Drawing on the details of this case—including the apparent breakdown of a court-mandated treatment program—Dr. Lieberman explores why psychosis-driven violence keeps recurring, why law enforcement is so often left to respond to what is fundamentally a medical emergency, and why New York's mental health infrastructure failed at multiple points before this outcome became almost inevitable. It's a sobering look at a system that allows vulnerable people to "die with their rights on" and a call for the structural changes needed to prevent the next tragedy.

Watch the video for Dr. Lieberman’s full commentary, or read the transcript below.

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On September 1st, a terrible thing happened in the middle of Manhattan in broad daylight. Two people were walking home through Times Square after work, and they were attacked by a woman who stabbed them with two butcher knives. One of the victims died. The other one was hospitalized for treatment. The perpetrator was Pamela Cisneros, a 49-year-old woman who, according to her father, had a long history of mental illness for which she was receiving treatment. Her brother said he believed the diagnosis of her illness was a bipolar disorder with psychotic symptoms.

Now, this terrible occurrence is not uncommon. Why? Because people who have severe mental illness, if they go without treatment, can be influenced by their symptoms: delusions, which are false beliefs, and hallucinations, which often take the form of voices directing them to do certain things and act on their delusions. And so it’s very likely that Ms. Cisneros, in a state of psychotic symptoms, was impelled by these to feel that these two people warranted being attacked in that way.

Now, the second part of this tragedy, this senseless death and injury, was that she was apprehended shortly after by police, who, when they couldn’t subdue her manually and she attacked them with the knives, were required to resort to force, meaning using their firearms, and Ms. Cisneros died. So this was death by cop, which often happens when people who are mentally ill run amok and do things that require intervention by law enforcement—who are not necessarily trained to be mental health providers.

Now, a couple of things are notable. We have many such instances around the country—and it’s sort of like a ticking time bomb before one of these things goes off and someone commits some type of injurious or lethal action because they’re under the influence of their symptoms. And our society allows this to happen because one, our mental health care system is woefully inadequate, and so there’s not access or availability for good quality mental health care (and even if there was, it’s not always affordable because insurance doesn’t cover it in a very substantial way). We allow people to reject the need for treatment who are manifestly not in their right mind. And we cynically refer to this ironic situation as allowing people to “die with their rights on.” Because what happens is they get apprehended by police and they’re at risk for being maimed or in this case, like Mrs. Cisneros, killed, because the police have to use some means to protect themselves and subdue the person.

This incident also reflects the fact that New York State did not deal with this situation sufficiently. According to her father, Ms. Cisneros was receiving a long-acting injectable medication, which likely means she was in a program called AOT, Assisted Outpatient Treatment, or Assertive Community Treatment. That means that she was required to take medication, and if she didn’t comply, then the clinic that she was being treated by had the right to go and find her and then administer treatment. In this case, the New York State Office of Mental Health didn’t do a very good job because in her case, the agency that they contract with to implement this program allowed treatment to lapse, which enabled her to go without treatment, therefore relapsing. And in the throes of the relapse, her symptoms were exacerbated, which then resulted in these senseless deaths.

And this happens time and time again, even though it’s totally unnecessary. It’s yet another incident about which everybody would say, “This is crazy. We can’t allow this to happen. There’s got to be something done.” And it’s a wake-up call to force the health care system—and in this case, the government of New York and the Office of Mental Health—to do a better job of ensuring that the people who need treatment because of severe mental illness get it, thus protecting the rest of society.

This week I joined NewsNation's "Katie Pavlich Tonight" (guest-hosted by Lauren Wright) to discuss the Lindsay Clancy trial as the jury weighs one of the hardest questions in criminal law: when severe mental illness takes hold, can a person be held responsible for what follows?

My view is that Clancy is not simply a perpetrator, but someone failed by a mental health system.

I also tried to be honest about the limits of my own field. Psychiatry is, in many ways, the "stepchild of medicine" — unlike a cardiologist with an EKG, we have no objective test to prove that a psychosis was present. Yet that is exactly what a jury is now being asked to determine. In Clancy's case, her illness had progressed to delusions she could not be reasoned out of and hallucinations that directed her behavior. At that point, she was an involuntary person, and thus she should not be held responsible.

Watch the full NewsNation segment on the Lindsay Clancy trial.

Lindsay Clancy's trial has entered the final stage, and the jury is now deliberating before rendering a verdict. Now, there's no question that she did kill her children. The question is whether she should be held personally responsible for it and punished as a consequence.

The key factors throughout history that mitigate such a horrible crime in violation of the law are knowledge and control—meaning whether a person had knowledge of what they were doing—that it was illegal and they had the ability to distinguish right from wrong—and also whether whatever was motivating them to commit this act, to take these behaviors on, was able to be controlled or not, or whether this was an irresistible thing.

For example, if a person is driving a car and they suddenly have a seizure—and they've never had any prior history of epilepsy or seizure disorder, it just spontaneously happens—but they then happen to have one, and they crash into another car and kill the driver, should they be held responsible? The law would say no, because the fact that they had a seizure made their behavior involuntary—they didn't have control over the car, and that was the cause of the accident and the death of the other person.

In Lindsay's case, her psychotic state rendered her, one, incapable of exercising the judgment that a person who was sane would have: that murder of children is heinous and a violation of the law. And secondly, the command hallucinations, the voices she was hearing, were not resistible. The beliefs she had were incorrigible. She believed the reality was that the devil was going to possess her children, and the voice she heard telling her to save them by killing them was something she felt she had to adhere to—and afterwards it told her also to take her own life.

So certainly what happened is terrible and is to be condemned. However, Lindsay Clancy was not the perpetrator. She was the victim. She was the victim of the illness, and she was the victim of our mental health care system, which was not able to do enough to diagnose what she was suffering from and to treat it effectively.

And thus here we are today, and Lindsay Clancy’s fate will be decided soon. And whether she’s to be remanded to a state mental institution for the foreseeable future or she's found guilty and is sent to prison—in either case, it's not a great outcome. But the point that should be made is that she's not responsible for what she did and shouldn't be punished as a criminal who did the horrible thing of a mother killing her own children. She did it under the influence of an illness that could have been identified and treated—and this could have been prevented.

