Preventing Evil Deeds

Banning assault weapons makes sense, but mass murders are about mental health.

Posted Mar 06, 2018

Wikimedia Commons
Source: Wikimedia Commons

In the wake of yet another horrendous mass school massacre (see my prior post), this time in south Florida, it is high time for mental health professionals to step up and take more responsibility for the prevention of these escalating explosions of murderous rage. Sadly, this was not the first and only Valentine's Day massacre at a school: On St. Valentine's Day 2008 at Northern Illinois University, a supposedly happy, stable, twenty-seven-year-old graduate student in social work randomly blew away five students and wounded eighteen before killing himself. The choice to attack on Valentine's Day, the celebration of love, is likely no accident in this most recent case and possibly others. It is a violent and explosive expression of the opposite emotion expressed on this day, one of hostility, hate, rage and resentment.

Fundamentally, this escalating sociological phenomenon is definitely a mental health matter. Having more guns than citizens in the United States is a significant factor in this violent epidemic. Certainly, making assault rifles less available to the general public is good policy, it seems to me. They make killing and maiming many people in mere seconds much too easy. But, then, so does a bomb. Or a truck. A machete. Or a hand grenade. The disturbed individual set on destroying the lives of as many victims as possible, and then, as occurs in most cases, offing him or herself, will likely find some way to do it. But, nonetheless, it is crucial to bear in mind that many, if not most, of the perpetrators of these evil deeds have either had contact with a mental health professional—or should have.

Because of the epidemic rise in anger, rage and violence in our culture, mental health professionals have a moral and ethical social responsibility to aggressively intervene with violent individuals such as the nineteen-year-old alleged shooter at Marjory Stoneman Douglas High School. I am not suggesting here that psychotherapists act like cops or carry concealed weapons, as President Trump stupidly and simplistically urges teachers do. (Perhaps he would like to see us regress back to the wild days of the old West, in which most men carried a concealed or holstered pistol or rifle.) Only that these kinds of vicious evil deeds must be directly addressed by the mental health profession, in tandem with law enforcement. In dealing with angry, belligerent or violent individuals, the police are frequently the first responders, though such potentially dangerous people are sometimes initially seen by a psychotherapist or counselor. So let's talk a little about what kinds of interventions are available to mental health professionals in managing and possibly preventing these tragic incidents. 

Police officers have extensive experience in confronting violent offenders. In California, for example, though they are not licensed mental health professionals, police have been trained in the legal criteria required for detaining a disturbed person: Peace officers have the legal power to place someone on a 5150, an involuntary psychiatric hold, as do clinicians specially trained and empowered to do so in designated facilities such as emergency rooms or crisis centers. If the officer/officers believe the person to be potentially dangerous to self or others, or gravely disabled by dint of a mental illness, that person can be taken against his or her will to a designated mental health facility for further evaluation by a mental health professional. Having worked in such facilities, I can attest that the judgment of police officers in these complex matters can sometimes be questionable. But once the person has been placed on a 72-hour-hold (5150) by the police and delivered to the emergency room for psychiatric evaluation, it falls upon the mental health staff to evaluate and decide whether, in their expert opinion, this person can be legally held against their will and hospitalized involuntarily if necessary. Or whether they can be released and sent home and/or referred for voluntary treatment. While we mental health professionals usually get these decisions right, I can also attest from my own experience working in a hospital-based psychiatric emergency room, that even well-trained and seasoned clinicians sometimes get it wrong. And when we do, the consequences can be catastrophic.

