Marjory Stoneman Douglas and Dorothea Dix: Unpacking Mental Health and Mass Shootings

By Coral Springs Talk from Coral Springs, United States (Rally at Marjory Stoneman Douglas High) [CC BY 2.0 (], via Wikimedia Commons

There was yet another horrendous school shooting in Parkland, Florida this week, and the country has begun our by-now-traditional cycle of arguing and politicians offering thoughts and prayers and nothing changing. You see, whenever a mass shooting shooting, in the immediate aftermath most citizen responses fall into one of three categories:

  1. Expressions of sympathy, horror, and shock relating to the nature of the tragedy;
  2. Calls for (and responses to calls for) tighter gun control; and
  3. Discussion surrounding the gunman’s mental health, access to mental health services generally, and rates of violence perpetuated by and experienced by people suffering from mental health issues

It would be inappropriate for me to comment on the first type of discussion, except to say that I am sympathetic, horrified, and saddened by the tragedy as well. And though I have many opinions about the second— I did work nearly five years at a public defender office in one of the most gun-control-loving states in our country — that’s another article for another day. As your Friendly Resident Clinician-Trained Advocate, I’m here today to talk about the third topic–because I’ve been writing about it for years, and it would appear that this issue has reached Craig Ferguson o’clock. If you’re in a hurry and want to know my point upfront, here it is: Most people with mental health issues don’t shoot people, and we have no way of knowing whether better access to treatment would have prevented this tragedy, but we should have better access to mental health treatment anyway.

Are you still with me? Okay, good, because we need to spend a few minutes talking about what ‘mental health issues’ even means.

(This is an important point, because as it happens it’s not universal, and this impacts conversations on the topic something fierce.)

The most commonly accepted (though not universally accepted) definitive text for what constitutes ‘mental illness’ is the Diagnostic and Statistical Manual of Mental Disorders. We’re currently all using the fifth edition, which was published in the spring of 2013. The DSM uses a code system in order to assist physicians and healthcare professionals with providing diagnoses. These codes exist for literally hundreds of distinct disorders, covering everything from mood- and anxiety-based disorders to pervasive developmental disorders to substance-related disorders to psychotic disorders to intellectual disability to personality disorders.

Symptoms of these disorders vary wildly, and it is straight-up medical malpractice to prescribe the same treatment for every disorder. In fact, not every mental health professional is even allowed to diagnose every single disorder on this list–some disorders (like, for example, Autistic Disorder) require screening by a neurologist. About one in five American adults has a diagnosable mental health issue, and these disorders impact every known demographic in this country (though some disorders are known to disproportionately affect populations above or below a certain age, and diagnosis for some, like personality disorders, is contraindicated before a person turns 18).

[Thus concludes the lecture section of this presentation. For now.]

‘Why are we talking about definitions here?’ I hear you ask.

I note all of this because it all adds up to mean that there is no one individual thing that every single person struggling with mental illness says or does in this country. This is a big deal, and it has to be where we begin this kind of discussion, because it means that almost from the very first words of a discussion on Facebook, twitter, or elsewhere many people are talking past each other.

I have heard many people mention recent studies on twitter and Facebook that show that people struggling with mental health issues are actually more likely than the average population to be the victims of violence. These studies reflect a common sense understanding that people who suffer from mental health issues may experience prejudice, discrimination, and vulnerabilities that are not shared by the general population. (There are also many studies linking mental health issues to penal populations, where people with some types of diagnoses may be particularly exposed and vulnerable, but I’ll get to that in just a moment.)

Yet, some people who commit atrocities, apparently including Nikolas Cruz, suffer from mental health issues; this is undeniable fact. Common sense (correctly) tells us that people who ingest substances that create an altered state of consciousness may also experience changes in their insight, perception, and judgment, all of which can lead to violent exchanges. Many (though certainly not all!) people who experience psychotic symptoms, when combined with paranoia, can see and hear things that are not there which cause them fear, and frightened people can sometimes engage in violence. This does happen, though it does not seem to be what happened at Parkland. This is why we, as a culture, have created a ‘not guilty by reason of insanity’ verdict for criminal trials over time–we understand that crime and mental illness may be linked and may affect culpability.

