Mass Shootings, Mental Illness and Stigma

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Devan Stahl, PhD

Over the past two months, we have witnessed two more mass shootings in Las Vegas and Sutherland Springs, TX. Once again, these incidents bring up the debates surrounding gun legislation and access to mental health care. In reference to the Texas shooting, President Trump commented, “This is a mental health problem at the highest level. It’s a very, very sad event.” Soon after, it was revealed that Devin Kelley, the Texas shooter, had briefly escaped from a mental hospital in 2012 after he made death threats against his superiors in the Air Force. Both the president and the media emphasized the connection between mental illness and mass shootings. In fact, Johns Hopkins University found that over one-third of all news stories about mental illness were connected to violence. Psychiatric journals are also more likely to publish articles connecting mental illness with aggression than mental illness and victimhood, even though persons with mental illness are ten times more likely to be victims of violent crimes, including police shootings. It is no wonder that 63% of Americans blame mass shootings on the failure of the mental health system.

When confronted with a mass shooting, it is hard not to assume that mass shooters are mentally ill. After all, what sane person could commit such a horrible act? The media and even psychiatric professionals are quick to look for associations between mental illness and mass shootings. After Adam Lanza took the lives of twenty children and six adults at Sandy Hook Elementary School, new research on the brains of mass shooters began. More recently, the brain of Stephen Paddock, who killed 59 people in Las Vegas, was shipped to the Las Vegas coroner’s office for a neuropathological examination to look for any “mental aberrance” to explain his behavior, even though neuropathologists admit correlating brain structures with behavior is “cloudy business.”

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Image description: a cardboard sign is tied to a tree, with lettering that reads “stop gun violence :(” in blue and red. Image source: Tony Webster/Flickr Creative Commons.

Research shows us, however, that the link between gun violence and mental illness is far more complicated than it would appear. In general, it is hard to generalize about mass shooters because they are relatively rare. Although there is some evidence to show persons with severe or untreated mental illness might be at increased risk for violence when experiencing psychotic episodes or between psychiatric hospitalizations, many of these studies have been heavily critiqued for overstating connections between serious mental illness and violence. On aggregate, there is not a strong connection between mental illness and gun violence.

Close to 18% (43.4 million) of adults in the U.S. have some form of mental illness, which is on par with other countries, yet Americans are ten times more likely to die from guns than other citizens in high-income countries. The American Psychiatric Association found that around 4% of violent crimes perpetrated in America are attributable to mental illness and only 1% of discharged psychiatric patients commit violence against strangers using a gun. Persons with mental illness are less likely than those without a mental illness to use a gun to commit a crime. The vast majority of people with severe mental illness, including schizophrenia, bipolar disorder, and severe depression are no more likely than any other person to be violent. There is simply no clear causal link between mental illness and gun violence.

On the other hand, research shows that there are much stronger predictors of individual gun violence than mental illness, including: alcohol and drug abuse, domestic violence, past or pending violent misdemeanor convictions or charges, and history of childhood abuse.

There are a number of problems with associating mass shootings with mental illness. First, it stigmatizes millions of people living with mental health conditions. Research shows that negative attitudes surrounding mental illness prevent people from seeking treatment. Linking mental illness with violence threatens to restrict the rights and freedoms we afford ordinary citizens. Second, the burden of identifying would-be shooters has now fallen on psychiatrists who are not necessarily equipped to identify violent gun criminals. A number of states now mandate psychiatrists assess their patients for their potential to commit a violent gun crime, but psychiatrists are not great predictors of gun violence, and some research shows they are no more able to predict gun violence than laypersons. Psychiatrists who fail to identify mass shooters may now be held liable for crimes they fail to predict. Third, linking gun violence to mental health therapies may not help to reduce gun violence. Few of the persons who are most at risk for committing a violent gun crime have been involuntarily hospitalized, and therefore would not be subject to existing legal restrictions on firearms. Finally, the focus on mental health obscures other reasons for our nation’s gun violence problem. By focusing almost exclusively on mental health, we fail to identify the myriad of other factors, including historical, cultural, legal, and economic conditions that contribute to gun violence in our country.

