Two Different Forensic Psychiatry Books

Is It a Polemic or a Legitimate Read in Its Field?

The first book that I wish to review, Alone With The Devil: Famous Cases of A Courtroom Psychiatrist, is an earlier book somewhat dated now, published in 1979 by a then fairly well-known West Coast American forensic psychiatrist Ronald Markham MD. First off if one accepts the premise that we are all product of at least her experiences and the times in which we have lived, then it is easy to place this book in an era earlier in Western and American psychiatry specifically in forensic psychiatry. This book may amuse some of the psychiatric readers and it may confuse a non-mental health professional through the use of its somewhat dated concepts and terms.

But it is nonetheless a fascinating read and I was very pleasantly surprised by the writing style, the slight flair for the dramatic in the detailed and insightful portrayals and analyses of the cases that this psychiatrist selected in this book. I was initially drawn to this book as I had read online reviews that it was somewhat of a misplaced, angry and doctrinaire polemic. Also, some reviews accused the author, who if he is still with us today must be in his 80s, of being somewhat of a show-off, and given to tooting his own horn in such a way that it detracted from this book. I did not really find this to be the case.

The cases that the author presented as a forensic psychiatric writer were not very well known for the most part. In the few cases that were somewhat well-known, the author gave details that I was largely not familiar with, though much of my own acquaintance with these few celebrity cases. Instead, he revealed background detail regarding their crimes and legal information that I found extremely interesting. I can safely say that the author did not trade on sensationalism or the common media stories that have long been associated with these few famous cases.

The vast majority of cases that he selected were not very well known if one had not lived primarily in Southern California during the 1970s and 1980s. Each case was selected for features that were quite different each from the next. The author focused just as much on the legal proceedings and upon the very great difficulties that the organs of the legal systems experienced during the prosecution and defense of these heinous murderers. Dr. Markham spared no criticism of figures involved including famous prosecuting and defense attorneys as well as a few judges who did not comport themselves as professionally as they should. The dated nature of this kind of information was part of its charm. The author gave fascinating accounts of courtroom behavior and maneuverings that likely would not be permitted in this day and time and would be regarded as unprofessional behavior at least. He bolstered his criticisms by quoting extensively from actual court transcripts that illustrated his shortcomings that he saw in his work as a forensic psychiatrist both inside and outside the courtroom proceedings.

This kind of detail is quite singular and have not read it in other historical forensic psychiatry textbooks. Likely his repetitive criticisms of the shortcomings of the legal process that occurred in many of these cases during their investigations and prosecutions form the basis for other online reviewers to call this book a bit of a polemic. I have no idea how this book was received in the first just several years after its publication, but I can imagine it was probably roundly vilified and criticized in its day in certain quarters that received acidic and telling critical observations from the author.

Further, the other value that I have referred to above, the selection of lesser-known cases of serial murderers, form the other pillar of value to this book. Each of the cases differed in major respects from the others in this book. Each of the murderers discussed were revealed to largely be very different each from the others. Some of the cases actually served out their sentences and lived to be released which I found somewhat shocking but which I realized, was part of the value of the reporting of these cases has at least one of the figures who was released from an all too short sentence for murder in the presence of a very atypical psychotic process.

Another telling thread that ran through many of these cases was the fact that the investigative law enforcement powers of identifying these killers were very primitive by today’s standards. Law enforcement agencies whose jurisdictions bounded up against each other very often did not coordinate information in an organized manner and in several of these cases, it was by sheer luck that the killers were identified and arrested. Of course, there was no DNA testing in those days, and profiles of types of crimes that could be checked online very quickly also were not yet on the scene. Information was not categorized, digitized or stored in relational databases at all. Comparable to the field of medicine that is only in the last decade or so graduated into the digitized medical record, law enforcement murder files and casebooks were paper-based, sitting in stacks on a detective’s desk. Anna detective investigating a murder committed in his jurisdiction had no idea that only one county and one major city away another homicide detective was struggling to generate leads on the very same murderer who simply drove across the county line to commit yet another murder undetected.

A Compelling Tale of the Actual Development of the Decision to Kill So Many

The second book is much more modern. It is the book written by William H Reid MD, a currently moderately well-known forensic psychiatrist. This is the book: A Dark Night in Aurora, Inside James Holmes in the Colorado Mass Shootings. This book was published in 2018 and concerns only one case that of James Holmes who shot up the cinema 16 theater in Aurora Colorado on July 20, 2012. Holmes was a graduate student at the University of Colorado Denver, in neurosciences on the on shoots medical campus in neurosciences. He had dropped out at the beginning of that current winter semester before the shooting in July 2012.

