Shooting down stigma

By Keir Liddle

mental-healthIn the wake of the latest US high school shootings debate has raged across the internet determining what can be done to prevent such tragedies from occurring in the future. Everything from tighter gun control to speculation about the mental health of the shooter has been discussed. But is it fair to assume that mental health  plays a part in spree shootings?

I have previously explored this issue in a post here .

Even high profile skeptics like Michael Shermer have denounced those who perpetrate such crimes as psychopaths and nutters laying the blame at the door of the shooter seemingly oblivious to the lack of information available about the shooters mental state at the time of the shooting or indeed of the huge body of research that debunks the idea that mental health and violence are strongly linked.

A 2003 review article explored the relationship between violence and mental health by asking the following questions: Are the mentally ill violent? Are the mentally ill at increased risk of violence? Are the public at risk? It’s conclusions may surprise those engaging in the lazy and ignorant circular reason that leads them to assume that someone committing such an atrocity must be mentally ill by definition as “sane people just don’t do that”.

The authors concluded that:

Mental disorders are neither necessary nor sufficient causes of violence. Major determinants of violence continue to be socio-demographic and economic factors. Substance abuse is a major determinant of violence and this is true whether it occurs in the context of a concurrent mental illness or not.

In simple terms mental health problems are not enough to make someone violent nor does someone committing an act of violence have to be mentally ill. Worryingly they found that members of the public exaggerate both the strength of the association between mental illness and violence and their own personal risk. Showing that mental health stigma is still a very real and pertinent issue. People still fear and fail to understand the nature and character of mental health problems and still fear those who are mentally ill as “others” who will cause them harm.

In a series of surveys spanning several real-life events in Germany, Angermeyer and Matschinger showed that the public’s desire to maintain social distance from the mentally ill increased markedly after each publicized attack, never returning to initial values. Further, these incidents corresponded with increases in public perceptions of the mentally ill as unpredictable and dangerous.

The reality is very far from the truth with research paper after research paper being published showing that the mentally ill are more often victims than perpetrators of violence. It is also worth noting that public perceptions of the link between mental illness and violence are central to stigma and discrimination as people are more likely to condone forced legal action and coerced treatment when they believe violence is an issue. The presumption that the mentally ill are violent also, counter-productively,c provides a justification for bullying and otherwise victimizing the mentally ill. Given that the most startlingly common factor in American high school shootings is a bullied, tormented and ostracised shooter I’m sure I don’t need to say much more to point out that this stigma and unfair association needs to be addressed.

People accept it as a common sense “fact” that those suffering from paranoid or delusions or psychosis are more prone to outbreaks of violence without feeling the need to substantiate this claim it is taken as a given. However in the study linked the prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from their non-substance abusing neighbourhood controls. Or to put it another way drug and alcohol abuse is a far better predictor of  violence than mental health is. The study also concluded that delusions were not associated with violence, even ‘threat-control override’ delusions that cause an individual to think that someone is out to harm them or that someone can control their thoughts.

What does the study have to say about the risk to the public from the mentally ill? The following is enlightening:

In the MacArthur Violence Risk Assessment Study the most likely targets of violence were family members or friends (87%), and the violence typically occurred in the home. Discharged patients were less likely to target complete strangers (10.7%) compared to their community controls (22.2%). 

And what if we could eliminate mental health issues in the US just how much violent crime would be prevented?  According to research violence in the community could be reduced by less than five percent. That leaves 95% of violence in the community carrying on as it is being carried out by those without mental health issues.

This study concludes that too much past research has focussed on the person with the mental illness, rather than the nature of the social interchange that led up to their violence. Consequently, we know much less than we should about the nature of these relationships and the contextual determinants of violence, and much less than we should about opportunities for primary prevention. Simply put we focus on something that may or may not exist within the offender rather than the social and environmental pressures that set them on the course to their violent act.

But mental health is a broad definition – is there perhaps room for these spree killers to be mentally ill? To have some identifiable mental health problem that we can detect and use to prevent future tragedies?

This article talks to forensic psychiatrist Paul Mullen about spree shootings (which he terms autogenic massacres) and his conclusions may surprise many. After analysing a number of killers, Mullen concludes,

“Most perpetrators of autogenic massacres do not … appear to have active psychotic symptoms at the time and very few even have histories of prior contact with mental health services.”

So why do we want to label spree killers as mental ill? Is it nothing more than wanting an “other” to be responsible for these atrocities? Do we just not want to accept that anyone has the potential for such horror within them preferring to view them as defective or damaged somehow?

I would ask anyone reading this who believes these people MUST be mentally ill to consider if they would section a child who struck back against their bullies and tormentors. Would the severity of the beating they gave their victims determine how “mentally ill” they might be or would it perhaps more reflect the severity of their torments?  Is there really any difference between someone lashing out with their fists and intending to do as much harm as possible and between someone who choose to use an extension to their own fist to achieve their revenge?

I would like people to consider the assumptions, fears and stigma that underly their presumption that spree shooters must be mentally ill.