A Remedy for Binge Eating Disorders

Glucagon-like peptide-1 (GLP-1) agonists were originally approved by the FDA to treat Type 2 diabetes and were later approved by the FDA for chronic weight management. They work by increasing insulin secretion, decreasing glucagon secretion, slowing gastric emptying, and regulating appetite—ultimately reducing food intake and increasing satiety, resulting in weight loss. Since they were first developed in the early 2000s, these medications have evolved to become more potent and are associated with greater weight loss than earlier versions. Use of GLP-1 agonists has risen rapidly in recent years: roughly 1 in 8 American adults (about 12%), or over 30 million people, currently use a GLP-1 medication, with as many as 18% reporting having tried one at some point.

Due to their appetite-suppressing qualities, GLP-1 drugs can produce real benefit in treating binge-eating disorders. While current data is somewhat limited, a systematic review of five studies with 182 participants found that GLP-1 agonists produced significantly greater weight loss, lower BMI, and reduction in waist circumference compared to controls.

A Pitfall for Restrictive Eating Disorders

But there is another side to the GLP-1 conversation related to eating disorders. Emergent research suggests that individuals may be using GLP-1 agonists to maintain restrictive eating disorders such as Anorexia Nervosa (characterized by extreme restriction of calorie intake) and Bulimia Nervosa (characterized by periods of binge eating followed by purging, strict dieting, or over-exercising) through rapid dietary restriction and weight loss.

This is not a minor concern. Anorexia Nervosa has the highest mortality rate among neuropsychiatric disorders, causing the deaths of roughly 5% of those affected within four years of diagnosis.

I have personally heard of these concerns from my fellow physicians. One colleague of mine living in a major city in the south recently told me of a patient who had started a GLP-1 and experienced a sudden change in her eating disorder. She had previously suffered from Bulimia Nervosa, but after starting on the GLP-1, her disorder changed to Anorexia Nervosa. While both disorders can be life-threatening and must be taken seriously, Anorexia Nervosa is considered more dangerous due to the rapid onset of physical deterioration associated with it.

Atypical Anorexia can also pose a challenge to physicians prescribing GLP-1 agonists. Atypical Anorexia Nervosa occurs when a person with Anorexia Nervosa remains at a weight in the normal range despite substantial loss. In other words, patients with Atypical Anorexia may present with obesity and medical co-morbidities, and physicians may misdiagnose them as having a Binge Eating Disorder and prescribe a GLP-1.

Finally, some evidence suggests that GLP-1 medications may trigger latent eating disorders. One physician described a patient who had recovered from Anorexia Nervosa ten years prior and had a full relapse after being prescribed a GLP-1, requiring hospitalization.

Overall, there is a documented rise in eating-disorder-adjacent presentations tied to GLP-1 use, concentrated in restrictive-type disorders and in relapse of previously recovered patients. In a recent study, 10% of people with eating disorders reported misusing GLP-1 drugs, and 9.9% admitted to using compounded products (or non-brand-name products, which exist in a regulatory gray zone) in order to achieve weight loss. But the overall data is still lacking—most current evidence is in the form of case reports, clinician surveys, and adverse-event data rather than population-level studies.

The Mental Health Angle

Thus GLP-1 drugs sit at a genuine clinical crossroads—they demonstrate real benefit for binge-type disorders and real risk for restrictive ones. And while GLP-1 agonists are not available over the counter, the barriers to acquiring them via prescription may put patients with restrictive eating disorders at risk.

The drugs themselves may also cause adverse mental health events as side effects. One study found 372 psychiatric adverse event reports (1.18% of all reports) associated with GLP-1 agonists, prompting an investigation by the European Medicines Agency into safety concerns. At the same time, however, regulators (including the FDA) ultimately didn’t confirm a causal link, and the broader psychiatric literature shows a modest antidepressant-like effect in some populations. Overall, findings are constrained by limited sample diversity, variable outcome measures, and consistent underrepresentation of individuals with psychiatric illness in the major trials.

Eating Disorders in Minority Populations

Minority populations also deserve far more attention in GLP-1 research. It is a persistent myth that restrictive eating disorders are absent among minority populations. Although Anorexia Nervosa is diagnosed less often in Black and Hispanic populations than in white populations, some researchers attribute this to underdiagnosis rather than true lower incidence—which means that some populations of color are less likely to be diagnosed or treated for Anorexia Nervosa despite having the same or similar symptoms.

There are no studies yet exploring the possible misuse of GLP-1 agonists for restrictive eating disorders among people of color—and given the risk of underdiagnosis for these populations, this should be flagged as a research gap.

A Call for Mental Health Screening

GLP-1 agonists are a genuinely useful drug class that can be therapeutic for one disorder and destabilizing for its near-neighbor. It is imperative, therefore, that psychiatric screening, not just BMI or waist circumference, play a role in prescription. Physicians should evaluate patients for mental disorders, focusing on restrictive eating disorders, before moving forward with prescription. They should also be on the lookout for atypical anorexia and ensure that racial bias is not coming into play.

In addition, further research, long-term studies, and clinical trials for these types of drugs must take patients with restrictive eating disorders into account. Finally, official data must be gathered as soon as possible to determine whether these drugs have led to an increase in restrictive eating disorders, especially in underserved or overlooked populations.

The Lindsay Clancy trial is going to wrap up in the next few days, but unfortunately, that won’t be the end of the journey for Lindsay Clancy.

Psychosis is something that is hard for people to understand who haven’t experienced it (which is most of us). And Lindsay Clancy was in the throes of a postpartum psychosis, which means that her mind had aberrations—like delusions, false beliefs, and hallucinations, hearing voices that weren’t real. But in the throes of a full-blown psychosis, your internal reality becomes your external reality. And the things that she heard and thought, she felt compelled to follow. She was receiving “communications” that were command hallucinations and delusions about how her children were going to be possessed by the devil and she needed to kill them to protect them.

Psychosis is like a rheostat, not like an on/off switch, meaning that when its symptoms are mild, they’re in the background—but when it’s full blown, they take you over; you become fully in their possession and under their control.

