Thread by @WheatNOil

I was asked in good faith to expand on this and so I will.

I do think that when so many use mental illness as a scapegoat for violence, we have a tendency to shut down discussions b/c of clear bad faith. However, that prevents us from having honest good faith discussions.

https://twitter.com/WheatNOil/status/1158035914674835456

I suspect many people link mass shootings with mental health because for someone to do something so horrible, there must be something 'wrong' with them. They must not be thinking right. They're "messed up" & that becomes synonymous with "mental illness".

So for starters, we should differentiate:
A mental illness should have a clear set of criteria for a specific condition. It's not a catch-all for all acts of deviance or horribleness.

Just because you do something 'bad', doesn't mean you're ill.

Just as if you're ill, it doesn't mean you're doing something "bad".

Let's take the example of a different behaviour than mass shootings: suicide.

We know suicide is linked to many different mental illnesses. Depression, Anxiety, Psychosis, Alcohol Use.

However, many if not most suicides are NOT directly due to a mental illness.

A great deal of suicides relate to the underlying environment in which an individual lives. Poverty, shelter, community, basic hope. Essentially your social determinants of health.

An environment can greatly increase the likelihood of a behaviour, like suicide.

So even in a case like suicide, where there is a clear link between symptoms and the behaviour, there's much more to it than just the illness.

In the case of mass shooters, even that link doesn't clearly exist.

Depressed, anxious, traumatized individuals generally aren't looking to harm others. They might want to harm themselves because of lack of self-worth, perceived isolation, feeling numb, feeling too much pain, thinking they're burden, etc etc but not generally others.

Even the times when they DO have thoughts of harming others, they know it's wrong. There's nothing inherent in their disorder that prevents them from knowing that.

There's no disorder where "wanting to shoot a mass number of random people" is a diagnositc symptom or behaviour.

Even when sometimes individuals with a mental illness do get aggressive, it's usually impulsive an reactive. Someone with ADHD who acts without thinking & regrets it afterwards. Someone who's panicking shoves someone out of the way.

'Sometimes' individuals with a mental illness can get so reactive it can be scary. They could have an explosive anger. However, generally speaking, these aren't pre-meditated attacks. It's explosive anger in the moment.

Not "I took a gun to a well populated area".

(As a side note, if someone DOES have explosive, impulsive anger related to a mental illness, one of my first recommendations would probably be to keep all guns away from that individual, same as I would for anyone impulsively or seriously suicidal.)

(Also a side note, generally speaking, an individual who reacts explosively in anger is still responsible for those actions. A mental illness doesn't, in most cases, explain away all culpability. Just provides contributing context.)

There are exceptions to what I'm talking about above. This might happen when someone has a disconnect with reality. We call that "psychosis". Usually these individuals struggle with hallucinations or delusions (fixed, false beliefs that someone can't shake).

These individuals can have their entire thoughts disorganized, like their thoughts jump from one topic to another with no connection. It feels like a jumble and even their speech doesn't follow any organized line.

Even in these cases, individuals with psychosis are MUCH more likely to be victims of violence than perpetrators. Their symptoms make them scared and fearful. They hide or act bizarrely & are targeted by others.

Even if they WERE to want to hurt others, their thoughts are often so disorganized that they can't put together an organized plan to act on it.

Now, sometimes there are individuals who have severe delusions that are organized enough to act on. These cases have absolutely happened before. Sometimes they have led to famous assassination attempts.

(Incidentally, individuals in this state are likely particularly susceptible to hateful rhetoric all too easily accessible these days. Their specific delusions may also be a product of their environment.)

It's important to note, these examples are quite rare. So it's possible for a mass shooter to have acted on a clear delusion fed by a mental illness. Every situation is individual. But when it happens, it's the minority of cases. It's not a major contributing factor.

Now, in saying all of these, there are individuals who, within their character, don't have much empathy for other people. We throw around terms in the public like narcissists or sociopaths.

Even those terms, though, have actual clear criteria. Whether you include them under the umbrella of "mental illness" has been a matter of debate. Some of those terms have made appearances in different areas in different iterations of the diagnostic manual for mental disorders.

What is clear, though, is that those "disorders" or "personality constructs" or whatever you call them, are not easily treated. There's no medication to take that away. Therapy can show 'some' benefit, but usually only in extremely motivated individuals.

Which brings me to my last point in this WAY too long thread. Let's say we ignore everything I wrote above and say mass shooters have a mental illness.

What should we do about it? What CAN we do about it?

There's no medication that's been shown to decrease desires to mass kill. Even medications that show some evidence in reducing aggression, really mostly help (modestly) with the impulsive, immediate, explosive anger aggression. Not the "plan a mass shooting" aggression.

Therapy is a term that gets thrown around a lot. But while therapy can be incredibly powerful, it is in fact hard work & not always effective. Someone has to WANT to do therapy. If they're not interested, they're generally not getting anything out it.

So to think we're going to find all these potential mass shooters treat their killing desires away is a bit naive.

It's not predominantly driven by mental illness. Even if it was, there's no evidence of good treatment options.

I'm stepping out of my scope to suggest I have a clear answer to stop all mass shootings. If I were to approach it from the perspective of my field?

We'd reduce access to the most lethal means. Same as we do with individuals with severe thoughts of suicide.

That, far and away, is the most important aspect of any mental health treatment. Take away the means. EVEN with effective treatment, people slip. Remove the means of lethality so they can't make an impulsive decision.

Obviously this thread is in response to the recent mass shootings, and at least one of those seems to be clearly related to white supremacy.

I have opinions on terror & white supremacy, obviously, but this thread is based on what I specialize in. That's not my specialty.

So as a mental health professional, may I suggest we look to the experts who specialize in radicalization & terror for what to do with some of these shootings.

If you want a mental health approach?

First, don't chalk this all up to mental illness. Even if some of these individuals ALSO have a mental illness, it's not the explanation for their actions.

If you REALLY want to make this mental health, then actually approach it that way.

Step 1 is reduce access to lethal means.

Step 2 is everything else.

Step 1 won't solve everything. But the entirely of Step 2 is meaningless without the 1st.

I’m going to tag this thread with another thread, citing some academic research supporting the conceptual arguments I made above.

https://twitter.com/carolineylchen/status/1158122051141623808?s=21