Words have consequences. When tragic circumstances like the recent shootings occur, our national dialogue seems to veer far from reality when it comes to the relationships between violence and mental illness. Unfortunately, I have experience with violence and with mental illness. I hope that I can use my brother and my son to illustrate a few facts.

First, my brother Scott was a person who lived with paranoid schizophrenia. He also grew up with severe dyslexia that he was able to overcome in his twenties. In his thirties, he was excited to be accepted in a graduate program in another state to pursue a degree in history, and stopped in Oklahoma City to visit a friend along the way for a few days. He and the friend went out for drinks on the evening of Valentine’s Day. His friend’s girlfriend felt really angry that her boyfriend chose to go out for drinks with his friend rather than do something with her. According to neighbors, she took Scott’s backpack apart, throwing its contents all over the front yard, while loudly screaming profanities. She then went inside the house, pulled a gun from one closet, bullets from another, loaded the gun, and then sat on the couch by the front door to wait for Scott and his friend to return home.

When they returned, the friend and girlfriend got into a loud argument, again according to the neighbors. We believe that Scott spent this time carefully repacking his backpack, because everything was back in its place when it was recovered still sitting on the front porch later. He then left the backpack just outside the front door and went back into the house, we think to say goodbye to his friend. By that time his friend had gone to sleep in the back of the house and the girlfriend had again taken her seat on the couch, with the loaded gun unfortunately. She initially reported that she yelled at Scott who just ignored her and kept walking toward where his friend was sleeping. She reported feeling really angry at what she perceived as this slight (in fact he would have been overwhelmed at the noise and would have ignored her rather than engage her). She aimed the gun at him and it initially misfired, but she shot again and hit him in the back of the head. He never regained consciousness, although it took him a couple of days to die.

Scott’s role as victim is a more common role in violence for people with mental illness than perpetrator. His killer also illustrates what the evidence points to regarding characteristics of the perpetrators of gun violence, particularly mass shootings. She was angry, drunk, entitled, and had a history of domestic violence. While I will agree that she was “not right”, those characteristics really are not specific to people with mental illness. One could argue that she may have had characteristics of a personality disorder, but I don’t know that she carried one of those labels. She was angry that her boyfriend went out on Valentine’s Day without her, felt entitled and believed that she had been done an injustice. She was drinking and/or using substances which increases the probability for violence for any of us. She had in fact stabbed a young man the year prior but he had lived, and I was told that her family paid him off so that he would not press charges.

The evidence base around mass gun violence says that there are specific risk factors. Mental illness is not one of those. People who have committed acts of mass violence are very angry. They feel they have been prevented from getting some status or position or some thing to which they are entitled. They have a narcissistic perspective on the world and believe that the act of violence will somehow set the record straight about their grievances. They tend to have a history of committing acts of domestic violence. Pour alcohol or substances into that mix and you have the potential for disaster.

Do people with mental illness engage in violent behaviors? They can just like the rest of us. There are a few areas of elevated risk. The greatest risk or people with mental illness related to gun violence is for suicide. This is because guns are an extremely lethal means of attempting to kill oneself. Suicide, not homicide, is the greatest risk for people with mental illnesses, especially those with major depression.

There are a few other specific areas of risk. In early psychosis, there is a somewhat elevated risk of harm to others, usually family members or others close to the individual. Aaron described hurting a close friend of his when he was a teenager living on the streets. His delusions took over his thought processes and he cut the young man over and over. Thankfully his friend did not die. Street justice is harsh and other youth in their circle beat Aaron nearly to death as a consequence. With time, Aaron got better at recognizing when his thoughts were twisting off; we refer to this as reality testing. He developed strategies to manage his thoughts and decrease the likelihood that he would hurt someone. I sometimes have wondered if part of what kept Aaron from coming home was a fear that he would hurt one of us.

A history of trauma can also contribute to violence. Aaron was tortured at Straight. He was raped and beaten on the streets routinely. Aaron later reported a number of other episodes of violence directed at the people who preyed on street kids. He believed he had killed some of them in those altercations defending himself or others, but it was never clear whether those beliefs were accurate. He was beaten by police officers both in my community and likely many others that he found himself in.

Alcohol and substance abuse also contribute to violence, but they are sometimes coping strategies for trauma survivors as well. Aaron got into lots of fights. He went to prison over one in which he was drunk and the other party in the altercation was high and they started shooting at each other because an old skanky girlfriend told each of them that the other was going to hurt her. Thankfully neither died, but Aaron was the better shot and so he caught the charges.

Like Scott, Aaron also illustrates another side to violence and mental illness. But how much of that violence was related to the trauma he experienced in Straight and on the streets, and to his alcoholism, rather than his severe mental illness? I am going to argue that, other than the fact that his illness put him at risk for severe and prolonged abuse in treatment, on the streets, and in our justice systems; all of which also predisposed him to alcohol and substance abuse, his mental illness itself only increased his risk during that period of early psychosis as a teenager.

So, to quote the youth who survived Parkland, I call BS, on the idea that we should blame mental illness for the recent mass shootings. Instead we need to look at what we are doing to perpetuate entitlement, narcissism and cults of anger and resentment. Do NOT lay this on the backs of people with mental illness. They carry enough of our crap as it is.

I am going back to my brother’s story because it did not end with his death. At her trial, his killer invoked an early version of the Stand Your Ground laws, at the time called the Make My Day law. She claimed that, in the absence of any other threat, his mental illness made him “weird and creepy” and that alone was sufficient grounds to justify taking his life. A jury of 12 Oklahoma City residents agreed with her and she walked. Our demonization of people with mental illness has consequences. What about his right to life?

We must recognize that mental health and mental illness are two separate constructs. Mental illnesses are specific categorizations of symptoms that affect some people. Mental health affects all of us and occurs on a continuum from languishing to flourishing. People who perpetuate gun violence may like my brother’s killer have crappy mental health but not a mental illness. An inclusive culture that creates opportunity for everyone; that leans into populations who feel isolated and left out, would go a long way toward prevention of violence and promotion of good health. But I fear we will not reach those at risk of violence if we wait until they are adults to begin to attempt to find them. They do not see themselves as a problem and will not be seeking our help. Effective prevention will need to reach everyone in the population in order to reach those who are at specific risk.

Prevention almost has to start with children in schools because that is the only place where you reach nearly everyone. I do not see an imposition of a medical model that relies on imposing diagnostic criteria on people we deem to be at risk as doable. For one we just do not have enough data, and we need not wait until enough people kill for us to categorize them in some way that informs action. At a universal or population level we need to promote mental health across all people, including people at specific risk for violence. This means routinely identifying strengths and enabling participation in lives that have meaning and purpose for everyone. It means teaching social and emotional skills, effective strategies for conflict resolution, self regulation strategies, and empathy. These will be better accepted if we stop confusing mental health and mental illness, and focus on helping all children, and eventually adults, to live happier lives.

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