Billboard - Stigma or Not?

I don't know how I missed the controversy but the APA has vigorously criticized a billboard that sends a message about inadequate access to mental health services and inadequate gun control.  I found out about it only through the APA listserv yesterday.  The Psychiatric News alert can be viewed here.  The billboard can be seen on major news services like NBC here.   If anyone can spare a photo of this billboard please e-mail to me and I will post it in the body of this essay.  The message basically states "Over 40 million Americans with mental illness - some can access care - all can access guns."  It is signed by Kenneth Cole.  He has a history of activist billboards and Twitter posts and is no stranger to controversy.  He has also discussed raising his brand's profile through the social responsibility messages.  In this case some APA members were outraged at what they perceived to be a stigmatizing message.

My perspective is that the message on the billboard is accurate. There is nothing to be gained by suggesting that Mr. Cole is trying to state that most people with mental illness are dangerous.  But there is the issue of whether a professional organization should be commenting on what they perceive as a controversial billboard in the first place, especially when it may be used to promote a brand name.  In this era of social media and the current trend for public shaming, I would suggest that scoring points in that landscape is the last thing any professional organization should be doing.

The fact is that most acute care psychiatrists are making these kinds of assessments every day in the United States and multiple times a day.  The vast majority of people designated to have a mental illness on this billboard do not need to see psychiatrists.  Acknowledging the fact that psychiatrists are actively engaged in violence prevention and that a small but significant number of people with mental illness are violent and aggressive and that it is a treatable problem is a very important message.  The potential benefits include:

1. Less stigma for people who are violent and aggressive as a result of severe mental illness.  The current bias is to see this behavior was willful and punish them based on a moralistic approach to mental illness.  That is until the violent and aggressive person is a family member trying to harm other family members.  At that point, there is no myth of mental illness and all of the talk about how the mentally ill are not aggressive is meaningless.

2. Clearly define the problem and develop centers of excellence for treating this problem.  In every metro area in the U.S. there are a handful of acute care psychiatric units and even fewer who accept violent and aggressive patients.  All of the violent and aggressive patients are typically brought to one or two hospitals that are set up to address the problem.  Those hospitals have protocols in place to treat the problem and many of them do a lot of civil commitments.  There is no funding source that is adequate to provide the level of treatment for these patients who must be hospitalized until they are no longer dangerous.  They also require more intensive staffing patterns by staff who must have a much higher level of training than in less intensive situations.

3. A denial of the potential for violence and aggression is inconsistent with the recently released Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.  That document has explicit commentary about the psychiatrist’s role in addressing aggression.  There are 41 references to aggression in the body of the paper including 13 bullet points on the Assessment of Risk For Aggressive Behavior (p 23).  There are thirteen references to firearms.

In my opinion, the assessment of violence and aggression that is typically done in crisis situations by psychiatrists is more extensive than what is captured in the guideline. As an example there is no discussion of transference or countertransference issues and how they affect the treatment team and their approach to the safe treatment of violent and aggressive patients.

4. A more clearly defined role among advocacy organizations is a better role for professionals. The political use of the term “stigma” is at times all encompassing and it obscures the real source of the problem. For example, stigma is not the reason why there are no services available for psychiatric care.  Managed care companies and the governments that subsidize them and sanctify their business tactics are the reason there are no services.  The APA has been talking about stigma for years and it has done absolutely nothing to increase services or stop the rationing.  The highly acclaimed parity legislation initiated by Senators Paul Wellstone and Pete Domenici has done nothing to break the chokehold on mental health by businesses and governments.  There is new legislation in the works to “enhance” the original parity legislation because it has no teeth and has not made a difference. Businesses do what they want with the blessing of state and federal governments.

5. In some cases advocacy organizations are at odds with clinical psychiatrists who are treating patients with severe mental illness and aggression.  One of the positions taken by at least one of these organizations is that psychiatrists could be easily replaced by “prescribers” in state hospitals where aggressive patients are sent.  The government in that case took the position that an administrator with no clinical experience could come into a state hospital setting and develop a program to treat patients with mental illness and violence and aggression.  That plan failed.

These are a few of the problems associated with denying the correlation between severe mental illness and violence and aggression in a subset of patients with severe mental illness. The reality is that there are thousands of psychiatrists that face these problems every day. Their goal is to keep people safe and prevent violence. Acknowledging what they do on a daily basis, supporting that work and the importance of that work to patients, families and the community is a step in the right direction.

