Psychiatry alone cannot solve the tragic problem of mass murder. Careful reflection on gun control laws, responsible media reporting and heroic reporting by intimates of potential perpetrators could help.
"Thankfully we had a responsible family member or we might have had a different outcome."
- Bolivar, Missouri Police Chief
Each time another mass shooting happens in the US, the response is entirely predictable. After the media coverage subsides a bit, a familiar sequence unfolds: Who is this person? How did the "mental health system" fail him? How did he get his hands on such a powerful arsenal? If only the actual tragedy was so predictable beforehand.
Mass murder predictable? Not likely. Preventable? Well, here is where I believe we have a bit of a chance. But it depends. How much do we really want to prevent mass murder? And by "how much" I mean: How much responsibility are we willing to take on in an effort to make a meaningful difference? We can talk about it for a few more decades, and in the meantime we will likely have a few more Sandy Hooks, Auroras, Virginia Techs or Columbines. I cannot mount an argument against those who proclaim these tragedies are impossible to predict or prevent solely with psychiatric efforts. I can't and I won't, because I agree with them. But I do believe there are other ways that are far more effective, and ultimately, far more beneficial for society.
It turns out that recently, Bolivar, Missouri narrowly avoided becoming the next Aurora. How? The mother of a potential mass murderer contacted police because she was worried that her son, Blaec Lammers, had intentions of shooting people during the opening of the final film in the popular Twilight vampire movie series. Predictably, the mother was right to be concerned. When Tricia Lammers' son was questioned by police, he said he had already bought tickets and "planned to shoot people inside the theater." Upon investigation, police found that Lammers "did have the weapons; he did have the ammunition ... and then he made the statements to the officer about what his plans were."
This leads me to one of my first suggestions on how to prevent mass murder. The mayor of Bolivar, or better yet the governor of Missouri, should give Tricia Lammers a medal. In fact, if neither party will do this, I will personally have one made and sent to her. The medal will be engraved with the words: "For Brave, Humane and Lifesaving Action."
How many can say that they saved potentially dozens of lives, while also saving the life and mental health of a family member? Tricia Lammers - I applaud you, and others should as well. Am I making too big a deal out of this mother's actions? I do not believe so. I think her act represents one of the strongest methods of prevention available. Third parties, particularly family members, are the most likely to have pre-offense knowledge or significant concerns.2 In other words, potential mass murderers often "leak their intent"3 to third parties who, in turn, remain quiet for various reasons.4 But it is important for family members to know that help and resources exist. Tricia Lammers was able to rely on some of these resources, most notably the National Alliance for Mental Illness, which has offices all over the country.
In contrast to Ms. Lammers, the silence of third parties seals the fate of both their loved one and scores of innocent people. Need another example? They are not difficult to find. Take the relatively recent case of Anders Behring Breivik who, on July 22, 2011, obliterated more than 70 innocent people in Oslo.7 Breivik's sister had been concerned enough to warn her mother at least two years prior to the tragedy.
At this point in time, most authorities agree that preventing mass murder requires measures well above and beyond the "mental health system."9 For example, after Jared Loughner perpetrated the tragic mass shooting in Tucson, mental health experts concurred that "homicides perpetrated with firearms against strangers by individuals with mental disorders occur far too infrequently" to predict or prevent with mental health efforts alone.10 Yet after the Tucson tragedy, there was still the familiar media refrain: "Did the system fail Jared Lee Loughner?"[emphasis added]
The "Mental Health System?"
When the inevitable human tragedy recurs, point not at the system - for you will be pointing at nothing at all. An apparition. A fiction created some 50 years ago, which only returns as a ghost in the night. And so it goes - American society seems comfortable to periodically point at and condemn the ghost every now and then whenever a serious haunting takes place. But many are not likely in a position to see the cycles psychiatrists see due to their permanent residence near the graveyard. We see the perpetual tragedies, followed by the haunting incantations: "The system ... the system failed him...."
