From the New York Times, February 20, 2018, by Amy Barnhorst:
SACRAMENTO — A few years ago, the police brought a 21-year-old man into the crisis unit where I work as an emergency psychiatrist. His parents had called the police after seeing postings on his Facebook page that praised the Columbine shooters, referred to imminent death and destruction at his community college and promised his own “Day of Retribution.” His brother reported to the police that he had recently purchased a gun.
When I interviewed the patient, he denied all of this. He had no history of mental illness and said he didn’t want or need any treatment. My job was to evaluate whether he met the criteria to be involuntarily admitted to a psychiatric hospital.
Each mass shooting reignites a debate about what causes this type of violence and how it can be prevented. Those who oppose further restrictions on gun ownership often set their sights on the mental health care system. Shouldn’t psychiatrists be able to identify as dangerous someone like Nikolas Cruz, the young man charged in the school shooting last week in Florida, who scared his classmates, hurt animals and left menacing online posts?
Mr. Cruz had suffered from depression and was getting counseling at one point. He was also evaluated by emergency mental health workers in 2016, but they decided not to hospitalize him. Why, some critics are demanding, didn’t he receive proper treatment? And can’t we just stop angry, unstable young men like him from buying firearms?
It’s much harder than it sounds.
The mental health system doesn’t identify most of these people because they don’t come in to get care. And even if they do, laws designed to preserve the civil liberties of people with mental illness place limits on what treatments can be imposed against a person’s will.
Here in California, as in most states, patients must be a danger to themselves or others because of mental illness before they can be involuntarily admitted to a psychiatric hospital.
This is a mechanism for getting people into treatment when they are too deep in the throes of their illness to understand that they need it. It allowed me to hospitalize a woman who tried to choke her mother because she was convinced her family had been replaced with impostors, and a man who had sent threatening letters to his boss because he believed she had implanted a microchip in his brain.
But the young man who had written about shooting his classmates was calm, cooperative and polite. The posts, he insisted, were nothing more than online braggadocio. He denied being suicidal or homicidal; he had never heard voices or gotten strange messages from the television. He admitted to having been bullied and was resentful of classmates who seemed to have more thriving social and romantic lives. But he adamantly denied he would be violent toward them.
What options did I have? It was clear to me that he did not have a psychiatric illness that would justify an involuntary hospitalization, but I was reluctant to release this man whose story echoed that of so many mass shooters.
I could fudge it a little, claiming to need more time for observation, and admit him to the hospital anyway. But within the week he would go before a hearing officer to contest being held against his will. The hearing officer would probably come to the same conclusion I had, that he was not dangerous because of a mental illness, and he would be free to go. The only advantage of this version of events would be that the order to release the man who might be the next mass shooter would not be signed with my pen.
Maybe the hearing officer would share my trepidation and commit him out of fear of the alternative. Then the hospital would have 14 more days to treat him.
The psychiatrist responsible for his care would know how to treat delusions, paranoia, mania, suicidal impulses, self-injurious behaviors, auditory hallucinations and catatonia. But there are no reliable cures for insecurity, resentment, entitlement and hatred.
The one concrete benefit of officially committing him would be that he could be prohibited from buying a gun from any federally licensed retailer. Of course, this would do nothing about any guns and ammunition he may already have amassed. Nor would it deter him from getting guns from private-party sales, which are exempt from background checks in many states.
I ended up admitting this patient, and he was released by the hearing officer two days later. He never took any medication, never reached the threshold for a federal firearm prohibition and left the hospital in the same state he arrived in. Like so many of his peers, he will not seek out therapy for the longstanding personality traits that seem to predispose him to violence and rage, and there is no way to impose treatment upon him.
The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence. Even if all potential mass shooters did get psychiatric care, there is no reliable cure for angry young men who harbor violent fantasies. And the laws intended to stop the mentally ill from buying guns are too narrow and easily sidestepped; people like Nikolas Cruz and my patient are unlikely to qualify.
Instead of hoping that imposing mental health treatment on everyone who shows “red flags” will put an end to mass shootings, we should focus on ways to put some distance between these young men and their guns.
Amy Barnhorst is the vice chairwoman of community psychiatry at the University of California, Davis.