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Mass Shootings and Mental Illness

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Abstract

Mass shootings understandably create outpourings of public horror and outrage. Nevertheless, and contrary to common media depictions and the general public’s beliefs, mass shootings are extremely rare events. These tragedies are influenced by multiple complex factors, many of which are still poorly understood. However, the lay public and the media typically assume that the perpetrator has a mental illness and that the mental illness is the cause of these highly violent acts of horrific desperation. Although some mass shooters are found to have a history of psychiatric illness, no reliable research has suggested that a majority of perpetrators are primarily influenced by serious mental illness as opposed to, for example, psychological turmoil flowing from other sources. As a result, debate on how to prevent mass shootings has focused heavily on issues that are 1) highly politicized, 2) grossly oversimplified, and 3) unlikely to result in productive solutions. In this chapter, we discuss the existing research, limited though it may be, on mass shootings and then examine the nature of the link between gun violence and mental illness. We consider the value of gun laws focusing on mental illness, with attention to their potential efficacy in preventing future mass shootings. We conclude by proposing that instead of the focus on mental illness, increased attention should be paid to sociocultural factors associated with mass shootings and exploring other interventions and areas for further research.
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Mass Shootings and
Mental Illness
James L. Knoll IV, M.D.
George D. Annas, M.D., M.P.H.
Common Misperceptions
Mass shootings by people with serious mental illness represent the
most significant relationship between gun violence and mental illness.
People with serious mental illness should be considered dangerous.
Gun laws focusing on people with mental illness or with a psychiatric
diagnosis can effectively prevent mass shootings.
Gun laws focusing on people with mental illness or a psychiatric diag-
nosis are reasonable, even if they add to the stigma already associated
with mental illness.
Evidence-Based Facts
Mass shootings by people with serious mental illness represent less
than 1% of all yearly gun-related homicides. In contrast, deaths by
suicide using firearms account for the majority of yearly gun-related
deaths.
The overall contribution of people with serious mental illness to vio-
lent crimes is only about 3%. When these crimes are examined in de-
tail, an even smaller percentage of them are found to involve firearms.
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82 GUN VIOLENCE AND MENTAL ILLNESS
Laws intended to reduce gun violence that focus on a population rep-
resenting less than 3% of all gun violence will be extremely low yield,
ineffective, and wasteful of scarce resources. Perpetrators of mass
shootings are unlikely to have a history of involuntary psychiatric hos-
pitalization. Thus, databases intended to restrict access to guns and
established by guns laws that broadly target people with mental ill-
ness will not capture this group of individuals.
Gun restriction laws focusing on people with mental illness perpetu-
ate the myth that mental illness leads to violence, as well as the mis-
perception that gun violence and mental illness are strongly linked.
Stigma represents a major barrier to access and treatment of mental
illness, which in turn increases the public health burden.
Mass shootings understandably create outpourings of public horror and
outrage. Nevertheless, and contrary to common media depictions and the gen-
eral public’s beliefs, mass shootings are extremely rare events. These tragedies
are influenced by multiple complex factors, many of which are still poorly un-
derstood. However, the lay public and the media typically assume that the perpe-
trator has a mental illness and that the mental illness is the cause of these highly
violent acts of horrific desperation. Although some mass shooters are found to
have a history of psychiatric illness, no reliable research has suggested that a
majority of perpetrators are primarily influenced by serious mental illness as
opposed to, for example, psychological turmoil flowing from other sources. As a
result, debate on how to prevent mass shootings has focused heavily on issues
that are 1) highly politicized, 2) grossly oversimplified, and 3) unlikely to result in
productive solutions.
In this chapter, we discuss the existing research, limited though it may be, on
mass shootings and then examine the nature of the link between gun violence
and mental illness. We consider the value of gun laws focusing on mental illness,
with attention to their potential efficacy in preventing future mass shootings. We
conclude by proposing that instead of the focus on mental illness, increased at-
tention should be paid to sociocultural factors associated with mass shootings
and exploring other interventions and areas for further research.
MASS MURDER IN THE UNITED STATES
Because of frequent and sensational media coverage, it may appear that the era
of mass shootings began in 1966, atop the tower at the University of Texas in
Austin, and became a part of American life in subsequent decades (Associated
Press 2007). However, cases of mass murder, of which mass shootings are a sub-
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Mass Shootings and Mental Illness 83
set, have been recorded over time long before mass shootings captured public
attention. For example, in the Bath school disaster of 1927, to this day the dead-
liest mass murder in a school in United States history, one man killed 38 Mich-
igan elementary school children and 6 adults and injured at least 58 other
people.
The farmer who perpetrated these attacks had run into financial trouble. His
wife was seriously ill with tuberculosis. He reportedly became angry after an in-
crease in taxes and losing an election in which he had run for town clerk. He first
killed his wife, then firebombed his farm, and then detonated explosives in the
Bath Consolidated School, before committing suicide by detonating a final explo-
sion in his truck. Like many modern-day mass murderers, he left a final com-
munication. Stenciled and painted on a board outside his property, his message
read, “Criminals are made, not born”—a statement suggestive of externalization
of blame and long-held grievance. Many “premodern” cases of mass murder often
involved a depressed and angry male who killed his family and then himself. Such
cases did not capture much media attention because they were regarded primar-
ily as “family business” and were “too close for comfort” (Dietz 1986, p. 481). In
contrast, mass shootings beginning in the 1990s and covered intensely by the me-
dia appeared to be a different type of violence, at least in the eyes of the public.
Heavily armed individuals who had meticulously planned a public massacre in
which they intended to spread as much destruction as possible and then kill
themselves seemed a new phenomenon. Compared with depressed and despair-
ing familicide-suicides, these “modern” cases seemed distant enough from the av-
erage persons experience to capture the publics attention with morbid fascination
over prolonged periods of time.
Mass shootings cause endless public speculation regarding causes and mo-
tives. However, high-profile cases of mass shootings, which typically receive the
most intense media coverage, are in fact the least representative of mass killings.
In reality, such rare cases are the result of many complex factors. Nevertheless,
the news media have heavily influenced the publics perception of mass murders
(Duwe 2005), offering simplified explanations that assume the perpetrator is ei-
ther “mad or bad.” After all, who but a madman would execute innocent people
in broad daylight, while planning to commit suicide or be killed by police?
Such simplistic explanations are easier for the media to report, as well as eas-
ier for the public to accept. Nevertheless, these explanations are often inaccurate
and based on little or no evidence. In addition, they stoke the political fires sur-
rounding debates concerning regulation of firearms while providing no construc-
tive suggestions to prevent future tragedies. Psychiatric illness, although present
in some mass murderers and mass shooters, is far from the most significant or
consistent finding from attempts to investigate the nature of these deeply trou-
bling events.
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84 GUN VIOLENCE AND MENTAL ILLNESS
MASS SHOOTINGS: WHAT IS KNOWN
A mass shooting is a specific type of mass murder. Mass murder is defined as the
killing of three or more victims at one location within one event (Burgess 2006).
The motives of mass murderers typically involve the desire to kill as many as pos-
sible; such a motive does not limit a perpetrator to a particular means (e.g., guns,
bombs, arson). Those who commit mass murder may use more than one means to
achieve this goal. For example, the mass shooting at an Aurora, Colorado, movie
theater in 2012 involved a perpetrator who also booby-trapped his apartment
with multiple bombs in an attempt to kill more people in addition to those killed
in the shooting. The Norwegian man who committed a mass shooting on Utøya
in 2011 set off a bomb in Oslo prior to the shooting. Nevertheless, guns are an
efficient and often accessible means to carry out the goal of killing multiple vic-
tims. Because of this fact, and given the difficulty of neatly categorizing specific
mass murder events as shootings versus murder by other means, the study of mass
shootings benefits from an examination of mass murder.
