In the wake of this weekend's double mass shootings -- one that claimed 22 lives in El Paso, Texas, another that left nine dead in Dayton, Ohio -- debate surged again over whether these incidents reflect some kind of failure by the mental health establishment.
In remarks Monday morning, President Trump blamed "hatred" and "mental illness" for the weekend shootings. But, perhaps anticipating this reaction, Sen. Chris Murphy (D-Conn.) to argue that "4 out of 5 mass shooters have no mental illness diagnosis, and half showed no signs on a prior, undiagnosed illness."
And then he made a political point: "Framing this as just a mental illness problem is a gun industry trope. Period. Stop."
That prompted a variety of reactions from others on Twitter. Some agreed that it was a valuable point, in no small part because linking such events to mental illness serves to stigmatize everyone with a mental illness.
Others, however, questioned how it's possible that someone can kill a dozen or more strangers, more or less at random, and yet this doesn't in and of itself indicate a mental illness. "So a healthy person does this?" asked one Twitter user.
Although Murphy did not cite his sources, one could have been a much-cited by forensic psychiatrists James L. Knoll IV, MD, and George D. Annas, MD, MPH, of SUNY Upstate Medical University in Syracuse New York.
In their review, Knoll and Annas acknowledged that the public and the media find the question hard to resist. As they put it rhetorically, "After all, who but a madman would execute innocent people in broad daylight, while planning to commit suicide or be killed by police?" But they then went on to cite research indicating that, in fact, only a minority of mass shootings (however defined) have been perpetrated by individuals with recognized mental disorders.
"Few perpetrators of mass shootings have had verified histories of being in psychiatric treatment for serious mental illness," they wrote. Although post hoc analyses indicate that they are full of rage and may harbor "fantasies of violent revenge" for real or imagined offenses against them, these may lie entirely beneath the surface until they put the fantasies into action.
"Such individuals function (perhaps marginally) in society and do not typically seek out mental health treatment," Knoll and Annas wrote. "Thus, in most cases, it cannot fairly be said that a perpetrator 'fell through the cracks' of the mental health system. Rather, these individuals typically plan their actions well outside the awareness of mental health professionals."
Although mass shooters may not meet DSM-5 criteria for a recognized disorder, "they do have an ill-defined trouble of the mind for which the mental health field has no immediate, quick-acting 'treatment,'" Knoll and Annas acknowledged.
So it's understandable that mental health professionals would object to suggestions that they are somehow at fault for mass shootings. Yet, surely they don't think that gunning down a dozen random strangers can ever be normal or rational. People continue to ask the "who but a madman" question.
ڴŮ put it to Knoll in an email Monday. His response was, in essence, that it's simply the wrong question.
"In my opinion, this is an intellectual sidestep that avoids contemplating more difficult questions. It is the path of least resistance, leading us away from the more relevant issues," he said. "[P]sychiatrists, and particularly forensic psychiatrists, understand that dark and depraved acts are frequently committed for other reasons besides mental illness -- indeed, most often committed for other reasons."
"Do we solve the matter by labeling it 'mental illness' and calling for greater scrutiny of 'troubled' individuals?" he continued. "I believe we solve nothing, and even risk making matters worse. This mindset makes us vulnerable to creating new, but misguided, laws. It furthers the medieval notion of equating mental illness with 'evil' or criminal behavior. Individuals who carry out these acts, very often, do not see themselves as mentally ill whatsoever or in need of treatment."
Knoll pointed out that there is little mental health professionals can do with or for individuals who don't want their help. "Mental health treatment has its limits, and is not traditionally designed to detect and uncover budding violent extremists," he told ڴŮ. He also commented that creating a diagnosis of "mass shooting disorder" would have no value.
Other authors have made similar arguments, mainly to make the case that formal psychiatric screening isn't likely to identify those likely to commit massacres. , Jonathan Metzl, MD, PhD, and Kenneth MacLeish, PhD, both of Vanderbilt University in Nashville, Tennessee, recounted the cringeworthy history of previous attempts to develop profiles of would-be mass murderers. Whereas now the Angry White Male Loner theory is prominent, the picture was literally darker not that long ago. "In the 1960s and 1970s, by contrast, many of the men labeled as violent and mentally ill were also, it turned out, black," they wrote.
More broadly, Knoll said, "every day we ignore the social and cultural aspects of this phenomenon, we put off making substantive, positive changes. I believe the challenge before us is to distinguish sensationalized media portrayals and single case examples from the large swath of individuals suffering from serious mental illness in this country who have nothing to do with mass shootings."
Addressing those social and cultural aspects, Knoll also noted that the wave of mass shootings that began in the late 1990s must have some propellant besides guns and mental illness, both of which have existed for a long time. He fingered the media as one.
"It seems difficult to deny that the media coverage since the late 90s" has made it certain that those who commit heinous crimes become celebrities, he said. Knoll noted the glorifying the Columbine High School shooters.
He put it this way in his email to ڴŮ: "If it is the case that a cultural script is a driving force behind the media and social propagation of mass shootings, a central prevention effort becomes how to halt or change the script? Here is an area where social change, perhaps beginning with today's youth, may work to replace the script with a better one, or at least make the current script unappealing or obsolete."