James Holmes dressed up in bazaar black tactical clothing and carried multiple weapons including a Glock pistol and an AR 15 type assault rifle. He mounted the stage in front of the screen at the midnight showing of the then-new Batman a dark night rising movie. He selected the time because he thought there would be fewer children at the time of the midnight showing. Nevertheless aside from this one feature of perhaps misplaced compassion, he still killed a dozen people and wounded over 50 others. He then went outside lay down his weapons and patiently waited to be apprehended. He is one of the few mass murderers who is not killed by law enforcement or as is still more common committed suicide at the scene such as the Columbine high school shooters Eric Harris and Dylan Klebold who both killed themselves inside the school.

Consequently, James Holmes could be extensively interviewed and evaluated both by law enforcement and by Dr. Reid and another forensic psychiatric examiner. Furthermore, the development of James Reed’s illness psychiatrically, and his thinking patterns both rational and psychotic could be witnessed, examined, and analyzed at great length because his written material in the form of emails and diary materials existed, and were preserved.

Dr. Reid was able to bring this disturbed young man’s development into a mass murderer into stark and very clear relief by quoting extensively from these materials in the book. This is one of the major features and values of this book as the written record left by this young man was invaluable and has come to be an incredible source of information regarding the mysteries of the development of the mass murder. This material alone makes this book more than worth its purchase and will help any reader to gain greater understanding of at least some of our current modern mass murderers and how they come to be who they are and why they commit their crimes. Many of them unfortunately for the purpose of education and understanding these individuals, defeat the possibility of retrospective, after the effects of their crimes, from being subjects of legitimate psychiatric and legal investigations by killing themselves. They remove themselves from our abilities to understand them and the motivations for their crimes forever. I need only remind the reader of the Las Vegas country music concert, Mr. Stephen Paddock who murdered over 50 individuals and wounded upwards of 500 more when he opened fire from his hotel room through its broken window with multiple automatic assault rifles committing the worst mass shooting known in American history to date.

For any reader, this book painstakingly documents this young man’s development beginning with a seemingly intact family and childhood developmental course in life through the beginnings of the earliest self-perceived seeds of intrusive and disturbed thinking patterns that began in middle school years and percolated through his high school years. On the surface and the likely truly internally, this young man had an ordinary happy childhood. He then experienced difficult events in his life that many youngsters in modern American life experience as well. For instance, his family moved at the beginning of adolescence and he took this initially fairly hard, but it was not causative in the development of his future psychotic mental illness. He maintained a fairly happy adjustment through high school and gave little sign during those years that an ominous internal corrupting psychotic process was beginning. And like so many individuals beginning to experience the ravages of adolescent era psychosis, he largely kept it a secret only occasionally leading a very few oddball and slightly bizarre ideas to emerge to those surrounding him in his life circles at that time. The author skillfully traces the development of this ominous process through the college years and into the first year of this young man’s graduate studies. And like any good story, part of the compelling plotline is the slow literary unfolding of the internal events and changes in thinking that led to the commission of this heinous crime in the dark theater during the midnight hour. This grips the reader in a most compelling manner. Dr. Reid never really speculates or theatrically takes literary license in the telling of the psychiatric story. He did not need to. He had over 20 hours of clinical interviews with this young man who was extremely and surprisingly I suppose, open and forthcoming with Dr. Reid. Dr. Reed also had access to voluminous documentation furnished by the young man himself. The author also interviewed many individuals including the family, consisting of the mother father and sister. He also interviewed teachers, high school classmates and college classmates as well. All these people who were also struggling to grasp, comprehend and explain this horrendous event to themselves, poured out their observations, memories and experiences with this young man adding to the detail and progression of the movement from a quiet preteen, teenager, college student, and young adult, to a cold-blooded mass murderer who killed four very bizarre, idiosyncratic reasons.

There are many other notable and worthwhile features of this singular book that I will leave to the future reader of this compelling book. But it also illustrates the maturation of the field of forensic psychiatry in the last quarter-century or so. The practitioners of forensic psychiatry nowadays are far better trained and skillful than at least some of the practitioners in the past. Most forensic psychiatrists have been trained in specialty post-adult psychiatry residency training programs in the subspecialty of forensic psychiatry. And Dr. Reid’s straightforward and dispassionate account of his work in this case ably illustrates the professionalism and skills of the modern-day forensic psychiatrist. This book will give the lay reader an excellent inside, fly on the wall vantage point to observe and begin to understand the complexities of the practice of forensically oriented psychiatry and hopefully a better appreciation for the vital role they play in growing the science and understanding regarding this frightening present day reality and the mentally disturbed violent and murdering offender.

