Gun Violence and the ‘Tincture of Time’


A number of years ago, during a trip to Disney World with my extended family, one of my older relatives approached me at breakfast complaining that his left ear hurt. As a doctor, my family expected me to “fix this problem.”

Aware of the risks of inappropriate use of antibiotics, and unable to properly diagnose an ear infection, I opted to wait, telling my relative that if the pain continued for another day or two, we would find an emergency clinic and have a doctor look in his ear properly.

This was not a popular decision.

The next morning, at breakfast, I noticed an unusual rash on my relative's scalp. As he was mostly bald, the small blisters on the left side of his head were quite obvious. He had shingles, and the ear pain the day before had been the first symptom. Waiting proved to be the wiser course and, now that the diagnosis was evident, a proper course of treatment—antivirals, not antibiotics—could be initiated.

In medicine, we call this waiting “tincture of time.”

In many cases, waiting is the most appropriate intervention. While patients often view this as “doing nothing,” in fact it is a form of active observation that in many cases is the best initial option. At times, the illness is self-limited; in other cases, such as my relative's earache, waiting is necessary to make the correct diagnosis.

People, especially those who are suffering, often do not want to wait, to study, to think about what interventions should be implemented based on a full understanding of a problem.

This is my response to the urgency in the wake of Newtown.

Sure, it was a hugely tragic event. So many young lives taken so suddenly, heroic teachers trying to protect their young charges, even the apparent suicidal despair of Adam Lanza. Just horrible, all of it.

But as our mayors and police chiefs point out, we have many Newtowns every day in this country: children (and adults) killed in drug disputes, in gang violence, in rage acted out within homes. Where is the outrage?

Like my relative, we want a quick fix. We wrongly perceive Newtown to be an acute problem, when in fact it is a blip against a background of chronic violence pervading our society—a scourge to which we are so inured that we do not even see it.

As with my relative's shingles, the virus of violence is harbored within our society, and occasionally it breaks the surface so dramatically that we cannot ignore it, at least for a few news cycles.

We are unable to accept that perhaps the best thing to do is to wait—to study the problem, to try to understand the cause or causes, to develop rational interventions for those causes.

This takes time.

Instead, we craft urgent laws requiring mental health providers to report their patients to the police, who presumably will intervene by removing guns. I have no problem with removing guns from people who cannot safely manage them—whether they have mental illnesses or not.

But how can a provider expect his patient to be open if he fears being dimed out to the police?

Perhaps this is the same-old, same-old. Four decades ago, providers asked the same question in the wake of the Tarasoff case, requiring California providers to protect potential victims of their patients, and it is not clear at all that providers' fears have come to pass. Colleagues tell me that people in California still seek treatment.

All I know is this: At times, the safest thing to do is to think about what you should do, before you do something that you cannot take back. All treatments have side effects, unintended consequences. Some are foreseeable, others less so.

This is true for individuals, and it is true for our society.

My prescription is tincture of time, not blind intervention to make the patient feel like I am doing something—anything—even when what I am doing will not help and may actually harm. 90-day supply, refill as needed.

Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and serves on the teaching faculty in the Psychiatry Department at the University of Maryland School of Medicine. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He welcomes readers' comments. Dr. Roskes' website is

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