Why we Need to to Stop Blaming “Mental Illness”
As a psychiatric social worker, some basic issues come to mind when public figures blame “mental illness” willy-nilly as the cause for mass murder.
1. People who commit mass murder are no more likely to be mentally ill than then general population. Unfortunately, it is an extremely common misconception* that perpetrators of such vile acts as shooting sprees/mass murder MUST be mentally ill even though study after study has shown that this is not the case. Data collected from 1996 to 2015 found that serious mental illness was a factor in only 14.8% of mass murders. People with serious mental illness account for about 1% of interpersonal violence. In fact, the SMI population is much more likely to be a victim of violence than a perpetrator. We do not accuse Islamic terrorists of committing their horrendous crimes due to mental illness, so why do we insist on saying that perpetrators without a clear motive are mentally ill? or that, based on the nature of the crime one must be mentally ill? The sad truth is that most mass murders are perfectly sane individuals who do not fit any known diagnostic criteria for a listed mental illness. They are likely to me angry, resentful, controlling, and somewhat paranoid-thinking men, but not to the extent that would constitute an Axis I or Axis II diagnosis.
2. Sanity is not static: mental status of an individual can change at any time—and we don’t always understand the underlying cause. There are plenty of people who fit the mold we expect to find in psychiatry—a first break in early adulthood, with family noticing an escalating change in behavior over several weeks or months, and clear warning signs like responding to internal stimuli (often displayed as talking to oneself out loud or appearing to be greatly distracted by one’s own thoughts) and/or marked increase in irritability, aggression, and change in behavior. Someone who is mentally stable one day may not necessarily be mentally stable the next day/week/month/year. There are also episodes of temporary (rather than chronic) psychosis brought on by stress, hormones, trauma, drugs, and medical issues. There are neurocognitive disorders which are difficult to identify and can only be definitively diagnosed at autopsy. Then there is the question is capacity–does a person with borderline mental redardation, or mild mental retardation have the impulse control and and/or executive functioning necessary for the use or purchase of firearms? why do the mentally ill become a target and not various other groups of diminished capacity?
3. The true common denominator among perpetrators is gender and a history of domestic violence. Men also accounted for 86% of gun deaths in the United States in 2015, according to an analysis by the non-partisan non-profit Kaiser Family Foundation. The CDC estimates that the gender ratio of gun violence is ~24:1. In the 97 mass shootings from 1982 to 2018–of incidents with four or more victim deaths–the shooter was male in 94 of them. This ratio does not reflect a similar difference in occurrences of mental illness represented in the genders. Some recent studies even suggest that women are more likely to have a mental illness than a man is, and yet men are many, many, times more likely to commit mass murder. A personality attracted to aggression/anger and holding grudges, combined with selfishness, victim mentality, and lack of empathy is the perfect storm often described by those people who knew the perpetrators. In fact, the spouse and/or domestic partner can frequently be found incorporated into the crime/MM (Devin Kelley, Charles Whitman, Kevin Jansen Neal). Some studies have concluded that more than half of the mass shootings from 2009 to 2016, specifically 54%, were related to to domestic or family violence.
4. Increasing the stigma of the “mentally ill” does no favors for getting people into treatment. It drives people to reject and avoid that label–both those with a mild mental disorder and those with severe and persistent mental illness, in my experience.
5. The extreme number of issues involved with trying to convince someone to comply with treatment—if and when they are actually introduced to mental health services—and the lack of adequate treatment available. Right now people are upset about the “missed warning signs”—but the question I have is what would have been done if the proper authorities did identify Mr. Cruz as a threat? He had not committed any crime so I doubt law enforcement would be able to incarcerate him or detain him for any substantial period of time . According to the family he lived with, he did not show any outward signs of mental illness. They say he was depressed, but that is certainly to be expected following the loss of your mother! What support and programs exist to rehabilitate this person and re-integrate them into society? And how do we force him to comply with said treatment if it is found? There is no evidence that Mr. Cruz ever made anything other than vague threats, which means that because he never verbalized a plan he doesn’t necessarily fit the criteria for psychiatric hold against his will. If he were held against his will, and then admitted, he would be forced into the one-side-fits-all mold of ~2week length inpatient psychiatric treatment. Assuming he did not refuse medication on the inpatient unit, Mr. Cruz would then likely be discharged with a 30day supply of medication and an appointment. As a 19 year-old, he would be able to refuse both his medication and follow-up outpatient treatment.
More Food for Thought
President trump wants to ban Muslims from entering the country because of Islamic terrorism. There have not been any acts of terror committed by terrorists radicalized outside the US since 9/11. All have been Americans or immigrants who were indoctrinated through the internet. Meanwhile, where is the outrage at our (mostly White) American males who commit mass murder? Is it somehow less evil because they have no identified ideology? Shouldn’t it be more concerning when a motive can’t be identified and not less?
The truth is Trump is not doing himself any favors by blaming mental illness for recent atrocities. There are myriad complex problems inherent in ‘fixing’ the mental health system and this would not even make a difference in the amount of mass murders if guns are still widely available. And then there’s the absurd hypocrisy of blaming the mentally ill when he himself signed an order in February 2017 that made it legal for more people with severe mental illness to legally obtain guns.
Despite president trump blaming people “with mental problems” for recent mass shootings, there has not been any legislation that would increase availability of mental health services nationally and very little in many—or most states. In NY there is a major push to get SPMI patients into the community. This is an over-correction for zealous institutionalization of the past and also a way to curb skyrocketing health care costs. And there has only been efforts to make it harder for individuals to obtain mental health care through attempts at dismantling the Affordable Care Act. And of course the undoing of an Obama era rule that required all incapacitated people to be added to the NCIS background list. The rule applied to any individual receiving monthly SSI money for mental illness and individuals assigned a legal guardian due to being unfit to handle their own finances–it would have added an estimated 75,000 more people to NCIS.
The services that are available are limited by the rights of the individual to refuse treatment. This system has been designed to protect individual rights over what is in the patient’s best interest. A psychiatrist is unable to overrule the rights of the patient to refuse medication in all but the most specific circumstances. A patient must be admitted to an inpatient ward, be an active danger to self and/or others (potential does not count), or so ill that they are completely unable to function. Then they are assigned a mental health lawyer and taken to court for Treatment-Over-Objection. The judge–who has no clinical experience–gets to decide whether to rule in favor of patient’s right to refuse (overruling the treatment team) or the two psychiatrists representing the facility and treatment team responsible for the psychiatric care of the individual. Once the patient is discharged from the inpatient setting which pursued TOO, they are no longer bound by TOO. The only thing that comes close (yet fails) to being able to force an individual to comply with psychiatric treatment outside of TOO is Assisted Outpatient Treatment. AOT is also court-ordered by a judge. Records must be obtained from at least five prior-treating facilities documenting aggressive and/or otherwise dangerous behavior. The ruling expires automatically if not reviewed in the designated 6 to 12 months. an AOT order grants that the AOT monitor in conjunction with the assigned case manager are able to involuntarily take the patient to a hospital for an emergency psychiatric evaluation lasting up to 72 hours–this basically the same thing as calling 911 and falls short of forcing the individual to comply with treatment.
Part III will be case studies, Part IV will be about angry man syndrome and the ego/personality aspects which are seen in MM perpetrators.