Psychiatry & Psychotherapy Podcast - What Causes Mass Shooting In America?

Episode Date: August 29, 2022

In this week's episode of the podcast, I interview Dr. Ragy Girgis, a clinical researcher at Columbia University in New York where he also completed his residency in psychiatry in 2009. He received a T32 (training grant) during this time and now conducts clinical trials and high-risk psychosis research. He practiced privately for a time, but is now a full-time clinical researcher. Although primarily a schizophrenia researcher, his interest led him to research the relationship between schizophrenia and mass shootings, leading to the creation of what may be the largest database on mass murder and mass shootings, studying cases dating all the way back to 1900. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Dr. David Puter has no conflicts of interest to report. Dr. Raji Gergis has the following complex of interest. In 2021, he was a paid consultant for IMS expert services. In 2020 and 2021, he was a paid consultant for Noble Insights, a research

firm. In 2020, he received book royalties from Wipth in Stock and book royalties from Rutledge, Taylor, and Francis. And in 2019 and 2020, he was an expert consultant for Fowler-White Burnett in Fort Lauderdale, Florida. All right, let's get to the show. go. All right, welcome back to the podcast. I am joined today with Dr. Ragi Gerges. He is a Columbia residency psychiatry graduate 2009. He had a T-32 teaching grant during that. He now conducts clinical trials, high-risk psychosis research. He did private practice for a while, but now is full-time research. He is doing research as well in mass shooting, and so reached out to me and had some thoughts that he wanted to put out there. So we, you know, had about 20 emails back and

forth. And here we are today going to break down what he considers the largest database on school shootings that exists, right? That's right. Mass shootings and actually mass murder in general. Yes. Okay. And so just for my audience, like, what got you excited about this topic or what kind of led to your interest in this topic? Sure. Well, first of all, thank you for having me on the podcast. I really appreciate it. I've really appreciated the discussions that we've had up until this point.

And I know that our next discussions, the ones that we're going to have over the next hour, hour and a half, are going to be really wonderful. So thank you so much. I am a schizophrenia researcher. That's my primary area of interest. As you said, I conduct clinical trials and brain imaging research. And over the last several years, I became interested in violence and schizophrenia and violence, psychosis, how they're related, how they're not related. And, I mean, most importantly, we all know that although having a psychotic disorder slightly increases the risk of violence, that increase in risk, that increase in risk is very slight.

The vast majority of violence is not perpetrated in general. The vast majority of violence in general is not perpetrated by psychotic people or people with mental illness in general. and especially mass murders. So we all know that you're a psychiatrist, I'm a psychiatrist, people in the mental health field know that. But unfortunately, one might not appreciate that based on what one might hear or see in the media

or other places. So our goal was to basically prove using proper research methods and evidence-based data, and research methods, that there is essentially minimal to no risk associated with or between mass shootings, mass murder in general, and psychotic illness. To do that, we basically put together this database. And again, we wanted to do it in a very systematic way, in a way that could be replicated, kind of like as if we were conducting a meta-analysis or a systematic review.

And we've published this all now. But we, again, through a lot of work and systematic methods, compiled about 1,800 mass murders, which we defined by any instance in which three or more, in which three or more fatalities occurred in one event with no cooling off period. These included mass shootings and were dominated by mass shootings. mass shootings comprise about 65 or 70, 70% of these mass murders, but also mass murders perpetrated with other methods, such as stabbings and cars, bombs, stuff like that. All those sorts of things. And how far did you go back historically?

We went back to 1900. Whoa. Okay. And we examined mass murder all over the world. We limited our database to personal cause mass murder, which means mass murder that doesn't occur in the context of, for example, some sponsored terrorism or gang violence or war or something like that. So someone could have a political motive for a mass murder, but that couldn't be group sponsored in any way or sponsored in any way. So this is just personal cause mass murder,

which comprises the vast majority of, for example, mass shootings that people are aware of and and are reported by the media. So we had about 1,800 of these. And another thing that we really wanted to do was compare groups. And that's really important because unless one, as you probably know, can compare groups, there are many variables that could, or characteristics that could maybe bias or confound or confuse a result. And that's why it's very important to compare groups as opposed to just looking at,

numbers in isolation. So our main comparison in our database and analyses was between people who perpetrate mass murder with firearms, otherwise called mass shootings, but with firearms. And they could use actually other methods in addition to firearms. But bottom line is one group committed mass murder with firearms or at least with at least one firearm and then a group of people or a group of events in which no firearms were used. And we found a number of things. One is that while 8% of the people among mass shooters had some sort of history of psychotic

illness or psychotic symptoms, 18% among individuals who perpetrated mass murder without firearms did. Okay. So eight versus 18. So 18%. So much higher in the people that did it without guns. Yes. Car, bombs, stuff like that. Yes.

And why that's important is that not just the absolute numbers themselves, it's the comparison. And the question is, is there some specific relationship between guns or mass shootings and psychosis? And this shows that there isn't. There isn't. When people who are psychotic perpetrate mass murder, they tend to do so with methods other than guns. So there is not some sort of specific relationship between guns and psychotic illness.

There are several other lines of evidence that support these findings. So one of those, as most people know, and as we also demonstrated in the paper, the vast majority, like 95, 96% of individuals who commit mass shootings are men. that number is lower, still very high, of course, and the proportion of individuals who perpetrate mass murder without firearms, who are male or men, is still very high. But when women perpetrate mass murder, they tend to do so without firearms. That's number one.

Number two, when women perpetrate mass murder, their psychotic, or have a history of psychotic illness, much more frequently. We're talking 30% or higher. Wow. And number three, speaking more to violence in general and its relationship to mental illness, but also related to this question

whether psychosis is related to mass shootings and gun violence in particular, the mechanism by which mental illness, especially psychotic illness, sometimes mood disorders, and substance use disorders or substances in general, slightly increased the risk of violence among people in general is by impairing impulse control.

