Ohio Governor Mike DeWine focused on mental illnesses this week in his response to the Oregon District shooting. Among other proposals, he called for increased access to inpatient psychiatric care, “wrap-around services,” early intervention training, online mental health services for students, training on risk factors, and red-flag legislation to keep guns out of the hands of the mentally ill.
Dayton-area health officials applaud these measures and any steps that will help improve the community’s mental health.
MORE: Oregon District shooting victim survived escape from oppressive country
But research has shown the behavioral factors that lead some to commit heinous acts of mass violence are more nuanced and complex than a label of mental illness.
Dr. Victoria Kelly, president of Ohio Psychiatric Physicians Association, said that mass shootings can seem so unbelievable, people might blame mental illness because it’s hard to picture what else could be the cause.
“I think that’s just the wrong path to go because we run the risk of making everything a mental disorder, which shouldn’t be the case either,” she said.
Kelly said it is frustrating when mental health professionals have to continuously fight stigma after a mass shooting.
“I think the other big thing is that in mental health, we care a lot about gun policy. And it’s frustrating to have to continue to have the same discussion that we need more research into this public health crisis. That’s just not happening,” Kelly said.
Studies of mass-shooters in the U.S. have found that about 25 percent have a diagnosed mental illness, which is a slightly higher rate than the percentage of people in the general population - 18 percent.
The National Council for Behavioral Health released a 96-page study this week titled "Mass Violence in America: Causes, Impacts and Solutions" which summarized research findings into mass shooters.
According to the report, the most common characteristics that mass shooters share are:
- They are male.
- They feel hopeless and harbor grievances related to work, school, finances or relationships.
- They feel victimized and sympathize with others who they perceive to be similarly mistreated.
- They have an indifference to life.
By the standards of mental health professionals, these attackers are in mental distress, which is different from having a mental illness.
“Perpetrators of mass violence may be motivated by mental distress from life events and circumstances or by the symptoms of mental illness. These are not the same and thus require different modes of detection and prevention,” the National Council report says. “At present, our current health care delivery system is not designed to address the causes or detect and provide interventions for people at risk for mass violence behavior.”
Others studies note another common trait: many have a history of domestic violence.
“It’s a pattern experts have noticed,” said Sarah Wolf-Knight, grants and advocacy manager at YWCA Dayton. “Not just domestic violence among these mass shooters, but also just this pattern of toxic masculinity.”
In Dayton, it’s still unknown publicly if the shooter was ever diagnosed with a mental health disorder or illness, although a woman who said she recently dated him said he told her he had bipolar and obsessive compulsive disorders. Neither his family nor investigators have confirmed that diagnosis.
RELATED: Would the governor’s 17-point plan have stopped Sunday’s mass shooting?
He did have a history of threatening women who he felt had wronged him. Multiple witnesses said he was disciplined in high school for creating a “hit list” of girls he wanted to rape and kill. His band performed a genre of music that focuses on violent imagery including raping and killing women.
“In more than a third of the public attacks over the past eight years we’ve been able to directly identify the perpetrators had committed some form of violence against women,” Wolf-Knight said. Talking about or actually brutalizing woman is the common denominator that appears long before the mass killing in dozens of these cases, she said.
And while the Southern Poverty Law Center has labeled male supremacy a hate ideology, it’s not a mental illness diagnosis.
Perpetuating stigma
The rush to label mass shootings as acts of “mentally ill monsters,” as President Donald Trump said this week, is often too broad, experts said.
“Since it is difficult to imagine that a mentally healthy person would deliberately kill multiple strangers, it is commonly assumed that all perpetrators of mass violence must be mentally ill,” the National Council report says.
When mental illness becomes the accepted reason for mass violence, it follows that restricting the liberty of people with mental illnesses and preventing them from owning guns are the solutions.
“This simplistic conclusion ignores the facts that mass violence is caused by several different social and psychological factors that interact with each other in complex ways, that many if not most perpetrators do not have a diagnosable mental illness and that the large majority of people with diagnosable mental illnesses are not violent toward others,” the National Council report says.
Following the Dayton shooting, the American Psychiatric Association said people with mental illness are far more likely to be victims of violent crime than perpetrators of violence.
“Rhetoric that argues otherwise will further stigmatize and interfere with people accessing needed treatment. Individuals can also be emboldened to act violently by the public discourse and divisive rhetoric,” the association said.
The term mental health casts a wide net that encompasses a range of behaviors and diagnoses. Similarly, the National Council notes that mental illness, “is a highly elastic clinical term that can mean many things but is often used without definition in the mass violence narrative.”
National Alliance on Mental Illness, one of the leading mental health advocacy groups, advocates for people with personality disorders as part of the mental health community. The organization also distinguishes between personality disorders and other diagnoses such as schizophrenia. Personality disorders, such as antisocial personality disorder (colloquially called sociopathy), are not curable but are treatable.
Kelly said personality disorders are an entirely different category than illnesses like bipolar disorder, schizophrenia, depression, or PTSD.
“Personality disorders are a pervasive pattern of experiencing life and it affects the way that you think about things. It affects your ability to regulate your mood, impulse control and function in interpersonal ways,” she said. “So that is different than bipolar disorder or schizophrenia, depression, where you might have isolated episodes.”
