On July 28, 2012, The New York Times ran a story with the headline “Colorado Shooting Suspect Was Getting Psychiatric Care.”1 Coincidently, July 28, 2012, was also the 9th of Av 5772 on the Hebrew calendar. This date on the Hebrew calendar is the anniversary of the destruction of both Temples in Jerusalem, as well as numerous other calamities that have afflicted the Jewish people throughout history. With the recent tragedy in Colorado and the high likelihood that questions about psychiatry will be inextricably tied into it, I believe guidance for us as practicing psychiatrists can be gleaned from this coincidence.
Told in Tractate Gittin 56a, the story of Kamsa and Bar Kamsa is the most well known Talmudic story about the 9th of Av and the destruction of the Second Temple. As the story goes, a man made a large party during the second Temple era and sent his servant to invite his friend Kamsa. The servant made a mistake and invited the party host’s enemy, Bar-Kamsa. When the night of the party came and Bar-Kamsa showed up to the party, the host threw Bar-Kamsa out, despite his protestations and his repeated offers to pay for increasing percentages of the cost of the party.
In retaliation for this embarrassing experience, Bar-Kamsa went to the Roman Caesar ruling Israel at the time and shared with him a lie that the Jews were planning an insurrection. When the Caesar heard this, he sent an animal sacrifice with Bar-Kamsa to the temple in Jerusalem with the thinking that if the sacrifice was accepted, there was unlikely to be a Jewish insurrection in the offing. Bar-Kamsa took the animal to Jerusalem but along the way injured it in such a way that it would not be acceptable for a sacrifice at the Temple. When the animal was not accepted for sacrifice, the angry Caesar responded by laying siege to Jerusalem, leading to the destruction of the Second Temple and the exile of the Jewish people.
What is the connection between this Talmudic story and the recent killings in Colorado? To answer this question, one must first answer the question of why Bar-Kamsa responded to a slight by a private person with actions intended to be detrimental to the whole Jewish nation? At the party from which he was thrown out, Bar-Kamsa looked around and saw several of the most prominent rabbis of the era in attendance. The rabbis’ collective silence as Bar-Kamsa was being so publicly humiliated caused his anger to extend to the entirety of the Jewish leadership.
In response to the killings in Aurora, Colorado, the nation will be turning to psychiatrists for our opinions. It is important, in light of the ongoing requests being issued by the press for expert opinions, that we not remain silent. Silence will ensure that the overwhelming majority of our patients will be painted with an unfavorable brush as the link between psychiatric illness and violence is bandied about.
If our code of ethics wisely bars us from offering “a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement,”2 what is the correct response to questions regarding what happened in Colorado? The answer is, our job is to educate the public that at the current time, a causative link between severe mental illness and violence has simply not been shown. “Severe mental illness alone did not significantly predict committing violent acts,” wrote the authors of a 2009 US study involving over 30,000 subjects to study if such a connection exists.3 Similarly, a European meta-analysis concluded that while people with psychosis may be prone to become violent, most of this excess risk is “mediated by substance abuse comorbidity.”4 An Australian study similarly found that increases in offending amongst people with schizophrenia were consistent with offending in the general public and those who were treated for co-occurring substance abuse “accounted for a disproportionate amount of offending.”5
Speech that reflects this ambiguity in the evidence base of a link between mental illness and perpetration of violence may help prevent further stigmatization of patients who require our help. In fact, while the evidence on whether patients with mental illness are more likely to commit crimes is ambiguous at best, the evidence that patients with mental illness will be crime victims is far more robust. Teplin6 found that the rate of violent victimization in the previous year for the mentally ill was 11 times higher than the general public. Helpful speech will educate the public that it may be said that we as a society must do a better job of protecting the mentally ill from those who would predate on this vulnerable group rather than that society has to do a better job of protecting itself from the mentally ill.
1. Frosch D. Colorado Shooting Suspect Was Getting Psychiatric Care. New York Times. July 27, 2012. http://www.nytimes.com/2012/07/28/us/colorado-suspect-was-getting-psychiatric-care.html. Accessed August 15, 2012.
2. American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. 2001. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/ethics-resource-center/educational-resources/federation-repository-ethics-documents-online/american-psychiatric-association.page. Accessed August 15, 2012.
3. Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009;66:152-161.
4. Fazel S, Gulati G, Linsell L, et al. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009;6(8):e1000120.
5. Mullen PE, Burgess P, Wallace C, et al. Community care and criminal offending in schizophrenia. Lancet. 2000;355:614-617.
6. Teplin LA, McClelland GM, Abram KM, Weiner DA. Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey. Arch Gen Psychiatry. 2005;62:911-921.