Friday, December 09, 2005

Prevention is not an Excuse

Many people believe that advocating for prevention for the mentally ill who potentially may harm others is just an excuse for letting them off the hook. I do not agree. Prevention is trying to keep a menally ill person from committing the act in the first place. Once a mentally ill person has committed a crime, it is up to the justice system to decide what is to become of them. As a forensic psychologist, it makes more sense to me to try and stop the person from harming others or themselves. I am not talking about rehabilitation for those who have already killed or hurt someone--but prevention that could save some innocent person's life.

Here is an example of email I get on a regular basis from those who call for punishment and see no place for preventative measures:

I just saw the the City Confidential special on the the so called "kids" who killed the Lillelids. They should all be dead right now - no sympathy for them - this is a clear case where old fashioned justice should have prevailed and all six should have been hung from the nearest tree. I will not spend a fucking dime on your dvd nor should anyone else. The only blame should go on the six twisted punks who did this and they should be glad that the case was not heard in my state of NC - or they would all be on death row right now - except for the youngest one maybe - hope he spends the rest of his life getting b--- fu---- in prison. Get a real job and stop wasting your time.


I can understand this view, but I have to ask the writer, wouldn't it have been better if this murder never happened? Do you really take such pleasure in the idea of six punks being b---fu---in prison that you would rather no effort have been made to keep them from committing the crime in the first place?

Perhaps this writer believes that no one can be stopped from engaging in a crime--that some killers are pre-programmed to kill at some point in their lives. But most killers do not just "snap." Gavin DeBecker, a leading expert on predicting violence, makes an important point about our denial of the warning signs of violence in his book, The Gift of Fear : "We want to believe that human violence is somehow beyond our understanding, because as long as it remains a mystery, we have no duty to avoid it, explore it, or anticipate it. We can tell ourselves that human violence is something that just happens without warning..."

I can see the warning signs coming with those I have worked with and try to get them help before their thoughts become reality. Working with violent people to provide therapy and make sure they take their medication is hard and at times, unrewarding. I do it because it can save innocent people and their families from the wrath of the mentally ill individual. I think this is a real job and an important one--it is too bad that some people would rather see others punished for doing wrong than from the wrongdoing being prevented in the first place.

43 Comments:

Blogger Gina said...

A true mental person can't really know what he is really doing , and if so then they shouldn't be left in society to wander around hurting citizens or them selves , and as for the person who thinks those kids should be B_ f in prison ,is a bit extreme , hey what if it were your child committing those crimes , would you wish the same for him/her ? we all have children , and you can never tell when a good kid can go bad or go off and do an extreme thing , just look at the Home schooled 18 year old that killed his girlfriends parents all because they for bade him to see her , whats going on with our kids today ? My gosh something is wrong somewhere and unless we just brush this aside as saying they are criminals and throw them in jail , we aren't going to learn anything , why could this happen ?

3:27 PM, December 09, 2005  
Anonymous Auld Pharte said...

Dr. Helen,

1. Would it be fair to say that most crime-related institutions, and institutional funding, are geared to react to crime rather than prevent it? I include police, the legal system, etc. in the question.

2. How widespread in professional circles is the belief that violence can be anticipated and prevented? I certainly understand the value of prevention rather than retribution, but I see little evidence of a significant trend in that direction.

3. What are the major impediments to a more pro-active approach to violent crime prevention, especially regarding subjects with no priors? I have to believe you encounter the issue on a regular basis. Are parents, for example, amenable to being told, "Your son/daughter is on the verge of committing murder." - no matter how kindly the question is posed?

Enjoy your Blog. Thanks for all the effort.

5:36 PM, December 09, 2005  
Blogger Helen said...

auld pharte,

Good questions.

1) Yes, the police etc. often cannot/will not do anything if there is a potential for violence. However, they often are told in advance of problems but do not respond. For example, in my video "Six", one of the kids was on probation and had a gun and police were called but did not put out a warning to other officers. The kids were stopped by a police officer who did not have a warning from the police--if he did, he could have taken the kids in rather than letting them go on and they ended up killing a family.