As noted, mass shootings are a subset of mass murders; mass murder is also
a catastrophic but rare phenomenon (Burgess 2006; Investigative Assistance for
Violent Crimes Act of 2012, Pub. L. No. 112-265, 28 U.S.C. § 530C[b][1][M][i]).
Given its extremely low base rate, mass murder (and thus mass shootings) can-
not be predicted, especially by persons outside the perpetrator’s social circle
(Saleva et al. 2007). Little research exists that would serve to better inform men-
tal health professionals or law enforcement regarding the problems that lead in-
dividuals to commit mass murder.
For example, in a clinical study of 144 individuals who had threatened some
form of violence against others, 8 were found to have threatened mass homicide
(Warren et al. 2011). All 8 subjects said they had intended to kill as many people
as possible, and all cases involved targeting a specific group against whom the
would-be perpetrator held a grievance. Over the 12-month study period, none of
the 8 subjects carried out or attempted to carry out their plans. However, 2 of the
8 assaulted a person unrelated to the targeted group. Future research may enhance
awareness of the presence of “identification warning behaviors” (Meloy et al.
2011).
Factors common among individuals who commit mass murder include ex-
treme feelings of anger and revenge, the lack of an accomplice (when the per-
petrator is an adult), feelings of social alienation, and planning well in advance
of the offense. Many mass murderers do not plan to survive their own attacks and
intend to commit suicide or to be killed by police after committing their as-
saults. However, in a detailed case study of five mass murderers who did survive, a
number of common traits and historical factors were found. The subjects had all
been bullied or isolated during childhood and subsequently became loners who
felt despair over their social alienation. They demonstrated paranoid traits such
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Mass Shootings and Mental Illness 85
as suspiciousness and grudge holding. Their worldview suggested a paranoid
mind-set; they believed others to be generally rejecting and uncaring. As a result,
they spent a great deal of time feeling resentful and ruminating on past humil-
iations. The ruminations subsequently evolved into fantasies of violent revenge
(Mullen 2004).
The Federal Bureau of Investigation (FBI) studied 160 cases of active shooter
incidents between 2000 and 2013 (Blair and Schweit 2014). An active shooter as
defined by the FBI and other federal agencies is “an individual actively engaged in
killing or attempting to kill people in a confined and populated area. Implicit in
this definition is that the subjects criminal activities involve the use of firearms
(Blair and Schweit 2014, p. 5). An average of 11.4 incidents of mass shooting oc-
curred annually, and the trend over the study period showed a steady rise in inci-
dents. The main findings of the FBI study included the following:
Th e va st m ajo rit y of sho oti ngs (70% ) occ urre d in eit her a pl ace o f bu sin ess or
an educational environment.
All but two of the shootings were carried out by a single individual.
The shooter committed suicide in 64 (40%) of the cases.
Most incidents (67%) ended before police even arrived and could engage the
perpetrator.
Of the 160 incidents, 64 (40%) qualified as mass murder.
Only 6 (3.8%) of the 160 cases involved a female perpetrator.
The U.S. Secret Service and the U.S. Department of Education conducted a
study focused on targeted school violence in the United States from 1974 to 2000
(Vossekuil et al. 2002). Therefore, this study involved shootings that had oc-
curred prior to the FBI study’s findings suggesting a trend of increased mass
shooting incidents from 2000 to 2013. Secret Service researchers analyzed 37 in-
cidents of targeted school violence (most of them involving guns) perpetrated
by 41 attackers during this time period. Key findings regarding school shooters
included the following:
A majority of perpetrators (68%, n=28) acquired guns used from their own
or a relative’s home.
Perpetrators had easy access to family-owned firearms.
Perpetrators often “leaked” their intent to peers.
Perpetrators often engaged in behavior prior to the incident that caused oth-
ers concern (e.g., weapon seeking, disturbing writings).
Perpetrators had often considered or attempted suicide.
Chapter 5, “School Shootings and Mental Illness,” provides a more detailed dis-
cussion of school shootings.
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86 GUN VIOLENCE AND MENTAL ILLNESS
From an etiological standpoint, the factors contributing to mass murder are
broad, and therefore analysis of any single incident should be approached using
a model that addresses individual biological, social, and psychological factors
(Aitken et al. 2008). Biological factors include possible brain pathology, as well
as psychiatric illnesses such as depression and psychosis. Psychological factors
include a negative or fragile self-image, paranoid dynamics, and retreat into vio-
lent and omnipotent revenge fantasies. Social factors include isolation, possible
ostracism by peers, and an absence of prosocial supports. In sum, the extant re-
search on mass murders suggests that these events are caused by a complex in-
teraction of emotional turmoil, psychopathology, traumatic life events, and other
precipitating factors unique to each case (Declercq and Audenaert 2011).
Careful study of individual cases of mass murder frequently reveals that the
offender felt compelled to leave some type of final message (Hempel et al. 1999;
Knoll 2010). These messages may be written, videotaped, or posted on the Inter-
net or social media networks (Aitken et al. 2008). The communications often
have great meaning to the perpetrators, who realize it will be the only “living” tes-
tament to their motivations and inner struggle (Knoll 2010). These messages are
rich sources of data that provide a more complete understanding of the perpetrator’s
motive, mental state, and psychological disturbances (Smith and Shuy 2002).
Available research has not produced a widely accepted typology of mass
murderers or mass shooters (Knoll 2012), and detailed examination of incidents
indicates that not all perpetrators are alike in their motivations and psychology.
Although no research has reliably established that most mass murderers and
mass shooters are psychotic or even suffering from a serious mental illness, in-
dividual case studies often reveal paranoid themes in these persons’ cognitions
(Knoll and Meloy 2014). The paranoia may not rise to the level of psychosis;
however, many are found to have been preoccupied with feelings of social per-
secution and fantasies of revenge against their perceived tormentors. Some ap-
pear to be driven by strong feelings of revenge born of social alienation or a
perceived injustice. For example, one 15-year-old who shot and killed his two
parents and two high school students and wounded another 25 students in 1998
in Springfield, Oregon (Frontline 2000) suffered intolerable anguish over feel-
ings of social rejection. His peers described him as morbid and preoccupied
with violence.
Others may in fact suffer from severe depression or, rarely, psychosis. For ex-
ample, in 2009, a 41-year-old naturalized Vietnamese immigrant killed 14 peo-
ple, wounded another 4, and then killed himself at the Binghamton, New York,
American Civic Association. The mans father reported that in the 2 weeks lead-
ing up to the tragedy, his son had stopped eating dinner, stopped watching tele-
vision, and become increasingly isolative (Chen 2009). A few days after the shoot-
ing, a local television news station received a letter composed by the shooter and
postmarked the day of the shootings. Careful analysis of the letter revealed long-
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Mass Shootings and Mental Illness 87
standing paranoid and persecutory delusions, as well as hallucinations (Knoll
2010). The shooter described his extreme resentment at being systematically
persecuted in a bizarre manner by “undercover cops,” whom he believed had de-
stroyed his chances of assimilating and working successfully in the United
States.
