health and safety issues related to violence essay

Advertisement

• Previous Article
• Next Article

The Effects of Violence on Communities: The Violence Matrix as a Tool for Advancing More Just Policies

Beth E. Richie is Head of the Department of Criminology, Law and Justice and Professor of African American Studies at the University of Illinois at Chicago. She is the author of Arrested Justice: Black Women, Violence, and America's Prison Nation (2012) and Compelled to Crime: The Gender Entrapment of Battered Black Women (1996) and editor of The Long Term: Resisting Life Sentences, Working toward Freedom (with Alice Kim, Erica Meiners, Jill Petty, et al., 2018).

• Cite Icon Cite
• Open the PDF for in another window
• Permissions
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Search Site

Beth E. Richie; The Effects of Violence on Communities: The Violence Matrix as a Tool for Advancing More Just Policies. Daedalus 2022; 151 (1): 84–96. doi: https://doi.org/10.1162/daed_a_01890

Download citation file:

• Ris (Zotero)
• Reference Manager

In this essay, I illustrate how discussions of the effects of violence on communities are enhanced by the use of a critical framework that links various microvariables with macro-institutional processes. Drawing upon my work on the issue of violent victimization toward African American women and how conventional justice policies have failed to bring effective remedy in situations of extreme danger and degradation, I argue that a broader conceptual framework is required to fully understand the profound and persistent impact that violence has on individuals embedded in communities that are experiencing the most adverse social injustices. I use my work as a case in point to illustrate how complex community dynamics, ineffective institutional responses, and broader societal forces of systemic violence intersect to further the impact of individual victimization. In the end, I argue that understanding the impact of all forms of violence would be better served by a more intersectional and critical interdisciplinary framework.

Rigorous interdisciplinary scholarship, public policy analyses, and the most conscientious popular discourse on the impact of violence point to the deleterious effects that violence has on both individual health and safety and community well-being. Comprehensive justice policy research on topics ranging from gun violence to intimate abuse support the premise that the physical injury, psychological distress, and fear that are typically associated with individual victimization are directly linked to subsequent social isolation, economic instability, erosion of neighborhood networks, group alienation, and mistrust of justice and other institutions. This literature also points to the ways that structural inequality, persistent disadvantages, and structural abandonment are some of the root causes of microlevel violent interactions and at the same time influence how effective macro-level justice policies are at responding to or preventing violent victimization. 1

The most exciting of these analyses have emerged from the subfields of feminist criminology, critical race theory, critical criminology, sociolegal theory, and other social science research that take seriously questions of race and culture, gender and sexuality, ethnic identity and class position, exploring with great interest how these factors influence the prevailing questions upon which practitioners in our field base their practice; questions such as how to increase access to justice, the role of punishment in desistance, the factors that lead to a disproportionate impact of institutional practices, and the perceptions about, and possibilities for, violence prevention and abolitionist practices. 2 Discussions about the future of justice policy would be well served by attending to this growing literature and the critical frameworks that are advanced from within it.

In this essay, I will attempt to illustrate how discussions of the effects of violence on communities are enhanced by the use of a critical framework that links various microvariables with macro-institutional processes. Drawing upon my work on the issue of violent victimization toward African American women and how conventional justice policies have failed to bring effective remedy in situations of extreme danger and degradation, I argue that a broader conceptual framework is required to fully understand the profound and persistent impact that violence has on individuals embedded in communities that are experiencing the most adverse social injustices. I use my work as a case in point to illustrate how complex community dynamics, ineffective institutional responses, and broader societal forces of systemic violence intersect to further the impact of individual victimization. In the end, I argue that understanding the impact of all forms of violence would be better served by a more intersectional and critical interdisciplinary framework.

Following a review of the data on violent victimization against African American women, I describe the violence matrix , a conceptual framework that I developed from analyzing data from several research projects on the topic. 3 I do so as a way to make concrete my earlier claim: that the effect of violence on communities must be understood from a critical intersectional framework. That is, my central argument here is an epistemological one, suggesting that in the future, the most effective and indeed “just” policies in response to violence necessitate the development of critical far-reaching systemic analysis and social change at multiple levels.

Violent victimization has been established as a major problem in contemporary society, resulting in long-term physical, social, emotional, and economic consequences for people of different racial/ethnic, class, religious, regional, and age groups and identities. 4 However, like most social problems, the impact is not equally felt across all subgroups, and even though the rates may be similar, the consequences of violent victimization follow other patterns of social inequality and disproportionately affect racial/ethnic minority groups. 5 When impact and consequences are taken into account, it becomes clear that African American women fare among the worst, in part because of the ways that individual experiences are impacted by negative institutional processes. 6

While qualitative data suggest that there is a link between social position in a racial hierarchy and Black women's subsequent vulnerability to violence, the specific mechanism of that relationship has yet to be described or tested. 7 However, despite new research that examines the effects of race/ethnicity and gender in combination, there has been a lack of systematic analysis of the intersection of race and gender with a specific focus on the situational factors, cultural dynamics, and neighborhood variables that lead to higher rates and/or more problematic outcomes of violent victimization in the lives of African American women. 8

These unanswered questions led to the years of fieldwork that informed the development of the violence matrix. I was interested in broadening the understanding of violence by analyzing the contextual and situational factors that correlate with multiple forms of violent victimization for African American women, incorporating the racial and community dynamics that influence their experiences. I was also concerned about the ways that state-sanctioned violence and systemic oppression contributed to the experience and impact of intimate partner abuse and looked for a way to incorporate “ordinary violence” and “the injustices of everyday life” into an analytic model. I offer this conceptual approach as a potential epistemological model because it proposes to enhance the scientific understanding of violent victimization of African American women by looking at gender and race, micro and macro, individual, community, and societal issues in the same analysis, whereas in most other research, rates of victimization are described either by gender or race, and typically not from within the contexts of household, neighborhood, and society.

More specifically, domestic violence, sexual abuse, and other forms of violence typically understood to be associated with household or familiar relationships are usually studied as a separate phenomenon constituting a gender violence subfield distinct from other forms of victimization that are captured in more general crime statistics. 9 The more general research that documents crimes of assault, homicide, and so on does not typically isolate analyses of the nature of the relationship between the perpetrator and the victim, even if it is noted. As a result, gender violence and other forms of violent victimization against women are studied separately, and their causes and consequences, the intervention and prevention strategies, and the needs for policy change are not linked analytically to each other. This leaves unexamined the significant influence of situational factors (such as intimacy) or contextual factors (such as negative images of African American women) on victimization, and on violence more generally.

Prior to describing the violence matrix, readers may benefit from a brief overview of the problems that it was designed to account for. African American women experience disproportionate impacts of violent victimization. 10 As the following review of the literature shows, the rates are high and the consequences are severe, firmly establishing the need to focus on this vulnerable group. The goal is not to suggest it is the only population group at risk or that racial/ethnic identity has a causal influence on victimization, but rather to look specifically at how race/ethnicity and gender interact to create significant disproportionality in rates of, perceptions about, and consequences of violence, and to develop an instrument to collect data that can be analyzed conceptually and discussed in terms of contextual particularities.

Assault . According to the Bureau of Justice Statistics, in 2005, Black women reported experiencing violent victimization at a rate of 25 per 1,000 persons aged twelve years or older. 11 In an earlier report, Black women reported experiencing simple assaults at 28.8 per 1,000 persons and serious violent crimes at 22.5 per 1,000 persons, twelve years or older. Black women are also more likely (53 percent) to report violent victimization to the police than their White or male counterparts. 12 Situational factors such as income, urban versus suburban residence, perception of street gang membership, and presence of a weapon influence Black women's violent victimization. Other variables are known to complicate this disproportionality, most notably income, age, neighborhood density, and other crimes in the community like gang-related events. However, few studies note or analyze their covariance. Additionally, reports after 2007 detail statistics on violent victimization for race or gender, but not race and gender; therefore, numbers regarding Black women's experiences are largely unknown.

Intimate partner violence . Intimate partner violence is a significant and persistent social problem with serious consequences for individual women, their families, and society as a whole. 13 The 1996 National Violence Against Women Survey suggested that 1.5 million women in the United States were physically assaulted by an intimate partner each year, while other studies provide much higher estimates. 14 For example, the Department of Justice estimates that 5.3 million incidents of violence against a current or former spouse or girlfriend occur annually. Estimates of violence against women in same sex partnerships indicate a similar rate of victimization. 15

According to most national studies, African American women are disproportionately represented in the data on physical violence against intimate partners. 16 In the Violence Against Women Survey, 25 percent of Black women had experienced abuse from their intimate partner, including “physical violence, sexual violence, threats of violence, economic exploitation, confinement and isolation from social activities, stalking, property destruction, burglary, theft, and homicide.” Rates of severe battering help to spotlight the disproportionate impact of direct physical assaults on Black women by intimate partners: homicide by an intimate partner is the second-leading cause of death for Black women between the ages of fifteen and twenty-five. 17 Black women are killed by a spouse at a rate twice that of White women. However, when the intimate partner is a boyfriend or girlfriend, this statistic increases to four times the rate of their White counterparts. 18 While the numbers are convincing, they are typically not embedded in an understanding of how situational factors like relationship history, religiosity, or availability of services impact these rates. 19

Sexual victimization . When race is considered a variable in some community samples, 7 to 30 percent of all Black women report having been raped as adults, and 14 percent report sexual abuse during their childhood. 20 This unusually wide range results from differences in definitions and sampling methods. However, as is true in most research on sexual victimization, it is widely accepted that rape, when self-reported, is underreported, and that Black women tend to underutilize crisis intervention and other supportive services that collect data. 21 Even though Black women from all segments of the African American community experience sexual violence, the pattern of vulnerability to rape and sexual assault mirrors that of direct physical assault by intimate partners. The data show that Black women from low-income communities, those with substance abuse problems or mental health concerns, and those in otherwise compromised social positions are most vulnerable to sexual violence from their intimate partners. 22 Not only is the incidence of rape higher, but a review of the qualitative research on Black women's experiences of rape also suggests that Black women are assaulted in more brutal and degrading ways than other women. 23 Weapons or objects are more often used, so Black women's injuries are typically worse than those of other groups of women. Black women are more likely to be raped repeatedly and to experience assaults that involve multiple perpetrators. 24

Beyond the physical, and sometimes lethal, consequences, the psychological literature documents the very serious mental health impact of sexual assault by intimate partners. For instance, 31 percent of all rape victims develop rape-related post-traumatic stress disorder. 25 Rape victims are three times more likely than nonvictims to experience a major depressive episode in their lives, and they attempt suicide at a rate thirteen times higher than nonvictims. Women who have been raped by a member of their household are ten times more likely to abuse illegal substances or alcohol than women who have not been raped. Black women experience the trauma of sexual abuse and aggression from their intimate partners in particular ways, as studies conducted by psychologists Victoria Banyard, Sandra Graham-Bermann, Carolyn West, and others have discussed. 26 It is also important to note the extent to which Black women are exposed to or coerced into participating in sexually exploitative intimate relationships with older men and men who violate commitments of fidelity by having multiple sexual partners. 27 Far from infrequent or benign, it can be hypothesized that these experiences serve to socialize young women into relationships characterized by unequal power, and they normalize subservient gender roles for women, although very little empirical research has been done to make this analytical case.

