Psychiatric Experts Provide 'Answers' During Sniper Saga, But at What Cost?

For a time last October, the entire country ducked as the media carpeted the nation with its wall-to-wall coverage of the sniper shootings in the Washington, D.C., area. Still sensitive to the threat of international terrorism and still stinging from the Sept. 11, 2001, attacks that included the Pentagon, it was no wonder that the mysterious assaults pushed public curiosity to the limit.

Who could be the perpetrator was a legitimate question people were desperate to answer. Whether the media's parade of experts helped provide the response in a constructive way, however, is not clear now that neither of the two suspects ultimately fit the profile that emerged in the weeks leading up to their arrest.

John Allen Muhammed, 41, and Lee Malvo, 17, were not the lone, white gunman the pundits often predicted would be captured. And there has been no early claim that mental illness will play a role in their defense.

While there were any number of forensic experts who speculated about the cause of the attacks, that psychiatrists joined the fray added to concerns that professional ethics and the public's perception of mental health care practitioners and mental illness may have suffered.

The National Alliance for the Mentally Ill (NAMI) issued a "StigmaBusters Alert," criticizing the link being drawn between mental illness and violence as an "irresponsible rush to judgment-based on inaccurate information, sensationalism, lack of balanced reporting, and stereotypical thinking." It singled out the New York Times for quoting a psychiatrist who "suggested" that the shootings were the work of someone with manic depression, without seeking other opinions that would have countered that view.

"What motivates the sniper?" wrote forensic psychiatrist Paul S. Appelbaum, M.D., in an Oct. 15, 2002, Washington Post editorial, a week before the suspects were captured. "I don't know and neither does anyone else."

Reflecting on the sniper episode in a subsequent interview with Psychiatric Times, Appelbaum, president of the American Psychiatric Association and chair of the department of psychiatry at the University of Massachusetts School of Medicine in Worcester, Mass., said that while psychiatrists were not the worst commentators, "there was a lot of bad behavior," and some of it came from them.

"There were certainly psychiatrists who ventured incredible explanations," Appelbaum said, although he declined to identify them by name. "I recall one who discussed with certainty the conclusion that the sniper was psychotic, pretending to know things that were going on in the sniper's mind that it was impossible for anyone to have known at that point."

Without anything meaningful to say and sometimes speculating beyond the "factual grounding," the experts, including some psychiatrists, appeared "silly," Appelbaum said. As a result, the public perception of the profession and of mental illness was harmed.

Appelbaum distinguished the sniper incident from other events in which psychiatric experts helped inform the public. Psychiatrists used the Andrea Yates case, in which a Texas woman murdered her five children, as a vehicle to explain postpartum depression and postpartum psychosis.

"I don't think the same happened in [the sniper] case," Appelbaum explained to PT. "Beyond general descriptions of the phenomenon of serial murder, which were mostly offered by the criminologists who were involved, there was little helpful that I saw in the media that our experts were commenting on."

That is partially the result of the selection process the media undertakes. "I don't know," is not the answer reporters are looking for, particularly the 24/7 cable news networks that must fill an enormous amount of time even when there is no breaking story.

"The press--like everyone else--looks for certainty, looks for some sort of definitive statement," Marc Graff, M.D., vice chairperson of the APA's Joint Commission on Public Affairs, told PT. "We all like answers; anxiety and uncertainty are not good for people; and the press, like any other group, looks for answers, and it does its best to find them. And if you say, 'I don't know,' they would like to find someone who can say 'I know.'"

According to Graff, who is also assistant clinical professor of psychiatry at the University of California, Los Angeles, School of Medicine, the media also often attract "pseudo-experts," or people who have difficulty resisting the temptation to respond to questions when the data are slim or nonexistent. "It depends on how healthy your narcissism is," Graff said. "I try to answer those questions which I know something about and give them the phone numbers of my colleagues who are experts in stuff I know nothing about. And not everyone can do that. Some people are self-proclaimed experts in everything, and I've met a few. And that's a disservice to our profession."

Saul J. Faerstein, M.D., a forensic psychiatrist in Beverly Hills, Calif., who has consulted in some of the nation's most notorious criminal cases, felt the media heat when he served as O.J. Simpson's psychiatrist in 1995. At the time, he resisted requests from nearly every national media outlet.

During the sniper case, reporters contacted Faerstein, who is clinical professor of psychiatry at the UCLA School of Medicine, after law enforcement officials discovered a note purportedly from the sniper that threatened to harm children. While he spoke to one reporter, his reticence to make specific comments meant he ultimately was not quoted.

"The stuff that I read in the paper from other people, which had been totally speculative, seemed so uninformed and inaccurate that I was hesitant to do it myself," Faerstein told PT. In reading these speculations, he added that he found "some of it useless and unhelpful." Faerstein nevertheless stated that he believed the commentary did not harm the public perception of the psychiatric profession.

What does occur is that psychiatrists bring to interviews their own background and specialization, causing them to make comments or predictions that will not likely be accurate.

"People who have a particular frame of reference or a particular specialty in psychiatry would be more likely to analyze the information and propose a theory based on their particular view of the problem," Faerstein explained. "That might give a very narrow focus without taking into account other possibilities. That doesn't reflect badly on the profession, but it may give a narrow view and it may not be accurate; but I don't think it's harmful, dangerous or destructive."