The important point here is that people who discuss violence and mental illness with regards to perpetration and people who discuss violence and mental illness with regards to victimization are both right, and it’s because for all practical reasons there are as many different kinds of people who suffer from mental health issues as there are kinds of people generally within the US. Saying “people with mental illness commit violent crimes” is about as useful as saying “people born with thumbs commit violent crimes.” You were born with at least one thumb, right? Have you used a gun for mass murder lately? Yeah, that’s what I thought.

[With much apologies to anyone out there reading this who was born with thumb aplasia–keep fighting the good fight, my friends.]

So having discussed the concept of mental health generally, there is an obvious corollary question as it pertains to any mass shooting tragedy, but particularly one like our most recent:

Why do I hear people talking about access to mental health treatment like it is going to fix this type of issue?

Access to services and insurance coverage for mental health is is a very big, very long discussion, and one I have written many, many pages about over many years of study. I will try to spare you the treatise and give you a Cliff’s Notes version. But first, I’m afraid there will need to be a history lesson.

[I did warn you that the lecture would resume at some point…]

At one point in time, mental health treatment in this country really was like something out of a horror story; there are numerous accounts of people being kept in dark places, chained to walls, lobotomized, and electrocuted, and otherwise just horribly mistreated. Much of the early reform for treatment of people struggled with mental health issues is credited to Dorothea Dix, an activist from the mid-1800s who remains something of a personal hero to me (even if many of her efforts were later subverted). Once we made the transition from chaining people in basements to creating and maintaining asylums, hospitalization remained the way that we as a country handled serious mental health issues for many decades.

[Arkham residents not pictured.]

Sometime around the 1970s, however, people began to heavily question the practice of institutionalizing people with mental health issues, largely because the thing doctors were noticing about putting people away for long periods of time is that they never seemed to really get better (though there were also administrative costs and a very famous study involved). There was a push to start initiating community-based care in clinics and comparable outpatient organizations–which is a model we still somewhat use today in this country to address issues of mental health.

The thing is, in some ways deinstitutionalization could not have happened at a worse time. You see, the push for deinstitutionalization happened largely in the 1960s and 1970s, which was a time when we were making changes to how health insurance worked in this country as well. And mental health coverage is, among other things, often incredibly expensive, even at the outpatient level. So this ultimately culminated in fewer community health options and more restricted insurance coverage for many people with mental health issues. In other words: People weren’t accessing treatment at the rates they should, because there were fewer places to get it and also it cost more. That’s still true today; less than half of people living with a mental health condition in this country receive evidence-based treatment for their conditions.

Around the time that deinstitutionalization began to reach its peak, people began to notice a disturbing trend about the interaction between mental health and prison systems: the percentage of inmates with mental health issues was going way up. Multiple recent studies have shown that prison populations now contain much higher rates of mental health issues than the general population.

Picture by By (Own work) CC BY-SA 4.0 via Wikimedia Commons

An honest and frank discussion about mental health issues in this country would be remiss if it did not also at least touch upon the plethora of other confounding and complicating factors about access to treatment (such as homelessness, incarceration, and autonomy in healthcare decisions, to name a few). But many people believe that fixing these difficulties in accessing services will drive crime rates down, and I think they are right–up to a point. Certainly the number of crimes that are committed due to untreated symptoms will decrease, and I firmly believe that a more streamlined substance abuse recovery system would make a huge impact as well. For these reasons, and because I believe that the American criminal justice system is a grossly inappropriate institution to rely on for mental health treatment, I am a huge proponent of increasing access to mental health treatment in this country.

…which brings us back to Nikolas Cruz. This section is the hardest section of this series to write, because it gets at the real heart of the discussion: How does access to mental health treatment affect tragedies like the one that happened at Marjory Stoneman Douglas High School in Parkland, Florida?

Much has already been written about Nikolas Cruz’s extensively-documented history of mental health issues, telling us that he was diagnosed with ADHD, depression, and “developmental and learning disabilities.” Given what I have read, if one of those “developmental disabilities” wasn’t conduct disorder, I will eat my hat. You see, there’s no noted correlation between ADHD and mass shootings — in fact, most of the main features of ADHD (disorganization, distractedness, inattention, forgetfulness, to name a few) don’t lend themselves to premeditated action at all. And the connection between depression and premeditated murder is attenuated at best. But …well, let’s talk about the diagnostic symptoms of conduct disorder, the adolescent precursor to Antisocial Personality Disorder (which cannot be diagnosed before age 18). I have bolded the things we see reported in the news as part of Cruz’s personal history before the Parkland shooting:

“A) A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following . . . criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

  1. Aggression to People and Animals
  2. Destruction of Property
  3. Deceitfulness or Theft
  4. Serious Violations of Rules

(The remaining diagnostic criteria relate to age, distinguishing from Antisocial Personality Disorder, and absence of signs of other disorders. He probably met the criteria for APD as well, though it would appear no one had diagnosed him with it; you can read those criteria here. The disorder also can occur with or without ‘limited prosocial emotions,’ which is a fancy way of saying ‘this person doesn’t appear to have normal levels of concern or empathy for other humans.’)

