The most-widely cited research conducted by Swanson et al found that only 4% of violent behavior towards others can reasonably be attributed to SMI; in other words, 96% of American violence is due to factors unrelated to diagnosis.
A 2014 study in the American Journal of Public Health analyzed a random sample of 25% of news stories on SMI and gun violence published in the national and regional news from 1997 to 2012. During this time period, the study found that “‘dangerous people’ with SMI were more likely than ‘dangerous weapons’ to be mentioned as a cause of gun violence.”
A subsequent study published in Health Affairs last year found that public associations of schizophrenia with violence rose “significantly” from 1996-2018. By 2018, over 60% of survey respondents associated schizophrenia with dangerousness, and as high as 59% supported coercive treatment.
The study’s authors concluded: “These findings reflect political discourse, not scientific data, and could lead to policies that would be ineffective and misdirect the search for the underlying roots of violence.”
Questioning the Dominant Narrative
On February 3, the Coalition for Smart Safety and the Consortium of Citizens with Disabilities (CCD) co-organized back-to-back briefings in the House and Senate to provide background and education about the pervasive myth linking gun violence and mental illness.
Comprised of leading local, state, and national disability rights, civil rights, education, mental health, and privacy organizations, the Coalition for Smart Safety formed last year “with the shared goal of affirming that mental health disabilities are not predictors of gun violence and should not be the focus of gun violence prevention proposals.” CCD is the largest coalition of national organizations “working together to advocate for federal public policy that ensures the self-determination, independence, empowerment, integration and inclusion of children and adults with disabilities in all aspects of society.”
Despite the nation’s laser focus early last week on the final days of the impeachment trial, both briefing rooms were packed with staffers and advocates. On the House side, the briefing was presented in conjunction with Reps. Grace Napolitano (D-Calif), and Jim Langevin (D-RI), both members of the House Gun Violence Prevention Task Force. The House briefing was livestreamed by the National Parent-Teacher Association.
An identical briefing followed on the Senate side, presented in conjunction with the offices of Senators Richard Blumenthal (D-NY), Bob Casey (D-PA), and Patty Murray (D-WA).
Last December, Murray, ranking member of the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education (LHHS), helped to get $25 million approved in dedicated Federal funding for gun violence research — the first time since 1996 that Congress has approved such funding.
Mental Illness Low On List of Causal Factors
Jonathan Metzl, author, psychiatrist, and director of the Center for Medicine, Health, and Society at Vanderbilt University, provided an overview of the research evidence on gun violence and mental illness. Metzl, who is also research director of The Safe Tennessee Project, a nonpartisan gun safety organization, and a frequent media commentator on mass shootings, said that in the aftermath of the Sandy Hook tragedy that “every time there would be a mass shooting, there would be some politician who would basically say, ‘This isn’t a gun problem. This is a mental illness problem,’ followed by a seemingly endless slew of media saying, ‘This disorder caused the mass shooting.’ I kept getting asked the question, ‘Does mental illness cause mass shootings?’”
Metzl is not unsympathetic to this gut reaction. “The aftermath of a period of mass shooting is a moment of terror, right? This idea of creating some boundary between ‘us and them,’ some kind of lingua franca that ‘only a crazy person would commit an act like that,’ is an understandable response.” He added that with a number of mass shooters, there were histories of psychiatric symptoms, adding to the pervasiveness of the myth.
However, as Metzl began to dig deeper into the data, he found that prevailing stereotypes and reality simply did not match up. “I started to list out the many factors that went into a mass shooting,” he said. “And the factors were things like the availability of firearms, substance use, recent firing from a job, trauma, things like that. Mental illness is often number 15 or 20 on the list. And so it was increasingly problematic, I thought, that mental illness was being isolated as being this one causal factor.”
