Michigan State University. Parkland. Uvalde. Charlotte. More places that have joined the list of unprovoked mass shootings. More everyday. Again, we ask “why?” More important is the question: “when?” When are we going to act on the doable to protect workplace, school and community safety? The anguished cries of families beg for changes. I’ve been pushing for changes for years and won’t stop.

So far in 2023 there have been over 80 mass shootings (where 4 or more people have been wounded or killed in an incident.) This number climbs daily. Most shootings are by a family member, gangs, a retaliation or associated with another crime. But mass the shootings at stores, churches, and schools shock and scare us the most. These are the places we expect to feel safe. In response, there is the repeated call to ban some guns. Let’s be honest, that is extremely unlikely to happen.

It is not just about the weapons, it is about the perpetrators, and what could have been done but was not done to prevent these tragedies.

If we focus on one group, (those with mental illness) we can make a difference. They comprise only a small amount of the mass shootings, but the number is not insignificant (particularly to the families of the victims). About 5% of mass shootings are related to untreated severe mental illness, about 25% are associated with a neurological or non-psychotic psychiatric disorder (including depression). Some estimate the percent of mass shootings involving mental illness is far higher.

Mental illness (MI) is a broad spectrum ranging from mild anxiety and sadness to severe mental illness (SMI) such as bipolar disorder, or schizophrenia. Within this very broad definition the correlation of violence and MI will be small. As a result, some continue to claim there is no difference between those with mental illness and those without MI when it comes to killing. However, that often-cited conclusion is from a study comparing those who were treated for MI and those with no MI. That study left out those with untreated SMI who have a fifteen-fold increased risk for violence compared with those who were in treatment. Add substance abuse and a prior history of violence and the risk is even higher.

And there is no definition of “normal” which includes unprovoked mass killing or violence. The absence of a prior diagnosis does not mean the person not struggling with symptoms of mental illness at the time of the shooting. The very act of violent killing is itself pathognomonic of a deeper disturbance.

There are common troubling characteristics of mass shooters. According to the National Institute of Justice these include: 1. Experience of early childhood trauma and exposure to violence at a young age (parental suicide, severe bullying, family violence and abuse), 2. Have an identifiable crisis point in the weeks or months prior to the shooting (e.g., relationship rejection, loss), 3. They studied actions of other shooters, 4. All the shooters had the means to carry out their plan coupled with a belief that life is not worth living.

An additional factor identified in a 2019 Secret Service report on risk for school shooters said most communicated their intentions to attack but others who saw these threats did not react.

A history of a felony or involuntary psychiatric hospitalization would also block permission to purchase or possess a firearm. Yet, many who had previous encounters with law enforcement were not prosecuted, or were plea bargained to lower levels (not felonies), and some with SMI and violent behavior were never involuntarily committed to a hospital, meaning their names never went into the National Instant Criminal Background Check System (NICS).

The recent tragedy at MSU is an example of a cascade of preventable mistakes. The shooter (Anthony McRae) had a history of mental illness (paranoid schizophrenia according to his uncle) and refused treatment his father had recommended. In 2021 he faced a felony charge for carrying a concealed weapon. In a plea deal he was charged with a misdemeanor instead. That same year he purchased two pistols. He became more isolated and quit his job after his mother’s death. There were other factors that predicted high risk But they were not acted on.

The Parkland shooter, Nicholas Cruz between age 3 and 19 had a history of 69 documented incidents where Cruz threatened someone, engaged in violence, talked about guns or other weapons or engaged in other concerning behavior according to the Florida Department of Children and Families. Law enforcement had 43 contacts with is family. He was adopted and after his adopted mother had recently died, there were recommendations that social service agencies follow up. It is unclear if anything happened. Because of confidentiality laws, records of his problems were never shared between law enforcement, school and government agencies. Although he had “hundreds” of hours of counseling in the past, it does not appear he was ever court ordered into inpatient or outpatient treatment. Although he had a record of violence and mental illness, nothing was placed on his NICS record which would block him from purchasing guns.

At age 19 Salvador Ramos killed his grandmother and then 19 school children and two teachers in Uvalde, Texas. He had been sexually assaulted as a child, struggled in school, was nicknamed “school shooter” by schoolmates, was bullied, came from an unstable family, would cut his face with a blade and tried to buy guns at age 17 to carry out his plans. He was known for violent talk, arguments with family, and posted videos of himself abusing a dead cat, and dry firing a BB gun at people. Many people were aware of his history and violent threats. No one reported it. His name was not on the NICS list. And as soon as he turned 18 he purchased guns and ammunition.

Dylan Roof, the convicted perpetrator of the Emanuel African Methodist Episcopal Church shootings, told his plans to at least two friends a week before the shooting. He came from a broken home, attended seven schools in nine years, and had a history of encounters with police. His pre-sentencing psychological report described him as a “ninth-grade dropout diagnosed with schizophrenia spectrum disorder, autism, anxiety, and depression,” among other problems. He had a prior drug arrest which should have prevented him from purchasing a weapon. Multiple breakdowns among law enforcement reporting meant his name never appeared in the NICS system during a background check.

Since a court ordered psychiatric hospitalization would have prevented all of them from purchasing a gun, why weren’t any of these men court ordered into inpatient treatment if there were so many signs of risk of violence and the presence of severe psychological problems?

First, there are serious shortages for inpatient treatment. Many with SMI can do well with outpatient counseling, medication, and close follow-up. Some need much more intensive treatment, especially those with a history of violence and refuse treatment. However, since the 1965 Medicare law, federal policy mandates psychiatric hospitals can have no more than 16 beds. Originally designed to reduce costs and incidents of abuse, the big institutions were forced to shut down. With no hospital beds to care for them, many are released if the simply state they will not hurt anyone rt they “promise” to get care.

