Mental Illness, Violence & Liberty

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The mass murder that occurred at Sandy Hook Elementary school has created significant interest in both gun control and mental health. In this essay I will focus on the matter of mental health.

When watching the coverage on CNN, I saw a segment in which Dr. Gupta noted that currently people can only be involuntarily detained for mental health issues when they present an imminent danger. He expressed concern about this high threshold, noting that this has the practical impact that authorities generally cannot act until someone has done something harmful and then it can be rather too late. One rather important matter is sorting out what the threshold for official intervention.

On the one hand, it can be argued that the relevant authorities need to be proactive. They should not wait until they learn that someone with a mental issue is plotting to shoot children before acting. They certainly should not wait until after someone with a mental issue has murdered dozens of people. They have to determine whether or not a person with a mental issue (or issues) is likely to engage in such behavior and deal with the person well before people are hurt.  That is, the authorities need to catch and deal with the person while he is still a pre-criminal rather than an actual criminal.

In terms of arguing in favor of this, a plausible line of approach would be a utilitarian argument: dealing with people with mental issues before they commit acts of violence will prevent the harmful consequences that otherwise would have occurred.

On the other hand, there is the obvious moral concern with allowing authorities to detain and deal with people not for something they have done or have even plotted to do but merely might do.  Obviously, there is rather serious practical challenge of sorting out what a person might do when they are not actually conspiring or planning a misdeed. There is also the moral concern of justifying coercing or detaining a person for what they might do. Intuitively, the mere fact that a person could or might do something wrong does not warrant acting against the person. The obvious exception is when there is adequate evidence to establish that a person is plotting or conspiring to commit a crime. However, these sorts of things are already covered by the law, so what would seem to be under consideration would be coercing people without adequate evidence that they are plotting or conspiring to commit crimes. On the face of it, this would seem unacceptable.

One obvious way to justify using the coercive power of the state against those with mental issues before they commit or even plan a crime is to argue that certain mental issues are themselves adequate evidence that a person is reasonably likely to engage in a crime, even though nothing she has done meets the imminent danger threshold.

On an abstract level, this does have a certain appeal. To use an analogy to physical health, if certain factors indicate a high risk of a condition occurring, then it make sense to treat for that condition before it manifests. Likewise, if certain factors indicate a high risk of a person with mental issues engaging in violence against others, then it makes sense to treat for that condition before it manifests.

It might be objected that people can refuse medical treatment for physical conditions and hence they should be able to do the same for dangerous mental issues. The obvious reply is that if a person refuses treatment for a physical ailment, he is only endangering himself. But if someone refuses treatment for a condition that can result in her engaging in violence against others, then she is putting others in danger without their consent and she does not have the liberty or right to do this.

Moving into the realm of the concrete, the matter becomes rather problematic. One rather obvious point of concern is that mental health science is lagging far behind the physical health sciences (I am using the popular rather than philosophical distinction between mental and physical here) and the physical health sciences are still rather limited. As such, using the best mental health science of the day to predict how likely a person is likely to engage in violence (in the absence of evidence of planning and actual past crimes) will typically result in a prediction of dubious accuracy. To use the coercive power of the state against an individual on the basis of such dubious evidence would not be morally acceptable. After all, a person can only be justly denied liberty on adequate grounds and such a prediction does not seem strong enough to warrant such action.

It might be countered that in the light of such events as the shootings at Sandy Hook and Colorado, there are legitimate grounds to use the coercive power of the state against people who might engage in such actions on the grounds that preventing another mass murder is worth the price of denying people their freedom on mere suspicion.

As might be imagined, without very clear guidelines and limitations, this sort of principle could easily be extended to anyone who might commit a crime—thus justifying locking up people for being potential criminals. This would certainly be wrong.

It might be countered that there is no danger of the principle being extended and that such worries are worries based on a slippery slope. After all, one might say, the principle only applies to those deemed to have the right (or rather wrong) sort of mental issues. Normal people, one might say in a calm voice, have nothing to worry about.

However, it seems that normal people might. After all, it is normal for people to have the occasional mental issue (such as depression) and there is the concern that the application of the fuzzy science of mental health might result in incorrect determinations of mental issues.

To close, I am not saying that we should not reconsider the threshold for applying the coercive power of the state to people with mental issues. Rather, my point is that this should be done with due care to avoid creating more harm than it would prevent.

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12 Comments.

  1. The coercive power of the state does not need to be law enforcement. To go back to the physical health analogy, vaccinations are required by law if I want to send my child to school. Not because they protect my child, although they do, but because they protect the public health. Colleges require health screenings for similar reasons. Mental health screenings (and if necessary, treatment) could be required for people who wish to engage in certain activities. That would help protect the public and not be punishing people for crimes that they have not yet commited.

