Friday, December 14, 2012

Guns Are Not Cooling Off Between Mass Shootings

I have previously posted my concerns about mass shootings and the general paralysis on dealing with this problem.  The gun lobby has unquestionable political power on this issue, but that is also due to judicial interpretation of the Second Amendment as it is written.  Today's New York Times describes a mass shooting at an elementary school in Connecticut.  At the time I am typing this, the death toll is 20 children, 6 adults, and the gunman.  This incident occurs three days after a shopping mall shooting in Oregon.

Most people would think that nothing would be more motivating for major societal changes than children being attacked in this manner.  Unfortunately this is not the first time that children have been victimized by mass shooters.  On October 2, 2006 a gunman shot 10 girls and killed 5 before committing suicide.  According to the Wikipedia article that was the third school shooting that week.  Altogether there have been 31 school shootings since the Columbine incident on April 20, 1999.

My question and the question I have been asking for the past decade is what positive steps are going to be taken to resolve this problem?  How many more lives need to be lost?  How many more children need to be shot while they are attending school?  Some may consider these questions to be provocative, but given the dearth of action and the excuses we hear from public health officials and politicians, I am left in the position of continuing to sound an alarm that should have been heard a couple of decades ago.  After all, the elections are over.  The major parties don't have to worry about alienating the pro-gun or the pro-gun control lobbyists and activists.  This will not be solved as a Second Amendment or political issue.  I have said it before and I will say it again - the basic approach to the problem is a scientific one and a proactive public health one that involves the following sequence of action:

1.  Get the message out that homicidal thoughts - especially thoughts that involve random violence toward strangers are abnormal and treatable.  The public health message should include what to do when the thoughts have been identified.

2.  Provide explanations for changes in thought patterns that lead to homicidal thinking.

3.  Provide a discussion of the emotional, personal and economic costs of this kind of violence.

4.  Emphasize that the precursors to homicidal thinking are generally treatable and provide accessible treatment options and interventions.

5.  The cultural symbol of the lone gunman in our society is a mythical figure that needs to go.  There needs to be a lot of work done on dispelling that myth.  I don't think that this repetitive behavior by individuals with a probable psychosis is an accident.  Delusions do not occur in a vacuum and if there is a mythical explanation out there for righting the wrongs of a delusional person - someone will incorporate it into their belief system.  The lone gunman is a grandiose and delusional solution for too many people.  If I am right it will affect even more.

6.  Study that sequence of events and outcomes locally to figure out what modifications are best in specific areas.

One of the main problems here may be the deterioration in psychiatric services over the past three decades largely as a result of government and managed care manipulations.  Ironically being a danger to yourself or others is considered the main reason for being in an inpatient psychiatric unit these days.  I wonder how much of the inertia in dealing with the problem of mass homicide comes from the same forces that want to restrict access to psychiatric care?  Setting up the remaining inpatient units to deal with a part of this problem would require more resources for infrastructure, staff training, and to recruit the expertise needed to make a difference.

The bottom line here is that the mass homicide epidemic will only be solved by public health measures.  This is not a question of good versus evil.  This is not a question of accepting this as a problem that cannot be solved, grieving, and moving on.  This is a question of identifiable thought patterns changing and leading to homicidal behavior and intervening at that level.

George Dawson, MD, DFAPA


  1. Limiting admissions to psychiatric inpatient hospitalization has reached a whole new level in Wisconsin. Now, not only can a psychiatrist or other mental health care professional or physician NOT place a patient on a hold, a police officer has to assess if the psychiatrist's concern is valid THEN calls a crisis team member to come out and evaluate the patient. The police officer and crisis worker are much less experienced in the area of dangerousness on the basis of mental illness yet it is their combined decision, not the psychiatrist's decision, if the person needs to be hospitalized. There is no medical training involved in this final decision making process so the idea that a patient with a BAL of 0.357 and a recent history of alcohol withdrawal with hallucinations who is currently suicidal and unable to contract for safety can be managed by her "friend" back at home who also has no medical training, seems like a good one. Often, there is no interest in hearing from the psychiatrist. I suppose they know that person's opinion or they would not have been called in the first place.
    What does the future hold? Starting January 1, 2013, psychologists, social workers and other mental health providers who are not M.D.s are going to be payed MORE for a diagnostic evaluation that does NOT include medical decision making. Psychiatrist, who will perform the same work with the benefit of adding medical decisions making, will be reimbursed at a lower rate. People have asked me why this is the case. Any ideas?

  2. Thanks for your observation. I started practicing in a community mental health center in Wisconsin and was very familiar with Ch51 and Ch55 the relevant Wisconsin statutes. They are online and I am not an attorney so here is the link:

    My interpretation is that the statutes have not changed. My read is that the police can detain people based on specific behavioral criteria and of course they should be the only people involved in actually detaining a person. Once the person is in a hospital setting they can request discharge and be assessed at that time for a 72 hour hold. There are cultural differences between counties and biases at every level of the system, but if you read the relevant sections of this statute especially Ch 51.20, commitment in Wisconsin can still occur not only for dangerousness but inability to care for oneself.

    On the issue of the change in payments starting January 1 please see my post on 90862 and coding changes. These codes are purely arbitrary to legitimize what is a political process. Changing codes does not assure any change in payment procedures, basically because the payer sources have so much power they can pay whatever they want for any service and they can also decide how long a person gets treatment in a hospital. As long as that is true, treatment decisions in the care of persons with severe mental illness will be based on business rather than clinical decisions.