Mental health services cannot prevent mass shootings

Each time the nation convulses after a mass shooting, whether now in Parkland, or previously in Las Vegas, Orlando, Sandy Hook, Sutherland Springs, Virginia Tech, San Bernardino, Fort Hood, Aurora, Columbine, and in too many other places, we plunge back into a debate on gun control.  Opponents of gun control argue this is a mental health issue, not a gun control issue.  They argue that the shooters should have been committed into psychiatric asylums and the fact they were not indicated a failure of the mental health system.

While it is true that our mental health system is fragmented, under-skilled, understaffed, under-resourced, and getting worse, having an excellent mental health system is not sufficient to stop these shootings.

While the shooters’ actions are reprehensible and incomprehensible to all of us, most mass shooters are not mentally ill.  The terms “crazy” or “psychotic” or “demented” have become colloquial, but in their meanings as descriptors of mental illness, they mostly do not apply.  It is possible for mental illness to lead to violence, although these situations are very rare.  The most common form of violence in the mentally ill is found in dementia—older people become disoriented and lash out at their caretakers.  Violence may also result from severe posttraumatic stress disorder when individuals re-experience prior traumatic events and defend themselves in the present.  Individuals who are very drunk or intoxicated can also become agitated and violent towards those around them.  This is becoming more common as new synthetic drugs invade our cities from abroad, the opioid and methamphetamine epidemics continue to rage, and the legalization of cannabis in certain states allow for extremely potent strains to spread across the country.  Individuals with chronic schizophrenia and other illnesses that cause paranoia may misinterpret reality and lash out in self-defense against people who did not actually intend harm.  Lastly, there are individuals who lash out impulsively and may harm others even when it was not their intention; this occurs in individuals who suffer certain types of seizures or have physical injury to their brains from trauma.

A mass shooting involves significant planning, organization, ability to save money, and sufficient social skills to acquire a gun and other needed equipment.  It is vanishingly rare, although not impossible, for someone with any of the above conditions to have such high-level functioning while their psychiatric symptoms are not adequately controlled. When the symptoms are controlled, then the risk of violence is much reduced.

Mass shooters may have co-occurring mental illness, such as depression, learning disabilities, posttraumatic stress disorder, anxiety disorders, substance use disorders, and others, but so do millions of other people across the nation.  In fact, individuals with serious mental illness are very frequently the victims of violence by people without serious mental illness.  The constant suggestion that the mentally ill are violent serves only to reinforce the already massive stigma against the mentally ill.

There are other causes of violence that are sociological and not psychiatric.  Millions of people around the country and the world have normalized violence as a way to resolve conflict or as a way to get needs met. Millions have been brutalized in broken families, rough neighborhoods, bad schools, or a crushing criminal system.  Surviving in many urban, suburban, and rural communities all over the United States is a dehumanizing and soulless grind that leaves most of us burned out, impotent, and angry.  In some particularly angry men, the consequences of this alienation become extreme and lead to mass shootings.

The mental health system is critical for the treatment of common and serious mental illness, but it cannot change the underlying social and economic factors that normalize violence and despair.  There is no antidepressant or psychotherapy to cure the effects of capitalism.

When a family member or the police officer brings a disturbed individual to the emergency room, a psychiatrist can assess if the person has a psychiatric illness and whether the person’s symptoms suggest an acute risk for suicide, for violence towards others, or inability to implement the most basic self-care.  If a psychiatrist is sufficiently concerned for the person’s safety, then the psychiatrist will involuntarily admit the person to a hospital for further evaluation.  Within a few days, if the psychiatric team continues to worry whether the person presents a risk for suicide, violence, or inability to care for self because of a psychiatric illness, the hospital can petition a court to extend the involuntary hospitalization and allow for medication treatment over the person’s objection.   The vast majority of these involuntary admissions last at most a week and there is very close oversight by courts to ensure that people’s rights are not unduly removed.  Chronic violent or criminal behavior cannot be treated in a psychiatric setting and is not grounds for involuntary admission.

If a person reports he is not suicidal, has no intention of harming others, is able to maintain his hygiene, and behave appropriately in the emergency room or in the first few days of an involuntary admission, he will be allowed to leave with referral to voluntary outpatient care.  Psychiatrists are not able to predict the future or read minds, and we will never be able to do so.  A person who does not report or demonstrate symptoms of mental illness cannot be held or treated against his will.  None of the shooters of the recent tragedies would have met criteria for prolonged psychiatric institutionalization.   It is unlikely their underlying violence could have been treated with psychiatric medications.  Acute psychiatric admissions are critically important and life-saving for people in psychiatric crises, but they cannot stop deeply alienated and angry men intent causing others to feel their pain.

There are measures that would be helpful.  Gun control advocates can also support expansion of certain mental health programs.  Expansion of drug addiction treatment and the decriminalization of drug use is critical to help foster less violent, more resilient communities.  While we do not have treatments for most addictions, we are able to treat opioid addiction and alcoholism.  Expansion of school-based counseling programs, increased support for pregnant women and new parents, and adequate staffing of child protective services would help ensure that at-risk kids and struggling families get the support they need earlier.  We need to ensure that community- and public-sector services are staffed with professionals with adequate training to address the needs of the clients.  Too often work that requires a psychiatrist or doctoral-level psychologist is given to a professional with only a bachelor’s degree because of budget constraints.  This leads to burned out staff who provide inadequate care.

The only way to truly prevent mass murders with assault weapons is to eliminate access to assault weapons. Blaming violence on mental illness or in deficiencies in the mental health system will do nothing to prevent future mass shootings. Mental health professionals have no expertise outside of the illnesses we treat; we are not able to predict violence in people who do not present with psychiatric symptoms.  Communities collectively have to bring back our alienated relatives and neighbors from the brink of extreme violence.  There is no other way.

Flavio Casoy is a community and emergency psychiatrist and a Fellow of the American Psychiatric Association.