Why Cho Was Not Committed

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Psychologist Jonathan Kellerman writes a thoughtful Wall Street Journal op-ed piece , with which I largely agree, grappling with the ethical responsibility of the mental health profession with respect to violence:

“If the Virginia Tech shooter had been locked up for careful observation in a humane mental hospital, the worst-case scenario would’ve been a minor league civil liberties goof: an unpleasant semester break for an odd and hostile young misanthrope who might’ve even have learned to be more polite. Yes, it’s possible confinement would’ve been futile or even stoked his rage. But a third outcome is also possible: Simply getting a patient through a crisis point can prevent disaster, as happens with suicidal people restrained from self-destruction who lose their enthusiasm for repeat performances.”

Kellerman does, however, place too much responsibility at the feet of the “liberationists” and “libertarians”, exemplified by R.D. Laing and Thomas Szasz for the historic failure of the mental health system to effectively address such issues. Would that Laing’s thought had had more of an influence! Kellerman summarizes the Laingian perspective as the principle that “[not] only wasn’t psychosis a bad thing, it was evidence of a superior level of consciousness”. But Laing’s opposition to psychiatric medication and hospitalization were just the window dressing on his more essential contribution — an existential perspective which gives inroads into the inner world of our psychotic patients that inherently humanizes our care. This is not incompatible with the responsible mainstream practice of clinical psychiatry, IMHO, and I can cherish Laing’s influence on my psychiatric philosophy without cognitive dissonance even though I medicate and hospitalize patients. About Szasz I have less kind things to say, especially given his collaboration with the Scientologists.

Deinstitutionalization and the failure of the community mental health system were not driven nearly as much by such idealistic philosophical vision as they were by the fiscal betrayal of the severely mentally ill — a socially insignificant constituency without serious advocates, and one our society is all too ready to shun and stigmatize — in the service of budgetary constraint. As Kellerman observes, “this was baby-and-bathwater time.” The crux of the matter, he goes on to observe,

“…[the] basic premise of Community Psych–that severely mentally ill people could be depended on to show up for treatment voluntarily–never made sense to me. The core of the most common and debilitating psychosis, schizophrenia, is degradation of thought and reason. So the idea that people with fractured minds could and would make rational, often complex decisions about self-care seemed preposterous.”

I would amplify on that; schizophrenia (and other major mental illness) involves not only a general degradation of reasoning but also a specific loss of insight into the nature of one’s illness and recognition of the need for treatment, known as anosognosia, that can be understood both in terms of psychological denial and neurochemical dysfunction of particular brain regions, and which makes noncompliance with followup treatment and medication the single most important cause of deterioration and relapse.

While exercising due diligence in raising caveats, Kellerman infers that Cho had a serious mental illness and, unfortunately, all we will have is speculation:

“Diagnosis from afar is the purview of talk-shows hosts and other charlatans, and I will not attempt to detail the psyche of the Virginia Tech slaughterer. But I will hazard that much of what has been reported about his pre-massacre behavior–prolonged periods of asocial mutism and withdrawal, irrational anger and hatred, bizarre writing and speech–is not at odds with the picture of a fulminating, serious mental disease. And his age falls squarely within the most common period when psychosis blossoms.”

I would be the first to assert that psychiatry is a markedly imperfect tool at best for the prediction and prevention of violence, and that once on the slippery slope of preventive detention the dangers outweigh the benefits. But Kellerman’s conclusion, that

“Penning up and carefully scrutinizing the killer was never an option. Not in Virginia or California or any other state in the union. Because in our well-intentioned quest to maximize personal liberty, we’ve moved conceptual eons away from taking the concept of dangerousness seriously”

should give us pause.