Part of my residency training in psychiatry was spent working on the locked unit at the Shattuck State Hospital in Massachusetts.  It was there that I learned strategies to keep people safe when voices or visions or delusions made them threaten others with harm—whether verbally or physically.  The strategies were very important, because some of the folks on the unit had never been violent, while others had been court-ordered to the Shattuck after committing very violent crimes, including murder.  We needed to protect not only the staff, but patients, too.
 
The lessons I learned at the Shattuck are ones that the Administration should keep in mind in dealing with Iran.  After all, Mahmoud Ahmadinejad appears either to be a pathological liar with extremely violent intentions and a willingness to distort history or to actually be delusional.  In either case, he qualifies as an inpatient on a locked psychiatric unit.
 
Here are lessons from the Shattuck:
 
1. It is highly desirable to listen to every patient, even those with delusions, because their truth may be audible, despite the content of their speech being insane.  Someone with grandiose delusions, who believes he is the savior of the planet, may actually be expressing deep feelings of low self-esteem.  Similarly, the desire to obtain nuclear weapons and destroy one’s neighbors may relate to internal feelings of having been annihilated.  So it may be with Iranians, whose self-esteem and willingness to be led by a madman (notice the contracted words mad and man), may reflect their internal feelings of vulnerability.

2. When a delusional or violently ill patient seeks to arm himself, he is to be watched extremely closely and repeatedly searched.  There can be no negotiation on this account, as the violent or delusional man cannot be trusted.

3. When the delusional or violently ill patient is found to have secreted away a weapon, it must be presumed that he fully intended to use it and that he will be very angry that he cannot.  Therefore, he must be rapidly disarmed and then placed in quarantine, lest he either rearm himself or attempt to show his strength using his fists or a discarded needle.  On a psychiatric unit, that means a room search, confiscating any weapon and placing the patient in the locked quiet room.  In Iran, it means destroying Iranian nuclear facilities, then isolating the country, then searching for any other threats.

4. Psychiatric patients at the brink of violence are not comforted by, nor dissuaded from that violence, by quiet speech or bargaining.  They are comforted by a show of force that convinces them that they are better off in the good hands of a healer than left to  the chaos of their own intentions.  Even four-point restraints can be a comfort to a man out of control whose mind knows not the limits of rational thought and action.

5. Time is of the essence.  When a psychiatrist on a locked unit feels a patient is about to become violent, the thought processes inside that patient often have been brewing for a very long time.  At that point, making the unit safe has to precede more elegant attempts at healing.

6. The other patients are watching.  This means that the psychiatrist’s response to a violent patient will either quiet the unit (for which you may read the Middle East) or inflame it.  Permissiveness is always perceived by the unstable as a call to chaos.

7. Always read the clinical history of every patient for any past episodes of severe violence.  The past is a good indicator of the future, even when great progress would seem to have been made.  Witness the recent embracing of terrorists by Muammar el-Qaddafi.

8. Keeping the unit safe is not about hating anyone.  Even the violent patient is a worthy human being at the core.  But that does not mean that the patient is not a grave risk to himself or to others.  There can be no fear of taking action, nor any joy in doing so.

As it was at the Shattuck, so it is in Iran.  I hope Dr. Obama is listening.

Dr. Keith Ablow is a psychiatry correspondent for FOX News Channel and a New York Times bestselling author. His book, “Living the Truth: Transform Your Life through the Power of Insight and Honesty” has launched a new self-help movement including www.livingthetruth.com. Dr. Ablow can be emailed at info@keithablow.com.

The murders of Arturo Gatti, possibly by his 23-year-old ex-stripper wife, and of Steve McNair by his 20-year-old lover, may reflect yet another sign that more Americans than we know —especially younger Americans — are losing their sense of self and, with it, their psychological and moral bearings.  

Certainly, crimes of passion are nothing new.  As has always been true, the killers of Gatti and McNair had to have had extreme life stories with major psychological fault lines reaching back, quite possibly, to childhood.  But in both cases, the victims were famous men who may well have offered the women in their lives temporary and fragile shelter from deep, unresolved questions about whether they could exist independently or would crumble into nothingness without their connections to fame and fortune. It is often those who feel dead themselves who take the lives of others.

Some may think it’s too big a leap to draw any connection between a lack of respect for life and the artificial, Internet-based, technology-fueled existences that too many of today’s teens and twenty-somethings have lived, but I’m not so sure.  I think that the kind of existential panic — the panic of having nothing real at one’s core — that can lead a young woman to murder her famous lover, rather than lose him, is a distant cousin of posting videos on YouTube of staged beatings and the deconstruction of real lives and relationships into profiles, IMs and tweets.

