What She Left Behind by Ellen Marie Wiseman (Book Review)

Screen Shot 2016-01-12 at 10.53.06 PMWhat She Left Behind

By Ellen Marie Wiseman

This book is composed of two interweaving stories. Clara, a woman who lived in the 1930s was committed to a mental institution against her will based on her wealthy father’s unhappiness about her Italian immigrant boyfriend and her refusal to marry the rich guy that her father picked out for her. The other story is about a current day teenager named Izzy who is a foster child of Peg and Harry after having lived with several previous foster parents since her mother unexplainably murdered her father. Peg is working on a museum project examining newly discovered suitcases of belongings of former patients (including those of Clara) of a now closed psychiatric facility, in order to gain some understanding of their lives. Izzy helps out with this project and finds the diary of Clara and becomes interested in her life.

Being a psychiatrist, I was initially drawn to this book with the idea that I would gain some insight into the lives and treatments of psychiatric patients living in the first half of the twentieth century. This was the case and it included vivid description of the treatment that was done at that time such as ice baths, insulin shock therapy and electroconvulsive therapy (ECT).

Although I never worked in a state hospital, when I toured them in the late 1960s, such treatments except occasional ECT under humane conditions were things of the past. As far as the possibility of someone spending most of their life committed to a mental institution based on the word of her father when she clearly did not have a mental illness, I would like to think that this would not have been possible. Certainly, in modern times from my experience someone being hospitalized against their will would have to go through a legal hearing with the patient being assigned an attorney if they don’t have one. Once in a hospital with treatment with modern-day medicines (which were not really available until the 1950s) most mental illness can be put at least in temporary remission with such treatment. Today, there would be reviews by multiple doctors with no mandate to keep the person in the hospital against their will unless they were a danger to themselves or others due to a mental illness. I would hope that nothing like Clara’s situation could occur today. Obviously, I can’t speak for every state hospital in the United States and certainly things were different in the 1930s.

There was another aspect of Clara’s case was particularly disturbing to me in that the psychiatrist in charge of her care was depicted as a mean, cruel, selfish man who was mainly responsible for Clara’s lost life. I felt it was an unfair indictment, which suggested all psychiatrists of that time might have been of the same cloth. I understand that the author has the creative choice to develop characters in whatever fashion she chooses. I probably would not be complaining if the character were a dishonest lawyer who did unsavory things in the interest of an interesting storyline but nevertheless, I felt that this book was stigmatizing my profession.

There was particular theme of this book, which also had a special interest to me. Three characters in the book were driven to try to understand their early origins. Izzy, understandably could not fathom why her beloved mother murdered her father. This ultimately led her to empathize with a schoolmate who had some parental trauma. It contributed to her mission to find Clara’s daughter who was essentially separated from her at birth, and hand over her mother’s diaries so she could know about her mother’s story. Clara’s daughter led a life of yearning to know what happened to her mother and Clara similarly went through life wanting to know what happened to her daughter. This is a variation of a theme, which I have seen played out in many people’s lives as well as in some interesting movies. Persons, sometimes separated at birth or when they are quite young often yearn to know their biological parent or parents with whom they may have had no relationship for decades. I have reflected on the psychodynamics of these issues in an earlier posting in this blog. Therefore, I was particularly interested to see how they played out as major motivating factors in the characters in this book.

I believe the author Ellen Wiseman has created an intriguing story that will hold the interest of the reader whether or not you come from a psychiatric background.

 

A Common Struggle: A Personal Journey through the Past and Future Mental Illness and Addiction By: Patrick J. Kennedy and Stephen Fried ( Book Review by Dr. Blumenfield)

Screen Shot 2015-11-18 at 6.27.58 PMA Common Struggle: A Personal Journey through the Past and Future Mental Illness and Addiction   By: Patrick J. Kennedy and Stephen Fried

This is a story, told in the first person of Patrick J. Kennedy. It is really two stories presented to us simultaneously. It is about Patrick Kennedy, son of Edward Kennedy and nephew of JFK and Bobby Kennedy. He has been a US congressman from Rhode Island for eight terms and was one of the staunch advocates for parity legislation, for mental illness, and addiction. Yet at the same time that he was leading the fight in the United States Congress to bring about these major changes in our healthcare system, he himself was secretly battling mental illness and addiction.

