Will Changing The Commitment Standard Decrease The Rates Of Mass Shootings?

A colleague sent me an e-mail this morning about a story that focuses on changing the commitment standard to a need for treatment rather than dangerousness.  She asked me if I thought it would be an effective measure so that more people with psychosis are treated decreasing the risk of mass violence perpetrated by psychotic persons.  As a background, most states have civil commitment statutes that involve imminent dangerousness.  That literally means that the person in question has already done something dangerous or they appear to be at high risk for doing something dangerous in the near future.  My first reaction is that it would not do a thing and here is why - states routinely ignore lesser standards and default to dangerousness because it limits court and treatment costs.  At least until there is a "bad outcome" and then for a while the standard is broadened again.

Let me illustrate what I mean by using the statutes that pertain to civil commitment in the state of Minnesota.  The following are the statutory definitions of a mentally ill or chemically dependent person who could be considered for civil commitment in the state:

Subd. 13.Person who is mentally ill.

(a) A "person who is mentally ill" means any person who has an organic disorder of the brain or a substantial psychiatric disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or to reason or understand, which is manifested by instances of grossly disturbed behavior or faulty perceptions and poses a substantial likelihood of physical harm to self or others as demonstrated by:

(1) a failure to obtain necessary food, clothing, shelter, or medical care as a result of the impairment;

(2) an inability for reasons other than indigence to obtain necessary food, clothing, shelter, or medical care as a result of the impairment and it is more probable than not that the person will suffer substantial harm, significant psychiatric deterioration or debilitation, or serious illness, unless appropriate treatment and services are provided;

(3) a recent attempt or threat to physically harm self or others; or

(4) recent and volitional conduct involving significant damage to substantial property.

(b) A person is not mentally ill under this section if the impairment is solely due to:

(1) epilepsy;

(2) developmental disability;

(3) brief periods of intoxication caused by alcohol, drugs, or other mind-altering substances; or

(4) dependence upon or addiction to any alcohol, drugs, or other mind-altering substances.

Subd. 2.Chemically dependent person.

"Chemically dependent person" means any person (a) determined as being incapable of self-management or management of personal affairs by reason of the habitual and excessive use of alcohol, drugs, or other mind-altering substances; and (b) whose recent conduct as a result of habitual and excessive use of alcohol, drugs, or other mind-altering substances poses a substantial likelihood of physical harm to self or others as demonstrated by (i) a recent attempt or threat to physically harm self or others, (ii) evidence of recent serious physical problems, or (iii) a failure to obtain necessary food, clothing, shelter, or medical care. "Chemically dependent person" also means a pregnant woman who has engaged during the pregnancy in habitual or excessive use, for a nonmedical purpose, of any of the following substances or their derivatives: opium, cocaine, heroin, phencyclidine, methamphetamine, amphetamine, tetrahydrocannabinol, or alcohol.

The first thing that should jump out at any reader is the fact that "dangerousness" most commonly defined as a "danger to self or others" is only one of several relevant criteria (see bolded sections).  A significant part of the statutory definitions for both mentally ill persons and chemically dependent persons has to do with self care.  Can they provide food, clothing, shelter, or medical care for themselves?  Can they manage their personal affairs?  I would suggest that the majority of people in this country with psychotic disorders and both substance use and psychotic disorders who are acutely disabled by those disorders meet this standard rather than threatening or aggressive behavior.  Suicidal ideation and behavior is also less common than deficits in functional capacity or self care.  There are also a number of important legal interventions that are as important as civil commitment to address these issues among them conservatorship or guardianship that provides substituted decision making for the person with impaired cognition due to mental illness.  I worked with an even better option in the State of Wisconsin and that was a parallel system of protective services and protective placement that could be used in place of civil commitment to assure that the person had adequate resources for their day to day needs and medical care.

The article I received today talks about mental health being the default position for legislators who do not want to take on the firearms issue.  The politics of this situation and the deadlock  are quite obvious so I won't belabor the point.  The legislator in this reference wants better training for the police and a commitment standard based on treatment considerations rather than "imminent dangerousness."  I have already demonstrated how imminent dangerousness is a de facto standard that the courts and managed care systems collude with, but it really has nothing to do with existing statutes on the books.  I will take a page from the gun advocates who claim we have enough gun legislation on the books it is just never enforced.  We have enough commitment standards on the books - they are never recognized or followed.  To say that the commitment standard is "imminent dangerousness" is simply false.    

The politics of civil commitment is always an interesting process and it does shed some light on why the standards are ignored.  It actually happens at all levels.  In Minnesota, if a person is on a 72 hold in a hospital they need to be seen during that time frame by a pre-petition screener from their county of residence. Pre-petition screeners come from many counties and they vary considerably in their clinical acumen and political orientation.  It becomes fairly easy to predict which counties will proceed with commitment and which will not.  Some counties have pre-petition screeners who actually consider themselves to be civil rights advocates and they will fight any suggestion of commitment.  That fight should occur at the next level and that is the county attorneys who represent the county in the commitments and the defense attorneys.  Outcomes vary with the personality of those attorneys and some of those outcomes are not good.  The final step is the probate court judge, commissioner, or referee responsible for making the determination of commitment.  The quality and experience at this level varies considerably ranging from judges who are consistent and handle cases very well to those who clearly make wrong decisions to judges who overstep their authority and start to make medical decisions such as ordering a specific medication or quantity of mediation per court order.  As far as I can tell there is no uniform training or standards for any member of the commitment process so variable outcomes should not come as a surprise.    

