Challenges abound in identifying, treating dangerous mentally ill people


After Newtown, the cry went out, “We’ve got to do something about mental health!” Oh? Yeah? What, exactly?

You may have read the story “I am Adam Lanza’s mother” by Liza Long. It went viral on the Internet just a few days after the Newtown shooting. But, if you missed it, you can read it here: http://thebluereview.org/i-am-adam-lanzas-mother/.

The story is sobering. I’ve “met” the author and her son several times over the course of my career in behavioral health. The other day I was asked during a radio interview whether I had ever treated a patient about whom I suspected a potential for doing egregious evil. Have I ever treated an adolescent or young man who fits the profile of a spree killer? Actually, the caller’s exact question was, “Do you ever get creepy feelings about a patient?”

Yes. Perhaps four or five times in the near 30 years I’ve been in this field. Yes, I’ve had a creepy feeling. Enough so as to refer the patient to extensive psychiatric testing, assessment and diagnosis. Enough so as to hope the patient will respond well to medication, yet always remembering that one of the unwritten diagnostic criterion for these types of mental illnesses is “flat refuses to swallow the pill and dares you to make him try.” I’ve had a creepy enough feeling to warn the parent(s), to initiate conversations about “safety plans” and to negotiate certain immutable boundaries that, if violated, carry the consequence of immediate trips to a psychiatric emergency room and/or, if necessary, calls to law enforcement.

But, here’s the deal. Mentally ill Americans have rights. We can’t live in a world where Steven Kalas can hospitalize you against your will because he has a creepy feeling, a hunch. Because his patient fits a profile. The law allows me to involuntarily hospitalize a patient who has made clear threats of “danger to self” or “danger to others” or is exhibiting clear signs of decompensation (absent reality contact, obvious personality disturbance, etc.)

However, I gotta tell you, most such hospitalizations are brief and provide little hope for the long term. The best health insurance plans increasingly don’t include funds for 30-plus-day stays (let alone six months) in cutting edge mental health facilities. Most times, the involuntarily committed patient is discharged after a few days of observation with a pharmacy prescription, some recommendations and perhaps a schedule of support groups.

Unless you’re wealthy, or unless you have evidence necessary to convince a judge to order a legal commitment to care … well, here’s the hard truth: Spree killers often haven’t done anything wrong until they pull the trigger for the first time.

Some psychiatric diagnoses are statistically associated with violence and the potential for violence. True sociopaths, for example. (I emphasize “true” because the word “sociopath” is these days being kicked around in sloppy colloquialism.) For instance, the shooters at Columbine, struck me as sociopathic. That is, not crazy.

Some paranoid schizophrenics are dangerous. But not the majority. Some acutely depressed people can be dangerous. The grandiosity of a pathological narcissist can swell to megalomaniacal proportions, and turn to violence. The despair of a pathological borderline can do murder.

But, hear me now: There is no DSM diagnosis including the criterion “Walks in and kills everybody.” I say again, something else is going on in this spree-killing phenomenon unique to our time.

In 2010, James L. Knoll published “The Pseudocommando Mass Murderer: The Psychology of Revenge and Obliteration” in The Journal of American Academy of Psychiatry and Law. For me thus far, Knoll provides the most helpful description of the mind of a spree killer:

“The pseudocommando is a type of mass murderer who kills in public during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. He has no escape planned and expects to be killed during the incident. Research suggests that the pseudocommando is driven by strong feelings of anger and resentment, flowing from beliefs about being persecuted or grossly mistreated. He views himself as carrying out a highly personal agenda of payback. Some mass murderers take special steps to send a final communication to the public or news media. … It is argued that revenge fantasies become the last refuge for the pseudocommando’s mortally wounded self-esteem and ultimately enable him to commit mass murder-suicide.”

Paranoid. Persecuted. Angry … and entitled to exact revenge. If we can identify these people before they snap, maybe we can intervene to make a “snap” less likely.

You can read Knoll here: http: //jaapl.org/content/38/1/87.short.

Steven Kalas is a behavioral health consultant and counselor at Las Vegas Psychiatry and the author of “Human Matters: Wise and Witty Counsel on Relationships, Parenting, Grief and Doing the Right Thing” (Stephens Press). Contact him at skalas@reviewjournal.com.