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Jennifer Skeem & Edward Mulvey, What Role Does Serious Mental Illness Play in Mass Shootings and How Should We Address It?, Criminology & Public Policy (forthcoming, 2019)

Abstract

A popular explanation for mass shootings is that the assailant “must’ve been mentally ill.” A popular policy solution is exceptionalist—enter more gun-disqualifying psychiatric records into the background check system to keep guns away from identified people with mental illness. We synthesized research on the connection between mental illness and common violence, gun violence, homicide, and mass violence. We focused on serious mental illnesses like schizophrenia, bipolar disorder and major depression, which are not the same as emotional distress from life circumstances and problematic personality traits. We found there is an association between serious mental illness and violence—but it is weaker than the public imagines or the media portrays; and rarely causal. Serious mental illness plays a limited role—it is neither a necessary nor sufficient condition for mass violence.

Policy Implications

Exceptionalist policies that assume serious mental illness is the cause of mass shootings will do little to prevent them—and they subject millions of nonviolent people with mental illness to stigma and unwarranted social control. Mass violence is a multi-determined problem. Because major risk factors for violence are shared, improvements in policies that keep guns out of the hands of dangerous people without mental illness, will also go far in preventing incidents involving those with mental illness. Chiefly, these steps include sharpening the criteria for gun-disqualification and temporarily removing guns from individuals at imminent risk for violence. The implementation of threat assessment teams and funding for crisis services for people with- and without mental illness may also be helpful.

What Role Does Serious Mental Illness Play in Mass Shootings and How Should We Address It?

In the wake of almost every highly publicized mass shooting in the US, an impassioned and familiar debate plays out in popular and political discourse over a central concern - what causes this terrible, recurring problem and how do we fix it? The positions are predictable. One side frames mass shootings as part of the larger complex problem of gun violence in the U.S., where over 350 people are injured by gunfire every day and about 100 of them die (Centers for Disease Control, 2018). This side argues that the principal policy solution is better gun regulation, including universal background checks for buyers, a ban on military style assault weapons and high capacity ammunition magazines, and crackdowns on gun trafficking (Webster & Vernick, 2013). The other side, including the National Rifle Association, largely blames mass shootings on deranged people. The problem is not guns, they argue, but mentally ill people who turn guns on innocents. The chief policy solutions then are to “fix America’s broken mental health system” (National Rifle Association, 2013) and to prevent people with mental illness from buying guns by systematically entering gun-disqualifying mental health records into the National Instant Criminal Background Check System (NICS; see Silver, Fisher & Horgan, 2018).

When one confronts the graphic news of a mass shooting—including horrific images, terrifying witness narratives about how multiple people were murdered in a public space, and heart-rending grief of those who lost loved ones—there is a natural pull to leap to mental illness as an explanation. After all, why would any person of sound mind indiscriminately massacre people...especially strangers or children? When trying to understand terrible acts of violence, one easy explanation is that the killer “must’ve been mentally ill” (Corrigan, as cited in Chen, 2018). Of course, such an explanation has a circular quality (i.e., “Why did this man do this terrible thing?” Because he is mentally ill. “And how do you know he is mentally ill?” Because he did this terrible thing.).

Despite its tautological quality, the explanation is popular. In a Washington Post-ABC News sponsored survey of about 1,000 randomly selected Americans, 63% of respondents believed that public mass shootings in the US are primarily due to mental health problems (compared to 23% who believed they are primarily due to inadequate gun control; Craighill & Clement, 2015). Based on a more rigorous survey of over 4,000 Americans, Barry, McGinty, Vernick and Webster (2013) found that most respondents (85%) supported gun policies and laws that specifically target and restrict people with mental illness. This is consistent with a much larger body of evidence that negative attitudes towards people with serious mental illnesses like schizophrenia and bipolar disorder are prevalent and persistent in the U.S.—and include the assumption that these people are particularly dangerous (see Link & Phelan, 2013; Pescosolido, 2013).

This assumption is fueled by the news media (McGinty, Webster & Barry, 2013), which disproportionately emphasizes a link between mental illness and violence. Although only an estimated 3-5% of violence in the U.S. is attributable to mental illness (Swanson, Holzer, Ganju & Jono, 1990), an analysis of U.S. news media coverage over two decades indicates that 38% of stories about mental illness focused on violence (McGinty, Kennedy-Hendricks et al., 2016). Similarly, analyses of film and print media reveal that a commonly featured theme is that “people with mental illness are homicidal maniacs who need to be feared” (Corrigan & Watson, 2002, p. 17). Moreover, when the link between mental illness and mass violence is ambiguous, the media often connects the dots. For example, there was little evidence that the assailant who massacred schoolchildren in Newtown, Connecticut had a serious mental illness (McGinty et al., 2014), but the media was quick to suggest his “acts of slaughter...strongly suggest undiagnosed schizophrenia” (e.g., Steinberg, 2012) and implied that the event could have been prevented by providing mental health services.

These perceptions are not totally removed from reality. Among the pool of “senseless rampages by troubled young men” (Swanson, 2011, p. 1369), there are certainly select “spectacular examples” (Stone, 2015)—real, high profile mass shootings where evidence suggests that the assailant had a serious mental illness. Familiar examples include the 2009 Virginia Tech shooting; the 2011 attempted assassination of a Congresswoman in Tucson, Arizona; and the 2012 movie theater shooting in Aurora, Colorado. Enhanced mental health services certainly may have prevented particular incidents.

Despite these examples—and despite a modest association between mental illness and violence (see below)—there is little compelling evidence that mental illness causes mass shootings, or that policy initiatives focused on mental illness will have a significant impact on these crimes. It is important to understand that mental illness is a “highly elastic clinical term that can mean many things but is often used without definition in the mass violence narrative” (National Council for Behavioral Health, 2019, p. 14). Emotional distress, anger, suspiciousness, and indifference to life often describe perpetrators of mass violence—and these psychological factors clearly appear as contributory factors in the conceptualization or execution of some shootings (see Lankford, 2018). There are policy-relevant differences, however, between mental illness and emotional distress (e.g., a person with bipolar disorder whose grandiose delusions impel them to violence vs. a disgruntled employee who is fired and becomes so enraged he seeks revenge). If efforts to prevent mass violence focus narrowly on identified people with serious mental illness, they may miss those who are acutely distressed and more at risk. Mental illness is neither a necessary nor sufficient condition for these incidents.

Nonetheless, the call for more services for people with mental illness emerges again and again as the broadly accepted compromise position to end heated debate after a mass shooting. It seems everyone can agree that this is a smart thing to do and should have an impact. We maintain, however, that there is little evidence to support this assumption. Our position, based on available evidence, is that policies focused narrowly on mental illness as a predictive factor and/or target of intervention are doomed to be both highly inefficient and highly ineffective.

In this paper, we unpack empirical support for the notion that mental illness is a distinct and powerful cause of mass shootings. This is important to do because this notion may have far-reaching and unintended consequences. The adoption of this notion (a) risks stigmatizing a huge and diverse population of people with mental illness, the vast majority of whom will never be involved in violence; and (b) drives support for laws and policies that invade the privacy of people with mental illness and restrict their liberties—regardless of whether they are fair or effective. In the wake of mass shootings, there have been calls for a “national registry” of people with mental illness and some jurisdictions have passed laws that require mental health professionals to report “dangerous patients” to local officials, who are then authorized to confiscate any firearms these people might own (Metzl & MacLeish, 2015). While such laws may be well-intentioned, they fan stigma and can deter people with mental health problems from seeking treatment—without making us much safer. An understanding of the link between mental illness and mass shootings could possibly inform more focused policies that promote public safety without unnecessarily infringing on the rights and privacy of people with mental illness.

We synthesize research from several areas to examine this issue. This is a necessary approach because of challenges to addressing this topic empirically—including the ambiguity inherent in defining “mental illness,” the difficulty of assessing the causal link between mental illness and a violent act, and the fact that mass shooting is an extraordinarily rare outcome variable. We begin by describing these challenges, and the resultant gaps in knowledge. Then, we synthesize available research on (a) the strength and nature of the relationship between mental illness and (mass) violence, and (b) the effectiveness of current policy initiatives that focus on mental illness and gun violence. After summarizing points of consensus and controversy from the available research, we address policy implications and the possibilities for fashioning policy more in line with empirical reality.

It is worth noting that we are not the only ones who have examined the research in this area and come to similar conclusions. There are other excellent reviews in the literature (e.g., Frattaroli, McGinty, Barnhorst, & Greenberg, 2015; McGinty, Webster, & Barry, 2014; Swanson, McGinty, Fazel, & Mays, 2015; see also National Council for Behavioral Health, 2019). Our intent is to provide a documented perspective on where mental illness fits in as a factor in mass shootings and to promote policy approaches that align with that evidence. In many ways, there is little new here. Policies that capitalize on—rather than ignore—what we know would be new.

