So, where did all the patients go?

J Am Acad Psychiatry Law 

Virginia Tech Mass Murder: A Forensic Psychiatrist’s Perspective
Emanuel Tanay, MD

Dr. Tanay is Clinical Professor of Psychiatry, Wayne State University Medical School, Detroit, MI
Address correspondence to: Emanuel Tanay, MD, 2980 Provincial Drive, Ann Arbor, MI 48104. E-mail: drtanay{at}

The April 2007 tragedy of 32 individuals’ falling victim to a mass murder committed by a psychotic student should call attention to the deplorable state of our nation’s care of the mentally ill. Unfortunately, the Virginia Tech tragedy has led to a misguided focus on the perpetrator’s individual psychology.

Most commentary neglects the social issue of the criminalization of mental illness. Today, psychotic individuals cannot be civilly committed to a hospital (if there is one) unless they have demonstrated their dangerousness by an overt act. However, that overt act frequently violates criminal law. Thus, our jails have become the default institutions for the care of the mentally ill. The criminal justice system intervenes after a crime has been committed, as it should. But in the past, provisions for the care of the mentally ill were more often preventive in nature.

In the 1970s, an unholy alliance of civil libertarians and fiscal conservatives brought about the destruction of the state hospital system that had served us so well from the time Dorothea Dix brought about its creation in the mid-19th century. Deinstitutionalization resulted in a shift of the care of schizophrenic individuals to outpatient clinics, which have few resources to manage severe psychotic illness. Long-term hospitalization has become a relic of the past. The current practice is to hospitalize an acutely psychotic individual and then discharge him or her after a short hospital stay. This approach is often the result of ideological and fiscal considerations, and less the result of considerations focused on good clinical care.

Since as yet there are no means of assuring the primary prevention of schizophrenia, we have to rely on reducing the suffering that this illness inflicts on patients, their families, and society. I believe that Mr. Cho was driven to become a mass murderer by his psychosis. He told us as much when he stated in the second video that he sent to NBC on the day of the tragedy, “Do you think I want to do this? Do you think I ever dreamed of dying like this in a million years? I didn’t want to do this.” Cho’s cry for help, demonstrated by bizarre behavior and writings both during this tragedy and for years before, went unheeded. Thirty-two people paid with their lives for the failure of our society to respond.

The underlying problem is the mental health system. The very name, a euphemism for the care of the mentally ill, bespeaks the reluctance of our society to recognize the thousands of citizens who have incurable psychiatric illness. The needs of people who have emotional difficulties and whose problems are treatable by psychotherapy and medication are different from the needs of those who have a life-long severe psychotic disorder. This reality is compounded by the myth that became popular in the 1960s that all persons with severe psychotic disorders are not dangerous. I have encountered countless homicides committed by such individuals whose behavioral pleas for help produced band-aid-type responses of a few days of hospitalization.

Persons with delusional ideas may have homicidal impulses that, depending on the setting, can result in a homicide. When I worked in the old-fashioned state hospitals, I had many homicidal patients who, in the institutional setting, were potentially dangerous but were unlikely to realize their impulses in that setting. The same individual in the community, by contrast, may implement his or her delusions.

Older psychiatric literature had many case studies of violence as a symptom of severe psychotic illness. But with the virtual elimination of the state hospital system, our ability to observe, much less study, the social interactions of these patients has declined. Thus, research has also been compromised.

It should come as no surprise that people tormented by delusions and hallucinations and with compromised ability to control their impulsiveness may engage in violence. This is not to say that all of them are violence prone.

The much-maligned state hospital system served us well until it fell victim to propaganda. I know this first-hand from my lifetime experience. During my residency at Elgin State Hospital in 1953, I encountered a memorable patient who had been admitted after demonstrating his dangerousness by amputating his own sexual organs. When I asked this patient (who had been at Elgin State Hospital for over two decades) what originally caused his hospitalization, he answered in a voice that I have never forgotten, “I came to get my mind straightened out and found a place where living is possible.” This is the essence of the old concept of asylum, the need for which has not been eliminated by current psychiatric treatments. Needless to say, Elgin State Hospital (which had 6,000 patients) no longer exists. My next employment as a psychiatrist was at Ypsilanti State Hospital, which also no longer exists. The hospital grounds are now Huron Valley Correctional Institution (a prison). So, where did all the patients go?


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