Afterword to ‘Every Last Tie’

Lying on my analyst’s couch, I was neurotic and complaining. It was 1998 and I was in the last year of my psychiatry residency. My neurosis was surging because I had recently been offered the opportunity for advanced training in forensic psychiatry by an intimidating living legend in the field: Phillip J. Resnick, md. Resnick’s forensic psychiatry training program was renowned for its rigor, intensity, and ego-annihilating tests of one’s abilities. I knew that entering into the world of a forensic expert whose list of cases reads like a highlight reel of American criminal justice would irrevocably alter my life.[1] It was one of those rare moments that one is aware of standing on the precipice of a major life change.

At the time of my analytic kvetching, Dr. Resnick was hard at work examining innumerable boxes of records and journals of a man known to most only as the Unabomber. Resnick had been retained by prosecutors who were anticipating that Ted Kaczynski would raise a mental health defense. What may not have been anticipated was the strength of Ted Kaczynski’s commitment to his ideals and his abhorrence to being labeled mentally ill. So strong was this opposition that he preferred the death penalty over allowing his defense attorneys to present mental health evidence.[2] Not only did he not believe he was mentally ill; more importantly, he did not want his philosophical ideals and opinions to be compromised or dismissed as the product of an unsound mind. After much difficult deliberation by the judge, attorneys, and Ted Kaczynski, the trial was preempted by a guilty plea that allowed him to avoid the death penalty.

My apprenticeship with Dr. Resnick began as he was wrapping up his work on the Unabomber case. Certainly I had heard of Ted Kaczynski already through the media, but I would come to learn much more about him during my time with Dr. Resnick. His teachings and commentary on the Unabomber case were factual and nonjudgmental and sought to truly understand him through a humanistic, albeit forensic psychiatric, lens. In addition to the forensic and psychiatric nuances, Resnick keenly perceived Ted Kaczynski’s inner desire for an emotional connection and a meaningful intimate relationship. It was this last point that stuck with me. It was simply a fact per the forensic data, and ultimately it burrowed into my psyche. I was left with an enhanced understanding of the poignancy of the human need for attachment, regardless of the choices we make and the harm we cause each other.

Attachment as a complex concept used by mental health professionals should be distinguished from its connotation in Buddhism. Buddhist psychology has begun to influence Western approaches to mental health in the form of mindfulness therapy. However, Buddhism is a 2,500-year-old tradition that has been famously described as coming to the West via the science of psychology.[3] In the Buddhist tradition, attachment (synonymous with desire, greed, craving, envy) is considered one of the “three poisons”—along with aversion (hatred, anger) and ignorance (distraction, self-deception, delusion).

From the time Homo sapiens first developed conscious self-awareness, “these primal motives have been at the root of all misery.”[4] Indeed, they are at work not only in individual minds, but also as ideologies motivating larger social systems.[5] The three poisons may be more clearly understood and then transcended through meditation, psychotherapy, and other compassionate mind-training techniques.

In a psychological context, attachment theory focuses on the dynamics of interpersonal relationships and on how we are profoundly influenced by caregivers during infancy. In this sense, attachment is not only a good thing, but crucial to one’s social and emotional development. A child requires a loving, reliable caregiver for healthy development. The work of John Bowlby and others on early attachment revolutionized how hospitals handled maternal-infant bonding immediately after birth. As a result, from the 1960s onward, hospitals have taken a more thoughtful approach to preventing childhood hospital trauma.[6] In my work with incarcerated individuals, a disruption in healthy attachment during childhood is a very common theme. Of course, mental health professionals understand that disorders resulting from impaired attachment are also determined by heredity and social factors that cannot be easily teased apart. In truth, this describes many phenomena in psychiatry, which is to be expected when dealing with the most complex and mystifying organ in the human body. Compared to other fields of medicine, psychiatry is relatively new, and despite impressive progress over the past several decades, there remain large scientific gaps wherein confusion may flourish. One misunderstood form of emotional suffering recognized in psychiatry has been called the schizoid personality. Mental health professionals are sometimes taught that such individuals are cold, aloof, and uninterested in relationships. This is a misunderstanding. It is not people that they avoid, but emotional intimacy, which they experience as intrusive, controlling, and at times even persecutory.[7]

Let us use the example of schizoid personality to call attention to the complexity and intensity of emotional suffering that so often goes overlooked due to our insistence that “legitimate” mental turmoil can only mean a complete loss of contact with reality. Here I invite the reader to employ “forensic empathy”—the technique of putting oneself fully and nonjudgmentally inside the mind of the subject. Consider the inner pain of the schizoid individual. He or she is trapped in an excruciating dilemma of sensitivity and hunger for meaningful intimacy versus a fear of humiliation and exploitation by other’s emotions. Social engagement is desperately needed, yet this desire is threatening and panic-inducing. Such individuals inevitably choose the only “reasonable” route available—isolation and inwardness. This type of suffering can be seen in ordinary persons, as well as intensely private intellectual and artistic geniuses such as Samuel Beckett, J. D. Salinger, and Franz Kafka.[8] It is a path that, followed too intently, leads to so much distance and inaccessibility that there can be no external checks on one’s well-being.

The life mission of the individual laboring under a schizoid mindset is essentially carried out in a secluded isolation chamber, where the only self-validation is the echo of inner struggles. There may come a point where the only way out appears to be deeper isolation. This produces crippling loneliness and enhanced reliance on one’s imagination—both of which must be paradoxically denigrated as signs of weakness, since they threaten one’s illusion of absolute self-sufficiency and total logic. One becomes an enemy of one’s self, yet needs this self for survival. It is an endgame with absolute zero on the horizon. All positive emotions and connections are extinguished, and the only thing to cling to in the face of an impending apocalypse is fidelity to one’s ideals. Despite all uncompromising, dogged efforts to achieve a secure and safe haven, the outside world and reality will make itself known in due course. When it does, it will be felt as an intolerable invasion of one’s sanctuary. In the throes of agonizing emotional deprivation, one may grasp for help from a last vestige of trust—one’s family. Yet when family can neither comprehend the intensity of one’s struggle, nor feel at ease with the presence of threatening inner torment, one must shut them out too while reeling from the sting of betrayal. One is then trapped with no escape, a fearful animal in a corner. At this point a preemptive strike becomes a rational strategy. If only someone would notice your fear and pain, lift you out of captivity and let you back into the wild, where at least you can continue searching the wilderness for sanctuary and freedom!

The New Asylums

Several years after my training with Dr. Resnick, I took the position of director of psychiatric services for the entire New Hampshire state prison system. I quickly found myself awash in human tragedy. Although I was initially motivated to study violence, I was overpowered by the suffering, despair, and tragic circumstances I encountered on a daily basis. One option for dealing with this was to form a hard callus over one’s emotions and empathic capacity. But having been exposed to Buddhist psychology and my own personal psychoanalysis, I found myself unable to seriously consider this route. The only avenue open to me was staring more deeply into the suffering while attempting to make sense of it.

