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Last week, a thirty-nine-year-old woman deliberately drove from her home in San Diego to the Silicon Valley city of San Bruno in northern California with one evil purpose in mind: to vent her spleen on the employees of YouTube whom she believed had been discriminating against her by failing to feature her posted videos, thus diminishing her income and exposure. Armed with a semi-automatic handgun (not an assault rifle, the most common weapon of choice by contemporary mass shooters), she randomly shot and wounded three workers, and then promptly killed herself. While this tragic assault can be seen as yet another in a seemingly endless epidemic of spree shootings plaguing America, it is notable in a number of ways, not the least of which has to do with the gender of the perpetrator. Here we have a relatively rare female mass shooter. Not the first. There have been several others. But they are the exception to the rule. Only about 3-5% of these assailants have been female all told, but over the past eight years there were at least two other women, including the one who participated with her husband in the shocking San Bernardino, California shootings in 2015. Could we be witnessing the early warning signs of a shift in the demographics and psychological profile of these violent perpetrators?
The appalling number of mass shootings in this country, particularly over the past twenty years (estimated at more than 200 and rapidly accelerating), starting, for example, notably with Columbine in 1999, and culminating most recently (prior to this incident) in the Parkland, Florida high school rampage (see my prior post), and, preceding that, the massive Mandalay Bay massacre (see my prior post), and, of course, Sandy Hook, were committed almost exclusively by men, with very few exceptions. Most, but not all, were relatively young men, averaging around thirty years of age, though the Vegas shooter, Stephen Paddock, was in his 60s. All, it could be argued, were alienated, isolated, disillusioned, frustrated, resentful and furiously angry (predominantly but not exclusively Caucasian) guys, typically suffering from feelings of inferiority, rejection, impotence, powerlessness, meaninglessness or insignificance, with the majority being both homicidal and suicidal.
Some were clearly psychotic or psychopathic, others more narcissistic, manic or depressed. (According to the Secret Service's National Threat Assessment Center, 64% of the studied suspects perpetrating violent attacks on government facilities or officials suffered from some significant symptoms of mental illness, with 25% having been prescribed drugs and/or psychiatrically hospitalized prior to the incident.) And almost all, I would submit, sought not only revenge for some perceived injury or injustice, but harbored a "wicked rage for recognition" (see my prior post), a ravenous hunger for fame, celebrity, or at least, notoriety, and a profound desire to somehow distinguish themselves and be remembered by history. In other words, to make their meaningless lives more meaningful and significant by committing one massive, memorable evil deed. Unable to find ways in life to express themselves constructively and creatively, to attain fame or celebrity, they resort to mass violence, settling for facile infamy. They choose to be remembered for and most closely associated with destructiveness and doing evil rather than doing good. Their ultimately negative and destructive actions are aimed at receiving the positive attention and recognition they feel was lacking in their lives, which also sadly appears to be the case with Ms. Aghdam, the now deceased alleged YouTube attacker.
We generally tend to think of women as being incapable of such violent behavior. But, as I stated two decades ago in my book Anger, Madness, and the Daimonic, "The unassailable facts that most mass murderers are men, and that men commit the overwhelming majority of violent crimes, do not necessarily mean that women are any less [angry and] cantankerous than their male counterparts. National surveys of domestic violence indicate that women assault their their partners at about the same frequency as do men. . . . For men are markedly the more violently aggressive of the two sexes, and, throughout history, have made precious little progress in peacefully managing anger and rage. It has been mainly men who wage wars, pillage cities, rape women, and do irrevocable violence to the environment. Men have always been the greatest mongers of aggression and violence. . . . Nevertheless, modern women--as they become more conscious of their own anger and rage--must also, like men, learn to confront their equal capacity for negative aggression, hostility, and even violence. . . . Women are not immune to the destructive predisposition historically associated with men: equality pertains also to the inherent potentialities for evil in either sex. In this perilous age of guns, bombs, and other high-tech killing devices, violence can no longer be conceived of as simply a function of brute strength. . . . Violence also has its feminine face" (pp. 51-53).
