The New Year rang in about an hour ago in Boquete, with the usual spectacular fireworks displays and partying. Once again I am home alone at this celebratory time. For three years now I've planned to party with the best of them, and at the last minute backed out to stay home and reflect. It's never an intentional decision to stay home and reflect. I'm not that noble. It's more a case of suddenly lacking the energy to get all dressed up to go socialize with people I see every day, anyway. Expats tend to turn out at restaurants or at social scenes. Panamanians party at home with family members. And although I'm fortunate enough to be invited to join a few Panamanian families, it seems for me New Year's eve is becoming a time of personal reflection. I've made the mandatory phone calls to close friends and relatives. The rest I'll take care of in the morning.
Just found an article I really like, written by a forensic psychiatrist for an online professional medical journal. It's a response to inquiries seeking some explanation for the recent events in Newtown, Connecticut. The online resource requires membership to access articles, so I can't paste a link that would be of any use to most readers. Instead, I've copied and pasted the article, with hopes that by acknowledging the author and source, I haven't violated any publishing regulations. I'm not familiar with Dr. Knoll. His article was published by medscape online. But it addressed many of my recurrent thoughts on the matter. I believe he has realistically identified multiple aspects of a very complex issue and has laid supporting foundation for the glaring "paradigm shift" that has got to take place---globally, and in the USA, especially. It's a very long article, best read at your leisure . Or perhaps when sleep eludes you...! Happy New Year everyone.
Mass Shootings and the Ethic of the Open Heart
James Knoll IV, MD Dec 20, 2012
From the poem, "Holes" by David Kaczynski
Here, feel this silver dollar shot through:
One side seductive, smooth,
the obverse, jagged.
When we pour our wrath into a small hole
we imagine the injury caused, but never its hardness
I believe there is reason to be optimistic. News media are focusing on emotions and healing. Politicians are saying only that they have no words to respond to the tragedy. These actions suggest an attempt to face the utterly unacceptable with an ethic of the open heart. The open heart "weeps with compassion for itself and others."  I'll not address here any details from the recent tragedy in Newtown, Connecticut. At this point, I, too, have no words when it comes to the jagged hole that was recently left in our hearts. I also have no details, nor access to the facts of the case, and have a policy of not commenting on these tragedies in their wake.
I've adopted this policy because I worry about distracting from the critical, solemn work of grieving and community healing. I also wish to refrain from speculation and do not want to give attention to the perpetrator at this point in time. Instead, I would like to address the subject of mass murder generally, and in a way that I hope will lead to constructive discussion. Having done some research in this area, I am often contacted in the wake of these tragedies. In this article, I will address some of the most common questions that are asked of me by the media, in addition to some of my own open-hearted reflections.
Unpredictable, but Possibly Preventable
Mass murder is not new, but in recent decades it has taken on a different tone. The tone has been affected by a cultural shift, easy access to high-power weapons, social media, and 24/7 media coverage of the tragedies. Although research had previously indicated that its incidence was not increasing, the data will now need to be reconsidered in light of the past several years. Each time another mass shooting happens in the United States, the response is entirely predictable. After the media coverage subsides a bit, a familiar sequence unfolds: Who is this person? Why did he do it? How did the "mental health system" fail him? How did he get his hands on such a powerful arsenal? Would that the actual tragedy was so predictable beforehand.
Mass murder predictable? Not likely. Preventable? Here is where I believe we have a bit of a chance. But it depends -- how much do we really want to prevent mass murder? And by "how much," I mean: How much responsibility are we willing to take on in an effort to make a meaningful difference? We can talk about it for a few more decades, and in the meantime we will probably have a few more Auroras, Virginia Techs, or Columbines. I cannot mount an argument against those who proclaim that these tragedies are impossible to predict or prevent solely with psychiatric efforts. I can't and I won't, because I agree with them. But I do believe that there are other ways that are far more effective and, ultimately, far more beneficial for society.
