Troubled Adolescents Need a Double Safety Net
The Senate's vote in favor of stricter gun-control measures, cast in
the shadow of another school shooting, is a milestone on the road to
decreasing the use of guns by discouraged and alienated adolescents to
impulsively act out anger. It is a reasonable inference that having less
access to guns will decrease apparently spur-of-the-moment rejection
and rage shootings such as the most recent one in Georgia. But it is
only the beginning. The next two steps include mending our managed-care-torn
safety net for at risk adolescents and a commitment to violence prevention
programs in our schools.
The current bill alone will not prevent well planned, premeditated attacks,
such as those in Littleton, Colorado last month, apparently spearheaded
by a teenager with a history of being medicated for obsessive-compulsive
disorder. Other aspects of the bill, which call for heavier penalties
against young criminals, would not even touch the lives of youths such
as the depressed young man arrested in the Georgia shooting--he apparently
had no criminal record and seemed, by most accounts, to be a "regular
kid" from a nice neighborhood. One needed next step is legislation
to remove the increasing restrictions by all too many managed care organizations
on the clinical care of seriously ill adolescents.
Parents and clinicians need to have the freedom to consider inpatient
hospital treatment for severely distraught adolescents, where depression,
Attention Deficit Disorder, or Obsessive-Compulsive Disorder may be precursors
to, or may mask psychosis, the loss of boundary between fantasy and reality.
Some adolescents could be helped by inpatient hospitalizations, which
give clinicians the opportunity to observe the youth while finding the
best combinations of medication and therapy. But currently, clinicians
and patients' families' ability to access inpatient care is severely
limited by managed care organizations. Their restrictions include near
automatic rejection of requests for long term inpatient treatment, a
Kafkaesque appeals process, and sometimes clinically irrelevant decision
criteria designed to insulate the managed care organization from liability
while denying inpatient care, burdensome documentation requirements.
Some clinicians who recommend "too many" hospitalizations have
been retaliated against, through chart audits and by being dropped from
plans through "economic deselection." And while managed care
companies no longer contractually impose gag clauses that would prevent
clinicians from talking about the limits of a patient's insurance coverage,
the roadblocks most companies have erected have left patients with the
similar inability to follow through on the best choices for them.
Other at-risk adolescents could benefit from a combination of long-term
outpatient counseling and medication. But health maintenance organizations
routinely limit therapeutic visits to doctors, in favor of 15-minute
medication management sessions. These short visits often prevent providers
from being able to treat, or even discern, the complex layers of mental
illness. For example, Depression or Obsessive Compulsive Disorder may
mask or become complicated by another major mental illness. Depression
may deepen into psychosis, or can be an early symptom of a Schizoaffective
Disorder with both depressive and paranoid features. Adolescents are
more likely than other patients to conceal their psychoses -- experiences
where the line between reality and fantasy is erased -- because they
are especially vulnerable to feelings of shame, pessimism and suspicion
of authority. Without the safety net provided by a therapeutic community,
or as a minimum, intensive individual, family and group psychotherapy
coordinated by highly trained mental health professionals, the adolescent
prone to violence is more likely to resort to it, as the only solution
to their unbearable shame and rage.
Adolescent psychosis driven violence is most likely to be self-directed,
and can take the form of risk taking behavior and suicide. But it can
also mix with social reality to create a volatile solution readily sparked
into violence by loss or humiliation. The Georgia 15-year-old who shot
six of his classmates had recently broken up with his girlfriend. The
two Colorado teenagers who killed 13 people, and then themselves, had
become obsessed with symbols violence and hate -- including Hitler --
after they came to believe they had been made outcasts by athletically
inclined classmates. Most adults who suffer disappointments of a similar
scale know that life goes on. Most adolescents don't. If you think this
is merely the result of the media or video games, take a look at one
of the most famous works about teenagers -- Romeo and Juliet --written
before "adolescence" was even a concept! The play takes us
down a steep slippery slope of social conflict in the context of a factional
dispute, all too common in adolescence. What begins as a sleight, plunges
the participants towards a killing, and ends in a double suicide.
Suicide is the third leading cause of death for teenagers aged fifteen
to nineteen in the United States. However, there is even good reason
to believe that among adolescents, it may actually be the leading cause
of death. The links between major mental illness, substance abuse, psychosis,
suicide and homicide are real, but are often neglected in today's depleted
clinical landscape. For example, depression can lead to substance abuse
combined with other risky behavior -- such as drunk driving. So some
fatalities stemming from drunk driving accidents can actually be part
of the deadly toll of "accidental suicide."
As a second step for preventing adolescent suicide, violence and "accidental
suicide," funding is needed to provide retraining for teachers and
educators to respond appropriately to signs of teenage distress. Many
such early warning signs are reported to have been present prior to the
Littleton killings. When teenagers greet each other with "Heil Hitler" salutes
in the hallways -- as they openly did in Columbine High School, educators
have the responsibility and need the training to consider that identification
with Hitler is a red flag. The boundary between private fantasy (feeling
mortified by a rejection as in "I could have just died", "I
could have killed him"), and social reality (suicide and homicide
attempts), is never altogether fixed and is especially fluid in adolescence.
Major mental illness can erode the already porous adolescent boundaries
between reality and fantasy. To rely on such boundaries and dismiss "Heil
Hitler" salutes as "a phase" that will "go away if
you ignore it" is a misconception. At a minimum, educators should
identify behaviors which can be indications of adolescents at risk, and
communicate their concerns to parents. Schools could hire trained counselors
who would assist teachers, parents and teenagers by offering therapy
and making referrals. Moreover, educators should watch for the emergence
of school factions, gangs, and cults. In Littleton, the Nazi-Gothic cult
used Hitler's birthday as a target date to retaliate against the perceived
slights and attacks by another, so called "jock" faction. There
are now a variety of age-appropriate programs, curricula, and educational
materials designed to counter ideological distortions of history (which
have made Hitler a hero to some) with real history, and which teach tolerance
and conflict resolution. What is now needed is the political will to
make mental health resources become genuinely accessible to those too
ashamed, too frightened or too pessimistic to surmount the very real
barriers to accessing care within our schools and our communities.
Harold Bursztajn, M.D. is a Director of the Program in Psychiatry & Law
at Harvard Medical School. As a psychoanalyst in Cambridge he provides
intensive treatment for adolescents and as a forensic psychiatrist consults
nationally to courts, schools, and organizations on violence prevention
and public safety. Irene Coletsos is a counselor in Boston with a long
standing interest in the health care problems of the mentally ill and
the homeless.