Community harassment . In addition to direct physical and sexual assaults, Black women experience a disproportionate number of unwanted comments, uninvited physical advances, and undesired exposure to pornography in their communities. Almost 75 percent of Black women sampled report some form of sexual harassment in their lifetime, including being forced to live in, work in, attend school in, and even worship in degrading, dangerous, and hostile environments, where the threat of rape, public humiliation, and embarrassment is a defining aspect of their social environment. 28 They also experience trauma as a result of witnessing violence in their communities. 29

For some women, this sexual harassment escalates to rape. Even when it does not, community harassment creates an environment of fear, apprehension, shame, and anxiety that can be linked to women's vulnerability to violent victimization. It is important to understand this link because herein lie some of the most significant situational and contextual factors, like the diminished use of support services and reduced social capital on the part of African American women.

Social disenfranchisement . Less well-documented or quantified in the criminological data is the disproportionate harm caused to African American women because of the ways that violent victimization is linked to social disenfranchisement and the discrimination they face in the social sphere. Included here is what other researchers have called coercive control or structural violence. 30 The notion of social disenfranchisement goes beyond emotional abuse and psychological manipulation to include the regulation of emotional and social life in the private sphere in ways that are consistent with normative values about gender, race, and class. 31 These aspects of violence against African American women in particular are conceptualized in the violence matrix, and include being disrespected by microracial slurs from community members and agency officials, and having their experience of violent victimization denied by community leaders. 32 African American women are also disproportionately likely to be poor, rely on public services like welfare, and be under the control of state institutions like prisons, which means that they face discrimination and degradation in these settings at higher rates. 33 These situational and contextual factors that cause harm are indirectly related to violent victimization and must be considered part of the environment that disadvantages African American women. From this vantage point, it could be argued that when women experience disadvantages associated with racial and ethnic discrimination, dangerous and degrading situations, and social disenfranchisement, they are more at risk of victimization. 34

The violence matrix ( Table 1 ) is informed by the data reviewed above and by my interest in bringing a critical feminist criminological approach to the understanding of violent victimization of African American women. It asserts that intimate partner violence is worsened by some of the contextual variables and situational dynamics in their households, communities, and broader social sphere, and vice versa. The tool is not intended to infer causation, but rather to broaden the understanding of the factors that influence violence in order to create justice policy in the future.

The Violence Matrix

The violence matrix conceptualizes the forms of violent victimization that women experience as fitting into three overlapping categories, reflecting a sense that the forms are co-constituted and exist within a larger context and in multiple arenas: 35 1) direct physical assault against women; 2) sexual aggressions that range from harassment to rape; and 3) the emotional and structural dimensions of social disenfranchisement that characterize the lives of some African American women and leave them vulnerable to abuse. Embedded in the discussion of social disenfranchisement are issues related to social inequality, systemic abuse, and state violence.

Consistent with ecological models of other social problems, the violence matrix shows that various forms of violent victimization happen in several contexts and are influenced by several variables. 36 First, violence occurs within households, including abuse from intimate partners as well as other family members and co-residents. Dynamics associated with household composition, relationship history, and patterns of household functioning can be isolated for consideration in this context. The second sphere is the community in which women live: the neighborhoods, schools, workplaces, and public spaces where women routinely interact with peers and other people. This context has both a geographic and a cultural meaning. Community, in this context, is where women share a sense of belonging and physical space. An analysis of the community context focuses attention on issues like neighborhood social class, degree of social cohesion, and presence or absence of social services. The third is the social sphere, where legal processes, institutional policies, ineffective justice policies, and the nature of social conditions (such as population density, neighborhood disorder, patterns of incarceration, and other macrovariables) create conditions that cause harm to women and other victims of violence. 37 The harm caused by victimization in this context happens either through passive victimization (as in the case of bystanders not responding to calls for help because of the low priority put on women's safety) or active aggression (as in police use of excessive force in certain neighborhoods) that create structural disadvantage. 38

The analytic advantage of using a tool like the violence matrix to explain violent victimization is that it offers a way to move beyond statistical analyses of disproportionality to focus on a more nuanced understanding of the relationship between contextual factors that disadvantage African American women and the situational variables leading to violent victimization. Two important features of this conceptual framework allow for this. First, the violence matrix theoretical model considers both the forms and the contexts as dialectical and reinforcing (as opposed to discrete) categories of experience. Boundaries overlap, relationships shift over time, and situations change. It helps to show how gender violence and other forms of violent victimization intersect and reinforce each other. For example, sexual abuse has a physical component, community members move in and become intimate partners, and sexual harassment is sometimes a part of how institutions respond to victims. This theoretical model examines the simultaneity of forms and contexts, a feature that most paradigms do not have. 39 The possibility that gender violence (like marital rape) could be correlated with violence at the community level (like assault by a neighbor) holds important potential for a deeper understanding of violent victimization of vulnerable groups and therefore informs the future of justice policy.

A second distinguishing feature of this conceptual model is that it broadens the discussion about violent victimization beyond direct assaults within the household (Table 1, cells 1 and 2) and sexual assaults by acquaintances and strangers (cells 5 and 8), which are the focus of the majority of the research on violence against women. It includes social disenfranchisement as a form of violence and social sphere as a context (cells 3, 6, 7, 8, and 9). In this way, the violence matrix focuses specific attention on contextual and situational vulnerabilities in addition to the physical ones. More generally, this advantages research and justice praxis. This approach responds to the entrenched problem of gender violence as it relates to issues of structural racism and other forms of systematic advantage. Models like this therefore hold the potential to inform justice policy that is more comprehensive, more effective, and, ultimately, more “just.”

My hope is that the violence matrix will deepen the understanding of the specific problem of violence in the lives of Black women and serve as a model for intersectional analyses of other groups and their experiences of violence. I hope it points to the utility of moving beyond quantitative studies and single-dimension qualitative analyses of the impact of violence and instead encourages designing conceptual models that consider root causes and the ways that systemic factors complicate its impact. This would offer an opportunity for a deeper discussion around violence policy, one that would include attention to individual harm, and how it is created by, reinforced by, or worsened by structural forms of violence. It would bring neighborhood dynamics into the analytical framework and engage issues of improving community efficacy and reversing structural abandonment in considerations of potential options. Questions about where strategies of community development and how the politics of prison abolition might appear would become relevant. And in the end, it would advance critical justice frameworks that answer questions about what 1) we might invest in to keep individuals safe; 2) how we might help neighborhoods thrive; and 3) how we might create structural changes that shift power in our society such that violence and victimization are minimized. More than rhetorical questions and naively optimistic strategies, these are real issues that must inform any discussion of the future of justice policy. A model like the violence matrix, modified and improved upon by discussions at convenings like those hosted by the Square One Project, offer some insights into both the what and the how of future justice policy. I hope that this essay is helpful in moving that discussion forward.

T. R. Young, “Beyond Crime and Punishment: Part 2–Democratic Proposals for Social Justice,” Critical Criminology 7 (2) (1996): 92–107.

Eva Broodman, “An Immanent Critique of the Prison Nation: The Contradictions of Carceral ‘Anti-Violence,'” Philosophy & Social Criticism 44 (5) (2018): 571–592; Angela Davis, The Meaning of Freedom, and Other Difficult Dialogues (San Francisco: City Lights Publisher, 2010); Shaun L. Gabbidon and Helen Taylor-Greene, Race and Crime , 3rd ed. (Thousand Oaks, Calif.: SAGE Publications, 2012); and Paul Leighton, Gregg Barak, and Allison Cotton, Class, Race, Gender, and Crime: The Social Realities of Justice in America (Lanham, Md.: Rowman & Littlefield, 2010).

Beth E. Richie, Arrested Justice: Black Women, Violence, and America's Prison Nation (New York: New York University Press, 2012).

Michele C. Black, Kathleen C. Basile, Matthew J. Breiding, et al., National Intimate Partner and Sexual Violence Survey: 2010 Summary Report (Atlanta: The National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011); Frederick P. Buttell and Michelle Mohr Carney, “A Large Sample Evaluation of a Court-Mandated Batterer Intervention Program: Investigating Differential Program Effect for African American and Caucasian Men,” Research on Social Work Practice 16 (2) (2006): 121–131; Erika Harrell, “Black Victims of Violent Crime” (Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 2007); National Center for Injury Prevention and Control, “Costs of Intimate Partner Violence against Women in the United States” (Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2003); Ruth D. Peterson, Lauren J. Krivo, and John Hagan, Divergent Social Worlds: Neighborhood Crime and the Racial-Spatial Divide (New York: Russell Sage Foundation, 2010); Patrick Sharkey, Stuck in Place: Urban Neighborhoods and the End of Progress toward Racial Equality (Chicago: University of Chicago Press, 2013); and Patricia Tjaden and Nancy Thoennes, Full Report on Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence Against Women Survey (Washington, D.C.: National Institute of Justice, 2000).

Natalie J. Sokoloff and Ida Dupont, “Domestic Violence at the Intersections of Race, Class, and Gender: Challenges and Contributions to Understanding Violence against Marginalized Women in Diverse Communities,” Violence Against Women 11 (1) (2005): 38–64; Darrell Steffensmeier, Ben Feldmeyer, Casey T. Harris, and Jeffery T. Ulmer, “Reassessing Trends in Black Violent Crime, 1980–2008: Sorting Out the ‘Hispanic Effect’ in Uniform Crime Reports Arrests, National Crime Victimization Survey Offender Estimates, and U.S. Prisoner Counts,” Criminology 49 (1) (2011): 197–252; and James D. Unnever and Shaun L. Gabbidon, A Theory of African American Offending: Race, Racism, and Crime (New York: Taylor & Francis, 2011).

Danielle McGuire, At the Dark End of the Street: Black Women, Rape, and Resistance–A New History of the Civil Rights Movement from Rosa Parks to the Rise of Black Power (New York: Vintage, 2010); R. L. McNeely and Jose B. Torres, “Reflections on Racial Differences in Perceptions of Intimate Partner Violence: Black Women Have to Be Strong,” Social Justice in Context 4 (1) (2009): 129–136; Casey T. Taft, Thema Bryant-Davis, Halley E. Woodward, et al., “Intimate Partner Violence against African American Women: An Examination of the Socio-Cultural Context,” Aggression and Violent Behavior 14 (1) (2009): 50–58; Shatema Threadcraft, Intimate Justice: The Black Female Body and the Body Politic (Oxford: Oxford University Press, 2016); and Eve Waltermaurer, Carole-Ann Watson, and Louise-Anne McNutt, “Black Women's Health: The Effect of Perceived Racism and Intimate Partner Violence,” Violence Against Women 12 (12) (2006): 1214–1222.

