Picture of Normand CarreyNormand Carrey is a child and adolescent psychiatrist at Dalhousie University, Halifax, Nova Scotia

I feel sad for the families of Warrant Officer Patrice Vincent and Corporal Nathan Cirillo, who were killed on October 20 and 22 in Quebec city and Ottawa, respectively. I equally feel sad for the countless other grieving families left up picking the pieces after a loved one is killed by someone where mental health issues are suspected.

After the murder of Corporal Cirillo, US Senator John Kerry wasted no time in flying to Ottawa before any analysis could take place as he announced without any doubt that these were pure unmitigated acts of terrorism. A cottage industry of TV pundits was trotted out to tell us that now we have something else to fear –self radicalization in vulnerable youth and the home-grown or lone wolf terrorist. It was good to hear, however, in the subsequent week, public debate with many callers reminding the experts about the role of mental health in such tragedies. Why did the media and politicians neglect to include in their debate and analysis of recent events other just as horrifying acts? Where was the mention of Justin Bourque’s killing of three RCMP officers in Moncton; Matthew deGrood, the student from Calgary – who aspired to study law- stabbing five classmates in April 2014; James Roszko’s shooting of four RCMP officers in Mayerthorpe in 2005, the worst loss of RCMP members in one day; and the massacre that perhaps most severely marked the Canadian psyche, Marc Lepine’s fatal shooting of 14 female engineering students in 1989?

Our visceral reaction is to demonize and to strip the perpetrators, who are fellow sentient beings, of their humanity. We would prefer to think about the perpetrators of inexplicable violent crimes as monsters who dare attack our most precious assets, our children, our sisters, or in Zehaf-Bibeau and Couture-Rouleau’s cases the symbols of national pride, our military and political institutions. Who has the intellectual or emotional fortitude to even start to understand these individuals within the quicksand landscapes of mental health diagnosis (schizophrenia and personality disorders, addictions or trauma that trigger psychotic or dissociative states, and a raft of other antecedent biopsychosocial risks factors). In some cases the associations are clear such as Vince Li the schizophrenic who butchered an anonymous passenger aboard a Winnipeg bus, stating he was responding to command hallucinations, whereas in other cases the public feels that the not-guilty-by-reason-of-insanity defense is a convenient expedient for clever lawyers. Quebec cardiologist, Guy Turcotte, described as an otherwise loving father murdered his two young children in a dissociative state, triggered in the context of a bitter separation. He was found not guilty by reason of insanity with a diagnosis of adjustment disorder, an insanity defense that is rarely used. The public outcry was so great that he is now awaiting a second trial.

Behind each of these acts of terror there is the story of the perpetrator struggling with his own devils; why some are triggered to act out against an imagined enemy or, paradoxically, their loved ones necessitates a careful assessment of all factors. Progress has been made in forensic psychiatry and, as with suicide, there is often no way to predict with any accuracy which ticking time bomb will detonate and which won’t. While traditional diagnoses (psychosis, mood disorders) that impair judgement continue to be assessed for in the mental status exam, psychiatrists have become more knowledgeable about the impact of dissociative states triggered by past (childhood abuse and neglect) or current trauma as well as the influence of substances on impulse control.

The old designation for a psychiatrist was the French term alienist, from an era where psychiatrists were mostly superintendents of asylums. The term suggests ambivalent feelings to what psychiatrists did – feelings that are quick to re-surface today when mentally ill patients commit horrific acts. Today, however, social media amplifies society’s judgements, abounding with emotional images and language, the primitive reflexive thinking of all good or all bad, responses that critically weaken rational public debate about crime and punishment. The Internet, whose impact on mental health is still poorly understood, provides a complimentary explanation of how vulnerable, disenfranchised youth become easy pickings for radical ideologists.

The threat of organized international terrorism is certainly out there whereas everything else (broken families, mental health, addictions, social determinants of health) is a mirror of our societal values, the devil inside each one of us, constantly testing the positive forces that bind us together and make us answerable to each other.

Many may feel that the mental health explanation is an expedient cop-out to exculpate the guilty whether they survive or turn the gun on themselves. In our pain its much easier to suspend judgement and accept what the politicians label as the devil out there, conflating mental health issues with one all encompassing term-international or home grown terrorism.

Psychiatry must continue to apply clinical acumen and judgement to dance that uneasy dance between being sensitive to public views while simultaneously explaining what motivates the mentally ill to act-out; the headlines betray the facts that the vast majority of people with mental health issues continue to suffer in silence. We must continue the unglamorous research into causality, both biological and social, and be advocates for more mental health resources rather than diverting those rare dollars to increased security measures and building more jails. Perhaps a more transcendent metaphor, applicable even to our modern times is 17th century poet and cleric John Donne’s meditations-

No man is an island,…any man’s death diminishes me,…..therefore never send for whom the bell tolls,… it tolls for thee.