While I had the resources, finances, and professional connections to enjoy the services of a private, highly trained psychoanalyst, I was in the fortunate and privileged minority. Tragically, we have not had a functional mental health system in the United States for the past fifty years. No one bothered to create one that would survive deinstitutionalization. The number of mentally ill persons in jails and prisons began growing in the early 1970s as a result of what some have called “deinstitutionalization,” which involved massive shutdowns of state hospitals. Correctional facilities then began to house persons with mental illness in record numbers, a phenomenon that came to be known as the “criminalization of the mentally ill.”[9] Research conducted over the last several decades clearly shows that the rate of severe mental illness in corrections is four to eight times higher than in the general population.[10] Yet only 22 percent of state prisoners and 7 percent of jail inmates receive psychiatric treatment while incarcerated.[11] Correctional administrators have long recognized that their facilities are being used as dumping grounds for those better served through early psychiatric intervention—but the resources are simply not available. To be sure, there are those in prison whose mental illness is merely coincidental to their criminal behavior, just as there are those whose cardiovascular disease is coincidental to their decision to commit a crime.[12] But the sheer numbers of persons with serious mental illness in corrections as compared to the general population cannot be explained by so facile a theory as the mad/bad dichotomy, thus the situation demands a closer analysis.

States have continued to cut funding for mental health care, and more than 80 percent of states have fewer than the bare minimum number of psychiatric beds.[13] The incarceration of large numbers of mentally ill persons has led to the challenge of providing competent psychiatric care within facilities that are oriented primarily toward security and custodial care. In Virginia, jails house more persons with serious mental illness than Virginia psychiatric hospitals do.[14] The Los Angeles correctional system has been referred to as America’s largest psychiatric facility.[15] The same can now be said for Chicago, and even the city where I now live—Syracuse. The disturbing reality is that American jails are now the primary venue for providing acute psychiatric inpatient treatment.[16] Caring for seriously mentally ill persons in corrections places a significant financial burden on state government and is a poor long-term financial strategy.[17] Nevertheless, until adequate community resources, additional psychiatric beds, and innovative alternatives are established, mental health services in corrections will remain a pressing and obligatory duty. How is the duty ensured? Presently, through costly and time consuming litigation.[18]

Inside U.S. jails and prisons, the mental health system is being “recreated,” at substantial cost and effort, to treat the burgeoning number of seriously mentally ill persons. To date, there is no legal mechanism that serves to substantively reduce the number of persons with mental illness from entering the correctional system. By contrast, law enforcement agencies are armed with broad, often unreviewable, discretion in determining the destination (jail versus hospital) of arrestees suffering from mental illness. Laudable efforts have been made to divert seriously mentally ill persons away from corrections (e.g., jail diversion and mental health courts), yet their effectiveness is unclear, and they cannot keep pace. At present the trend shows no signs of reversing itself.

Over a decade ago, an American Psychiatric Association president put it about as plainly as one can: “A reasonable person could not fail to see the correlation among decreased funding for mental health resources, the closure of hospital beds, and homelessness and criminalization.”[19] “Transinstitutionalization,” the shift from mental health services to prison spending, has been the subject of academic and public discourse for quite a few decades. The theory underlying transinstitutionalization was published over seventy years ago. According to Penrose’s Law (circa 1939), there will be a relatively stable number of persons confined in prisons and mental hospitals in any industrialized society.[20] If the population of one is reduced, the other will increase to compensate—sort of like squeezing a balloon on one end and having the other end get bigger. It appears that Penrose’s Law is still applicable, and not just in the United States: other countries too are finding that as the number of psychiatric hospital beds is reduced, the number of people in prison rises.

In my role as a psychiatrist treating patients in the correctional and forensic system, I have witnessed innumerable tragedies resulting from our nonsystem of mental health: unnecessary deaths, suicides, and many thousands suffering from mental illness who found themselves called “inmate-patients” in the “New Asylums.”[21] Looking deeper into this chasm, one finds another, even more unsettling trend. The relegation of psychiatry to the criminal justice system is not confined to adult mental health. Child psychiatrists now find themselves wondering whether “the national crisis in child community mental health services” is “contributing to delinquency and causing the juvenile justice system to become the dumping ground for youth who are inadequately served.”[22] What makes this trend so disturbing (besides the loss of important youth mental health resources) is that it is occurring at a time when the juvenile justice system is losing its rehabilitative focus and becoming more punitive.

Stepping back and taking stock, it becomes difficult to escape the conclusion that society equates mental illness with criminality, danger, and violence. But even if one were to assume a direct association between violence against others and serious mental illness, the overall contribution of severely mentally ill persons to violent crimes is only about 3 percent.[23] When gun violence is considered, the percentage drops even lower. Further, in the absence of substance abuse, there is no significant relationship at all between psychiatric disorders and firearm violence.[24] Research in behavioral science has progressed to the point that we have a much better grasp of the clinical risk factors associated with violence and how to manage them. Such concerning risk factors are present in a small fraction of persons with serious mental illness, and they include acute psychosis, noncompliance with treatment, substance use, past violent behavior, and persecutory delusions.[25] But focusing broadly on all persons with mental illness as a “risky” population can be analogized to the unwarranted panic observed after 9–11, when anyone of Middle Eastern ancestry was viewed with heightened suspicion. It is not only a form of hysteria, but also slows progress in the treatment of mental illness by keeping it hidden and stigmatized.

The term “stigma” is synonymous with shame, disgrace, and humiliation. To stigmatize means to brand, slur, or defame. The term was rediscovered to an extent in the 1960s by famed sociologist Irving Goffman, who noted that “stigma is a process by which the reaction of others spoils normal identity [emphasis added].”[26] Thus, a social stigma, at its core, is the spoiling of the identity of certain persons, resulting in their alienated, exiled status. A powerful literary example of this is seen in Kafka’s famous story “The Metamorphosis,” which explores not only alienation, but also the profound betrayal that accompanies it. The main character, Gregor, wakes up one morning to discover that he has turned into a “monstrous vermin.” The analogies with mental illness in the story are notable. Even Gregor’s own family responds to him with horror and shuns him. Gregor’s existence is transformed into an exercise of tolerating fear, isolation, and betrayal. At one point, his boss has an instinctive reaction on seeing Gregor: “His hand pressed over his open mouth, slowly backing away, as if repulsed by an invisible, unrelenting force.”[27] His family shuts him away in a room, forgets him, and leaves him to die. Why, after so many years, do we continue to stigmatize mental illness? Part of the reason is deeply historical in its roots. The primitive notion that evil and mental illness are overlapping, related phenomena has been consistently perpetuated by the media and Hollywood movies. The ancient belief that evil is somehow involved in the origin of mental disease lingers in the shadows, and awaits resurrection in the wake of rare, horrific tragedies.

