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PERSPECTIVES

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence

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Jonathan M. Metzl, MD, PhD, Jennifer Piemonte, MS, and Tara McKay, PhD

Abstract: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lone wolf” individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagno- ses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to prevent serious acts of violencemore generally—will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp in- crease both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special ur- gency to this agenda.

Keywords: gun violence, mass shootings, mental illness, psychiatric research, racial justice

Indiscriminate shooting rampages in public places accounted for approximately 0.5%of homicides in the United States in 2019,1,2 yet an estimated 71% of adults experienced fear of

mass shootings as “a significant source of stress in their lives,” causing 1 out of 3 people to avoid certain public places, accord- ing to a national survey by the American Psychological Associ- ation.3,4 In their responses to heightened community concerns over the threat of mass shootings, numerous public officials in recent years have pointed to “mental illness” as a simplified ex- planation for these terrifying acts of violence.5 The “deranged shooter” narrative resonates with a persistent (if largely false) belief amongmajorities of adults in the United States: the notion that people diagnosed with serious psychiatric disorders such as

he Department of Medicine, Health, and Society (Drs. Metzl and ), Vanderbilt University; Joint Program in Psychology and Women’s nder Studies, University of Michigan (Ms. Piemonte).

l manuscript received 18 February 2020; revised manuscripts re- 25 June and 6 October 2020, accepted for publication subject to revi- October 2020; revised manuscript received 2 November 2020.

pondence: Jonathan Metzl, MD, PhD, 300 Calhoun Hall, 2301 ilt Place,Nashville, TN37235-1665. Email: [email protected]

ght © 2021 The Author(s). Published byWolters Kluwer Health, Inc. on f the President and Fellows of Harvard College. This is an open access distributed under the terms of the Creative Commons Attribution-Non ercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi- ownload and share the work provided it is properly cited. The work cannot ged in any way or used commercially without permission from the journal.

0.1097/HRP.0000000000000280

d Review of Psychiatry

schizophrenia are likely or very likely to be violent.6 This con- struction of the problem relies on an elastic and pejorative definition ofmental illness and places psychiatrists in an often unwelcome yet strategic spotlight.7

On the one hand, the public’s a priori definition of mass shooters as seriously mentally ill invites and reinforces unrealistic expectations that mental health experts should be able to predict andprevent acts ofmass violence. It tends to inspire public support for restrictive policies and interventions targeting psychiatric pa- tients.6 On the other hand, the “deranged shooter” story can give mental health professionals a powerful voice and audience— people look to them for answers and solutions—which trans- lates into opportunities to reframe the debate over what should actually be done about mass shootings in the United States.

What can psychiatrists and other mental health clinicians, researchers, and policy makers do to foster evidence-based solu- tions topreventmass shootings, and tomitigate thepopulation risk of firearm injuries in general, without adding to the burden of stigma and social rejection that people who are recovering from mental illnesses may feel when others assume they are dangerous?

Existing scientific evidence paints a complex—if incomplete —picture of the causes of mass shootings and other acts of se- rious violence. Until recently, a congressional ban on federal funding for most gun-related research has prevented scientists and scholars from conducting the full range of interdisciplinary studies that would provide a better understanding of the prob- lem and point the way to effective solutions.8

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In what follows, we outline a four-part strategy for future research in mental health and complementary disciplines that will broaden our understanding of these tragic events and how to effectively prevent them.

First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lone wolf” individuals, and must rather situate such destructive motivations within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any ap- parent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and le- thality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, le- gal, and political, but also psychological, aspects of private gun ownership in the United States; what is needed is a sustained inquiry into how these dimensions might shape the contours of gun violence as a broader public health prob- lem. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to prevent seri- ous acts of violence more generally—will require an ex- panded body of well-funded interdisciplinary research that is informed and implemented through the sustained engage- ment of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior—especially inmarginalized communities—adds special urgency to our agenda.9

Acts of mass murder implicate the psychologies of perpe- trators. A better understanding of the reasons behind their behaviors—a kind of “rationality within irrationality”10—re- mains important to the hope of preventing such crimes in the future.11 Retrospective analyses suggest that a nontrivial minor- ity of high-profile mass shooters demonstrated clinical symp- toms, including paranoia, depression, and delusions, at some point in their lives.12–14 Still, the assumption thatmass shootings are driven solely or even primarily by diagnosable psychopa- thology stretches the limits ofmental health expertise. It also sets up a false expectation that advancing neuroscience and better therapies tomanage psychiatric symptomswill provide “the an- swer” to solving gun violence. There is no existing or forthcom- ing unified theory of impaired brain functioning or of cognitive, mood, or behavioral dysregulation that could adequately ex- plain mass shootings or multiple-victim gun homicides.