So impulse control is what we would consider in the kind of ego psychology realm of psychodynamics is an ego function. So impulse control is an ego function that most people have, and obviously this lies along a spectrum. So mental illness, especially psychotic illness, affective disorders, substance use disorders impair, control. Research has shown that the effect of substance to use, affect disorders, psychotic illness, mental conditions in general on impulse control is greater in women. That is probably because young men, the people who generally perpetrate mass murder, already have problems with impulse control. So all these lines of evidence support

our own data and results and our general conclusion that psychotic illness does not have some sort of specific relationship with or to guns and mass shootings. Okay. And I want to step back a little bit and talk about the prevalence. So you said the prevalence was seven per billion people from 1990 to 19. 1970, and it's increased to 14 per billion people. Is that correct? That's right. So the rate, and so these are rates, these aren't absolute numbers.

These are rates, and I'm glad that you mentioned that, the rate of mass shootings per billion people between 1900 and 1970 was extremely constant at about seven, like six point eight or something like that, but about seven. the rate of mass murder perpetrated with other methods between 1900 and 1970 was exactly the same. I mean, incredible. Wow. Since 1970, the rate of mass shootings, again, per billion people, these are rates, has increased fourfold to 20 feet per billion people. The rate of mass murder committed with methods other than firearms has increased twofold to 14. There's a lot to wound pack here. And that means a lot of things and that has a lot of implications.

Specifically, with regards to how that affects our thinking about the relationship between psychotic illness and mass shootings is another result that we did include in our paper also, and that I'll share here. And that is that we also, and again, this reinforces the importance of examining mass murders over time and worldwide and all sorts of different types, is that we examined the relationship or the association between psychotic illness and mass shootings, mass murder in general, over time. And what we found is that basically the percentage of mass shooters among mass murders in

general has gone down over time. So while the rate of mass shootings has increased, the rate or the percentage or proportion of mass shooters with some sort of history of psychotic illness has gone down. So another or some more data supporting the thesis that psychotic illness and mass shootings don't have some sort of specific relationship or association. I will mention people with psychotic illness seem to be slightly overrepresented among those in the general population. However, that overrepresentation is very small and accounts for a very small minority

of mass shootings. Furthermore, as you probably know, people such as my colleagues, Paul Alpabam, Jeffrey Swanson, other people, experts in the field have already published very effective, clear, detailed strategies for decreasing mass shootings and gun violence in general among people with psychotic illness and mental disorders in general. Those strategies are effective, have been proven. All this is to say that, well, again, the number of mass shootings, shootings that needs to occur for any cause needs to be zero. If we really want to make a difference in how often these sorts of events occur, we need to probably put more attention on and focus

on other things besides mental illness. Yeah. So I think it's, when I look at that number seven per billion, I think to myself, like, that is a very small number. I mean, contrasts that just the general homicide rate of 6.5 per 100,000 of the U.S., you know, like we're talking about a very, very small number. Yet, when I meet young patients nowadays, it is in their mind that this is a reality that they could experience in their high school, you know? So it's like, I almost feel the fear has got into a place that's like, it's like every high schooler I meet. Like, this is something that they talk about. Like, I have one patient who is proficient in firearms and yet would never post a picture of them shooting a firearm for the fear or even talk about it with people, you know,

that they're proficient in this, that they've competed and stuff because they're afraid of being labeled a potential mass shooter, right? And what do you think about that sort of like the level of fear seems disproportionately higher than the reality of, like, what would actually kill a young person. I hear what you're saying. This is a very important observation. I'm glad you've brought this up, and we've discussed it before. It's critical.

One, I see the same thing. And I've spoken with many people, and people say the same thing. People are very distressed about this. And they should be. It's very distressing. It's very distressing. And that in and of itself is important. The distress, you know, to some degree, comes.

from the media's romanticization of gun violence, unfortunately, which even more unfortunately, is self-perpetuating and self-reinforcing. It scares a lot of people, like you said, and it makes a lot of people just scared of this sort of thing. And it is very scary. I think there are very few people who aren't scared about it. Like I said, it's unfortunately self-reinforcing. And there are many other lines of evidence and reasons why basically there's a consensus among experts at this point, but one consensus strategy for decreasing mass shootings, especially the type of mass shooting that most of us are aware, the school shootings, the very public shootings, which represent in themselves actually a minority

of mass shootings, and hopefully we'll get to that in a bit, would be for media in general to stop publishing personal information or photographs of those sorts of things of individuals who perpetrate mass shootings and mass murders. That would have two effects. One, it would decrease the number of mass shootings. I think most experts have come to a consensus about that. And number two, it would decrease the fear that we all live in that we're going to go through one of these things.

It is possible. And we should be scared. These shouldn't be happening. Even 28 per billion. And that's events. That's not victims. that's events is way too high. The majority of these do happen in America. So that that rate is a worldwide rate. The rate obviously in America would be much, would be much higher. I guess it would

be if we have, if we have about 5% of the population, it would be five times that. So it would be approximately 150 per billion. And these sorts of things should never happen. And they often target unfortunately the people who are most vulnerable, young people at schools and those sorts of things. It's very scary. And I want to say to my audience is that like the left side of my brain that's more like kind of just pure reason is like, I shouldn't fear this. This is not something that's going to lead to my death, right? The other side of my brain, you know, I was in, I was living in like San Bernardino area

after the San Bernardino shooting. And I specifically remember like not wanting to go to parades, not wanting to go to farmers markets, not like when I go to a grocery store like sit or, you know, kind of situational awareness was elevated. You know, when I go to a coffee shop, I would sit in a place where I could see the front door. Like, I had a plan on what I would do if someone came in with a gun. So there's like the emotional reactive side of me, right? And then there's also like the reason, like, okay, like the reality is, is that this is a very, very rare event. The place that it takes place the most often is on the media. I'm afraid that even if, news stations stop talking about the person, someone is going to. You know, like on TikTok, I remember after the last shooting, like there's a lot of people who were gaining hundreds of thousands of, you know, fans a day from reporting very closely what was going on.