Conducting these psychiatric evaluations on the fly is not easy, and making such crucial decisions to temporarily deprive a person of his or her freedom, is not taken lightly, even for the seasoned psychiatrist or psychologist. The disturbed patient brought in by the police must be observed and interviewed by clinicians in order to determine whether he or she fully meets what are in California called LPS criteria (Lanterman-Petris-Short Act) or the so-called Baker Act in Florida. Is this person presenting a clear and present, acute and imminent danger to self or others? One of the factors considered carefully when assessing suicidality or homicidality is whether there is easy access to a means of successfully carrying out the act. When a suicidal and/or homicidal patient has immediate access to a gun, for example, this is a big red flag that raises the level of dangerousness significantly. Such a person may vehemently deny any intent to use that weapon to commit suicide or homicide, but that denial must be assessed for veracity, based in part on previous behavior and collateral reports regarding the patients prior statements and actions according to family, friends, and co-workers, as well as on current mental status and psychiatric diagnosis and prognosis. For instance, is the patient experiencing "command hallucinations": a disembodied subjective voice telling him or her to kill. (According to one news report, Cruz had been hearing "voices in his head" telling him how to conduct the killings, voices he described as "demons.)" Is he or she in the midst of a manic or major depressive episode? Or is the person exhibiting impaired judgment or poor impulse control possibly due to being under the influence of some intoxicating substance? All of these scenarios increase the risk that suicidal or homicidal fantasies may be acted upon imminently. And demand immediate intervention. Remember, the danger must be acute and imminent in order to involuntarily hospitalize someone. But it would not be unusual, even in cases where such imminence is not clearly present and the patient cannot be involuntarily hospitalized, for a clinician to recommend and arrange for removing any guns or other easily accessible potential means of committing suicide or homicide from the patient's environment.

Here in California, psychotherapists in private practice do not have the legal power to place a patient on a 72-hour hold themselves. But they do without a doubt have the responsibility for assessing whether their client or patient is potentially a danger to self and/or others, and, if so, to make sure that he or she is further evaluated psychiatrically. Thus, the psychotherapist may need to decide to breach the client's confidentiality and contact the police, or, alternatively, the local psychiatric emergency team, who can contact and talk with the patient and, if appropriate, place him or her on an involuntary hold in order to receive further professional evaluation. Moreover, under the Tarasoff Decision, the psychotherapist has the ethical and legal duty to warn any known intended victims and to notify the authorities should a patient make credible threats to harm others or destroy their property. Generally speaking, psychotherapists must be sensitive to such statements as well as actions and other warning signs, not minimize the danger, while, at the same time, refraining from overreacting to the patient's potentially therapeutic verbal expression of anger or rage. No easy task. 

So what more, if anything, can mental health professionals do to prevent such senseless killings? Such madness. Clearly, Nikolas Cruz, the alleged shooter, was and is a deeply disturbed, extremely angry, alienated young man, who, from the sound of it, without proffering a formal diagnosis from afar, had reportedly exhibited some signs in recent years of what could speculatively be associated with diagnoses such as Oppositional Defiant Disorder, Conduct Disorder, ADHD, Antisocial Personality Disorder, and possibly Borderline Personality Disorder, Autism Spectrum Disorder or Schizoaffective Disorder. He was expelled from school and ostracized from his peers. He was probably profoundly depressed by the traumatic losses in his life—including the prior death of his adoptive father and the recent death of his adoptive mother—suicidal, and furious about what he perceived (and with some merit) to be his unfair and cruel fate. He had reportedly been seen and assessed in 2016 by a crisis intervention specialist at some point, but was evidently never placed on a psychiatric hold, apparently not meeting in his or her judgment sufficient legal criteria to do. Even if he had been "Baker-acted," such involuntary hospitalizations tend to be quite brief, in California, a maximum of three days initially, after which the person is free to go unless there is a formal legal hearing to try to extend the hold. Whether he was receiving psychotherapy is not clear to me. If so, what went on in those sessions? How should a therapist deal with someone like Mr. Cruz? This angry, violent, vicious and dangerous young man?