An important part of his personal story was a discussion of alcoholism in his family. Not only was the author an alcoholic but his brother, mother, and father, Ted Kennedy also struggled with this condition. It is significant that all of them except his father ultimately recognized their problem and entered various programs to help themselves. His mother battled alcoholism for a prolonged period of time and yet her condition was not recognized by family members despite the fact that they knew about several hospitalizations and treatment programs that she had undergone.

One of the most revealing insights about his father that he revealed in this book is how Ted Kennedy was traumatized by the tragic death of his three brothers, JFK, Bobby Kennedy, and his oldest brother, Joe Jr., who was killed in World War II. An additional major trauma for Ted Kennedy was the death of the young woman in Chappaquiddick, an incident well covered by the press.

It was not a simple pathway for the author to recognize his own problems. Even after a period of therapy with Psychiatrist Peter Kramer, author of the well known book (Listening to Prozac). Kennedy felt this treatment was helpful but did not eliminate his addiction problem or allow full acceptance of his bipolar condition. He vividly described how he would convince himself that he didn’t have any problems if he didn’t drink in public or take “illegal” drugs.

Patrick Kennedy served in the Rhode Island legislature and was elected as the youngest member of the US Congress in 2004 during a period that his addiction and mental illness was hidden from the public. It was also pretty much hidden from himself.

His colleagues in the US Congress ultimately became aware of his attempts to hide his drinking problem. Kennedy describes an important event for him when in 1996, Minority Leader, Dick Gephardt, offered him the prestigious chairmanship of the Congressional Campaign Committee on the condition that he stop drinking. This made him realize how he was denying that he had a problem that was known to others.

It wasn’t until 2005 that he publicly admitted that he was suffering from a mood disorder that was being treated by a psychiatrist. While his own struggle continued, he became more effective in his advocacy in the US Congress. One misconception he believed had to be clarified concerned Nancy Reagan’s “Just Say No” campaign against drugs. He felt that this missed the main point that addiction is not something you can simply say no to, just as you can’t say no to cancer. It is a disease and by implying you can just say no stigmatized people who have the genetic propensity to have this disease.

As much as the story of Kennedy’s recognition of his own illness of addiction and mental disease and how he battled it is quite enlightening, the battle for a definitive bill in the US Congress is just as revealing.

The events leading up to the 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act are quite interesting and complicated. They are also quite personal to Patrick Kennedy. It took place at the time that he was relapsing to alcohol and painkillers and also was having an exacerbation of his bipolar condition. While Patrick Kennedy was one of the leading champions in the House of Representatives for this legislation, his father, Ted Kennedy, was a major supporter of this bill in the US Senate. This was also at a time that the senior Kennedy was dying of a brain tumor. Compromises had to be made in the bill and the Senate was reluctant for the legislation to be as comprehensive in various aspects and details of the bill as was wanted by the House of Representatives. There also was a question how the legislation would deal with the new surge of mental health problems occurring in soldiers returning from the war. There was a concern that it should cover PTSD as well as addiction in the returning servicemen. Patrick Kennedy described the dramatic moment that his dying father came to the senate floor to vote for the final version of the bill to the applause of the US Senate.

Even with the passage of this extraordinary legislation, the battle for adequate parity for healthcare support was far from over. The proof and the success of this landmark bill would depend on the implementation by the federal and state governments and certain local rulings are expected to eventually reach the Supreme Court. The 2016 presidential race can certainly also be expected to impact the success of implementation of this legislation. As of this writing, it appears that the Republican candidates may be reluctant to support the implementation of this legislation and provide funding for new programs.

Patrick Kennedy decided to leave the United States Congress in 2010. Since departing from Congress, he has continued to be a leading advocate to bring about implementation of the 2008 legislation for mental illness and addiction. In this regard, among many other things, he has worked with two important organizations in which he plays very active roles. The Kennedy Forum (kennedyforum.org) gathers experts in mental health and addiction and holds important conferences that they hope will ensure implementation of the 2008 legislation. They are also committed to promoting a translation of neuroscience into the preventative and treatment interventions for mental health and addiction. The second organization in which Patrick Kennedy is involved is One Mind (onemind.org), which is dedicated to the promotion and support of “brain health” and creating a fast track for treatment. Their current focus is on new approaches to treat and cure PTSD but they look forward to applying solutions for all brain disease including depression, Parkinsons, ALS, dementia, Alzheimer’s disease, and addictions.

