In the aftermath of every mass shooting, politicians and pundits talk about ways to avoid the next one. Increasingly, the explanation seems to focus on the connection between gun violence and mental health; while liberals and conservatives typically see the details differently, this is one of the few places where they sometimes agree. With more mental health services, the argument goes, potential shooters would be stopped before they pull the trigger.
But to Jeffrey Swanson, Duke University professor of psychiatry and behavioral sciences, we’re getting important things wrong. Swanson, a longtime authority on the relationship between mental health and gun violence, thinks the picture is more complicated, and that we don’t really understand how anomalous mass shootings are. (Since the conversation took place, there has been a shooting at a college in Arizona.)
The interview has been lightly edited for clarity.
We’ve had another mass shooting; this one at an Oregon community college joins a long line that includes Newtown, Aurora and Columbine. How do we misread this phenomenon, especially the link between gun violence and mental illness?
We have a huge problem with firearm-related injury and mortality in this country – gun violence. We focus on it when there is a horrifying mass-casualty shooting. That’s really unfortunate because the mass shooter is very atypical of two problems that we end up talking about at that time. One is the problem of untreated mental illness; the vast majority of people with mental illnesses are not violent and never will be. We also end up talking about gun violence, and talking about it through the prism of the mass shooter.
Meanwhile, the 92 other people who died on the day those individuals lost their lives in Oregon, over half of them are suicides, who died by their own hands. And that’s a huge public health opportunity. That’s also an opportunity for mental health intervention because mental illness is a much stronger vector in suicide than it is in homicide. Fifty to 75 percent of the variance in suicide is related directly to mental illness. If we could just change a little the proportion of people who use a gun when they try to end their lives, we would save a ton of people. If people try to use anything but a gun, on average [in a suicide attempt], about five percent of them die, and the rest survive. But if they use a gun, 85 percent of them die, and 15 percent will survive.
You’ve said saying that paying more attention to mental illness, and funding it more robustly, would help individual people, but it would not have a huge effect on what we’ve seen in Oregon, Newtown, Aurora, and these other places?
I don’t think so. The mass shooters are easy to profile, but that’s if you have this remarkable device called the retrospect-oscope – you look back, now you define them to get this picture of angry, alienated, isolated, maybe a little delusional young men. But, that fits the description of tens of thousands of other angry, alienated young men, who aren’t going to do that. So, it’s a very small needle in a big haystack. I don’t think we’re going to live in a country where we won’t have people like that.
In my view, what we should do is do what we can to prevent them from having access to an efficient killing technology. This is not only true of mass shooters, but also of a much more common kind of homicide. We don’t have an exceptional violent crime problem; our rate of crime is just average compared to countries in western Europe, the UK, Japan and Australia. But, we do have an exceptional homicide problem; our homicide rate is much higher. The reason is because when assaults happen in this country, they are far more likely to involve firearms. So, you get two angry, impulsive, intoxicated young men, and then they get in a fight in the UK, somebody gets punched in the nose. Here, somebody pulls a gun, and you have a dead body.
This is reflected in our homicide rates. Instead of trying to figure out how we should precisely predict and intervene when there is a mass shooting, why not prevent the unpredicted? That’s hard to do in our country because where we start with our policy is that we cannot broadly limit legal access to guns because firearms are constitutionally protected. And they are also extremely prevalent here. We have to try to figure out who are the risky people who shouldn’t have access to guns.
There are things that we can do at a couple points in this equation. One is the point of access, when people buy a gun. We could have more precise criteria to limit some people from buying guns… The criteria we have right now that we’ve inherited from the 1968 Gun Control Act, passed on through the Brady Law in 1994, are under-inclusive and over-inclusive at the same time. They identity lots of people who aren’t dangerous and never will be, but they fail to identify some who really are.
We did a study last year -- a national survey, a psychiatric epidemiological study -- and we estimated the prevalence of two things: people who have angry, impulsive behavior, the kind of pathological anger of people who, when they get angry, smash and break things, who get into physical fights, and access to firearms. We estimated that 9 percent of the adults in this country have impulsive anger behavior traits and have access to guns, 1.5 percent have impulsive angry behavior and are carrying guns around with them. So, I think that is a bad combination on the face of it.
But, those individuals, even though they have mental health problems, it’s not stuff like schizophrenia. It’s personality disorders, it’s fear and anxiety, it’s alcohol problems. That’s not the kind of stuff that people get involuntarily committed for, and thereby lose their gun rights. We need to think about people like that and the horrible incident we have at Chapel Hill, where three young students were shot by an angry young man. People knew that he was angry, out of control, and had guns, but there was nothing to be done. It turned out he had all these guns.
Just as an example, in many states, people can get a conviction for a violent misdemeanor. So, you get into a bar fight, you punch somebody in the nose, you get an assault charge, but it is a misdemeanor. In many states, that does not prohibit someone from purchasing and possessing a gun. I think it should. Some states take those records -- California is an example -- and they prohibit guns from violent misdemeanors. There is good research that shows that actually limits or reduces violent gun crime.
