Marjory Stoneman Douglas and Dorothea Dix: Unpacking Mental Health and Mass Shootings

By Coral Springs Talk from Coral Springs, United States (Rally at Marjory Stoneman Douglas High) [CC BY 2.0 (], via Wikimedia Commons

There was yet another horrendous school shooting in Parkland, Florida this week, and the country has begun our by-now-traditional cycle of arguing and politicians offering thoughts and prayers and nothing changing. You see, whenever a mass shooting shooting, in the immediate aftermath most citizen responses fall into one of three categories:

  1. Expressions of sympathy, horror, and shock relating to the nature of the tragedy;
  2. Calls for (and responses to calls for) tighter gun control; and
  3. Discussion surrounding the gunman’s mental health, access to mental health services generally, and rates of violence perpetuated by and experienced by people suffering from mental health issues

It would be inappropriate for me to comment on the first type of discussion, except to say that I am sympathetic, horrified, and saddened by the tragedy as well. And though I have many opinions about the second— I did work nearly five years at a public defender office in one of the most gun-control-loving states in our country — that’s another article for another day. As your Friendly Resident Clinician-Trained Advocate, I’m here today to talk about the third topic–because I’ve been writing about it for years, and it would appear that this issue has reached Craig Ferguson o’clock. If you’re in a hurry and want to know my point upfront, here it is: Most people with mental health issues don’t shoot people, and we have no way of knowing whether better access to treatment would have prevented this tragedy, but we should have better access to mental health treatment anyway.

Are you still with me? Okay, good, because we need to spend a few minutes talking about what ‘mental health issues’ even means.

(This is an important point, because as it happens it’s not universal, and this impacts conversations on the topic something fierce.)

The most commonly accepted (though not universally accepted) definitive text for what constitutes ‘mental illness’ is the Diagnostic and Statistical Manual of Mental Disorders. We’re currently all using the fifth edition, which was published in the spring of 2013. The DSM uses a code system in order to assist physicians and healthcare professionals with providing diagnoses. These codes exist for literally hundreds of distinct disorders, covering everything from mood- and anxiety-based disorders to pervasive developmental disorders to substance-related disorders to psychotic disorders to intellectual disability to personality disorders.

Symptoms of these disorders vary wildly, and it is straight-up medical malpractice to prescribe the same treatment for every disorder. In fact, not every mental health professional is even allowed to diagnose every single disorder on this list–some disorders (like, for example, Autistic Disorder) require screening by a neurologist. About one in five American adults has a diagnosable mental health issue, and these disorders impact every known demographic in this country (though some disorders are known to disproportionately affect populations above or below a certain age, and diagnosis for some, like personality disorders, is contraindicated before a person turns 18).

[Thus concludes the lecture section of this presentation. For now.]

‘Why are we talking about definitions here?’ I hear you ask.

I note all of this because it all adds up to mean that there is no one individual thing that every single person struggling with mental illness says or does in this country. This is a big deal, and it has to be where we begin this kind of discussion, because it means that almost from the very first words of a discussion on Facebook, twitter, or elsewhere many people are talking past each other.

I have heard many people mention recent studies on twitter and Facebook that show that people struggling with mental health issues are actually more likely than the average population to be the victims of violence. These studies reflect a common sense understanding that people who suffer from mental health issues may experience prejudice, discrimination, and vulnerabilities that are not shared by the general population. (There are also many studies linking mental health issues to penal populations, where people with some types of diagnoses may be particularly exposed and vulnerable, but I’ll get to that in just a moment.)

Yet, some people who commit atrocities, apparently including Nikolas Cruz, suffer from mental health issues; this is undeniable fact. Common sense (correctly) tells us that people who ingest substances that create an altered state of consciousness may also experience changes in their insight, perception, and judgment, all of which can lead to violent exchanges. Many (though certainly not all!) people who experience psychotic symptoms, when combined with paranoia, can see and hear things that are not there which cause them fear, and frightened people can sometimes engage in violence. This does happen, though it does not seem to be what happened at Parkland. This is why we, as a culture, have created a ‘not guilty by reason of insanity’ verdict for criminal trials over time–we understand that crime and mental illness may be linked and may affect culpability.