With the issue of civil commitment laws that use a treatment standard, they are already on the books but  they are rarely followed.  That has to do with the culture of rationing mental health services as much as anything.  How do I know this?  I have been part of conversations where staff involved in a commitment were told by a county bureaucrat that they were doing "too many commitments" and it was "costing the county too much money".  I never really understood that argument because all of the people involved are there, on salary, and show up every day whether there is anyone in commitment court or not.  The cost should be the same if one person shows up for a hearing or 20 people show up.  At 5 o'clock everybody goes home, so there is no overtime.  I have never seen the court so saturated that they could not move through the necessary hearings and decisions.  The only thing that this false economic pressure creates is a change in the way the commitment statute is interpreted.  Suddenly the ONLY rule is "dangerousness to self or others".  That also translates to "imminently dangerous to self or others".  Notice that the statute says nothing about "imminently" and any form of the word danger is limited to a special section at the bottom about "Mentally Ill and Dangerous".    

I conclude the changing the commitment standard and expecting that to have an impact on mass violence will not work, basically because that treatment standard is already on the books and it is routinely ignored.  In Minnesota, the entire chemically dependent person statute is frequently ignored and I often hear "we don't commit anybody for chemical dependency."  There are a number of financial, avoidance of work incentives, and lack of quality standards that have facilitated that process.  It is readily observable by any psychiatrist who sees their patient back, realizes that they did not receive any care in a hospital, and notes the patient was discharged at his or her request because "they were not imminently dangerous".  The financial interests of managed care systems and the counties involved overlap perfectly at that point.

Once again I keep coming back to the old term "quality".  Quality care never involves discharging a disabled person because it is convenient to do so and it can be rationalized by a "community standard" that is determined by everybody except the experts involved and in this case the state statutes..

The focus of psychiatric professional organizations should be on defining what that standard of care should be and how to optimize treatment instead of throwing in with a managed care model for rationing care.  Rationed care has resulted in a non-existent system of care for the patients with psychosis.  And as long as that system remains non-functional, the small percentage of people who are violent and psychotic will also not get the care they need.

The prevention of violence by individuals with psychosis starts with improving the standard of care for everybody rather then trying to pick the violent individuals out of the crowd. 

George Dawson, MD, DFAPA 

Persecutory Delusions, Psychiatric Treatment, and Violence Prevention

For 23 years I ran an acute care inpatient service where the main focus was preventing violence and suicide.  That is the default function of inpatient units these days and it has been decided  by businesses and governments rather than organized psychiatry.  Organized psychiatry used to take an interest in quality care in hospitals but it has largely been abandoned to the hospitals and organizations that run them.  The regulatory bodies for inpatient care tend to focus on a number of parameters that are irrelevant to quality care.  With such a fragmented regulatory and administrative approach, the focus on quality of care depends solely on the personnel on each unit and how well they work together as a team.  The majority of patients are admitted these days because of concerns about aggressive behavior and suicide.  In my experience, good inpatient teams are highly successful in assessing and treating those problems.

One of the key treatment interventions is determining the people with the highest risk potential for the most intensive treatment interventions.  The treatment outcomes in terms of averting aggressive and suicidal behaviors are generally good.  Given the relatively rare occurrence of aggression or suicide post discharge the actual power of the treatment intervention is unknown.  The potential severity of outcomes precludes any placebo controlled clinical trials.  No human subjects committee would authorize a placebo arm and since many patients are on involuntary status or court holds.  No probate court judge would go along with it either.

The March 2014 edition of the American Journal of Psychiatry has some the most most extraordinary content I have ever noticed in that publication.  Among the articles is a paper called "Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia".  It adds significantly to the literature on psychosis and violence.  The study focuses on the United Kingdom Prisoner Cohort Study and it looked at risk factors for future violence in prisoners who were incarcerated for a violent crime after they were released.  It is a study that could be done on patients who were acutely hospitalized and released because of the naturalistic design and use of nonviolent participants as a comparison group.  That authors were interested in looking at whether the presence of psychosis predicted future violence and if there was any specific pattern of symptoms.  They were also interested in looking at the issue of whether or not treatment was helpful.

The sample consisted of 1,717 prisoner screened at baseline and 967 followed up (787 men and 180 women).  Selection was based on incarceration for at least 2 years for a violent crime and release date within 12 months of the start of the study.  All participants were given a number of structured research assessments to establish diagnosis.  At follow up, the diagnoses of the patients in the study included 94 meeting diagnostic criteria for schizophrenia, 102 for drug induced psychosis, and 29 for delusional disorder.  Only the subgroup with schizophrenia scored higher on psychopathy scores.  Violent behavior at follow up was established by self-report and a national computer police database that classified violence against persons.  According to that database 22.9% of participants were violent between release and follow up (mean 39.2 weeks).

 In terms of the relevant results, the delusional disorder and drug induced psychosis subgroups were no more likely than the the participants without psychosis to be violent at follow up.  Persons with untreated schizophrenia were more than three times as likely to be violent that the non-psychotic participants at follow up.  In that group those with persecutory delusions were more likely to be violent than those with other symptoms of psychosis.  The authors briefly review the indirect evidence supporting their findings including treatment non-adherence and risk of violence, risk of violence at first presentation of treatment rather than subsequent episodes, and psychosis as a risk factor for violence.  They point out that to their knowledge this is the only study of violent recidivism in prisoners that looks at the issue of psychosis as a risk factor.

The actual treatment provided in this case was critical.  In terms of violence prevention any treatment provided in prison only or in prison and on release was effective in preventing violence.  They point out that identification of more people needing treatment by their study methodology may have led to more active treatment of study participants.  They quote data on that fact that in prisons in the UK only about 1/4 of prisoners with severe mental illnesses are identified by mental health teams with that specific function and that of those identified only 13% are accepted into case management.  Overall in the UK less than 1/4 of prisoners who screen positive for psychosis are given a mental health appointment at the time of discharge.

