No applause from me

The APA came out with a press release today in response to President Obama's initiative to reduce gun violence and prevent future mass shootings.  Although the release "applauds" these proposals they seem to be short on the mental health side. From the APA release:

“ We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. We strongly urge the Administration to close loopholes involving so-called ‘non-quantitative treatment limits’ and to ensure that health plans deliver a full scope of mental health services in order to comply with the law. Such action will best ensure that Americans get the full range of mental health services we believe they are intended to receive under federal law.”

So I guess the APA is applauding the initiative but encouraging the closing of loopholes. Call me a skeptic but 20 years of rationing mental health services and cutting them to the bone through managed care intermediaries and aggregating those managed care intermediaries into accountable care organizations does not bode well for the "full range of mental health services". The APA seems to have the naïve position that you can support managed care tactics and provide increased access to quality mental health services.

The next point in the APA release supports school screening and enhanced mental health services in schools for both violence prevention and to identify children at risk or in need of current mental health services. Those are certainly laudable goals but there is minimal evidence that screening is effective. There is also the problem of a lack of infrastructure.  Twenty years of rationing and restricting access to psychiatric services has resulted in long waiting lists or completely unavailable services. If you talk with a child psychiatrist, they will tell you that the current system is set up to offer medications in place of a more comprehensive approach to psychiatric treatment. At the social services level, residential treatment for children with severe problems is practically nonexistent. As a recent example, I was informed last week of a school social worker who could not get a child assessed for admission to an adolescent psychiatric unit and when that was not possible could not get an appointment to see a psychiatrist in a major metropolitan area. Screening for problems does not make any sense unless there is an infrastructure available to address those problems when they are found.

The final point in the APA release addresses the issue of physicians being able to discuss firearms at home with their patients. This has been a standard intervention for physicians ever since I have been practicing and it is always part of an assessment for suicide and homicide risk. There was a state initiative last year making it illegal for physicians to discuss firearms in the home with their patients. Part of the rationale for that law was that it could result in firearm owners being identified and placed them at theoretical risk for their firearms to be confiscated by the state.  I can say from experience that my discussions with patients about firearm safety and the discussions of other physicians that I have been aware of have been highly productive and have probably saved countless lives. The best example I can think of is talking with a primary care physician who asked me to take a look at a closet full of firearms that he convinced patients to turn into him over the years before he turned them into the police. Those patients were all depressed and suicidal and at high risk for impulsive acts. He would not have been able to make that intervention with a gag law in place preventing those discussions.

What about the President's original release?  It had 84 instances of the word "mental" usually as "mental illness" or "mental health".  As noted above it has received some accolades from the APA and other members of the mental health community. It elicited a strong and poorly thought out response from the NRA  who produced a YouTube video accusing the President of being elitist and a “hypocrite” because his daughters had armed security but he expected that everyone else’s kids would be protected by gun free zones.  The White House responded quickly:

“Most Americans agree that a president’s children should not be used as pawns in a political fight,” said Jay Carney, the White House press secretary. “But to go so far as to make the safety of the president’s children the subject of an attack ad is repugnant and cowardly.”

The full text of the White House 22 page document is located at this link.  It is ambitious and covers a lot of ground in terms of the specific regulation of firearms, school safety, and increasing mental health services. The firearm regulation is most specific in that it closes background check loopholes, bans assault weapons, outlaws armor piercing bullets, and sets the maximum magazine size at 10 cartridges.  Part of this document is a "call to Congress" so it is not clear to me how much can be accomplished by the President's executive orders as opposed to Congressional action.  I am reminded of the NRA President last weekend stating that Congress would never pass a ban on assault weapons.  The Executive Order section of that part of the document lists the following activities:

1.  Addressing unnecessary legal barriers in health laws that prevent some states from making information available about those prohibited from having guns.