One such example of a rare, horrific tragedy occurred on December 14, 2012, when twenty-year-old Adam Lanza shot and killed his mother, then went on to shoot twenty children and six adults at the Sandy Hook Elementary school. Lanza then committed suicide by shooting himself. Shortly after the Sandy Hook tragedy, a senator announced that he supported measures to keep guns “out of the hands of criminals and the mentally ill.”[28] This was followed by a national press conference in which the National Rifle Association vice president stated that “our society is populated by an unknown number of genuine monsters. People that are so deranged, so evil, so possessed by voices and driven by demons, that no sane person can even possibly comprehend them. How can we possibly even guess how many, given our nation’s refusal to create an active national database of the mentally ill?” [[29] Such statements, widely disseminated by the media, merely reinforce the presumptive association between “criminals,” “evil,” and “the mentally ill.” The sad and sobering fact is that the misguided association needs no further reinforcement. Research has clearly shown that there remains a strong stereotype of dangerousness and desire for social distance from those suffering from mental illness.[30] And somehow the irrationality has increased over time. A comparison of the research from 1950 and 1996 showed that perceptions of persons with mental illness as violent or frightening have not decreased; rather, they have substantially increased. In short, persons with serious mental illness are more feared today than they were half a century ago.[31]

Where is the outrage? Why isn’t resolving the problem of criminalizing persons with mental illness the top priority of the American Psychiatric Association? (I suspect it is hidden behind a wall of emotional and political suppression, since immersing oneself in the U.S. correctional system is more than most can tolerate.)[32] The research results allow us to make some general assumptions about society’s current beliefs about mental illness.[33] The beliefs may be paraphrased as follows: People with mental illness are dangerous and unpredictable, and People with mental illness are not welcome in free society.[34] It becomes hard to escape the conclusion, as suggested by the research on public beliefs, that society’s primary motivation is to achieve social distance from individuals with serious mental illness. But where to banish unwanted persons? The “asylums” of a bygone era, now closed or demolished, are no longer a viable option. The remaining options would appear to be banishment to the streets (homelessness) and correctional institutions. We have reached an age in which we no longer see it as acceptable to execute persons with intellectual disabilities.[35] Thus one hopes that we might be proceeding toward an era in which this enlightenment may extend to declining to use prisons as our de facto mental health system.

Creation of a legitimate mental health system will take place incrementally based on our efforts, or not at all based on our complacency.

Moreover, no change will come without more reliable and effective treatments for psychiatric disorders. The indistinct shadows concealing mental illness must be dissolved by the light of demonstrable, as well as practical medical science. Only then will there be hope for reducing societal stigma, fear, and unseemly projections. Only then will mental illness be taken as the serious public health issue that it is. And only then will it be removed from the places where we send people for punishment, and returned to the healing attendance of the mental health profession.

Modern Mass Shootings and Mass Distraction

Lately mass shootings continue to stir the debate about mental illness and violence. Despite enhanced media coverage, mass shootings by people with serious mental illness remain exceedingly rare events and represent a fraction of a percent of all yearly gun-related homicides. This should be contrasted to firearm deaths by suicide, which account for the majority of yearly gun-related deaths. The most recent research suggests that although the incidence may be increasing in recent years, there is an average of only 11.4 mass shooting incidents per year,[36] making these tragedies exceptionally hard to anticipate and avert.[37] The problem of mass shootings and the motives of the shooters in present-day society stand apart from mental illness generally. The recent phenomenon of mass shootings in the United States results from a combination of factors, including sociocultural ones that must be understood clearly if these rare and horrific tragedies are to be prevented. Investigating sociocultural factors in Western society requires considering the issues of narcissism and media responsibility. Narcissism may be considered the classic American pathology, but there is concern that it may be proliferating “virally” and gaining momentum.[38] Is the changing character of mass shootings over the past few decades the product, in part, of our increasingly narcissistic values?

In The Narcissism Epidemic, Twenge and Campbell note that while crime has dropped overall since the 1990s due to a variety of factors, crimes related to narcissism (or a wounded ego) are directly relevant to mass shootings. Harvard psychologist Steven Pinker laid out an impressive overview of how violence among Homo sapiens has greatly declined over the centuries due to a “civilizing process.”[39] Pinker now wonders if we might have reached a point of limited returns. The harder-to-achieve gains may arguably lie in the realm of attenuating the problem of narcissism. Twenge and Campbell note that “narcissism and social rejection were two risk factors that worked together to cause aggressive behavior,” and these have certainly been described in the histories of mass shooters.[40] They conclude, “Given the upswing in the narcissistic values of American culture since the 90s, it may be no coincidence” that mass shootings became a prominent concern around this time.

I have often wondered whether extensive media attention in the ’90s may have propagated a Western “script,” resulting in a perverse glamorization of the act—particularly in the eyes of subsequent perpetrators.[41] Consider the highly popular song “Jeremy” by the American rock band Pearl Jam, released in 1991. It reached the top five on Billboard charts, is still heard regularly on radio stations, and was inspired by a high school student who killed himself in front of his classmates. Like most popular songs of an age, it is simply a reflection of sentiments prevalent at the time: “Clearly I remember / Pickin’ on the boy ... But we unleashed a lion ... Jeremy spoke in class today ... Try to forget this, / Try to erase this / From the blackboard.”

The study of individual cases of mass shootings that have occurred since the ’90s suggest that perpetrators often felt socially rejected, and perceived society as continually denouncing them as unnecessary, ineffectual, and pathetic. To use a schoolyard metaphor, they are the kid always picked last for the sports team. Instead of bearing the burden of the humiliation in the multitude of ways that schoolchildren do, they plan a surprise attack to prove their hidden “value.” They become martyrs of the excommunicated—too egotistic to surrender to and benefit from what they cannot accept about themselves. The very public, dramatic, and perhaps theatrical nature of mass murder seems to speak clearly to a “need for recognition from an audience.”[42] The staged and exposed act of revenge has the function of establishing a connection with spectators who will not soon forget what they have seen. Western culture has constructed a vast and powerfully influential religion devoted to celebrity and fame. We now hold celebrity up as the single greatest achievement in life—one that should be attained at all costs. In place of what should be profound shame, there appears to be an aura of undeserved notoriety and infamy accorded to certain individuals who proclaim by deed: “I carry profound hurt—I’ll go ballistic and transfer it onto you.” News media have always been in the business of searching for “the right sort of madness” to capture the public’s imagination.[43] This may involve exploiting violent and tragic acts and/or overemphasizing the alleged role of serious mental illness. The end result is that these tragedies can now “be evoked from the nation’s collective memory in a word or two”—“Columbine” or “Virginia Tech.”[44]