Another example is for us to pass laws -- like California, Connecticut and Indiana have -- that I call preemptive dangerous-persons gun-seizure laws. Those laws are important because we just have so many guns in our country -- 310 million in private hands. So, if all we do, even if we have perfect background checks and perfect criteria, is stop them from buying a new gun from a federally licensed dealer, and meanwhile, they’ve got six, seven, 10 guns at home… that’s not going to deter them.
So gun removal law like California’s Gun Violence Restraining Order might’ve held in the case of Elliot Rodger in Santa Barbara, where his family knew he was disturbed, but when they called the police and the police couldn’t do anything. This puts a legal tool in the hands of family members, who are maybe in the position to know that a loved one is disturbed or is suicidal. They can go to a judge in a civil court proceeding, and law enforcement can be empowered to take their guns away.
There are legal due-process protections; it is temporary, so they can get their guns rights back if they don’t pose a risk to public safety. So that, in theory, can address the problem of the fact that we have so many guns and they’re so lethal but Constitution-protected. But, the Supreme Court decision, D.C. v. Heller, is very clear that this is a right, but it is not an unlimited right. The limits are what a lot of policy-making and litigation are trying to figure out.
Do you think that the way we talk about mass shootings has the risk of demonizing or scapegoating mentally ill people?
I think so. It adds to the tremendous burden of social rejection and stigma that people with mental illnesses face all the time. It is bad enough that they have a miserable disease that affects their brain’s ability to regulate mood and perceive reality, but then if you live in a country and a community where people think you are too dangerous and violent, people act on the basis of what they believe to be true. If you’ve learned everything you knew about schizophrenia by watching television in this country, you’d think every person with schizophrenia was a homicidal monster. And they’re not. The vast majority are not violent, and they’re trying to recover from these illnesses. Meanwhile, we live in a country that ignores people with mental illness until there is a violent incident like this.
The mental health system in many states is fragmented, overburdened and under-resourced and, as a result, you get people waiting in emergency departments for two, three, or four days because there isn’t a psychiatric bed. We have more people on any given day in big-city jails with serious mental illnesses than we ever had in the largest asylum in the middle of the 20th century. I think it is a scandal, but it doesn’t relate to mass shootings in any meaningful way, which is not to discount how horrifying they are.
I may be unclear. Some people ask, "Are mass shooters mentally ill or not?" You don’t to be a psychiatry professor to know that when someone goes out and deliberately massacres a bunch of strangers, it is not an act of a healthy-minded person, but rather of a deeply disturbed person. And it is deeply irrational. It is appalling, but to make policy based on that rare [event]…. Although it doesn’t seem rare because it seems like it’s happening all the time and yes, they’ve increased in frequency. But from a population perspective -- the denominator is millions and millions -- and there is this needle in this big huge haystack. It doesn’t make it easier to predict ahead of time.
But, you can find lots and lots of people with serious mental illness on any given day in Los Angeles County Jail or the Cook County Jail or Riker’s Island. Those are the new asylums.
It’s interesting now, politically, because you have all these prominent voices in the public square like Rep. Tim Murphy, a congressman from Pennsylvania, who is a psychologist and is working really hard to get his mental health legislation passed, which would do a lot of things. I don’t think it addresses the issue that the system is very underfunded, but he basically sells this legislation as a way to prevent mass shootings. He’s got an A-plus rating from the NRA, and this is a way to put a solution to the gun problem without ever mentioning guns. So, you get some strange bedfellows in this whole conversation.
You’ve said that we need to think of violence as a communicable disease. Tell us what you mean by that.
Violent behavior as an individual act doesn’t occur in a vacuum. It is in a social context, in a social environment. I’ve done research that examines the risk factors of adult interpersonal violent behavior, and it is not caused by just individual motivation.
It is caused by things like growing up in a community and a social context where, as a child, you are exposed to violent victimization. People who are victimized when they’re growing up and are trying to form a personality, and figure out who they are and who they’ll be when when they grow up.
All that we know about violence is that it is intertwined, too, with poverty and social disadvantage, and that people who are around other people with violent behaviors are more likely to behave violently. The three factors -- even for people with serious mental illness -- are child victimization, substance abuse and exposure to violence in the environment around you, a neighborhood where you see crime and violence around you. Take those three things away, and you’re left with someone who might have mental illness, but is not more violent or less violent than the general population.
I’m saying get upstream, and address the social determinants of violence. We [need] better social safety nets, and healthier communities where kids are protected, [we need to spend] some of the money we’re spending on interdiction and enforcement of drug laws and provide substance-abuse treatment for people when they need it.
We don’t think of those things as violence prevention strategies. If we did all those things, and at the same time did a good job of limiting access to lethal means when someone is inclined to harm someone else, I think incrementally we would live in a less violent society.
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