Please stop diagnosing without examining these suspects clinically. It is so unprofessional !

I DO AGREE MENTAL "CONDITIONS" SHOULD BE CALLED DISEASES OR ILLNESS AND NOT ONLY DISORDERS. CHANGING THE NAME TO DISORDERS DID NOT HELPED TO DIMINISHED THE STIGMA. IT WOULD BE RIDICULOUS TO CALL A COLD OR HEPATITIS, DISORDERS. LETS STOP BEING CONDESCENDING AND PATRONIZING WITH MENTAL TRIBULATIONS.
ARTURO MENDOZA-LOPEZ, MD

Let's just ignore the fact that none of these proposed solutions would have actually done anything to stop this horrible crime. However, I am glad that the author finally had an epiphany about the existence of evil, something that four year olds with common sense seem to grasp better than adults under the influence of moral relativism.

Let's deal with these proposals point by point. These were clearly not thought out at all.

1. Autism, Asperger, and most every other mental condition worthy of our prime focus should be called diseases, not disorders.

Lanza's immediate motivation was fear of commitment and competing for the love of his mother. We have no information that he was particularly concerned nor motivated by DSM5 epistemological nor phenomenological debates over the definition of disease vs. disorder. Moreover, we have no information that Asperger's had anything to do with extreme violence. If his mother had designs on having him civilly committed, then it is likely that the diagnosis was actually more serious. I do not like the implication that Asperger's explains this crime, because at this point there is no evidence of that, and in general Asperger's patients are not known to be particularly violent.

2.All such diagnoses should be made or certified by a psychiatrist to qualify for medical insurance coverage

Lack of insurance coverage has nothing to do with this situation. His parents were wealthy and his mother was trying to get him institutionalized. If there is any "coverage"issue, it is the unreasonable burdens associated with involuntary commitment. Bringing his issue up in the context of this news story smack of ghoulish exploitation and lobbying. Moreover, James Holmes of the Aurora mass murder did receive treatment and still went ahead with his terrible deeds.

3. Do not make public diagnoses of anyone not personally examined, per our Goldwater Rule

This is a good idea that the author should have heeded by not assuming that he has Asperger's or that this had anything to do with the murders.

4. This tragedy, following too many others, should spur further study of where criminal behavior ends and psychiatric disease begins, if indeed there is even such a line.

This idea is predicated on the idea that "normal" human behavior is "good" and fails to take into account the natural state of man as an aggressive species. I can understand why the author took so long to get a grasp on evil. This pursuit is no especially useful anyway. There is no evidence that Hitler was legally mentally ill, and it pure fantasy that psychiatry could have done what it took millions of Allied troops to accomplish.

5.All psychiatrists should spend some clinical time in a correctional institution, either during residency or later for continuing education.

Are you really advocating mandatory prison service for CME certification? Again, there is no evidence that this would have done anything to stop Lanza and this is completely tangential to the issue at hand.

6. Find better ways to educate the public about the early signs of homicidal risk.

Apparently the staff at the school already was concerned as was his mother but they were unable to have him civilly committed. Notice that the author said nothing about overly permissive involuntary commitment laws that have been a disaster for 50 years.

7. Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior

This sounds perilously close to a Soviet style snitch program and is a clear violation of civil liberties.

8. Provide better resources in order to improve early treatment of homicidal ideation.

Again, Holmes had treatment and this did not stop him. Many people with homicidal ideation will not admit it and when they do, you are lucky to be able to detain them in most states for more than 72 hours.

9. Convene a representative body of those injured by public violence and loved ones of those murdered, to work on a national Task Force to reduce mass murder.

Ah, the task force, the bureaucratic answer to all problems. The same kind of task forces that made DSM5 a mess. Apparently Holmes was reported to a danger assessment team and nothing happened. How exactly would this task force have stopped any of the recent mass murders?

10. Advocate for a special anniversary date or holiday, December 14th, to not only remember the Connecticut tragedy or others like it, but also as a way to monitor how we are doing as a nation and a profession in trying to prevent more such tragedies.

This reminds me of the maudlin Princes Diana days of mourning in Great Britain. How about letting the people who were affected by the tragedy mourn privately with dignity instead of instigating a public spectacle, just in time to put a permanent downer on the holidays? If this is the trend, are we going to have national days of mourning for each and every mass murder? If not, why not? Are those victims less deserving? How far do we go back? The Homestead Steel Strike of 1892? The Boston Massacre?

