As a forensic psychologist, I spend lots of time with the perpetrators of heinous events like the recent school shooting in Newtown, Connecticut. My role and responsibility is to inform the court or the perpetrators’ attorneys of issues—especially mental health issues—that might impact how the accused proceed through the legal system. Sometimes I render an opinion about whether an individual is “fit for trial,” address “mental status at the time of the crime” or advise judges of treatment issues prior to sentencing. My time with these individuals is quite unique as I learn their life stories, their problems and their motivations. I get to know them very well, in some cases better than either their attorneys or their family, if they have one.

We are adding “Newtown” to a list of places in America that have witnessed unexpected violent episodes—Columbine, Aurora, Virginia Tech to name just a few. While the list appears long, what happened in Newtown is a rare event, like an airplane crash or other infrequent disaster. I spend most of my time with people who are charged with crimes nowhere near the violence level of Newtown. It just seems like mass shootings are increasingly common because of the publicity attached to them. “Many [readers] must have noticed an increase in the subjective probability that an accident or malfunction will start a thermonuclear war after seeing a movie in which such an occurrence was vividly portrayed.” —Amos Tversky and Daniel Kahneman in Cognitive Psychology (1973)Psychologists call this phenomenon “availability heuristic”—salient, infrequent events appear to be more frequent because of the notoriety paid to them, particularly in the press. It is almost impossible to predict rare events. As early as the 1950s, statisticians, specifically Paul Meehl, demonstrated that in order to ensure that a rare event will not occur again, for example by detaining a dangerous person, multiple non-dangerous people would have to be detained as well.

Our gut instinct after Newtown-type events is to assume violence in our country is increasing. The truth is that violence in America has decreased significantly in the past decade. The rate of homicides per 100,000 people in the U.S. in 2010 was about the same as it was in 1950. Since 1993, the rate of violent victimization in the U.S. has dropped 70 percent from 50 per 100,000 to 15 per 100,000. Bureau of Justice Statistics data support these conclusions.

The vast majority of people affected by mental health disorders are not violent—again, an example of mistaken beliefs resulting from the publicity attached to high profile crimes. Actuarial data indicate that people with mental illness are more likely to be VICTIMS of crime, NOT violent perpetrators. In fact, most of the people with mental illness whom I evaluate for the courts have not engaged in violent acts and are NOT charged with violent crimes.

Often, upon returning home after an evening at the jail, I read with interest newspaper accounts of high profile, devastating events like Newtown. I am struck by the political debate that ensues: “How can we keep our children/community safe?” In his response to the Newtown tragedy, President Barack Obama has issued a call for action to prevent future violence against innocent victims. So, what exactly should Americans do?

“Simple” solutions abound: More gun control, more religion (prayer in schools), more limits on violence in the media and more accessible services for people and families affected by mental illness. The first three suggestions raise tricky constitutional issues, so I am not optimistic that they will become workable solutions, neither through congressional nor Supreme Court action. “Embracing the term “evil” into the lexicon and practice of psychiatry will contribute to the stigmatization of mental illness, diminish the credibility of forensic psychiatry, and corrupt forensic treatment efforts.” — James L. Knoll The issue of religion and society has rekindled the debate about whether people who engage in criminal behavior are “mad” (meaning “sick”) or “bad” (meaning “evil”). One’s position on this spiritual debate informs their preference for dealing with criminal behavior. “Sick” people need treatment while “bad” people need punishment, and ultimately redemption.

Empirical data aids the assessment of risk of future violence. While most violence in this country is not perpetrated by people with mental illness, there are “signs” that have been found to correlate with aggressive acts. A combination of active psychotic symptoms, substance abuse and a history of violence or current hostile attitudes are risk factors for future violent acts. The availability of a weapon to individuals who demonstrate such signs—especially if they are engaging in threatening behavior—adds to the risk. Even in the absence of a history of violent behavior, a person may demonstrate clear signs of violent potential, such as buying a gun or admitting thoughts of harm to others. Clearly, the lay public needs to be aware of these signs and symptoms, because such individuals do not always come to the attention of mental health professionals.  Like a fever, behaviors noted above should alert practitioners to the need for an intervention.

If we consider violence to be a public health problem—an issue that results in needless or excessive deaths in our community—we know that prevention is always the most cost-effective way to address the issue. In 2003, a federal Task Force on Early Mental Health Intervention issued a report on behalf of the Surgeon General at the time, Dr. David Satcher. Satcher noted that mental health was just as important as physical health, yet we lack a national commitment to mental health equivalent to the federal government’s investment in childhood immunizations, for example. We still lack that commitment, now a decade since the report was issued. The report concluded that social-emotional competence in young children is as important an element of their development as their physical health. Among the efforts called for to foster social-emotional competence among our children included the following points:

  • De-stigmatization of mental health problems;
  • Integration of social-emotional health screening and intervention services into primary health care and early education settings;
  • Coordination and collaboration among relevant service agencies;
  • Family involvement in determining service needs and policies;
  • Research aimed at broadening the range of effective diagnostic and intervention strategies;
  • Expanding training of mental health professionals to prepare them to serve young children, their families and caregivers;
  • Parity funding for mental health screening and intervention at the level provided of primary health care.

As I review the recommendations of the Satcher-era panel, I reflect upon the person sitting in front of me in a yellow jump suit with leg irons and a belly chain. Had ANY of the recommendations listed above been implemented, would he/she be sitting in front of me today? The truth is that I don’t know. The other sad truth, however, is that few, if any, of the recommendations above have been implemented, depending on the community in which one lives. Nationwide, community-funded mental health services have been cut deeply, reducing individual and family access to needed effective mental health services. Research assessing the effects of these budget cuts is woefully lacking.

Mental health is part of overall health, but increasing mental health services is only part of the solution. People who don’t understand enough about mental health to know when there is a problem will not access services. People who are troubled need to be brought to the attention of professionals: teachers, co-workers, law enforcement officials, physicians, friends and family. Most troubled people will not commit violent acts, but they still need help. Help in the long run might prevent bad outcomes.

One conclusion of which I am confident is that when I sit with my forensic clients I am never fearful for my own personal safety. Aggressive behavior is always a function of both the individual and the situation. While I am not a therapist and my role is to assist the legal system, I present myself with an attitude of understanding and interest, not judgment. I never consider a person “bad” even though some have done “bad” things. My presence doesn’t instill threat or fear in the person. I listen with interest to their stories. With better interventions, earlier in their lives or with better attention to the warning signs of their mental state at the time of the events leading to their crimes, perhaps my services would not have been needed.

Some of the people I see suffer from serious mental illness; some do not. Some have histories of previous criminal activities, others do not. All of my patients are troubled, alienated and “lost” souls in every dimension of the term. Perhaps policymakers tasked with making the difficult decisions on allocating scarce public resources should spend some time with my patients as well. Their decisions about public funding might just change.

Or perhaps I should invite my neighbors to join me at the jail instead. An electorate willing to invest in public mental health and public safety may prove even more effective.

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The views and opinions expressed here are those of the writer and do not necessarily reflect those of Boise State University or the College of Social Sciences and Public Affairs.

  • Gary Payne

    Dr. Hatzenbuehler,

    Thank you for your thoughtful analysis and summary. The challenge is great in Idaho because many view government as essentially intrusive and prefer to react when there is an adverse outcome rather than apply what we know will reduce risk. The current effort to reform the mental health system in Idaho reduces government responsibility for essential mental health services.

  • http://www.facebook.com/rswenson1024 Richard P. Swenson

    Excellent article, Dr. Hatzenbuehler. I hope the folks in Washington, DC have a chance to read it.