2.  Improving incentives for states to share information with the system.

3.  Ensuring federal agencies share relevant information with the system.

4.  Directing the Attorney General to work with other agencies to review our

laws to make sure they are effective at identifying the dangerous or untrustworthy individuals that should not have access to guns.

The school safety initiative seems more nebulous. There is funding for 1000 "school resource officers and school based mental health professionals" and the recommendation to train 5000 additional “social workers, counselors, and psychologists.”   Considering the fact that there are probably close to 100,000 schools, this seems like a drop in the bucket.   Ensuring that each school has an emergency plan for contingencies like mass shootings does not seem to be a novel idea.  Creating safer school climates and reducing bullying has already been initiated in many school districts. There seems to be a clear lack of public health measures in the school that would reduce the likelihood of violent events.

The mental health initiative is equally lacking. In addition to the deficiencies I pointed out initially in this document, there is discussion of providing mental health training to teachers and school staff. There is probably evidence that teachers and school staff may over identify mental illness rather than under identify it.  Is this really a problem and will this level of screening be effective?   The document describes the initiative here as "increasing access" to mental health services. Screening larger numbers of students and identifying them as having potential problems actually creates a bottleneck in the system rather than increasing access.  The suggested mental health interventions in this document fall short in terms of both primary and secondary prevention of mental illness and associated aggressive behavior. Depending on a managed care model that has an established track record of dismantling the mental health infrastructure and providing limited access to poor quality care will do nothing to accommodate increasing referrals other than assure that referred students will be rapidly medicated.

My final analysis of the President’s initiative today is that it may be a starting point.  He is certainly taking the issue seriously and deserves plenty of credit for that.  His support for reopening firearm safety research that was closed by the gun lobby is important. What will become of the firearm regulation is anyone's guess at this point. The school and mental health initiatives are largely symbolic and I would not expect them to have any impact. What is sorely needed is the American Psychiatric Association coming out with standards, quality guidelines, and medical education initiatives to improve the care of people with severe mental illnesses who also happen to be aggressive.  An important piece of those guidelines should include the public health measures that were previously mentioned on this blog and those measures should also play a much larger role in any Executive initiative.

George Dawson, MD, DFAPA

What is wrong with the APA's press release about the NRA statement?

The APA released a statement about the NRA's comments, probably Mr. LaPierre's statements on Meet the Press on Sunday and a separate NRA release. There are several problems with the APA statement:

1.   The American Psychiatric Association expressed disappointment today in the comments from Wayne LaPierre…

Why would the APA be "disappointed" in a predictable statement from a gun lobbyist?  I really found nothing surprising in Mr. LaPierre's presentation or the specific content. As I previously posted, the NRA predictably sees guns as the solution to gun violence.  The concept "more guns less crime" has been a driving force behind their nationwide campaign for concealed carry laws. The concealed weapons that are being carried are handguns and handguns are responsible for the largest percentage of gun homicides in the United States. It is probably a good idea to come up with a solution rather than reacting to a predictable statement.

2.  The person involved in the shooting is named…

Although it is controversial, there is some evidence that media coverage is one factor that can lead predispose individuals to copy a particular crime.  Although this press release is a minimal amount of information relative to other news coverage, it does represent an opportunity for modeling techniques for more appropriate media coverage and that might include anonymity of the perpetrator.  The NRA release makes the same mistake.

3.   In addition, he conflated mental illness with evil at several points in his talk and suggested that those who commit heinous gun crimes are “so possessed by voices and driven by demons that no sane person can ever possibly comprehend them,” a description that leads to the further stigmatization of people with mental illnesses.

It is always difficult to tell how rhetorical a person is being when they use terms like "evil" and "demons". If they are considered to be descriptive terms for a supernatural force that suggests an etiology of mental illness that was popular in the Dark Ages.  Evil on the other hand does have a more generic definition of "morally wrong or bad;  immoral; wicked”.  In this case it is important to know if the speaker is referring to a definition that is based on evil as a supernatural force or a more common description. This is another educational point. People who experience voices and irrational thoughts involving homicide can be understood. Psychiatrists can understand them and can help them to come up with a plan to avoid acting on those thoughts and impulses and getting rid of them.  The NRA release is basically an indication of a high degree of naïveté in thinking about the unique conscious state of individuals.  The APA release should correct that.

