The Daily - Friday, Feb. 23, 2018

Episode Date: February 23, 2018

President Trump, conservatives and the National Rifle Association have once again tried to steer the national conversation after a mass shooting to the mental health of the people who pull the triggers, rather than the weapons they use. But how can the mental health system stop gun violence when mental illness is so rarely the cause of it? Guest: Dr. Amy Barnhorst, the vice chairwoman of community psychiatry at the University of California, Davis. For more information on today’s episode, visit nytimes.com/thedaily.

From The New York Times, I'm Michael Barbaro. This is The Daily. Today, President Trump, conservatives, and the NRA are all again pointing to mental illness in response to a school shooting. But how can the mental health system stop a shooting when most shooters aren't mentally ill? It's Friday, February 23rd.

I don't believe that this insane monster should have ever been able to obtain a firearm. Ever. I do not think that he should have gotten his hands on any kind of weapon. That's number one. This individual was nuts. We don't know right now exactly why this deranged individual did this. Crazy madman

been on evil. And a wacko came in and shot the five of them. Who were shot by this madman. They're homicidal maniacs. People like this with mental health issues. This troubled young man fell through the cracks. The failure of America's mental health system. This is a mental health problem. There is a mental health epidemic here which is being confused for a gun problem. Again, this is a mental health issue. This is not a gun issue. The common theme with these kinds of shootings is mental illness and this is something that we should

not be ignoring. Would you like me to, how would you like me to refer to you? Doctor? Amy? Professionally, Dr. Barnhorst. Personally, you can always call me Amy, but professionally, Dr. Barnhorst. Okay. So, Dr. Barnhorst, tell me about the day of this appointment. Well, it started out as just a usual day in a busy crisis unit. So, I work as an emergency psychiatrist in a crisis unit that's adjacent to an inpatient psychiatric hospital in California. We see people who are acutely ill or acutely in crisis, maybe people feeling suicidal and depressed,

maybe some folks who were brought in because they were hearing voices. And then the police brought this kid in. He was a 21-year-old, and his parents had called the cops because they had gotten concerned about some of the stuff he'd been posting on social media. of gotten increasingly hostile, but were generally vague up until, you know, the last few days where he had made some specific references to the Columbine shooting and something about some death and destruction. And one of the things he referred to in his Facebook page was a day of retribution. And when the police went to his house and spoke with the parents, the brother mentioned that this patient had told him he was going to try to buy a gun. And the brother thought he had done so, but wasn't sure. And why did the police bring him to your office?

They've been told about this posting on Facebook, which is alarming. Why did they bring him to you? Well, he really hadn't committed a crime, so they couldn't arrest him. But I imagine that the police were pretty worried about this guy. You know, he certainly had a lot of concerning signs, and I think they brought him to us in the hopes that maybe the mental health system would be a way that we could prevent him from going down a bad path. So what are you doing first? What's your role in this moment? So my first thing is I get the chart and I flip through it and kind of see what's going on. For this young man, I probably would have had any records we had on him, which was none.

And the legal hold that the police brought him in on, which was just a piece of paper with a few lines, might be something as simple as making threatening postings on Facebook, comma, might have bought guns, says brother, comma, parents worried. In this case, I had fairly little except that ominous information. So I always build a picture in my mind of what people are going to be like before I meet them. But he did not really jive with my mental image that I had built up. What do you mean? If I had met this young man and he seemed, for example, like in a manic episode where he was impulsive, where he was talking really fast,

where he was delusional and grandiose, that might be indicative that he was in fact mentally ill and that maybe this idea about threatening up his school was secondary to a mental illness that could be treated, and thereby we could prevent the shooting or the act of violence. But in the case of him, I mean, he looked not like somebody with a mental illness. He didn't have any of those signs. He was a nice enough kid, not particularly angry to me, although it was easy to see that he had some darkness in him. And I think he was a little sullen and depressed, not happy with his social standing and how things had been going at his school. He said that he didn't think he had a

mental illness. He didn't want treatment. He didn't need treatment. He seemed more like a sad brooding kid who was hurt and realized he had done something wrong and really wanted to go home. So ultimately, you're trying to determine if this post on Facebook was coming from a place of mental illness or possibly something else. Yeah. So I'm trying to figure out if he is going to meet criteria to be involuntarily admitted to a psychiatric hospital. Okay. And in California, in order to be admitted to a psychiatric hospital involuntarily, you have to meet one of three criteria to either be dangerous to yourself, dangerous to somebody else, or gravely disabled, which means that you're not

able to provide for your own basic needs, like your food, clothing, and shelter. And you have to meet one of those three things because of a mental illness. So even if this young man is angry or showing a propensity towards violence, you'd need to determine that these emotions are coming from a mental illness in order to involuntarily commit him. Right. So at this point, I'm making a primarily clinical decision about whether or not I should admit this young man for treatment. But I also know that my clinical decisions have legal implications for him because there is a difference between an admission to a hospital and a commitment. As a doctor, what I do is I make the clinical decision to admit someone to a hospital and a commitment. As a doctor, what I do is I make the clinical decision to admit someone to a hospital. The commitment is a legal process that is done by

