America, Love It or Heal It

A blog about health, health care, and health care reform

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Our daily neuroses and occasional psychoses

The dust had hardly settled on the Sandy Hook elementary school when the most futile of all debates began: is the lack of mental health infrastructure at fault for Sandy Hook, or are the mentally being unfairly blamed for violence? Both positions are both right, and they are both wrong.  Mostly, it’s a matter of definition: what does it take to define someone as “mentally ill”?

If you read the bible of the fine folks over at the American Psychiatric Association - the Diagnostic and Statistical Manual (DSM-4) - you will find that depression, schizophrenia, and a variety of other wide-cast diagnoses fit into one category (“axis I”), while mental retardation and personality disorders are kicked over into another category (“axis II”).  There is little biological evidence (or even sociologic evidence) for these categories. Indeed, I think that rightly-maligned Sigmund Freud invented a better paradigm back in the day when he separated the “neurotic” (those with routine disturbances that interfere with everyday life) and the “psychotic” (those entirely and dramatically disconnected from reality).  

The mantra “The mentally ill are not violent” belies a few unfounded statistical presumptions.  We presume that probability predicts individual behavior on a one-to-one basis – that is, if mentally ill people are more likely to be victims than perpetrators, that mentally ill people are never perpetrators of violence.  This is not true, either statistically or factually.  We also presume that we have included all diagnoses in this statistic; unfortunately, anti-social personality disorder (sometimes known as “sociopathy” or “psychopathy”) accounts for a disproportionate number of folks taking up space in our jails for violent crimes, but is an axis II diagnosis - if you include this as a mental illness, that assertion that mentally ill people are not violent becomes false almost from the outset.  Most importantly though, there is the very important fact that no matter what the diagnosis, in general we all agree that what was happening in the heads of people like Jared Loughner, Seung-Hui Cho, and Adam Lanza when they chose their climactic acts was not within the realm of what the general public is going to call “normal.”  Something was off.  Something was saddened, something was angered, something was vengeful, maybe something was delusional, but something was off.

Often, circular reasoning is employed to then declare these perpetrators to be mentally ill.  In one manner, this circular reasoning is an offense against science and common sense.  But we still have to address the idea that the mind-set of these perpetrators was outside of the norm, outside of what I decided to do when I got up out of bed this morning, outside of what you thought was the best course of action last time you were red with anger at another person, outside of what any but the rarest individuals are going to find acceptable.  What we have to address is that every one of these killers – the Columbine shooters, the Aurora shooter, the Virginia Tech shooter, and now Adam Lanza – was in a very bad head space.  This place may have been schizophrenia, this place may have been mania, this place may have been any number of zones housed under Freud’s umbrella of “psychosis.” Or this place may have been the fascination of sociopathy or psychopathy - that shadowy realm of people who lack the brain parts that install conscience, social anxiety consequent to bad behaviors, and compassion in the rest of us. Or this place may have been so much more mundane: without hallucination, without delusion, without a manic rush, without anything much more dramatic than what Freud would have called “neurosis.”   This is the province of excessive anxiety, of excessive anger, of depression, of hopelessness, of revenge and remorse, of distorted senses of self and justice.  These are much harder to diagnose – what is the DSM-4 criteria for “hopelessness brought on by years of bullying”? or “unbridled anger at being turned down by every woman ever, even it it’s because you were creeping them out?”  There is no mass shooter who does not turn up some kind of emotional landscape of motivation (indeed, because there is no human action that exists outside of its emotional context).  What is so disturbing is that so many of the motivations are not inside the comforting world of “crazy;” they fall decidedly into the non-comforting world of the very distraught, but entirely sane.  That which Freud would have called neurotic.

This is why the mental health advocates are so very right, and so very wrong: because the instinct to blame violence on psychosis is so righteously inaccurate, and so very prone to stigmatizing and marginalizing people who are more often victims than perpetrators of violence.  And because, simultaneously, the need to treat mental unwellness is key to preventing these kinds of tragedies.  But we have to consider “mentally unwell” not as the minority of psychotics (or the super-minority of psychopaths), but in the majority of neurotics.  Neurosis – that’s most of us on a very bad day.  That’s the anxiety that makes teenagers cut themselves just for the sharp twinge of relief.  That’s the anger that makes people punch walls, or their wives.  That’s the depressive tendency that makes it just kinda hard for some people to get out of bed some days.  This stuff is insufferably common, even boring, but it is the stuff of mental unwellness on a scale that dwarfs manic episodes, psychotic depressions, and schizophrenic delusions. It’s you and me, on the bare edge of our roughest times, with just a touch more explosiveness than most of us can hammer together.  But it probably explains more modern massacres than either frank psychosis or frank sociopathy.  

This demilitarized zone between psychosis and neurosis is where the hard work of general mental health begins.  It begins with coming to grips with the idea that mental illness is not limited to the obvious – it includes the states of mind that are simply unwell, unwell enough to cause harm.  This territory traverses some entirely unsavory phenomena – developing anger management techniques for men who threaten their partners, or addressing the understated white male rage that seems to underpin so many of these shootings.  It ends with the place where we started: that psychosis does not in and of itself predispose one to violence, but that the gamut of Freudian psychosis, neurosis, and straight-up psychopathy does appear in just about every act of mass violence we know.  We can start with the idea that the mentally ill are not necessarily violent, and end with the idea that some kind of mental unwellness underlies – by that circular definition that people who shoot children are necessarily not within the norms of mental status that we accept – nearly every episode of mass violence.  Without these two contradictory notions coexisting in real time, we will forever bicker about whether the mentally ill are at fault or not, when the real question is not about fault, but how to support and nurture mental wellness in all the myriad of forms it can take. Without understanding the breadth of the problem, we have no hope of ever preventing its consequences.