  2. One aspect of instances of prior mass murders by deranged individuals (I can’t really address this instance for lack of facts.) is that immediate family members have very frequently (roughly half of studied cases) unsuccessfully sought the intervention of authorities because of outbursts of threats or episodes of violence that, because of our concerns for civil liberties, were addressed by family courts rather than criminal courts. Prior to about 60 years ago such cases would have been addressed with confinement to a mental health facility. Now the working assumption is that psychiatric drugs will suffice. Statistics seem to indicate a correlation between the prevalence of this approach to mental health issues and an increase in murders and mass murders.

    To me this indicates that, as a society, we are harboring a corporate conception of personhood that is misguided and misleading when we deal with humans who are exceptions to our general rules.

  3. This interesting article questions the use of psychopathology as a method to reduce gun violence in schools. The article mentions Dr. Gupta’s opinion that the threshold for intervention of people with mental health issues is too low, and Mike LaBossiere questions what the threshold should be. There is much to disagree with here.

    First, Dr. Gupta is a neurosurgeon, not a moral judge. Violence is an interpersonal or social phenomenon, often with political dimensions. Psychosurgery could be used to isolate and cure political critics. It could be used to enslave those of different education, or other racial color. Profiling by mental health will only lead to more persecution of Blacks, Hispanics, and perhaps Muslims in the future. As an example, there is the famous case of Marinus van der Lubbe, who was a mentally deficient man tortured into confessing to starting the Reichstag fire in Germany 1931. False accusation was not uncommon before this, but modern media has been able to bring new insight into political attacks and conspiracy theories.

    Second, there are serious doubts whether pathology can be used to identify a potential deviant. The techniques are not much more sophisticated than a phrenologist looking for bumps on the head as a sign of criminality. I agree with Mike LaBossiere when he writes there is “dubious accuracy” if trying to use mental health science to predict violence.

    The article suggests that the utilitarian argument is to deal with people with mental issues before they commit acts of violence to prevent the harmful consequences that otherwise would have occurred. I disagree. What is being described is known as the retributive theory of justice, not utilitarian. The utilitarian theory of justice wants to punish an innocent person as a deterrent to crime. The utilitarian school conflicts with the retributive school. Everyone on a jury may have a different opinion on the subject of punishment, but once the therapeutic idea takes hold, justice is determined by experts who want to cure instead of punish. Both the retributive and utilitarian schools deviate with the traditional method of justice. To the ancient Greeks, judges healed the mind and physicians healed the body.

    There is something bothersome about the Sandy Hook incident. It is hard to believe than a 20 year old could mastermind this type of incident. There is no connection published so far. Another question arose whether Sandy Hook had a school access control system. If so, how did an armed assassin get past the door? If so, the gunman must have been able to present himself as an authoritative figure to get past the door. There is the possibility of a media cover-up or blackout.

    Although it is more to do with psychology than philosophy, it is fair to ask what actual type of person could do such a thing. The first thing to note is that since 2005 there have been a dozen different mass shootings at schools in America. Why schools? There are other easy targets with shopping malls, churches, sports arenas, and public transit. There must be something that would attract violence in a school. The pattern to suspect is someone who is involved closely with the school administration or someone involved with the municipal public services.

    What can philosophy offer about the problem?

    There is nothing new about propaganda. The technique was well described in Plato’s Republic Book II. Socrates’ ideal republic allows for limited personal freedoms and social mobility, is staunchly antidemocratic, and uses strict censorship and propaganda, to the extent of banishing all poets from the city. The description of the technique began with this:

    Socrates: Then the first thing will be to establish a censorship of the writers of fiction; give the censors tales of fiction which is good, and reject the bad; and we will desire mothers and teachers to tell their children only the authorized ones.

    School shootings were happening and laws were passed to try to prevent this, and school shootings are still happening. So what can be done? First, tell the truth about who is doing the shootings. If it is a public servant who works closely with the school boards, then say so. Such information would be far more valuable when trying to identify potential assassins rather than use highly questionable psycho-pathological shenanigans as an excuse for a political attack.

    The only place when truth and justice appear in the same phrase is the comic book Superman motto “a never-ending battle for truth and justice.” Are truth and justice possible in the real world? That is subject for another time.

  4. Anyone who has family members or friends with mental health issues can tell you that mental health is far from an exact science and that diagnostic criteria vary from psychiatrist to psychiatrist, depending on rapidly changing trends in labeling psychic problems (which are often not really illnesses) and on which drugs are in fashion and being promoted by the pharmaceutical industry.

    So I’d say that it would not be a good idea to rush to confine people with “potentially” dangerous mental health issues. There is also the possibility of abuse of medical power and of families trying to get rid of problematic members or those whose patrimonies and fortunes are juicy targets to administer for “sane” family members.

    That being said, the tragedy of Sandy Hook reminds us that free psychiatric care should be available for all members of society who feel that they need it.