It turns out that recently, Bolivar, Missouri, narrowly avoided becoming the next Aurora. How? The mother of a potential mass murderer contacted police because she was worried that her son, Blaec Lammers, had intentions of shooting people during the opening of the final film in the popular Twilight vampire movie series. Predictably, the mother was right to be concerned. When Tricia Lammers' son was questioned by police, he said that he had already bought tickets and "planned to shoot people inside the theater." Upon investigation, police found that Lammers "did have the weapons; he did have the ammunition...and then he made the statements to the officer about what his plans were." 
This leads me to one of my first suggestions on how to prevent mass murder. The mayor of Bolivar, or better yet, the governor of Missouri, should give Tricia Lammers a medal. In fact, if neither party will do this, I will personally have one made and sent to her. The medal will be engraved with the words:
For Brave, Humane, and Lifesaving Action
How many can say that they saved potentially dozens of lives, while also saving the life and mental health of a family member? Tricia Lammers, I applaud you, and others should as well. Am I making too big a deal out of this mother's actions? I do not believe so. I think her act represents one of the strongest methods of prevention available. Third parties, particularly family members, are the most likely to have preoffense knowledge or significant concerns.  In other words, potential mass murderers often "leak their intent"  to third parties who, in turn, remain quiet for various reasons.  But it is important for family members to know that help and resources exist. Tricia Lammers was able to rely on some of these resources, most notably the National Alliance on Mental Illness, which has offices all over the country. [7,8]
In contrast to Ms. Lammers, the silence of third parties seals the fate of both their loved ones and scores of innocent people. Need another example? They are not difficult to find. Take the relatively recent case of Anders Behring Breivik who, on July 22, 2011, obliterated more than 70 innocent people in Oslo.  Breivik's sister had been concerned enough to warn her mother at least 2 years prior to the tragedy. 
At this point in time, most authorities agree that preventing mass murder requires measures well above and beyond the "mental health system."  For example, after Jared Loughner perpetrated the tragic mass shooting in Tucson, mental health experts concurred that "homicides perpetrated with firearms against strangers by individuals with mental disorders occur far too infrequently" to predict or prevent with mental health efforts alone.  Yet after the Tucson tragedy, there was still the familiar media refrain: "Did the system fail Jared Lee Loughner?"[emphasis added] 
Friends, Romans, countrymen, lend me your ears; I come to bury the system, not to praise it. When the inevitable human tragedy recurs, point not at the system, for you will be pointing at nothing at all. An apparition. A fiction created some 50 years ago which only returns as a ghost in the night. And so it goes. American society seems comfortable to periodically point at and condemn the ghost every now and then whenever a serious haunting takes place. But many are not likely in a position to see the cycles that psychiatrists see due to their permanent residence near the graveyard. We see the perpetual tragedies, followed by the haunting incantations: "The system... the system failed him..."
After one tragedy in Massachusetts, the phantom apparition was summoned yet again: "Many people wondered aloud whether the system had failed both the suspect and the victim. How had [the victim] ended up alone in a home with a psychotic man who had a history of violence and was off his medication?... Did he need the tighter supervision of a hospital?"  To his great credit, the state's former mental health director responded, "Will this case be the canary in the coal mine? Will it signal that we've gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?" Alas, would that it were so. So many canaries have succumbed by now that our consciences have become ghostly aviaries.
It is my contention that there exists no legitimate "system" in the United States when it comes to mental health treatment. Despite this, we most certainly want to believe in one, particularly so that when tragedies occur, we will have something to cast our outrage upon. For example, when asked where they placed blame for the Tucson shooting, a majority of Americans said in a USA TODAY/Gallup Poll that they placed a "great deal of blame on mental health system failures."  Because it is possible that the term "mental health system" may be thrown about loose and fast, let us consider it with a bit more precision.
From a literal perspective, one might define a system as an organized, regularly interacting set of principles forming a network -- especially for distributing something or serving a common purpose.  Even more germane, the Surgeon General's report on Mental Health  gives us the following definition: "[D]iverse, relatively independent, and loosely coordinated facilities and services -- both public and private -- that researchers refer to, collectively, as the de facto mental health service system" [emphasis not added].  Because a particular legal term has been invoked, let us examine the definition of de facto. Here we discover both a lay and a legal definition, respectively:
- Exercising power or serving a function without being legally or officially established;
- Used to characterize...a state of affairs that must be accepted for all practical purposes, but is illegal or illegitimate.