2. Predicting violence is of course, difficult. The Hare Psychopathy Checklist is an instrument that correlates with violence--these tests are extensive and of course, rarely given to most people prior to their committing crimes. Psychiatry and psychology are limited in predicting violence. However, we continue to be used as experts because we have specialized knowledge and understanding of the mentally ill and those who are dangerous. There are only a few studies looking at prediction of violence--one studied court-ordered pretrial risk assessments and found that 39% of the defendants rated by clinicians as having a medium or high likelihood of being violent committed a violent act during a two-year follow up--compared to 26 % of the defendants predicted to have a low risk of violence--statistically significant but not overly so.

3.There are certain types of killers who have few priors--school shooters, some mass murderers, family killers etc. might have no criminal record but many have psychological problems that have been brought to the attention of a mental health professional. Parents usually are desperate for help--but there are few mental health programs out there that take kids who are violent. They do not typically need to be told their child is in trouble--most know, but the juvenile justice system will not take them until they committ a crime and the mental health system has few residential programs for kids. They can get them into therapy and some medication but this is not always enough. Kids who are really violent fall between the cracks. There are, of course, some parents at schools who do not believe their child has a problem. If I evaluate their child, I talk with them in a way that says, lets help this kid to get on a better path--Under Tarasoff (a legal case) of course, psychologists must inform others if a client threatens to harm another person and has the means to do so.

7:33 PM, December 09, 2005  
Anonymous Auld Pharte said...

Thank you.

9:28 PM, December 09, 2005  
Anonymous Anonymous said...

People need to understand that there is so much going on with kids today that it is nearly impossible to predict anything with legal certainty. However, just because we can't be sure does not mean we should not try.

I am a teacher and there is a tendency in my field to blame the parents... and yes there are a lot of horrible parents out there. But even then there are a lot of good parents out there who are struggling to prevent their kid from doing something that will hurt them in the long run. I doubt very seriously that there is a magic bullet out there that will solve this problem. We will never completely solve these sorts of problems in our society but the key to a good society is we must keep trying, and reduce these troubles.

One of the problems with a society based on law is the fact that laws can only apply to an event that has happened. They can not apply to hypothetical situations that might occur. There is a tradeoff between freedom and security that we must accept. However it is silly to believe that kids should make that same tradeoff. They are KIDS! They should not have the same freedoms we have, and in return they should have increased security in their lives. It is our job as adults to provide them with that security.

The most important need a kid has is attention. Too many adults do not understand that there is no such thing as 'bad' attention to a kid. All attention is good to a kid, whether he gets it because he made an A or if he gets it because he threw a rock through a window. We need to remember this.

Proud to be a teacher.. Bert

10:12 PM, December 09, 2005  
Blogger Greg Kuperberg said...

It is a completely noble goal to save innocent people from the wrath of the mentally ill with preventive treatment. But the e-mail that you received makes clear that nothing can save convicted criminals from the wrath of society. Prison rape is an absolutely outrageous and inexcusable crime, but it is also widespread in America. This letter-writer is so consumed by malice towards complete strangers that he openly wishes it on them. Too many Americans think that way. It is as if they do not believe that rape, torture, and murder are truly unacceptable, rather that good people have the privilege to inflict them on bad people.

11:43 PM, December 09, 2005  
Blogger a psychiatrist who learned from veterans said...

My daughter teaches a preAP 8th grade science class, her first job, and has been disappointed by the hostility of a number of students, enabling by parents. She stepped out in the hall a moment to see the progress of student down the hall recently and got locked out of her classroom. Told at lunch that it was Z by several students, she asked Z about it the next day, ? in class. 'You can't punish me because you can't prove it was me,' says Z. "I really don't care who did it or that they did it as much as that this contentiousness is bothersome," she tells me. Asking the school counselor to ask the parents for evaluations of kids with apparent problems, she is told, 'We can't do that. The school would have to pay for medications.' The implication is that suggesting behavioral issues would be deeply offensive to the families and the children.

1:50 AM, December 10, 2005  
Blogger Gina said...

Helen ,

I came across this article that was posted in a date site of all places , what do you make of it , I have never seen a study like this one ..