Suggesting that it is too stigmatizing to discuss that issue is not a step in the right direction.




George Dawson, MD, DFAPA



Supplementary 1:    I contacted Kenneth Cole (the company) through the web site and asked them to send me an image of their billboard for use in this post.  I included a link to the post so the specifics could be read as well as the entire blog.  I was advised that although they appreciate my interest, the image was proprietary and therefore they could not send it to me.  I don't know if they are claiming that about every image or just the one I wanted them to send me.  It made me wonder if they are aware of how widespread the image is used on the Internet.

Supplementary 2:   I was graciously sent a photo of this billboard by a resident New Yorker.  I contacted Kenneth Cole again and was told again that I could not even use an independent photograph of their billboard for this post.  I really doubt that any place else displaying these billboard photos has gotten permission from them, but I am just a guy writing a blog and can't afford to get into it with them.  So there you have it.  Go to any one of the other hundreds of places on the Internet that have posted this picture to view it.

    

A Gun In The Snow

A colleague of mine was out for a walk today.  It is a brisk winter day in Minnesota.  There is about 6 - 8 inches of snow cover.  He was walking across the street and found this handgun laying there.

He took a picture of the gun and called the police to pick it up.  They were there in 20 minutes.

My views on violence and gun violence are fairly well known. My recent position has been that arguing with gun advocates and the pro-gun lobby in Congress is futile.  But when I saw this posted on Facebook with the accompanying story I couldn't help but think: "Guns are so common they are falling on the ground like wallets."  Only a fool believes that this level of gun availability does not result in death and injury of all kinds including accidents, suicides, and homicides.  Only a fool believes that with this level of gun availability it is possible to prevent guns from ending up in the hands of people who are not competent to use them.  I live in a state that passed a concealed carry law that  is basically the right to carry a concealed firearm.  It passed a few years ago by tacking it on to unrelated legislation.  The gun and holster look like a common one that is sold to those who complete a brief concealed carry course.  The main argument of the concealed carry contingent was that they were supermen of sorts.  There was literally nothing that would compromise their judgment if they were carrying a handgun.  Since then there have been a number of incidents involving concealed carry owners showing that in fact problems happen.  In the most notable incident a concealed carry owner opened fire on an undercover police officer.  I think it is safe to assume that there are probably at least as many lapses of judgment involving concealed weapons as there are driving automobiles.  The main difference is that people spend more time driving.  The reporting of these incidents is not transparent and that is typical of much gun legislation.

On a worldwide basis, small arms fire is a leading cause of death and disability.  I had the opportunity to see how some of that was transacted when I lived in Africa for two years.  In travelling as little as 100 miles there were frequent roadblocks at times.  The intent of the roadblocks was not clear but each roadblock was manned by police or paramilitary personnel and everybody was heavily armed.  The American friend that I most frequently traveled with told me about a time he got out of his car to ask if there was a problem.  One of the police officers pushed the barrel of a machine gun into his chest and prodded him back to his car.  He previously served in a country where a fellow volunteer accidentally drove through a police checkpoint because there was nobody around.  It appeared to be abandoned.  He made it a short distance before he was shot through the head by soldiers out of sight up on a hill.

In the US, besides the obvious problems with the legal availability of firearms there is also the issue of the black market and stolen firearms.  Since 1994 an average of 232,000 firearms are stolen every year and 80% of those are not recovered.  Stolen guns account for 10-15% of the guns used in crimes.  The majority of guns used in crimes are purchased by proxy or so-called straw purchase sales including other tactics like diversion of guns to criminals by licensed gun dealers.  There are several common sense changes that can occur in firearm policy that might make a difference in the sheer number of firearms in the general population and their availability to criminals.

This week marked another school shooting.  It marked the anniversary of the Sandy Hook Elementary School shootings.  In practically every school shooting easy access to firearms is a major part of the problem.  There are clear models for what happens to firearm deaths when some restrictions are placed on their access.  Fareed Zakaria has a new feature Global Lessons on Guns on his Sunday news program GPS.  Last Sunday he reviewed gun policies in Japan.  Getting a license to have a firearm in Japan is very difficult.  The authorities need advance information on where it will be stored and they need a detailed floor plan of the residence where it will be stored.  In a country of 130 million people there were a total of 4 firearm homicides last year.  By contrast, in the United States with a current census of 317 million people, there were 31,672 firearm related deaths (see Table 1-1 and 1-2).  The example from Japan is also interesting because it looks at the issue of violent video games.  They are played at a higher rate in Japan than the U.S. and it obviously had no impact in the context of extremely limited gun availability.

