A community gathering on the one-year anniversary of the shooting at Sandy Hook Elementary. (Photo: Deb Nystrom/Flickr)

As this week marks the second anniversary of the school shooting in Newtown, and brings us a deadly hostage crisis in Sydney and a killing spree in the suburbs of Philadelphia, our collective conversation about why these tragedies happen, and how we can prevent any more of them, continues.

But a new paper published in the American Journal of Public Health by Jonathan Metzl and Kenneth MacLeish of the Center for Medicine, Health, and Society at Vanderbilt University cautions broad-based reform based on individual events. After synthesizing decades of research in psychiatry, psychology, sociology, and journalism, they argue that popular opinion about the links between mental illness and gun violence is often misguided, and, if extrapolated into policy change, even harmful to public health overall.

Metzl and MacLeish urge readers to abandon easy answers, and to examine the roots of their beliefs. “Anxieties about insanity and gun violence are also imbued with oft-unspoken anxieties about race, politics, and the unequal distribution of violence in US society,” they write. I spoke to one of them, Jonathan Metzl, this week; here is an edited and condensed version of that conversation.

Your paper points out that less than five percent of gun-related killings in the U.S. are perpetrated by people with mental illness diagnoses. But it makes sense that there would be a connection in most people’s minds between mental illness and, if not violence in general, certainly the kinds of mass shootings that dominate the news.

Sure, we’re very clear about that; I don’t think anybody on any side of the gun debate would disagree with the notion that along with other factors, mental illness certainly plays a role in many of the high-profile mass shootings. What I mean by that is that a number of the shooters of recent high-profile crimes have had some sort of history of mental illness, or symptoms suggestive of mental illness, in ways that make you think that that was a contributing factor. But what we see, even in those instances, is that the question of what particular mental illness is at play, and what the causal link is, between the symptoms and the actual shootings, is often pretty complicated.

What we see portrayed in the media is that mental illness is the one causal link; but we wanted to say that it’s more complicated than that.

For example, after the Arizona shooting, or the Isla Vista shooting, or the Sandy Hook shooting, there’s been a kind of rush to diagnose the shooters, and people have thrown around a host of different diagnostic terms—everything from Asperger's disorder, to autism, to schizophrenia. But even in these cases, we see, first of all, that the immediate diagnoses are very often incorrect, and second, that there are a host of factors that are involved in our attempts to explain these unexplainable crimes. Mental illness is often just one of those factors. What we see portrayed in the media is that mental illness is the one causal link; but we wanted to say that it’s more complicated than that.

I guess it often seems like the easy thing to identify as the problem, and the easy solution to point to: If we could just treat everyone’s mental illnesses, then this wouldn’t happen anymore. I’ve been guilty of that too.

Right, and the other issue is that a number of the mental illnesses that are thrown around after mass shootings—like Asperger's disorder, for instance—really have no broader link to violent behavior at all. Again, in no way are MacLeish and I trying to say that mental illness isn’t a factor of mass shootings, because clearly it is, but the logical leap people make is, therefore, to prevent crime, we should stop people with these diagnosed mental illnesses from having guns.

What we argue is that that’s ineffective, and that people with these diagnoses are much more likely, broadly, to be the victims of crime—not the perpetrators of crime. And if somebody has a long-term, chronic mental illness diagnosis, they are actually less likely to commit a gun crime. It’s exactly the opposite of what you would think in the aftermath of these shootings.

I want to add that our paper also looks at not just the stereotypes of mental illness that are involved in constructing anxieties about guns, but also how questions of race, and even racism, help shape fears of guns and gun violence.

You say that it doesn’t make sense to make broad policy changes regarding mental health care and gun control in the wake of mass shootings. But for many people, I think it feels like those are the only times that policy changes could be possible. So what are the kinds of policies that have been proposed in times like those, and what’s your opinion of them?

Well I think we can see the kinds of policies that have been, not just proposed, but passed. The only legislative changes that we’ve made, for the most part, are requiring psychiatrists, mental health practitioners, or therapists to report potentially dangerous patients to authorities. So in a way, the logical move that’s being made here is, we’re taking a mass shooting, and then trying to generalize through that mass shooting. We think that’s the wrong approach.

First of all, psychiatrists are not great predictors of which ones of their patients are going to become violent and which ones aren’t. Psychiatrists see many patients over the course of a day or a week who threaten violence, and there’s nothing within psychiatric diagnostic categories that help them predict who will be violent and who won’t.

We see, first of all, that the immediate diagnoses are very often incorrect, and second, that there are a host of factors that are involved in our attempts to explain these unexplainable crimes.

The second reason is that, if you look at not just mass shootings, but all shootings, there are factors other than mental illness that are far more predictive of who is going to commit gun crime. I certainly agree that after mass shootings, those are the times that we mobilize to rally around “Let’s do something about gun crime.” But there are two questions at play that we have to ask as a society. One is, do we want to prevent the next mass shooting? Another is, do we want to prevent gun crime more broadly? And I think the second question is a far more useful question, because it’s much harder to prevent mass shootings; they’re just very hard to predict.

So you show in your paper how imagining psychiatrists as the first line of protection, and reporting their patients who have violent fantasies to law enforcement or whatever, doesn’t really make sense. But then should politicians and lawmakers be making those kinds of predictive decisions?

We should be doing things [to prevent violence], but our argument is that there should be cooperation between lawmakers and mental health practitioners. I think it’s more of a community prevention effort. If you look at what the factors are for gun violence, it’s pretty clear that it’s not just a mental health issue or a political issue; it’s a larger social issue.

If you look at what is most predictive of gun violence more broadly, it’s things like substance use, alcohol use, interpersonal conflict, violence within social networks and family networks, and past histories of violence. These are all factors that force us to think that we need collaboration between medical databases and other kinds of databases.

Finally, I was interested in that section where you talk about how different definitions and diagnoses of mental illnesses have changed over time (looking at schizophrenia and PTSD, for instance), even though the behaviors themselves haven’t changed.

Right, that part came from the book I wrote, The Protest Psychosis, which looks at how our assumptions between violence and mental illness have changed radically. We didn’t always think about people with schizophrenia, for example, as being violent. It’s important to keep in mind that our ideas about what mental illness is can dramatically impact the assumptions we make.