the judge or the hearing officer. And that's the checks and balances in the system that make sure that some doctor can't just admit people willy-nilly and hold them in a hospital indefinitely with no liberties. And so if he is committed, then his name goes into a federal database of people who are prohibited from purchasing guns. And any time a federally licensed dealer does a background check, his name will come up as a prohibited person and he won't be able to buy a gun. But he'll still be able to purchase from private party sales and from internet sales and from gun shows where in most states they don't do background checks. And so this is how someone like you interacts with what most people think of as the federal background check system.

Yes. That's used for gun purchases. Yes. Doctor, this feels very complicated, what you're describing, because so often people are expressing violent thoughts, but mental illness is not clear. And yet, as a doctor, you want to prevent them from carrying out these acts, I assume. So how do you grapple with people who fall short of that glaring mental illness, but who are expressing violent thoughts? I mean, it's hard because we do see people every day, especially in a crisis setting, that we want to help, but they don't meet the criteria for involuntary help, and they

don't want help. And so we have to let them go. And sometimes that involves people with the potential for violence. And it is a balance between people's civil liberties and their right to make choices that I may not think are the best choices. It's really hard from the vantage point of being a psychiatrist to prevent violence since most violence is not caused by mental illness. About 4% of community violence is attributable to severe mental illness. 4%. 4%.

So that would mean that 96% of the rest of violence that occurs in a community has nothing to do with mental illness. Correct. Do you know how mental illness relates to mass shootings, specifically, in terms of cause and effect and scale? Yeah. I mean, so this is a tricky question. We get into semantics a little bit here because, you know, it's hard to stand by an argument that people who make posts like this or that anybody who goes into a school and opens fire on students is some paragon of psychological well-being. I

mean, I think everybody would agree that these people are not mentally well per se. But that is really different than actually having a specific mental illness like schizophrenia or bipolar disorder or major depressive disorder. A lot of the characters of these mass shooters are similar. And that's not to say that none of them have mental illness because some have, but a lot of them are just really angry, resentful, bitter young men who have similar histories of social isolation. They've been bullied. They've harbored revenge fantasies. They have an entitlement towards social standing, towards attention from women. They feel like they're not getting the popularity, the attention, the recognition that they deserve. So there's this idea that they're better than everybody thinks they are, and they kind of want to show the world that. So how would the treatment of someone like that differ from the kind of treatment they would need if they were determined to be mentally ill?

It seems like in either case, some kind of treatment is needed. So what's the difference? Well, one of the big differences, you know, we do have medications for things like schizophrenia and bipolar disorder. We don't have medications for things like resentment, hatred, anger at the world. We can't fix that so well. So there's no way to admit somebody like that to a psychiatric hospital, treat them over the course of the two weeks that we might be able to have them, and then completely change the personality that they've spent their whole life building up. that they've spent their whole life building up. And it sounds like this young man who's standing in front of you fits that profile more than one of a clearly mentally ill person. Absolutely.

He fits the profile of the angry, socially isolated young man with no mental health history. So what's going through your head as you make this decision whether or not to admit him? So in my mind, I'm thinking to myself, this young man does not appear to be mentally ill to me. He does appear to potentially be dangerous, but that's not something that is going to be changed by admitting him to a psychiatric hospital. something that is going to be changed by admitting him to a psychiatric hospital. And if I send him home, then I'm concerned that I, you know, had my chance to intervene with the next mass shooter and I did nothing. And now he's back home with his gun.

We'll be right back. So, Dr. Barnhorst, you've spoken to this young man. You've learned that he has posted on Facebook something quite scary. You've learned that he may have just purchased a gun. You don't know. And now it's your job to decide whether or not to commit him for a serious mental illness. What do you decide to do? He did not look to me like he had a mental illness. He did not look to me like he technically met the standards for involuntary commitment. But I really didn't want to be wrong. And in the end, I decided to admit him. Because there's some leeway in the statute. So it's ultimately up to the judge to make the decision of whether or not he gets committed officially. So I admitted him.

So you erred on the side of caution to get him into this kind of mental health legal pipeline. I did. It sounds, doctor, like you're saying part of you understood quite clearly that he might not be mentally ill, but you were making a kind of civic as well as medical decision to keep him out of the general population. I mean, one of the principles of practicing medicine is that the higher the risk of the possibility, the more certain you want to be that it's not the case. So if I'm worried that somebody might or might not go home and punch a wall, I'm willing to be fairly liberal in making a mistake

there, much more so liberal than if I'm worried somebody might or might not go home and shoot up a school. You can live with one, not the other. I'm willing to let them a little bit of freedom. If the risk of my giving them some freedom and letting them go is that they might shoot a bunch of people into school, I need to be really, really confident that I'm right and that that is not going to happen. And what happened? I admitted him to the hospital. He went before the hearing officer a few days later, and the hearing officer determined that he was not dangerous because of a mental illness. And then he's no longer involuntarily held, so he's free to go.