Every detail is scrutinized. And there's just like this obsession that we have in America over, like, will tell me everything about this person that did this event. you know i mean some of the most downloaded podcasts are true crime podcasts right so it's like there there's a hunger and an appetite for this but what you're saying is that somehow that we need to educate people to not talk about or to glorify right is that is that what you mean by the romanticization of like it's the shooter that's romanticized and like spoken about so much that it gains them so much attention that it leads to like

almost like an increase in future shooters by that sort of attention that's given. Is that what you're talking about? That's definitely part of it. That goes into motive. And first I want to correct the number. I said since the U.S. represents about 5% of the world's population, that the rate in the U.S. would be something more like 150, it would actually be more like somewhere between 4 and 600, 4 and 600 per billion.

But yes, going to, well, first I'll say this. Asking the media to stop reporting on personal characters, they can still report about the event, but asking the media to stop reporting on personal characteristics and sharing photographs of perpetrators is not a big, big ask. Think about how they do that when any sort of new story involves a minor. Very simple, very simple. They do all the right.

That's not a big ask. And that then would, if the media then were to stop reporting on those things, secondary media in these cases or secondary news media like other sorts of social media would follow suits. I don't think that would be a big thing. Now, back to the romanticization of gun violence. Yes, news media or any media reporting on these events, and in particular sharing personal information about perpetrators is an indirect way of

romanticizing romanticizing gun violence, although that, I think, speaks more to the direct motives that a lot of these school shooters and especially the public shooters shooters have. Again, it's a consensus, I think, among experts

and that a lot of the motives are a lot of the motive, a large part of the motive, you know, motive is complicated and multifactorial, but a lot of the motive for perpetrating mass shootings among many of these, especially young,

young males and whatnot, is their desire for notoriety. A lot of them are very down and out, very empty. Many of them have decided to end their lives, again, somewhere between 30 and 50% of these individuals, suicide during the events or the attack. So they've decided to end their lives. They're empty. They feel rejected by the world, whether or not the world is actually rejecting them. So they feel that society is rejecting them. They feel very angry about society. They're deeply narcissistic and they crave no variety. So define, just define deeply narcissistic. Like what are we actually talking about? Because I know it can be used in like popular terminology where I'm curious what you mean by it specifically. In this sense, these these young individuals

feel that they're much more special than they in certain ways than they otherwise are and basically deserve some sort of, again, fame or notoriety in a way that is not consistent with their accomplishments or who they are,

what they've produced. It would be normal for a world-class individual who's accomplished a lot, whether a scientist or an athlete or something else, to expect some sort of notoriety. That would be expected.

They've accomplished something great. But unfortunately, there are a large number of people who have not necessarily accomplished anything for which they would expect society to deem them as famous. Right. We think they deserve that sort of fame. And committing a mass shooting instantly moves them from someone that no one will pay attention to.

potentially no girl would date, you know, maybe they're ostracized and kind of like a loner, you know, and rejected, they feel this rejection. And I think it's important that you specify that it could be the rejection by everyone could be also not quite reality, right? Like there could be, like, I'm thinking specifically how often depressed people think that they have less social contacts than they really do. So they have this sort of nihilistic viewpoint that leads them to this despondency of like, okay, how do I gain notoriety?

And look, the public has this solution, gain notoriety right away by committing this horrible crime. So that's kind of your thought? Or would you change anything or add some nuance to any of that? No, you got it. And unfortunately, you're exactly correct about all of that. By definition, what they're feeling is not based in reality, including the rejection, often that does occur in the concepts of some sort of romantic feeling. And again, unfortunately, you know, most people are aware that one way to gain a lot of notoriety and infamy,

especially if you're planning on ending your life very soon is to perpetrate a mass shooting in an environment such as a school or some sort of public place. Unfortunately, that is what it comes down to. And this is what probably the majority of experts in the field think of this point. All the more reason why we really have to ask the media to stop giving a platform for these people,

even after death, even after death. Yeah. Yeah. And I think it's kind of like how the ape, when they see a snake, they stop and watch the snake, right? And they call their buddies over to watch the snake. And they'll stand there for like two hours watching this big snake, you know, keeping a little distance but to watch the snake. It's like, or like just naturally we want to focus on negative things. Like our brains are kind of wired that way so that we can like potentially protect ourselves.

And I think so in that way, we have this, like, fascination with these perpetrators of this, these horrible acts because they're so horrible and so just absolutely heart-wrenching, right? Children, nothing is worse than the killing of children. It's just, like, absolutely just disgusting. And so we just naturally give an inordinate amount of attention. It's like, how do we change ourselves, you know, educate ourselves? It's like how do we sort of, as a culture, say, like, no, we're not going to do this anymore. I don't know.

Do you have any more sort of reflections on that? You're right again. It's hard not to be drawn in by these sorts of stories. Just like it's hard not to be drawn in by any story that's so hearts believe and is impossible to even, you know, really fathom for 99.99% of, percent of people. And again, unfortunately, the perpetrators know that. The media probably knows that. And again, we would ask for media to stop reporting on personal attributes of these people and stop publishing their photographs. That should do something. It won't stop all mass shootings, but that would be a start. And then there are obviously other strategies that we,

you know, we can talk about and that would affect other types of mass shootings. Like I mentioned, And the school shootings, those very public shootings, actually comprise about 10 to 50% of all mass shootings. In America, especially, 25% of mass shootings happen in the context of some criminal act. And again, not gang-related, not otherwise, but they usually involve someone with a gun, often planning to, for example, commit some crimes such as theft or something like that, in that context having to, in their eyes, perpetrate a mass shooting in order to, you know, make sure they don't get caught or that type of thing. That actually comprises about 25% of mass shootings in America. And that is unique among America. That is not seen in other countries. That is

quite unique about America. The other... Wait, can you say that again? What's unique about America? Say that again? So when we examine mass shootings across countries, this particular type of mass shooting or motive, if you want to say, for mass shooting. The kind of criminal motive or the mass shooting occurring in the context of a crime is quite unique to America. Quite unique. That's not seen as much in other countries. Huh.

