Does Psychiatry Really Have the Answers for Large-Scale Shootings?

Another school shooting in America. 

I’m not sure blaming the broken mental health care system is going to solve this. Although, it is broken, to be sure. But I wonder what we are going to do for our desperate, isolated, angry young people. Clearly there is something psychologically wrong with someone who wants to take a gun and start shooting people in a public space, I just don’t know if it’s the kind of psychological problem the American public believes it is. It certainly doesn’t look like schizophrenia or autism.

Mental illnesses don’t increase the risk for violence. Most mentally ill people are at risk for being victims, not perpetrators. Statistics on violence have shown this again and again. I have treated severely mentally ill people for twenty years, since I was a medical student at the Arkansas State Hospital, and while I have occasionally been afraid of a very sick patient (afraid they might lunge at me like a scared animal trying to fight its way out of a corner where it was trapped), none of them could have orchestrated something as well-planned as a large-scale shooting.

Serious mental illnesses rob the mind of its ability to organize and plan. Labeling a shooter as “sick” is understandable, but they don’t suffer from a sickness I’m treating, even in a psychiatric urgent care clinic. 

I used to conduct evaluations for competency and sanity at the Bexar County jail here in San Antonio, Texas- for years. The vast majority of the cases I saw involved a mentally ill person refusing to leave a public space because he or she was confused. Occasionally the defendant would make a ruckus- perhaps yelling at a store clerk or knocking over merchandise. Just as often the charge would be assault against a family member- a mentally ill person would be paranoid and afraid, and might lash out against a loved-one. The worst cases involved a mentally person harassing someone, maybe believing there was a romance occurring when it just didn’t exist. No one I saw in the jail system looked like a potential shooter.

My primary interest is the treatment of teens and young adults and I have a pretty good reputation in my community. I’ve taken specialty training in forensic (legal) psychiatry. I now work in psychiatric urgent care. If anyone in my profession should have the expertise to identify what kind of mental illness ties to mass shootings, it might be me. And I don’t think I’ve ever treated someone who, without my help, might have been capable of something like this. Not one time.

I don’t think I’ve ever seen anyone in a mental health evaluation or a forensic assessment that I could identify as a potential large-scale shooter. I’m not sure potential shooters come seeking care. In 2012, after the Newtown shooting, I wrote this:

     What I fear is not the patient who comes to see a psychiatrist like me. I fear the delusional, suicidal, alienated person who hatches some other plan to cope with his desperation. I fear the young man who is preoccupied with violent video games and who feels alone in a world that cannot comprehend the depths of his need for acceptance. I fear the ends to which he will go show the world what he is feeling.
     …They try to connect with peers, but usually are awkward and out of step with the rest of the group. Peers try to redirect them with subtle rebukes of the unwanted behavior, but they just don’t comprehend. Their desperation grows, and their alienation compounds... They hint to friends over the weeks or months leading up to the incident, but never say quite enough to cause someone to make a report. Perhaps they even want to be stopped. Maybe a police raid at the front door would satisfy the urge for significance and would initiate a connection to caring treatment providers…
     The dramatic showmanship of a school shooting is the act of an enraged suicidal young man who wants to “win big” in his last round of the violent first-person shooter game, but this time he wants to do it in the real world for the rest of us to see. He wants to leave the world with the highest score, with the most number of innocents dead, and with his name on CNN news. He wants to show us with his actions what he could never express with his words.


Posted on October 5, 2015 .