The Daily - ‘Most Violence Is Not Caused by Mental Illness’

Episode Date: June 8, 2022

After a series of deadly mass shootings in the United States, the National Rifle Association and some Republican leaders and conservatives are pointing to mental illness.This approach raises a question: How can the mental health system stop gun violence when mental illness is so rarely the cause of it?We revisit a conversation from 2018 with a psychiatrist who is wrestling with that challenge.Guest: Dr. Amy Barnhorst, the vice chairwoman of community psychiatry at the University of California, Davis. Want more from The Daily? For one big idea on the news each week from our team, subscribe to our newsletter. Background reading: Many Republicans opposed to more gun control have called instead for investing in mental health programs, increasing funding for law enforcement and bolstering security at schools. Many Democrats say they are missing the point.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday. 

From The New York Times, I'm Michael Barbaro. This is The Daily. Republican leaders, conservatives, and the NRA are all again pointing to mental illness in response to a series of deadly mass shootings. But that raises a question. How can the mental health system stop a shooting when most shooters aren't mentally ill? Today, we revisit a conversation I first had in 2018

with a psychiatrist who is wrestling with that challenge. It's Wednesday, June 8th. this individual was nuts. We don't know right now exactly why this deranged individual did this. Crazy madman, been on evil. And a wacko came in and shot the five of them. Who were shot by this madman. They're homicidal maniacs. People like this with mental health issues.

This troubled young man fell through the cracks. The failure of America's mental health system. This is a mental health problem. There is a mental health epidemic here which is being confused for a gun problem. Again, this is a mental health issue, this is not a gun issue. The common theme with these kinds of shootings is mental illness, and this is something that we should not be ignoring. Anybody who shoots somebody else has a mental health challenge, period. Would you like me to,

how would you like me to refer to you? Doctor? Professionally, Dr. Barnhorst. Personally, you can always call me Amy, but professionally, Dr. Barnhorst. Okay. So, Dr. Barnhorst, tell me about the day of this appointment.

Well, it started out as just a usual day in a busy crisis unit. So, I work as an emergency psychiatrist in a crisis unit that's adjacent to an inpatient psychiatric hospital in California. We see people who are acutely ill or acutely in crisis, maybe people feeling suicidal and depressed, maybe some folks who were brought in because they were hearing voices. And then the police brought this kid in. He was a 21-year-old, and his parents had called the cops because they had gotten concerned about some of the stuff he'd been posting on social media.

hostile, but were generally vague up until the last few days where he had made some specific references to the Columbine shooting and something about some death and destruction. And one of the things he referred to in his Facebook page was a day of retribution. And when the police went to his house and spoke with the parents, the brother mentioned that this patient had told him he was going to try to buy a gun. And the brother thought he had done so but wasn't sure. And why did the police bring him to your office? They've been told about this posting on Facebook, which is alarming. Why did they bring him to you?

Well, he really hadn't committed a crime. So they couldn't arrest him. But I imagine that the police were pretty worried about this guy. You know, he certainly had a lot of concerning signs. And I think they brought him to us in the hopes that maybe the mental health system would be a way that we could prevent him from going down a bad path. So what are you doing first? What's your role in this moment? So my first thing is I get the chart and I flip through it and kind of see what's going on. For this young man, I probably

would have had any records we had on him, which was none. And the legal hold that the police brought him in on, which was just a piece of paper with a few lines, might be something as simple as making threatening postings on Facebook, comma, might have bought guns, says brother, comma, parents worried. In this case, I had fairly little except that ominous information. So I always build a picture in my mind of what people are going to be like before I meet them.

Mm-hmm. But he did not really jive with my mental image that I had built up. Hmm, what do you mean? If I had met this young man man and he seemed, for example, like in a manic episode where he was impulsive, where he was talking really fast, where he was delusional and grandiose, that might be indicative that he was in fact mentally ill. was in fact mentally ill, and that maybe this idea about threatening up his school was secondary to a mental illness that could be treated, and thereby we could prevent the shooting or the act of violence. But in the case of him, I mean, he looked not like somebody with a mental illness. He didn't have any of those signs.

He was a nice enough kid, not particularly angry to me, although it was easy to see that he had some darkness in him. And I think he was a little sullen and depressed, not happy with his social standing and how things had been going at his school. He said that he didn't think he had a mental illness. He didn't want treatment. He didn't need treatment. He seemed more like a sad, brooding kid who was hurt and realized he had done something wrong and really wanted to go home. So ultimately, you're trying to determine if this post on Facebook was coming from a place of mental illness or possibly something else. Yeah.