Buttell and Carney, “A Large Sample Evaluation of a Court-Mandated Batterer Intervention Program”; Shannan Catalano, Erica Smith, Howard Snyder, and Michael Rand, “Female Victims of Violence” (Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 2009); Michelle D. Mitchell, Gabrielle Hargrove, Marietta H. Collins, and Martie P. Thompson, “Coping Variables that Mediate the Relation between Intimate Partner Violence and Mental Health Outcomes among Low-Income, African American Women,” Journal of Clinical Psychology 62 (12) (2006): 1503–1520; and Shondrah Tarrezz Nash, “Through Black Eyes: African American Women's Constructions of their Experiences with Intimate Male Partner Violence,” Violence Against Women 11 (11) (2005): 1420–1440.

Janette Y. Taylor, “No Resting Place: African American Women at the Crossroads of Violence,” Violence Against Women 11 (12) (2005): 1473–1489; Nikki Jones, Between Good and Ghetto: African American Girls and Inner-City Violence (New Brunswick, N.J.: Rutgers University Press, 2010); and Jody Miller, Getting Played: African American Girls, Urban Inequality, and Gendered Violence (New York: New York University Press, 2008).

Carole E. Jordon, “Advancing the Study of Violence against Women: Evolving Research Agendas into Science,” Violence Against Women 15 (4) (2009): 393–419.

Buttell and Carney, “A Large Sample Evaluation of a Court-Mandated Batterer Intervention Program.”

Harrell, “Black Victims of Violent Crime.”

Callie Rennison, “Violent Victimization and Race, 1993–98” (Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 2001).

Shannon Catalano, “Intimate Partner Violence in the United States” (Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice, 2006).

Tjaden and Thoennes, Full Report on Prevalence, Incidence, and Consequences of Violence against Women .

Kim Fountain and Avy A. Skolnik, Lesbian, Gay, Bisexual, and Transgender Domestic Violence in the United States in 2006: A Report of the National Coalition of Anti-Violence Program (New York: National Coalition of Anti-Violence Programs, 2007), https://avp.org/wp-content/uploads/2017/04/2006_NCAVP_DV_Report.pdf; Valli Kanuha, “Compounding the Triple Jeopardy: Violence in Lesbian Relationships,” Women and Therapy 9 (2) (1990): 169–184; and Diane R. Dolan-Soto and Sara Kaplan, New York Lesbian, Gay, Transgender and Bisexual Domestic Violence Report (New York: New York City Gay and Lesbian Anti-Violence Project, 2005), http://avp.org/wp-content/uploads/2017/04/2005_AVP_DV_Report.pdf .

Emiko Petrosky, Janet M. Blair, Carter J. Betz, et al., “Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence–United States, 2003–2014,” Morbidity and Mortality Weekly Report 66 (28) (2017): 741–746.

Taft et al., “Intimate Partner Violence against African American Women.”

Catalano et al., “Female Victims of Violence.”

Tricia B. Bent-Goodley, “Perception of Domestic Violence: A Dialogue with African American Women,” Health and Social Work 29 (4) (2004): 307–316; Blanca Ramos, Bonnid E. Carlson, and Louise-Ann McNutt, “Life-Time Abuse, Mental Health and African American Women,” Journal of Family Violence 19 (3) (2004): 153–164; Christina G. Watlington and Christopher M. Murphy, “The Role of Religion and Spirituality among African American Survivors of Domestic Violence,” Journal of Clinical Psychology 62 (7) (2006): 837–857; and Carolyn West, “Black Women and Intimate Partner Violence: New Directions for Research,” Journal of Interpersonal Violence 19 (12) (2004): 1487–1493.

Patricia Tjaden and Nancy Thoennes, Extent, Nature, and Consequences of Intimate Partner Violence (Washington, D.C: U.S. Department of Justice, National Institute of Justice, 2006).

Helen A. Neville and Jennifer Hamer, “'We Make Freedom': An Exploration of Revolutionary Black Feminism,” Journal of Black Studies 31 (4) (2001): 437–461.

Christina A. Byrne and David S. Riggs, “Gender Issues in Couple and Family Therapy Following Traumatic Stress,” in Gender and PTSD , ed. Rachel Kimerling, Paige Ouimette, and Jessica Wolfe (New York: The Guilford Press, 2002), 382–399; Jacquelyn Campbell, “Health Consequences of Intimate Partner Violence,” The Lancet 359 (9314) (2002): 1331–1336; Chicago Coalition for the Homeless, “Unlocking Options for Women: A Survey of Women in Cook County Jail” (Chicago: Chicago Coalition for the Homeless, 2002), https://www.issuelab.org/resources/46/46.pdf ; Cheryl Sutherland, Chris Sullivan, and Deborah Bybee, “Effects of Intimate Partner Violence versus Poverty on Women's Health,” Violence Against Women 7 (10) (2001): 1122–1143; and Tjaden and Thoennes, Full Report on Prevalence, Incidence, and Consequences of Violence against Women .

Samuel Perry and Cyrus Schleifer, “Race and Trends in Pornography Viewership, 1973–2016: Examining the Moderating Roles of Gender and Religion,” Journal of Sex Research 56 (1) (2019): 62–73; Charlotte Pierce-Baker, Surviving the Silence: Black Women's Stories of Rape (New York: W. W. Norton & Co., 1998); and G. Erlick Robinson, “International Perspectives on Violence against Women,” Archives on Women's Mental Health 6 (3) (2003).

Pauline B. Bart and Patricia H. O'Brien, Stopping Rape: Successful Survival Strategies (Elmsford, N.Y.: Pergamon Press, 1985); and West, “Black Women and Intimate Partner Violence.”

National Victims Center and Crime Victims Research and Treatment Center, “Rape in America: A Report to the Nation” (Arlington, Va., and Charleston, S.C.: National Victim Center and Crime Victims Research and Treatment Center, 1992).

Victoria Banyard, “Measurement and Correlates of Prosocial Bystander Behavior: The Case of Interpersonal Violence,” Violence and Victims 23 (1) (2008): 83–97; Victoria L. Banyard and Sandra A. Graham-Bermann, “A Gender Analysis of Theories of Coping with Stress,” Psychology of Women Quarterly 17 (3) (1993): 303–318; and West, “Black Women and Intimate Partner Violence.”

Walter Dekeserdy and Marilyn Corsianos, Violence against Women in Pornography (New York: Routledge, 2016); and Jody Raphael and Jessica Ashley, “Domestic Sex Trafficking of Chicago Women and Girls” (Chicago: Illinois Criminal Justice Information Authority and DePaul University College of Law, 2008).

Campbell, “Health Consequences of Intimate Partner Violence”; West, “Black Women and Intimate Partner Violence”; Shannan M. Catalano, The Measurement of Crime: Victim Reporting and Police Recording (El Paso, Tex.: LFB Scholarly Publishing, 2006); and Gail Wyatt, “The Sociocultural Context of African American and White Women's Rape,” Journal of Social Issues 48 (1) (1992): 77–91.

Esther Jenkins, “Black Women and Community Violence: Trauma, Grief and Coping,” Women and Therapy 25 (2) (2002): 29–44.

Evan Stark, Coercive Control: How Men Entrap Women in Personal Life (Oxford: Oxford University Press, 2009).

Joshua M. Price, Structural Violence: Hidden Brutality in the Lives of Women (Albany: SUNY Press, 2012).

Raphael and Ashley, “Domestic Sex Trafficking of Chicago Women and Girls.”

Michelle Gaseau and Keith Martin, “Secrets Behind Bars: Sexual Misconduct in Jails–Jails Take Proactive Role to Prevent Illegal Behavior,” Corrections.com; Kaaryn Gustafson, Cheating Welfare: Public Assistance and the Criminalization of Poverty (New York: New York University Press, 2011); and Gabriel Winant, “Black Women and the Carceral State,” Dissent 63 (3) (2016): 147–151.

Mary Bosworth and Jeanne Flavin, Race, Gender, and Punishment: From Colonialism to the War on Terror (New Brunswick, N.J.: Rutgers University Press, 2007); Mimi Kim, “From Carceral Feminism to Transformative Justice: Women-of-Color Feminism and Alternatives to Incarceration,” Journal of Ethnic & Cultural Diversity in Social Work 27 (3) (2018): 219–233; and Elizabeth Sweet, “Carceral Feminism: Linking the State, Intersectional Bodies, and the Dichotomy of Place,” Dialogues in Human Geography 6 (2) (2016): 202–205.

Richie, Arrested Justice ; and Susan Schechter, Women and Male Violence (Boston: South End Press, 1982).

Urie Bronfenbrenner, “Ecological Systems Theory,” in Six Theories of Child Development: Revised Formulations and Current Issues , ed. Ross Vasta (London: Jessica Kingsley Publishers, 2016), 187–249.

David Gurnham, “A Critique of Carceral Feminist Arguments on Rape Myths and Sexual Scripts,” New Criminal Law Review 19 (2016): 141.

Banyard, “Measurement and Correlates of Prosocial Bystander Behavior.”

Jordon, “Advancing the Study of Violence against Women.”

Email alerts

Related articles, related book chapters, affiliations.

• Online ISSN 1548-6192
• Print ISSN 0011-5266

A product of The MIT Press

Mit press direct.

• About MIT Press Direct

Information

• Accessibility
• For Authors
• For Customers
• For Librarians
• Direct to Open
• Open Access
• Media Inquiries
• Rights and Permissions
• For Advertisers
• About the MIT Press
• The MIT Press Reader
• MIT Press Blog
• Seasonal Catalogs
• MIT Press Home
• Give to the MIT Press
• Direct Service Desk
• Terms of Use
• Privacy Statement
• Crossref Member
• COUNTER Member  
• The MIT Press colophon is registered in the U.S. Patent and Trademark Office

This Feature Is Available To Subscribers Only

Sign In or Create an Account

• Current Issue
• Past Issues
• Get New Issue Alerts
• American Academy of Arts 
and Sciences

American Gun Violence & Mental Illness: Reducing Risk, Restoring Health, Respecting Rights & Reviving Communities

Intentional injuries claimed nearly two hundred lives every day in the United States in 2020, about two-thirds of them suicides, each a story of irretrievable human loss. This essay addresses the complex intersection of injurious behavior with mental illness and access to firearms. It explores what more can be done to stop gun violence while respecting the rights of lawful gun owners, preserving the dignity of persons with mental illnesses, and promoting racial equity. Strategies to prevent firearm injury in the United States are uniquely conditioned by a constitutional right to bear arms, the cultural entrenchment and prevalence of private gun ownership, and strident political disagreement on regulatory solutions to stem gun violence. Broad implementation of a range of complementary policies is needed, including community-based programs to address the social and developmental determinants of violence, improved access to a continuum of mental health services, firearm restrictions based on behavioral indicators of risk (not mental illness, per se), licensing for firearm purchase or ownership, comprehensive background checks for firearm purchase, and supply-side approaches to interrupt illegal firearm markets.