As this list suggests, conduct disorder is noteworthy because potential symptoms are disregard for social norms, aggression, destructive tendencies, and a lack of showing of empathy for other people. In other words, the very things that might cause someone to commit this kind of atrocity are potentially enough to diagnose someone with a mental health disorder in the DSM.

(I want to be very clear that diagnoses such as conduct disorder or antisocial personality disorder are by no means a guarantee that someone will commit this kind of atrocity; a person who frequently skips school and then lies about it can be slapped with the same exact diagnosis. As with so many things, it’s a question of severity and also a subjective assessment on the clinician’s part.)

APD Exhibit A: Nikolas Cruz. APD Exhibit B: This guy.

Diagnoses like conduct disorder and antisocial personality disorder are controversial, because some people believe they merely convert criminal behavior into a mental health issue. And antisocial diagnoses are notoriously resistant to treatment, though I personally believe they can be treated in some instances and it is my sincere hope that we identify more effective treatment for these diagnoses soon.

Would access to mental health treatment have prevented this tragedy? It’s tough to say; as a few articles have noted, Florida’s track record of access to treatment is abysmal, and studies show that adequate treatment can definitely reduce instances of violence in general. And perhaps more to the point, Cruz should have had access to treatment because we should live in a country where people receive reasonable evidence-based treatment for their health issues. But on the other hand, we don’t actually have evidence-based practices for treating antisocial issues like conduct disorder, and Cruz’s personal history is a ticky-box nightmare — in particular, there is a long-documented correlation between zoosadism and premeditated murder, and those studies I just mentioned weren’t about premeditated violence; they were about violence generally (and often impulsive violence at that). Treatment — for his documented diagnoses or otherwise — might have prevented this, but it also might not have. And we can’t know, because he didn’t get access to treatment, and then this tragedy happened, and we can’t take it back again.

Access to mental health treatment is a very important issue to me, and I will continue to advocate vociferously for better access to care and services until the day I die. As the first two sections of this series suggest, I do believe that it is incredibly important that we address this issue, for reasons of public safety and humane social welfare. But it is not a panacea, and it is disingenuous and dangerous to discuss the issue as if it were. The fact of the matter is, none of us can know whether it would have helped in this instance. We should have better access to treatment because our entire society benefits from better access to treatment, and it shouldn’t take a horrendous tragedy like this to discuss it.

Living in Troubled Times: A Trauma Resilience Roadmap

Photo courtesy of Wikimedia Commons




Do This Immediately (or: Emergency Recentering Treatments)



Here’s a sample beginner list:

1) Watch my favorite movie;

2) Read some really awful fanfic;

3) Look at cat GIFs on the Internet;

4) Cookiepalooza;

5) Play Rock Band




Here’s a sample second-stage list:

1) Easy activities — I’ve been doing these all along

2) Medium Activities — try some of these if I can

3) Hard Activities — I’m not ready for these yet





This Should Probably Be More Self-Evident Than It Is

Though I don’t believe the inherent morality of humankind is improving with time, the available technology, and particularly our ready access to information, absolutely has. In Jackson’s era, it was possible to go one’s entire life believing racist things that were never disproved within one’s immediate frame of reference. In our current information-laden era, in contrast, it is possible to go to websites whose express purpose is to research rumor and belief and articulate their factual underpinnings — and we have ample scientific evidence negating the idea of racial superiority. Further, the entire nation literally just lived through eight years of efficient governance by a Harvard-educated black man. No one is saying that Obama was not an effective President; in fact, the common Breitbartian complaint and battle cry is that it’s necessary to undo all that President Obama accomplished–because that is a long list.

In other words, antebellum America had commonplace racist beliefs and rigid societal structure that strongly restricted disproof of these beliefs. We, in contrast, have ready access to Snopes and a black President.