  5. Lee Jamison,

    How many cases have occurred in which families sought intervention and the person did not engage in violence?

    As you note, there is an emphasis on drugs, perhaps because the facilities for treating or confining people were significantly reduced under Reagan in the US. The efficacy of such drugs seems somewhat unclear and they do often have severe side effects. Somewhat ironically, some drugs actually make people more likely to engage in harmful behavior.

  6. Dennis Sceviour,

    According to the media reports (which might be wrong) he physically shot his way into the school. While schools do often have secure doors and windows, they will only delay someone who is determined to break in and who has the tools to do so (in this case a .223 rifle and plenty of ammunition). Shotguns are often used by police forces to breech doors.

  7. http://www.guardian.co.uk/world/2012/dec/19/france-europe-news

    This is very interesting, given the op.

    French psychiatrist sentenced to one year in jail (suspended) for not warning about dangerous patient (future axe murderer).

  8. http://www.guardian.co.uk/world/2012/dec/19/fears-mad-axeman-murders-statistics

    The homicide rate in the U.K. has increased since the 1950’s, but the number of those committed by the mentally ill has remained constant, which indicates that the percentage of those committed by the mentally ill has decreased.

    Out of 100 persons with mental health issues with risk factors for committing violent crimes only one commits (known) violent crimes.

  9. One use of guns is to hunt, for food say, another it to resolve differences by killing (with the gun/s) the opposing person/persons. Often these differences do not differentiate between the innocent (non arm bearing) and non-innocent (opposing combatants). Slaughter of innocents is undertaken by people who are defending, or opposing a different group of people, whether it be for scarce resources, money, land, or hegemony of religious observance. When non combatans are slaughtered, we do not say (automatically) that those carrying out the slaughter have a mental illness. The Brevik case revolved around this issue, as Brevik wanted a guilty verdict, not a diminished responsibility – or more strongly – he did not know what he was doing. Now in terms of individuals we are enjoined to decide whether this person, or that person has a proclivity to violence, and pronounce them a danger to society and mentally “deranged”.We are not enjoined to decide, whether a society, tribe, etc. are a danger to their neighbours and (conjointly) mentally deranged because of this proclivity (or proclamation of their intention to anhiliate). We would then be saying that any ethnic cleansing, for example was strong evidence of mental derangement, rather than, evil, or intolerance.We tend to look for general causes, differences, history etc. I know there are exceptions, with leaders. History and social norms Poll Pot, the Killing fields, Vietnam etc., seem to excuse the individuals, but in a, on the whole, war free society, such slaughtering on an individual basis, is regarded as strong evidence of mental derangement.
    We then move to a need to identify such individuals prior to the acts which would strongly identify them as “pathologically” violent (or strongly psychopathic). Without an early and longitudinal study of every individual in that society, one would be likely to miss such individuals “emerging”, and as been noted by Mike la Bossiere, we might well wrongly diagnose.
    My own perspective on this is from mental health, where I worked in psychiatric nursing. I entered when the institutions were being abandoned for more enlightened and social care regimes. The old institutions were truly awful, with many people there who had no real diagnosis, but were a bit odd, or had been naughty. On the other hand, there were individuals who had committed acts of violence against others, either under the influence of some delusional state (psychosis), or were psychopaths. These individuals, were in secure units under strict supervision. Some were deemed fit to be released (again a slow mediated process).
    Now the early (and clear) identification of such individuals is fraught with problems of labeling and giving an identity to conform to – that is producing what is trying to be identified and “treated”. Now we tread the ground between strict causation and tendency. But it seems that unless we can say without doubt that we can diagnose a mental health path with some degree of accuracy, we cannot identify who will become the violent psychopath (will we distinguish them from someone who has violent outbursts, due to frustration or being abused as a child). This is not a matter of incarcerating those with certain tendencies to protect the rest of society. If we can only identify a possibility that is surely not sufficient to deny someone what is basically their life. If we do then the individual does not count, which is in effect what the ethnic cleanser says, as much as the “psychopathic” killer.

  10. There are number of problems here.

    Mental health services can generally not predict whether a patient will actually commit an act of violence. There is a wonderful quote, you can find in the 1966 Time magazine archive, from the psychiatrist of the University of Texas at that time. Charles Withman had attended the psychiatrist, and told him of his fantasy of climbing to the top of the university water tower and shooting people. The psychiatrist dismissed this as unimportant, as it was a common fantasy of the students of the University.

    Students under stress have fantasies of burning their universities down. Violent fantasies are not absolute indicators that the subject will enact those fantasies – or that they have serious mental health problems.

    The next problem. If a person is in a genuine crisis, and they are having violent fantasies, which they do feel a strong urge to enact, if they fear incarceration through divulging these fantasies to a mental health professional, they will not. They will go untreated and there will be a greater danger that they will carry out acts of violence.

