[This was written some time ago in another venue. Thought it appropriate to re-post]

Unfortunately there have been three terrible mass murders within the past week. In each case guns were used. Also, in each case the perpetrator was crazy as a loon or in more politically correct parlance mentally disturbed. As always in such cases the left wing anti-gun lobbys scream for more gun control but are absolutely silent on the issue of forced or involuntary treatment of deranged individuals. This is today's antinomy.

I will do but a brief review because most of the following data is well known if not well publicized. Many, many more crimes are prevented by guns in the possession of citizens the are perpetrated by guns in the hands of citizens. In every venue when guns have been taken away (United Kingdom, Australia, India) violent crime rises dramatically. In every venue where guns are owned by private citizens and particularly where concealed carry is permitted, violent crime drops dramatically (Florida, New Hampshire, Oklahoma, Texas and many other states). We can go on and on and back-and-forth about phony statistics and individual beliefs but the above is factual.

The chief source of these mass murders is not the availability of guns. It is a serious flaw in our social and legal system that permits severely deranged, crazy, psychotic, angry and potentially very violent people on the street all of the time.

Approximately 30 years ago the Federal Government, not State Governments mandated release of involuntarily committed psychiatric patients across the country. State hospitals were shut down. Patients were moved to the"least restrictive environment" and a system of Community Mental Health Centers was developed. (I do not mean to imply that the state hospitals across this country at the time in question were wonderful, clean, therapeutic and delightful environments. There were some very good ones but there were many bad ones that provided little care in miserable conditions). It was postulated that these individuals would be happy to have more freedom, and eagerly co-operate with programs to provide them with counseling, medication, job training, and reintegration into mainstream society. Wow, did this fail! What did evolve were thousands and thousands of Board and Care homes which generally went from bad to disgusting and awful. Owners of such facilities became millionaires. Very, very few of the patients voluntarily went to the mental health centers for any reason. They were not counseled, they were not medicated, they were not really integrated into society. They lived in squalor and many took to the streets. Left-wing civil liberties groups and pushed for more and more restrictive laws to prohibit involuntary commitment, involuntary treatment and long-term institutionalization of the chronically and persistently severely mentally ill patients. But this is just background information. Keep it in mind as our discussion proceeds.

If one cares to look at the history of the "shooters" in virtually every incident that has occurred, be it at a school, a mall, a post office, a business or in the streets, these people are crackers. I can not find one incident of a fine, normal, upstanding, healthy, popular, individual in these awful events. Whether students shooting in a school or college, or an adult driving his pickup truck into a fast food restaurant and shooting strangers at random these are all people with a history. Some had been identified as having significant mental illness but were not in treatment because of their right to refuse it. Others were obviously weird and disturbed but were never made to be treated.

With regards to the schools: Public schools are obliged to provide an adequate education for all in their community. Special education services now mandated by the Federal Government are available for children with special needs when these needs are identified.  Schools routinely and by mandate screen children for vision and hearing problems, speech problems and often for learning problems. Parents are advised as to problems in these areas and advised to seek medical or other professional assistance. Religious or political beliefs will not, in most cases, override identified medical problems and the need for treatment in children. If the child experiences repeated epileptic convulsions in class, or severe asthma attacks in class, or is virtually deaf or blind and the parents ignore repeated advice and admonitions schools will by mandate inform child protective services or whatever the name of the local agency is that deals with child abuse and neglect. Failure to provide proper recommended medical care usually is considered child neglect and potential endangerment. As a result the epileptics, asthmatics, vision and hearing impaired students get the help and treatment they need. Speech therapy and occupational therapy is provided by schools.  IEPs assist children with learning disabilities.

Ahh, but what of the children with emotional/behavioral/social/psychiatric problems? You know, the quiet malcontent, the avoidant asocial or antisocial kid who is never included and frequently is tormented. The ones whose anger and resentment grow year by year. The school can do some psychological testing. They can identify but in most cases not  formally diagnose emotional or psychological problems including; depression, autism, Asperger's syndrome, even actual ADHD. They can recommend professional consultation to the parents. Rarely can they require it.

Not all of the "shooters"demonstrated active behavior problems. Not all were suspended and expelled. But, to my knowledge, virtually every one of them had been identified as having problems; being different or odd or weird or quiet, or avoidant. Virtually everyone was ostracized. Virtually every one was unable to accept invitations to join the mainstream and to go along.