Patrick Kennedy does not bemoan problems. He is clearly a man not only with a vision but with plans and solutions. He concluded his book with a scorecard of how we should rate our public officials who have the opportunity to pass legislation and make changes. Also at the end of the book, he had a section for people who are dealing with their own mental illness and addiction. He tells them not to be alone in this struggle and how important it is to get treatment. Finally, sandwiched in this book was a series of photographs of many well known members of his family. It brought back many memories to this reader of the great accomplishments of many members of the Kennedy family and of the tragic events that they experienced.

It should be noted that at the time that Patrick Kennedy wrote this book, he was three and a half years sober. He has shown that he is a very accomplished and insightful man. I believe we are going to hear a great deal about him in his advocacy. He has provided in this book a valuable historical account of the reasons to fight for the proper care of mental illness and addiction. I am sure he has a bright future and many people will benefit by his skills and his passion.

 

Role of Psychiatrist or Other Mental Health Therapist With Patients Who Have Thoughts of Killing Themselves and/or Someone Else.

Screen Shot 2015-04-16 at 2.48.39 PMAs details emerge various news stories of terrorism, and murder/suicide events, there are important questions being raised about how should a mental health therapist approach patients who may have the potential for violence towards themselves or others.

I would suggest that the following questions should be considered.

  1. What should a psychiatrist or another mental health therapist do when a patient says that they have had thoughts about killing themselves in a violent manner that could injure other people? Would the response be different if the self-destruction was only directed towards themselves in a non-violent manner such as taking an overdose as compared to potentially hurting other people as well? Should there be a different response to the above question if the patient is a school teacher, a bus driver, an airline pilot, or a scientist who works with Ebola?
  2. If a therapist knows that a patient has been suicidal in the past but is not so at present with therapy and medication, should the therapist be obligated to inform the patient’s employer if the job is a critical one such as those described above? Also, how we do factor in the fact that depression can be a recurrent condition?
  3. What are the possible consequences  if therapists were mandated to report patients who have had suicidal thoughts or violent fantasies?

General Discussion

Screen Shot 2015-04-16 at 7.25.57 PMJust having fleeting suicidal thoughts does not make someone a risk for hurting themselves. Similarly, having an angry murderous thought toward someone who you might resent does not make you a potential killer. There are many factors which a clinician must consider in evaluating the suicidal and danger potential of a patient. Is the patient psychotic? Is the patient having a severe depression which might include not sleeping or eating, crying, losing weight, etc ? Has the person acted on impulses in the past? Is there a history of violence towards self or others? Does the therapist and the patient feel comfortable that the patient would talk to the therapist if he or she felt that the feelings were intensifying? Does the patient have an immediate means to violence, such as access to a gun? Are there family members who can help monitor the patient in between sessions? These and many other factors enter into the evaluation of the seriousness of the threat that the patient may have to themselves or others. This is tricky business, but mental health professionals do it all the time.

The overwhelming majority of people with mental illness are not dangerous to themselves or other people. It should also be noted that mental health therapists do not have a sure method of predicting dangerous behavior in the future. We may be good in retrospect at explaining behavior and actions as the result of psychological factors (called psychic determinism), but we cannot claim the ability to predict behavior with great accuracy. We know a great deal about various forms of mental illness such as  schizophrenia where there is a break with reality. In most of these situations, the diagnosis is quite clear. Depression affects a very large number of people. There is a wide range of etiological factors of depression from grieving and situations involving loss and disappointment to biological types of major depression which can come on without any particular relationship to a loss or disappointment. There are also can be variations of mood such as bipolar or major depression which can even be at a psychotic level.Screen Shot 2015-04-17 at 12.50.56 PM

Suicidal thoughts often accompany various forms of depression. There can be passive thoughts such as a person who does not care about anything and might not want to eat or drink or take care of themselves. In such situations, a person frequently expresses the idea that they do not care if they wake up or not. Sometimes, persons may act suicidal or make suicidal threats or even try to hurt themselves as part of “cry for help.” In other words, the main thought of such person would be a desire to be stopped and given help. This doesn’t mean that they might not actually seriously hurt themselves.

People can become depressed to the point where they feel they cannot tolerate life or may feel worthless and that they do not deserve to live. Such a person might choose a suicidal method that would be more likely to be fatal. In some situations, this person, is intent on making a statement to someone else in their life, and they would want their suicide to have an impact on a family member or someone close to them. Sometimes, tremendous anger at themselves or others is part of the motivation for suicidal thinking.

