The Only Gun Legislation In the Past 30 years Is Nothing To Get Excited About

 

The only thing more annoying than seeing self-congratulatory legislators not solving another problem is when they discuss their rationale for their latest decision.  That was in full view on CBS This Morning Today as Tony Dokoupil interviewed four senators Chris Murphy (D), Thom Tilis (R), John Conryn (R), and Kyrsten Sinema (I).  In the interview Sen. Murphy suggests there is evidence that “the law is starting to have some impact” according to “criminologists”.

But what is the evidence?  A summary of the bill is available at this link and it is more readable that the final version on the same web site. One of the provisions was enhanced background checks for gun purchasers 18-21 years of age.  That has resulted in 230 denials. Sen. Tilis commented that 107,000 people between the ages of 18-21 applied to purchase a gun and therefore only 0.2% were denied. No comment on the negatives of putting another 100,000 guns out on the street. I tried to find data on the NICS database but it is not available for 2022.  We don't know if a 0.2% denial rate is an exception or if it is expected.  This report states the overall denial rate was 3.92%.  He goes on to say he is proud of the fact that they have passed the “biggest investment in mental health” in history and “we all agree that behavioral health had to be the foundation of everything we did.”  

Hold on Senator! Granted I am only a psychiatrist and not a behavioral health expert – but this seems like bullshit to me. The federal government and their cronies in behavioral health managed care have been rationing services while making massive profits for the past 30 years. It is as likely that your funding intervention will have as much impact as it did on the opioid epidemic.  It also happens to be a gun extremist narrative to divert attention from the primary problem of far too many guns.

Senator Sinema suggests that “every single person” who picks up a firearm and engages in mass violence is mentally disturbed.  If that were true (and it is not) – the suggested funding through the usual channels will not impact mass shooters. Mass shooters are a product of gun extremism. They see politicians every day talking about guns as the solution to many problems. Stand your ground laws that encourage both gun violence and exoneration of the gun user. They see people being shot and killed or shot at for trivial reasons.  They see indignant gun extremists claiming that “the government” wants to kick your door down and confiscate your guns – even though with the massive number of guns in this country it is physically impossible.  They see armed “militia” intimidating state legislators on their own capitol grounds. They see social media threats about the use of arms. Most importantly – they see daily mass shootings in the United States and nobody doing anything about it. Politicians seem to blame the victims, in some cases the police, or globally “wrong place-wrong time.” You do not have to be mentally ill to be confused or driven by those messages and emotion.

Most notably – there continues to be no background checks for all gun buyers and no assault weapons ban.  There was some joking about not being able to agree on a definition of an assault weapon.  That is a basic definition and it has been defined by Congress in the past but it appeared to be off the table for this crew.

Dokoupil makes a point that violence in America seems to drive legislation and maybe the tradeoff for a Second Amendment is that there will always be violence in America. He cites examples of gangsters in the 1930s and violence in the 1970s with riots and radical politics.  That is a good sound bite but it ignores the fact that there has been no gun legislation through the past 30 years of gun violence and this anemic bill was the result of a level of gun violence that should have been an embarrassment for any legislator.  He misses the obvious point that even in the Wild West (see Tombstone Ordinance of 1881), you had to check your gun when you came into town and post-World War II we had decades of common sense gun legislation that did not involve the massive carrying of firearms.  During those decades – nobody under the age of 21 could own a handgun, guns were used for hunting, and the Second Amendment was interpreted the way it was written.  During those decades the NRA was focused on gun safety and hunting rather than flooding the streets with guns. 

There was some rhetoric about how an extreme mass shooting incident led to the bipartisanship necessary to pass this mediocre bill. First off - that is an extremely high bar.  How many catastrophes does it take to move Congress?  The answer is obviously hundreds. Secondly, it is obvious that partisanship was alive and well right in the room.  None of the Senators could even touch the assault rifle issue? Assuring the rights of people refused firearm purchases was a higher priority?  Gun extremism is alive and well and as long as one party finds it necessary to fan the culture war flames - very little movement would seem possible and that is exactly what we have seen for decades.  

The gun extremism of one political party and their judges is the current problem. An atmosphere of unabated gun extremism is unlikely to have any desired effect on mass shootings, gun homicides, gun suicides, or accidental deaths. I have attached a few paragraphs on what gun extremism is below. This is my definition. I have written about potential solutions in the past – but clearly people would rather listen to the clear thinking of their elected officials instead.

 

George Dawson, MD, DFAPA

Previous Posts:

Likely and Unlikely Causes of Mass Shootings

Another Note on Gun Extremism - An Appeal to Grandparents

Gun Extremism Not Mental Illness

Elements of Gun Extremism

1:  Misinterpreting the Second Amendment:

The culture war political party and their judges ignore the text of the Amendment which is simply:

A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

Gun extremists ignore the preamble that gives the rationale for the right to bear arms and instead isolate the clause about the right to keep and bear arms and generalize it to the entire population and any firearms.  The well-regulated Militia in this case is every states National Guard.  Arms in those days were muzzle loaders that could fire 2 rounds per minute if you were an expert contrasted with 45 rounds per minute from an AR-15 semiautomatic rifle. A fully automatic AR-15 can fire 700-900 rounds per minute. Courts have taken additional steps to say that gun permits can be superfluous and that anyone requesting one should be issued one – with rare exceptions.  Local legislatures have gone ahead with permitless carry and concealed carry laws.

In debating gun extremists, a common argument is that it is protection from tyranny and that is why the Amendment is there.  When I suggested that using weapons against the US government was treason, a famous gun advocate suggested “it would depend on who won.”  Clearly there is nothing about tyranny associated with the amendment.  Gun extremists favor lawlessness and insurrection.  Their judges do as well.

2:  Putting everyone at risk:

One of the famous gun extremist arguments is that more guns results in less crime.  That is clearly not the case and the number of defensive uses of firearms does not have a significant impact on crime.  In the meantime, there are more gun suicides, homicides, accidental deaths, mass shootings, and deaths from the impulsive use of an available firearm in the US than any other high income country.

