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The Questions We’re Asking in the Orlando Aftermath…

In the wake of extreme violence in Orlando, FL, along with numerous other relatively recent mass shootings, one wonders if someone should have intervened with these troubled individuals before the violence occurred. But who is that someone, how would that person have known that intervention was needed, and what if anything could that person have done to help the troubled individual and potentially prevent tragedy?

A Few Basic Facts About Mental Illness

Generally speaking, mental illnesses create mild to severe disturbances in a person’s thinking and behavior. Symptoms of various psychological disorders (mental illnesses) typically revolve around mood, social withdrawal, personality, and personal habits. With the majority of psychological disorders outward expressions of violence are only slightly more common than in the general population. That last sentence is very important, so I’m going to restate it: The link between mental illness and violence is minimal. In fact, research shows that outward expressions of violence are considerably more likely to be triggered by dysfunctional (abusive, neglectful, or addicted) families, personal stressors, and socioeconomic factors than by a mental illness.

The simple truth is that most mentally ill people are able to live relatively normal lives if/when they receive proper diagnosis and treatment—usually a combination of individual counseling, peer support groups, and medications designed to control and/or regulate their most troublesome symptoms. So the vast majority of mentally ill people, even those with a severe mental illness, can and do live and safely interact in their families and communities, holding good jobs, paying taxes, and generally contributing to society in positive ways.

Unfortunately, some mentally ill people (there is no way to know how many) do not seek or accept professional assistance until their illness drags them to rock bottom. It’s a bit like getting a common cold and knowing something is wrong, but continuing to run around in bad weather with no coat on until eventually you’ve got pneumonia. An illness that could easily and simply be treated—in this case with bed rest, orange juice, chicken soup, aspirin, and a little bit of TLC—spirals out of control and eventually becomes dangerous.

Common Signs of Mental Illness

There are numerous signs and symptoms of mental illness. (Again, I want to reiterate the fact that mental illness does not by itself increase the risk of violent activity in any meaningful way.) Some signs of mental illness are more easily observed than others, but none can be masked 24/7/365. So when a person is mentally ill, his or her family members, employers, teachers, friends, neighbors, and the like are almost certain to witness troubling behaviors at least occasionally.

Warning signs for mental illness may include:

• Confused thinking (not knowing where they are, why they are there, or who they are with)
• Prolonged depression/sadness
• Ongoing social withdrawal
• Prolonged irritability
• Excessive fears and/or anxiety, perhaps to the level of paranoia
• Drastic changes in eating and/or sleep habits and other areas of self-care
• Delusions (believing in things that are not real)
• Hallucinations (seeing and/or hearing things that are not real)
• Inability to cope with daily life
• Self-harm or thoughts/threats of self-harm (cutting, burning, suicidal ideation, etc.)

Admittedly, many if not all of these symptoms can and often do have causes unrelated to a psychological disorder. For instance, confused thinking, depression, prolonged irritability, social withdrawal, delusions, hallucinations, and self-harm are common symptoms of Alzheimer’s disease, which is a medical rather than a psychological condition. Of course, the fact that a person has a medical rather than a psychological disorder does not mean the abnormal behaviors should be ignored and left untreated.

Violence: The Obvious Risk Factors

As mentioned above, mental illness by itself does not significantly increase the risk of violence. However, research clearly shows that mental illness in conjunction with certain other factors, including childhood abuse, early-life family dysfunction, past violence, substance abuse, and a variety of societal disadvantages, does increase the risk. In general, the two biggest indicators of potentially violent behaviors are a past history of violence and substance abuse issues.

Previous Violence

Research consistently tells us that people who’ve acted violently in the past, especially those who’ve been arrested for violent behaviors, are much more likely than others to become violent in the future, regardless of any psychiatric diagnoses. Other research tells us that mentally ill people who do not have a history of violence are unlikely to become violent in the future (without other factors coming into play).

