MASS MURDERS AND INSANITY

The NRA party line is that people who commit mass firearm homicides are simply insane. Therefore, the problem of firearm homicide is basically a public health issue; if we were sufficiently adept at identifying and treating mental illness, the problem of mass firearm homicide would go away. Not so, say experts in mental illness. Most mass murderers are not insane, and Americans are not more prone to mental illness than citizens of other countries in which mass firearm homicide is almost nonexistent. The explanation for the daily occurrence of mass firearm homicides in the United States is simply this: the easy availability of military grade weapons with high capacity magazines.

If what people do is any reflection of who they are, then Devin P. Kelley, who slaughtered 26 churchgoers recently in Texas, surely was a madman.

Before the atrocity, he had attempted to sneak weapons onto an Air Force base after making death threats to his superiors, according to a local police report. In 2012, he had escaped from a mental hospital in New Mexico to which he had been sent after assaulting his wife and fracturing his stepson’s skull. A video of the church killing reportedly shows Mr. Kelley working his way methodically through the aisles, shooting some parishioners, even children, at point-blank range.

“I think that mental health is your problem here,” President Trump told reporters after that particular killing spree.

It is true that severe mental illnesses are found more often among mass murderers. About one in five are likely psychotic or delusional, according to Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century. Although the figure for the general public is probably closer to 1 percent, many experts place that at a higher number.

Most of these murderers do not have any severe, diagnosable disorder. Though he was abusive to his wife, Omar Mateen, who killed 49 people in an Orlando nightclub, had no apparent serious mental illness. Neither did Stephen Paddock, who mowed down 58 concertgoers from a hotel window in Las Vegas.

Ditto for Dylan Roof, the racist who murdered nine African-American churchgoers in South Carolina in 2015, and Christopher Harper-Mercer, the angry young man who killed nine people at a community college in Oregon the same year.

Nor does anything in these criminals’ history — including domestic violence, like Mr. Kelley’s — serve to reliably predict their spectacularly cruel acts. Even if spree killers have committed domestic violence disproportionately more often — and this assertion is in dispute — the vast majority of men who are guilty of that crime never proceed to mass murder.

Most mass murderers instead belong to a rogue’s gallery of the disgruntled and aggrieved, whose anger and intentions wax and wane over time, eventually culminating in violence in the wake of some perceived humiliation.

“In almost all high-end mass killings, the perpetrator’s thinking evolves,” said Kevin Cameron, executive director of the Canadian Center for Threat Assessment and Trauma Response. “They have a passing thought. They think about it more, they fantasize, they slowly build a justification. They prepare, and then when the right set of circumstances comes along, it unleashes the rage.”

This evolution proceeds rationally and logically, at least in the murderer’s mind. The unthinkable becomes thinkable, then inevitable.

Researchers define mass killings as an event leaving four or more dead at the same place and time. These incidents occur at an average of about one a day across the United States; few make national headlines.

At least half of the perpetrators die in the act, either by committing suicide (Mr. Kelley is said to have shot himself in the head) or being felled by police.

Analyzing his database, Dr. Stone has concluded that about 65 percent of mass killers exhibited no evidence of a severe mental disorder; 22 percent likely had psychosis, the delusional thinking and hallucinations that characterize schizophrenia, or sometimes accompany mania and severe depression. (The remainder likely had depressive or antisocial traits.)

Adam Lanza, who in 2012 killed 26 people at Sandy Hook Elementary in Newtown, Conn., exhibited insanity characterized by extreme paranoia in the months leading up to his crime, isolating himself in his room.

But what to make of John Robert Neumann Jr., who in June shot and killed five former co-workers at a warehouse in Orlando before turning the gun on himself? Mr. Neumann was not overtly psychotic, as far as anyone knows, and this is far more typical of the men who commit mass killings generally.

“The majority of the killers were disgruntled workers or jilted lovers who were acting on a deep sense of injustice,” and not mentally ill, Dr. Stone said of his research.

In a 2016 analysis of 71 lone-actor terrorists and 115 mass killers, researchers convened by the Department of Justice found the rate of psychotic disorders to be about what Dr. Stone had discovered: roughly 20 percent.

The overall rate of any psychiatric history among mass killers — including such probable diagnoses as depression, learning disabilities or A.D.H.D. — was 48 percent. About two-thirds of this group had faced “long-term stress,” like trouble at school or keeping a job, failure in business, or disabling physical injuries from, say, a car accident.

Substance abuse was also common: More than 40 percent had problems with alcohol, marijuana or other drugs.

Looking at prior studies, and using data from his own work, J. Reid Meloy, a forensic psychologist who consults with the F.B.I., has identified what he believes is a common thread: a “paranoid spectrum,” he calls it.

At the extreme end is patent psychosis. But the majority of people on this spectrum are not deeply ill; rather, they are injustice collectors. They are prone to perceive insults and failures as cumulative, and often to blame them on one person or one group. “If you have this paranoid streak, this vigilance, this sense that others have been persecuting you for years, there’s an accumulation of maltreatment and an intense urge to stop that persecution,” Dr. Meloy said. “That may never happen. The person may never act on the urge. But when they do, typically there’s a triggering event. It’s a loss in love or work — something that starts a clock ticking, that starts the planning.” Mental health treatment might make a difference for the one in five murders who have severe mental disorders, experts say. Prevention is also possible in a few other cases — for instance, if the perpetrators make overt threats and those threats are reported.