Jeffrey W. Swanson is Professor in Psychiatry and Behavioral Sciences at Duke University School of Medicine. He is a Faculty Affiliate of the Wilson Center for Science and Justice at Duke Law School, the Center for Firearms Law at Duke Law School, and the Center for Child and Family Policy at Duke Sanford School of Public Policy. He has published in journals such as JAMA , Health Affairs, American Journal of Psychiatry, American Journal of Public Health , and Law & Human Behavior.

Mark L. Rosenberg was the Founding Director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, and the former President and CEO of Task Force for Global Health. He is the author of Patients: The Experience of Illness (1980) , Howard Hiatt: How This Extraordinary Mentor Transformed Health with Science and Compassion (2018), and Real Collaboration: What Global Health Needs to Succeed (with Elisabeth S. Hayes, Margaret H. McIntyre, and Nancy Neill, 2010), and editor of Violence in America: A Public Health Approach (with Mary Ann Fenley, 1991).

In the summer of 2022, following a pair of highly publicized mass-casualty shootings in upstate New York and West Texas, a bitterly divided United States Congress responded to a groundswell of public outrage and forged a path to consensus on the first major piece of gun violence legislation in over twenty-five years. 1 After decades of federal dithering on gun violence, lawmakers enacted a statute that (among other things) promotes the temporary removal of firearms from people at high risk of suicide or violence against others, expands background checks with a waiting period for gun buyers under age twenty-one, and toughens penalties for illegal gun trafficking. But these provisions were wrapped in a bill that makes no mention of firearms in its title–the Bipartisan Safer Communities Act–and designates the large majority of its $13 billion in funding for expanding mental health services in the community and in schools. 2 Why did lawmakers think gun violence and mental illness had to be addressed together in a bill about community safety, as if they were the same problem? And how did we get to that point?

This essay examines the prevailing assumption that mental illness and violence are strongly interconnected, and that the key to reducing gun violence is therefore to reinvigorate our nation’s failing public behavioral health care system with new capacities to identify, confine, and treat mentally ill people who are potentially violent. There is no question that more effective and accessible mental health services are sorely needed, especially in schools and many neglected communities. If appropriately channeled, the new federal funding could be a welcome resource for that purpose. But while improvements in mental health services may prevent some gun suicides, we argue that such improvements will do little, by themselves, to stem the tide of firearm homicides. Mental illness and gun homicides are two different public health problems that intersect on their edges. Recognizing them as such allows us to see that a broad set of interventions, policies, and legal tools is needed to address the upstream social determinants as well as proximal causes of gun violence—to mitigate its devastating consequences for individuals and communities—but also, and separately, to improve outcomes for people with serious mental illnesses. We advocate and know that it is possible to use science to identify effective, equitable, and feasible ways to reduce gun violence while respecting the rights of lawful gun owners, and to do so without adding to the burden of stigma that people with mental illnesses often bear when others regard them with misplaced fear and scorn.

What is the nature of the problem, and why has it been so intractable to policy solutions? Despite increasing public concern over the nation’s long-running epidemic of gun violence, federal officials have largely been unable to act effectively to limit the death toll. The rate of firearm-related mortality increased 45 percent between 2010 and 2021. 3 Efforts to prevent gun violence have been stymied by an intensely politicized disagreement over the very nature of the problem to be solved: Is gun violence mainly about “dangerous people” or “dangerous weapons”? How that definitional question is framed and answered tends to bifurcate policy choices into those that restrict access to firearms and those that restrain the behavior of people perceived to threaten public safety—including, importantly, people with mental illnesses who are so often stereotyped as prone to violence and scapegoated for mass shootings. We argue that policy options that force such a dichotomous choice are unnecessary and counter-productive. Rather, both approaches are important, and even politically feasible in combination, as the Safer Communities Act illustrates. In what follows, we examine dimensions of both problems: gun violence and inadequately treated mental illness in the community. We discuss how these problems are related and not related, and highlight critical opportunities to implement a range of complementary, evidence-based solutions.

What are the dimensions of gun violence in the United States? More than 1.7 million people have been injured by firearms within the borders of the United States since the beginning of the twenty-first century, and more than 700,000 have died, a total surpassing the combined American military combat death toll of World War I and II combined. 4 Fifty-nine percent of those gun deaths were suicides, 37 percent were homicides, and the remaining 4 percent were attributable to law enforcement actions or injuries that were unintentional or of unknown intent. Mass shooting fatalities—incidents in which at least four people are murdered with a firearm—terrify the public and galvanize media attention, but they account for less than 1 percent of gun homicides. On the day of any mass shooting that claims four or more lives, an average of 124 others perish from firearm-related injuries in the United States. 5 Circumstances surrounding these deaths are diverse, ranging from suicides to gang shootings, domestic violence incidents, and arguments gone bad between impulsive, intoxicated, armed young men in the middle of the night. This is the drip, drip, drip of quotidian gun violence in America.

We do not mean, in any way, to trivialize mass shootings with this relative comparison of lives lost. Indeed, the impact of mass shootings goes far beyond their death toll. A 2019 national survey by the American Psychological Association found that 71 percent of U.S. adults reported experiencing fear of mass shootings as “a significant source of stress in their lives,” causing one out of three people to avoid certain public places. 6

Over the past two decades, while chronic disease mortality declined substantially, the gun suicide rate increased by 17 percent and the gun homicide rate by 57 percent. 7 What is different about firearm-related violence, and why does it seem so refractory to public health experts’ efforts to solve the problem? Why are we not prioritizing public resources to address gun violence in any way commensurate with the fiscal and social costs that the problem represents? The aforementioned new legislation appropriates $13 billion—not trivial—to a public health problem that costs our society an estimated $557 billion each year. 8 This total includes costs to the health care system, the criminal legal system, lost productivity and opportunities, and an attempt to place a dollar value on the lingering distress and void that victims of gun violence leave in the emotional and social lives of their loved ones and communities. There are additional costs to a great number of other people who may not have personally known victims of violence but suffer psychological trauma and high levels of anxiety simply from living in a community marked by daily violence.

What are the dimensions of serious mental illness as a public health problem? Approximately fourteen million adults in the United States suffer from a serious mental illness that causes a functional disability in one or more important areas of life activity. 9 These are severe health conditions such as schizophrenia, bipolar disorder, and recurring major depression that impair the brain’s capacity to reason and regulate mood. They tend to strike young people in their late teens or twenties, often curtailing their opportunities for educational attainment and employment, and wrecking their social relationships. To have some chance at recovery and achieving their human potential, people afflicted with these disorders typically need specialized interventions, treatment, and support over an extended period. For some, their needs require services across a continuum of care, from case management, intensive outpatient treatment, and pharmacotherapy to periodic but timely hospitalizations and longer-term psychosocial rehabilitation.

That one out of three people with a serious mental illness got no treatment at all in the past year—an estimated five million total—is a tragedy and nothing short of a national scandal. 10 These are some of the most marginalized and disadvantaged members of our society, often friendless and estranged from their families, left to navigate alone a public system of care that is fragmented and overburdened, where barriers to access loom large and the professional work force is far too thinly spread. How did this happen?

In the middle of the twentieth century, one-half million adults with serious mental illnesses were housed in large state mental hospitals throughout the United States, under generally dismal conditions. They were often confined against their will and for lengthy periods of time, many of them subdued by high-dose chemical regimens of major tranquilizers and neuroleptics. All that has changed. Today, less than one-half of 1 percent of adults with serious mental illness (about forty thousand people) are treated in state psychiatric hospitals. 11  The need for inpatient psychiatric beds far exceeds the supply. 12 Many adults who experience a serious mental health crisis spend days boarding in an emergency room with little treatment while they wait for an inpatient psychiatric bed to become available. 13 Approximately one hundred thousand are living in homeless shelters or on the streets. 14

The majority of these unfortunate members of our human community are no more dangerous to others than anyone else. But they might as well be, because most adults in the United States believe that mentally ill individuals are violent, and people in general (along with the politicians they elect) tend to act on what they believe to be true. 15 This often means supporting policies that resort to coercive and punitive interventions to remove mentally ill individuals from society, without due regard for their dignity and basic humanity. An estimated 740,000 people with mental illnesses are incarcerated in state prisons and local jails. 16 On any given day, more people with disabling behavioral health conditions can be found in our biggest city jails than ever inhabited the largest asylums in the mid-twentieth century.

The causes of the dramatic historical shift in the way our society has treated (or abandoned, more accurately stated) people with mental illnesses are numerous and complex. 17 Scholars have proposed several reasons, including the discoveries in the 1950s of new pharmacotherapies that promised (prematurely, as it turned out) definitive relief from psychiatric symptoms with minimal outpatient medical management; the withering sociological and humanitarian critiques of so-called “total institutions” in the 1960s; 18 the civil libertarian reforms of involuntary commitment laws in the 1970s—disqualifying all but the “imminently dangerous” from the hospital care that many still needed and leaving them to “rot with their rights on;” 19  the divestment and devolution of centralized public mental health authorities with the advent of managed care and privatization of behavioral health services in the 1980s; 20 the continuing disappearance of subsidized and low-cost housing in many of our biggest cities; 21 and epidemic waves of illicit drug use and a misbegotten policy of mass incarceration in the 1990s, 2000s, and beyond. 22 All of these factors together contributed, in complex and intertwining ways, to a phenomenon that is often referred to elliptically as “deinstitutionalization,” but which amounted to a cruel betrayal of people with serious and disabling mental illnesses.

This is the sad state of affairs that many politicians and pundits presumably are referring to when they respond to mass shootings by saying, in essence, “Fix mental health.” Texas Governor Gregg Abbott exemplified this view in his statement following the massacre of school children in Uvalde in 2022:

We as a state, we as a society, need to do a better job with mental health. Anybody who shoots somebody else has a mental health challenge. Period. We as a government need to find a way to target that mental health challenge and to do something about it. 23

Abbott’s statement, while resonating with public opinion and widespread fear of the mentally ill, collides with empirical data. The vast majority of people with serious mental illness are not violent toward others. Only an estimated 3 percent of gun homicides are perpetrated by people with serious mental illness, and as we discuss in more detail later, 4 percent of all violent behavior risk is attributable to serious mental illness in multivariable analysis. 24 It is not that mental illness poses no relative increased risk of gun violence at all, but it is not the place one would start to reduce gun violence.