Synthesis of Relevant Research

Challenges in Studying the Link Between Mental Illness and Mass Shootings

Appropriately defining mental illness. How often are mass shootings motivated by mental illness? The answer to this question will depend on how broadly one defines mental illness, including its type, severity, and acuity. First, it is important to recognize that mental illness encompasses a wide variety of conditions. Hundreds of disorders are listed in the principal manual used for psychiatric diagnoses in the U.S. (APA, 2013). These include “psychotic” disorders (marked by false beliefs, hallucinations, and impaired reality testing), “internalizing” disorders (marked by extreme, recurring affective states like anxiety or depression), and “externalizing” types of disorders (defined mostly by substance abuse or antisocial behavior). Externalizing disorders are well established correlates of violence and are much more strongly associated with violence than psychotic or debilitating affective disorders (Swanson et al., 1990; Steadman et al., 1998; Elbogen & Johnson, 2009). But externalizing disorders are rarely regarded as grounds for legally excusing violent or other criminal behavior (see Peterson et al., 2014).

Second, research robustly indicates that most symptoms associated with mental disorders exist on a spectrum of severity—meaning that many symptoms are present to some degree even in the “normal” population (Clark et al., 2017). That is true not only for commonly experienced symptoms like anxiety and sadness, but also for symptoms usually associated with serious disorders, such as auditory hallucinations and paranoid thinking (Appelbaum, 2017). It can seem arbitrary to specify a threshold above which the presence of one or more symptoms signifies a disorder. Anger, for example, is a “fundamental and functional human emotion” that happens to be associated with some serious disorders (Novaco, 2011a). Anger has been discussed as a motivating factor for mass shootings and robustly predicts violence among people both with- and without mental illness (Gardner, Lidz, Mulvey, & Shaw, 1996; Novaco, 1994; Novaco, 2011b; Swanson et al., 2015). Approaching anger as a symptom every time a person with mental illness experiences it (and using extreme anger to signify mental illness) risks pathologizing a normal emotional state.

Third, serious disorders like schizophrenia and bipolar disorder are episodic, meaning that they ebb and flow as a function of time and treatment. People with these illnesses can experience episodes of acute symptoms (that might motivate violence) interspersed with periods of recovery (where symptom-motivated violence is unlikely; see Douglas & Skeem, 2005). Demonstrating that active symptoms temporally precede and increase the likelihood of a violent incident is a basic prerequisite for showing that symptoms are a causal risk factor for violence (see Kraemer et al., 1997), and this type of evidence is scant or nonexistent in the literature (McGinty, 2018).

In short, if one defined mental illness expansively—i.e., included all types of mental health conditions, set a low threshold for calling normative traits symptoms, and ignored whether symptoms were active at the time of an incident—the definition could encompass many or most mass shooters. After all, mental illness is quite common—nearly half of the U.S. population will meet formal criteria for one or more mental illnesses during their lifetime (see Schaefer et al., 2017). Mental illness—defined broadly—could be even more common among mass shooters, who tend to be described as troubled, unsuccessful, or socially disenfranchised—“often hopeless and harboring grievances that are frequently related to work, school, finances or interpersonal relationships; feeling victimized and sympathizing with others who they perceive to be similarly mistreated; indifference to life; and often subsequently dying by suicide” (National Council for Behavioral Health, 2019, p. v).

This broad definition of mental illness, however, would pathologize features, traits, and experiences that have little to do with most people’s conceptions of mental illness. In the process, it would pathologize millions of individuals who would not be viewed by most people as “mentally ill”; at least, not until they committed some heinous act. Of the 40 million people in the U.S. with more than one diagnosable mental illness, the vast majority are never violent (NCBH, 2019). Perhaps more importantly for our purposes, this broad definition would also fail to advance our understanding of the extent to which mental illness causes mass shootings and should be targeted to prevent these crimes. The mere presence of a mental illness does not establish that it played a causal role in the incident.

In this paper, we focus on serious mental illnesses like schizophrenia, bipolar disorder, and major depression which often impair people’s functioning or sense of reality. We primarily emphasize active symptoms of psychosis like delusions and hallucinations, which can directly motivate violence (e.g., a young man attacks his family because he believes they have become agents of the devil and are using devices to control his mind). Our relatively narrow definition of mental illness is consistent with legal definitions of the link between mental illness and violence: Most people who have been adjudicated not guilty by reason of insanity have a primary diagnosis of schizophrenia and ostensibly were responding to psychotic symptoms at the time of their offense (Callahan, Steadman, McGreevy & Robbins, 1991). Our definition is also consistent with research on mental illness and violence, which tends to emphasize major mental disorders and symptoms of psychosis (see Monahan et al., 2001; Peterson et al., 2014).

Accurately diagnosing mental illness. Once mental illness has been delimited, the next challenge is to measure it accurately in a given case. This can be a difficult task in routine clinical settings, where formal assessment resources are typically limited. In the field of psychiatry, there is ongoing concern—even in well-regarded clinics—about clinicians’ limited rates of agreement with one another about a patient’s diagnosis (see Vanhuele, 2017). Although structured interviews have been developed to standardize assessment, and thus improve diagnostic agreement, they are rarely used outside research settings.

The context of mass shootings exponentially increases the difficulties inherent in systematically and accurately diagnosing mental illness. A substantial proportion of mass shooters die during the incident, preventing direct assessments of their mental state at the time of the offense (e.g., Stone, 2015). Although a well-documented history of psychiatric treatment and/or trustworthy and consistent clinical diagnoses can establish the presence of a serious mental illness (if not its link with the incident), the absence of such documentation is not dispositive because people with mental illness often do not receive treatment (NIMH, 2019).

The biggest problem, however, lies in the generation of informal diagnoses of mental illness in the shadow of rare, deadly, and often highly publicized shooting sprees. Studies of mass shootings tend to rely on police reports and media accounts of incidents, which are often incomplete or wholly unavailable and regularly variable in content (e.g., Duwe, 2007; Taylor, 2018). Many studies include reports and speculation by neighbors, friends, and relatives (often post-hoc) that an assailant suffered from mental illness. These informal diagnoses are undoubtedly influenced by the violent act itself (see above)—as people search for explanations and discover “red flags” that only come into focus with hindsight (Fox & Fridel, 2016).

As Stone (2015, p. 76) notes, “as dramatic as massacres and rampage murders tend to be, not all are dramatic enough to warrant inclusion in books and Internet articles on the topic” and a large number rely on questionable sources of information about the presence of mental illness. In this paper, we focus on a priori formal assessments of mental illness and heavily weigh those informed by validated diagnostic tools. To us, this seems the most valid way to assess the a priori, and thus causative role, of mental illness in these incidents.

Explaining mass violence, as a rare act. There is consensus that mass shootings are extraordinarily rare events, though incidence estimates vary as a function of differences in definitions and data sources used to identify incidents (e.g., an FBI database, media accounts and other “open” sources). Following the FBI’s approach, a mass shooting is often defined as an incident in which four or more victims are killed with a firearm by an offender without a cooling off period. Based on data compiled by the Congressional Research Service, Krouse and Richardson (2015) reported that there have been, on average, about 21 mass shootings per year in the U.S. since 2000. Many of these shootings involve ‘familicides’ (murder of one’s family) or murders committed as part of other criminal activity (robberies, drug disputes, gang conflict). Public fear seems much more strongly driven by the subcategory of public mass shootings, which Duwe (2017) defines as those that occur “at a public location in the absence of other criminal activity, military conflict or collective violence.” Duwe’s (2017) estimates indicate that there have been, on average, about 3 public mass shootings per year in the U.S. over recent decades. Despite growing public fear, there is little evidence that the rate of (public) mass shootings has increased over time—although there has been an increase in their lethality (Duwe, 2017; Fox & Fridel, 2016).

The fact that public mass shootings almost never occur is a formidable barrier to developing any solid evidence base on the ‘average causal effect’ of serious mental illness. As explained by Swanson (2011, p. 1370), efforts to inform public health interventions can be thwarted by either “a small effect size or a rare outcome event”—and studies of how to prevent mass shootings by people with mental illness face both challenges at once. The few studies of mass violence that are relevant to the focus of this paper describe profiles of assailants, including limited markers of whether they ever experienced mental illness (see above). These descriptive data are not amenable to robust causal modeling of mass shootings; for every individual who fits the profile, there are tens of thousands of others with the same profile who will never commit a mass shooting.

Talking about an empirically demonstrated association between mental illness and mass shootings is thus suspect from the outset. As Swanson (2011) observes:

When researchers talk about violence and mental disorders in general—and about what they know about the prevalence and correlates of violence among people with serious mental illness in the community—they are not talking about mass shootings, which are extremely rare. They are talking largely about behaviors that are common enough to study systematically with representative samples, such as fist fights, pushing and shoving among family members, and sometimes threats made with weapons (p. 1369).

When researchers include studies of people with serious mental illness drawn from psychiatric and justice settings, they’re often also referencing behavior that results in arrest for a violent crime (e.g., assault, robbery, etc.). Any estimates about the strength of the relationship between mental illness and mass violence have inherent uncertainty.

In this paper, we examine the results of studies on common forms of violence because they provide the soundest evidence base for understanding the role of mental illness in precipitating violence. The essential problem is that the extent to which results generalize from common violence to mass shootings is unclear. Because there is no other choice for arriving at data-based policy recommendations, we triangulate evidence on mental illness and common violence to help inform understanding of mass shootings. We believe reasonable assumptions can be drawn to inform prevention efforts, despite fragmentary evidence (see Swanson, 2011; Swanson, McGinty, Fazel & Mays, 2015).

Evidence on the Link Between Mental Illness and (Mass) Violence

Serious mental illness is modestly associated with violence. Although data generally suggest that serious mental illness plays only a minor role in common violence, estimates vary based in part on the reference population or setting. The risk associated with serious mental illness is generally greater in community samples that represent the general population than in psychiatric samples or justice-involved samples (we return to this point later). In this subsection, we emphasize community samples.