Terry Russell, executive director for NAMI Ohio, which is the state-level chapter, said blaming mental health problems can stigmatize everyone. He emphasized that treated mental illness and untreated mental illness are different situations and said untreated mental illness can sometimes play a role in violent crimes, though overall people with mental health issues are no more likely to commit violent crimes than others.
“We believe that those committing these senseless acts that have an untreated mental illness may have exhibited symptoms prior to their crimes. We must educate everyone in society to recognize these symptoms but more importantly be capable of referring to immediate treatment,” Russell said.
Characteristics of a mass shooter
Mass shootings are incredibly rare, accounting for two-tenths of one percent of all homicides. Couple that with the fact that many of perpetrators end up dead, and it’s a very difficult phenomenon to study scientifically, experts told the Dayton Daily News.
“Even though it’s rare, it does seem to be accelerating,” said Dr. Randon Welton, associate professor of psychiatry and director of residency training at the Wright State University Boonshoft School of Medicine. From 2011 to 2014 there was one mass shooting every 64 days, up from one every 200 days from 1982 to 2011.
“It would be tough to explain that acceleration by mental illness, because mental illness hasn’t tripled since 2011,” Welton said.
The U.S. Secret Service compiled information on 28 mass attacks in public spaces during 2017.
The only things 100 percent of the attackers had in common was that they were all male and they all had experienced acute stress in the past five years due to life events including but not limited to a job loss, the end of a marriage or a family health crisis.
The next most common factor was aggressively narcissistic behavior, which was seen in the histories of 82 percent of attackers.
“Some inappropriately asserted control over others, as observed by their histories of domestic violence, sexual assault, harassment, or harming animals. Others had a history of violent or angry outbursts following interpersonal conflicts with co-workers, neighbors, or family members,” the report says. “Some attackers displayed an inflated sense of self or entitlement, unrealistically believing that they were deserving of certain relationships, successes, or benefits, with some reacting angrily when they did not obtain what they believed they deserved.”
RELATED: FBI launches investigation into Dayton shooter, citing ‘violent ideologies’
Nearly 80 percent of the attackers studied that year had a history of concerning or threatening communication. About half had a history of substance abuse, 32 percent had prior domestic violence incidents, and a quarter followed an ideology that played into their crime such as being a white supremacist or conspiracy theorist.
Welton said none of these factors on their own predicts a mass shooting, but in combination they elevate the risk.
What can be done?
In the wake of the mass shooting and the resurfaced conversation on mental health, Ohio Medicaid Director Maureen Corcoran highlighted mental health investments already in the works by the DeWine administration.
DeWine recently signed an executive order that took changes that were coming for behavioral health services and made those changes effective Aug. 1.
This includes higher reimbursement rates for crisis services, which can include crisis providers that ride along with police, crisis providers that admit people who might otherwise be brought by police to a jail, and agencies that evaluate people at hospital emergency rooms to see if they need to be admitted to a psych hospital.
“We wanted to make some targeted investments that would help stabilize services and make sure that we didn’t lose access to services that exist,” Corcoran said.
The DeWine administration is also working on increasing supports for helping children be emotionally and behaviorally healthy from an early age, such as a pilot telehealth program that will let schools remotely connect children with a behavioral provider.
These are all needed improvements, experts said, and will certainly help prevent deaths, especially from suicide. But alone they will likely not stop future mass shooting incidents.
Red flag or extreme risk protection laws, for example, are a solution being put forward that would allow families and law enforcement to petition a judge to temporarily remove firearms from individuals at imminent risk for using them to harm themselves or others. And while the data shows that many mass shooters do exhibit concerning behavior ahead of their crime, a much smaller percentage make direct threats about their target. It makes it difficult to prove an “imminent” risk, Welton said.
“We can predict people who are at a higher (risk), but predicting when they’re going to be violent we’re really bad at,” he said. “In hindsight you can build a case for mental illness or mental distress, but the key is could you have done that before hand?”
Personality traits like narcissism, victimhood and toxic masculinity can be worked on with therapy, but it’s a long process, Welton said.
“Disgruntlement, there’s no pill for that,” he said. A 72-hour psychiatric hold is not the answer for these individuals. They would have to consent to many days, weeks and years of therapy to learn where their warped view of reality stems from, and how to better cope with stress and disappointment, he said.
The YWCA in Nashville is working to combat toxic masculinity from an early age through a program called Amend Together. The Dayton chapter of the YWCA is hoping to get a grant to bring the program here.
The idea is to dismantle harmful stereotypes in boys so they don’t grow up to be domestic abusers.
“It’s really this narrow and repressive definition of what we in society have been telling people what it means to be man,” Wolf-Knight said. “Designating manhood to be defined by things like violence, sex, status, aggression, so that’s what a lot of men are raised thinking that that’s what they need to be or demonstrate in order to be considered a man.
Health officials hope investment in early interventions with kids will prevent mass shootings down the road by producing adults who have empathy, can cope with stress and failure in healthy ways and don’t turn to violence as a solution.
“If you take those individuals who are already pre-determined to commit things like domestic violence because of the way they were conditioned culturally and societally, (combine that with) access to weapons, and even knowledge of some of these other mass shootings that they are influenced by and are able to look at these things on the internet,” Wolf-Knight said. “I think it all probably comes together to increase that prevalence.”