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How to Prevent Mass Shootings and Gun Violence: Inpatient Mental Hospitals

Teddi DiCanio only occasionally writes on political matters, but has a bent towards history. She contributed to a book on American trials.

What Should We Do With Mass Shooters?

If we truly could spot and catch potential mass shooters, what would we do with them? How would we treat them and where would we put them? He who commits a mass shooting and survives, his destination is prison or execution. No question.

He who is caught at the threat stage, doctors must ascertain if the threats are credible and make a diagnosis. Is this someone spouting off? Or more? Judges, too, have a say.

Can this alleged potential shooter be treated for whatever is driving his thoughts towards violence? Answer, maybe—sometimes. Where do we put him for that treatment? And where do we put him if he doesn’t respond to treatment? Not into a mental hospital. Not for long anyway.

Examining Violence: Public Health and Going from One Extreme to Another

Once upon a time, states ran large mental hospitals. Once upon a time, it was too easy to commit someone to such a facility, despite civil laws governing commitment. Today, just try to find a bed, even for a short stay, let alone a long stay.

The number of beds available for inpatient commitment has shrunk more than 90% since the 1950s. At the same time, the country's population has doubled. The need for more beds in long-term facilities is not often mentioned in the debate over remedies.

The problem of violence and death by violence is much bigger than the mass shootings. Many in the mental health field think of violence as a public health issue that should be studied just as physical illnesses are. Thousands die each year in the United States from the use of guns.

For the year 2020, according to numbers from the Centers for Disease Control (CDC) tracking homicide, firearms top the list of causes in almost every age group, by a wide margin. Two exceptions. There are no gun related homicides in the 55 to 64 age group and the group of victims, age 1 to 4 years, comes in at 24.1%.

All other age groups come in at over 50%, often way over. Suicide percentages are high, too. (See first table.)

After the murders at Uvalde, all the reasonable, necessary goals talked about for decades echoed across the land. Ban assault weapons. Increase to twenty-one, the age to legally own certain weapons. Institute serious background checks for any weapon sold. That last one was the most consistent point mentioned, coming from people of many political persuasions.

While checking records may alert authorities to some potential problems, records are not always well-kept or easy to find. Those responsible for checking do not always do a proper job. And those with no records constitute a predicament.

As for noticing violent postings on internet sites, these postings exist in the midst of oceans of digital ink, and may not be noticed. If they are noticed, or if someone overhears a strange conversation, the quandary is: do these seem serious enough to report to law enforcement? Once reported, what comes next?

CDC National Violent Death Statistics by Method

The numbers are extraordinary. But guns are fast and easy to pick up in a moment of anger or despair. Use a knife or hands, the perpetrator must get closer and the victim has a better chance of dodging or running.

Age group of deceasedHomicide, Use of Guns by PercentageSuicide, Use of Guns by Percentage

1 to 4

24.1 of 311 deaths

N/A

5 to 9

53.8 of 169 deaths

None

10 to 14

76.5 of 285 deaths

38.6 of 581 deaths

15 to 24

92.3 of 6,466 deaths

52.3 of 6,062 deaths

25 to 34

86.4 of 7,125 deaths

46.1 of 8,454 deaths

35 to 44

79.0 of 4,482 deaths

44.0 of 7,314 deaths

45 to 54

70.1 of 2,542 deaths

47.2 of 7,249 deaths

55 to 64

None

54.3 of 7,160 deaths

Justifiable Homicide and Self-Defense

According to the Federal Bureau of Investigation’s Uniform Crime Reporting Program (UCR), in the year 2017, there were 298 justifiable homicides, involving a firearm, done by private citizens. Self-defense. That same year, 10,380 homicides were committed with guns.

As for the use of firearms in other self-defense situations, with non-lethal outcomes, the FBI reported their use was very small. For the years 2014 through 2016, they were used in about 1.1% of the cases. (See second table.)

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Mental illness plays a role in some of these incidents. But it is not just the mental state of a perpetrator that could be a problem; mental illness plays a role in vulnerability and thus becoming a victim.

Self-Protective Behaviors in Violent Crime Situations

Seat belts, smoke detectors, and first aid kits are just-in-case safety items. The numbers indicate guns are not the same. Possible exception? If you know you have a serious enemy who means you harm, you have a case to own a gun for self-defense.

Behavior of the VictimTotal Number of IncidentsPercentage

Took no action or kept still

6,528,900

40.5

Threatened or attacked with firearm

177,300

1.1

Threatened or attacked with another weapon

234,800

1.5

Threatened or attacked without a weapon

3,641,300

22.6

Non-confrontational tactics (talking whether reasoning or yelling, running, trying to attract attention, calling police, etc.)

4,811,700

29.9

Other reaction

695,700

4.3

Unknown reaction

25,900

0.2

Result of Cutting Costs and Good Intentions: Disaster

The 1950s saw the first medications to treat symptoms of psychosis. As more medications become available, it seemed feasible for many patients to live outside of hospitals, with the rest of society. Thus, in 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act. The purpose of the act was to provide money for facilities and research.