The accompanying editorial by Large is interesting in reviewing the issue of screening versus not screening populations for psychosis and whether that prevent violence.  Several studies have concluded that "risk assessment is insufficiently sensitive to provide a basis for protection of the public."    Without looking at all of the references (I would expect to find significant flaws) the issue is really not a screening issue.  This study happens to appear like it is a screening, but the diagnostic approach is probably much more vigorous than most assessments in correctional settings.  The issue is that you have a person sitting in front of you telling you that they have persecutory delusions and are at risk for continued violence secondary to those delusions.  There is also a significant subgroup who are at personal risk for self harm related to these delusions that the authors either did not find or they did not comment on.  The Large commentary also focuses on antipsychotic medication as the treatment for psychosis and in the UK psychotherapy is also a treatment modality.  He makes the observation that treatment across the entire spectrum is important in that less treatment in the currently treat group will also result in more violence.

This study is useful in the US for several reasons.  County jails have become the largest psychiatric hospitals in the United States largely as a result of government and business policy.  Inpatient units may be useful for acute violence but there is an uneasy relationship with county jails.  Hospital policy may result in suicidal and acutely aggressive psychotic patient being treated in jail settings and using methods that would be seen as completely inappropriate in a medical or psychiatric setting.  Psychiatric follow up in jail settings is often fragmented and it is not uncommon to see medical treatment started and stopped based on the availability of medical staff or prescription medications.  I would consider the UK to be much more enlightened with regard to mental health policy than the US and to have more medically based resources for anyone with a psychosis diagnosis.  I can't imagine follow up numbers from American jails being any better than they are in the UK.

All of this creates a problem for the person with psychosis, persecutory delusions, and violent behavior.  The focus of much of the literature seems to be protecting the public from them but when you are their treating psychiatrist the arguments you are making to them is to protect them from their delusional thoughts.  That will not happen in a rationed, carved out environment that has shifted progressively more care for the severely mentally ill to correctional settings.  The other interesting  cultural phenomenon is that there is no coverage of this study or similar studies in the press.  Their bias seems to be to look at the sensational results of psychosis associated violent crime,  suggest that more treatment might be needed, attribute causation to being in the wrong place at the wrong time, and suggest that we all need to move on (lurch forward?) toward the next catastrophe.

This study provides a platform for a better approach to public policy and a more patient centric approach to violence prevention.

George Dawson, MD, DFAPA    


1: Keers R, Ullrich S, Destavola BL, Coid JW. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry. 2014 Mar 1;171(3):332-9. doi: 10.1176/appi.ajp.2013.13010134. PubMed PMID: 24220644.

2:  Large MM. Treatment of psychosis and risk assessment for violence. Am J Psychiatry. 2014 Mar 1;171(3):256-8. doi: 10.1176/appi.ajp.2013.13111479. PubMed PMID: 24585326.




 



    

The News Media and Mental Illness - A Continued Problem

Although the media can certainly pump up the volume on trivia like the DSM-5 their coverage of the critical day-to-day issues involving mental illness continue to be lacking in both depth and breadth.  It is weak.  From a depth perspective I will point to an article about a man convicted of shooting at people on the I-96 freeway in southeastern Michigan.  His reason for the shootings?  He thought he was getting coded messages from the Detroit Tigers to shoot people.  He also believed that military helicopters were hovering above his home and that his home contained "advanced technologies" that caused his daughter to develop a skin disease and his wife have a miscarriage.  The article contains a layman's description of a not guilty by reason of mental disorder defense and that defense was never advanced based on a judges ruling.  As a psychiatrist familiar with these criteria there is an overwhelming bias to convict people who are mentally ill and mentally compromised.  That is why the defense is generally a failure.  In this case the defendant did not have the opportunity to present that defense because as the article explains:

"Diminished capacity is a claim that says a defendant was unable to form specific intent required to commit a crime under the law by reason of mental illness, and as a result, the defendant’s responsibility in the alleged crime is diminished. The judge earlier ruled that the defense could not make this argument because it failed to give proper notice of a defense of insanity."

In other portions of the article we learn that he has been treated for an unnamed mental illness since 2009.  The symptoms are described as delusions that respond to medication and the delusions associated with the shooting incidents are currently in remission.  When the defendant is asked about whether he knew that firing a gun into an automobile might hurt someone.  His response was "In hindsight - yes".  I have not seen the final sentencing after a no contest plea but he faces up to 12 years in prison on firearms and assault charges after they decided to drop a terrorism charge.

From a breadth of coverage perspective, I will suggest a second article that points out the critical shortage in acute care inpatient beds with the capacity to address severe mental illness and aggressive behavior.  In those case Virginia State Senator Creigh Deeds discusses an incident where his son stabbed him and subsequently shot himself.  After the incident Senator Deeds states that the read his son's diary and it said that if he killed his father he would go directly to heaven.  In his taped discussion he talks about all of the relevant points that I try to cover here involving stigma, a lack of respect for providers, and diversion of resources to more areas of care that are viewed as more prestigious - like Cardiology.  Amazingly, Virginia apparently has a rule where you must be released from the emergency department if they can't find a psychiatric bed within 6 hours.  Based on his proposed reforms it doesn't seem like there has to be much of an effort to look elsewhere.  The sequence of events has been managed care companies shutting down psychiatric bed capacity by defunding it.  That is followed by states deciding to act like managed care companies and either shutting down their capacity or getting completely out of the field.  The end result is a pool of people who cycle in and out of short stays on inpatient units to overcrowded emergency departments to the street and back again.  Many permanently drop out of that cycle when they become homeless or go to America's newest mental hospitals - the county jail.  This is a problem everywhere in the United States.  I used to qualify that by saying it was a problem in areas of high managed care penetration.  Today that is everywhere.

Apart from the isolated pieces that are written with the obvious intent to get somebody a Pulitzer Prize, these stories are typical of what you see in the press.  The first article lacks basic information on what mental illness is and how decision making in a delusional state bears no resemblance to answering questions "in hindsight" after the delusions are gone.  It lacks psychiatric perspective.  Any newspaper reporter probably has access to acute care psychiatrists to tell them about those problems.  In that situation reporters always want a "diagnosis" of the person in the news and psychiatrists cannot speculate on that without having examined the patient and getting their release for that information.  But they can provide a rich perspective based on their clinical experience treating thousands of similar problems and the effect of delusions on a person's conscious state.  They can also provide an opinion on the mental illness defense in this country as well as the state of psychiatric services to treat the problem.  I know that I would be happy to provide those details.  At the minimum somebody in charge of journalism school curricula needs to examine how reporters can come out and ignore all of those facts.  I might even suggest objective criteria for coverage as at least 5 times the words used to cover the least relevant mental illness story that year.  I would give the least relevant story this year as anything having to do with the DSM-5.  On that basis a lot of additional writing needs to be done on these two stories.

