Mental Illness and Gun Violence: Disrupting the Narrative

Mental illness receives prominent attention in the U.S. dialogue on gun violence, despite evidence showing that most people with mental illness are never violent and most gun violence is not caused by mental illness (“violence” refers here and throughout to interpersonal violence, not suicide) (1). Messages linking mental illness with violence increase social stigma, which contributes to low treatment rates and other negative outcomes among people with mental illness (2). Nonetheless, mental illness continues to be a central topic in gun violence debates such as the one prompted by the February 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida. Why does the narrative of mental illness as a major cause of gun violence persist, and how can it be disrupted?

The Evidence

Mental illness is associated with a statistically significant increased risk of violence, but most people with mental illness are never violent. In the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; wave 1, 2001–2002; wave 2, 2004–2005), the 12-month prevalence of any violent behavior was .8% among people with no mental illness, 1.7% among people with any mental illness, and 2.9% among people with serious mental illness. All of these estimates excluded individuals with a substance use disorder, which increases risk of violence among people with and without mental illness: in the NESARC, 2.9% of people with a substance use disorder alone and 10.0% of people with serious mental illness plus a substance use disorder had any violent behavior in the past 12 months. The estimated one-year population-attributable risk of interpersonal violence associated with mental illness is 4%, meaning that approximately 96% of all gun violence incidents in the United States are caused by factors other than mental illness (1).

Much of the public dialogue about mental illness and gun violence has been prompted by mass shootings. High-quality research quantifying the relationship between mental illness and mass shootings specifically is not available because of the statistically rare nature of such events, but the evidence clearly suggests that many mass shootings—as with other types of gun violence—are driven by factors with stronger and more direct links to violence than mental illness (1).

As noted above, substance use—particularly alcohol use—is linked with violence, as are anger, impulsivity, and experience of traumatic life events. Poverty, low education attainment, and issues stemming from systemic discrimination, such as racial residential segregation, also contribute to gun violence in the United States (1). Access to guns is a key risk factor that interacts with all of these other factors to produce gun violence.

The Narrative

Counter to the evidence above, mental illness is frequently framed as a cause of gun violence. Let’s consider four likely drivers.

High-profile mass shootings where serious mental illness played a documented role.

The fact that there are prominent examples of mass shootings in which psychotic symptoms played a role, such as the 2011 shooting in Tucson, Arizona, reinforces the narrative. Communication research shows that audiences tend to generalize the traits of these types of powerful but atypical examples to the broader phenomenon (2). A generalizing statement might be “In the Tucson shooting, the perpetrator’s actions were driven by the symptoms of mental illness; therefore, all mass shootings are caused by mental illness.” The fact that these perpetrators are frequently reported as having “mental illness,” a misleadingly broad term that includes common conditions such as anxiety, may both confuse audiences and increase public stigma toward the nearly half of Americans who experience any type of mental illness during their lifetime.

Difficulty conveying correlation versus causation in the relationship between mental illness and violence.

Many risk factors for violence, including substance use, trauma, and poverty, are also risk factors for mental illness. Just because a perpetrator had mental illness does not mean that mental illness caused the violent behavior (or that effective mental health treatment would have prevented such behavior). In reality, other risk factors for violence, which often co-occur, may have contributed to both the violent behavior and the mental illness (1). This correlation-versus-causation idea is not intuitive, and it can be challenging to convey to the public why, for example, efforts to document the role of mental illness in mass shootings by measuring the proportion of perpetrators with a history of mental illness are misleading.

The blurry distinction between mental illness and mental wellness.

Angry, erratic, or impulsive behaviors are often held up as proof of a perpetrator’s mental illness. Although these behaviors clearly signal a lack of mental wellness, they do not necessarily indicate a mental illness that can be addressed with treatment. As noted in a February 2018 New York Times editorial by Vice Chairwoman of Community Psychiatry at the University of California Davis Amy Barnhorst, “there is no reliable cure for angry young men who harbor violent fantasies” (3).

Interest groups’ desire to divert attention away from guns.

Gun rights groups such as the National Rifle Association (NRA) disseminate mental illness–focused messages to divert public attention away from the role that easy access to guns plays in gun violence. Similarly, these groups advocate for improving the mental health system as an alternative to strengthening gun restrictions.

Disrupting the Narrative

It is important to disrupt, as opposed to counter, the pervasive narrative about mental illness as a cause of gun violence. Attempts to counter powerful though atypical examples of scenarios in which mental illness led to gun violence—for example, the mass shooting in Tucson—with complex and unintuitive facts about the true epidemiologic relationship of mental illness and violence are unlikely to change attitudes of the general public, although such messages may be more effective with policy makers and others interested in gaining deeper understanding of the issue (4). Messages that oversimplify in an attempt to destigmatize—“people with mental illness are no more violent than people without mental illness”—are easily dismissed by audiences who have internalized prominent examples of scenarios in which the symptoms of mental illness led to violent behavior.

Disrupting the narrative by reframing the causes of gun violence is a more promising approach. The youth movement arising from the February 2018 mass shooting in Parkland has focused on easy access to firearms, as opposed to mental illness. We should avoid repositioning the blame for gun violence on other stigmatized conditions such as substance use disorder, but a focus on dangerous behavior holds promise. This is the approach taken by the Consortium for Risk-Based Firearm Policy, a group focused on developing policies to keep guns out of the hands of people who meet evidence-based indicators of dangerous behavior known to increase risk of future violent acts (4). In addition to alignment with the research evidence, this framing appears to resonate with a range of stakeholders. Mental health consumer groups have supported the consortium’s approach in multiple states, and the NRA endorsed the consortium’s gun violence restraining order (GVRO) policy in March 2018. The GVRO policy creates a civil restraining-order process allowing courts to temporarily remove firearms from individuals exhibiting dangerous behavior.

Should we disrupt the mental illness and violence narrative, or is drawing attention to mental illness as a cause of violence, although misleading and stigmatizing, the best way to increase investment in the public mental health system? In a recent study, our team found that nonstigmatizing messages emphasizing barriers to treatment and stigmatizing violence-focused messages were equally effective in increasing the public’s willingness to pay additional taxes to improve the public mental health system (5). Policy leaders interested in increasing investment in mental health services therefore have an effective, nonstigmatizing alternative to violence-focused messages, supporting disruption of the mental illness and violence narrative.