If you cannot easily assess a person’s history, possible signs of a violent past and a possibly violent present include:

• Ambient anger (generalized anger directed at nothing in particular or everything in general)
• Severe localized anger (strong anger directed at a specific person, institution, or situation)
• Frequent outbursts of anger (either ambient or localized)
• Consistent defiance of authority
• Ongoing petty crimes (theft, vandalism, and the like)
• Threats of violence (toward self or others)

Substance Abuse

Once again, all sorts of research tells us that mental illness alone does not significantly increase the risk of violence. However, mental illness coupled with alcoholism and/or drug addiction does. For instance, one study looking at schizophrenia found that 8.5% of people with a schizophrenia diagnosis but no other mental health diagnoses had been convicted of at least one violent crime. This was only slightly above the percentage for the population as a whole. However, a dual diagnosis of schizophrenia and substance use disorder (alcohol and/or drug addiction) more than tripled the percentage, upping it to 27.6%. Meanwhile, research looking at bipolar disorder has produced similar results, with the likelihood of violent behaviors increasing from 4.9% for bipolar disorder alone to 21.3% for bipolar disorder plus substance abuse issues.

How to Best Respond

In general, people with a serious mental illness, even when that illness is coupled with a history of violence and/or a substance use disorder, respond well to proper treatment. As such, even those at risk for violent behaviors can be helped, potentially preventing future violence. The difficult part is getting these individuals started with proper treatment (including treatment for substance abuse issues when appropriate) and convincing them to fully participate in the process—attending therapy and group support sessions, taking medications as prescribed, staying sober, etc.

Most of the time the treatment process begins with an intervention of some sort, hopefully long before the mentally ill person hits bottom.

• If you are worried about a family member, you might consider hiring a therapist to meet with you and your troubled loved one to discuss the basics of the problem and the various options for treatment. If you are worried about possible violence, of course, you are better off making a call to the police, your local social services agency, and/or the local Emergency Room, as these organizations nearly always have staff members trained to deal with crisis situations.
• If you are worried about mental illness and potential violence in someone other than a family member, do not attempt a private intervention. In these cases it is always best to call the police, your local social services agency, or the Emergency Room.

Unfortunately, our society’s mental health system is painfully underfunded and therefore overwhelmed by those needing care. In fact, our lack of state-funded housing and treatment for the mentally ill is somewhat astounding. Because of this, the people who do not want treatment can easily slip through the cracks. And even the people who would happily accept assistance are often turned away thanks to inadequate resources. Yes, a few such people are lucky enough to have good insurance and/or families who are willing and able to pay for needed care, but the majority of mentally ill individuals do not have that level of external support.

Exacerbating matters is the lack of properly informed and directed treatment regimens for dually diagnosed individuals, in particular those who are mentally ill and also addicted. Much of the time, the mental illness is treated (to one degree or another) but the substance use disorder goes unaddressed. Other times the reverse occurs. Either way, only half of the problem is dealt with, so the troubled individual has little chance to heal and to integrate into society in healthy ways.

Still, we should not live in fear of every strange person we pass on the street. Strangeness, and even mental illness, are not indicative of potential violence. In cases of extreme violence, other less easily spotted factors are nearly always in play. Consider the Orlando shooter, who was employed and married and cogent enough to organize a plan for his attack. In other words, we’re talking about a guy who on the surface looked a lot like everyone else.

The simple and sad truth about the shooting in Orlando (and similar situations elsewhere) is that we are not very good at predicting violent behavior, even in the medical and psychiatric professions. In fact, except for identifying a past history of violence and/or substance abuse issues coupled with serious mental illness, we have little chance of picking a potentially violent person out of a crowd. The good news is that access to empathetic, well-informed treatment and safe, supportive housing environments can make all the difference in the world for seriously mentally ill and potentially violent individuals—but only if our society becomes more willing to provide (to pay for) these mental health essentials.

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