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A portrait of Adam Lanza: Gun control and mental health system at a crossroads

January 16, 2014

The story of guns and mental illness is one of converging truths about two badly broken systems – one for caring people with mental illness and another for regulating guns – that come together tragically. The true inadequacies of both systems are seen especially in young men who are no longer children but whose parents can’t help them, and who are at a time of life when neither gun laws nor the mental health system seem to pay attention to them. Access to guns is easy, and among the huge pool of troubled youth, there are a few whose lives cross that access.

Behavioral Healthcare interviewed several mental health experts a year after the horrific Newtown tragedy; some offered insights, albeit speculative, into the mind of Lanza; others said emphatically that the best solution to gun violence is, as they said in the immediate aftermath of the shootings, to limit access to guns for everyone.

‘You would have to detain the haystack’

Three experts in mental illness and the law concur:  All told BH that gun violence by the mentally ill is so rare that looking for it is like looking for a needle in a haystack. “You would have to detain the haystack,” said Jeffrey W. Swanson, Ph.D., professor in psychiatry and behavioral sciences at Duke University.

Let’s say the mental health system was not overburdened, said Swanson. The overall problem of gun violence would go down by 4 percent. “If you want to have a discussion about improving the mental health system, great. But we want to shine the light on the need to improve mental health but not by increasing stigma.”

This is not to say that guns and mental illness mix. But is Lanza an example of multiple casualty shootings by troubled young men, or is there a public health problem with guns? Swanson, along with his colleague Marvin S. Swartz, M.D., and Paul Appelbaum, M.D., past president of the American Psychiatric Association, emphatically state that the problem is guns, not mental illness. Here’s why: Of the 85 gun-related deaths that occur every day in the United States, fewer than four deaths (3.4 deaths or 4% of the daily total) are linked to mental illness.

Swanson adds that while crimes like Lanza’s are very rare, young men whose profiles are similar to those of Lanza are not: “The average 17-year-old has a good chance of living in a home with multiple firearms,” he said. “Add to that the characteristics of young men who have had some psychopathology, are isolated, probably angry, and perhaps delusional, perhaps something else – it’s not a very small set.”

“There are two converging sets of truths here,” said Swartz, who is professor in psychiatry and behavioral sciences at Duke University School of Medicine. “One is that the mental health system is fragmented and under-resourced, and the other is that we have a terrible problem with gun safety.” The convergence of these two important, but inadequate systems in the Newtown massacre couldn’t help but be painfully tragic. Neither system is “up to the task,” Swartz said.

Swartz stated that, in hindsight, there could have been many ways that better “systems” might have altered the ultimately tragic decisions made or not made by Nancy Lanza with regard to her son: “If,” he suggested, “she had better access to family services for troubled kids, she might have gotten better guidance.”

So, even as mental health professionals try to dispel public misperceptions about people with mental illness, there is no denying the fact that the focus on mental health problems that resulted from the Newtown tragedy has brought considerable benefit to the mental health field – namely, Congressional attention and increased funding.

The police report

The Connecticut state police released the final report on the Adam Lanza Newtown massacre of December 14, 2012, on December 27, 2013. It is severely redacted, but does indicate that when offered help for her son’s mental illness, Lanza’s mother declined. The report is based on interviews with many of the people who knew the troubled young man starting in his early years. It forms the basis of the state’s division of criminal justice report, released November 25, which concluded that the investigation found no motive for Lanza’s shooting of 20 schoolchildren, six school staffers, his mother, and himself.

Significantly, the report also concluded that there was no connection between Lanza’s mental health problems and the crime. But this question received special attention, since Lanza’s history included a diagnosis of Asperger’s disorder (a diagnosis which was folded into the autism spectrum in DSM-5) and had been noted to have odd behaviors including a preoccupation with violence.

In the wake of the December 2012 Newtown shooting, the mental health field spent an anguished year trying to dispel the notion that people with mental illness are more likely to commit violence – they’re not, they’re more likely to be victims – while at the same time taking advantage of welcome consideration by lawmakers about the limitations of our current mental health system.  

Elsewhere in Congress, efforts by a broad coalition of groups to place greater restrictions on access to certain guns and accessories (assault style weapons and high capacity magazines) failed. Gun advocates suggested that the mentally ill were a key culprit in gun-related violence and argued, with some success, for restrictions based on mental health history. 

A forensic psychiatrist’s view of Lanza’s crime

“This may be a unique crime as far as mass homicides go,” said Joseph Simpson, MD, Ph.D., staff psychiatrist for the Los Angeles County Department of Mental Health and forensic psychiatrist who has conducted more than 600 evaluations. “I believe the diagnosis of autism (for Lanza) is probably accurate,” he told BH.  With that condition, one of the main deficits is being able to imagine what another person or creature feels, he said. It’s also common for people with autism to be preoccupied with specific interests, said Simpson. Unfortunately in this case, Adam Lanza’s fascination was with violent crime and mass murder. His autism, combined with a fascination with violent video games and mass murders, resulted in a person who “didn’t think about how he was going to destroy other people’s lives,” said Simpson.