As by saying “a crazy person did it” all you are highlighting is your own ignorance of the specific situation and your unwillingness to accept that “normal” people may be implicated in either perpetrating these acts or creating the environment that causes them to take place.

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7 Responses to Shooting down stigma

  1. It seems to me perfectly reasonable to regard going into a school and shooting 26 people as pretty powerful evidence of mental disorder. After all, there seems no good reason for such behaviour.

    Two things do NOT follow.It does NOT follow that mentally ill people are on the whole more dangerous than the rest of us – indeed, the evidence cited suggest the contrary. And, importantly, it does NOT follow that gun control is irrelevant.

    Even if most maniacs are far from homicidal, every society contains a few homicidal maniacs. In China, as we saw recently, such a person can get a knife and stab 20 children (all surviving) before being overpowered. In the US, as we have seen, he can get an assault weapon.

    • The vast majority of people with mental disorders are not violent. All of the research indicates that mental health is not necessary or sufficient to explain incidents of violence.

      So no I don’t think it is reasonable to assume that someone who commits such an act has a longstanding mental health disorder.

      Indeed most diagnoses are post hoc and arrived at by methods that look distinctly like a “fait acompli”. By analysis of killers writings and interactions and the like after the fact (but not their peers who never kill anyone or indeed never become diagnosed with a mental health issue).

      Indeed to assume that only crazy people ever do crazy things is I feel a dangerous and distracting assumption and assertion.

      As outlined above the common factors are bullying/family instability. Or in other words environmental factors and stressors.

      Now you can hold onto the belief that only those with mental health problems and disorders would react in such a way but that still leaves you with the problem that these individuals do not by and large display mental health problems before these events. There is rarely contact with mental health services before they occur.

      But that could be down to lack of access to healthcare under Americas barbaric lack of universal healthcare. However there is also rarely any school reports expressing concerns about these particular students.

      So these are severely mentally ill people who display little or no obvious signs of being mentally ill or mentally distressed before the events.

      You could perhaps make a more convincing argument for “temporary insanity” or a “psychotic break” but that isn’t a mental health condition.

      Certainly you could assert that those who are stopped and survive the shorting sprees themselves are mentally ill. But that’s not evidence that they were before the event simply that the event preceded their diagnosis of mental disorder. A diagnosis given in light of their actions not uncovered before their actions.

      In short saying “a crazy person did it” is of utterly no use intellectually, in terms of dealing with the issue or addressing it.

      It does however, ironically, make it more likely to happen in the future and increases the likelihood those with mental health problems will face stigma, discrimination, harassment and victimisation.

      All because, in my view, we are uncomfortable in accepting that same people can do insane things. Driven to them by environmental and social pressures and stressors rather than there simply something “wrong” with them.

  2. The question this article spurs me to ask is, “When is violence “normal” and when is it a sign of pathology?” The reality is that there all kinds of violence that are considered normal. Some may be illegal, but most people would not regard them as a sign of mental illness. And then there are acts which are so difficult to imagine oneself committing that it is almost impossible to empathize with the state of mind of someone committing them, and these are the acts we tend to identify as “crazy.”

    Certainly, the evidence is strong that most mental health problems do not include a predisposition to violence among their defining characteristics. Of course, the line between normal variation and mental illness is often fuzzy anyway, and behavior that in one era is considered within the bounds of normal may in another get a DSM diagnostic code. So one can’t automatically assume that behavior which is widely seen as unacceptable necessarily indicates mental illness.

    On the other hand, how can one consider the systematic murder of one’s mother and large numbers of innocent children followed by suicide an act someone can commit who is mentall normal? Doesn’t the who concept of “normal,” or “neurotypical” cease to have meaning if it doesn’t allow us to predict that an individual will not commit such acts except under the most bizarre circumstances (combat stress, torture, perhaps prolonged indoctrination of some kind, etc)?

    I understand the concern about stereotpying mental health problems, but I also don’t see how it is useful to consider insane behavior not to be indicative of something fundamentally wrong with the person exhibiting it. The idea that anyone is capable of any kind of atrocity regardless of the presence of any mental abnormality is as facile a generalization as the idea that mental illness automatically comes with a risk of violent behavior.

    It would be itneresting to look at incidents like this systematically and try to identify whether or not there are patterns of behavior suggestive of an underlying pathology in the perpetrators. Certainly, these folks often seem not only quite bizarre after the fact, when caught alive, but also seem to frequently have histories of atypical behavior. Of course, recall bias and such makes informal asessment of such things prone to error, but I don’t find the study cited above compelling evidence that it is appropriate to assume individuals committing mass murder are mentally normal until proven otherwise.

  3. The point underlying this post is that it is predominantly environmental factors that lead to these spree shootings. Some people may be more vulnerable to this environmental pressures than others and some may have easier access to the means with which to respond in this way to them.

    You can’t, without adopting totalitarian controls on schoolchildren, identify or control or even reliably guess which kids are going to be more affected by these pressures. There are no reliable risk factor indicators.

