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.

 

Discussion of Patient Who Heard Neighbor Say He Put Someone to Sleep

The following is the second case originally presented in this blog several weeks ago for comments. Included are two invited comments and any further comments from the readers are welcome

Case #2

A senior psychoanalyst  is supervising a junior colleague who is treating the  following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor  have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

Response from invited discussant Sheldon Frank. M.D.  Dr. Frank is a child and adult psychiatrist practicing in South Florida.

The implications from this patient’s statement about her neighbor are not clear. Legally, there doesn’t appear to be enough factual information to warrant any kind of report by the therapist. Therapeutically, it is warranted that the anxiety around the interchange be brought up to the patient for examination / reaction on her part. The result could be, for instance more (or less) of a hint by the neighbor as to possible criminal activities and/or plans; and perhaps  even a conflict within the patient as to whether she needs to contact the authorities.

 

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

The patient’s recounting of her male neighbor’s comment is basically heresay, and therefore does not warrant her or the supervisor’s obligation to report it to the police.  However, the issue may connect with her distrust and fear of men. It certainly invites further exploration in regard to her father’s insensitivity and untrustworthy behavior. One might wonder whether her father was ever physically abusive toward her or her mother. If so, possible fantasies of being injured or killed by a man should be explored. I would also pay attention to dream material involving aggression by men. If the therapist is male, one would expect manifestations of a negative transference at this stage of treatment.

 Other comments received about this case :

 It seems quite clear that the patient has been told about a murder. If the therapist is denying this, he or she will not be able to understand any conflicts that the patient has in dealing with this information. Learning about a serious crime by a person who is likely to commit other such crimes does ethically obligate the therapist and the patient to notify the authorities. If you hesitate in doing this, is it because of the nature of the murder.? If it were immediately after 9/11 and the neighbor indicated that he was involved in the planning of that crime, would that push the therapist and the patient to action ? Does the ethical rule apply only to multiple murders? Of course, notifying the authorities could endanger the life of the patient and the therapist (and maybe even the supervisor) . Even if the information was given anonymously to the police, once they started investigating the neighbor, the hit man and his boss could soon figure out the only person who was told about the “putting to sleep” was the therapist. He or she could be eliminated or “made to talk ” and tell that the the other person that was told was the supervisor .  Then they both could be put to sleep.  So maybe it is best to just deal with the therapeutic implications of this interchange between the neighbor and the patient  as well as the interchange between the patient  and the therapist.  It must be significant that the patient and her father shared a big secret (that of the father’s affairs). Now circumstances have occurred where the patient and the therapist are sharing a special secret . Understanding this may move the therapy forward in a productive manner.  Dr. A (name withheld by request )

Comments are welcome in the comment section below and will be added to this blog.

Nazi Extermination of Mental Illness

IIn 1922 Alfred Hoche a German psychiatrist co-authored a document demanding the extermination of persons he believed were a burden to society. In 1933 Adolph Hitler followed up on this by introducing obligatory sterilization of people with diseases he believed to be inheritable including mental retardation, schizophrenia, affective psychosis, and alcoholism. In July 1939 a plan was developed with the assistance of leading psychiatrists for the extermination of this group of people. Torrey and Yolken in their analysis of the literature believe that the entire population of people with schizophrenia (between 220,000 and 295,000 people) living in Germany at the time were either sterilized or killed. After the invasion of Poland the systematic murders of patients in various psychiatric hospitals were carried out. There are reports of only two psychiatrists who chose to stay with their patients and both perished. This plan to eliminate schizophrenia did not succeed probably because it is not entirely a genetic disease. We should never forget those whose lives were taken during this time and how and why they they were killed.

Year End Reflection on Those Taken From Us

There are certain times of the year such as religious holidays, anniversaries and the New Year where I find myself reflecting on those people who are no longer with us. As we come to a new year and the end of the first decade of the 21st century that is one of those times. As a son, I think about my parents which leads me to remember other relatives and dear friends who have died and whom I miss. As a Jew I think of the Holocaust and the extermination of millions of people who were murdered because they were  born Jewish. I know history is filled with other similar events which have occurred even in the recent past and may approach the evil nature and magnitude of Hitler’s work.