The other type of mass shooting that is seen all over the world, and comprises about, including America, and comprises about 50% of mass shootings, is the type of mass shooting in which some middle-aged man undergoes some sort of severe acute life stressors such as loss of a job, loss of all of their money, separation from their partner

has the partner leave them or something like that. And they, again, very acutely, like just, you know, in the moment, gain access to a gun and usually kill their family, their close ones, and then usually generally themselves. And a lot of these people

don't have mental illness of any sort. I mean, most most mass murders in general don't have mental illness, especially mass shooters. Most don't. But this type also generally doesn't, but a lot of them, if not, most of them tend to suicide. And then like I said, they, they kill their family members or close acquaintances in the context of what's going on in their lives. So I've thought about that statement, like most mass shooters don't have mental illness. And when I posted this publicly, I got this here. huge sort of uproar of like, well, how could you say that there's not something

psychologically wrong about these people? And so I think can you differentiate something being psychologically wrong? We've talked about them being more narcissistic, fragile egos, this entitlement, this sort of sort of some fixed thoughts, isolation. Like that seems like there's mental health issues going on, but how do you differentiate that between like your statement? Most of them don't have mental illness. This is, I think, the crux of the issue, especially for us and for people listening to this podcast, I imagine. I think there are a couple of things going on here, and we will go into the psychological side of it for sure, because that's what's important. But to back up even further, go more upstream of it, one thing I discussed in a number of forms, including in a book that I wrote a year or two ago, is that a lot of people, I mean, this is probably obvious, but a lot of people don't understand what mental illness is for a number of reasons.

reasons. I think a lot of people still equate mental illness with immorality, bad behavior, demons, Satan, those sorts of things, if someone believes in those sorts of things. I think that's, I think that's kind of the first hurdle we need to get over. And I think that's a large part of this. There really are a large number of people, a large minority, if not a majority of people who really think that mental illness is a moral failure and related to sin and those sorts of things. It isn't. You know, bad behavior is most often not caused by mental illness. Bad behavior has a lot of causes. But I think that's the first step. We have to realize that mental illness is not equivalent to bad behavior or sin or demons or anything like that.

I speak from a, from a perspective of being a Christian and, you know, caring a lot about my community. And then writing the book that I wrote a few, a few years ago, knowing that probably the majority of people in my own community, you know, do believe that mental illness and sin and bad behavior are kind of, if not one in the same, very closely related. And I've tried to fix those sorts of beliefs. Faulty notions. Those perceptions. Yeah. And so you've tried to sort of talk to the audience that believes different than you. That is probably a more sort of less educated, you know, not educated in the science of mental illness and the studies and the brain stuff that goes on.

and the neurodevelopmental consequences of mental illness. Yeah, when I'm talking to people like that, it's like sometimes really hard to get through. And sometimes I start with delirium because even their grandma can have delirium and they're not going to believe their grandma's possessed all of a sudden acutely when they have a urinary tract infection.

Sometimes I go from there to try to talk to them about, you know, therefore there are these diseases like schizophrenia probably being the one most commonly associated with like demons where they have very sort of you know spiritual themes often in their hallucinations and delusions but you know you take a schizophrenic patient who all they read is delstoewski and they believe they're in some sort of doostoevsky novel and you take them and put them into um i've treated some psychiatrists over in um the middle east uh coaching more coaching not not actual like therapy but coaching and these psychiatrists will tell me

like all the delusions and hallucinations are around Muhammad, you know, and Islamic themes. So is that kind of what you're saying, or is there other sort of things you're mixing into that as well? That's exactly what I'm saying. That's exactly what I'm saying. A lot of what you're describing are the context, and that's part of the reason why a lot of people think that mental illness and, you know, and sin and Satan those sorts of things are kind of one of the, the same. There's the contents of delusions and allusionations and it's often religious because religion is important to a lot of people. And so obviously the content is going to reflect that. It doesn't mean that religion and mental illness are the same or there's a causal relationship or a cause and effect relationship between them, especially between, you know, sin and mental

illness or vice versa. It doesn't it doesn't logically make sense. It's certainly not scientifically or neurobiologically. And it's hard to get people to, including educated people, probably maybe not, obviously, people within the field, although many within the field, but certainly and hopefully not people within the field who are also religious. But I think that's one major hurdle. And it sounds like you also understand that that's kind of an issue. Yeah.

But bring that home to where we're talking about mass shooters and mental illness. And, okay, so most people don't understand what mental illness is. mass shooters, according to you largely don't have mental illness, but they have something else. Do you consider a moral component? Maybe we'll not jump there quite yet, but you can answer, kind of bring it, bring it home with what you're talking about there. Right. Well, I will tell you, I will tell you, I do think there's a moral component to mass shootings and killing people and doing, doing bad things like that. I think at some point, you know, I definitely don't think mental illness is involved in the majority of these. And for the most part,

these, and in most cases, mental illness, if a perpetrator has mental illness, it's incidental. And we've actually also shown that in the paper that in most cases, it seems like mental illness is actually quite incidental. I think this, you know, at some point, evil just, you know, takes this course. And this is maybe going to get to the next part of the discussion, what we're going to talk about and what you are kind of referring to about the ego and impulse control and ego functions and all these sorts of things. And that is, at least in the psychodynamic world. Obviously, as you know, but maybe for other people,

there are different theories of the mind and ways of thinking about how the brain works and motivations and what we call psychodynamics and whatnot. But there are kind of many ways to look at this. For one who isn't, and I imagine a lot of people, obviously, aren't religious. The way we think about it from at least a psychodynamic perspective, And certainly, as we were discussing before, being a Columbia trained psychiatrist myself, I tend to see things from the psychodynamic perspective.

Not that I'm not affected and think very highly of many other perspectives. I was just most influenced by the psychodynamic perspective. And so we see things in kind of the Freudian way, the Kernbergian way, and those sorts of ways. There are what we call ego functions. And ego functions are characteristics and traits. such as our ability to manage our anxiety tolerance, to maintain stable affects or moods, to plan, you know, cognition is an ego function.

Impulse control, our ability to control our impulses is an ego function. The id is or represents our fundamental, maybe slightly more primitive drives. And then we have a super ego, which other people might call conscience and those sorts of things, you know, also, you know, balances the id and helps control things. Either way, what we know for sure is that this seems obvious, but people who commit mass shootings and these sorts of very tragic events

have difficulties with impulse control. Mental illness can affect impulse control, like we've discussed, although, again, most people who commit and perpetrate mass shootings and mass murder in general don't have mental illness. So where does impulse discontrol come from? I mean, this is the nature versus nurture thing. But for a number of reasons, chronic life stressors or even acute life stressors can affect our ability, can control our impulses. You know, everyone functions at different levels of, again, from the psychodynamic sense, what we describe as levels of personality organization.