The Active Shooter Controversy

Just two days ago I became aware of the controversy over a new version of the very popular video game “Active Shooter.” The game’s designers have included a module/section/world–whatever that permits the player to select a school shooter experience. As predictable, instant outrage has erupted everywhere in the media. My reaction was typical I suppose, thinking things like this is not appropriate, this is the height of bad taste, how could anyone be so heartless/clueless etc. My second line of reactions centered on anyone who has suffered trauma from school shootings lost someone to such incidents etc.

Then I realized that my son and I have this game and have played for a few years. He is my last “yearling” as I sometimes call him, near graduation, avid video game player since his youngest days with a Nintendo DS etc. I also realized that this kind of game and this game itself is one of the few I can master. I can shoot bad guys and terrorists through the rifle’s sights. I can hold my own in car racing games, Donkey Kong, and older generation games. All these have the forgiving characteristic that the controls are very simple; anything more complicated and I cannot keep up or play at all. After a few years of trying and occasional exasperated tutoring from my son, it has been clear to him for a long time, I have maxed out my hand-eye, and hand finger coordination and dexterity and I will never ever get beyond a certain level. So when he buys a new game, he will say, “Dad this is too hard for you (too, like all the others).” When we peruse the new games highlighted in his various game magazines, he will point to some fluff or “baby” game and tease me that this is one I can handle.

So this is my confession, the one person shooter, sniper type games are ones I can handle in my gaming dotage, and this game I enjoy and like. Gets out my aggression harmlessly etc. I also take goofy solace in thinking that if all kids are as skilled as my son and ALL his friends are on this type game, the Taliban do not stand a chance if they invade here. First, their gun-owning fathers will wipe them out and the sons will take care of the second wave as all dads would look on with pride. I am safe here and video games probably help to make it so…

But this issue of treating school shootings so cavalierly has ‘crossed the line’ for almost all of us. It was inevitable this would happen in our take any opportunity to make money society I suppose. I do not think that somehow trivializing school shooting into a widely loved video game will subtly train teens to not do such horrific acts. So no, I do not see some noble methodology of prevention at work here.

Continue reading

Are Racists Mentally Ill?

This writer and now ‘aging’ psychiatrist finds this debate overdone and not very useful. In the last few years we of course as anyone would acknowledge, have had an epidemic it would seem, of mass shootings of all kinds. Many stories from many different viewpoints have tried to protect the mentally ill from the unavoidable but troubling intrusion into our views of our rapidly changing social matrices in this country, from being tagged almost reflexively and automatically with the reputation of being the single most associated group of persons responsible for mass shootings.

Story after story based on replicated and widely accepted research over the last few decades repeatedly shows that the chronically mentally ill are far more likely to be VICTIMS of crimes and violence than the perpetrators.

But it is equally if not increasingly hard to escape the avalanche of media stories the last few years reporting to us the mental states of more mass shooters that sound for all the world as disturbed in some manner or other. The two adolescents who perhaps are viewed by many in Aurora CO who shot up their own Columbine High School killing over a dozen persons certainly had some form of haywire thinking and disturbed dynamics. Truman Capote’s book that riveted this nation decades ago as he wrote of the pair who killed almost randomly for sport innocent persons, a family, in the Midwest comes to my mind as perhaps unwittingly having something to teach us about the two Columbine mass shooters. One in each pair was dominant and one was the follower. One of the Columbine pair has been called disturbed with various diagnostic attributions such narcissistic, paranoid, etc. Some historical and behavioral data had emerged in the months after their shooting of being loners, angry, odd, dressing in almost Goth black raincoat type clothing and such, but in many views, we really have not had enough reliable information to say much more than descriptive explanations.

An example of a very likely true, clearly psychotic mass shooter was Mr. Ferguson who shot and killed several people on I believe the Long Island RR line a number of years ago. There was great debate over his mental state as he tried to act as his own defense, was bizarre in the courtroom. His shooting act was chilling as he walked purposefully through the commuter train car or cars calmly methodically shooting persons with his pistol. He was still convicted and given multiple life sentences and likely was another example of a mentally ill person who committed such an egregiously horrific crime that the jury could not bring themselves to find him not guilty by reason of insanity and leave uncertain his lifetime fate, meaning leaving open the possibility that he would be able to released someday if he improved etc. It is still not appreciated by the public at large that NGRI persons are incredibly rarely EVER released as parole board members everywhere almost always never grant a release for fear of another heinous act occurring. One of “Manson’s girls,” who was terminally ill with brain cancer several years ago was denied parole in spite of her terminal condition and even John Hinckley who shot President Reagan outside the Washington DC Sheraton has not been parole (yet and it is not clear he will be) even though he has been granted passes outside the hospital with his long attentive parents.

