Jul 20, 2012

What it takes to prevent mass killings

Today's Colorado movie-theater violence struck a chord. I have been working on anti-violence for such a long time, and hate seeing these tragedies keep playing out.

I believe we have lost the social capacity to detect and prevent public violence connected to people's deteriorating mental states. I think a big part of this is due to mental illness being so fearful and stigmatizing. We know that suggesting that a person needs help will be taken as a disgraceful accusation. This makes us push thoughts of dangerousness out of our heads. The only antidote is to build up our society's capacity to grapple with dangerousness.

This will not be easy. It's almost like people everywhere unconsciously resist learning what to watch out for. We seldom hear anything about how to interrupt a real threat as it is gathering steam. Even mental health advocates shun the topic of the violence of the mentally ill. They say that the vast majority of people with mental illness are nonviolent and vulnerable, which is true as far as it goes. A few groups do try to scare us with talk about diagnosed dangerous folks running amok, mostly to push their own legislative agenda about forced treatment.

Most of the mass killers I've read about display pieces of one diagnosis or another, but are disconnected from our treatment systems. There is often some dispute about whether the person is mentally ill in a formal sense, or whether or not the system could have helped the person before they acted violently. Still I think many of these mass killings are detectable and preventable, if ordinary people knew just a little bit more about how people break down, and about when to start worrying, and about when to call. We already know who to call.

Countless incidents of violence are interrupted every day in communities throughout the world. They do not make the news because they remain non-events. That's why I believe ordinary non-clinical non-experts are our first line of defense for killings and suicides in our public spaces. Gun control laws cannot help once a person is armed. Forced mental health treatment laws cannot benefit people who are not enrolled in mental health care.

What do people need to learn?

We need to know how to recognize when a threat is building up, and when to call it in. We need to learn a little bit about threat and safety factors. Police already know how to respond appropriately.

And at a more basic level, we really need to know how to talk to our neighbors about how they are doing.

Whenever I hear of a public killing or suicide, I run through this list of threat factors.

-- Was the person communicating effectively before the incident?
-- Was there a statement to be made?
-- Did the person at the center of the incident have major trouble in his life?
-- Was there a triggering event involving shame and embarrassment?
-- Was the person “putting on” a violent identity?
-- Was the person developing tunnel vision?
-- How many mental illness related behaviors were manifesting around the person?

Here’s the checklist of mental illness-related behaviors I am referring to.

-- Hallucinations
-- Delusions
-- Excessive fears or suspiciousness
-- Inability to concentrate
-- Sadness coming out of nowhere, unrelated to events or circumstances
-- Extreme excitement or euphoria
-- Pessimism, perceiving the world as gray and lifeless
-- Expressions of hopelessness
-- Loss of interest in once pleasurable activities
-- Thinking or talking about suicide
-- Sitting and doing nothing
-- Friendlessness
-- Abnormal self-involvement
-- Dropping out of activities
-- Decline in academic or athletic performance
-- Hostility, from one formerly pleasant and friendly
-- Indifference, even in highly important situations
-- Inability to express joy
-- Inappropriate laughter
-- Inability to concentrate or cope with minor problems
-- Irrational statements
-- Peculiar use of words or language structure
-- Involvement in automobile accidents
-- Drug or alcohol abuse
-- Forgetfulness and loss of valuable possessions
-- Attempts to escape through geographic change
-- Frequent moves or hitchhiking trips
-- Bizarre behavior (skipping, staring, strange posturing)
-- Unusual sensitivity to noises, light, clothing
-- Hyperactivity or inactivity (sometimes alternating)
-- Deterioration in hygiene or personal care
-- Unexplained weight gain or loss
-- Sleeping too much or being unable to sleep

But what might we do before an incident?

I actually use this same list when I am talking with a friend or working with someone in the community. I am not a clinician, but I know if I identify enough of these factors, or if I start reacting emotionally or physically to this screening process, I should start thinking seriously about making a call. The police can respond with a friendly check-in visit. This might be enough to keep the person and others in the community safe.

Fortunately, I’ve never been in a spot where I have had to be the person calling something in. I do expect real threats of impending violence to be rare. On the other hand, I try to connect people with treatment all the time. I know what it is like to take a friend to the psychiatric emergency room. And I know many families that must face these hard choices all the time.

At a more basic level, everyone can learn how to have a friendly check-in conversation with a friend or neighbor. It’s important to have a way to be supportive, non-stigmatizing, and focused on safety. Four questions can get this started. These are just topics. Cover them in order, but phrase them any way you like.

1. What have you accomplished since the last time we talked? (This injects a little positivity into the conversation -- at the very least this conversation is happening right now).

2. What are you facing? (We all have something that is challenging to us. The person doing the checking can share first. Remember, there's no reason to make this creepy or intrusive).

3. Who are your allies? (This checks for isolation. People who have real help and good social connections usually have less risk).

4. What is your plan? (This checks for rigid tunnel vision thinking).

I developed this four-question check-in to help people support each other, and promote general safety. People have a built-in capacity to size each other up when they have face-to-face conversations. If a conversation leaves you a little concerned, it's worth checking things out, possibly with a call to a knowledgeable friend or to a clergy member, or mental health professional if you know one.

But if your conversation, or what you observe, leaves you worried sick, make the call.

1 comment:

Paul Komarek said...

From today's New York Times:

But as investigators combed through the contents of his apartment on Sunday — its explosive booby traps now defused — new details began to emerge of his activities in the weeks leading up to the rampage. They sketch a picture of man once captivated by the science of the human mind growing increasingly interested in weapons and how to use them.

On June 25, Mr. Holmes e-mailed an application to join the Lead Valley Range, prompting the owner, Glenn Rotkovich, to call back, more than once, to invite him to a mandatory orientation meeting. Nobody ever answered, but Mr. Rotkovich described the voice message as nearly incomprehensible.

“It was this very guttural, very heavy bass, deep voice that was rambling incoherently,” Mr. Rotkovich said. “It was bizarre on a good day, freakish on others.”

Mr. Holmes never called back about joining. "