Metzl’s research went even further to reveal the opposite of the “violent madman” stereotype so ingrained in public consciousness. “There was a lot of data that I thought was convincing, which was showing that people with diagnosed mental illness were actually less likely to shoot somebody and less likely to commit mass shootings,” he said.
This is partly because “negative symptoms” that can lead to a diagnosis, such as low energy, low mood, and disorganization, were actually protective factors against committing violence, because people having these experiences were less likely to be out in public, Metzl explained.
“Here was another example of the stigmatization being really at odds with what was happening in the real world,” he added.
Metzl said that psychiatrists are likely to be “poor predictors” of whether an individual will become violent, at least in part because “the population of patients that psychiatrists are seeing are less likely than a more dangerous group—the sane—to go shoot somebody else.”
For Metzl, the concern is that when people make the erroneous link between mental illness and gun violence, they are less likely to pursue solutions that address the true root causes of gun violence. Instead, they are more likely to focus on getting better at predicting who will be the next “ticking time bomb,” he said.
While Metzl did not mention it by name in his remarks, last year just such a proposal made headlines. Bob Wright, head of the Suzanne Wright Foundation and a friend of President Trump, floated a proposal to the White House called Stopping Aberrant Fatal Events by Helping Overcome Mental Extremes (SAFEHOME). According to this proposal, SAFEHOME would be part of a new agency, the Health Advanced Research Projects Agency (HARPA), modeled after DARPA, or the Defense Advanced Research Projects Agency.
With an estimated price tag of $40-60 billion, SAFEHOME is supposed to utilize tracking software to detect signs of “mental health” concerns that could portend mass shootings. But according to Jessica Baron, a tech ethicist who blogged about SAFEHOME as “pseudoscience:” “just because we have AI and machine learning that can process massive amounts of behavioral data doesn’t mean it actually works.”
Metzl concluded by stating that we as a society need to be asking much broader cultural questions about gun violence, such as “Why do we need so many guns in the first place? Why do people mistrust each other?” and “What do guns mean to the population of gun owners?”
Since the year 2013, there have been more guns than people in America, making the country an outlier among all the world’s nations.
A Societal Belief That Is Just “Completely Wrong”
Josh Horwitz, director of the Coalition to Stop Gun Violence (CSGV) which develops and advocates for evidence-based solutions to reduce gun injury and death, admitted that he had once believed in the link between mental illness diagnosis and mass shootings. After bringing together experts who showed him the data, he now feels that the idea of mental illness causing mass shootings or violence in general is “just completely wrong,” adding: “I’ve had to change my thinking about it after about 23 years of doing this.”
Horwitz explained that gun violence is complex and multifactorial, encompassing interpersonal and intimate partner violence, suicide, police violence, and accidental deaths. Therefore, there is no one cure. As far as policymaking at his organization, Horwitz no longer gives the mental illness link any credence. “I don’t spend any time on that,” he said.
From an epidemiological perspective, Horwitz noted that if there are nearly 45 million people in America diagnosed with a mental illness in any given year, the likelihood that any one person in this group would use a gun to commit a homicide is extremely small.
“Thinking about screening 45 million people for things that they are not a risk for is a gigantic waste of resources,” Horwitz said. “When we think about stopping gun violence, focusing on people who are less likely to be violent makes zero sense, and it’s also incredibly stigmatizing.”
“What we need to do is focus on the real risks of gun violence,” he added. Known risk factors unrelated to psychiatric diagnosis or disability include alcohol or drug misuse; a prior history of violence; being male and young; and a recent relational, social, work or financial loss.
While alcohol and street drugs are commonly associated with an increased risk of committing gun violence, psychiatric medications were not mentioned at the briefing and are rarely included in media or academic discussions of mass shootings. Yet psychiatric drugs, most notably antidepressants, have long been associated with an increased risk of violence in a percentage of individuals, with several mass shooters having taken such drugs. As early as post-Columbine in 1999, psychologist Peter Breggin warned about a possible connection, as one of the shooters was taking the antidepressant Luvox at the time.