Symptoms of mental illness by themselves rarely cause vio- lent behavior and thus cannot reliably predict it. Certain psychi- atric symptoms, such as paranoid delusionswith hostile content, are highly nonspecific risk factors that may increase the relative probability of violence, especially in the presence of other cata- lyzing factors such as substance intoxication.15,16 Yet the abso- lute probability of serious violent acts in psychiatric patients

82 www.harvardreviewofpsychiatry.org

with these “high risk” symptoms remains low. In general, fo- cusing on individual clinical factors alone leaves too much unexplained, as it tends to ignore the important social con- texts surrounding mass shootings and multiple-victim homi- cides.17 To assume that gun violence is primarily a problem confined to a perpetrator’s brain may impede inquiry into a ranges of factors that could be crucial to a full understanding of mass shootings—factors such as the perpetrator’s sex, race, socioeconomic status, relationships, attitudes, personal history, the place where a shooting occurs and the perpetra- tor’s (dis)connection to it, and the ways in which local gun cultures and unrestricted access to guns might create the con- ditions under which these events become more likely.

How canmental health research change the dominant nar- ratives surrounding mass shootings and multiple-victim ho- micides, and thus broaden debates about the community effects of gun violence? Our selective literature review and re- search agenda present a strategy for moving beyond the “diagnose-the-mass-shooter” framework to a perspective that emphasizes the multi-determined nature of gun trauma. In so doing, we advocate for broadening the scope of concern and the potential contribution of mental health experts and researchers to include the larger gun-violence epidemic, rec- ognizing its structural dimensions as within their purview, es- pecially at the intersection with social science, public health, and other complementary disciplines.

AN AGENDA FOR MENTAL HEALTH RESEARCH INTO MASS SHOOTINGS AND MULTIPLE-VICTIM GUN HOMICIDES

1. Move Beyond Simplistic Mass Shooter Profiling and Media-Driven “Diagnose-the-Shooter” Formulations to Situate Destructive Motivations Within Larger Social Structures and Cultural Scripts Politicians and media commentators often quickly label mass shooters as “mentally ill” without defining the term and before any valid psychiatric history is known, simply on the basis of the aberrant nature of the crime itself: “What sane person could do such a thing?” Media-stylized accounts of the motivation of mass shooters tend to rely onmisleading stereotypes of the inher- ent dangerousness of mental illness. When such accounts are widely adopted as master explanations for shooting rampages, the easily recognizable features of the narrative can obscure the role of many other potentially important contributing factors. These might include the perpetrator’s stressful economic circum- stances and level of social disadvantage,maladaptive personality development in response to early-life trauma, the psychological sequelae of domestic violence exposure, aggrieved resentment and smoldering anger against individuals or groups perceived to be hostile and threatening,18 and male gender and aberrant constructions of masculinity—all enhanced by the disinhibiting effects of substance intoxication and easy access to a semi- automatic firearm. These kinds of vectors and background con- ditions, often interacting with each other in complex ways, can

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be far more germane to comprehending a particular act of mass violence than a diagnosis of acute psychopathololgy.19

Recent studies suggest that approximately 25% of mass murderers had exhibited a mental illness, but most of them had not appeared on the radar of either the mental health or law enforcement systems.13 Similarly, a Federal Bureau of In- vestigation (FBI) study of 63 active-shooter incidents between 2000 and 2013 found that 25% of shooters were known to have been diagnosed with a mental illness of some kind, rang- ing fromminor tomore serious disorders. The study concluded that “formally diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence.”12

These relatively weak associations highlight how mental ill- nesses in themselves rarely cause violent behavior and are not reliable predictors of multiple-victim gun crimes.16,20