3:  Increased risk with handguns and assault rifles:

Before the gun extremism culture took over – guns in the US were used for hunting and target shooting. Some people thought they were necessary for self-defense but they were clearly in the minority.  The NRA ran Hunter Safety Courses to teach safe use of hunting firearms.  Gun extremism is a result of the culture wars approach to American politics. When one party realized they did not have much to run on they decided to make a few things up.  Gun extremism was one of those results.   Gun extremism has resulted in the proliferation of handguns and assault rifles.  Both of those weapons are designed for shooting people not wildlife. Gun extremists try to minimize the role of assault rifles by claiming that they are not fully automatic like the military version but they can still release a flurry of high velocity rounds capable of penetrating many walls – as fast as you can pull the trigger.  That is not a hunting firearm.  No need for a lot of physics - just recall that the kinetic energy of a mass is a function of the square of its velocity.  Weapons with high muzzle velocity like assault rifles will have much more energy to damage the target.

4:  Increased risk with permitless carry:

 As the gun extremists became more radical there was a progression of loosening of gun regulations.  Initially to carry guns in public you had to have a permits. In many states that required an application and background check from a county Sheriff.  For a concealed carry permit, training was required. Continued radicalization has resulted in the abolition of many of those laws so that you can purchase a handgun and carry a concealed handgun without a permit or training.  You just must meet minor age criteria. It is obvious that this is the goal of gun extremists across the USA.  Permitless carry will make every community more dangerous. Just ask your local men and women of law enforcement. 

5: The idea that gun carriers are supermen or superwomen:

In other words if you meet criteria to carry a gun your were by definition responsible and did not make any mistakes leading to the loss of life or injury. Epidemiology teaches that just having a gun on the premises greatly increases the likelihood of death by accidental injury or suicide. Every year hundreds of police officers are injured by accidental discharge of their firearms and they have more extensive and ongoing firearms training than typical gun owners, especially in this era of vanishing qualifications. The obvious political goal of gun extremists is to eliminate any qualifications except for age and possibly (if a NICS check is run) a history of felony crime or domestic violence.   

6:  The new era of shoot first ask questions later:

There have been many incidents in the news of people being shot at and in some cases killed for ringing a doorbell or accidentally driving down the wrong road. In well televised road rage incident, a man fires several rounds from a semiautomatic handgun through his own windshield at a car he mistakenly thought had fired a gun at him.  Not a thought about how far those bullets travel and who else he might hit on a busy freeway. Is this the kind of country we want to live in?  This is the country we currently have courtesy of gun extremists. 

7:  All we have to do is enforce existing laws:

This is a favorite of gun extremists as they continue to roll back existing gun laws. The also use the slogan "If guns are outlawed only outlaws will have them."  That slogan is obviously flawed at two levels.  First, nobody has ever suggested outlawing guns and as I pointed out earlier - it is physically impossible at this point.  Secondly, nobody seems to consider where outlaws get guns. A large source is theft from legal gun owners. About 380,000 guns are stolen in 250,000 incidents in the USA each year.  In other words, one of the largest sources of illegal guns in the hands of outlaws is legal guns from legal gun owners.   Keeping the streets flooded with guns keeps that process going. 

Image Credit:  Thanks to Rick Ziegler.

 

Killer Mike's Gun Recommendations for Families

I watched TMZ Live yesterday. They interviewed the rapper Killer Mike. Harvey Levin was his usual overcomplimentary self. He asked the rapper about his recommendation that every family should have "multiple guns, all sorts of guns" and this is what he said:

"5 - 5. I have always just said 5. You should have a revolver, a semi-automatic pistol, you should have a shotgun, you should have one bolt action rifle, and you should have a semi-automatic rifle."

When questioned about the semi-automatic rifle:

"I said semi-automatic, military is fully automatic. It's not military - it just looks cool. It can look like a race car but it doesn't go 200 miles an hour. My thing is simply this - the founders of the Constitution saw a need to fight tyranny at some point and they believed that that could happen again so they wrote that provision so to get to the ultimate answer you got to dig up those old white guys and ask them. I'm simply applying - I'm going by the rules that were given to me in the Constitution - nothing more-nothing less."

When asked about the risk of an increasingly armed and divided population, Killer Mike points out that the fastest growing group of gun owners is black women and he does not want to get in the way of black people enjoying their freedom.

In terms of stopping gun violence he was in agreement with curfew and an exception for working adolescents. He believes that no new gun laws are needed and echoes the line that there are enough laws to take care of the problem already on the books and that criminals are not going to follow the laws anyway. That ignores the fact that almost all mass shooters have no criminal record and in many cases have recently purchased firearms that they use in the mass shooting crime.  Instead he recommends "Stop the Bleed" classes and joining gun associations or gun clubs. His rational is that if you have a tool that can cause harm you should be educated about what to do for that harm.  Unfortunately if you get hit anywhere in the body - the education you will need is how to be a trauma surgeon and even then you had better be at a Level 1 trauma center. 

Consistent with the previous writing on this blog Killer Mike is clearly behind gun extremism and normalizing it as a constitutionally derived right. Obvious gun extremist rhetoric includes the claim that just because an assault rifle is not fully automatic it is somehow less worrisome. Anyone who has fired an AR-15 knows that you can fire as many high velocity rounds just as fast as you can pull the trigger and if that gun is discharged in a residential community that bullet is going a long way and in some cases through multiple buildings.  In fact, all of the weapons he recommends for the family will penetrate multiple walls and are a potential risk for the entire neighborhood.  The normalization of assault rifles by the NRA and Republican party was a move away from the use of guns for hunting to the use of guns for killing people and there is no way around it.  From the testing link this was a quote about the assault rifle result.  It speaks to the mechanism of assault rifles as a combination of high velocity and bullet deformation and tumbling:

"Though the 5.56 bullets showed the most deformation, they were also terribly penetrative (19 panels, or nine walls) and, beyond the first two or three panels, created relatively large holes as they tumbled along their paths."

Just as a reminder this is the full text of the Second Amendment:

"A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed"

Nothing about tyranny. Gun extremists ignore the preamble. The "well regulated militia" these days is each state's National Guard.  This country went through a period of gun regulation that was widely accepted and reasonable until one political party realized they did not have many ideas to run on and decided to make guns a part of that culture war. I don't know Killer Mike's political affiliations.  There may be a subcultural effect since this same show regularly reports gun violence and deaths within the rapper community.  

The problem with all forms of extremism is that it is an appeal to emotion and it typically ignores the facts. Killer Mike sees the problem as encroaching on the rights of black people but that doesn't address the problem that firearm homicides have increased in the black community by 39% from 2019-2020 (1). We know that the political rhetoric that more guns for defensive purposes does not put a dent in those numbers and that these are almost always impulsive homicides based on gun availability.