The important point here is that people who discuss violence and mental illness with regards to perpetration and people who discuss violence and mental illness with regards to victimization are both right, and it’s because for all practical reasons there are as many different kinds of people who suffer from mental health issues as there are kinds of people generally within the US. Saying “people with mental illness commit violent crimes” is about as useful as saying “people born with thumbs commit violent crimes.” You were born with at least one thumb, right? Have you used a gun for mass murder lately? Yeah, that’s what I thought.

[With much apologies to anyone out there reading this who was born with thumb aplasia–keep fighting the good fight, my friends.]

So having discussed the concept of mental health generally, there is an obvious corollary question as it pertains to any mass shooting tragedy, but particularly one like our most recent:

Why do I hear people talking about access to mental health treatment like it is going to fix this type of issue?

Access to services and insurance coverage for mental health is is a very big, very long discussion, and one I have written many, many pages about over many years of study. I will try to spare you the treatise and give you a Cliff’s Notes version. But first, I’m afraid there will need to be a history lesson.

[I did warn you that the lecture would resume at some point…]

At one point in time, mental health treatment in this country really was like something out of a horror story; there are numerous accounts of people being kept in dark places, chained to walls, lobotomized, and electrocuted, and otherwise just horribly mistreated. Much of the early reform for treatment of people struggled with mental health issues is credited to Dorothea Dix, an activist from the mid-1800s who remains something of a personal hero to me (even if many of her efforts were later subverted). Once we made the transition from chaining people in basements to creating and maintaining asylums, hospitalization remained the way that we as a country handled serious mental health issues for many decades.

[Arkham residents not pictured.]

Sometime around the 1970s, however, people began to heavily question the practice of institutionalizing people with mental health issues, largely because the thing doctors were noticing about putting people away for long periods of time is that they never seemed to really get better (though there were also administrative costs and a very famous study involved). There was a push to start initiating community-based care in clinics and comparable outpatient organizations–which is a model we still somewhat use today in this country to address issues of mental health.

The thing is, in some ways deinstitutionalization could not have happened at a worse time. You see, the push for deinstitutionalization happened largely in the 1960s and 1970s, which was a time when we were making changes to how health insurance worked in this country as well. And mental health coverage is, among other things, often incredibly expensive, even at the outpatient level. So this ultimately culminated in fewer community health options and more restricted insurance coverage for many people with mental health issues. In other words: People weren’t accessing treatment at the rates they should, because there were fewer places to get it and also it cost more. That’s still true today; less than half of people living with a mental health condition in this country receive evidence-based treatment for their conditions.

Around the time that deinstitutionalization began to reach its peak, people began to notice a disturbing trend about the interaction between mental health and prison systems: the percentage of inmates with mental health issues was going way up. Multiple recent studies have shown that prison populations now contain much higher rates of mental health issues than the general population.

Picture by By (Own work) CC BY-SA 4.0 via Wikimedia Commons

An honest and frank discussion about mental health issues in this country would be remiss if it did not also at least touch upon the plethora of other confounding and complicating factors about access to treatment (such as homelessness, incarceration, and autonomy in healthcare decisions, to name a few). But many people believe that fixing these difficulties in accessing services will drive crime rates down, and I think they are right–up to a point. Certainly the number of crimes that are committed due to untreated symptoms will decrease, and I firmly believe that a more streamlined substance abuse recovery system would make a huge impact as well. For these reasons, and because I believe that the American criminal justice system is a grossly inappropriate institution to rely on for mental health treatment, I am a huge proponent of increasing access to mental health treatment in this country.

