Bedlam Revisited

Bedlam Revisited
Why the Virginia Tech shooter was not committed.

Monday, April 23, 2007 12:01 a.m. EDT
Wall Street Journal

I was in graduate school, studying clinical psychology when they began shutting down the asylums. The place was California, the time was the early 1970s, and “they” were an unprecedented confederation of progressives, libertarians and fiscal conservatives.

From the left marched battalions of self-styled mental health “liberation activists” steeped in the writings of Scottish psychiatrist R.D. Laing. Though he denied being opposed to his own profession, Laing’s notion that madness could be a reasonable reaction to an unjust society, or even a vehicle for spiritual transformation, helped fuel the anti-psychiatry movement of the post Love-In era. The most radical of Laingians carried revisionism one step further: Not only wasn’t psychosis a bad thing, it was evidence of a superior level of consciousness.

The libertarians were fueled by Thomas Szasz, an iconoclastic psychiatrist who was, and remains, an outspoken foe of virtually every aspect of his chosen specialty. Hungarian-born in 1920, and witness to vicious state exploitation of medical practice by the Nazis and the communists, Dr. Szasz pushed an absolutist dogma of individual choice, finding ready converts among members of the Do-Your-Own-Thing generation. Though his early essays offered much-needed critiques of the Orwellian nightmares that can result when autocracy corrupts health care, Dr. Szasz devolved into something of a psychiatric Flat-Earther, insisting in the face of mounting contrary evidence that mental illness simply does not exist. Currently, he serves on a commission, cofounded with the Church of Scientology, that purports to investigate human rights violations perpetrated by mental health professionals.

Accepting the arguments of the liberationists and the libertarians at face value led to the assertion that no matter how bizarre, disabling or life-threatening a person’s hallucinations and delusions, involuntary treatment was never called for. And to the assertion that violation of that premise created yet another class of political prisoners.

While moderate members of the anti-asylum movement were willing to concede that psychosis might pose difficulties for a few individuals, they insisted that society had no more right to force psychoactive drugs upon mental patients than it did to hold down diabetics for insulin injections. If treatment was to be offered, it needed to be consensually contracted between caregivers and care-recipients on an outpatient basis. That fit perfectly with the sensibilities of conservative scrooges searching for ways to cut the state budget, and all too happy to dismantle a massive state hospital system denigrated as inefficient at best and inhumane at worst. The replacement chosen was an untested, less costly treatment model: the community mental center.

How nice that everyone agreed.

Everyone, that was, except for many families of hospitalized, hopelessly-decompensated, often self-destructive and occasionally violent psychotics. They’d lived with the reality of severe mental illness and wondered what “freedom” would bring. But there weren’t enough of these families to matter.

Were the state hospitals wretched nightmare-palaces straight out of “One Flew Over the Cuckoo’s Nest”?

A few were. But many were well-run institutions for patients in wretched circumstances, providing optimal care within the limitations of what constituted psychiatric treatment at that time: a handful of poorly understood psychotropic drugs and supportive talk-therapy. Perhaps more important, they offered clean beds and three squares a day, which led to them being belittled as warehouses. But the protective environment of the best state hospitals has yet to be improved upon, or even matched.

No matter, this was baby-and-bathwater time.

When I entered graduate school in 1972, so pervasive was the push to deinstitutionalize that a newly minted course was added to the mandatory curriculum: Community Psychology, a cobbled-together travesty that stood apart from all my other coursework due to its emphasis on polemics and aversion to science.

The basic premise of Community Psych–that severely mentally ill people could be depended on to show up for treatment voluntarily–never made sense to me. The core of the most common and debilitating psychosis, schizophrenia, is degradation of thought and reason. So the idea that people with fractured minds could and would make rational, often complex decisions about self-care seemed preposterous.

One day, I voiced that opinion in class, questioning if any mechanisms were being set in place to prevent a flood of schizophrenics from ending up on the streets, homeless, helpless, victims of crime and, in some cases, victimizers. The Community Psych professor–one of the liberationists–responded with a patronizing smile and a folksy account of the success of a program in rural Belgium or some such place, where humble working folk created a therapeutic milieu by volunteering to house psychotics in their humble homes and everything ended up peachy.

I didn’t challenge what amounted to flimsy anecdotal data, but I did question its relevance to the plight of thousands of severely mentally disabled individuals set loose in vast urban centers. The professor’s smile tightened and he changed the subject; and I resolved to get through this joke of a prerequisite and concentrate on becoming the best psychologist possible.

By the time I received my doctorate in 1974, the doors to many of the locked wards had been flung open and the much vaunted community mental health centers were being built–predominately in low-rent neighborhoods. A few years later, government funding for these allegedly humane treatment outposts had been cut, as yet more fiscal belt-tightening was inspired by findings that they didn’t work.

