[Vision2020] Warning Signs of Violent Acts Often Unclear

[Art Deco]

  [image: The New York Times] <http://www.nytimes.com/>

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January 15, 2013
Warning Signs of Violent Acts Often Unclear By BENEDICT
CAREY<http://topics.nytimes.com/top/reference/timestopics/people/c/benedict_carey/index.html>and
ANEMONA
HARTOCOLLIS<http://topics.nytimes.com/top/reference/timestopics/people/h/anemona_hartocollis/index.html>

No one but a deeply disturbed individual marches into an elementary school
or a movie theater and guns down random, innocent people.

That hard fact drives the public longing for a mental health system that
produces clear warning signals and can somehow stop the violence. And it is
now fueling a surge in legislative activity, in Washington and New York.

But these proposed changes and others like them may backfire and only
reveal how broken the system is, experts said.

“Anytime you have one of these tragic cases like Newtown, it’s going to
expose deficiencies in the mental health system, and provide some
opportunity for reform,” said Richard J.
Bonnie<http://www.law.virginia.edu/lawweb/faculty.nsf/FHPbI/1146996>,
a professor of public policy at the University of Virginia’s law school who
led a state commission that overhauled policies after the 2007 Virginia
Tech shootings that left 33 people dead. “But you have to be very careful
not to overreact.”

New York State legislators on Tuesday passed a gun bill that would require
therapists to report to the authorities any client thought to be “likely to
engage in” violent behavior; under the law, the police would confiscate any
weapons the person had.

And in Washington, lawmakers said that President Obama was considering a
range of actions as part of a plan to reduce gun violence, including more
sharing of records between mental health and law enforcement agencies.

The White House plan to make use of mental health data was still taking
shape late Tuesday. But several ideas being discussed — including the
reporting provision in the New York gun law — are deeply contentious and
transcend political differences.

Some advocates favored the reporting provision as having the potential to
prevent a massacre. Among them was D. J. Jaffe, founder of the Mental
Illness Policy Org <http://mentalillnesspolicy.org/>., which pushes for
more aggressive treatment policies. Some mass killers “were seen by mental
health professionals who did not have to report their illness or that they
were becoming dangerous and they went on to kill,” he said.

Yet many patient advocates and therapists strongly disagreed, saying it
would intrude into the doctor-patient relationship in a way that could
dissuade troubled people from speaking their minds, and complicate the many
judgment calls therapists already have to make.

The New York statute requires doctors and other mental health professionals
to report any person who “is likely to engage in conduct that would result
in serious harm to self or others.”

Under current ethical guidelines, only involuntary hospitalizations (and
direct threats made by patients) are reported to the authorities. These
reports then appear on a federal background-check database. The new laws
would go further.

“The way I read the new law, it means I have to report voluntary as well as
involuntary hospitalizations, as well as many people being treated for
suicidal thinking, for instance, as outpatients,” said Dr. Paul S.
Appelbaum<http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=psa21&DepAffil=Psychiatry>,
director of the Division of Law, Ethics, and Psychiatry at Columbia
University’s medical school. “That is a much larger group of people than
before, and most of whom will never be a serious threat to anyone.”

One fundamental problem with looking for “warning signs” is that it is more
art than science. People with serious mental disorders, while more likely
to commit aggressive acts than the average person, account for only about 4
percent of violent crimes over all.

The rate is higher when it comes to rampage or serial killings, closer to
20 percent, according to Dr. Michael Stone, a New York forensic
psychiatrist who has a database of about 200 mass and serial killers. He
has concluded from the records that about 40 were likely to have had
paranoid schizophrenia or severe depression or were psychopathic, meaning
they were impulsive and remorseless.

“But most mass murders are done by working-class men who’ve been jilted,
fired, or otherwise humiliated — and who then undergo a crisis of rage and
get out one of the 300 million guns in our country and do their thing,” Dr.
Stone said.

The sort of young, troubled males who seem to psychiatrists most likely to
commit school shootings — identified because they have made credible
threats — often do not qualify for any diagnosis, experts said. They might
have elements of paranoia, of deep resentment, or of narcissism, a
grandiose self-regard, that are noticeable but do not add up to any
specific “disorder” according to strict criteria.

“The really scary ones, you have a gut feeling right away when you talk to
them,” said Dr. Deborah Weisbrot, director of the outpatient clinic of
child and adolescent psychiatry at Stony Brook University, who has
interviewed about 200 young people, mostly teenage boys, who have made
threats. “What they have in common is a kind of magical thinking, odd
beliefs like they can read other people’s minds, or see the future, or that
things happening in their dreams come true.”

Even if such instincts could be relied on, the mental health system is so
fragmented in the country that it is hard to know whether the information
would get to the right person in time. According to Dr. Bonnie, the
Virginia law professor, the Virginia Tech gunman was ordered to outpatient
treatment by a judge more than a year before his rampage but was never
hospitalized, which would have shown up on a background check.

The state database now includes such cases, after the reforms. “But we’re a
state that has a centralized database like that; in many states there’s no
one place to get it all; it’s all kept locally, community by community,”
Dr. Bonnie said.

The federal background check database, which is supposed to have updated
information from states, has only a patchwork, because of the wide variety
of state laws on reporting, experts said. Even if it were entirely up to
date, it would not catch the many millions who never see a mental health
professional despite deep distress.

Some experts, like Dr. Appelbaum, say the Connecticut school shooting
offers the kind of opportunity that only comes once every generation or
two: to rethink the entire mental health system. It might include
appointing a presidential commission; re-envisioning community mental
health care; focusing more on vigilance for problems in young people, and
reducing stigma.

“It seems to me an opportunity to step back and rethink what the entire
system should look like,” Dr. Appelbaum said.


-- 
Art Deco (Wayne A. Fox)
art.deco.studios at gmail.com
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