Epidemiological studies of representative community samples are specifically designed to answer basic questions about the prevalence of, and links between mental illness and violence in the general population. These studies yield three main messages (Elbogen & Johnson, 2009; Swanson, Holzer, Ganju & Jono, 1990; Van Dorn, Volavka & Johnson, 2012; for studies beyond the U.S., see Fazel, Gulati, Linsell, Geddes & Grann, 2009; Fazel, Smith, Chang & Geddes, 2018). First, the vast majority of people with serious mental illness living in the community are not violent. For example, based on a sample of over 10,000 participants in the U.S. assessed in the seminal Epidemiological Catchment Area (ECA) study, Swanson et al. (1990) found that the one-year prevalence rate for self-reported minor and serious violence was only 7%, among people who met formal diagnostic criteria for schizophrenia, bipolar disorder, or major depression alone. Second, people with mental illness in the community are more likely to become involved in violence than those without mental illness. In the ECA study, the one- year prevalence rate for violence was about 2% for people without mental illness or substance abuse compared to 7% for those with mental illness alone, for a relative risk estimate of 3:1 for people with- and without mental illness (Swanson et al., 1990). Third, and perhaps most importantly, only a tiny fraction of violence can be attributed to mental illness alone. The one-year population attributable risk of violence associated with mental illness alone was 4% in the ECA study (Swanson et al., 1990; see Fazel et al., 2009 for a meta-analytic-based attributable risk estimate of 10% for psychosis). This estimate, which accounts for the strength of risk and number of people in the risk category, suggests that 96% of the common violence that occurs in the general population would continue even if the elevated risk of violence among people with mental illness was eliminated.

Although we don’t know whether these results generalize from common violence to mass shootings, they are quite consistent with the results of two relevant studies of gun access and gun violence. First, data from an epidemiological study indicates that people with mental illness in the community are no more likely to acquire, possess, or carry guns than those without mental illness (Ilgen, Zivin, McCammon & Valenstein, 2008). Second, and more importantly, analyses of data on former psychiatric inpatients from the landmark MacArthur Violence Risk Assessment (MVRA) study suggests that both the absolute- and relative- risk of gun violence among people with mental illness is quite low.

In the MVRAS study, Steadman et al. (1998) conducted comprehensive clinical assessments of over 1,000 psychiatric inpatients and the followed them in the community for up to one year after hospital discharge to determine whether they were involved in violence, based on self-report, collateral informant reports (e.g., friends or family members), and arrest records. At one of the three study sites, investigators also assessed a census tract-matched, community comparison sample of 490 people without mental illness. Based on data from the psychiatric sample, Steadman et al. (2015) found that the one-year prevalence of violence involving the use of a firearm among discharged psychiatric patients was 2% (gun violence against strangers was even more rare, at 1%). Based on data from people who said they had access to firearms in the community comparison sample and the matched psychiatric subsample, Baumann and Teasdale (2018) found that people with mental illness were no more likely to be involved in violence over a 20-week period than their neighbors without mental illness. Also, the effect of access to a firearm on violence was not moderated by patient/non-patient status. These results are consistent with findings that guns are less likely to be involved in violent crime arrests for people with serious mental illness compared to the general population (Swanson et al., 2016).

And what of mass violence itself? The few descriptive studies available (see above) vary in the time periods examined, the types of incidents they include (Ns≈27-235), the rigor with which they define and assess mental illness, and—thus not surprisingly—their results. In studies that define mental illness expansively and include untrained ‘diagnoses’ made in the wake of the rampage (two serious methodological problems explained above), estimates of the proportion of mass shooters with confirmed or suspected mental health problems range from 30% (Duwe, 2007; Taylor, 2018) to 60% (Duwe & Rocque, 2018; Follman, Aronsen & Pan, 2019). In studies that focus on formal diagnoses of psychotic disorders (including those made after the incident), estimates range from 13% (Follman et al., 2015) to 15% (Fox & Fridel, 2016). In a comprehensive analysis conducted by a forensic psychiatrist who carefully distinguished psychosis from other conditions—including normative traits of hostility and subclinical paranoia (see above)—the estimate is 17% (Stone, 2015). In a study conducted by forensic psychologists, 23% of juvenile mass murderers had some documented psychiatric history but only 6% were judged to have been psychotic at the time of the incident (Meloy, Hempel, Mohandie, Shiva & Gray, 2001).

It is difficult to draw firm conclusions from these studies. In our view, the weight of this light evidence base suggests that people with serious mental illness are overrepresented among mass shooters, but only a minority of mass shooters have experienced serious mental illness (perhaps 20%). But it is wholly unclear how often mental illness is a central feature of, or directly causes, mass shootings. In fact, it is even unclear whether mental illness has a relationship with violence that is independent of other correlated risk factors. Data on mass violence are limited, descriptive, and unable to shed much light on the issue. In the remainder of this section, we turn to relevant research on common violence, where the effect of mental illness and other risk factors can be better disentangled.

Major risk factors for common violence are shared by people with- and without serious mental illness. A consistent finding in research conducted with community (Swanson, 1994; Van Dorn et al., 2012), psychiatric (Monahan et al., 2001; Swanson et al., 2002), and correctional (Bonta, Law & Hanson, 1998; Bonta, Blais & Wilson, 2014; Skeem, Winter et al., 2014) samples is that the most robust risk factors for violence are shared by people with- and without mental illness—including demographic factors (e.g., male sex, young age, low socioeconomic status), histories of victimization and exposure to violence (e.g., childhood maltreatment, trauma), substance abuse and involvement with drug markets, histories of violence and other criminal behavior, and antisocial traits including poor anger controls and impulsivity. Once these general factors are taken into account, the association between mental illness and violence is greatly diminished or nonexistent. Moreover, among people with mental illness, these general factors tend to predict violence more consistently and powerfully than clinical factors like the seriousness of a disorder, psychotic symptoms, and treatment compliance. Concretely, when people with mental illness behave violently, it is usually (though not always) for the same reasons as people without mental illness.

The results of the MVRA study of former psychiatric patients (see above) can be used to illustrate these points. First, by comparing patients with their neighbors—many of whom lived in disadvantaged high-crime neighborhoods—the MVRA design accounted for general risk factors that can wash out the weaker influence of mental illness (Swanson et al., 2015). In this study, Steadman et al. (1998) found that substance abuse problems explained most of the (remaining) relationship between mental illness and violence. Specifically, patients without substance use disorders were no more likely to be involved in violence over any given 10-week period in the one-year follow up period than their neighbors without substance abuse (rates were 3% and 5%, respectively). Patients with substance use disorders, however, were more likely to be involved in violence than their neighbors without these disorders (rates were 22% and 11%). The nature of violent incidents was similar for patients and their neighbors; frequently targeting family members and friends and most taking place at home. Put another way, serious mental illness alone did not raise risk of violence in this study, unless it co-occurred with substance use problems (Monahan et al., 2001). This is consistent with other findings that mental illness combined with substance abuse increases risk of violence (e.g., Van Dorn et al., 2012; Witt, Van Dorn & Fazel, 2013).

Second, focusing on the entire MVRA patient sample, the single strongest predictor of violence—among a vast array of 134 contenders—was antisocial traits included in a leading measure of psychopathy (Skeem & Mulvey, 2001). This measure distills risk factors that apply to people with- and without mental illness, including past violence and other criminal behavior, impulsivity and poor anger controls, as well as the broader interpersonal trait of antagonism (e.g., callousness, distrust, combativeness, arrogance, manipulativeness; Skeem, Miller, Mulvey, Tiemann & Monahan, 2005). In contrast, symptoms of psychosis like hallucinations and delusions did not predict patients’ violence in the MVRA study (Monahan et al., 2001). In a careful analysis of MVRA data, Appelbaum, Robbins and Monahan (2000) found that the relationship between violence and “threat-control override delusions” (i.e., false beliefs that others will harm one or that outside forces control one’s mind) was largely artifactual. Typically, it seems, the relationship may “be accounted for by an association between a generally suspicious attitude toward others—with associated anger and impulsiveness—and violent behavior” (Monahan et al., 2001, p. 77).

These findings are echoed by the results of a rare intensive longitudinal study that tested the relationship between symptoms and violence at the weekly level. Based on a study of 132 former psychiatric patients identified as at high risk for repeated involvement in community violence, Skeem, Schubert, Odgers, Mulvey & Gardner (2006) found that high risk patients with increased anger in one week were significantly more likely to be involved in violence the following week. This was not true, however, for other symptom constellations including anxiety, depression, and threat/control override delusions. Level of substance use played a stronger role than symptoms in these patients’ risk state— there was an increased likelihood of violence on days following the use of alcohol or multiple drugs (Mulvey et al., 2006).

The fact that people with-and without- mental illness share major risk factors for common violence—like anger, substance abuse, and suspiciousness—is important to consider in the context of mass violence. As noted earlier and observed by Stone (2015)—who estimated that 17% of mass murderers experienced psychosis—there is a continuum between normative traits and symptoms even for this rare form of violence: “Given that the majority of mass murderers are men of a decidedly hostile nature, animated by avenging what they conceived as victimization by others, not surprisingly those in the grips of a psychotic condition were most often depicted as ‘paranoid schizophrenic.’”

