Like everyone else, I was stunned and horrified by the savagery of the massacre in Newtown, Connecticut. So many lives lost, so many families devastated. As a father and a grandfather, I could not stop imagining the horror I would feel if my own loved ones had been among the victims. The monstrous and terrifying fury of the attack and the pitiful helplessness of the victims compel most of us to think about our own safety, to yearn for a fuller measure of control over our destinies and the fates of our children and our children's children.
As the initial wave of horror washed over me, I felt certain that the young man who committed these atrocities was suffering from a severe mental illness, probably paranoid schizophrenia, very much like the gunmen in other massacres that have occurred in recent years. One only had to look at the pictures of the shooter of Gabby Giffords, the Batman/Aurora shooter, and this young man in Newtown to recognize the obvious madness written on their faces. I kept wondering, why are people like this allowed to live among us?
I immediately recalled the deinstitutionalization programs of the ‘60s and ‘70s, state policies that closed one mental hospital after another in the name of progressive mental health, policies typically accompanied by additional “reforms” that gutted the mental health services that were supposed to support the social functioning of the mentally ill patients who were being discharged. In state after state, one saw more and more of the mentally ill walking the streets during the day and sleeping on sidewalk gratings, or doorways, or in subway cars and buses at night. It was a policy of wholesale neglect promoted under the banner of humanitarianism, community-based treatment, or civil rights. The deinstitutionalization policies of 40 years ago are still with us. And we are still paying the price.
As Joe Nocera stated in a New York Times op-ed piece on December 28, 2012, “The state and federal rules around mental illness are built upon a delusion, that the sickest among us should always be in control of their own treatment, and that deinstitutionalization is the more humane route.” An unholy alliance had formed between well meaning, but naive reformers, budget conscious legislators, and insurance companies seeking to cap their costs. It is an alliance that seems to have held through all the intervening decades, despite the terrible toll it has taken.
Commitment laws have been gutted in the belief that severe mental illness is a political and social problem, rather than a health issue. It is almost impossible to commit anyone these days, and when a sick individual is committed, he or she is generally discharged within days. Moreover, commitment generally requires proof of “imminent danger,” a criterion that would be difficult to demonstrate. With this high bar, would the Newtown shooter, the Gabby Giffords shooter, the Batman/Aurora shooter have been recognized as the menaces they were?
Sadly, the Department of Justice continues its campaign to weaken commitment laws. Commitment in a mental hospital, they argue, “segregates” the mentally ill person from the community and this, they hold, is bad for the patient and violates his or her civil rights. The premise is that everyone should be treated equally and treated within the community, regardless of their degree of pathology or danger.
The president of the American Psychiatric Association, Dilip Jeste did not help the situation when he rather defensively pointed out that this kind of violence cannot be blamed on mental illness. He cited the statistic that only 4 percent of mentally ill people are thought to be potentially violent. However, he neglected to mention, and thereby missed a powerful opportunity to argue for increased funding and facilities for mental health treatment, that it is precisely this 4 percent who commit the violence.
Of course, I recognize that outrage at the destructive social policies of the last decades is psychologically useful in a moment of helplessness. It bolsters one's sense of security, one's belief that such horrors as the New-town massacre are avoidable, that a more perfect world is within our reach if only we had the wisdom, courage, or determination to seize it. As the week wore on, I heard other rallying cries, equally certain, equally indignant, equally desperate: The basic problem is “obviously” guns. Guns should be restricted, assault style rifles should be banned, background checks should be more rigorous when guns are purchased.
Many promote these arguments with the same vigor and certainty with which I argue for better treatment of the mentally ill. And just as there are those who argue for community treatment and civil rights of the
Bob Pyles, M.D., is president of the American Psychoanalytic Association.
mentally ill, others oppose gun control, citing their own civil rights and the importance of the Second Amendment and other legal protections in the Bill of Rights.
I am sure that there are many other points of view: social explanations that attribute causal importance to the social and cultural dislocations of modernity, the social isolation of families in distress, and disintegration of traditional communities and the traditional remedies of communal life. In the days that have passed since the initial shock of the Newtown massacre, I have been reading, contemplating the nature of such episodes, and reflecting; reflecting on the dubious certitude with which I clung to my initial convictions. Simplistic or single-factor explanations provide an illusion of control, an illusion which promotes emotional coping, to be sure, but which does nothing to help us deal with the horrifying realities of explosive, murderous rage.
Simplistic or single-factor explanations provide an illusion of control, an illusion which promotes emotional coping, to be sure, but which does nothing to help us deal with the horrifying realities of explosive, murderous rage.
