In Search of Motives

This post really needs no introduction. Dr. Miller disagreed with a lot in my introduction and Dr. Ostacher’s recent piece about seeking motives for senseless acts of violence. Obviously, we at Sensible Medicine love to post well-reasoned responses to our articles. This is a great one.

Adam Cifu

In The Futile Quest for ‘Why’, Dr. Michael Ostacher talks about the issue of motive in murder of the United Healthcare CEO, Brian Thompson. Dr. Ostacher makes the point that humans are complex and so are their motives, and as such, we shouldn’t look to people to explain why they’ve done what they’ve done. “It is especially absurd (usually unproductive and, in some cases, dangerous) to find in a killer any kind of motivation,” Dr. Ostacher writes.

Humans are indeed complex and, as the writer points out, we don’t always know why we do what we do. To top that off, individuals vary tremendously with regard to how much insight they have. It is human nature to want to know why someone does something heinous, and if the perpetrator is alive to answer questions, I would contend that we certainly can learn something from their explanation of their behavior. We think about a crime one way if a person killed because they were defending themselves from a real and obvious threat to their life -- in which case they have committed no crime. This is different than if they were defending themselves from a delusional enemy. And murder is a completely different act if done for reasons of anger, jealousy, revenge, hatred, or ideology. The legal system creates consequences based on motives; one can be acquitted, sent to a hospital for treatment, sent to a correctional facility for varying lengths of time or, depending on the state, sentenced to death. This is often based on the motive, the forethought, and the intention behind the crime. It sounds important to me.

When we hear that there has been a mass shooting (for example), we often go down one of two paths: It is a gun problem and so we need more gun control legislation, or it's a mental health problem, and if only we could force people to get psychiatric care, then these things wouldn't happen. We don't have a great definition for what it means to be mentally ill; our Diagnostic and Statistical Manual has hundreds of diagnoses that one "meets criteria" for by having specific constellations of symptoms. It is not a simple as saying that one must be ‘crazy’ to have done such a crazy thing, and we gain nothing by blending Mad and Bad into a single entity, or by assuming that one can’t be both.

Psychiatric disorders are very common. Half of all people will have an episode of a psychiatric condition during their lives, and 1 in 5 will suffer from a mental disorder in any 6 month period. There is no psychiatric disorder where “homicide” or “gun violence” are a symptom, or a direct result of an illness, and saying "it's a mental health issue" really tells us nothing. Mental illness is common but mass shootings are not, even among people who have paranoid delusions or command hallucinations. For most people, these phenomena are terribly distressing and there is no temptation to act on deeply disturbing symptoms. What we do know is that acts of violence are associated with intoxication and with childhood exposure to violence — and these risk factors may also co-exist with (or cause) mental illness.

More recently, we've added a third explanation for these horrific acts: terrorism. Again, this is something that we once had a definition for -- it was once used to describe mass murders done for (mostly) religious and political motives, it has now been broadened to include acts of domestic terrorism, hate, and ideology.

So far there is little to know about the killing of the United Healthcare CEO -- we can assume there is much more to the story. The ghost gun weapon will add a new dimension to our discussions of gun control, and so far, the public has made the presumption that this is a crime of ideology, one that some people support and feel is a valid reason for violence. What we do know is that this killer does not fit a mold –- from what we have heard so far, he was not bullied or a loner, and it appears he was well-liked and accepted. From the outside, it seems he had so much -- intelligence, education, wealth, popularity -- the things we think might protect against criminal behavior.

We ask Why because we are curious. We ask Why because it alters the consequences. And finally, we ask Why with the hope of understanding and preventing. To say there is no point because a killer is "crazy" or a killer simply can't know their own motivation simply stifles the conversation before it even begins.

Of note: I have purposely omitted the name of the alleged killer.

Dinah Miller, M.D. is a psychiatrist and writer in Baltimore and is co-author of Committed: The Battle Over Involuntary Psychiatric Care ( Johns Hopkins University Press, 2016).

Photo Credit: Smart