There are the healthier personality organizations. And these corresponds to what people may be better familiar with, defense mechanisms, that they're healthy defense mechanisms, there are less healthy defense mechanisms. The healthier and mature defense mechanisms include things like altruition and those sorts of things. And those are what we call it. Those would be used by people who are, how we describe it, organize it at a more mature level.

Then we have the kind of neurotic level of personality. organization, which still lies on the healthier side of the spectrum. These people, they have intact reality testing. They use neurotic-based defenses, which are, again, considered relatively healthy. They have consolidated identities. They know who they are. They understand how they relate to other people. Those are what we describe as object relations and object being a person. I'm an object. You're an object. People are referred to as quote-unquote objects. So they understand where they begin and end. They understand where other people begin and ends. And then we have, so those people generally do not commit mass murder or mass shootings.

In the context of a very acute stress, one can then start using more immature defenses and kind of function at a lower level personality organization. But for the most part, these people aren't the people who are going to commit mass shootings and mass murder and those sorts of things. Then we then we move into the less mature or less highly functioning levels of personality organization, the borderline organization that the lower end, the psychotic level of organization. These people use splitting-based defenses like like splitting, projection, projective identification, those sorts of things. They, they tend to have something that we call identity diffusion. their object relations aren't good.

They don't have as good of a sense of where they begin and end and where other people begin and end. They don't have as stable a sense of themselves. And the reality testing is impaired. People at the borderline level of organization tend to have relatively good reality testing, though their reality testing is not quite as stable as someone with a higher level of personality organization.

So it doesn't take quite as much stress to impair the reality testing. And then at the psychotic level of organization, again, from the personality organization framework, not from the, not from the DSM, Axis 1, speaking of DSM 4 more so, but Axis 1 description of, of, and categorical description of diseases. So the psychotic, people who function at a psychotic level of personality organization have poor reality testing, use psychotic level defenses and have severe identity, identity diffusion. So there are a number of people who go through life, and certainly most people who go through life with a borderline or even a psychotic level of personalization, certainly who don't commit mass murder and perpetrate

these sorts of things. But there are some who are more susceptible, again, because of nature or nurture or other things, who are, as we discussed, confronted with some sort of severe acute stress, are unable to handle it and act out. It's a great review of kind of that psychodynamic organization of neurotic, borderline, psychotic. And I would add, borderline here is not borderline personality disorder. And it's more like what defenses they're choosing,

what their reality testing is. So you're saying, although these people have more, of the psychotic level of personality organization. They don't meet a criteria for like a specific mental illness. Like they don't have schizophrenia. They don't have bipolar. And so the majority of them do not have a mental illness proper, like a DSM diagnosis. Is that what you're saying? Thanks for clarifying. This is an important distinction. Everyone has a personality. No one's personality is perfect. We all function at different levels of personality organization. This is completely distinct from mental illness per se.

Mental illness, which is much more, it's categorical, even if it's not categorical and it's, in the lives along a spectrum. We're not talking about mental illness here. We're talking about a different way of thinking about one's personality, organization, or character structure. This is completely different for mental illness. And this gets more into what, like you said,

a lot of people who aren't steep in this sort of thing or been taught these sorts of things might not understand. Again, we all have personalities and we all have defense mechanisms and ways that interact. This is all about basically just ways of interacting with the world. And this is how we in the kind of psychodynamic field or who are who were taught psychodynamic theory, think about personality structure and again, behavior and how we interact with the world, motives and what determines behavior and what we're, what we, we decide to do and what we decide not to do, what we want to do, what we decide not to do. There are many other ways of looking at it.

You know, there are other ways of looking at it also. This is kind of the psychodynamic perspective on just basic drives and motivations and behavior and character structure. I think at this point, I've heard Joe Rogan a couple times say either on Twitter or somewhere else, and this just annoys me to no end, that, you know, there's all these people committing these mass murders on medications. and it's the medications that cause the mass murders, you know,

or at least that's the way it seems like he's talking about it, where I was looking at this, the mass shooter database, which is much smaller than yours, but it's the prior episode I did on this, and they just came out with an update, and they found that out of the 182 cases that they have, 34 were in known mental health treatment in the past six months.

So a very small percentage, in mental health treatment at all. And out of the 182, there were only 43 that had ever been prescribed psychiatric medications. The rest had no evidence of psychiatric medications. And I put on my website actually a list of all the medications so that you could look at all of the cases. And it's a very, it's a cornucopia of medications. Like it's not like there's one class of medications that these people were on. They're on sleep meds.

antipsychotics, antidepressants, Xanax, you know. And so it's, as I look at this list, there's no sort of theme, you know, like, oh, it's SSRIs, right? Anything that you can add on, like, medications being the cause of these events or, you know, the lack of mental health treatment that most of these people go through prior to the events? This is such an important question. I'm so glad you asked this question. very definitively answered this question for you that psychiatric medications play no role in mass shootings and mass murder. I can be so definitive because I've examined 1800 of these

and very few. I could probably count them on what we're talking about, a couple of percents maybe or less are on medications. A lot of them who are taking medications at the time of the event were not really taking them. I've reviewed some of these also. And in some cases, what they would say, the report was actually that they found traces of some sort of psychiatric medication in the person's blood.