It is easy to blame mass shootings on the “abnormal brain”–it is far more difficult to uncover or come to terms with the systemic causes of gun violence that wreak havoc on our communities. There are good reasons to ensure all Americans have access to mental health services, but access to such care is unlikely to stem the tide of mass shootings in our country. Mental illness has become a convenient scapegoat for politicians on both sides of the aisle when it comes to mass shootings, but it is time we begin to look more closely at other culprits.

Devan Stahl photoDevan Stahl, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 30, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Stahl: Disability and the Decisional Capacity to Vote

References

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21 Responses to Mass Shootings, Mental Illness and Stigma

  1. drpaul says:

    Connecting the occurrence of mass shootings with undetected and preventable mental health illness begs the fundamental question of whether we can all define similarly what we mean by the word: HEALTH. What better forum than this one to sustain a reduction of the cognitive dissonance underlying our nation’s healthcare reform? As one possible effort, I have defined a new definition for HEALTH, and its close “relatives” of Caring Relationship, Social Capital and COMMON GOOD. The HEALTH definition builds on a variation of the Capability concept. My intent for these definitions was to form a basis for meaningful healthcare reform.

    See http://www.nationalhealthusa.net/home/rationale/

    Paul Nelson, M.D.
    Omaha

    • Devan Stahl says:

      Good point Dr. Nelson. Of course, the way in which we define health can have tremendous impact on what we look for in medicine and what remedies are appropriate to offer. Definitions of health and disease are widely debated in the philosophy of medicine. In public health, there are also debates surrounding what health related questions physicians should ask their patients. For a good example of this debate as it relates to guns, see a previous “Bioethics in the News” blogpost by Dr. Sean A. Valles here: https://msubioethics.com/2016/11/17/public-health-ethics-of-gun-violence/

  2. Terah says:

    Dr. Stahl,
    I couldn’t agree more. Our country’s leaders are using mental health as a “scapegoat” and avoiding more likely culprits. Your points hit home, too. It is simple to point a finger at something that may make sense (that being mental health as ’cause’ for mass shootings) but the research just isn’t there.
    Considering this (that the research isn’t there) what do you see as the role of the people who know this to be true? We can share and share and share over and over again that there is no research to back their claim, but still we are lacking movement in the belief. Also, what is the role of psychiatrists when their voices aren’t heard either?
    Is this, perhaps, the government’s attempt at taking the spotlight off of failed gun control and moving it to the failing mental health care of our nation (which– we may argue is also the fault of the government…)?

    • Devan Stahl says:

      Great questions Terah. Psychiatrists know these facts to be true, but given the public opinion polls I cited, their voices clearly aren’t be heard as clearly as those politicians who continue to cite mental illness as a cause of gun violence. Many politicians likely know the stats, but I also fear many do not and themselves need to be better informed. One thing those of us in the health care profession need to do is become more media savvy so we can offer counter-narratives in a public forum. Social media is a powerful tool that politicians have certainly taken advantage of, but health care providers and academics need media training (and often institutional support to become more active in this way). Many professional organizations lead media training seminars to help folks develop a responsible and effective social media presence. Another thing you and other can do is to reach out to media outlets (particularly ones that have a strong online presence) to offer to write about issues you have expertise in and are passionate about. Many national news outlets allow you to pitch blog posts to beat editors and I think many would welcome physicians to be the experts on particular issues that relate to health care.