It is my contention that there exists no legitimate "system" in the US when it comes to mental health treatment. Despite this, we most certainly want to believe in one, particularly so that when tragedies occur, we will have something to cast our outrage upon. For example, when asked in a poll where they placed blame for the Tucson shooting, a majority of Americans said in a USA Today/Gallup Poll that they placed a "great deal of blame on mental health system failures." Since it is possible that the term "mental health system" may be thrown about loose and fast, let us consider it with a bit more precision.
From a literal perspective, one might define a system as: an organized, regularly interacting set of principles forming a network - especially for distributing something or serving a common purpose. Even more germane, the Surgeon General's report on mental health14 gives us the following definition: "[D]iverse, relatively independent, and loosely coordinated facilities and services - both public and private - that researchers refer to, collectively, as the de facto mental health service system" (emphasis not added). Since a particular legal term has been invoked, let us examine the definition of de facto. Here we discover both a lay and a legal definition respectively:
1. Exercising power or serving a function without being legally or officially established;
2. Used to characterize... a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate.16
Thus, per the Surgeon General's own definition, the "system" is at best, unofficial and at worst illegitimate. Why might it be that in 2012, we have no "legal or legitimate" mental health system? Returning to the Surgeon General's report, we are told that: "Effective functioning of the mental health service system requires connections and coordination among many sectors.... Without coordination, it can readily become organizationally fragmented, creating barriers to access. Adding to the system's complexity is its dependence on many streams of funding, with their sometimes competing incentives."
So it appears that both lack of coordination and funding inconsistencies confound the system. But as it turns out, these are problems that have never been adequately addressed since the time of their inception - deinstitutionalization. Deinstitutionalization was the term used to describe the rapid emptying out of state mental hospitals beginning in the 60s and 70s due to a number of factors, including: the patients' rights movement, financial reasons, early hopes for a "magic bullet" in the form of antipsychotic medications and the never-realized hopes for adequate community mental health services. Thus, deinstitutionalization became "trans-institutionalization" - also referred to as the "criminalization" of mentally ill persons.17, 18 Extremely laudable efforts have been made to divert persons with serious mental illness away from corrections (e.g., jail diversion and mental health courts).19, 20,21 But the fact remains that there are large numbers of persons with serious mental illness in the correctional system, and the trend shows no signs of reversing itself.
In Virginia, jails now house more persons with SMI than do Virginia psychiatric hospitals.22 The Los Angeles correctional system has been referred to as America's largest psychiatric facility.23 It is now jails that serve as the "predominant settings for providing acute psychiatric inpatient treatment."24 During this era of retribution, corrections facilities earned their designation as "the new asylums." Correctional administrators readily concede that their facilities are being used as "dumping grounds for many individuals who could be better served through early intervention in noncustodial environments because other options are just not available."26 But alas, "interventions in noncustodial environments" are in short supply in 2012.
Couldn't this have been foreseen? Quite unlikely I believe, for a variety of reasons, including: "The fact that most deinstitutionalized people suffer from various forms of brain dysfunction [which] was not as well understood when the policy of deinstitutionalization got under way." Indeed, it was poorly planned deinstitutionalization that created our present illusion of a system "by discharging people from public psychiatric hospitals without ensuring that they received the medication and rehabilitation services necessary for them to live successfully in the community."30 The mental health system has failed no one, simply because there is no system to speak of. Thus, we must look elsewhere for solutions to violent outbursts by mass murderers, most of whom have never accessed mental health care to begin with.
Mass Murder - What is it?
Mass murder is no recent phenomenon. It has occurred since well before the Charles Whitman shooting in 1966 at my alma mater, the University of Texas at Austin. However, access to powerful, automatic firearms, media attention and a possible glorification of the phenomenon among certain vulnerable, disaffected individuals are factors making present day mass murders unique.