Even though I think there are better approaches for psychiatry to focus on than strictly gun policy and confrontations with a pro-gun lobby we need a basic level of awareness that current gun laws in the US are probably not what the Framers of the Constitution intended.  I think they would be as shocked as anyone if they found a gun in the street.  They would be equally shocked to find out that 7 times as many Americans die every year as a result of firearms than died in the Revolutionary War.  (see Table 1)

George Dawson, MD, DFAPA

Psychiatric care versus gun control - an expected outcome

Just in case you are keeping score the Senate voted down some modest gun control proposals last week.  The issue of coming together over mental health care to address one of the dimensions of mass shootings also did not happen.  In the political calculus, it makes sense that if legislators did not fear the gun control lobby they had a lot less to fear from a mental health lobby ambivalent about dovetailing improved mental health care with gun control.

The pro gun advocates especially the NRA have always underscored the idea that they support law abiding citizens having access to firearms.  Their mantra for years has been that if there are more obstacles to law abiding citizens getting guns then only criminals would have them.  Never mind the significant number of accidental deaths every year and the fact that firearm suicide is consistently greater that firearm homicide in this country.  That detail is not lost on psychiatrists interviewing patients who have told us that they were impulsively looking for a gun to kill themselves and the only thing that prevented it was a background check and a waiting period.  The main provision of the attempted legislation was an extension of background checks.  If the pro gun lobby believes that it is protecting the right of law abiding citizens to purchase firearms, there should be no problem at all with universal background checks.  That should cut across all venues where firearms are bought and traded.  I have not heard a single rational explanation for voting down extended or universal background checks.

Reaction to the failure of this legislation was as swift as the Sunday morning talk shows.  Bob Scheiffer interviewed family members of the victims of the Sandy Hook incident on Face the Nation.  They were clearly upset about the vote in the Senate as captured in this quote from Neil Heslin father of 6 year old Jesse Heslin one of the victims of this incident:

"....As simple as a background check, putting aside the assault weapon ban or limitation or control, it's just a stepping stone of the background check with the mental health and the school security. I think the most discouraging part of this week was to, after the vote, to see who voted and who didn't vote, support it, and realize it's a political game. It was nothing bipartisan about it, at all. And we aren't going to go away. I know I'm not. We're not going to stop until there are changes that are made."

In the vacuum of no discussion of the vote against the bill or partisan rhetoric, very little was said in the press about the money behind the vote.  OpenSecrets.org did an excellent job of showing that like most things in American politics it looks like a significant factor.  Their research clearly shows that the pro-gun lobby can outspend the gun control lobby by as much as 15:1 with most of the money going to Republicans.  There are a couple of things working against the pro-gun lobby and all of that money - public support for common sense gun measures like background checks is at an all time high.   The second factor is difficult to say out loud but in American culture you can depend on it.  There will be more incidents and the pro-gun solutions (armed guards in schools, keeping the guns out of the hands of criminals and the mentally ill) are not really solutions.  The pro-gun lobby has demonstrated that they do not take that task seriously.

George Dawson, MD, DFAPA

Senate Blocks Drive for Gun Control.  NYTimes April 17, 2013.

S. 649 Roll Call Vote

The run on guns and ammunition - is this mass psychogenic illness?

I was watching my usual Sunday morning news programs two weeks ago when I heard that Wal-Mart had such a run on their ammunition supply customers that they were limiting sales to three boxes per customer per day.  That brings up the image of tens of thousands of people going to Wal-Mart every day to buy their three boxes of ammo.  What is it about the American psyche that drives this behavior and the recent stockpiling of guns?

It reminded me of the Y2K situation from over a decade ago.  Do you remember that scenario?  In the antithesis of the Terminator series, computers would be crippled by inadequate programming to account for the change to the 21st century.  The power grids would collapse.  The logistics of food and medical supplies would be paralyzed.  There would be chaos in the streets.  In Minnesota in the middle of winter that translated to a run on electrical power generators.  It got to the point that one of the big home stores cancelled their return policy for generators.  I never noticed it but I wonder if the generator aisle at the Home Depot ever looked like this gun shop display.