Now, the next thing was that her clinical care in the system failed her. First, her OBGYN may have noticed that she was having some symptoms or listened to her complaints. But the question was, how does the OBGYN ensure that she gets good reproductive psychiatry care? And that’s where things broke down. She had a lot of doctors involved—too many cooks in the kitchen—but nobody was taking charge. Nobody was the overall quarterback for this. And as a result, she received multiple medications—and actually not the right medications, because she was having a psychosis, and she only had one brief trial of an antipsychotic drug. The rest of the medications she received were anti-anxiety medications or antidepressant medications or sleep medications. And those were given at sub-therapeutic doses and for not long enough periods of time. So she really didn’t have a chance because she was receiving the wrong medications to counteract her symptoms.

And finally, what will happen is that even if she does get an NGRI (not guilty by reason of insanity) verdict—which she deserves because she’s more the victim of her illness and the system’s failures than she is a perpetrator of something—that’s not going to be the end of it because she will then be remanded to a state forensic psychiatric hospital, which is akin to being in a correctional facility. The criteria for her to be discharged would be when she’s no longer a danger to herself or the community. But that criteria may not be applied until months or years after she’s been there.

It’s a shame, because this is something that happens with recurrence and is totally identifiable and totally predictable. It’s the system that is inadequate to meet the demands of pregnant women, both during and after pregnancy, who suffer from it.

A Decline in Lethal Human Violence

The history of humankind has been impressive in all respects, including first and foremost the one that I’m involved with as a physician—advances in medical science. And civilization has progressed in a way that has made things better for people: given them a better quality of life, extended life expectancy, and also kept them safe and protected. In other words, the likelihood in the modern age of somebody having their life foreshortened by lethal violence from war, crime, assault, and robbery is less than ever in human history.

Believe it or not, this is the safest time in human history to be living—knowing that your life may end because of an accident or a disease, not because of some lethal form of violence.

Now, violence is the manifestation of an inherent drive in human beings: aggression. Aggression was adaptive, at least in ancient times, because we needed shelter, we needed food, we had to protect our families. But over the advances of civilization, with laws, with ethics, with government, with law enforcement, with better living conditions, we’ve sublimated this aggression into adaptive forms like competition in sports, achievement through professional activities, discovery through science and engineering, and all kinds of other things that provide new technology.

That adaption has kept us safer than before. And if you need proof, you can look at the data—since ancient times to the present, the likelihood of somebody’s life ending from lethal violence is lower than ever before.

The only time that it has shown a rise has been in the 20th century with World War I and World War II. So this is really another manifestation of the advances of civilization and how they have been salutary for humankind.

There’s one exception, however—and that’s something called Personal Deviant Violence.

Personal Deviant Violence is a term that my colleagues and I are using to encompass specific forms of violent behavior that are lethal.

Types of Personal Deviant Violence

The main type of personal deviant violence that we’re hearing about now is called personal mass violence—defined by law enforcement agencies such as the FBI as a single perpetrator, more than three victims, a motive that is mysterious or unknown, and the victims generally being either strangers or people that don’t have a clear connection to the perpetrator.

In addition to mass violence, the other types of personal deviant violence that we talk about are:

Intra-family violence, such as parricide, as in the tragedy with Rob Reiner and his wife from their son Nick; or infanticide, such as occurred tragically with Andrea Yates, the woman in Texas who drowned her five children under the influence of her psychotic symptoms.

There’s political violence, of which President Trump has been a victim in his term.

There’s a form of severe stalking that can occur.

And then probably the most notorious of all is serial killing—as exemplified by David Berkowitz, the .44 caliber killer, Son of Sam; the Zodiac Killer; the Boston Strangler; and Jeffrey Dahmer, the cannibal. These are instances which occur much less frequently now. They peaked in the late 80s and 90s, and our culture is given the credit for why this is happening less than before. Because thinking back to the 80s, this is the era of political strife in the aftermath of the counterculture, which also produced people like Charles Manson. So these have subsided, but in their place, personal mass violence and familicide have risen dramatically.

And even though the overall arc of lethal violence has decreased, these types of violence are being stimulated by our culture and by the degrees of freedoms that are given to people. And then in the United States, they’re amplified in their lethality by the ready access to firearms, including assault weapons.

Now when these things occur, there’s tremendous penetration of the media and reaction by the public of, “This is horrid. How could this possibly happen? We don’t get it. This has got to stop.” But after that, people move on with the 24-7 news cycle, and they regard these as kind of unpredictable, non-understandable acts of fate or freaks of nature—like you’re driving down a road and your car goes over some stones and one of the pebbles is propelled by the tires into the windshield and your windshield cracks—something you couldn’t avoid. Or you’re on a golf course and a thunderstorm begins and there’s a lightning strike.

But these are not acts of nature; they are not unpredictable, they are not unforeseeable, and they are not unpreventable. These forms of violence are the ones that have eluded the civilizing effect that has occurred in our society over the various millennia that humankind has existed. These are understandable, foreseeable, the individuals who are vulnerable to them are identifiable—and therefore they are preventable.

But instead, we’re turning into a gulag. We’re turning into a correctional system where we have metal detectors in every building we enter, or we have searches of our bags. We’re not looking at the reasons for this violence and how it can be stopped. We’re simply listening to the grisly stories to titillate us. And that is the fault of the media––they tell the story and entertain but without informing the public.

And so we’re calling on media and the government to pay attention to the fact that these instances are increasing dramatically. In fact, the Gun Violence Archive counted more than 400 mass shootings in 2025—defined as any incident in which four or more people are shot. That's more than one a day.

This is inconceivable and intolerable. And if there were nothing that we could do because this is simply like global warming or some other type of inexorable process that is so complicated we haven’t been able to figure out a solution to it, then so be it.

But it’s not.

And as psychiatrists, we’re calling upon the institutions of society that are positioned to influence the factors which are stimulating these behaviors to think about this—and to take steps to try and eliminate these causal or accelerant factors.

In the span of three months, psychedelic medicine crossed two important thresholds.