Mental illness plays a larger role in common violence for lower- than higher-risk populations. An essential point is that mental illness can be more predictive of violence in lower risk than higher risk samples and subsamples. First, as noted earlier, mental illness is more strongly linked with violence in community samples than in psychiatric and correctional samples. Given that dangerousness is a criterion for psychiatric admission and criminal behavior precedes involvement in the justice system, the latter populations are already distilled for risk level. The general risk factors for violence mentioned above are more prevalent in these referred populations and tend to “wash out” the small effect of mental illness seen at the population level. For example, based on a meta-analysis of 204 diverse studies, Douglas, Guy, and Hart (2009) found that the simple association between psychosis and violence was greater in community settings (OR=3.26) than other settings—in psychiatric (OR=1.69), forensic psychiatric (OR=0.91) and correctional (OR=1.27) settings, the association was “smaller than small” (see Chen, Cohen & Chen, 2010).

Second, even within a relatively homogeneous sample, people with mental illness at lower risk for violence are more influenced by clinical factors than their higher risk counterparts. Based on a sample of 1,445 psychiatric patients who were all diagnosed with schizophrenia and enrolled in a drug trial, Swanson et al. (2008) identified two different risk groups. Acute psychotic symptoms and treatment nonadherence significantly predicted violence for lower risk patients (with no early history of antisocial behavior, violence rate=14%), but not their higher risk counterparts (with an early history of antisocial behavior, violence rate=28%). Similar findings emerged in a study by Winsper et al. (2013), who studied 670 patients experiencing a first episode of psychosis—who as a group are younger, less often treated, and at greater risk for violence than other patients (Large & Nielssen, 2011). The authors found that psychotic symptoms played more of a role in violence for first episode patients with less serious histories of delinquency, compared to their counterparts with greater histories of criminal behavior (Winsper et al., 2013)

The extent to which “mass shooters” conform with lower or higher risk profiles for common violence is unclear. Of the few spectacular examples of mass shooters with serious mental illness referenced above, some had prior contact with the psychiatric (if not correctional) system; others did not. For common violence, however, it is important for policymakers and practitioners to consider the settings where people with mental illness are encountered (i.e., community, psychiatric or correctional settings) and the extent to which they have general risk factors for violence—because this may signal the extent to which serious mental illness plays a medium, small, or trivial role in violence.

In a minority of cases, psychosis seems to directly cause violence. Across settings, causal risk factors for violence are the best targets for effective prevention and intervention efforts. Applying the criteria of Kraemer et al. (1997; see also Monahan & Skeem, 2016), there is little compelling evidence that serious mental illness is a strong causal risk factor for violence, at least at the whole-group level. Nevertheless, limited descriptive evidence suggests that—for an important minority of incidents— psychosis directly causes violence and other forms of criminal behavior. A direct relationship may be defined as one in which symptoms strongly or exclusively motivate violence (see Peterson et al., 2014)— for example, a patient with persecutory delusions who preemptively strikes out to “protect” herself or himself (Link, Steuve & Phelan, 1994).

Such situations are rather rare. Based on standardized data obtained from patients and collateral informants in the MVRAS study, Skeem et al. (2016) found that symptoms of psychosis had immediately preceded 12% of violent incidents, for the subset of high-risk patients who had been repeatedly involved in violence. Similarly, in studies where investigators reliably coded the extent to which symptoms versus other factors motivated criminal behavior among justice-involved people with mental illness (based on standardized interviews and record reviews), psychosis (4%; Junginger et al., 2006) and broader symptoms (7%; Peterson et al., 2014) were judged as direct causes of a minority of crimes. These figures are echoed by those obtained on more serious forms of violence. Based on a national clinical survey of documentation associated with 1,594 people convicted of homicide in England and Wales, Shaw et al (2006) determined that 10% had experienced symptoms of mental illness at the time of the offense.

This picture becomes murkier when one thinks of symptoms as being an indirect cause of a violent incident. Even when symptoms are present, there are many possible indirect relationships between symptoms and violence, i.e., violent incidents in which both symptoms and other general risk factors play an interactive role in motivating the incident (Juninger et al., 2006; Peterson et al., 2014). An example is an individual with bipolar disorder who cannot stop talking nonsensically and provocatively, thereby provoking a drunken fight over politics at a family get together (Mulvey & Schubert, 2016). Symptoms can combine with factors like intoxication, risky social contexts, criminogenic peers, and hostility to help potentiate violence (see Swanson et al., 2015).

Conclusions about the relationship between mental illness and (mass) violence. Among people who study mass violence, there is controversy about its link with mental illness. Duwe & Rocque (2018) believe the majority of mass public shootings are linked with mental illness—and argue that these extreme events are so rare that research on common violence will not generalize. Conversely, Fox and Fridel (2016) believe there is, at best, a tenuous connection between mental illness and mass shootings; when the focus is placed on serious mental illness and the most serious methodological limitations of profiling studies are considered, only a small minority of mass shootings are linked with mental illness. This perspective is echoed by Stone, who estimates that less than one-fifth of mass killers had a serious mental illness—“the rest had personality or antisocial disorders or were disgruntled, jilted, humiliated or full of intense rage” (see Rosenwald, 2016).

We believe the latter perspectives rest on the strongest empirical support. This position is based on triangulating studies of mass violence with more methodologically sound research on common violence, gun violence, and homicide (despite the limits of common evidence for uncommon things, Swanson, 2011). The most convergent evidence suggests there is a modest association between serious mental illness and (mass) violence—but a far weaker association than the public imagines or the media portrays.

This association implies that serious mental illness is a weak risk marker that may help predict violence in certain populations. This association does not imply causation, however. The fact that serious mental illness rarely explains violence is barely recognized in common discourse about mass violence. If the goal is not just to predict mass violence, but to intervene in the most efficient and effective ways to prevent mass violence, it is important to identify and target causal risk factors. Among people with serious mental illness, general risk factors like substance abuse, antisocial traits, anger, and a history of maltreatment predict violence much more strongly than psychosis or other clinical factors. Psychosis and clinical factors seem to play a role primarily among people with few of these general risk factors who are less likely to be violent in the first place. It seems most mass shootings are not directly caused by serious mental illness and would not be prevented by policies that assume otherwise. Mass violence is caused by multiple social, situational, and psychological factors that interact with one another in complex ways that are poorly understood and difficult to predict in advance.

Evidence on Current Policy Initiatives on Mental Illness & Gun Violence

As suggested earlier, those who attribute mass shootings to mental illness suggest that the solution lies in fixing the mental health system (a herculean task) and restricting the liberty of people with identified mental illnesses. Here, we address actual policy initiatives, which primarily seek to restrict access to firearms for people with mental illness. Given detailed reviews available elsewhere (e.g., McGinty et al., 2014, Rozel & Mulvey, 2017, Swanson et al., 2015)—and the fact that the generalizability of this information to mass violence is unclear—we provide a targeted summary here.

Gun violence as a broad problem. Gun violence is a much broader problem than mass shootings, and it is important to keep both in mind when formulating broad policies. Mass shootings account for less than one percent of gun murder victims in the U.S. (Matthews, 2018). Gun violence, however, may be viewed as encompassing not only violence directed toward others, but also violence directed toward oneself. Of all firearm fatalities in the U.S., the majority are suicides (Centers for Disease Control, 2018). Although serious mental illness explains little interpersonal violence, it is a strong risk factor for suicide. Analyses of MVRAS data indicated that—in the context of firearm access—people with mental illness were no more likely to be involved in violence than their neighbors (see above) but were substantially more likely to report suicidality (OR=4.7, Baumann & Teasdale, 2018). Experts argue that gun control for people with mental illness primarily makes sense as a suicide prevention strategy (Swanson et al., 2015).

Federal approach: Screening gun purchasers for mental health records. Given the U.S. Supreme Court’s interpretation of individuals’ Second Amendment rights to own firearms (McDonald v. City of Chicago, 2010; District of Columbia vs. Heller, 2008), governmental authority for preventing firearm violence is mainly restricted to keeping guns out of the hands of individuals determined to be dangerous. One gun-disqualifying restriction that passes constitutional muster is a longstanding federal prohibition on firearms for people with a history of mental health adjudication (Gun Control Act, 1968; 18 USC 921(a)(21)(c))—which primarily references people who have ever been involuntarily civilly committed to treatment. There are also prohibitions for people with a history of felony conviction. Current federal law requires firearms dealers to conduct a background check of prospective purchasers for such disqualifying conditions (Brady Act, 1993; 18 USC 922(t)). These background checks are implemented using the National Instant Criminal Background Check System (NICS), a national electronic registry in which states can enter records of individuals prohibited from having a gun, including those with a history of felony conviction or mental health adjudication.

Although NICS has been in effect since 1998, few states entered mental health records in NICS based on legal concerns about disclosing confidential health information and on data limitations. Following a mass public shooting at Virginia Tech that was linked with mental illness, Congress passed an NICS Improvement Amendment Act (2007) that incentivized states to enter more mental health records. The act also permitted restoration of gun rights to people who had once been disqualified for mental health reasons but were deemed no longer dangerous. In the five years following this act, there was a ten-fold increase in the number of gun-disqualifying mental health records submitted to NICS—with the 3 million mental health records submitted in 2013 accounting for nearly one-third of all gun-disqualifying conditions (see Swanson et al., 2015). Despite this increase, mental health records account for a tiny fraction of firearm purchase or transfer denials in the U.S. (e.g., 6% of all denials in 2015; Karberg, Frandsen, Durso & Buskik, 2017).