This Western cultural script is more clearly seen as a violent death parade celebrating infamy, in a bid for what Western culture prizes the most—celebrity by any means necessary. These sociocultural factors have been significantly amplified by the Internet and social media. The use of YouTube and other Internet platforms represents an attractive stage and sanctuary for individuals trapped by their conflicting needs for social attachment. Will the isolating virtual socialization of the Internet serve to worsen matters or ultimately provide a solution? For alienated, angry, vengeful individuals, their future and the future of their victims hang in the balance. Yet I have some fear that the Internet’s virtual connectedness will only perpetuate the alienated loner’s conflict: his wish for social connection versus his deep-seated mistrust. The pretense of genuine connections can be sustained well into young adulthood, leaving the individual without real experience in developing healthy social attachments. Such individuals will eventually awaken to the reality of their isolation. This will lead to feelings of being unwanted. And as Christian Schüle has written, “whoever is not needed is not a full member of society. Whoever feels this could run amok. In his blind rage at a wasted life, a person running amok sensationally highlights a functionally civilized society’s most extreme recourse to its archetypal reflexes: in the martial pose of the victor, the individual takes revenge for the community’s apparent failure to devote attention to him and acknowledge his self-worth.”[45]

The final written communication of a recent mass shooter from California is entirely consistent with this pattern of alienation and malignant envy—culminating in a violent bid for fame and validation: “Humanity has rejected me. Exacting my Retribution is my way of proving my true worth to the world.”[46]

Kindling a Light

As far as we can discern, the sole purpose of human existence is to kindle a light in the darkness of mere being.

—Carl Jung, Memories, Dreams, Reflections

I first met David in 2012, when I served as program chair for the Forty-Third Annual Meeting of the American Academy of Psychiatry and the Law (aaPL). I was in a position to recommend any keynote speaker I chose. A former trainee of mine had seen David Kaczynski speak and highly recommended him. David seemed like an excellent choice to me, not only because of all he had been through, but also because of all he had done for others. (I later learned about his countless speaking engagements advocating for improved mental health treatment, his anti–death penalty work and having helped run a shelter for runaway youth.) But in truth, I suppose my path to meeting David began much earlier, as a boy who was often preoccupied with violence and death.

When I was a boy about ten years old, I saw something that would stick in my memory for the rest of my life. It was a Time magazine cover. At the center was a large vat of Kool-Aid. Surrounding the vat were some nine hundred dead bodies. I’m not sure if it was that I was unable to process what it meant, or perhaps that I could process it only too well—the mind of a child is so open and honest. Regardless, I fixated on it. Later my schoolteacher gave us the assignment of writing a short story. While other children were writing stories about sports figures or the family pet, I was busy crafting an attempt to fathom something dreadful. In my story, I was a Jonestown member who managed to escape by feigning death. I can only speculate on my teacher’s reaction to my work. If it signaled the need for a concerned parent-teacher conference, I was not included. Retrospectively, I am inclined to wonder whether this was an early warning sign that I might become a forensic psychiatrist. (About twenty years later, I would interview and become friends with one of the few living survivors of the Jonestown tragedy, who then lectured with me at a national conference.)[47] Since then, I always carried with me a teasing, mocking question: Can you find the beauty in absolute ugliness?

Much of my career—as a physician and later as a forensic psychiatrist—has been focused on similar themes: violence and death have been a daily focus of my concern. I come from two generations of physicians, and my family lost several patriarchs at an early age—one from mental illness and suicide. An ancient Zen Buddhist–influenced text advises that “meditation on inevitable death should be performed daily.”[48] After my mother died at an early age from progressive multiple sclerosis, I found that meditation on death became an unavoidable condition. Through psychotherapy, meditation, and assistance from those wiser than me, insights came over time. I believe my family chose a field that concerns itself with trying to see death coming, prepare for it, and, if possible, stave it off. But of course, this is an illusion. Having discovered this, I shifted my focus to the ways in which our denial of death creates virtually all of our suffering.[49][50][51] I chose to go into the medical discipline that deals with the mind. Since Buddhists have been studying the mind for some twenty-five hundred years, its philosophy and psychology have much to offer. Through the study of both psychiatry and Buddhism, it became apparent to me that two of the mind’s greatest foes are fear and a powerful pull to value one’s self, even at the expense of peace and gratitude.

In 2012, I readied myself to introduce David’s talk at aaPL in front of the country’s leading forensic psychiatrists. At what is usually a stiff, formal setting, I immediately felt a sense of calm sincerity and kindness on meeting David. When the time came for me to introduce David, I set aside my prepared introduction and spoke from the heart. I introduced him as a “humanitarian, poet, and Buddhist.” After David’s talk and the extended standing ovation that followed, many colleagues approached me to say it was the best talk they had ever heard at aaPL. Another pulled me aside to tell me: “He radiates compassion.”

A Trip to Sandy Hook

I was pleasantly surprised by a thoughtful series of e-mail exchanges with David in November 2012. On December 14, 2012, and the days that followed, I was busy avoiding news media requests and keeping my children from watching the nonstop coverage out of Newtown, Connecticut. Then David contacted me again to see if I would be interested in joining him and two Buddhist teachers to speak as a part of the Sandy Hook Promise. I agreed without a moment’s hesitation. Part of the mission of the Sandy Hook Promise is to have an open dialogue on all the relevant issues, a dialogue that includes various and opposing views. David had been invited by Sandy Hook Promise leaders to give a presentation titled “Violence, Loss and Emotional Healing: A Buddhist Perspective.”[52]

The goal of our presentation was to explore the commonalities of mindfulness, Buddhism, and psychiatry as they applied to healing after severe trauma. I viewed my role as primarily to support, listen, and provide some basic information about “psychiatric first aid” in the immediate wake of mass trauma. Both expert consensus and common sense suggest that community support improves well-being in the wake of a mass tragedy, and the formation of the Sandy Hook Promise plainly suggested that this community understood what they needed to do.[53] I spoke about how mass trauma survivors appear to cope early on by cultivating (1) a sense of safety, (2) a sense of calm, (3) a sense of personal and community efficacy, (4) feelings of social connectedness, and (5) a realistic sense of optimism.

Indeed, these key coping efforts had been demonstrated by the Norwegian community not even a year and a half before the Sandy Hook tragedy. On July 22, 2011, Norway experienced immeasurable loss and trauma when a lone, angry individual named Anders Behring Breivik killed over seventy innocent people in a meticulously planned attack. Many of the victims were young teenagers attending a Youth League event. Immediately afterward, there was a remarkable and courageous response, much like that of Newtown.[54] The posttragedy reflections of the medical first responders were focused on collective responses of “strong engagement and feelings of togetherness.”[55] It was very important to them at the time “to be compassionate and caring,” in addition to enduring “the pain of others, without having a solution.”[56] The Norwegian psychiatric professionals understood clearly how to assist with the early signs of acute stress and unbearable grief. In particular, they knew that one of their most valuable contributions would be “to listen,” and help survivors “find new strength and meaning in a changed life.”[57]