The answer to how to reduce gun violence is not increasing guns and I don't care what your rationale is - but that is the residue of this interview that started with that question.

George Dawson, MD, DFAPA

References:

1:  Kegler SR, Simon TR, Zwald ML, et al. Vital Signs: Changes in Firearm Homicide and Suicide Rates — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2022;71:656–663. DOI: http://dx.doi.org/10.15585/mmwr.mm7119e1

Likely and Unlikely Causes of Mass Shootings

     

The pace of mass shootings and school shootings in the United States continues unabated at this time. I am writing this like I have written many posts in the past – a few days after a mass shooting in a school.  I just heard a news reports saying that this was the 167^th school shooting since Columbine on April 20, 1999.  NPR posted a story saying that there is a shooting or a potential for shooting in schools every day (1) – based either on a gun discharge of someone brandishing a firearm in school. They reference the K-12 School Shooting Database stating that this is the 39^th incident this year that involved gunfire on school grounds.

The media descriptions of the current incident follow much of the coverage in the past about unclear motive, shocking circumstances, unpredictability, questions of an “emotional disorder” and counseling, and the devastating impact on families and the community. I saw a forensic psychiatrist interviewed speculating on the aggressive dynamics based on the detail that the shooter recently disclosed a transsexual orientation.  A clergyman was interviewed and suggested the shooter was really looking for the school minister who was providing counseling.  One of the shooter’s fiends was interviewed.  She was contacted immediately prior to the incident and promptly notified authorities – but by then it was too late. The video of the SWAT team running through the hallways and eventually running toward gunfire and killing the shooter keeps playing.  In some cases that video is compared directly to the Uvalde, Texas video  and comments are made about this is a much better example of how law enforcement should respond. I saw some of these reports where they put up the response time on the screen.  

There are the usual expressions of “enough is enough” and “we don’t send our kids to school for this to happen.”  Republican Representative Tim Burchett came right out and said what most people were thinking: “ We’re not gonna fix it….” But then to make it more palatable he added: “criminals are gonna be criminals.”  He thought we needed a “revival” to “change peoples’ hearts in this country.” Later he disclosed he was home schooling his daughter (3).

I am already on record on this blog writing about the real cause of mass shootings and gun violence in general and it is the politics of gun extremism.  The Republican party has figured out that gun extremism works for them along with several other easily demagogued social issues like abortion, voter suppression, education, anti-science, anti-climate change, and more recently “wokeism”. That has led to a series of initiatives to drastically reduce gun regulations.  There has been an undeniable increase in deaths due to gun violence.  Mass shootings, suicide, homicide, and accidental deaths are all routinely ignored as calls for regulations that were effective for decades until Republican advocates rolled them back – even though gun regulations in the past were never a problem.

The typical rhetoric used is a gun extremist interpretation of the Second Amendment.  In the case of voters, it was the usual emotional appeal that “they” were coming to take their guns.  Anyone familiar with the distribution of guns in the United states realizes this is an impossibility, but it is a rallying point for emotional rather than rational appeals.  In recent years we have seen the rhetoric extended to mental illness as a cause of mass shootings.  There is some confluence with antipsychiatry factions who falsely equate psychiatry with the pharmaceutical industry and suggest that antidepressant drugs cause the mass shooting phenomena.  This post will provide clear evidence to the contrary.

On the issue of common psychiatric disorders in comparing the countries that utilize the most antidepressant prescriptions – the prevalence of those disorders is consistent among the United States and the other countries at the top of the list.  These disorders include depression, anxiety disorders, and substance use disorders – conditions that antidepressants are all commonly prescribed for. English speaking and European countries had similar prevalence (4) with possibly lower prevalence in Asia. There are similar variations in the estimated prevalence of schizophrenia and mood disorders in different areas of the world (5, 6).  

A good summary document on the research about mental illness and mass shooting incidents is available from the Treatment Advocacy Center (10).  They summarize the results of several studies as indicating that at least one third of the perpetrators had "serious untreated mental illness."  Their review is remarkable for a wide range of methodologies and selection biases that probably overestimates the number of cases of severe mental illness in mass shootings.  Smaller sample sizes generally showed a greater number of cases of severe mental illness.  In the case of a study by Stone (11) he found that 32% of 228 mass killers had severe mental illness but during the sampling period there were 1,000 incidents.  The variation is often considered due to methodological differences in the surveys but as previously illustrated– even significant differences in incidence and prevalence of these disorders is unlikely to account for the huge differences in gun deaths between the USA and other countries.  The main difference is that people with the same mental illnesses have much easier gun access in the US.

Several studies of people involved as shooters have shown that some of them have psychiatric diagnoses and in some cases they are being treated by psychiatrists.  Some are prescribed medications but the toxicology at the time of the incident is typically not available. In a related study of murder-suicide by the New York City Medical Examiner’s office that of 127 cases over a 9-year period only 3 (2.4%) were taking antidepressants (7).  Two were taking amitriptyline and 1 was taking sertraline. The authors made the point that antidepressant use in this case series was much lower than the expected population rate.  In a series of 27 elderly men who killed their spouse and then died by suicide – more disease conditions and depression were seen as possible predisposing factors – but none tested positive for antidepressants (8).  When considering the prescribing of antidepressants in general,  epidemiological studies suggest that most of these medications are prescribed by non-psychiatrists. With the proliferation of non-physician prescribers, managed care strategies designed to accelerate antidepressant prescribing based on limited assessments, and widely advertised televisit prescribing it is likely that gap between psychiatrist and other prescribers has increased substantially and will continue to grow.

The argument has been made that people become agitated, suicidal, and homicidal on antidepressants. This is a recurrent theme that is often related to medicolegal considerations, criticism of the pharmaceutical industry, and psychiatric criticism.  There is often a suggested scenario of the antidepressants (especially selective serotonin reuptake inhibitors or SSRIs) causing agitation or activation making suicidal or aggressive behavior more likely.  After reviewing the existing evidence the FDA has placed a black box warning for suicidality in "children, adolescents, and young adults".  There are also warning and counseling bullet points on clinical worsening as evidence by: "emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down".  Standard medical and psychiatric practice advises the patient of these potential risks and what the plan should be if they occur.  In 35 years of clinical practice my observations were that these symptoms were rare and most likely to occur if an antidepressant was discontinued and the patient experienced significant sleep disturbance. The patients I treated with severe aggressive behavior were generally untreated for psychiatric disorders and often had substance use disorders.  A recommendation I have not seen is that all of these incidents should be studied from a prospective comprehensive psychiatric standpoint as they occur with no selection bias.  That study should include toxicology, detailed collateral information, analysis of available medical records, and post mortem analysis if relevant.

