Editor:
Although I do not have the experience of practice in the United States, I do have a direct interest in the Virginia Tech tragedy, as I have a child studying there, and I take issue with the editorial by Professor Tanay.1
I do support the concept of the reinstatement of some places of asylum as places of peacefulness and restoration rather than institutions of incarceration. However, Professor Tanay's remarks are an opportunist political statement rather than a scientific examination of the problems related to the prediction of violence and its prevention by adequate treatment or detention.
Working in the forensic setting, I am well aware of the inadequacy of the transformation of the old-style hospital system to acute care units and the problems of providing services to the acutely disturbed.2 However, our ability to predict and prevent incidents such as that which occurred at Virginia Tech remains limited.
Violence in the psychiatrically disturbed has various origins and is more complex than simply the influence of delusional ideation. In this case the perpetrator (in some ways as much a victim as those he attacked) may well have undertaken his action out of hopelessness arising from both his increasing sense of alienation and cognitive changes impairing his ability to have a sense of control over his inner and external environments.3
As this is often an early presenting symptom, it is particularly important to be sensitive to the issue in first-episode cases, and it should be emphasized to family physicians as well as psychiatrists in all fields of practice. While recognition may mandate custodial treatment in a high-risk period, to suggest that long stays in a hospital are beneficial is highly questionable, as the result may simply be a sense of further disempowerment. It is to be remembered that, for many, violence is an expression of power, and this sense of empowerment by extreme acts is unfortunately reinforced by the media responses and particularly by the publication of visual material as occurred in the Virginia Tech matter.
- American Academy of Psychiatry and the Law
Reply
Editor:
I was delighted that my editorial, “Virginia Tech Mass Murder: A Forensic Psychiatrist's Perspective,” was read in Wollongong, NSW (Australia). I am not sure why Dr. Davies considers my views to be an “opportunistic political statement rather than a scientific examination of the problems related to the prediction of violence.” My concerns are clinical and humanitarian. Chronic paranoid schizophrenics and their victims do not have a constituency; therefore, even if I were a politician (which I am not), I would not be advancing my popularity by expressing such views.
The problem of predicting dangerousness to justify commitment is a political red herring designed to criminalize the institutional care of severely psychotic individuals. The concept of dangerousness is an intellectual trap. A diagnosis of a condition (for example, being suicidal or homicidal) is not a prediction of an event. The validity of my diagnosis of a paranoid schizophrenic with homicidal delusions is not invalidated by the absence of a dead body.1 However, the promoters of criminalization of mental illness use this fallacious reasoning to claim that psychiatrists are “unable to predict dangerousness” and therefore should play a minimal role in civil commitment. A medical diagnostic procedure is thus transformed into a legal contest. Neither patients nor society benefit.
Dr. Davies captures the spirit of what I am troubled by in his own article, “Prisons: Mental Health Institutions of the 21st Century,” to which he makes reference in his response to mine. It is indeed a sad consequence of the criminalization of mental illness that prisons have become the default institutions for the care of chronically psychotic individuals.
