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I Could Have Been a Killer's Psychiatrist

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Currently the public has little information about the mental status of killer Adam Lanzus, though much has been speculated.  Since the December 14th shooting of six adults and 20 children ages six to seven at Sandy Hook Elementary, the public outcry for gun control and increased awareness about mental illness has flooded media. We are still understanding the association between mental illness and violence. The American Psychiatric Association Council on Law and Psychiatry (Access to Firearms by People With Mental Illness: Resource Document, Arlington, Va., American Psychiatric Association, 2009) states:

The 'absolute risk' message is that the vast majority of people with mental illness in the community are not violent. The 'relative risk' message is that people with serious mental illness are, indeed, somewhat more likely to commit violent acts than people who are not mentally ill. And the 'attributable risk' message is that violence is a societal problem caused largely by other things besides mental illness (ready availability of guns, for example).

As a child/adolescent and adult psychiatrist working with high-risk populations, I'll describe some of the difficulties in providing care to the small number of those with severe mental disturbances with the potential to commit violence.

My clients span the entire age range, are low-income, and insured under Medi-Cal.  Imagine that one of these shooters, will call him "Anychild," had been identified in early childhood -- maybe described as shy, a "loner," with low frustration tolerance, easy irritability, and occasional aggressive outbursts. When a child has problematic behavior concerning for a mental disorder, there are typical methods of entry to see me:  via caretakers, the school, police or discharge from a psychiatric hospital.

Perhaps Anychild's teacher identifies him as someone needing help, and sends him to the school counselor. Now the counselor is responsible for his psychological well-being. When the counselor feels the student has more severe mental distress, (s)he refers the student to an outside agency for specialized mental health services. We need more school counselors, and additional training in mental health. If the client is from a low-income family and has Medi-Cal, there are a wide variety of community-based services with experience working with these clients. If the client's family has health insurance, there are very few options. We need better reimbursement rates to entice more psychiatrists to be on insurance panels.  Few psychiatrists accept insurance due to poor reimbursement rates, the need to pay off long-accrued debt (four years college, four years medical school, four years adult psychiatry residency, two years child/adolescent fellowship), and the desire to work with the "worried well" private pay population. We need a debt-forgiveness program to make it easier for psychiatrists who want to work with difficult, high risk populations.

If Anychild's family had private health insurance, he probably was eligible for 20 therapy sessions and some psychiatric sessions if available.  If not, and his disturbing behavior continued, the school would have few resources available -- they've already sent him out for specialized mental health services.  We need expanded mental health coverage in our insurance policies. Anychild is now in middle school, and teachers and students continue to notice how "odd" or different he is.  He's now bullied, without the skills to be able to reach out for help. He continues to isolate himself, but his family and community have become used to him, "he's just like that." We need to implement effective anti-bullying programs.

Anychild doesn't have a diagnosis of parity (a severe mental illness), since diagnoses in youth are often clinician-dependent. The field of child/adolescent psychiatrist is still in adolescence itself and some diagnoses are not exceptionally reliable or valid. The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), version 5, is expected to be released in 2013 after much controversy. We need improved reliability and validity of psychiatric disorders.

Taking a different route, if Anychild had public insurance through Medi-Cal, he would have more options of services available to him. He comes to the community-based clinic where I work.  Many of our clients are "high-risk" youth so we work in a multi-disciplinary team of case workers, social workers, therapists, and myself as the psychiatrist.  We learn that the child's family system is contributing to worsening his mental health, due to parental conflict, financial stress, unstable jobs, or the other plethora of stressors that all parents struggle with.  Children do not live in a vacuum -- we clinicians see them individually for treatment one hour each week, but do not have a true sense of the environment they live in during the rest of their lives.  Overwhelmingly, working with the family to help support their child, inform clinicians, and empower/support parents, can help build upon naturally occurring strengths in the family and child. But family-centered care is often not reimbursed well by Medi-Cal or private insurances.  We need more funding in family-centered care.

Since family-centered care is not paid for, we have to work with the youth individually.  Anychild is now a teenager, writing disturbing journal entries at home, and drawing explicitly violent images at school.  As therapists, we can assist using the therapies currently available.  But mental heath interventions are not as well-studied as physical health interventions.  We are still learning about what interventions work for whom, what aspects are effective, and why. A therapeutic approach could work well for one person with anxiety, but not for another. This is where the notion of personalized medicine comes to play. We need more research into clinical mental health interventions. Ideally, research questions and interventions would naturally grow out of clinical work with these populations.  But as a clinician who dedicated my early professional life to clinical training (not research training), it is difficult to find funding and entry into the research world.  We need more funding and support to clinicians interested in pursuing clinical research.

Many say that school shootings or mental illness are not high priority, either due to the small number of victims (said for school shootings), or the need to deal with life-threatening problems (said for mental illness).  Yes, school shootings are scarce, and there are more victims in automobile accidents. But the heinous murder of our children forces us to bear witness to indelible violence. For those who have already survived personal traumas in their past, a community trauma such as the mass shooting can trigger further mental distress.

We need to start investing in the prevention and early intervention of mental disorders.  In the past five years, I've had two severe clients who were Anychild -- who could have easily been one of the mass murderers that have disrupted America recently.  Thankfully, the school, police, family, social workers, case managers, and myself all worked together to ensure the safety of themselves and others. It is the system that we need to support, when we say we need more awareness about mental illness.

Martin Luther King said in his "Eulogy for the Martyred Children " (1963), "... We must be concerned not merely about who murdered them, but about the system, the way of life, the philosophy which produced the murderers."

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