What does concern him, however, is that the lay public may view these theories as establishing a connection between mental illness and violence that is unwarranted and inaccurate. "That is a big problem because one of the most important messages psychiatry is trying to put out is that mentally ill people do not have a higher rate of dangerous[ness] than the rest of the population," Faerstein said. When psychiatric experts link the violence to a potential psychiatric history or profile, it helps undo this effort because the public immediately assumes that the violence is associated with someone who is mentally ill.

But Michael Welner, M.D., chairperson of The Forensic Panel, a forensic consulting firm in New York City, and clinical associate professor of psychiatry at New York University School of Medicine, is undeterred. Since the sniper shootings began, he has appeared in the media dozens of times, including guest shots on CNN's Larry King Live, broadcast interviews on every national network and quotes in nationally circulated print publications. He has plenty to say, and, according to him, it is a public service.

"I think, in your role as a psychiatrist, there's a lot that you can contribute so long as the boundaries of your expertise are clear to the listening or reading or viewing public," Welner said in an interview with PT. "And if you don't do it, then some armchair [schlock] will, who will be exceptionally misleading."

According to Welner, depending on the story there are any number of areas where psychiatric expert commentary can help the public and law enforcement. For instance, mental health care professionals can advise people on how to cope with the uncertainty of disaster-like situations. They can also clarify that the perpetrator is not some "monolithic super criminal." "A sensible behavioral scientist can set the public straight about how these people are likely to be failures who will ultimately undo themselves because they are so inept and inadequate," Welner said.

Giving the public an understanding of the characteristics of a spree killer may also facilitate law enforcement's efforts by encouraging people to convey relevant information: "In that sense, forensic psychiatry ... [has] a good understanding about people who become involved in spree killing and what kinds of common qualities they have."

Rather than damaging the profession, Welner insisted that the best commentary came from mental health care practitioners: "I think that psychiatrists had a far more mature contribution to make than nonpsychiatrists did, and I'm not simply being provincial about this."

As for the possibility of enhancing the stigma of mental illness by linking it to violence, Welner denied that his kind of commentary does anything to make things worse. "Violence is a behavioral problem issue. Violence is a behavioral problem. Violence is a behavioral science issue," Welner told PT. "It may be an expression of brute criminality, but it is pathology. Antisocial behavior is a psychiatric problem. The fact that we don't have a treatment to make antisocial people prosocial doesn't mean that it's any less psychiatric. It's just essentially the equivalent of the cancer that we have not yet cured."

Welner believes that what is important is to make certain that the behavioral component of violence is what is emphasized and to avoid linking it to mental illness unless there is reason to believe that a mental illness is involved. "Psychiatrists have to appreciate our discipline for the serious science that it is," Welner said. "We have that expertise, in certain respects and within certain limits, to contribute whether it is appreciating the qualities of the behavior that we are seeing or whether it is assisting the public to come to terms with the chaos that is visited. If we aren't qualified, then what did we go to train for all these years?"

Dorothy Otnow-Lewis, M.D., a psychiatrist with academic appointments at both New York University School of Medicine and the Child Study Center at Yale University School of Medicine, has studied serial killers for more than two decades. It was her comment in the New York Times that NAMI criticized in its news alert. In an Oct. 10, 2002, article, the paper reported that Otnow-Lewis said, "The sniper's claim to be God struck her as 'clearly psychotic, very out of touch with reality.'" In addition, she opined, "He may be highly manic and 'getting more delusional and more revved up' with each execution."

However, Otnow-Lewis, in an interview with PT, pointed to a Nov. 4, 2002, Newsweek article that referred to her as "one of the few talking heads to get it right during the long sniper siege." She insisted that her comments were appropriate and based upon her years of experience.

"It would be dangerous and improper to make a diagnosis without having evaluated the person," Otnow-Lewis explained. When asked about whether there is any evidence of severe mental illness, she referred to her experience and confirmed that--from her viewpoint--those who go on periodic rampages may suffer from episodic psychosis.

As for the sniper situation, Otnow-Lewis acknowledged having said, "if he really did write on that tarot card 'I am God,' ... this is consistent with a delusional man and delusions are psychotic symptoms. ... And so I did say that if indeed he had written that, and if indeed he believed it, that he was delusional."

As for whether the profession is compromised by these opinions, Otnow-Lewis denied that there are dangers. "I think a lot of people talk off the top of their heads without having had any experience with this and sort of parrot the descriptions of 'sociopaths' that are contained in textbooks," Otnow-Lewis told PT. "They talk, never having seen many, many serial killers, and I think that is really unwise."

It is unlikely the controversy over talking heads will result in any changes to professional or ethical rules, according to APA's Graff. The "Goldwater" rule already proscribes specific comments about public figures or others who have not actually been evaluated. So people will continue to comment.

"It's hard enough to construct a therapeutic intervention with a patient who you know well and [who] you have in your office and [who] you've been treating," Appelbaum said. "To try to do it for somebody who you don't know, whose motives are obscure to you and whose reaction you can't predict is a fool's task."