Thus, per the Surgeon General's own definition, the "system" is at best unofficial and at worst illegitimate. Why might it be that in 2012 we have no "legal or legitimate" mental health system? Returning to the Surgeon General's report, we are told that: "Effective functioning of the mental health service system requires connections and coordination among many sectors...Without coordination, it can readily become organizationally fragmented, creating barriers to access. Adding to the system's complexity is its dependence on many streams of funding, with their sometimes competing incentives." 
So, it appears that both lack of coordination and funding inconsistencies confound the system. But as it turns out, these are problems that have never been addressed adequately since the time of their inception -- deinstitutionalization. Deinstitutionalization was the term used to describe the rapid emptying out of state mental hospitals beginning in the 1960s and '70s due to a number of factors, including the patients' rights movement, financial reasons, early hopes for a "magic bullet" in the form of antipsychotic medications, and the never-realized hopes for adequate community mental health services. Thus, deinstitutionalization became "trans-institutionalization," also referred to as the "criminalization" of mentally ill persons. [20,21] Extremely laudable efforts have been made to divert persons with serious mental illness away from corrections (eg, jail diversion and mental health courts). [22-24] But the fact remains that there are large numbers of persons with serious mental illness in the correctional system, and the trend shows no signs of reversing itself.
In Virginia, jails now house more persons with serious mental illness than do Virginia psychiatric hospitals.  The Los Angeles correctional system has been referred to as America's largest psychiatric facility.  It is now the jails that serve as the "predominant settings for providing acute psychiatric inpatient treatment."  During this era of retribution, correctional facilities have now earned the designation "the new asylums."  Correctional administrators readily concede that their facilities are being used as "dumping grounds for many individuals who could be better served through early intervention in noncustodial environments because other options are just not available."  But alas, "interventions in noncustodial environments" are in short supply in 2012.
Couldn't this have been foreseen? Quite unlikely, I believe, for a variety of reasons, including: "The fact that most deinstitutionalized people suffer from various forms of brain dysfunction [which] was not as well understood when the policy of deinstitutionalization got under way."  Indeed, it was poorly planned deinstitutionalization that created our present illusion of a system "by discharging people from public psychiatric hospitals without ensuring that they received the medication and rehabilitation services necessary for them to live successfully in the community."  The mental health system has failed no one, simply because there is no system to speak of. Thus, we must look elsewhere for solutions to violent outbursts by mass murderers, most of whom have never accessed mental health care to begin with.
The answer to "why" is: It depends. It depends upon the mind of the individual perpetrator and of the accumulated bio-psycho-social factors that affected him. And then, after all of that is considered (no simple endeavor), layer on top the fluid vicissitudes of an extremely distraught and nihilistic individual who has access to firearms and ammunition. When all of this is truly considered, one begins to see that the answer to "why" is a highly unsatisfying "it depends" and "it is complex." I can analyze a case in minute detail and proceed to give you the complex answer. Your eyes will invariably glaze over.
It is possible to study individual cases in great detail and gain a better understanding of that individual, his motivations and mental anguish. A well-trained, experienced forensic psychiatrist, who has access to all the evidence, will be very likely to give you a reasonably reliable answer to the question of "why" for a single case. But then, how does this translate into prediction or prevention on a large scale? It often doesn't. Still, there are lessons to be learned in a broad sense. But these lessons cannot be expected to make a material difference because we have not yet understood the deeper lesson that these events are pointing us to. We are not listening carefully enough. This has become ritual. A ritual of sacrifice. These recurring tragedies are solemn appeals begging us "to expose to the light of reason the role played by violence in human society."  Rituals have meaning beyond the act itself, and they communicate a message. The message communicated here is:
"I carry profound hurt. I'll go ballistic and transfer it onto you."
