Psychiatrists, psychologists and other mental health professionals deal with and diagnose a wide spectrum of conditions from mild anxieties, substance abuse, learning disabilities, mental retardation, and marital-family-vocational relationship problems, to severe mental illness. Severe mental illness can be well-treated, not treated well, or not treated at all. Some psychological treatments like “anger management classes” help angry persons without established psychiatric diagnoses, but don’t cure them, or completely cure potential for violent behavior. The messiest and most dangerous of mentally ill persons are adolescent or young adult males with severe personality disorders.

The Spectrum of Mental Illnesses: A Brief Introduction

The typically anxiety neurotic person, is keenly aware of their psychic pain. Their psychological pain, like the pain of a severe medical disorder, frequently brings them to a physician, clergyperson, or therapist. Significant numbers of military veterans and civilians suffer from trauma-related PTSD which requires medication and psychotherapy. Their treatment is often more complicated if there is concurrent substance abuse. However, effectively treated anxiety neurotic persons are not a huge danger for gun violence.

A psychotic (Schizophrenic, Bipolar or Psychotically Depressed) person, like Jared Loughner who shot Arizona congresswomen Gabrielle Giffords, is in massive denial about his disorder. The denial of a psychotic person like Laughner is the result of their brain chemistry’s disarray. In addition, the psychotic person often refuses to take medication and stay with counseling. Psychotherapy and judicious medication prescription can help psychotic persons have clearer thought processes enabling them to work and relate more normally to other people. Well treated and followed-up psychotic persons are no more prone to gun or other violence than the normal population.

Severe Personality Disorders: The Most Messy and Dangerous Mental Ill-Heath Situations

Persons with a personality or character disorder are commonly in denial about their offensive, cruel, selfish, un-empathetic, anti-social, disrespectful, inordinately dependent, or destructive  thoughts and behavior. They in essence are unaware or barely aware of the psychological skin in which they have lived in for most of a life. Persons with personality and character disorders only acknowledge a problem when their behavior causes pain or difficulty for others. When confronted, they often blame the messenger who presented the bad news to them. According to people with severe personality or character disorder, the police who confront them, the boss who fires them, or spouse that leaves them, are the problem

People with Severe Personality Disorders readily assume that their view of the world is the only true or important view. They are often the last to recognize if ever their destructiveness or dangerous potential for lethal violence. They are very hard to engage in therapy or treatment programs.

Severe Personality Disorders such as:  Borderline Personality, Malignantly Narcissistic, Antisocial Personality Disorder, or Sadistic Psychopathic Personality Disorder are not psychotic disorders like Schizophrenia, Psychotic Depression, or Bipolar Disorder (formerly Manic-Depressive Disorder) . Severe personality disorders are often chaotic, impulsive, suspicious, and have poor insight and emotion regulation. These severe personality and character disordered individuals are often far more difficult to treat than severe schizophrenic or depressed persons. Psychiatric medications often have limited usefulness and they tend to act-out their emotional problems rather than talk them through in psychotherapy. Just when a psychotherapist gets into the core conflicts of these persons, they flee treatment, use addictive substances, or act-out their problems into behavior, occasionally toward the therapist.

Persons with severe personality disorders, while socially dysfunctional, are not technically psychotic but can be very dysfunctional. They do pose severe problems and a great expense for American society. They, like “normal” persons who are intoxicated and enraged, should not possess guns. A glibly recommended “anger management” program is beyond insufficient for persons threatening or strongly hinting about violence. These persons who very much need close watching and follow-up, are often the most difficult to relate to and resist contact or become threatening. Truthfully, employers, school administrators, and even police or mental health clinics, often want them to just go away and get out of their hair. They are not pleasant and often find intimidating or vexing of therapists stimulating, even calming or enjoyable.

America faces an epidemic of severe personality disorder problems. Particularly young adult, disaffected, alienated, socially isolated, angry males preoccupied with guns and violent videogames. Some of these individuals even impulsively defy and attack police. Young angry, alienated, and rejected teenagers can be dangerous and prone to violence, even mass murder. But they are not suffering from diagnosed major psychotic mental illness. They are often found however under the psychiatric umbrella. Their acting out behavior often gets labelled “behavior disorder.” They often talk to friends or over the internet about violent acts and mass murder, often amidst ideologic slogans of left wing or right wing racist or white supremacy themes. Few psychotherapists have enough strength of personality to persist and be helpful in their treatment. More aggressive treatment programs and legal mandates for treatment of these young people need to be creatively developed and implemented aggressively in our communities. Persistent follow-up with them is absolutely critical!

