On "increased focus on mental health" to combat mass murder or as an alternative to or component of gun control

[Bliz]

My intention here is to focus on the mental health angle here specifically, and NOT start another gun control thread on whether it's a good idea, will criminals be the only ones to have guns, etc. etc. etc. Naive, I know, but here goes.

In response to Newtown and Aurora and other events, one of the angles that has come up a lot lately has been whether we can lessen the frequency of these sorts of attacks by providing more money for mental health, stricter regulations on access for people with mental health problems, or similar solutions. But how feasible is that really? ANd how do we weight the individual liberty of someone who may or may not be dangerous vs the danger they pose to others? I found the article below really interesting, since I had not heard a response from the psychiatric community to that idea before. I'm also including below the thoughts and opinions of the father of a friend of mine, who was formerly the mental health director for a state department of corrections. I know we have some mental health professionals on this board, and would be very interested to hear their take.

http://www.city-journal.org/2012/eon1221td.html

Theodore Dalrymple Newtown’s Unanswerable Questions

It is not likely that psychiatrists could have prevented the massacre.

21 December 2012

The horrific massacre of the innocents in Newtown was bound to result in a search for preventive action so that nothing like it could ever happen again, and hence also for its real or final cause. To ward off fatalism, we tell ourselves that the massacre could, and therefore that it should, have been prevented; or alternatively, that it should, and therefore that it could, have been prevented. But as the cacophony of opinion demonstrates, the world is an irreducibly complex place. Agreement about what ought to have been done has all too predictably not been reached.

It is tempting to argue that the perpetrator must have been insane, for if such a person isn’t insane, who is? We close the circle by then explaining his action by his insanity. In other words, we know the perpetrator was insane because he did x, and that he did x because he was insane. Molière satirized such reasoning 300 years ago: the doctor explains that opium makes people sleepy because of its dormitive quality. Let us suppose for the sake of argument, however, that the perpetrator did have a psychiatric condition that could have been diagnosed before his terrible act: What follows from this?

First, he was of age (20) to refuse to see a doctor if he so wished, and he might very well have so wished. By all accounts, there were no grounds on which psychiatric attention could have been forced upon him. He was strange, he was socially isolated, his mother worried about him; but he was a good student and had committed no acts that would have justified compulsory treatment, as would have been the case if (for example) he had attacked someone under the influence of delusion.

Second, even if he had agreed to consult a psychiatrist, there is no certainty that the psychiatrist could have done anything for him and thus averted the disaster. Nor would the psychiatrist necessarily have had any reason to suspect a mass killing as a possible outcome in this case; the best predictor of future behavior is, after all, past behavior, and the killer had (as far as has been revealed) no history of violence. Further, the psychiatrist would probably have seen several, perhaps many, similar cases that did notend in mass killing—an outcome that after all remains rare. The Newtown killing might have taken a psychiatrist by surprise as much as anyone else.

In fact, psychiatrists are no better than others at predicting violence by disturbed people, except possibly among the psychotic. They tend to overestimate the dangers, and in making predictions, they face the problem of the false positive and the false negative. In the case of a false positive, you think that someone is dangerous when he isn’t; in the case of a false negative, that he is not dangerous when he is. False predictions of rare events (such as mass killings) generally outweigh true ones by a large factor—an important point to remember, especially if you wish to grant or withdraw civil liberties on the basis of such predictions.

Not long ago, I was asked to participate in an inquiry into a spate of murders committed by psychiatric patients. The killings seemed to be statistically abnormal (recalculation showed that they were not). We were asked to determine whether there was a single type of act, or omission, by the psychiatric services common to all the murders which might help explain them. It immediately became clear that the standard of practice was extremely low. The nurses, in particular, had filled out an immense number of forms, hundreds or even thousands of them. Many dealt with the dangerousness or otherwise of the patients and were designed precisely to avert the possibility of violence or murder. I suspected that the nurses thought that filling in forms was their work, and that when they had done this they had achieved something. They mistook process for outcome.

Yet, except in one case, I found no evidence that the low standard of practice had actually resulted in a preventable killing, despite the immense power of the retrospectoscope—the medical instrument that provides us with wisdom after the event and that sometimes does lead to improvements in practice that saves lives, though at other times it provides us only with scapegoats. In this instance, I should have been provided with, say, 20 medical records, among them those of the killers, without knowing the outcome of the cases, and asked to decide blindly which resulted in murder, and why. In the event, all I could say was that the standard of practice ought to be raised, irrespective of whether the existing standard failed to prevent the murders.

