January 12, 2011

Five Questions on the Tucson, Ariz., Shootings for Psychologist Joel Dvoskin, PhD

A mental health expert explains how to recognize danger signs, talk to children about the tragedy and more

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Joel Dvoskin, PhD, is a clinical psychologist based in Tucson, Ariz. He is author of numerous articles and chapters in professional journals and texts, including a number of articles that deal with treatment of people with serious mental illness and co-occurring substance use disorders. He has been qualified as an expert witness on these and related issues in numerous state and federal courts throughout the United States.

Dr. Dvoskin is a member of several expert teams for the Civil Rights Division of the U.S. Department of Justice, focusing on the rights of inmates, detainees and patients housed in various forms of secure confinement. He frequently provides training to clinicians in the treatment of people with serious mental illness and/or substance abuse disorders. Dr. Dvoskin served as acting commissioner of mental health for the state of New York, overseeing 31 state psychiatric hospitals, 25,000 staff, and the care of more than 100,000 New Yorkers with serious mental illness. For 11 years before that, he was director of forensic services and associate commissioner for forensic services for the New York State Office of Mental Health. He has testified in numerous class actions regarding the treatment and suicide prevention for people with serious mental illness and/or co-occurring mental health and substance use disorders in hospitals, prisons and jails throughout the United States.   

Q. Given the fact that most people with mental illness are not dangerous, what are signs that often distinguish the dangerous individual?  And what should a person do if he or she knows someone who exhibits these signs?  

Dr. Dvoskin:  It is absolutely correct that most people with mental illness do not pose a risk of serious violence to others. It is easy to predict events after they have occurred, and it is easy to overgeneralize from characteristics of known offenders. The problem, however, is that these characteristics apply to thousands and thousands of people, almost none of whom will commit an act of extreme violence. This is why "profiles" are of so little use in preventing violence. However, it is very easy to identify troubled people and troubling situations, and to use kindness and common sense to provide help for people who obviously need it. As many people have observed in the aftermath of this tragedy, community mental health budgets all over the U.S. have been cut, deeply reducing the mental health system's ability to provide user-friendly and effective crisis response and community mental health services to people who need them. In the meantime, if you know of a person who has suddenly experienced an extreme and negative change in functioning, appearance, demeanor or behavior, you can try to steer that person to a mental health service provider or alert people who might be in a position to help: school counselors, community mental health providers or members of the clergy.

To give one example, suppose that a normally cheerful person becomes sullen and apparently angry, muttering obscenities and unwilling to discuss what is wrong over several days. While there is no way to know whether this person is going to commit an act of violence or suicide, they are clearly in despair and in need of some help. The person who observes this behavior should make every effort to get that person help, or to refer the matter to someone who can. If the person's words or actions are so extreme that they frighten people, the police have (perhaps sadly) become very skilled at safely bringing people to emergency departments where they can be assessed and treated, if necessary without their consent. However, I want to urge that coerced treatment is often unnecessary if community-based treatment is of a high quality, in adequate supply, and easy for people to access.  

Q. Some people are pointing to the vitriolic rhetoric among pundits and politicians as bearing some responsibility for the shooting rampage. What do psychologists know about how much impact such discourse has on people who are mentally ill? Is there really a cause-and-effect relationship here?

Dr. Dvoskin: The most fundamental principle of human behavior is that all behavior, including violence, is an interaction between individual people and the environments in which they live. This is certainly true of interpersonal violence and suicide. It is not possible to attribute a particular act of violence to any one cause, as violence is almost always caused by a multitude of individual and environmental factors. 

There is a great deal of research suggesting that the media people consume influences their behavior, including violence and aggression. This includes fictional depictions of violence in movies, television shows and video games, as well as news reports.   

As to the effects of vitriolic political rhetoric, the degree to which it influences violent behavior, at least to my knowledge, is not known. It is also not clear if people with mental illness are more affected by vitriolic political rhetoric than others.  

Q. What should parents tell their children about this incident – especially since one of the dead was a 9-year-old child?

Dr. Dvoskin: Don't be afraid to talk to your kids about these events. The most important thing after any trauma is to maximize real and perceived safety for the child. In this case, law enforcement is reporting no reason to believe that this is anything more than the act of one person, who is now in custody. Letting kids know that they are safe is likely to help and not likely to make things worse. 

Don't flood kids with too much information. The best way to decide how much information is appropriate is by the questions children ask you. Answer their questions honestly and directly, but remember that they are kids, so keep it simple (depending upon their age).

Parents should not lie to their children when talking about this tragedy. To the extent that children are unable to trust their caregivers, it is very difficult for them to feel safe.

Don't "pathologize" normal human responses to frightening events. If your children are frightened or upset, it doesn't mean there is anything wrong with them. However, if problems such as misbehavior, sleeplessness or other signs of depression or anxiety become especially severe or extreme, then seek professional help.

Limit kids' continued exposure to television coverage of the event. Depending upon their age and developmental status, they might not be able to tell if it's one event being repeated or many events. This is especially true of younger kids. Parents might even want to limit their own television watching.

Pay attention to your own fears and anger. It is unlikely that you will successfully hide your feelings from your children, who usually pay keen attention to what you say and do. Take care of yourself, and if your own feelings or behavior become extreme and problematic, don't be afraid to seek help for yourself as well. 

If it is necessary to refer the child to a mental health professional, as always, step one is screening and assessment. Assess the child as a child, in totality, and in developmental context. Kids who have exaggerated reactions to what they see on TV may be kids who aren't strangers to trauma. The real question is  why this event traumatized  this child. Remember, we treat symptoms, not the event that caused the symptoms. The vulnerability of every individual, child or adult, varies, and one size never fits all. One significant question is whether or not the child was already in treatment. Community trauma can bring to the fore issues that were already there. I would recommend that one avoid the temptation to treat what isn't evident. In other words, don't assume symptoms that aren't there, even if one thinks they should be. 

Q. How can community leaders help individuals who may have been traumatized by this tragedy?

Dr. Dvoskin: Most of the suggestions above regarding children would apply to adults as well. Community leaders should convey a sense of competence and duty. In order to restore a sense of public order and the beginning of a return to a state of well-being, citizens need to believe that people with power and authority are acting wisely. 

The aftereffects of community trauma are often measured in years, not days. Do not assume that people (adults or children) who seem to be handling things well will continue to do so in the days, weeks and months to come. On the other hand, in my opinion, it is a very bad idea to tell people what they are going to experience (e.g., symptoms of post-traumatic stress disorder). There is typically a wide array of responses to community trauma, and we don't want to create pathology by the power of suggestion. In addition, one doesn't want to pathologize normal human reactions to traumatic stress.

Q. What if anything can mental health experts do to try to prevent situations like this from recurring?

Dr. Dvoskin: The question implies that mental health professionals are the first line of defense against events such as this. While we have an important role to play, prevention is key and requires thoughtful action by a wide array of people and institutions. Step one involves identifying troubled people and troubling situations and bringing them to the attention of appropriate “authorities,” such as teachers, co-workers, law enforcement, physicians, friends, family and significant others. While troubled people very likely won’t commit an act of serious violence, they are still in need of help. Getting them appropriate, timely treatment might prevent a suicide or some other bad outcome.

Second, institutions need to communicate with each other in a coordinated effort. In some jurisdictions, police and mental health authorities work closely together to respond quickly and skillfully to crises. We also need better psychoeducational programming in schools, better coping assistance programs in the workplace and better community services to help individual, couples and families in distress as early as possible.

This takes all of us; an electorate that is willing to invest in public mental health and public safety. 

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