Simpson added that Lanza had the presence of mind to choose a place that wasn’t protected – a school. “He didn’t just start shooting in front of his house,” he said. “He wanted to be successful at this.”

In addition, Lanza was diagnosed with obsessive compulsive disorder (OCD), a diagnosis which, like autism, usually does not create a crime situation, said Simpson. People with OCD don’t like the feelings it gives them, he said, adding that some people with OCD have obsessions that they are going to cause harm to people, that they’re going to lose control and attack or kill people, but they don’t act on these obsessions. In fact, they try to get help for their condition. People with autism, on the other hand, don’t even recognize that there is a problem – they are happy with their obsessions. “Lanza’s OCD wasn’t with violence,” said Simpson. “Violence was something he enjoyed, as with the videogames.”

Lanza’s case is unique compared to other recent mass shooters because he did not have a total break with reality, said Simpson. “Most of the mass shooters hate everyone, or they’re delusional,” he said. “I don’t think Lanza was thinking in terms of anger and rage at the world.”

As for why Lanza killed his mother, nobody will ever know, said Simpson. “It could be argued that his mother could have stopped his plans.” The report does show that she left the house for three days, coming home the night before the shooting. He killed her before he went to the school. Lanza was only communicating with his mother by email, noted Simpson, saying he was not surprised that she wasn’t able to do more to help him. “The people who should have done better were the father and the brother,” he said. Lanza’s father and mother were divorced; Lanza had cut off communications with his father and brother several years before the shooting.

However, Lanza should never have had guns, said Simpson. Lanza’s mother should “never have indulged his interest in guns,” he said. “There’s something seriously wrong with her in allowing that situation to continue.”

Simpson describes Lanza as “the one-in-a-million case where someone has an obsession with violence and no empathy.” He said Lanza probably wanted to “top” the other mass shooters. Had he survived, he probably would not have succeeded in an insanity plea, said Simpson. “The insanity plea in this country is designed for severely impaired people,” he said. “It’s a difficult standard to meet.” When Simpson does evaluations for California, he tries to find out if the defendant “thinks what he was doing was justified because he was acting in self defense,” he said. “Sometimes they’re so ill that they think they are getting a command from God,” he said. “Those severe cases can make a good insanity plea,” he said.

In Lanza’s case, Simpson maintained that there would be little that could be seen to justify such a plea. “Autistic people are not violent people,” he said. “It’s not like schizophrenia, which is intermittently violent. They are just very interested in certain issues. But with Lanza, what he was interested in happened to be terrible.”

Asked what could have prevented Lanza’s crime, Simpson responded: “I don’t know that there’s anything other than the mother not giving him access to guns.” And he stressed that it is very difficult to predict, let alone prevent, gun violence by looking at an individual’s mental health history. “Many people are in the beginning stages of mental illness, and there isn’t enough evidence to intervene and put them in a hospital,” he said.

Civil commitment

In the wake of the Newtown tragedy, five states have enacted stricter gun rules, including universal background checks and assault weapons bans, said Swanson. But the result is a mixed bag. Connecticut, for example, passed a law that bans armor-piercing bullets but extended the state’s prohibition on gun ownership to include any individual who voluntarily signs into a psychiatric hospital. “That has flummoxed the mental health people,” said Swanson, noting that in Connecticut there is very little formal civil commitment. So, many patients in Connecticut are brought in involuntarily - on a short-term hold - and then they are persuaded to sign in voluntarily or they are discharged.

A December 2013 report from the Consortium for Risk-Based Firearm Policy, to which Appelbaum, Swanson, and Swartz contributed, concluded that mental illness is not unimportant, but it is connected to a very small proportion of the overall violence. “If we are going to talk about mental illness, let’s talk about when they come in for help,” said Swanson. “And that’s a time we should put up a wall between the person and the guns.”

Aging out

Lanza was aging out of youth services and transitioning to the adult world, noted Swartz. “You can imagine that the mother was desperate,” he said. “She was probably doing anything she could trying to engage her kid in a system.” When special needs youth get to be adults, they enter into a world in which resources are even more scarce, he said. “You can empathize with her desperation.”

The father of Jared Loughner, the Arizona shooter – of a similar age – was also at a loss about what to do with him, said Swartz. “There’s some evidence that he was trying to figure out how to get him help.” And James Holmes, the Colorado shooter, already had a psychiatrist and a threat assessment team concerned about him. “There are all kinds of points of leverage,” Swartz continued. “But when they all fail at the same time, we have these cases.” The constant that could be changed is the guns.

The bottom line: access to guns doesn’t go with severe mental illness, and people with mental illness need a lot better access to treatment than they are getting now.

For the police report issued December 27, go to http://cspsandyhookreport.ct.gov/.

For the criminal division report issued November 25, go to http://www.ct.gov/csao/lib/csao/Sandy_Hook_Final_Report.pdf.

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