In choosing a reference (9) for international comparison of mass shooting phenomenon it is important to consider how the database is constructed. In choosing reference 9, the author described a clear rationale and methodology.  The basic criteria include an incident where there are at least 4 shooting deaths and the shooter is acting alone and not due to criminal or terroristic motivations. Since mass shootings in the US have been motivated by neither – there would be no equivalent comparison with incidents in the US. The author also compares the US to the 35 United Nations definition economically developed countries (see Supplement 1). The time frame of 1998-2019 was chosen.  On that basis half of the countries did not have a single mass shooting incident, ten had more than one, five had more than 20 fatalities, and the US had 12 times as many incidents as the country with the second most mass shootings. Much greater detail is included in the original reference.

I prepared two reference tables based on this data (click on either table for a better view).  The graphic at the top of this page does not include suicide and homicide rates for each country.  The table below includes both of these rates.  Data sources are referenced in the tables.  

 

The countries are arranged by defined daily doses (DDD) of antidepressant medications.  DDD is a World Health Organization (WHO) defined metric for medication utilization. It looks at the total amount of a defined class of medication using the Anatomic Therapeutic Chemical (ATC) classification based on the usual prescribed dose of medication. In that system antidepressants are listed as a class.  US data are highlighted in the table because they represent the focus of this post.

What are some likely and unlikely observations from the Table.  First, it is unlikely that antidepressant prescriptions are a proximate cause of mass shootings.  The countries bracketing the US in antidepressant utilization (Iceland and Portugal) each had no mass shooting during the period of interest (1999-2018).  Second, gun availability stands out as an obvious factor in mass shootings, gun related suicides, and gun related homicides.  Third, gun availability in the US (120.5 firearms per 100 person) nearly equals gun availability in every other country in the table (128.4 firearms per 100 persons).  Fourth, no country had homicide rates similar to the US, but 3 of the countries had similar suicide rates but much lower rates of gun suicides. The reference study looks at locations, relationships, and firearms as relevant points but no comments on mental illness or toxicology at the time of the incident. The author also points out that in many countries mass shootings trigger government intervention focused on decreasing the likelihood of future shootings.  Except for a time limited assault rifle ban that does not happen in the United States.  The gun regulatory landscape is headed in the opposite direction with a movement to permitless access to handguns.

In summary, the gun violence landscape in the United States is bleak. Despite rationalizations that this is really a mental illness or mental illness treatment problem there is no real supporting evidence, since the distribution of mental illnesses in the US is the same as comparable countries with no to few mass shootings. There is low quality evidence that mental illness may be a factor in 15-30% of incidents - but the only way to explain why that is a factor is those people have much easier access to firearms.  The overwhelming evidence is that this is a problem of gun extremism, gun access, and sociocultural factors like subcultural acceptable violence, media notoriety, and politically reinforced messaging about gun use. The only way to address the problem based on international examples is to decrease gun access.  That is unlikely as long as one major party and their appointed judges need to activate their base with false messaging and flood the country with easy to access firearms.  They bear the ultimate responsibility.

George Dawson, MD, DFAPA

 

Supplementary 1:  UN Classified Developed Countries (total of 36) for reference 3 in Table and reference 9 below:  Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom, and the United States.

 

 References:

1:   Florido A, Summers J. By one measure, the U.S. has had a shooting on school grounds almost every day.  https://www.npr.org/2023/03/28/1166630346/by-one-measure-the-u-s-has-had-a-shooting-on-school-grounds-almost-every-day

2:  K-12 School Shooting Database:  https://k12ssdb.org/all-shootings

3:  Winter J.  After the Nashville shooting a faithless remedy for gun violence. New Yorker.  Amrch 29, 2023:  https://www.newyorker.com/news/daily-comment/after-the-nashville-school-shooting-a-faithless-remedy-for-gun-violence

4:  Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol. 2014 Apr;43(2):476-93. doi: 10.1093/ije/dyu038. Epub 2014 Mar 19. PMID: 24648481; PMCID: PMC3997379.

5:  Goldner EM, Hsu L, Waraich P, Somers JM. Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature. Can J Psychiatry. 2002 Nov;47(9):833-43. doi: 10.1177/070674370204700904. PMID: 12500753.

6:  Waraich P, Goldner EM, Somers JM, Hsu L. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J Psychiatry. 2004 Feb;49(2):124-38. doi: 10.1177/070674370404900208. PMID: 15065747.

7:  Tardiff K, Marzuk PM, Leon AC. Role of antidepressants in murder and suicide. Am J Psychiatry. 2002 Jul;159(7):1248-9. doi: 10.1176/appi.ajp.159.7.1248. PMID: 12091219.

8:  Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001 Winter;9(1):49-57. PMID: 11156752.

9:  Silva JR. Global mass shootings: Comparing the United States against developed and developing countries. International Journal of Comparative and Applied Criminal Justice. 2022 Mar 21:1-24.

10: Treatment Advocacy Center.  Serious Mental Illness and Mass Homicide. June 2018,  https://www.treatmentadvocacycenter.org/key-issues/violence/3626-serious-mental-illness-and-mass-homicide

11:  Stone, M. F. (2015). Mass murder, mental illness, and men. Violence and Gender. 2015; 2, 51-86.

 

 

 

Racism and gun violence both exist in an overtly gun extremist society: They cannot be explained away by mental illness.

I suppose I should have not been very shocked that a Wall Street Journal editorial this morning (1) chose to double down on both gun rights and the myth that racism is not a problem and had nothing to do with the recent mass shooting – while scapegoating both mental illness and the rationed system of mental health care that we have in this country.  For good measure he added another conservative agenda item - that there was also blame for the public health officials like Dr. Fauci for mismanaging the pandemic.  This post is to straighten all of that out.

