What stood out for me was that this young man talked about thoughts of killing people. He did so to the point of worrying his psychiatrist: She called in a second psychiatrist for a consultation, alerted the university’s threat assessment team, contacted an out-of-state parent, and considered admitting him on an involuntary hold. While many patients say they might hurt someone if provoked or threatened, few discuss thoughts of killing indiscriminately. But when people do talk about killing, we do our best to flush out their intentions, whether it is a fantasy or a plan, if they’ve been violent before. This shooter had no history of violence, and he hid from the psychiatrist the fact that he was acquiring weapons and actually planning a massacre. His psychiatrist diagnosed him with social anxiety, obsessive-compulsive disorder, and possible schizotypal personality disorder. He was prescribed an antidepressant, and later offered an antipsychotic, which he refused.
Three of the four psychiatrists who evaluated the defendant for the legal proceedings made a diagnosis of schizoaffective disorder. (The fifth psychiatrist for the prosecution never examined the defendant.) Dr. Reid made a diagnosis of schizotypal personality disorder. Everyone agreed that the shooter had a mental illness that influenced his actions. When it came to ascertaining the defendant’s mental state at the time of the crime, there was a glitch: The first psychiatrist for the defense examined the defendant only once, days after the shooting, and not again until 3 years later, right before the trial. His exam was limited: The defense attorney was present in the room, and he had instructed the psychiatrist not to ask about the shooting. The attorney interrupted the interview twice, and it’s not the usual practice to place these conditions on a forensic evaluation. After that exam, there was some misunderstanding about who was in charge of the treatment, and the defendant refused the services of the jail psychiatrist. It was not until 4 months later when the inmate became dehydrated, delirious, and psychotic that he finally was evaluated and treated. Despite the abundance of psychiatric information available, no direct and complete assessment was made by a psychiatrist immediately before the shooting, or in the months right after.
When we try to understand what motivates someone to commit such a heinous act, we look for psychosis. If the person suffers from paranoid delusions and believes his behavior is in self-defense, the behavior becomes understandable and justifiable. Even if it’s less organized, if it is the clear result of a psychotic thought process, we often attribute the behavior to illness. Usually, people with psychosis are too disorganized to enact complex plans, to acquire and learn to use ammunition, to plot out when and where there will be potential victims, and to plot out this degree of planning.
This shooter had an odd belief that if he killed people, he would attain “human capital.” Their deaths might fortify him, increase his value and decrease his suffering, and thereby prevent him from dying by suicide. Dr. Reid talks about whether it’s a delusion, an overvalued idea, or just an unusual belief. The shooter was aware that others don’t agree with this, that they would see it as wrong and criminal, and he thought there was only a 50% chance that it would work. If this were a delusion, it was not one we typically see, nor was it accompanied by more usual perceptual phenomena. Ultimately, there was no consensus on whether the patient was psychotic at the time of the shooting. On antipsychotic medication, he continued to believe that if he killed people that he would attain their human capital. In his book, Dr. Reid concluded that he remained dangerous.
Because the shooter told the university health center psychiatrist that he did not want to be locked up, she considered involuntary hospitalization, but she did not believe he would meet criteria for commitment. I saw nothing that indicated whether he was offered voluntary inpatient care with an explanation that hospital treatment is not the same as being locked up and might help alleviate his suffering. We don’t know if he could have been persuaded to enter the hospital willingly, but I suspect that this would have been difficult to justify to an insurer. There’s nothing to indicate that a hospitalization would have prevented this massacre.
Dr. Dinah Miller
From my perspective, I concluded that if individuals say they are thinking about killing strangers, they may be at risk of violence. This is a much smaller group of people to target for intervention than everyone with mental illness or everyone who is odd. This particular shooter appears to suffer from some type of mental derangement that does not fit neatly into our current psychiatric nomenclature or respond to our current treatments, and thoughtful psychiatric intervention – which he had – could not prevent his actions. It seems the only thing that would have changed this outcome is if someone had discovered his arsenal before July 20, 2012.
*Please note: The shooter’s name is intentionally omitted from my review.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).