Still, it is noteworthy that Abbott’s blanket statement about people who shoot others refers to “mental health challenges,” not necessarily serious diagnosable mental disorders. It stands to reason that many, if not most people who shoot to kill another human being are experiencing, at the time, negative emotions antithetical to a state of mental well-being: feelings of anger, fear, anxiety, frustration, resentment, isolation, hopelessness, or despair. These fall on the extreme end of the spectrum of normal human emotions that most people might experience at some points in their lives. Psychotherapy or pharmacotherapy may help some people who experience distressing and destructive feelings. In 2020, one in five adults received some mental health treatment in the past twelve months, including 17 percent who had taken medication for their mental health and 10 percent who received counseling or therapy from a mental health professional. 25 But we do not have a behavioral health care system that is designed, organized, and financed to deliver interventions to even a fraction of all the people who experience undesirable emotional states. Even if we did, it is far from clear that currently available interventions would work well enough, and for enough of the people at highest risk, to expect to make a dent in gun violence. Meanwhile, the types of psychopathologies that our mental health system is mostly designed to treat contribute very little to the problem of gun homicides.

What causes gun violence: dangerous people or dangerous guns? How does the answer to that question constrain policy solutions, and is it the right question? At its simplest level, gun violence requires two components: injurious behavior and access to a firearm. The perception that gun violence is caused primarily by one of these ingredients or the other creates an explanatory conflict that has come to characterize our nation’s highly politicized cultural divide over private rights and public safety. But finding our way to real solutions requires us to move away from this either/or perspective. In our view, both ingredients are important and even complementary concerns. Unfortunately, discussion of gun policy in the public square has become so polarized that many see only a dichotomous choice. To the right of our political center, gun rights advocates tend to view even limited gun regulations as a slippery slope that will lead to all civilians losing their guns. To the left, public health law scholars argue that government should play a major role in regulating the public’s access to firearms. This view underlies safe storage requirements, the restriction of guns in sensitive places, disqualification of people at risk of harming themselves or others from possessing guns, giving law enforcement officers and judges the clear legal authority to remove guns from people who behave dangerously, and the legal prohibition of certain types of guns and ammunition.

The argument for gun regulation assumes that there will always be some people in the community at risk of harming others at certain times, but we cannot predict or control that risk with any degree of precision. Therefore, the argument goes, we should try to minimize the catastrophic damage that such behavior can do when potentiated by a firearm, by restricting access to the most lethal technologies, for certain people, at certain times and places. But comprehensive regulatory strategies to prevent firearm injury in the United States are uniquely constrained by a constitutional right to bear arms, the fact that four out of ten Americans live in a household with a gun, and the degree to which the American public is strongly divided between those committed to gun rights and those committed to gun control. 26 Thus, while many other advanced countries have successfully avoided a more serious gun violence problem by broadly restricting legal access to firearms in their populations, U.S. policymakers have had to focus selectively on prohibiting certain groups of putatively dangerous people—such as those convicted of a felony or involuntarily committed to a mental hospital—from purchasing or possessing guns. 27 Having relied on this approach for more than fifty years, the United States still suffers with a per-capita firearm fatality rate that is more than five times higher than Canada’s, eight times higher than Denmark’s, twelve times higher than Australia’s, fifty-three times higher than the United Kingdom’s, and 203 times higher than Japan’s gun death rate. 28

Clearly, policies that rely on point-of-sale firearm prohibitions for people with a mental health adjudication or criminal record have not been enough to reduce gun violence in America. Moreover, the institutions responsible for determining whether someone has a gun-disqualifying record—mainly the criminal legal system and the public sector mental health care system—operate in the long shadow of America’s legacy of racial discrimination. Unsurprisingly, gun restrictions fall disproportionately on communities of color, as does the burden of gun violence itself. 29 Thus, targeted categorical restrictions on who can purchase a gun from a licensed dealer have not only failed to solve America’s gun violence problem, but arguably have perpetuated racial inequities. 30 Gun violence prevention policy in the United States faces the triple challenge of saving lives, respecting individuals’ constitutional rights, and promoting racial justice—and must accomplish these goals despite stiff political headwinds.

An evidence-based approach to gun violence prevention is specifically limited by the U.S. Supreme Court’s interpretation of the Second Amendment, and by the state of our knowledge about which policies, legislation, and programs are most effective in both protecting the rights of law-abiding gun owners and reducing gun violence. In D.C. v. Heller (2007), the Court held that individuals, not just standing militias, have a constitutional right to possess firearms for personal protection in the home. 31 In Bruen v. New York Pistol and Rifle Association (2022), the Court substantially expanded gun rights by declaring that it was unconstitutional for a state to require an applicant for a concealed-carry license to show they had a good reason to walk around with a handgun; rather, they have a right to do so, if they are not otherwise prohibited. 32 Justice Clarence Thomas’s opinion for the majority thus limits states’ ability to craft discretionary concealed-carry licensing schemes. It also requires lower appellate courts going forward to consider only constitutional “text, history, and tradition” as the criteria for deciding Second Amendment challenges to states’ existing gun restrictions. This could limit opportunities for public health science to weigh in to help courts decide whether gun-related laws today are narrowly tailored or they serve a compelling government interest (such as saving lives). 33

The Court’s opinion aligns with libertarian values on the political right, marked by a general aversion to government infringement into private life and the belief that individual moral actors are solely responsible for the consequences of their bad choices. This view tends to bifurcate the population into “good people” (us) and “bad people” (them). The bad people cannot be expected to abide by gun laws, and the good people do not need such laws. According to this view, the main effect of gun control laws is to restrict good people’s access to the protective weapons they need to defend themselves from the bad people. The corresponding policy solution is to have fewer laws restricting good people, and fewer bad people in the community.

The narrative that equates gun violence and mental illness is an important example of this approach. In his immediate response to a mass shooting in 2019, former President Donald Trump proposed to address gun violence by building more psychiatric hospitals in which to confine the “crazy people” that he assumed were always responsible for mass shootings: “I think we have to start building institutions again,” he said, “because you know, if you look at the ’60s and the ’70s, so many of these institutions were closed, and the people were just allowed to go onto the streets. . . . We can’t let these people be on the streets.” 34

In his view that America’s gun violence problem is about mental illness, not guns, the former president has prominent company. In 2018, after seventeen people were shot to death in a high school in Florida, Republican Senator from Iowa Joni Ernst stated: “The root cause is not that we have the Second Amendment. It is that we’re not adequately addressing mental illness across the United States. We need to focus on that.” 35 The next year, after twenty-two people were shot to death at a Walmart in El Paso, Texas Governor Gregg Abbott again responded by saying, “Bottom line is mental health is a large contributor to any type of violence or shooting violence.” 36 And putting this view in the most succinct and provocative way, author Ann Coulter stated, “Guns don’t kill people, the mentally ill do.” 37

Are they right? And how would we know? If mental illness were a driving cause of gun violence, we might expect the firearm fatality rate to be higher in states with less public funding for mental health services, fewer psychiatric beds per capita, and a higher estimated prevalence of untreated mental illness in the community. It is not. Instead, gun-related homicide and suicide rates tend to be higher in states with more guns per capita and weaker gun laws. 38 At the same time, it would be a mistake to conclude that mental health in the population is totally unrelated to gun violence; as we have suggested, most people who intentionally use a firearm to injure another person or themselves are not paragons of mental well-being. But they probably have never been involuntarily committed to a psychiatric hospital and would not be legally restricted from owning a firearm on the basis of a mental health–related adjudication record. We need better criteria. 39

The case of the shooter in Parkland, Florida, illustrates this problem. It is clear that the shooter had concerning problems and risk factors for violence in his past, but it is far from clear that he would have qualified for a gun-disqualifying mental health adjudication. 40 That is because the federal and state criteria for denying a gun purchase are not only overbroad, but too narrow. While many people who cannot legally buy guns would pose little risk of harm even if they could, many who actually do pose a risk—people with impulsive and destructive anger traits, for example—have no record that would deny them a firearm. 41

Analyses of mass shooters suggest that the perpetrators often suffer from social, emotional, and behavioral difficulties, but most have not been hospitalized against their will, nor have they been given a diagnosis of serious depression, bipolar disorder, or a thought disorder. Frequently, they have character disorders and a pattern of escalating risk marked by “changes in behavior, demeanor or appearance, uncharacteristic fights or arguments, and telling others of plans for violence, a phenomenon known as ‘leakage.’” 42 They typically do not have the sorts of mental health diagnoses that tend to characterize involuntarily committed psychiatric patients who thereby lose their gun rights. 43

Sometimes, legally mandated outpatient psychiatric treatment—either in the form of a civil court order or a condition of a criminal case diversion—can help to leverage access to intensive services for people whose mental illness has affected their ability to recognize their own need for treatment and to comply with recommended treatment, resulting in a deleterious pattern of repeated involuntary hospitalizations, arrests, or violent behavior. 44 Outpatient civil commitment and analogous legal dispositions also typically confer a firearm restriction under federal or state law. But in general, we do not have a system or procedures in place to identify high-risk individuals who have no record of a mental health adjudication or felony criminal conviction. We need criteria that are sensitive, specific, and comprehensive enough to help identify individuals at high risk of violence and ensure that they cannot purchase and possess firearms.

If we could develop the capacity to identify persons with escalating patterns of risk, and a fair and effective legal process to prevent such persons from acquiring guns, we would be better able to prevent gun homicides and suicides. Such a system requires public participation in gathering information about individuals at risk of harming themselves or others. While certain potential problems arise when enlisting the public in surveillance of their neighbors, there are also plenty of examples in which the public plays an important role in public health interventions. 45 This is the model underlying the implementation of extreme risk protection orders (also known as red flag laws), which have been shown to be effective in preventing firearm-related suicides in Connecticut and Indiana, where laws have been instituted at the state level. 46 The effectiveness of widespread public participation in the Air Force suicide prevention program is another example. This intervention consisted of instructing every single person in a targeted unit—from officers, enlisted personnel, and their families to service providers like beauticians, barbers, and commissary staff—to be on the lookout for anyone who seemed depressed, despairing, or hopeless. All individuals who appeared to have these symptoms were referred to mental health professionals for screening and interventions where appropriate. This intervention in which “the public” was mobilized resulted in previously unheard of reductions of suicide of 25–40 percent. 47

Negative and stigmatizing messages about the supposed dangerousness of mentally ill people are destructive and insidious, in part because they resonate with what a large proportion of the public already believes. Data from the 2006 General Social Survey suggest that Americans believe that people with schizophrenia are especially dangerous. After reading a vignette about an individual with common symptoms of schizophrenia, 60 percent of respondents reported that they viewed the described individual as likely or very likely to be dangerous toward others, even though the vignette description did not include any information about violent behavior or characteristics. 48

Fear and social opprobrium directed toward “the mentally ill” are rooted in Western cultural-historical beliefs going back to ancient times. People who behave in extremely strange ways—for example, those who appear to see invisible visions and hear inaudible voices, who hold bizarre beliefs or succumb to extreme emotions incongruent with the shared experience of others—have often been treated with fear, have been socially ostracized, and thought to be in need of redemptive or miraculous healing. Biblical narratives about demonic possession converge with modern descriptions of psychotic illness. It stands to reason, then, that mental illnesses would serve as a convenient scapegoat for gun violence, perhaps especially for those people with more traditional and conservative habits of thought.