So I'm trying to figure out if he is going to meet criteria to be involuntarily admitted to a psychiatric hospital. Okay. And in California, in order to be admitted to a psychiatric hospital involuntarily, you have to meet one of three criteria. To either be dangerous to yourself, dangerous to somebody else, or gravely disabled, which means that you're not able to provide for your own basic needs, like your food, clothing, and shelter. And you have to meet one of those three things because of a mental illness. So even if this young man is angry or showing a propensity towards violence, you'd need to determine that these emotions are coming from a mental illness in order to involuntarily commit him. Right. So at this point, I'm making a primarily clinical decision about whether or not I should admit this young man for treatment. But I also know that my clinical decisions have legal

implications for him because there's a difference between an admission to a hospital and a commitment. As a doctor, what I do is I make the clinical decision to admit someone to a hospital and a commitment. As a doctor, what I do is I make the clinical decision to admit someone to a hospital. The commitment is a legal process that is done by the judge or the hearing officer. And that's the checks and balances in the system that make sure that some doctor can't just admit people willy-nilly and hold them in a hospital indefinitely with no liberties. And so if he is committed, then his name goes into a federal database of people who are prohibited from purchasing guns. And any time a federally licensed dealer does a background check, his name will come up as a prohibited person and he won't

be able to buy a gun. But he'll still be able to purchase from private party sales and from internet sales and from gun shows, where in most states they don't do background checks. And so this is how someone like you interacts with what most people think of as the federal background check system. Yes. That's used for gun purchases. Yes.

Doctor, this feels very complicated, what you're describing, because so often people are expressing violent thoughts, but mental illness is not clear. And yet, as a doctor, you want to prevent them from carrying out these acts, I assume. So how do you grapple with people who fall short of that glaring mental illness, but who are expressing violent thoughts? I mean, it's hard because we do see people every day, especially in a crisis setting, that we want to help, but they don't meet the criteria for involuntary help, and they don't want help. And so we have to let them go. And sometimes that involves people with the potential for violence. And it is a balance between people's civil liberties and their right to make choices that I may not think are the best choices. It's really hard from the vantage point of being a psychiatrist

to prevent violence since most violence is not caused by mental illness. About 4% of community violence is attributable to severe mental illness. 4%. 4%. So that would mean that 96% of the rest of violence that occurs in a community has nothing to do with mental illness. Correct. Do you know how mental illness relates to mass shootings specifically in terms of cause and effect and scale? Yeah.

in terms of cause and effect and scale? Yeah. I mean, so this is a tricky question. We get into semantics a little bit here because, you know, it's hard to stand by an argument that people who make posts like this or that anybody who goes into a school and opens fire on students is some paragon of psychological well-being. I mean, I think everybody would agree that these people are not mentally well per se. I mean, I think everybody would agree that these people are not mentally well per se. But that is really different than actually having a specific mental illness like schizophrenia some have. But a lot of them are just really angry, resentful, bitter young men who have similar histories of social isolation. They've been bullied. They've harbored revenge fantasies. They have an entitlement towards social standing,

towards attention from women. They feel like they're not getting the popularity, the attention, the recognition. That they deserve. That they deserve. So there's this idea that they're better than everybody thinks they are, and they kind of want to show the world that. So how would the treatment of someone like that differ from the kind of treatment they would need if they were determined to be mentally ill? It seems like in either case, some kind of treatment they would need if they were determined to be mentally ill. It seems like in either case, some kind of treatment is needed. So what's the difference? Well, one of the big differences, you know, we do have medications for things like schizophrenia

and bipolar disorder. We don't have medications for things like resentment, hatred, anger at the world. We can't fix that so well. So there's no way to admit somebody like that to a psychiatric hospital, treat them over the course of the two weeks that we might be able to have them, and then completely change the personality that they've spent their whole life building up.

And it sounds like this young man who's standing in front of you fits that profile more than one of a clearly mentally ill person. Absolutely. He fits the profile of the angry, socially isolated young man with no mental health history. So what's going through your head as you make this decision whether or not to admit him? So in my mind, I'm thinking to myself, this young man does not appear to be mentally ill to me. He does appear to potentially be dangerous, but that's not something that is going to be changed by admitting him to a psychiatric hospital. And if I send him home, then I'm

concerned that I, you know, had my chance to intervene with the next mass shooter, and I did nothing. And now he's back home with his gun. We'll be right back. So, Dr. Barnhorst, you've spoken to this young man. You've learned that he has posted on Facebook something quite scary. You've learned that he may have just purchased a gun, you don't know. And now it's your job to decide whether or not to commit him for a serious mental illness. What do you decide to do? He did not look to me like he had a mental illness.

He did not look to me like he technically met the standards for involuntary commitment. But I really didn't want to be wrong. And in the end, I decided to admit him because there's some leeway in the statute. So it's ultimately up to the judge to make the decision of whether or not he gets committed officially. So I admitted him. So you erred on the side of caution to get him into this kind of mental health legal pipeline. I did. It sounds, doctor, like you're saying part of you understood quite clearly that he might not be mentally ill, but you were making a kind of civic as well as medical decision to keep him out of the general population. keep him out of the general population?