A further point: it is unlikely that we will ever have a full medical explanation of events such as the Newtown killings. Even if investigation proves that the perpetrator had Asperger’s syndrome, much would still remain to be explained. After all, people must have suffered from Asperger’s syndrome before there were any mass killings of the Newtown type. The behavioral expression of a psychiatric condition takes place in a social and cultural context.

This context is perhaps propitious to young mass killers (quite apart from the effect of imitation or emulation). In an article in Le Monde, a professor of sociology at Strasbourg University, David Le Breton, quotes a German schoolboy who killed 15 people in a school in Winnenden in 2009: “I’m fed up, I’ve had enough of this meaningless life which is always the same. Everyone ignores me, no one recognises my potential.” This reeks of resentful, narcissistic grandiosity, the result of an imperative to be an individual at a time when individuation is more difficult than ever.

Theodore Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute.

And the thoughts of my friend's dad:.

Having dealt with violent people most of my life working in Corrections there are many issues involved in anticipating/predicting violence and the actual acts of violence. I agree with Dr. Dalrymple's conclusion that the best predictor of future behavior is past behavior.

The other factor he discusses is mixing up process with outcome as he describes nurses' documentation. I cannot tell you how many times I've seen staff document behavior thinking they've completed their task (which is correct from an administrative standpoint) rather than paying attention to those behaviors documented which in fact may be indicators of imminent or near imminent unlawful behaviors and actually doing something.

I've had a good deal of experience in attempting to stop violence, the most frequent of which was violence directed at self. Attempting to stop individuals from self injurious behavior such as cutting, which was a major issue in one of our youthful offender institution, was not merely stopping the contraband which was the means of injury. That is virtually impossible, especially over time, even in a prison. Diminishing the motivation to harm oneself was the key and more difficult task. At one point we had over 100 self inflicted cuttings a month in one institution. We examined the contributors to those cuttings and we eventually reduced those to less than a dozen a month. Not perfect but much better.

What were the causes of the cutting? They were several. One was stronger inmates intimidating or even raping weaker inmates. Rather than going to staff they chose to cut themselves and go to the infirmary. Others took the same route to get out of the dorm due to gambling debts. They couldn't go to staff because gambling is illegal, but they could get moved if they cut themselves. The largest number were those who were in isolation/segregation due to disciplinary reports. Some had disciplinary reports because they cut themselves (damaging state property, i.e., themselves) Almost all had problems with idleness. There were other issues including some associated with mental illness though that was actually the smallest percentage of cutters.

We addressed this by changing some of the policies and associated practices governing people with disciplinary reports. The biggest factor was getting inmates who were not working or in programs into appropriate activities. Those efforts are what resulted in major reductions in self-mutilations. The problem was not the means by which these individuals harmed themselves, but rather it was the motivation(s) i.e. we did not identify the weapon as the problem. Of course changing individual and group behavior in an institution is relatively easier than identifying, monitoring, and intervening with someone in the "free world."

The President and Congress are well intentioned to address the violence issue, but amending the gun laws will only nibble at the margins. Those elected officials will have accomplished something to address the problem by passing legislation (process), but it likely will have little effect on actual outcome. It's the old adage, if you only have a hammer everything looks like a nail. They will not address some of our mental health laws which inhibit intervening before a person has actually committed a violent act or the threat of violence is imminent. To do so would force legislators to address the difficult issue of individual freedom vis a vis the potential danger to others which is difficult to predict.

Our elected officials also will not rely on behavioral health research, social psychologists, cultural conditions, and other factors which may be associated and in interaction with forces which lead a person to commit such terrible and evil acts against others. And even if they did, there is nothing that legislation itself can do to prevent such violence. Distorted thinking and values of individuals must be changed which in turn may change the culture which influences, animates and supports harmful thoughts and values. In many, if not most cases, it begins with the family and its supports. Any change there would take the same number of years or more, if at all, that it took to get to the point where we are today. Such efforts don't lend themselves to such short term solutions as legislation which often are about as effective as New Year's resolutions. The media, particularly broadcast media with their talking heads and the Internet, also don't offer anything which actually is thoughtful enough to point us to actions which actually might make a difference.

[Busch1724]

My wife works in corrections. We talk about this quite often. We always come back to one point of agreement. In lamens terms, we've developed a generation or two of children that don't know how to cope with stress in a meaningful way. I think everyone could agree with that. What causes it? Those are areas my wife and I disagree slightly but have thoughts in common.

The one thing we agree on is that political correctness has weakened our sensibilities and makes those susceptible to having issues bring those issues to the forefront in a violent manner before dealing with them in an appropriate manner.