? dose of ''shizophrenia'' makes the people more creativ and more sexy. That was the research result of 2 psyhologists who analysed the sexual behavior of famous artists. In the mosts cases of famous artists, madness and genius are too close. The psyhologists came to the conclusion that the people who have a inclination to shizophrenia, are more creativ and charismatic and have also more success in love hunting.

Exactly the same factors who predispose the human beings to shizophrenia, make their creativity and sexuality too high. The same research showed also that the artistic people have more sucess in love hunting. The 2 psyhologists, Daniel Nettle of Newcastle University and Helen Keeno of open University in Milton Keynes, described their research in the magazine ''Proceedings of the Royal Society B''.

The psyhologists have tested 452 professionel artists, hobby-artists but also other no creativ people. Artists have more sexual partners, more fantasy and passions, and that that's true for the both of the sexes. The research showed also that the creativ people have more obsessions, flight tendencies and problems regarding the way who see the reality. They can also ignore easier other people or act more impulsively or brutaly, but also attract easier sexualpartners.

8:01 AM, December 10, 2005  
Blogger Helen said...

Bert,

There is such a thing as bad attention--kids need to learn right from wrong--telling a child that everything they do is great to build their self-esteem can not only be ineffective but downright dangerous. Of course kids need some positive attention--but we should teach them that throwing a rock through a window is wrong. Some kids engage in these acts because they are fun--they are not so much looking for attention as excitement.

If we always have to wait for a crime to occur before doing anything about it, then the government (or liberals) have no right to interfere in any way with our rights to bear arms or protect ourselves. If the mental hospitals will not hold those who are dangerous and those who are mentally ill are completely free of obligation to take meds etc. then we as a society have no right to complain when someone gets killed on the runway of a plane. It is a trade-off as you suggested.

8:10 AM, December 10, 2005  
Anonymous Anonymous said...

Be careful with what you call "prevention" and on whom you are practicing "preventive measures". As the Nazis were coming power they enacted the "laws against crime" which allowed them to imprison and sterilize innocent gypsy men. It was to "prevent crime" and "protect the women and children" you see, it wasn't to commit torture, abuse, and genocide against people they did not like. Funny - I guess preventing gypsy children from ever being born was not seen as destroying children, and somehow a way of "protecting" children - as long as you weren't a gypsy.

And also remember that there is always an agenda - mental health laws have constantly been used throughout history to steal, abuse, and incapacitate. Family members used to steal estates and imprison spouses and relatives by declaring someone "mad". The Soviets imprisoned dissidents by classifying them as mad - after all, what sane person could disagree with glorious communism? And then up until the 70's here in the US many quacks - often racist, sexist, classist, eugenicist, and population control nuts - used "promiscuity", "laziness", and "simplemindedness" as excuses to sterilize, lobotomize, and imprison people.

Violent crime has been declining steadily for many years now. Now is not the time to let politicians and bureaucratic/medical hacks use tragedies to take precious and hard won freedoms away. Funny how this all just happens to benefit them politically and increase the size and powers of government.

8:11 AM, December 10, 2005  
Anonymous Anonymous said...

Dr. Helen-

When you advocate that mentally ill people "take their meds" I assume that you mean legitimately diagnosed people. You know, direct personal interview, informed consent, if a legal matter Constitutional Due Process, etc. And of course there must be no medical or legal fraud involved. Am I correct in that assumption?

8:23 AM, December 10, 2005  
Blogger Helen said...

Anonymous (8:11):

The Nazis hurt, killed and tortured the mentally ill--I am advocating help for people who are unhappy with their illness by tryng to make their life (and their families) better. If you cannot tell the difference between assisting people with problems and torture, killing etc., you are not logical enough to be having this type of conversation.

To Gina:

I do not know this study so I cannot comment on it. I do know that there are studies tying mental illness to creativity etc. Kay Redfield Jamison, a psychiatrist, writes on this topic--she has a book entittled, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament.

8:30 AM, December 10, 2005  
Blogger Helen said...

anonymous (8:23):

Have you been watching "One Flew Over the Cuckoo's Nest" one too many times? Today, it is barely possible to get people who are blatantly suicidal (or homicidal for that matter) help at all. Gone are the days of the butterfly nets. Now we can't get anyone into a hospital.