In two longitudinal studies—one conducted in Connecticut and the other in two Florida counties— Swanson and his colleagues (2013, 2016) evaluated the implementation and effectiveness of background checks in preventing violent crime (not the narrower class of gun-related violent crime) among people with serious mental illness. The investigators merged administrative mental health, arrest, and court data to examine the effectiveness of background checks generally (considering both criminal records and mental health adjudications) and the value added by mental health adjudications specifically. The value added by mental health adjudications was examined by comparing monthly trends in violent crime among ‘gun disqualified’ and ‘not gun disqualified’ people with mental illness— before and after 2007, the time when these jurisdictions began reporting gun-disqualifying mental health records to NICS because of the NICS Improvement Act. The results of the two studies are generally similar.

In the Connecticut study, Swanson et al. (2013) found a difference in the effectiveness of background checks between two key groups of people with mental illness: those with- and without a criminal record. Gun-disqualifying mental health records added value in reducing violent crime only for the latter group (those without a criminal record, who were lower risk and not already gun-disqualified). There was a larger drop in violent crime in 2007 for those with gun-disqualifying mental health records than for those without gun-disqualifying mental health records. In contrast, there was no effect of background checks on violent crime among people with mental illness who also had a criminal record. The investigators estimated that the overall impact of the gun-disqualifying mental health condition was very small—less than one half of 1% reduction; or 598 crimes instead of 612 expected crimes among 15,524 people with mental illness.

Generally, both studies suggest that gun-disqualifying mental health records, which are largely accounted for by involuntary hospital commitment, are correlated with violent crime (see Swanson et al., 2015) and add value for a small subgroup. These gun-disqualifying mental health records are limited indices of risk, however—perhaps including risk for mass violence. One study of mass violence (which shares the limitations of others noted above) suggests that very few assailants would have been disqualified from purchasing a gun based on a mental health adjudication. Specifically, based on a retrospective analysis of 106 public mass shootings committed over a 25-year period, Silver, Fisher & Horgan (2018) found that only 5 (4.7%) had a gun-disqualifying mental health record.

In the bigger picture, background checks are far from perfect and do little to prevent gun violence on a large scale. There are two main problems. First, background checks often fail to keep guns out of the hands of dangerous individuals who are prohibited from owning them. Although this is partly because of problems with implementing background checks, two other dynamics are at play; (a) guns can be purchased without a background check from a private party, online, or at a gun show and (b) guns are already are in plentiful supply in U.S. households (see Rozel & Mulvey, 2017).

Consider data on over 81,000 people with serious mental illness in the Florida study (Swanson et al., 2016). Of these people, 28% were ineligible to purchase a firearm—mostly because of a felony criminal record (21% of the total sample) rather than a mental health adjudication (7% of the total sample). This subset of people who were ineligible to purchase a firearm accounted for 62% of violent gun crimes (and 28% of suicides) in the sample. Clearly, background checks did not prevent these people from accessing and using firearms. This is consistent with findings based on the general population.

The second problem with background checks is that the eligibility criteria often fail to identify risky people—and could be improved. In the Florida sample of people with serious mental illness, 38% of violent gun crimes (and 72% of suicides) involved people who were legally eligible to own firearms (Swanson et al., 2016). The improvements in eligibility criteria that would yield the greatest gains in identifying risky people are those that focus on evidence-informed risk factors for violence like past convictions for misdemeanor violence, current domestic violence restraining orders, and recent substance abuse crimes (McGinty et al., 2014). Clearly, the definition of mental illness-focused conditions could be updated and sharpened (current federal law broadly refers to a person “adjudicated as a mental defective”). Even so, these refinements are likely to yield only relatively modest gains in preventing violence (but may go farther in preventing suicide; see Swanson et al., 2015, 2016).

Promising state approaches: Removing firearms from individuals at high risk of violence to self or others. Given the limitations inherent in relying upon background checks to prevent gun violence— including the general availability of guns—a growing number of states are implementing additional. Unfortunately, some policies have specifically targeted people with mental illness and may deter people from seeking treatment and reinforce stigma associated with mental illness (see Swanson, 2013). For example, a controversial law enacted in New York in the aftermath of the mass shooting in Newtown introduced a requirement for mental health professionals to report to law enforcement any patient they believed was at substantial risk for violence so the patient’s name could be checked against a handgun permit registry, his or her permit could be revoked if relevant, and the gun could be seized (NY SAFE Act, 2013). A more refined approach has been recommended by a consortium of national gun violence prevention and mental health experts—that is, “mechanisms to remove firearms from individuals who pose a serious risk of harm to self or others” (McGinty et al., 2014, p. e23). Risk-based firearm removal laws are an appealing supplement to a more focused background check system because these laws recognize that many individuals at risk for violence (a) have ready access to firearms, (b) are not at risk simply because they have a mental illness, which accounts for only a small proportion of unique variance in interpersonal gun violence, and (c) fluctuate (increase or decrease) in their risk state over time.

The last point is worth underscoring as important for people both with- and without mental illness. Symptoms ebb and flow over time (see above) and “at certain times...small subgroups of people with serious mental illness are at elevated risk for violence” (McGinty et al., 2014, p. e22). Risk state can also ebb and flow over time as a function of stressors, substance abuse, emotional states, and other factors for people without serious mental illness—including those who have chronic problems with impulsive, angry, and/or antisocial behavior. Preemptive firearm removal does not rely solely on accurately identifying the characteristics of individuals at high risk status generally. It also capitalizes on intervening with the “right” people at the “right” time.

Risk-based firearm removal laws—sometimes called “red flag laws”—are now in effect in at least sixteen states and the District of Columbia (see Swanson et al., 2019; https://efsgv.org/extreme-risk- laws/ ). Despite differences in their names and mechanisms, the laws have share common elements. Specifically, the laws provide a civil court order for gun removal (avoiding criminalization)—and target individuals who possess firearms and are known to pose high risk of harming themselves or others in the near future. The criteria for gun removal do not require that the individual have a mental illness or disqualifying record. Police are allowed to search for and remove firearms (with an initial warrant and subsequent court hearing)—and gun removal is time-limited (typically to 12 months).

For example, one mechanism allows law enforcement officers to remove firearms when they identify someone who poses a threat to themselves or others. Police often are the first to respond to crises in the community involving people with- and without mental illness, where they must assess threat and take appropriate action. This mechanism allows them to remove firearms when necessary to protect citizens from harm. A second approach provides family and intimate partners with a restraining order mechanism that temporarily prohibits the purchase of firearms or removes firearms already in possession, when an individual is in crisis and acting in a dangerous manner (Fratteroli et al., 2015).

Because these approaches are new, little is known about their implementation or effectiveness in preventing gun violence. Swanson et al. (2017; 2019) rigorously evaluated these laws in Connecticut and Indiana: Results were inconclusive for violence prevention because of low base rates, but promising for suicide prevention. In a recent descriptive study, Wintemute et al. (2019) found that California’s “red flag law” had been used to prevent mass shootings in 21 (of 159) cases—and to date, none of the threatened shootings had occurred. These data are very limited, but promising.

Anecdotal reports indicate that the process of obtaining and implementing civil court orders for gun removal is unwieldy, which can limit their immediate effectiveness and adoption by law enforcement personnel. Clearly, more careful work must be done on both the realities of implementing these orders and their resulting effectiveness in addressing what are often fluid risky situations.

Conclusions about policy initiatives that target gun violence and mental health. The little available evidence suggests that policy initiatives that specifically seek to restrict access to firearms for identified people with serious mental illness will do little to prevent gun violence on a large scale. Despite advocates’ early insinuations, the country’s problem with mass violence does not appear attributable to having too few mental health disqualifying records entered in the NICS. Gun disqualifying mental health criteria could be refined and improved (see Swanson et al., 2015), but it seems that the lion’s share of improvement in prevention would be for suicide, not violence. Because robust risk factors for violence are shared, improvements in policies and practices that keep guns out of the hands of dangerous people without mental illness will also go far in doing so for dangerous people with mental illness. Risk-based firearm removal laws are conceptually promising and congruent with what is known about the intermittent link between mental illness and violence; these need to be rigorously evaluated.

Policy Implications

Toward policy that aligns with what we know. The analysis above indicates that we have very limited and questionable direct evidence about the connection between mental illness and mass shootings, given formidable challenges to research designs that could support causal inference. Retrospective descriptions of perpetrators are informative but must be juxtaposed with more rigorous evidence.

The best evidence we have about the connection between mental illness and violence more generally—from common violence to homicide—indicates that whatever the connection is, it is more nuanced and less direct than most people think and are led to think by media coverage. The designation of “the mentally ill” is so broad and pejorative that its use for policy purposes is ineffectual and outdated. It is clear that a large, heterogeneous group of citizens have serious mental illness—and the vast majority are never involved in violence. It is also clear that the presence of a mental illness usually does little to raise the likelihood of violence above and beyond the wide range of risk factors that promote violence among people with and without mental illness. Importantly, when mental illness is related to violence, it is a dynamic force; over time, it can emerge forcefully, or it can subside and simply be a background factor. Finally, many people with mental illness that could be at risk for violence are not actively engaged in mental health treatment. It is not simply a matter of consistently detecting individuals with the highest risk when they are seen routinely; risk changes, there are no consistent, immutable markers, and mental health professionals might very well never even see them.

