Monday, April 23, 2007

We are all Responsible for Preventing Violence

Here is a terrific op-ed by Jonathan Kellerman that makes some great points about the problems within our mental health system (Hat Tip: Dan Collins, Protein Wisdom):


Talk to anyone who's tried to commit a dangerously violent child or parent for even a few days: A stranger with a law degree will show up at the hearing and paint you as a fascist. So it's far too much to expect anything resembling a decisive approach to those whose level of threat remains at the verbal level.

Given the excesses of the past--husbands committing troublesome wives, involuntary sterilization of those judged defective--extreme caution is warranted. But like drunk drivers, we sway from one side of the legal road to the other and find the sensible center lane elusive.

Unless we confront the unpleasant fact that the brains of a small percentage of our citizens incubate dark, disturbed thoughts that can blossom into vicious behavior, we can look forward to repeats of last week's outrage.


It is these disturbed and dark thoughts that the majority of people do not want to think about. As one who in the past, has listened to countless hours of the most disturbing of thoughts, they no longer bother me except to understand what they mean and what I can do about it but my hands are often tied--by the system, by legalities and by denial. I think the words of Gavin De Becker, the author of The Gift of Fear are warranted here:

We don't need to learn about violence, many feel, because the police will handle it, the criminal-justice system will handle it, experts will handle it. Though it touches us all and belongs to us all, and though we each have something profound to contribute to the solution, we have left this critical inquiry to people who tell us that violence cannot be predicted, that risk is a game of odds, and that anxiety is an unavoidable part of life.

Not one of these conventional "wisdoms" is true.


Amen, Mr. De Becker, for if we all stick our heads in the sand and say that violence is not preventable, like so many are doing, then we are truly lost.

42 Comments:

Anonymous Wally Bock said...

The Kellerman piece is excellent. Thanks for pointing to it. Note his connection between closing mental health facilities and the homeless issue.

10:31 AM, April 23, 2007  
Anonymous Anonymous said...

The phenomenon is so rare that loosening up the rules would result in the horror stories he mentioned - spouses or family members falsely committing people, committing people to shut them up, etc. In fact those horror stories already happen even with the supposedly strict rules in place now.

People aching to control others and strip away their rights and freedoms will always use tragedies as an excuse. Which is somewhat sick in its own right, using a tragedy to act out your own neuroses and agenda.

And regarding "denial" - you realize that is argument by definition, right? It sets the clinician up as infallible - either the person admits the clinician is right or the person is lying to themselves, there is no scenario where the clinician is wrong, by definition. That might be correct in a world where all clinicians were infallible, omnipotent, god-like, etc. (talk about "magical" thinking) But in a world where clinicians can be wrong, mistaken, corrupt, criminal, pathological, self-interested, biased, prejudiced, racist, argueing from ignorance, incompetent, etc. it can be very far from the truth or reality.

11:16 AM, April 23, 2007  
Blogger TMink said...

Good point about denial. It is a very sharp knife and needs to be used with caution. My training was in intersubjectivity. It focuses more on the two people in the room than the more authoritarian, older model that looks at one patient and one doctor.

So when I think denial, I wonder what I did to either misunderstand the situation, or what I might have done that makes it difficult to discuss the situation. I am at least 50% responsible for most of the stuff that happens in the room.

Older modesl frequently used "denial" as a euphemism instead of saying "I am the smart, healthy one and you are the dumb ill one so listen to me sickie."

Trey

12:03 PM, April 23, 2007  
Anonymous carol said...

I'm pretty sure I could have been committed as a child circa 1960, if my mother had had the money and support from her ex (my father). I was odd enough, difficult enough, and quite inconvenient. And she was quite good at confusing her desires with my best interests.

I can't help but think of that, and I suppose it's "irrational" of me.

But where do you draw the line? Especially, when I think of the flawed psychotherapy back then, the God-like paternalism of the practitioners. And as subject to fads as the therapeutic community is, are things any better?

12:46 PM, April 23, 2007  
Blogger Helen said...

Anonymous 11:16:

The denial that those who are suicidal or homicidal need hospitalization for more than a day or two is what I am referring to. It has to do with mental health funding. Hospitals do not have the federal or state funding to keep many people in the hosptital, even those who want to stay.