In April, President Donald Trump signed an executive order making it federal policy to accelerate psychedelic research and “appropriate drug approvals” for serious mental illness. Then, in July, Eli Lilly agreed to acquire AtaiBeckley, a biotechnology company developing psychedelic and psychedelic-derived treatments, for approximately $2.8 billion upfront and as much as another $1 billion if specified clinical and regulatory milestones are reached. AtaiBeckley’s lead candidate is an intranasal formulation of mebufotenin benzoate, a synthetic form of 5-MeO-DMT, which is being developed for treatment-resistant depression. The transaction has been announced but has not yet closed.

These developments are understandably being read as validation of the field. But they validate two things more clearly than they validate the medicines themselves: that the federal government wants development to move faster, and that a major pharmaceutical company believes the commercial opportunity is substantial.

Neither political commitment nor market valuation is a scientific verdict.

That distinction matters because psychedelic therapies may indeed become important treatments. Patients with treatment-resistant depression, post-traumatic stress disorder, substance-use disorders, and other disabling illnesses urgently need better options. The current evidence contains credible signals of benefit, and those signals justify serious investment and accelerated research.

But urgency is not the same as haste. The American Psychiatric Association, while welcoming federal support for research, responded to the executive order by emphasizing that the scientific evidence remains inadequate to endorse psychedelic treatments for psychiatric disorders outside approved investigational studies. It called for trained clinicians, controlled settings, and the same scientific and ethical standards applied to other promising medicines.

The central problem is not that psychedelic drugs have been proven ineffective or unacceptably dangerous. It is that their effects are unusually difficult to evaluate—and unusually difficult to separate from the circumstances in which they are administered.

Consider blinding, one of the foundations of a reliable clinical trial. In an ordinary drug study, neither patients nor investigators are supposed to know who received the active medication and who received the placebo. But a person who undergoes an intense alteration in perception, emotion, or sense of self will often know that an active psychedelic has been administered. The therapist may know, too.

A study may therefore be double-blind on paper while being functionally unblinded in practice. Participants who believe they received the active treatment may expect to improve. Those who believe they received the placebo may become disappointed or disengaged. Therapists and evaluators can also be influenced, consciously or not, by their assumptions about treatment assignment. FDA reviewers identified this problem explicitly during their assessment of MDMA for PTSD, observing that the drug’s acute effects made blinding nearly impossible and created a risk of expectancy bias.

Then there is the question of what the treatment actually is.

Many psychedelic protocols combine a drug with preparatory meetings, hours of monitored administration, psychological support, and post-session “integration.” These elements may be essential to safety and perhaps to efficacy. But they also make it difficult to determine whether improvement results from the molecule, the psychological intervention, the therapeutic relationship, expectancy, the carefully constructed environment—or some interaction among them.

This is not an academic distinction. Regulators, clinicians, and insurers need to know what they are approving, delivering and paying for. Is it a drug? A drug-plus-psychotherapy package? A highly specialized clinical service? Could the same results be reproduced by ordinary treatment centers, or do they depend on unusually committed investigators and carefully selected participants?

The FDA’s review of MDMA-assisted treatment offers a cautionary case. Published Phase 3 trials had reported clinically meaningful improvements in PTSD. Yet the FDA subsequently concluded that the application did not provide substantial evidence of effectiveness or establish adequate safety for approval in its submitted form. The agency raised concerns about incomplete collection of events relevant to impairment and abuse potential, uncertainty about durability, unusually high prior MDMA exposure among participants, possible selection and expectancy bias, and the representativeness of the study population. It recommended another randomized trial with blinded long-term follow-up.

That decision did not prove that MDMA cannot work. It showed that positive symptom scores do not settle every question that matters.

Durability is especially important. Depression, PTSD, and addiction are generally chronic or recurrent disorders. An improvement lasting several weeks may be valuable, but it does not by itself tell clinicians when patients should be retreated, which patients are likely to relapse, what maintenance care they will require, or whether repeated exposure changes the benefit-risk balance. Long-term studies must assess functioning, hospitalization, suicidality, substance use, employment, relationships, and quality of life—not merely changes on a symptom scale.

Safety also cannot be inferred solely from the relatively low rate of catastrophic events in small, highly screened trials. Research participants are commonly selected to exclude people with psychosis vulnerability, bipolar-spectrum illness, unstable substance use, significant cardiovascular risk, or complicated medication regimens. Yet many of the patients who seek these treatments after approval—or outside the medical system—will have exactly those characteristics.

Medication discontinuation adds another layer of risk. Patients may be asked to taper antidepressants or other psychiatric drugs before receiving a psychedelic. That taper is not an administrative detail. It can produce withdrawal symptoms, relapse, suicidality, or destabilization and should be studied and monitored as an active clinical intervention.

The word “psychedelic” itself can obscure more than it clarifies. Psilocybin, 5-MeO-DMT, MDMA, ketamine, and ibogaine are not interchangeable versions of the same treatment. They differ in receptor pharmacology, subjective effects, duration, cardiovascular risk, abuse liability, therapeutic rationale, and required medical infrastructure. Ibogaine’s arrhythmia risk, for example, creates fundamentally different monitoring requirements from those associated with psilocybin. Policy that treats all of these compounds as one therapeutic movement risks flattening clinically consequential differences.

President Trump’s order does not, in its text, direct the FDA to approve a particular drug or discard statutory approval requirements. It establishes priority pathways, supports a Right to Try mechanism, orders greater federal-state and public-private collaboration, allocates at least $50 million for such efforts, and seeks faster consideration of rescheduling after successful Phase 3 development. It also specifies that timely approvals remain for drugs meeting the standards of the Federal Food, Drug, and Cosmetic Act.

That qualification should govern implementation. Acceleration should mean removing needless administrative delay, improving interagency coordination, and generating better evidence more efficiently. It should not mean lowering the evidentiary threshold because the illness is serious, the political leadership is enthusiastic, or investors have already assigned a multibillion-dollar value to the field.

