The U.S. Culture(s) thread

There is an identifiable population that is extremely dangerous, volatile, and likely to commit violent crimes, but is not diagnosable as mentally ill. The pattern we see time and again is that people who act out in violent ways are men who already have an established pattern of being threatening, cruel, and violent. They often have been perpetrators of domestic violence—indeed, felony domestic violence is the best predictor of murder. They have a chronic pattern of failure to modulate their aggressive feelings. Violent crimes are committed by violent people, almost always men who are lonely, isolated, blame others for their problems, and lack the skills to manage their anger.

The Parkland, Florida, killer had years of violent, erratic outbursts. He had made threats to numerous people and carried out physical assaults. Multiple people had called the FBI before the shooting to report that they thought he was dangerous, including his mother, who said he had “anger issues.” The Pulse nightclub killer in Orlando, Florida, was involved in violent altercations as a teen and had a history of violent spousal abuse. His first wife said that leaving him saved her life. The Columbine killers created a website where they posted death threats against specific individuals, wrote of their desire to kill teachers and students at the school, wrote about making pipe bombs and explosives, and like the Parkland killer, were known to the police. The Virginia Tech killer was known by staff to be cruel and menacing. At least one student had a no-contact order against him.

The question is what we do with these people. It’s a difficult question, because we are put off by them. Their bristling hostility makes it easy to dislike being around them. In response to criticisms that students did not reach out to the Parkland killer, one survivor exclaimed “You didn’t know this kid!” Students at Stoneman Douglas said if the school ever had a mass killer it would be him. The poet Nikki Giovanni, who taught the Virginia Tech killer, said the idea that he was mentally ill was “crap”—he was “mean.” He was so mean that other students and faculty feared him. They wondered, based on his writing, if he might become a killer. We know who these men are.

As we have tried to understand, as a society, what would cause someone to commit this kind of violence, we have considered the notion that these people are “mentally ill.” It has been suggested that we can ensure our safety by taking guns away from the mentally ill. The message works because of a general lack of understanding of “mental illness.” In reality, the vast majority of people with mental health diagnoses are sad and anxious rather than violent. The most frequently used mental health diagnoses are for variants of anxiety, depressive disorders, and trauma. When we talk about mental illness, we are talking about the stressed working mom you see on the bus, the grieving widower down the street, the anxious child. Twenty percent of all US adults have some form of mental illness, but very few of them have mental illness that will increase their likelihood of violence. Even in the smaller group of people with a serious mental illness, violence is extremely rare. It can happen: Paranoid schizophrenics can occasionally be violent when they are having an episode of psychosis. But paranoid schizophrenia is very rare, and paranoid schizophrenics have been involved in only two of the 49 mass shootings since 2011.

This troubling stereotype is not just wrong, it gets in the way of finding a real solution to our violence problem. The people who commit violence are emotionally disturbed—anger is a normal and an important emotion, but their ability to manage their angry impulses is severely compromised. And yet, people who are violently angry are not mentally ill by our current standards. Instead of treating them, we call them assholes and we avoid them. Can we do better than that? I think that we not only can, but that we must.

These people have spent their lives emotionally out of control. When we acknowledge that this is a pattern, we can begin to address the underlying issues feeding violence in this country. And it extends beyond mass shootings. This is also the problem of the police officer who becomes predator rather than protector of the peace, prison guards who torture prisoners, and the people at political rallies that promote or act out violence against perceived political enemies. We are a culture with serious anger issues. We can begin to address the issue by understanding what anger is, how it can be healthy, and how it can get out of control.

Recent advances in neuroscience provide us with a picture of anger at the physiological level, and an understanding of how it can go awry. Our brains have a sophisticated system that allows us to quickly assess our environment, determine whether there is danger, and respond—the fight-or-flight mechanism. When we perceive a threat in our environment, we rapidly shift into a state of hyperalertness. Blood shifts to our extremities, we breathe faster, and the heart pumps faster. The physiological changes get us ready to fight or flee. If we recognize the situation to not be a threat after all, our bodies return to their resting state. Long ago, evolution determined that this system helps keep us alive in the wild.

But how we judge things to be safe or threatening is a nuanced, individual process. Neuroscientists like to say that brain cells that fire together, wire together. Brain cells establish “habits.” In other words, experience has a profound effect on how readily we move in and out of fight or flight. The individual who exhibits dangerous anger dysfunction and is violence-prone is stuck biologically in a never-ending cycle in which the fight-or-flight response takes charge and everything is perceived as a threat. This is a brain that has never effectively learned to calm itself. It is not functioning optimally, and its owner suffers significantly from near constant emotional distress. This is why violence predicts future violence. When this happens, the self-protective survival mechanism has become a malfunctioning system.

