Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
Dr. Dinah Miller
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).