I do not know what will come forth from the recent tragedy but I amcertain that if no change takes place, then this will be followed byan even more spectacular outcome. This article is excellent andclearly shows us our real options.
To start with, mental health management and therapies are all farless than any hoped for ideal. The trend lines are positive in termsof developing protocols, but management of the victims has beenthrown back on the families who are generally overwhelmed andnaturally inept at working with the problem if only because they lackdistance. In fact it surely worsens the risk.
Effective gun control protocols are necessary. The correct way is toinsist on a high level of weapons training oriented to the weaponbeen licensed and ongoing refresher training in order to maintain thelicense. This is tough, but it satisfies the personal need to packwith societies need to have the weapon handled by highly trainedindividuals. It says nowhere in the constitution that the price ofcarrying a weapon will be free of responsibility. It is theresponsibility that we enforce.
In the recent case, the training program by experienced third partieswho would be expected to vouch for the trainee is quite capable toslap a hold on such a kid. Even better, the mother needed a seriousindependent perspective in her life. If you do not understand whatis flowing through a person's mind, then it must be simple sense tosecure the weapons. That did not happen here.
A turn down by an experienced third party could have led directly tomandatory supervision of the weapons at a secure site.
My core point is that weapons use like car use is a jealouslyprotected privilege and not a right.
How to Prevent MassShootings
Wednesday, 19 December2012 00:00By James L Knoll IV, Truthout
http://truth-out.org/opinion/item/13351-how-to-prevent-mass-shootings-a-case-in-point
Psychiatry alonecannot solve the tragic problem of mass murder. Careful reflection ongun control laws, responsible media reporting and heroic reporting byintimates of potential perpetrators could help.
"Thankfully wehad a responsible family member or we might have had a differentoutcome."
- Bolivar, MissouriPolice Chief
Each time another massshooting happens in the US, the response is entirely predictable.After the media coverage subsides a bit, a familiar sequenceunfolds:Who is this person? How did the "mental health system"fail him? How did he get his hands on such a powerful arsenal? Ifonly the actual tragedy was so predictable beforehand.
Mass murderpredictable? Not likely. Preventable? Well, here is where I believewe have a bit of a chance. But it depends. How much do we really wantto prevent mass murder? And by "how much" I mean: How muchresponsibility are we willing to take on in an effort to make ameaningful difference? We can talk about it for a few more decades,and in the meantime we will likely have a few more Sandy Hooks,Auroras, Virginia Techs or Columbines. I cannot mount an argumentagainst those who proclaim these tragedies are impossible to predictor prevent solely with psychiatric efforts. I can't and I won't,because I agree with them. But I do believe there are other ways thatare far more effective, and ultimately, far more beneficial forsociety.
It turns out thatrecently, Bolivar, Missouri narrowly avoided becoming the nextAurora. How? The mother of a potential mass murderer contacted policebecause she was worried that her son, Blaec Lammers, had intentionsof shooting people during the opening of the final film in thepopular Twilight vampire movie series. Predictably, themother was right to be concerned. When Tricia Lammers' son wasquestioned by police, he said he had already bought tickets and"planned to shoot people inside the theater." Uponinvestigation, police found that Lammers "did have the weapons;he did have the ammunition ... and then he made the statements to theofficer about what his plans were."This leads me to oneof my first suggestions on how to prevent mass murder. The mayor ofBolivar, or better yet the governor of Missouri, should give TriciaLammers a medal. In fact, if neither party will do this, I willpersonally have one made and sent to her. The medal will be engravedwith the words: "For Brave, Humane and Lifesaving Action."
How many can say thatthey saved potentially dozens of lives, while also saving the lifeand mental health of a family member? Tricia Lammers - I applaud you,and others should as well. Am I making too big a deal out of thismother's actions? I do not believe so. I think her act represents oneof the strongest methods of prevention available. Third parties,particularly family members, are the most likely tohave pre-offense knowledge or significant concerns.2 Inother words, potential mass murderers often "leak theirintent"3 to third parties who, in turn, remainquiet for various reasons.4 But it is important for familymembers to know that help and resources exist. Tricia Lammers wasable to rely on some of these resources, most notablythe National Alliance for Mental Illness, which has offices allover the country.
In contrast to Ms.Lammers, the silence of third parties seals the fate of both theirloved one and scores of innocent people. Need another example? Theyare not difficult to find. Take the relatively recent case of AndersBehring Breivik who, on July 22, 2011, obliterated more than70 innocent people in Oslo.7 Breivik's sister had beenconcerned enough to warn her mother at least two yearsprior to the tragedy.