Let me preface these remarks by saying that I have no information about the most recent mass shooting other than what is reported in the media.  The author of the editorial does not seem to either. What I do have is 22 years of experience in acute care psychiatry and involuntary care. That’s right – for 22 years I was one of the guys you would have to see if you were admitted to my hospital on a legal hold for behavior that involved threatening or harming other people or yourself.  That included all kinds of violence - homicide, suicide attempts and severe self injury, and violent confrontations/shoot outs with the police.  I had to evaluate the situation with the considerable assistance from my colleagues and decide if that person could be released or needed to be held for further assessment and treatment. People (including psychiatrists) like to summarize that situation by saying: “Nobody can predict future dangerousness” and that is certainly true. But we do pretty well in the short term (hours to days).  We also do well coming up with a plan to prevent future violence.

The details about the most recent mass shooting are still being reported at this time, but so far include interviews with the families of the victims, police reports, videos, and excerpts from a manifesto written by the perpetrator.  According to reports that manifesto discussed Replacement Theory as a potential motive for the mass shooting.  Replacement Theory is a white nationalist, far right ideology that claims non-whites are a threat to the white majority in several countries including the US. A corollary is that the Democrats are trying to get aligned with more non-white voters to develop more political power. This is the rationale currently given in the media for the actions of the mass shooter who scouted neighborhoods and said very explicitly in documents that his intent was to murder as many black people as possible. He had no difficulty obtaining firearms legally – even though he was detained and sent for an emergency evaluation a little less than a year earlier for stating “murder-suicide” in response to an online question about what he planned to do upon retirement.  Those details and his response talking about how he got out of it and continued to plan to kill people are at this link.  

As a psychiatrist and member of the American Psychiatric Association, I can’t speculate on the diagnosis of anyone who I have not personally assessed and if I did do an assessment – I would need a release from the person to discuss any details.  The editorialist is under no constraints speculating that “signals were missed” and that “psychotic young males whose outlet is killing” is not the object of his column.  Instead, he makes the claim that he is really concerned about the post pandemic mental illness and addiction trends in this country. He is apparently not consulting the correct sources about what has happened in this country in terms of mental health care before the pandemic.

I will start with his anchor point in the 1970s.  At about that time Len Stein, MD and coworkers invented Assertive Community Treatment and a number of additional innovative approaches that were focused on keeping people with severe mental illnesses in their own homes.  Dr. Stein was one of my mentors and in seminars he would show what Wisconsin state hospital wards used to look like. About a hundred patients in one large room with their cots edge-to-edge and all wearing hospital pajamas. By the time I was working with him in the 1980s, those folks were living independently supported by case management teams and psychiatrists. Dr. Stein and his colleagues also ran a community mental health center that included crisis intervention services and outreach. That model of community mental health and crisis intervention is still practiced and has been covered in the New England Journal of Medicine.  Psychiatric residents are still trained in community mental health settings and many prefer to practice there.  Counties are not as enthusiastic and have shut down many if not most community mental health centers.

Community psychiatry is an obvious 50-year-old solution but it has to be funded. The same is true of affordable housing.  In some cases that housing needs to be supervised and also a sober environment. Both community psychiatry and affordable housing are casualties of business rationing that can only occur with the full cooperation of both state and federal governments. The current system costs about a trillion dollars in overhead that is directed to Wall Street profits and unnecessary meddling by middle managers. The only people who “sweep mental health under the rug” are large healthcare organizations and state bureaucrats who disproportionately ration it.  The "science of mental health" is not difficult at all.  Being forced to do it for free is difficult.

The 1980s were a critical time in establishing the managed care industry and taking all healthcare out of the purview of physicians.  While rationing psychiatric resources was being ramped up, services to treat alcoholism and addiction were essentially demolished. Suddenly you could not longer get detoxification services at most hospitals.  People were sent to social detox units run by counties where there was no medical coverage.  The thinking was that if a person developed medical complications like seizures or delirium tremens they could always be sent back to the hospital. The biggest risk was continued substance use and immediate relapse. Residential and outpatient treatment facilities never materialized.  Inadequate funding was a significant problem.  The managed care industry played a role in that case as well with absurd expectations and limits on treatment.  It is no accident that treatment for substance use disorders basically became non-existent.  None of the disproportionate rationing of mental health or substance abuse treatment is new.  It has been like this for 30 years because it is the government endorsed model of care.  

Overall, this editorial is a smokescreen over the proximate issues of guns and racism.  The author trivializes this as political rhetoric when in fact the rhetoric has all been pro-guns and pro-white supremacy.  It is the only rational explanation for turning the United States into an armed camp that has progressively increased the likelihood of gun violence. We are not talking about a pandemic precipitated phenomenon.  The gun violence has been multi-year and the pro-gun party has “doubled down” on it to make it more likely.  As far as politics go – now that we know how a partisan Supreme Court works – the Heller decision and the resulting liberalization of gun ownership should not come as a surprise.  On the issue of hate crimes, I can’t really think of anything more relevant in a case based on the public disclosures.  This was a specific crime directed at black Americans intentionally perpetrated in a neighborhood that was scouted ahead of time for that ethnicity. Brushing that aside to claim that this is a response to an embarrassing record on mental illness, when there is no evidence that is a factor is disingenuous.

American history including other recent mass shootings tells us that racism can be a causative factor.  What is never addressed is the omnipresent gun culture in the USA.  People with an apparent need for military weapons and handguns and politicians willing to give them unlimited access to carrying them in public, carrying them without permits, and stand your ground laws - encouraging violent confrontations with firearms.  All fueled by one party and their affiliated special interests.

Disingenuous discourse and misinformation is what we typically see these days. If you want the facts about what needs to be there in terms of a functional mental health system (and I know there are absolutely no business people and very few politicians that do) – ask a psychiatrist. If you want to know about what gun control needs to be in effect rather than claiming that psychiatrists are not preventing gun violence from people with no mental illness – you can also ask me.

I could put all of those details on a 4” x 6” card and it would work. 

But there is certainly nobody on the right or at the WSJ who wants to know that either.

 

George Dawson, MD, DFAPA

 

References:

1:  Daniel Henninger. The Next Pandemic: Mental Illness.  Wall Street Journal. May 18, 2022.

Graphics Credit:  Eduardo Colon, MD

The Kenosha Trial

 

I watched the Rittenhouse trial closing arguments on 11/15/2021.  Let me preface these remarks by saying that this post is not a commentary on the guilt or innocence of the defendant.  It is not a commentary on his behavior, speech, or mental status.  It has absolutely nothing to do with psychiatric evaluation or treatment. This post is all about common sense and how that has been suspended in the United States - especially over the past 10-20 years.