    Mental health is, in a sense, a complete red herring in dealing with this issue. The issue will only be solved by tackling the social and environmental causes. By dealing with the bullies and removing the access to weaponry essentially.

  4. Well, I would dispute the notion that environmental pressures are the main force leading to such events, and I wonder how one defends that in terms of empirical evidence. I think the individual predisposition to certain kinds of behavior, which is predominately genetically determined, is a huge factor, and dismissing this is inconsistent with contemporary evidence for the relative roles of environment and genes in generating behavior.

    That said, I agree that the efforts to prevent such tragedies must focus primarily on the environmental conditions that permit them, since the temperment or predispositions of individuals are not controllable, and we don’t yet have the ability to predict individual behavior accurately enough to aim preventative measures (whether positive, such as mental health treatment, or negative, such as incarceration) at individuals without a great risk of error and, as you say, unacceptable interference with individual liberty. And I absolutely agree that access to weapons is probably the most signficant risk factor that sensible public policy could change with a real impact on the amount of harm such events cause.

    Labeling such individuals as “crazy” doesn’t. of course, do anything to prevent such tragedies. I am not convinced of the article’s main argument that such labeling is automatically incorrect or inappropriate, but of course I agree it doesn’t get us anywhere in terms of sensible and effective preventative measures, apart from recognizing that rational decisions-making and weighing of risks and consequences cannot be assumed in the perpetrators, and so preventative strategies cannot rely on these behaviors (e.g. one cannot simply increase the criminal penalties and assume this will deter such crimes). Fundamentally, I still think it is fair to presume that most of these people are acting in ways that can be fairly labeled irrational and abnormal when they commit these acts.

  5. Ben Makin says:


    I’ve become very intrigued by the theory put forward in a paper entitled “Suicide by Mass Murder” which argues that we may understand this phenomenon more if we look at it as a flamboyant suicide loaded with meaning and messages, rather than as a rampage which happens to end in an awful realisation of what has been done. Two other incidents spring to my mind – one is the double suicide in Meyerling where there is a strong suggestion that Crown Prince Rudolf killed 17 year old Mary Vetsera in order to make him screw up his courage to kill himself several hours later. The second is from the two tornado pilots, John Nichol and John Peters, shot down in the first gulf war. One was married with children, the other was single. Just before they were captured, the one who was single suggested that they should not surrender but “go out all guns blazing Butch and Sundance style” but the other refused to comit suicide in such a heroic way. Instead both were imprisioned in Abu Grahaib and released at the end of the war.

    If the mass killings in schools are primarily suicides rather than murders, then we have to ask the question “do you have to be mentally ill to commit suicide”? Do read the paper I linked to or this article about it – they are interesting.


  6. I think it is likley that these events include suicide as a planned part of the act given how often they end with suicide or with the killing of the perpetrator by police, which is probably not unexpected by that person. I’m not sure, though, that I understand how that necessarily changes the issue of what role mental health plays in the process and what public policies make sense to limit the risk of such events. The paper seems to me to shoehorn the events discussed into an a priori post-modernist narrative about culture, gender relations, and a whole set of issues that seem less to emerge from the analysis than to be a frame into which the events are stuffed by main force. The authors actually admit there is good evidence that all the people they talk about had demonstrable histories of mental illness and then proceed to ignore that completely in favor of their preferred explanations.

    That males are responsible for most of the violence in pretty much every society ever studied is well established. But the universality of this pattern seems to me to be more consistent with a biological than a cultural explanation. Rather than a “culture of hegemonic
    masculinity…[which] creates a sense of aggrieved entitlement conducive to violence,” the near monopoly on this kind of mass murder held by males (almost always males under about 40 years of age) also seems to have more to do with how the young male brain functions than how we are taught to conceptualize our experience.

    As for the question if one has to be mentally ill to commit suicide, might that not be answered, to some extent, by the degree to which suicide can be called a “normal” behavior? In a given cultural context it often is, and again this is a widespread phenomenon not especially associated with the U.S. This makes it seem less likely that it is a behavior predominantly exhbited by people with mental illness. But that’s not a point I know enough to argue strongly.

    On the other hand, it is much rarer to find a cultural context in which mass murder of children, with or without suicide, is considered a normal behavior. So arguably it is more reasonable to consider it a sign of mental illness. And FWIW, the article does stipulate that there was evidence of mental health problems in all the perpetrators discussed.

    So whether or not these acts are intended to accompany a suicide or give it more of an impact, I’m not sure that has anything to do with the issue of whether the people who commit them can be called “normal” or not in terms of mental health.

    I wonder if there are any reliable statistics on the incidence of a history of mental illness among people who commit such crimes. It is clear that most mental health problems do not include a predisposition to violence, but I’m not sure if these kinds of extreme forms of violence are mostly committed by people with a history of mental health problems. Mental illness may not be a sufficient condition for such behavior, but is it a necessary one?

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