To date, the phenomenon of mass murder has also eluded classification in a
broadly accepted system. One proposed system is based on the concept of homi-
cide-suicide, derived from the work of Marzuk et al. (1992) and further adapted
by Knoll (2012). Homicide-suicide, an event in which an individual commits a
homicide and subsequently (usually within 24 hours) commits suicide (Bossarte
et al. 2006; Felthous and Hempel 1995), is a distinct category of homicide with
features that differ from other forms of killing. Homicide-suicide is also a rare
event, estimated to occur at a rate of 0.20–0.38 per 100,000 persons annually
(Bossarte et al. 2006; Coid 1983). The majority of homicide-suicides are carefully
planned by the perpetrator as a two-stage sequential act. Marzuk et al. (1992)
proposed classifying homicide-suicides by the relationship the perpetrator had to
the victim (e.g., spousal, familial), along with the perpetrator’s motive (e.g., jeal-
ousy, altruism, revenge) (Marzuk et al. 1992). Given that mass murder often ends
in the suicide of the perpetrator and has been described as “suicide with hostile
intent” (Preti 2008), a classification system similar to that used for homicide-
suicide would seem to make sense. An accepted classification system for mass
murder would be helpful in coordinating future research efforts. Table 4–1 gives
a proposed classification system for mass murder based on the homicide-suicide
classification system of Marzuk et al. (1992). In this proposed system, relation-
ship is defined as “relationship or link between victims and perpetrator” to em-
phasize the fact that some perpetrators may have no meaningful interpersonal
relationship with their victims but instead may have only a connection (link) via
some mutually shared activity such as work or school.
This relationship link-motive classification scheme allows for multiple
permutations that can be applied to best describe each individual case. Notably,
mental illness does not appear consistently as a factor except in two of the six
classification groups. For example, in this system, the School-Resentful type of
mass murderer includes offenders who target schoolmates and have the motive
of hostile revenge. Depression and/or suicidal threats are likely to be present
prior to the offense, but not necessarily. These individuals are often described as
bullied, disaffected, or socially alienated students who are motivated by feelings
of rejection or humiliation by peers. The perpetrator often communicates intent
to third-party peers (Knoll 2012; Vossekuil et al. 2002). Examples of murderers
who fit this description include the shooters at Virginia Tech and Columbine,
Colorado (Cullen 2010).
The Workplace-Resentful type describes the aggrieved or disgruntled em-
ployee or ex-employee who is upset with a supervisor, coworker(s), or some
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88 GUN VIOLENCE AND MENTAL ILLNESS
TABLE 4–1. Proposed classification system for incidents of mass murder
Type Victim Relationship Motive Offense location
Paranoid
cognitions SMI
School-Resentful Peers, teachers Yes Resentment/revenge Educational environment + +/–
Workplace-Resentful Coworkers,
supervisors
Yes Resentment/revenge Place of business + +/–
Indiscriminate-Resentful Arbitrary No Resentment/anger Variable, place of easy
access to many victims
++/
Specific Community–
Resentful
Identifiable group,
culture, or political
movement
Variable Resentment/revenge Variable according to
location of targeted group
++/
Pseudocommunity-Psychotic Misperceived
persecutors
Variable Paranoid delusions Variable according to
persecutory delusion
++
Familial-Depressed Family, spouse, or
ex-spouse
Yes Severe depression
Possible psychosis
Revenge
Family domicile + +
Note. Classification scheme: relationship (relationship or link between victims and perpetrator)+motive (primary rationale driving the perpetrator). SMI=serious
mental illness, defined as psychosis or delusional disorder meeting DSM-5 diagnostic criteria (American Psychiatric Association 2013).
Source. Adapted from Knoll 2012 and Marzuk et al. 1992.
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Mass Shootings and Mental Illness 89
aspect of the work environment and who commits murder in the workplace. These
individuals typically externalize blame for their problem onto others and feel
they have been wronged. They are very likely to have depression, as well as par-
anoid and/or narcissistic traits. Persecutory delusions may sometimes be seen;
howe ver, me ntal i llnes s is no t nece ssa rily p resent. An exa mple of t his cate gor y is
the Atlanta day trader who shot and killed 9 people and injured 13 more in 1999.
He entered two adjacent Atlanta day-trading firms, stating, “I hope this doesn’t
ruin your trading day” before carrying out the shootings. Shortly afterward, he shot
himself. This individual was motivated by depression and anger, as well as seri-
ous financial and marital troubles. He had developed a highly resentful, hopeless
attitude about his life and career. His suicide note stated, “I don’t plan to live very
much longer, just long enough to kill as many of the p eople that greedily sought
my destruction” (Barton 1999; Cohen 1999).
The Indiscriminate-Resentful type describes the generally rageful, depressed,
and often paranoid individual who vents anger arbitrarily in some public place.
The victim group may be chosen randomly or on the basis of convenience or ease
of access to large numbers of people. An example of t his category is the man who
shot and killed 22 and injured 19 others at a San Diego, California, McDonald’s
restaurant in 1984 (Mitchell 2002). This angry but nonpsychotic man told his
wife immediately prior to the offense that “society had their chance” and that he
was leaving to go “hunting humans.” No evidence indicated that he felt particu-
larly aggrieved by that specific McDonald’s restaurant or its employees. Rather,
the evidence indicated that he had chosen the location due to his familiarity with
his target and his knowledge that large numbers of potential victims were likely
to be present.
In a seminal paper on mass, serial, and sensational homicides, Park Dietz
(1986) described a type of mass murderer he termed the “pseudocommando,” who
plans out the offense ritualistically and comes prepared with a powerful arsenal
of weapons. The proposed classification system includes two types of pseudo-
commando-style mass murderers: the Specific Community–Resentful type and
the Pseudocommunity-Psychotic type. Both categories include individuals who
have paranoid character traits and are driven by strong feelings of anger and re-
sentment.
The Specific Community–Resentful type may include disgruntled clients or
others harboring deep resentment toward an identifiable group, culture, or polit-
ical movement. In contrast, the Pseudocommunity-Psychotic type includes only
those experiencing paranoid or persecutory delusions flowing from a psychotic
disorder. In terms of the relationship to the victims, the pseudocommando-
ps ycho tic mass mur derer foc uses o n a g roup that he d elusi onall y be lie ves is per-
secuting him. Dietz noted that the pseudocommando may focus his resentment
on a specific community based in reality or on a “pseudocommunity” that he
defines on the basis of psychosis or strong paranoid cognitions.
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90 GUN VIOLENCE AND MENTAL ILLNESS
Finally, the Familial-Depressed type involves a member of a family unit who
is suffering from severe depression with possible psychotic features. Motives
may flow from cognitions distorted by depression and hopelessness, psychosis,
and/or resentment toward an estranged spouse. A typical scenario involves a
depressed father who kills his entire family, viewing the act as a delivery of his
family from what he perceives to be continued hardship or stressors (Selkin
1976).
MASS SHOOTINGS AND MENTAL ILLNESS:
IS THERE A CONNECTION?
The publicity regarding mass shootings unfortunately overshadows another
public health tragedy that affects exponentially more people: the daily toll of
morbidity and mortality due to the more common types of gun violence, includ-
ing suicide. Rarely, if ever, do these events receive the same media attention as
mass shootings (Pinals et al. 2014). As discussed in Chapter 2, “Firearms and Sui-
cide in the United States,” evidence overwhelmingly demonstrates that suicide,
not homicide, is the most significant public health concern in terms of guns and
mental illness. Indeed, the small amount of research on firearm removal laws
suggests that removal by police “was rarely a result of psychosis; instead, risk of
suicide was the leading reason” (Parker 2010, p. 241).
Even if one assumes a direct association between violence against others and
serious mental illness, the focus must be narrowed to the population of indi-
viduals with serious mental illness associated with less than 3% of all violence
(Fazel and Grann 2006). Furthermore, current research suggests that in general
there is a minimal relationship between psychiatric disorders and violence in the
absence of substance abuse (Martone et al. 2013). Thus, the assumption that all
persons with mental illness are a “high-risk” population relative to violence gen-
erally and gun violence in particular lacks supportive evidence. The likelihood
of error and oversimplification is substantial when mental illness is considered
on “the aggregate level” such that a “vast and diverse population of persons di-
agnosed with psychiatric conditions” is considered to uniformly represent people
who are at risk of committing gun violence against others (Metzl and Macleish
2015, p. 241).
