12 January 2011

Do We Need A Better Early Warning System?

Meet Mr. Loughner

Jared Lee Loughner, the Tuscon assassin, was a troubled young man.

It was clear that he was a problem, possibly a violent one, in the community college he attended:

Pima Community College, in Tucson, issued a statement identifying Loughner as the suspect. It said he was a student from the summer of 2005 to fall of 2010, but he was suspended Sept. 29 for conduct violations. It said he agreed to withdrew from the college on Oct. 4.

The college said that from February to September of 2010, Loughner had five contacts with college police for disrupting classrooms and the library. It said he was prohibited from returning to the college.

A spokesman for the college said Loughner's videos troubled administrators and campus police, leading to his suspension. In one video, he "claims that the College is illegal according to the U.S. Constitution, and makes other claims," the college's statement said.

Loughner and his parents, Amy and Randy Loughner, met with administrators, who required him to be obtain a certification that "in the opinion of a mental health professional, his presence at the College does not present a danger to himself or others." . . .

Lynda Sorenson said she took a math class with Loughner last summer at Pima Community College's Northwest campus and told the Arizona Daily Star he was "obviously very disturbed."

"He disrupted class frequently with nonsensical outbursts," she said.

The community college alerted his parents that there was problem, something that they probably already knew. He apparently lived at home with them.

While he has in college, he was prosecuted for a minor drug related charge:

The Arizona Republic reported that the charge was for possession of drug paraphernalia. The charge was dismissed in 2008 by the city attorney after Loughner entered a pre-trial diversion program.

He left his high school after his junior year, despite not leaving the area, and around the time he started in at community college:

Tamara Crawley, director of the Marana Unified School District in Tucson, said Loughner attended Mountain View High School in Tucson for three years but withdrew after completing his junior year in 2006. . . . [A high school and college classmate] described him as having a lot of friends "until he got alcohol poisoning in '06" and dropped out of school.

He wrote odd and disburbing things on the Internet.

In November, less than two months after he was kicked out of college, Loughner had bought a Glock, purchased legally from a Sportsman's Warehouse in Tucson. Less than two months after that six people are dead and fourteen people are wounded, many of them seriously.

Spree Killings Are A Distinct Kind Of Crime

When one looks at the profile of people who commit these kinds of horrific one time explosions of violence, a good share share of them are people like Loughner. The warning signs in Loughner's case were similar to those involving Matthew J. Murray who went on a shooting spree in Arvada and Colorado Springs in 2007. They resemble those of Aaron Synder who tried to kill Governor Ritter in 2007. They have similarities to those shown by Seung-Hui Cho, who carried out the Virgina Tech massacre in 2007. They resemble Robert A. Hawkins who carried out the Westroads Mall shooting in 2007. They show resemblances to Eric Harris and Dylan Klebold who carried out the Columbine High School massacre in 1999.

These cases aren't that different from that of Malik Nidal Hasan, the Army medical officer who was responsible for the Fort Hood shooting in 2009, and Kyle Aaron Huff who carried out the Capitol Hill massacre in Seattle in 2006. They resemble Charles Joseph Whitman who in 1966 went on a shooting rampage at the University of Texas at Austin.

The Malaysians had a word for these kind of acts carried out by these kinds people long before we did that has entered the English language in the phase "running amok", although the force of the term has been diminished from overly casual use in English. The home made equivalent ideom, which has the Malayian meaning of "amok" is "going postal." The more clinical term used by the FBI for this kind of individual is "spree killer".

Spree killings aren't very common, but they do occur at a more or less steady pace all over the world and inevitably make headlines when they happen. The spree killers are almost always men. They almost always commit suicide, are killed by someone else in the course of their spree, or are caught and detained for life.

These men are very distinct psychologically from serial killers, from people who are part of criminal gangs or are "professional" criminals who kill in the course of their crimes, from paid hit men, from people who are normal when they aren't drunk or on drugs, and from people who carry out mass killings in connection with aggressive approaches to a position of authority like police, national guardsmen or soldiers.

While they often have grievances and concerns with a political slant and perhaps colored by the political and religious discussions of the day, and these men generally act alone or with a very small circle of troubled friends rather than as part of an organization, often have vague or irrational agendas. Generally, there is no "sane" person personally coaxing them to engage in violence.

Their crimes involve pre-meditation and planning, and the people who commit them are no doing so with any hope of bettering themselves. They expect to die or be incarcerated forever. These are acts more akin to suicide than to homicides carried out with a rational motive. They are terrorist suicide killings carried out by rebels without a cause that makes any sense. The lack of self-regard make them immune to the deterrence threat of punishment in the criminal justice system. Who cares about the death penalty when you expect that there is a good chance that you will die in the course of your crime anyway?

The Problem Of Definition

In an ideal world, we would have a well honed societal early warning system that would alert authorities to what family members, classmates, co-workers, school administators, bosses, and maybe even police already know, that a particular individual has a real problem and is at grave risk of causing massive harm to other despite having no strong history of violence causing injury, and would have a way of intervening to prevent this individual from causing harm to others.

