I have worked as a licensed clinical social worker in the health/mental health field in a variety of settings for 40 years. Hopefully, with age has come some wisdom I would like to share.

The “dirty little secret” no one will talk about is this: There is no successful mental health treatment for antisocial personality disorder with fixed delusional disorder.

This appears to be the closest diagnosis we have for mass killers, including the recent ones.

There are no oral antipsychotic medications or long-lasting injections that effect change.

In addition, one cannot force injection medications, as decided by our courts.

Psychotherapy does not work, since people think there is nothing wrong with them.

Only external controls work — confinement in jail, threat of such or as close monitoring as allowed by the law. Confinement in a mental health facility has limited effectiveness, since a person can refuse medication and “wait it out” and be discharged if not a danger to self or others during confinement.

The delusions and delusional thought system continue even with nonviolent people; with the latter, the delusional intrusions lessen (with medication) as a person learns to live with reality (therapy) and grasps the negative feedback of sharing such to others — hence, not antisocial and treatable. Such people still “believe” the delusions, but their importance is lessened by medication, and they have a desire to function in this world. Often the delusions are not violent but still troublesome.

The only time I have seen a delusion “disappear” is when someone is truly bipolar and in a manic phase, usually off his or her medications. It clears up right away, and the person realizes all of this when he or she becomes well. These people do not suffer from a delusional disorder.

Additionally, as a person goes on and off antipsychotic medication over the years, the medication is not able to “jump the synapses” and hit the dopamine receptors.

In effect, just like with some cancers: no effective treatment. Studies show refractory (not treatable) mental illness could be as high as 20% for psychotic disorders, including schizophrenia.

This is not to discourage mental health treatment. I still believe in treatment and see a variety of successful outcomes as both a psychotherapist and supervisor of a mental health clinic in Pittsburgh.

If medical issues are not always curable, what makes one think all mental health disorders can be treated?

Most experienced mental health clinicians do not view the concept of evil as incompatible with helping others who are suffering from a mental illness. In fact, many times a person is a victim of such evil in their lives.

I do not think it is fair to blame the “mental health system” for failures with (usually) young men who are antisocial, delusional and yes, act in evil ways.

We do not blame oncologists for cancer that ends up as terminal.

We need to realistically know what is and is not possible with any illness/disorder. Sometimes a person fits no specific diagnosis/category.

“Getting mental health treatment” is not the answer, since it takes a willing participant by definition, and, if successful treatment is stopped, then the “cancer” returns.

James Disantis lives in Freeport.

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