In My Voice: Decoupling Mental Illness and Violence as a Psychiatrist
“Focusing on shoring up the mental health system as a way to prevent mass shootings or other violence is not an effective strategy.”
Throughout Mental Health Month, we will be sharing Q&As with individuals who have experience with different aspects of mental health and gun violence. Today, we share a Q&A with Dr. Amy Barnhorst, MD. Dr. Barnhorst is a member of the Consortium for Risk-Based Firearm Policy and the Vice Chair of Community Psychiatry at UC — Davis.
What is the most common misconception the general public has about serious mental illness?
One of the most common misconceptions about mental illness is that people with mental illness are responsible for much of the violence in our world. Although often portrayed as violent by the media, people with serious mental illnesses like schizophrenia and bipolar disorder have about the same risk of violence as demographically similar people (same age, same neighborhood, same education level, etc.) who don’t have those illnesses.
Only about four percent of violence that goes on in our communities happens because of serious mental illness; the rest is due to other risk factors for violence like drugs and alcohol, poor coping skills, history of childhood trauma, etc. People who drink heavily, get in fights, and have angry outbursts are much more likely to perpetrate violence than someone with schizophrenia, for example.
You’ve written that “hate is not a mental illness.” Can you elaborate on that concept and how it applies to our work in the gun violence prevention movement?
Although mass shootings comprise a very small percentage of violence in our country, they garner a lot of attention and create a lot of fear. And the perpetrators are often presumed to have a mental illness, maybe because we struggle to find any other reason why they might have done something so horrible.
But what is far more common is that they have a set of traits like anger, resentment, entitlement, and an inability to empathize with others. These traits are not necessarily indicative of a mental illness, won’t always lead them into the mental health system, and don’t usually respond well to involuntary treatment. So focusing on shoring up the mental health system as a way to prevent mass shootings or other violence is not an effective strategy. Focusing on keeping guns from dangerous people is likely to have a much larger impact.
What role does lethal means safety counseling play in your work? Why is it important?
I work in an involuntary psychiatric hospital, so I see lots of patients who periodically think about ending their lives for a variety of reasons. Sometimes a hospitalization can be really helpful for them, but other times we are just keeping them safe until they can go home, where the real healing can happen.
It’s hard to get the suicide risk down to zero, but we want to reduce it as much as we can before sending them home. I certainly don’t want to send them home to something that could be the difference between an attempt and a death if they slip back into a bad space, so I try to engage my patients and family members in lethal means planning. This means making sure there are not large amounts of lethal medications in the house and that there are no guns they can access.
What factors can contribute to suicide?
There are a number of different risk factors that contribute to suicide, some of which can be treated by a mental health professional (if that patient is willing) and some of which reflect broader issues that are harder for a provider to fix.
Symptoms like anxiety, depression, insomnia, heavy drinking, and command auditory hallucinations can be risk factors for suicide and are potentially treatable by mental health professionals.
Social stressors are also a big contributor, and it is much harder for us to fix someone’s homelessness, relationship loss, grief from the passing of a loved one, or recurrent childhood traumas.
What do you say to those who claim that suicide is not preventable?
People come to the decision to attempt suicide by so many different pathways that I don’t think there is a simple way to prevent it. But there is a lot of potential to significantly reduce certain types of suicide.
For people who have long-term suicidal thoughts associated with mental illnesses like bipolar disorder, severe depression, or schizophrenia, making mental health resources more plentiful and easier to access is crucial.
It is harder to intervene with people who make impulsive suicide attempts, because there is not a lot of warning time in which to act. In these situations, making sure they don’t have access to something lethal can make a huge difference.
What factors make it difficult for people to seek help and/or comply with treatment recommendations? How can we address those factors?
We need more resources, plain and simple. We need better insurance coverage for mental health care, more psychiatrists, more trained therapists, more mobile crisis teams that can intervene at the scene of a crisis, more law enforcement officers trained in helping people with mental illness, more medication options with fewer bad side effects, the list goes on.
What do you say to your patients when they feel they cannot get better, that there is no hope?
Many people suffer from mild situational depression or anxiety. Often it will go away on its own eventually, but that can take months or even years. Counseling or therapy can help speed up the healing, and in some cases where symptoms are more severe, medications might be beneficial.
As with addiction, one of the first steps is admitting that you have a problem and that you need help, then taking the steps to seek out the right kind of help. Other mental illnesses require lifelong management, which can include therapy, medications, or lifestyle monitoring.
I think the hardest thing about any crisis situation is keeping the perspective that it will eventually be over. In medicine, we call this the “tincture of time.” But in the heat of the moment, whatever emotional intensity someone is feeling can feel like the only thing they will ever feel again. This is the very definition of hopelessness — thinking that your suffering will never end. Just being able to believe that there will be a way out, even if you can’t see it, is enough to turn the tide in a positive direction for many people.