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Despite repeated police intervention, including a merry-go-round of emergency evaluations and hospital discharges, Jeffrey Yao, the Winchester, Massachusetts, man who stabbed a 24-year-old woman at the public library, was diagnosed with untreated schizophrenia. His parents were aware of his condition and the community at large, yet there was no recourse to providing care to an unwilling patient until he committed a crime of harm to another or himself.

Nikolas Cruz, the Parkland, Florida, shooter, has a long history of mental illness. He had been involved in Junior Reserve Officer’s Training Corps and had access to guns. We all know the rest.

The point with these two cases is the fact that both young men had untreated serious mental illness (SMI) and access to weapons.

I am a Certified Family Life Educator who works with family members uprooted by the mental illness of loved ones in their families (www.growastrongfamily.org). The issue of violence in general and gun violence in particular comes up in the course of the work. Family members are on the front lines, providing care and resources to their adult loved ones who are often too ill to function as independent adults. Individuals with SMI confer great burdens to their families in particular and their communities in general. Within the scope of the work, there is the first priority of developing a safety plan to defuse crises and promote the well-being of all. This usually includes developing a profile of their loved one and making it available to the local police (when they are needed to intervene) as well as whatever community mental health resources are available. Families understand, all too well, the potential for violence when their loved ones are untreated or undertreated. Family members are often handcuffed by a system that excludes their feedback and maintains a stance of the “civil rights” of people with SMI over family investment. That is the current scenario. So, we ask, what is the relationship, if any, between gun violence and mental illness?

Our society has been impacted by an unprecedented amount of death due to gun violence. Some of these incidents are very dramatic as in mass murders (when four or more people are killed), although gun violence tops the list in suicides and homicides (Baumann & Teasdale, 2018). As so many have pointed out, the main issue with respect to firearms is their availability: “More guns, more deaths.” Gold & Simon (2016) note that two thirds of all people who die by firearms each year have committed suicide (and have a significant psychiatric disorder) and tend to be Caucasian middle age males. The bulk of the remaining third are homicides related to interpersonal violence (and do not have significant psychiatric disorder) and tend to be urban youth of color. The key component in firearm violence, whether by suicide or homicide, is access.

And because a substantial proportion of the precursors of homicidal behavior can be prevented by early intervention with at-risk youth and their families, prioritize preventive interventions to decrease the burden of future violent behavior among at-risk youth.

An interesting aside in this discussion is that the rules for hunting with guns are very different from the rules for who can get a gun for nonhunting purposes. Most states require hunters to pass both written and field tests for the safe handling of the guns (Cook & Goss, 2014, p. 57). Nonetheless, the scope of this piece does not include changing the laws or reducing the availability of firearms, although those are worthy endeavors for those who are interested in advocacy. The scope of this piece is to explore the relationship, if there is one, between gun violence and mental illness.

The research evidence conclusively shows that a large majority of people with SMI are never violent and that most interpersonal violence in the United States (95%–97%) is not attributable to mental illness (Swanson et al., 2014; McGinty et al., 2018). What are we talking about here, in terms of numbers of adults affected by SMI? The Center for Behavioral Health Statistics and Quality (2015) published from the results of a 2014 survey indicated that “1 in 5 adults aged 18 or older (18.1% or 43.6 million adults) had any mental illness in the past year, and 4.1% (9.8 million adults) had serious mental illness.” These numbers are consistent with those acquired over the past decade.

This leads us to ask, what, then, does predict the likelihood of gun violence? As Powers (2017, p. 132) summarizes so well, “A history of violent behavior, a history of childhood abuse, substance use at the time of an emotionally charged event and the availability of a firearm…. In addition, substance abuse appears to be a major predictor of violence whether it occurs along with a concurrent mental illness or not.”

