Better mental health care: The right answer to the wrong question in preventing violence

Yesterday’s Washington Post has a nice story under the self-explanatory headline: Most mass shooters aren’t mentally ill. So why push better treatment as the answer? Drawing on work by Columbia University forensic psychiatrist Michael Stone, Post reporter Michael Rosenwald notes that a surprisingly small fraction of mass shooters suffer from severe mental illnesses such as schizophrenia or psychosis. Yet politicians often call for “better mental health care” in response to mass shootings or other atrocities.

This focus on mental illness does bring some benefits. It might bring desperately-needed resources to our beleaguered mental health system and to valuable bench science and clinical research. Public safety concerns have occasioned valuable discussion of ways we might improve inpatient psychiatric care, for example by altering Medicaid policies that block reimbursement for much residential care. Congress is also focused on some valuable measures to make it harder for dangerous or suicidal people to buy guns or to maintain access to dangerous weapons. We could certainly use additional resources for prohibited-possessor databases that may have produced missed opportunities to prevent shootings at Virginia Tech and Charleston, SC.

Although civil libertarians rightly worry, it is always important to consider whether we have struck the right balance in matters such as outpatient commitment that are pertinent to a subgroup of people living with mental illness. Interventions such as forensic assertive community treatment can be helpful in this area.

Acknowledging all that, conflating dangerousness with mental illness can bring profound harms and provide a misleading guide to public policy. Discussing mental illness in the context of mass shootings only intensifies the accompanying stigma. This ironically causes more people to hesitate before seeking help from the mental health system. It is also a fairly transparent effort to divert public attention from policies such as universal background checks that might be helpful in reducing gun violence.

Framing the violence conversation in terms of severe mental illness also feeds into false hopes that we can specifically identify the most dangerous people. Unfortunately, this is rarely possible until after an atrocity has occurred. In so many cases, a mass shooter has left various red flags that seem painfully obvious in hindsight, but where no truly actionable information was previously available–particularly in a society that trusts virtually everyone to own a gun who is not a convicted felon or is one of the very tiny minority who have become legally enmeshed in the institutional system of psychiatric care. The Planned Parenthood shooter, for example, was an eccentric loner who scared his neighbors. I know of nothing in his prior record that would have barred him from purchasing lethal weapons.

Ironically, stereotypes about the severely mentally ill also lead us astray when we do have specific warning signs that someone is dangerous. Elliot Rodger went on a shooting spree in Isla Vista, California. I don’t believe police should have predicted this, but they did have specific warnings. As I noted in the Washington Post, Rodger’s parents and other people were sufficiently frightened that they contacted police. Several officers went to Rodger’s house and conducted a short interview with him. And they left–determining that Rodger was not an imminent threat to himself or others.

It’s easy to second-guess. The officers didn’t scan California’s Dealer’s Record of Sale (DROS) database, which would have identified Rodger’s scary handgun and ammunition purchases. They never viewed various Youtube videos Rodger had posted, which had rightly alarmed his parents. The real problem was that the officers were probably looking for the wrong things. They were looking for someone out of touch with reality, and that wasn’t him. Rodger was perfectly capable of holding a lucid conversation at his front door. He wasn’t schizophrenic or psychotic. He was just incredibly angry with other people.

A more sensible conversation at the nexus of violence and mental illness must start in a different place.

First, we need better tools to keep potentially dangerous people away from lethal weapons. Most of these men and women cannot and should not be involuntarily committed. Yet they show other signs of dangerousness. A better background check system might help here. So would innovations such as gun violence restraining orders. We might also look more carefully at gun purchases made by young adults who may have life difficulties, but who have had less time to accumulate a legal and psychiatric track record. Some groups of people on disability who require the help of a representative payee might also merit heightened scrutiny for firearm purchases. We might also restrict certain weapons such as AR-15s that appear especially connected with mass homicides. This wouldn’t appreciably reduce homicides, but it would help.

More important, we should bolster our mental health safety-net, particularly components at the nexus of criminal justice and substance use. Dangerous people with mental health issues often experience co-occurring substance use disorders. Efforts such as Hawaii HOPE and Dakota 24/7 can be very helpful with this population.