In the case of Senator Deeds, his analysis of the problem in this brief soundbite is spot on.  He needs a broader platform to advocate for his plan and support against the people who are opposing him and the 6 hour rule in state of Virginia.  He should work the the American Psychiatric Association, receive their support, and have access to their social media venues.  The APA should come out with their own solution to this problem.  I cannot think of anything more absurd and more consistent with a managed business approach to treating severe health problems than this 6 hour rule.  At some point the patient and their severe problem is totally meaningless relative to business concerns.  And Senator Deeds is right.  That doesn't happen with any other medical problem in the emergency department.

It only happens with mental illness.

George Dawson, MD, DFAPA

What Is Really Going On At The Minnesota Security Hospital?

The Minneapolis StarTribune posted a recent story about the Minnesota Security Hospital (MSH) on December 27, 2013 that was updated today.  The article raises concerns about patient treatment and safety at this facility both for patients and staff.  It should be read by everyone with an interest in how state mental hospitals function.  It is of particular interest to Minnesota residents who may have a relative being treated at this facility but also anyone concerned about the image of the state and how it treats residents with severe mental illnesses.  From a policy standpoint it should be an issue of great importance for both local psychiatric societies and the American Psychiatric Association (APA).

Let me preface my remarks by saying that I have no inside knowledge of what is occurring at the MSH beyond what I read in the papers.   The first concern is about the information base for the article and who is interpreting that information.  That is contained in the fourth paragraph of the article at the very end of that paragraph:

"Nearly two years after the hospital's professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show.  Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records, and agency files reviewed by the Star Tribune."

The problem here is that there is nobody at the Star Tribune who is an expert in the treatment of patients with severe mental illness and aggression.  The second problem is that there is a significant conflict of interest anytime a journalist has access to clinical material with a potential sensational interpretation.  From my experience journalists will make that interpretation out of ignorance or for the purpose of enhancing the dramatic impact of the story.  In this article the names of two patients are disclosed.  Journalists are not confidentiality bound to not disclose the names of patients and there may be some public documents with the names of these patients.  My experience with journalists has been that they want to talk to actual patients with real names, and really do not understand the problems with that.  There are always many potential weaknesses when considering a journalistic source.

There is a precedent for the review of confidential hospital records by expert unbiased reviewers and that was the Medicare Peer Review Organizations (PRO) system.  In that process, physicians who were experts in the field in question were rigorously screened for conflicts of interest.  As an example, they could not have any affiliation however peripheral with the hospital or clinic being reviewed.  The compensation for reviewing the records was trivial and you could not make a living at it.  Reviewers were expected to be practicing medicine full time and not be an administrator.  As a reviewer, I reviewed tens of thousands of pages of hospital records - many from state hospitals for both quality problems and utilization problems.  A newspaper reporter looking at a patchwork of records, memos, and files from multiple sources is hardly an adequate standard to draw any conclusions.  A reporter can make it seem like the hospital is a "bad" place for restraining people or in this case failing to restrain a person.

A potentially rich source of information is the hospital's former medical director - Dr. Jennifer Service.  She has one quote in the article about how the MSH is "broken", but it provides no details.  My speculation is that there is nobody who had a better front row seat to what happened than Dr. Service and possibly the previous medical director.  In the treatment of severe mental illness and aggression the medical director or clinical director has a critical role in making sure that there are no administrative factors that adversely affect the treatment team or their ability to provide care and a safe environment.  A common mistake is that administration believes it can effect change and they do not pay close enough attention to the impact on the clinicians providing care.  When treating aggressive people any environmental change like that can result in increasing aggression and chaos in the treatment environment.  The Legislative Auditor's Report suggests several areas where the therapeutic neutrality of the environment and staff cohesion were problematic.  During 23 years of conducting team meetings, my experience was that psychiatrists are an integral part of the team and should be the team member most experienced in team dynamics, countertransference, and approaches to violence prevention.  There is no indication that occurred on teams at the MSH and in fact, participation is described as marginal.

There are other potential conflicts of interest here that potentially bias the story.  Minnesota Department of Human Services apparently administers the place.  In this case Commissioner Anne Barry talks about the goal of increasing the likelihood of discharge by making community living environments more available.  Since DHS also administers all of those environments in the state it should be a relatively easy task.  Why is it not being done?  Are there people who realistically cannot be discharged without recreating a hospital environment for them in the community?  In the cases where that has happened have there been more adverse outcomes?  Are those environments more humane than the hospital environment where the patient was initially?  The Deputy Commissioner talks about accountability, but DHS seems like one of the most opaque state agencies out there.  Lately they seem to have moved into the area of micromanagement of the treatment providers especially around the issue of aggressive behavior.  Are the administrators of DHS responsible for the failed programs at the MSH?  Commissioner Barry talks about a more "therapeutic environment".  Is she qualified to determine what that is?  And finally the Legislative Auditor's Report alludes to a report by previous consultants.  Who were these consultants and where is that report?