When we acknowledge that this is a pattern, we can begin to address the underlying issues feeding violence in this country.

Research in the field of neuroscience over the past decade has also demonstrated the remarkable plasticity of the brain: its ability to grow and strengthen new connections throughout the lifespan. That means it can change emotional habits. The brain can be taught to change its anger response by quieting the brain circuits that support fight or flight. The process involves tools such as mindfulness, tai chi, and yoga, all of which use repeated practice to strengthen the brain’s ability to focus and cope with emotions. New developments in trauma treatment have shown us that the body is also a powerful part of our system of learned responses. Becoming aware of emotions as they are felt in the body can sometimes be easier than recognizing them in our minds. Excellent resources on this include Bessel van der Kolk’s The Body Keeps Score and Peter Levine’s Healing Trauma. There are very effective treatments available for those trapped in fight or flight.

The tools are there to help dangerously angry men before they act on their rage with AR-15s. What we lack is an effective system for getting individuals who are angry, isolated, and dangerous to those who could help them.

One of the most challenging reasons that we lack such a system is the nature of the problem. The individual who has anger dysfunction and is violence-prone, unlike almost any other physical or emotional dysfunction, is uniquely, powerfully unappealing. This emotional disorder evokes no empathy in the rest of us. We think “He’s an asshole!” “Expel him from school!” “Lock him up!” “Let him live on the street!” “Teach him a lesson!” Or, simply, “It’s not my problem.” Anger in others is a threat that triggers our own fight or flight response. It often triggers a counterattack in others. Mass killers are frequently, perhaps universally, the victims of chronic, sometimes tortuous bullying. Many, if not all, grew up in homes where there was domestic violence, emotional and physical abuse. They are emotionally fragile. They’re threatened by hostility from others, and they also engender it. The dislike and hostility they raise in others leaves them isolated, and the bullying feeds a vicious cycle where kids with minimal emotional self-control are baited into greater and greater levels of hostile defensiveness.

Violent angry people also do not go looking for help on their own. Because they live in a state of perpetually feeling under threat, they trust no one and do not seek out support.

So, the first problem in treating them is to find them. Schools are on the front line for identifying these individuals as kids. In the school environment, isolation and hostility can pretty readily be observed, often by teachers and administrators, and certainly by fellow students. And in fact, some schools seem to be on the cutting edge of dealing with the crisis, far ahead of the field of mental health. Peace of Mind in D.C. and Mindful Schools in California, which each offer a curriculum for mindfulness; Passage Works, a Colorado program for teachers and staff to integrate mindfulness into their work; Mindful Teachers, a website of resources for teachers; and Peace In Schools, which provides programs for teens and training for teachers, are burgeoning all around the country. Jus Tme is a rapper who writes music about mindfulness and visits elementary schools to work with kids. These programs provide much needed skills for emotional coping and stress reduction for all kids, and also serve to identify kids who struggle the most with these skills.

Schools need criteria to identify these kids and get appropriate intervention. They also are at the front lines for providing protection from bullying and a supportive environment for all students, including those with anger dysfunction. Schools should be supported for the work they are already doing to teach staff and students the skill of being able to center, calm, and focus themselves.

The next step is for the field of mental health to provide treatment for those students whose needs exceed the school’s available resources. This treatment should integrate the evidence-based, cutting edge findings of neuroscience research to directly address the underlying issues in rage-filled, violent individuals. Too often, hostile kids identified as “a problem” get a mental health referral, but are quickly dumped because they fit no diagnosis and are difficult to work with. Mental health professionals need to take a good look at this problem. These kids have some of the most emotionally devastating problems and most deficient coping skills, and are some of the most dangerous people in the world.

It is also important that this constellation of symptoms becomes recognized by the police and the court system. Many mass killers have had multiple earlier interactions with the law, but the pattern and potential for violence went unrecognized. Repeated violence, threats against someone’s life, webpages devoted to hatred, and reports of violence from family and school are all indications of someone in imminent need of intervention. We need to reassess our standards for imminent risk to self or others and probable cause for search, taking into account the profile of the violence-prone, anger-dysfunctional individual.

