Not enough articles examine mental illness and gun violence in the United States. What is the connection between ‘mental illness and ‘gun violence’/violent behaviour? In recent months, the US has experienced a rise in gun violence. The current surge in violence is highly concerning and the reason highly contested. Regardless, the connection between gun violence and mental illness continues to be misunderstood.
Even more troubling is the stigma around patients exhibiting HI/SI (homicidal suicidal ideation) in the public mental health system. No one can say SI is without its privileged status in the HI/SI binary and viewed as less of a public safety issue. Call centers, warmlines, and hotlines are all geared to target SI or suicidal ideation. When someone is suicidal, it is considered a mental health issue needing urgent and careful clinical attention. However, people presenting as homicidal, or a danger to others, are considered a substantial public safety issue requiring police intervention.
Are the sick or mentally ill more likely to kill people? Not at all. However, when mentally unwell people are not given the right outlets and resources like hotlines and walk-ins without a clinician calling 911 or the local sheriff, people with mental health disorders will continue to hurt people unnecessarily if helpful and stigma-free treatment existed for people suffering from homicidal ideation.
Consider the loose nature of established and commonly agreed-upon definitions, especially within the mental health discourse. The terms ‘disorder’, ‘illness,’ and ‘diagnosis’ are sometimes used interchangeably despite having different meanings and applications. Even the word ‘mental health,’ the most generic and monolithic of all terms in the discipline, is commonly confused and rarely talked about in a way where everyone is on the same page. So, let’s move past a post-modern take on the issue.
First, let’s go ahead and probe into recent gun violence in the US. Mentally ill people can be violent and use weapons— either as a direct or indirect result of a heightened or mistreated condition. Untreated symptoms can make people or anyone (mentally ill or just resource-deprived) more dangerous, unpredictable, and desperate. The violence can be manifested inward. Mental ill people can be destructive or exhibit harmful behaviors toward themselves because their condition and symptoms are misdiagnosed, or mismanaged, in terms of their mental health treatment.
Mentally healthy people can also be dangerous and hurt people. First, on a political level, in terms of the military-industrial complex. Wars and mutually agreed upon violence; permissible killing presents a massive hiccup in the debate. But really, people are quite capable, when they are well or living a civilian life domestically hurt, kill their loved ones, strangers, or even sport. Mentally healthy people also hurt their fellow man during peacetime. The police and justice system call these behaviors homicide and murder. People aren’t mentally ill when they commit violent crimes like murder or assault, yet these people continue to make up a large percentage of people committing violent crimes. Let’s face it. People will kill anywhere, and in any condition, for almost any reason, whether sick or healthy.
Sadly, the more we crosswalk and compare, the more it seems people are built to kill, hurt, and harm others with guns or other violent means. Why am I suggesting this? Because only truly engrained harmful actions can carry out human instincts and behaviors proficiently at any level of human cognition, health status, sex, gender, age, religion, and every intersection of humanity.
Humans kill people for a diversity of reasons. Humanity can and is dangerous at times. Either by a person who is sick mentally or someone hell-bent on claiming life and harming others. The issue is how to assess which reason, why, and to what degree is lethality or suicidality? For tragedies like in Texas or any other number of school shootings, clinicians need to read the red flags a little closer or at least not miss them altogether.
Let’s explore a few caveats. Using myself as a case example, I have done many unfathomable things during my time of mental health issues. I still cannot express regret for many of the behaviors I feel were wrong. Since my diagnosis, I have also done wonderful, beautiful things in my lifetime and would never want to forget these memories. The light outshines the darkness every time my freedom is involved. People with mental health issues cannot ever give up this privilege – the right to fail.
Society grants people with mental illness this privilege, at least some do. Other cultures, states, and countries place limits on weapons and the movement and freedoms of people with mental health conditions. Suppose we continue allowing guns to circulate in the market. In that case, there will need to be more guidance from the current regulations and laws that guide psychotherapy and treatment of people with mental health disorders in the US.
In New York State, as in many other states in the US, unless you are mandated to or in a forced treatment program, you can fail out of society and be admitted to a psychiatric hospital for rehabilitation. Commonly called assisted outpatient treatment (AOT). People labeled V-SPMI (violently and persistently mentally ill) cycle back into the system. The pattern should go from being a patient in the hospital to independent living. But sometimes, life and mental condition take their turn.
Some states operate differently and offer people fewer freedoms. Some states provide more privileges but less supportive services. The endorsement of the right to fail must be a national human right for public mental health care recipients. Next to the modern mission of the New York Office of Mental Health and other states, mental health regulatory bodies profess dignity, hope, and recovery.
The sickest irony, no pun intended, is when people pay attention to the history of our mental health system. The all-important pendulum or risk continuum is called ‘dignity in risk, or risk of harm.’ By basic definition, ‘dignity of risk’ is the right to take chances when engaging in life exploration experiences and the right to fail in these activities or life without harming oneself or someone else.
For many Americans, ‘risk of harm’ is an impending threat. People with mental illnesses are not trusted, their judgement and insight may be impaired, and the public risks substantial physical injuries to themselves or others. Healthy people aren’t always trustworthy and could put the public in harm’s way just as much as their mentally ill counterparts.
And so, the debate still rages on in 2022.
The truth is, publicly, since deinstitutionalisation, society isn’t sure about the future of people living with diagnosed mental health conditions in the community. Unfortunately, the current mental health treatment doesn’t know the answers to essential questions and continues to be off the mark when predicting outcomes. Clinicians will need to do more to assess and predict public safety outcomes correctly.
Do professionals ever really know what other people can do? Clinicians assess for safety concerns and look at the complete clinical picture of a person before releasing their patients into the community. I think clinicians must begin to be more tuned into the degree of harm and predict the threat level. For example, clinicians may think someone is at risk of suicide but fail to indicate a more significant, more severe threat to him or herself or the public at large.
To do so, clinicians will need to be more trained in de-escalation and crisis intervention. Without knowing how bad it can get, it is challenging to get a read on what could happen if there is a sudden loss or drop in impulse control and what that might mean for someone who is actively homicidal or suicidal. Indeed, lethality is scaled. In terms of HI, SI, and potential risk of harm, clinicians sometimes forget these considerations are less static and exist as an abstraction and continuum.
So, all things considered? And is this enough? Everyone makes their own decisions moving forward.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.