Screen Shot 2015-04-16 at 2.51.07 PMAs it is well-known by police, some suicides are connected with a murder of someone else, usually a person well-known to the perpetrator. This may frequently be a family member or someone where there is an intense conflictual relationship. Sometimes, the suicide and the murder of the other person may involve a work situation such as a boss or a co-worker. The circumstances of someone being fired or humiliated at work or school might fit in to this category. These are not common, but they do happen.Screen Shot 2015-04-16 at 2.50.44 PM

This brings us to the situation of a suicide and multiple or mass murders. While such situations are extremely rare, they become very well publicized and well remembered. Sometimes they become examples for copycat acts by someone else. Limited research upon this group suggests that major depression is frequently present in the person who carries out this act. Also anger and rage and the feeling of being wronged may be present. There also may be some grandiose or narcissistic feelings where the perpetrator wants to become famous or remembered. While alcohol and drugs can always be a factor as it can loosen up one’s conscience and any inhibitions, it is not always present in this particular type of suicide connected with mass murder, since it often takes careful planning and requires a clear mind to carry them out. In retrospect, a study of each of these cases usually reveals particular stresses, rejection, and usually tremendous anger.

Can a therapist see the makings of a potential catastrophe and do something to prevent it? The answer is yes, we do that all the time when we work with people who have suicidal thoughts, but we can’t do it every time. Treatment works! But not all the time. There are many people who have experienced severe depression even with suicidal thoughts and even may have made a suicidal attempt and then recovered with treatment. Treatment can be psychotherapy, medication, or both. This is the reason that therapy has to be available, and a person should be able to enter the therapy and feel secure that they can express all their thoughts in a safe environment

But what if the therapist concludes at some point in the treatment that the patient is an immediate serious threat to themselves or someone else? At that point, there is an obligation for the therapist to hospitalize the patient. Hopefully, the patient would agree to such hospitalization. But even if the patient does not agree, there is a procedure (that varies from state to state) in which patients can be hospitalized against their will. In the State of California, it is called a “5150”, and if necessary, the police will assist a therapist based on the information provided from the mental health professional to take the patient  to the hospital. Then at the hospital, based on the information provided by the therapist and any family or friends available plus another evaluation by a mental health professional at the hospital, a patient can be legally hospitalized against his or her will. Then there can be subsequent legal proceedings to extend this hospitalization.Now, you may ask isn’t this breaking the confidentiality of the doctor-patient relationship? Yes of course it is, but this is obviously in the patient’s best interest. On occasion, during the course of therapy, the patient will ask me, “Is everything we say in therapy confidential?” I would reply, “Yes, unless I feel you were a true danger to yourself or someone else, and then I would act accordingly.”

Screen Shot 2015-04-16 at 2.47.41 PMThere is another situation to consider. What if the therapist becomes aware that the patient is seriously suicidal and/or a danger to someone else but they are not in present in the therapist’s office? Perhaps, they have left a message for the therapist or they do not show up for an appointment and the family described some behavior that the therapist understands means a danger situation to the patient or someone else. In such a case, the therapist is obligated to notify the police and have them attempt to find the patient and institute a “5150” based on the information that the therapist has provided. In California, the law further mandates that if the therapist feels that there is a clear danger to someone else , and the therapist knows who that person is, the therapist has to act according to the Tarasoff case. The Tarasoff case involved a situation at the University of California where a therapist knew that the patient would attempt to hurt another person. As a result of this case, in California, if a therapist believes that another person is in danger, the therapist must notify that person or be sure that that person has been informed by the police. Every effort must be made to contact the person who is believed to be in danger. So therefore, reflect on the thought, what if the therapist is treating an airline pilot and the therapist came to believe that the pilot who was not available to be brought to the hospital but might be flying a plane which he could be planning to  crash as part of a suicide murder. According to the Tarasoff precedent, the therapist would be obligated not only to notify the police and try to hospitalize the patient, but would also be obligated to be sure the airline was notified of the potential danger.

So now let’s return to the three questions which I raised at the beginning of this article.