Older shooters such as those at Virginia Tech and the one who drove his pickup truck into the fast food restaurant had histories. Histories of violence, contact with the police, contact with emergency psychiatric services -- frequently with brief involuntary admissions --  brief incarcerations.

As a psychiatrist with more than 30 years of experience -- a preponderance of it with children and adolescents -- I can state with clear and firm authority that very few of the children, adolescents and adults who need treatment the most get it. Why? Because our culture, driven by left wing liberals and the ACLU continuously agitate for "patient's rights" at the expense of victims and society. When the child with epilepsy or asthma or deafness is referred for medical assistance it is almost always accepted by parents. Yet when recommendations are made for psychiatric and/or psychological evaluation and intervention the follow-through rate is poor. And it is very difficult for the school to report most of these cases to a child protective services agency because they do not have a clear diagnosis and treatment recommendation that has not been followed. No one would listen if the school guidance counselor called child protective services and said something along the lines of "there's this really quiet, sort of angry, malcontented kid who does poorly in school, doesn't appear to have any friends, has poor social skills, and has become ostracized by his peer group and is often the butt of jokes". Even a statement to the effect that some school psychological testing suggests some problems the school cannot make a diagnosis nor force the child and family into treatment. It becomes easier and seemingly necessary ultimately to let these kids be quietly angry malcontents whose alienation mounts steadily as they become more and more estranged. Unless they say or do something that triggers police intervention or a mandatory safety evaluation there is no formal contact with the healthcare or legal systems. Even then little usually happens because if there is not evidence of imminent risk to self or others such individuals are released and rarely pursue treatment. Court ordered treatment does occur but the efficacy is poor because the patient and family are not invested in change.

A contrarian will argue that I advocate forced psychiatric treatment and/or commitment of anyone who might be a little bit different, quirky, a loner, dances to a different drummer, or is just a bit awkward socially. Obviously this is not the case. Retrospective review of the histories of these "shooters" are remarkably similar and uniformly scary. One does not see or hear interviews of neighbors, teachers or classmates who say "I can't believe it, he's the last person I would think to do something like that!" These circumstances bear little or no resemblance whatsoever to the unfortunate and not uncommon scenario when a husband or wife or lover snaps and a murder suicide occurs (although in many of these cases one of the individuals has a history of mental illness or arrests).

Notwithstanding the claims of Scientologists, voodoo doctors and sundry other quacks modern psychiatry has made enormous gains in the past three decades. Diagnostic accuracy, neuropsychiatric medical evaluation, psychotherapy and pharmacotherapy are pretty accurate and effective. Yet the stigma, the disinformation and ignorance, and the resistance persist. Protective services and courts have no problem intervening when an identified medical problem exists. The separation of psychiatry from medicine, always something of an artifice to begin with, remains. Sadly there are some poor psychiatrists out there but there are legions of non-medical "mental health providers" unqualified to make diagnoses or proper treatment plans and their deficiencies become the psychiatrist's burden.

So, what's the point here? The point is that we have a systemic social problem with a very nasty, deadly and frequently avoidable incidence. This problem has nothing to do with guns, bullets, access to guns (or knives, bricks, hammers, rocks, slingshots, Molotov Cocktails...). It has to do with denial avoidance and ignorance. It also has to do with an overcorrection on the left with respect to "involuntary treatment", denigration of psychiatry, and the collective wish that those quiet, unhappy, angry and discontented kids would just go away. Do most of them become mass murderers? No. Do many of them end up in and out of the legal and/or mental health systems? Yes. Do we force everyone who's a little bit different to undergo a psychiatric evaluation and treatment as if on a bad episode of the Twilight Zone? Certainly not. But it is not acceptable to maintain this collective denial and believe that firearms are at fault. The similarities between the three "shooters" of the past week are too eerily alike. I do not have the details but I suspect that in each case, as in so many in the past, a quiet angry killer had been sending signals for a long, long time. Signs and signals that teachers, counselors, even parents ultimately chose to deny or to attribute to individualism and the hopeless wishfulness that they would either grow out of it or just go away. Neither will happen.

 [see also my previous post http://www.psychologytoday.com/blog/attention-please/201101/tucson-terro...

About the Author

Dr. Jory F. Goodman

Jory F. Goodman, M.D., is a practicing psychiatrist in Beverly Hills, with more than thirty years of clinical experience.

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