According to psychologist and criminologist Anne Campbell in her book Men, Women, and Aggression (1993), "Maleness and aggression have become linked to the point where it is easy to forget about women's aggression. It takes place far less often than men's, and it rarely makes headlines. It is private, unrecognized, and frequently misunderstood." She correctly points out, as shown in her study of women in the U.S. and U.K., that women have different styles of dealing with feelings of the anger, rage and resentment that typically lead to violent behavior in men, noting that, "the vast majority of homicides committed by women are of their husbands or lovers, specifically those who have physically abused them." (Consider, for instance, biology professor Amy Bishop Anderson, who shot and killed three and wounded another three of her colleagues with a handgun at the University of Alabama in 2010 after having been denied tenure at the school. )
However, In this case, we have a middle-aged woman reportedly enraged with the powers that be at YouTube, a female who, while never having worked there, felt persecuted, oppressed and abused by the company, committing this evil deed, evidently attempting to kill anonymous employees whom she did not personally know but collectively blamed for suppressing her videos and the income they provided. Moreover, she had been reported missing by her family in San Diego and, around 2 A.M., discovered by police in a Mountain View parking lot sleeping in her car the night before the shooting, some 30 miles from YouTube headquarters in San Bruno. While details of what happened during that encounter are sketchy and unclear, it appears that despite being notified that her family was seriously concerned about this woman's behavior, the police surprisingly never conducted a search of her vehicle. Was this partly due to her gender? Presumably, had they done so, her loaded gun may have been found, the same gun she allegedly used the next day to practice with at a local gun range and then to shoot up the YouTube campus. Nor did they deem it appropriate to take her to the emergency room to have her evaluated by mental health professionals. Had they done so, her true motivations, intentions, and state of mind may have been detected, and this tragedy possibly prevented. Instead, the police spoke with her for a short while, contacted her family, accepted her story that she was sleeping in her car due to family problems, and let her go.
Hindsight is always 20-20. Clearly, in retrospect, Ms. Aghdam was an imminent danger to others and to herself that night, and could have legally been psychiatrically hospitalized on these grounds, in which case her armed assault and suicide conceivably could have been thwarted. Police in South Florida had even more alarmingly been notified on numerous occasions that Nikolas Cruz, the nineteen-year-old alleged perpetrator, possessed guns and had threatened to use them prior to that mass shooting last month. This all raises some basic and crucial questions regarding how law enforcement and mental health professionals deal with the emotionally disturbed individuals with whom they, as first responders, come into very regular contact. In contrast to the Parkland perpetrator, though there is no information available indicating that the YouTube shooter had any prior psychiatric history, it would not be surprising to find that she did. Even if she did not, it is likely that her family and/or friends were for some time prior to and leading up to this crime quite concerned about her behavior and state of mind. The same is true of virtually every mass shooter, male or female.
This obscene sociological phenomenon of mass shootings, of men and now women running amok, is fundamentally a mental health matter, one that has been festering for several decades. It has become a deadly epidemic, which not unlike the plague, polio tuberculosis or smallpox, requires both intensive treatment and aggressive prevention. Left untreated and unchecked, it can potentially consume American culture, destroying the very fabric and integrity of our society. Moreover, it can metastasize or spread contagiously to other countries, as has already begun to happen in recent times.
Historically, most mass shooters knew their victims in some way, but the trend more recently has been toward more anonymous, seemingly random acts perpetrated upon strangers in public places, such as the Las Vegas and San Bruno attacks. Having more guns than citizens in the United States is a significant factor in this violent epidemic. Certainly, making assault rifles less available to the general public is good policy, it seems to me. They make killing and maiming many people in mere seconds much too easy. But, then, as we have seen demonstrated domestically and in terrorist attacks in other countries, so does a bomb. Or a truck. A machete. Or a hand grenade. The disturbed individual set on destroying the lives of as many victims as possible, and then, as occurs in most cases, offing him or herself, will likely find some way to do it. But, nonetheless, it is crucial to bear in mind that many, if not most, of the perpetrators of these evil deeds have either had previous contact with a mental health professional—or should have.
Because of the epidemic and unprecedented rise in anger, rage and violence in our culture, mental health professionals have a moral and ethical social responsibility to aggressively intervene with violent individuals. I am not suggesting here that psychotherapists act like cops or carry concealed weapons, as President Trump stupidly and simplistically urges teachers do. (Perhaps he would like to see us regress to the wild days of the old West, in which most men carried a concealed or holstered pistol or rifle, and did not hesitate to use them.) Only that these kinds of vicious evil deeds must be directly addressed by the mental health profession, in tandem with law enforcement. In dealing with angry, belligerent or violent individuals, the police are frequently the first responders, though such potentially dangerous people are sometimes initially seen by a psychiatrist, psychologist or counselor. So let's talk a little about what kinds of interventions are available to mental health professionals in managing and possibly preventing these tragic incidents.