Several years after the mass tragedy in Norway, I would have the chance to study and lecture with the Norwegian forensic psychiatrist who performed the second forensic evaluation of the perpetrator, finding that he did not meet the Norwegian standards for the insanity defense.[58] It was a unique opportunity to study the mind of a mass murderer who lived after the incident, since many intend to die after carrying out the massacre. Breivik had published his own “manifesto,” revealing his motivations as anti-Muslim and hoping to incite a revolt against multiculturalism. His writing of over fifteen hundred pages was titled 2083 a European Declaration of Independence and was disseminated via e-mail some three hours before his massacre. Confirming how today’s mass murderers can be influenced by their predecessors, Breivik heavily plagiarized Ted Kaczynski’s Industrial Society and Its Future, deleting and inserting key words to promote his own agenda. Breivik turned himself in immediately after his massacre, and Norway witnessed an unprecedented criminal trial. After the first round of experts concluded he suffered from paranoid schizophrenia, a second round of expert evaluation was ordered. The second experts diagnosed Breivik with narcissistic personality disorder. Much of the debate focused on whether Breivik’s self-centered grandiosity arose to the level of a delusion. Ultimately, he was found not to meet Norway’s standard for the defense of not guilty by reason of insanity; he is currently serving twenty-one years in prison (the maximum penalty in Norway). Unsurprisingly, Breivik proclaimed he did not recognize the legitimacy of the court or its decision.

The strength and awe-inspiring resilience I witnessed during the Sandy Hook Promise presentation humbled me. In particular, I noticed how the people of Newtown made it clear that they did not want to be viewed as helpless victims. The Newtown community had known from the beginning what they needed to do, and they were well along the path toward establishing a sense of efficacy and optimism. The audience asked thoughtful questions about how best to reach out to show support for families of victims, and—in an overwhelming display of compassion—to the family members of the offender. Here David spoke with great authority and empathy. The Newtown audience knew that they had before them the person who was best equipped to answer this question, and they wanted to seize the moment. David spoke in his usual eloquent, humanistic, and compelling style. He concluded his insightful answer by saying: “We will always love our family members, but we detest what they did.”

Posttrauma Reflections

Until you’ve eaten with a chimp and bathed with a chimp, you don’t know a chimp.

—Sandra Herold, owner of Travis the Chimp

The synagogue where our Sandy Hook Promise talk was held was packed to standing room only. Just before taking our seats on the stage, we were informed by a community leader that “things were still raw.” The statement felt less like a warning, and more like a protective blessing bestowed upon us. After we had given our talks, there was time for audience questions and comments. A man in the audience whom I imagined to be a Newtown father/brother/uncle/Little League coach stood up to ask the question I feared but knew was coming. He spoke calmly, but looked pained: “I need to ask this question of the doctor.” And then he asked it, the question all of us wanted the answer to: “How could someone do what he did—to the little children?”

This was the question only Adam Lanza could definitively answer. But now the most relevant data was irretrievable. I wanted to give the man in the audience an answer that would both solve the puzzle and alleviate suffering. I felt the strong pull of answers that would have relieved my discomfort. I could oversimplify by raising the specter of “evil.” I could give a detached recitation on the bio-psycho-social underpinnings of human violence. The gravity of the moment flattened all intellectual and academic explanations. Taking a measured breath, and channeling some of David’s open-hearted sincerity, I summoned the most honest answer I could: “Sometimes ... anger can be so intense that it can become blinding.” There was a pause, and I feared my answer was not enough. I had held back due to my wish to say something that would facilitate healing. I had held back out of fear that anything I might say about Adam Lanza would come across as excusing his actions. Months later, I began to research the Lanza case in the same fashion I had analyzed other mass shootings. As usual, in retrospect, the familiar progression was there waiting to be uncovered. On December 20, 2011, Adam Lanza called a radio show to speak about a domesticated chimpanzee named Travis. Travis unexpectedly attacked his owner’s friend in a horrific manner and was killed by police. Adam said to the radio host:

When we see a chimp in that position, we immediately know that there’s something profoundly wrong with the situation. And it’s easy to say there’s something wrong with it simply because it’s a chimp, but what’s the real difference between us and our closest relatives?

Travis wasn’t an untamed monster at all.... He was civilized....

Look what civilization did to him....

And his attack wasn’t simply because he was a senselessly violent, impulsive chimp. The best reason I can think of would be that he was overwhelmed at the life that he had, and he wanted to get out of it by changing his environment I just—just don’t think it would be such a stretch to say that he very well could have been a teenage mall shooter or something like that.

Around the time of his radio show call, Adam Lanza made several posts on a popular Internet thread titled “You know what I hate?” He wrote:

Culture. I’ve been pissed out of my mind all night thinking about it. I should have been born a chimp....

Now I’ve calmed down and am left lying on the floor, numbly perplexed over the foreign concept of loving life.

The Buddhist tradition teaches that meditation is a practice one must become familiar with to train one’s mind. More importantly, it is a practice that should ultimately be realized in one’s daily life, not just while sitting on a cushion. When the current of the mind whisks us away, we notice this, and then return to the present. This pattern is an eternal recurrence in both our minds and our lives. Repeatedly, we are hit by both small waves and devastating tsunamis. The practice of bringing ourselves back to life trains the mind to return to a state of equanimity. We are reborn into the present, over and over. On December 14, 2012, Adam Lanza committed mass murder and suicide. Days later, a group from the Newtown community formed the Sandy Hook Promise organization. Their Sandy Hook Promise states: “Our hearts are broken, but our spirit is not.” With their hearts broken, they turned toward their spirit. And for the benefit of others, they started again.

How might we as a society learn from these tragedies? We think far too shallowly about these events. We concern ourselves with metal detectors, “profiles,” and preventing “the mentally ill” from obtaining firearms. It is time we thought deeper, cultivating respect for how to teach compassion and personal responsibility in individual minds. These tragedies invite us to take a more substantive, meaningful look at how we view psychological suffering and violence as a species. They call us not only to reform our mental health system, but also to face ourselves with an open and fearless heart. The fearless and open heart searches for happiness, yet is willing to let go of pain, frustration, and that which it cannot get or avoid. An open and fearless heart seeks to take responsibility for its own anger. It does so by learning how not to externalize blame, by being willing to examine itself, and by cultivating responsibility. In the final analysis, no matter “what social or biological factors are involved, ultimately we must take responsibility for our anger.”[59]

Mental and emotional turmoil occurs in us all. It is the elephant in the room that must be denied lest one be accused of seeing elephants. How seriously do we want to study and understand the mind? It is no trivial claim that our very future as a species depends on it. At what point will we begin to honor the vital importance of the mind, its awesome power and its infinite possibilities? To do so we must devote sufficient attention, time, and resources. Given what we currently understand about biology, the psychology of personality styles, and social influences, is it an unthinkable stretch to consider the following? Take an individual endowed with exquisite sensitivity, high intelligence, and a paradoxical nature (distant yet sensitive, aloof yet easily hurt). Might such a person be influenced by an incremental convergence of early trauma, intense parental expectations, and then teenage trauma resulting in profound existential confusion? Continuing forward cautiously, is it too fantastic a supposition that this individual might come to view human intimacy as oversocialization? If so, this person may well view intimacy as a serious cruelty and destruction of personal freedom. Alone and with time to think, this person might begin to ruminate about how the system of socialization results in unforgivable sacrifices.

