Last Saturday’s early-morning massacre at a crowded movie theater in Aurora, Colorado, stands as one of the most horrific rampages in American history. But before anyone had any clue as to James Holmes’ motive for such a heinous act—even before the bodies had been removed from the site of the carnage—websites and social media were abuzz with suspicions that the gunman was either mentally ill, or was under the effect of psychotropic medications—one (or both) of which may have contributed to his crime.
As of this writing, any statement about Holmes’ psychiatric history is pure conjecture (although as I post this, I see a Fox News report claiming that Holmes mailed a notebook to “a psychiatrist” detailing his plan—more will surely be revealed). Acquaintances quoted in the media have described him as a shy person, but have reported no erratic or unusual behaviors to arouse suspicion of an underlying mental illness. Until recently, he was even enrolled in a graduate neuroscience program. Some reports suggest that Holmes had spent weeks engineering an elaborate and complex scheme, hinting at some highly organized—albeit deadly—motive. Nevertheless, the fact remains that we simply don’t know about any diagnosis, medication, or other psychiatric condition or treatment, which might shed light on Holmes’ frame of mind.
Those who focus on Holmes’ mental state at the time of the murders seem to fall in one of two camps. Some argue that medications (if he were under the influence of any) may have enabled or facilitated this horrific act. Others say that if Holmes had been diagnosed with a psychiatric illness, then this catastrophe serves as proof that we need more aggressive treatment—including medications—and services for the mentally ill.
It will be some time before we get answers in Holmes’ case. And to me, that’s just as well. Determining whether he has a mental illness, or was under the influence of psychotropic drugs last weekend, unfortunately reframes the question in such a way that further propagates the rift between these two factions, and fails to address how we should handle future cases like Holmes’ more humanely. If, for example, Holmes is found to suffer from untreated schizophrenia, our society’s (and profession’s) reaction will be to lobby for more aggressive treatment, greater access to medication, more widespread screening programs, and, perhaps, a lower threshold by which to hospitalize psychotic individuals we deem as potentially “dangerous to others.” If, on the other hand, a toxicology report reveals that Holmes had an antidepressant or antipsychotic in his bloodstream at the time of the murders, our inclination will be to restrict our use of these drugs, remove them from our formularies, and the outcries against psychopharmacology will grow ever louder.
Whether Holmes has a mental illness or not is irrelevant. He was in crisis—probably for quite some time before last weekend—and that‘s what matters. There was no one—and no way—to reach out to him and meet his needs in such a way to prevent this tragedy, and that, in my opinion, transcends whether he is “mentally ill” or not.
How can we fix this? In his column in Monday’s New York Times, David Brooks almost provides a solution. He writes, correctly, that prevention of such catastrophic events occurs through “relationships”—relatives or neighbors, for instance, who might recognize a change in someone’s behavior and encourage him to get help. Admittedly, establishing a caring relationship with someone who suffers a history of trauma, grief over a recent loss, poor self-esteem, pathological narcissism, or acute psychosis may be difficult. But relatives and neighbors are indeed often the first to notice questionable behavior and are well positioned to help those in need. Perhaps in Holmes’ case, too, we’ll soon learn of some classmates or coworkers who felt something was amiss.
Brooks goes on to argue that it’s the responsibility of that neighbor or relative to “[get] that person treatment before the barbarism takes control.” He doesn’t define what sort of “treatment” he has in mind. But he does say that killers are “the product of psychological derangements, not sociological ones,” so the aggressive treatment options he endorses presumably include more aggressive psychological (or psychiatric) treatment. But to expect a neighbor or relative to help an individual access treatment is precisely a sociological phenomenon. It puts the onus on our culture at large to pay attention to how our neighbors think and act, and to offer a helping hand or a safe environment (or a locked psychiatric unit, if it has progressed that far) to those of us who think and behave differently or who are suffering a crisis.
That, unfortunately, is not what Brooks is arguing for. (After all, the title of his essay is “More Treatment Programs.”) If mass murderers suffer from psychological problems, which is what Brooks seems to believe, the solution “has to start with psychiatry.” But this introduces the longstanding problem of defining that arbitrary border between “normal” and “abnormal”—a virtually impossible task. And, of course, once we pathologize the “abnormal,” we’re then obligated to provide treatments (antipsychotic medication, involuntary hospitalization, assisted outpatient treatment, forced drugging) which, yes, might decrease the likelihood of further dangerousness, but which also compromise patients’ civil rights and do not always enable them to recover.
Brooks is right on one point. Relationships are part of the answer. Relationships can provide compassion and support in one’s most difficult times. One take-home message from the Aurora tragedy should be that people like Holmes—regardless of whatever he is even “mentally ill” at all—need the security and comfort of safe, trustworthy individuals who are looking out for his (and society’s) best interests and who can intervene at a much earlier stage and in a much less aggressive way, perhaps even avoiding conventional psychiatric treatment altogether.
Getting to that point, unfortunately, requires a sea change in how we deal more compassionately with those in our society who are different from the rest of us—a change that our nation may be unwilling, or unable, to make. If we fail to make it, we’ll be stuck with the never-ending debate over the validity of psychiatric diagnoses, the effectiveness of psychiatric drugs, the ethics of forced treatment, and the dilemma of defining when antisocial behavior becomes a “disease.” In the meantime, troubled souls like James Holmes will continue to haunt us, left to their own devious plans until psychiatric treatment—or worse—is the only available option.
Posted by stevebMD 
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