Now with the recent tragic incident in Charlottesville earlier in this month of August 2017 at the protest rallies over the Confederate statue issues with Neo Nazis-white supremacists etc., and then the “Alt. Left” groups and other anti-Confederate/Nazi protest groups, the conversation may be starting to include the politically or “sociologically” motivated purveyors of violence as witnessed by the article, “Alt. Right Racists Mentally Ill? Some Psychiatrists Say Yes.” This is not a new line of conversation or speculation. We have been theorizing upon and trying to understand the motives of the new forms of mass violence and their practitioners, such as the self-immolation of the Tibetan monks protesting “Red China’s” forceful annexing of Tibet in the 1950’sthe waves of airplane bombings and mass killings and airjackings by the PLO in the 1970’s. Since those times, there have been many new forms of mass violence that were or felt new to us: an often forgotten phenomenon was the fedayeen who regularly tried to cross into Israel from surrounding then enemy Arab countries during the “Intifada.” This was collectively the three waves over nearly two decades of the uprisings of politically moivated Arab unaffiliated “soldiers” of the struggle agains the then labeled in the then current political jargon “Zionist occupiers” of Palestine, e.g., Israelis on the borders of the country.

Since then we have had other forms of mass violence and shootings, largely overshadowed in current times by the almost weekly incidents of bombing, well organized shootings in both unsettled and failed states such as Syria and Iraq, and western countries in Europe and our own 9/11 super tragedy 16 years ago with the airplanes crashing into the Twin Towers of New York City killing over 3,000 persons.

For instance, we had a very few isolated school ambush shootings by young students outside of their schools who shot students with rifles they purloined from home. These early teen boys always operated solo. Most were tried and juveniles and some as adults some under questionable criteria as far as age. Adam Lansky shot up dozens at the Sandy Hook elementary school was portrayed as an alienated loner,and speculation has included a number of possibly psychiatric diagnoses for him including Asperger’s Syndrome (formerly covering and meaning mild autistic spectrum disorder as it is semantically labelled now with the Fifth Edtion of the American Psychiatric Association’s Diagnostic and Statistical Manual, the longstanding compendium of American psychiatric diagnoses since the 1950’s; Europe, Britain and most other countries use the “ICD-10” compendium of diagnoses which also includes all diagnoses of the rest of all of the medical world of labels and not just psychiatric ones as the “DSM” does.

Another mass shooting phenomenon was the rash of post office shootings that took largely in the 1980’s in this country. The typical scenario was a postal worker would bring a rifle to work, enter the workplace and start shooting, though often trying to target resented supervisors and bosses. There were many social and labor law issues involved in many of those cases as post incident investigations revealed, or put more simply, on the job grudges and resentments, or, anger over being fired. Those adult readers old enough will remember the then current phrase applied to these incidents, “going postal.” Psychiatric issues and diagnoses were not trotted out much at all in those days.

There is yet another category of mass shootings which is still with us today and accounts for a sizeable number of smaller mass shootings nonetheless if three or four or more persons are killed (3 and 4 being the minimum numbers of fatalities required for a shooting to be defined as a mass shooting in the two schools of thought on the subject currently). This category is as good an example as any of the scientific differences of opinions that have appropriately occupied authorities of whether the shooters are mentally ill in the usual sense or not. These are the (almost always) male shooters who stalk, follow, seek out and eventually kill their estranged wives in public places which sadly takes the lives of others in the rampage. These men usually are found to fit the often very specific and eerily similar profiles of severely insecure, massively physically and emotionally abusive husbands, who stalk their wives, monitor their car mileage, often forbid them to work or function much at all outside the home, have independent friends even female but especially male, follow them even when the wives are on innocent errands such as shopping for groceries at the store and a myriad of other bizarre suspicious acts of over control. Some will examine their wives’ underwear, and nowadays for several years plant listening devices in their own homes or the wives’ cars, or install GPS devices to track their wives’ travels in the family or wife’s car. And even without ANY sign of infidelity at all, these men are usually so “delusional” (a symptomatic and even diagnostic term opening the door for the mentally ill debate) constantly accuse them of having affairs.

