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Hosted by Editor in Chief Lorenzo Norris, MD, Psychcast features mental health care professionals discussing the issues that most affect psychiatry.

Aug 21, 2019


Show Notes

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 29 and 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. 

Dr. 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 Erikson’s conceptualization 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 perpetrators.
  • Mass shootings are shown to cluster in ways similar to suicide contagion.

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 attacks.
    • 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. 2.
  • 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 firearms safety.
  • 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 violence:

  • 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 permit.
  • Testing competency/shooting ability with guns before giving a permit.
  • 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 problem

  • 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 field.
  • Research into firearm violence prevention is incredibly underfunded, primarily because of the restrictions embedded in the Dickey Amendment.
    • 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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