To be effective in preventing mass violence, broad policy recommendations aimed at differential treatment of people with mental illness (e.g., exclusion of gun ownership) would require a consistently applied process for identifying this group and a demonstrated causal link between group membership and the behavior being prevented. Given that these requirements do not exist, the question then becomes one of focusing existing policy so that it might better achieve its stated goals while avoiding unintended consequences (e.g., overspending on an inefficient system, unnecessarily restricting the rights of people with mental illness, further reducing engagement in needed services).

As we touch upon above, there are some ways to better align our current practices and policy with the limited role that mental illness plays in mass shootings. We make several specific recommendations in that spirit. Our recommendations should be considered alongside a broader set of policy recommendations on “Countering Mass Shootings in the United States” (Nagin, Koper & Lum, this volume). Those broader recommendations include staunching the growth of high capacity firearms, curtailing access to firearms for people at high risk for violence, improving threat detection systems, and reducing fatalities at mass shooting events.

First, follow the recommendations of a consortium of national gun violence prevention and mental health experts, which include (a) enacting new prohibitions on individuals’ ability to purchase and possess firearms based on evidence-informed risk factors for violence, and (b) implementing promising mechanisms for the temporary removal of firearms from individuals who pose a serious risk of harm to self or others (McGinty et al., 2014). We also include the recommendations of Swanson et al. (2015) to clarify and refine existing mental health firearm disqualification criteria related to involuntary commitment because the current policy of banning ownership for life based on a record of involuntary commitment is too broad to be effective and promotes stigmatization. The adoption of alternative risk-based criteria for disqualification (e.g., repeated domestic violence convictions) and introduction of limited periods of disqualification (e.g., temporarily prohibiting people from buying or possessing firearms after a short-term involuntary hospitalization) would be considerable improvements.

Allowing for temporary removal of a firearm based on documented indicators of increased risk of violence (along with a process for restoring firearm access) would accord with what is known about the dynamic influence of many factors related to violent incidents. Such a process of removal and possible reinstatement would also have the added benefit of reducing the likelihood of people with mental illness avoiding mental health treatment or of friends or family members avoiding reporting increases in risk state, for fear of a lifetime ban.

Second, fund research that enriches our picture of gun violence in general, mass shootings in particular, and the role of mental illness in these incidents. The historical ban on federally funded research on gun violence has left practitioners and policy makers with little empirical guidance for innovation. More knowledge is needed about policy-relevant risk factors for gun-related violence and suicide among those with- and without serious mental illness. As mentioned above, the overlap between mental illness and stronger risk factors for violence is considerable and complicated. Investigating the relative influence and interactive effects of mental illness and specific risk factors could inform prevention efforts. Such work could provide more differentiated and nuanced criteria for the policy approaches alluded to above, including criteria for background checks and risk-based firearm removal. Such work could also inform clinical approaches with identified high risk individuals, enriching our current myopic view that providing generic mental health services (focused on symptoms) will automatically translate to risk reduction and violence prevention.

Research that rigorously examines the implementation and impact of the policies recommended above on gun-related violence and suicide among people with and without serious mental illness would be particularly valuable. More broadly, research comparing the effectiveness of different jurisdictions’ approaches to, and definitions of, mental illness-related gun prohibitions could help refine future efforts in this direction. As the researcher Lewin (1941) famously said, “if you want truly to understand something, try to change it.”

Third, promote collaborative work with media representatives to develop and implement reporting guidelines for mass violence generally, and for mass violence and mental illness specifically, to avoid fanning stigma related to mental illness. It is clear that speculation about the presence of mental illness in media reports on high profile, violent incidents fuels the public’s perception that the mere presence of a mental disorder explains the commission of a heinous, violent act. Guidelines about the boundaries and use of solid documentation regarding mental illness, the importance of acknowledging that the presence of mental illness does not explain the incident or establish any cause and effect relationship, and the avoidance of derogatory terms for mental illness would be substantial steps forward (see Chen, 2018; https://www.reportingonmassshootings.org/ ).

Fourth, involve and educate mental health service professionals about the positive (if limited) role they can play in promoting and implementing more effective gun violence prevention policies. Although serious mental illness plays a limited role in violence, all kinds of people may come to the attention of mental health professionals when they are experiencing crises—including crises that involve risk of suicide or violence. If the new policy approaches outlined above are adopted, mental health care professionals are likely to have an expanded role in assessing risk and in monitoring and preventing gun violence. These professionals may also be involved in assessments and hearings regarding temporary removal and reinstatement of firearm access, particularly for individuals under their care.

As a result, mental health professionals will have to develop standards of care to help clinicians identify, prioritize, and monitor cases that are genuinely (not stereotypically) at risk for proximate violence (Skeem & Mulvey, 2001) and to become proficient with firearm access and safety practices (Rozel & Mulvey, 2017) as well as lethal means reduction (NCBH, 2019). Clinicians will also have to become adept at methods for keeping individuals engaged in services. If consistent monitoring and assessment becomes central to treating individuals at high risk for violence (whether they have a serious mental illness or not), mental health professionals will have to expand their abilities to engage and retain these individuals in therapy.

Identification is the first and most fundamental step. For that reason, we recommend that clinicians (and a designated leader in their organization) become educated in evidence-based methods for assessing risk of common violence and in threat assessment (see below). Clinically feasible screening protocols and structured risk assessments are the exception rather than the rule in clinical settings, even though they consistently outperform clinical intuition (Skeem & Monahan, 2011). Having a screening process in place to identify individuals who are at risk will allow professionals to prioritize higher risk cases for timely provision of quality services, which is an ongoing challenge in overburdened and underfunded behavioral healthcare settings.

Beyond recognizing that serious mental illness appears connected with a limited but important subset of mass violence, clinicians must also seek to prevent violence when other people in crisis come to their attention—including those with problematic personality traits who have had recent stresses and are fixated on thoughts and feelings of injustice (NCBH, 2019). Because these people are not prototypic clients and may never come to the attention of clinicians, mass violence must be approached as a broader communitywide problem. As noted in the report of the National Council for Behavioral Health (2019)

perpetrators of mass violence may be motivated by mental distress from life events and circumstances or by the symptoms of mental illness. These are not the same and thus require different modes of detection and prevention. At present, our current health care delivery system is not designed to address the causes or detect and provide interventions for people at risk for mass violence (p. 54).

Fifth, implement and evaluate threat assessment and management teams. Threat assessment teams are multidisciplinary groups that often include professionals in law enforcement (where the model was developed), behavioral health, law and/or risk management, and human resources. When individuals who may pose a threat of (mass) violence come to the team’s attention (via referrals from schools, workplaces, etc.), the team evaluates where the individual is along a theoretical “pathway to violence,” assesses his or her risk, and intervenes as appropriate by providing services or supervision (for details and resources, see NCBH, 2019). These teams recognize that violence is multidetermined and that risk varies across time within an individual. Given that many perpetrators of mass violence plan their attacks over considerable periods of time and “leak” signs to others, these teams appear to be a promising—if not evidence-based strategy. There is evidence from controlled studies that, in school settings, such teams have beneficial effects on bullying and perceptions of safety (effects on violence are unknown, given low base rates; see Cornell, 2018).

Although it is beyond the scope of the present review, effective implementation of such teams requires innovative funding strategies—for the teams themselves and, more importantly, for effective crisis response services. Crisis mental health services can help people at risk, both with- and without- serious mental illness.

Conclusion

In some circles, mental illness has become the accepted putative reason for mass violence and restricting the liberty of people with mental illnesses has emerged as the accepted putative solution. In broader circles, when confronting the challenging issue of reducing mass shootings, it is certainly tempting to conclude that “fixing the mental health system” is the smartest way to go.

We are all for improving mental health services for people with mental illness; we passionately believe these services should be better funded, more accessible, better coordinated, and more innovative. Most mental health systems largely process cases and try to provide services to avoid crises. From a public health perspective, current mental health systems are inadequate for the immense task of providing quality services to the large number of people with serious mental illness who need them.

Our review, however, suggests that improvements in the delivery of psychiatric services to people with serious mental illness will do little to prevent common violence, gun violence, or mass violence. From a public safety perspective, effective mental health services would prevent some unpredictable symptom-related incidents of violence, particularly among otherwise low-risk people with mental illness. However, as observed by Stone (2015, p. 84), there will still be the needle-in-the- haystack—rare, “spectacular examples” of public mass shootings involving “young men barely 20, with no record of previous mental hospitalizations and no compelling reason why they should not have been permitted to buy rifles.”

Exceptionalist policies that focus on mental illness are not even close to a “magic bullet” policy response for mass violence. It is time that policy makers and mental health professionals stop pretending (seemingly largely for their own benefit) that this is “the” solution. Smart, well-intentioned people have taken on the hard work of rethinking what can be done to better counter mass shootings in the United States (e.g., Nagin, Koper & Lum, this volume). It is time to do it.