Case in point: I had a client a few years back who told me he was going home to kill himself. I called the proper authorites (as is my duty as a psychologist) and was told that they would not send anyone to pick him up but I could drive him in my car to the nearest emergency room. Yeah, right--the guy was also homicidal--there was no way I was putting him in my car etc. Try dealing with a suicidal or homicidal person in today's milieu--and as far as informed consent, due process etc. If you believe that the mentally ill should be left to their own devices-then do not bitch and complain when they are held responsible for their actions--in the courts or on the runway.

9:28 AM, December 10, 2005  
Anonymous Anonymous said...

helen-

I can quite easily tell the difference between hurting and torturing someone and helping them. But there is a difference between "helping" and helping someone. After all, the power to do something FOR someone is also the power to do something TO someone.

Early in their rise to power the Nazis used "prevention" arguments to horribly abuse and assault other people. They falsely classified people as mentally ill and then claimed that they needed to imprison and assault them to "prevent" crime.

I was merely stating that one should be wary of "prevention" arguments because they can and have been used to carry out and rationalize horrible abuse. Particularly in the context of people who were not actually mentally ill but falsely classified as such for various reasons.

What's illogical about that?

With the hysterics that have been whipped up after 9/11 and the various school shootings, there are legitimate concerns about what political and bureaucratic hacks want to do to "prevent" crime.

9:29 AM, December 10, 2005  
Anonymous Anonymous said...

Dr. Helen-

There is plenty of abusive, fraudulent, and involuntary psychiatry/psychology going on nowadays, just look around at some of the advocacy and anti-psychiatry sites.

I have no problem holding someone accountable when they actually commit a crime. Not so for trying to trump up a reason to do something to an innocent person you don't like.

9:39 AM, December 10, 2005  
Blogger dadvocate said...

Anonymous, etc.

When I worked at the mental health center we often did competency evaluations for courts. It was extremely rare that the evaluation indicated the person to be mentally incompetent by reason of insanity according to the law but the perpetrators rarely suffered the same consequences for a crime as a "normal" person.

A significant number of our patients were under our treatment due to court order after they committed a crime. Many of the crimes were minor but one of my patients had murdered his mother and another had committed over 20 acts of arson with some of the buildings being of historical significance. The arsonist was a very intelligent but mentally ill man who to watch buildings burn.

None of these patients spent any significant time behind bars. Even the patients that came to the mental health center on a daily basis had hours of unsupervised time each day. A drug test might be administered once a month. In our society, the label of mental illness excuses much, maybe too much.

10:02 AM, December 10, 2005  
Blogger Helen said...

dadvocate,

I agree--what bothers me is the inconsistency--the mentally ill should never have to submit to any restrictions etc. based on their illness but at the same time, if they commit a crime, they should not be held responsible because they are ill. It is like saying that a fifteen year old is competent to sign for an abortion but is not competent to consent to the sex that was involved in the first place. I think it just has to do with what some of the advocates want--men should not have sex with 15 year old girls so that is called statutory rape while these same advocates are for abortion rights so a fifteen year old suddenly becomes competent to consent. Likewise, the mentally ill should be free to do anything they want--even threaten others, not take meds if they do not want to etc. while wanting them to be excused from punishment if they actually commit a crime.

10:23 AM, December 10, 2005  
Anonymous Anonymous said...

Helen

I agree with you. What I was trying to say is from a kid's point of view, there is no 'bad' attention. They just want attention. It is our job to teach them the difference between bad and good. And I agree totally with you about the self-esteem bit. They should be taught about self-respect, which is something you earn, as opposed to self-esteem, which is something you are given. My kids can tell you that I never give good grades... they are required to earn them.

Bert

10:59 AM, December 10, 2005  
Blogger Helen said...

Bert,

You sound like a fair and good teacher--I just get tired of the authority figures who harp on self-esteem to the exclusion of teaching critical thinking etc.

11:44 AM, December 10, 2005  
Anonymous Anonymous said...