Obviously, Nikolas Cruz needed therapy. But what type of therapy? Psychoanalysis? Cognitive-Behavioral Therapy (CBT)? Dialectical Behavior Therapy (DBT)? Existential Therapy? Anger Management? Psychopharmacological therapy? (He reportedly was taking prescribed psychiatric medications.) Cruz and similarly angry and antisocial young men across America (mere adolescents really) desperately need to form a relationship with a therapist who can contain, tolerate, acknowledge and accept their rage. (See my prior posts.) To sit in a small and intimate consulting room with such patients can be a terrifying—and potentially perilous—experience for psychotherapists. Even in a forensic jail-setting, when the inmate is shackled and handcuffed, hearing and seeing such rage can be intimidating. Most mental health professionals avoid doing so in various ways, including the overuse of psychiatric drugs to dampen down what existential psychologist Rollo May referred to as the "daimonic." Or they quickly refer the patient elsewhere, or try to cognitively talk the person into not being so angry, teaching patients to behaviorally "manage" their anger, which is usually a euphemism for suppressing it. Mainly because they, the mental health professionals, are afraid, not only of the patient's fury and capacity for violence but, unconsciously, of their own repressed rage, a problematic kind of negative countertransference. In most cases, because of this denial of the daimonic in patient's and in themselves, clinicians naively underestimate the human potentiality for evil. They fail to recognize or minimize the inherent human capacity, and in some, proclivity, for evil deeds. 

If we are going to be of any greater assistance in preventing these grotesque crimes in the future, mental health professionals must put aside their pseudoinnocence and start accepting and addressing the reality of evil in the world, and the potentiality to commit evil deeds in our patients. We must be willing to unequivocally and courageously intervene when a patient presents an imminent danger to others or themselves. Acutely suicidal patients with homicidal impulses or fantasies feel they have nothing more to lose by acting on those hateful impulses to cruelly kill or maim as many victims as possible before dying themselves. We often forget that mass murderers are more or less destroying their own lives as well as that of their victims in the decision to kill. Intervention in such acute cases should, whenever possible, begin with placing the patient on a 72-hour hold for his or her own safety and that of society. But that is only the first step in treating this problem. Once discharged, the patient needs to be followed and carefully monitored by the psychotherapist. But what if he or she does not want therapy?

This is one of the ways these potentially dangerous individuals fall between the cracks in our system. I believe that we need to change this. Once someone has been deemed to meet full criteria for involuntary hospitalization as a danger to others in particular, following discharge, they should be legally compelled to attend court-ordered weekly or bi-weekly psychotherapy sessions (individual or group) for some protracted period of time (e.g., one year) so as to allow the mental health professional to closely monitor his or her mental status, and to intervene again if necessary. This sort of constant monitoring of the patient's mental status (e.g., suicidal and/or homicidal ideation) may seem antithetical to how some psychotherapist's practice, but it is absolutely essential with this population. Additionally, they should simultaneously be forbidden to possess firearms for at least that time period. Such a policy could, in my estimation, mitigate the increasing frequency of these evil deeds. (Indeed, there is currently a law on the books in California that, under specified circumstances, allows the confiscation of guns from severely and chronically mentally ill individuals.) 

The California Board of Psychology recently implemented a controversial new Continuing Education requirement for all licensees specifically on assessing and dealing with suicidal patients. (Controversial, because some psychologists objected on the grounds that clinical psychologists already have expertise in this area.) Since most mass shooters are suicidal as well as homicidal, such additional training is valuable. But I would implore licensing boards for psychologists, social workers, psychiatrists, counselors and other mental health professionals to similarly require specialized training in assessing and intervention of potentially homicidal persons. Moreover, the mental health profession needs to become more integrated and involved with law enforcement, schools, probation programs, etc., serving as clinical consultants on policy and practice. We must become experts on violence and the psychology of evil. For the evil of violence is what we are confronted with today. Though our violence epidemic is a sociological and cultural symptom, one clearly exacerbated by easy access to weapons of war, it is primarily and fundamentally a mental health issue that must be more effectively addressed by mental health professionals. For that is our professional purpose and responsibility both to patients and society.