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Op-Talk | Can Psychiatrists Stop Gun Violence?

By Anna North�� ���������� Times�� December 16, 2014

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Soon after the 2012 shooting at Sandy Hook Elementary School, President Obama made mental health care a major part of his plan to curb gun violence. And this week, following the two-year anniversary of that crime, Rep. Tim Murphy is calling for federal legislation he believes would help stop mentally ill people from becoming violent. “I remain firmly convinced we can make tremendous legislative strides in preventing mass tragedies involving someone with a serious mental illness,” he writes at The Guardian.

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But according to one recent analysis, mental-health screening may not be the best way to prevent mass shootings — and expecting psychiatrists to identify potential shooters may do more harm than good.

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In a paper published in the American Journal of Public Health, Jonathan M. Metzl and Kenneth T. MacLeish investigate a number of common beliefs about mental illness and gun violence, including the idea that “psychiatric diagnosis can predict gun crime before it happens.” They write that “legislation in a number of states now mandates that psychiatrists assess their patients for the potential to commit violent gun crime.” ����������, for instance, “requires mental health professionals to report anyone who ‘is likely to engage in conduct that would result in serious harm to self or others’ to the state’s Division of Criminal Justice Services, which then alerts the local authorities to revoke the person’s firearms license and confiscate his or her weapons.”

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However, they argue, asking psychiatrists to judge who’s likely to become violent may be the wrong approach. They cite research showing that most gun violence isn’t committed by people who are determined to have mental illness — and that most people with mental illness don’t commit violence. According to one study, “the risk is exponentially greater that individuals diagnosed with serious mental illness will be assaulted by others, rather than the other way around.”

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And psychiatrists may not be able to tell which of their patients will become violent: Dr. Metzl and Dr. MacLeish write, “research dating back to the 1970s suggests that psychiatrists using clinical judgment are not much better than laypersons at predicting which individual patients will commit violent crimes and which will not.” They note that “psychiatric diagnosis is in and of itself not predictive of violence, and even the overwhelming majority of psychiatric patients who fit the profile of recent U.S. mass shooters — gun-owning, angry, paranoid white men — do not commit crimes.” Thus, “population-based literature on guns and mental illness suggests that legislatures risk drawing the wrong lessons from mass shootings if their responses focus on asking psychiatrists to predict future events.”

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“It’s understandable that people are searching for answers at these very trying moments” after mass shootings, Dr. Metzl told Op-Talk — but “if you’re really trying to stop gun crime, the mentally ill are the groups of people we probably have to fear in many ways the least.”

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And asking psychiatrists to become the first line of defense against mass shooting could have real risks, both for people with mental illness and for society as a whole. “A number of people with mental illness are already mistrustful of medical authority,” Dr. Metzl said, “so if psychiatrists are mandated to report them to authorities, you can see understandably that it might actually lead people to not seek treatment.”

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“In a way,” he added, “this mental illness conversation obfuscates a larger and more meaningful conversation that we could potentially be having among people on all sides of the political spectrum.”

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He and Dr. MacLeish aren’t the first to question whether mental-health screening can really prevent future shootings. At The Atlantic in 2013, Garance Franke-Ruta wrote about proposals to create a nationwide database of people with mental illness to keep them from getting guns:

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“More than half of Americans experience one or more mental illnesses over the course of their lives, and around 26 percent of Americans over age 18 each year experience at least one, primarily anxiety disorders and mood disorders like depression. The overwhelming majority of them are no danger to anyone at all. But with so substantial a portion of the country going through bouts of one thing or another over the course of their lives, the idea that any federal database could capture enough information to encompass every one who might one day be a threat anywhere is akin to hoping for a government staff of precogs.”

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Also in 2013, Dr. Jeffrey Swanson, a professor of psychiatry and behavioral sciences who has studied gun violence, told Ryan Jaslow of CBS News that mass shootings “are almost inherently unpredictable, and often perpetrated by people with no gun-disqualifying mental health or criminal record — until it’s too late.”

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And in a ����������er story published in November, Maria Konnikova notes that “according to two recent Gallup polls, from 2011 and 2013, more people believe that mass shootings result from a failure of the mental-health system than from easy access to guns.” However, she writes, research consistently shows that “mental-health problems do increase the likelihood of violence, but only by a very small amount.” As for whether psychiatrists can predict violence, she points to a 1993 study showing that 53 percent of patients psychiatrists thought would commit violence actually did so within six months — but so did 36 percent of the patients doctors thought wouldn’t be violent.

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Dr. Metzl believes psychiatrists and other mental health practitioners should have a role in the national discussion around guns — just not the role of telling authorities which of their patients will become violent. Rather, “there needs to be a new politics to how psychiatry engages with the gun debate.” As it stands now, he said, that debate isn’t really addressing questions like “why do people feel like they need guns” and “what are the implications of being surrounded by guns in people’s daily lives.”

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“Psychiatry could have a much louder voice on those particular issues,” he said. “I think medicine has a social responsibility, because of the epidemic of gun violence, to try to reframe the question, and it hasn’t done so yet.”

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