E. Torrey Fuller
E. Torrey Fuller

People with Schizophrenia Also Targeted by Hitler

As as a psychiatrist,  I also find myself  reflecting at these times on the systematic murder by the Nazi’s  of people because they had a mental illness! This addition to my personal memorial list is relatively new to me since I only recently became aware of the details of Hitler’s systematic singling out mental disease,  especially schizophrenia due to recent writing of E. Fuller Torrey, Robert Yolken and others. Yes,  I had  known how the Nazi’s in their attempt at racial purity were targeting other groups in addition to the Jews but I did not appreciate how people with Schizophrenia were being especially chosen. I was originally alerted to this piece of history by an article in Psychiatric News by Mark Moran in November of this year which also referred to an article by Torrey and Yolken in the September 2009 issue of the Schizophrenic Bulletin

Psychiatrist May Have Given  Birth to this Plan

Alfred Hoche
Alfred Hoche

Some further review turned up  additional information which suggested that Hitler’s thought process on this may have had it’s roots in events that occurred in 1922. At this time the psychiatrist Alfred Hoche and the lawyer, Karl Binding, published a document titled “Extermination of Life Unworthy Creatures” , using that ominous term for the first time and demanding extermination of persons who constituted “a burden” to the society, ravaged by World War I. They argued, in this document, that excessive humanitarian ideas be abandoned in the interest of what they called  “the higher state morality” implying that the existence of an individual is worthless if unfitting to the interest of society.  Shortly after Adolf Hitler took power in 1933, an act was passed, translated as Act on Preventing an Inheritable Burdened Progeny” The act introduced the obligatory sterilization of persons suffering from inheritable diseases, including, among others, mental retardation, schizophrenia, affective psychoses, epilepsy, and alcoholism. Implementation of the act, associated with the sterilization of approximately 350,000 persons in Germany, induced a wide discussion during which only the Catholic Church expressed a negative attitude toward the act.

Physicians Including Psychiatrists Participate in Extermination Plan

The next stage was the elimination of these people as well as the Jews. The approach to the Jews is well documented. However how Hitler utilized physicians including psychiatrists to approach the eliminations of psychiatric patients was not as well understood at least by myself. In July of 1939, an agreement between Hitler, the Reich Chancellory head, Lammers and the leader of the Reich’s physicians, Dr. Leonardo Conti, resulted in the formation of a strictly secret commission for the extermination of patients, directed by Philip BouhIer and called T4 (according to its official address at Tiergartenstrasse 4, in Berlin). The commission included, among others, recognized professors of psychiatry and neurology: Carl Schneider from Heidelberg, Paul Nitsche from Halle, Werner Heyde from Wurzburg. The commission was to choose methods of extermination (at the beginning carbon monoxide was used) and provide opinions on the lists of patients submitted for extermination by psychiatric hospitals, using official questionnaires. This occurred two months before the invasion of Poland. Apparently gold fillings were removied from the teeth of the deceased and used to partially pay for this program. Torrey and Yolken in their analysis of the data estimate that between 220,000 and 295,000 people with schizophrenia were either sterilized or killed which according to them represented all of those people with schizophrenia living in Germany at the time.

Extermination Plan Continued After the Invasion of Poland

After attacking Poland in September, 1939, the Germans began in the very same month a systematic murder of patients in Polish psychiatric hospitals that were situated in the captured parts of the country. The action of murdering these patients  took a similar course in all psychiatric hospitals.HItler The schedule was typical of Nazi mass crimes, followed a specific plan, and was performed scrupulously. After taking control of a hospital under a German director, no patient could be released from the hospital under threat of the death penalty. All the patients were counted and transported out in lorries to an unknown destination. Each transport was accompanied by armed soldiers from special SS detachments, who returned without the patients after a few hours. The patients were said to be transferred to another hospital, but circumstances showed that they had been killed.

In October, 1939, approximately 1,000 patients (children and adults) of the psychiatric hospital in Owinska, near Poznan, began to be transported out in an unknown direction. At the same time, a chapel and a rich, 100-year old medical library were destroyed. The hospital was turned into SS barracks and burned at the end of war. Extermination of patients from the hospital in Owinska requires special attention since on that occasion for the first time new methods for the mass killing of people were implemented. Investigations conducted after the war by the Commission for Examination of Nazi Crimes demonstrated that the special Gestapo unit  took care of the patient evacuation. The patients, dressed only in worn clothes, were transported out in lorries, each lorry accommodating 25 patients and some armed SS men. Distressed and protesting patients were quieted with injections of narcotics. According to witnesses, the lorries drove first toward Poznan where the patients were crowded into an old fort.  Each of the bunkers accommodated approximately 50 persons. The gates were sealed up with clay, and carbon monoxide was fed into each bunker, killing the patients within 10-20 minutes. Corpses of the murdered patients were dragged out by a group of prisoners of the fort, and other prisoners transported them and buried them in a forest close to Oborniki.

