Finding the killers among us

Tmoment following every mass killing when the media turn their attention to the shooter’s mental health. After Aurora, Sandy Hook, Isla Vista and, most recently, the WDBJ TV shooting in Virginia, pundits wondered: Could the tragedy have been averted if only the killer had received better psychiatric care?

But looking to our mental health system to address the problem of mass shootings is misguided and potentially even harmful, for a few reasons.

First, it distracts from a discussion of other potential solutions, such as stricter firearms policy or media coverage guidelines to reduce the likelihood of copycat killings.

Second, it tends to perpetuate a stigmatizing stereotype about the savagery of people with mental illness. Nearly 40 million people in this country suffer from a mental illness, including more than 13 million with severe mental illness — the overwhelming majority of whom are not violent.

Third, and most important, we should not turn to mental health practitioners to curb mass violence because there is little evidence that we — I work as an emergency psychiatrist — can effectively predict or prevent it. To understand why requires an appreciation of some fundamental epidemiology.

Although mass killings generate significant media coverage, they’re statistically uncommon when compared with other crimes. An FBI study of “active shooter incidents” found that between 2000 and 2013, there were 160 such events (just over 11 per year) in a country of more than 300 million people.

In some high-profile cases, the shooters had been diagnosed with serious mental illness; in others, they had not. A recent study by the advocacy group Everytown for Gun Safety found that mental health concerns about the perpetrators had been raised beforehand in only about 12% of mass killings between 2009 and 2015.

Identifying a potential mass murderer is, then, like searching for a needle in a haystack. Actually, it’s more like searching for a particular piece of hay in a haystack because mass murderers appear indistinguishable from countless other troubled individuals who will never pull the trigger.

We simply don’t have tools to forecast who among the general population — or even among a subpopulation of mentally ill people — will go on to commit an atrocity. According to news reports, several recent mass shooters were in psychiatric treatment before their crimes, and none of their psychiatrists determined that they were imminent threats to public safety.

Another problem is that we are limited in our ability to treat homicidal tendencies. People who intend to kill rarely reveal their plans or seek help. There is no medication or talk therapy guaranteed to prevent mass murder, particularly if a person has given no indication of his aims.

The best we could hope for is to identify a higher-risk group of people whom we could target for preventive treatment. But the only truly reliable, foolproof clinical intervention is long-term institutionalization, meaning we would need to hospitalize or incarcerate members of that higher-risk group.

Here we get into “Modest Proposal” territory. Who would make up such a higher-risk group? All people with a mental illness? Perhaps all people with certain mental illnesses such as schizophrenia or autism or narcissistic personality disorder? Because men seem to perpetrate most of these crimes, maybe all men with certain mental illnesses? Disgruntled former employees? Troubled young men who live with their parents? Postal workers?

In order to prevent one mass shooting, how many innocent and harmless people would we feel comfortable institutionalizing, perhaps indefinitely? Furthermore, why would anyone voluntarily access even outpatient treatment if the threat of long-term institutionalization were a likely outcome?

Second Amendment absolutists believe that gun-control measures intolerably curtail Americans’ liberty; a mental health “solution” to mass killings would lead to far more dramatic restrictions.

I wish that mental health professionals could prevent the horrible loss of life and community grief that mass shootings cause. But we need to be realistic. We should enhance access to services because highquality treatment may improve the lives and ease the suffering of those with mental illness, not because we will halt mass violence. We should not promise what we cannot deliver.

Matthew Goldenberg is an assistant professor of psychiatry at the Yale University School of Medicine.