American law permits involuntary mental health treatment and civil detention for someone who presents a danger to himself or others, aluded to by Pima College in the Loughner case, and we also have a civil restaining order system in place that receives quite heavy use in cases where the danger to others that is particularized to a small number of identifable others. Existing law, although ineffectively implemented, also prohibits those who have been involuntarily committed from buying guns, but bureaucratically, there is not good systemic integration of involuntary commitment records with instant background check systems, and substantively, this narrow definition of mental health problems is grossly underinclusive, particularly in an era in which over the last four decades or so, outpatient treatment of mental health issues have become the near universal approach to treating these issues with institutionalization limited to a very narrow subset of all people with serious mental health problems.

But, the existing system isn't very effective. It isn't clear who is responsible for intervening. It often isn't clear to those around the disturbed individual, especially in the case of an adult, who has the authority to intervene and what that authority entails. Most of all, it isn't clear when intervention is appropriate because often no one person has enough information to clearly establish a danger to others alone, even if many people have enough information to suspect it, and because the symptoms that establish that someone is a danger to others are not well defined.

This is particularly problematic in the American legal system, because our legal system and political culture is particularly suspicious of intrusions on autonomy and freedom for the greater good based on acts on might take, rather than acts one has taken.

On one hand, it is frequently obvious to those who interact with them that something is future spree killers are disturbed individuals. On the other hand, it is often not at all obvious where the line should be drawn. Perhaps one man in a thousand is as intuitively "off" as the people who end up committing spree killings, even though only a handful of spree killings take place in any given year in the entire United States, out of a population of tens of millions of men in the age range of people who commit these crimes.

Statistically, spree killings aren't a major cause of death. But, the immense psychological trauma they impose on the population makes them notable.

An ability to identify a group of fifty thousand people in the United States, from whom it is extremely likely that almost all of the several spree killings a year will be committed would be pretty impressive, compared in scale to the massive and not very effective probation and parole system we have in place. Since most spree killers obtain weapons legally, and many lack adequate mental health care, and a good share of no one who feels responsible for monitoring their well being.

If those individuals could be identified, disqualified from owning firearms via the database used to screen gun purchasers now, pro-actively offered and nudged into seeking mental health treatment, and subjected to light monitoring that would reveal major life changes or disruptions in mental health treatment and would be specifically designed to have a group of designated informants among school, work, family, treating medical professionals, and social contacts who would feel some slight obligation to alert a monitor if the person's situation seemed to be taking a turn for the worse, and that monitor had the authority and responsibility to intervene in those situations, a lot of these incidents could be prevented. The level of intervention required could be somewhat less intense than the kind of supervision that someone on probation or parole receives and still have a measurable effect. It might be that a large set of people so identified would have less intense supervision, simply being banned from purchasing firearms, offered free access to mental health treatment, and annually checking in close associates to let them know who to call if the circumstances changed or the situation appeared to escalate, while others who posed a higher risk would be monitored much more intensely. This would take a tiny share of the societal resources that we devote to the criminal justice system to implement, and it would also help to destigmatize mental illness and reduce the fear people have of the mentally ill who were not identified as high risk.

The payback of this kind of system would be considerably greater than simply reducing the incidence of spree killings for one out of a ten thousand supervised individuals. For every spree killer, there are no doubt tens or hundreds of people or more with a profile that puts them at high risk of becoming spree killers, who commit suicide, who would otherwise kill a particular loved one, who would neglect or abuse a child, who would lapse in taking psychiatric medicines and as a result see their careers and educational aspirations and personal relationships collapse, who would want mental health treatment if they knew it was available and could gain access to it, who cause serious damage to property, who kill someone's beloved pet, who injures others, who commits "suicide by cop," who ends up in prison, or who engages in reckless acts that endanger the public that are on the line between accidents and generalized malice.

Few people who fit a "spree killer" profile may actually commit a spree killing, but a very large share of people who fit that profile would benefit personally, and/or have people associated with them who would benefit, from intervention in their lives.

But, crafting an operational definition that is inclusive of almost all potential spree killers, while excluding people who are not at high risk for being either spree killers or otherwise being a danger to themselves or others, that can be vigorously applied without undue abuse and without unduly impairing the liberties of people who are merely "different" or have principled objections to the mainstream medical approach to treating mental health conditions is not an easy task.

Yet, this must be the kind of definition that becomes as distinct a part of popular culture as CPR instruction, "drop and roll" for people who are on fire, "direct pressure" as the cure all for bleeding, "don't drive drunk," "no means no" and other public health and safety messages, and to be effective, it has to win widespread societal acceptance from a significant share of people even in a lot of fairly anti-authoritarian subcultures. It needs to have the perceived authority of science behind it. It needs to be accepted as legitimate, if not by all people who fit this definition, at least, by a large share of all people who are friends and family and colleagues of people who fit this definition. The closest precedent would probably be the system that requires a large swath of people to report child abuse and neglect and provides a place for others to report it voluntarily.