My answers would be as follows:

  1. If the therapist believes that the patient is a serious threat to hurt themselves or someone else, he or she should act in a responsible manner to hospitalize the patient as soon as possible, even if this hospitalization has to be done on an involuntary basis. In California, if the patient has identified a threat to another person, every effort should be made to notify that person of the threat (in other states, there may be variation of this expectation). I believe the responsibility of the therapist is the same no matter what kind of work responsibility or employment the patient may have.
  2. If the therapist knows that the patient has been suicidal in the past but is not a suicidal threat to themselves or any danger to anybody else at the present time, the therapist is not obligated to inform the employer even if the job is a critical one, such as an airline pilot or a scientist working with dangerous bacteria, etc. The fact that depression is a recurrent condition does not change my opinion on this issue. An employer can make a decision that people with a history of epilepsy, or heart disease, or depression or suicidal ideation, should not work in critical positions. I would not necessarily agree with this position, but an employer certainly could make such a policy. Also, if a therapist is requested by his or her patient to provide information to an employer, the therapist should do that in a truthful manner.
  3. If therapists were mandated to report patients who have suicidal thoughts or violent fantasies, this would create a situation where people who had emotional conditions that might on occasion bring up suicidal thoughts or fantasies of violence would be quite reluctant to seek help. Therefore, people who would benefit by treatment would not be receiving it and I believe this would create, overall, a more dangerous situation.

Disclaimer

I am not an attorney nor do I claim expertise in legal issues which often differ from state to state. I also am not necessarily reflecting the ethical position of the American Psychiatric Association or other professional organizations. I am writing as one experienced psychiatrist who has confronted variations of these questions in clinical practice and has discussed such issues with my colleagues, mentors and students over the years.

I would also recommend a recent article in the New York Times by Erica Goode dated April 9, 2015 titled, “The Mind of Those Who Kill, and Kill Themselves.”

Dr. Blumenfield is the Sidney Frank Distinguished Professor Emeritus at New York Medical College. He currently is in private practice in Woodland Hills, California. For more information about Dr. Blumenfield go to  http://mblumenfieldmd.com/

 

How Should Treatment For Mental Illness Prevent You From Owning A Gun?

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IMPORTANT ADDENDUM: Please see link to an important statement about this topic at the end of the blog

I personally favor strict gun control laws. I also believe that that there should not be stigma against people with mental illness. People should be able to see a mental health professional with the confidence that their treatment will be confidential. The exception to this latter point is when the mental health professional believes that the person is  a danger to themselves or someone else, the mental health professional is obligated to act and notify police if indicated and/or hospitalize the patient. This obligation should not be a secret to the patient and anyone seeing a therapist should understand that would be  the appropriate and ethical behavior to be followed in those circumstances.

There may very well be a conflict in the first sentence in the above paragraph and the statements which follow. My thinking about this subject was stimulated by a recent op-ed piece in the NY Times  by Ms. Wendy Burton a former political speech writer titled “Please Take Away My Right to a  Gun” . Ms Burton argues although she might be tempted to get a gun for self protection she also realizes that her depression condition would make her more likely to use it against herself.

She quotes statistics from the Center for Disease Control and Prevention that 38,364 Americans committed suicide in 2010 and 19,392 used a gun.

Federal Law Concerning Mental Illness and Right to Own a Gun

Possession of a firearm by the mentally ill is regulated by both state and federal laws.  The federal law  states “ It is unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person “has been adjudicated as a mental defective or has been committed to any mental institution.” Mentally defective is obviously an outdated term and I am guessing that would probably be interpreted to mean mentally disabled. (meaning low IQ or significant brain damages etc ). I assume that the term “committed“ to a mental institution means some type of  legal involuntary hospitalization. However, I believe that in some states  a person can sign themselves in to a hospital  and be considered to be “committed” and can be held against their will for a certain period of time even if they change their mind and wish to leave. If a person is held in a mental hospital against their will but then is released by a judge  or by another or more senior doctor after the circumstances are clarified, is that person considered to be committed?

