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Monday 17 December 2012

Tragedy and Mental Health

In the wake of disasters such as Newtown, Columbine, Polytechnique Montreal, the Portland Mall, and others, the sequence of events has become depressingly predictable.

At the first reports of the events, the news trucks are scrambled as fast as the SWAT teams. Live feeds come in from the site, with excited reporters darting around for scraps of information. If the event is sufficiently “significant” - by which is meant a high enough death toll, the coverage goes into overdrive.

Driving around town doing errands this past Friday, a Canadian station punctuated one of its hourly news broadcasts with the dry observation that a US network had suspended all of its afternoon programming to focus exclusively on the event, just as it might do with the Superbowl.

In the course of the coverage we are treated to reporters scrounging for survivors and, in this case, worried parents, so that we can hear every detail of what they saw. If they saw nothing, they are asked how they feel, and this is reported as breaking news. The father of the shooter in this instance apparently found out from a reporter coming to his home for a reaction shot, and his response was duly recorded in story after story.

The script in these events calls for the shooter or shooters to be identified and then turned into celebrities. Their names and photographs are repeated over and over again until everyone on the street remembers them. In the Newtown tragedy a scrap of blurry archival video showing the boy from the rear was played repeatedly. Or so I’m told. If they were bullied or otherwise felt wronged, their grievances are aired publicly for the entire world to hear. Osama bin Laden himself couldn't get his point of view so widely disseminated.

The possibility that the quest for fame and media coverage may be among the causal factors in these incidents is studiously avoided – although that too would be dissected by the media if they could find their way around the irony.

Next in the sequence is the enlisting of mental health professionals to offer their opinions about an individual they have never met and about whom they know nothing. They pick their way gingerly around the issue, carefully avoiding direct statements that may later be refuted. These are typically given no more than five minutes on screen, as the appearance is an exercise in saying nothing.

The focus then widens. The possibility that the widespread availability of guns may be a problem is briefly considered. As one currently-viral facebook post puts it, “One failed attempt at a shoe bomb and we all take our shoes off at the airport. Thirty-one school shootings since Columbine and no change in our regulation of guns.”

Not entirely true, of course, at least in Canada. Our government has taken decisive action – responding to a badly-implemented gun registration law by cancelling the program altogether and shredding the information they spent millions to collect.

Politics is the art of the possible – you have to respond to moments of opportunity when they arise. So maybe it is not surprising that various groups seize upon tragedies like this to push their agendas.

One of the scripts, which scarcely needs dusting off as it is brought out so regularly, is the need for increased funding for mental health services. Given what I’m about to say, let me be clear: I do think that mental health services are poorly funded in most countries, and what funds are available are even more poorly managed. Let’s take that as a given.

The assumption, however, is that increased mental health funding will result in lower rates of school shootings and other mass killings. With better funding would come better screening of the population. Individuals at risk of perpetrating events such as these would be identified. Treatment would ensue, and tragic outcomes would be averted. The rate of mass killings would decline.

All of this is possible. But I am not aware of any evidence that any of these assumptions is true. If you survey mental health clinicians, many believe these ideas, and they may well be right. Certainly there is little reluctance for anyone to express these beliefs in the media.

What we seldom hear is the converse opinion, which is also held by many people.

Imagine a world in which the funding for mental health programs is doubled or trebled.  My own belief is that this would not have any significant impact on the incidence of mass killings.

That may not be a popular idea, and so I suppose I should have strong evidence to back it up. I don’t. In the absence of clear evidence, it is merely an opinion – just as the belief that an army of clinicians could reduce mass killing is an opinion.

I’m not alone in holding this idea, and others have doubtless thought it through better than I have. But here’s my reasoning, such as it is:

With better funding would come better screening of the population. Cadres of new clinicians would have to go looking for clients, and we would institute mass screening of students, disaffected employees, and other citizens. This seems both unlikely and undesirable. I strongly doubt that improved mental health funding would result in more community screening, and if it did there would be an outcry.

Individuals at risk of perpetrating events such as these would be identified. The common refrain after events like these is “he was such a nice, quiet boy; I would never have imagined him doing something like this.” This from friends, family, and neighbours. Later it often emerges that there were signs from facebook postings or other online activity. Mental health workers have no magical ability to divine dangerousness, and have access to considerably less information about the people they see than the person’s own family. We might be able to identify people at somewhat higher risk of perpetrating mass murder by looking at specific variables – like the fact that someone happens to be male – but the resulting number of false positives would make this pointless.