In some sense, each mass shooting incident is unique. Sub- stance use comorbidity and a range of putative risk factors ranging from the shooter’s level of economic distress and housing insecurity to politically extremist attitudes and ideol- ogy, to social isolation have been cited as stressors in analyses of mass shootings.21No single variable emerged as a common feature of mass shooters. Still, the “diagnose-the-shooter” narrative persists and furthers a number of stigmatizing ste- reotypes, such as the notion that persons with mental illness resemble “ticking time bombs.”11,22 Representations of peo- ple with mental illness as being irrationally and unpredictably violent can have real adverse consequences, ranging from community resistance to the placement of housing and treat- ment facilities for people with mental illness in particular neighborhoods, to the escalation of tense interactions be- tween people with mental illness and law enforcement offi- cers, often resulting in avoidable arrests and incarcerations and sometimes ending in fatal shootings by the police.23,24

Defining an appropriate role for mental health practi- tioners in preventing mass shootings is inherently difficult. While recent studies have found that the majority of mass shooters did not show signs of acute psychosis or serious mood disorder, the estimated prevalence of psychiatric disor- der is still higher among these perpetrators than in the general adult population. As we have already suggested, there is some evidence that certain combinations of clinical symptoms and affect patterns may temporarily increase risk of gun violence. Researchers have identified delusions, fixation, and perceived persecution as clinical symptoms that may precede violent be- havior.16,25 But does this implicate psychopathology in mass shooting, and therefore call for psychiatric surveillance and risk assessment to prevent at least some of these events?

Ironically in this context, disorders such as major depres- sion and schizophrenia are often marked by psychomotor slowing, negative affect, intellectual disorganization, social isolation, and other symptom clusters that would seem to ren- der a person less likely to plan and implement a complex gun crime.18,26 It is perhaps not surprising, then, that some studies have found that persons diagnosedwith these mental illnesses are less likely than non–mentally ill offenders to use firearms

Harvard Review of Psychiatry

in violent crimes.27 Along these lines, Swanson and col- leagues28 found that adults with serious mental illnesses in public behavioral health systems in Florida were at least no more likely than other adults in the general population to be arrested for a gun-related violent crime.

A study of individuals who were clinically fixated on harming members of Congress found that having a psychiatric diagnosis alone was not associated with aggression or actual violent behavior. More relevant predictors included the indi- vidual’s motives and means.29,30 The MacArthur Violence Risk Assessment Study31 identified a group of 100 repeatedly violent individuals in a sample of 1136 discharged psychiatric inpatients but found that psychosis immediately preceded only 12%of violent incidents. The researchers concluded that “psy- chosis sometimes foreshadows violence for a fraction of high-risk individuals, but violence prevention efforts should also target factors like anger and social deviance.”32 In addi- tion, the MacArthur study found that only 2.4% of the study participants engaged in any act of firearm-involved violence, defined to include brandishing or threatening someone with a gun, over the 12-month follow-up period.31

A large U.S. study of schizophrenia patients in the commu- nity found that 5.4% of participants engaged in at least one act of injurious violence during an 18-month follow-up pe- riod, but baseline symptoms of psychosis or depression did not predict injurious violence. Rather, the significant predic- tors were severity of illicit drug use (hazard ratio = 2.93), re- cent violent victimization (hazard ratio = 3.52), childhood sexual abuse (hazard ratio = 1.85), andmedication nonadher- ence (hazard ratio = 1.39).33 These findings would suggest that the large majority of patients with schizophrenia do not engage in acts of serious violence, and even when they do, psychiatric symptoms alone do not provide a sufficient expla- nation for their violent behavior.

Still, “mental health” remains the focus of many existing regulations as well as proposed policies to prevent gun vio- lence in the community. Despite evidence that there is no strong connection between gun crime and mental illness,2 fed- eral law since 1968 has prohibited firearm purchase or posses- sion by anyone with a record of involuntary civil commitment to a psychiatric hospital or other mental health–related adjudi- cation.34 A few studies have suggested that this restriction pre- vents some violent crime—and gun crime, in particular—but its population-level impact is severely limited since very few patients are involuntarily committed.35,36 The vast majority of violent gun crimes are perpetrated by people who would never be committable to a psychiatric hospital, and the im- portant correlates of violent behavior tend to be the same in psychiatric and nonpsychiatric populations—for example, being young, male, or socially disadvantaged, exposure to trauma in early life, and using drugs and alcohol to excess. Future research into mass shootings and other acts of serious violence should move beyond the diagnostic template that looks for psychopathology to adequately explain the perpe- trator’s behavior.