Helen

Oh believe me I despise the teaching of self-esteem even more than you do. I fight it every day, trying to make them see that a proper logical thought process is the way you solve problems. I teach Algebra (everyone's favorite subject) and I try to make them understand that the logical process that I am teaching them is the same process that will help them later on in life when they are making any critical decision. Self-esteem is a direct attack on this logical process, giving them false ideas of what their outcome should be in life, no matter what their input. You know the saying, garbage in, garbage out, which is true... well self-esteem teaches kids garbage in, diamond ring out.

Bert

12:44 PM, December 10, 2005  
Anonymous Anonymous said...

Of course there are some instances where the opposite is true. Take your GIGO example. If you put a diamond in and get garbage out, and can clearly see that some people are corrupting and defrauding the system, or the system itself is corrupt, then the logical course of action is to not tolerate the system and correct it.

Teaching someone that something blatantly resembling slavery or apartheid is acceptable is obvious nonsense. And of course any "teacher" trying the old "I'm stealing from you to 'help' you" routine is just a crook.

6:16 PM, December 10, 2005  
Blogger Assistant Village Idiot said...

anonymous 929

Yes, political regimes have used psychiatry as a cover for their more evil ends. I suppose it doesn't hurt to keep that in the back of your mind when setting policy. The opposite problem is much more to the point today: we have difficulty keeping people who desperately need treatment, because the law -- and our capacity -- does not allow it. I'm not sure what you are reading on advocacy and antipsychiatry sites, but it would pay to remember that the writers there have far more of a need to reinterpret the facts. Advocates tend to be drawn from poorly-treated manics and borderline personality disordered people. It's not that they have no truth and nothing to offer, but that they have so much crap and denial surrounding their claims that you can't sort out what's up.

I have that conversation often on the acute psychiatric unit, from patients who would dearly love to think that we are keeping them illegally or immorally because they are different or we don't like them. We wouldn't have the room to do that even if we wanted to. They are just scoring a zero on the aware-o-meter, that's all. People have to be provably dangerous.

Related: we have a specialty unit which allows videotaping frequently (lots of legal hoops for that). I have watched patients who are now treated watch the tapes of what they looked like when they came in. You would think that would be instructive. Often, it isn't. People accuse us of doctoring or staging the films, or more frequently, 24 hours later they are already starting to minimize and deny what is too painful to remember.

Could we again return to times when we went around locking up the politically inconvenient? I suppose anything's possible eventually. We don't seem to be trending that way.

6:16 PM, December 10, 2005  
Anonymous Anonymous said...

asst. village idiot-

Right, anyone that states something you disagree with or can't immediately confirm is "full of crap and denial". And anyone in conflict with your worldview obviously must fit into some diagnostic cubbyhole somewhere.

I really wish you had more power to imprison, medicate, lobotomize, sterilize, and electroshock people without their informed consent. All based on your informed medical opinion, of course. What a utopia that would be.

10:08 PM, December 10, 2005  
Blogger Assistant Village Idiot said...

When you bring up lobotomize and sterilize -- surely you know that such things were 50 years ago? And if the patient is not able to give informed consent, there is a fairly rigorous process in NH of getting a guardian, who may or may not grant consent for such things as medication and ECT's.

Come watch my people suffer, tormented by fears that we are going to eat them or torture their children, with us unable to do anything for them, because they are not actively and provably dangerous. It's fun to explain why we can't do anything to their parents, too. Or talk with my patient who killed her children while psychotic, the thought of suicide never far from her mind these last fifteen years.

You may attempt to capture the moral high ground about what horrible, cruel, and power-bestirred people we are. Apparently no facts will dissuade you.

6:21 PM, December 11, 2005  
Anonymous Anonymous said...

AVI-

Some of the sterilizations, lobotomies, etc. extended well into the 70's including, I believe, even some of the controversial alleged targetting of minorities.

Here's a skeptical account that admits there were some forced procedures:

http://www.straightdope.com/columns/020322.html

A federal court order was issued in 1974 after it was proved that two black girls were involuntarily sterilized.

While I don't doubt that there are some genuinely ill people in distress, I think you underestimate how much abusive "treatment" is going on out there, much of it fraudulent, covert, and/or "off the books".