I mean, one of the principles of practicing medicine is that the higher the risk of the possibility, the more certain you want to be that it's not the case. So if I'm worried that somebody might or might not go home and punch a wall, I'm willing to be fairly liberal in making a mistake there, much more so liberal than if I'm worried somebody might or might not go home and shoot up a school. You can live with one, not the other. I'm willing to let them a little bit of freedom.

If the risk of my giving them some freedom and letting them go is that they might shoot a bunch of people into school, I need to be really, really confident that I'm right and that that is not going to happen. And what happened? I admitted him to the hospital. He went before the hearing officer a few days later,

and the hearing officer determined that he was not dangerous because of a mental illness. And then he's no longer involuntarily held, so he's free to go. So you had to let him go. The system had to let him go. Yeah, we had to let him go. The system had to let him go. Yeah, we had to let him go. So doctor, does this man end up on the federal background check system, given the way this is played out? No, because the judge did not certify his commitment in court, he does not land on the federal background check system's list of prohibited persons. the Federal Background Check System's list of prohibited persons.

But because I admitted him to the hospital, he does meet criteria for a five-year prohibition just within California. That prohibition will expire in a couple years. And were he to move to another state, he would still be able to buy a firearm there in the meantime. Do you think that this system failed this young man in this moment and as a result failed the rest of us you know it's hard for me to say that this system failed this young man because this young man is not who the system was set up to help

he's not somebody that we have a treatment or a cure for because he wasn't mentally ill. The unfortunate part is the criminal system couldn't help him either because he hadn't done anything criminal. So what do you think when you hear gun rights advocates talking now so much about mental health? Do you think there's an understanding of what that actually means in practice? I think there's not. And I think it's important for folks to have a better sense of what it looks

like played out in practice, which is it doesn't look very good. There's not a lot that in actuality we can do for these people. And the irony is I think a lot of the folks who point towards the mental health system as being a less restrictive way of decreasing gun violence because they don't want to lose their rights to own firearms. The part of that they're missing because they don't see what happens in the real mental health world is that if we were going to really try to prevent violence and mass shootings within the mental health system, we would have to expand the net of who we were allowed to involuntarily detain and hold enormously in order to find those one or two people

in thousands that might actually perpetrate mass violence. Would we have to therefore expand the definition of mental illness? I mean, it's hard to expand the definition of an illness, but I think we would be talking about dramatically expanding the reaches of the mental health system and largely the involuntary mental health system, because mostly we're looking for people who are not seeking treatment on their own. So what that looks like is that we would lower the bar really far in terms of who we would be able to involuntarily commit.

And it would be almost every angry young man who had a history of social isolation, being bullied, who had an interest in violent video games and collecting guns, who ever made macabre sounding Facebook posts or comments about wishing everybody at his school were dead. That's actually a lot of people. And it's easy in hindsight to look at mass shooters and say they showed all the warning signs. But when you look forward, that's a lot of people that you would have to take out of their world and out of their lives and involuntarily detain in the mental health system

and probably to not much end. What do you mean to not much end? Well, eventually we have to let them go. It's unlikely that we'd be able to fix them. So even if we were allowed to keep them for three weeks or three months, I don't know that we would be really solving the problem. We would just be keeping them out of circulation for a little while. Doctor, I wonder how often you think about this young man who you admitted and then who

the court system let go, and who now roams the world. I think about him every time there's a school shooting. Doctor, thank you very much. Thank you. what could become the first major new set of federal gun restrictions in decades. One of the proposals under discussion is the creation of a system that would screen gun buyers under the age of 21 for juvenile offenses and previous episodes involving mental health. We'll be right back.

Here's what else you need to know today. In a closely watched election on Tuesday night, residents of San Francisco voted to remove the city's Democratic District Attorney, Chessa Boudin, who faced criticism that his liberal policies have led to an increase in crime. There is little evidence that Boudin's policies have contributed to San Francisco's rising crime rate, but his message of leniency for criminals has nevertheless upset voters and served as a warning to Democrats

that voters are worried about crime. And a panel advising the FDA has recommended that the agency authorize the use of a fourth vaccine against COVID-19, made by the biotechnology firm Novavax. Unlike the COVID vaccines from Pfizer and Moderna, which rely on messenger RNA, the Novavax vaccine employs traditional vaccine technology used in vaccines against the flu. That, experts said, might encourage vaccine skeptics to try the Novavax vaccine. by Annie Brown, Claire Tennisgetter, Rachel Quester, Lindsay Garrison, Michael Simon-Johnson,

Theo Balcom, Ricky Nowetzki, and Muj Zady. It was edited by Lisa Tobin, Paige Cowan, and Lisa Chow, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landvirk of Wonderly. That's it for The Daily. I'm Michael Barbaro. See you tomorrow.