Gun violence: Picking out the crazies

"He's not a criminal," I told the court. "He's sick."

Teeth, the "defendant," regarded me impassively, his face wooden and expressionless, as usual.

Teeth was a Vietnam veteran, a Marine. He was tall, lean and muscular; though quiet and unobtrusive, he conveyed the impression of a tightly wound spring.

One of our nurses dated him -- once -- and although he was pleasant and reserved, he showed her his arsenal. Automatic weapons, high-powered rifles and an assortment of handguns -- enough to arm a small army.

Teeth lived at the tribe's assisted-living facility, mainly for the subsidized rent and meals. When he began to organize his quarters along military lines, including a "defensive perimeter," other residents grew uneasy.

Our public health nurse visited him periodically, observing his apartment's armed-camp disposition and other signs of increasing paranoia.

Teeth never made threats, never personally menaced anyone. Yet everyone realized his condition was deteriorating, and feared at any moment, he might snap.

He showed clinical features of a "thought disturbance," possibly a form of schizoaffective disorder, superimposed on PTSD.

After consulting with the PHN and others, and based upon my own encounters with him in clinic and ER during recent months, I requested a formal commitment hearing.

He was duly committed, after spending a few days in the local mental health holding facility, aka jail. He responded well, and I continued to treat him in succeeding years. Despite my previous intervention, we got along fine.

Teeth was one of the easy ones.

During gun control debates, champions of free-range weaponry dismiss Americans' easy access to guns as irrelevant to the burgeoning increase of gun violence and mass shootings.

We just need better mental health screening and treatment, they say, so crazy people aren't allowed the same access to deadly weapons mentally healthy gun nuts enjoy.

Most mentally ill people aren't violent. However, one could plausibly maintain perpetrators of mass shootings are, by definition, mentally ill.

Simply pluck them out of the lines at gun shows, and all will be well for the rest of us.

It's not that simple.

Sometimes such craziness is unplanned and impulsive, with no clear history of any mental disturbance at all. Call it "temporary insanity" (not a medical term). We're not going to interdict those guys with any degree of screening. There's nothing like a gun to turn an insecure wimp into the Terminator.

Many mass shooting are orchestrated in advance, carried out with precision. The implications are obvious: "Crazy" people can be deceptively intelligent and crafty despite other brain malfunctions.

Often the perpetrator's friends and neighbors profess surprise at his behavior. He seemed friendly, kept to himself. We had no idea.

Even family members can find it hard to comprehend, or at least admit, that something seriously wrong is happening. He seemed more withdrawn. He was acting funny, but he didn't actually do anything bad.

Denial is tempting under such circumstances. If you can't do anything about it, why not live with it?

Should his family decide he needs to be "evaluated," that can be problematic. He might not agree their problems are his problems -- they just don't understand, they're making a big deal out of nothing. So he won't cooperate with an evaluation and might actively resent attempts to route him to his family doctor, much less a shrink.

Those with sufficiently distressing mental symptoms might voluntarily consult health-care providers at some point. Can't the doc or counselor blow the whistle?

It's not that simple.

First, it can be difficult to tell whether a person with subtle premonitory symptoms is really mentally ill, as opposed to undergoing temporary situational stresses. Even with a high index of suspicion for violence-prone mental illness, the provider can't just call the cops.

There is the matter of confidentiality. The doctor-patient relationship is privileged. A doc must preserve confidentiality as a matter of law and professional ethics; even crazy people have rights.

Confidentiality can be breached only if the patient presents a "clear and imminent danger to self or others." Clear -- sometimes. Imminent? That can be a tough call. He hasn't hurt anyone in the past six months -- how can I say he's going to in the next 24 hours?

Often the only unequivocal proof of mental illness comes when the afflicted pulls the trigger.

Once we do sound the alarm, we need local law enforcement support. Pending legal proceedings, the dangerous mentally-ill warrant protective custody. Cops need some reassurance the doc's claim will hold water, so they themselves won't be charged with unlawful detention.

If detainees are committed, the "meet 'em, treat 'em, and street 'em" standard kicks in. When treatment seems reasonably successful, they're discharged on medication, which many soon stop taking. They're "lost to follow-up."

Meds run out and aren't refilled; or Joe just stops them due to side-effects, or because he feels OK and "doesn't need it anymore."

Long-term inpatient treatment has become impractical, if only because newer drugs and rising costs have shut down chronic care facilities.

Now we use prisons instead.

Sometimes shooters just buy their guns; sometimes they swipe relatives' firearms.

Either way, it's far too easy.

So long as guns are as common as table salt, and widespread mental illness is so resistant to preventive intervention, we'll continue to tally the mounting casualties, shrug our shoulders, and await the next tragedy.

Jon Hauxwell, MD, is a retired family

physician who grew up in Stockton and now lives outside Hays.

hauxwell@ruraltel.net