---------- Post added January-11th-2013 at 12:49 PM ----------

Obviously there are many, many more factors. Realistically you can't narrow it down to one, but we do agree that people take things way too personally these days and when things don't happen the way they think it should...issues pop up much more easily than before.

---------- Post added January-11th-2013 at 12:55 PM ----------

There are aspects of mental health that are cheap to address, and many aren't. One of the things that my wife and I believe is that the cheapest thing to address first is this whole idea of being offended, disrespected, victimized, etc. over trivial things. Many crimes, violent and non violent, are the result of these petty disagreements that build up.

[Son of Gadsden]

My opinion on it is this: Yes, if it doesn't infringe any rights, which I think would be difficult.

People should also need to take psyche tests to have children, own cars, buy alcohol, etc...but that won't happen either.

Who enforces this? The states are broke. The Union is broke.

If someone could come to an agreement on how to install something like this effectively, and by that I also mean cost effectively...if the states pass it, go. However, Congress has no power to pass something like this, and I'll fight that every step of the way.

Without a doubt, the insane are to blame, but we have to fight this problem Constitutionally. Making haste to put laws in place without reading them, and arguing that "Forget the Constitution and politically correctness! This has to get done!" is why we are in the mess we are in in the first place, and how places like Nazi Germany became the way they were. (Generally I stay away from Nazi comparisons, they seem to be ill mannered, but in this situation, it's a good comparison)

So yes, I think it should be on the table. I agree with most of the above, I just think we need to make sure it's on the RIGHT table.

[Bliz]

Without a doubt, the insane are to blame, but we have to fight this problem Constitutionally. Making haste to put laws in place without reading them, and arguing that "Forget the Constitution and politically correctness! This has to get done!" is why we are in the mess we are in in the first place, and how places like Nazi Germany became the way they were. (Generally I stay away from Nazi comparisons, they seem to be ill mannered, but in this situation, it's a good comparison)

You should have stuck with your general approach. It's not a good comparison. And there are much better ways to get a point across.

Whether it's congress or the state actually implementing such a thing is completely irrelevant for purposes of this thread. The question is whether there are actually viable opportunities down that road at all. Not a power apportionment about who gets to sign the piece of paper that puts them into play.

[Jumbo]

The one thing we agree on is that political correctness has weakened our sensibilities and makes those susceptible to having issues bring those issues to the forefront in a violent manner before dealing with them in an appropriate manner.[...There are aspects of mental health that are cheap to address, and many aren't. One of the things that my wife and I believe is that the cheapest thing to address first is this whole idea of being offended, disrespected, victimized, etc. over trivial things. Many crimes, violent and non violent, are the result of these petty disagreements that build up.

I could hardly imagine a more ridiculous thing ("political correctness") to feature in a response to this topic and give serious weight to in such a serious matter.

If I were to make a shoot from the hip with a "guess" somewhat affected by the feeling of disdain I have at the moment, it would be that you're simply using a major social concern, actually involving life-and-death matter at its extreme, to trot out a very shallow yet "strong" to you, personally, sociopolitical peeve.

[Son of Gadsden]

You should have stuck with your general approach. It's not a good comparison. And there are much better ways to get a point across.

Whether it's congress or the state actually implementing such a thing is completely irrelevant for purposes of this thread. The question is whether there are actually viable opportunities down that road at all. Not a power apportionment about who gets to sign the piece of paper that puts them into play.

There are probably less sensitive ways, but all that aside. The point of the comparison is that our feds have already rolled so far from the Constitution, the system is just about beyond repair...and that is why we have the mess we have today. Nazi Germany is an example of what can be if it is allowed to continue. However, this is irrelevant to the post, you're right. And it is not my intent to hijack your thread.

The signing of the paper, however, is of much importance to the thread. You can't expect 50 states to all agree on a legal document...especially such a controversial one...so it's going to be different for each state...and it is very important that that happens. Without it, I disagree that this should happen.

[NavyDave]

I would focus on giving those retarded mass murderers a dirtnap via a firing squad working from the ankles up. I do not care if they are diagnosed as mentally challenged. Killing women and children should be an automatic purging from society via the death penalty.

Parents, like the mother of this monster who knew her son was crazy but ignored the dangers, should get prison time if their children maim and or kill someone when they knew he or she should be institutionalized prior to the fact.

[Busch1724]

I could hardly imagine a more ridiculous thing ("political correctness") to feature in a response to this topic and give serious weight to in such a serious matter.