Lilly’s involvement could bring substantial benefits. Large pharmaceutical companies have resources for manufacturing, multicenter trials, regulatory science, and pharmacovigilance that smaller biotechnology firms often lack. But the deal also illustrates how financial expectations can become attached to regulatory milestones. Part of the contingent consideration is tied to the initiation of a Phase 3 trial and to eventual FDA approval and DEA rescheduling of AtaiBeckley products. That is normal transaction design, but it underscores why regulators and investigators must remain insulated from market narratives of inevitable success.

Before widespread approval, pivotal trials should formally measure whether participants, clinicians, and raters correctly guessed treatment assignment. Psychological-support models should be defined, monitored for fidelity, and subjected to independent oversight. Longer follow-up should establish relapse rates, retreatment needs, and functional outcomes. Adverse-event systems should capture not only experiences labeled unpleasant but also apparently “positive” effects relevant to impairment or abuse potential. Therapist credentialing, boundaries regarding touch, session recording, grievance procedures, site accreditation, and emergency protocols should be treated as core patient protections rather than optional professional customs.

Approvals may also require postmarketing registries and risk-management programs capable of detecting uncommon psychiatric, medical, and interpersonal harms. And policymakers should distinguish FDA approval of a particular product for a particular indication from decriminalization, state service-center programs, retreats, microdosing, and the broader wellness market. These are different systems making different claims and offering different protections.

Psychedelic medicine does not need another cycle of extravagant promise followed by scandal and retrenchment. It needs disciplined translation.

Caution is not an argument for prohibition. Nor is it indifference to patients who are suffering. It is the discipline required to prevent enthusiasm from outrunning knowledge—and to ensure that genuinely effective treatments survive the consequences of premature commercialization.

Patients deserve urgency. They also deserve evidence strong enough to bear the weight now being placed upon it.

We should hasten slowly—but hasten we must.

A version of this post originally appeared in Psychology Today.

In this Shrink Short, Dr. James McKnight unpacks why stigma translates into lower treatment rates for Black, Latino, and Asian American adults. Drawing back on Shrink Speak Shorts: The Mental Health Gap for People of Color Part 1: Lack of Workforce Representation, Dr. McKnight argues that stigma reduction and workforce diversity aren’t separate fixes but interlocking solutions—each reinforcing the other in the effort to make mental health care feel like basic care, not a last resort.

I vividly recall a discussion in which I participated regarding a young man whose story has troubled me ever since. He was a promising third-year college student at Winston-Salem University. Intelligent. Motivated. The kind of young person with every reason to expect a bright future.

He volunteered to participate in an LSD research study.

Shortly afterward, he developed psychosis.

Whether the psychedelic directly caused the illness, precipitated an illness that would have otherwise emerged later, or interacted with some vulnerability we still do not understand, the outcome was devastating. He never fully recovered, eventually leaving college as his life took a dramatically different course.

As psychiatrists, we know that psychosis is rarely explained by a single factor. Genetics play an important role, but they are only part of the picture. Brain development, environmental stressors, sleep deprivation, previous substance use, individual differences in brain chemistry, and chance may all contribute. Psychedelic drugs may also act as a trigger in susceptible individuals—even those with no known family history of schizophrenia or other psychotic disorders.

In this young man’s case, there was no known family history of psychosis. The only obvious risk factor was one we recognize all too well: he was a young man in the age range when schizophrenia and related disorders most commonly first appear.

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His story has remained in the back of my mind, and it came rushing back unexpectedly during a very different experience.

Recently, my wife and I decided to try THC gummies that had been marketed as a sleep aid. What followed surprised me. Instead of becoming sleepy, I became profoundly paranoid. I began hallucinating—at one point, clothes draped over a chair transformed into what looked like a “friendly lion.” I developed irrational beliefs that I might be dying. Waves of fear alternated with deep despair. At one point, I was convinced I was on the verge of a panic attack. Holding onto my wife and reminding myself that someone I trusted was beside me helped keep me grounded.

The experience lasted nearly eight hours.

Intellectually, I knew what was happening. I am a psychiatrist. I understood that the THC was altering my perception and that these frightening experiences were drug-induced. But understanding something and believing it in the moment are two very different things.

During those hours, I kept thinking about that young man from Winston-Salem University.

What if my brain never bounced back?

What if this wasn’t temporary?

Fortunately, it was. By the next day, I felt like myself again.

I also recognize that I made a mistake. The gummy contained 15 milligrams of THC, and the manufacturer recommended starting with one-quarter to one-half of that dose. I took the entire gummy.

Even so, the experience reminded me how dramatically people can respond differently to the same substance. My wife took the identical dose. She experienced far more than a pleasant buzz, but nothing approaching the paranoia, hallucinations, or terror that I experienced. That variability is exactly what concerns me.

As psychedelic therapies move closer to FDA approval for certain psychiatric conditions, we should absolutely follow the science wherever it leads. If these treatments prove to be safe and effective for carefully selected patients under appropriate medical supervision, they may become an important addition to psychiatric care.

But approval is not the finish line. It is the beginning of a much larger responsibility.

Once treatments become commercially available, there is always pressure to expand access. Clinical protocols that are carefully followed in research settings may not be followed as rigorously in everyday practice. Patients may receive inadequate screening for risk factors such as a history of psychosis or bipolar disorder. Some individuals may assume that because a substance is FDA approved, it is safe for everyone. Others may seek higher doses, combine psychedelics with other drugs, or use them outside the therapeutic settings in which they were originally studied.

We have seen versions of this story before with opioids, benzodiazepines, stimulant medications, and increasingly potent cannabis products. Scientific promise can coexist with real risk, particularly when treatments move from controlled research environments into widespread use.

That is why the research matters so much.

Clinical trials cannot simply demonstrate that psychedelics work for the average participant. They must also help us identify who benefits, who does not, and who may be harmed. They need to include participants from diverse racial and ethnic backgrounds, different ages, both sexes, people with varying medical histories, and individuals from different socioeconomic and cultural backgrounds. Diversity in research is not about checking boxes—it is about ensuring that findings are applicable to the patients we actually treat. Differences in genetics, metabolism, coexisting illnesses, environmental exposures, and access to care can all influence both effectiveness and safety.