At this point in time,most authorities agree that preventing mass murder requires measureswell above and beyond the "mental health system."9 Forexample, after Jared Loughner perpetrated the tragic mass shooting inTucson, mental health experts concurred that "homicidesperpetrated with firearms against strangers by individuals withmental disorders occur far too infrequently" to predict orprevent with mental health efforts alone.10 Yet after the Tucsontragedy, there was still the familiar media refrain: "Didthe system fail Jared Lee Loughner?"[emphasis added]
The "MentalHealth System?"
When the inevitablehuman tragedy recurs, point not at the system - for youwill be pointing at nothing at all. An apparition. A fiction createdsome 50 years ago, which only returns as a ghost in the night. And soit goes - American society seems comfortable to periodically point atand condemn the ghost every now and then whenever a serious hauntingtakes place. But many are not likely in a position to see the cyclespsychiatrists see due to their permanent residence near thegraveyard. We see the perpetual tragedies, followed by the hauntingincantations: "The system ... the system failed him...."
It is my contentionthat there exists no legitimate "system" in the US when itcomes to mental health treatment. Despite this, we most certainlywant to believe in one, particularly so that when tragedies occur, wewill have something to cast our outrage upon. For example, when askedin a poll where they placed blame for the Tucson shooting, a majorityof Americans said in a USA Today/Gallup Poll that they placed a"great deal of blame on mental health system failures."Since it is possible that the term "mental health system"may be thrown about loose and fast, let us consider it with a bitmore precision.From a literalperspective, one might define a system as: an organized, regularlyinteracting set of principles forming a network - especially fordistributing something or serving a common purpose. Even moregermane, the Surgeon General's report on mental health14 givesus the following definition: "[D]iverse, relatively independent,and loosely coordinated facilities and services - both public andprivate - that researchers refer to, collectively, as the defacto mental health service system" (emphasis not added). Sincea particular legal term has been invoked, let us examine thedefinition of de facto. Here we discover both a lay and a legaldefinition respectively:
1. Exercising power orserving a function without being legally or officiallyestablished;
2. Used to characterize... a state of affairs thatmust be accepted for all practical purposes, but is illegal orillegitimate.16
Thus, per the SurgeonGeneral's own definition, the "system" is at best,unofficial and at worst illegitimate. Why might it be that in 2012,we have no "legal or legitimate" mental health system?Returning to the Surgeon General's report, we are told that:"Effective functioning of the mental health service systemrequires connections and coordination among many sectors.... Withoutcoordination, it can readily become organizationally fragmented,creating barriers to access. Adding to the system's complexity is itsdependence on many streams of funding, with their sometimes competingincentives."
So it appears thatboth lack of coordination and funding inconsistencies confound thesystem. But as it turns out, these are problems that have never beenadequately addressed since the time of their inception -deinstitutionalization. Deinstitutionalization was the term used todescribe the rapid emptying out of state mental hospitals beginningin the 60s and 70s due to a number of factors, including: thepatients' rights movement, financial reasons, early hopes for a"magic bullet" in the form of antipsychotic medications andthe never-realized hopes for adequate community mental healthservices. Thus, deinstitutionalization became"trans-institutionalization" - also referred to as the"criminalization" of mentally ill persons.17, 18 Extremelylaudable efforts have been made to divert persons with serious mentalillness away from corrections (e.g., jail diversion and mental healthcourts).19, 20,21 But the fact remains that there are largenumbers of persons with serious mental illness in the correctionalsystem, and the trend shows no signs of reversing itself.
In Virginia, jails nowhouse more persons with SMI than do Virginia psychiatrichospitals.22 The Los Angeles correctional system has beenreferred to as America's largest psychiatric facility.23 Itis now jails that serve as the "predominant settings forproviding acute psychiatric inpatient treatment."24 Duringthis era of retribution, corrections facilities earned theirdesignation as "the new asylums." Correctionaladministrators readily concede that their facilities are being usedas "dumping grounds for many individuals who could be betterserved through early intervention in noncustodial environmentsbecause other options are just not available."26 But alas,"interventions in noncustodial environments" are in shortsupply in 2012.
Couldn't this havebeen foreseen? Quite unlikely I believe, for a variety of reasons,including: "The fact that most deinstitutionalized peoplesuffer from various forms of brain dysfunction [which] was not aswell understood when the policy ofdeinstitutionalization got underway." Indeed, it was poorly planned deinstitutionalizationthat created our present illusion of a system "by dischargingpeople from public psychiatric hospitals without ensuring that theyreceived the medication and rehabilitation services necessary forthem to live successfully in the community."30 The mental healthsystem has failed no one, simply because there is no system to speakof. Thus, we must look elsewhere for solutions to violent outburstsby mass murderers, most of whom have never accessed mental healthcare to begin with.