So you had to let him go. The system had to let him go. Yeah, we had to let him go. So, doctor, does this man end up on the federal background check system, given the way this is played out? No, because the judge did not certify his commitment in court, he does not land on the federal background check system's list of prohibited persons. But because I admitted him to the hospital, he does meet criteria for a five-year prohibition just within California. That prohibition will expire in a couple years. And were he to move to another state, he would still be able to buy a firearm there in the meantime. Do you think that this system failed this young man in this moment and, as a result, failed the rest of us?

You know, it's hard for me to say that this system failed this young man because this young man is not who the system was set up to help. He's not somebody that we have a treatment or a cure for because he wasn't mentally ill. The unfortunate part is the criminal system couldn't help him either because he hadn't done anything criminal. So what do you think when you hear gun rights advocates talking now so much about mental health? Do you think there's an understanding of what that actually means in practice? I think there's not. And I think it's important for folks to have a better sense of what it looks like played out in practice, which is it doesn't look very good. There's not a lot that in actuality we can do for these people. And the irony is, I think a lot of the folks who point towards the mental health system as being a less restrictive way of decreasing gun violence because they don't want to lose their rights to own firearms.

the net of who we were allowed to involuntarily detain and hold enormously in order to find those one or two people in thousands that might actually perpetrate mass violence. Would we have to therefore expand the definition of mental illness? I mean, it's hard to expand the definition of an illness, but I think we would be talking about dramatically expanding the reaches of the mental health system and largely the involuntary mental health system because mostly we're looking for people who are not seeking treatment on their own. So what that looks like is that we would lower the bar really far in terms of who we would be able to involuntarily commit. Every angry young man who had a history of social isolation, being bullied, who had an interest in violent video games and collecting guns, who ever made macabre sounding Facebook posts or comments about wishing everybody at his school were dead. That's actually a lot of people. And it's easy in hindsight to look at mass shooters and say they showed all the warning signs. But when you look forward, that's a lot of people that you would have to take out of their world and out of their lives and involuntarily detain in the mental health system,

and probably to not much end. What do you mean, to not much end? Well, eventually, we have to let them go. It's unlikely that we'd be able to fix them. So even if we were allowed to keep them for three weeks or three months, I don't know that we would be really solving the problem. We would just be keeping them out of circulation for a little while. you think about this young man who you admitted and then who the court system let go and who now roams the world?

I think about him every time there's a school shooting. Doctor, thank you very much. Thank you. Here's what else you need to know today. Please welcome the Executive Vice President of the National Rifle Association, Wayne LaPierre. Thank you very much.

I appreciate this opportunity. We have serious discussions ahead and serious issues that impact each and every one of us. On Thursday, after a week of silence since the school shooting in Florida, the head of the NRA spoke out at an annual gathering of conservative activists. As usual, the opportunists wasted not one second to exploit tragedy for political gain. They hate the NRA. They hate the Second Amendment.

They hate individual freedom. LaPierre rejected growing calls for stricter gun control and instead proposed, as he has in the past, that schools across the U.S. protect themselves with armed guards. Our jewelry stores all over this country are more important than our children. Our banks, our airports, our NBA games, our NFL games, our office buildings, our movie stars, our politicians, they're all more protected than our children at school. Does that make any sense to anybody?

I want my schools protected just like my banks are protected. At the White House on Thursday, President Trump had a similar message. We have to harden our schools, not soften them up. A gun-free zone to a killer or somebody that wants to be a killer, that's like going in for the ice cream. That's like, here I am, take me. Trump reiterated a proposal made earlier in the week that teachers be armed. This time, he suggested giving bonuses to teachers who are qualified to carry a weapon. Frankly, they'd feel more comfortable having the gun anyway,

but you give them a little bit of a bonus. So practically for free, you have now made the school into a hardened target. On Thursday afternoon, the sheriff's department in Broward County, Florida, announced that the only armed deputy stationed at Stoneman Douglas High School had taken cover in the parking lot outside, rather than going into the building when the shooting began. The Daily is produced by Theo Balcom, Lindsay Garrison, Rachel Quester, Annie Brown, Andy Mills,

Ike Sreeskandarajah, Claire Tennesketter, Paige Cowan, and Michael Simon-Johnson, with editing help from Larissa Anderson. Lisa Tobin is our executive producer. Samantha Hennig is our editorial director. Our technical manager is Brad Fisher, and our sound engineer is Peter Sale. Our theme music is by Jim Brunberg and Ben Landsberg of Wonderly. Special thanks to Sam Dolmick,

Michaela Bouchard, and Aura de Kornfeld. That's it for The Daily. I'm Michael Barbaro. See you Monday.