4.  The APA notes that people with mental illnesses are rarely violent and that they are far more likely to be the victims of crimes than the perpetrators

The actual numbers here are irrelevant.  Psychiatric epidemiology cannot be casually understood and the media generally has the population whipped up about the notion of psychiatric overdiagnosis of everything anyway. The idea that some mentally ill persons are dangerous is common sense and forms the basis of civil commitment and emergency detention laws in every state of the union. Advocates need to step away from the notion that recognizing this fact is "stigmatizing". The APA needs to recognize that their members in acute care settings are dealing with this problem every day and need support. It is an undeniable fact that some persons with mental illness are dangerous and it is an undeniable fact that most of the dangerous people do not have mental illness. Trying to parse that sentence usually results in inertia that prevents any progress toward solutions.

The APA seems to have missed a golden opportunity to suggest a plan to address the current problem. The problem will not be addressed by responding to predictable NRA rhetoric.  There several other nonstarters in terms of a productive dialogue on this issue including - the specifics of the Second Amendment and specific gun control regulations. The moderator of Meet The Press made an excellent point in the interview on Sunday when he asked about closing the loophole that 40% of gun purchases occur at gun shows where there are no background checks. It was clear that the NRA was not interested in closing that loophole. The main problem is that the APA has no standing in that argument. Second nonstarter is the whole issue of predictability. Any news outlet can find a psychiatrist somewhere who will comment that psychiatrists cannot predict anything. That usually ends the story. If your cardiologist cannot predict when you will have a heart attack, why would anyone think that a psychiatrist could predict a rare event happening in a much more complicated organ? Psychiatrists need to be focused on public health interventions to reduce the incidence of violence and aggression in the general population and where it is associated with psychiatric disorders. 

What about Mr. LaPierre’s criticism of the mental health system?

“They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine.  We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this…”

Is it an accurate global description of what has happened to the mental health system in this country? He certainly is not using the language of a mental health professional or a person with any sensitivity toward people with mental illness.  There are numerous pages on this blog documenting how the mental health system has been decimated over the past 25 years and some of the factors responsible for that. Just yesterday I was advised of a school social worker who not only was unable to get a child hospitalized but could not get them an outpatient appointment to see a psychiatrist. The government and the managed care industry have spent 25 years denying people access to mental health care and psychiatrists. They have also spent 25 years denying people access to quality mental health care that psychiatrists are trained to provide. We have minimal infrastructure to help people with the most severe forms of illness and many hospital inpatient units do discharge people to the street even though they are unchanged since they were admitted.   Any serious dialogue about the mental health aspects of aggression and violence needs to address that problem.

That is where the APA’s voice should be the loudest.

George Dawson, MD, DFAPA

Supplementary Material:  Quotes from and locations of transcripts – feel free to double check my work.

MTP transcript  12/23:  http://www.msnbc.msn.com/id/50283245/ns/meet_the_press-transcripts/t/december-wayne-lapierre-chuck-schumer-lindsey-graham-jason-chaffetz-harold-ford-jr-andrea-mitchell-chuck-todd/#.UNlaJ-RqYrV

"I'm telling you what I think will make people safe. And what every mom and dad will make them feel better when they drop their kid off at school in January, is if we have a police officer in that school, a good guy, that if some horrible monster tries to do something, they'll be there to protect them." (p2)

"Look at the facts at Columbine. They've changed every police procedure since Columbine. I mean I don't understand why you can't, just for a minute, imagine that when that horrible monster tried to shoot his way into Sandy Hook School, that if a good guy with a gun had been there, he might have been able to stop..."—(p3)

