After many mass shooting murders in the US, many elected officials and members of the public condemn the shooters as mentally ill, and want to forcefully control their access to guns. The issue has many dimensions. For example, most mass shootings in the US are by white men, but when they are caused by Muslims, the politicians and members of the public condemn them as terrorists. When African-Americans do the shooting, they are condemned as being racially motivated. What is mental illness, and how severe must it be before action is taken to restrain the freedom of those who have it? A third dimension is that by ascribing the cause of mass murder to mental illness, we provide an excuse, a relief from responsibility for the crime.
Many disability rights advocates get upset when gun violence is ascribed to people with mental illness. They cite statistics showing that only a very small percent of people with mental illness commit violent acts. There is a growing tolerance for mental aberration in the disability advocacy community. They call it “neurodiversity,” and characterize it as another way of being, and acceptable. The issue is complicated by a lack of community mental health services in the US; very weak ability for law enforcement to preventively detain mentally ill people who may pose a threat to public order; police thrown into a role of mental health first responders; overlap of mental illness with other social problems such as homelessness; poor reporting to keep guns away from the mentally ill; weak mandatory reporting systems for mental health practitioners (where reporting must only be done for patients who violently and viably threaten a specific person); difficult and fraught diagnosis; even after diagnosis, treatment often through pills, which patients may decide not to take; and confusion, between violent acts like domestic violence and questionable ailments like “anger management issues.”
What can be done? Is it worth doing anything? Are any actions politically feasible? States vary greatly regarding what can be done with a person judged by mental health experts to be dangerous toward themselves or others. Temporary commitment to a mental health facility might last only 24 or 48 hours. We do not have a preventive detention system in the US.
Every campus should have threat assessment protocols so officials can work with mental health/law enforcement professionals to handle situations that could result in violence or harm. “Identify and keep a list of who to call in a crisis. Develop a close working partnership with emergency responders…Create a close working partnership with mental health professionals who can assist school officials in evaluating and assessing potentially dangerous students who may threaten or intimidate others.”
Address root issues, such as poverty, social inequality, and school failure. Gun availability has multiplier effects when combined with risk factors for youth violence involvement as mental health problems, alcohol and drug abuse, and school failure or disengagement. “The lethality of guns means it is important to keep guns away from youth who are engaged in violence as a goal, beyond reducing youth involvement with violent events.”
Ensure state compliance with requirements to post mental health records in the National Instant Criminal Background Check System. Require federal agencies to share records with NICS. Establish clear reporting guidelines for when and how mental health records need to be posted in the Background Check System so states are accountable.
Expand firearm prohibitions to include alcoholics and problem drinkers. This could reduce alcohol-related violence. Substance abuse is associated with an increase in violent behavior. It’s a more significant risk factor than mental illness. Create and make more severe penalties for using a gun while drinking alcohol, as well as for using a gun while on medications that cause aggressive behavior. Federal firearm laws do not prohibit alcoholics from possessing firearms, and only 16 states have statutes prohibiting alcohol abusers from possessing firearms.
Provide Mental Health Services and Screen
Fully fund mental health services. Fund them through a tax on guns, ammunition, and permits dedicated to mental health screening, counseling, and services. Institute and expand programs that work through schools to identify and help students with mental health issues, help families with at risk children, and adults with crisis counseling to help create a safer environment.
-Ensure access to mental health care, including treatment and medication.
-Establish 24/7 walk-in crisis centers.
-Provide annual mental health screenings in schools, as is sometimes done for vision, hearing, and dental issues. Maintain confidentiality as necessary, but don’t let confidentiality interfere with necessary services. It’s a common misconception that FERPA, the Family Educational Rights and Privacy Act, prevents schools from disclosing the identity of a dangerous student, and that HIPPA, the patient privacy act, prevents disclosing the identity of a dangerous patient.
A diagnosis of a major mental disorder — especially of schizophrenia — is associated with a lower rate of violence than one of a personality or adjustment disorder. A co-occurring diagnosis of substance abuse is strongly predictive of violence. Psychopathy is more strongly associated with violence than any other risk factor. The presence, type, and content of delusions is not associated with violence. A suspicious attitude toward others is related to later violence. Hallucinations do not elevate the risk of violence. If voices command a violent act, however, the likelihood of violence is increased. Thinking or daydreaming about harming others is associated with violence, particularly if they are persistent. The higher a patient scores on an anger scale, the more likely he is to be violent later.
Under various federal laws, students with emotional disorders are supposed to receive free and appropriate services in public schools so they can remain in school and succeed in life. However, due to the high cost of these services, school budgetary cuts, resistance by some school districts, and the lack of knowledge by parents, many students drop out or do not receive the services they need. These Acts should be fully funded and enforced.
Expand the Australian concept of Mental Health First Aid training. It is like traditional first aid: help people quickly in an emergency. The course increases mental health literacy and improves the mental health of trainees, making them more confident in dealing with people with mental illness. Participants learn how to detect a number of mental illnesses, including schizophrenia, bipolar disorder, psychosis, substance abuse, depression, anxiety and eating disorders, and how to respond through a five-step action plan, “ALGEE:”
- Assess for risk of suicide or harm.
- Listen non-judgmentally.
- Give reassurance and information.
- Encourage appropriate professional help.
- Encourage self-help and other support strategies.
Loosen the consent requirements for mental health treatment. However, this runs the risk of Soviet-style forced mental health treatment for those who don’t need it. Include insurance coverage for mental health care.
Recognize the Prevalence of Evil
Broaden the discussion beyond mental health to include evil, and learn to recognize its signs. James Scully, MD, former CEO of the American Psychiatric Association, says, “The idea that mental illness and evil are one and the same thing is…a relic of the past and has no place in our public dialogue. People who are clearly not mentally ill commit violent crimes every day.” Most mass shooters are not mentally ill but instead are very angry and/or seeking vengeance. According to the psychiatrist James Knoll, “[T[here are factors common to mass murderers, such as extreme feelings of anger and revenge…lack of an accomplice (in adult mass murder), feelings of social alienation, and planning/organizing the offense…a number of common traits and historical factors were found. The subjects had all been bullied or isolated as children, turning into loners who felt despair over being socially excluded…described as suspicious, resentful, grudge-holders who demonstrated obsessive and inflexible thinking…narcissistic and coped with personal problems by blaming others. Their worldview was characterized by seeing most others as rejecting and uncaring…spent a great deal of time nurturing their resentment and ruminating on past humiliations. The ruminations evolved into fantasies of violent revenge. They did not see their own violent death as a deterrent…because they perceived it as bringing them fame with an aura of power.” Besides access to a gun, other factors often found in killing family members include the presence of a stepchild, substance abuse by the perpetrator, domestic violence, jealousy, and economic stress.
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