A few psychiatrists in this day and age will recognize the formula. It has a name. It used to be called "projective identification" at a time when psychiatrists were able to do psychotherapy with their patients. It is the process by which humans do unto the other that which they cannot stand within themselves. If you are mathematically minded, try instead: X experiences feelings that belong to Y that Y is unable to process. Thus, Y projects them onto X. Let Y represent the mass murderer. Let X stand for victims, families, and much of society.
Is this psychobabble? The name may be, but the process is quite real and has been observed for centuries: "The notion that we can transfer our guilt and sufferings to some other being who will bear them for us is familiar to the savage mind."  He seeks to "shift the burden of his pains and sorrows to another, who will suffer them in his stead."  Understand these dynamics and you will begin to have a clearer and more satisfying answer to "why."
Mass murder, strictly defined, is the killing of 4 or more victims at 1 location within 1 event.  It is both a rare and catastrophic event that is usually carried out by a single individual. Mass murder is distinguished from both spree and serial murder. In the case of serial murder, there are at least 2 victims, the victims are killed in a noncontinuous fashion (ie, there is an emotional "cooling off" period between murders), and the murders usually involve a sexual component. [34,35] In contrast, a spree murder involves killings at 2 or more locations with very little time in between murders and no cooling-off period. [34,36] The type of mass murder discussed here involves that carried out by a single, heavily armed individual who is very likely to expect to die as a result of the event. This further distinguishes it from gang-related mass murder, in which the perpetrators do not typically expect to die, and their motive involves various forms of profit, drug trade, or territorial disputes. 
At the present time, it is typically the high-profile cases that are most heavily covered by the media, yet these are the least representative. In many cases, the precise number of victims may be arbitrary. Research has been slow in the area of mass murder, and there is not yet an officially accepted typology. However, it is clear that not all mass murderers are alike in their motivations and psychology. Some may be driven by strong feelings of revenge born of social alienation or a perceived injustice. Others may also suffer from severe depression or, rarely, psychosis. Still others may resemble terrorists with idiosyncratic political beliefs. Such was the case with a Polish chemistry professor who was recently arrested before he could blow up a parliament building. Dr. Brunon Kwiecien openly supported Breivik and wished to carry out a similar attack, but on a larger scale.  His wife alerted authorities after he asked her how he could make a biological "dirty bomb." When he was apprehended, he was found to be in possession of high-powered, military-grade explosives, bomb-making equipment, several hundred rounds of ammunition, a bulletproof vest, and a pistol.
The majority of research indicates that there are factors common to mass murderers, such as extreme feelings of anger and revenge, the lack of an accomplice (in adult mass murder), feelings of social alienation, and planning/organizing the offense. In a detailed case study of 5 mass murderers who were caught before they were killed, a number of common traits and historical factors were found.  The subjects had all been bullied or isolated as children, turning into loners who felt despair over being socially excluded. They were described as suspicious, resentful, grudge-holders who demonstrated obsessive and inflexible thinking.
Not surprisingly, they were also narcissistic and coped with personal problems by blaming others. Their worldview was characterized by seeing most others as rejecting and uncaring. As a result, they spent a great deal of time nurturing their resentment and ruminating on past humiliations. The ruminations evolved into fantasies of violent revenge. They did not see their own violent death as a deterrent, particularly because they perceived it as bringing them fame with an aura of power.
Careful study of individual cases of mass murder often reveals that the offender felt compelled to leave some type of final message. [40,41] These messages may be written, videotaped, or posted on the Internet or social media networks.  Very often, these messages are rich sources of forensic psychiatric data that help us get a deeper understanding of the perpetrator's motive, mental state, and psychological disturbances.  These communications often have great meaning to the perpetrator, or he would not have bothered to record them. He often realizes that they will be the only "living" testament to his motivations and inner struggle. 
In sum, the factors associated with and contributing to mass murder are complex and multidetermined. Biological factors may include possible brain pathology, as well as psychiatric illnesses. Psychological factors include a negative or fragile self-image, a strong sense of entitlement, and vulnerability to humiliation. Social factors include social isolation/alienation, being bullied, and marital or financial loss.