In a world that worships reality TV parents who turn their children into entertainment automatons and a psychologically disturbed pop star whose celebrity was initially forged through enslavement to his sadistic father, respect for one’s own life and that of others can start to erode.  Gaining fame and saving face on Facebook is what matters, and the loss of image can feel like the loss of everything.  I hope I’m wrong.  I hope that cases of extreme violence are now just the same as they always were — outlying cases that are no predictor of anything about the rest of us.  

But as a psychiatrist who has made it part of my life’s work to resist dismissing my instincts, I now sense something ominous about our culture reflected in the worst deeds of the most violent among us.  I fear we are at risk for losing respect for one another and for human life.  I fear our fragile God-given capacity for empathy is under siege. I fear that in obsessing over “Blanket” Jackson (and I feel a little disturbed by even writing his preposterous name), who was dangled over a railing by a father who may not have fathered him at all, we open the door to outlandish acts of dramatic violence that would make for decent psychological thrillers, but are now the stuff of what we call “real” life.

Today we heard of a shooting at the Holocaust Museum in Washington, D.C. that appears to be the work of a single gunman, whom authorities believe to be a man in his late 80s by the name of James Von Brunn. If this is the suspect in custody, he is actually a World War II veteran and vocal member of the Holy Western Empire, which at this point, seems to be a white supremacy group.

It is sad to see people resorting to violence to settle their differences. And we have to be aware that we still need to be vigilant in our efforts to protect ourselves — despite the feeling of some Americans that security measures in this country have become too intrusive. It’s important to support our men and women in uniform, who at both the local and national levels, do a terrific job of keeping our country safe.

What this man did was an act of terrorism — domestic terrorism.

But the big question is: What’s the psychological profile of this shooter? If you look at some of the psychological profiles of past shooters, they are all different in their own way. However, there always seem to be some common themes.

Most of these people are angry at someone or a group of people, and share a psychotic belief that their misfortunes are predicated on the actions of those they hate.

Usually they are loners — they feel rejected by others or by society as a whole.

For some, substance abuse and depression are common themes, but even knowing these common themes, it is almost impossible to differentiate between who will just withdraw from society and who has the potential to snap and hurt innocent people.

I pray for those hurt in this tragedy and hope that we are able to create systems that could perhaps better identify high-risk people and prevent future tragedies from occurring.

The tragedies are coming one after another.  In Binghamton, NY, Jiverly Voong kills13 at the American Civic Association.  In Pittsburgh, Richard Poplawski guns down three police officers.  In Graham, Washington, James Harrison kills his five children and then shoots himself.  All told, 57 people have died in multiple killings in the last month alone. 

What’s behind the carnage?  Could our troubled economy, with rampant job loss and the specter of home foreclosure weighing on our collective psyche, be pushing people over the edge?  Or is the answer to be found in the minds of a small number of people who have been quietly gathering rage and losing control for many months or years.

I think the answer is both.

Mass murderers have one thing in common:  They have lost the capacity for empathy.  They no longer see others as fully human, so they don’t worry over causing them to suffer.  They no longer see the life stories of others as sacred, so they don’t worry over bringing them to a violent end.  I believe this chasm of inhumanity opens because mass murderers have stopped valuing their own lives.  They are dehumanized to the extent that depression or paranoia or rage — or all three combined — have displaced everything else inside them—including love, whether for themselves or for others.

The road to becoming a murderer may have its roots in childhood, when abuse and neglect begin to make a child shut down his or her emotions, in order to stop feeling so much pain.  That dark psychological process can cast a long shadow, preventing the future killer from resonating with the pain of others.  Unrestrained by empathy, it leaves that person freer, in a terrible way, to be violent. 

It might well be the case that those who shut down emotionally and begin storing paranoia and rage inside them have less “hearty” or resilient nervous systems.  Maybe they have lower levels of serotonin than others among us who would preserve our humanity in the face of equally traumatic events.  Maybe they have absolutely no one who is obviously proud of them or shows concern for them or at least shares kind words with them.  Maybe they are unlucky enough to have head injuries that erode their capacity to control their emotions and leave them with shorter fuses.

But while the roots of the paranoia and rage that fuel mass killings may run bone deep, today’s stresses can set ablaze the deepest cauldrons of emotion.  We have among us many, many people who are on the edge psychologically.  They do not have reservoirs of self-esteem to carry them through job losses that make them feel like failures — as workers or fathers or husbands.  They cannot draw on stores of optimism to believe that things will turn out alright in the end, because things were not alright for them, often from the very beginning.  They may already be suffering with depression that can, in some of its forms, lead not only to anxiety and irritability, but also to paranoia and thoughts that life is not worth living.  Perhaps they have already turned to bankrupt strategies to keep their emotions at bay, including alcohol or illicit drugs, substances that lower self-control and are involved in the majority of violent crimes.

