10 Myths (and Corresponding Truths) About Mass Violence: How Psychiatrists Can Help

It would be nearly impossible to peruse any media, engage in any conversation, or interact in any workplace without coming across the topic of the increased number of mass violence episodes (usually mass shootings) in the United States. With this in mind, I wanted to share evidence and thoughts surrounding myths about these episodes… as well as their corresponding truths. Although this is important in terms of accuracy, it is even more germane as it pertains to appropriate messaging by psychiatric professionals to our patients and our communities.

Myth #1: “We live in a more violent world than ever.”

Although the number of firearm deaths is increasing (please see Myth #7), we have seen decreases over time of other violent events. This is important to many of our patients suffering from anxiety or trauma-based illnesses. This myth and its messaging can lead to worries regarding lack of control, fatalistic projections, and learned helplessness. Additionally, it is important to note that most of the violence in the United States is not categorized as mass shootings. For instance, approximately 70 women are killed with firearms every month in situations of domestic violence.¹

Myth #2: “All of these perpetrators are mentally ill.”

The truth is that the majority of the individuals acting as mass shooters do not possess diagnosable or treatable mental illnesses. In other words, mass shootings are not predominantly attributed to those with mental illness. In fact, it is much more common for those living with mental illness to be a victim of a crime, not the perpetrator.² If you examine all violent events, only a very small percentage (3% to 4%) are committed by individuals with mental illness. Although that number rises a bit when looking solely at incidents of mass violence, it is still quite small when looking at the overall data set (15% to 20%).^3,4

Myth #3: “Patients with severe and persistent mental illness are routinely dangerous.”

Debunking this myth is massively important; we need to properly message this to decrease stigma, increase access, and provide a safe community for those with severe and persistent mental illness (SPMI). Longitudinal studies have demonstrated that the majority of those with mental illness are not violent,⁵ and even more so, there is little to no evidence that there are high rates of firearm violence directed to others. On the rare instances in which violence is seen in the SPMI population, it is not usually perpetrated with guns, and it is not directed toward strangers and the general public.⁶ The 3 main items that tend to correlate as predictive factors for homicidal violence (whether one has a mental illness or not) is anger, intoxication, and access to firearms.⁷

Myth #4: “Mass shootings are the most prevalent violent issue facing society now.”

Although episodes of mass violence are low incidence events (compared to all violent events), they are very powerful in terms of emotion, victims, and media coverage. In fact, other violent acts occur much more frequently. For instance, there were approximately 500 deaths from mass shootings between 2000 and 2016. During that same time period, there were almost 320,000 suicide firearm deaths.⁸ Moreover, recent data has shown the suicide numbers to be at least twice that of all homicides.⁸ Thus, from a public health standpoint, the rise in suicides dwarf that of homicides and other violent deaths (not just mass shootings).

Myth #5: “Enacting legislation focused on the mentally ill will decrease mass shootings.”

Part and parcel to Myth #2, this makes mathematical sense as there would not be significant change by focusing on 15% of the cases. By falsely looking at mental health, we are missing characteristics that have been found to be markedly more common in assailants, including domestic violence, misogyny, and feelings of isolation and alienation (with rumination on perceived slights, particularly in the workplace). Additionally, most individuals who commit these shootings exhibit planning/practicing and cognitive appraisal. These actions are not consistent with psychosis, which is associated with the inability for self-care, nor would these traits be detected by present civil commitment statutes.⁹

Myth #6: “Mental health screening and risk factors are the best way to predict mass shooting events.”

Very similar in tone to Myth #5, Federal Bureau of Investigations data has shown perceived victimization, rumination, and premeditation amongst perpetrators is more indicative of intent than mental health status. Similarly, Secret Service data has noted personal grievances, past violence, and a history of felonious events as predictive.¹⁰ As such, the most common predictors are not symptom domains normally seen in psychiatric illness. That being said, we have a lot to offer the field given our skills in risk assessment, interviewing, and inter-agency collaboration.

Myth #7: “Access to firearms is not a risk factor for episodes of mass violence.”

Although this topic comes with a great deal of emotion and history, it is noted to be an important part of messaging any conversation around mass violence. The US firearm homicide rate (from all causes) is 25 times higher than our peer high-income countries.¹¹ Not surprisingly, the US gun death rate per 100,000 citizens is 3.24 compared with an average of 0.19 from our peer countries. Combine this with the fact that the United States has 44% of the world’s firearms (while only having 4.4% of the world’s population).¹² Thus, it can be noted that American crime, in general, is more lethal than peer countries.

Myth #8: “Laws and policies addressing firearm access will not mitigate the risk of mass violence.”

Extreme risk protection orders in several states have been noted to reduce population level firearm suicide rates.¹³ Another intervention strategy is banning large capacity magazines. Interestingly, states without such bans have seen increased incidence of mass shootings and higher fatality rates when shootings occurred.¹⁴ Lastly, state legislation focusing on firearm restraining orders resulted in a 10% decreased intimate partner violence.¹⁵

From a suicide risk mitigation perspective, this degree of effect is consistent with the Lethal Means Safety literature,¹⁶ which notes that individuals do not displace aggression (ie, they do not just find another way). Consequently, legislation pertaining to firearm access has the ability to reduce several categories of gun violence (eg, suicide, mass homicide, and intimate partner violence).

Myth #9: “Schools are markedly more violent/dangerous than ever before.”