All of the signs point to this being a record year for gun and ammunition sales.  The National Instant Criminal Background Check System (NICS) has a record number of checks.  Nine of ten of the top highest days and 10/10 of the top ten highest weeks for gun checks since the system was started in November 1998 have occurred within the past two months (see below).   The charts below give the NICS checks month by month since then and the actual listing of top days and weeks for checks.  Although there is usually a disclaimer about how checks do not necessarily equate to gun purchases, the issue has been studied and for each check there is about a 70% chance that a firearm will be acquired taking into account all of the possible outcomes. (click to enlarge)

Another perspective comes from the Bureau of Alcohol, Tobacco, Firearms, and Explosives.  They keep a record of firearm manufacturing in the US by the type of firearm and also whether or not a firearm is exported.  The data going back to 1998 is available on their web site.  I plotted that data for rifles, pistols, revolvers, and shotguns on the following graph.  Some interesting trends noted include the fairly recent increase in rifle production. There were relatively flat revolver and shotgun sales, and a sharp increase in pistol production over the past decade.   The year 2004 is also an interesting inflection point for rifle sales since that was the year that the ten year ban on assault rifles expired.   Without knowing the exact breakdown of rifle sales, the rise at that point combined with flat rate of shotgun sales suggests that the rising rate represents sales of assault rifles or military style weapons that are not necessary for hunting.

All of the signs point to a greater prevalence of guns in homes and communities especially hand guns.  Not only that but it appears that Americans are arming themselves at a much higher rate than at any time since we started to keep these statistics.  They also appear to be arming themselves using handguns and possible military style weapons that are not typically used for hunting.  Hunters are frequently mentioned in NRA and pro-gun rhetoric but they certainly are not responsible for the huge increase in hand gun sales.  If we are ruling out hunters who is buying the guns?

My guess is that it comes down to people arming themselves because they believe that they need protection.  Although a previous post here clearly shows that the violent crime rate is at an all-time low there are numerous self protection ideologies.  At one time or another I have heard the following arguments:

1.  Protect yourself against violent criminals (even though there are fewer of them and they seem to be committing fewer violent crimes than at any point in the past 30 years).

2.  Protect yourself against terrorists.  My guess is that terrorists would not be foolhardy enough to walk into any well armed American neighborhood and start a gun fight

3.  Protect yourself against the government.  This is an interesting argument because it basically is the same thing as treason.  When I argued that point with a famous gun advocate he pointed out that it would depend on "who won".  Some conservative and liberal politicians of both parties have made this argument, including Minnesota's well known liberal Senator Hubert H. Humphrey.  The basic argument is that if the government becomes completely unresponsive to the people for one reason or the other - we should have enough firepower to overcome it.  I guess if we can't vote the bums out - there is always another way.

4.  Protect yourself against your neighbors.  This is the survivalist argument.  The survivalists believe that we are always "9 meals away from chaos".  It is therefore logical to stockpile food.  When the apocalyptic event happens, you need enough guns and ammo to shoot anyone who threatens you or your food stockpile.

5.  Protect yourself against the zombies.  That's right - you thought the zombie apocalypse was just fiction.  I happened to catch an episode of Doomsday Preppers that was full of information ranging from how zombies might scientifically happen to staircase design that would slow them down long enough so that you could administer the old "double tap". 

An inspection of the above list suggests that there are many more imagined than real threats.  Possibly several orders of magnitude greater if you are considering that all of your neighbors who ignored your warnings about the apocalypse are either coming for your food or have contracted the virus that turns them into zombies and want to eat you for food.  In that scenario - how much ammo is enough?  All of this would be more fodder for the film industry if it was not true at some level.  Very few real threats and many imagined would seem to be driving the current gun buying frenzy.  After all - what would happen if any of the mass scenarios unfolded and we did not have enough guns and ammo?

I don't want to go too far out onto a limb here.  For all of you DSM5 detractors - don't worry there is no diagnostic category to critique.  I think that there is room for studying the problem, but it would involve collecting data from the gun purchasers and we all know that would not fly.  Anyone knows that if you can be identified - the government can kick your door down and take your guns.  

George Dawson, MD, DFAPA

FBI NICS Web Site

FBI Instant Background Checks November 30, 1998- January 31, 2013.

ATF Annual Firearms Manufacturing Report and Export Report 2011.

ATF Statistical Web Site