Just as importantly, we need long-term follow-up. Most clinical trials tell us what happens over weeks or months. Psychiatry often requires us to think in years. If a treatment carries even a small risk of precipitating persistent psychosis in susceptible individuals, we need to understand that risk before the treatment becomes commonplace—not after.

The young man from Winston-Salem reminds me that behind every discussion of policy or drug approval is a human life. His experience does not prove that psychedelics are inherently dangerous, nor should it be taken as evidence that they have no therapeutic value. But it does remind us that caution is not the enemy of innovation. It is what makes innovation worthy of the trust we place in it.

Let’s not put the cart before the horse. Science should lead the way—and it should do so carefully, transparently, and with the humility to recognize what we still do not know.

People of color face mental health challenges at high rates — and get treatment far less often. Why?

In this Shrink Short, Dr. James McKnight breaks down one major piece of the puzzle: who’s actually in the room providing care. From the makeup of Assertive Community Treatment (ACT) teams to the “leaky pipeline” that pushes providers of color out of the field over time, this episode digs into the reasons representation gaps persist in psychiatry — and why closing them isn’t just symbolic, but clinically essential.

Some of the numbers may surprise you.

Dr. McKnight brings more than three decades of experience in working with underserved populations in urban settings and is deeply committed to expanding the scope of services and improving the standard of care.

A graduate of the Morehouse School of Medicine, Dr. McKnight did his post-graduate training at Emory University Medical System. Dr. McKnight’s career in New York City has predominantly focused on Harlem, one of the communities where the gap between mental health need and mental health access is most acutely deficient. He is Board Certified in adult, child, and adolescent psychiatry with clinical expertise spanning depression, bipolar disorder, schizophrenia, ADHD, mood disorders, and substance use.

Dr. McKnight’s background aligns closely with the mission at the heart of ARETÉ Science: the belief that comprehensive, high-quality mental health care should be available to every American, regardless of background or circumstance. His work in an underserved urban community speaks directly to the treatment gap our organization was founded to close.

ARETÉ Science was founded with a mandate to eradicate stigma, promote awareness, and ensure access to quality care for the roughly 70 million Americans living with mental health and brain disorders. Dr. McKnight joins a mission-driven team working across three stages of action: galvanizing public awareness, driving policy reform, and ultimately ensuring accessible, quality care for all.

We are fortunate and glad to have him with us.

But pulling the rug out from under the science is not the right answer. And unfortunately, that’s the strategy with which our current Secretary of Health & Human Services, RFK Jr., is toying.

Rather than pursuing meaningful reforms, MAHA has aligned itself with the anti-psychiatry movement—a movement that has contributed significantly to the gaps in mental health care that persist today.

Watch the full Shrink Short to learn more.

The landscape today has changed considerably – yet challenges to successful treatment persist.

Following our previous episode examining Bipolar Disorder for World Bipolar Day, the latest Shrink Short delves into the current treatment options available and the obstacles that continue to stand in the way of lasting stability.

Watch the full episode to learn more.

But awareness is not treatment. And compassion means little when people with untreated severe mental illness are left to sleep on sidewalks, cycle through emergency rooms, languish in jails, or die prematurely from neglect, exposure, suicide, addiction, and preventable disease.

America tells itself a reassuring story about mental illness: that have we moved beyond the cruelty of the old asylums. We have embraced civil liberties. We have replaced coercion with humane community care.

But that story is only partly true. We dismantled a deeply flawed system, but we failed to build an adequate one in its place.

The result is a new form of cruelty—neglect dressed up as freedom, abandonment disguised as compassion.

Across the country, people with untreated schizophrenia, bipolar disorder, severe depression, and other serious psychiatric illnesses are left at the mercy of diseases that can impair judgment, distort reality, and destroy their very capacity to seek help. Families plead for intervention and are told there is nothing to be done. Doctors are constrained by law, liability, bed shortages, and bureaucracy. Police officers become the default responders to psychiatric crises they are not trained for.

And too often, intervention comes only after deterioration has become catastrophe.

We call this “respect for autonomy.” But autonomy means little when illness has robbed a person of the ability to recognize that he is ill. Freedom cannot mean the right to freeze under an overpass, scream at invisible tormentors, or descend into psychosis while everyone with the power to help waits for disaster before they can intervene.

This is not freedom. It is abandonment.

Abraham’s Story

The New York Times recently published a heartbreaking guest essay titled, “Why Is My Son Being Left to Die on the Streets?” In it, a mother describes watching her adopted son, Abraham, descend into schizophrenia after displaying erratic behavior during his senior year of high school.

Like many people with schizophrenia, Abraham did not believe he was ill. He could not be persuaded to accept treatment. But because he was 18—a legal adult—his family had little power to intervene. His parents could see the danger. They could see the illness. They could see the disaster ahead.

The law saw only an adult exercising his rights.

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That is the terrible paradox at the center of our mental health system: at the moment a person may be most impaired, most vulnerable, and most in need of protection, the people who love him most are often stripped of the ability to help.

Under current law, families like Abraham’s are frequently forced to wait to seek help until a loved one becomes an imminent danger to himself or others. Even then, involuntary hospitalization is often brief. Continued treatment may require court approval. Long-term psychiatric beds are scarce. Residential treatment options are limited. Community-based services are overburdened. The promise of deinstitutionalization—that people would receive comprehensive care in the community—was never fulfilled at the scale required.

Federal policy has made the problem worse. The IMD exclusion, a provision of the Social Security Act, restricts Medicaid funding for many psychiatric facilities with more than 16 beds, limiting access to the structured, sustained care that some severely ill patients need.

So families hear the same refrain again and again: “There is nothing we can do.”

But that is not true.

There is much we can do. We simply have not chosen to do it.

The Civil Rights Failure of Our Time

Fear, stigma, misunderstanding, and rigid legal doctrines have produced a system that fails the sickest patients most consistently. Privacy laws can keep families in the dark. Hospitals discharge patients before they are stable. Communities lack adequate outpatient services. Courts often act only when a crisis has already arisen.

Worst of all, people who lack insight into their own illness are treated as though they are freely choosing the conditions of their own destruction.

This is why untreated severe mental illness is one of the great civil rights failures of our time.