  3. Emalie says:

    I also couldn’t agree more with your perspective. Tackling mental illness and access to health of course isn’t easy. But it seems much easier (and less political perhaps?) than tackling those systemic causes you mentioned that perpetuate gun violence in our country. All of these factors should be taken into account to find out why people in the US are at a higher risk as compared to other industrialized countries to die from gun violence. A history of domestic violence is a much clearer indicator for the potential of gun violence than mental illness is- the fact that this seems to be overlooked in our society to me, points to our unwillingness to address our “toxic masculinity” that pervades US culture. It’s much easier to restrict the gun rights of a person with a mental illness than it is to restrict the rights an abuser (since so much abuse goes unreported). In Canada, if someone wants to buy a gun, their partner must be notified. I wonder how a requirement like this would be thought of in our country? It seems like we’re at the point where any restriction is rejected by people fearing our guns will be taken away. But obviously, what we have in place now isn’t working.

    • Devan Stahl says:

      Good points Emalie. Ours country is of course not the only one that deals with the underlying causes of gun violence, including domestic abuse or ‘toxic masculinity.’ Men are much more likely (in all countries) to commit gun crimes. The only real difference between the US and other countries seems to be the accessibility of guns. I cannot imagine many would support the partner notification laws you cite from Canada. I also wonder what the implications of this would be for women who buy guns to protect them from their own abusers. If our legislators fail to pass any reasonable gun restrictions, which most Americans favor, then we are left to deal with the other multivariate and difficult to manage causes of gun violence which, in some ways, seem much more difficult to root out, such as domestic violence and sexual abuse, but would reap other benefits besides reducing gun violence.

  4. Karlee says:

    Very interesting topic! I think it is easy to scapegoat those with mental illness as cause for mass shootings, rather than address our policy on gun control. I fear that this use of scapegoat may cause people to become violent with those with mental illness. Many politicians consider themselves experts now and unfortunately the real experts are unable to have their voice hear. How do we fix this? How do we educate those who do not want to listen?

    • Devan Stahl says:

      Thanks for your comments Karlee. Not only are we creating an environment in which the public is becoming more fearful of people with mental illness, we have also failed to train police officers to deal appropriately with persons with a variety of mental disabilities, which is perhaps why they are more likely to be shot by police. The rise in distrust of “experts” is not helping matters, and is part of larger, systemic issues our country (and other industrialized countries) is currently dealing with. Rather than wait for public trust to turn, those working in the mental health field must become more adept at speaking to the public in ways that resonate, including social media, as I said above.

  5. Eve P. says:

    I agree that people in our country like to blame gun violence on mental illness. When the country is notified of a mass shooting in the news I always hear people around me say “that person must have been mentally unstable” or “that person clearly was crazy”. Hearing these statements goes to show that it is not just politicians who blame mass shootings on mental illness but also “regular” people in society do. I found it interesting to learn from your post that now psychiatrist can be held liable if they did not screen someone for being likely to cause a mass shooting and that person commits gun violence. To me this seems unfair because like you stated psychiatrist aren’t trained to be able to completely identify if someone will commit this act. For me personally I think the issue with these mass shootings go beyond the discussion of mental illness. I believe that there needs to be a bigger discussion on the easy access to guns in our country. I do not believe there are enough regulations/precautions set in place for individuals to obtain guns. I feel there needs to be higher restrictions for all people to get guns and there needs to be more laws about the type of guns people (outside of the military) are allowed to obtain. I think the conversation around gun violence needs to change. Politicians need to look beyond blaming mental illness on mass shootings and instead look at changing the laws set in place for citizens to obtain guns. The question I often ask is how do we get politicians to understand that there needs to be a reform on gun control policy?

  6. Cyndi says:

    Great topic for discussion! I agree, we are becoming a society that uses mental health as an scapegoat to not hold criminals accountable for their actions. But I also think that unfortunately it also depends on the color of ones’ skin. If the offender is anything other than “white”, the attacker is automatically view by the media and others as a terrorist, a criminal, or someone that does not belong in this country. On the other hand, if the attacker is white, the media just assumes that it is link to mental health problems and automatically starts to do research on the attackers family background and finds ways to justify their actions. We have to hold criminals accountable for what they are doing regardless of what they look like, and not allow them to blame their action on a metal health problem. It is one thing to try to advocate for those that have reached out for help and have caused harm, versus those that have never reached out and want a way out.