Nonetheless, there does seem to be a relationship between mental illness and gun violence. According to the mass shootings database (1982–2018) compiled by Mother Jones (Follman, Aronsen, & Pan, 2018), of 105 perpetrators, 55 had a prior history of mental illness; 17 had no prior history of mental illness; and the rest? Unclear. All were male except for four females: One committed the act with a male partner; two had prior mental illness, the other had an unknown history. Recent studies have found, for example, that the likelihood of committing violence is greater for people with a major mental disorder than for those without. Moreover, new data suggest that more than half of the nearly two hundred mass shootings that took place in the United States since 1900 were carried out by those either diagnosed with a mental disorder or with demonstrable signs of serious mental illness prior to the attack (emphasis mine; Duwe & Rocque, 2007; Follman, 2012; Newman, Fox, Roth, Mehta, & Harding, 2006; Phipott-Jones, 2018; Silver, 2006).

What does it mean that the “likelihood of committing violence is greater for people with a major mental disorder than for those without?” Isn’t this bias against the mentally ill? Isn’t this stigma based? Cook and Goss (2014) and Jaffe (2017) both noted that untreated SMI  (e.g., schizophrenia, bipolar disorder, and depression), especially when paired with substance abuse, are at increased risk of committing violence against others. In more than 20 studies, individuals with SMI tend to be three to five times more likely to commit violence than are people without such a diagnosis. Most of the violence perpetrated by these individuals tends to be directed at those whom they know and in private spaces. Furthermore, they tend to commit suicide rather than commit homicides by more than two to one, and SMI is estimated to be a factor in 80% to 90% of self-inflicted deaths. To reiterate, “Epidemiologic studies show that the large majority of people with serious mental illnesses are never violent. However, mental illness is strongly associated with increased risk of suicide, which accounts for more than half of US firearms-related fatalities” (Swanson et al., 2015, p. 368). And yet, as we have seen, more than half of the mass murders in the past century have been committed by individuals with an SMI diagnosis.

We can develop safety education plans for families in collaboration with others in mental health and law enforcement environments

Cook and Goss (2014, p. 60) suggested that “One strategy for reducing gun violence is to reduce criminal violence generally. This means that if we reduced alcohol and drug abuse, offered better treatment for mental illness, reduced school dropout rates, and deployed police resources more strategically, crime rates would fall and gun violence would be a lesser concern.” This same thinking holds true for suicide by gun rates: Address the conditions that lead to suicide and the rate of suicide by guns would decrease.

Brent et al. used a public health approach and recommend the following: Restrict access to assault weapons and other high-magazine firearms. Treatment of psychosis, antisocial personality disorder, and substance abuse can lower homicidal risk. Augment treatment infrastructure and workforce to provide improved access and rapid assessment of at-risk patients. And because a substantial proportion of the precursors of homicidal behavior can be prevented by early intervention with at-risk youth and their families, prioritize preventive interventions to decrease the burden of future violent behavior among at-risk youth.

The most comprehensive response to this issue comes from Jaffe (2017), the Executive Director of Mental Illness Policy Org, and the author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. This well-researched volume is a must-read for anyone who is interested in the issues related to mental illness and violence. This well-researched tome is significant in that it poses solutions to reduce the adverse impact of violence by the untreated individual with a co-occurring diagnosis of serious mental illness and substance use disorder. The other piece that is so important to understand is the impact of these individuals on their families—the interpersonal violence that is perpetrated and the trauma of suicidal behavior or success that these families must manage.

In addition to diagnosis, Jaffe recommends the following:

• Use the term mental illness in nomenclature to establish the focus on illness that can be treated.
• Ensure that criminal justice leaders are on mental illness policy committees because the criminal justice system has become the mental illness system.
• Preserve hospitals by eliminating limits on the length of hospital stays for people with SMI.
• Redefine the Health Insurance Portability and Accountability Act and other privacy acts so that parent-caregivers are members of the health care team.
• Invest in research and treatment for this population.
• Instead of treatment after violence to self or others, enable involuntary commitments to Assisted Outpatient Treatment. Involuntary treatment criteria include those who are gravely disabled (provide own basic needs); likely to deteriorate without treatment; lacks capacity (unable to understand the need for treatment); and consider past history.
• Screen civilly committed patients and mentally ill prisoners who are about to be released because they are most at risk of violence when untreated.
• Train law enforcement.
• Create and expand mental health courts.
• Enact a “Guilty Due to Mentally Ill” plea mandating long-term mental illness treatment to minimize the risk of repeat offense due to mental illness, including time served in a hospital.
• Fund programs that have evidence that they work for this population including access to doctors and medications.
• Create supported housing and group homes. Establish intensive case management and assertive community teams.
• Open clubhouses.