Another good illustration of how conflicts of interest potentially bias the StarTribune article was the issue of accusations of maltreatment by professional staff.   The first is an allegation that a psychiatrist "committed maltreatment" by threatening an uncooperative patient with electroconvulsive treatment.  DHS investigators concluded that this happened but their finding was overturned by the DHS Inspector General.  The State Ombudsman for Mental Health and Developmental Disabilities apparently believed it happened and made a request for the DHS Commissioner to reconsider the finding.  The Inspector referred the matter to the Board of Medical Practice.  In the second case, 2 nurses were accused of maltreatment.  From the way the article is written it appears to be related to the incident where the patient was "slamming his head repeatedly into a concrete wall" and they were unable to get an order to physically restrain the patient.  The nurses were fined and reported to the nursing board.  Based on the incidents of maltreatment and another incident where a patient did not receive timely assessment for a stroke the DHS Commissioner extended the hospital's probation through 2014.  There are many problems with employees paying the price for chaos in the system.  Administrators often do not recognize the professional obligations of the staff.  I have personally seen quality psychiatric staff paralyzed by indecision that was brought about by administrative mandate or personnel problems.  The other problem here is that DHS appears to be the administrator, investigator and judicial process rolled into one.  We have a number of political appointees (DHS, Ombudsman, Board of Medical Practice) charged with deciding the professional fate of a physician who seems to be practicing in the worst of possible scenarios.  It should not be too surprising that MSH is unable to recruit and hire psychiatric staff.

The Legislative Auditor's Report is probably a better source of information than the newspaper report, but it has the same lack of input from experts.  It is useful from the perspective of bureaucratic information on the details that can be counted like the number of psychiatric contacts, number of hours of therapeutic contact, number of staff injuries for a certain period of time, etc.  One of the areas that is most interesting to me as a psychiatrist is the frequency of patient contact by psychiatrists.  The report gives an example of a recent census of 321 patients.  It provides an exhibit showing that from a policy standpoint the suggested frequencies of contact are monthly, quarterly, or semi-annually.  These frequencies are interestingly lower than the frequency of contact in some 19th century German asylums.  I can recall that Binswanger made a point of seeing all 200 patients in his asylum every week.  The report said that of the 321 patients in the study 45% had been seen in the previous month, an additional 24% 1-2 months earlier, 17% 2-3 months before and 4% greater than 3 months before.  Going from a full complement of eight psychiatrists to a total of two psychiatrists and 1 nurse practitioner is an obvious problem in terms of contact.  Actual contact with psychiatrist is an insufficient metric for treating patients and other quality measures need to be developed.  

If the article and the Legislative Auditor's report are even partially accurate with regard to facts, the glaring problem here appears to be that there is nobody in charge who knows how to run a hospital that treats people with severe mental illness and problems with aggression.  It is probably more correct to say that at this point we have not been presented with any positive evidence that there is a person in charge with the necessary qualifications.  The information presented in the StarTribune article does not suggest a clash of cultures.  There is no psychiatric hospital culture that I am aware of where there is confusion about whether or not a patient should be allowed to injure themselves.  The second problem is that this hospital needs psychiatrists who are trained to treat severe mental illness and aggression.  They do not need to be forensic psychiatrists, but they do need expertise in treatment of severe mental illness.  Forensic psychiatrists are basically needed to perform specific evaluations of criminal responsibility but the priority here is described as patient and staff safety.  The people needed in this situation currently work in a number of acute care and community settings.  They are very comfortable with the treatment of major psychiatric disorders and the associated medical comorbidity.  It is safe to say that they enjoy working with these problems and talking with the people who have them.  They are also sensitive to the needs of their co-workers and can establish the necessary environment of mutual trust and neutrality needed to succeed.

There may not be anyone around who remembers that Minnesota has solved a similar problem in the past.  The year was 1990 and there were significant problems staffing the major state hospital in the system - Anoka Metro Regional Treatment Center.  At that time, a Medical Director who was recently out of training was hired and he hired several colleagues from the same generation.  They were all enthusiastic and interested in providing quality care.  The state offered them competitive salaries.  Within a very short period of time a cohesive staff developed and they became a favored training site for medical students.  Treatment at the state hospital improved dramatically and several of the psychiatrists in that cohort went on to become leaders in the state in the provision of psychiatric services to patients with severe mental illness.

That still seems like a good idea today.


George Dawson, MD, DFAPA

Paul Mcenroe.  Minnesota Security Hospital: Staff In Crisis Spreads Turmoil.  StarTribune, December 27, 2013.

Office of the Legislative Auditor.  Evaluation Report: State-Operated Human Services.  February 2013.

Additional Clinical Note 1:  Looking back over my post it is clear that I do not answer the question that is the title.  Like most people I am speculating based on an imperfect data set.  The main difference is that I am also speculating as an expert based on what needs to happen to provide the safest scientifically based treatment for people who are mentally ill, aggressive, and may have failed most if not all of the available treatments.  I also recall that some past state hospital problems were resolved that has not been brought up in the discussion so far.

More on Homicide Prevention – LA County Style

I have been developing a theme of how to prevent homicide and mass killing for more than a decade.  As previously posted, I think that this needs to be done independent of the firearms issue with a public health focus on both primary and secondary prevention.  There have been a couple of developments recently that I would like to highlight and whether or not they are consistent with the public health approach.

The first is an article in the NY Times today on a unique approach to school threat assessment and intervention.  The article describes LA County’s School Threat Assessment Response Team.  Several threat scenarios are described that trigger a multidisciplinary response from team members representing law enforcement, school officials, and mental health.  The way the program is described it is unique in terms of engagement.  Threats at school generally result in one dimensional and fragmented approach to the problem.  The school has a protocol that may result in suspension.  Referral to mental health providers is frequently a limiting step due to the lack of appointments, insurance problems, or debate over whether the school system or the health care system is responsible for assessment and treatment.  This patchwork system is a set up for people with severe problems falling through the cracks.

The LA County response is for the team to make a rapid same day assessment at the point of the threat and at the student’s home including looking at their room.  How many times have we read about the marginal teenager who is thrown out of school for threatening behavior and they end up sitting in their room focused on the same thought patterns or watching other forms of violent activity on the Internet or in video games?  Getting right into that environment seems like a powerful intervention to me and one that is likely to yield better results.  The main reason for failure in situations where a threat has been identified is that lack of follow up.    People who are threatening and aggressive are not likely to care if they are thrown out of school and they are not likely to follow through with mental health interventions.  The response team also spends time educating people about how to communicate in emergency situations where there are many misunderstandings about confidentiality.

