It is hard to find enough superlatives to describe the intellectual stimulation and pleasure I found in reading Gun Violence and Mental Illness. I was delighted when I was asked to review this book, as I have been following professional discussions surrounding guns and mental illness and have been personally concerned about the public's misperception that all gun violence is linked to mental illness. I wondered whether I would find any new helpful information or new ideas in a 434-page edited volume, despite its being edited by two leading forensic psychiatrists, Drs. Liza Gold and Robert Simon. Gun violence and mental illness are two subjects that, as a citizen, clinician, and forensic psychiatrist, I thought I knew too much about already. Well, I was wrong! Although edited by Drs. Gold and Simon, its contributors include a multidisciplinary group of professionals who define topics, discuss in detail evidence-based research regarding mental illness and firearm violence, and then propose revisions to clinical practice, advances in public policy, and needed research in this complicated area.
In her brief Introduction to the book, Dr. Gold delineates the problems that media coverage of mass shootings has presented. Such media coverage typically includes images of the perpetrators, who are portrayed as wild-eyed, dazed, or bizarre-looking young men. These images are inevitably accompanied by speculation that the perpetrator of a mass shooting had a mental illness and that it caused the deadly attack. The media reinforce the stigmatization of mental illness and unfortunate public belief that all individuals with mental illness are violent and dangerous. Dr. Gold defuses the mistaken belief that mental illness is the primary cause of gun violence and notes that mental illness and gun violence are complex public health problems that only rarely overlap at the time of a mass shooting. She supports her argument by reviewing evidence-based statistics that reveal that the number of people killed in mass shootings each year represent less than one percent of all firearm homicides. In contrast, two-thirds of all people who die by firearms each year (66%) have committed suicide. Most homicides and the bulk of all the remaining one-third of firearm deaths, are related to interpersonal violence. In contrast to homicides, most people who commit suicide have a significant psychiatric disorder.
Just a bit of a preview for the potential reader follows. This book is divided into two sections. Part I: “Defining the Problems,” and Part II: “Moving Forward.” Each chapter in the book is organized in the following manner. First, common misperceptions of a topic are advanced; next, evidence-based facts designed to refute the common misperception are summarized. The body of each chapter is an extensive review by a well-recognized authority, followed by statistical information and a thorough literature review that support evidence-based facts. Finally, each chapter concludes with a series of suggested interventions.
In Part I, I found three chapters of particular interest to me. In Chapter 1, “Gun Violence and Serious Mental Illness,” authored by Emma E. McGinty, PhD, MS, and Daniel W. Webster, SciD, MPH, after first discussing common misconceptions and evidence-based facts, the authors list the following series of suggested interventions.
Expanding firearm prohibition to include:
More individuals with a history of violent behavior that greatly increases the risk of perpetration of future violence toward others, specifically individuals convicted of violent misdemeanor crimes and those subject to ex parte domestic violence restraining orders should be temporarily prohibited from purchasing or possessing firearms.
Individuals with a history of risky substance abuse, which heightens the risk of violence toward others, specifically individuals convicted of multiple offenses of driving while intoxicated and multiple misdemeanor crimes involving controlled substances, should be temporarily prohibited from purchasing or possessing firearms.
Persons at high risk for substance abuse should be screened and provided evidence-based treatment when substance use disorder is identified.
The authors support a public health model approach, noting that the public health approach has been used to address several complex public health problems, such as motor vehicle safety, tobacco use/abuse, and car seats for children.
In Chapter 4, entitled “Mass Shooting and Mental Illness,” Drs. Knoll and Annas end their excellent contribution by suggesting the following interventions:
Policies and laws should focus on those individuals whose behaviors identify them as having increased risk for committing gun violence, rather than on broad categories, such as mental illness or psychiatric diagnoses.
Public health educational campaigns should emphasize the need for third-party reporting of intent or warning behaviors to law enforcement.
Institutions and communities should develop specialized forensic threat assessment teams to evaluate third-party reports of potential dangerousness.
Resources should be increased to provide enhanced education, beginning in elementary school, with a focus on constructive coping skills for anger and conflict resolution, mental health, and mental wellness education.