This must be done cautiously and deliberately. Criminalizing emotional distress is not the goal. We should be seeking to heal the individual while protecting the public. This requires a response of compassion to those who frighten or anger us, and that is no small thing. There will always be kids who are exposed to devastating circumstances and who move toward defensive hostility and revenge, but it is a rare situation that there is not an adult who could identify such a child, and see that they get help. The responsibility is on all of us not to turn our backs on the lonely, ostracized and angry, even when we find them off-putting and offensive. The fact that they raise such negative emotions in others should be recognized as evidence of the degree to which they need help. This does not mean that we must take them in, or put our lives at risk, and absolutely does not require that we give them a pass for socially unacceptable behavior. It does not even require that we like them—only that we get professional help for them, and that we do not allow our defensive reaction to them to feed into a vicious cycle of escalating anger.

Well-meaning people have suggested kids “walk up” and be nice to troubled loners. We need to be careful about putting too much responsibility on the peers of deeply troubled kids. Yes, kindness and compassion for everyone is important, but the idea that “walking up” will solve the problem is overly simplistic. These are deeply troubled and potentially dangerous individuals. We don’t want to suggest to children that, by offering friendship to a viciously angry person, any single person can fix them. This is an error often made by abused women. These individuals need help that is structured, intensive, and comprehensive. If this is the standard offered by society, kids will be learning how to cope effectively with anger, their own as well as that of others.

And here is one more important truth: We need to calm our minds as well. Anger feeds anger. The rage of mass killers is fed by the hostility around them. They are not alone in their inability to manage anger. You may be able to easily think of someone in your life—maybe yourself—who can’t have a political discussion without exploding, or a child who bullies others, or someone who emotionally abuses a spouse, or someone who flips out when they get cut off in traffic. Anger self-awareness and modulation is on a spectrum, and our genetic inheritance and our life experiences combine to dictate where we fall on the continuum. But we are all on it, and we could all benefit from increased focus on how we harness and react to our feelings of anger. We cannot expect those with the most tenuous hold on their emotions to heal until those around them stop feeding their fear and rage.

America’s problem of violence needs to be addressed on many levels. We can begin by recognizing anger-dysfunctional, violence-prone individuals as suffering from a debilitating and potentially dangerous condition. The mental health field needs to take a lead role in educating the public about dysregulated anger and its treatment as well as working closely with schools and law enforcement to build a system of early identification and treatment for what is, without exception, the most dangerous emotional dysfunction one can have. The NRA could also play a valuable role in this. Rather than perpetuating false narratives about mental illness and violence, the organization could acknowledge how dangerous it is for violently angry people to have to guns, and could be a powerful voice in moving us toward an effective system to restrict their access.

Perhaps this all comes down to this truly American dilemma: Are we going to focus exclusively on our personal rights, or do we recognize the need to also turn our attention to the needs of the community as a whole and the importance of each individual within it? It turns out that this should not be an either-or question. At the end of the day, our personal peace and well-being depends upon the peace and wellbeing of every individual, too.

More than half of those who died by suicide had not been diagnosed with a mental health condition, said Dr. Anne Schuchat, principal deputy director of the CDC.

"These findings are disturbing. Suicide is one of the top 10 causes of death in the US right now, and it's one of three causes that is actually increasing recently, so we do consider it a public health problem — and something that is all around us," Schuchat said. The other two top 10 causes of death that are on the rise are Alzheimer's disease and drug overdoses, she noted.

In 2016 alone, about 45,000 lives were lost to suicide.

"Our data show that the problem is getting worse," Schuchat said.

Increases in 49 states

Using data from the National Vital Statistics System for 50 states and the District of Columbia, CDC researchers analyzed suicide rates for people 10 and older from 1999 through 2016.

Overall, the US experienced a 25% rise in the rate of suicides during that period, with individual states ranging from a 6% increase in Delaware to a nearly 58% increase in North Dakota, the researchers say.

All states except Nevada experienced an increase; although Nevada showed a 1% decrease in suicide, the state's suicide rate was still high, ranging between 21 and 23 suicides for every 100,000 people through the years studied, the researchers say.

Suicide rates were four times greater in the highest state compared with the lowest when calculated on an annual basis during the most recent time period, 2014 to 2016.

Montana experienced about 29 suicides for every 100,000 people — the highest in the nation — compared with about seven people out of every 100,000 in the District of Columbia — the lowest. As a whole, the nation saw 15 people dying by suicide for every 100,000 in 2016.