One of my now favored examples of the dilemmas of debating this mental illness issue with regard to someone showing kooky social behavior but with a gun and actively shooting and endangering lives, is the North Carolina man who some months ago travelled to Washington DC to spray a favored pizza place with bullets with an automatic military like rifle because he subscribed to the then “fake news” Internet circulated falsehood that Hillary Clinton was running a child sex trafficking ring in the basement of this long established pizza place favored by federal government workers. He received recently a prison sentence of around 4 years and apparently did express remorse and difference with his driving beliefs at the time of sentencing. Was he mentally ill at the time of the commission of his act or not? Was he treated before trial and regain his proper sense of reality. I do not know.

On a broader front, are all jihadists mentally ill? I doubt it. But they are committed to their beliefs for the most part. Some may be not so bright shills recruited by savvy terrorist operatives who know how to spot such individuals who are vulnerable. This is not a radical concept; pimps regularly know in the big city bus stations, for instance, how to spot naive girls to recruit into prostitution or so the social commentary has alleged backed up by law enforcement scholars who study such phenomena. And then there is the complicated touchy issues of strongly held religious beliefs. Are any such beliefs manifestations of types of widespread social mental illnesses? Were the rallying recruiting speeches of the Crusaders working up knights and serfs in Europe in the Middle Ages to march to the Holy Land and slaughter the Arab and Muslim peoples who lived there mentally ill? Are present day radical, minority Islamic beliefs of 72 virgins awaiting any male jihadist suicide bomber psychotic or just social belief systems?

Then we have our own oddball, weird and at times very bizarre religious cults who engage in mass murder or mass suicide that occasionally still manifest themselves, though this behavior seems to have decreased dramatically since James Jones’ mass preaching poisoning of hundreds of his followers in their isolated colony of Guyana a few decades ago. Were the Symbionese Liberation Army who provoked their deaths in their irrational suicidal standoff with the police in the 1970’s all psychotic. Were Charles Manson’s followers, especially the four women, all psychotic. We do know that Manson has been psychotic almost all his adult life but at least some of his followers were the typical, in a sense, weak followers, with no set identities or internal guiding principles of their own making them massively vulnerable to psychotic charismatic leaders like Manson.

Closer in our own social history as examples of hard to classify violent, aberrant “hate” groups of the past would be the anarchists of the early 1900’s, the Ku Klux Klan since its start in the years of Reconstruction in the South in the 1870’s by Nathan Bedford Forest the former Confederate, the American Nazi Party of the pre World War II years in this country, the very atypical religious or social isolationist groups such as the extreme fringe group of the two towns of polygamist non mainstream Mormons towns on the Arizona and Utah, Colorado City etc., Those groups have long been a question mark and in the last two decades as some women have left or escaped those colonies, it became clear the polygamy at least by the leader Warren Jetts was a stalking horse for sexual addiction and abuse of young women, even teenagers, for which he was convicted several years back. Are those folks all mentally ill in some ways that facilitate their adopting lifestyles so different and in some ways harmful to themselves and their children?

In any case, my point that I have belabored perhaps too much is that one can easily cite group and group, individual after individual who does “crazy” things and we cannot easily or cleanly decide if he/she/they are mentally ill or not.

The article cited above makes for interesting reading. It largely focuses on the question of whether ‘racists’ are mentally ill, more paranoid than anything else, and on the decades of controversy that has accompanied this kind of question. The author Jessica Firger from Newsweek magazine focuses well and appropriately on one of the leading authorities a black psychiatrist, Dr. Alvin Poussant of Harvard and his views, his experiences and lines of reasoning on this question. I will hasten to add that a white racist supremacist, hearing that Dr. Poussant is black, would immediately react, regard all this as black propaganda or worse and dismiss any of the issues that Dr. Poiussant and many others have raised since the 1960’s.

If I were to take the position that full mental illness that is biologically based brain disease and as such could be easily agreed upon by most as the “real thing,” then all these other categories are more social than biologically based. AT least insofar as the limits of our knowledge of these behavioral patterns and mental belief patterns permit us to diagnostically joust with them.

I am prepared to state that part of me would not be surprised at all that in decades to come, our brain research efforts find that the so similar wife abusing murdering husbands have a brain disorder. The behaviors appear at the time to be so similar, so predictable from one individual to another, that I feel it is very possible that this type of such similar behavior is brain disordered driven in a complicated biological manner we do not understand yet. If this was the case in a subset of such individuals, we theoretically in the footsteps of well mapped out and reliable paths of scientific investigation  we have been so well served by for the last 200 years or so, identify the mechanisms of operation of aberrant brain processes, say involving one or more “rage centers” of the brain such as the amygdala and construct a blocking treatment that would act at the site of cellular or brain system dysfunction. But I really doubt even if this scenario were to be established and confirmed that it would account for more than a subset of such individuals. Many other developmental [“growing up” experiential] factors could easily account for and lay the groundwork for such malignant behaviors. Social factors, free will, making choices and all the other elements of personal governance of one’s emotions and behaviors in one’s everyday personal life, could count just as much if not more. Personal choice and responsibility still do and will count for something’ we are not brain-driven automatons. It will always be a complex mixture. Human nature I expect will always defy reductionism.

