By Doug Olsen, PhD, RN, associate professor, Michigan State University College of Nursing, and AJN contributing editor. Olsen regularly addresses topics related to nursing ethics.
There are many good reasons to provide better mental health care in the United States; however, the prevention of mass murder is not one of them.
Mental disorders involve great suffering, and many people who could find some relief through treatment either don’t receive it in a timely fashion or never receive it at all. After the large psychiatric hospitals of the mid-20th century discharged their patients in waves of deinstitutionalization starting in the 1970s, many of the resources that were promised to support these people in the community never materialized. In recent decades, many persons with mental disorder have ended up in the prison system, often for minor offenses, where treatment, if received at all, can be harsh and inadequate. (See: Early, P. (2006). Crazy: A Father’s Search Through America’s Mental Health Madness). A
Adequate resources to support all persons with serious and persistent mental illness in the community would prevent and alleviate a tremendous amount of suffering. We know these patients exist; we know that community housing and vocational and social skills training are effective.
Victims or perpetrators? But should mental health care be improved simply to prevent violence and mass murder? Some mental disorders do carry a small but increased risk of violent behavior, which might be decreased with better treatment. But statistics indicate that people with mental disorders are more likely to be victims of violent crime than perpetrators. Better treatment would inevitably prevent some of this crime against those with mental illness, simply because there would be fewer untreated and highly vulnerable people to exploit.
The prediction problem. Unfortunately, it is unclear that mass murders like those at the Sandy Hook Elementary School in Newtown, Connecticut, or at the movie theater in Aurora, Colorado, would be prevented by improved mental health care in the U.S. Many experts have recently pointed out that violence by persons with mental disorders—or by anyone, for that matter—is difficult to predict. And such incidents as these highly publicized mass shooting are so statistically rare that they are nearly impossible to predict, except in the very short-term case of specific warning signs such as threats.
In addition, mass murder is not the result of a single type of psychopathology; some of the killers appear to have been quite psychotic, while others seem to be fully in touch with reality. Much of the public discussion fails to recognize the complex reality of mental disorder diagnosis. A diagnosis of mental disorder is a description of a behavior pattern that can be reliably recognized and causes the individual distress, dysfunction, or deviation from social norms. This is in contrast to many medical conditions, where diagnosis is made through identification of an etiologic factor or factors.
After they have committed their crimes, we can be pretty sure that these shooters have a mental disorder—but before they have acted, the meaning of certain patterns of behavior or their possible violent outcome is far harder to discern.
Callous–unemotional traits as warning signs? An article by Liza Long, “I Am Adam Lanza’s Mother,” seems to describe what is currently called conduct disorder with callous–unemotional features. The state of the art means for identifying this disorder is a survey called the “Inventory of Callous–Unemotional Traits,” which seeks agreement or disagreement on statements like “I do not care who I hurt to get what I want” and “I do not feel remorseful when I do something wrong.” (Kimmonis, et al., 2008)
Diagnosis done this way only gets us as far as identification, with the presumption that if we can identify cases reliably, then interventions can be tested. Identifying persons who may become violent, and developing ways to prevent that violence, would be a great advance. But this is a hope for the future; most mental health treatment remains imperfect. The public should not mistake these labels as answers when they are only descriptions.
Basing policy on compassion, not fear. If we argue for increased mental health services with the primary goal of seeking to prevent violence, we risk publicly branding any person who seeks or needs treatment as someone who is potentially dangerous. I already know of one household that, after the Sandy Hook shooting, is resisting visits from a relative with autism. If services are created based solely on the rationale that they will prevent violence and protect the public, they will have a warped focus, in contrast to services designed to benefit suffering persons. An authentic desire to care for others arises from human concern, not fear.
We do need more and better services for persons with mental illness, especially community-based residential treatment, skills building, and recovery-oriented care. Will this prevent violence? Possibly, if you believe as I do that the ultimate route to violence prevention is the reduction of misery. But violence reduction is not the reason to provide better treatment for persons with mental illness. The reason we should improve service is to prevent and alleviate the suffering of people whom society is currently treating with indifference.
Kimmonis, E. et al., (2008). Assessing callous–unemotional traits in adolescent offenders: Validation of the Inventory of Callous–Unemotional Traits. International Journal of Law and Psychiatry, 31, 241–252