Some research has identified a small but higher fraction of homicides (not
specific to those involving firearms) committed by individuals with schizophre-
nia than by those in the general population (Bennett et al. 2011; Schanda et al.
2004). Despite this small but elevated risk, the rate of stranger homicides com-
mitted by individuals with schizophrenia or chronic psychosis is extremely low. On
the basis of a meta-analysis from 1999, one stranger homicide is perpetrated by
someone with a psychotic illness per year in a population of 14.3 million (Niels-
sen et al. 2011). Assuming a U.S. population of 320 million, approximately 23 peo-
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Mass Shootings and Mental Illness 91
ple a year on average are killed by an individual with a psychotic illness. In con-
trast, an average of about 330 people in the United States are struck by lightning
per year (Jensenius 2014). A person is about 15 times more likely to be struck by
lightning in a given year than to be killed by a stranger with a diagnosis of schizo-
phrenia or chronic psychosis.
Few perpetrators of mass shootings have had verified histories of being in
psychiatric treatment for serious mental illness. Rather, detailed case analyses
reveal that individuals who commit mass shootings often feel aggrieved, are ex-
tremely angry, and have nurtured fantasies of violent revenge (Knoll 2010). Such
individuals function (perhaps marginally) in society and do not typically seek out
mental health treatment. Thus, in most cases, it cannot fairly be said that a per-
petrator “fell through the cracks” of the mental health system. Rather, these in-
dividuals typically plan their actions well outside the awareness of mental health
professionals.
SALIENT YET UNDEREXPLORED SOCIOCULTURAL FACTORS
IN MASS SHOOTINGS
The majority of attention following mass shootings focuses on the role of mental
illness, and sociocultural factors have received comparatively little examination.
Gun violence “in all its forms has a social context,” which is not meaningfully
captured by psychiatric diagnoses in isolation (Metzl and Macleish 2015, p. 247).
Mass shootings by disgruntled individuals have occurred in Western civiliza-
tion since the invention of the gun. Alienation and social rejection are social
phenomena that undoubtedly existed even before recorded history. Neverthe-
less, mass shootings over the past two to three decades have led to speculation
about whether these differ from mass shootings of the past or whether they rep-
resent the same phenomenon in a more modern age. Another salient concern
is whether the powerful social influence of today’s media and Internet technol-
ogy plays a significant role.
As noted above (see “Mass Shootings: What Is Known”), the FBI study finding
that the incidence of mass shootings has increased over the past decade hints at
other, possibly more relevant factors associated with these events relative to
mental illness or psychiatric diagnosis. Since the 1990s, mass murders, and es-
pecially mass shootings, have arguably taken on a different quality, influenced
by a cultural shift, social media, and expansive news coverage of the tragedies.
Mullen (2004) described the results of his detailed forensic evaluations of five
pseudocommando mass shooters who were captured before they were killed or
could commit suicide. Most perpetrators acknowledged being influenced by
previous mass killers who received significant media exposure. This led Mullen
to propose the concept of a Western cultural “script” as one of several factors
that contribute to the propagation of these tragic events.
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92 GUN VIOLENCE AND MENTAL ILLNESS
Certain psychosocial characteristics are common among perp etrators of mass
shootings. These include problems with self-esteem, a persecutory/paranoid
outlook, narcissism, depression, suicidality, and a perception of being socially
rejected (Knoll 2012; Modzeleski et al. 2008; Mullen 2004; O’Toole 2000). In a
review of school-associated homicides in K–12 settings, Flannery et al. (2013)
noted that “[a] need remains for researchers and commentators to examine other
factors beyond the individual that may explain school shootings, including cul-
ture, the social ecology of the school or other community factors” (Flannery et
al. 2013, p. 6). They cited studies (Brown et al. 2009; Flannery et al. 2001) sug-
gesting differences between urban and suburban school shootings, and pro-
posed that some acts are related to the perpetrator’s perception of threats to his
social identity. Suburban and rural shootings may be characterized by social
alienation, whereas urban incidents are typically associated with interpersonal
violence, often in the context of different kinds of relationships (see Chapter 3,
“Gun Violence, Urban Youth, and Mental Illness”). Social marginalization and
familial dysfunction are other common findings among mass shooters (New-
man et al. 2005).
The call to investigate cultural and community factors seems particularly
meaningful when attention is paid to the messages perpetrators leave behind.
For example, one mass shooter from Montreal, Quebec, in 2006 wrote, “Its so-
ciety’s fault.. .. Society disgusts me” (Langan 2006). The Sandy Hook Elementary
School (Newtown, Connecticut) shooter posted online in late 2011, “[You know
what I hate]...Culture. Ive been pissed out of my mind all night thinking about
it” (Sandy Hook Lighthouse 2014). The Isla Vista, California, shooter posted
a manuscript online in 2014 stating, “Humanity is a cruel and brutal species”
(Rodger 2014). Further investigation of sociocultural factors of mass shootings,
particularly in Western society, necessitates a consideration of the issues of nar-
cissism and media responsibility.
NARCISSISM AND MASS SHOOTINGS
Narcissism may be considered the classic American pathology (Twenge et al.
2008), but concern is growing that it may be proliferating “virally” and gaining
momentum (Twenge and Campbell 2009). Is the changing character of mass
shootings over the past few decades due, in part, to our society’s increasingly
narcissistic values (Twenge et al. 2012)? Narcissism has been demonstrated in
the motivations and statements made by certain mass shooters since the 1990s.
In 2007, a man who shot nine people in an Omaha, Nebraska, mall before kill-
ing himself left a suicide note that stated, “Just think tho [sic] I’m gonna be fa-
mous” (Kluger 2007; Nichols 2007). A similar message was communicated by
the Columbine offenders, who stated on a preshooting video, “Isn’t it fun to get
the respect we’re going to deserve?” (Twenge and Campbell 2003, p. 261).
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Mass Shootings and Mental Illness 93
Twenge and Campbell (2009) noted that crime has dropped overall since the
1990s due to a variety of factors, but crimes related to narcissism (or a wounded
ego) have not had a corresponding drop and are directly relevant to mass shoot-
ings. These authors further noted that “narcissism and social rejection were two
risk factors that worked together to cause aggressive behavior” (p. 199), and these
factors have certainly been apparent in the histories of mass shooters. They con-
cluded, “Given the upswing in the narcissistic values of American culture since
the ’ 90s, it may b e no coincide nce that mass shoo ting s became a nat iona l pla gue
around the same time” (p. 200).
Similarly, Pinker (2011) has laid out a comprehensive overview of how vi-
olence among Homo sapiens has greatly declined over the centuries due to a
civilizing process,” but speculates that humans might have reached a point of
limited returns. He indicates that further gains, which may be harder to attain,
arguably also lie in the realm of attenuating the problem of narcissism.
Extensive media attention in the 1990s may have propagated the Western
“script” described by Mullen (2004), resulting in a perverse glamorization of the
act of mass killing, particularly in the eyes of subsequent perpetrators. The study of
individual cases of mass shootings that have occurred since the 1990s suggests that
perpetrators often felt socially rejected and perceived society as continually de-
nouncing them as unnecessary, ineffectual, and pathetic. Instead of bearing the
burden of the humiliation, they plan a surprise attack to prove their hidden “value.