"The most common method was firearm, followed by hanging or suffocation, followed by poisoning," Schuchat said. "Opioids were present in 31% of individuals who died by poisoning." She added that intentionality is difficult to determine in cases in which a person dies by overdose.

Deborah Stone, lead author of the study and a behavioral scientist at the CDC, said Thursday, "We typically see that firearms make up about half of all suicides, and that tends to be pretty consistent."

Schuchat noted that the researchers "focused in on 27 states where we have extensive data from the death investigations to try to understand the factors or circumstances leading up to suicide."

These data, derived from the National Violent Death Reporting System, showed that 54% of those who committed suicide in 2015 did not have a known mental health condition. Digging deeper, the researchers found that several circumstances, including the loss of (or problems in) a relationship, were more likely to trigger a suicide among those who did not have a mental health condition.

Regions and demographic groups were also compared.

Economic factors behind suicide

The Western area trend of high increases in suicide rates could be related to the fact that people in rural areas have less access to services as they more slowly benefit from the economic recovery than other parts of the nation, she said.

"We don't have all the answers. There may be several, but we knew that economic factors can increase the risk of suicide and that limited access to care, behavioral and social services may also increase the risk of suicide," Schuchat said.

Recent government reports have highlighted rising rates of suicide among women. "The percent increase was higher in women, but it's important to say that men have a three to five times higher rate than women," Schuchat said. The rising suicide rate for women, then, is "increasing but at a much, much lower level" than for men.

Veterans are also "overrepresented" in the report, she said.

"Veterans made up about 18% of adult suicides but represent about 8.5% of the US adult population," Schuchat said, noting that not all veterans who died by suicide were recent veterans. Still, the researchers found a 10% higher risk of suicide among people who had served in the military.

Middle-age adults had the highest increase.

"This is a very important population right now in terms of national statistics," Schuchat said, noting the high rates of drug overdose in this group as well as "deaths of despair" described in social science literature. She believes this group may have been hardest-hit by the economic downturn, but she added that unknown factors probably contributed.

"We think a key message is, there's not just one group; many are at risk," Schuchat said.

Whether or not they had a mental health condition, '''most people who died by suicide had experienced "one or more factors that may have contributed, including a relationship problem, a crisis in the recent couple weeks and problematic substance abuse," she said.

Alarming

K. Bryant Smalley, a professor of community medicine and psychiatry at the Mercer University School of Medicine, described the mental health care challenges experienced by patients in rural areas as the "three A's": availability, accessibility and acceptability of care.

Smalley, who was not involved in the new research, pointed out that about 85% of federally designated mental health professional shortage areas are rural.

"Due to higher poverty rates, higher likelihood of hourly pay and productivity-based labor, and lack of transportation infrastructure, mental health services are often not accessible even if they are available in a rural community — that is, even though it is there, many people either cannot get to it or cannot afford (either directly or indirectly) to go," he said.

Add to that, rural areas have very high levels of stigma surrounding mental health services. "Rural residents face lower levels of anonymity in seeking services due to the close-knit nature of rural communities," Smalley said. The possibility of "someone seeing your car parked at the only psychologist's office" means rural residents are less likely to seek care when needed.

Dr. Sandro Galea, dean and Robert A. Knox Professor at the Boston University School of Public Health, said the National Vital Statistics System is the "best system we have of keeping records in the country." Galea, who was not involved in the new study, added that for this reason, the new research should be taken "very seriously."

"There have been previous reports recently that have shown suicide is one of the major contributors to a decrease in life expectancy in this country, which makes it even more alarming," he said.

"The paper makes a clear case, correctly, about the fact that there is no one cause for suicide," he said, adding that "availability of means" makes death possible.

"A lot of suicide is a one-time effort, so having guns available, for example, makes one more likely to complete suicide, but that in and of itself is not an explanation for why suicide is going up," Galea said.

"CDC data shows that suicide happens to everybody," he said. "Social and life and economic stressors are the ones that create the conditions for suicides to happen."

If you feel extreme distress, you can call 1-800-273-8255, the National Suicide Prevention Lifeline, to speak with someone who will provide free and confidential support 24 hours a day, seven days a week. If you want to learn how to help someone in crisis, you can call the same number.

The CDC also recommends its own policies, programs and practices for prevention.

Shuchat said there are simple steps anyone can take to help someone at risk. "Beginning a conversation, helping keep them safe, helping them connect and then follow up with them," she said. "We don't think every single suicide can be prevented, but many are preventable."

Nobody ever gets prosecuted for it.