Police officers have extensive experience in confronting violent offenders. In California, for example, though they are not licensed mental health professionals, police have been trained in the legal criteria required for detaining a disturbed person: Peace officers have the legal power to place someone on a 5150, an involuntary psychiatric hold, as do clinicians specially trained and empowered to do so in designated facilities such as emergency rooms or crisis centers. If the officer/officers believe the person to be potentially dangerous to self or others, or gravely disabled by dint of a mental illness, that person can be taken against his or her will to a designated mental health facility for further evaluation by a mental health professional. Having worked in such facilities, I can attest that the judgment of police officers in these complex matters can sometimes be questionable. But once the person has been placed on a 72-hour-hold (5150) by the police and delivered to the emergency room for psychiatric evaluation, it falls upon the mental health staff to evaluate and decide whether, in their expert opinion, this person can be legally held against their will and hospitalized involuntarily if necessary. Or whether they can be released and sent home and/or referred for voluntary treatment. While we mental health professionals usually get these decisions right, I can also attest from my own experience working in a hospital-based psychiatric emergency room, that even well-trained and seasoned clinicians sometimes get it wrong. And when we do, the consequences can be catastrophic.
Conducting these psychiatric evaluations on the fly is not easy, and making such crucial decisions to temporarily deprive a person of his or her freedom, is not taken lightly, even for the seasoned psychiatrist or psychologist. The disturbed patient brought in by the police must be observed and interviewed by clinicians in order to determine whether he or she fully meets what are in California called LPS criteria (Lanterman-Petris-Short Act) or the so-called Baker Act in Florida. Is this person presenting a clear and present, acute and imminent danger to self or others? One of the factors considered carefully when assessing suicidality or homicidality is whether there is easy access to a means of successfully carrying out the act. When a suicidal and/or homicidal patient has immediate access to a gun, for example, this is a big red flag that raises the level of dangerousness significantly. Such a person may vehemently deny any intent to use that weapon to commit suicide or homicide, but that denial must be assessed for veracity, based in part on previous behavior and collateral reports regarding the patients prior statements and actions according to family, friends, and co-workers, as well as on current mental status and psychiatric diagnosis and prognosis. For instance, is the patient experiencing "command hallucinations": a disembodied subjective voice telling him or her to kill. (According to one news report, Nikolas Cruz, for instance, had been hearing "voices in his head" telling him how to conduct the killings, voices he described as "demons.") Is he or she in the midst of a manic or major depressive episode? Or is the person exhibiting impaired judgment or poor impulse control possibly due to being under the influence of some intoxicating substance? All of these scenarios increase the risk that suicidal or homicidal fantasies may be acted upon imminently. And demand immediate intervention. Remember, the danger must be acute and imminent in order to involuntarily hospitalize someone. But it would not be unusual, even in cases where such imminence is not clearly present and the patient cannot be involuntarily hospitalized, for a clinician to recommend and arrange for removing any guns or other easily accessible potential means of committing suicide or homicide from the patient's environment.
Here in California, psychotherapists in private practice do not have the legal authority to place a patient on a 72-hour hold themselves. But they do without a doubt have the responsibility for assessing whether their client or patient is potentially a danger to self and/or others, and, if so, to make sure that he or she is further evaluated psychiatrically. Thus, the psychotherapist may need to decide to breach the client's confidentiality and contact the police, or, alternatively, the local psychiatric emergency team, who can contact and talk with the patient and, if appropriate, place him or her on an involuntary hold in order to receive further professional evaluation. Moreover, under the Tarasoff Decision, the psychotherapist has the ethical and legal duty to warn any known intended victims and to notify the authorities should a patient make credible threats to harm others or destroy their property. Generally speaking, psychotherapists must be sensitive to such statements as well as actions and other warning signs, not minimize the danger, while, at the same time, refraining from overreacting to the patient's potentially therapeutic verbal expression of anger or rage. No easy task.
So what more, if anything, can police and mental health professionals do to prevent such senseless killings? Such madness. Clearly, Nikolas Cruz, the alleged high school shooter in Parkland, was and is a deeply disturbed, extremely angry, alienated young man, who, from the sound of it, without proffering a formal diagnosis from afar, had reportedly exhibited some signs in recent years of what could speculatively be associated with diagnoses such as Oppositional Defiant Disorder, Conduct Disorder, ADHD, Antisocial Personality Disorder, and possibly Borderline Personality Disorder, Autism Spectrum Disorder or Schizoaffective Disorder. He was expelled from school and ostracized from his peers. He was probably profoundly depressed by the traumatic losses in his life—including the prior death of his adoptive father and the recent death of his adoptive mother—suicidal, and furious about what he perceived (and with some merit) to be his unfair and cruel fate. He had reportedly been seen and assessed in 2016 by a crisis intervention specialist at some point, but was evidently never placed on a psychiatric hold, apparently not meeting in his or her professional judgment sufficient legal criteria to do. Even if he had been "Baker-acted," such involuntary hospitalizations tend to be quite brief, in California, a maximum of three days initially, after which the person is free to go unless there is a formal legal hearing to try to extend the hold.
