Rethink Mental Illness

Rethink Mental Illness (Photo credit: Wikipedia)

A picture of Loughner taken by the Pima County...

A picture of Loughner taken by the Pima County Sheriff's Office's forensic unit, which saw widespread distribution via media outlets. (Photo credit: Wikipedia)

James Holmes

James Holmes (Photo credit: DonkeyHotey)

Systems that address procedures for managing violence need to improve on identifying risk for violence and taking appropriate precautions.  Forty-three of the 62 mass murderers of the last 3 decades have been young white males (Alan Singer 12/15/12, Huffington Post).  There were several recent, well publicized, multi-victim shootings in Colorado, Wisconsin, Oregon, and Connecticut, as well. We need to find ways to prevent the overwhelming number of mass murders in the last 3 decades.  This article looks at the similarities among 6 suspected and convicted mass murderers.

The research suggests some of the characteristics of mass murderers.  There appear to be two groups of mass murderers: 1) Psychopaths, some of whom have had severely adversive childhood experiences and 2) Psychotic individuals that are not in treatment, may be abusing substances and have experienced multiple overwhelming past and recent stresses or losses.  Recent mass shootings suggest an additional set of risk factors that can come together to create a “perfect storm” of violence. I propose that the more of these violence risk factors a person has, the more likely the person is to become violent toward others. Knowing the risk factors of young adult mass murderers, in particular, can help professionals provide effective treatment for those at risk that come to their attention before there is a tragic act. These risk factors include: belief in aggression as a means to an end, mental illness with substance abuse and without treatment, severe problems at school or at work, difficulty getting along with others, anger management problems, violent communications, and major life stressors which injure self-esteem.  

This article examines what is publicly available about some of these factors among 6 known or alleged mass murderers: Seng Hui Cho (Virginia Tech shootings, allegedly killed 32 and wounded 17, deceased), Jared Lee Loughner (Gabriel Giffords shooting, killing 6 and wounding 14, involuntarily medicated, pled guilty), Anders Breivik (Norway shooting and bombing, where 77 were killed, found not guilty by reason by insanity, arrested during the shooting), and James Holmes (alleged Colorado Theater murderer, 2012, where 12 were killed and 58 were wounded, has pled guilty),  Jacob (Jake) Tyler Roberts, 22 years old, deceased allegedly by his own hand, after shooting and killing 2 and wounding a third person in a Portland, Oregon shopping Center on December 11, 2012.  Roberts allegedly stole a gun, wore a protective mask and gear, and carried 2 guns and several fully loaded magazines to a local shopping mall filled with Christmas shoppers.  Finally Adam Lanza also allegedly died from a self-inflicted gun-shot wound after murdering 20 precious young children and 6 adults, including his mother. 

It is the additive nature of multiple risk factors that increases a person’s risk for violence and each person’s particular mix of risk factors may be different.   That is why there may not be a single profile of young adult male mass murderers.

Mental Illness and Substance Abuse

It is likely that all 6 of the mass murderers examined here had mental health problems.  Seng Hui Cho, Jared Lee Loughner, Anders Breivik, Jake Roberts, and James Holmes had been diagnosed as mentally ill.  Breivik, Loughner, and Roberts likely had a dual diagnosis that included mental illness and substance abuse.  The Telegraph reported that neighbors described Adam Lanza as a very troubled youth subject to outbursts.  A babysitter reported that Lanza had temper tantrums and needed to be closely watched as a child.  

The media reported that Seng Hui Cho was suspected of mental health problems since childhood.  According to a friend of Loughner’s, Bryce Tierney, Jared Lee Loughner acted strangely since high school and Jared was told to leave his college campus and not return until he had a mental health evaluation that proved he was not dangerous.  It appears that no one followed up to see that the evaluation took place.  At trial for the murders at the Gabrielle Gifford’s gathering, Loughner was declared incompetent to stand trial, diagnosed with Schizophrenia and was medicated against his will.   

On Tuesday, 8 June 2012, Professor of Psychiatry Ulrik Fredrik Malt testified that Anders Breivik was diagnosed with Asperger syndrome, Tourette syndrome, narcissistic personality disorder and possibly paranoid psychosis. It is unlikely that no one noticed he was severely mentally ill and dangerous before he slaughtered 77 people in Norway in July of 2011. If others noticed that he was mentally ill, treatment might have been helpful to stabilize him before the murders occurred.

The media reports that James Holmes was seeing a psychiatrist 6 weeks before the shootings and she alerted the Risk Assessment Team at the college. Those known to have undergone or been recommended for a mental health assessment and treatment before their attacks occurred are Seng Hui Cho, Jared Lee Loughner, and James Holmes. Several that knew Adam Lanza suspected that he had serious mental health and social problems from a young age.    The reduction of community mental health funding and lack of focus on prevention over the last few years may have contributed to some people not getting the help they needed early in their illness, thus the inability to prevent some very tragic acts of violence.   It is also possible that parents do not want to take their children for a mental health assessment because they feared ridicule or being blamed as “bad” parents.

Interpersonal Problems and Social Awkwardness

Five of the 6 persons in this article reportedly were socially awkward or had interpersonal difficulties. Additionally for mass murderers, interpersonal difficulties and oddities are often noticed long before the psychosis is evident or the shooting events occur.  Seng Hui Cho and James Holmes reportedly had difficulties in relationships to others. Beivik’s peers included extremists that advocated hatred of other groups of people.  Jared Lee Loughner, reportedly, had an exaggerated sense of his own importance and disdained other people that he thought were not as smart or important as he was, according to an interview with his friend, Bryce Tierney, in Mother Jones. He eventually stopped hanging out with his few friends and reportedly slept a lot, using “lucid dreaming.” Adam Lanza was reportedly socially awkward in High School, although very intelligent (Telegraph). Some considered him to be “odd” and he was described as a loner.