Narcissism is strengthened and rigidified by obsessive ruminations along
the lines of “I am right and I’ve been treated badly or wronged (by other people or
by life).” It could be said that the mass sho oter’s persecutory and narcissistic mind-
set seeks a form of reverse specialness. By becoming a lone protestor against an
“unjust” reality, the mass shooter creates and assumes a powerful victim role in
which he can “win”—even by losing. This interest in the narcissistic antihero has
conspicuously permeated Western fiction and popular culture, in which follow-
ers thrill to the exploits of characters who possess the “dark triad” of personality:
narcissism, psychopathy, and Machiavellianism (Jonason et al. 2012). Western
society in particular has had a long-standing fascination with the antihero, the
outlaw, the Bonnies and Clydes and John Dillingers of American history (Kun-
hardt and Kunhardt 1995; Spillane 1999). Their short, violent lives became the
stuff of romanticized, tragic legend.
Western culture has also come to include a vast and powerfully influential
value system devoted to celebrity and fame. In place of what should be profound
shame, an aura of undeserved notoriety and infamy is often accorded to certain
individuals who commit horrible crimes (Brin 2012). The very public, dramatic,
and at times theatrical nature of mass murder seems to speak to a “need for rec-
ognition from an audience” (Neuman 2012, p. 2). The staged and exposed act of
revenge has the function of establishing a connection with spectators who will
not soon forget what they have seen.
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94 GUN VIOLENCE AND MENTAL ILLNESS
It might be theorized that the Internet and social media have amplified the
high value placed on celebrity and the Western cultural script of the tragic anti-
hero. The use of video-sharing Web sites and other Internet platforms perpetu-
ates the alienated loner’s conflict: his wish for social connection versus his deep-
seated mistrust of others. This can create an isolating virtual socialization that is
sustained well into young adulthood, leaving the individual without real expe-
ri enc e in d eve lop ing hea lthy soc ial a tta chm ent s, a nd r esu lti ng u lti mat ely in f eel -
ings of being unwanted. The final written communication of the Isla Vista
shooter reflects precisely such a pattern of alienation and malignant envy, cul-
minating in a violent bid for fame and validation: “Humanity has rejected me....
Exacting my Retribution is my way of proving my true worth to the world” (Rod-
ger 2014).
MEDIA COVERAGE: RESPONSIBLE REPORTING AND STIGMA
After the Sandy Hook tragedy in 2012, a senator announced that he supported mea-
sures to keep gunsout of the hands of criminals and the mentally ill” (Strauss
2012). Shortly thereafter, a National Rifle Association official stated in a press
conference that “our society is populated by an unknown number of genuine
monsters. People that are so deranged, so evil, so possessed by voices and driven
by d emons, that no sane pe rson can e ven p ossibly comp rehend them. . . .How ca n
we possibly even guess how many, given our nation’s refusal to create an active
national database of the mentally ill?” (The Washington Post 2012). Such state-
ments, widely disseminated by the media, reinforce the existing societal presump-
tive association between “criminals,” “evil,” and “the mentally ill.” In fact, such
misguided associations need no further reinforcement. The lay public requires
little persuasion to associate mental illness with criminality and evil (Coulter
2013).
Significant research data indicate that erroneous and negative attitudes to-
ward persons with mental illness are widespread in society (Bizer et al. 2012).
The term stigma is synonymous with shame, disgrace, and humiliation. To stigma-
tize means to brand, slur, or defame. Fear, anxiety, and the need to find quick and
clear-cut solutions lead to common but mistaken beliefs that reinforce the stig-
matization of individuals with mental illness. These myths include beliefs that
people with mental illness (Link et al. 1999) are more dangerous than people
without mental illness, are personally to blame for their illness, and have no
“se lf-c ont rol .”
Approximately 50 years after deinstitutionalization of individuals with mental
illness, the misconception that these persons are “ticking time bombs, ready to
explode into violence” remains a deeply ingrained societal belief (Appelbaum
2004). Research by Link et al. (1999) demonstrated strong stereotypes of these
individuals’ dangerousness and the desire for social distance from those with men-
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Mass Shootings and Mental Illness 95
tal illness. Comparing the research from 1950 with that of 1996 further indicates
that perceptions of persons with mental illness as violent or frightening have
substantially increased rather than decreased. In short, persons with serious
mental illness are more feared today than they were half a century ago (Phelan et
al. 2000). One of the most problematic results of laws that perpetuate the myth
tha t m ent al il ln es s i s lin ke d t o g un vi ole nc e i s t he rei nf or cem en t o f su ch ne gativ e
stereotypes. Such reinforcement adds to the considerable stigma associated with
mental illness, while having no appreciable effects on the incidence of mass kill-
ings that often drive the policy interventions.
Early news media coverage after a mass shooting may refer to the shooter as
“mentally unstable” or “mentally ill,” often prior to gathering any definitive infor-
mation. News debate shows often feature speakers who call for measures such as
creating a database of individuals with mental illness in an effort to prevent fur-
ther tragedies. Such dialogue is unhelpful and further strengthens erroneous
public views about mental illness and gun violence. Media coverage following
collective traumas has been observed to have public health effects, particularly
in terms of stress-related symptoms (Holman et al. 2014). With increasing re-
liance on social media as a source of news, media errors may easily exacerbate
public stress, as well as exacerbate the problem of sensationalizing tragedies
(Berkowitz and Liu 2014).
Thus, interventions designed to improve media responsibility should dissuade
this and similar dialogue in the aftermath of a mass shooting. Efforts to develop
a universal reporting code that would appropriately cover the tragedy and re-
duce the impact of the “copycat” effect have been recommended; these generally
include avoiding emphasis on perpetrators and neither glorifying nor demon-
izing them (Etzersdorfer and Sonneck 1998). Media should consider avoiding
much emphasis on the perpetrator while emphasizing victim and community
recovery efforts. Future research should focus more distinctly on which ele-
ments of media coverage are problematic and which are more effective in pro-
moting public health goals (Schildkraut and Muschert 2013).
INTERVENTIONS TO PREVENT MASS SHOOTINGS
GUN LAWS FOCUSING ON MENTAL ILLNESS
Equating mental illness and gun violence toward others in an effort to solve
the overall problem of gun violence in the United States is an example of what
the Greek philosopher Epictetus described as grasping a problem “by the wrong
handle” (Gutheil et al. 2005; Pies 2008). In the wake of a frightening tragedy,
reactive attempts to reduce gun violence by focusing on people with mental
illness represent an intervention with no supportive evidence of practical
efficacy.
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96 GUN VIOLENCE AND MENTAL ILLNESS
From 2007 to 2013, as a result of the National Instant Criminal Background
Check System (NICS) Improvement Act of 2008, mental health record submis-
sions to NICS increased tenfold (Federal Bureau of Investigation 2013, 2014).
Less than 1% of all firearm purchase denials were based on these records (Swan-
son et al. 2015). However, during this same period, the FBIs study of active shoot-
ers reflected an increasing trend of mass shooting incidents (Blair and Schweit
2014). The NICS background check system requires, for reporting regarding
mental health, that the individual have a history of prior civil commitment, a le-
gal adjudication of not guilty by reason of insanity, or an adjudication of not
competent to stand trial. Thus, for a background check to deny firearm purchase
to a potential mass shooter, that individual would have to 1) have a history of
prior civil commitment (and that history would have had to have been reported
to NICS) and 2) attempt to purchase a gun legally. The existing body of research
on mass shooters suggests that a history of civil commitment or legal adjudica-
tion of criminal insanity or incompetence to stand trial is practically unheard of
among perpetrators of mass homicide and mass homicide-suicide.