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2. Scrutinize any Apparent Correlation of Violence with Mental Illness for Evidence of Racial Bias in the Official Systems That Define, Measure, and Record Psychiatric Diagnoses, as Well as Those That Enforce Laws and Impose Criminal Justice Sanctions U.S. popular and political discourse frequently applies the mental illness descriptor to white male shooters, but analysis of whiteness itself, or discussions of whiteness as a race or eth- nicity, are usually omitted from published studies about U.S. mass shootings.37–39 By contrast, race and ethnicity often play a key role in accounts of mass shootings when the perpe- trator is not white. For example, after the 2007mass shooting at Virginia Tech University perpetrated by a college student of Korean-American heritage, media outlets reported that Asian-Americans experienced fear of retaliation and felt forced to issue an apology on behalf of their “group.”40

A content analysis of news documents covering mass shootings from 2013 to 2015 found that white and Latinx male perpetratorsweremore likely to have their crimes attrib- uted to mental illness than were shootings by black men.41

White men were qualitatively described as more sympathetic characters than black and Latinx men, who were more often labeled as violent threats to public safety.41 Despite the popu- lar stereotype of mass shooters being white, statistically just over half (57%) of the perpetrators of FBI-defined mass shootings since the early 1980s have been white, and the ma- jority of victims of mass shootings in recent years have been nonwhite individuals.42,43 When a mass shooting occurs and the identified perpetrator is black, content analysis shows that politicians’ press briefings, media reports, and research articles rarely mention mental health and illness in descrip- tions of the perpetrator. Rather, such incidents are more likely to be described under rubrics such as “gang disputes,” “drive- by shootings,” or other forms of “urban” violence, often with little further elaboration on motives or effects.44,45

These white/black dichotomies in the definition of mass shootings carry implications for resource allocation for study- ing these incidents and for potentially interrupting their causal pathways and mitigating their harmful consequences to individuals and communities. Defining urban violence as essentially out-of-range for our concern with mass shootings makes it much more difficult for researchers to discover the ways in which these shootings, too—as commonplace as they have become in certain urban neighborhoods—can have pro- found and lasting psychological and community effects.46

Mass shootings in urban areas have received little attention from mental health researchers, and the relatively few studies on this topic mostly amount to superficial, group-based com- parisons between urban and suburban perpetrators. For exam- ple, Knoll47 describes aspects of social identity in summarizing how urban and suburban perpetrators seem to differ, citing an urban “honor culture” and strong, group-based “social hierar- chies” as the context for urbanmass violence, in contrast to the image an isolated loner who commits amass shooting in a sub- urban public setting.

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Meanwhile, a large body of research has focused on the link between violence and mental illness in general, much of it relying on data from the criminal justice system, forensic fa- cilities, state psychiatric hospitals, or other publically funded systems in the community. Due to the historical nexus of ra- cial discrimination and economic disadvantage—which had led indirectly to entrenched disparities in arrest and incarcer- ation as well as to involvement with the public behavioral health system—individuals who are identified as violent (or at risk of violence) in official institutional settings tend to be disproportionately people of color.48–50

These systems curate and disseminate the records of felony conviction and involuntary civil commitment that are used to determine that a person is ineligible to possess firearms under federal or state law. Specifically, official agencies report gun-disqualifying records to the FBI’s gun-purchase back- ground check database, with the result that racial disparities in the reporting institutions’ practices and policies tend to be reproduced in the implementation of firearm restrictions that are applied to putatively risky categories of people.51 As one example, a large study of gun restrictions in a population of adults with serious mental illnesses in Florida found that black individuals made up 15% of the surrounding popula- tion but 21% of the study group in the public behavioral health system, 31% of those disqualified from guns due to a mental health adjudication, and 36% of those disqualified due to a criminal record.28,49