Like so many who have watched "One Flew over the Cuckoo's Nest" one too many times, you may believe that the majority of patients are just being thrown in mental hospitals willy-nilly at the drop of a clinician's hat. You would be sorely mistaken. For there are thousands of homeless schizophrenics living in the streets and shelters that prove otherwise. Perhaps you think this is humane, but for someone who is suffering from a psychotic break and is in pain, I am not so sure that it is.

12:46 PM, April 23, 2007  
Blogger Eric said...

One of the most awful experiences I've had in this regard was seeing my sister barely stabilized in the psych unit -- only to be "discharged" (dumped in the street) by callused nurses who acted as if she was just a normal person who'd had a tonsillectomy, told her to take her meds as they gave her a prescription she was incapable of having filled. I urged them not to do it, but they had their administrative "guidelines" as to how long people should be kept, and they didn't want to even talk to me -- her brother who had gone to a huge amount of trouble to have her committed -- because of "patient confidentiality." (I realize there are reasons for HIPAA privacy rules but in practice they seem like a cruel joke.)

The cost per day is unbelievable, btw and no one wants to pay -- certainly not the government or the insurance companies. (Hence the "guidelines.")

Of course, the monthly social security disability checks ensure the chronically mentally ill will at least be preyed on by someone -- in the name of keeping them "independent." Because of these fictions, it's very hard to take care of such family members when push comes to shove.

I don't know how the families put up with it.

3:19 PM, April 23, 2007  
Blogger Dan Collins said...

Helen--

Thanks for the h/t. I'm very invested in this, because I have a son who developed childhood onset schizophrenia when he was 9. When he becomes 18, he will have the legal right to decide whether or not he wishes to continue to take his medication, although his judgment is severely affected. We will have to go through formal proceedings in order to change that, but that is what we must do.

Fortunately, he's a very sweet person, but he does feel his affliction, and obviously feels it most deeply when he's closest to reality as the rest of us, more or less, perceive it. It's very hard for us, as parents, because we want him to be happy even as we want him to be well.

NAMI is the principal advocate for the mentally afflicted in the US, and it recognizes the tragic turn that mental health treatment has taken in the US and elsewhere, as a result of the supposed "liberalization" of policy. I have personally counselled many parents, spouses and siblings who wish to provide the best possible treatment for their affected loved ones, who find that they are continually fighting the law in the process of trying to do so, as if living with mental illness were not hard enough in the first place.

All I can say, anonymous, is, I pray for your sake it never visits you. I'm not asking for absolute moral authority; I'm just asking for the power to help my stolen child.

3:20 PM, April 23, 2007  
Anonymous Jim said...

"But where do you draw the line? "

Carol, that's the big question. The question has t do with the autonomy of the individual, and society is going through another bout of soul-searchng and redefinition. It's the same question that is at the heart of the abortion debate - where does the individual begin and end?

It really isn't a medical question. It's deeper than that.

5:45 PM, April 23, 2007  
Blogger Helen said...

Hi Dan,

This is a very important topic and one that I believe that warrants more public discourse. I only wish that those who are against hosptitalization for the mentally ill or medication or follow-up etc. could be required to take in a dangerous individual who is off their drugs for three months and then be questioned about the accuracy of Thomas Szasz's ideas. I hurt for the families of some of the mentally ill, for they often have no place to turn and few resources. Of course, the regular path of those who are schizophrenic is not a violent one, but when a person is both psychotic and dangerous, the consequences can be hell. I have seen this first hand and it is a nightmare.

6:34 PM, April 23, 2007  
Anonymous LissaKay said...

While not as dire a situation as Dan's, I can relate with what I have gone through with my son, and even to a lesser extent my daughter. My son has bipolar disorder, and even when he was clearly a minor, 13 years old, and clearly a danger to himself, I had to fight tooth and nail to get him the care he needed. I literally had to beg and plead to get past the triage nurse at a local mental health facility to get an appointment with the psychiatrist. It was a horrible nightmare, to see my son so clearly in pain, but not receiving the level of care needed - the wrong medication, no therapy, nothing but plenty of insinuations that his problems were my fault, that I was a bad mommy and just needed to discipline him more.

Now that he is 19, he can choose to not take medication, which is what he is doing now. He insists there is nothing wrong with him. For now, he seems stable and in control of himself. Even though he has never shown any propensity towards violence to others at all, I know full and well that remains a possibility. All I can do is try to stay aware of what is going on with him. But even so, unless he becomes a clear threat to himself or others, no one - police, hospital, doctor, 911 - will do anything at all, and by then it may well be too late.