    And onto a more complex problem. Who decides who is insane and a danger – and the nature of the danger they pose. Why are so many middle-class American teenagers being placed on psychiatric medications. Many teenagers are weird – this may pass or flower into fully fledged non-conformance (the conservative middle-class suburb is just not for everyone). Weird teenagers are very definitely not the kind of young people, old people like. Is suburban psychiatry being used as a tool to try force social conformance. I knew someone who was a weird teenager at the time of the Columbine shooting, they had a taste for strange clothes and strange music – at the behest of their school they found themselves incarcerated in private psychiatric facility, placed on powerful anti-psychotic drugs, and put through a “teen rehab”, which bore many similarities to the North Korean brainwashing of Sinatra’s Manchurian Candidate.

    And now onto the awful truth. The mentally ill have been demonised throughout history. Even today, in popular culture, ultimate evil is always depicted as the exclusive domain of the mentally ill. The axeman always has to be mad. This is a way society has of shielding itself – evil is given an alien otherness. Anders Breivik was not insane. Adolf Eichmann was not insane. Hannah Arendt’s banality of evil, is too terrifying and difficult to consume – instead mental health is chosen as a scape goat. The sins and crises of society are cast onto the goat, it is taken outside the town, and conveniently shoved over a cliff.

    Adam Lanza, in all likelihood was not insane. He was definitely in a crisis, but not pyschotic. His life may have been terrible. His Aspergers may have meant social, sexual, and economic exclusion. This may have meant he was trapped with a neurotic and paranoid mother – like Norman Bates, except Nancy Lanza was no hallucination. A nagging and controlling mother, with no possibility of escape, may have driven him to suicidal despair and rage at the world that excluded him and ignored him. When schizophrenics lash out, it is in terror and delusion – there is an incoherence to their violence. As one psychiatrist said of Breivik, a floridly psychotic schizophrenic would have difficulty operating a car let alone carrying out detailed plan.

    Is Lanza the product of a social crisis. Or that the psychic crisis is within suburbia itself. And Lanza may be an extreme expression of something that is more common – something that does not have the otherness of mental illness.

  11. JMRC,

    Good points.

    Sorting out the folks who are likely to do things from those who are not is rather challenging-especially before anything is done. It is not uncommon for people to say after some terrible event that the person who did it seemed “nice” or “normal” or perhaps “odd, but not violent.”

    One thing that is somewhat scary is to consider that the people who do such things were just like us and something happened, big or small, that took them someplace that we did not go. What if anyone of us could just go there one day?

  12. JMRC.
    I find your perceptions interesting but I feel that, from my experience, they are slightly off the point. I think we can agree on the demonisation of mental health patients and their violence. Few are violent and you are more likely to be attacked in the streets for your wallet.
    Fantasies of violence are common and usually symbolic and fleeting. Im not sure about the American mental health law on detaining someone,who expresses such a fantasy, but it is here, a little more open than a sure fire correlation between expressing a fantasy (or fear – more of concern, or a plan – more concerning still). Someone who has reached the plan stage is unlikely to approach anyone. I t is like someone who plans their suicide they don’t divulge it – it is their path of meaningful action for them. The idea that incarceration is automatic is incorrect (here in the UK). This of course is part of the public mythology of mental illness, that patients are violent and are incarcerated.

    One of the problems of psychiatric diagnosis is that it tries to assign a category, whereas there might be a number of problems – anxiety, depression, rather than “insanity”. Eye contact is important in an assessment, noticing whether they are making contact, or have some other inner “conversation”/evaluation going on. The “otherness” of mental illness, as you put it is here – the reflective isolation. Most mental health problems are not of that sort and even when they are it is often a matter of getting to know the person as a person, but this take time.
    Now one can be psychotic and insane, but not necessarily suffering from a raging chaotic terrifying schizophrenia -where they are God in the morning and a terrified child in the evening. These psychotic but not falling apart, will be the paranoid schizophrenics – the most difficult to treat – focused on the “threat”. Perhaps Brevik was more in that camp, or/and simply a psychopath.

    Finally lanza, who as you say was Aspergic. Aspergics are not psychopaths, they have difficult in reading other people and they have a delight in detail and order (like many academics). Yet they can also find the frustration of order too much and get somewhat aggressive.They can however get psychotic and have delusions, but in general suffer more from mood swings.I do not know about his social circumstances, but as you say he seemed to react to them, with disastrous consequences.

    I cannot understand a society with open gun access, that cannot comprehend that its citizens use these weapons to massacre each other occasionally. To react with the notion that we need to detect such people before they engage in such acts so we can then maintain this open access, is surely ignoring a fact about us all – that if our life is in danger we will fight to protect it – that may involve harming our assailant. The second point is that we may define threat in ways that turn out to be false, and for some delusional.Countries also do this as do individuals, as I suggested in my first post.

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