"There are so many different ways he could have done it. And there's an endless amount of ways a monster.."—(p6)

"I don't think it will. I keep saying it, and you just won't accept it. It's not going to work. It hasn't worked. Dianne Feinstein had her ban, and Columbine occurred. It's not going to work. I'll tell you what would work. We have a mental health system in this country that has completely and totally collapsed. We have no national database of these lunatics." (p6)

"23 states, my (UNINTEL) however long ago was Virginia Tech? 23 states are still putting only a small number of records into the system. And a lot of states are putting none. So, when they go through the national instant check system, and they go to try to screen out one of those lunatics, the (p6)

"I talked to a police officer the other day. He said, "Wayne," he said, "let me tell you this. Every police officer walking the street knows s lunatic that's out there, some mentally disturbed person that ought to be in an institution, is out walking the street because they dealt with the institutional side. They didn't want mentally ill in institutions. So they put them all back on the streets. And then nobody thought what happens when you put all these mentally ill people back on the streets, and what happens when they start taking their medicine."We have a completely cracked mentally ill system that's got these monsters walking the streets. And we've got to deal with the underlying causes and connections if we're ever going to get to the truth in this country and stop this"—(p7)

NRA transcript 12/21: http://home.nra.org/pdf/Transcript_PDF.pdf

"The truth is that our society is populated by an unknown number of genuine monsters — people so deranged, so evil, so possessed by voices and driven by demons that no sane person can possibly ever

comprehend them." (p2)

"Yet when it comes to the most beloved, innocent and vulnerable members of the American family — our children — we as a society leave them utterly defenseless, and the monsters and predators of this world know it and exploit it. That must change now!" (p2)

"As parents, we do everything we can to keep our children safe. It is now time for us to assume responsibility for their safety at school.  The only way to stop a monster from killing our kids is to be personally involved and invested in a plan of absolute protection. The only thing that stops a bad guy with a gun is a good guy with a gun. Would you rather have your 911 call bring a good guy with a gun from a mile away ... or a minute away?" (p5)

"Now, I can imagine the shocking headlines you'll print tomorrow morning: "More guns," you'll claim, "are the NRA's answer to everything!" Your implication will be that guns are evil and have no  place in society, much less in our schools. But since when did the word "gun" automatically become a bad word?" (p5)

"Is the press and political class here in Washington so consumed by fear and hatred of the NRA and America’s gun owners that you're willing to accept a world where real resistance to evil monsters is a lone, unarmed school principal left to surrender her life to shield the children in her care?" (p6)

Additional Reference:

Copycat Phenomenon in medical literature (references 5, 13, 20, 26 are most relevant).

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

More On Homicide Prevention

As the number of mass homicides becomes even more noticeable it is getting some attention in the psychiatric press. This months Psychiatric News has a story that looks at the issue of "explanations" for mass killings. There were a couple of new terms that I was not familiar with such as "rampage violence" or "rampage", "autogenic", or "pseudo-commando" killings.  The perspective in the article was generally public health research or the perspective of forensic psychiatrists. Inconsistencies were apparent such as:

"... Much research has shown that mental illness in the absence of substance abuse does not lead to violence and that most crimes are committed by people who have not been diagnosed with mental illness."

Followed by:

"Even when behavior reaches a level troubling to family or neighbors, getting an affected individual into treatment is difficult, especially in a society that highly values individual liberty..."

Are they referring only to those people who are abusing substances or only those people who become violent as a result of mental illness? My experience is that both categories are important and that is illustrated within the same article that refers to a study of five "pseudo-commando" murders where common traits were noted including the fact that all of the subjects were "suspicious, resentful, narcissistic, and often paranoid".

