what I will restrict my comments to here.
The call for "better" mental health care is based on an assumption, and that assumption is that the shooters in all of the above named incidents (and countless more before them) were mentally ill. I call it an assumption because we don't really know for sure in many of these cases - in retrospect there may be aspects of their behavior that was odd or alarming, but many of these men were not formally evaluated for mental illness prior to their shooting sprees. For instance, regarding the Connecticut shooter, Adam Lanza, there are quotes in the news that he has a "personality disorder" or "Asperger's Disorder". Most readers of the news have no idea what these terms mean, and I am pretty sure that the law enforcement official who used the term "personality disorder" was making his own non-professional diagnosis. For the time being though, I am going to let the assumption of mental illness stand.
So what does "better" mental health care really mean? My reading between the lines of what people are saying would lead me to believe that they are talking about easy access to mental health care. Access is a function of availability and affordability: there must be a mental health treatment program that is locally available, and the person seeking care must be able to afford the care or have the care paid for through some sort of safety net, such as Medicare, Medicaid, or free clinic.
People access mental health care in one of two ways - they either seek out and present themselves voluntarily for treatment, or they are taken into police custody for the purposes of an involuntary mental health evaluation due to behavior that is so alarming that there is a concern for the safety of the person or for the safety of others.
So here is my question for those who propose that "better" mental health care would have prevented these tragedies: Would any of these young men have voluntarily sought out help? Obviously none of them had crossed enough of a threshold until their killing spree to provoke being taken into custody for involuntary evaluation and treatment.
The other issue is that if these young men had presented voluntarily for treatment would the treating professional have been able to prevent the tragedy by either predicting it would happen, or by providing treatment that eliminated the threat of harm?
Here we come to a fantasy that some of the public seem to have about mental health professionals - that somehow a professional should just know that a person is dangerous. The truth is that we wouldn't know unless they told us, at which point under the Tarasoff ruling we would have the duty to warn both potential victims and law enforcement. But in order for Tarasoff to come into play, there must be a credible threat against a specific person or persons. As far as predicting future violent behavior, the only reliable predictor of future behavior is past behavior. If a person has a history of violence, it is easy to predict the probability (not the certainty) that they will be violent in the future, however, the nature of the predicted violence would probably be along the lines of what they had already committed.
As for providing treatment that eliminates the threat of harm, especially to a person presenting voluntarily for treatment, who is to know? You cannot prove a negative. In my 27 years of providing mental health treatment I may have prevented hundreds of mass killings, but we will never know because those killings never happened. It is equally possible (and much more probable) that I have prevented no killings at all in my 27 years of treating people.
It is only in retrospect that we look for and find traits in these individuals that make us think that someone should have known and done something before they went over the edge and became killing machines. At the time those retrospective behaviors or traits were actually occurring, most of the people around them probably thought the person was odd, eccentric, or just plain weird. And odd, eccentric, or just plain weird aren't enough to predict future violent behavior, and certainly aren't enough to justify involuntary treatment. The truth is that bad things happen and there is likely nothing that can be done to prevent bad things of this type to continue to happen. Steps may be taken to mitigate the harm that occurs when some individual implodes and becomes a mass murderer, but those steps are not likely to come from mental health. When one of these men is apprehended alive, the safest bet is to lock them away for a very long time, regardless of their mental state.