Friday, May 30, 2014

Leakage in Violent Intentions and Why Professionals May Not See It

Psychiatrist Richard A. Friedman recently wrote an opinion piece for the New York Times about why professionals may not be able to identify those with violent intentions.  In it he states that mental health professionals predict or identify at a level no better than chance.  He also states what many of us in this field already know but the public largely does not; that is, only a few mental illnesses carry with them an increased risk for violence, such as schizophrenia, bipolar disorder and major depression.  And most people with mental health issues are not violent.  He notes that the role of substance abuse, which is much more prevalent that the disorders listed above, is often overlooked or not cited in specific cases.  Due to the media's portrayal of "shooter" incidents the public is developing a distorted view of these events which leads to faulty conclusions.  These include: "fixing" the mental health system will reduce these events, and it should be easier to identify killers because it's so easy to see after the fact.  There's also a related notion that keeping firearms out of the hands of the potentially violent should be an easier thing to do.

These conclusions are faulty for several reasons, not the least of which is the assumption that science is or should be able to help us identify killers.  While we are not without some applicable knowledge and skill, it has not advanced to the point where predictive power is very strong or even anywhere near that.  We assume that being in psychological care can reduce or eliminate risk in all cases.  While I certainly believe that many negative situations are avoided or contained by competently applied therapy, it is also true that anyone can mislead us if they choose.  We are not magicians.  And no, we can't read minds either.

The concept of "leakage" of violent intent is relevant here.  Studies of those who have chosen to harm others indicate they communicate their intent many times, and often long before the violence is carried out.  But how often does this leakage occur in the therapy session?  I submit to you that it is very rare, especially in cases in which the client knows they are being monitored by others who are worried.  The therapy hour is one of 168 hours in the week.  How hard would it be for any of us to maintain a mask for one hour compared to 167?  If you are intelligent enough, not very hard at all.  For the most part, the leakage occurs outside of the therapy hour, while the violent are moving and posting on social media among us.  It may happen in bits and pieces, or it may happen all at once, but it is us, the general public, that will see the lion's share of the messages.  Even if it is leaked in the therapy hour, there is currently no magic bullet, as it were, to swiftly contain and manage the potentially violent person.  As has been noted elsewhere, a mental health hold or commitment may last only hours or days.  Then what?

There are no simple answers to this problem.  Any solutions are likely to come from many quarters, including mental health systems (I use that phrase loosely because there is no actual "system" in this country), law enforcement, firearms statutes, families, and the general public.  But one element we all need, which the concept of leakage reveals, is a commonly taught survival tool of recognizing and reporting leakage.  It ought to be taught just as CPR is taught, and just the signs of heart attack and stroke are taught.  (We could do better even with those better understood conditions).  You cannot manage a threat until you know how to recognize it, and until you have a sound way of mustering support.  We are a long way off from having either.