    It is interesting that psychiatrists could potentially be held liable for not screening a client that could potentially cause a mass shooting or commit violent crimes. I do not think this is fair for psychiatrist because someone could have a violent past but it does not necessary mean they will cause harm. What about gun control and keeping the perpetrators accountable for their actions. I understand that this is a sensitive conversation, but I am happy that we continue to discuss these ideas! Hopefully we can make progress with our policies, before we mourn over another tragedy that could have been prevented.

    • Devan Stahl says:

      Laws holding psychiatrists accountable are certainly controversial, both in the case of gun violence, but also more generally. We have asked psychiatrists to do something they are not necessarily trained to do and while failing to provide such training through funding sources.
      And you are of course right about when mental illness is brought up after a violent crime. On average, white men are much more likely to commit mass shootings https://www.statista.com/statistics/476456/mass-shootings-in-the-us-by-shooter-s-race/ but the public and media is much more likely to cite mental illness as a contributing factor when the perpetrator is white. We have a long way to go on the issues of guns, mental illness, race, and religion.

  7. Emily says:

    Great topic for discussion! This has been an ongoing topic that society and politicians have put a stigma to. I do feel that politicians are using mental health as a “scapegoat” on both sides. This is a bigger problem than everyone thinks and people are quick to jump to gun control or mental health picking sides. I think there needs to be stricter gun control, more education (hunter safety course), or a more advance background examine before someone has access to a gun. If not more gun control more education about a mental illness along with access to treatment. There needs to be a change society needs to be informed and educated.

    • Devan Stahl says:

      Thanks Emily, greater public dialogue on mental illness may help to decouple it from gun violence. Unfortunately, we seem to talk about gun control in the public quite a bit, but our elected representatives do very little about it.

  8. Zoie Barker says:

    Dr. Shahl,
    Thank you for providing such an enriching topic for discussion. I too see significant barriers preventing growth in keeping the topic of gun violence centered around mental health. We are missing the mark completely, and we are holding individuals accountable that shouldn’t be. As you mentioned, Psychiatrists are no better at predicting gun violence than the everyday person, therefore it would be unfair to hold them accountable. We don’t hold gun shop owners accountable if a person that purchases a weapon at their store goes on a killing spree, therefore Psychiatrists should not be held accountable. I believe there will need to be a significant shift in the dialogue around gun culture in order to see real change, and I am not quite sure about what that shift will need to look like or how that will begin. Do you have any thoughts around that?

    • Devan Stahl says:

      Thanks for your comments Zoie. There is precedent for holding psychiatrists accountable to protecting third parties when a patient poses a significant threat. In the Tarasoff v. Regents (1976), a psychiatrist failed to warn a young woman when his patient made a credible threat against her life and later carried out her murder (https://www.cga.ct.gov/2013/rpt/2013-R-0089.htm). Some states (but not all) have upheld the requirement for psychiatrists to break confidentiality and warn third parties when a patient makes a direct threat of violence toward them. More recently in Volk v. DeMeerleer (2017), the Supreme Court of Washington held a psychiatrist liable for not notifying third parties of a patient’s potential violence, even though the patient had not expressed direct threats against anyone (the patient killed his ex-girlfriend and son) https://wire.ama-assn.org/practice-management/patient-psychiatrist-confidentiality-hampered-liability-ruling
      It seems many courts are willing to hold psychiatrists accountable for their patient’s violent acts in ways we would not hold others (sellers of guns) accountable. Whether or not this is appropriate is up for debate.
      For all the reasons mentioned in my post, however, holding psychiatrist accountable is unlikely to stem the tide of gun violence in our country and unfortunately, its hard to imagine what will given our legislators reluctance to fund any measures to do so.