Alternatively, the perspective from the political left has maintained that gun violence prevention should focus mainly on guns, even while efforts to pass gun-related legislation at the federal level have been stymied by the political power of gun rights advocates, as led and mobilized by the National Rifle Association ( NRA ). As a single-issue lobbying group, the NRA has been most effective in mobilizing resistance by spreading the myth that any data collection, research, or policy discussions around gun control will lead to all civilians losing their guns. The NRA has also been effective in convincing gun owners that their identity as gun owners is closely linked to their identity as someone who cares about protecting their family and their country. The NRA conducted a campaign to stop all federal funding for gun violence prevention research for more than twenty years, with the result that there remain large gaps in our scientific knowledge about what causes and how to prevent gun violence. 49

What do we know about mental illness and gun suicides? Guns were used in over half the suicides in the United States in 2020–24,292 out of 45,979 suicide deaths—and suicides account for about six out of ten firearm-related fatalities. 50 Mental illness is a strong contributor to suicide, but suicide is caused by many other factors as well and often cannot be prevented by mental health treatment alone. Access to firearms is one of the most important modifiable determinants of suicide mortality in the United States. Evidence-based firearm restrictions and policies that limit gun access to people who pose a clear risk of intentional self-harm could prevent many suicides without infringing the rights of lawful gun owners. 51

Epidemiological research has demonstrated that the relative risk of suicide is eight times higher in persons with serious psychiatric illnesses and substance-use disorders. 52 Conversely, populations with greater access to mental health care have much lower suicide rates. 53 These findings suggest that the most effective suicide prevention approaches will consist of finding high-risk persons with mental health problems and helping them to get appropriate treatment. This strategy would include protocols for screening and risk assessment for suicide in schools and clinical settings, educating the public to recognize very early signs of depression, hopelessness, or suicidal intent in others, and how to refer them to professionals for help. This approach has proven effective to a certain degree in certain settings, but behavioral health treatment is not always effective and it fails to prevent many suicides. 54 The suicide rate among patients recently discharged from psychiatric hospitals is one hundred times higher than the rate in the general population. 55 Analysis of data from the National Violent Death Reporting System finds that 27 percent of those who died from suicide were currently receiving treatment for a mental health or substance abuse condition at the time of their suicide. 56

There are many risk factors for suicide that are not related to either mental illness or addiction problems and these are not within the purview of standard mental health treatment. Averaging many different studies, the proportion of suicide risk that is attributable to mental health disorders is about 57 percent for males and 77 percent for females; the remainder of the risk is attributable to social, economic, circumstantial, and other factors that are not directly connected to psychopathology. 57 Interventions that address access to lethal means have untapped potential to prevent a large number of suicide deaths. 58 Most people who try to end their own life get a second chance, but fatality rates vary dramatically by the method of intentional self-harm. People who use firearms rarely survive; almost nine out of ten die. 59 In the United States, even though men have lower rates of depression, they are nearly four times more likely than women to die of suicide, and greater access to firearms is one reason for this. 60 Gun-safety and safe-storage practices can thus have a beneficial impact on suicide prevention, especially in the male population. The challenge is to keep guns out of the hands of people at highest risk of suicide, without unduly infringing the Second Amendment rights of many gun owners who are unlikely to harm anyone.

What do we know about mental illness and interpersonal violence? Are mental illness and interpersonal violence causally related, and if so, how? This is a simple-sounding question with a slippery answer, one that varies widely with the elastic definitions of its primary terms. 61 If we define mental illness broadly to include every pathologized pattern psychiatrists have ever characterized as conditions for which people might need their professional help—distorted thoughts, dysregulated moods, dysfunctional behavior, destructive relationships, deviant personalities, or debilitating substance use—then serious violent behavior itself can easily stand as a defining indicator of some form of mental illness. The argument goes, anyone who would shoot to kill another person must not be thinking clearly and must be mentally ill.

The most salient example of this definitional tautology is the common construal of any public mass-casualty shooting as the act of a sick mind. If we believe this to be literally true (in a clinical sense), we must ignore or deny scientific studies showing that most mass shooters do not, in fact, have a major diagnosable psychiatric disorder. Instead, they tend to be angry, alienated, resentful young men in the thrall of a deviant cultural script, and with easy access to an instrument designed to kill multiple people in seconds. 62

A much different answer is obtained when our questions define mental illness and violence independently and more precisely. For example, by how much, if at all, do the symptoms of certain well-described psychiatric illnesses—schizophrenia, bipolar disorder, and major depression—statistically increase the likelihood that people with these illnesses will intentionally engage in violent behaviors toward others within a discrete period of time? Will they hit, push, shove, kick, choke, or throw something at another person, or use a weapon like a stick, knife, or gun to harm or threaten someone? And how much does risk of violence, defined in this way, statistically increase in the presence of excessive alcohol and illicit drug use, whether alone or in combination with serious psychiatric conditions?

The first empirical answers to these questions came more than three decades ago from the landmark National Institute of Mental Health ( NIMH ) Epidemiologic Catchment Area ( ECA ) study. 63 A careful understanding of the study’s groundbreaking design and method is important to seeing why its powerful findings mattered then, and still matter now. Research teams conducted structured psychiatric diagnostic interviews with more than ten thousand randomly selected adults living in Baltimore, St. Louis, and Los Angeles and surrounding areas. The ECA researchers conducted a lengthy confidential household interview with each selected participant, first gathering systematic information about the presence or absence of symptoms of specific behavioral health disorders as codified by the American Psychiatric Association’s diagnostic manual. 64 After the data were assembled, a computer algorithm was used to analyze each respondent’s symptom pattern and mimic a trained psychiatrist’s diagnostic assessment; a putative lifetime diagnosis of one or more psychiatric disorders was assigned to those who had ever met the corresponding clinical criteria, a past-year diagnosis to those who qualified with active symptoms in the previous twelve months.

The ECA study’s interview also included questions about whether the participant had ever engaged in specific violent behaviors, and how recently. The behaviors included getting into a physical fight while drinking, hitting or throwing things at a domestic partner, hitting a child hard enough to cause a bruise or require medical attention or bedrest, engaging in physical fights that came to swapping blows with other people (not a domestic partner or child, irrespective of drinking), and using a weapon such as a stick, knife, or gun in a fight.

Importantly, the study’s community-representative random sampling design avoided the selection bias inherent in two kinds of previous research: retrospective studies of violence in psychiatric patients found in hospitals, secure forensic facilities, and intensive community treatment programs; and studies of psychopathology in people arrested or incarcerated for violent crimes. 65 These earlier studies tended to vastly overestimate the connection between interpersonal violence and mental illness in the community, and it is not difficult to see why. They only looked at the very small proportion of mentally ill individuals who had already been identified as violent, or who needed treatment in a confined or supervised setting to mitigate the risk of harm.

The ECA study found a modest but statistically significant association between having a serious mental illness alone (schizophrenia, bipolar disorder, or depression without co-occurring alcohol or drug-use disorder) and committing one or more acts of interpersonal violence in the previous year. Approximately 7 percent of adults with these disorders reported that they had engaged in some minor or serious violent behavior in the previous year, compared with 2 percent of the general population of adults without these illnesses.

To test whether the increased relative risk might be explained by other correlates of violence that could be more common in people with mental illnesses, the researchers conducted a multivariable analysis that accounted for the independent and covarying effects of age, sex, race, marital status, and socioeconomic status (the latter being a composite of information on income, educational attainment, and occupational prestige). The results held up in a controlled model. Stated in terms of relative risk, then, people with serious mental illnesses were about three times more likely to be violent than those without those illnesses. When respondents with co-occurring substance use disorders were included among those with the aforementioned disorders, the prevalence of any violence went to 12 percent in the past year, and 25 percent ever in the person’s lifetime. 66

But the findings could be viewed another way. The absolute risk in people with serious mental illnesses was very low. While it was true these individuals were three times more likely to be violent than other people, it was equally true that the vast majority—97 percent—did not engage in violent behavior. Moreover, the ECA data could be arrayed to answer yet another question, and perhaps even a policy-relevant question about violence and mental illness. If we were to succeed in curing all serious mental illnesses (or at least eliminating any excess violence-risk linked to them), how much less violence would we have in society? The ECA data’s answer to that intriguing counterfactual question was that violence would go down by approximately 4 percent, and 96 percent of it would remain.

But if not mental illness, then what is the major driver of violence? The ECA project had an answer to that question, too—one that has been confirmed and elaborated in many other studies in the ensuing decades. 67 The analysis showed there is no one cause, no one explanation, and therefore no one solution to the problem. Rather, violence is caused by many factors that interact with each other in complex ways. Much of it is about demographics, resources, and position in social structure. Violence rates are by far the highest in young men with lower incomes, less education, and either no employment or poorly paid jobs with little prestige. 68 What role does hopelessness play in making violence a way to relieve anger and frustration, a way that does not seem to the shooters to come with a particularly high cost? Should our mental health “system” try to find and help people who are feeling angry and hopeless? What would it take to build the capacity for this?

Alcohol and illicit drug use disorders dramatically increase the risk of violent behavior, especially in combination with other risk factors. In the ECA study, approximately 34 percent of the population risk of violence was attributable to substance abuse; there are several reasons for this. Part of the correlation is due to the pharmacological effects of psychoactive substances. Alcohol, for example, is a central nervous system depressant that can alter mood, distort judgment, heighten perception of threat and malevolent intent from others, and disinhibit aggressive impulses. Intoxication may enable otherwise controlled negative affective states—such as feelings of anger, resentment, envy, or jealousy—to find expression in overtly injurious physical acts of violence directed at others. Psychoactive substances may also increase violence-risk in some individuals by exacerbating certain psychiatric symptoms, such as persecutory delusions, which can sometimes motivate instrumental acts of violence as retaliation for imagined victimization.

Problematic substance use can lead to violence by creating extreme conflict in social relationships, and by exposing affected individuals to social networks such as those involved with illegal drug markets where violence might be normalized. Finally, the nexus of alcohol and drugs and violence can be self-perpetuating, through observed and learned behavior in early development, reinforcement of substance use and violence as a maladaptive response to conflict or economic deprivation, and exposure to environments where these are linked in socially toxic surroundings. We as a country do not have the capacity to treat all those suffering from addiction to alcohol or other drugs. There are, however, compelling arguments—social, economic, medical, and moral—why we should develop that capacity.

