Seventeen people were killed and many more wounded at a Parkland, Florida, high school in the 30th mass shooting of the year. The president tweeted: “So many signs that the Florida shooter was mentally disturbed. … Must always report such instances to authorities, again and again!” In a later speech he stated: “We are committed to working with state and local leaders to help secure our schools and tackle the difficult issue of mental health.”
After the Sutherland Springs, Texas, church shootings last fall, he was more explicit: “This isn’t a guns situation. … This is a mental health problem at the highest level.”
Mental health services are in great need of strengthening, certainly, but they should not be a distraction from real solutions for the societal disorder that is violence.
I had the rare privilege as a psychiatrist to participate in the World Health Organization’s launch of its “World Report on Violence and Health” more than 15 years ago, which helped revolutionize violence prevention worldwide through a public health approach. Since applying the ecological model to violence, we have discovered that social, cultural, economic and environmental factors are far more reliable predictors of violence than individual factors. To try to predict violent behavior in individuals is a fool’s errand, since when and how violence occurs is almost accidental, depending largely on situational factors, state of mind, social support, environment and access to weapons. Probability in terms of the long-term process is more precise, while rates of violence in society are almost entirely predictable and preventable.
What do we mean by this? Where societal trends and epidemics are concerned, individual characteristics tell us very little, while social conditions tell us a lot: 30 years of intensive research have revealed a great deal to us in terms of what prevents violence. What we can do to treat individuals, one at a time, is of course important but limited, while there is a great deal we can do to prevent enormous suffering and tragedy, at very little cost. The World Health Organization and two United Nations bodies documented, for example, how 133 countries changed policies, instituted laws, offered services, strengthened law enforcement and implemented programs to reduce global homicide rates by 16 percent in 12 years.
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First, we should not conflate mental illness with violence. Mentally ill individuals are no more violent than the general population, and even where they are violent, the acts themselves arise more from social causes, such as substance use or a lack of social networks, than a specific mental disorder.
Nor is it productive to blame only the individual. The individual has a role in carrying out the act, certainly, but is also part of a cycle of violence where the perpetrator is almost always also a victim of trauma and stress. Societal and cultural norms are highly influential, such as the acceptability or glorification of violence and extremist ideologies. However, the most powerful predictors are almost all socioeconomic policy-based: At the societal level, violence rates rise and fall almost identically as the rates of inequality.
Secondly, as horrific as mass murders are, they account for only a fraction of murder victims in America. More than 90 percent are killed in single-victim homicides, and these are “normalized” as a part of our general conditions of living. Therefore, if we wish to reduce the toll of violent deaths, we need to give more attention to the 160 lives that are lost to violence every day, mostly hidden from public view.
Thirdly, although its effects are even less recognized by many people, structural violence is an important concept. It refers to the avoidable limitations that societies place on groups of people, which can be political, economic, religious, cultural or legal in nature, and usually originate in institutions that exercise power of particular subjects.
There is a reason why we call this “violence”: It turns out to be the deadliest. Structural violence causes more than 10 times the rate of deaths from suicide, homicide, mass murders and warfare combined. And because these limitations are embedded within social structures, it is not uncommon for people to view them as nothing more than ordinary problems that they encounter in the course of their day-to-day lives.
Structural violence can be illustrated by the hypothetical situation where people desperately need health care, education, political power or legal assistance, but are unable to access them easily due to restrictions in the existing social order. Unlike more obvious forms of violence, where a person or group of persons perpetrates physical harm on another person or group, structural violence occurs insidiously without much notice. It is also the most potent and immediate cause of many other forms of violence, including gun violence.
Individuals should not be considered in isolation. Everyone is part of an ecology, and the most effective way to prevent individual violence, far before it even becomes an issue, is to care for society. A correct understanding about the problem is paramount in providing effective, proper care.
That the National Rifle Association blocked the Centers for Disease Control and Prevention, the nation’s public health agency, from funding gun research for more than two decades was perhaps the most harmful effect of all. That the American Psychiatric Association has prohibited psychiatrists from educating the public about the dangers of a powerful leader’s endorsement of violence in key public speeches, and how it can lay the groundwork for a culture that gives rise to epidemics of violence, possibly adds to the dangers.
The most lethal violence is silent. Therefore, while responding to the urgencies at hand, we must also work toward fixing the larger social, cultural, economic and even political systems that contribute to a poor state of collective health. Policies that prevent violence not only save lives, suffering, medical and mental health expenses and criminal justice expenditures, but enhance unity and integration in our communities, society and nation. We should therefore consider violence as a whole, and prevent it as if our own problem, for we are all responsible.