Newtowns Unanswerable Questions
It is not likely that psychiatrists could have prevented the massacre.
21 December 2012
The horrific massacre of the innocents in Newtown was bound to result in a search for preventive action so that nothing like it could ever happen again, and hence also for its real or final cause. To ward off fatalism, we tell ourselves that the massacre could, and therefore that it should, have been prevented; or alternatively, that it should, and therefore that it could, have been prevented. But as the cacophony of opinion demonstrates, the world is an irreducibly complex place. Agreement about what ought to have been done has all too predictably not been reached.
It is tempting to argue that the perpetrator must have been insane, for if such a person isnt insane, who is? We close the circle by then explaining his action by his insanity. In other words, we know the perpetrator was insane because he did x, and that he did x because he was insane. Molière satirized such reasoning 300 years ago: the doctor explains that opium makes people sleepy because of its dormitive quality. Let us suppose for the sake of argument, however, that the perpetrator did have a psychiatric condition that could have been diagnosed before his terrible act: What follows from this?
First, he was of age (20) to refuse to see a doctor if he so wished, and he might very well have so wished. By all accounts, there were no grounds on which psychiatric attention could have been forced upon him. He was strange, he was socially isolated, his mother worried about him; but he was a good student and had committed no acts that would have justified compulsory treatment, as would have been the case if (for example) he had attacked someone under the influence of delusion.
Second, even if he had agreed to consult a psychiatrist, there is no certainty that the psychiatrist could have done anything for him and thus averted the disaster. Nor would the psychiatrist necessarily have had any reason to suspect a mass killing as a possible outcome in this case; the best predictor of future behavior is, after all, past behavior, and the killer had (as far as has been revealed) no history of violence. Further, the psychiatrist would probably have seen several, perhaps many, similar cases that did not end in mass killing—an outcome that after all remains rare. The Newtown killing might have taken a psychiatrist by surprise as much as anyone else.
In fact, psychiatrists are no better than others at predicting violence by disturbed people, except possibly among the psychotic. They tend to overestimate the dangers, and in making predictions, they face the problem of the false positive and the false negative. In the case of a false positive, you think that someone is dangerous when he isnt; in the case of a false negative, that he is not dangerous when he is. False predictions of rare events (such as mass killings) generally outweigh true ones by a large factor—an important point to remember, especially if you wish to grant or withdraw civil liberties on the basis of such predictions.
Not long ago, I was asked to participate in an inquiry into a spate of murders committed by psychiatric patients. The killings seemed to be statistically abnormal (recalculation showed that they were not). We were asked to determine whether there was a single type of act, or omission, by the psychiatric services common to all the murders which might help explain them. It immediately became clear that the standard of practice was extremely low. The nurses, in particular, had filled out an immense number of forms, hundreds or even thousands of them. Many dealt with the dangerousness or otherwise of the patients and were designed precisely to avert the possibility of violence or murder. I suspected that the nurses thought that filling in forms was their work, and that when they had done this they had achieved something. They mistook process for outcome.
Yet, except in one case, I found no evidence that the low standard of practice had actually resulted in a preventable killing, despite the immense power of the retrospectoscope—the medical instrument that provides us with wisdom after the event and that sometimes does lead to improvements in practice that saves lives, though at other times it provides us only with scapegoats. In this instance, I should have been provided with, say, 20 medical records, among them those of the killers, without knowing the outcome of the cases, and asked to decide blindly which resulted in murder, and why. In the event, all I could say was that the standard of practice ought to be raised, irrespective of whether the existing standard failed to prevent the murders.
A further point: it is unlikely that we will ever have a full medical explanation of events such as the Newtown killings. Even if investigation proves that the perpetrator had Aspergers syndrome, much would still remain to be explained. After all, people must have suffered from Aspergers syndrome before there were any mass killings of the Newtown type. The behavioral expression of a psychiatric condition takes place in a social and cultural context.
This context is perhaps propitious to young mass killers (quite apart from the effect of imitation or emulation). In an article in Le Monde, a professor of sociology at Strasbourg University, David Le Breton, quotes a German schoolboy who killed 15 people in a school in Winnenden in 2009: Im fed up, Ive had enough of this meaningless life which is always the same. Everyone ignores me, no one recognises my potential. This reeks of resentful, narcissistic grandiosity, the result of an imperative to be an individual at a time when individuation is more difficult than ever.
More by Theodore Dalrymple: