violence – Go Retire Psychiatrist

The recent New York Post story about the man who shoved a 76-year-old retired schoolteacher down a flight of subway stairs caught my attention.

The assailant had been sent to Bellevue for a court-ordered psychiatric assessment for similar agitated behavior not long before this assault. My understanding from news stories is that he was held for a day or so and released. Shortly after his release, he killed someone.

There were statements made by psychiatrists who decried the decision to release the assailant so quickly, given his history of repeated attacks.

This reminded me of an incident a little over 25 years ago when I was an assistant professor of psychiatry at the University of Iowa attending a short course in administering electroconvulsive therapy (ECT) for a study of continuation pharmacotherapy for preventing relapse following ECT at New York State Psychiatric Institute (NYSPI) at Columbia University. It was published in 2001 in JAMA although I was not a coauthor, of course, given my limited role:

Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001 Mar 14;285(10):1299-307. doi: 10.1001/jama.285.10.1299. PMID: 11255384.

It was my first visit to New York and while there were a lot of sights to see (I took one fascinating Gray Line bus tour), my main goal was to complete the ECT training at NYSPI, which was scheduled for 2 or 3 days. I passed with flying colors and my training staff members threw me a little party with wine and cheese in an office with a giant window giving us a splendid view overlooking the Hudson River.

However, the memory is clouded by a scary incident on the New York subway, which I used to get from my hotel to NYSPI. One morning, when I was packed in the car with many other riders, a very agitated man got on who started to yell incoherently in everyone’s face—including mine. It was impossible to tell exactly what he was upset about, but he was apparently psychotic. He moved from person to person, got right in our faces and spewed gibberish and curses about something nobody could make sense of. He seemed right on the edge of attacking somebody.

I watched him move from one passenger to another. His behavior was the same with each one. He would get within an inch of their noses and shout at them. Not one of them reacted. They seemed eerily calm. They never made eye contact. I was afraid that, sooner or later, he would blow his top because they were ignoring him.

He got to me and yelled in my face and I just copied what everyone else was doing. I assumed a blank expression and didn’t look him in the eye. He practically screamed “Look at me!” For a split second, I thought he would try to hurt me. But he didn’t. He just moved on to someone else. I was so relieved when I reached my stop and got off.

I can’t clearly recall whether I spoke to my staff at NYSPI or not. I must have. I have a dim memory of one of them telling me that all of the people on the subway were doing the right thing by ignoring the man. I could not understand how anyone could ride the subway every day and tolerate that kind of confrontation without reacting. It’s kind of like an animal freezing, almost like an opossum’s response to a threat. Play dead.

But the opossum’s reaction is an involuntary reaction to extreme fear. It’s a catatonic state, which is kind of ironic because psychiatrists use ECT to treat catatonia in humans. I don’t want to give you the impression that New York is all bad. Sena and I had a great time on vacation there around 9 years ago. But humans ignoring danger in their faces is not involuntary in situations like what happened on the subway 25 years ago. It’s a calculated risk, a decision to ignore threats. Twenty-five years later, it looks like New York hasn’t changed.

The attack a few days ago by what was most likely a mentally ill person on staff at the recently opened GuideLink Center in Iowa City reminded me of what may appear to be disparate views by mental health professionals on the link between mental illness and mass violence perpetrators.

The GuideLink incident involved a person who assaulted GuideLink staff and who also left bags containing incendiary devices at the center and another building in Iowa City. The person is being charged with terrorism and is currently in custody in the Johnson County Jail.

I have not seen information about any injuries sustained by the mental health center staff. There were no explosions or fires at either location where incendiary devices were left. Bomb squad experts removed the devices. It’s not clear whether the perpetrator had been a GuideLink Center client.

The GuideLink Center opened in February 2021 and by all reports is a welcome and very much needed crisis stabilization mental health resource in the community. The staff members are dedicated to their calling.

Dr. H. Steven Moffic, MD, a retired psychiatrist who writes for Psychiatric Times, readily says that the perpetrators sometimes do have mental illness that at least contributes to committing acts of mass violence. Dr. George Dawson, MD, another retired psychiatrist, seems to say that the major reason for mass shootings is the ready availability of guns, a culture of gun extremism, and mental illness accounts for a small proportion of acts of mass violence.

But neither Dr. Moffic nor Dr. Dawson say that it’s only either mental illness or guns (or other instrument of mass violence) that lead to acts of mass violence. Both are important.

I’m a third retired psychiatrist and by now some readers might be asking themselves whether they should listen to any retired psychiatrist. Experience counts.

Speaking for myself, as a general hospital psychiatric consultant I was frequently faced with violent patients in the general hospital. Often, I found it necessary to ask a judge for a court order to involuntarily hospitalize a violent and/or suicidal patient on a locked psychiatric unit by transfer from an open medical or postsurgical unit.

In order to obtain an order in the state of Iowa, I had to be able to state to the judge that the patient in question had a treatable mental disorder and was an acute threat to himself and/others. In most situations, I had an open bed on a locked psychiatric unit available ahead of time.

Even if a Code Green was necessary, I usually had an inpatient resource to which I could move the patient. A Code Green is a show of force or takedown maneuver by a specially trained team to control a violent patient while minimizing injury to everyone involved.

I don’t know if that kind of approach is even possible in a community crisis stabilization setting like the GuideLink Center. I think it’s fortunate that it partners with many other community resources including the Johnson County Sheriff’s Office.

The outcome of the incident at the GuideLink Center was that the overall safety of the staff, the patient, and the community was preserved. More resources like this are needed everywhere. They deserve all the support we can give them.