The overall tone of the article is that we may be too focused on mass homicide because only a small number of people were killed in these incidents compared to the 30 to 40 people per day who die from homicide and that violence prediction may be a futile approach. There is also commentary on why neither the Democrats or Republicans want to comment on this issue. An uncritical statement about the "support for gun ownership" being at an all-time high is included in the same paragraph.  Like most things political in the US, all you have to do is follow the money.

The same issue was covered in the September issue of Psychiatric Times.  Lloyd Sederer, MD takes the position that apathy fueled the lack of a sea change in gun control following the incident when Congresswomen Gifford was shot and several people at that same event were killed.  He includes an apathetic quote from Jack Kerouac and a nonviolent activist quote from Gandhi.  Allen Frances, MD makes the reasonable observation that understanding the psychology of a mass killer will not prevent mass homicide, but proceeds to stretch that into the fact that this is a gun issue:

"We must accept the fact that a small cohort of deranged and disaffected potential mass murderers will always exist undetected in our midst."

and

"The largely unnoticed elephant in the room is how astoundingly easy it is for the killers to buy supercharged firearms and unlimited rounds of ammo.  The ubiquity of powerful weaponry is what takes the US such a dangerous place to live."

He goes on to suggest that there are only two choices in this matter: accept mass murder as a way of life or adopt sane gun policies with the rest of the civilized world.

I don't think that gun laws are the best or only approach.  The idea that "supercharged" firearms are the culprit here or the extension to banning assault weapons as the solution misses the obvious fact that even common widely available firearms - shotguns and handguns are highly lethal.  Anyone armed with those weapons alone would be unstoppable in a mass shooting situation.  Secondly, the effects of stringent firearms laws have mixed results.  The mass shooting in Norway is an example of how tight firearm regulation can be circumvented.  It is well known that there are a massive amount of firearms under private possession in the US, making the effect of firearm legislation even less likely.  There are also the cases of heavily armed citizenry with only a fraction of the gun homicides that we have in the US.  Michael Moore's comparison of the US with Canada in "Bowling for Columbine" comes to mind.

The previous posts on this blog suggest clear reasons why gun ownership is at an all-time high. The problem is that much can be done apart from the gun ownership issue and the solutions are available from psychiatrists who are used to assessing and treating people with mental illness, severe personality disorders, threatening behavior, or history of violent or aggressive behavior. The critical dimension that is not covered is the issue of prevention and the necessity of an open discussion about homicide and how to prevent it. Education about markers that are associated with mass homicide is useful, but the focus needs to be on how to help the person who starts to experience homicidal ideation before they lose control.  That is also consistent with a humanistic approach to the problem.  I have treated many "deranged and disaffected potential mass murderers" who went back to their families and back to work.  We need a culture that is much more savvy about the origins of violence and aggression.  It is too easy to say that this behavior is due to "evil" and maintain attitudes consistent with that approach.  Time to develop research on the prevention of mass homicide, identify the individuals at risk, and offer effective treatment.

George Dawson, MD, DFAPA

Aaron Levin.  Experts again seek explanations for mass killings.  Psychiatric News 2012 (47)17: 1,20.

Lloyd I. Sederer.  The enemy is apathy.  Psychiatric Times 2012 (29)9: 1-2.

Allen Frances.  Mass murderers, madness, and gun control.  Psychiatric Times 2012 (29)9:1-2.

"Preventing Violence: Any Thoughts?"

The title of this post may look familiar because it was the title of a recent topic on the ShrinkRap blog.  That is why I put it in quotes.  I put in a post consistent with some the posts and articles I have written over the past couple of years on this topic.  I know that violence, especially violence associated with mental illness can be prevented.  It is one of the obvious jobs of psychiatrists and one of the dimensions that psychiatrists are supposed to assess on every one of their evaluations.  It was my job in acute care setting for over 25 years and during that time I have assessed and treated all forms of violence and suicidal behavior.  I have also talked with people after it was too late - after a homicide or suicide attempt had already occurred.