This post is about open carry laws in the United States. Open carry laws make it possible for people to carry firearms publicly without risk of arrest or search for merely having possession of those firearms. The original intent of these laws was to reduce the risk to hunters and target shooters when they were transporting their firearms home.  There are still regulations in many states about how those firearms need to be transported but the original open carry laws were to make sure that there was not a problem carrying the firearms to the home where they would be stored.

Over the past 10 years, we have seen a striking change in how firearms are carried in public and it is the direct result of these open carry laws. The most striking change has been the appearance of heavily armed men open carrying military style semi-automatic rifles and handguns. They were also often wearing bullet proof vests, body armor, and helmets. In some cases, they were also disguised so that their facial appearance was obscured.  Some of these groups were self-identified as militias or paramilitary groups.  Militias always have a sacred role in firearm debates in the United States because when the Second Amendment was written and approved 230 years ago – this was the wording:

“A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

The Second Amendment is interpreted unambiguously by gun advocates as a Constitutional right to own firearms and the most open interpretation is firearms of any kind and as many firearms as a person wants.  The sheer number of firearms possessed by Americans is a matter of public record available in many places so I do not plan to repeat it here. Record gun violence in the United States is also a matter of public record due to suicides, homicides, and accidental deaths.  The United States also has record number of mass shootings each year that can also be found in the public record and I will not repeat it here.   

For now, I want to briefly focus on the concept of militia and the idea that it is well regulated.  Militias are defined as able bodied residents between the ages of 17 and 45 years old who can be called to defend a specific state or the United States.  Private militias acting outside of the federal code definition are illegal.  That includes all groups who are not called to duty by a state governor or the federal authorities.  Even if these groups appear to be uniformed and operating under some command structure, they are illegal organizations.  All 50 states prohibit private militias from doing what state authorized militias do.  They are also prohibited from engaging in paramilitary training and in some states brandishing firearms in a way that it could be construed as threatening. Apart from these laws about militias, states also have terroristic threat statutes, and statutes that restrict firearm access to anyone with a history of domestic violence. There is a patchwork of additional law regarding background checks, safe storage of firearms, and collecting statistic data on firearm violence.  There is a currently a loophole in background checks because unlicensed private gun sellers are exempt from conducting background checks on potential purchasers.    

For at least 20 years, gun advocates and lobbyists have pushed open carry and concealed carry laws to the point that they are both unnecessary and a threat to public safety. There is no better example than when groups of private militias or heavily armed private citizens show up at public events or protests. History illustrates that these events can lead to confrontations, injuries, and even deaths when they are managed by law enforcement or the state militia – the National Guard. Is it realistic to think that untrained private citizens or illegal militias will do a better job?  Is it reasonable to have open carry laws on the books so that these individuals or groups can potentially function in a number of ways that contradict other laws about assuming police functions or threatening other citizens?

The only logical conclusion you can come to is that both heavily armed private citizens or unregulated militias with a stated purpose of assuming the function of well regulated militias or law enforcement have no standing at all and are much more likely to add more heat than light to the situation.  They knew that in Tombstone, Arizona back in 1881, when they passed the ordinance at the top of this post. This ordinance (in one way or another) precipitated the Gunfight at the OK Corral. We need to recognize that heavily armed citizens roaming around in our communities is unnecessary and a recipe for disaster.  Open carry laws need to be rolled back to 1881 or about 130 years after the Second Amendment was passed.

I anticipate plenty of blowback about that opinion. My only goals are public health/public safety and preventing both unnecessary deaths and the kinds of confrontations that led to this trial in Kenosha. I also wanted to get this opinion out there before there was a verdict by the jury, because at that point those opinions on what happened will fall along partisan lines. Few people seem to recognize the seriousness of this issue – both in terms of the high personal and financial cost of gun violence – but also the destabilizing effect it has on the country.      

I also realize that there is a sense of hopelessness in the United States that we will ever have sensible firearm rules resulting in safer communities.  For a generation there has been a massive misinformation campaign about gun rights. It is possible to have a Second Amendment the way it is written and have safer communities.  Rolling back open carry laws is the place to start. 

 George Dawson, MD, DFAPA

 

References:

Transcript Prosecuting Attorney Closing Remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-prosecution-closing-statement-transcript

 

Transcript Defense Attorney Closing remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-defense-closing-statement-transcript

 

Supplementary 1: (posted on 11/19/2021 @ 12:49 PM):

I just saw the news that the defendant in this case was found not guilty on all charges.  Staying with the theme of this post that verdict is all the more reason why open carry laws need to be rolled back. I expect the usual posturing about the need for firearms to be used for self protection, but the public health issue remains - people bringing firearms to public gatherings or even to the local supermarket is a setup for violent confrontations and their outcomes. I encountered a statistic today that armed demonstrations are six times likely to turn violent than unarmed demonstrations.  If physicians and their professional organizations don't feel they can change the law - they can advocate for common sense measures and provide the supporting data.  Primary prevention of gun violence needs to start long before there are any court proceedings. 

Supplementary 2: 

I recalled today that I took an NRA Hunter's Safety Course when I was ten years old in a remote northern part of a state.  That course was taught by a military veteran who vetted us before we could even get in to the course.  He made us promise that we would no longer play with toy guns.  The main rule of the course was "Never point a gun at another person whether you think it is loaded or not."  Somewhere along the line that rule seems to have been lost by modern gun advocates. 

The Current Moral Crisis In The United States

 

It is fashionable these days to talk about moral crises that really aren’t moral crises. The level of rhetoric is at the point where disagreements can be spun as moral crises, while people are dying in the streets. The best examples I can think of are the long-standing epidemics of gun violence and racism. New examples are cropping up every day. There are current trends in violence against Asian Americans and Jews against the backdrop of long-standing trends. Discrimination and violence against black Americans is finally acknowledged as being widespread and is the basis of an activist civil movement and hopefully systematic reforms.

All of the statistics to back up my statements in the first paragraph are easily available and I am not going to post all those references here. Since I started writing this blog one of my concerns has been gun violence and how to stop it given the level of interference with common sense gun law reforms by one of the major parties and major lobbying concerns. I saw the attempt to counter that political interference as being futile and focused more on public health interventions and possible psychiatric intervention. The latest good review of that approach is available in a review by Knoll and Pies (3).  For many years I have advocated that homicidal ideation should be seen as a public health intervention point and that it should be part of the strong public health message. To this day nothing has happened. Public health organizations do have research-based suggestions such as locking up firearms and common-sense gun laws like banning large capacity magazines, banning assault rifles, and universal background checks, but the general lack of progress in that area is not reassuring. There has been some movement in allowing more research on gun violence, an area that was previously blocked by gun lobbyists.

