There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018. It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis. Since it popped up it is being posted to Twitter by more and more psychiatrists. It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior. Dr. Barnhorst gives examples of people who allegedly make threats and then deny them. She discusses the legal standard for commitment and its subjective interpretation. For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side. That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted. If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released. That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.
If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them. Unless his legal status changes they may give him the guns back. In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back. I am not aware of any psychiatrist who has done that. The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done). That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial." Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled. Unfortunately not all states participate in this check system and there are numerous exceptions if they do.
I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms. At the political level there is no nuance. At this level the degree of distortion is the greatest. The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not. The legal arguments are slightly more informed, but still fairly crude. Like most legal arguments they threaten or reassure. For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities. On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires. The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.
At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression. It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing. They are successful at stopping violence acutely and on a long term basis. Given the legal biases they cannot do it alone. There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system.
Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:
"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence."
She cites "angry young men who harbor violent fantasies" as basically being incurable. The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one. The facts are seldom considered. There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates. The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology. There are for example school shooter databases that record events as anytime a firearm is discharged in a school. That results in a very large number of weapon discharges but most where nobody is injured. There are databases that just list events but there is no analysis of whether mental illness was a factor or not. In mass shootings in half the cases the shooter is killed or suicides. Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available. The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.
The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1). The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses. I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.
He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill. His definition of mentally ill as essentially being psychotic. He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic. Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment. Using this conservative methodology - it is apparent that mental illness in this population is not rare at all. What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.
My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:
1. Increase the purchase age to 21 years. Eliminate access to military style weapons.
2. All purchases must be cleared through the NICS system. All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.
3. The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria. In other words, you are eliminated from gun purchases if you have been reported for these problems. That may sound a bit stringent but I think there is precedent. You cannot make threats about air travel at an airport. If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
the are special instructions on what it takes to keep firearms from you. I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).
4. At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.
5. Uniform protocols need to be in place for terroristic threat assessment. It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention. The person making the threat should be removed from that environment and contained pending further investigation.
6. On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start. Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence. There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.
7. On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems. Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings. In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff. They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings. Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.
8. In the early years of this blog - I was an advocate for violence prevention and I still am. Violence and aggression have the most stigmatizing effects of any mental health symptoms. I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients. It needs to be seen as a public health problem and education and prevention are a first step.
Those are my ideas this morning. I may add more to this page later. If you have a real interest in this topic Dr. Stone's paper is a compelling read. If I find others of similar quality I will post them here. Don't hesitate to send me a reference if you have one.
The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter. And yet there is a clear overepresentation of mental illness in this population. Some level of cooperation as suggested above will result in a much tighter system for addressing this issue. We do it in airports and in domestic violence situations. We can also apply more uniform and stringent expectations to schools.
George Dawson, MD, DFAPA
References:
1: Amy Barnhorst. The Mental Health System Can't Stop Mass Shooters. New York Times February 20, 2018. Full Text Link
2: Stone MH. Mass Murder, Mental Illness, and Men. Violence and Gender. Mar 2015: 51-86. Free Full Text Link
Graphics Credit:
Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.
Layered arguments graphic was done by me in Visio.