In Chapter 5, Dr. Peter Ash follows the chapter outline proposed by Dr. Gold. First he cites three common misperceptions:
Shootings in K-12 schools and in institutions of higher education are a major source of gun violence morbidity and mortality.
There is a profile of a “lone commando” gunman who is responsible for mass shootings at schools.
School gun violence occurs because people with severe mental illness have “snapped.”
Tertiary prevention efforts have also evolved with more experience of mass shootings. Improvements in police response tactics have been shown to reduce the carnage in some cases. After extensive literature review, Dr. Ash concludes his thought-provoking chapter by suggesting excellent interventions:
Screening and mental health resources for troubled youth in grades K-12 should be increased.
Antibullying programs should be supported in grades K-12.
More threat assessment teams in K-12 should be funded and implemented.
Students at all levels in grades K-12 and in institutes of higher education should be educated to take all threats or threatening behavior seriously and report it to appropriate personnel: “If you hear something, say something.”
School campuses should improve target hardening to reduce damage during an attack. Target hardening through such means as restricting access to K-12 schools and classrooms, practicing lockdown procedures, and arming staff make it more difficult for a shooter to kill in large numbers. However, such efforts come at a cost to the atmosphere of schools. Dr. Ash notes that such policies would change the ambience of schools and schools would no longer be calm, peaceful places for learning.
Who can argue with these suggested interventions? I can't.
In the section (Part II) entitled “Moving Forward,” although all chapters were of interest, I found two chapters especially informative.
In Chapter 12, Josh Horwitz, JD, Anna Grilley, MSPH, and Kelly Ward, JD, provide an in-depth discussion of the Gun Violence Restraining Order (GVRO). The GVRO is similar to a process used in the civil court system to intervene to prevent firearm violence from occurring. Family members, intimate partners, or law enforcement officials can petition the court to temporarily prevent an individual from accessing firearms if they believe the individual is in crisis, whether or not that individual has a mental illness. GVROs are available in a few states now: California, Indiana, and Connecticut. They differ in several respects, but are a creative, promising, and innovative policy for decreasing access to firearms to individuals who are at increased risk of harming themselves or others.
In Chapter 13, “Relief from Disabilities, Firearm Rights Restoration for Persons Under Mental Health Prohibitions,” authored by Dr. Gold and Attorney Vanderpool, the authors first discuss three common misperceptions. They then comment on evidence-based facts. I was surprised to learn that individuals prohibited from owning firearms on the basis of mental health criteria may be able to have their gun rights restored. The federal government and most states have Relief From Disabilities (RFD) statutes that provide a legal process through which individuals under mental health firearm prohibitions can petition to regain their gun rights. The evidence-based literature in this area is sparse, but the authors do review it. The chapter then provides a model for mental health RSD evaluation. The authors suggest a series of interventions:
State statutes should require independent psychiatric or psychological evaluations of RFD petitioners, similar to those of Oregon, and should specify that these evaluations include violence and suicide risk assessment. Absent such statutes, courts and administrative agencies that hear RFD petitions should consider adopting policies requiring mental health risk assessments as part of the evidence to be considered in RFD hearing.
This book is a major achievement edited by two leading and well respected forensic psychiatrists. It was copyrighted in 2016 and is an excellent compendium of the current state of our knowledge in the area of the relationship of gun violence and mental illness. The playing field is ever changing. I hope that new editions will be issued with regularity. The questions it addresses are complex, difficult, and emotionally charged, but critical. This book is also an invaluable resource for all mental health professionals, general physicians, public health officials, politicians, reporters, and others, in understanding the complex connection of mental illness and gun violence. It is a very timely analysis of these subjects. It also advances vexing new questions that merit additional evidence-based research and commentary. Most important, the authors propose innovative and creative public policy solutions to emotionally charged problems. I congratulate Professors Gold and Simon for this book on a subject about which as a professional, a clinician, and a citizen, I am deeply concerned. Their book is a major achievement!
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2016 American Academy of Psychiatry and the Law