Author and sociologist Anthony Ryan Hatch, who wrote about psychiatric drugs and interpersonal violence in his book Silent Cells: The Secret Drugging of Captive America, told Mad in America last month: “I think that more research needs to be done to try to figure this out. Because this combination of widespread societal psychotropic drug use and the mass availability of weapons is creating a situation where far too many of us are dying and being injured. Although it’s very difficult for me to say that A causes B.”
While Horwitz acknowledges that there is no singular cure for gun violence, his organization has been focused on a specific set of policy reforms: “extreme risk protective orders” (ERPOs), also known as “red flag laws” or “gun violence restraining orders (GVROs). As of this writing, such laws have been passed in 17 states and the District of Columbia.
ERPOs have been implemented in a variety of ways. Some laws discriminate on the basis of psychiatric disability and diagnosis, and some focus only on non diagnosis-specific risk factors. New York’s 2013 SAFE Act is one of the earlier and more controversial ERPO laws, as it requires mental health professionals to report on individuals who are “likely to engage in conduct that would result in serious harm to self or others, regardless of whether a legal firearm is implicated,” even though mental health professionals are typically poor predictors of violence.
“Think of a domestic violence restraining order, except it’s available to any family member,” Horwitz explained. “That family member can say ‘my loved one’s at risk’ because of evidence-based risk factors of violence: past acts of violence, threats of violence, drug or alcohol abuse, impulsive anger.” He added, “The studies are pointing in the right direction that these laws that are focused on the actual risk factors, rather than mental illness, are saving lives.”
“We have to stay focused on the facts.”
Kelly Vaillancourt, director of policy and advocacy with the National Association of School Psychologists, shared her concerns about mental health services in schools being touted as the solution for school shootings. “If we’re really going to be serious about tackling the issue of gun violence, we have to stay focused on facts,” she said. “To conclude that a child or an adolescent who is exhibiting symptoms of depression or anxiety is more predisposed to commit an act of violence does nothing but perpetuate an incorrect stereotype.”
“What we absolutely have to move away from is the notion that we provide school mental health services because kids with disabilities or kids who have a mental illness are violent,” Vaillancourt said.
Vaillancourt mentioned her organization’s concerns about policies that profile students on the basis of disability or diagnosis. “It is completely inappropriate for schools to be using any kind of profile to say, ‘Oh, you’re a student with a disability, therefore you must need these types of services.’ Or, ‘you’re a student with a mental illness. Therefore, we automatically assume that you pose a threat of violence.’”
One example, not specifically referred to by Vaillancourt, is the “school safety” policy implemented in Florida in the wake of the Parkland shooting, which sparked controversy over a requirement that students disclose past referrals to mental health services when registering for public schools. Writing about this law for the Center for American Progress (CAP), Azza Altiraifi and Valerie Novack warned: “This policy will disproportionately harm marginalized students, especially those who may exhibit aberrational behaviors as a result of a disability but who pose no actual threat.”
Vaillancourt said that her organization is hearing about such discriminatory policies being enacted around the U.S. “I strongly encourage those of you that are in communities where you’re hearing this is happening to do everything you can to stop it. Because that is not how we should be addressing school mental health.”
The final speaker was William Kellibrew, director of the Office of Youth and Trauma Services with the Baltimore City Health Department, which has helped to train over 31,000 city employees and community members in trauma-informed approaches.
Kellibrew shared his personal experience as a survivor of a gun violence tragedy that claimed his mother and brother. “It shaped the rest of my life,” he said. He spoke of being misunderstood by teachers and bullied by other students for staring out the window and for other behaviors he developed in the wake of the traumatic events.
Searching for news reports of his family tragedy a decade after the fact, what struck Kellibrew was a report in the Washington Post that described him as having witnessed the shooting but as being “unhurt.” Kellibrew said, “It actually crushed me 10 years later to know that that was the report about my experience. I was far from ‘unhurt.’ I was devastated.”