Medicaid expansion is another essential tool. People at-risk of violence frequently require health coverage. Places such as Cook County do an admirable job signing people up, including most people passing through the Cook County Jail. That allows individuals access to key services, and it supports the entire ecosystem of mental health care. We are just learning how to use this new tool to its best advantage.

We have a long way to go. I recently spent an evening in the basement of Cook County Jail. A woman was discharged who was experienced sad mental health and substance use issues, along with various other life challenges. She was a nonviolent offender, one of the thousands of urban rabble who pass through our jails every day. A local social service agency arranged for her to have an appointment at a local hospital early the next day. She would need to take a couple of busses to get there. I’m not sure anyone can or will follow up if she didn’t show up. I fear that her next mental health system encounter will happen right there in the jail, next time she’s arrested for petty thievery, drug possession, public intoxication, or some similar crime.

The boring blocking-and-tackling of our mental health system needs to work better for this woman, and for so many others. It’s the hard work that must be done. Of course, tt’s tempting to rally support for such efforts with claims that these might prevent mass shootings or other scary violence. Most dangerous people don’t experience severe mental illness, and most people living with severe mental illness aren’t dangerous. So most of this political rhetoric is empty bluster. Whatever its short-term utility, the right answer to the wrong question often causes unexpected harm.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

15 thoughts on “Better mental health care: The right answer to the wrong question in preventing violence”

  1. I think there's a complicated dynamic going on where "better mental health care" is being supported by both sides (ahem) of the gun-violence debate, each for very different reasons. The anti-gun-control people talk a lot about it (with minimal action) because "keep guns away from crazy people" is a good line to deflect from the problem of proliferating guns in the hands of people who are not — speaking in a very narrow legalistic fashion — crazy. Meanwhile, pro-gun-control people tend to support it because "better mental health care" seems to them a good thing in itself, and mass shootings seem like a good hook to hang it on.

    It would be nice (as you suggest in your closing) if eventually our attitudes toward mental illness broadened sufficiently so that "Is this person an unusually imminent danger to self or others" and "Would this person be able to use insanity/diminished capacity as a defense to any crime they committed" weren't the beginning and end of official interactions with people who need help with their state of mental health.

  2. One thing that to me at least seems like it would have been a great help to Rodgers' family would be if those databases were public. It seems clear that they were already worried and if they'd known their kid was buying weapons, they'd have been in a better position to do more. As in fact would have been the police, who probably don't have as much time to run db checks on every single person they come across.

    It seems so obvious that gun sales should be public in most cases that it surprises me no one talks about it. (Unless maybe there's been a new law passed and it just hasn't kicked in.)

    I can believe that most mentally ill people aren't dangerous… but as to the larger issues, if we look at police involved incidents, my guess is mental illness is causing a big chunk of those too, so it's not *really* as if mental illness and violence aren't related. Most of us have no idea how to handle mentally ill people, so we call the police to do it. And then, if it doesn't go well, we get mad at them. Now who's crazy? ; )

  3. It seems a bit odd to announce that most mass killers are not 'mentally ill ' with a link that states, "Instead, they were more often ruthless sociopaths whose ­behavior, while unfathomable, can’t typically be treated as mental illness." Perhaps mental health professionals do not regard "ruthless sociopaths" as "mentally ill", but who would regard them as mentally healthy?

    I assume the point of stating that these killers aren't mentally ill is to shield those with relatively harmless (to others!) derangements from undue burdens, but directing attention towards the equally harmless mentally healthy (And not just in a narrow legalistic fashion!) is no more appropriate. We need to learn to identify and deal with sociopaths better.

    1. The problem, or one of them, is that "mentally healthy" and "mentally ill" creates a binary system that does not at all match reality. It's a continuum without any bright lines to indicate which side a person is on. Worse, an individual's place on that continuum isn't constant; we all move back and forth as a consequence of variables to numerous and subtle to measure.

      Also, there are so many different kinds of mental illness that it isn't even a linear continuum. Psychosis is not neurosis and neither is sociopathy. How does autism, which touches me personally, fit into this question? How about bipolarity? Dementia?

      Narrow definitions of "mentally ill" are the only ones that are at all useful; otherwise, you find your net catching huge swathes of the population, many of which have nothing to do with each other.

    2. Adding to J_Michael_Neal's reply, it's not just identifying "sociopaths"; it's identifying the small portion of them at risk of committing serious violence. Most sociopaths are no physical danger to anyone, just as most mentally ill are no danger to others. Distinguishing between the harmless odd duck and the dangerous odd duck is a hard problem.