What is the connection between gun violence, racism, and violence toward our fellow Americans?  I think there are all based on the same interpersonal dynamic. That dynamic is seeing another person as being significantly different from you, attributing negative characteristics to them, and using both of those premises for treating them different from you up to and including perpetrating violence toward them.  In psychiatric jargon, we use the term projection to capture this process or in the extreme projective identification. These are not psychiatric diagnoses, but defense mechanisms that are distributed across the population even though they may be more likely in people with specific psychiatric diagnoses.

In my readings over the years I have been looking for a likely origin or at least first sign of this kind of thought pattern. In other words, have people been thinking like this since the beginning of recorded time, or is this a new phenomenon?  In the course of that reading, I came across a book written by the anthropologist Lawrence Keeley called War Before Civilization. In this book, Keeley explores the idea of the noble savage from prehistoric times.  In other words, were pre-historic people inherently peaceful as some had suggested or were there early signs of violence and aggression. A review of the evidence suggests that the majority of human prehistoric civilizations engaged in frequent warfare and total warfare – in other words attacks not limited to combatants and decimating the opposition’s infrastructure and ability to make war.  Keeley reviews the motivations and consequences of primitive warfare in great detail including tactics (surprise attacks, slaughter of noncombatants, and general massacres) and specific practices like mutilating dead bodies. There is clear evidence the latter functioned in part to dehumanize and humiliate the enemy and send a message to the survivors. These dynamics were not limited to prehistoric man and have continued through modern times and modern warfare.

A recent report referencing Keeley’s book appeared on Scientific Reports (2) this week.  It was a reanalysis of a Nile Valley burial site of 61 people from about 13,400 years ago. It is thought to be some of the earliest evidence of Homo sapiens interpersonal violence.  In that analysis over 100 lesions were identified in the skeletal remains from what appeared to be projectile weapons.  Examining the mortality curve of the individuals in the cemetery showed that it was consistent with multiple burials rather than a single event.   The stone artifacts examined were consistent with spear or arrow heads. Some we designed to kill by lacerating and causing blood loss. Some were discovered embedded in bones, but others were discovered within the area where the body was discovered and that was viewed as being consistent with the ability to penetrate the body.  The authors conclude that the majority of people in the cemetery died of blunt or sharp force trauma and that there were multiple episodes of interpersonal violence.  Some of the combatants had been wounded multiple times prior to death.  They also concluded that these episodes were most likely the result of “skirmishes, raids or ambushes” likely related to territorial disputes that may have been affected by the weather. (p. 9).

What can be inferred from this long history of human violence and aggression? First, groups of humans have been perpetrating violence against one another since prehistoric times. Second, during these episodes total warfare was very common and the human cost of war is always high. The estimated percentages of deaths in ancient society were generally higher than in modern society for a number of reasons. That was not a deterrent to ancient humans.  Third, the psychological states during these episodes of violence show a potentially broad range of thinking leading to aggression.  Very limited incidents such as the theft of livestock or a rumor of a sexual affair between members of different tribes or villages may be all that was required to start a series of retaliations leading to all out war.  Once a violent conflict ensued – there were thought patterns and rituals in place to justify the killing, prevent bad outcomes for the killers, humiliate the dead, and embarrass their families.

The current moral crisis in America seems to have a direct link with prehistoric behaviors. It is enacted by aggressive behavior that is described as racism, antisemitism, and gun violence, but the dynamic is the same one described in ancient man.  In other words, once a person can be seen and characterized as an enemy (for whatever reason),  it is very easy to vilify them, attribute the worst possible motivations to them, and use that as a basis for rationalizing aggressive behavior. In the past weeks, I saw two elderly Asian American women attacked at a bus stop by a man wielding a knife. The attack as so violent that the large blade of the weapon broke off inside the body of one of these women. In a more recent event, a heavily armed long time employee shot 9 of his coworkers and then killed himself when he was surrounded by police.  In both cases, the “motivation” for the violent behavior is unknown.  There is a suggestion of mental illness, but the majority of people with diagnosed mental illnesses and even the same diagnoses are not violent or aggressive. The sheer volume of mass shootings in the United States suggests it is more of a cultural phenomenon here than anywhere else but that is confounded by the easy availability of firearms.  The main difference between modern and ancient times is that we have a societal structure that is designed to contain violence and aggression and prevent larger outbreaks.  It is clearly ineffective at this point in preventing violence.

I am suggesting a common thought process here that does not require any psychiatric diagnosis and one that can be intervened upon and self-monitored.  In order to perpetrate discrimination, hate crimes, and even homicidal violence toward others 3 conditions have to exist.  First, the potential victims of violence need to be seen as sufficiently different from the perpetrator so that he can attribute unrealistic negative attributes to them and rationalize his aggressive action.  Second, the attacker can see himself as sufficiently different from the potential victims that he feels threatened by them and can rationalize attacking them for that reason alone.  A common example is that the attacker feels victimized by his coworkers and feels the need to strike out at them.  And finally, the attacker must have a plan to either seriously injure or kill the victim(s). All of these thought patterns can be considered derivative of thoughts present in ancient man leading to the wide ranging aggression and warfare described in the references.

I think there is much to be said for intervention based on the observations in this post.  For the time I have written this blog, I have advocated for intervention based on homicidal or aggressive behavior. When I worked as an acute care psychiatrist – treating violence and aggression was easily half of my job.  If we can suggest that persons with suicidal ideation or self-injurious behavior contact a crisis intervention service or hotline – why don’t we have a similar suggestion for people with homicidal thinking?  And further what about general education about the primitive origins of these thought patterns.  Just the other day I posted the following:

“Ridiculing people who died of C-19 and were antivaxxers and anti-maskers is bad form - plain and simple.

Bring civility back and restart civilization.

It starts with recognizing the value of a single human life.”