The LA approach is innovative and exactly what is needed to assess and intervene in crisis situations involving threats and dangerous behavior.  In situation after situation, tragedies occur when people people come to the attention of someone and there is no clear map for assessment and treatment.  That is true in the school system, in colleges and universities, in the workplace and in family situations.  I have personally talked with people who said that they either did not know what to do or they actively tried several resources and were told that there were no appointments available or that the person was not dangerous enough to treat and unless they agreed to a voluntary assessment and treatment that nothing could be done.  But it doesn’t stop at that point.  I am also aware of situations where there clearly was enough evidence that the person was dangerous enough to meet criteria for an emergency assessment but it was not done of the person was released for the emergency department.  In many of these cases there was an adverse outcome.  What is the problem?

There is a significant bias against aggressive and violent people.  To some extent that bias is self protective.  Any reasonable adult knows the obvious advantages of avoiding conflicts or even irrational behavior.  There are always plenty of stories in the news about the lack of Good Samaritans in situations where an aggressive act is being perpetrated in public.  Many psychological explanations of this behavior are offered but I think the obvious motivation is avoiding the conflict and possible injury.  That same code of silence often applies in cases where there have been sudden changes in behavior and the person involved has a treatable problem.  A second level of bias is the moralistic approach to aggressive and violent behavior that equates this behavior with bad moral conduct.  That applies in situations where criminals use aggression to intimidate people and get what they want.  It does not apply when the aggression is a symptom of mental illness.

The bias extends beyond members of the general public.  The health care system is activated by a legal concept called “dangerousness” or “imminent dangerousness”.  Every state has different statutory requirements and those statutes are interpreted on a highly variable basis across every county in the state.  In some counties it comes down to some of the public officials involved seeing themselves as protectors of people’s rights.  In other counties, assessment and treatment are more of a priority.  At the level of the health care system there is another layer of bias.  The overwhelming bias these days is that people should not be assessed or treated in a psychiatric facility for more than 4 or 5 days and any assessment or treatment should be kept to the bare minimum.  It is easy to find different clinicians make entirely different decisions when presented with the same potentially dangerous patient.  The end result is a patchwork of acute care settings where people can go for help.  Because of all the biases involved unless an aggressive act has been committed the likelihood of an intervention occurring is basically a coin toss.

That is why the LA County response is so important.  It is an intervention that activates a rational response to threats from people who are likely in distress and possibly mentally ill.  There is no dangerousness standard initially and that is a critical departure from the current nonsystem.  The goal of the LA County response is to engage the person and their social network and not make a one-time assessment and decide to admit or discharge the patient based on a dangerousness concept.  The LA County response is unique in that it is based on behavior and the goal is to help the person involved rather than decide on whether or not they should be committed.  The overall approach is very similar to community psychiatry case management teams except LA County teams seem to have more latitude because they are not limited initially by commitment standards.

The is an excellent approach to the problem and I hope that it is researched, expanded to mental health crisis teams and widely adopted if effective.  I don’t know why it would not be effective.

George Dawson, MD, DFAPA

Erica Goode.  Focusing on Violence Before It Happens.  NY Times March 14, 2003.

"The only thing that stops a bad guy with a gun is a good guy with a gun"

That is a direct quote from the NRA's chief lobbyist Wayne Lapierre.  In the same NYTimes piece he goes on to say that declaring our schools gun free zones serves only: "“tell every insane killer in America that schools are the safest place to effect maximum mayhem with minimum risk.”  There has been some mild outrage in response to this comments but I don't know what people would expect from the NRA.  They see guns as a solution to everything.  They literally believe that with guns there is less crime despite the hard data that points to the fact that the USA has the highest (by far) homicide rate by firearms, the highest rate of gun ownership, and the highest rate of assault deaths of any of the top 30 countries of the Organization for Economic Cooperation and Development.  In fact, this NY Times graphic of the data shows that over half of the homicide rate is firearm related.  The total homicides in the US at 9,960 is nearly seven times greater than the total of all the other countries on the list.  The total number of suicides by firearms greatly exceeds this number (18,735 in 2009).  It seems to me that the gun data suggests that we currently have maximum mayhem with maximum risk.

Getting back to the proposed NRA solution.  Let's look at the arithmetic first.  Just considering the number of public schools in the US, current data from the National Center for Education Statistics puts that number at 98,817.  Assuming a cost of one armed guard per school with vacation coverage and benefits I would conservatively estimate a cost of about $100,000 per year or a total of about $9.8 billion dollars per year.  That is a substantial outlay of capital for what is an unproven strategy.  According to the Wikipedia list there have been 40 school shootings since 1989.  Using a a mean number of schools during the period (or about 91,638) would mean that the odds of one of these armed guards encountering a shooter would be about 2/91,638 on an annual basis.  The Transportation Security Administration responsible for airport security has a total budget of  $7.7 billion and they cover 450 airports but confiscate 1,300 firearms and 125,000 prohibited items per year.  $929 million of the TSA budget is for the Federal Air Marshal Service that assigns agents to commercial flights.  To put an armed guard in the schools would roughly cost what it costs to secure air travel in the US.  The main difference would be that school guards might have a much lower level of vigilance than air travel security and they would need to be very vigilant to head off a sudden and potentially very lethal attack.