Ten suggestions, ten completely irrelevant, ineffective, expensive failed prescriptions. Yet there not a word about such obvious issues as obviously failed family dynamics. We do have evidence that the mother enabled his lack of maturity and allowed unacceptable behavior in her home by allowing him to take over two rooms while remaining idle. She obviously lacked common sense by not getting rid of weapons in a situation in which she could be overpowered by a younger unstable male. There are reports that the courts were concerned about parenting skills at the time of their divorce. We know that the father was not involved in his obviously troubled son's life (though in his defense he simply may have given up in frustration at the obvious pathological dynamic between mother and son). We know that the murderer (notice that I do not use the nonjudgmental term "gunman" or "suspect" as the media do) had warped Oedpial issues, feeling that his mother loved the school more than him, and he took out the ultimate Oedipal revenge. I think it is pretty obvious at this point that the writings of Sigmund Freud and psychoanalysis in general are more explanatory than any abstruse debate about Asperger's and its DSM5 classification.

As far as the gun debate, I have little faith that gun control would be any more effective than the War on Drugs or Prohibition and will probably make things worse. Chicago has strict gun control and had over 500 murders last year. Whatever feelings the Sandy Hook administrators had on this issue, I guarantee you at their moment of impending doom, they all wish they had an armed off duty cop or ex-IDF officer in the vicinity. Psychiatrists should be loathe to focus on tools and the first to focus on pathological psychodynamic issues instead.

James O'Brien, M.D.
Forensic Psychiatry
Mira Loma, CA

Thank you, Dr. O'Brien, for taking the time to respond so specifically to what you perceived I was saying. It's sort of a blog on its own, especially since I think I didn't make some of my points clear enough to you. First, a general clarification and then to respond to your specifics. For better or worse, I indeed used this tragedy to try to make some general points about the problems in psychiatry. There was nothing there about what diagnosis I thought the perpetrator might have. I think everything we know about him is right now peacemeal, and inadequate to make any specific conclusions. Concerning your specifics:

1. I was trying to say the opposite of what you imply I said about Asperger's, so I agree with you.
2. I agree that insurance had nothing to do with this situation, since by all accounts the family could have even self-paid. As to James Holmes, the information available is that his treatment was incomplete and hospitalization was likely necessary.
3. I strongly stated that I try to abide by the Goldwater Rule and so did not imply any diagnosis. From the little I know about Mr. Lanza's history, to me it is consistant with something other or more than Asperger's, but I am only saying this in response to your comment.
4. I don't think Hitler was ever seen by a psychiatrist; it sure would have been interesting to see what a child psychiatrist would have done if he was seen by one during childhood. There is also a reference at the end that I have been writing about evil for some time now, and actually won a national healthcare journalist's award for doing so.
5. I think some brief time working or observing in a correctional institution, either during residency or for CME, would round out the education of any psychiatrist, and also confront most with the question of "evil".
6. I discussed the need for more involuntary treatment in a prior blog ,"Is It Time for Re-Institutionalization?"(April 20, 2012), so please review that to see that I agree with you.
7. Why is this Soviet-style? Don't we have a similar responsibility for reporting for other dangerous behavior, ranging from child abuse to HIV, without any Soviet-like repercussions?
8. Again, I was not commenting on specific cases, just to improve early treatment anywhere possible. It sure seemed to me working in prison that many of the inmates (and, of course, their victimes) could have benefitted from early treatment instead of later incarceration.
9. The task force for DSM did not include the public or politicians and, in that way, was filled with conflict-of-interest, including a potential financial windfall for the APA. Not a good comparison.
10.Just pick a date. Don't we have something similar now for Memorial Day, except this is for those who have been killed in war. What about those innocently killed in peacetime in our society?

Finally, I would be very cautious about psychodynamic speculations at this time, although I was trained that way and still use that perspective. Freud called doing that "wild analysis". There is absolutely no evidence of a disastrous Oedipal conflict here, even though the family situation could easily lead to such speculation. Our field has been oh-so-wrong to blame mothers in the past, ranging from schizophrenogenic mothers to the "cold" mothers causing Autism. I, for one, was quite saddened that bells were generally not rang for the perpetrator's mother. The bell also had tolled for her before - and when - she was killed.