Almost invariably, when serious consequences are attached to conduct or a condition that is described overinclusively, a large share of all people who suffer those consequences come under the overbroad part of that definition. For example, a surprisingly large share of first degree murder prosecutions involve women who kill their infants in the throes of childbirth or criminal accomplices who did not anticipate that a murder would be committed in the crime that they were involved in and had no personal participation in that murder. Similarly, a very large of racketeering cases involve relatively minor white collar crimes committed in an organized way, rather than anything closely resembling the kind of mafia activities that generated political support for RICO's tough sentences.

Slight overbroadness in defining a high risk category risks bringing far more people than necessary into the net, making the program much more expensive to manage, making the people who run the system less alert to the risk among those they are monitoring than they need to be, and making the intrusion into liberty interests involved much greater.

Another approach to deal with the limits of lay expertise in mental health diagnosis akin to the reasonable suspicion for a "Terry stop" v. probable cause for a "search or seizure" distinction in U.S. law under the 4th Amendment, would be to have a low threshold at which an individual could simply be compelled to receive a mental health evaluation and diagnosis, while limiting anything else to individuals who were diagnosed in a voluntary or involuntary mental health evaluation as suffering from a particular set of symptoms, or were found by some sort of public body (perhaps a tribunal or public office) to have that set of symptoms based on information received in cases where diagnosis is unavailable. Mental health evaluations might also be made a standard part of every criminal case more serious than a traffic stop, even if it is resolved with a diversion program or deferred prosecution.

A two tiered approach might also make members of the public less wary of intervening, as insisting that someone seek professional advice is less weighty making a complaint about someone that would lead directly to significant personal consequences for the person about whom authorities were alerted.

Including a voluntary diagnosis would disturb a bedrock foundation of confidentiality in the mental health care system, but the justification that privacy is necessary to cause people to seek help might be less compelling in a context where the government had the legal authority to compel someone to seek mental health evaluation and diagnosis on the basis of a reasonable suspicion (or probable cause to believe) merely that the individual was clinically mentally ill and could benefit from treatment. And, the individual alerting the system to the need might simply be told as feedback that "an inquiry was conducted based upon the information provided and that it was resolved in accordance with the law" rather than provided with detailed information on how it was handled. In all likelihood, in many cases, alerts would come for individuals who had already been evaluated and diagnosed and were in the system, and would simply lead to a brief memo to a designated mental health care provider.

I don't have great faith that psychiatrists can generally determine with much accuracy at all using existing methods whether or not someone poses a risk of future dangerousness. But, I do have greater comfort that psychiatrists can be reasonably accurate in diagnosing mental health conditions, and that it is possible to distinguish mental health conditions in which there is an elevated risk of someone fitting a "spree killer" profile from those where there is no elevated risk of that kind of activity, and the set of diagnoses where there is an elevated risk is, I suspect, a rather modest subset of all mental health conditions, and this designation is one case where a blanket gender distinction probably makes sense given the gross disproportion of men to women who commit these incidents. (The only American woman who might even remotely qualify is Caril Ann Fugate who claimed innocence but was convincted in a crime that her boyfriend admittedly was involved in committing in 1958 in Nebraska in a episode that is in any case a poor fit to the mental health driven spree killing model described above.)

In an ideal world, an in depth mental health inquiry and background check might be linked to eligibility to purchase guns, since spree killings are almost exclusively committed by people who have purchased firearms, allowing people who choose not to purchase guns and as a result pose far less of a threat to the public to escape supervision in most cases, and casting the mental health inquiry as rationally related and narrowly tailored to a right to do something in particular that poses an elevated risk, a bit like a driver's license, rather than as a punishment. After this inquiry was completed, it would be revocable if new information came to light, but might not have to be re-examined for each new purchase. This kind of inquiry also would have prevented at least some of the small number of shooting range shootings that take place, such as the attempted suicide pact of twins at the Family Shooting Center in Colorado in 2010, where at least one of the suicidal twins had a history of despondancy.

In the current political climate, that is probably not a possibility in the short run, given the strong association of the ascendant Tea Party faction of the Republican party with the Second Amendment and weak gun control laws. Although, even the NRA has supported improved record keeping to prevent those who have been civilly committed from being able to lawfully purchase guns, and many gun owners recognize that a large share of gun control efforts are driven by events like spree killings, and that gun control efforts might be far less intense if there were reasonable measures in place to reduce their incidence, even though spree killings a tiny share of all gun murders. The Heller ruling of the U.S. Supreme Court in 2008 that declared the right to bear arms for self-defense to be a constitutional right made clear in dicta that prohibitions under current laws on gun purchases by the mentally ill were permitted under the Second Amendment.

While the short run political climate may make this approach untenable, I think that one long run, bipartisan secular change in policy attitudes over the rest of my lifetime is going to be increasing intolerance of predictable and preventable tragedies. The more clear it becomes that there is a way to prevent tragedies, the more pressure there will be to take strong measures to prevent them.

Notably, along these lines, in Britain, Doctors agreed this summer to breach medical confidentiality if patients who own guns become seriously mentally ill.

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