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Frattaroli, S., McGinty, E. E., Barnhorst, A., & Greenberg, S. (2015). Gun violence restraining orders: Alternative or adjunct to mental health-based restrictions on firearms? Behavioral Sciences & the Law, 33(2–3), 290–307. https://doi.org/10.1002/bsl.2173

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#mental illness #crime #violence #motivation #mental illness and crime #criminology #public policy #deviance #behavior #exceptionalism #mass violence #mass shooting #active shooters #discrimination

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mermaidmind · 7 years

Text

HOW TO FLEX & TROLL A SCENE

FLEX

Jajajajaja, DAT ADAM-Flex mode activated Flex! - Flex! Flex, troll a scene! Flex! - Flex! Flex, troll a scene! Flex!

[A] Swerve, swerve, swerve, swerve! Ich lache euch alle aus, so wie Mr. Wixa Dein weak ass Flow hat mich getriggered - jaja Blitzgewitter, wenn ich flex auf dem Track mit dem Brickminister - jaja Mittelfinger an die Gagos und ihren Mist auf Twitter Ihr seid outdated so wie Windows Vista Ihr meint ihr wärt die Future - ha, sicher sicher, klar

[T] Ey Flowwechsel, die so fresh sind, hat keiner von euch Low-Levels Will ich 'nen fordernden Gegner, dann müsst ich mich klonen oder meinen Bro battlen You don't get it - Nee, versteh'n tut ihr gar nix, für euch sind wir nur ein Fehler der Matrix Was wollt ihr tun wenn DAT ADAM auf's Gas tritt?

[A] Oh damn, oh damn, das hätte niemand gedacht Ey die YouTube-Lelleks zeigen steady, wie man es macht Sag mir, wer von den Lames packt so viel Stil in die Parts? Wir machen das selbe mit der Scene wie Freezer mit Namek

[T] Boom, we blow it up und Deutsche Rapper callen Domian, brrrr Ohne Spaß, wir drei sind on fire wie Ponita, ey Ihr Style ist nich' eigen und weiter verbreitet als Comic Sans, ey Bei weitem ist keiner so nice wie die Hydra - You know it, bruh

[Bridge] Yee, man – you know these German Rappers? Oh, fuck em man They want to be like American Rappers so bad right now Yee, that’s true They just talkin 'bout fucking bitches, making money and all that lame ass boring shit

[A] Geh und zähl dein Cash, zähl dein Cash Wir sorgen für 'nen Themawechsel In der Welt ist stupid sein jetzt der Megatrend Geh mal weg, denn wenn wir sprayen, dann mit Vehemenz Permanent sind die DFA-Boys in ihrem Element

[T] Und bleiben wie sie sind, einfach nur gechillt - Uns zu haten hat leider keinen Sinn Drei verspielte Kids zeigen ihre Skills, droppen Hits und besteigen den Olymp, schweben über Beats, leben die Musik - Jede Selbstkritik wäre Blasphemie Lad ne Gun mit den Versen und den Skeems, ziel auf euch und entleer das Magazin

[A] Wir spitten fire wie ein Charizard Immer große Klappe wie ein Karnimani, bruh Wir durchschauen all ihre Moves, Homie, Sharingan Der Sound ballert, wie ein fucking Kamehameha

[T] Wir flexen so ab wie 'ne Kreissäge Echt lächerlich, dass ihr euch einredet, dass das, was ihr macht, die Future ist Ich lach über euch und die Scheißszene Hahahaha, hahahaha, hahahaha, hahahaha

[Bridge] Yo brother Mhm? You know, german rappers are really creative Oh really? Yea, they are creative when it comes to inventing new sell-out moves You know, they want you to buy their album years before they even put out some music They put stupid shit no one needs in ugly boxes and call them deluxe, just to push their revenue, which leads to better chart rankings in Germany That’s hella whack!

[A] Yeah - genau das sind die Moves mein Homie Jaja - warum sind sie solche Tools mein Homie Oh damn - Wir sind cold wie ein fuckin' Snowman Und wie ein Virus für ihr fuckin' Program Sie sind trapped im Jetzt und wir schon im Morgen jajaja

[T] Ja, wir sind die motherfuckin Babas Zerfetzen in Sekunden wie Piranhas Eure Promo ist nicht mehr als Propaganda Bin zwar kein Japaner, aber euch nenne ich Baka Haha haha - Ihr seid alle lachhaft Mein Magen tut weh, weil ich so lach, es ist unfassbar Hahahahahaha - Wir bändigen Flames wie der Avatar

[A] Tell me, wenn sie der New Shit sind - warum bringen sie dann nichts Neues? Manchmal gönne ich mir, was in diesem Land als Cool Shit gilt Und bin disappointed - Fucking disappointed! - Einfach nur annoying, urgh Und wir soll'n also die sein, die hier Toys sind? Was vor Jahr'n schon von uns kam bringen Blitzmerker erst heute Wir changen das Game, lowkey und die Missets wollen es leugnen

[T] Ye ye ye yeee, Ihr wollt die Hydra ignoriern, aber seid heimlich interessiert Sogar nach drei fucking Bonghits rap ich noch tighter ein als ihr Ihr könnt' den Style nicht imitiern - Da brauch echt keiner diskutiern Ey, wir sind dope und ihr seid whack - Geht das rein in euer Hirn?

JAWS

[T] T-Brick Ich bin der Master der Bescheidenheit und halt' nicht viel von Eitelkeit, doch wenn ich in der Booth bin, Homie, lass' ich all die Scheiße frei, die Platz verbraucht in meinem Mind Wenn ich mit Bars baller', dann baller' ich nicht zum Zeitvertreib

Ich baller' den Einheitsbrei aus manifestierter Peinlichkeit zurück in all seine Einzelteile, diese Gagos! Keiner von denen ist einfallsreich und all ihre Tracks haben kein Detail Meine Bestimmung ist sie zu zerfetzen, die Erde zu retten und fly zu sein

Nenn mich Light, denn der, über den ich nur eine Line in mein fucking Rhymebook schreib, wird binnen Sekunden 'ne Leiche sein Jede Zeile ein Meilenstein, yeah Zeig mir einen, der meint sein Style ist nice, ich reiß ihn klein mit Leichtigkeit, wouh denn von ihnen ist keiner nice, wouh Alles, was ihnen fehlt, hab ich mir einverleibt, wouh Im ganzen Business schwimmen nur noch kleine Fische und dazwischen wirkt DAT FUCKING ADAM wie der weiße Hai

[T] Wie der Weiße Hai Wie der Weiße Hai Wie der Weiße Hai Wie der Weiße Hai Hai Hai

[A] Ohh Shit - Mehr Impact als ein fucking Asteroideneinschlag Homie, du weißt, Homie, du weißt - Wir geben den Ton an zurzeit So far ahead und das ohne zu tryen Gomenasai, Homie, Gomenasai, sai, sai!

Ey, tut mir doch Leid, dass unser Shit so damn nice ist und sie nicht peil’n, dass nur zu pretenden nicht reicht Wenn du so dope bist, dann zeig es - Homie, du weißt

DAT FUCKING ADAM versorgt deutsche Mucke mit Style Fuck all of your numbers, kommt runter vom Hype Ey, die Future zerreißt

[T&A] Wie der Weiße Hai Wie der Weiße Hai Jaws Wie der Weiße Hai Wie der motherfucking Weiße Hai jajaja, Jaws Wie der Weiße Hai Wie der Weiße Hai Wie der Weiße Hai Wie der motherfucking Weiße Hai Jajaja, Jaws

Swiggy Swiggy

[T] Swerve motherfucker, swerve motherfucker Swaggiest motherfucker on earth, motherfucker Hair blue like a smurf, motherfucker Niemand so swiggy in dieser world, motherfucker

Flyer als jeder verdammte bird, motherfucker I'm the first, der mit jedem Verse burned, motherfucker So gestört motherfucker - Sieh und learn, motherfucker We the best, no matter what you fuckin’ heard, motherfucker

Nenn uns Rihanna, we work work work, motherfucker We are stupid and contagious, so wie Kurt, motherfucker Nach diesem Track bist du bald, denn unsere Mucke rasiert Alles, was wir machen ist Rauf- und Runterpumpe-Musik

Fühl mich unverwundbar auf Beats - Hab keinen wunden Punkt, ich bin T Bin am Feuer speihen in der Booth und drum herum ist mein Team, Hydra Ganz egal, was ich tue, ye, drum herum ist mein Team, die Hydra Niemand so swaggy in dieser world motherfucker

[A] Jaaa - wir sind so swiggy swiggy swiggy swiggy Ja ja - wir sind so swiggy swiggy swiggy swiggy ey DAT ADAM is swiggy swiggy swiggy swiggy Ja ja - wir sind so swiggy swiggy swiggy swiggy

[T] Swerve swerve swiggy swiggy Damn damn swiggy swiggy Swerve swerve swiggy swiggy Damn damn swiggy swiggy

Swerve - swiggy swiggy Damn damn swiggy swiggy Swerve swerve swiggy swiggy Damn damn swiggy swiggy

Swerve - swerve - swerve - swerve

[A] Damn motherfucker, damn motherfucker Keiner so fire wie meine Fam, motherfucker Hydra ist der Name und ist program motherfucker Jeder hier in meinem Team ist Head, motherfucker

Sie sind salty, salty, salty, Kikkoman motherfucker Wir sind childish und slayen wie Peter Pan, motherfucker Yeah, die Fingergun macht steady click click bang, motherfucker Und die scene wird von den YouTube-Kids gesprengt, motherfucker