Focusing only on the mentally ill here, an idea behind the act was that, with support, patients on meds could live—and work—outside of a hospital. Then the creation of Medicaid provided a motivation for the demise of state public mental hospitals.

The Medicaid program, enacted to help provide healthcare to the poor, was, and is, funded by a mix of state and federal monies. This proved to be an incentive to get out of directly providing, and paying for, the care and treatment of the mentally ill. The states were happy to be delivered from the cost of maintaining these expensive hospitals.

But results were uneven. The transfer of patients out into the world was haphazard. A stable, reliable system of community facilities, that could effectively replace the sad warehousing of the mentally ill, never really came about. Sufficient funds—and planning—were never available for establishing and running all these clinics.

Moreover, long-term inpatient treatment was still necessary for some, but that was disappearing. Then, when Ronald Reagan pushed to reduce taxes and slash government spending, the situation worsened.

A series of court decisions complicated matters by making it nigh impossible to commit someone. Obviously, those hospitals weren't needed to get the seriously ill off the streets, into intensive treatment, and into long-term or, perhaps, even permanent residential care.

Today, someone experiencing a severe psychotic episode, if brought to an ER by family or police, may spend several days in that ER as medical personnel try to find an available bed somewhere—anywhere.

Or the patient might be given some meds and sent home. Will the patient take those medications? Medications can have side effects, terrible side effects. Or, once a patient has run through his meds, can he (or she) get more?

Finally, for some people, medications don’t seem to work well or at all. So, to get back to the original questions, if we can actually find what appear to be a potential shooters, how do we treat them? First, we have to have places to put them.

Hospitals to Jails

Since 1951, the number of inpatient beds for the mentally ill, provided by the states, has dropped by 91%. Over the years, as this shift took place, states eventually started spending enormous amounts of money on jails and prisons instead.

The jails have become the de facto ‘insane asylums.’ This started becoming apparent decades ago. In 1991, ABC broadcast a story on its program 20/20, Jail for the Mentally Ill. Why are They Here?

More than 20 years later, in 2013, CBS's 60 Minutes looked at the same problem. Mentally ill people, with no place to go, often end up in jail.

In that episode, Imminent Danger, Tom Dart, Sheriff of Cook County in Chicago, Illinois, said “I've got probably 2,500, 2,800 people with mental illness in my jail today. And you look at their backgrounds, they've been in here 50, 60, 100, we have some people who've been in here 400 times.”

The kinds of "crimes" that bring them to a jail are often petty. The inmates get medication, maybe, hopefully the right ones. Once out, they may or may not take medication. Many have trouble obtaining their medications. Most of these people are not really dangerous.

But within this untreated population are a few who are dangerous and some of those are responsible for mass shootings. Also interviewed for Imminent Danger was psychiatrist, Dr. E. Fuller Torrey. He said, “About half of these mass killings are being done by people with severe mental illness, mostly schizophrenia. And if they were being treated, they would've been preventable.”

Yes, there are mental hospitals and people do get committed, but usually not for long, maybe two months for serious cases. Insurance companies don’t want to pay for long-term commitment.

The idea is: Fix them up; give them their pills; let them go. State and federal governments do not seem much interested in paying for commitment either. Serious mental health illnesses do not fit into any idea of managed care, which is the world of medicine today.

Managed Care and Mental Health: Not a Good Blend

There are various types of managed care. All work at containing expenses. For example, Preferred Provider Organizations use moneys, paid either by client premiums and/or government sources, to create closed networks of providers.

Within these networks, companies negotiate prices. Primary physicians refer patients to network specialists or for therapy or for special tests, as they deem truly necessary, "managing" the overall care of their patients. The idea is to have a system tracking the patient, both to ensure needed care is provided and to prevent runaway costs.

This system does not work well for those who suffer serious mental illnesses, such as schizophrenia or bi-polar disorder (manic depression), or paranoia.

One night a young man, covered in blood, was walking down the street in the town I was then living in. This town, small and quiet, generally has one murder every forty to fifty years. For some time, the father of this young man had desperately been trying to commit his son to a mental facility. This night, the young man had stabbed his father to death.

United States vs. Switzerland: Difference in Attitude

While mental health and poverty and discrimination all play a role in gun violence, at least two other things play a role. Availability of weapons is one. Guns are easy to obtain in the United States.

The other is a romantic attitude towards the gun. The gun helped win the Revolution as men ran to turn back the British at Lexington and Concord. (That would not have been enough to win the war.) It helped open the west. (Farming and ranching established control of the west.) Very important is the fact that it is a mainstay of action films. (Hollywood is such a bastion of realism)

The attitude of Switzerland is very different.

Swiss males start learning as boys how to handle guns. This practice is part of the basis for the old adage, "Switzerland does not have an army; it is an army." Switzerland is a land of four major languages, divided into several cantons.

Although its army is smaller than it once was, all Swiss are committed to elaborate preparations to defend their mountains should it become necessary. That kind of preparation has kept people like Hitler at bay.