Arithmetic aside, there is also the question of associated costs.  In medicine we are familiar with the screening arguments for breast and prostate cancer.  There is always a false positive and false negative cost.  With false positive PSAs and mammograms there is the ordeal of unnecessary biopsies and exposure to other unnecessary tests.  There is no way to estimate the impact of armed guards at schools.  Currently there are about 500,000 violent crime and over a million thefts committed against teachers in America's middle and high schools.  In a previous Institute of Medicine report,  the authors found that a  "substantial number of boys" carry firearms in schools.  That same study reported:

"Despite all this effort to keep guns from children  the committee was somewhat astounded at the ease with which the young people in these cases acquired the weapons they used.  Only in the Jonesboro case were the powerful weapons in the home of one of the too well secured for them to access.  But it was easy to defeat the security measures of another relative and get hold of a powerful semiautomatic rifle with a scope.  In general, it is easy for young teens to circumvent both the law and informal controls designed to deny them weapons they use in their crimes." (ref 1)

There is also the risk of unintentional discharge of weapons.  The New York City Police Department keeps a public record of all weapons discharges from its 33,497 police officers.  According to this report there have been 15-27 "unintentional discharges" per year over the past ten years.  With a school workforce nearly three times as large and possibly less vigilant than an NYPD officer that is potentially a lot of accidental discharges.   How many are acceptable in and around our schools?  The false negative/false positive cost of putting  armed guards into schools based on these factors is really unknown.  

Considering this problem has also led me to think about some epidemiological concepts that we were all taught in medical school.  Primary prevention measures are designed to reduce the incidence of new cases of disease.  Secondary prevention is focused more on people who are identified as being at risk but who are unaware of the fact that they may have the problem.  Tertiary prevention occurs after the problem is declared.  In the case of suicidal or homicidal behavior that means after the critical incident occurs.  This paper looks at these concepts in the case of suicidal behavior.  As far as I can tell there has been no exhaustive look at a timeline of all of the preventive factors that occur prior to mass shooting events or school violence events.  The usual method of analysis is looking at cases for a common profile and as the IOM report showed - there was none.

This analysis cannot predict whether the NRA stand on guns in schools will be protective or not.  It is much more complex than a statement that guns are a solution to gun crimes.  Based on what we know about these situations a key strategy is preventing the shooter from picking up the weapon in the first place.

George Dawson, MD, DFAPA

1.  National Research Council and Institute of Medicine. (2003) Deadly Lessons - Understanding Lethal School Violence.  Case Studies of School Violence Committee.  Mark H. Moore, Carol V. Petrie, Anthony A. Braga, and Brenda L. McLaughlin, Editors.  Division of Behavioral and Social Sciences and Education.  Washington, DC: The National Academies Press.

2.  Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271. doi:10.1371/journal.pmed.1000271

3.  New York City Police Department.  Annual Firearms Discharge Report 2011.

4.  Meet  the Press Transcript. Sunday December 23, 2013.  Wayne LaPierre discusses current NRA positions on school safety and gun control.

Violence Prevention - Is The Scientific Community Finally Getting It?

I have been an advocate for violence prevention including mass homicides and mass shootings for many years now.  It has involved swimming upstream against politicians and the public in general who seem to believe that violence prevention is not possible.  A large part of that attitude is secondary to politics involved with the Second Amendment and a strong lobby from firearm advocates.  My position has been that you can study the problem scientifically and come up with solutions independent of the firearms issue based on the experience of psychiatrists who routinely treat people who are potentially violent and aggressive.

I was very interested to see the editorial in this week's Nature advocating the scientific study of mass homicides and firearm violence. They make the interesting observation that one media story referred to one of the recent perpetrators as being supported by the United States National Institutes of Health and somehow implicating that agency in the shooting spree and that:

"In this climate, discussions of the multiple murders sounded all too often like descriptions of the random and inevitable carnage caused by a tornado or earthquake".

Even more interesting is the fact that the National Rifle Association began a successful campaign to squash any scientific efforts to study the problem in 1996 when it shut down a gun violence research effort by the Centers for Disease Control and Prevention. The authors go on to list two New England Journal of Medicine studies from that group that showed a 2.7 fold greater risk of homicide in people living in homes where there was a firearm and a 4.8 fold greater risk of suicide.  Even worse:

 "Congress has included in annual spending laws the stipulation that none of the CDC's injury prevention funds "may be used to advocate or promote gun control"."

This year the ban was extended to all agencies of the Department of Health and Human Services including the NIH.   There is nothing like a gag order on science based on political ideology. 

The authors conclude by saying that rational decisions on firearms cannot occur in a "scientific vacuum".   That is certainly accurate from both a psychiatric perspective and the firearms licensing and registration perspective. Based on their responses to the most recent incidents it should be clear that politicians are not thoughtful about this problem and they certainly have no solutions. We are well past time to study this problem scientifically and start to design approaches to make mass shootings a problem of the past rather than a frequently recurring problem.

George Dawson, MD, DFAPA

Who calls the shots? Nature. 2012 Aug 9;488(7410):129. doi: 10.1038/488129a. PubMed PMID: 22874927.

"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. 

Mass shootings - How Many Will Be Tolerated?

I have been asking myself that question repeatedly for the past several decades.  I summarized the problem a couple of months ago in this blog.  In the 12 hour aftermath of the incident in Aurora, Colorado I have already seen the predictable patterns.  Condolences from the President and the First Lady.  Right wing talk radio focused on gun rights and how the liberals will predictably want to restrict access to high capacity firearms.  Those same radio personalities talking about how you can never predict when these events will happen.  They just do and they cannot be prevented. One major network encouraging viewers to tune in for more details on the "Batman Massacre." 

We can expect more of the same over the next days to weeks and I will not expect any new solutions.  Mass shootings are devastating for the families involved.  They are also significant public health problems.  There is a body of knowledge out there that has not been applied to prevent these incidents and these incidents have not been systematically studied.  The principles in the commentary statement listed below still apply.  

It is time to stop acting like this is a problem that cannot be solved.