4:46 AM, December 12, 2005  
Anonymous dweeb said...

The reason people equate prevention advocacy with post crime leniency is they're hard to separate in the framework of a consistent morality. If you believe there was something someone other than the criminal could have done to prevent a crime, and that there is a responsibility to take preventive action, then you're stuck with the logical conclusion that someone other than the criminal bears responsibility when preventive action is not taken and the crime occurs. There's a transfer of culpability, from the criminal to those who didn't act preventively, and a corresponding moral imperative to temper punishment, or even apportion some of it to the would be preventer. How can society punish a perpetrator when, as was told to Officer Krupke, "it's [at least partially] society's fault!" Prevention advocacy is a two-edged sword.

You're also overlooking basic libertarian principles, which conflict on several levels with prevention advocacy. In a free society, government/society can't go around interfering in the lives and choices of individuals based on what they're likely to do, maybe going to do, etc. We're all familiar with the adage "My right to swing my fist ends at your nose." That means that society can't step in until contact is made between the hypothetical fist and nose. The mere swinging does not reach the threshhold for societal interference.

There's also the scientific caveat that correlation does not equal causality. The social sciences used to determine when preventive intervention is called for are notoriously statistical, with nothing even approaching the scientific laws well known to the physical sciences in Newton's day. Thus, prevention advocacy calls for interfering with an individual because that individual's traits, circumstances, or harmless behavior have a high degree of correlation with later criminal actions. However, if we accept such correlation as the basis for (often coercive) societal intervention, then why not the abundant correlations of race, fatherlessness, poverty, and minority tastes/viewpoints with eventual criminal behavior? Clearly, that's a road no reasonable person wants to venture down, but it's an extrapolation that's been pointed out by many people.

People often overlook that liberty does not come without a cost in terms of security. A free society is restrained from acting proactively to protect its members from one another; deterrence through punishment after the fact is the only means available to it without interfering in the lives of individuals who have not committed any crimes. This is well illustrated in the movie "Minority Report," about a society where tested and verified prescience is used to convict people in advance of crimes they will commit in the future. Government can't prevent others from violating our rights, it can only punish them after the fact, and hope that others will be deterred by example. The USA's unique right to bear arms is partially an acknowledgement that we all bear a certain responsibility for self protection, because the cost to liberty inherent in expecting government to protect us adequately is too high.

5:31 PM, December 12, 2005  
Anonymous LissaKay said...

I am the mother of a teenager who has bipolar disorder. So many times I have watched the news ... the deputy in Loudon Co, the Campbell Co student, the young couple in PA ... and so many other horrifying acts carried out by children ... and I think, there, but for the Grace of God, and lithium, go I ...

The woman in Texas who brutally killed her children ... voices told her to do it. Her mental health issues had gone all but ignored for years. She had extremely severe post-partum depression, verging into pyschosis. No one did anything. Her children are now dead. And it is too late for her as well.

Michael Harvey, who killed the deputy in Loudon County ... he had problems. He was being treated with Paxil. From descriptions given by his peers, I saw a lot of bipolar symptoms. Paxil and bipolar is a deadly combination.

My own son had his scrapes with the law and a couple of forays through Knox Co Juvenile Justice, most recently, just two months ago. I don't know if we were extremely lucky to have a public defender and a probation counselor who "get it" and a judge who listened and heard that my son needed HELP, not incarceration ... but my son was given his one last chance. We now have hope that he will attain and sustain a productive and satisfying life.

My son is, so far, an example of what can be achieved, despite severe mental disorders ... with a little luck and a mom who knows how to get what her child needs ... I even took on Gov Bredesen, and I still have words for him over this damn TennCare issue.

11:01 PM, December 13, 2005  
Blogger Helen said...

Lissakay,

Glad your son is doing better. His case is the type of prevention I think is so important. It is best to catch the mental health issues and treat them prior to a child or adult doing something that may affect the rest of their lives or someone else. The kids themselves often know they need help and therapy and sometimes medication is a good method if a person has bipolar illness. Of course, inpatient treatment can be necessary but that is where the problem comes in--it is very hard to get a kid into a treatment facility for any length of time.

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