      And of course it's not a sharp line, and in some contexts a certain amount of sociopathy can be adaptive–think of the hard-charging businessman who manipulates his way to the executive suite. (Some of the anecdotes about Steve Jobs have made me wonder.)

      1. So, we need to learn to identify the people who are a risk, instead of just treating the great mass of people as though they were risks.

        My point is the very link used to show that the mentally ill are not a particular risk, actually states something quite different: That the people who are a risk happen to have a mental pathology which isn't, for whatever reason, officially deemed to be a "mental illness".

        But they're still not normal people, and we should learn to identify them, so that we can leave the normal people, who are no particular risk, alone.

        1. You still don't get it: there's no identifiable state of "normal." That's especially true if you're going to try to predict behavior.

  4. Aren't most gun deaths either suicide, gang-related, domestic violence or simple stupid accidents? I realize mass-shootings have an emotional valence, but seem a cheap way to score political points when the real issue lies elsewhere. I'd be perfectly fine with a repeal of the 2nd amendment to just take the needlessly dangerous toys away. However, I realize that is akin to abolishing the 13th amendment in the eyes of the fetishist. I'd assume there are less extreme fixes. But I just hate dishonest policy arguments.

    1. Your basic problem here is akin to Paul's 'narrow legalistic fashion' remark: Treating people with a VERY common set of interests and views as somehow aberrant.

      I've always found that tendency on the left a bit curious; Here you are, catering to the rights, dignity, and even mere convenience of tiny, genuinely aberrant groups, like homosexuals ,or the even rarer gender delusional, and along comes a group that comprises several tens of percent of the population, and suddenly they're "fetishists", whose views matter only because they're too many to steamroller over. Curious.

      Your point is right, though. Most gun deaths are either suicides, or crimes committed by a small fraction of the population, (Who I think we should prioritize identifying.) but multiple homicides are a tiny fraction of the problem. They should not be driving policy.

      1. I don't see gun rights as interesting or meaningful though, where I do think people's skin color, gender, religious beliefs, etc. are. I don't think people have the right to all kinds of things: bicycles, knives, tanks, swimming pools, etc. The right to bear arms has its own specific considerations; I'm just not moved by them as others are. Plenty of people aren't moved by gay rights, for instance. That's fine, we can argue. And yes, part of my claim is that it is a fetish.

        edit: I realize I'm obligated to explain the fetish remark. I apply it to those who would enshrine guns as a specific constitutional right. Most people love pizza. But if you enshrined the specific right to eat pizza, I would call that a fetish. Sure, eating is a right, and so is self-defense. But the requirement that it must be a gun I'm suspicious of as "an excessive and irrational commitment".

        1. "But if you enshrined the specific right to eat pizza, I would call that a fetish."

          If there were an amendment in the Bill of Rights saying something like, "Proper nutrition being necessary to the health of the population, the right to transport and consume pizza shall not be infringed.", you might argue that the author of that amendment was a bit obsessed. The people who claimed that eating pizza was a constitutional right would merely be literate. The point being that the RKBA IS enshrined in the Constitution as a specific constitutional right, that's just a brute fact. Your thinking it oughtn't be doesn't alter that.

          I tend to think that, at the point where you're declaring a quarter or more of the adult population 'fetishists', you really need to consider whether you might be the one with the problem.

          1. Fair enough. I completely agree that something to do with arms is a constitutional right. How to interpret the 2nd amendment is obviously debatable. I'm fine with people arguing it means having all manner of guns. I just then argue for a repeal in that case. Either way, I find the notion of needing to have guns as a right silly. Maybe that is my fetish. I'm OK with that.

  5. I'm not saying you're wrong but if the government wasn't the one doing it, wouldn't that lessen the "danger" to 2nd A rights? And would increase the deterrence of having a gun to begin with. And be a warning sign to those with the most information, our friends and families?

  6. Why politically mislead people about mental illnesses? Curious question.

    When did we not want to be mislead about mental illnesses? We have a long history of wanting to be mislead, rather than wanting to know.

    It follows the pattern of wanting to be mislead about women, wanting to be mislead about ethnicities, and a host of other issues.

    We preserve the need not to know as long as we can.

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