Mass Murder - Whatis it?
Mass murder is norecent phenomenon. It has occurred since well before the CharlesWhitman shooting in 1966 at my alma mater, the University of Texas atAustin. However, access to powerful, automatic firearms, mediaattention and a possible glorification of the phenomenon amongcertain vulnerable, disaffected individuals are factors makingpresent day mass murders unique.
Mass murder, strictlydefined, is the killing of four or more victims at one locationwithin one event.28 It is both a rare and catastrophic event that isusually carried out by a single individual. Mass murder isdistinguished from both spree and serial murder. In the case ofserial murder: There have been at least two victims, the victims arekilled in a non-continuous fashion (i.e., there is an emotional"cooling off" period between murders), and the murdersusually involve a sexual component.29 In contrast, a spree murderinvolves killings at two or more locations with very little time inbetween murders and no cooling off period.31 The type ofmass murder discussed here involves those carried out by a single,heavily armed individual who is very likely to expect to die as aresult of the event. This further distinguishes it from gang-relatedmass murder, in which the perpetrators do not typically expect todie, and their motive involves various forms of profit, drug trade orterritorial disputes.33
At the present time,it is typically the high-profile cases that are most heavily coveredby the media; yet these are the least representative. In many cases,the precise number of victims may be arbitrary. Research has beenslow in the area of mass murder, and there is not yet an officiallyaccepted typology. However, it is clear that not all mass murderersare alike in their motivations and psychology. Some may be driven bystrong feelings of revenge born of social alienation or a perceivedinjustice. Others may also suffer from severe depression or, rarely,psychosis. Still others may resemble terrorists with idiosyncraticpolitical beliefs. Such was the case with a Polish chemistryprofessor who was recently arrested before he could blow up aparliament building. Dr. Brunon Kwiecien openly supported Breivik,and wished to carry out a similar attack, but on a largerscale. His wife alerted authorities after he asked her how he couldmake a biological "dirty bomb." When he was apprehended, hewas found to be in possession of high-powered, military-gradeexplosives, bomb-making equipment, several hundred rounds ofammunition, a bulletproof vest and a pistol.
The majority ofresearch indicates that there are factors common to mass murdererssuch as: extreme feelings of anger and revenge, the lack of anaccomplice (in adult mass murder), feelings of social alienation andplanning/organizing the offense. In a detailed case study of fivemass murderers who were caught before they were killed, a number ofcommon traits and historical factors were found.35 The subjectshad all been bullied or isolated as children, turning into loners whofelt despair over being socially excluded. They were described assuspicious, resentful, grudge-holders who demonstrated obsessive andinflexible thinking.
Not surprisingly, theywere also narcissistic and coped with personal problems by blamingothers. Their worldview was characterized by seeing most others asrejecting and uncaring. As a result, they spent a great deal of timenurturing their resentment and ruminating on past humiliations. Theruminations evolved into fantasies of violent revenge. They did notsee their own violent death as a deterrent, particularly because theyperceived it as bringing them fame with an aura of power. Carefulstudy of individual cases of mass murder often reveals that theoffender felt compelled to leave some type of finalmessage.36,37 These messages may be written, videotaped orposted on the internet or social media networks.38
In sum, the factorsassociated with, and contributing to, mass murder are complex andmulti-determined. Biological factors may include possiblebrain pathology, as well as psychiatricillnesses. Psychological factors include a negative orfragile self-image, a strong sense of entitlement, and vulnerabilityto humiliation. Social factors include socialisolation/alienation, being bullied and marital or financial loss.
Mass Murder - Canit be Prevented?
Mass murder is quiterare, and depends on the fluid vicissitudes of an extremelydistraught and nihilistic individual who has access to firearms andammunition. This must be kept firmly in mind when attempting toformulate preventive solutions. The reality is that mass murdercannot be "predicted" as such, particularly by personsoutside the perpetrator's social circle.39 Any hopes ofprevention must rely on various approaches acting together to providea widely-cast safety net.40
How much does societytruly wish to tackle this problem? Yes, it's rare, but the fallout isprofound, devastating and long-lasting. I conclude that it is societythat must first decide if it cares enough to take meaningful action.I will forever advocate for better mental health services andimproved access to care. However, at the present time, measures suchas screening for prior psychiatric treatment (often in the distantpast) among individuals who want to legally purchasefirearms represents no meaningful intervention.41, 42, 43 HereI refer to the Brady Act and relevant portions of the NationalInstant Criminal Background Check System (NICS). Not only does thepresent patchwork of inconsistent NICS procedures across the countrydo nothing to solve the problem, but it is also wasteful of preciousresources.