A range of effective public policies to prevent gun violence must address both lethal means and the behavior of people at risk—tailoring restrictions on access to guns, expanding access to behavioral health services, and mitigating the cultural, social-economic, and political determinants of using guns in harmful ways. The potential for developing and expanding a complementary, evidence-based approach to both improving mental health and reducing gun violence in the population gives us reason to hope we will one day live in a society with greater community well-being and far less gun violence. A general strategy to reduce the burden of gun violence without infringing on the rights of law-abiding gun owners is to keep guns away from people who should not have them. This is difficult, but not impossible.

There are several parts to the task. First, we need to identify all the people who are already legally prohibited from possessing firearms and ensure that, in fact, they do not have access to firearms, which could be done through comprehensive record reporting, expanded background checks, and tamping down illegal transfers on the secondary gun market. Second, we need to identify people who are at high risk of using guns to harm themselves or others but do not yet (for various reasons) have a gun-disqualifying record and could pass a background check to buy a gun from a licensed firearm dealer. These individuals, too, should be separated from firearms. Reforms are needed in our existing legal criteria for prohibiting guns—especially in some states—so that the restrictions would apply to high-risk individuals such as those convicted of violent misdemeanors, persons subject to temporary domestic violence orders of protection, and those with multiple drunk-driving convictions. 69

The criteria of mental illness, when further specified and judiciously applied, may be one way to identify high-risk individuals, that is, to the extent that injurious behavior directed toward others or themselves is indeed related to some particular manifestations of mental illness. Examples include suicidal depression, paranoid delusions with homicidal command hallucinations, and posttraumatic stress rooted in violent victimization, especially when these states of compromised mental health are combined with alcohol or other drug intoxication. But we need ways to focus on the highest risk subjects rather than trying to prevent violence by “fixing the mental health system.” If violence-prevention is the primary goal, we should focus narrowly on ways to identify and deliver timely interventions to people at high risk of harming themselves or others, at limited times when they are at their highest risk. Interventions should both provide access to treatment services and remove access to lethal means. For people experiencing a dangerous mental health crisis, extreme risk protection orders ( ERPO s) used in conjunction with short-term involuntary hospitalization illustrate how different legal tools can work together to address both the how and the why of a potential suicide.

There are certainly improvements to be made in our behavioral health care system that could reduce vectors of violence in the community, at least indirectly—for example, expanding drug-addiction treatment and certain criminal diversion programs, and fixing the psychiatric bed shortage (or misallocation, poor distribution of inpatient capacity). These efforts could help alleviate several aspects of the problem that are made worse by untreated psychiatric illness: homelessness, mass incarceration of people with serious mental illnesses, and emergency room boarding of acutely ill psychiatric patients. Each of these problems amounts to a domestic humanitarian crisis of its own, in a country that must do far better.

Involuntary commitment criteria may help to select a population at higher risk of gun violence; the existing criteria that include dangerousness to self or others are specific and make sense, as long as there are opportunities for restoration of rights after a suitable period of time has passed to allow risk to subside. 70 But involuntary commitment to a hospital has never been a very sensitive criterion for gun disqualification, and is even less so now, in a world after deinstitutionalization has run its course and we have very low rates of psychiatric hospitalization (whether involuntary or not). Thus, trying to disqualify only such people from purchasing guns will miss the largest group of persons with symptoms of mental illness who go on to commit violent acts. A longitudinal study of 23,292 previously hospitalized, public-sector patients with a diagnosis of serious mental illness in Connecticut reported that 96 percent of violent crimes in the study population were perpetrated by individuals who had never been involuntarily committed to a hospital, a group ostensibly receiving less inpatient treatment and who did not lose their gun rights through the mental health prohibitor. 71 A nationally representative psychiatric epidemiological study described a group of adults with impulsive anger problems and access to firearms, comprising an estimated 8.9 percent of the adult population of the United States. A substantial proportion of these individuals with destructive and uncontrolled anger combined with gun access met criteria for some type of psychopathology (including personality disorders and substance use disorders), but only one in ten had been admitted to a hospital for a mental health problem. The majority with this risky combination of impulsive anger and access to guns would not have lost their firearm rights through involuntary commitment. 72

A clinical or judicial finding of dangerousness in conjunction with brief emergency psychiatric hospitalization for evaluation should be leveraged to at least temporarily limit a mentally ill person’s ability to legally purchase a firearm, irrespective of whether a formal involuntary commitment occurs. Studies suggest that violence-risk in psychiatric patients is not necessarily inherent or persistent but rather a function of fluctuating risk factors that select people into different clinical settings at different moments in the course of their illness. Violence-risk tends to be elevated during times of crisis and is most likely to become apparent in periods immediately surrounding contact with the mental health care system during these crises. Involuntary commitment proceedings tend to occur at such times and result in a legal restriction of firearms. Short-term holds for a psychiatric examination also coincide with crises but, in twenty-eight states, do not affect firearms rights. This is an opportunity for reform. 73

What reforms are most needed and would work best to prevent gun violence and improve outcomes for people with mental illnesses? The Safer Communities Act was an encouraging step, in that it incorporates interventions and policies that were scientifically investigated and found to be effective. Research can help to design and evaluate interventions that will simultaneously reduce gun violence and protect the rights of law-abiding citizens. Basically, this means keeping guns out of the hands of persons who cannot legally have them but allowing law-abiding citizens to have and use them. Examples of programs and policies that do this include gun licensing, safe storage regulations, enforcement of laws prohibiting gun ownership by persons convicted of domestic violence felonies or misdemeanors, ERPO s or red-flag laws, waiting periods, and uniform background checks without loopholes. Science can also help us find and evaluate more programs and interventions like these. 74

There should not be a forced choice between suicide-prevention policies that increase the public’s access to mental health treatment interventions and those that decrease at-risk individuals’ access to firearms. Both approaches have their place and should be complementary. Both approaches should also be designed to target individuals at high risk for shooting themselves or another. Gun restrictions that apply to people with mental illnesses must be narrowly focused on behavioral indicators of suicide risk to avoid stigmatizing people in recovery and unduly restricting the rights of millions of people who pose no elevated risk of harming themselves or others. 75 But crisis-focused behavioral health care interventions are unlikely to substantially curtail the population-level prevalence of suicidal thoughts and self-injurious behaviors. In the interest of keeping more people alive who will inevitably experience the impulse to end their own life, policy-makers in the United States should put more emphasis on expanding the use of tailored legal tools to reduce such individuals’ access to firearms. The statutory reforms summarized below are targeted, achievable modifications to existing constitutionally tested policy templates that could save lives when enacted at the state or federal level.

First, state legislators should expand and sharpen gun-prohibiting legal criteria to better align with risk. 76 This would ensure that a greater proportion of individuals at risk of suicide would not have access to a gun during a season of hopelessness or a moment of intoxicated despair. States should prohibit purchase and possession of or access to firearms for a temporary period of time by persons with a record of a brief involuntary hold for a psychiatric examination. And they should prohibit purchase and possession of or access to firearms for persons with a record of repeated alcohol-impaired driving, because these individuals are very likely to suffer from alcohol-dependence disorder, which is an especially robust risk factor for lifetime suicide risk. 77 State legislators could institute a time-limited gun prohibition—five to ten years—applicable to anyone who acquires a second DUI conviction. 78 This would not prevent such a person from ever feeling suicidal, but it would reduce their access to the most lethal method of suicide and make any future suicide attempts much more survivable.

Second, state legislators should enact and widely implement ERPO laws that enable police officers or, in some states, concerned family members and health care providers to seek a civil restraining order to temporarily remove firearms from a person who is behaving dangerously. 79 The twenty-one states and the District of Columbia that have already enacted such laws could improve them, and those states that have not yet enacted such laws can design and implement them using funds made available from the Safer Communities Act. ERPO s should confer a purchase prohibition in the FBI ’s background-check database to prevent persons who are behaving dangerously from acquiring firearms. ERPO s should be applicable to persons under age eighteen who meet the risk-criteria specified in the statute. Clinicians should be authorized to petition for an ERPO for their patients who pose a significant risk of harming themselves or others. States should authorize ERPO petitioners to include physicians and other primary care and mental health care providers. States should adopt an innovative policy known as precommitment against suicide ( PAS ), or voluntary self-enrollment in the NICS . 80 The PAS amounts to a self-initiated, opt-in waiting period for buying a gun, and it could save many lives. 81

To meaningfully reduce gun violence, more community-based work is needed that is focused neither on guns nor persons with mental illness. When we talk about firearm-injury prevention, we typically consider prevention strategies that are directly tied to individuals who possess firearms, such as safe storage, background checks, ERPO s, licensing, and carrying. From the legal design of gun restrictions to the mechanical design of guns themselves, these are all clearly important, but we need more. The roots of our gun-violence problem run deeper, and so must our policies to contain and excise it. The roots that need to be examined include the social and economic determinants of gun violence like poverty, racism, discrimination, and lack of access to jobs, health care, and quality education. 82 Evidence-based policies for prevention of community violence include promoting family environments that support healthy development, providing quality education early in life, strengthening young people’s skills, connecting youth to caring adults and activities, creating protective environments such as by changing the physical design of communities, intervening to lessen harms and prevent future risk, street outreach, and hospital-based programs for victims and survivors of gun violence. Many of these latter types of strategies have been emphasized by the White House and others as part of their efforts to address community violence. 83 Political strategies to develop bipartisan support for laws and policies such as the Safer Communities Act will, incrementally and over the long term, reduce the gun violence toll.

Ecologist Garrett Hardin first used the term “tragedy of the commons” to describe what happens when individuals have access to a community resource for which they do not have to pay. 84 They tend to take only their self-interest into account and deplete the public resource. For example, if there is a common pasture in a town where families can let their cows graze for free, there will soon be too many cows eating too little grass and the commons will be stripped bare. Alexandra Spiliakos, writing for Harvard Business School Online, aptly describes this phenomenon:

[Individuals tend to] . . . make decisions based on their personal needs, regardless of the negative impact it may have on others. In some cases, an individual’s belief that others won’t act in the best interest of the group can lead them to justify selfish behavior. Potential overuse of a common-pool resource—hybrid between a public and private good—can also influence individuals to act with their short-term interest in mind, resulting in the use of an unsustainable product and disregard for the harm it could cause to the environment or general public. 85

An individual’s decision to purchase a firearm for personal protection is a self-interested act that carries little real cost—until the tragedy of the commons eventually follows. When many people in the community feel the same need to acquire their own guns, the purpose of the first individual’s self-interested act is defeated. Everyone is less safe when all are armed. More guns will be stolen and resold illegally and used to commit crimes. In turn, more people will feel unsafe and perceive a need to acquire guns. Even more guns will be purchased, and more residents will feel threatened. The U.S. gun industry, the NRA , and a generation of politicians in their sway have capitalized on this phenomenon, to the ultimate detriment of our civil society and at the cost of many lives lost and families and communities damaged by fear and anxiety.