The problem is that all of the foregoing is far too speculative. Furthermore, this line of thought is so taxing to one’s mental economy that a more expeditious substitute is required.[60] One timetested, undemanding route is to declare such an individual evil. But doing this still leaves one with the nagging problem of how the person “became that way” in the first place.[61] Moreover, declaring someone evil instantly summons the supernatural and mythological, leading us further away from rational thought. The real causes of violent behavior will always be different from the way people think of evil, because evil is defined through myth and illusion. This has been termed the “myth of pure evil” by a social psychologist who notes that “the face of evil is no one’s real face—it is always a false image that is imposed or projected on the opponent.”[62] Another hurdle to a better understanding of human violence is that our desire to know the “face of evil” battles with our desire to keep it partially obscured. The latter is necessary for keeping it the repository of unpleasant projections. Indeed, “humanizing” a monster “makes him less compelling as the embodiment of evil.”[63] The celebrity status of serial killers in American culture reflects precisely such contradictory desires.[64] There is also the comforting conclusion that the killer is an “alien” aberration whose detection has made society a much safer place. The tendency to keep evil obscured is consistent with lay notions that evil is beyond comprehension and that those who commit evil acts lie outside the demarcation of being human.[65] Ultimately psychiatric researchers and clinicians cannot succumb to the myth of evil, since it will have the pernicious effect of shutting down scientific progress and treatment efforts.[66]

If we choose to be serious about treatment efforts, there can be no avoiding the reality that mental illness affecting the individual will invariably have an impact on family members. The experience of the family struggling to help a loved one with mental illness deserves much more attention than it has been given to date. Although the ordeal David and his family have suffered is an extreme one, I have no doubt that legions of families will be able to relate. Every day in America, families are challenged by the torturous hardship of ensuring lifesaving mental health care for their loved ones. Many have been pushed beyond the brink of what the strongest family could be expected to handle. They face not only deep concern about getting effective treatment for their affected kin, but also fear and confusion about what they observe. In some cases, they may even fear for their loved one’s safety—as well as their own.

Despite all this, family can be some of the strongest medicine, and there are a number of things that families can do to stack the odds in their favor.[67] For example, here are some recommendations from my colleague Dr. Lloyd Sederer (medical director of the New York State Office of Mental Health), who has substantial experience consulting with families struggling to help their loved one with mental illness:[68]

Don’t go it alone.

Document observations that are concerning to you. Learn the “mental health system” rules.

Seek family therapy if needed.

Understand that you are engaged in a marathon, not a sprint.

Not going it alone means be ready and willing to reach out. A group that is highly regarded and plays a critical role in supporting families is the National Alliance on Mental Illness (nami).[69] nami advocates for access to services, treatment, support, and research. There are hundreds of state nami organizations, with groups in communities across the country. Attending a nami meeting, one quickly gets the sense of a supportive community of family members ready to help each other. Many nami members have substantial experience with obtaining help and treatment resources in their locale and thus serve as invaluable advisers to those who are less experienced. Documenting observations has to do with noticing and writing down factual descriptions of a loved one’s concerning behavior. This can be important because in the midst of a crisis, it may be difficult to provide authorities or doctors with the critical evidence they need to ensure treatment. Written documentation of objective data by a family member can serve as either evidence needed for hospitalization or important data establishing a proper diagnosis. Learning the mental health system and how it works allows one to be a better advocate for a loved one in need of treatment. Often nami and other nami members can assist with this. In addition, a trusted psychiatrist or mental health professional can provide important information about who to speak with and, just as important, the proper things to say to ensure treatment.

The family working to help their loved one should view the process as a long-term one that is unlikely to have a quick resolution. There will most likely be setbacks, periods of despair, and serious testing of family morale. In a family system, one person often represents the “hub” of the family wheel. Traditionally this hub has been the mother, but it may be any other grounding, stabilizing personality. The hub keeps the family centered and on track. Should the hub disappear, the “spokes” of the family are vulnerable to flying apart, and the circle of the family is in jeopardy of breaking down. It is not uncommon that the person who represents the hub or heart of a family has an innate sense of when one of the spokes is seriously troubled. She may then find a way to communicate her concern to other family members. Indeed, she often knows which family member is best suited to be his brother’s keeper. In other cases, it may be that the fear and turmoil that naturally accompanies the harrowing experience of coping with a seriously mentally ill loved one threatens to split the seams of family attachments. In such cases, family therapy may be of significant benefit and should be sought from an experienced and credentialed family therapist. The overarching view of family therapy considers the styles and systems of interactions in a family unit, which are crucial for the psychological health of all members.

Sometimes individuals with serious mental illness do not understand or believe that they are suffering from disturbing symptoms. All solicitations to consider treatment may be rejected, and any family member who expresses concerns about the need for treatment may be seen as a traitor or enemy. This dynamic often causes strain and distance between family members, threatening to split the family apart along its fault lines—be they past grievances, differing values, or unspoken loyalties. This is why families must remain cohesive and seek some way to bring disruptive emotional forces into the light of day. If those forces remain hidden, they will keep tearing the family apart; but if we can see them for what they are, we can address them directly and strengthen the bonds that have been under strain.

Coda

An event is not under its own power but depends on many present causes and conditions as well as many past causes and conditions. Otherwise, it could not come into being.

—His Holiness the Dalai Lama,
How to See Yourself as You Really Are

David came along at a time in my life when I desperately needed a real-life model of someone with an open and fearless heart. Over the past several years, David has graciously invited me to help teach in a series of workshops and retreats in which we work with survivors of trauma. I still get more out of the meetings than the attendees do. And so there you have it—the brother of the Unabomber is helping to heal the battle-scarred forensic psychiatrist who was exposed to his brother’s case as a young trainee.

David Kaczynski—humanitarian, poet, Buddhist—is a consummate example of walking the path of the open and fearless heart. He did not turn away from the unfathomable fallout connected with his brother. Rather, he turned toward it, and then inward to find the courage to open his heart and help others. In doing so, he fully accepted responsibility. Acceptance of responsibility is an acquired skill that is cultivated by training the mind. An open heart means freedom and the mature ownership and control of our own thoughts, feelings, and actions. The steps to freedom lie within each individual, not in outer circumstances. It may be that this lesson is not widely taught in schools these days. Everyone wants freedom, yet freedom can remain only where there is skillful and appropriate restraint and responsibility. Here is our opportunity to walk the path of the fearless heart, as David has. It is possible to use these indescribably horrendous events to “either wake ourselves up or to put ourselves to sleep.”[70] They represent the unacceptable to the absolute degree, but we must not turn away—only toward.