7:17 PM, April 23, 2007  
Blogger Dan Collins said...

While he's well, see if you can get him to sign a waiver for access to his medical records, lissakay.

Helen, if you'd like to have some video I took of Aidan before he lit his nightshirt on fire and we decided we couldn't deal with it on our own, to post, I can send it. He stated that he was dead, that he was a ghost, that we'd killed him, that his real parents had been taken and that we were replicas substituted in their place. If, as a parent, that doesn't rend your heart, nothing ever will.

Any of you who have such issues need to contact NAMI, if you haven't. There's no need for us to have to suffer going it alone, and no virtue in reinventing the wheel.

7:53 PM, April 23, 2007  
Anonymous CaptDMO said...

Call me old school.
I'm a firm believer in effective behavior reinforcement between 2mos and 3(or so) years.
OF COURSE there are extreem cases, but nowhere NEAR as many as currently being officially "diagnosed" by dangerous hacks with "It's not their fault because......feed 'em meds.".

11:48 PM, April 23, 2007  
Anonymous anonymom said...

"We are all Responsible for Preventing Violence"

Come on! I can't be the only one who heard an echo of "It takes a village..."

12:09 AM, April 24, 2007  
Anonymous Anonymous said...

Dr. Helen,

Thank you for encouraging a public debate on this problem. Many secondary school systems fail to meet the needs of students with severe psychological problems, while also failing to protect students and faculty from any potential threat. Why failures occur should be a topic of public discussion. One may consider my school system as an illustration of the malaise found in many schools.

A summery of problems:

Several teachers attempted to intervene in various situations where students showed "red flag" behavior patterns. Yet, documenting and reporting signs of instability in students does not solve a developing problem, when we encounter apathetic counselors who refused to take action about potentially dangerous students, or principals more interested in avoiding offending influential parents, than preventing a future crisis.

Our parents as a group have very high expectations of their children. Every child must be a state champion, a scholar and have perfect emotional balance. Parental expectations often lead to their inability to confront serious emotional problems in their children. Administrators and counselors did not want to be the bearers of bad news. Past local history warns of parents
“destroying the messenger” instead of taking action to repair the problem. I was stunned to read the school's welcoming banner announcing that it was a 100% drug-free zone, and other such boasts claiming it was a crime and violence-free school.

To further complicate the situation, this is a small school located in a highly affluent area. Many of the school personnel and parents grew up and attended the same school during their youth. This pattern created a two-tiered system of rules for specific groups of students, staff and faculty. Bullying is epidemic. It is too complicated to explain in this post, but the school system and the city are exceptionally political to an unhealthy degree. This is significant because it makes it outright risky to address behavior problems of students belonging to the “protected class”.(Yes this situation is bizarre). As a result, many students are allowed to escalate negative behaviors until a catastrophe finally occurs. For example, one student was caught in several serious situations including felony theft) but was let-off the hook due to his status. He later burned down a dorm.(I am not kidding)

For a small school system we have had a series of major problems including suicide, murder and students threatening to murder staff and students on numerous occasions.

In sum, the environment is breeding a potential disaster. The example of one student history demonstrates this pattern of ignoring a problem.

For the purpose of telling the story, call the student Sam.

During Sam’s sophomore year – teachers reported that he would sit in class and draw pictures of women being hung, with satanic symbols and the like. In another class Sam informed several students that he fantasized about gunning down a number of faculty members and fellow students during graduation. Sam also informed a group of friends that his father had physically abused him. His concerned friends went to faculty members in an attempt to get help for Sam. After faculty members reported their concerns, the counseling department and administration responded by having a brief meeting with Sam. Sam denied the story, of course. Afterwards he and his parents threatened the students, which caused them to deny their original report to faculty members. The teachers were left hanging, and nothing was done. Teachers on Sam’s graduation “hit list” were forced to allow him back into their classes. During Sam’s junior year he submitted a major writing piece which included a graphic section describing skinning rabbits alive. Again, nothing was done. The incidents continued and by the time Sam reached his senior year, the faculty was terrified of him. Sam never received professional counseling, while school counseling and administration looked the other way. Sam’s treatment cleared the way for an onslaught of vandalism against the private property of faculty members. Various teachers found property in their rooms trashed or stolen, their cars “keyed” and windows broken. One out-of-control student visited the home of a second-year teacher, and deposited feces upon the man’s front porch.

