Aug 21, 2019
Jack Rozel, MD, returns to the MDedge Psychcast to discuss gun
violence and a new report from the
National Council for Behavioral Health. In episodes
33, Dr. Rozel talked with Lorenzo
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, about this topic in the wake of the
shooting last year at the
Tree of Life synagogue in Pittsburgh.
Rozel is medical director of
resolve Crisis Services at the Western Psychiatric Institute
and Clinic of the University of Pittsburgh. He also is
president-elect of the American Association for Emergency
Psychiatry and a member of the National Council. Dr. Rozel can be
found on Twitter @ViolenceWonks.
Later, Renee Kohanski, MD,
discusses betrayal in the context of Erik
of trust vs. mistrust. Dr. Kohanski, a member of the MDedge
Psychiatry Editorial Advisory Board, is a psychiatrist in private
practice in Mystic, Conn.
Show notes by Jacqueline Posada, MD, consultation-liaison
psychiatry fellow with the Inova Fairfax Hospital/George Washington
University program in Falls Church, Va.
Gun violence in the United States
- Mass violence with guns is a distinctly American problem
occurring with greater frequency and severity in the United States,
compared with other countries.
- The United States has a broad swath of firearm violence: Deaths
by suicide account for 60% of gun deaths, and the remaining 40% are
deaths by homicide.
- 1%-2% of homicides are completed in mass shootings, which are
defined as an event in which a gunman indiscriminately shoots four
or more people.
- Firearm homicides have been trending downward, while mass
shootings have increased.
- Mass shootings might be influenced by media coverage; media
exposure about mass shootings can incite possible
- Mass shootings are shown to cluster in ways similar to suicide
Responses to mass shootings/violence
- The National Council for Behavioral Health addresses mass
violence by releasing a new report:
- The report, called “Mass Violence in America: Causes, Impacts
and Solutions,” was written by a group of 30 multidisciplinary
experts, including Dr. Rozel.
- It was released in response to stigma and incorrect messages
linking psychiatric diagnoses to mass violence.
- The report reviews models aimed at preventing violence and
understanding threat assessment.
Predicting violence and diffusing threats
- Pathway to
violence is a model for predicting mass violence generated by
data and analysis of violent acts by the Los Angeles Police
Department, U.S. Capitol Police, U.S. Marshals Service, and the
U.S. Secret Service.
- Grievances: Violence often starts with a grievance. Clinicians
might be familiar with patients who are “grievance collectors” and
do not get along with any person, whether at work, family, or
society at large.
- The pivot: A transition from simply having a grievance to
violent ideation and wanting vengeance through violence.
Psychiatrists certainly will see people who express violent
fantasies. Perpetrators of violence shift from fantasy into
research about planning and preparing to attack.
- Clinicians want to identify the point at which people feel
aggrieved and should become most concerned when these people begin
to get certain fixations.
- Preparation: The person will start to acquire weapons and
tactical clothing; probe into vulnerabilities of their targets,
conduct “test attacks”; and eventually carry out the final
- Identification: The grievance stage is the most effective place
to intervene, once the identification has been made, and
potentially diffuse a violent outcome.
The United States holds a unique position when it comes
to gun ownership, violence
- The United States is one of the three countries in the world
that allow citizen access to firearms in their constitutions.
- With 393 million civilian-held firearms, the United States has
more civilian-owned firearms than the next 39 countries combined.
- India, which has 70 million civilian-held firearms, ranks No.
- Regardless of what happens with gun control following each mass
shooting, the guns already are out there in civilian hands.
- Behavioral health clinicians must talk with patients about
- A person living in the United States is 10 times more likely to
die of firearm-related suicide and 25 times more likely to die of
firearm-related homicide, compared with people living in other
economically developed countries.
Components of proposed legislation that could reduce gun
- Increasing mental health access: Violent acts can be attenuated
through access to mental health with anger-management classes and
interventions at emotional regulation.
- Implementing universal background checks for gun purchases.
Currently, this policy varies from state to state.
- Requiring a background check to obtain a concealed carry
- Testing competency/shooting ability with guns before giving a
- Increasing access to gun violence restraining
orders, also called gun violence prevention orders. The
restraining orders are aimed at temporarily stopping people who
pose a threat to themselves or others by buying or possessing a
firearm. The number needed to treat to prevent suicide with this
type of restraining order is 11-20.
Education and research that could address the
- Research about the pathway to violence model and threat
assessment can be used to create training for the array of
professions that touch on violence – such as police, gun stores,
teachers, and health care professionals. Training can focus on
de-escalation and recognition of individuals at risk of
perpetuating violence against themselves and others.
- Training for health care professionals should not be limited to
just a psychiatry rotation, but also in emergency medicine and
primary care, since gun violence affects patients within every
- Research into firearm violence prevention is incredibly
underfunded, primarily because of the restrictions embedded in the
- Named for the
late Rep. Jay Dickey of Arkansas, the provision specifies that
“none of the funds made available for injury prevention and control
at the Centers for Disease Control and Prevention may be used to
advocate or promote gun control.” This amendment remains a huge
obstacle to any group seeking to research gun violence.
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Knoll IV JL and GD Annas. Mass shootings and
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Violence and Mental Illness. Arlington, Va.: American
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Silver J et al. Foreshadowing targeted violence: Assessing
leakage of intent by public mass murderers.
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Swanson JW et al. Gun violence, mental illness, and laws that
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Rahman T et al. Anders Breivik: extreme beliefs mistaken for
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National Council for Behavioral Health.
Mass violence in America: Causes, impacts, and solutions. 2019
Mass shooters and murderers: Motives and paths. National
Collaborating Centre for Mental Health. Violence and aggression:
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Betz ME and GJ Wintemute. Physician counseling on firearm
safety: A new kind of cultural competence. JAMA.
of Columbia v. Heller (2008).
Rostron A. The Dickey amendment on federal funding for research
on gun violence: A legal dissection. Am J Public
Health. 2018 Jul;108(7):865-7.
“More research could help prevent gun violence in America.”
Rand Review. 2018 Jul 10.
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