As a result of these entrenched selection effects, much of what we know regarding the intersection of violence and mental illness extends only as far as people with mental ill- nesses who are socially and economically marginalized or use public services. But this misleading picture is often used to justify further institutionalization or incarceration that dis- proportionately affects people of color, producing an insidi- ous feedback loop between biased data and discriminatory practice. Studies that are able to account for a range of social correlates of violence inmultivariablemodels tend to find that the statistical association between violence and race is much attenuated, as is the link between violence and mental illness as defined in the official records of state agencies.31,52

In summary, racial bias can creep into available data and distort our understanding ofmass shootings and other gun vi- olence, limiting the scope of what should be a broader and more productive inquiry into the complex causes and effects of gun-related injury and death. What, for instance, are the psychologies that underlie shootings in areas of concentrated urban poverty, and what particular traumas emerge in their wake?53,54 What are the traumatizing effects for young peo- ple who frequently hear gunshots or have seen shootings or dead bodies?55,56 How can mental health expertise be effec- tively deployed to address these more quotidian, but no less problematic, aspects of gun violence in the United States?

Reckoningwith the biases in its own framework can then aid mental health research to promote anti-racist work57—such as collaborating with community-based violence interrupters,58

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Future Psychiatric Research into American Gun Violence

imagining and advocating for structural change, and addressing how gun victimization in black communities intersects with other unequal systems, including health care, education, and community safety.46

3. Promote Awareness of the Social and Political Determinants of Firearm Violence To better understand the role of firearm access in the occur- rence and lethality of mass shootings and other forms of gun violence, research should be guided by an overarching framework that incorporates not only social, cultural, and political, but also psychological, aspects of private gun own- ership in the United States. Mental health researchers should play a key role in a sustained collaborative inquiry into how these dimensions might shape gun violence as a broader pub- lic health problem. Following the lead set by public health scholarship, adopting such an approach would enable mental health researchers to contribute productively to building in- terdisciplinary evidence for gun laws and policies that are both effective and equitable, minimizing potentially adverse collateral consequences for at-risk individuals who are sub- ject to restrictions.59Mental health professionals and scholars could have much to offer, for example, in the development of better guidelines for restoring firearm rights to persons with gun-disqualifying records in their remote past.60

A study byReeping and colleagues61 found that stateswith more permissive gun laws and higher rates of gun ownership also tend to have higher rates of mass shootings. But do these patterns mean that gun laws are effective, or do they reflect the intersectionality of other social and economic differences among states? Research by Steadman,31 Tuason,62 and others suggests that serious acts of violence attributed to “mental ill- ness” often are more robustly associated with socioeconomic factors that may also be indirectly linked to mental illness, in- cluding unemployment, insecure housing, histories of trauma, or lack of access to care.63 Perhaps the broader determinants of population well-being, illness, injury, and death can indepen- dently affect all of the following: cultural attitudes toward gun ownership; responses to social conflict; policies and laws concerning gun access; the motivations of a mass shooter; and the probability of being able to carry out an act of mass vi- olence.64 Understanding such potential connections through interdisciplinary research that includes a trained mental health lens could help to both reduce gun violence and improve other dimensions of population well-being over time.

4. Use Community Engagement to Expand the Scope and Impact of Research to Prevent Mass Shootings and Other Gun Violence Effective policies and interventions to reduce the incidence of mass shootings and other acts of serious violence will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained en- gagement of researchers with affected communities and other stakeholders. Within the mental health community, persons

Harvard Review of Psychiatry

with lived experience as well as some family members and ad- vocates have been loath to engage with gun violence preven- tion efforts in the past, due to the perception that these efforts play upon the public’s exaggerated fear of people with mental illnesses and thus exacerbate the stigma and scorn that mentally ill individuals feel from others.65

In reality, people in the communitywho are recovering from seriousmental illnesses often havemore to fear fromother peo- ple. Like other vulnerable populations,54,66,67 persons diag- nosed with mental illnesses are statistically more likely to be victims than perpetrators of violent crime.18,68,69 They repre- sent between 25% and 58% of those shot and killed by police officers each year,70,71 and there is an apparent interaction be- tween race andmental illness when citizens are shot by law en- forcement officers. A recent study found that when police shot and ki

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