There was much agreement with the post, but also several people who suggested that I was naïve for not being able to recognize enemies or that I was a “better person” for being able to overlook the behaviors of a group of people who were potentially dangerous to others.  My post was not about moral superiority or not recognizing enemies – it is all about the fact that disagreement should not lead to enmity and beyond that we are all members of the same tribe.  We all came from Africa. And seeing differences between us that do not exist is probably ancient thinking that obscures the fact that we are all a lot more similar than we are different.  As I explained to some of the critics of my post, they seemed to be focused on the exceptions rather than the rule.  They also seemed to be making arbitrary exceptions based on seeing more differences than similarities. 

We are currently at a crossroads in this country.  People are making money and generating political capital by emphasizing differences and exploiting the primitive thinking that I have outlined in this post.  Much of the aggression plays out at a symbolic level in social media, but the Insurrection at the Capitol building and the increasing levels of physical violence illustrates that it is far from always symbolic. Americans have traditionally left ethics and morality up to religious institutions where it may be presented at an abstract level.   

It is time to get back to the basic premise of why every person is unique and needs to be treated with respect by virtue of being a member of the human race. It seems like an obvious but untested approach to reducing interpersonal violence at all levels in a society that is not currently equipped to prevent it.

 

George Dawson, MD, DFAPA

 

References:

1:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

2:  Crevecoeur I, Dias-Meirinho MH, Zazzo A, Antoine D, Bon F. New insights on interpersonal violence in the Late Pleistocene based on the Nile valley cemetery of Jebel Sahaba. Sci Rep. 2021 May 27;11(1):9991. doi: 10.1038/s41598-021-89386-y. PMID: 34045477 (Open Access).

3:  Knoll JD, Pies RW.  Moving Beyond "Motives" in Mass Shootings.  Psychiatric Times 36(1) Jan 13, 2019. Link

Permissions:  Graphic above is from reference 2 per the following Creative Commons license. 

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to theCreative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creative commons. org/ licenses/ by/4. 0/.

Mass Shootings Again and Again

There seems to be some optimism that Congress may be more motivated to do something about mass shootings in America given the recent events.  As I have said before - I will believe it when I see it.  Gun control is the prototypical deadlock in the USA, largely due to the effects of the gun lobby and their resistance to common sense gun legislation such as universal background checks, ban on high capacity magazine, and ban on assault weapons.  If anything, the rhetoric in these areas has intensified.  The assault weapons for example are described as not more than semi-automatic weapons just like hunting rifles.  Forget about the fact that the Sandy Hook Elementary shooter fired 154 rounds in 4 minutes from the 10-30 round magazines he  brought with him - killing 26 people 20 of whom were children.  Putting "mass shooting" in the search box in the upper right hand corner of this block will pull up about 14 essays dating back 7 years to 2012 including a proposal to consider violence prevention as a public health intervention.

Another important level of the deadlock is the Supreme Court. Interpretation of the Second Amendment can occur at several levels and in the current Court 5/9 justices are Republican appointees making restrictive gun legislation less likely.  Gun advocates controlled the narrative about the Second Amendment early on so that the preamble is typically ignored.  Gun advocate rhetoric is basically that gun ownership of practically any gun one might want to own is an unconditional right.

Over the years the pattern remains the same.  The issue of mass shooters disrupting American society and killing people is always minimized relative the "rights" of gun owners. The spokespeople on this issue don't even attempt to address the problem. They immediately produce pro-gun rhetoric and maintain that nothing needs to be done.  They are obviously wrong about that.  Mass shootings are the problem.  That is not a gun rights problem or a gang violence problem. It is a problem of keeping guns out of the hands of mass shooters. A secondary public health issue is keeping guns out of the hands of suicidal people. Limiting access is a known solution to both problems. Every reasonable solution should be available to solve that problem including universal background checks and outright bans on weapon types and permanent bans of some people purchasing firearms as well as confiscation and destruction of firearms.

The police response to terroristic threats is instructive. 30 years ago, I received a fax from the local police that a person had purchased a handgun and they were "letting me know" about it.  I called them back immediately and they told me: "We can't do anything because they haven’t done anything yet." Within a few weeks I was personally threatened at home with a handgun concealed under a newspaper and they were planning to use it. Flash forward 20 years and I had a similar threat on my voice mail. I called the police in; they listened to it and told me they were going out to talk to the caller. They called me and said they had talked with him, and that if he contacted me again, they were going to arrest him for terroristic threats. I never heard from him again.

The threshold for police intervention needs to be at least this low for every person identified as a potential threat with access to firearms. Terroristic threats or behavior should be the threshold for police intervention.  In the NICS system persons who have been convicted of misdemeanor domestic violence or subject to a restraining order for harassing, stalking or threatening are prohibited persons and they would fail this federal background check that rejects firearm purchases. In many cases, early signs were noted by members of the public and family members, but it was not clear which authorities should be contacted and how the problem should have been approached.  The protocol for identifying potential mass shooters and the response by the police needs to be standardized and widely applied.  The police response in almost every locality is also a political issue as evidenced by the very gradual adoption of consistent domestic violence laws.

There has been some blurring of boundaries between psychiatrists and the police - most notably by the Tarasoff laws that transfer what I consider to be a police action (warning potential victims) to clinicians.  In many states now, commitment laws are decided by the police since only they are allowed to put people on mental health holds. This is a completely illogical approach to psychiatric emergencies and holds.  There should be a clear division between clinicians and the police.  Clinicians do not take custody of people or discuss confidential information outside of what is legally required and that generally is to specific government authorities and not members of the public.

There have been no public health interventions focused on mass homicide prevention. I have been an advocate for this for a long time. There needs to be a campaign that focuses on anger control and what the resources might be to address it. On acute care psychiatric units, much of what is focused on has to do with the prevention of aggression and violence it has several causes. The message that anger - especially if it involved aggression even to the point of homicidal thinking and planning is a treatable problem and it can be treated before anyone is hurt or that person's life is ruined. Instead of treating it we have allowed mass homicide to persist as a way to express anger in a subculture of largely men. There are many forces in social media reinforcing this inappropriate expression of anger.

Although I have mentioned psychiatric problems here and see violent psychiatric patients as being part of the problem, they are not by any means the major part. I am sure that a personality disorder diagnosis exists in many of these remaining men, but the majority have not had any psychiatric contact. 

Psychiatry in itself will never be a solution to the problem without cultural changes at the level of this violent subculture and their way of expressing their anger and the law enforcement culture seriously resetting the threshold for intervention.  There also has to be a clear intervention to keep highly lethal firearms out of the hands of potential mass shooters. 

Pro-gun rhetoric never addresses that basic point.



George Dawson, MD, DFAPA