The Roanoke Shooting and Forcible Psychiatric Treatment

A psychiatrist argues that "a vast majority of these tragedies" could be prevented by more aggressive mental health interventions.


Fox News

Referring to last week's shooting in Roanoke, Columbia University psychiatrist Jeffrey Lieberman argues in a New York Times op-ed piece that "a vast majority of these tragedies are preventable" through earlier, more aggressive, and more coercive "mental health care." Since psychiatrists have never been good at predicting violence, this claim invites skepticism, and Lieberman never backs it up.

The closest he comes is an anecdote about a college student who "quit the football team, left school and went home" at the beginning of his sophomore year:

He was withdrawn, disheveled, talked to himself and was suspicious of his friends and family. His parents knew something was wrong and sought treatment. When a mobile crisis team was called to the house he refused to engage with them. Although he clearly was ill, he was not aggressive, so they told his parents to continue monitoring their son's behavior and to call if he became a threat to himself or others. The next day he stabbed his twin half-brothers with a kitchen knife, killing one of them and severely injuring the other. 

The implication is that the college student should have been treated against his will, even though there was no evidence that he posed a threat to others. If only that had happened, Lieberman suggests, the attack could have been prevented.

Even if we accept that counterfactual supposition, it is not clear how it applies to the "vast majority" of shootings with multiple victims. Northeastern University criminologist James Alan Fox, an expert on mass murders, notes that the perpetrators of such crimes typically do not resemble the college student described by Lieberman:

Notwithstanding a few high-profile defendants—such as James Holmes in Aurora, Colo., and Jared Loughner in Tucson, Ariz.—whose mental health issues are well-documented, no clear relationship between psychiatric diagnosis and mass murder has been established.

Mass murderers generally do not hear voices or suspect that they are being followed. More typically, they are miserable, but not to the point that they'd be hospitalized or lose their ability to purchase guns.

Vester Lee Flanagan II, the perpetrator of last week's shooting, fits that description. Coworkers described him as touchy, volatile, and perpetually disgruntled—to the point that his employer recommended counseling and ultimately fired him. But Flanagan did not meet the legal criteria for commitment to a mental hospital or for losing his Second Amendment rights. Legislators can expand those criteria, of course, but that would inevitably affect lots of abrasive oddballs who, despite their off-putting quirks, pose no real threat to others. As Fox puts it:

People cannot be denied their Second Amendment rights just because they look strange or act in an odd manner….

While there are some common features in the profile of a mass murderer (depression, resentment, social isolation, tendency to blame others for their misfortunes, fascination with violence, and interest in weaponry), those characteristics are all fairly prevalent in the general population. Any attempt to predict would produce many false positives. Actually, the telltale warning signs come into clear focus only after the deadly deed.

Yet Lieberman seems to think anyone who exhibits "bizarre and disruptive behavior" like Flanagan's should be forced to undergo psychiatric treatment, just in case. "We are reluctant to infringe on people's civil rights by forcing them to accept treatment," he writes, "even though we do just that for communicable infectious diseases such as tuberculosis and various sexually transmitted diseases." But unlike communicable infectious diseases, the conditions Lieberman wants to forcibly treat cannot be objectively verified and cannot be transmitted to other people. When it comes to justifying the use of force, those seem like pretty important distinctions.

Lieberman notes that 45 states have laws that "enable doctors to obtain a court order that requires severely mentally ill patients who meet certain legal criteria—if they are unable to care for themselves or are unwilling to take medication—to adhere to treatment." He calls for more aggressive use of such court orders against "a small number of people who have psychotic disorders, and known risk factors for violence, such as drug abuse and a history of violence."

It's hard to see how this prescription is relevant to the case at hand. Flanagan, after all, was able to take care of himself, and he does not seem to have been prescribed any psychiatric medication that he refused to take. So he apparently did not meet the criteria for a court order. Whether he was "severely mentally ill" or had a "psychotic disorder" is purely a matter of speculation. Even assuming that such a determination can be confidently made with a live person, there is no way to locate this purported condition in Flanagan's dead body or brain.

In any case, according to the American Psychiatric Association, "96% of people with serious mental illnesses never act violently." Presumably that is why Lieberman adds "known risk factors for violence" to his criteria for coercive treatment. It is debatable whether Flanagan had a history of violence. While his coworkers had alarming encounters with him, it looks like none rose to the level of assault. So far I have not seen any references to drug abuse. In short, Lieberman latches onto this case to argue that more use of court-ordered psychiatric treatment would stop the "vast majority" of mass shootings, but he does not even show how the policy he advocates could have stopped Flanagan, let alone most other murderers.