Recalling the very low percentage of violent acts that are attributable to se-
rious mental illness, and considering that most of these acts do not involve guns,
it becomes difficult to avoid the conclusion that the contribution to public safety
of laws directed toward individuals with mental illness in preventing gun vio-
lence is likely to be small (Appelbaum and Swanson 2010). In addition, these spe-
cial laws require resources and funding when cost-effective use of resources is a
pressing matter. It would seem imperative to “question whether a comprehen-
sive registry [of individuals with mental illness] would have prevented any of
the mass killings in recent years, and whether the expenditures of the more than
one hundred million dollars needed to create and maintain the registries for
persons with mental health histories could be better spent on broader public-
safety targeted interventions that might yield greater overall benefits to society”
(Pinals et al. 2014, p. 2).
EFFORTS TO IDENTIFY EFFECTIVE INTERVENTIONS
Mass shootings are multidetermined, extremely rare events with no simple pre-
ventive solution. The fact that they occur “too infrequently to allow for statis-
tical modeling” suggests that a focus on mass shootings will serve as a question-
able “jumping-off” point for “effective public health interventions” (Metzl and
Macleish 2015, p. 426). Although research suggests that in recent years the in-
cidence of these events may be increasing (see earlier section “Mass Shootings:
What Is Known”), mass shootings are still relatively infrequent, making these
tragedies exceptionally hard to anticipate and avert (Blair and Schweit 2014;
Saleva et al. 2007). Given the extremely low base rate of mass murder in general
and of mass shootings in particular, psychiatric efforts will be best spent in di-
rections other than prediction (Dressing and Meyer-Lindenberg 2010).
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Mass Shootings and Mental Illness 97
Prevention efforts must rely on multiple approaches used in conjunction to
provide the widest possible safety net. For example, third parties, particularly
family members, have important roles because they are the most likely to have
preoffense knowledge or significant concerns (Associated Press 2007). In addi-
tion, potential mass murderers often leak their intent to third parties who may not
report violent threats or plans to authorities for various reasons (Katsavdakis et al.
2011; Kluger 2007), including not recognizing the seriousness of the potential
threat.
Nevertheless, as Aitken et al. (2008) note, “prevention may only be possible
when somebody warns that such behavior may occur....Acquaintances often
acknowledge concerns prior to the incident” (p. 265). Messages or leaked intent
may be communicated verbally, or in writing via Internet pages, or through so-
cial media outlets such as YouTube. Family members or social contacts may be
the only people in a position to take steps to have the potential offender evalu-
ated and treated (Orange 2011). Therefore, family members of individuals who
may present with increased risk of gun violence, with or without mental illness,
should be provided with information about existing help and resources. They
should be provided with support for notifying authorities and understand that
doing so is a potentially heroic and compassionate act that may save the lives of
others as well as their loved one’s.
The FBI study of active shooters concluded that training and exercises for both
police and citizens were indicated, especially given the brief period over which the
shootings unfold (Blair and Schweit 2014). However, the FBI study placed pri-
mary emphasis on prevention efforts from a community standpoint. Future re-
search should consider mass shootings that were prevented and/or aborted,
with an eye toward identifying crucial preventive factors. Specialized threat assess-
ment teams in Australia and the United Kingdom have been helpful in terms of
enhancing prevention of low-frequency, high-intensity events (Meloy and
Hoffmann 2014). Similar multidisciplinary teams in the United States should be
explored, w ith a focus on the two areas of greatest concern noted in the FBI study:
places of education and workplace violence.
For general mental health professionals, careful clinical risk assessment and
management may be stressed as a part of overall competent psychiatric patient
care (Mills et al. 2011; Swanson 2008). Future research will undoubtedly enhance
awareness of “warning behaviors” for targeted violence, and mental health clini-
ci an s w il l b est se r ve p at ie nts at ri sk b y c raf ti ng a r is k m ana ge men t p la n at cl in ica ll y
relevant or critical times (Meloy et al. 2011). Special attention should be given
to “availability of means, planning, preparation, and the acknowledged commit-
ment to put the words into action irrespective of consequences” (Warren et al.
2011, p. 151). Risk assessments of individuals with strong revenge fantasies will
need to consider the intensity and quality of these fantasies, vulnerability to ego
threats, and relevant biopsychosocial variables (Baumeister et al. 1996).
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98 GUN VIOLENCE AND MENTAL ILLNESS
Public education regarding mental illness and effective interventions can
serve to lessen fears of those with serious mental illness and decrease the stigma
attached to serious mental illness. For many decades, sexual health education
has been taught to teens and adolescents. However, a similar focus on mental
health education is rare in children’s early education. Well-informed and com-
passionate education on mental health and mental wellness may not only re-
duce future stigma but also serve as a beneficial public health intervention. Such
education could become increasingly sophisticated as children progress through
school. In particular, this education may serve as an early preventive effort, while
encouraging more open discussion in schools about important mental health
issues.
CONCLUSION
Mass shootings by people with serious mental illness remain exceedingly rare
events and represent a fraction of a percent of all yearly gun-related homicides.
In contrast, firearm deaths by suicide account for the majority of yearly gun-
related deaths. Although gun restriction laws that focus broadly on mental ill-
ness are an understandable initial reaction, they will be extremely low yield
and wasteful of scant resources. Furthermore, such laws perpetuate the myth
that mental illness leads to violence and gives the public the incorrect message
that me ntal i llnes s is significantl y asso ciated w ith gu n viol ence d irected toward
others.
The problem of mass shootings and the motives of the shooters in present-
day society stand apart from mental illness generally. The recent phenomenon of
mass shootings in the United States is likely a result of a combination of factors,
in cludi ng s oci ocu ltu ral ones tha t must be b ett er und ers too d if the se t raged ies are
to be prevented. Mental health clinicians will best serve patients at risk of harm
to themselves and/or others by crafting a risk management plan at clinically rel-
evant or critical times. As opposed to prediction, structured clinical risk assess-
ment and management may be stressed as part of an overall competent psychi-
atric patient care effort (Knoll 2009; Swanson 2008; Webster et al. 2013).
Whether or not individuals who perpetrate mass shootings suffer from a di-
agnosable serious mental illness, they do have an ill-defined trouble of the mind
for which the mental health field has no immediate, quick-acting “treatment.
That said, if such individuals were motivated to overcome long-standing, per-
vasive feelings of anger, persecution, revenge, and egotism rather than act on
them, they would presumably be more likely to improve their circumstances in
nonviolent ways. Psychiatry may be able to assist individuals who are determined
and willing to engage in treatment, form healthy social connections, and pursue
other prosocial interventions. For these individuals, more resources need to be
made available, as discussed elsewhere in this volume.
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Mass Shootings and Mental Illness 99
Unfortunately, some disturbed individuals are likely to remain inaccessible
to whatever interventions mental health professionals have to offer. This situa-
tion accounts, at least in part, for the fact that measures such as screening for
prior psychiatric treatment (often in the distant past) among individuals who
want to legally purchase firearms do not represent meaningful interventions
(Brady Handgun Violence Prevention Act of 1993, Pub. L. No. 103-159, 18
U.S.C. § 922 [s1–s6]; Norris et al. 2006; Simpson 2007). Experience and research
have demonstrated that more promising, higher-yield interventions include
both 1) third-party reporting of warning behaviors or leaked intent and 2) social
and media responsibility (Meloy and O’Toole 2011; Meloy et al. 2011; O’Toole
2014).
On a fundamental level, the behavior and motives of mass shooters must be
distinguished from psychiatric diagnoses. The belief that these categories over-
lap or have a direct causal association is not supported by available evidence.
More importantly, interventions to decrease the morbidity and mortality of gun
violence based on such overgeneralized views are not likely to be successful and
may cause more harm than good.