I have no trouble blaming the mother's actions and calling his motives Oepidal, which I am broadly defining as homicidal feelings toward a competing maternal love interest (if not necessarily the literal father). We know that this twenty year old man was motivated to mass murder because he feared his mother in his eyes loved the people at the school more than himself. This at an age where he should have been dating and been reasonably independent. The mother is the second most culpable party here. She chose to turn her spacious and expensive home into the Bates Motel, instead of helping her son become a man. Not getting the weapons out of the house while she had a relative living with her as she was trying to have him committed for psychiatric illness was completely reckless and irresponsible. I have absolutely no problem judging the mother's parenting skills, weapons safety procedures, common sense and finding them all deficient. The children and the adults at the school were completely innocent/blameless, she was not, and clearly enabled this tragedy.

We are all judgmental, some of us just choose to admit it. There needs to be more dialogue in this society about how families are screwing up their children and less talk about public funding and government policy. Something "had to be done" after 9-11. What we got was the TSA, the NSA, the Patriot Act and the Iraq War. These problems need to be thought through before we make sweeping changes that are likely to make things worse. Histrionic policy is histrionic acting out and almost always backfires.

Thanks for your follow-up response, Dr. O'Brien. So I can understand better where you are drawing your conclusions, can you provide us the sources for "We know that . . .".
Although I am quite loathe to blame the mother here without detailed knowledge of the family history, and after all she is a victim as well and can't give her side of the story, I am all for improved parenting. Do you have suggestions of how this can be improved?
And, wouldn't it be helpful to hear the father's side of the story (unless I missed it)?

Steve

For Dr. O'Brien,

Stable should be "unstable". Freudian slip?

Then, again, unless we hear more from people who knew how she viewed her son, her view of him - conscious or unconscious - is all speculation.

Certainly, you are right about securing the guns, but here, too, we don't know how that was handled yet (or ever).

Most mothers who have a severely mentally ill child usually try to take care of them as best they can, often at home, and even alone, until they realize that is not helping and may even be harmful and risky. Maybe this mother would have reached that conclusion eventually, too.

Ann Sparks,

Thank you for your comment. I'm still struggling with defining and finding "evil", but no trouble agreeing with you that we should be using a bio-psycho-social-SPIRITUAL model of care for most anything medical or psychiatric.

Non-sense.

Dear Dr. Moffic,

As a prison psychiatrist, I very much enjoyed your well-written article about the Connecticut tragedy, especially your recommendation that all psychitrists do some time behind bars, so to speak. Unfortunately, California is leaning toward the stance that hiring psychiatrists to treat mentally ill inmates is a "failed model" (for a number of reasons, mostly related to recruitment), and would like to replace us with nurse practitioners and physicians assistants. In my opinion, this would be a step in the wrong direction. Your article argues for more psychiatric involvement in diagnosis and treatment, not less. In light of the tragedy, I couldn't agree more. Perhaps one of the unintended effects of this latest mass shooting will be a change in public policy with respect to the treatment of the mentally ill; psychiatry is still, unfortunately, the ugly stepchild of medicine. It will be interesting to see if that attitude changes.

Sincerely,

David Krassner, MD
Staff Psychiatrist
California Men's Colony State Prison
California Department of Corrections and Rehabilitation

Thanks all for the variety of reactions. Some brief responses, in order:
Phillip Thomas: I don't know if you meant the whole article was non-sense or psychiatrists are. Might help us all if you elaborate.
David Krassner: As much as I admire any psychiatrist working in a prison, I admire you even more from what I understand are the conditions in the California prisons. Not so longer ago, a reporter from California called me to ask my opinion of group psychotherapy being done with the prisoners in cages (by a psychologist, not a psychiatrist).
Enrique Gatura: I trust you did not think I was doing anything like breaking an ethical principle by diagnosing someone without examining them, let alone breaking confidentiality. You are so right if you were referring to some medical commentators tossing out Asperger's Spectrum or Schizophrenia for the perpetrator. All that does, I'm afraid, is increase the stigma for those who have such diagnoses.

One more comment on the comments:

Arturo Mendoza-Lopez: Amen! And this is in our power to change.