Mass murder, strictly defined, is the killing of four or more victims at one location within one event.28 It is both a rare and catastrophic event that is usually carried out by a single individual. Mass murder is distinguished from both spree and serial murder. In the case of serial murder: There have been at least two victims, the victims are killed in a non-continuous fashion (i.e., there is an emotional "cooling off" period between murders), and the murders usually involve a sexual component.29 In contrast, a spree murder involves killings at two or more locations with very little time in between murders and no cooling off period.31 The type of mass murder discussed here involves those carried out by a single, heavily armed individual who is very likely to expect to die as a result of the event. This further distinguishes it from gang-related mass murder, in which the perpetrators do not typically expect to die, and their motive involves various forms of profit, drug trade or territorial disputes.33
At the present time, it is typically the high-profile cases that are most heavily covered by the media; yet these are the least representative. In many cases, the precise number of victims may be arbitrary. Research has been slow in the area of mass murder, and there is not yet an officially accepted typology. However, it is clear that not all mass murderers are alike in their motivations and psychology. Some may be driven by strong feelings of revenge born of social alienation or a perceived injustice. Others may also suffer from severe depression or, rarely, psychosis. Still others may resemble terrorists with idiosyncratic political beliefs. Such was the case with a Polish chemistry professor who was recently arrested before he could blow up a parliament building. Dr. Brunon Kwiecien openly supported Breivik, and wished to carry out a similar attack, but on a larger scale. His wife alerted authorities after he asked her how he could make a biological "dirty bomb." When he was apprehended, he was found to be in possession of high-powered, military-grade explosives, bomb-making equipment, several hundred rounds of ammunition, a bulletproof vest and a pistol.
The majority of research indicates that there are factors common to mass murderers such as: extreme feelings of anger and revenge, the lack of an accomplice (in adult mass murder), feelings of social alienation and planning/organizing the offense. In a detailed case study of five mass murderers who were caught before they were killed, a number of common traits and historical factors were found.35 The subjects had all been bullied or isolated as children, turning into loners who felt despair over being socially excluded. They were described as suspicious, resentful, grudge-holders who demonstrated obsessive and inflexible thinking.
Not surprisingly, they were also narcissistic and coped with personal problems by blaming others. Their worldview was characterized by seeing most others as rejecting and uncaring. As a result, they spent a great deal of time nurturing their resentment and ruminating on past humiliations. The ruminations evolved into fantasies of violent revenge. They did not see their own violent death as a deterrent, particularly because they perceived it as bringing them fame with an aura of power. Careful study of individual cases of mass murder often reveals that the offender felt compelled to leave some type of final message.36,37 These messages may be written, videotaped or posted on the internet or social media networks.38
In sum, the factors associated with, and contributing to, mass murder are complex and multi-determined. Biological factors may include possible brain pathology, as well as psychiatric illnesses. Psychological factors include a negative or fragile self-image, a strong sense of entitlement, and vulnerability to humiliation. Social factors include social isolation/alienation, being bullied and marital or financial loss.
Mass Murder - Can it be Prevented?
Mass murder is quite rare, and depends on the fluid vicissitudes of an extremely distraught and nihilistic individual who has access to firearms and ammunition. This must be kept firmly in mind when attempting to formulate preventive solutions. The reality is that mass murder cannot be "predicted" as such, particularly by persons outside the perpetrator's social circle.39 Any hopes of prevention must rely on various approaches acting together to provide a widely-cast safety net.40
How much does society truly wish to tackle this problem? Yes, it's rare, but the fallout is profound, devastating and long-lasting. I conclude that it is society that must first decide if it cares enough to take meaningful action. I will forever advocate for better mental health services and improved access to care. However, at the present time, measures such as screening for prior psychiatric treatment (often in the distant past) among individuals who want to legally purchase firearms represents no meaningful intervention.41, 42, 43 Here I refer to the Brady Act and relevant portions of the National Instant Criminal Background Check System (NICS). Not only does the present patchwork of inconsistent NICS procedures across the country do nothing to solve the problem, but it is also wasteful of precious resources.
