Thursday, February 22, 2018

Psychiatrist Says: Don't Blame Us for Nikolas Cruz

Don’t blame us? So says psychiatrist Amy Barnhorst in a New York Times op-ed. Don’t blame us for failing to appreciate the danger posed by a Nikolas Cruz… or a James Holmes or an Adam Lanza. We could not tell that they were dangers. When we ran our checklist of psychotic traits they passed with flying colors. Our profession, and the society’s concern with civil liberties, has tied our hands. We should not change our laws about involuntary hospitalization. We should not change the way that psychiatrists diagnose mental illness. We should take away their guns.

Considering that everyone who knew Nikolas Cruz,--everyone but the professionals charged with protecting the community-- knew that he was dangerous. The police had visited the Cruz home nearly forty times. He had announced to the world that he wanted to be a school shooter. The FBI had been informed. Social services had visited him. It seems to some of us that these government agencies failed miserably in their task of evaluating Cruz’s homicidal mania. This tells us either that they were all incompetent—don’t eliminate that possibility—or that psychiatry is sorely deficient when it comes to diagnosing certain cases. Why might it by so deficient? Perhaps it has been infected with its own variety of political correctness, contaminated by an excessive concern for civil liberties.

Can there be too much concern for civil liberties? Of course, there can. And yet, the anguished parents and children who have been filling our television screens with their outrage do not take aim at the failures of the system. They blame it all on the NRA and on guns. In truth, Barnhurst does too. She begins her essay by minimizing and trivializing Cruz's symptoms:

Shouldn’t psychiatrists be able to identify as dangerous someone like Nikolas Cruz, the young man charged in the school shooting last week in Florida, who scared his classmates, hurt animals and left menacing online posts?

Mr. Cruz had suffered from depression and was getting counseling at one point. He was also evaluated by emergency mental health workers in 2016, but they decided not to hospitalize him. Why, some critics are demanding, didn’t he receive proper treatment? And can’t we just stop angry, unstable young men like him from buying firearms?

As mentioned, Cruz was far more than an angry young man. He was shouting as loud as he could that he was homicidal. No one believed him. We note that a James Holmes, who shot up a movie theatre in Aurora, CO was consulting with a psychiatrist. The psychiatrist had diagnosed him as a paranoid schizophrenic. She wanted him to be committed. The system would not allow her to do it… because Colorado laws would not permit it. The same holds true of Adam Lanza, whose mother wanted to have him committed. Connecticut’s involuntary commitment laws did not allow it. The state legislature had voted down tougher laws a couple of months before Lanza opened fire at the Sandy Hook Elementary School.

Barnhorst is correct to note that many of these psychotics and psychopaths do not present for treatment. And she notes correctly that the state interest in protecting civil liberties restricts what psychiatrists can do. And yet, in the Cruz case, the signs were everywhere. He was shouting them every chance he got. Only a deaf, dumb and blind band of bureaucrats could have missed it.

She wrote:

The mental health system doesn’t identify most of these people because they don’t come in to get care. And even if they do, laws designed to preserve the civil liberties of people with mental illness place limits on what treatments can be imposed against a person’s will.

Yet, when making their diagnoses, psychiatrists and judges rely on the word of the patient. They take it at face value. Of course, the prospective patients can look up the signs of psychosis on the internet and then lie to the judges and the psychiatrists. This leaves us with only the most extreme cases:

Here in California, as in most states, patients must be a danger to themselves or others because of mental illness before they can be involuntarily admitted to a psychiatric hospital. This is a mechanism for getting people into treatment when they are too deep in the throes of their illness to understand that they need it. It allowed me to hospitalize a woman who tried to choke her mother because she was convinced her family had been replaced with impostors, and a man who had sent threatening letters to his boss because he believed she had implanted a microchip in his brain.