“Patient’s Rights” For Dangerous Mentally Ill Persons, Their Possession of Guns, and Paradoxes About Their Treatment: A Radical New Approach Required!

Gun violence and mass murders in America must stop. The section below approaches the issue from the perspective of working psychosocially and legally with violent mentally ill persons.

In the author’s opinion, mentally ill persons who attempt or overtly threaten violence should have their civil rights suspended. Immediate psychiatric and psychological evaluation and a treatment plan must occur. The threshold for detection of violence needs to be much lower than it is currently. After a violent threat or potential threat is detected, an inextricable part of such detected violence potential is the loss of the individual’s Second Amendment rights for an indefinite time. All Americans must be mindful that their civil rights are contingent on their taking responsibility for the control of their behavior. Violent threats or actions mean loss of the privilege of their civil rights until they satisfy a civil process to regain their civil rights. This would probably require major changes in the law.

A Proposed Community Based Process for Handling the Civil Rights of Violent Persons

Prompt and thorough evaluation should be done on anyone threatening or showing warning signs of potential violence. Once a diagnosis is established the following should be mandated by law.

The suspension of basic “Patients’ Civil Rights” should be legally mandated until the patient is fully and positively involved in their treatment; and on the road to outpatient recovery or stability in a psychiatric hospital. At the point when treatment compliance is established, a select community committee of a lawyer, a psychiatrist or psychologist, a teacher, a psychiatric social worker, and a mature layperson should monitor and act as resources for the patients and their family. In the in-patient setting, the patient advocate, a psychiatrist and another patient capable of serving could monitor the issues described below. This mental health group should oversee and assure the community that the following requirements have occurred:

1---Cooperation with in-patient treatment parameters or regular attendance at all out-patient treatment sessions must occur for twelve consecutive months.

2---Responsibility of the patient to take all psychiatric medications prescribed by the psychiatrist or trained prescriber for a minimum of twelve months has occurred.

3---Attendance at all recommended individual, group or family therapy sessions has occurred for twelve months.

4---No episodes of violent or menacing behavior has occurred according to the therapist(s), family, spouse, or police authorities.

5---Violations of this process and the person will start the process over again with a new community committee. After the twelve months of responsible compliance the community committee will re-assess the further treatment plan compliance on a yearly basis for three years before any gun can be purchased or possessed by the individual.

6---National, state and local community records of this violence prevention program shall be readily available to gun show and firearm vendors for universally required  background checks for all gun purchases in America.

Objections Anticipated

Some will argue for sure that the above process is too stringent and restrictive. Others will say it is too weak. Many mental health clinicians feel that procedures like those advocated above will prevent violent persons from seeking help. If a potentially violent person is in treatment, such a process would prevent them from mentioning or exploring violent fantasies. In theory, the ventilating of such violent fantasies are often felt to diminish violence potential or more importantly, help the person to understand the sources of their anger and how to change, control or extinguish the potential for violent behavior.

The author feels that a vital part of the therapy of a potentially violent person is the learning of the futility of violence to resolve or gain anything. Confrontation with one’s personal responsibility to obey the law and not harm other people or animals starts in childhood and wisdom about it is hopefully cumulative during family, school and church or community experiences. The above process would encourage active awareness of individual responsibility, and legal and social obligations. The experiences of community members on the community committees will increase public awareness of the issues and ensure careful follow-up of violent or potentially violent persons.

Image credit: Paget Michael Creelman

Peter Olsson was an assistant professor of psychiatry at Dartmouth Medical School and an adjunct professor of clinical psychiatry at Baylor College of Medicine in Houston. He retired from active clinical work to write full time in September 2011. Olsson received the Judith Baskin Offer Prize in 1980 for his paper, "Adolescent involvement in Cults and the Supernatural". Dr. Olsson is a Fellow of the American Academy of Psychoanalysis and a distinguished life fellow of the American Psychiatric Association. For his publications see the Olsson website.   www.drpeterolsson.com