If I were to make a shoot from the hip with a "guess" somewhat affected by the feeling of disdain I have at the moment, it would be that you're simply using a major social concern, actually involving life-and-death matter at its extreme, to trot out a very shallow yet "strong" to you, personally, sociopolitical peeve.

It's not a sociopolitical peeve. I can see how to got that out of my post. With that said, I guess I could have stated it better is that the victimization of people in general has left us with many people that are predisposed to react to stressful situations in a destructive manner. I'm not talking about PC as it relates to law, policies, etc. My wife and I talk about how stereotyping (which is wrong) makes many with mental health issues feel victimized. As an example, she deals with quite a few in corrections that are bi-polar. Instead of dealing with the bi-polarism in a constructive way they use societie's views of a bi-polar individual's profile as an excuse to commit the crimes that they do. Where the political correctness (well-intentioned and ill-intentioned) part comes into play is the role feeling sorry for those people (which we all do, hopefully) or those that are not politically correct and shun those individuals and would rather isolate them instead of treating them. The isolation causes trauma and the willingness to act out. That is an unintended consequence of PC, is the constant labeling of people and the creation of isolation.

Hope that somewhat makes sense.

[Tulane Skins Fan]

I guess the ultimate question is for those who think we need to "drill down on this mental health issue" more in order to prevent these mass shootings: "what do you think we should do differently?"

Its not as if mental health isn't treated in this country. And you aren't going to stop people from getting mental health disease. I see a lot, not all but a lot, of this mental health angle to be a distraction. A lot of people in this country are committed to treating and prevent mental illness.

[HOF44]

Mental health treatment in this country has pretty much been abandoned. There was a time that the state had long term care available in mental hospitals. As a society I suppose we came to the conclusion that the cost was not worth it. This resulted in harmless mental cases becoming homeless on our streets and more violent and less stable being handled by our court and prison system generally after a crime had been committed to land them there.

[Tulane Skins Fan]

Mental health treatment in this country has pretty much been abandoned. There was a time that the state had long term care available in mental hospitals. As a society I suppose we came to the conclusion that the cost was not worth it. This resulted in harmless mental cases becoming homeless on our streets and more violent and less stable being handled by our court and prison system generally after a crime had been committed to land them there.

What is the basis for any of this? Mental health is as serious an issue in the medical community as it has ever been. Why do you say it has been "abandoned"?

[Bang]

Who enforces this? The states are broke. The Union is broke.

.

I see this as a major block.

Not necessarily that they're broke, because even if they weren't, people do not want to pay for anything anymore.

It seems to me the notion of community or country has devolved into "me", and "mine".

But they are broke, which means money will need to be raised,, and that'll never happen.

Unfortunately, I think this, and likely any other measure anyone tries to come up with, will be punted into the political abyss and never ever implemented, but argued over constantly.

status quo stays.

~Bang

[HOF44]

What is the basis for any of this? Mental health is as serious an issue in the medical community as it has ever been. Why do you say it has been "abandoned"?

In the 80's the Feds pretty much got out of the mental care business on the scale they had been in it before. I probably should have rephrased that too, mental care for those incapable of paying for it via insurance or their own funds has mostly disappeared. The sad part is the people that need it the most are least capable of paying for it.

Link

Cuts in funding for mental health services continued throughout the 1980s, with the emphasis being on the provision of services via the private sector. Overall, the number of beds available to the mentally ill in public and private hospitals dropped ov er forty percent between 1970 and 1984 (Reamer, 1989). Most of this decline was due to cuts in public hospitals. During the 1980s, the number of beds provided by general hospitals in psychiatric wards and in private hospitals for the mentally ill increase d. In 1970, there were 150 private psychiatric centers; in 1980, there were 184; by 1988, there were 450 in the United States. General hospitals offering psychiatric services increased from 1,259 in 1984 to over two thousand in 1988 (Reamer, 1989, 25; LaF ond and Durham, 1992, 115-16). With such growth in the private sector, there were substantial profits to be made in mental illness, assuming that the patient had adequate health insurance. Those without medical insurance frequently did not receive adequat e care.

[Tulane Skins Fan]

In the 80's the Feds pretty much got out of the mental care business on the scale they had been in it before. I probably should have rephrased that too, mental care for those incapable of paying for it via insurance or their own funds has mostly disappeared. The sad part is the people that need it the most are least capable of paying for it.

Link

I'm not saying you're wrong, but that article is pretty dated itself.

And I guess you think mental health would be better if the federal government had a bigger role? Can you elaborate on that? Is there evidence that people with mental health conditions can't get help if they want it today? As a corollary to all this, what impact will Obamacare have on that?

[HOF44]

I'm not saying you're wrong, but that article is pretty dated itself.