…which brings us back to Nikolas Cruz. This section is the hardest section of this series to write, because it gets at the real heart of the discussion: How does access to mental health treatment affect tragedies like the one that happened at Marjory Stoneman Douglas High School in Parkland, Florida?

Much has already been written about Nikolas Cruz’s extensively-documented history of mental health issues, telling us that he was diagnosed with ADHD, depression, and “developmental and learning disabilities.” Given what I have read, if one of those “developmental disabilities” wasn’t conduct disorder, I will eat my hat. You see, there’s no noted correlation between ADHD and mass shootings — in fact, most of the main features of ADHD (disorganization, distractedness, inattention, forgetfulness, to name a few) don’t lend themselves to premeditated action at all. And the connection between depression and premeditated murder is attenuated at best. But …well, let’s talk about the diagnostic symptoms of conduct disorder, the adolescent precursor to Antisocial Personality Disorder (which cannot be diagnosed before age 18). I have bolded the things we see reported in the news as part of Cruz’s personal history before the Parkland shooting:

“A) A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following . . . criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

  1. Aggression to People and Animals
  2. Destruction of Property
  3. Deceitfulness or Theft
  4. Serious Violations of Rules

(The remaining diagnostic criteria relate to age, distinguishing from Antisocial Personality Disorder, and absence of signs of other disorders. He probably met the criteria for APD as well, though it would appear no one had diagnosed him with it; you can read those criteria here. The disorder also can occur with or without ‘limited prosocial emotions,’ which is a fancy way of saying ‘this person doesn’t appear to have normal levels of concern or empathy for other humans.’)

As this list suggests, conduct disorder is noteworthy because potential symptoms are disregard for social norms, aggression, destructive tendencies, and a lack of showing of empathy for other people. In other words, the very things that might cause someone to commit this kind of atrocity are potentially enough to diagnose someone with a mental health disorder in the DSM.

(I want to be very clear that diagnoses such as conduct disorder or antisocial personality disorder are by no means a guarantee that someone will commit this kind of atrocity; a person who frequently skips school and then lies about it can be slapped with the same exact diagnosis. As with so many things, it’s a question of severity and also a subjective assessment on the clinician’s part.)

APD Exhibit A: Nikolas Cruz. APD Exhibit B: This guy.

Diagnoses like conduct disorder and antisocial personality disorder are controversial, because some people believe they merely convert criminal behavior into a mental health issue. And antisocial diagnoses are notoriously resistant to treatment, though I personally believe they can be treated in some instances and it is my sincere hope that we identify more effective treatment for these diagnoses soon.

Would access to mental health treatment have prevented this tragedy? It’s tough to say; as a few articles have noted, Florida’s track record of access to treatment is abysmal, and studies show that adequate treatment can definitely reduce instances of violence in general. And perhaps more to the point, Cruz should have had access to treatment because we should live in a country where people receive reasonable evidence-based treatment for their health issues. But on the other hand, we don’t actually have evidence-based practices for treating antisocial issues like conduct disorder, and Cruz’s personal history is a ticky-box nightmare — in particular, there is a long-documented correlation between zoosadism and premeditated murder, and those studies I just mentioned weren’t about premeditated violence; they were about violence generally (and often impulsive violence at that). Treatment — for his documented diagnoses or otherwise — might have prevented this, but it also might not have. And we can’t know, because he didn’t get access to treatment, and then this tragedy happened, and we can’t take it back again.

Access to mental health treatment is a very important issue to me, and I will continue to advocate vociferously for better access to care and services until the day I die. As the first two sections of this series suggest, I do believe that it is incredibly important that we address this issue, for reasons of public safety and humane social welfare. But it is not a panacea, and it is disingenuous and dangerous to discuss the issue as if it were. The fact of the matter is, none of us can know whether it would have helped in this instance. We should have better access to treatment because our entire society benefits from better access to treatment, and it shouldn’t take a horrendous tragedy like this to discuss it.