The reality is that mass murder cannot be "predicted" as such, particularly by persons outside the perpetrator's social circle.  Any hopes of prevention must rely on various approaches acting together to provide a widely cast safety net.  Yes, it's rare, but the fallout is profound, devastating, and long-lasting. I conclude that it is society that must first decide whether it cares enough to take meaningful action. I will forever advocate for better mental health services and improved access to care. However, at the present time, measures such as screening for prior psychiatric treatment (often in the distant past) among individuals who want to legally purchase firearms represents no meaningful intervention. [46-48]
Here I refer to the Brady Handgun Violence Prevention Act and relevant portions of the National Instant Criminal Background Check System (NICS). At the present time, this system is an inconsistent patchwork across the country, with different states handling the issue quite differently. There are many other problems with the NICS system, but they are beyond the scope of this article. However, suffice it to say that pouring precious resources into a system that evaluates anyone with a history of involuntary hospitalization (sometimes 20 years prior) who is also honest enough to go buy a firearm legally does not seem to me to be a meaningful intervention.
Experience has shown us that, at this point in time, the higher-yield interventions are:
- third-party reporting of concerns or leaked intent;
- sensible gun control laws; and
- media responsibility.
Having already addressed the issue of third-party reporting with the example of Lammers' mother, I now turn to the perennial and contentious subject of gun control in the United States. It turns out that countries with less stringent gun control laws have been observed to have a higher risk for mass murder than countries with stricter laws.  In contrast, consider an Australian observational study done in the wake of a highly publicized 1996 mass shooting in Tasmania.  The study compared mass murders before and after Australia enacted gun law reforms that included removing semiautomatic firearms, pump-action shotguns, and rifles from civilian possession. In the 18 years before the gun laws, there were 13 mass shootings in Australia. In the 10.5 years after the gun law reforms, there were none.
Dr. Allen Frances (Chair of the DSM-IV Task Force) has framed the situation a bit more bluntly. He believes that we have only 2 choices: "Accept mass murder as a part of the American way of life...[or] Get in line with the rest of the civilized world and adopt sane gun control policies."  But Dr. Frances' latter option seems difficult for many to consider, let alone accept. Others, such as filmmaker/activist Michael Moore, have speculated that it is our deep-seated, long-standing fear that keeps us clutching at our guns. [52,53] I will not lay out here all of the debate but would only point out that there is "no other democracy on the face of earth that experiences this type of gun violence. We are the only free society that has yet to address this problem." 
Our rates of gun violence far exceed that of other countries. In a Time Magazine piece on gun violence in the United States, Fareed Zakaria noted that: "The gun-homicide rate per capita in the U.S. is 30 times that of Britain and Australia, 10 times that of India and four times that of Switzerland. When confronted with such a large deviation, a scholar would ask, Does America have some potential cause for this that is also off the chart? I doubt that anyone seriously thinks we have 30 times as many crazy people as Britain or Australia. But we do have many, many more guns." 
Given these associations, and the fact that at the present time psychiatry is largely impotent to "stop" or "predict" mass murder, what can be done? Perhaps confronting gun-related violence as a serious public health issue is a start -- for example, adopting sensible restrictions "such as eliminating the sale of semi-automatic weapons."  This is an approach that has already been advocated by both the American Psychiatric Association and the International Association of Chiefs of Police. But, of course, it must ultimately be society that decides to take this path. If and when it does, it will be critical for the regulations to be applied nationally or otherwise be doomed to failure: "A piecemeal approach to firearms regulation that affects only some cities or states cannot be expected to produce a robust effect on gun-homicides or mass shootings." 