This is probably obvious to you, as well it should be, but it also has an important corollary that I haven’t heard anyone talking about:

In this era of ready information, belief in the myth of white supremacy requires more than mere ignorance; it requires active and intentional disregard of available knowledge. For this idea to find purchase, it must be inherently more comforting to the recipient than an acceptance of meritocracy. The myth of supremacy is a security blanket that white racists are refusing to outgrow, and rather than accepting facts they are cocooning themselves in untrustworthy and laughably false information in order to protect the myth. There is no ‘empathy’ that will get around this, because it is the reaction to the myth of superiority that is driving it and the person has already preemptively rejected egalitarian progress.

This is why it is so hard to ‘go high when they go low.’ This is why ‘meeting people halfway’ is a myth. White supremacy in this day and age is a primitive ego defense driven by an ugly desire to see other people fail, and it actively drives society backward.

Advocating to Callous Listeners: Five (Not-So-Easy) Steps

This is a very strange Martin Luther King Day. In my lifetime, we’ve always had a long way to go on race relations–I think most people agree we were not enjoying a post-racial society before the November election–but this is the first time that a President-Elect picked a fight with a civil rights legend the weekend before his inauguration. And, more importantly, this behavior does not exist in a vacuum–our President-Elect ran on a blatantly racist, homophobic, ableist, and Islamophobic platform, and though he did not win with a majority, he did win. And his victory (such as it was) emboldened racist people throughout the country to say what they really think–or, as was the case in many school bathrooms and Congressional floors throughout the country, do what they really think. And most of us who are decent human beings are horrified by this, and want it to change.

However, when many of us with these reactions tried to talk to our family/colleagues/friends/neighbors’ cats who supported Trumpian politics, we had a second horrifying realization: This person we were speaking to did not care about fellow human beings. “The Black Lives Matter movement started because people are dying,“ we told them, and to our abject horror, they just didn’t care. Appealing to a sense of humanity did not work, because the listener did not view the subject population as people.

And this is the point where many of us well-meaning advocates, and especially allies, start to draw a blank about what to even do next. Recognizing the humanity of fellow human beings is so basic to us that we don’t know what to do when someone rejects it–the carburetor in our brain stops turning over, and we stand there sputtering, “But they should!” And we’re right–they should–but they still don’t.

I know something of this challenge, because I spent four and a half years writing about mitigating factors of very marginalized and vulnerable people for a living. Talking to people about their experience above has made me realize it might be helpful to talk about my trial and error process. To that end, I’ve drafted a quick primer on an unofficial five-step process I’ve identified over years as a professional advocate for speaking to listeners who have already reject moral and empathy-based arguments. Though this is by no means exhaustive and makes certain assumptions about the relationship between the speaker and the listener, I’m hoping it’s a helpful start for the average ally and advocate.

1. Let Go of ‘Should,’ And Recognize ‘Is’

This is the first step, but it’s also by far the hardest–if you can manage it, the rest becomes much easier. Most people reading this probably agree that anyone with the empathy God gave a grapefruit thinks that other human beings dying through preventable means is bad. The natural corollary that extends from this understanding is that this person we are speaking to does not, in fact, have the empathy God gave a grapefruit. There’s a real impulse to reject not just that person, but the whole rest of the process–“Well this person is terrible, so until they aren’t, I’m done.” And I hate to break this to you, Dear Reader, but if you have set out to advocate you are not, in fact, done–or at least, not just because this person should have empathy and doesn’t. Nobody is going to make those people play by the rules of basic humanity. People who show they lack empathy to a degree that appalls you still sometimes need to be dealt with, and walking away in those situations is a luxury we’re losing the ability to exercise. You gotta even. I’m sorry.

This doesn’t mean that you have to think this person is wonderful, of course–as soon as you are done interacting with that person in that context, it is appropriate (and even healthy) to blow off steam about how awful it was to engage with them. It’s part of the human condition. But you definitely can’t have a win condition without even playing the game, and that means recognizing the reality in front of you.

