As the coronavirus pandemic begins to wane in the U.S., a number of public mass shootings have once again reminded us of the epidemic of gun violence in our country. The FedEx shooting in Indianapolis, the massage parlor shooting in Atlanta, and the Boulder supermarket shooting were only a few of the 160 mass shootings (defined as four or more people killed) in the first four months of 2021. Each of these horrific incidents leaves us wondering what could possibly motivate someone to walk into a public space and open fire on a group of strangers. Perhaps because of the scale of such violence, the indifference to human life, and of the lack of obvious gain for the perpetrator, many assume that there must be some sort of defect in the mind of the shooter — and thus that they must be mentally ill.
While there is an association between mass shootings and mental illness, it is a weak one. There are examples of mass shootings perpetrated by people who are driven by delusions or hallucinations that alter their perception of reality, but these are few and far between. More often, the shooters are driven by a grudge against an employer, a family member, or a peer.
Though they may have mental health problems, few mass shooters have been formally diagnosed with a serious mental illness. Most lack overt signs of hallucinations or delusions that would affect their ability to understand what they were doing, or to recognize that it was wrong. Instead, many have traits of narcissism, depression, inability to empathize, and entitlement — indicators of poor coping mechanisms, but not necessarily treatable mental illnesses. And though in retrospect it seems like these traits could help identify potential mass shooters, these traits are common and therefore lack predictive value.
Each time a mass shooting happens, we ask what we could have done to stop it. If one assumes that the shooters are driven by mental illness, it follows that fixing our mental health system is a reasonable solution. And our mental health system is certainly broken: there is a dire provider shortage, too few inpatient beds, a lack of intensive outpatient services, too little supported housing, too few ways to intervene when a person is too sick to accept help.
But the mental health system is a blunt instrument to prevent mass shootings at best. While a minority of these shooters might have benefitted from treatment to reduce psychotic symptoms, the majority appeared to be driven more by entitlement, misogyny, white supremacy, or a desire for revenge — conditions that are notoriously difficult to treat. Not to mention, it’s difficult to get people into treatment if they are not willing to go voluntarily. Few recent perpetrators rose to the attention of the authorities in a manner that would have qualified them for involuntary psychiatric services.
Even if mental health treatment doesn’t ameliorate the risk of violence, there are mental health-associated firearm prohibitions that could prevent would-be mass shooters from having access to guns. However, these prohibitions don’t apply until a person is formally committed by a judge during a psychiatric hospitalization, or otherwise found to lack the capacity to manage their affairs. This process can happen days or even weeks into their hospitalization and treatment, and many people who are brought in involuntarily don’t make it to that checkpoint. They are discharged home to their guns, with their rights to own them and to buy more still intact.
So, what can healthcare providers do in the event they become concerned that one of their patients might perpetrate a mass shooting?
Healthcare providers working in primary care, emergency, pediatric, and psychiatric settings may face situations where a patient makes concerning statements, or a family member or friend expresses concern. A recent report from the FBI showed that over half of mass shooters make internet posts or other communications to people that publicly hint at their plans prior to acting — a phenomenon called leakage. This leakage may be brought to the attention of their healthcare provider.
Providers have options in these situations. Because of the diverse motivations behind mass violence, one of the best preventative strategies is to immediately remove the person’s access to firearms. This means getting guns out of the home and prohibiting them from purchasing more. In many states, law enforcement or family, and in some cases, healthcare providers or employers, can petition a judge for an Extreme Risk Protection Order (also known as “red flag laws”) that will allow for removal of currently owned firearms and place a temporary prohibition on buying more. These orders are based on threats and risk, and in most states, don’t require a diagnosis of a mental illness. While research has shown they can be a portal into mental health services for those who need it, they can also prevent violent fantasies from becoming a reality by removing weapons regardless of motive. Some states also have specific workplace or school protective orders that provide additional protection for potential targets in addition to firearm restrictions.
Psychiatric hospitalization may be warranted if it appears that a patient is a danger to others because of a mental illness. While treatment may decrease some contributing symptoms, providers should familiarize themselves with state and federal firearm prohibitions based on mental health interventions so they are aware of how the person’s firearm rights may be affected. Even if the person does merit inpatient treatment, ancillary steps should be taken to ensure prompt removal of their access to weapons rather than relying on mental health-related prohibitions.
If the person of concern is a minor, it is crucial to engage parents, caregivers, and other family members. Many states have child access prevention laws that make it illegal for adults to store firearms in a way that minors could access them. Preventing access by removing guns from the home or locking them up is vital, as the majority of school shooters get their firearms from home or from a family member.
Healthcare providers should also engage and collaborate with any law enforcement teams who may be involved in threat mitigation. HIPAA allows for disclosure of protected health information in cases where there is an imminent or serious threat of harm, as long as that disclosure is made to someone who can lessen the threat. Law enforcement may have helpful collateral about criminal charges, protective orders, and firearm access.
Many firearm violence prevention organizations, healthcare systems, and healthcare providers have become interested in supporting programs for clinicians to become more knowledgeable about preventing firearm injury and death. And in 2019, California became the first state to fund such an initiative, giving $3.84 million to the development of the BulletPoints Project. Addressing the issue of gun violence will take significant reform across our society, but clinicians can play an important role in preventing this type of injury and death in their own patients.
Amy Barnhorst, MD, is the Vice Chair for Community Mental Health at the UC Davis Department of Psychiatry and the director of the BulletPoints Project, a state-funded effort to develop and disseminate a curriculum to teach healthcare providers across California how to counsel at-risk patients about firearms.