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The Right to Massacre?

NEW YORK – The shootings of United States Congresswoman Gabrielle Giffords and others in Arizona last month are but the latest in a series of mass shootings in the US in which the (alleged) perpetrator suffered from an apparent mental disorder. Predictably, the Arizona tragedy has elicited calls for policy changes. But what, if anything, should be done differently?

The vast majority of severely mentally disordered individuals are not violent. Predicting which few without a prior history of violence will become violent is almost impossible. At the same time, proposals to protect society from the dangerously mentally ill pose basic civil-liberties issues.

A Russian reporter, Andrei Sitov, raised this question when he asserted at a White House press conference that American freedom was complicit in the Arizona shootings: “As to why – it does not seem all that incomprehensible, at least from the outside. It’s the reverse side of freedom. Unless you want restrictions, unless you want a bigger role for the government…This is America, democracy, freedom of speech, freedom of assembly, the freedom to petition your government. And many people outside would also say the ‘freedom’ of a deranged mind to react in a violent way is also American.”

President Barack Obama’s press secretary answered defensively that American values do not endorse violence. That is true, but irrelevant. The question is whether American values favoring individual rights somehow facilitated the Arizona tragedy. After all, rates of severe mental illness are about the same across the developed world, yet the US seems to have more such shootings than do other countries.

One freedom-related suggestion is that the US needs stricter laws that keep guns out of the hands of the mentally ill. But the alleged shooter had never been formally diagnosed as mentally ill, so such targeted laws would not have prevented him from obtaining a gun. General gun control is essential, but unlikely for now.

The US also needs more accessible mental-health services. Although his college demanded professional evaluation before he would be allowed to return, the suspect in the Arizona shootings, it seems, failed to seek help from Tucson’s available services. Unlike those with physical illnesses, mentally ill individuals often are unaware – even vehemently deny – that they have a problem, thus forgoing treatment and losing desperately needed disability benefits.

Many colleges have increased monitoring of students’ odd behavior by threat-assessment teams. But such mass screening is notoriously ineffective in predicting violence, often yielding enormous numbers of misidentified threats. For example, psychiatric screening for suicide risk in one New York high school identified 44% of the student body as being at risk. Similarly, screening for loose, eccentric thinking yields mostly individuals who never become psychiatrically disordered.

In the months before the shootings, the suspect’s behavior displayed marked signs of serious mental problems, including confusing speech, disruptiveness in class, bizarre imagery, deterioration in social, academic, and occupational functioning, and a dramatic personality change. With such blatant signals, why didn’t others intervene? Arizona law allows any interested party to report an individual’s bizarre or threatening behavior to the authorities, who can involuntarily commit the individual for psychiatric evaluation.

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Though his community college suspended the suspect for his threatening demeanor, it took no further action. One reason is that American educational privacy laws severely restrict the sharing of information, even with parents, let alone with other authorities. Additional privacy protections for medical records sometimes make it difficult to notify parents when a child is troubled.

Moreover, the US Constitution prohibits preventive detention: even severely disturbed individuals cannot be detained involuntarily unless judged an imminent threat to themselves or others. College counselors apparently did not think that the suspect met this demanding threshold. Although disruptive, the suspect was able to function – as shown by the disciplined nature of the attack.

Such protections should not be surrendered easily. The irony of Sitov’s comment is that during the Soviet era, Russian political dissidents were psychiatrically diagnosed, institutionalized, and drugged into submission. Soviet Premier Nikita Khrushchev, paving the way for the political abuse of psychiatric diagnosis, argued that, “Of those who might start calling for opposition to Communism…, we can say that clearly their mental state is not normal.”

The line between angry political extremism or eccentric normality and delusional mental disorder is tricky to draw. If restrictions on involuntary commitment to prevent crime are eased, zealous prosecutors could circumvent civil liberties. Such abuses have emerged when preventive institutionalization has passed constitutional muster, as in the laws some US states have enacted in order to incarcerate “sexually violent predators.”

So, what can be done? Sitov was correct to the extent that the Arizona shootings were likely facilitated by a uniquely American interaction between legal protection of individual privacy and freedom, lack of strong community bonds and resources, and easy access to handguns. Americans must acknowledge that educational and medical privacy laws require limited exceptions for notification of family and authorities when clear signs of severe mental illness surface, so that colleges and other institutions can take timely action.

Adequate community mental-health services with educational outreach can induce disturbed youth to get help voluntarily. Perhaps prudent loosening of the imminent-harm standard for involuntary commitment in clear cases of severe disorder might be helpful. Screening, if carefully targeted to limit errors, also may have a role to play. Finally, improved gun control vis-à-vis the severely mentally ill is imperative.

Such measures might have prevented the Arizona shootings. A stronger community response, supported by limited exceptions to legal restrictions on information-sharing, could have allowed involuntary evaluation of the suspect.

If he refused treatment and was released because he posed no imminent threat, his severe mental disorder would nonetheless have been diagnosed. Placing him immediately on a “watch list” for weapons – frequently updated under strengthened laws – could have prevented him from purchasing the gun and ammunition he subsequently used.
Jerome C. Wakefield is a professor at New York University’s Silver School of Social Work and Professor of Psychiatry at NYU’s School of Medicine.

Copyright: Project Syndicate, 2011.

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