These are the people who are at risk to become the next Jiverly Voong, Richard Poplawski or James Harrison.  They are a job loss, a divorce or a repossession away from utter hopelessness that can tap their underlying stores of self-hatred and hatred for others and lead them to project it outside themselves, in an explosion of violence. 

There are many such people in the world.  They are victims of life events beyond their control who then victimize others, exponentially.  Psychological arithmetic is sometimes cruel:  The suffering of one person can multiply itself into the suffering of many.

This economy and these times are dangerous potential triggers.  Anyone who says otherwise should sit with me in my office and listen to some of the good and decent people, many from fine families, many with histories of great success, with wonderful potential futures, who can’t see any future for themselves, anymore. 

Anyone who says otherwise should listen to these “lucky” people, now down on their luck, who irrationally see themselves as permanent failures — not just economically, but personally.  Then imagine if you were the product of trauma, with only the most fragile sense of self, thinking the world was already against you.  Imagine how a pink slip hits you then.  Imagine if it comes with news that your wife is leaving you or cheating on you — with a real man.  Imagine if you stop thinking you’re a man at all, not even a human being, that everyone is laughing at you, that you’re powerless and forgotten and destined for nothing but emptiness.  Imagine trying to contain all that. 

Some people don’t.  Instead of containing it and processing it, they project it.  Economic chaos makes that outcome more likely.  The sooner we stop denying that fact, the sooner we can begin putting in place the needed resources to reach out in a real way to those who think — wrongly — that they are beyond help, and prevent the deaths we can.

Dr. Keith Ablow is a psychiatry correspondent for FOX News Channel and a New York Times bestselling author. His newest book, “Living the Truth: Transform Your Life through the Power of Insight and Honesty” has launched a new self-help movement. Check out Dr. Ablow’s website at livingthetruth.com or e-mail him at info@keithablow.com.

During August, 1984, Josef Fritzl, then 48, imprisoned his 18-year-old daughter Elisabeth in a damp and moldy secret room he had constructed beneath his home.  Over the ensuing years he raped her numerous times, “fathering” seven children with her.  One of those children died shortly after birth due to breathing complications Fritzl allegedly neglected to address — an act for which he was on trial for murder.  He had already pled guilty to incest and to threatening to gas or electrocute Elisabeth and her children if they attempted to escape.  Now, he has admitted to all the charges against him.

Fritzl had a history of sex crimes.  He had exposed himself to women before progressing to violent rape at knifepoint.  He was arrested for that rape, but ultimately freed.

Fritzl’s actions are so monstrous that they might seem to defy any attempt to begin to understand them.  Certainly, there is no psychological explanation that could begin to excuse them.  But, if we look for possible roots of Fritzl’s evil, a few may be traceable back to his own childhood development: Fritzl’s pathological relationship with his mother and his childhood in Nazi Germany.  I shared my perspective on both topics with John Glatt, whose book on Fritzl called Secrets in the Cellar, was just published.

According to Glatt, Fritzl described very powerful impulses to have sex with his mother. He actually prided himself on being as strong a person as she was and, therefore, able to resist having a sexual relationship with her.  This implies that Fritzl’s mother either attempted to seduce her son, or that he at least believed she was attempting to do so. And if that is the case, then imprisoning Elisabeth underground and creating a family with her could be a kind of reenactment of Fritzl’s buried childhood fantasies and fears of incest (or his actual incestuous experiences, if they occurred).  With Elisabeth, however, he was the aggressor, the one in control, rather than the potential victim.  So it may have been transmuted Oedipal desires that Fritzl brought to life in the dirt beneath his home, this time taking his daughter captive, rather than being captured himself.

It also bears noting that Fritzl’s personal development — including his battle against such fierce Oedipal desires — took place against the political backdrop of Nazi Germany. Remember, Fritzl threatened to gas his children if they escaped their underground prison.

Fritzl grew up within half a mile of the Mauthausen death camp in Amstetten.  He would literally have seen and smelled smoke rising from the crematorium.  The mingling of secrecy and an organized death camp with his sexual fantasies is hard to ignore, given the dark, buried chamber he constructed to father a second family by repeatedly raping his own daughter.

Why Elisabeth?  Perhaps she was especially sensitive.  Maybe she represented something he lacked. Humanity.  Sensitivity.  A magical, emotional, intuitive quality. Maybe looking at her in the light of day threatened to reconnect him with what he had lost in his own character, an innocence that had been taken from him.  Better to bury her.