What people might not realize is that the blood levels of those medications were very low, essentially sub-therapeutic, so not therapeutic. So the person really wasn't taking the medication. They were actually untreated. As everybody, the field knows, if there's any risk of violence among people with mental illness, and again, that risk is only slightly higher among people with mental illness than not. That's almost exclusively

among unmedicated people. So one, I can be so definitive about this because the number of mass murders and mass shooters who are actively taking therapeutic doses of medications, this doesn't include people who may be misusing them, like someone who may be severely abusing a, you know, a that can be abused wouldn't count. But the number of people taking psychiatric medications who perpetrate mass murder is about one or, you know, a cup, one or two percent total. You mentioned the number from the people from the Violence Project. They have a great database. They've done so much in this field. We cite their work. They're really fantastic. The only difference I would say, you mentioned a slightly higher number. The reason why their

number is slightly higher is because they have in their database a sample that is representative of an important subgroup of mass shooters. And that is a subgroup of mass shooters, whom we are most familiar with and who tend to receive the most attention in the media. It is also the case, as you're probably aware, that people who have mental on this, or let me put it the other way, mass shootings and mass murder perpetrator, mass shootings or mass murder that are perpetrated by people who have mental illness tend to receive the most media attention. They receive more media attention than mass murder and mass shootings perpetrated by people who don't have mental illness. And a lot of the mass murders and mass shootings that have received the most attention,

or these ones that have received the most attention do have a disproportionately high number of people who might have had metronous. Again, it's not very high, but it's higher than what the wheel number is. And that may be, you know, contributing to these different numbers. Either way, that's why it's, you know, it's helpful to have groups and larger numbers and whatnot.

So I can tell you definitively, we've reviewed 1,800 of these, literally 1 or 2% are on therapeutic doses and medications. and I will go a step further. My research focus is on psychopharmacology or the study of psychiatric medications. And there is a wealth of data to suggest that psychiatric medications

specifically improve impulse control. Their direct effect is to improve impulse control. There's a wealth of data to support this. So that's why I can say, that there is essentially no debate about this. Psychiatric medications do not contribute to mass shootings and mass murder. Yeah, that's good. I think I'm still sort of thinking about this, like the personality organization,

than being more on the borderline or psychotic personality organization. So higher impulse control, higher denial, more primitive defenses, so more projective identification, more, you know, blaming other people for their own stuff, you know, rather than sort of taking responsibility for their own emotions, putting it on other people, you know, projecting it out there. Those, when I think about these people, they may, they may not be like the prototypical, like, person that's going to come into your office, but I still think that they would really benefit from prolonged psychotherapy. Any thoughts on that?

I agree with you 100%. That's exactly what psychotherapy is for. That's why Freud and Kernberg and Cohut and Beck and all these people are so important. I'm a medication person. That's what I do. I'm a psychopharmacologist, but I know very well that medications are great, and they treat a lot of people, and they improve impulse control and these sorts of things. But psychotherapy is just as important as medications, if not more important. I recommend that to almost all of my patients.

And it is only through psychotherapy that a lot of these dynamics and struggles and difficulties with identity diffusion can be treated. Can you just define identity diffusion? Because I think it might be a term that people haven't heard before. Sure. Yeah, to say it in a way that is maybe less technical. Identity diffusion involves a lot of things, but maybe one way of showing what identity diffusion is,

is in how one values oneself. I know that I know that I'm valuable because I'm a person and because I have thoughts and feelings, and these feelings are valuable, just because I'm imbued from birth with these sorts of values and characteristics. I know the same thing about you. You are valuable, and what you think and feel

is valuable because you are who you are and you're an independent person and it's okay to have those sorts of those sorts of things whether we disagree or not and that's just that's just normal and what you think about yourself for me doesn't affect me in any way

or my value or my worth and vice versa someone with identity diffusion wouldn't think that way someone with identity diffusion would value themselves not solely based on their own self-worth, which itself might be lacking, but they would put too much emphasis on what other people think about them, how other people treat them, and vice versa. They would use defense mechanisms such as projective identification, which you basically already just described, but that is where

that that's a situation in which I attribute my feelings, which, if we're talking about mass shootings, and mass shooters could be that unconsciously, I feel that I have little self-worth. I have little value to give to society or anyone. But rather than sit with those feelings, think about why I feel that, and understand that those feelings are coming from me, I would, again, because there's identity fusion and there's not much of a boundary or border between you and me, I would project those feelings onto you, those feelings about me onto you, so that it's no longer

me who thinks that I'm of no value and I have low self-worth and I can't offer much to other people. I would think that that's you thinking those things. And now you're the bad object or bad person. You're the one who doesn't think I'm valuable. You're the one who thinks I'm a bad person or isn't worth anything. that's that's kind of a description of one example of of identity diffusion and projected identification in action okay yeah i appreciate that okay let's let's move on to what you think about kind of the culture and the acculturation and violence like in movies and video games and you know when i interviewed the people from the

mass shooter database they talked about how they didn't think that there was an association between like violent video games and mass shooting. But it seemed like you kind of thought that that, you know, media played a role to some degree. Can you, can you maybe share with me your thoughts and where you get your thoughts? Sure. This is very important. It's not just about video games, but video games are certainly part of media. I'll describe this in a few ways. So as we mentioned before, the rate of mass shootings and mass murder general, but let's just talk about mass shootings was stable between 1900 and 1970, and then increased fourfold after 1970.

One can speculate as to why this is the case, but, you know, this suggests, and all the other data that we discussed and data that we haven't discussed suggests that it's just that gun availability is important. There's no doubt. Gun availability is important. But to go into this a little bit more, one other thing we showed in our paper is that other methods of perpetrating mass murder are actually, or actually results in many more fatalities than guns. So a lot of people think that people use guns to commit mass murder because guns kill the most people. Guns are extremely deadly. However, there actually are other methods which are quite available and can be more, can be more destructive. Yet people choose guns.

guns, gun violence and mass shootings dominate mass murders in general. So the question is, why are people choosing guns when there are potentially other methods that are maybe more deadly and even potentially very available or even more available? So why are people still choosing guns? So number one, I want to mention this, this suggests that managing gun availability is even a bigger issue because people will choose guns. People just want to use guns. It's not just that they want to cause damage and commit mass murder. It's that they want to use guns to commit mass murder. That's critical. That's critical. And this might seem like, like, you know, yeah, isn't that obvious. But this is, I think, one of the most important observations from our study. It's that people

don't just want to kill. They want to particularly commit this mass murder using guns. There's something interesting. It's something about guns. Yeah, as you say that, it's almost like it's more personal than just a bomb going off. Exactly. It's more

like I am causing this. I'm shooting this thing at you and you are dying. It's like it seems much more sort of visceral than a bomb being placed and then getting away. from the bomb, you know? And also much more like, oh, I'm the cause of this, you know, if they're looking for notoriety. It's like there's no doubt who caused this.