Experience has shownus that, at this point in time, the higher yield interventionsare:
1. Third-partyreporting of concerns or leaked intent2. Sensible guncontrol laws3. Mediaresponsibility
Having alreadyaddressed the issue of third-party reporting with the example ofLammers' mother, I now turn to the perennial and contentious subjectof gun control in the US. It turns out that countries with lessstringent gun control laws have been observed to have a higher riskof mass murder than countries with stricter laws.44 In contrast,consider an Australian observational study done in the wake of ahighly publicized 1996 mass shooting in Tasmania.45 The studycompared mass murders before and after Australia enacted gun lawreforms that included removing semiautomatic firearms, pump-actionshotguns and rifles from civilian possession. In the 18 yearsbefore the gun laws, there were 13 mass shootings in Australia. Inthe 10-and-a-half years after the gun law reforms, there were none.
Dr. Allen Frances,chairman of the DSM-IV, has framed the situation a bit more bluntly.He believes we have only two choices: "Accept mass murder as apart of the American way of life ... [or] get in line with the restof the civilized world and adopt sane gun controlpolicies."46 But Dr. Frances' latter option seems difficultfor many to consider, let alone accept. Others, such as MichaelMoore, have speculated that it is our deep seated,long-standing fear that keeps us clutching at our guns. 48 Iwill not lay out here all of the debate, but would only point outthat there is "no other democracy on the face of earth thatexperiences this type of gun violence. We are the only free societythat has yet to address this problem."49
Our rates of gunviolence far exceed that of other countries. In a piece on gunviolence in the US, Fareed Zakaria noted that: "The gun-homiciderate per capita in the US is 30 times that of Britain and Australia,10 times that of India and four times that of Switzerland. Whenconfronted with such a large deviation, a scholar would ask, 'DoesAmerica have some potential cause for this that is also off thechart?' I doubt that anyone seriously thinks we have 30 times as manycrazy people as Britain or Australia. But we do have many, manymore guns."
Given theseassociations, and the fact that at the present time, psychiatry islargely impotent to "stop" or "predict" massmurder, what can be done? Perhaps confronting gun-relatedviolence as a serious public health issue is a start. For example,adopting sensible restrictions "such as eliminating thesale of semi-automatic weapons."51This is an approach that hasalready been advocated by both the American Psychiatric Associationand the International Association of Chiefs of Police. But of course,it must ultimately be society that decides to take this path. If andwhen it does, it will be critical for the regulations to be appliednationally, or otherwise be doomed to failure: "A piecemealapproach to firearms regulation that affects only some cities orstates cannot be expected to produce a robust effect on gun-homicidesor mass shootings."
The issue of mediaresponsibility in helping to prevent mass murder has been highlightedsince the Columbine and Virginia Tech tragedies. It became clearafter these events, that some perpetrators were, in part, motivatedby the infamy they saw past mass murderers receive via news coverage.Although some news media may be disinclined to admit it, they mayoften be in the business of searching for "the right sort ofmadness" to capture the public's imagination.52 This mayinvolve exploiting violent and tragic acts carried out by mentally oremotionally disturbed individuals. In reality, it is a difficult taskto report the occurrence of a mass murder in such a way that thepublic is adequately informed, yet certain details (e.g., numbers ofvictims, whether the offender was killed, etc.) are not reported.Efforts to develop a universal reporting code have been recommendedthat would appropriately cover the tragedy and reduce the impact ofthe copycat effect.53 Most recommendations involve ensuring thatthe perpetrator is neither glorified nor demonized. In fact, avoidingmuch emphasis on the perpetrator seems to be a good general rule.Rather, media should emphasize victim and community recovery efforts.
As a psychiatrist, Idesperately wish that improved psychiatric care and access totreatment could save the day. I have little doubt that over theyears, unsung mental health heroes have averted possible mass murdertragedies. Yet it seems all too clear to me that this is simplynot a problem that psychiatry can solve on its own. No one shouldexpect psychiatry to do the impossible - it already has its handsfull with the possible. Therefore, I am suggesting threeadditional methods of prevention that should be seriously consideredif we wish to confront the tragic phenomenon of mass murder: carefulreflection on gun control laws, responsible media reporting, andfinally - acknowledging the heroism of Tricia Lammers in the hopesthat more will follow her example.
Hiç yorum yok:
Yorum Gönder