Whether Cruz was receiving psychotherapy is not clear to me. If so, what went on in those sessions? How should a psychotherapist deal with someone like Mr. Cruz? Or Ms. Aghdam? Obviously, both of these troubled individuals needed therapy. But what type of therapy? Psychoanalysis? Cognitive-Behavioral Therapy (CBT)? Dialectical Behavior Therapy (DBT)? Existential Therapy? Anger Management? Psychopharmacological therapy? (Mr. Cruz reportedly was taking prescribed psychiatric medications. Whether Ms. Aghman was as well is unclear at this time. ) Cruz and similarly angry and antisocial young men (and women) across America (many mere adolescents really) desperately need to form a relationship with a therapist who can contain, tolerate, acknowledge and accept their rage. Their profound feelings of disappointment, frustration, betrayal. (See my prior posts.) To sit in a small and intimate consulting room with such patients can be a terrifying—and potentially perilous—experience for psychotherapists. Even in a forensic jail-setting, when the inmate is securely shackled and handcuffed, hearing and seeing such rage can be intimidating. Most mental health professionals avoid doing so in various ways, including the overuse of psychiatric drugs to dampen down what existential psychologist Rollo May referred to as the "daimonic." Or they quickly refer the patient elsewhere, or try to cognitively convince the person not to be so angry, teaching patients to behaviorally "manage" their anger, which is usually a euphemism for suppressing it. (Which only makes it stronger and more dangerous.) Mainly because they, the mental health professionals, are afraid, not only of the patient's fury and capacity for violence but, unconsciously, of their own repressed rage, a problematic kind of negative countertransference. In most cases, because of this denial of the daimonic in patient's and in themselves, clinicians naively underestimate the human potentiality for evil. They fail to recognize or minimize the inherent human capacity, and in some, proclivity, for evil deeds.
If we are going to be of any greater assistance in preventing these grotesque and demonic crimes in the future, mental health professionals must put aside their pseudoinnocence and start accepting and addressing the reality of evil in the world, and the potentiality to commit evil deeds in our patients. We must be willing to unequivocally and courageously intervene when a patient presents an imminent danger to others or themselves. Acutely suicidal patients with homicidal impulses or fantasies feel they have nothing more to lose by acting on those hateful impulses to cruelly kill or maim as many victims as possible before dying themselves. We often forget that mass shooters are more or less destroying their own lives as well as that of their victims in taking the fateful decision to kill. Intervention in such acute cases should, whenever possible, begin with placing the patient on a 72-hour hold for his or her own safety and that of society. But that is only the first step in treating this problem. Once discharged, the patient needs to be followed and carefully monitored by the psychotherapist. But what if he or she does not want therapy?
This resistance to treatment is one of the ways these potentially dangerous individuals fall between the cracks in our system. I believe that we need to change this. Once someone has been deemed to meet full criteria for involuntary hospitalization as a danger to others in particular, following discharge, they should be legally compelled to attend court-ordered weekly or bi-weekly psychotherapy sessions (individual or group) for some protracted period of time (e.g., one year) so as to allow the mental health professional to closely monitor his or her mental status, and to intervene again if necessary. This sort of constant monitoring of the patient's mental status (e.g., suicidal and/or homicidal ideation) may seem antithetical to how some psychotherapist's practice, but it is absolutely essential with this population. Additionally, they should simultaneously be forbidden to possess firearms for at least that time period. Such a policy could, in my estimation, mitigate the increasing frequency of these evil deeds. (Indeed, there is currently a law on the books in California that, under specified circumstances, allows the confiscation of guns from severely and chronically mentally ill individuals.)
The California Board of Psychology recently implemented a controversial new Continuing Education requirement for all licensees specifically on assessing and dealing with suicidal patients. (Controversial, because some psychologists objected on the grounds that clinical psychologists already have expertise in this area.) Since most mass shooters are suicidal as well as homicidal, such additional training is valuable. But I would implore licensing boards for psychologists, social workers, psychiatrists, counselors and other mental health professionals to similarly require specialized training in assessing and intervention of potentially homicidal persons. Moreover, the mental health profession needs to become more integrated and involved with law enforcement, schools, probation programs, etc., serving as clinical consultants on policy and practice. We must become experts on violence and the psychology of evil. For the evil of violence is what we are confronted with today. Though our violence epidemic is a sociological and cultural symptom, one clearly exacerbated by easy access to weapons of war, it is primarily and inherently a mental health issue that must be more effectively addressed by mental health professionals. For that is our professional purpose and responsibility both to patients and society.
Ironically, we are in a period of rapidly diminishing interest in, appreciation of, and support for psychology and psychotherapy, due in part to a cultural denigration and devaluation of what psychotherapy can offer both the individual and society. Governmental funding for mental health services is disappearing, and disturbed individuals are less likely today to seek professional help. Perhaps such tragedies will begin to open people's eyes (and purse strings) to the dire need for more, not less, mental health services in this country, at a time when they are more desperately needed than ever before.