Reality is more complicated than any absolute explanations we formulate to explain it and will not yield to the simple social remedies put forth by reformers, legislators, pundits, or by anyone with a single “fix” for this phenomenon. We need to grapple with some challenging facts: Mass homicidal behavior of the kind we witnessed in Newtown is often committed by individuals with no prior history of criminal conduct. Some have been in treatment before they commit their crimes. Some may be in treatment or be on medication at the time they commit their crimes. They are not all disadvantaged or socially marginalized people. Adam Lanza, the Newtown shooter, lived in a well-to-do neighborhood and could have found and afforded excellent treatment—if he wanted to get help.
We need to do more than to identify the “one true” cause, lobby for the one best remedy, or attribute causal responsibility to a host of social or psychological factors. We need to understand this phenomenon and we need to understand the individuals who commit such crimes. We need to know how to recognize these very sick individuals and we need to know how to treat them.
I am convinced that we, the community of psychoanalysts, can make a contribution of significant value to this effort. As analysts, we are accustomed to understanding mental life and its pathological vicissitudes at a focal depth that is unique among the sciences. We have been studying vexing questions of aggression, hostility, hate, and violence for many decades. In a recent article published in the Bulletin of the Menninger Clinic (volume 71, number 2, Spring 2007), Walter Menninger describes the valuable contributions that psychoanalysts have already made to our understanding of violent behavior. Here is the synopsis of his article, “Uncontained Rage: A Psychoanalytic Perspective on Violence”:
Explosions of violent behavior have periodically riveted public attention. While such behavior may be associated with a major psychiatric illness, there is a continuing challenge to understand the emotional underpinnings of such behavior, the sources of aggression, hostility, anger, hate, rage, and violence. Analysts from Freud to Karl Menninger to Kernberg to Kohut have speculated as to the confluence of psychological and real forces that prompt violent outbursts. Other analysts have explored the manifestation of aggression and rage in infancy and childhood (Henri Parens). Critical elements prompting such behavior include (1) an individual perceives a narcissistic injury that is experienced as being profoundly unfair, (2) the individual has no hope for achieving a reasonable resolution of the injury, (3) the individual reaches a decision that the injury cannot be tolerated further and must be responded to with action, (4) the individual has access to weapons to enhance the capacity and urgency to respond, and (5) the individual feels a sufficient sense of potency and/or disregard of the consequences to initiate violence.
Thus far, we (the American Psychoanalytic Association) have made a series of recommendations to Secretary of Health and Human Services Kathleen Sebelius and are continuing to work closely with her office. You can read a summary of our specific recommendations on page 7. These include a strong argument for strengthening commitment laws and increasing the funding for the treatment of the mentally ill. These positions have been put forward on our behalf by APsaA's attorney and Capitol Hill advocate, James C. Pyles.
This is a good start, but it is only a start. We must now bring together the understanding we currently have, while pressing ahead with a concerted effort to gain the knowledge that still eludes us. I have no illusions about the scope of our expertise. I do not think that psychoanalysts will master this problem alone, working independently, without the collaborative efforts of those in allied disciplines who likewise devote themselves to this challenge. Nor am I confident that other disciplines, even a consortium of other disciplines, can master the complexities of explosive mass homicide without our unique understanding of depth psychology. Mass murder of this kind originates in a mental process that is not evident on the surface,
in a part of the mind that is unfamiliar to experts in other disciplines.
If our nation is to master the challenge of mass homicide, we will need the coordinated efforts of a national coalition of psychologists, psychiatrists, social researchers, and psychoanalysts. Our national leaders need to create such a coalition of collaborating professions and disciplines, and we must be part of it. We can, and must, work with our colleagues in neighboring professions and professional societies to promote such collaboration and advance its work.
For now, we in APsaA must think about how we can best contribute to this effort. We must develop the working parties to examine and research the causes and dynamics of these problems. We must do it soon, for episodes like the massacre in Newtown are occurring at an escalating rate. And we must use our current knowledge, as well as the understanding we acquire through our collective research efforts, to advise our leaders on matters of public policy.
Nearly 100 years ago, Freud recognized that the primary contribution of psychoanalysis would never be the case-by-case treatment of patients, because the impact of our clinical practice is far too small in relation to the wider population of persons suffering from psychological disorders. In his 1918 address to the Fifth Psychoanalytical Congress in Budapest, Freud called on his followers to develop new methods to provide psychoanalytic help to “the masses.” Today, we recognize the wisdom of Freud's 1918 call for “mass psychotherapy.” But we are also called by today's circumstance to go beyond Freud's vision. Today, we are driven by our common sense of horror and, at the same time, inspired by our social responsibility as professionals to extend our historic mission.
Today we recognize that the most important challenge for psychoanalysis, indeed perhaps the most critical contribution we can make to the world in which we live, is to develop our expertise in areas of social need, and to convey that expertise to those who fashion the public policies by which we live or die.