Aaron Alexis and mental illness
Aaron Alexis was very obviously disturbed for a considerable period prior to the shooting in the Washington Navy Yard on Monday, and no one did much about it. I’m concerned at how heavily the media seems to have focussed on the issue of his security clearance, with the suggestion that this is a failure of prevention because the place where Alexis went crazy was a Navy base. It would be equally tragic if he’d gone on a shooting spree in a post office, supermarket, or hospital. What’s shocking is not that he had a security clearance, but that someone with such intense problems could slip through the social fabric so readily.
Alexis clearly wanted to lead a good life. The time he spent in Buddhist practice seems to point to that, and so do the many fond recollections of him that have surfaced in Fort Worth. And that makes his case even sadder in some ways than those of Adam Lanza at Sandy Hook, James Holmes at Aurora, or Seung-Hui Cho at Virginia Tech, none of whom seems to have made a very active attempt to forestall his derangement. The story coming out of D.C. is of a man at war with himself and with the world around him, and unfortunately that latter war carried the day.
His parents appear to have a moral center, as indicated by the words of his mother:
I don’t know why he did what he did, and I’ll never be able to ask him why. Aaron is now in a place where he can no longer do harm to anyone, and for that I am glad. To the families of the victims, I am so, so very sorry that this has happened. My heart is broken.
We often rush to blame parents in situations such as this one, but that is a grave mistake. Parents do not cause mental illness, and they are not responsible for the acts of their children. All one can wish of Cathleen Alexis is that she had seen the signs and pointed her son toward help. But children can hide a great deal from their parents, and Aaron Alexis had left home a long time ago. We must believe in his mother’s pain; she no more expected this than did the rest of us.
As we wonder how Aaron Alexis’s mental illness went untreated, we have to consider three problems: stigma, screening, and access to care.
Stigma haunts the whole field of mental health. Very few people with mental illnesses commit crimes, and it is misleading and unhelpful to suggest otherwise. It needlessly shames people with legitimate complaints and causes them to hide their mental-health status from those around them. People who seek treatment for mental illness are not, in general, the ones who go on killing sprees. It is untreated mental illness that is to blame. Our response to a tragedy such as this must not be to make people afraid to seek help, but to propel such people toward the help they need. And that requires reducing the stigma attached to seeking treatment, not exacerbating it, as always seems to happen in the wake of such tragedies.
Screening is virtually nonexistent. Alexis was clearly depressed, and he was also delusional. The story of his complaining that microwaves were being sent through the hotel ceiling to keep him awake is a story of someone with escalating psychosis. The story of his fight at the airport in Virginia, where he accused a woman he didn’t know of laughing at him, reflects acute symptomatic paranoia. The issue of his getting so angry that he fired bullets into the tires of the car of someone who had disrespected him is indicative of extremely labile mood states. And on and on. Not long ago, he went to a V.A. hospital with acute insomnia, which is sometimes a sign of underlying mental disorders, and yet no one screened him there for mental illness, not even for P.T.S.D., which should be a standard procedure at V.A. hospitals.
There is no question that most Americans with mental disorders are not receiving treatment, even though there are now very useful, if still somewhat primitive, treatments for most mental illnesses. Some people are picked up after they commit extreme, bizarre, or horrific acts—but aside from that, almost no one receives medical help who does not self-identify as having a mental-health complaint. Self-identification is the province of the privileged, of people with a sophisticated understanding of what mental health is and what can be done when it betrays us.
There are excellent screening tools available for those who may not self-identify. The Jed Foundation, set up by Phillip and Donna Satow after their son took his own life as a college sophomore, has instituted screening of college students for depression, and has turned up vast numbers of students at risk for suicide who would not otherwise have been identified. The Jed tools are now in use at fifteen hundred universities in the United States. If we can do this at schools under the aegis of a single family-run nonprofit, we can do it in many other contexts as well. But few people get screened. We therefore fail to pick up on the pain and confusion of people such as Alexis, we do not contain the violence of which some people with untreated mental illness are capable, and we likewise do not contain the epidemic of suicide in young Americans.
Even those who stand up to the stigma and who get identified in screening often struggle to get access to care. Parity legislation requires companies employing more than fifty people that offer coverage for mental health to provide the same level of coverage for mental-health interventions as for medical and surgical ones. Nonetheless, people with mental illnesses struggle to get treatment except when they have advanced psychosis. Psychiatry continues to be treated as some kind of luxury. Those whose insurance covers it might get medication—but without supportive therapy, they may not understand why they need to take the medication, or what to do if it doesn’t seem to work. Denying coverage is a lunatic policy. We should do all we can to make sure that people are screened; that their conditions are identified as early as possible; that they have access to safe, affordable care; and that they don’t sacrifice basic freedoms when they seek treatment.
Mother Jones (cited by Emily Bazelon in an excellent story in Slate) did an analysis of sixty-two mass shootings and reported this:
Nearly 80 percent of the perpetrators in these 62 cases obtained their weapons legally. Acute paranoia, delusions, and depression were rampant among them, with at least 36 of the killers committing suicide on or near the scene. (Seven others died in police shootouts they had little hope of surviving, regarded by some experts as “suicide by cop.”) And according to additional research we completed recently, at least 38 of them displayed signs of possible mental health problems prior to the killings.
We can castigate perpetrators and their families all we want; we can tighten security procedures; we can subject those among them who survive to extreme punishments. We need to address gun control, which would help to curtail the ability of such tortured souls to ruin the lives of others and themselves.
But until we develop a social model that includes finding and treating those who suffer from these complaints, we will be subjected to scenes like the one at the Navy Yard over and over again. Some shootings, like Columbine, are perpetrated by people of whom no one would ever have expected such violent acts. Those events, which appear random, will be difficult to contain. But many are perpetrated, as this one was, by people who are clearly disturbed. Some cases are hard to pick up. Alexis’s was not.