Treatment would ensue. Mental health treatment is almost always voluntary. Most perpetrators do not seem to have seen themselves as mentally ill and so would probably not seek out or cooperate with treatment. The very hostility of their acts suggests a belief that the problem lies outside themselves and that they are justified in their rage. As well, the perpetrators usually seem to be middle-class individuals who would already have access to the mental health system if they chose to seek it out (there may be data on this point, and perhaps data that contradict this observation, but mass shooting does not usually seem to be a crime of the impoverished).

Tragic outcomes would be averted. If treatment was provided, the risk of offending would be eliminated, or at least much lowered. This might be true, though there is scant evidence in support. One argument against is the number of instances in which perpetrators (such as the accused in the Aurora theater shooting) were already in some form of treatment. There is a problem with this, obviously: deeply troubled young men are more likely to be in treatment anyway, and perhaps treatment reduces their likelihood of offending without, unfortunately, eliminating it. But we would still need evidence to claim decisively that mental health services reduce risk at all.

So if we can’t troll through the population, if we can’t really identify risk very well, and we can’t control risk should it be found, it’s hard to see how increased mental health funding will eliminate school shootings.

A colleague of mine once observed that mental health clinicians are the ones who chase after the horse after the barn door has been left open. By this reasoning, we would be no more likely to reduce the incidence of shootings than by increasing the number of emergency trauma surgeons.

Why bother making this point? In times of tragedy, it’s always tempting to go for the easy answers. Let’s just increase mental health funding. And mental health clinicians, all too aware of the gaps in service, are reluctant to contradict anything that might result in a more comprehensive and well-funded system.

But this particular problem may not be caused by the lack of mental health care – not much, at any rate. The real culprits almost certainly lie elsewhere: the availability of guns, the aggrandizement of violence in media and its actual practice in the artificial world of video games, a cultural sense of entitlement and rage. And an obsession with celebrity causing some to seek it in the only way a young, talentless male can manage: by destroying the lives of others. A method that is based not on distortion but on an accurate perception of the consequences of amassing a high body count.

Inevitably, I can be criticized on the same grounds as anyone else who spouts off, sans information, in a public forum. What makes me think I know any more than anyone else? I don't. This is just one more of an avalanche of blog posts by people far removed from the circumstances. The irony isn't lost on me. But frustration makes me point, as others are doing now, at one of the many likely culprits. So let's lighten it up with a quiz question.

Quick, name these celebrities:

  • The perpetrator of the Newtown tragedy.
  • The Aurora theater killer.
  • The Columbine boys.
  • The Norwegian extremist who killed teens at an island campout.
  • The Montreal Polytechnique shooter.

I won’t reveal the answers, because they have been elevated to the public consciousness more than enough.

But if you came up with any of their names, try Part 2: Name one, just one, of their victims.


  1. The post touches on some good points about the typical response that happens after a mass shooting particularly the media focus. My criticism of the post would be the main argument suggests a binary (its either or framework) in terms of the causes of mass shootings and violence. For instance, either the events are the result of mental health issues or the result of other factors such as the availability of guns, the aggrandizement of violence in media and a cultural sense of entitlement, rage and an obsession with celebrity. Violence is complex, unpredictable and related to a multitude of risk factors that all come into play. In addition, violence can be managed if it is properly assessed, managed and identified.

    The approach that we take in threat assessment field is you can not predict violence so the focus should be on preventing violence by assessing and managing risk factors through structure professional judgement (use of framework in assessment and management). Unfortunately, many in the mental health field are not trained in this approach and rely on professional judgement (training, intuition, skills). This type of approach has been shown to be far less effective at preventing violence than structured professional judgement. Hence, I agree and disagree with the author if we fund more mental health services and the predominant approach is professional judgement than yes nothing will change. However, if more mental health professionals are trained in structured professional judgment approaches than I believe acts of violence like in Connecticut can be prevented.

  2. I have been concerned about this drum beat as well. It is a simplistic view as to a fix to this problem. Some do not seek treatment or believe they need it and if it becomes even more of a stigma they will not. A screening can only do so much. It is not always lack of access to treatment either. Though that is a problem for many for the shooters not so. This last one the family was well off, Aurora he had been in treatment, Columbine Harris was on meds. It is the guns that make it the problem. No access to these type of guns then the tragdies won't be of this caliber. Thank you for saying what I have been thinking.