Suggested Interventions
Policies and laws should focus on those individuals whose be-
haviors identify them as having increased risk for committing
gun violence, rather than on broad categories such as mental ill-
ness or psychiatric diagnoses.
Public health educational campaigns should emphasize the
need for third-party reporting of intent or concerning warning
behaviors to law enforcement.
Institutions and communities should develop specialized foren-
sic threat assessment teams to evaluate third-party reports of
potential dangerousness.
Resources should be increased to provide enhanced education,
beginning in elementary school, with a focus on constructive cop-
ing skills for anger and conflict resolution, mental health, and
mental wellness education.
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... Rhetoric that fts into Foucault's framework can be seen in government reactions to mass shootings in the U.S. After the 2012 Sandy Hook mass shooting, a NRA representative was quoted as asking why the United States had not yet made "an active national database of the mentally ill" [178]. The connection between mental illness and violence is a common media narrative in the wake of mass shootings. ...
... The connection between mental illness and violence is a common media narrative in the wake of mass shootings. However, of all violent crimes committed in the United States, only three percent are committed by people with serious mental illness, and people with mental illness are more likely to harm themselves than someone else, let alone commit a mass shooting [178]. In 2018, in the wake of the Parkland shooting, then U.S. President Donald Trump argued in favor of the reopening of asylums, being quoted as saying "part of the problem is we used to have mental institutions...where you take a sicko like this guy [the shooter]" [172]. ...
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The 􀀀eld of digital mental health is making strides in the application of technology to broaden access to care. We critically examine how these technology-mediated forms of care might amplify historical injustices, and erase minoritized experiences and expressions of mental distress and illness. We draw on decolonial thought and cri-tiques of identity-based algorithmic bias to analyze the underlying power relations impacting digital mental health technologies today, and envision new pathways towards a decolonial digital mental health. We argue that a decolonial digital mental health is one that centers lived experience over rigid classi􀀀cation, is conscious of structural factors that in􀀁uence mental wellbeing, and is funda-mentally designed to deter the creation of power di􀀂erentials that prevent people from having agency over their care. Stemming from this vision, we make recommendations for how researchers and de-signers can support more equitable futures for people experiencing mental distress and illness.
... Rhetoric that fts into Foucault's framework can be seen in government reactions to mass shootings in the U.S. After the 2012 Sandy Hook mass shooting, a NRA representative was quoted as asking why the United States had not yet made "an active national database of the mentally ill" [178]. The connection between mental illness and violence is a common media narrative in the wake of mass shootings. ...
... The connection between mental illness and violence is a common media narrative in the wake of mass shootings. However, of all violent crimes committed in the United States, only three percent are committed by people with serious mental illness, and people with mental illness are more likely to harm themselves than someone else, let alone commit a mass shooting [178]. In 2018, in the wake of the Parkland shooting, then U.S. President Donald Trump argued in favor of the reopening of asylums, being quoted as saying "part of the problem is we used to have mental institutions...where you take a sicko like this guy [the shooter]" [172]. ...
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The feld of digital mental health is making strides in the application of technology to broaden access to care. We critically examine how these technology-mediated forms of care might amplify historical injustices, and erase minoritized experiences and expressions of mental distress and illness. We draw on decolonial thought and critiques of identity-based algorithmic bias to analyze the underlying power relations impacting digital mental health technologies today, and envision new pathways towards a decolonial digital mental health. We argue that a decolonial digital mental health is one that centers lived experience over rigid classifcation, is conscious of structural factors that infuence mental wellbeing, and is fundamentally designed to deter the creation of power diferentials that prevent people from having agency over their care. Stemming from this vision, we make recommendations for how researchers and designers can support more equitable futures for people experiencing mental distress and illness.
... Those who are pro-firearm carrying perceive shooters, especially mass killers, would be less likely to commit acts of firearm violence on campuses if they knew that students and faculty also carried concealed firearms and could defend themselves. There are at least three concerns with this reasoning (Broomé and Russell 2018;Hayes et al. 2020;Knoll and Annas 2016;Kruzel 2018). ...
... First, a significant portion of mass firearm killers intend to commit suicide (Knoll and Annas 2016). Thus, for this segment of mass shooters, the threat of potentially dying during shooting may not be much of a deterrent. ...
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... A growing source of mental health stigma involves media and political narratives following mass shootings that present misconceptions about nonexistent links between mental health problems and gun violence (McGinty, Webster, & Barry, 2013). Instructors are encouraged to challenge this stigma by presenting, and encouraging discussion about, research demonstrating people with mental health problems are often victims of violent crime and mental illness does not cause mass shootings (see Knoll & Annas, 2016). ...
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In ethics courses, students need to begin or continue their transformation from smart, motivated people to ethical, self-reflective professionals. This chapter focuses on some principles and strategies to achieve that goal, including backward design, developing an effective course atmosphere, the nature of teaching and learning ethics, and skill development. Rather than thinking first about classroom activities, reading assignments, and topics, instructors who use backward design start with consideration of the goals they wish their students to achieve, then move on to how they will assess whether students meet those goals. Only then can they design specific, effective activities and assignments for a course. We explore several other principles and assumptions relevant to the teaching of ethics. We do this by presenting an instructor’s observations and reflections on his graduate ethics course, followed by three graduate students’ views of (a) the course and (b) how the instructor attempted to actualize these principles.
... of gun-related homicides, many firearm policies tend to focus on individuals with mental illness despite their low violence risk (Knoll & Annas, 2016;Lankford, 2015;Thornicroft, 2020). Though there have been mixed results regarding connecting the effects from general gun access bills on violence (e.g., Fleegler et al., 2013vs. ...
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... Despite making up less than 5% of the world's population, the US is home to 31% of all global mass shootings (Evans, 2019), yet people with severe mental illnesses are responsible for less than 1% of all gun-related homicides that occur each year (Knoll & Annas, 2018). In 2019, indiscriminate shootings accounted for 0.5% of homicides in the US (Metzl et al., 2021). ...
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The current commentary takes a closer look at the issue of mass shootings in the United States and the stigma experienced by those with a serious mental illness. Mental illness is not a predictor of gun violence. However, false assumptions of mental illness only reinforce the negative belief that individuals who have mental illness are dangerous and violent, exacerbating the stigma already attached to those suffering from mental illnesses. Linking gun crime to mental illness is a barrier to seeking treatment and having a mental illness does not necessarily imply an individual will commit indiscriminate acts of violence. Research reports that most mental health symptoms were not related to gun violence, but easy access to firearms, and other demographic variables, were identified as the primary cause. Mass shootings exert a strong influence on public policy and public perception. There needs to be a shift in attitudes toward mental illness.
... Previous research on mass shooters has found significant variation in the severity of their mental health problems (Knoll & Annas, 2016;Lankford, 2018;Lankford & Cowan, 2020;National Council for Behavioral Health, 2019;Peterson & Densley, 2019), so it is certainly possible that Johnson and Long would differ in this way. Substantial variation appears in mass shooters' influences as well. ...
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Two of the worst targeted attacks on American police officers in recent history occurred within eleven days of each other. Although it seems clear their proximity was not merely attributable to chance, the connection between these incidents, and the implications for understanding copycat violence, have never been fully explored. This study analyzes the perpetrators of these attacks from a “thresholds of violence” perspective, which suggests the first actor in a sequence is more likely to be disturbed and violence prone, while subsequent actors are typically less disturbed but more socially influenced. Results suggest the thresholds model has both merits and limits. The first attacker did have more psychological problems and violence in his past, and the second did seem more influenced by violent role models. However, there were also many similarities between them, and both attacked due to a combination of internal and external factors. If this study's findings are generalizable, higher risks of becoming a copycat offender may exist for individuals who have (1) personal similarities with previous attackers, (2) a history of psychological problems, (3) a history of interest in violent actors, and (4) recent escalation in their online behavior. Recommendations are offered for future research, offender profiling, and violence prevention.