The responses to my post are instructive and I thought required a longer response than the brief back and forth on another blog.  The arguments against me are basically:

1.  You not only can't prevent violence but you are arrogant for suggesting it.
2.  You really aren't interested in violence prevention but you are a cog machine of the police state and inpatient care is basically an extension of that.
3.  You can treat aggressive people in an inpatient setting basically by oversedating them.
4.   People who are mentally ill who have problems with violence and aggression aren't stigmatized any more than people with mental illness who are not aggressive.

These are all common arguments that I will discuss in some detail, but there is also an overarching dynamic and that is basically that psychiatrists are arrogant, inept, unskilled, add very little to the solution of this problem and should just keep quiet.  All part of the zeitgeist that people get well in spite of psychiatrists not because of psychiatrists.  Nobody would suggest that a Cardiologist with 25 years experience in treating acute cardiac conditions should not be involved in discussing public health measures to prevent acute cardiac disorders.  Don't tell anyone that you are having chest pain?  Don't call 911?  Those are equivalent arguments.  We are left with the curious situation where the psychiatrist is held to same medical level of accountability as other physicians but his/her opinion is not wanted.  Instead we can listen to Presidential candidates and the talking heads all day long  who have no training, no experience, no ideas, and they all say the same thing: "Nothing can be done."

It is also very interesting that nobody wants to address the H-bomb - my suggestion that there should be direct discussion of homicidal ideation.  Homicidal ideation and behavior can be a symptom.  There should be public education about this.  Why no discussion?  Fear of contagion?  Where does my suggestion come from?  Is anyone interested?  I guess not.  It is far easier to continue saying that nothing can be done.  The media can talk about sexual behavior all day long.  They can in some circumstances talk about suicide.  But there is no discussion of violence and aggression other than to talk about what happened and who is to blame.  That is exactly the wrong discussion when aggression is a symptom related to mental illness.

So what about the level of aggression that psychiatrists typically contain and what is the evidence that they may be successful.  Any acute care psychiatric unit that sees patients who are taken involuntarily to an emergency department sees very high levels of aggression.  That includes, threats, assaults, violent confrontations with the police, and actual homicide.  The causes of this behavior are generally reversible because they are typically treatable mental illnesses or drug addiction or intoxication states. The news media likes to use the word "antisocial personality" as a cause and it can be, but people with that problem are typically not taken to a hospital.  The police recognize their behavior as more goal oriented and they do not have signs and symptoms of mental illness.  Once the psychiatric cause of the aggression is treated the threat of aggression is significantly diminished if not resolved.

In many cases people with severe psychiatric illnesses are treated on an involuntary basis.  They are acutely symptomatic and do not recognize that their judgment is impaired.  That places them at risk for ongoing aggression or self injury.  Every state has a legal procedure for involuntary treatment based on that principle.  The idea that involuntary treatment is necessary to preserve life has been established for a long time.  Civil commitment and guardianship proceedings are recognition that treatment and in some cases emergency placement can be life saving solutions.

The environment required to contain and treat these problems is critical.  It takes a cohesive treatment team that understands that the aggressive behavior that they are seeing is a symptom of mental illness.  The meaning is much different than dealing with directed aggression by people with antisocial personalities who are intending to harm or intimidate for their own personal gain.  That understanding is critical for every verbal and nonverbal interaction with aggressive patients.  Aggression cannot be contained if the hospital is run by administrators who are not aware of the cohesion necessary to run these units and who do not depend on staff who have special knowledge in treating aggression.  All of the staff working on these units have to be confident in their approach to aggression and comfortable being in these settings all day long.

Medication is frequently misunderstood in inpatient settings.  In 25 years of practice it is still very common to hear that medication turns people into "zombies".  Comments like: "I don't want to be turned into a zombie" or "You have turned everyone into zombies" are common.  I remember the last comment very well because it was made by an observer who was looking at people who were not taking any medication.  In fact, medication is used to treat acute symptoms and in this particular case symptoms that increase the risk of aggression.  The medications typically used are not sedating.  They cannot be because frequent discussions need to occur with the patient and a plan needs to be developed to reduce the risk of aggression in the future.  An approach developed by Kroll and MacKenzie many years ago is still a good blueprint for the problem.