What does this mean for us as Family Life Educators? We are trained education and prevention professionals. We are uniquely qualified to offer educational materials, resources, and programs to facilitate the discussion on what SMI is, its correlation with violence (including gun violence), and to promote treatment and safety for the community at large. We may enter settings where our essential knowledge about family systems, developmental and life span issues, family, and public policy efforts can be advantageous to everyone. We can examine the solutions outlined here and select materials to advertise, market, and improve the outcomes for our society. We can develop safety education plans for families in collaboration with others in mental health and law enforcement environments. In addition to clinical types of safety plans that families are encouraged to use, Bucher (2018) has published an excellent handbook Defusing the Mental Health Triangle: Safety Procedures for Families During Crises at Home. This resource is one very useful and effective tool that FLEs can use. Every Family Life Education professional should be a part of the solution.

References

Baumann, M.L., Teasdale, B. (2018). “Severe mental illness and firearm access: Is violence really the danger?” International Journal of Law and Psychiatry 56(2018) 44-49

Brent, D. A., Miller, M. J., Loeber, R., Mulvey, E. P., Birmaher, B. (2013). Ending the Silence on Gun Violence.  Journal of the American Academy of Child & Adolescent Psychiatry, 52.  Issue 4 , 333 – 338

Bucher, N. P. (2018). Defusing the mental health triangle: Safety procedures for families during crises at home. Thomaston, ME: Indie Author Books. 

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/

Cook, P. J., & Goss, K. A. (2014). The gun debate: What everyone needs to know. New York, NY: Oxford University Press.

Duwe, G., & Rocque, M. (2018, February 23). Actually, there is a clear link between mass shootings and mental illness. Los Angeles Times. Retrieved from http://www.latimes.com/opinion/op-ed/la-oe-duwe-rocque-mass-shootings-m…

Duwe, G., & Rocque, M. (2007). Mass murder in the United States: A history. Jefferson, NC: MacFarland.

Follman, M. (2012, November 9). Mass shootings: Maybe what we need is a better mental-health policy. Mother Jones. Retrieved from https://www.motherjones.com/politics/2012/11/jared-loughner-mass-shooti…

Follman, M., Aronsen, G., & Pan, D. (Updated September 6, 2018). US Mass Shootings, 1982–2018: Data From Mother Jones’ Investigation. Mother Jones. Retrieved from https://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-full-data/

Gold, L. H., & Simon, R. I. (2016). Gun violence and mental illness. Washington, DC: American Psychiatric Publishing.

Jaffe, D. J. (2017). Insane consequences: How the mental health industry fails the mentally ill. Amherst NY: Prometheus Books.

McGinty, E. E., Goldman, H. H., Pescosolido, B. A., & Barry, C. L. (2018). Communicating about Mental Illness and Violence: Balancing Increased Support for Services and Stigma. Journal of Health Politics, Policy and Law, 43(2), 185–228. http://doi.org/10.1215/03616878-4303507

Newman, K., Fox, C., Roth, W., Mehta, J., & Harding, D. (2006). The Social Roots of School Shootings, Cambridge, MA: Perseus.

Philpott-Jones, S. (2018). Mass shootings, mental illness, and gun control. Hastings Center Report, 48, 7–9. doi:10.1002/hast.832

Powers, J. (2017). Blaming gun violence on the mentally ill is easy, but ignorant. In B. Maury (Ed.), The reference shelf: Guns in America (pp. 130–132), Ipswich, MA: H. W. Wilson.

Silver, E. (2006). Understanding the relationship between mental disorder and violence: The need for a criminological perspective. Law and Human Behavior, 30, 685–706.

Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology, 25, 366–376. http://doi.org/10.1016/j.annepidem.2014.03.004

Mara Briere, M.A., CFLE, has founded a small social service agency called Grow a Strong Family, a non-profit Family Life Education company that offers support, services, education, and skills to families with loved ones with mental illnesses. www.GrowAStrongFamily.org