This is another dangerous misconception that can lead to more harm than good. Although the media focuses on this extensively, the actual numbers of school shootings pale in comparison to other violent acts, like suicide or intimate partner violence. In fact, you are 10 times more likely to encounter violence at a restaurant compared to school, and 100 times more likely to encounter violence in your own home.¹⁷

Myth #10: “Focusing solely (or primarily) on mental illness issues with regard to mass shootings does no harm, right?”

Wrong. Using mental illness as the primary focus in these scenarios is not only inaccurate (as described previously) but it is also quite stigmatizing. In addition, when media coverage focuses on mental health as the driver in these tragedies, there is also a delayed wait time to enter outpatient psychiatric services (the irony). For example, a data set from 1997 to 2012 revealed that news sources focused on “dangerous people with illness” more so than “dangerous weapons.”¹⁸

Practical Implications

Now that we better understand these myths as well as the proper messaging to combat them, what do we do next as a profession? In other words, just because the majority of these cases are not perpetrated by individuals with primary mental illness, it does not mean that the field of psychiatry does not have a part to play—or that we should not be active in the conversation.We need to be involved in assistance, assessment, and we need to be present on the rare cases in which these events do involve someone with mental illness.

The field of threat assessment is an excellent example of a collaboration involving law enforcement, mental health, and several other federal agencies. They have many excellent suggestions regarding notification (ie, “if you see something, say something”) as well as reminding anyone involved to “never worry alone.”¹⁹ Many of the individuals who commit these crimes do not snap, but instead plan and prepare for months preceding the incident. Hence, there are instances of direct sharing of plans, and other times, more indirect “leaking” of intent.²⁰ Threat assessment teams allow for longitudinal analysis and observation of individuals with these risk factors. Our field has an excellent opportunity to work with such stakeholders to improve identification and follow-up in such cases.

Concluding Thoughts

We have an important role in educating others about these 10 common misconceptions pertaining to mass violence. We must leverage solid research and data to help paint a more accurate picture. The reason we need to discuss the truth behind these issues is not only for the purpose of clarity but also to make sure that we are messaging appropriately in our advocacy and support of our mission. In doing so, we are advocating for not only our profession, but also for our communities at large.

Dr Thrasher is the president of the American Association for Emergency Psychiatry (AAEP), the medical director of crisis services in Milwaukee County, Wisconsin, and president elect of the Wisconsin Psychiatric Association.

References

1. Everytown analysis of CDC, National Violent Death Reporting System (NVDRS), 2019. https://everytownresearch.org/maps/mass-shootings-in-america/#domestic-violence-was-a-part-of-most-mass-shootings

2. Brekke JS, Prindle C, Bae SW, Long JD. Risks for individuals with schizophrenia who are living in the community. Psychiatr Serv. 2001;52(10):1358-1366.

3. CDC Leading Cause of death reports. National and regional 1999-2010; February 2013.

4. Metzl JM, MacLeish KT. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015;105(2):240-249.

5. Steadman HJ, Mulvey EP, Monahan J, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998;55(5):393-401.

6. Gun violence and victimization of strangers by persons with a mental illness: data from Macarthur Studies. Psychiatr Serv. 2015;66(11):1238-1241.

7. Monahan J, Steadman HJ, Silver E, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorders and Violence. Oxford Press; 2001.

8. Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018. https://www.cdc.gov/injury/wisqars/index.html

9. Swanson JW. Explaining rare acts of violence: the limits of evidence from population research. Psychiatr Serv. 2015;62(11):1369-1371.

10. “Mass Violence in America: Causes, Impacts and Solutions.”National Council for Behavioral Health, Medical Director Institute, August 2019.

11. Fox K. How US gun culture compares with the world in 5 charts. October 3, 2017. Accessed July 18, 2022. https://www.wral.com/how-us-gun-culture-compares-with-the-world-in-5-charts/16993476/

12. Fisher M, Keller J. Why does the U.S. have so many mass shootings? The New York Times. November 7, 2017. Accessed July 18, 2022. https://www.nytimes.com/2017/11/07/world/americas/mass-shootings-us-international.html

13. Kivisto AJ, Phalen PL. Effects of risk-based firearm seizure laws in Connecticut and Indiana on suicide rates, 1981–2015. Psychiatr Serv. 2018;69(8):855-862.

14. Klarevas L, Conner A, Hemenway D. The effect of large-capacity magazine bans on high-fatality mass shootings, 1990–2017. Am J Public Health. 2019;109(12):1754-1761.

15. Zeoli AM, Webster DW. Firearm policies that work. JAMA. 2019;321(10):937-938.

16. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry. 2002;181:193-199.

17. Nekvasil EK, Cornell DG, Huang FL. Prevalence and offense characteristics of multiple casualty homicides: are schools at higher risk than other locations? Psychology of Violence. 2015;5(3):236-245.

18. McGinty EE, Webster DW, Jarlenski M, Barry CL. News media framing of serious mental illness and gun violence in the United States, 1997-2012. Am J Public Health. 2014;104(3):406-413.

19. Thrasher T. Debunking 4 myths around mass shootings. Psychiatric Times. April 12, 2021. https://www.psychiatrictimes.com/view/debunking-4-myths-around-mass-shootings

20. Averting Targeted School Violence: A U.S. Secret Service Analysis of Plots Against Schools. US Department of Homeland Security, United States Secret Service, National Threat Assessment Center. Accessed July 18, 2022. https://www.secretservice.gov/sites/default/files/reports/2021-03/USSS%20Averting%20Targeted%20School%20Violence.2021.03.pdf