There is a romantic, like we said, a romanticization of gun violence in general and mass shootings. So what happens around 1970? So there are issues with gun availability and those types of things, which are very important. We need to manage gun availability. Part of that, though, even more upstream. And again, we need to manage gun availability. That will make a difference because that is one constant. But how do we manage this romanticization of gun violence? Or how do we even know that romanticization of gun violence is an issue

or the culture of gun violence is an issue? Before 1970, the primary influences on young people, people in general, but young people in particular were the family or parents and teachers. that they were the primary influences. It wasn't until the 70s, 80s, 90s, and obviously today, where the primary influences on young people especially became the media. So they're the primary influences. The media, and we're talking about movies and television and video games and these sorts of things.

The music industry. Music industry. They romanticized. Very violent. They were romanticized violence, gun violence. those sorts of things. It's not just a matter of, well, I'm, you know, it's, these things are romanticized and they need to stop.

So back to the specific association that you mentioned between video games and mass shootings or gun violence, these cultural, so these effects are cultural. They affect cultural. They're not, these sort of effects wouldn't be seen on an individual basis. For example, I am, so what you're saying is, you know, there's no relationship. I've read some of these studies examining relationships between violent video games and gun violence and people have perpetrated gun violence. Basically what they show is that, well, several previous studies showed in association, but there were some more recent studies, which were, you know, well conducted, the studies themselves were fine.

It's just important to interpret them, you know, the right way. Basically, what these studies showed is that there wasn't necessarily a higher prevalence of playing violent video games among people who were violent than people who weren't violence. And so the conclusion made was that there's no relationship between video games and then violence and those sorts of things. So again, these effects are not necessarily one-to-one direct effects. They are effects on culture. So music effects are culture. video games affect the culture, movies affect the culture. I wouldn't have had to see one specific movie or played one specific video game or played any amount of video games for something to affect me,

because these effects are seen across cultures. For example, just within psychiatry, you know, I, you know, like we said, I was trained in psychodynamic psychotherapy. That's how I think about things. That's when I administered therapy or conducted psychotherapy. That's the type of therapy I administer. That doesn't mean that I and what I learned were not affected by other fields of psychotherapy and other practitioners of psychotherapy and other theories. I mean, we were because all of these are related. They're not siloed and completely independent. The same way that the video game industry and the movie industry and music industry and television

are all related. So if one becomes maybe a little more violent, the other will become a little more violent. If one romanticizes gun violence a little more, the other will. So that's kind of how we see things. Again, I'm trying not to use specific details. I don't want to be too ambiguous.

I'm trying not to use specific details or examples because I don't want to make, I don't want to bring up specific examples or people or games or movies or those sorts of things. I hope the examples that we're using are clear and explanatory enough. Yeah. Yeah, I do think maybe for the vast majority of people, it doesn't impact them or they're not being more violent because of these things.

Actually, I think violence has had a precipitous drop since the Middle Ages, and a precipitous drop from like maybe 20,000 years ago. I mean, there's data to support, like, 50% of men were killed by other men, you know, like, because their bones had, like, axe wounds to them, you know, and stuff like that, like old, ancient, archaeological bones that they've dug up, like 50% looks like male-on-male trauma, right? So you think about, like, how homicide has decreased over time, and I think it's actually very hopeful. I think, like, it's like, or at least like the very,

cognitive, like the part of me that's like can look at statistics and be detached from it, you know? Yet you would never know that looking at are like the movies that we watch. It's like violence is very common or the video games that we play. You know, it's like I've kind of decided this year to detach my kids from media on the weekdays completely. Like no media. And it's interesting. I have a lot of, well, not a lot, but I've had a lot of patience over years who are like in Silicon Valley and you know part of different big companies there that produce media or you know social media and a lot of them raise their kids with no social media you know like I've never had a like a higher end person at one of these companies who says yeah I let my kids

have Instagram from the age of like 10 you know never it's always like no I I I I specifically chose the school because they don't have computers and because they don't, you know, they don't do media and screens. So it's interesting there's this parallel that I see between like people who are in the field producing that content, not allowing their kids to do it. And so we have to have some wisdom as parents, right? If any of the audience members are parents, like how much media should we allow? And we did a two-week vacation, which is very unusual. I think it was the first two-week vacation I've ever taken. And I said to my wife, the one thing I want is no media for the kids.

Wow. And so the whole time, and lo and behold, the kids, like, after the first couple days, they stopped arguing as much. They were, of course, you had two parents at bay, so maybe that had an influence. You know, and we're in nature, so maybe that had it. influenced, but they were like having a great time together, you know? And we had meals, all meals were together. And so I think it's a good message of like constraining our media for ourselves and for our kids. I think what you're saying is that a lot of this is intuitive. One doesn't necessarily need to know the data or be a psychiatric researcher, a person who research is mass

murder to know that some of these things are just intuitive. Some of these strategies are intuitive. I think this is that is about right? Intuitive and like there's some practical like before we like try to fix, you know, some large system that we have no control over. Let's let's work on our own media consumption, our own, you know, family media consumption. So that, you know, I'm always thinking about like, what do I actually have the power to control, you know? Like, and, move into more of a self-efficacious place rather than like, oh, this external stuff is going on and we have no control over it, you know. Does that make sense? That makes a lot of sense. You know, change starts with, you know, each one of us, the individual. I can make the most, I can have the most effects or make the most difference myself and whatnot. So, yeah, I agree with you 100%. We all need to take responsibility for this sort of thing as much as we,

can obviously. There's always so much we can too, but yes. Yeah. You know, then and I think as mental health clinicians, we get people into our office that we, you know, there may be those people that you're like, wow, there's something about this person that I'm a little bit more concerned about, you know? Like, when you think about mass shooting, there's two patients I've had in my whole career that, like, raise my sort of like, okay, if there were anyone who would, of any of my patients that would commit these crimes, it would be these two people. I see. And, and, trying to maybe get them the treatment that they need. Because I do think that one in particular responded to about seven years of therapy.