Serious School and Job Difficulties

It appears that 5 of these 6 mass murderers had school or job difficulties of a significant nature.  Seng Hui Cho had difficulties in his college classes and with peers. Jared Lee Laughner was asked to leave college because some people feared he was dangerous.  James Holmes had been successful in school, but allegedly failed an exam before he attacked people in the Colorado theater.  Anders Breivik allegedly was rejected by the military and was bankrupt at one time.  It is reported that Jake Roberts did well at his job, but quit prior to the killings.

Major Life Stressors with Attacks to the Ego

Five of these men had major life stressors that could have produced blows to the ego or reduced self-esteem. Seng Hui Cho experienced stress in his classes. He was mostly non-verbal, but was allegedly pressured to be verbal in one of his classes.  Jared Lee Laughner reportedly was asked to leave college and not return until he had a mental health evaluation. James Holmes allegedly was not performing well and withdrew from college after having an excellent academic record, then failing.  At 18, Breivik lost 2 million kr on the stock market (Wikipedia) and attempted to enlist in the military but allegedly was found “unfit for duty.”   News reports allege that Jake Roberts quit his job and was evicted from home prior to killing 20 children and 6 adults.  Friends reported that Jake dropped out of sight earlier this year and received an eviction notice in July of 2012 and he began giving away belongings, supposedly to move to Hawaii. .  It is thought that Jake’s driver’s license was also revoked.

Access to Guns and Explosives

All found some access to guns. Two of the six appeared to have access to a collection of guns.  Breivik amassed a supply of guns and a large quantity of fertilizer to be used for explosives before his 2011 attack. Adam Lanza had access to 6 guns legally owned by his mother.

Additive Nature of Certain Risk Factors

The media has reported that of the 6 men described here, it is likely that 6 had mental health problems, 3 had substance abuse problems, 5 had interpersonal problems or social awkwardness. 5 had school and job difficulties, and all 6 experienced major life stressors that likely were blows to the ego. All had access to guns.  All of these mass murderers had 4 – 6 of the 6 risk factors.   The mix of risk factors was different for each. 

It is hypothesized that when at least 4 the following risk factors occur together in a relatively short period of time in a male in his 20’s, examination by a mental health professional to see what services might be needed is prudent: 1) severe interpersonal problems or social awkwardness, 2) major job/school difficulties, 3) a major life stressor with a blow to the ego, 4) severe and chronic mental illness, 5) substance abuse and not engaged in treatment, 6) access to or fascination with guns. It is logical that poor problem solving and anger management skills may also be important, but this could not be determined at this time.  The formula(s) would need to be tested, but taking a risk management perspective, it might be better for family members, employers, and schools to reach out to men with these characteristics with an array of services that could reduce their risk of engaging in a tragic event. It will be cost effective in the long run to do so.

The need for Change

A dialogue is needed about 1) How to determine whether someone is dangerous to self or others; 2) what can be done when professionals or family members have concerns about a person's dangerousness to others; 3) whether danger must be imminent in order to have someone committed to a forensic hospital for a thorough evaluation and treatment. 4) Where is the line between personal rights to freedom and public safety?

The pendulum has swung from keeping people in hospitals for the mentally ill too long to making it almost impossible for someone to be committed to a hospital to determine if he or she is going to harm himself or other people. While most mentally ill people are not dangerous, some are.   Some individuals do sometimes stop taking their medications and become dangerous. That problem has to be fixed while protecting individual rights. A balance must be found.

A second problem is that the lack of accuracy of clinical judgment for predicting future risk of dangerousness.  However, mental health professionals in the US continue to use clinical judgment to determine if someone is dangerous. There are valid and reliable tools to increase the accuracy of the determination of dangerousness and appropriate treatment plans, but they are not widely used in the US. They are widely used in Canada, however. A new conversation around this issue is needed. 

A third issue is the continued discharge of patients from psychiatric hospitals for severely and chronically mentally ill persons (since 1968) without a thorough evaluation of their dangerousness to the community when they do not have the structure of the hospital to help them organize their lives.  Additionally, there has been insufficient funding to care for these people in the community since community mental health centers were created in the 60’s. It is hoped that the Affordable Care Act with better integration of physical and mental health care will reduce the overall cost of healthcare and improve the provision of mental health services. More readily available, economic, and higher quality mental health and substance abuse services could help prevent future violence.

 A fourth issue is the ability of those who have been determined to be mentally ill and dangerous to obtain firearms.  All of the laws in this area need to be re-examined, as some states are already doing.  Laws for the restoration of the right to purchase guns after having been declared mentally ill and dangerous are often very weak and ill defined.  These must be re-examined, as well.

The fifth issue involves the policies of some colleges to not report a dangerous student to the authorities or send the student to the emergency room for an evaluation once he leaves the college.  New rules for College threat assessment that include reporting dangerous individuals to local authorities or provide for emergency evaluations are needed. 

As society changes, so does its needs.  There appears to be a need to re-examine outdated legislation and rules regarding community responses to persons that are at risk to be dangerous to others.  This will involve new partnerships among a variety of community agencies including schools, colleges, law enforcement, juvenile services, the mental health system, the physical health system, community members, and families.  It will also involve a commitment to research on risk factors of dangerousness.

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–Dr. Kathy Seifert

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