On a more serious level, several teachers received death threats, and nothing was done about it. One teacher recorded a death threat on the home phone and took it to the police. The student’s phone was traced, and it turned out to be a student who had been flunked by the teacher. However, the student claimed it was not his voice, and that he had left his phone at a party. The police decided that a phone number id and the voice recording was not enough. Nothing was done by the police or by the school administration. Needless, to say, some students interpreted this decision as a green light to future such behavior.

Most educators have heard many stories echoing this sort of problem. However, in the past we heard such stories only about high-crime, inner-city school systems, not upper-income suburban schools. Educators now face the choice of deciding whether a student is issuing serious threats and whether their administration is able or willing to protect them from students suffering from untreated mental illness. Parents worry that their children will not be protected from a student that throws desks at teachers, intimidates the class and yet, is allowed to return. Administrators worry about encountering lawsuits from wealthy parents after expelling their child for exhibiting some of the early described behaviors. Everyone is concerned with a variety of issues, but not providing the necessary treatment for the student.

It concerns me that within this storm of demanding parents and children lacking healthy behavioral boundaries; we may overlook the line between students exhibiting behavior problems, and those developing a full-blown mental illness. Eventually, some adolescent will silently explode, and become a potential threat.

How in the middle of these factors, can a positive, emotionally secure learning environment exist?

1:22 AM, April 24, 2007  
Blogger Clayton said...

As I pointed out at http://www.claytoncramer.com/weblog/2007_04_22_archive.html#5017639412223685594, after quoting Kellerman:

This Texas Law Review paper by Bernard Harcourt http://www.law.uchicago.edu/files/harcourt/institutionalized-final.pdf examines institutionalization--as measured by both prison and mental hospital inmates. He makes the shocking discovery that if you combine both measures and plot them against U.S. murder rates for the period 1928-2000, there is an almost perfect negative correlation: as institutionalization (in either prison or mental hospitals) goes up, murder rates go down, and vice versa.

There's a lot of evidence that many of those who are currently locked up in prisons are mentally ill. It would appear that the great experiment of the 1960s--deinstitutionalization--simply transferred violent mentally ill people from mental hospitals to prisons, after a few decades of suffering, both by those mental patients, and by the society as a whole.

1:46 AM, April 24, 2007  
Blogger Andy said...

Interesting. Isn't there a personality test that can detect sociopaths - apparently they have lower physiological reactions, and come up emotionally "dead" in response to emotive terms.

Perhaps some kind of screening when people come to the attention of the authorities?

5:25 AM, April 24, 2007  
Anonymous Kent said...

Andy,

My knowledge of polygraphy makes me very wary of personality tests such as you describe. A person wired to a machine, and told that his freedom may depend on his subconcious responses, is simply not going to respond normally. No one would under that kind of stress. The result is an unacceptably high false positive rate.

This is true even if the absolute false positive rate seems small. I can illustrate with an example from the work of a Dr. Zelicoff, formerly at Sandia National Laboratories. Zelicoff used the example of polygraphy as a screening tool for spies among nuclear laboratory workers. If the polygraph has a false positive rate of 2% (that is, 2% of those tested came up as deceptive but were actually honest), which is pretty darn low; and if 10,000 nuclear laboratory workers were tested (that's a very rough estimate how many there are in this country); and if ten of these are spies, then the polgraph will finger perhaps eight of the ten spies, but it will also incorrectly finger 200 honest men. I don't find that acceptable.

This problem exists for any screening procedure, even quite an accurate one (as in the example), if the abnormal group being screened for is a very small fraction of the population.

Now consider that neither polygraphy nor, in all likelihood, the test you describe has anything as good as a 2% false positive rate. Consider that sociopathology is quite uncommon; perhaps not as low as 1 in 1000, but not much higher. The overwhelming majority of those fingered by your test would be ordinary folks who are no threat.

Lesson? Your test had better be awfully accurate. And, even then, you can't justify its use as a screening tool; at best, it can only confirm a diagnosis already suspected.

Helen,

To answer your question about Blogger, yes, I'm finding it impossible to post under my Blogger ID. Very frustrating.

9:45 AM, April 24, 2007  
Anonymous Willbdone said...

I grew up with the perspective of a daughter of mother who struggles with mental illness. In her case, she started out depressed/suicidal in the mid 70s (when I was 7). By the 80s her mental health had declined enough that she was able to get on disability. During that time she had many trips to the psyche ward. In the late 90s she got on section 8 housing and has thankfully been living independently. She does enter a psychotic phase at her worst. I have been called by concerned neighbors and landlords over the years. She may scare people with her bizarre behavior, but she has never physically harmed anyone.