George Dawson, MD, DFAPA

A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education

Wartime atrocities

The recent mass murders in Afghanistan and the analysis of the events in the press highlight my contention from an earlier post that the press really does not do a good job in these situations. We can expect a continued exhaustive risk factor analysis and discussions by various pundits. The accused soldier clearly had a lot of exposure to combat stress, there is a history of traumatic brain injury, there is a possible history of substance abuse, and there are multiple psychosocial factors. So far we have seen the statements by people who knew him describing this event as completely unpredictable based on his past behavior. The debate will become more polarized as the lawyers get involved. The real truth of the matter is never stated.

What we know about these incidents is more accurately described by anthropologists than psychiatrists or psychologists. The best book written on this subject is Lawrence Keeley’s War Before Civilization.  In that book Dr. Keeley explores the contention that primitive peoples were inherently peaceful compared to modern man and a warfare that was waged was brief, fairly nonlethal, and stereotypic. In order to explore that theory, Dr. Keeley ends up writing a fairly definitive book on the anthropology of warfare. There are more lessons in that book about war and peace then you will ever hear on CNN or in the risk factor analysis that is produced in the popular media.

So what do we know about the mass murder of civilians during warfare? The first thing we know is that it is commonplace. It happens in every war and no military force despite their level of training is immune to it.  In prehistoric times, the most frequent scenario was a surprise attack on a village with the goal of killing as many inhabitants as possible. In Keeley's review, that number was generally around 10% of the population and that could have devastating consequences for a particular tribe including the complete dissolution.

Keeley also makes the point that: “Only the "rules of war," cultural expectations, and tribal or national loyalties make it possible to distinguish between legitimate warfare and atrocities.”  He gives the examples of Wounded Knee and My Lai as well as larger scale bombings of Hiroshima and Dresden.  My Lai was a highly publicized incident from my youth. It occurred during the Vietnam War when the US Army massacred hundreds of Vietnamese noncombatants – largely women, children, and old men.  In that situation, 26 soldiers were charged and only one was convicted. The convicted soldier served 3 1/2 years under house arrest.

In addition to outright killing, mutilations of bodies and the taking of body parts as trophies continue to occur in modern civilized warfare in much the same way that these practices occurred in primitive warfare.  Haley reported on a series of Vietnam veterans seen in psychotherapy and the special problems that exist in patients who have been exposed to or participated in wartime atrocities. Based on the literature at the time she suggested that the war in Vietnam resulted in a disproportionate number of atrocities.

My current final analysis of the situation is that there are important social and cultural determinants of war and the inevitable wartime atrocities. Risk factor analysis and analysis of individual biology is very unlikely to provide an explanation for what occurred. The moral, legal, and political environment has changed since Vietnam and that is obviously not a deterrent. A comparison of the final legal charges and penalties in this case with what happened in Vietnam will be instructive in terms of just how far those changes come. If there is a conviction, there will be a lot of pressure to portray the convicted soldier as very atypical and probably as a person who underwent a significant transformation of his conscious state.  There will be many theories. The idea that this transformation predictably occurs during warfare will not be discussed. I have already heard some experts talking about the thousands of soldiers who go though similar situations and seem to do just fine.

The best approach to these events is a preventive one that includes minimizing the exposure to war instead of being involved in the longest war in American history.  I don't expect that much will be said about that either.

George Dawson, MD

Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

Haley SA. When the patient reports atrocities. Specific treatment considerations of the Vietnam veteran. Arch Gen Psychiatry. 1974 Feb;30(2):191-6.

Violence and Gunplay - Why Nobody is Informed by the Media Anymore

Mass shootings have been a phenomenon of my lifetime.  I can still clearly remember the University at Texas-Austin shootings that occurred  on August 6, 1966. A single gunman killed 16 people and wounded 32 while holed up on the observation deck of an administrative building until he was shot and killed by the police. I first read about it in Life magazine. All the pictures in those days were black and white. Some of those pictures are available online on sites such as "Top 10 School Massacres.”  I generated this timeline of mass shootings when Google still had that feature in their search engine. 

The problem of course is that the mass shootings never really  stop.  In the USA, the press is so used to them that they seem to have a protocol.  Discuss the tragedy and whether or not the perpetrator was mentally ill, had undiagnosed problems or perhaps risk factors for aggression and violence.  Discuss any heroic deeds. Make the unbelievable statement that the victims were "in the wrong place at the wrong time."  And then move on as soon as possible.  There is never a solution or even a call for finding one.  It is like everyone has resigned themselves to to repetitive cycles of gunfire and death.  It is clear that the press does not want to see it any other way.

When you are practicing psychiatry especially in emergency situations and hospitals, you need to be more practical.  When I took the oral boards exams back in 1988 and subsequently when I was an examiner, one of the key dimensions that the examiners focused on was the assessment of dangerousness.  Failing to explore that could be an exam failing mistake.  Any psychiatric inpatient unit has aggression toward self or others as one of the main reasons for admission to acute care and forensic settings.  With the recent fragmentation and rationing of psychiatric services, many people who would have been treated in hosptials are diverted to jails instead.  That led one author to describe LA County jail as the country's largest psychiatric facility.  

I have introduced the idea of looking for solutions into professional and political forums for over a decade now and it is always met with intense resistance.  Some mental health advocates are threatened by the idea that it will further stigmatize the mentally ill as violent.  Many people consider the problem to be hopeless.  Others see it as the natural product of a heavily armed society and no matter what side you are on that argument - that is where the conversation ends.

In an attempt to reframe the issue so that this impasse could possibly be breached the Minnesota Psychiatric Society partnered with the the Barbara Schneider Foundation and SAVE Minnesota in the wake of a national shooting incident to suggest alternatives.  Rather than speculate about psychiatric disorders or gun control we were focused on solutions that you can read through the link below.

The actual commentary was never published by the editor who apparently stated that there was a conflict of interest because we seemed to be fishing for research dollars.   It appears that the press can only hear the cycle of tragedy, speculation about mental health problems, and the need to move on.  The problem with that is that we continue to move on to another shooting.

George Dawson, MD


A Commentary Statement submitted to the StarTribune January 18, 2011 from the Minnesota Psychiatric Society, The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education