A young man who had been threatening to kill people was brought in by his parents to consult with Dr. Barnhorst. She describes his demeanor:

But the young man who had written about shooting his classmates was calm, cooperative and polite. The posts, he insisted, were nothing more than online braggadocio. He denied being suicidal or homicidal; he had never heard voices or gotten strange messages from the television. He admitted to having been bullied and was resentful of classmates who seemed to have more thriving social and romantic lives. But he adamantly denied he would be violent toward them.

What options did I have? It was clear to me that he did not have a psychiatric illness that would justify an involuntary hospitalization, but I was reluctant to release this man whose story echoed that of so many mass shooters.

It may well be the case that the young man was not psychotic or psychopathic. He might have been putting on a show to get attention. And yet, Barnhorst took the path of caution and had him committed. Whatever point she makes about the non-treatment of Cruz, Barnhorst herself took the path of good judgment. She erred on the side of caution:

I ended up admitting this patient, and he was released by the hearing officer two days later. He never took any medication, never reached the threshold for a federal firearm prohibition and left the hospital in the same state he arrived in. Like so many of his peers, he will not seek out therapy for the longstanding personality traits that seem to predispose him to violence and rage, and there is no way to impose treatment upon him.

As it happens, we do not know what effect the commitment had on him. We do not know what would have happened if his parents and the authorities had simply ignored him. Perhaps the minimal intervention, performed by parents and Dr. Barnhorst, accompanied by a couple of days in the hospital had helped him. We do not know. We cannot say that it had no effect or that doing nothing would have had the same effect.

By committing him to the hospital, Barnhorst made it impossible for him to buy a gun from a federally licensed gun dealer. Since we are all wondering how Nikolas Cruz was allowed to purchase a gun, this is not necessarily a bad thing.

Barnhorst continues:

The one concrete benefit of officially committing him would be that he could be prohibited from buying a gun from any federally licensed retailer. Of course, this would do nothing about any guns and ammunition he may already have amassed. Nor would it deter him from getting guns from private-party sales, which are exempt from background checks in many states.

And yet, if  you believe, as she does, that the problem is more the availability of guns than government failures to intervene, she undermines her argument by suggesting, correctly, that guns are everywhere. As one has often mentioned, there are now 300 million guns in private hands. Will new gun control laws reduce their number and make it impossible for people who want to acquire them from acquiring them.... from friends or family?

We might agree that we should toughen up the laws involving gun purchases. And yet, if the psychiatric profession is unable to identify people who pose potential risk, what good would such laws serve?

Even if all potential mass shooters did get psychiatric care, there is no reliable cure for angry young men who harbor violent fantasies. And the laws intended to stop the mentally ill from buying guns are too narrow and easily sidestepped; people like Nikolas Cruz and my patient are unlikely to qualify.

Some of the mass shooters are angry young men. Some are Islamist terrorists. (When they are Islamists, the hue and cry tells us not to be Islamophobic.) But, Nikolas Cruz was far more deranged that Barnhorst suggests. Thus, the problem was a psychiatric profession that was incapable of seeing what so many of those around Cruz had seen clearly for years. If Cruz had been committed, he would not have been able to buy a gun. If Cruz had consulted with Dr. Barnhorst, she would have done the responsible thing and erred toward caution. She would have had him committed. The real story here is that no one did.


Redacted said...

Blaming the NRA for mass gun homicides would be more convincing to me if they'd publish the list of NRA members who have committed mass gun homicides. My advice to the NRA is, if you're taking flak you're over the target.

We do, IMO, need to swing the pendulum back a bit on involuntary committments. Thomas Szasz, for example, made good points about "crazy" behavior, but he was clearly wrong in his absolutism about civil committments. This a mental health matter that is being renarrativized as a "gun problem"

Jack Fisher said...

Involuntary commitment for 72 hours or less would work, if personal rights are carefully protected, this can be initiated by family, the police or mental health professionals, and maybe extend that to school personnel. So would a California-style temporary order barring an individual from possessing or purchasing firearms, again, with proper judicial oversight.

Anonymous said...

Sam L. said...

There's plenty of blame to go around.