... A presença de várias vítimas em um único local e em um mesmo evento é descrita como um assassinato em massa (mass murder) 4,7 . O número exato de vítimas necessário para caracterizar este tipo de homicídio é arbitrário, com algumas autoridades sugerindo quatro vítimas, enquanto outras sugerem o número mínimo de três. ...
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Introdução: Um evento homicida com a presença de várias vítimas pode ser definido como um assassinato múltiplo, porém esse termo refere-se a uma categoria mais ampla que compreende as subclassificações: assassinato em massa, assassinato em série e assassinato relâmpago. Objetivo: Revisar as definições desses termos, abordando os aspectos psiquiátricos que podem estar presentes em cada um dos tipos de homicídio múltiplo, buscando atualizar a classe médica e os demais profissionais que trabalham com essa temática e instrumentalizar suas ações de investigação, avaliação e tratamento. Método: Revisão narrativa visando discutir o estado da arte e atualização do conhecimento sobre assassinato múltiplo. Discussão: A literatura aponta que assassinato em massa, assassinato em série e assassinato relâmpago possuem características específicas, que vão além do número de vítimas e compreendem as características psicopatológicas de seus perpetradores, desde a ausência de qualquer transtorno psiquiátrico até quadros de transtornos antissociais, narcisistas ou psicóticos. Conclusão: O conhecimento de suas definições e particularidades possibilita o uso adequado dos termos, assim como auxilia o raciocínio diagnóstico acerca dos transtornos psiquiátricos que podem estar presentes nos criminosos que cometem tais atos.
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The chapter describes and critically evaluates predictors of MM in adolescents. The review combines psychological and criminological theories, aiming to better understand the phenomenon. The methodology includes (1) literature review of scientific papers and (2) software-based text-analysis on crime-news. This integration will provide a critical view of adolescents who commit MM from both scientific and media content. Through a detailed description of MM's risk factors among adolescents, this chapter aims at increasing parents', school leaders', school counselors', social workers', teachers', and health professionals' knowledge on the phenomenon. In this way, families and institutions may be able to build prompt, preventative, and tailored strategies to counteract MM.
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Conventional wisdom has regarded low self-esteem as an important cause of violence, but the opposite view is theoretically viable. An interdisciplinary review of evidence about aggression, crime, and violence contradicted the view that low self-esteem is an important cause. Instead, violence appears to be most commonly a result of threatened egotism--that is, highly favorable views of self that are disputed by some person or circumstance. Inflated, unstable, or tentative beliefs in the self's superiority may be most prone to encountering threats and hence to causing violence. The mediating process may involve directing anger outward as a way of avoiding a downward revision of the self-concept.
Article
Objective: Persons with mental illness and/or substance abuse are frequently perceived by the public to be dangerous. This has resulted in an increase in state legislation restricting their ability to purchase, possess, register, obtain licensure, retain, and/or carry a firearm of any sort. The purpose of this article is to educate clinicians about the impact of firearms statutes and restrictions for their patients. Many state statutes mandate that treating psychiatrists report such gun possession to state justice or police departments. Psychiatrists may also have a statutory role in an appeals process. Method: The firearms statutes of the 50 states, the District of Columbia, and Puerto Rico and the Federal National Firearms Act were surveyed, with particular attention paid to the ability of persons with mental illness and/or alcohol or substance abuse to obtain firearms. The results were tabulated. Results: These statutes are not uniform. They vary in their definition of mental illness, the type and duration of gun restriction, reporting practices, the confidentiality of medical information, and the immunity of clinician reporters and appeals processes. Conclusion: Clinicians would be wise to familiarize themselves with the provisions of the relevant statutes in their particular states. This will allow them to identify the consequences to their firearm-possessing patients, understand their own roles and obligations - if any - and better consider potential clinical and ethical issues for particular patients.
Article
Objective: This study aimed to determine the population impact of patients with severe mental illness on violent crime. Method: Sweden possesses high-quality national registers for all hospital admissions and criminal convictions. All individuals discharged from the hospital with ICD diagnoses of schizophrenia and other psychoses (N=98,082) were linked to the crime register to determine the population-attributable risk of patients with severe mental illness to violent crime. The attributable risk was calculated by gender, three age bands (15-24, 25-39, and 40 years and over), and offense type. Results: Over a 13-year period, there were 45 violent crimes committed per 1,000 inhabitants. Of these, 2.4 were attributable to patients with severe mental illness. This corresponds to a population-attributable risk fraction of 5.2%. This attributable risk fraction was higher in women than men across all age bands. In women ages 25-39, it was 14.0%, and in women over 40, it was 19.0%. The attributable risk fractions were lowest in those ages 15-24 (2.3% for male patients and 2.9% for female patients). Conclusions: The population impact of patients with severe mental illness on violent crime, estimated by calculating the population-attributable risk, varies by gender and age. Overall, the population-attributable risk fraction of patients was 5%, suggesting that patients with severe mental illness commit one in 20 violent crimes.
Article
Using clinical judgment alone, mental health professionals cannot predict individual patient violence much more accurately than chance. Clinicians could improve their prediction of violence if they routinely used structured risk assessment instruments, but they don't; the use of such tools for screening is not currently the standard of care in the United States and is not commonly reimbursed by insurance. The author argues, however, that clinicians actually can predict and prevent violence if they consider their patients as a group from the perspective of public-health epidemiology. Optimizing treatment for all patients will help prevent violence by the few who pose a risk of violence, even when such patients are not identified in advance.
Book
This expanded and updated new edition reflects the growing importance of the structured professional judgement approach to violence risk assessment and management. It offers comprehensive guidance on decision-making in cases where future violence is a potential issue. Includes discussion of interventions based on newly developed instruments. Covers policy standards developed since the publication of the first edition. Interdisciplinary perspective facilitates collaboration between professionals. Includes contributions from P.Randolf Kropp, R. Karl Hanson, Mary-Lou Martin, Alec Buchanan and John Monahan.
Article
This study explores the relationship between social media and threats to journalism’s authority during coverage of the mass shootings at Sandy Hook Elementary School. Two related threats are examined. One threat concerned widespread errors in early reporting of the shootings. A second threat came shortly after, in the aftermath of a communication professor’s blog claiming a conspiracy between media and government. Through textual analysis of news articles, columns, and blogs, the study considers the concepts of paradigm repair, boundary work, what-a-story news, and memory in the renegotiation of journalistic authority. Findings suggest that with increased reliance on social media for reporting, increased media errors threaten the boundaries of appropriate professional journalistic practice, which both mainstream and social media attempt to rebalance.
Article
The American Psychiatric Association, ("APA"), with more than 36,000 members at present, is the Nation's leading organization of physicians who specialize in psychiatry. APA provides for education and advocacy and develops policy through Position Statements. It promotes enhanced knowledge of particular topics relevant to psychiatric practice and patient care through Resource Documents. Since 1993, the APA has developed various positions and resource materials related to firearms and mental illness, incorporating evolving themes as new issues emerge. This paper reflects the APA's 2014 Resource Document on "Access to Firearms by People with Mental Disorders." This article is derived from work done on behalf of American Psychiatric Association and remains the property of APA. It has been altered only in response to the requirements of peer review. Copyright © 2015 American Psychiatric Association. Published with permission (original adopted by the American Psychiatric Association 2014). Copyright © 2015 American Psychiatric Association. Published with permission (original adopted by the American Psychiatric Association 2014).