But other factors must be weighed. “In my large file of mass murders, if you look decade by decade, the numbers of victims are fairly small up until the 1960s,” said Dr. Stone. “That’s when the deaths start going way up. When the AK-47s and the Kalashnikovs and the Uzis — all these semiautomatic weapons, when they became so easily accessible.”

               THE BOTTOM LINE?

Attempting to discover the vast numbers of people who possess mental disorders that might be potential murderers is clearly impossible. Even if we could detect those most likely to perform such acts, society’s rules usually preclude any attempts to force them to undergo treatment prior to any acts of violence. Thus the only possible countermeasures are—prior to all firearms purchases—careful background checks for past mental disorders or violent and/or other antisocial acts. This must also be coupled with rigorous general restrictions of assault weapens capable of rapid repetitive fire into multiple targets.

Perhaps the demented leaders of the N.R.A. should be brought in for mental evaluations prior to more mass shootings!

The ultimate irony? If one believes that insanity should disqualify all persons from gun ownership, then the opinions of 27 mental health experts (http://www.mortontavel.com/2017/10/09/) should be enough to prevent Trump himself from getting his hands on any lethal weapons, especially of the nuclear variety!

 

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SECOND AMENDMENT AND HEALTH: WHAT DID OUR FOUNDERS INTEND?

As a physician concerned with health issues, I am impelled to examine the original conditions underlying our country’s current allowance of the widespread presence of firearms. Hopefully, this may provide better insight into our present dilemma.

After a lively debate in 1789, the final version of the second amendment to the U.S. Constitution read: “A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed”   Its meaning has provoked more controversy in our own time than when it was originally adopted.

After the American Revolution, there was great concern about states’ rights; five states had even called for prohibition of a permanent standing federal army because of the perceived threat posed by a professional army under federal control. Thus the prevailing intent was to allay the fear that would have limited states’ rights. The armed forces that won the American Revolution actually consisted of a Continental Army that was formed by a conglomeration of state and regional militia units together with regular French armed forces. Allowing for a powerful U.S. federal force at that time was all too reminiscent of the recently defeated tyrannical forces of England

In United States v. Miller (1939), the Supreme Court seemed to have supported this collective concept by ruling that the federal government and the states could limit any weapon types not having a “reasonable relationship to the preservation or efficiency of a well regulated militia.”   By contrast, the more recent Supreme Court decision (Heller v. District of Columbia, 2008) found the right to bear arms an inherent and nearly unlimited individual right, which was clearly at odds with the founders’ original intentions that referred to a right of collective defense in the form of militias. Most scholars believe this right was to apply when the sanctions of society were breached by the violence of oppression, clearly a collective endeavor.

Now that our federal government controls a strong national defense force, bearing of arms is no longer a state or local responsibility, and the individual “right” to bear arms is, in reality, not really a right but a privilege to be granted individuals with permission of local jurisdictions, within broad and reasonable limits provided by the federal government. In reality, local militias are now passé, and individuals have no need to claim rights that were formerly accorded to defend against militant groups—be they Indians, foreign forces, or our own federal forces.

When the second amendment was introduced, the standard firearm was a musket that, under the most favorable conditions, could fire a single shot every 15 seconds for at least 4 minutes before usually slowing down because of fouling in the barrel—a method clearly inadequate for mowing down large numbers of unarmed people in packed assemblages. It thus seems clear that our founders—were they made aware of the devastating potential of modern rapid firing weapons such as assault rifles (AK 47) and their ilk—would have urged sensible limitations to this so-called individual “right” to bear arms. Obviously, the constitution requires constant reinterpretation in response to changing circumstances, as evidenced by abolition of slavery, school desegregation, and others too numerous to list.

More sensible control of firearms is a desire shared by the majority of our population that includes gun owners themselves. Thus all individuals should carefully monitor the preferences of our candidates for public office and vote accordingly, a vote that should also take into account the individual proclivities most likely to select future Supreme Court justices willing to reassess the control of firearms in a modern context.

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FIREARM VIOLENCE IN THE UNITED STATES: A MEDICAL OPINION

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   Most people don’t realize that over 30,000 people are purposely shot to death each year in the U.S. Moreover, rates of firearm-related violent crimes continue to climb, having increased by 26% since 2008. To gain perspective on these numbers, firearm deaths have now reached a yearly rate that equals that of automobile fatalities. What we can do to stem such violence is urgent but hampered severely by the rabid supporters of the second amendment and, of course, the gun lobby. Some clarification recently has been shed on this problem by a study appearing in the prestigious medical journal, the AMA sponsored Archives of Internal Medicine. These authors explored the question whether more restrictive firearm laws in a given state are associated with fewer shooting deaths. To answer this question, using sophisticated statistical methods, they measured the association between the rate of shooting deaths in a state-by-state rating (divided into quarters) of strength of legislation designed to limit sale and use of firearms. Their results were very illuminating: Those states with the fewest firearm regulations, as exe