I have been an active NAMI member in my community and found NAMI a refreshing resource to connect with. I am in a very small minority though...The majority of people who frequent the meetings are concerned parents of a child with mental struggles.

Clearly as Kellerman has wisely pointed out, the "sensible center lane" has been elusive. Concerned family members are left with minimal options in the case of a non-compliant family member who has no insight into their own illness. We treat Alzhemiers patients with more compassion. We recognize when they need full time care...

When you are a family member who knows your parent (or child, brother/sister) better than any doctor, and you see your family member deteriorating before your eyes, there should absolutely be more options than simply standing by and waiting for the worst to happen.

------

On a final note of my ramblings...Our local NAMI owns 2 group homes. In the case of one, we are trying to make it a 24 hour care home that could accomodate the seriously mentally ill. Many of these people in our county are ending up in nursing homes.

My heart goes out to all the families who as Kellerman pointed out in his article, are facing the harsh realities of the "freedom" that came from dismantling the state hospital system...

9:57 AM, April 24, 2007  
Blogger Helen said...

Kent,

The actual number of psychopaths in the US is somewhere around 1% of the population, that is 1 out of 100 people--not a small amount by any means. The state of the art in testing for psychopathy is the Hare Psychopathy Checklist, a detailed assessment instrument by Robert Hare who found a high correlation between violence and psychopathy.

You can read here for more information:

http://www.crimelibrary.com/criminal_mind/psychology/robert_hare/9.html

10:25 AM, April 24, 2007  
Anonymous Kent said...

What is the false positive rate of the Hare Psychopathy Checklist?

If it's as good as 5%, you'll still finger five normal individuals for every psychopath, even at a psychopathology rate of 1%. Is that acceptable? Perhaps, but it's going to depend a lot on how the test is used.

11:46 AM, April 24, 2007  
Anonymous Viola Jaynes said...

Dr. Helen, I could not agree with you more on this. We must always be looking for better solutions - always!

7:51 PM, April 24, 2007  
Anonymous Anonymous said...

helen-
(I'm the original anonymous 11:16)

Like so many who have watched "One Flew over the Cuckoo's Nest" one too many times, you may believe that the majority of patients are just being thrown in mental hospitals willy-nilly at the drop of a clinician's hat. You would be sorely mistaken. For there are thousands of homeless schizophrenics living in the streets and shelters that prove otherwise. Perhaps you think this is humane, but for someone who is suffering from a psychotic break and is in pain, I am not so sure that it is.

No, I don't think every mental patient is thrown into institutions willy-nilly. But I do know that there are a lot of normal, innocent people that are falsely diagnosed, innaccurately diagnosed, etc. I'd rather have some mentally ill people wandering around free than innocent people being locked up, being forcibly drugged, being abused, etc. because someone wanted to take their money, discredit them to avoid liability, keep them quiet, etc. Ditto for false or inaccurate diagnoses done in the name or rent-seeking by the mental health industry.

It's unusual that you can recognize the injustice of women making false rape or abuse claims against men for financial gain, abuse, smearing, the upper hand in legal disputes, etc. but don't realize the mental health system is also a potential vehicle for similar kinds of abuse.

12:17 PM, April 25, 2007  
Anonymous Anonymous said...

kent-

The result is an unacceptably high false positive rate.

Exactly. A test that produces too many false positives is worse than worthless. Time for the test makers to go try to find another way to milk the government and others.

12:20 PM, April 25, 2007  
Anonymous TMink said...

Anon wrote: "But I do know that there are a lot of normal, innocent people that are falsely diagnosed, innaccurately diagnosed, etc."

I do not know that. One person is too many, but I do not see a lot of normal, innocent people drugged up on psych drugs as a result of money grubbing. There are better ways of making money, trust me. And most of us that half way know what we are doing have a waiting list.

There are some psychiatrists in my town that give every child the same meds because they see every child as bipolar (when they are not)but they are incompetent (and generally foreign trained) doctors not money grubbers.

And there are some therapists who see every patient as multiple personailty disordered or whatever their pet diagnosis is, but they are generally obsessed and in need of treatment themselves.

But neither group is the majority in my experience. I would like to read about your experiences that led you to make your sweeping statements about money grubbin mental health practioners.

Trey

9:58 AM, April 26, 2007  
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