There is no doubt based on all the information in the press that she failed to properly secure the weapons in the home from a relative she thought to be mentally stable. This is the number one responsibility of a gun owner. There is no doubt that her living arrangements with her adult son were indicative of a pathological mother-son relationship.

I have no doubt had she survived that she would have been sued for everything she had.

She is clearly culpable both morally and legally.

If she is a victim it is of her own lack of judgment. I am not willing to put her in the same innocent victim category as the six year olds.

Being nonjudgmental is the hubristic false virtue of our times. It is like the question on the MMPI, "I never get angry". A positive response doesn't mean you don't get angry, it means you are in denial of normal human emotions. You will often notice that the people who claim never to make judgments are in fact always making judgments.

One thing we can do individually is inquire about firearms in the house when we see a suicidal or homicidal patient and do everything possible within HIPAA to encourage relatives to remove them.

type stable should be "unstable"

I believe evil (and likely mentally ill as well) did visit Newtown, CN December the 14th. Everyone knows that those who are not evil would not have done such a thing. Not even most cases of mental illness can be said to cause this level of human destruction without apparent justifiable cause.

As a Nurse Practitioner, I have worked in mental health and addictions. With the treatment of addictions, we always look at the spiritual aspect of the patent. Clearly addiction is a SPIRITUAL DISEASE. Whether you want to call it evil or not, is totally up to you. Now that I have had a number of years in addictions, I can say that there are many illnesses beyond drug addiction, that have a foundation in SPIRITUAL DISEASE: Drug Addiction, Alcoholism, Gambling Addiction, Eating Addiction, Sexual Addiction, Internet Addiction, Codependency... and the list goes on.
I ask, "Why would we think that shootings that occur are anything less then a SPIRITUAL CONDITION?" Particularly when coupled with IQ or mental health deficits!

Let's truly get back to treating the WHOLE patient, body, mind and spirit. It seems that phobias regarding religion and spirituality are crippling this country to the point of no return. Let us turn the trend around and look at 12-Step Recovery on a larger scale... because it's not just addicts and alcoholics that have spiritual deficits!

So spot on about evil. I would add that it's impossible to make value judgments about "good" without acknowledging the existence of its ugly cousin.

The presence of absence of a spiritual life in this family is not something we are likely to hear about from the media. We know all about the Bushmaster, we know nothing about how Lanza learned right from wrong, if he ever did.

The saying that all happy families are alike is true. There are two or three ways to make a happy family, there are millions of ways to screw it up. It is patently obvious that the mother blew it as a parent and and community member, and I find it frustrating that this permissive insistence on moral equivalence makes it a thought crime to call someone out for blame. This is nothing but intellectually vapid moral vanity and a form of enabling in its own right.

I'm curious, do you consider Adam Lanza a victim as well?

Hmm, Dr. O'brien. The dreaded question I was awaiting. Well, I applauded those churches that rang 28 bells instead of 26 a week later. It is hard to imagine that Adam Lanza was mainly responsible for his life and completely responsible for his choices, but then again, we just don't know enough about him. Probably his father and brother could tell us the most, but even then, do they know if he was having command hallucinations or some sort of delusions? One of Loughton's victims in Arizona forgave him.

So, I would probably consider Adam Lanza a paradoxical victim of sorts. Would you not, given your analysis of the mother's role in this?

When I worked with young African-American males in prison, and found out about verifiable severe trauma in their childhoods, along with limited options to get past that, I felt they, too, were victims of sorts. Or, what about prisoners who do horrible things and are found to have certain kinds of changes in their brains?

How much personal free will do people like that have? If they are "evil", can that be helped in any way? Sociopaths probably not, but many of those I saw seemed to have underlying severe trauma, though by no means all of them. Not an easy question to answer simply yes or no.

Oh, I make judgments most of the time, though less and less as I get older and realize I really know less and less than I thought, even though I am becoming more child-like again.

Too bad we don't know what was running through his conscious and unconscious mind.

I don't think sociopathy and narcissism are mutually exclusive. Those who do the research find many more sociopaths outside of prison.

Yes, we need more connection and discussion of religion and psychiatry, of evil and ethics, etc.

I guess I'm not surprised, either, that you think you've got that situation analyzed since you seem to think you know what I am thinking: "Yep, just as I thought".