Over the past century, powerful movements have fought discrimination based on race, gender, religion, disability, and sexual orientation. Those struggles expanded our understanding of dignity and justice. Yet people with severe mental illness remain among the most neglected members of society, their suffering obscured by stigma, legal abstraction, and a distorted absolutism about autonomy.

We have mistaken the right to refuse care for the right to be free.

True freedom does not mean the right to deteriorate untreated on the street. It means the right to timely, humane, medically appropriate care. It means access to effective medication, psychotherapy, rehabilitation, supported housing, assertive community treatment, assisted outpatient treatment when necessary, and inpatient or residential care when independent living is impossible.

It means acting before a family is destroyed, before a person is incarcerated, before violence erupts, and before suicide becomes the final symptom of public indifference.

A Moral Reckoning

The squalor and abuses of the old asylum system were real. They must never be repeated. But the answer to past cruelty cannot be present-day abandonment. The answer to wrongful confinement cannot be to let people “die with their rights on.”

We need more psychiatric beds. We need serious reform of the IMD exclusion. We need stronger community treatment systems. We need laws that permit earlier intervention when severe illness destroys a person’s capacity for self-protection. We need to involve families while preserving due process. And we need policymakers to recognize untreated psychosis for what it is: not an expression of liberty, but a medical emergency.

Mental Health Awareness Month should be more than a season of slogans. It should be a summons.

A summons to build the system we promised when we emptied the institutions.

A summons to defend those who cannot defend themselves.

A summons to stop calling neglect compassion.

The question is not whether we care about people with severe mental illness. The question is whether we have the courage to act before their suffering becomes irreversible.

For Abraham, his family, and thousands like them, that courage is already long overdue.

Although the world is less violent than it has ever been by nearly every measure, this form of violence is rising exponentially.

It is characterized by distorted thinking, emotional dysregulation, an irrational magnification of grievance, and the erosion of the internal and external restraints that keep people from acting on their worst impulses.

It is perpetuated by the lack of a functional mental health system.

And it’s driving much of the violence we see in our headlines.

Watch the full Shrink Short to learn more.

The latest Shrink Short breaks down the recent executive order directing federal agencies to fast-track psychedelic drug review — an order reportedly prompted by a text from podcaster Joe Rogan to the president. While the enthusiasm around drugs like ibogaine is understandable, the existing data falls far short of what’s needed for approval, and bypassing rigorous clinical trials puts patients at serious risk.

The psychedelics conversation is heating up — but are we repeating the mistakes of the cannabis era? A sobering parallel to medical marijuana, which moved through ballot boxes instead of the FDA, is evident; once commercial interests take hold, safety safeguards tend to lag behind. Not all “psychedelics” are the same, the science is still catching up, and the people who pay the price for premature policy are patients — not investors or podcast hosts. Watch the full Shrink Short to learn more.

But there is one form of violence that has not declined—rather, in the modern era, it has exploded. We call this phenomenon personal deviant violence.

Personal Deviant Violence

Personal deviant violence, which emerged in the twentieth century and continues to rise with alarming rapidity, encompasses serial murders, familicide, violent stalking, and mass murder. While these forms of violence are ostensibly different, they share common characteristics and an underlying basis. These crimes are not carried out by armies, tribes, gangs, or organized movements. Rather, they are committed by solitary individuals—often against strangers, sometimes against family members—against targets of a distorted obsession or delusional fixation. The motives are often mysterious, incoherent, theatrical, imitative, or nihilistic.

Personal deviant violence is not a random accident of history, nor is the phenomenon an incomprehensible mystery. Rather, it is the predictable outcome of cultural and social changes that took hold in the latter half of the twentieth century and have accelerated in the twenty-first. These forces exploit psychological vulnerability and act in concert with deficient and dysfunctional mental health policies and care systems. They are further enabled in an environment with liberal access to addictive recreational intoxicants and high-powered firearms. And they are spurred on by eroded restraint, the potential for glorification of grievance, and the celebration of notoriety. The recipe for this volatile brew is unmistakable: The brain supplies the vulnerability. Culture inflames it. Society tolerates it. And the mind unravels, leading to violence.

Consequently, we face a national crisis approaching epidemic proportions that demands insightful analysis, unflinching understanding and reasoned action—not slogans, denial, political exploitation, or moral evasion.

Violent Stalking

The least lethal and most infrequently described form of personal deviant violence is violent stalking, defined as an obsessive fixation on a specific person, frequently a public figure.

Perhaps the archetype of the violent stalker is John Hinckley, Jr., whose assassination attempt of President Ronald Reagan in 1981 was driven by his delusional infatuation and relentless efforts to gain the attention and win the affection of the actress Jodie Foster after seeing her in the movie “Taxi Driver.” Thankfully, violent stalking is usually accompanied by enough broadcasting from the perpetrator that it can be stopped before it results in fatalities.

Serial Murder

Serial killers have long existed in human societies. From Jack the Ripper to Albert De Salvo (the Boston Strangler), the Zodiac Killer, Ted Bundy, John Wayne Gacy, Jeffrey Dahmer, and David Berkowitz—the “44 caliber killer”—these offenders kill repeatedly over time, often for reasons rooted in sexual attraction, paraphilia, psychopathy, or delusional belief. These types of crimes are sensational and incite extreme emotional reactions from the public. Their frequency has waxed and waned over time, and DNA evidence has proven an inhibitor in the modern era.

Intrafamilial Homicide

Familicide or intrafamily violence can take a variety of forms including parricide (children killing parents), fratricide (killing siblings), and infanticide (parents killing children). This type of personal deviant violence has become more common of late, although it rarely makes the headlines. Motives are often fueled by substance abuse, psychosis, or psychological vulnerability.

Personal Mass Violence

The most visible—and fastest growing—form of personal deviant violence is personal mass violence. As defined by the FBI, personal mass violence is the killing of multiple people by a single perpetrator for irrational, exaggerated, or grievance-fueled motives.