The issue of media responsibility in helping to prevent mass murder has been highlighted since the Columbine and Virginia Tech tragedies. It became clear after these events that some perpetrators were, in part, motivated by the infamy they saw previous mass murderers receive via news coverage. Although some news media may be disinclined to admit it, they may be in the business of searching for "the right sort of madness" to capture the public's imagination.  This may involve exploiting violent and tragic acts carried out by mentally or emotionally disturbed individuals. In reality, it is a difficult task to report the occurrence of a mass murder in such a way that the public is adequately informed while withholding certain details (eg, numbers of victims, whether the offender was killed, etc.). Efforts to develop a universal reporting code have been recommended that would appropriately cover the tragedy and reduce the impact of the copycat effect.  Most recommendations involve ensuring that the perpetrator is neither glorified nor demonized. In fact, avoiding much emphasis on the perpetrator seems to be a good general rule. Rather, media should emphasize victim and community recovery efforts. I would add here that from what I have seen so far of the orthodox news media's coverage of Newtown, it seems that they are getting this message and are doing an exemplary job.
As a psychiatrist, I desperately wish that improved psychiatric care and access to treatment could save the day. I have little doubt that over the years, unsung mental health heroes have averted possible mass murder tragedies. Yet, it seems all too clear to me that this is simply not a problem that psychiatry can solve on its own. No one should expect psychiatry to do the impossible -- it already has its hands full with the possible. Therefore, I am suggesting 3 additional methods of prevention that should be seriously considered if we wish to confront the tragic phenomenon of mass murder: careful reflection on gun control laws, responsible media reporting, and acknowledging the heroism of individuals such as Tricia Lammers with the hope that more will follow her compassionate, responsible example.
How might we as a society enhance the value of one's effort to bare his own burden (with the assistance of qualified others), understand it, and transform it from "vinegar into honey"?  We think far too shallowly about these events. We concern ourselves with metal detectors, security systems, "profiles," preventing "the mentally ill" from obtaining firearms. This is shallow, facile thinking. It is time that we thought deeper, in order to cultivate a respect for how to teach compassion, nonviolence, and personal responsibility in individual minds. Then we'll be going beneath the surface of this problem which has repeated itself by now a sufficient number of times to teach us.
It is my contention that these recent tragedies invite us to take a more substantive, meaningful look at how we view psychological suffering and violence as a species. In essence, it is a call to face ourselves with an open and fearless heart. Can we begin to acknowledge the role of the mind and the vital need to train the mind such that we leave behind the savage ways of doing unto the other that which we cannot stand within ourselves? The fearless and open heart searches for happiness, yet is willing to let go of pain, frustration, and that which it cannot get or avoid. An open and fearless heart seeks to take responsibility for its own anger. It does so by learning how not to externalize blame, being willing to examine itself, and cultivating responsibility. In the final analysis, regardless of "what social or biological factors are involved, ultimately we must take responsibility for our anger." 
I would like to conclude with a plea that, in the wake of an unfathomable tragic event, we make thoughtful, wise decisions that do not lose sight of the big picture. This is perilously easy to do, and forensic types like me are all too familiar with the adage that egregious cases often stimulate rash, ill-conceived laws. My plea is for us to keep sight of our duty to life, which brings me back to the ethic of the fearless, open heart. An open heart means freedom and the mature ownership and control of our own thoughts, feelings, and actions. The steps to freedom lie within each individual, not in others or outer circumstances. It may be that this is not a lesson that is widely taught in schools these days. Everyone wants freedom, yet it is tolerable "only when there is a common restraint on it. The restraint is called ‘responsibility' and is defined as a virtue." 
Here is our opportunity to walk the path of the fearless heart. It is the case that we may use these indescribably horrendous events to "either wake ourselves up or to put ourselves to sleep."  Yes, they represent the unacceptable to the absolute degree, but we must not turn away -- only towards, never away.  In closing, I should mention that David Kaczynski, whose poem I opened with, is an example of walking the path of the open and fearless heart. He did not turn away from the unfathomable fallout connected with his brother Theodore. Rather, he turned inward and found the courage to open his heart and help others. In doing so, he fully accepted responsibility. Responsibility has different meanings. Here, it is used to mean "the ability to respond with a variety of constructive choices" rather than react out of anger.  Responsibility is an acquired skill that is cultivated by training the mind. And I say again: The open, fearless heart searches for joy. It weeps with compassion for itself and others.
When the individual is in conflict within himself he must inevitably create conflict without, and only he can bring about peace within himself and so in the world, for he is the world.