Ja, ja wir moven außerhalb der Frames, motherfucker Fucking hot, aus deinen Boxen sprühen jetzt Flames, motherfucker Geben keinen Fuck auf die ganzen big names, motherfucker Was sie droppen ist repetetive und lame, motherfucker

Oh geez, oh damn, keiner flowt so wie die Gang, jajaja Ganz egal, was ihr so denkt Wir kommen mit der Heat ins Game - ja, ja, ja Jeder, der so lieblos rappt, ist no match für diese Band - nah, nah, nah Watch out homie, we go ham, here to stay, gehen nie mehr weg

Und ich grinde die Plants Während sie vorm Benz posieren ziehen wir vorbei in 'nem Tesla Hasserfüllte Gagos kriegen keinen Respekt, nah Sie wollen es haten, doch finden es eigentlich fresh

Ha! Ey Rap macht so Spaß Mit ihm zu spielen ist pure fun Alle stellen sich viel zu sehr an Guck mal, ich brauch nicht mal 'nen Reim

Shoutout an DAT ADAM Und die Hand voll and'rer cooler Rapper, die ich kenne Monster auf dem Beat, doch wenn er aus ist mehr so Lennon Dass wir die besten im Land sind, ist bitter wie 'ne Lemon

[T] Bam bam - Der Blunt ballert, aber nicht wie in eine Pumpgun, sondern wie Tritte von Van Damme - Homie, die Chrome EP war erst der Anfang Ich brenne so wie Meramon - Ich werde noch mehr brennen so wie Meramon Und meine Heißigkeit steigt mit jedem Song - Du wirst brennen, wenn du mir in die Quere kommst,

denn jeder meiner Verses killt wie ein Shinigami Dass du denkst, dass du dope bist find ich funny, he, denn das stimmt nicht, sorry! Jedes mal, wenn ich mir anseh’, was grade so trendet, frag ich mich, ob das ihr Ernst is' - No Joke! Davon krieg' ich einen Kotzreiz und zur Beruhigung hau ich mir 'nen Jibby an und danach noch ein

Wir sind ein eingespielteres Team als diese Turtles bro, bro und den anderen einen Schritt voraus genau wie dieser Sherlock Holmes, bro Mit gestörten Flows rasieren wir auf Turnup-Shows Wir machen Welle und sie schwimmen mit als wären sie Surfer, bro, bro

[A] Ey, yeah, yeah Flow straight aus der future wie Trunks (Future Trunks, nicht der Kleine) Ich, baller um mich doch ich use keine gun (Fingergun, fingergun, fingergun!) They do it for money we do it for fun! (we do it for fun) Scheiß auf Bottles im Club wir rollen Doubies im Park

Ab diesem Jahr ist jedes Jahr nur unser Jahr (nur unser Jahr) Denn die Sounds sind hotter als der Planet Mustafar (Mustafar) Das was sie bring ist und bleibt nur dritte Wahl

Yeah, yeah Guck, meine Crew sieht aus wie ein Anime-Cast Ihre wie ein Haufen fucking Wannabe-Stars Fake ass, lying ass, copy and paste ass hitters, ich kann euch nicht ab, nah

Mitleid für die Lames, denn sie tauschen ihre Seele gegen fame, Profit over everything - Das gottverdammte Motto ihrer ehrenlosen Gang Immer so late, weil sie gar nichts getten, wow Fuckboys tragen jetzt Versaceketten und Affen fangen an uns alles nachzuäffen, bruh

Weirde, weirde, weirde Welt - Ich throw das Peace Sign ab und zieh am J, denn all der weak shit macht mich so angry Ich will wieder Richtung space (wieder Richtung space, wieder Richtung space)

Steig in mein Spaceship in ABC Basic und schrei: "Nieder mit dem Game!" Homie es ist DAT FUCKING ADAM, wer uns jetzt noch nicht kennt Der merkt sich besser diesen Namen, denn wir nehm'n euch bei der Hand und führen euch in die future, damit ihr auch mal hier ankommt, bitch!

Goody Goody

[T] Yeah, ihre Crew macht Kampfansagen, yeah - Meine Crew macht Hanfparade, yeah Sie sind Riesenaffen, aber ich werd' ihn'n den Schwanz abschlagen oder sie werfen ihn ab, als würd ich Salamander jagen Callt schon mal den Krankenwagen, yeah

Ey, meine Crew so fucking hot, als würde sie in Magma baden Und ihre so faceless - Ich kann sie mir noch schlechter merken als 'n viel zu langen Manganamen

Ganz andere Liga, yeayea - Anderes Kaliber, yeayea Sie machen vielleicht Business, aber glaube mir, von innen sind sie alle nur Verlierer, huh Katon: Goukakyuu no Jutsu: Man sieht Feuerbälle immer, wenn ich Flows kick' But you won't get it, wenn du nur ein fucking clone bist Please wait a minute 'cause my phone rings

Okay, ich hebe nicht ab Ich bin grade beschäftigt mit dem nicht geben eines Fucks Der ganze Planet fängt an zu beben durch den Bass Du kannst diesen Sound nicht fühlen, Homie, rede keinen Quatsch, Homie, rede keinen Quatsch

Ich bleib' auf dem Teppich, doch bin trotzdem fly so wie Aladdin Und hab' gegen Missets schon seit der Geburt an 'ne Allergie

[A] Ich rolle meinen Doobie, smoke ihn im Jacuzzi Dope in meiner Lunge, Strohhalm drin im Smoothie Oh, mir geht es goody Es ist almost wie im Movie, oh, mir geht es goody Oh, mir geht es goody Oh, mir geht es goody Oh, mir geht es goody Oh, mir geht es goody Oh, mir geht es goody Oh, mir geht es goody

[T] Ruft besser einen Feuerwehrwagen, denn dieser Track ist der Burner Ihr drückt den Replay-Button, bevor ihr das Ende gehört habt Wir sind die Rapper der Future, muss ich das echt noch erörtern? Ich scheiß auf alle anderen, die nichts außer Whackness verkörpern,

denn ich bin Deutschrap-Fan und ich bin echt enttäuscht Mein favorite Rapper hierzulande ist mein bester Freund und der Rest der Leute, deren Shit noch klar geht, kann ich an meinen Fingern abzählen

Ich mein' das nicht persönlich, haha, ist doch alles goody Ich will nur ein bisschen nerven wie die Kids bei Call of Duty Ihr seid kein Hindernis ihr Rookies Das ist noch lange nicht alles also fick nicht mit meinen Brudis!

Aha, aha - Besser als wir geht nicht Wir sind superkalifragilistikexpialigetisch und ihr seid alle berechenbar als wärt ihr geometrisch und dabei der reinste Abfuck, wie der fette Block bei Tetris

Ich bleib' auf dem Teppich, doch bin trotzdem fly so wie Aladdin Und hab' gegen Missets schon seit der Geburt an 'ne Allergie Ich bleib' auf dem Teppich, doch bin trotzdem fly so wie Aladdin Aladdin, Brudi - Und hab' gegen Missets 'ne Allergie

S/O

[A] Yah, yah, yah - My whole team got my back Sie wollen uns down reden, auch wenn sie keinen von uns wirklich kennen Doch es interessiert mich nicht - Was der Rest meint, interessiert mich nicht,

denn my whole team got my back Yeah, egal, was ich mach' und wohin ich geh Wir lassen uns nie im Stich Keine Family ist so real im Biz, yea yea

Businessheads wir haben keine Zeit für sie Bitch, guck wir teilen gern Shit, doch die Vibes sind nicht richtig Nein, nein, nein sie peilen nicht die Vision Paper über alles ist nicht meine Religion

Ey und wir sliden durchs Biz und die meisten hier sind so damn versteift auf ihr Image Doch nicht mein Team, mein Team Das Motto heißt „Freedom und Realness“

[A] Yea yea, shoutout to my friends, yea Proud to be with them them, yea Down until the end, yea Yea they got my back Yea they got my back Yea they got my back Yea they got my back Yea they got my back

[T] Yeah - Die Hippies sind back Und hitten das Lab mit Jib' im Gepäck Du weißt wer es ist - Hydra, Hydra, Hydra Das ist nicht nur 'ne Band, nicht nur ein Trend, nicht nur 'ne Gang, das ist die Fam

Und alles was ich need in my life Brauch' nur die kleine Pi, mein Team und das reicht, denn jeder von denen weiß, wer ich bin und bestärkt mich darin zu sein, wie ich bin - Keiner bestimmt!

Und Missets fangen an uns als verrückt zu betiteln, denn diese Missets mögen gar nicht, wenn man glücklich und real ist, denn dank den Medien sehen sie nur noch künstliche Feelings und ich hab damals echt geglaubt, irgendwas stimmte mit mir nicht,

aber okay okay, heut' ist es okay Die Welt wird wieder bunt, wenn deine Freunde dich verstehen Noch immer Misfit, aber heut' ist es ok Ich lass' einfach fließen und steh' meinen Träumen nicht im Weg, yea

denn my whole team got my back, yea denn my whole team got my back denn my whole team got my back My whole team got my back My whole team got my back

[M] Ok, ich jump rein jetzt Ich bin drin jetzt Ich fühl es, ja

I'm a better me since I found my family Look at my team we’re free Look at my, look at my team, we’re free

#datadam #howtoflex&trollascene #htf&tas #ep #lyrics

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