Experience has shown us that, at this point in time, the higher yield interventions are:
1. Third-party reporting of concerns or leaked intent
2. Sensible gun control laws
3. Media responsibility
Having already addressed the issue of third-party reporting with the example of Lammers' mother, I now turn to the perennial and contentious subject of gun control in the US. It turns out that countries with less stringent gun control laws have been observed to have a higher risk of mass murder than countries with stricter laws.44 In contrast, consider an Australian observational study done in the wake of a highly publicized 1996 mass shooting in Tasmania.45 The study compared mass murders before and after Australia enacted gun law reforms that included removing semiautomatic firearms, pump-action shotguns and rifles from civilian possession. In the 18 years before the gun laws, there were 13 mass shootings in Australia. In the 10-and-a-half years after the gun law reforms, there were none.
Dr. Allen Frances, chairman of the DSM-IV, has framed the situation a bit more bluntly. He believes we have only two choices: "Accept mass murder as a part of the American way of life ... [or] get in line with the rest of the civilized world and adopt sane gun control policies."46 But Dr. Frances' latter option seems difficult for many to consider, let alone accept. Others, such as Michael Moore, have speculated that it is our deep seated, long-standing fear that keeps us clutching at our guns. 48 I will not lay out here all of the debate, but would only point out that there is "no other democracy on the face of earth that experiences this type of gun violence. We are the only free society that has yet to address this problem."49
Our rates of gun violence far exceed that of other countries. In a piece on gun violence in the US, Fareed Zakaria noted that: "The gun-homicide rate per capita in the US is 30 times that of Britain and Australia, 10 times that of India and four times that of Switzerland. When confronted with such a large deviation, a scholar would ask, 'Does America have some potential cause for this that is also off the chart?' I doubt that anyone seriously thinks we have 30 times as many crazy people as Britain or Australia. But we do have many, many more guns."
Given these associations, and the fact that at the present time, psychiatry is largely impotent to "stop" or "predict" mass murder, what can be done? Perhaps confronting gun-related violence as a serious public health issue is a start. For example, adopting sensible restrictions "such as eliminating the sale of semi-automatic weapons."51 This is an approach that has already been advocated by both the American Psychiatric Association and the International Association of Chiefs of Police. But of course, it must ultimately be society that decides to take this path. If and when it does, it will be critical for the regulations to be applied nationally, or otherwise be doomed to failure: "A piecemeal approach to firearms regulation that affects only some cities or states cannot be expected to produce a robust effect on gun-homicides or mass shootings."
The issue of media responsibility in helping to prevent mass murder has been highlighted since the Columbine and Virginia Tech tragedies. It became clear after these events, that some perpetrators were, in part, motivated by the infamy they saw past mass murderers receive via news coverage. Although some news media may be disinclined to admit it, they may often be in the business of searching for "the right sort of madness" to capture the public's imagination.52 This may involve exploiting violent and tragic acts carried out by mentally or emotionally disturbed individuals. In reality, it is a difficult task to report the occurrence of a mass murder in such a way that the public is adequately informed, yet certain details (e.g., numbers of victims, whether the offender was killed, etc.) are not reported. Efforts to develop a universal reporting code have been recommended that would appropriately cover the tragedy and reduce the impact of the copycat effect.53 Most recommendations involve ensuring that the perpetrator is neither glorified nor demonized. In fact, avoiding much emphasis on the perpetrator seems to be a good general rule. Rather, media should emphasize victim and community recovery efforts.
As a psychiatrist, I desperately wish that improved psychiatric care and access to treatment could save the day. I have little doubt that over the years, unsung mental health heroes have averted possible mass murder tragedies.Yet it seems all too clear to me that this is simply not a problem that psychiatry can solve on its own. No one should expect psychiatry to do the impossible - it already has its hands full with the possible. Therefore, I am suggesting three additional methods of prevention that should be seriously considered if we wish to confront the tragic phenomenon of mass murder: careful reflection on gun control laws, responsible media reporting, and finally - acknowledging the heroism of Tricia Lammers in the hopes that more will follow her example.