And President Trump, like many people before him, is pointing to mental health — not guns — as the cause of the church massacre.
All Things Considered host Kelly McEvers talked with NPR health policy correspondent Alison Kodjak about the Trump administration's record on mental health care.
Actually, most mental health professionals would dispute that, says Kodjak.
An issue brief from the Bazelon Center, written back in 2013 after the Newtown, Conn., massacre, says it's unfair to tie the two. "We know how to enable individuals with significant psychiatric disabilities to succeed," the paper says. It says services such as supported employment and housing, are very effective at keeping people with mental illness out of emergency rooms, psychiatric hospitals and jails.
"Affording people with serious mental illnesses the services they need is a critical goal, but it is not a solution to gun violence," the report says.
That's not to say that people who commit mass shooting never suffer from mental health issues, Kodjak points out, in Texas and in other shootings.
As far as mental health care goes — the president's record isn't very strong if you measure it by where he puts federal money, Kodjak says.
He supports repealing the affordable Affordable Care Act, which for the first time required insurance companies to cover mental health care. The law also expanded that coverage to millions of people who didn't have it before.
Before the initial shock wore off in the aftermath of yet another horrific American mass shooting—before we knew about the extent of the injury and death, or the events that transpired or the biography and motives of yet another angry white male armed with a semi-automatic rifle and a grudge—before we really knew anything, President Donald Trump jumped into the fray with a diagnosis. “Mental health is your problem here,” Trump
opined from Tokyo in his first comments after 26 people died when a gunman opened fire on a church service in Sutherland Springs, Texas. “This isn’t a guns situation,” he said. “This is a mental health problem at the highest level.”
Respectfully, Mr. President: It’s not that easy. As a psychiatrist who’s taken a hard look at the connection between
mental health and gun violence, I’ve seen where this conversation leads, which usually involves trying to prevent “mentally ill” people from buying guns and involving mental health practitioners in that effort. I’ve also seen mental health invoked as an argument
against gun control, because who can stop a crazy person from killing people anyway?
What I haven’t seen is a serious attempt to grapple with just how complex and fraught it is to come up with a policy that works. For example, there’s accumulating evidence that psychiatrists can’t predict violence from their patients. How are we supposed to intuit when someone with, say, severe depression is capable of mass murder? More broadly, I think I speak on behalf of many experts on mental health when I say I wish politicians and other public figures would stop using mental illness as a shield against talking about the complex social issues related to gun violence—mass shootings and also the everyday gun violence to which we’ve become accustomed—in America.
The mental health claim comes from both ends of the political spectrum. National Rifle Association President Wayne LaPierre faulted “delusional killers” for gun violence in the United States immediately after the school shooting at Sandy Hook, while calling for a “
national registry” of persons with mental illness. New York Governor Andrew Cuomo told reporters after the Sandy Hook school shooting, “People who have mental health issues should not have guns.” Cuomo backed a bill in the New York Senate that would have required mental health professionals to report “dangerous patients” to local officials. But defining a “dangerous patient” is a lot harder than it might seem.
Assailants in many high-profile U.S. mass shootings do have psychiatric histories. Alleged Texas shooter Devin Kelley once escaped from a
mental health facility. James Holmes “was seeing a
psychiatrist specializing in schizophrenia” before he opened fire in a crowded movie theater in Aurora, Colorado. Jared Loughner, Adam Lanza, Isla Vista, California, shooter Elliot Rodger—all of these shooters, too, had histories suggestive of mental illness. In hindsight, these people should not have had access to weapons, and one would hope that a functioning system of background checks or registries might have raised more red flags.
But there are reasons why we psychiatrists so rarely endorse the simplistic “mental health problems cause mass shootings” argument, or its logical policy extension: that our mental health expertise should therefore be able to
predict gun crime before it happens, and that psychiatrists should be a part of some sweeping dragnet to catch potential shooters or mass killers.
First, and perhaps most important, very little evidence supports the notion that mental illness
in and of itself causes assaults on other people, let alone gun crimes or mass shootings. This makes sense when you think about it. No current psychiatric diagnosis manifests itself in core symptoms that include aggression toward others, and many mental illnesses in fact produce the opposite effect. Schizophrenia, for instance, is frequently marked by what are called
negative symptoms, such as apathy and social withdrawal.