And I guess you think mental health would be better if the federal government had a bigger role? Can you elaborate on that? Is there evidence that people with mental health conditions can't get help if they want it today? As a corollary to all this, what impact will Obamacare have on that?

I don't claim to be an expert in the field, but having lived through those times it was pretty obvious that the spikes in homeless and in the prison population coincided with public mental health care being cut. The system now is largely for profit, and a lot of people that could benefit greatly can't get access. I'm not really sure the effect Obamacare will have on mental health. I imagine someone in the field here on the board would have better insight that I would.

[Busch1724]

I'm not saying you're wrong, but that article is pretty dated itself.

And I guess you think mental health would be better if the federal government had a bigger role? Can you elaborate on that? Is there evidence that people with mental health conditions can't get help if they want it today? As a corollary to all this, what impact will Obamacare have on that?

Even though funding has declined, hasn't funding for rehabilitation for inmates increased? If I remember quickly, there has been a funding shift from care business to funding these issues with counselors in prison.

[Tulane Skins Fan]

Even though funding has declined, hasn't funding for rehabilitation for inmates increased? If I remember quickly, there has been a funding shift from care business to funding these issues with counselors in prison.

I don't know.

I don't understand what people think should be done about the "mental health issue" that has cropped up. I don't generally perceive a lack of access to mental health care providers to be a reality in this day and age, but I could be wrong. I presume that Obamacare provides valuable access to mental health care for many people, including the poor in that it created many new avenues to all kinds of healthcare for poor people.

I didn't understand the advocates of exploring the mental health issue to be arguing we need more federal government involvement. But, I could be wrong about that.

I don't have the answers to most of these questions, and I'm not an expert either. If you think we need to "address the mental health issue in this country" though, as a lot of gun rights advocates are claiming in the wake of mass shootings, please come up with an explanation of what that means. And then we can all evaluate and debate that. But so far, I've just heard "we need to address mental health." I agree.... how? What's wrong now? Etc.?

[HOF44]

And then we can all evaluate and debate that. But so far, I've just heard "we need to address mental health." I agree.... how? What's wrong now? Etc.?

In my opinion there needs to be more funding allocated. Should that be Fed, State, or private??? I'd love to hear from some people on the inside that went through the de-funding back in the 80's and the conditions now, and what they think would be a solution, or if everything is a ok.

[LadySkinsFan]

In the 80's the Feds pretty much got out of the mental care business on the scale they had been in it before. I probably should have rephrased that too, mental care for those incapable of paying for it via insurance or their own funds has mostly disappeared. The sad part is the people that need it the most are least capable of paying for it.

Link

HOF44, I agree with you that mental health services are woefully inadequate, especially when our society has chosen to jail mentally ill people after they have committed crimes (whether violent or not) rather than treat them in hospital settings and give them proper care, and we have Reagan and the Republicans to thank for that, with their continued fight against health care on behalf of the for profit health insurance industry. Also, we treat mental illness as a dirty secret to hide away, did in the past and do so now.

Does HIPAA preclude setting up a database linked to the databases accessed to screen people when they purchase a gun? Would this help? When I filled out the Fed and VA forms, there were questions there regarding mental illness, but all one has to do is answer negatively and I don't think there is a way to check for mental illness like there is for felonies.

That said, G. Gordon Liddy said on his radio program that he no longer owned guns due to his felony convictions, but Mrs. Liddy did, and gee they just happened to be stored on his side of the bed. So we can pass all the laws aimed at restricting gun purchase and possible gun ownership, but that doesn't mean that people who want to shoot other people won't have access to guns. I'm presuming that the Newtown murderer's mother possessed those guns legally (purchase/permit IAW CT law) and the murderer had access to them. So what is to prevent someone bent on killing people from access to guns except at the sales point, if then for mental illness, like for checking for felonies?

[added after the last couple of posts]

Mental healthcare does not provide the high profit margins of other types of care. The meds are typically expensive, housing and in-patient care is expensive, and we as a society have allowed for profit corporations to dominate our healthcare services, where increasing the bottom line profit is the most important aspect of that industry, not care for human beings in all of their illness including mental. Until profit is taken out of the healthcare services, we will not see proper care of human beings. That doesn't mean that R&D needs to be lessened or that people won't be paid a living wage, but it does mean that human beings are not treated as a commodity. Additionally, we won't have any kind of "competition" until there is a non-profit, sliding scale, public option available that is attached to people themselves, and not to their employers, and that people can rely on whether they are employed or not. This program would get employers out of the healthcare business, which they should welcome.