Opinion | The Danger of Binary Thinking in Mental Health Care

Background: “Either/Or” Thinking

Binary thinking — either/or thinking — is the opposite of quantified, dimensional thinking and it is especially dangerous in medicine and mental health. It is the thinking of division. It falls short of even one dimension of complexity. For example, who can deny the ever-present tendency to identify flank fullness with or without ascites, a heart attack with or without chest pain, and, as a cautious mental health corollary, self or other murder with or without mental illness.

Is this either/or thinking an ingrained tendency or tactic in mental health? To be sure, when employed — inadvertently or intentionally — it can effectively obscure meaningful understanding beyond mere description. It represents a cognitive shortcut or defense against intolerably complex problems. Indeed, in mental health, this approach has caused the extremely traumatized public to find it impossible to make sense of interviews or commentary, or to trust in those responsible for mental health care.

Foreground: Dimensional Thinking

I trained and practiced in the intensely disturbed and disturbing world of the psychiatric emergency room. Whatever the personal or professional challenges, self or other danger required quantification, not “yes/no” reductions.

Acute psychological pain, strange motivations, weird intoxication, and atypical forms demanded differentiation from enduring and rigid mental health issues often characterized by bizarre interpersonal manipulation, self-centered gross disregard of others, and other personality disorders, some of which can lead to dangerous and deadly behavior. There were also persons admitted who had self-amputated body parts, driven stakes through victims’ hearts, murdered siblings, or engaged in unusual strangulation. Some self-murder cases involved unobvious side effects to antidepressant medications, various forms of akathisia, and dissociative acute stress disorders.

Revisiting the opening binary caveat, are murderous acts the result of the presence of an acute, psychopathologic state, as in delusions and hallucinations? Or, on the contrary, could they represent an enduring trait of deficient psychological health with lasting interpersonal callousness and hostility?

Acute and chronic conditions can exist in the same person, in the same context, and at the same time, such as enduring heart failure with new onset STEMI or lasting type 1 diabetes mellitus with acute ketoacidosis. A mental health example illustrates that although acute paranoid schizophrenia is not a personality disorder, it may feature long-term patterns of eccentric behavior.

In this respect, the awful acts of predatory violence currently seizing our nation cannot be reduced to an either/or resolution. The latest attack in Allen, Texas, is the country’s 22nd mass killing (defined as an attack where four or more people died, not including the murderer) in 2023. Without fail, the first question of many following these dreadful events represents yet another binary expression: “Did mental health play a role?”

An A/B Dimensional Formula

As an illustration, violence can be identified by point A, absence point B, and written AB. This, of course, ignores dimensionality, which if accounted for, would look like: A … … … B.

In a more correct formulation, where AB represents cross-factor products, not only are there intermediate points between A and B, but there are also dimensional points above and below the line. Therefore, in the vast space of self or predatory ideation and acts, there are many intersecting coordinates, such as age, gender, race and ethnicity, religion, shame and humiliation, family history, non-psychotic pathology, neurologic illness, medications, parent authoritarian style or overprotection, legal issues, alcohol and substance abuse, early onset behavioral disorders, and availability of firearms and other lethal methods. The list goes on.

Final Acts of Self or Other Murder, and Suicide by Cop

A healthy and adaptive personality requires the ability, on balance, to understand the plight of others who are less fortunate. This develops in children by stressing the validity of their feelings and providing consistent self and unconditional attentive love. A temperament without integration of empathic competency is a mixture leading to consolidation of impulsivity, grandiosity, and heartlessness. That is, they lack a conscience and have associated cognitive inconsistencies, rigid maladaptive prejudices, and persistent irresponsibility. The unique and shared acute and chronic features of a consolidated narcissistic sociopath (narcissistic and antisocial personalities) can be particularly challenging and potentially dangerous.

Children who are raised with hostility or who are indifferently regarded by caregivers are taught that failure leads to less love and affection. The child’s sorrowful experiences of abuse, exclusion, abandonment, and/or humiliation, when re-experienced in older adolescence or young adulthood by shaming, may replicate the early narcissistic injury. This internalized trauma, often unobvious to or unanticipated by family, friends, clinicians, or teachers, can then be projected dimensionally (i.e., outwardly and murderously upon others, inwardly or savagely upon self, or both).

Highlights

1. Yes/no binary thinking is particularly dangerous in medicine and mental health.
2. Severe mental illness, including psychosis, is less reliably predictive of mass murder.
3. Many mass shooters either take their own lives at the scene (final act) or were killed by law enforcement (suicide-by-cop).
4. The distinctive and shared features of the narcissistic sociopath are unusually dangerous.
5. A personality temperament without integration of empathic competency is a mixture leading to consolidation of impulsivity, grandiosity, and callousness.

Recommendations

1. Be suspicious of simplistic, single-plane analyses.
2. Focus on early family dynamics and social drivers as significant violence accelerants, regardless of “pure” diagnosis, in persons when coupled with experienced or threatened interpersonal shame.
3. The federal law background check for “mental defective” is obsolete, vague, and requires an upgraded and comprehensive definition.
4. Beyond means restriction and safe storage, increase red flag law judicial burden of proof to “clear and convincing,” a standard consistent with mental health civil commitment.
5. Universal and synchronized mental health background checks for all guns, including soft and higher ballistic armor sales, represent a potential solution to some categories of gun violence.

It stands to reason that additional training in, and screening for, unusual violence phenotypes, with enhanced cooperation among schools, mental health, and legal institutions, should reasonably interrupt and reduce the rate and awful burden of deadly self-harm and other violence.

Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry at UC, Irvine and University of Colorado, Denver. He is a reviewer for Academic Psychiatry and founder of eMed Logic, a non-profit originator and distributor of violence assessments. Copelan is also a presenter for the National Association of School Psychologists (NASP) Speaker’s Bureau, and a consultant to the American Association of Suicidology.