It seems to me a remarkable paradox that my initial journey into the heart of darkness, with intent to stare into the abyss, led to something I could never have predicted. It led to the brother of the Unabomber, one of the most compassionate and open-hearted people I’ve ever known, who taught me a lesson about how we are all interconnected. Hoping to find proof of beauty in absolute ugliness, I had become cynical. How wonderfully unexpected that it was David Kaczynski who finally taught me there is always the possibility of compassion, even in the darkest of places.

[1] J. Knoll and Phillip J. Resnick, “Master Educator,” Journal of the American Academy of Psychiatry and the Law 35, no. 2 (2007): 154–157.

[2] US v. Kaczynski 239 F. 3d 1108—Court of Appeals, 9^th Circuit, 2001.

[3] Daniel Goleman, Destructive Emotions: A Scientific Dialogue with the Dalai Lama (New York: Bantam Dell, 2004).

[4] B. Bodhi, “Reflections on the Fire Sermon,” Parabola 37, no. 1 (2012): 11–17.

[5] E. Wilson, The Social Conquest of Earth (New York: Liveright, 2013).

[6] J. Bowlby and J. Robertson, “A Two-Year-Old Goes to Hospital,” Proceedings of the Royal Society of Medicine 46, no. 6 (1953): 425–427.

[7] J. Masterson and R. Klein, Disorders of the Self: New Therapeutic Horizons: The Masterson Approach (New York: Brunner/Mazel, 1995); N. McWilliams, Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2^nd ed. (New York: Guilford, 2011), chap. 9.

[8] B. Simon, “Beckett’s Endgame and the Abortion of Desire,” in Simon, Tragic Drama and the Family: Psychoanalytic Studies from Aeschylus to Beckett (New Haven, CT: Yale University Press, 1993), chap. 7; see also Franz Kafka’s Letters to Milena (New York: Shocken Books, 1990), especially “Alone I continue living, yet when a visitor arrives it kills me.”

[9] C. Quanbeck et al., “Mania and the Law in California: Understanding the Criminalization of the Mentally Ill,” American Journal of Psychiatry 160 ( July 2003): 1245–1250.

[10] L. N. Robins and D. A. Reiger, eds., Psychiatric Disorders in America: The Epidemiologic Catchment Area Study (New York: Free Press, 1991); J. Rich, S. Wakeman, and S. Dickman, “Medicine and the Epidemic of Incarceration in the United States,” New England Journal of Medicine 364, no. 22 (2011): 2081–2083.

[11] D. J. James and L. E. Glaze, Mental Health Problems of Prison and Jail Inmates (Washington, DC: Bureau of Justice Statistics, 2006).

[12] N. R. Gross and R. D. Morgan, “Understanding Persons with Mental Illness Who Are and Are Not Criminal Justice Involved: A Comparison of Criminal Thinking and Psychiatric Symptoms,” Law and Human Behavior 37, no. 3 (2013): 175–186; J. Baillargeon et al., “Psychiatric Disorders and Repeat Incarcerations: The Revolving Prison Door,” American Journal of Psychiatry 166, no. 1 (2009): 103–109.

[13] B. Kuehn, “Criminal Justice Becomes Front Line for Mental Health Care,” Journal of the American Medical Association 311, no. 19 (2014): 1953–1954.

[14] “State Trends: Jails Are Housing Majority of Mentally Ill,” Mental Health Law Reporter 25, no. 10 (2007): 78.

[15] E. Torrey and M. Zdanowicz, “Prison and Jails Are No Place for People with Mental Illness,” Idaho Statesman, November 25, 2002, http://www.psychlaws.org/GeneralResources/article109.htm.

[16] H. Lamb, L. Weinberger, J. Marsh, and B. Gross, “Treatment Prospects for Persons with Severe Mental Illness in an Urban County Jail,” Psychiatric Services 58, no. 6 (2007): 782–786.

[17] T. Kupers, Prison Madness (San Fransico: Jossey-Bass, Publishers, 1999).

[18] J. Metzner, “Class Action Litigation in Correctional Psychiatry,” Journal of the American Academy of Psychiatry and the Law 30 (2002): 19–29.

[19] M. Goin, “Fiscal Fallout: Patients in the Criminal Justice System,” Psychiatric News 38, no. 13 (2003): 3, 44.

[20] L. Penrose, “Mental Disease and Crime: Outline of a Comparative Study of European Statistics,” British Journal of Medical Psychology 18 (1939): 1–15.

[21] E. Fuller Torrey, Out of the Shadows: Confronting America’s Mental Illness Crisis (New York: John Wiley & Sons, 1997), excerpts at http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html (accessed March 30, 2015).

[22] T. Grisso, “Do Childhood Mental Disorders Cause Adult Crime?,” American Journal of Psychiatry 164, no. 11 (2007): 1625–1627.

[23] S. Fazel and M. Grann, “The Population Impact of Severe Mental Illness on Violent Crime,” American Journal of Psychiatry 163 (2006): 1397–1403, http://ajp.psychiatryonline.org/article.aspx?articleid=96905.

[24] C. Martone et al., “Psychiatric Characteristics of Homicide Defendants,” American Journal of Psychiatry 170 (2013): 994–1002.

[25] J. Swanson et al., “A National Study of Violent Behavior in Persons with Schizophrenia,” Archives of General Psychiatry 63, no. 5 (2006): 490–499; S. Ullrich, R. Keers, and J. Coid, “Delusions, Anger, and Serious Violence: New Findings from the MacArthur Violence Risk Assessment Study,” Schizophrenia Bulletin 40, no. 5 (2013): 1174–1181; C. Webster, Q. Haque, and S. Hucker, Violence Risk Assessment and Management: Advances through Structured Professional Judgment and Sequential Redirections, 2^nd ed. (New York: Wiley-Blackwell, 2013); J. Coid et al., “The Relationship between Delusions and Violence: Findings from the East London First Episode Psychosis Study,” Journal of the American Medication Association Psychiatry 70, no. 5 (2013): 465–471.

[26] E. Goffman, Stigma: Notes on the Management of Spoiled Identity (New York: Prentice Hall, 1963).

[27] F. Kafka, “The Metamorphosis,” in The Complete Stories. Ed. N. Glatzer (New York: Shocken Books, 1971), 100.

[28] Daniel Strauss, “Rubio Supports ‘Comprehensive Study’ of Gun Laws,” TheHill.com, December 17, 2012, http://thehill.com/blogs/blog-briefing-room/news/273273-rubio-supports-comprehensive-study-of-gun-laws.

[29] “Remarks from the NRA Press Conference on Sandy Hook School Shooting” (transcript), Washington Post, December 21, 2012, http://www.washingtonpost.com/politics/remarks-from-the-nra-press-conference-on-sandy-hook-school-shooting-delivered-on-dec-21–2012-transcript/2012/12/21/bd1841fe-4b88–11e2-a6a6-aabac85e8036_story.html.

[30] B. G. Link, J. C. Phelan, M. Bresnahan, A. Stueve, and B. A. Pescosolido, “Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance,” American Journal of Public Health 89, no. 9 (1999): 1328–1333.