In closing, My other main thought is that much pathology is social. We seem to have forgotten this concept in the accelerating seductive world of biologically explained psychiatry and mental health sciences. Social diagnoses are tricky quagmires, with squishy, uncertain data as their underpinnings. Much of their analysis will likely have to remain as the level of social epidemiological quantification, counting how prevalent such and such condition of a pattern of behavior and what social factors, economics, widespread stressors, accelerated change and a myriad of other factors will have to comprise the meat of the measurement of these conditions. This is the area that Big Data, once it is understood better how to apply such new mathematical analysis to such multiply layered bodies of information, can be of help. This could help structure social policy of applied in a non-totalitarian manner, and perhaps lend some degree of social predictably. But more than that, I doubt may be possible. Much of it will be most successful as we already experience today, in the area of social behavior, measuring our ‘click through rates,’ on the Internet and helping to shape our human nature drive consumerism.


Alt. Right Racists Mentally Ill? Some Psychiatrists Say Yes

Yahoo News

Jessica Firger
Newsweek19 August 2017

The scores of people carrying flaming torches and chanting “Jews will not replace us” last weekend in Charlottesville, Virginia, bore the message of the “alt-right,” the name given to the white supremacist movement dedicated to eradicating religious and ethnic minorities from America. This racist uprising will be followed by at least nine rallies this weekend—ostensibly dedicated to free speech but sure to broadcast messages of hate—across the U.S., held by members of the Ku Klux Klan, neo-Nazis, and other groups.


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The ‘Unite the Right’ rally in Charlottesville, VA, where white supremacists march with tiki torchs through the University of Virginia campus. Getty Images/Zach D. Roberts

Many find the sight of hundreds of racists chanting their intentions for a so-called “ethno-state” and the forceful removal from America of anyone who isn’t white horrific. But others—namely, some psychiatrists—see these individuals as mentally ill. Which leads to a disturbing question: Are we seeing the emergence of a nationalist movement fueled by prejudice or a widespread personality disorder that requires psychiatric care? Answering that dredges up long-held notions about racism in America.

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In the 1960s, Alvin Poussaint, now a professor of psychiatry at Harvard Medical School, was providing medical and psychological care to civil rights activists in Jackson, Mississippi. As a black psychiatrist in the South, he often feared for his life. He witnessed many acts of violence, cared for victims of racist acts and had frequent run-ins with state troopers. Once, when he told an aggressive police officer that he was a doctor, the officer continued to call him “boy” with a hand on the gun in his holster.  “I saw the malignancy of the racism much more clearly, and the genocidal element of the extreme racism where they wanted to kill you,” Poussaint tells Newsweek.

He wondered if that hatred was an actual sickness that could be diagnosed and potentially treated. When he was in his early 30s, and a prominent psychiatrist at Tufts Medical School, Poussaint and several other black psychiatrists approached the American Psychiatric Association (APA) with the idea that extreme racism wasn’t just a social problem or a cultural issue. To these professionals, extreme racism—the kind that leads to violence—was a mental illness.

Poussaint and his colleagues wanted the APA to include extreme racism in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a “delusional disorder.” The DSM is the definitive guideline used by mental health clinicians to diagnose patients.

The DSM is not infallible. Over the years, it has provided insights into the country’s ever-changing values and belief systems. Homosexuality, for example, wasn’t completely omitted from the DSM until the late 1980s. The last time the APA revised the DSM (in 2013) they declined the request by a group of psychiatrists to add pornography and sex addiction to the index. For psychiatrists updating the guide—a process that can take more than a decade—doing so means wrestling with the very nature of humanity, what is normal and abnormal when it comes to behavior and beliefs.

Poussaint wasn’t arguing about the relatively milder beliefs that cause a person to stereotype and classify groups of people negatively. Rather, he and the other psychiatrists were addressing the kind of racism that leads to violent behavior, like killing and injuring people by driving a car into a crowd, as happened in Charlottesville. That extreme form of racism, said Poussaint, could reasonably be classified as paranoid and delusional.