On December 7, 1939, approximately 1,200 patients were transported out of the neighboring psychiatric hospital in Dziekanka, near Gniezno. Selection of the patients for the transport was made personally by the hospital director, Ratka, who had just changed his citizenship to German and put on an SA uniform. Later on, the hospital kept providing psychiatric services for patients of German nationality and also served other, peculiar aims. On orders from Berlin, the hospital was disguised to represent a place of burial of the exterminated patients even if most of them had never visited the hospital. Families of the patients were falsely informed that the patients being searched for were buried at the hospital cemetery, and the families were even charged for the care for these graves. After the war, it was found that the psychiatric hospital in Pruszkow near Warsaw played a similar role. Families of the murdered patients were referred to the hospital and told that their relatives had been brought to the hospital, but died natural causes.

The sanatorium in Koscian for neurological and psychiatric patients lost approximately, 500 patients who were murdered and the institution then appropriated for other purposes. Patients in psychiatric hospitals in Warta (approximately 580 patients), Gostynin (approximately 100 patients), and Choroszcz (564 patients) were shot in the neighboring forests while patients of Kochanowka hospital (approximately 540 patients), Nazi loading on trainnear Lodz were killed in the sealed lorries using engine exhaust. In the psychiatric hospital of Lubliniec, 194 children were killed with high doses of luminal. The existence of the psychiatric hospital in Kobierzyn, near Cracow ended on June 23, 1942. The hospital was surrounded by soldiers in helmets and SS uniforms, the patients were loaded into lorries and cattle trucks, and the patients were transported to Auschwitz to gas chambers. Severely ill patients were transported to the hospital cemetery and shot there. A total of 566 patients died in that action.

The above data that originated from individual hospitals do not unfor­tunately create a complete image of the extermination of patients. It is difficult to estimate, e.g., how many of the psychiatric patients in the hospitals died due to drastically lowered food rations. Systematic starvation increased the mortality of patients several fold. It should be mentioned that this statistic does not pertain to patients of German origin who were fed better. The numbers of known victims also fail to include crimes which have not been documented. At the end of the war, the Nazi authorities destroyed evidence of their own crimes, as they pulled back from the captured territories. In most cases, extermination of patients was executed with no preliminary formalities (in the Reich it was preceded by filling in of questionnaires) and unexpectedly. The data quoted above originated from hospital registers that escaped destruction or from secretly prepared lists of those patients who were transported out of the hospitals.

Most Psychiatrists Don’t Protest but Two Psychiatrists Chose to Stay with Their Patients

I apologize for somewhat wordy unpleasant detail of this blog but I felt the story had to retold. My source for much of the above detail which I have shortened comes from the previously mentioned reference  Project Inposterum.

Torrey made the  point of emphasizing how while psychiatrists played a leading role in these horrendous events, he is not aware of any protests against the policy from organized German psychiatry. He notes “if you wanted a bright future in Nazi Germany you would not be enhancing your prospects by saying “we shouldn’t be doing this.” However the above link  gives two instances in Poland where psychiatrists chose the path of staying with their patients. Dr. Józef Bednarz, (see date of 1932 in this link ) Director of the Psychiatric Hospital  in Swiecie in Wisla, who rejected the chance to escape, did not want to leave his patients, and was shot with them in November of 1939.

Grave of Dr. Halina Jankowska
Grave of Dr. Halina Jankowska

Dr. Halina Jankowska, the eminent psychiatrist, and her nurses on  August 23, 1944, during the Warsaw Uprising rejected the chance to leave their patients in the Hospital of Saint John of God and died with them in the ruins of the bombed hospital

How Did This  Extermination Effect the Future of Schizophrenia ?

Torrey and Yolken also make the point that the Nazi reasoning  for killing patients with schizophrenia was also founded on an erroneous notion that the disease was entirely genetic. In fact the number of existing cases or the prevalence of the disease after the war was low as expected, because of the killings.  However the incidence or number of new cases was high suggesting that factors other than genes played an important role in schizophrenia. Studies have  found that the incidence rate in Germany 20 years after the last patient was sterilized or killed were 2 to 3 times the rates in the US and England . It was postulated that the most likely explanation is that social conditions after the war produced environmental factor such as famine, illnesses  and poverty which led to an increase in new cases of schizophrenia

Of course what ever we can glean from the results of this horrible “experiment “ will never provide any justification for what was done. I do that believe that we are obligated to use  any data that emerges from this event to better help people in the future just as we can use the data from other unspeakable Nazi experiments on helpless victims  to make people’s lives better in the future. In doing so we need to never  forget those whose lives were taken including  why  and how they were killed.

May This Be A Good Year for All of You

While I chose to write the last blog of the year on a somber topic, I do want to also end with an optimistic greeting to all of you.  I appreciate the interest and encouragement that many of you have given me as I have undertaken this weekly blog . I know that there are many people who share my interest and concern about educating the public about all aspects of  mental illness.

I wish everyone of you a most Happy New Year.

Comments Are Always Welcome