The rise in this terrifying form of violence began in 1966, when Charles Whitman murdered his wife and mother before he armed himself with his hunting rifle, climbed to the top of the University of Texas Tower, and shot at strangers for 96 minutes, killing 16 and wounding 49 people. Since the tragedy of the “Texas Tower Sniper,” the United States has experienced an accelerating rate of such incidents—indeed, they have become so frequent that they begin to blur into each other. Each additional massacre shocks the nation anew, is etched in our collective national memory, and adds to our growing psychic toll. We don’t become inured to news of these events, however. On the contrary, we become sensitized, meaning that the next attack hits harder because it lands atop accumulated fear and worry.

The following is a representative list of the range of carnage that personal mass violence has inflicted on American society.

The Paradox of Fear

The rise of personal deviant violence goes against the grain of human history. It is at once anomalous and paradoxical—an aberration that defies civilization’s long march toward greater safety and civility. For even as the objective risk of dying violently has fallen to historic lows, our collective fear of violence has never been more acute. The paradox sharpens further when one considers that these acts account for less than a fraction of 1% of all lethal violence, yet they exert influence far beyond their statistics. Their power lies not in their numbers, but in their nature.

Striking without warning, in places once considered ordinary and safe, they select victims at random and often without discernible motives. In doing so, they introduce a pervasive uncertainty into daily life—the unsettling sense that danger is no longer bounded by place, time, or reason.

The effect is disproportionate and profound: communities are terrorized, public spaces elicit phobic fear and apprehension, and a steady drumbeat of media-driven spectacle leaves the national psyche on edge, its sense of safety insidiously eroded.

Breaking the Cycle: Diagnosing and Curing the Problem

The forms of personal deviant violence appear different in their outcomes, and their perpetrators differ in biography and ideology. Some wrap themselves in religious or political rhetoric. Others are consumed by grievance. Still others have descended into psychosis. But beneath the surface distinctions lies a shared mental architecture: distorted thinking, emotional dysregulation, grievance magnification, and the erosion of internal restraints—interacting with a culture that amplifies outrage, rewards spectacle, and makes lethal tools easily accessible.

Personal deviant violence in America is no longer rare enough to shock us into sustained action, yet it is not common enough to feel preventable. Each new attack ignites outrage, debate, and paralysis—until the next one arrives. As incidents accelerate in frequency and lethality, public spaces feel increasingly fragile and institutional responses increasingly reactive. We are trapped in argument while the pattern intensifies. We continue to treat each attack as an isolated tragedy when they are not. Personal deviant violence is a repeated pattern that can be understood, foreseen, and prevented.

For sixty years, we have debated guns, media, ideology, and policing. Those debates matter. But they orbit a deeper question we have avoided: why do certain vulnerable individuals in modern America cross the line from alienation to annihilation? Until we confront that question directly—socially, culturally, clinically, and systemically—the cycle will continue.

Yet the shift from prohibition to widespread medical and recreational use has not come without consequences. Emerging evidence suggests a range of unintended public health risks, particularly for younger users. As other psychoactive substances are now being considered for medical legalization, it is essential to reckon with the lessons learned from marijuana’s rapid expansion—and to proceed with greater caution and clarity.

Watch the latest Shrink Speak Short to learn more.

In deciding where to apply and which colleges to attend, students weigh numerous factors, including the quality of faculty and curriculum, appearance of the campus, the prestige and reputation of the university, cost and availability of financial aid, the nature of campus social life, and even the caliber of the sports teams. The one area that students and their parents will likely fail to take into account, however, is the quality of the school’s mental health services—an omission that could have serious consequences in the years ahead.

Why should access to quality mental health services matter when students are deciding where to attend college? The simple answer is that the college years and student experience are closely aligned with the onset of mental disorders in young people. Depression, schizophrenia, bipolar anxiety, and eating and substance use disorders all commonly develop in adolescence and young adulthood. When you combine this reality with the stresses of today’s college environment, you end up with a substantial number of students who may well need mental health care during the period of their college education.

This situation is borne out by the fact that approximately 30 percent of matriculating college students are taking psychotropic medications. College entails circumstances and experiences that many students will encounter for the first time—being away from home and independence from parents, rigorous academic demands, exposure to recreational drugs and alcohol, and sexual freedom. This novel and challenging environment is complicated by the increased frequency of on-campus physical and sexual violence as well as the rising occurrence of self-harmful behaviors and suicide.

Moreover, young people today must contend with stressors that previous generations never encountered at this scale or intensity. Heavy social media use has been consistently linked to poorer mental health among young adults, including depression driven by social comparison, disrupted sleep, and emotional burnout. At the same time, a 24/7 media environment—shaped by algorithms designed to maximize engagement—delivers a constant stream of commentary on global crises and polarizing issues, heightening baseline anxiety. Campus culture can further compound this pressure: students who hold controversial or non-mainstream views often report a reluctance to speak openly, contributing to a climate of self-censorship.

Unfortunately, most schools are ill-prepared to meet the manifest needs of their students and lack adequate, much less optimal mental health services. Rather than addressing the problem fully and proactively, they react to individual crises or clusters of incidents when they occur. Recent examples of this include a rise in suicides and suicide attempts, with notable incidents at the University of Wisconsin-Platteville and Middlebury College, and campus unrest related to Israel-Palestine protests. Universities were unprepared for these crises––yet few have taken steps to improve mental health services in their wake.

Historically, healthcare has not been central to the mission of institutions of higher education. As student health services have evolved, mental health has been an afterthought, only somewhat reluctantly incorporated into the repertoire. Indeed, universities remain unsure of and even ambivalent about how much responsibility they should assume for the young charges in their care. At the same time, many parents are wary of educational institutions taking over the health care of their children. Consequently, university administrators find themselves in a no-win situation.

Nevertheless, I would advise universities to take a proactive approach to student mental health and establish state-of-the-art, comprehensive youth mental health services. Adopting this strategy is the right thing to do, and it will mitigate the risk to students and the institution––more than making up the costsof providing these services.

For their part, students and their parents must be open to the possibility that the students might need mental health services, often urgent, at some point during their college careers. For this reason, they would be well advised to include the quality and availability of mental health services along with traditional considerations as they decide where to attend.

A version of this article originally appeared in Psychology Today.