How improving the public mental health system can help to prevent mass homicide

The role of public mental health policy in preventing violent crime.

By Joel Dvoskin, PhD, ABPP

A great deal has been written and said recently about the people who commit acts of mass homicide. Like many of my colleagues, I have received numerous inquiries from the electronic and print media, asking me why someone would do something like that, often requesting a "profile" that would allow us to identify mass murderers in advance so that we might prevent these catastrophic events in the future.

Anyone with a TV knows that there is no shortage of self-styled experts who are quick and happy to explain the motivation of a person they have never met and know virtually nothing about. Much of the data upon which they base their uninformed speculation turns out to be wrong, or based on the motivations of past offenders who may or may not be similar to the latest perpetrator of such crimes.

As with all profiles, the vast majority of reported factors are what we can call "non-specific indicators." These are characteristics such as anger, social awkwardness, social disconnectedness, depression, and feelings of personal insignificance. The problem with these elements of a "profile," of course, is that each of them describes literally millions of people who will never commit a violent crime in their life.

Some "experts," including mental health professionals who ought to know better, presume that the highest-risk group for mass homicide are "the mentally ill (sic)." As most of the readers will know, this phrase is typically used to describe people who have a diagnosis of a psychotic disorder such as schizophrenia, and who perhaps have at one time or another been psychiatrically hospitalized. And while a few perpetrators of mass homicide appear or were reported to have a serious and persistent psychotic disorder, a far greater number could be more accurately described as people who were in acute distress. It is relatively easy to identify people with schizophrenia, especially when they are struggling, and almost impossible to know in advance whose anger, sadness, and other forms of psychological distress will result in homicide.

Thus, when the media call, they find me predictably disappointing. I typically tell them that I have no idea why the person did what they did, and that "profiles" are comprised of misleading generalizations and stereotypes that serve no purpose whatsoever.

That something is difficult and complex is a poor justification for not trying. While it is true that we have not demonstrated any skill in predicting and preventing mass homicide among Americans, there is at least one manner in which we have demonstrated a remarkable ability to prevent another, much more common outcome of intolerable psychological pain – jail suicide.

Suicide rates in the United States have sadly risen in recent years. There are undoubtedly many reasons for this phenomenon, potentially including 12 years of very difficult economic circumstances, the decimation of the public mental health system due to federal, state, and local budget crises, and perhaps the social isolation that some observers have noted among average Americans. However, despite the general rise in suicide rates, corrections professionals and correctional psychologists have been extraordinarily successful in preventing suicides in our nation's jails. Thanks to a handful of national leaders such as Lindsay Hayes, a simple system of suicide prevention has emerged, based on cost-effective primary, secondary, and tertiary preventive strategies.

Today's jails are constitutionally required to have a suicide prevention program. The standard of care mandates that every single inmate entering the system be screened with a few simple questions aimed at identifying those who are willing to admit that they are thinking about killing themselves. This screening is of course designed to yield false positives, and every detainee who screens positive is watched in a suicide-resistant place until they can receive a relatively brief interview by a mental health professional. Those who are deemed at heightened risk of suicide are then placed on suicide watch and provided with psychological and psychiatric services until the suicidal episode is over.

A cynic might well ask, "Won't suicidal people simply lie about their intentions, making it impossible to prevent their death?” The answer is that a relatively few detainees who are bound and determined to die will defeat the jail’s preventive efforts. In contrast, the vast majority of suicidal detainees talk about their extreme psychological distress, perhaps because they are ambivalent about their wish to die. Suicidologists describe this ambivalence not as a wish to die, but as a wish to end psychological pain. Since most jails suicides are also impulsive, safely negotiating the first few days of detention has dramatically reduced the suicide rate in America's jails.

I realize that this preventive strategy may not translate to the prevention of mass homicide. However, the vast majority of perpetrators of these shootings end up dead. Even those who survive have essentially ended their life as a free person. Thus, it may be useful to at least think about suicide prevention as a model for identifying and helping people who were in extreme psychological distress.

Of course, of the millions of Americans in psychological distress, only a miniscule few will commit acts of spectacular violence. We should not, therefore, help them because they're going to kill somebody. Quite simply, we should help people in extreme psychological distress because they need help. In the process, we may well prevent tragic episodes of mass homicide, but we will never know it. That's the worst part about this work; you seldom get to know what you prevented.

This leads me to conclude that one absolutely correct response to the tragedy at Sandy Hook Elementary School is to restore the ability of the public mental health system to respond in a timely and competent manner to emotional and psychological crises. When help is easily available and user-friendly, perhaps the next would-be assassin will decide that there is another, better way to end their psychological pain.