2. Identify Goals (Ahead of Time, if Possible)

You’ll note that I said above, “People…sometimes still need to be dealt with.” The obvious corollary is that sometimes, they don’t. The best way to avoid banging your head against a human brick wall for an hour is to have a good idea of whether you need to deal with this person–and the easiest way to do that is to identify your goals. And even when you do need to talk to a person, having a firm understanding of what you’re trying to achieve helps you get in, say what you have to say, and get out–so it’s very helpful to know going in. What are you trying to achieve by talking to this person? Do they control access to a resource you need? Are they engaging in a damaging behavior you want to stop? Are they voting all of our human rights away in the first week of their first session before your eyes? (Spoiler: If your answer is “I want to let them know that their ideas are bad and they should feel bad,” I recommend walking away.)

To help you see what I’m talking about, let’s go through an example scenario–for the purposes of this essay, let’s pretend we are members of Congress, which is both a helpful universal and a pleasant daydream. Mitch McConnell is holding another Senate vote about the Affordable Care Act. The Senate committees have come up with alternate legislation, and it’s just forty blank pages followed by the words “Buy an HRSA.” People may die if we can’t convince some of the Republican Senators who voiced early opposition to the lack of “replace” in the phrase “repeal and replace” to vote differently this time around.

3. Look for Carrots and/or Sticks

Okay, so: You’ve accepted that the obvious appeal to humanity won’t work, because the listener is a jerkfaced jerk. But they’re a jerkfaced jerk who has a thing you need. Now what?

Here’s where the first thing I mentioned becomes really important–because figuring out what is going to be effective requires an understanding of what motivates that person. Please note that I am not adding my voice to the chorus of white people saying that everything will be fine if we just give white supremacists more empathy, which I believe is a dangerous model of thought at best. But in order to advocate, you need to know what a carrot and/or a stick would look like for this person, because everybody has their own carrot and stick–and you can bet that a racist callow person’s stick and carrot probably don’t look like yours.

To continue the example above, let’s talk about what would constitute a relevant carrot and stick for your average Republican Senator. Though this is an incredibly complex topic, for the purposes of this exercise let’s assume the carrot probably looks like money, or political capital. The stick probably looks like being voted out of office.

So as we’re navigating negotiation with these Senators, we need to either figure out why the ACA will save/earn them money or figure out why they should fear what their constituents will do if they accept this legislation.

4. Offer a Carrot or Raise a Stick, and Preferably One that You Believe

This is another hard but crucial step, because it requires you to take on the listener’s paradigm long enough to persuade them. It honestly does help to believe what you are saying, for several reasons. First of all, a credible argument tends to carry more weight; a thing even you don’t believe is generally not that persuasive to other people. But more importantly, an argument you can accept as true helps you remember is that speaking this person’s language doesn’t mean you hold their values, or that you agree with them–it just means you need something from them and you have to figure out how to coalition-build in order to make that happen. It’s helping them figure out why they want to do this thing you want them to do anyway. (And lastly, though perhaps this should go without saying, it is never a good idea long-term to lie your way to a built coalition, as this creates many problems for both you and others throughout the process.)

Let’s go back to our replacement plan vote. Though I’m generally a carrot person by personality and trade, in this instance I think the stick is easier to argue. As I noted above, this is incredibly complicated, but for now let’s pick one stick: That preserving the ACA probably will not save these Senators money, but constituents relying on the ACA will not be happy to see their health insurance evaporate–even if they currently don’t know it. Elaborating on that is where the advocacy starts, and ideally is the vehicle by which change happens. Awesome and canny Senators that we are, we talk with the folks who are already wavering about why their instincts are good and this move is risky. We note their specific reelection dates. We note how long it would take the ACA to be effectively repealed. We observe how close the end date will be to their campaign season. We heroically refrain from yelling at them. We generally try to persuade them that their scary inhuman boss won’t even be their boss in two years if they do this now. In an ideal world (or at least, in this tiny scenario we have built), we are successful.

5. Take Care of Yourself After the Rinse/Repeat Cycle Ends

Most people’s minds aren’t changed in a single five-minute session; it takes a lot of work and internal screaming and fantasizing about shaking them by the shoulders. This process is hard on a person, and appropriate self-care should be treated as a necessary step. Do what you need to do in order to stay healthy, and that tends to be different things for different people. I encourage you to think of self-care as the final step of the advocacy process, because it’s that crucial.

To wrap up, let’s talk about final steps in the Congress scenario. After several grueling hours of arguing convinces my Republican colleagues to vote against the bill, I am tired and hungry. So I reward myself. By eating their share of the vote-o-rama pizza.