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In July 2017, Ku Klux Klan protests planned removal of General Lee statue from park in Charlottesville, Virginia. Chet Strange/Getty Images

The APA was unreceptive. “There was a lot of resistance to the idea,” he says. The problem, Poussaint explains, was that those in charge saw racism as too ubiquitous to diagnose. “They felt racism was so embedded in culture, that it was almost normative, that you had to deal with all the cultural factors that lead to this behavior,”

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Members of the APA also argued that the extreme racism is a mental illness claim lacked hard science. That objection was weak, says Poussaint, because many mental health diagnoses  listed in the DSM don’t have a solid scientific premise, including personality disorders. Some APA members said classifying extreme racism as an illness would excuse terrible beliefs and reprehensible behavior.

But Poussaint wasn’t interested in excusing or stigmatizing behavior; he wanted to help people he believed were sick. Inclusion in the DSM, he insisted, could allow individuals suffering from extreme racism to access services such as state-mandated psychiatric counseling, and therefore benefit society because, “it could protect people they might otherwise attack.”

Poussaint still believes extreme racism is a form of paranoia and should be treated that way. In therapy, a psychiatrist would help the patient understand the origins of their racism. “Like any psychotherapy or treatment you would try to tie it all together,” he says. “Other psychiatrists have testified and acknowledged such individuals may improve from treatment when they come to understand these beliefs and why they are projecting them onto other people and acting out.”

Racism as a Symptom

The question of whether extreme racism is a mental illness still haunts psychiatry. About 15 years ago, Carl Bell, a psychiatrist at Jackson Park Hospital Family Medicine Clinic and professor of clinical psychiatry at the University of Illinois at Chicago’s School of Medicine, resurrected Poussaint’s attempt to convince the APA to classify racism as a mental disorder. But Bell tried a different tack from Poussaint. He viewed extreme racism as a type of pathological bias that signaled an underlying personality disorder.

Bell proposed adding pathological bias to the DSM as a trait of personality disorder. With that addition, extreme bigotry would be a major criterion for the diagnosis. The broad term could also apply to individuals who direct violence and hatred toward other groups, such as gays or women.

But again, the APA said no. “When I raised this issue for the personality disorders working group they shut me down,” says Bell, “they were like, ‘Hell, no.’” As in decades past, the APA justified their objection on the grounds that racism is and always has been entrenched in society.

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“The difficulty is that if you are in a racist society, how do you tease that out from biology or personality?” says Bell, who could not even convince the APA to study why racist thoughts and action manifest in some people during manic episodes.

The Association did finally issue a statement in 2006 acknowledging that some psychiatric factors cause a person to become racist, although “further research would be needed to explore this hypothesis.” The group also noted that racist beliefs and behavior often cause depression and psychiatric illness in people who are subject to them. In a statement provided to Newsweek about its approach to prejudice-based violence, Saul Levin, CEO and Medical Director of the APA, said, “The APA has a longstanding policy noting the negative impact of racism and mental health. APA policy supports public education efforts and research on racism and its adverse impact on mental health.”

Bell and other experts continue to view some instances of racism as a symptom of other disorders. Racist thoughts and actions are often a manifestation of some other established and diagnosable mental disorder, says Bell. People with narcissistic personality disorder—a mental condition many experts have claimed Trump has —often have fixed values rooted in racism. Dylann Roof, the teen white supremacist convicted of killing nine black people at a church in Charleston, South Carolina, in 2015, had been diagnosed with schizoid personality disorder. People with conditions such as schizophrenia and bipolar disorder often experience extreme paranoia related to race or ethnicity, though not always violence.


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Outside the court hearing for James Alex Fields, the suspect who drove his car into a crowd in Charlottesville, Virginia, Matthew Heinbach, of the white nationalist Traditionalist Workers Party, shouts at journalists. Chip Somodevilla/Getty Images

There is also evidence that most of us harbor prejudices, leading some experts to believe we are hardwired to discriminate in some fashion (though not specifically against others). The Implicit Association test (IAT), a tool used to understand the roots and extent of bias, measures impulses of subconscious racism—for example, whether we associate certain types of people with negative or positive feelings. The test, which was developed by social psychologists at Harvard, the University of Virginia and the University of Washington more than two decades ago, has been taken by more than 17 million people. The results show that at least 90 percent of Americans are at least slightly biased against people unlike themselves. Psychologists remain split on where to draw the line, though. Some say discrimination requires a diagnosis when thoughts become actions. But others doubt whether acting on racist beliefs warrants a label of its own.

