Can acts of violence be prevented or predicted?
A conversation with assistant professor of psychiatry Benjamin Nordstrom
The murder, in December 2012, of 20 children and six adults at Sandy Hook Elementary School in Newtown, Conn., has prompted a great deal of discussion about the causes of such acts and what, if anything, might be done to prevent them. A common topic in this discussion is mental illness, and whether cuts to mental health services have increased the risk of acts of mass violence. Dartmouth Medicine editor Amos Esty asked Benjamin Nordstrom, an expert in the intersection of mental illness and crime, to give his thoughts on the shooting in Newtown and its relation to treatment of mental illness.
DARTMOUTH MEDICINE: Since the shooting in Newtown, Conn., there has been a lot of discussion of mental illness and violence. Is there a link between the two?
NORDSTROM: In general, the vast majority of people with mental illness have no increased risk of violence at all. It also depends on how you define mental illness. For certain constructs, such as antisocial personality disorder, borderline personality disorder, and psychopathy, then, yes, the propensity for violence is increased. But when people think about the mentally ill, they're usually thinking about people with depression, bipolar disorder, or other such conditions, and those conditions do not have any elevated risk of violence.
DM: In some sense, it seems that by definition there must be some sort of mental disturbance in anyone who carries out a mass shooting or similar act of violence.
NORDSTROM: Right, it's sort of by definition an aberrant, abnormal behavior. But not all aberrant, abnormal behavior is necessarily sick behavior. Sometimes it is just bad behavior. Certainly there are examples of people committing these crimes who do appear to have a mental illness, such as the man who shot Congresswomen Gabrielle Giffords. According to his defense team, he appears to have had some significant mental illness. But that doesn't mean that in general we can infer that people with such illnesses are more likely to behave like that.
DM: Given what you've said, that there's generally not a connection between mental illness and violence, other than for a few specific conditions, why do you think mental health is always raised as an issue when acts of mass violence occur?
NORDSTROM: I think it goes back to your comment that obviously there is something wrong. These acts are incredibly deviant behavior, and those of us who aren't prone to such behavior have trouble understanding how it could happen, how a person could be capable of such unbelievable malice. So people say that the culprit is "sick in the head." In a colloquial sense, they're completely correct. But in a more exact sense, when you think about mental illness and who the mentally ill are in this country, I think it's a real injustice to conflate these two populations. The vast, vast majority of people with mental illness are not prone to that sort of behavior at all. But I think there's something in us that is so uncomprehending of how someone could behave that way, and "sickness" is an easier construct to understand than "evil."
Benjamin Nordstrom, MD, PhD
- assistant professor of psychiatry at Geisel
- Director of addiction services at the Dartmouth Psychiatric Research Center
- Dartmouth Medical School (MD, 2001)
- University of Pennsylvania (PhD, 2011)
- Columbia University Medical Center and New York State Psychiatric Institute
(residency in psychiatry and fellowship in addiction psychiatry)
DM: So is it possible for treatment of mental illness to reduce the risk of violence?
NORDSTROM: Again, it turns on the issue of what we call a mental illness and the type of violence you're talking about. Treatment can reduce the likelihood of more routine interpersonal violence, such as pushing or shoving, that sometimes happens when somebody is in the midst of an exacerbation of an underlying condition. But violence such as the Newtown shooting is obviously very different. There really is no treatment for antisocial personality disorder. There's no treatment for psychopathy.
DM: Since the Newtown shootings, one part of the discussion of violence and mental illness has been the issue of cuts to mental health treatment and the general inadequacy of mental health resources. Do you think that discussion has been helpful in raising awareness of these issues?
NORDSTROM: I think we'll have to see how this plays out. As a psychiatrist, I'm always pleased to see people talking about the importance of mental health care and the importance of improving access to care. That said, I don't think that anyone could say that improved mental health care would have reduced the likelihood of any of the recent mass shootings.
DM: Is it possible to draw any general conclusions about who might be prone to commit this kind of act, or are mass shootings too rare to do that kind of analysis?
NORDSTROM: Historically, that has been the problem. These events are so sporadic that it's hard to do any good studies of mass shooters and understand or predict who is going to behave this way. Psychiatrists and psychologists are very bad at predicting long-term risks of violence. When people are hospitalized, we can predict pretty accurately the short-term risk of small-scale violence, such as shoving a nurse. But we're not capable of predicting with any accuracy whether a person is likely to carry out a mass shooting, or really any other kind of violence out in the community.
The vast majority of people with mental illness have no increased risk of violence.
DM: Have you seen anything in the discussions since Newtown of how to prevent such events in the future that you think might succeed?
NORDSTROM: We know from the research done on mass shooters that the vast majority of the time they warn somebody about what they're going to do. We also know that mass shooters tend to be people whose interests become much more oriented toward violence and guns. We want people to realize that if they see someone displaying this collection of behaviors, it's a good time to speak up, to alert the authorities—whether it's authorities at school or the police or mental health professionals. Draw attention to the fact that this person seems to be on a concerning trajectory. That's probably the most useful thing to come out of this discussion. I also think that it is terrific to have a national discussion about why the U.S. has higher rates of homicide than other similar cultures around the world. But in terms of specific remedies, I think very little has been brought up that we could say with any kind of confidence would be likely to reduce the probability of such events in the future.
DM: So do you think there's anything that could be done that might help reduce the likelihood of such an event?
NORDSTROM: There is certainly something that is social about mass shootings, that is a socially contagious behavior. It's possibly that rethinking how we report on these tragedies could be helpful. For example, not ever using the shooter's name—not discussing the shooter, not giving them the infamy that they're seeking. That's not to say that there shouldn't be a discussion of how something like this happens. But just as the media generally do not report the names of victims of sexual assault, even though they could, because of a sense that it's not the right thing to do, perhaps the same sort of practice could guide reporting on mass violence. That might prevent the people who carry out these acts from gaining the kind of fame that they're looking for and that attracts other people like this.
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