There is no group of people stigmatized more than those with mental illness and aggression.  It is a Hollywood stereotype but I am not going to mention the movies.  This group is also disenfranchised by advocates who are concerned that any focus on this problem will add stigma to the majority of people with mental illness who are not aggressive or violent.  There are some organizations with an interest in preventing violence and aggression, but they are rare.

At some point in future generations there may be a more enlightened approach to the primitive thoughts about human consciousness, mental illness and aggression.  For now the collective consciousness seems to be operating from a perspective that is not useful for science or public health purposes.  There is no better example than aggression as a symptom needing treatment rather than incarceration and the need to identify that symptom as early as possible.

George Dawson, MD, DFAPA

Colorado Mass Shooting Day 2

I have been watching the media coverage of the mass shooting incident today - Interviews of family members, medical personnel and officials.  I saw a trauma surgeon at one of the receiving hospitals describe the current status of patients taken to his hospital.  He described this as a "mass casualty incident".  One reporter said that people don’t want insanity to replace evil as a focus of the prosecution.

In an interview that I think surprised the interviewer, a family member talked about the significant impact on her family.  When asked about how she would "get her head around this" she calmly explained that there are obvious problems when a person can acquire this amount of firearms, ammunition, and explosives in a short period of time.  She went on to add that she works in a school and is also aware of the fact that there are many children with psychological problems who never get adequate help.  She thought a lot of that problem was a lack of adequate financing. 

   

I have not listened to any right wing talk radio today, but from the other side of the aisle the New York Times headline this morning was "Gunman Kills 12 in Colorado, Reviving Gun Debate."  Mayor Bloomberg is quoted: “Maybe it’s time that the two people who want to be president of the United States stand up and tell us what they are going to do about it,” Mr. Bloomberg said during his weekly radio program, “because this is obviously a problem across the country.”

How did the Presidential candidates respond?  They both pulled down the campaign ads and apparently put the attack ads on hold.   From the President today: " And if there’s anything to take away from this tragedy, it’s a reminder that life is fragile.  Our time here is limited and it is precious.  And what matters in the end are not the small and trivial things which often consume our lives.  It’s how we choose to treat one another, and love one another.  It’s what we do on a daily basis to give our lives meaning and to give our lives purpose.  That’s what matters.  That’s why we’re here."   A similar excerpt from Mitt Romney: "There will be justice for those responsible, but that’s another matter for another day. Today is a moment to grieve and to remember, to reach out and to help, to appreciate our blessings in life. Each one of us will hold our kids a little closer, linger a bit longer with a colleague or a neighbor, reach out to a family member or friend. We’ll all spend a little less time thinking about the worries of our day and more time wondering about how to help those who are in need of compassion most."

These are the messages that we usually hear from politicians in response to mass shooting incidents.  At this point these messages are necessary, but the transition from this incident is as important.  After the messages of condolences, shared grief, and imminent justice that is usually all that happens.  Will either candidate respond to Mayor Bloomberg's challenge?  Based on the accumulated history to date it is doubtful.
  
A larger question is whether anything can be done apart from the reduced access to firearms argument.  In other words, is there an approach to directly intervene with people who develop homicidal ideation?  Popular consensus says no, but I think that it is much more likely than the repeal of the Second Amendment.

George Dawson, MD, DFAPA

Barack Obama. Remarks  by the President on the Shootings in Aurora Colorado.  July 20, 2012

Barack Obama.  Weekly Address: Remembering the Victims of the Aurora Colorado Shooting.  July 21, 2012.

Mitt Romney.  Remarks by Mitt Romney on the Shooting in Aurora, Colorado.  NYTimes July 20, 2012.