Because crazy people rarely showed up for treatment voluntarily, and when they did, the treatment milieu consisted of queuing up interminably at Thorazine Kiosks.

And now we had a Homeless Problem.

And everyone was astonished.

Estimates vary but there’s no doubt that a significant percentage of people living on heating vents, pushing their belongings in shopping carts, squatting in city parks and immersed in the squalor of tent cities suffer from severe mental disease. And their psychosis is often exacerbated by drug and alcohol abuse–what is, essentially, a regimen of self-medication that should make a Szaszian proud.

Many of these unfortunates end up as victims of violent crimes. A few become victimizers and when they do, watch out. For though it is true that schizophrenics are responsible for a proportionally lower rate of violent offenses than the general population (because many forms of the disease engender passivity and physical inactivity), when crazy people do act out the results are often horrific: bloody spree killings ignited by paranoid thinking and the angry urgings of internal voices.

Which brings us to outrages such as the Virginia Tech massacre.

Diagnosis from afar is the purview of talk-shows hosts and other charlatans, and I will not attempt to detail the psyche of the Virginia Tech slaughterer. But I will hazard that much of what has been reported about his pre-massacre behavior–prolonged periods of asocial mutism and withdrawal, irrational anger and hatred, bizarre writing and speech–is not at odds with the picture of a fulminating, serious mental disease. And his age falls squarely within the most common period when psychosis blossoms.

No one who knew him seems surprised by what he did. On the contrary, dorm chatter characterized him explicitly as a future school-shooter. One of his professors, the poet Nikki Giovanni, saw him as a disruptive bully and kicked him out of her class. Other teachers viewed him as disturbed and referred him for the ubiquitous “counseling”–an outcome that is ambiguous to the point of meaninglessness and akin to “treatment” for a patient with metastasized cancer.

But even that minimal care wasn’t given. The shooter didn’t want it and no one tried to force him to get it. While it’s been reported that he was involuntarily committed to a “Behavioral Health Center” in December 2005, those reports also say he was released the very next morning. Even if the will to segregate an obvious menace had been in place, the legal mechanisms to provide even temporary “warehousing” were absent. The rest is terrible history.

That is not to say that anyone who pens violence-laden poetry or lets slip the occasional hostile remark should be protectively incarcerated. But when the level of threat rises to college freshmen and faculty prophesying accurately, perhaps we should err on the side of public safety rather than protect individual liberty at all costs.

If the Virginia Tech shooter had been locked up for careful observation in a humane mental hospital, the worst-case scenario would’ve been a minor league civil liberties goof: an unpleasant semester break for an odd and hostile young misanthrope who might’ve even have learned to be more polite. Yes, it’s possible confinement would’ve been futile or even stoked his rage. But a third outcome is also possible: Simply getting a patient through a crisis point can prevent disaster, as happens with suicidal people restrained from self-destruction who lose their enthusiasm for repeat performances.

At the very least, in a better world, time spent on psychiatric watch could’ve been used to justify placing the Virginia killer on a no-buy gun list. I’m not naïve enough to believe that illegal firearms aren’t within reach for anyone who really wants them, but just as loud dogs deter burglars and crime rates drop during harsh weather, sometimes making life difficult for a would-be criminal is enough.

But all this remains in the realm of fantasy. Penning up and carefully scrutinizing the killer was never an option. Not in Virginia or California or any other state in the union. Because in our well-intentioned quest to maximize personal liberty, we’ve moved conceptual eons away from taking the concept of dangerousness seriously.

The best predictor of future violent behavior is past violent behavior, yet we regularly grant parole to murderers, serial rapists, chronically assaultive individuals and habitual pedophiles. Even when we do attempt to segregate low-impulse multiple offenders with effective tools such as with three-strikes laws, liberationist clamor never ceases.

Talk to anyone who’s tried to commit a dangerously violent child or parent for even a few days: A stranger with a law degree will show up at the hearing and paint you as a fascist. So it’s far too much to expect anything resembling a decisive approach to those whose level of threat remains at the verbal level.

Given the excesses of the past–husbands committing troublesome wives, involuntary sterilization of those judged defective–extreme caution is warranted. But like drunk drivers, we sway from one side of the legal road to the other and find the sensible center lane elusive.

Unless we confront the unpleasant fact that the brains of a small percentage of our citizens incubate dark, disturbed thoughts that can blossom into vicious behavior, we can look forward to repeats of last week’s outrage.

Dr. Kellerman is clinical professor of pediatrics and psychology at USC’s Keck School of Medicine and the author of 27 crime novels and three books on psychology, including “Savage Spawn: Reflections on Violent Children” (Ballantine, 1999). His current novel is “Obsession”(Ballantine, 2007 ).