[31] J. Phelan, B. Link, A. Stueve, and B. Pescosolido, “Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to Be Feared?,” Journal of Health and Social Behavior 41, no. 2 ( June 2000): 188–207.

[32] R. Ferguson, Inferno: An Anatomy of American Punishment (Cambridge, MA: Harvard University Press, 2014).

[33] Portions of this discussion are adapted with permission from J. Knoll, “Fearful Synergy: Society and Psychiatry Perpetuating the Criminalization of the Mentally Ill,” Correctional Mental Health Report 10, no. 1 (2008): 3–4, 12–16.

[34] G. Bizer, J. Hart, and A. Jekogian, “Belief in a Just World and Social Dominance Orientation: Evidence for a Mediational Pathway Predicting Negative Attitudes and Discrimination against Individuals with Mental Illness,” Personality and Individual Differences 52 (2012): 428–432; B. G. Link, J. C. Phelan, M. Bresnahan, A. Stueve, and B. A. Pescosolido, “Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance,” American Journal of Public Health 89, no. 9 (1999): 1328–1333.

[35] See Atkins v. Virginia, 536 S. Ct. 304 (2002), and Hall v. Florida, 134 S. Ct. 1986 (2014).

[36] J. Blair and K. Schweit, A Study of Active Shooter Incidents, 2000–2013 (Washington, DC: Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, 2014).

[37] O. Saleva, H. Putkonen, O. Kiviruusu, and J. Lonquist, “Homicide-Suicide—An Event Hard to Prevent and Separate from Homicide or Suicide,” Forensic Science International 166 (2007): 204–208.

[38] J. Twenge and W. Campbell, The Narcissism Epidemic: Living in the Age of Entitlement (New York: Free Press, 2009).

[39] S. Pinker, The Better Angels of Our Nature: Why Violence Has Declined (New York: Viking, 2011).

[40] Twenge and Campbell, The Narcissism Epidemic.

[41] P. Mullen, “The Autogenic (Self-Generated) Massacre,” Behavioral Sciences and the Law 22 (2004): 311–323.

[42] Y. Neuman, “On Revenge,” Psychoanalysis, Culture and Society 17 (2012): 1–15.

[43] J. Ronson, The Psychopath Test: A Journey through the Madness Industry (New York: Riverhead Books, 2011).

[44] Associated Press, “Mass Public Shootings on the Rise, But Why?,” April 21, 2007, http://www.nbcnews.com/id/18249724#.U7TIE9FOWUk.

[45] C. Schüle, “Tokyo Subway Dreams: Underground Meditations,” in Tokyo Compression Three, ed. M. Wolfe (Hong Kong: Asia One Books, 2012).

[46] Elliot Rodger, “My Twisted World,” available at https://www.documentcloud.org/documents/1173808-elliot-rodger-manifesto.html.

[47] “Mass Murder and Mind Control: Understanding the Jonestown Tragedy,” presentation at the annual meeting of the American Academy of Psychiatry and the Law, Miami, FL, October 20, 2007.

[48] Y. Tsunetomo, Hagakure: The Book of the Samurai, trans. W. Wilson (Tokyo: Kodansha International, 1979).

[49] E. Becker, The Denial of Death (New York: Free Press, 1973).

[50] T. Pyszczynski, S. Sheldon, and J. Greenberg, In the Wake of 9/11: The Psychology of Terror (Washington, DC: American Psychological Association, 2006).

[51] J. Schimel, J. Hayes, T. Williams, and J. Jahrig, “Is Death Really the Worm at the Core? Converging Evidence That Worldview Threat Increases Death-Thought Accessiblity,” Journal of Personality and Social Psychology 92 (2007): 789–803.

[52] “Violence, Loss and Emotional Healing: A Buddhist Perspective,” March 13 at Adath Israel, Newtown Bee, March 1, 2013, http://newtownbee.com/news/news/2013/03/01/violence-loss-and-emotional-healing-buddhist-persp/6291.

[53] S. Hobfoll et al., “Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence,” Psychiatry 70, no. 4 (2007): 283–315; A. M. Vicary and R. C. Fraley, “Student Reactions to the Shootings at Virginia Tech and Northern Illinois University: Does Sharing Grief and Support over the Internet Affect Recovery?,” Personality and Social Psychology Bulletin 36, no. 11 (2010): 1555–1563.

[54] S. Sollid, “When Worst Comes to Worst—the Long Road Home,” Tidsskrift for den norske legeforening (Journal of the Norwegian Medical Association) 131 (2011): 1748.

[55] F. Thrana, “Endure the Pain of Others,” Tidsskrift for den norske legeforening (Journal of the Norwegian Medical Association) 131 (2011): 1747–1748.

[56] C. Haug, “Reflections,” Tidsskrift for den norske legeforening (Journal of the Norwegian Medical Association) 131 (2011): 1739.

[57] G. Dyb, “Lean Forward and Be There,” Tidsskrift for den norske legeforening (Journal of the Norwegian Medical Association) 131 (2011): 1751–1752.

[58] C. Leonard, D. Annas, J. Knoll, and T. Terje Tørrissen, “The Case of Anders Behring Breivik—Language of a Lone Terrorist,” Behavioral Sciences and the Law 32, no. 3 (2014): 408–422; and “Breivik: All-Consuming Hatred Approaching Psychosis?,” copresented with Terje Torrissen, md, at Forty-Fourth Annual Meeting of the American Academy of Psychiatry and the Law, San Diego, CA, October 25, 2013.

[59] R. Leifer, Vinegar into Honey (Ithaca, NY: Snow Lion Press, 2008).

[60] B. Masters, The Evil That Men Do: From Saints to Serial Killers (London: Black Swan, 1997).

[61] L. Watson, Dark Nature: A Natural History of Evil (New York: HarperCollins, 1995).

[62] R. Baumeister, Evil: Inside Human Violence and Cruelty (New York: Henry Holt and Company, 1997).

[63] G. Gabbard, “Book review: Hannibal,” American Journal of Psychiatry 156, no. 11 (1999): 2001.

[64] D. Schmid, Natural Born Celebrities: Serial Killers in American Culture (Chicago: University of Chicago Press, 2005).

[65] T. Mason, J. Richman, and D. Mercer, “The Influence of Evil on Forensic Clinical Practice,” International Journal of Mental Health Nursing 11 (2002): 80–93.

[66] J. Knoll, “The Recurrence of an Illusion: The Concept of ‘Evil’ in Forensic Psychiatry,” Journal of the American Academy of Psychiatry and the Law 36, no. 1 (2008): 105–116.

[67] L. Sederer, The Family Guide to Mental Health Care (New York: W. W. Norton, 2013).

[68] L. Sederer, “When Mental Illness Enters the Family,” tEd Talk, 2014, January 6, 2015, https://www.youtube.com/watch?v=NR00-JXuFMY.

[69] See http://www.nami.org/.

[70] Pema Chodron, When Things Fall Apart: Heart Advice for Difficult Times (Boston: Shambhala, 2007).