And, you know, me as a clinician got him in with a resident clinic for a number of years. And I think he really did respond. And the other guy was a little bit more difficult. And I think he did really value the therapy he was in. It was at a college I was helping out with, and I was his psychiatrist, and he had a therapist. Just keeping him in therapy, it was like his one person, because he was kind of odd. It was hard for him to connect with other human beings. He got angry, he got defensive very quickly.

He seemed very impulsive, and he kind of had this more cold, like, less warm aspect to him. But he really valued the connection. And so I think part of the work that we could do is like, how do we work through our own counter-transpect? transference. If we have someone in our office, that maybe is a little bit more off-putting, a little bit harder to connect with. The first patient, he had some racist views. He had some racist tattoos on him. When he was manic, he actually became very racist. And I won't say too many specifics, but it was very off-putting to a lot of the residents at first. But when he was well-controlled with antipsychotic and lithium, he eventually wanted to get rid of those tattoos. And he actually married someone of the race at which he was prejudiced against, which was awesome kind of interesting.

I think what you're speaking to is critical, and it kind of synthesizes a lot of what we've discussed, in particular about mental illness, but even outside of mental illness, because people who don't have, you know, again, categorical definitions or, you know, categorical descriptions of mental illness can benefit. But I think what you're saying, again, this kind of synthesizes everything or captures a lot of what we're saying, what we've been saying. And that is that, you know, just having people in treatment is so helpful. So medicating people helps. We know that.

These mass murders, mass shooters, for the most part, I mean, almost exclusively are not taking medication. If any of them were to start a medication, they would almost definitely improve. But also therapy. Just being in treatment helps so much, whether someone has, you know, depression or psychosis or anxiety disorder or anything. Just being in treatment therapy in and of itself helps, but just being in treatment, we know goes a long way towards helping mental illness in general and these sorts of things. To describe it in psychodynamic sense, there are basically three hurdles to any sort of major bad behavior. We can, include mass shootings among that, but for personal mental illness or otherwise, one is one's

own inhibitions or limitations, conscience or if one's religious, God, or ego functions, if one thinks about this from a psychotamus perspective. The second is the hurdle of the inhibitions or the moral system that we internalize from those people around us. Those could be our parents, partners, close friends, or our clinicians, our therapists or psychiatrists. So people who may not have, you know, the strongest egos in the psychiatric sense of the world, psychiatric sense of the world can internalize the ego's functions, in this case, let's say, impulse control, of their clinician, whether they're getting medications or in a formal psychotherapy, which certainly will help.

that's so important that that's why we are so we as a as a field or care so much about getting people into treatment we just like you said it's just about getting people into treatment the treatment will then take care of itself and obviously people have to give good treatment but whether there's medications or therapy whatever having that relationship with a good object the psychiatrist the therapist whatever, in and of itself is so therapeutic, is so helpful, and can, you know, can help a lot of these things, even for people who don't have, you know, categorically defined or described mental illness. Yep.

And then were you going to say a third thing? Because I think you said the first two. So sure. Then the third would be society or culture. Okay. That we understand, you know, these can be the police. We know we don't want to get in trouble. Or these can be that we understand that society wouldn't.

accept this or we understand that this is you know frowned upon or whatever but once you know gun violence or you know gun culture is romanticized or accepted or whatever you know that that third hurdle is not as high and and becomes a problem and and i would say to that third one the the myths and the stories that we tell our kids and you know are so important and to control that to some degree agree. You know, it's like, so instead of media, I read my kids The Hobbit. And I didn't know what to expect what I didn't know what morals were going to come out of that. But lo and behold, like, it is amazing in how it talks about greed, and how it talks about selflessness, and how it talks about courage. And so I'm having those conversations with my kids. My kids are young, six and eight

years old. It's, it was a great book to read to them. And it's those types of, like, stories. I think that get imprinted and that we need, right? So it's that you think about the stories of the society, and I want to do more of this in the future in my podcast talking about like Achilles and the Iliad and the Odyssey. And, you know, there's aspects of what is courage, what is forgiveness? You know, with Achilles, you have this kind of like very sort of narcissistic character. But at one point, he does this forgiving act, which kind of becomes a central point of the Iliad. And so like there's there's these myths that have been told to whole, you know, you imagine the young people of those, those of that day and these myths informed them. And so I think it's really important that we

think about this as parents, like what stories are we telling our kids to teach them these lessons and not just leave it up to some YouTube, you know, person playing Minecraft, which my kids love to watch, you know, to sort of inculurate them into what is, what is it, what is right and wrong. You know what I mean? The best stories for children, but for all of us, have these strong moral values within them or systems, you know, good versus evil, right, versus right and right and wrong, you know, those sorts of things. Those are generally the most part of the story is because we unconsciously or consciously,

but certainly unconsciously, understand the difference between, or. understand the difference between right or wrong, whether we behave in, you know, commensurate way. But we understand unconsciously what is right and wrong. That just kind of jives with us. And so, of course, we're most attracted to stories that involve strong kind of moral messages. Yeah. Well, I think this is a good place to stop. This has been a really good discussion. I hope you guys have enjoyed it. If you're on Twitter, is that a good place to sort of see what you're you're up to? Is that where you'd like to leave? What's your Twitter handle? I'm not on Twitter, actually. You're off. But people can find out about what we do and reach me very easily by just

typing in my name, first or last name, and for Columbia University. And they will be immediately directed to my webpage, which has my contact information, email address, information about me and what we do in our research here and with the mass shooting database. We've published one paper, another has been accepted. We're going to be publishing a few more in the next few months to years. And I'll link that paper in the article that we will post, which I hope you'll first author on my website, Psychiatrypodcast.com, and it'll be in the resource library.

So if anyone wants to dig into that article, I'll link that there. And yeah, thank you so much for coming on. I think it's really helpful to have someone who's both a clinician trained in psychiatry, but also doing the research and, you know, spending the thousands of hours digging into this stuff so that we can get a closer glimpse of reality. So I appreciate that. Thanks for having me on, David, and having a discussion about these sorts of topics, which are very difficult to talk about. All right. We'll leave it there. Thank you so much.