We probably should continue this discussion via personal e-mail. I don't disagree with your premise, though I would add that sometimes you can treat "bad" behavior (say, brought on by ADHD or PTSD or Schizophrenia). I also fail to understand why you are not including the father in how this whole scenario evolved. My basic point and question is that we just don't know enough to pinpoint where all the blame should go, though, of course it seems apparent that blame certainly goes to the murderer.

Shalom?

As I tried to way, and you now say. Enough until we know more, if we do end up knowing more.

Yep, just as I thought.

Keep working on the "understanding evil"project. I warn you, though, once you figure it out, you may have to make judgments.

This is something we all understood at four, but many of us were talked out of in college.

Lanza had enough free will to stop shooting others once the cops were coming. Then he turned coward. Sounds like there was some free will going on.

Sociopaths can be "helped" with their evil tendencies with the threat of force and by isolating them in prisons (though most prisoners are really narcissists and not sociopaths).

You're making this a lot harder than it is. The fact that Lanza's mother was an enabler doesn't make him a victim. Evil always has accomplices.

Too bad DSM-5 task forces didn't consider moral relativism a disorder.

It is axiomatic that you will get more bad behavior if you tolerate, excuse or reward it.

The Talmud says:

כל מי שנעשה רחמן במקום אכזרי
סוף שנעשה אכזרי במקום רחמן

Kol mi shena`asa rahaman bimqom akhzari
Sof shena`asa akhzari bimqom rahaman

All who are made to be compassionate in the place of the cruel
In the end are made to be cruel in the place of the compassionate

In other words, if those who are kind when they should be cruel are apt to be cruel when they should be kind.

It dishonors the innocent children to consider Lanza a victim, or his mother as blameless.

I guess I'm quaint for trusting ancient wisdom more than current intellectual fads.

Because the father wasn't criminally negligent with weapons safety like the mother. And he didn't allow a 20 year intelligent and able bodied male to stay at home doing nothing while drifting into a sick fantasy world. I would like to know more about what the judge said during the 2008 divorce about their parenting. There are situations where the mother makes it impossible for the father and vice versa, but we need to know more.

I would also like to know more about his history of treatment. From what we know so far, personality disorder is a lot more explanatory than Asperger's (which, by the way, is not a disease like pneumococcal pneumonia). I wonder if there was something more that we don't know about.

Shalom.

What about the reckless use of medication given by psychiatrists to teenagers without proper supervision. Especially too children of gun owners? Medications can take time to work and in that period of time the person could be in a roller coaster ride of mood ewings wnd physical pains. Not a good combo for a young kid on top ot teen age angst.

Andrew Martinov, thanks for the timely concern, as there has begun some wild speculation that the perpetrator at Sandy Hook was on medication, which caused side effects, that then led to the tragedy. Right now, as I said before, that speculation is like a Rorschach Test, since we know so little about him. Certainly, we should all be concerned about reckless prescribing and inadequate supervision of situations like you mention. Psychiatrists know that medications like antidepressants can cause akathesia, a very distressing restlessness, which can make the patient feel much worse and even precipitate suicidal feelings. Beyond that, sometimes patients don't take medication correctly. Adolescents, as you say, make everything more difficult, due to normal angst and the involvement of parents. Psychotherapy is often an important treatment component. However, despite all those potential problems, medication is much more likely to be life-saving than life-losing.

It's just more than a little disappointing that in a psychiatric journal so much emphasis is placed on bureaucracy and public policy as a "solution" (not to mention numerous unrelated ideas and speculation about medication) rather than looking at defective family structure, which is our wheelhouse, or at least used to be.

And we do know enough about this family that blame can be placed. Letting your able bodied 20 year old take over the house while allowing him to remain idle in the absence of a father in the presence of weapons is obviously not going to end well, even if he never becomes a murderer.

"Advocate for a system of safe reporting of those felt to be at- risk for homicidal behavior"

Your wish was granted in New York state:

http://www.usatoday.com/story/news/nation/2013/01/15/ny-gun-law-therapy/...

The road to hell is paved with good intentions, and I'm sure the vast majority of therapists in New York are Cuomo supporters.

This is what happens when "emergency" legislation is passed based on headlines, not critical thinking.