What about a person who voluntarily  enters a mental hospital to be treated for a mental condition completly unrelated to any potential violence. For example hospitalization for anorexia, incapacitating obsessive compulsive disorder, addiction to pain medication prescribed by doctors etc. In fact if the condition was such that the person couldn’t care for themselves, they might have even been admitted on an involuntary basis (“ committed “).

imagesState Laws Concerning Mental Illness and Right to Own a Gun

Now I wondered about the wording of the various state laws. I went to the NCSL-National Conference of State Legislatures  website . All I can say is that it is quite a mixed bag on this subject. My state of California says the following :

A person is barred from possessing, purchasing, receiving, attempting to purchase or receive, or having control or custody of any firearms if the person:

  • Has been admitted to a facility and is receiving in-patient treatment for a mental illness and the attending mental health professional opines that the patient is a danger to self or others. This prohibition applies even if the person has consented to the treatment, although the prohibition ends as soon as the patient is discharged from the facility;
  • Has been adjudicated to be a danger to others as a result of a mental disorder or mental illness or has been adjudicated to be a mentally disordered sex offender. This prohibition does not apply, however, if the court of adjudication issues, upon the individual’s release from treatment or at a later date, a certificate stating that the person may possess a firearm without endangering others;
  • Has been found not guilty by reason of insanity of enumerated violent felonies. A person who is found not guilty by reason of insanity of other crimes is barred from possessing firearms unless a court finds that the person has recovered his or her sanity;
  • Has been found mentally incompetent to stand trial, unless there is a subsequent finding that the person has become competent;
  • Is currently under a court-ordered conservatorship because he or she is gravely disabled as a result of a mental disorder or impaired by chronic alcoholism

Oklahoma law briefly  states : Oklahoma prohibits knowingly transferring a firearm to:

  • A mentally or emotionally unbalanced person.

images-2Texas goes into a great deal of detail :

A person is ineligible for a license to carry a concealed weapon if the person:
(1)  has been diagnosed by a licensed physician as suffering from a psychiatric disorder or condition that causes or is likely to cause substantial impairment in judgment, mood, perception, impulse control, or intellectual ability;
(2)  suffers from a psychiatric disorder or condition described by Subdivision (1) that: (A) is in remission but is reasonably likely to redevelop at a future time; or (B) requires continuous medical treatment to avoid redevelopment;
(3)  has been diagnosed by a licensed physician, determined by a review board or similar authority, or declared by a court to be incompetent to manage the person’s own affairs; or
(4)  has entered in a criminal proceeding a plea of not guilty by reason of insanity.

The following constitutes evidence that a person has a psychiatric disorder or condition described by section (1), above:
(1)  involuntary psychiatric hospitalization;
(2)  psychiatric hospitalization;
(3)  inpatient or residential substance abuse treatment in the preceding five-year period;
(4)  diagnosis in the preceding five-year period by a licensed physician that the person is dependent on alcohol, a controlled substance, or a similar substance; or
(5)  diagnosis at any time by a licensed physician that the person suffers or has suffered from a psychiatric disorder or condition consisting of or relating to:
(A)  schizophrenia or delusional disorder;
(B)  bipolar disorder;
(C)  chronic dementia, whether caused by illness, brain defect, or brain injury;
(D)  dissociative identity disorder;
(E)  intermittent explosive disorder; or
(F)  antisocial personality disorder.

The other states vary greatly. Take a look at that link .

Of course the big question might be how is this information determined.

Hospital Records, Gigantic Database or Honor System?images-3

Will the information used to prevent someone from getting a gun permit  come off of insurance records, Medicaid, Medicare forms etc? Will there be a gigantic database of all mental health treatment? Or will this just be the honor system of the person applying for a gun permit? What will happen if someone reports to the  government that they know so and so was treated for a mental condition by such and such doctor or hospital and shouldn’t have a  gun permit? Will mental health professionals  have to release their records or  have to testify about their non- hospital treatment? Will there be any obligation if  a therapist learns in the course of therapy that a patient is applying for a gun permit but actually doesn’t meet the criteria of the state or perhaps of  some new all encompassing federal law??

Let’s Have a Dialog About This Subject

Now is the time for mental health professionals to join in the dialog that this country is going through. Let’ start it here. There are about 15,000 viewers /week on this blog according to the statistics which I get from word press but you are usually exceedingly reticent to send in comments. Perhaps this subject can be the exception. It may be very helpful to mental health professionals and patients if we participate in this national discussion. Please click on the comments button and let’s hear your thoughts on this subject. What should the law be concerning mental illness and the right to own a gun and how should such a law be worded? I also encourage readers outside the United States give us your viewpoint.

ADDENDUM: I was very pleased to see a recent letter by Dilip Jeste, M.D.President of the American Psychiatric Association which makes some very important points on this subject. Click here for the link Jeste_cropped

 

 

 

 

 

Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.