Second, it is very difficult to obtain a court ordered involuntary commitment. Laws only allow involuntary commitment if the patient is a present danger to themselves or others. Patient advocates often work to block involuntary commitments citing a goal of protecting the patient’s rights to refuse care. However, forty percent of those with SMI have a condition called “anosognosia” meaning they literally are not aware they have an illness despite delusions, hallucinations, paranoia and inability to care for themselves. Already overworked and facing the likelihood that efforts to mandate inpatient care will be fruitless, many courts, law enforcement and doctors will simply release the patient. It’s the easy route.

Third, no one communicates the troubling history. Because of HIPAA confidentiality laws, when a patient in a SMI crisis is brought to a hospital, the doctors are blocked from contacting family, other hospitals and counselors to find if there are any patterns of behavior of concern. If they knew all the details, a more accurate diagnosis and risk assessment could be made.

Fourth, instead of care, many are homeless, or in jail for lesser crimes. The vast majority of those receive no treatment. Those few homeless with SMI who are in apartments with supportive treatments on site, fare much better. But cities and states provide inadequate funding to met the needs of the many who benefit from supportive housing.

Fifth, even if someone with SMI does commit a crime, severe police shortages, politicians who push for cashless bail or block arrests, and district attorneys who refuse to prosecute at all means no crime gets on the record, no judge orders a psychiatric evaluation or no one mandates care for the person with SMI.

I understand the passion behind those who want to ban the sale of some guns, hoping this will prevent shootings, the simple fact is America has more guns than there are people. It would be an impossible task to eliminate them from our nation. And even when cities have big restrictions on gun possession, criminals, and gangs still have them. But there are other achievable goals.

If our focus is on guns: Rather than ban some guns from all people, ban all guns from some people. And that means take specific actions toward early detection, prevention, treatment and reporting of those at risk for violent acts. This is where change is achievable.

1. Stop underfunding or defunding police. Blaming police for crime is misguided. Yes, there is 1% who cause problems, but communities should not be subjected to safety risks because of the few. Communities need more well-trained police, with well-trained supervision, and courts that prosecute crimes. I know of no study in human behavior which shows a decrease in violent crime where there are no consequences. In fact, the opposite is true. The certainty of arrest and prosecution are deterrents to crime. Let police be police, to keep communities safe. Hire other social workers to assist in mental health emergencies to provide care. But let police do their job.

2. Schools and workplaces must remain vigilant. Shooters look for soft (unguarded) targets. I’ve seen many schools/workplaces take the safety issues lightly and not take the proper steps to train and equip staff on all levels to prevent attacks, identify youth/employees at risk, and intervene correctly.

3. Make quality treatment for mental illness more accessible by funding more qualified mental health professionals. Half the counties in the U.S. have no psychiatrist or psychologist. And many of those do not treat SMI and/or youth. With a critical shortage of child psychiatrists, patients may wait on average 7-10 weeks for a first appointment if the doctor is even taking new patients. Since half the cases of severe mental illness emerge by age 14, and 75 percent by age 24, and we know that early treatment greatly improves prognosis, these delays to care cause harm. Simply put, we need to fund thousands of more providers, and more outpatient clinics and inpatient hospitals.

4. Fix HIPAA laws. Doctors need to communicate with families and institutions to know if a patient has a history of violence, and is there someone to care for a patient after discharge. In the past, I tried to change the law to allow for special limited circumstances of “compassionate communication” where doctors could reach out to families. A complete history is as vital to a correct diagnosis of mental illness as an x-ray is to a diagnosis of a broken leg. We need to change the law, and judges should be allowed to order doctors to reach out to other sources to get a history under limited circumstances to evaluate a risk for violence.

5. Put data in NICS data base. No arrest means no data. Plea bargains to eliminate felony charges, means no data. No data, means NICS is worthless. All responsible for preventing this data from being recorded in NICS share the responsibility for gun sales to those at risk for violence.

6. Hollywood has a role. Violence sells and Hollywood has made billions out of promoting, romanticizing and encouraging extremely graphic violence, in battle scenes, crime, revenge, gangs, science fiction and superheroes. Studios know if you want to make a profit, blood=billions. But it also numbs audience tolerance levels of depictions of violence, and teaches viewers violence is acceptable and encouraged.

7. Individuals must take responsibility. When a family knows another member in the household has an SMI they share a responsibility to rid the house of firearms or make certain they are securely stored. We must also make it easier for families to get help for themselves and family member, and providers need to listen when families express legitimate concerns.

8. Support community supports. A child who from a troubled family, already showing symptoms of concern, it is essential to engage with people who care. Churches play a vital role in the lives of families, and communities. Prayer has been blocked in schools, and media is quick to mock anyone who talks about the value of prayer and church in the lives of children. This media bullying hurts a youth’s desire to turn towards one of the key places where love, support, forgiveness and family is still valued. When a child has lost everything else, no government run institution has ever been able to replace that source of hope and support.

While I was in congress, I worked hard to fix these problems. We made a lot of progress but key provisions were deemed too expensive. One study by the congressional budget office in 2016 said lifting the limits on the number of hospital beds would cost $1.2 billion extra per year. However, a study by the Schizophrenia and Psychosis Alliance of America released in 2021 reported the one-year cost of schizophrenia and SMI in the USA in 2020 was over $280 billion (including medical care, housing, justice system and family costs). That is the cost of a failing system. Unfortunately, congress does not measure projected dollars saved, only dollars spent. If you judge by the cost of not caring, enacting these priorities is actually a massive saving. But to those families who will re-live these traumas forever, you cannot put any dollar value on the lives lost that were preventable.

© 2023 Tim Murphy