Kellibrew has learned through his life and work that “healing and recovery are possible.” He emphasized that “managing and struggling with mental health challenges is not a death sentence, or something that we should be afraid of. Nor should it prohibit us from living our best lives. What prohibits us from living our best lives is when we lack the support, and we’re attacked with labeling and stigma about who we are.”
He concluded that for young people who have survived traumatic events, “getting support as fast as we can to go ‘upstream’ and address some of the challenges is important, but (surviving a traumatic event) certainly isn’t a predictor of violence. I’m sitting right here with you.”
Kellibrew added: “I’m just glad to be part of a framework that says that these things aren’t connected in the way that people are connecting them.”
Debunking the Master Narrative
During the panel discussion, Jonathan Metzl mentioned that as someone who often engages with the media as a commentator, he has begun to notice some improvement in how mass shootings have been reported over the last decade. “I remember when I first started this, I would get asked questions like ‘What’s the diagnosis of the shooter?’” he said. “Another one I remember was: ‘Is Asperger’s linked to a higher risk of mass shooting?’ I do think we’ve gotten much more nuanced about this as a society.”
Metzl referred to the racialized dimension of the media and public rhetoric around mass shootings, which also has gotten more attention in recent years. “There’s a politics to which kinds of mass shootings get called ‘mass shootings caused by mental illness,’ and which ones get dismissed as ‘gang-related’ or ‘drive bys,’ (which is) just kind of an easy shorthand for ‘urban violence.’”
Discussing the media stereotype of the mass shooter as a “white mentally ill loner,” he explained how it “plays into all of these kinds of historical stereotypes about whiteness and intellect and factors like that. And it leads to calls to stop these kinds of shootings. But particularly when the victims are from communities of color, it never gets called ‘mental illness.’ It’s very quick shorthand for ‘there’s nothing we can do about it because it’s not a disorder of the brain, it’s a disorder of the neighborhood, it’s a disorder of the culture,’ or things like that.”
Metzl added, “There’s a long history of what gets called ‘mental illness’ being divided along racial lines.”
He also noted that a narrow focus on changing the media narrative may miss another important aspect of this issue. “The media is also reporting on gun laws. So I think part of the issue is that it’s not just enough to tell the media to do a particular thing. It’s actually linked to pushing for more responsible gun laws.”
He added, “I think that in a way, the media here sometimes deflect from the judiciary here, and what kinds of laws are being implemented.”
The latest Federal legislation to link SMI and violence is S. 2690, Sen. John Cornyn’s (R-TX) Restoring, Enhancing, Securing, and Promoting Our Nation’s Safety Efforts (RESPONSE) Act of 2019. The RESPONSE Act was introduced into Congress last fall following two back-to-back mass shootings in Cornyn’s home state of Texas last August. Cornyn’s legislation focuses on access to mental health treatment, including involuntary treatment; increased surveillance of America’s schoolchildren; and greater collaboration between mental health and law enforcement authorities. The bill currently has seven Republican co-sponsors.
The RESPONSE Act is similar to former Rep. Tim Murphy’s Helping Families in Mental Health Crisis Act, bipartisan mental health legislation introduced in 2013 following the Sandy Hook tragedy. Until Murphy resigned from Congress in 2017, the Republican Congressman and psychologist from Pittsburgh appeared in the press after every mass shooting, blaming people with SMI for gun violence. Murphy currently serves on the board of directors of the Schizophrenia and Related Disorders Alliance of America (SARDAA).
Maria Town, President and CEO of the American Association of People with Disabilities (AAPD) served as the moderator for both briefings. “We need to make sure we’re actually centering the voices of people with psychiatric disabilities in these conversations,” she said. “That speaks to making sure we’re telling the whole story.”
Town added, “All too often, you hear from everyone else but people with psychiatric disabilities.”