  9. Adriana says:

    Overall, I agree with what was said in this post. It is more common for people now to link mass shootings with mental illness. Even the president mentioned how the shooting in Las Vegas recently was a “mental health problem at the highest level”. With that being said, mental illness is unfortunately being used as a scapegoat for these mass shootings. Instead of tackling the other aspects that contribute to mass shootings; i.e. gun control/access. Mental illness is a serious issue but the fact that politicians are using it to their own benefit is sad and disgusting to say the least. It puts more of a stigma on those who are suffering from mental illnesses because of them being more linked to aggression than victimization.
    However, what I do think is missing in this post and in the general conversation is race and ethnicity. If a brown or black individual commits a crime, they are labeled as terrorists and automatically seen as a criminal. On the other hand, if a white individual commits a crime such as a mass shooting, they are rarely referred to as terrorists. The narrative is more towards a victim of mental illness or a “lone wolf”. When one white individual does a mass shooting, all white people are not stereotyped as “mass shooters”, but when a middle eastern individual commits a crime, all middle eastern people are labeled as terrorists. The president of the United States has been quick to label people who have committed crimes as terrorists when their skin color is anything darker than white.

  10. Devan Stahl says:

    Good points Adriana, as I said above to Cyndi, there is certainly racial bias when it comes to linking mental illness with gun violence. There is actually quite a bit of data to back that up. While I focused on mental illness in this post, there is more to be said about racial bias and Islamophobia when it comes to how we report on violence in America. Words such as ‘terrorism’ should be used with all persons who commit acts of terror against people in our country. We need to hold the media more accountable when they fail to do this, but fortunately, many media outlets are beginning to do just that.

    https://www.thenation.com/article/how-to-understand-white-male-terrorism/
    https://www.huffingtonpost.com/entry/domestic-terrorism-white-supremacists-islamist-extremists_us_594c46e4e4b0da2c731a84df
    https://www.washingtonpost.com/posteverything/wp/2015/06/18/call-the-charleston-church-shooting-what-it-is-terrorism/
    https://www.vox.com/world/2017/10/2/16396612/las-vegas-mass-shooting-terrorism-islam

  11. Brandi Hammond says:

    While I was reading this blog post I found myself agreeing with every statement Dr. Stahl made. I have had many discussions regarding this topic in my courses so far. From these discussions I found that many people relate gun violence to mental disorders without research to support or show causation. I blame this “relation” on the media surrounding mental disorders because the media presents information that proves their stories to be true. For example, when relating gun violence to a mental disorder, the media will state that “his schizophrenia caused him to act out violently.” So this statement could have some validity, but the media does not mention anything else about his life that could have determined his violent behavior such as experiencing domestic violence or child abuse. The absence of this information causes there to be confusion and misunderstandings with mental disorders and what each specific disorders entail. From my experience with using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) violence is rarely mentioned as a prominent behavior of any mental disorder (APA, 2013). Dr. Stahl also mentioned a similar finding in the American Psychiatric Association when comparing individuals with mental disorders to individuals involved in gun violence. A solution to this problem could be informing people through media outlets about mental disorders and how violence is rarely related to them. I have seen some attempts on Facebook, Instagram, and with Mental Health Awareness Month, but we need to do more. We need to stop stigmatizing individuals who have a mental disorder, but how do we do this appropriately and efficiently? Any suggestions?

    • Devan Stahl says:

      Thanks for your reflections Brandi. For those who work in the mental health profession, it is important to be aware of the public misconceptions about mental health. Social media platforms are a good start, particularly for younger populations who get the majority of their news from these sites. We can also do better in calling the news media out when they perpetuate stereotypes. If you feel strongly, write op eds, pitch short blogs to major news media outlets that have an online presence, and write for local newspapers that reach members in your community. Perspectives can change when the right kind of information gets out.

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