This Is Not Normal

The fact that many people who act on extreme racist beliefs lead high-functioning lives may also stand in the way of labeling this demographic as mentally ill. In the early 1960s, Jewish author and journalist Hannah Arendt covered the trials of Nazi war criminal Adolf Eichmann for the New Yorker. She was shocked that “half a dozen psychiatrists had certified Eichmann as ‘normal,’” despite the fact that he orchestrated the mass murder of millions of Jews. One psychiatrist described his familial relationships as not just normal but desirable.

In the decades following the Holocaust, the idea that someone who commits crimes against racial and ethnic minorities could still be considered sane by psychiatrists was unsettling, says James M. Thomas, an assistant professor of sociology at the University of Mississippi. “Many people turned to the explanation that there must be something wrong with the German psyche to have allowed this to happen.”

Social scientists knew that creating a clinical definition was critical. They understood that stigmatizing extreme racism could help society wake up to the abnormality of this pathology, and possibly prevent other genocidal acts. Three psychologists devised the California F-scale —F stands for fascist—a test used to evaluate a person for “authoritarian personality type.” They thought  understanding how people were seduced by Adolf Hitler’s rhetoric could help prevent future such movements. Although the F-scale fell out of favor, it enabled psychologists to identify common traits of people who cling to dangerous ideologies. They included an inflexible outlook, strong allegiance to leadership, a tendency to scapegoat others and a willingness to lash out in anger and violence.


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In Charlottesville, Virginia, on July 8, 2017, members of the Ku Klux Klan gesture during a rally calling for the protection of Southern Confederate monuments. Andrew Caballero-Reynolds/AFP/Getty Images

Sander Gilman, who teaches psychiatry at Emory University, and co-authored with Thomas the book Are Racists Crazy?, agrees that dangerous racists leading seemingly normal lives are hard to identify. “Racists, sadly, cope quite well with daily life,” says Gilman. “They have a take on the way the world should be, and that take functions in the world they live.”

Gilman does not favor a standalone diagnosis of extreme racism, and believes that attempts to categorize such people as mentally ill masks the greater problem of society allowing them to commit vengeful acts. “Those people are evil. They’ve made bad choices, but they’re not choices you can then attribute to mental illness,” says Gilman. “The minute you do that you let people off the hook.”

Are Mass Shootings “Contagious”?

Mass shootings have become such a “fact of life” in the Western world, that there are now website “trackers” of these awful events. This seems to have started with the question of whether mass shootings “have always been with us,” or whether they are indeed, becoming more frequent. Writers, observers, political figures, journalists, and others have been opinionating on this question now for several years. The positions that various public pronouncements have taken, have been all over the map on this vexing question. Persons of a traditionalist point of view have not given en masse the perhaps expected response that we should worry so much publicly about this supposedly new mass phenomenon. Persons who have been publicly sanguine about this issue have been social conservatives who often react with a “don’t rock the boat,” view and can be those from the Conservative Right, or those from the often worry-wart Socially Left. Political persuasions have interestingly enough, not seemed to have shaped persons’ opinions as much stereotypical thinking might have trained one to expect.

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Do We Know Any More 50 Years After Texas Tower Sniper?

Just days ago, August 1, was the 50th anniversary of the gruesome 1966 University of Texas at Austin Tower sniping murders in which Charles Whitman, a 25 year old student shot 16 people to death and wounded 30 others. It took three brave police who forced their way onto the walkway on the tower, to shoot him to death with their pistols to end the massacre. Since as a psychiatrist, long interested in this kind of phenomenon since early unsettling forensic contact with a few shooters, I came across through my trust ever roving “search bots,” this article from NPR news on one of their blogs, recounting this fateful incident, “Gun Violence and Mental Laws, 50 Years After Texas Tower Sniper,” by Lauren Silverman.

Charles Whitman, the Texas Tower Sniper
Charles Whitman, the Texas Tower Sniper

I was quite young then, but my father’s entire extended family was from Texas and we were riveted to the television as the “tapes” of the scene were played over and over on the evening news for a few days. I had been to the mall/quad/courtyard in front of the Tower before and since the incident, but watching the scene, especially the scene of the young man covering the body of a friend with his own in the open and being shot at, was literally unbelievable in that day and time. The entire nation stopped for a few days as the horrors of the event were absorbed and the trauma processed as best one could. I recall that it was one of those events that one who lived through it, would remember the rest of their lives, where they were when they heard the news and recalls the shattering effect of the evening television news scenes. It ranked in “trauma impact” up there with the assassination of President Kennedy, the Cuban Missile Crisis, the landing of Apollo 11 on the moon during that night in 1969 and other such indelible events that our brains cannot expunge.

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