Depression often produces low mood and low energy—sufferers fail to find enjoyment in things, and frequently just stay home. In this sense, many of the most common mental illnesses cause patients to withdraw from society, rather than violently attack it.
These kinds of symptoms help explain why
national surveys of everyday U.S. gun violence frequently show persons diagnosed with mental illness vastly
under-represented as perpetrators when compared with a far more volatile population: the sane.
If there were a Propensity to Mass Violence disease, perhaps it would make a little more sense to involve psychiatrists in identifying potential mass murderers
. But absent a formal means of assessing predictive violence, such as a diagnosis, mental health practitioners are often left to trust the power of their observations when asked to gauge which one of the thousands of patients they see might go on to commit a violent act such as a mass shooting. And, unfortunately, we’re not that great at it. As gun expert Jeffrey Swanson succinctly puts it when summarizing a great deal of research, “psychiatrists using clinical judgment are
not much better than chance at predicting which individual patients will do something violent and which will not.” Tragically, such knowledge is often gained only after the fact. And programs that attempt to force psychiatrists to report potential shooters—such as the one supported by Governor Cuomo in New York and similar programs in other states—often result in
dramatic over-reporting of psychiatric patients, who are then added to government surveillance lists.
This is not to suggest that mental health practitioners are completely in the dark about risk factors for gun violence or mass shootings. But more often than not, a number of extra-clinical, societal factors are far more predictive of gun violence than is mental illness alone. Substance use, male gender, past histories of violence including domestic abuse, social networks and the availability of firearms all
correlate with nonsuicide gun violence more strongly than does psychiatric diagnosis; and of course, these factors can affect all populations, not just psychiatric ones. Gun violence is often a problem of
us rather than a problem of
them, and should be addressed as such.
In the broader sense, asking us to diagnose mass shooters in isolation feels impossible without addressing the larger contexts that surround the rise in mass shootings in the United States, like the dramatic increase in civilian owned assault rifles and other weapons of mass casualty. Many current analyses link this expansion to trends in mass shootings. As the
New York Times recently put it, “the only variable that can explain the high rate of mass shootings in America is its astronomical number of guns.” Yet this expansion of guns in everyday life has gone hand in hand with a narrowing of the rhetoric through which U.S. culture talks about the role of guns and shootings. Insanity in the aftermath of mass shootings then becomes the only politically safe place to discuss charged issues such as gun violence prevention or strategies for public safety.
For these and other reasons, psychiatrists like me often cringe when we hear statements like Trump’s, and hem and haw when asked by journalists whether particular mental illnesses lead to specific mass shootings. It’s not that we don’t think that a person’s psychological history is important to understanding their actions—quite the opposite. Rather, it’s often our sense that reducing gun crime solely to a “mental health problem at the highest level,” as the president did with the Texas shooting, dangerously oversimplifies the questions we ought to be asking about mass shootings.
As such, I believe there are more meaningful ways for psychiatrists to help in the effort against gun violence and mass shootings: by also addressing shifting American beliefs and attitudes around guns, and about our increasingly polarized reactions to mass shootings. As but one example, in 1999, far more gun owners
cited hunting, rather than self-protection, as the main reason they owned guns. By 2013, those attitudes had shifted: 48 percent said protection was the main reason to own a gun, while 32 percent pointed to hunting. The question of why Americans feel so unsafe around, and mistrustful of each other seems like a pressing one for mental health experts. Mental health expertise might also help us step back from the highly polarized conversations that emerge after mass shootings, and allow people of differing ideologies to find common ground.
Despite the mental health-gun violence dichotomy offered to us by politicians looking for easier answers, the Texas shooting was both a “guns situation” and a “mental health problem.” A problem brought about by the actions of an immensely troubled individual, and a reflection of increasingly lethal realities of everyday life in America. Psychiatrists are eager to help reduce gun violence. But when politicians ask us to predict the impossible, or reduce complex social phenomena into “mental health” issues, it’s often just an excuse for their own failure to address the problem.