This focused beginning reflects a very different attitude than that found in the states. The country’s defense is a serious issue and they tackle it together. They exhibit no exhilaration or romanticism. Their arguments over control of firearms—and they do have them—do not reflect the either/or extreme political positions found in the United States.

The Swiss have strict controls about who can and cannot have weapons and how they are to be handled and stored. A man, when leaving the service, can no longer automatically keep his weapon. He must obtain a special license. For anyone still in the service, as of 2007, the law has been he may not keep ammunition for his gun at home. The ammunition is kept at a central arsenal until such time as it is needed.

Still, many Swiss own guns and, as mentioned above, guns are swift and easy to use in moments of anger or despair. This is reflected in the number of domestic gun-related homicides, suicides, and accidents even in Switzerland.

But street violence, particularly gun-related, is much rarer than in the United States. Switzerland has had only one mass shooting, which happened a couple of weeks after 9/11. That incident led to one of their serious examinations about how they handled their weapons.

Congress Acts, But No New Hospitals

The United States Congress has passed their first real gun control measure in almost thirty years. President Joseph Biden signed the bill on June 25, 2022. Included are ways to increase the ability to keep guns out of the hands of those who could be a threat to themselves or others.

The new statute encourages states to pass red flag laws which would allow law enforcement, family or acquaintances to ask the court to remove guns from people considered to be dangerous.

The category of those barred from owning weapons, due to conviction of domestic abuse, has been expanded. Previously, it included spouses, unmarried couples who had had children together, and couples who had lived together. The new statue includes non-cohabiting intimate partners. They need not have ever been married or have children.

The bill has allocated $750 million dollars for various intervention programs, including special drug courts, veterans courts, and mental health courts. Mental health programs for the young and school safety programs are incorporated.

As for derailing possible young shooters—and many of the mass shooters tend to be quite young—the law allows authorities access to the juvenile records of young people trying to purchase a firearm. Evidence of serious violence and mental illness will be easier to find.

Power Struggles, Inaction, Death

Providing for mental health in this package is hopeful, and not just because of this particular issue of violence and guns. If a country will not try to tackle serious problems, how can it solve them? Or, at least, mitigate them?

A country obsessed with a power tug-of-war—our group is right and will run everything—would rather say "no" than negotiate. Without serious, sincere conversations, all the possibilities the human imagination could produce never come to be.

Such a country is not taking care of itself. A country that does not take care of itself, risks dying. Such a country has abandoned its reason for being. It certainly is not, in the words of the United States Constitution, trying to “promote the general welfare.”

There is no reason the United States could not study violence as a public health issue. There is no reason the United States could not create a better mental health care system—including more inpatient facilities—and be willing to pay for it. Neglected problems always become more expensive—and sometimes deadly—be they cancers, climate change, or mental health and violence.

Sources

ABC. “Jail for the Mentally Ill. Why are They Here?” 20/20, April 19, 1991.

Anders, Caroline. “Trauma physicians have become depressingly prepared for mass shootings.” The Washington Post. July 1, 2022.

DiCanio, Margaret, Ph.D. The Encyclopedia of Violence: Origins, Attitudes, Consequences. Facts on File. New York. 1993.

Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Violence Policy Center. Washington, D.C. May 2020.

Frank, Robert G., Ph.D. “The Creation of Medicare and Medicaid: The Emergence of Insurance and Markets for Mental Health.” Psychiatric Services. April 1, 2000. https://doi.org/10.1176/appi.ps.51.4.465

Gleeson, Cailey, Kelly Gooch, and Aha Paavola. “19 cities, states that declared public health crises for gun violence, mental health, racism.” Becker’s Hospital Review. November 30, 2021.

https://www.cdc.gov/injury/wisqars/index.html

Judd, Donald. “Biden signs bipartisan gun safety bill into law: ‘God willing, it’s going to save a lot of lives.’” CNN. June 25, 2022.

Kirby, Emma Jane. “Switzerland guns: Living with firearms the Swiss way.” BBC News, Zurich. February 19, 2013.

Klein, Michael J. “Did the assault weapons ban of 1994 bring down mass shootings? Here’s what the data tells us.” The Conversation. June 8, 2022.

Llana, Sara Miller. “Switzerland has lots of guns. But its gun culture takes different path from US.” Christian Science Monitor. March 7, 2018.

Myers, Joe. “Global Risks Report 2020.” World Economic Forum.

Namburi, Niharika and Prasanna Tadi. “Managed Care Economics.” National Library of Medicine. NIH. February 2. 2022.

Pramuk, Jacob. “Congress passes most significant gun reform bill in decades, sends it to Biden.” CNBC. June 24, 2022.

Rosenbaum, Janet E. “Gun Utopias? Firearms access and ownership in Israel and Switzerland.” Journal of Public Health Policy. Vol. 33,1 (2012): 46-58. doi:10.1057/jphp.2011.56

Wright, Sarafina. “Kaiser Permanente Launches Center for Gun Violence.” The Washington Informer. June 22, 2022.

© 2022 Teddi DiCanio

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