Surely, we can’t know the precise way the toxic ingredients of Josef Fritzl’s heart and mind mingled to create a monster. He hasn’t revealed enough of his childhood and adolescence for a complete map to be drawn from horrors he experienced to the ones he perpetrated.  But Fritzl’s complete lack of empathy for his daughter Elisabeth, his wife and all the other children in his home and beneath his home means that someone showed him no mercy at a critical point as his personality took form.  Because there are no new monsters that spring, fully formed, onto the planet.  In well over a decade evaluating and treating violent men and women, I have found every single one capable of monstrous acts was created, not born.

Dr. Keith Ablow is a psychiatry correspondent for FOX News Channel and a New York Times bestselling author. His newest book, “Living the Truth: Transform Your Life through the Power of Insight and Honesty” has launched a new self-help movement. Check out Dr. Ablow’s website at livingthetruth.com or e-mail him at info@keithablow.com.

Police in St. Johns, Ariz., allege that an 8-year-old boy gunned down his father, Vincent Romero, and his father’s co-worker, Timothy Romans, using a .22-calibre rifle.  They say the crime was planned and methodically carried out.  Prosecutors have not yet announced whether they will seek to try the 8-year-old as an adult.

First things first:  Without access to the information that police have at this time, the public should withhold judgment about the veracity of the 8-year-old boy’s confession. False confessions are common enough in traumatized, eager-to-comply adults, let alone kids.  Three other children between the ages of 7 and 8 have confessed to murder since 1958; none of them committed the killings.

Assuming that the boy in Arizona is indeed the perpetrator, mental health professionals will have the task of trying to ascertain why he committed two murders.  Already, neighbors and friends and school officials have commented that the boy seemed perfectly normal, seemed to have a good relationship with his dad and had no history of violence.

As a forensic psychiatrist I have evaluated many killers and testified about them in court, not to mention treating dozens of very violent people.  And I promise you that, if responsible for these murders, there is indeed a psychological explanation why the boy committed them. 

Possible explanations include the boy suffering an underlying mental illness causing a delusion (a fixed and false psychotic belief) or hallucinations.  Conditions like bipolar disorder, for example, can (in a great minority of cases) trigger paranoia and even voices commanding one to carry out actions that would normally be abhorrent to the afflicted individual.   No one has suggested that Romero’s son suffered such a condition, but clinicians will need to rule out the possibility.

If the boy has been under treatment for any psychiatric symptoms with medications, the possibility of a medication side effect has to be explored.  Some psychoactive medications can, in rare cases, prompt violence against oneself or others.  The same is true, by the way, for some medicines used to treat medical conditions, like asthma.

Even in an 8-year-old, the remote chance that a mind-altering substance could be involved — perhaps belonging to someone else who was present at his school or in his home — has to be excluded.  That should be relatively easy to do by taking a detailed history from the boy and testing his blood and urine. 

Neurological explanations have to be entertained.  An MRI or CT scan of the alleged killer’s brain can tell investigators whether or not pathology like a brain tumor could be responsible.  The possibility is small, but can’t be dismissed out of hand.  Even an infection of the 8-year-old’s cerebrospinal fluid — the fluid that bathes the spinal cord and the brain—has to be formally eliminated as a possibility.

Chances are, however, that the why for these killings would reside in the emotional pathology of the alleged killer, not his brain pathology.  Some trauma or series of traumas, near or far in time, has to have occurred, in order to make this child either desperate enough to kill or cold-blooded enough to kill.  In sixteen years practicing psychiatry, I have never met a murderer who was born evil.  In every case, I eventually learned the circumstances that extinguished that person’s empathy.

So if this 8-year-old boy is indeed a murderer, the search will be for the roots of his violence.  We have only a hint which questions to ask from the news coverage to date.  But here are a few:  Why was the boy’s father awarded sole custody of him?  Why is his mother residing in Mississippi, rather than closer to him?  What are the details of the boy’s living arrangement, including the fact that his father had rented out a room in the house to his co-worker?

The truth of this 8-year-old and his alleged violence is knowable.  The key to finding it is in asking enough questions and never buying into the myth that killers are born.  They are made.  And when one is made by age 8, enough bad has happened in eight years to make the unthinkable actually occur.

Dr. Keith Ablow is a psychiatry correspondent for FOX News Channel and a New York Times bestselling author. His newest book, “Living the Truth: Transform Your Life through the Power of Insight and Honesty” has launched a new self-help movement. Check out Dr. Ablow’s website at livingthetruth.com or e-mail him at info@keithablow.com.