Consider another relevant example: imagine that a single unsheltered person with mental disability appears on a village green, asking for money to survive. Other citizens feel generous and open their wallets. But when many citizens in large urban centers encounter a growing mass of homeless people with untreated serious mental illnesses encamped on the streets and in city parks, everyone feels threatened; eventually, a whole community’s sense of security erodes. In that social environment, imagine that a single act of violence occurs and is attributed to a “homeless mentally ill” subway denizen. Public fear escalates as public trust recedes. Media narratives amplify the story and accentuate its resemblance to a culturally entrenched urban myth about violent insanity. Is it any wonder, then, that a mass shooting prompts cries to “fix mental health”? Or that popular state laws authorizing mandatory outpatient mental health treatment—Kendra’s Law in New York, Laura’s Law in California, and Kevin’s Law in Michigan—are named for victims of homicides committed by people with serious mental illness?

The tragedy of the commons helps us understand how the proliferation of guns can erode the social fabric. With this in mind, we must take the measure of gun violence not only on the dimension of public safety, but overall community well-being. For many individuals, guns provide pleasure, affinity with other gun owners, a sense of personal efficacy, and security. But at a certain point, as economist David Hemenway and his colleagues have shown, a large number of guns in a community is associated with increased levels of homicide, suicide, and unintentional injury. 86 These, in turn, bring increased anxiety, fear, and loss. A sense of danger from homeless persons with behavioral health disorders in the community also contributes to increased anxiety and diminished quality of life. The erosion of the social safety net imposes great burdens on many communities. In responding to all these actual and perceived threats, accurate and effectively delivered information can help individuals and communities reduce their risks and destigmatize mental illness.

In moving toward prevention, it will be important to address the social and economic determinants of health that so often result in infectious diseases and injuries taking a disproportionately large toll on the poor and marginalized communities. Lingering racial disparities and inequality in the functioning of our nation’s health care organizations, human services and social welfare institutions, and (perhaps especially) in our criminal legal system all reflect our cultural habits of thought as well as political priorities. These are historically entrenched but can be dislodged to make way for serious reforms. To be sure, thoroughgoing change is needed both in social structures and attitudes that perpetuate racial inequality in communities most adversely affected by gun violence. But the very proposed solutions to the problem must also avoid reproducing and reinforcing the patterns of racial inequality already embedded in these systems, such as expanding draconian prison sentences for certain gun-related infractions that are likely to fall heavily on overpoliced and overincarcerated young Black men.

The social and economic determinants of gun violence are complex and long-standing, and they are intertwined with the abandonment of disempowered and marginalized communities. These include people of color and those with serious mental illnesses, but also the legions of traumatized veterans, and the unemployed or underemployed workers now marooned in economically moribund small towns and rural and agricultural communities left behind by global economic development. Urban gun homicide and rural gun suicide are very different problems with distinct causes, yet they echo from common canyons of human despair. We need a different way of approaching these long-standing and complex problems. They are all too often ignored because they have many causes, require multisectoral collaboration, and cannot be solved without a substantial appropriation of public resources. They also take far longer to solve than the length of a politician’s term in office: most politicians want to support programs that are likely to yield easily measured and impressive results before they are next up for reelection. In this light, the Bipartisan Safer Communities Act provides a heartening exception to what has been a dismal norm in the bitterly divided politics of our day: that our existing democratic governance structures seem to have lost the capacity to deliver substantial, equitable, and evidence-based solutions to difficult social problems.

Critical policy opportunities are emerging to reduce gun violence and create safer communities with healthier people. To seize these opportunities, we must communicate effectively. How we communicate information about gun violence to legislators and the public is vitally important. 87 We have learned from our country’s experience with COVID -19. We now have a range of interventions that might be thought of as “vaccines against violence”: firearm licensing, universal background checks, ERPO laws, safe storage, and laws that prohibit persons with records as violent misdemeanants, habitual drunk drivers, or domestic abusers from purchasing firearms. Over time, research can help us identify and test more and more of these “immunizations” against firearm injuries. But we will still need to overcome our own version of vaccine hesitancy. We will have to overcome the myth that research and policy to prevent gun violence will lead to everyone losing all their guns. This is a myth that has polarized our citizens and politicians into two camps: gun rights and gun control. We must develop the evidence base for gun violence prevention, but that by itself will not be enough. With science, we can find those interventions that will both reduce the toll of gun violence and protect the rights of law-abiding gun owners. But vaccines don’t prevent illness; vaccinations do. Laws like the Safer Communities Act provide an opportunity for effective prevention, but they must be implemented to have an impact. We must draw upon the important lessons from marketing and behavior change to design campaigns that will reach gun owners and gun violence prevention advocates alike, to reinforce the notion that they share a common goal in wanting to reduce the toll of gun violence. We can find ways to do this by working in our homes and our communities.

We need to put the public back into an active role in public health, whether the prevalent affliction to be solved is COVID -19, serious mental illness, or gun violence. Government institutions—even operating at all levels—cannot by themselves do everything necessary for effective prevention. As we saw in the Air Force experiment for suicide prevention, a bigger impact than ever before was achieved by mobilizing and involving the whole community. 88 Solving big problems like gun violence and mental illness require ambitious policies. They also require individual people who care deeply for their families, friends, neighbors, and communities—people who learn to care, perhaps especially, for those they may disagree with. The golden rule provides a good guide. There is a way out of the morass of gun violence in which we currently find ourselves. We remain optimistic that we can solve this problem if we have the courage to act, the moral compass to steer us toward equity, and the wisdom to use science to find those solutions that both reduce gun violence and protect the gun rights provided by our Constitution.

• 1 Sheryl Gay Stolberg, “ For Gun Violence Researchers, Bipartisan Bill Is a ‘Glass Half Full,’ ” The New York Times , June 27, 2022.
• 2 Bipartisan Safer Communities Act of 2022, Pub. L. No. 117–159, 136 Stat. 1313 (2022).
• 3 Centers for Disease Control and Prevention ( CDC ), “ WISQARS : Web-based Injury Statistics Query and Reporting System ,” last modified August 23, 2023.
• 5 This is a daily average calculated from CDC data reporting a total of 45,222 firearm-related deaths in the United States in 2020, the latest year reported as of this writing.
• 6 Wendy Rubin, Stress in America: Stress and Current Events (Washington, D.C.: American Psychological Association, 2019). See also American Psychological Association, “ One-Third of U.S. Adults Say Fear of Mass Shootings Prevents Them from Going to Certain Places or Events ,” August 15, 2019.
• 7 Melonie Heron, Deaths: Leading Causes for 2017 , National Vital Statistics Reports, vol. 68, no. 6 (Atlanta: Centers for Disease Control and Prevention: 2019).
• 8 Everytown for Gun Safety, “ The Economic Cost of Gun Violence ,” July 19, 2022.
• 9 Substance Abuse and Mental Health Services Administration ( SAMHSA ), “ 2020 NSDUH [National Survey of Drug Use and Health] Detailed Tables ,” January 11, 2022.
• 11 Ted Lutterman, Robert Shaw, William Fisher, and Ronald Manderscheid, Trends in Psychiatric Inpatient Capacity, United States and Each State, 1970 to 2014 (Alexandria, Va.: National Association of State Mental Health Program Directors, 2017). See also Ted Lutterman and Ronald Manderschied, Trends in Total Psychiatric Inpatient and Other 24-Hour Mental Health Residential Treatment Capacity, 1970 to 2014 (Alexandria, Va.: National Association of County Behavioral Health and Developmental Disability Directors, 2017).
• 12 Eric Slade and Marisa Elena Domino, “Are There Enough Inpatient Psychiatric Beds?” in The Palgrave Handbook of American Mental Health Policy , ed. Howard H. Goldman, Richard G. Frank, and Joseph P. Morrissey (London: Palgrave Macmillan, 2020), 129–169.
• 13 Kimberly Nordstrom, Jon S. Berlin, Sara Siris Nash, et al., “ Boarding of Mentally Ill Patients in Emergency Departments ,” Western Journal of Emergency Medicine: Integrating Emergency  Care with Population Health 20 (5) (2019): 690–695.
• 14 U.S. Department of Housing and Urban Development, “ HUD 2015 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations ,” October 27, 2015.
• 15 John S. Rozel and Edward P. Mulvey, “ The Link between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice ,” Annual Review of Clinical Psychology 13 (2017): 445–469.
• 16 Jennifer Bronson and Marcus Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011–12 (Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2017).
• 17 Gerald N. Grob, “ The Paradox of Deinstitutionalization ,” Society 32 (5) (1995): 51–59. For a more recent review and commentary, see Andrew Scull, “ ‘Community Care’: Historical Perspective on Deinstitutionalization ,” Perspectives in Biology and Medicine 64 (1) (2021): 70–81.
• 18 Erving Goffman, Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961). The book comprises four free-standing essays that are considered classics in twentieth-century sociology: “On the Characteristics of Total Institutions,” “The Moral Career of the Mental Patient,” “The Underlife of a Public Institution,” and “The Medical Model and Mental Hospitalization.”
• 19 Paul Appelbaum, Almost a Revolution: Mental Health Law and the Limits of Change (Oxford: Oxford University Press, 1994). See also W. Lawrence Fitch and Jeffrey W. Swanson, who write, “Allowing people to ‘rot with their rights on,’ as Paul Appelbaum and Thomas Gutheil once put it (echoing Darryl Treffert, in his 1973 letter), is inhumane—assuming, of course, that the treatments occasioned by commitment, even if provided over objection, are effective and can prevent or mitigate such suffering.” W. Lawrence Fitch and Jeffrey W. Swanson, Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice (Rockville, Md.: Substance Abuse and Mental Health Services Administration, Office of the Chief Medical Officer, 2019), 26. See also Paul S. Appelbaum and Thomas G. Gutheil, “ ‘Rotting with Their Rights On’: Constitutional Theory and Clinical Reality in Drug Refusal by Psychiatric Patients ,” Journal of the American Academy of Psychiatry and the Law 7 (3) (1979): 306–315; and Darold A. Treffert “ Dying with Their Rights On ,” American Journal of Psychiatry 130 (9) (1974): 1041.
• 20 David Mechanic and David A. Rochefort, “ Deinstitutionalization: An Appraisal of Reform ,” Annual Review of Sociology 16 (1990): 301–327.
• 21 Meghan P. Carter, “ How Evictions from Subsidized Housing Routinely Violate the Rights of Persons with Mental Illness ,” Northwestern Journal of Law & Social Policy 5 (1) (2010): 118–148.
• 22 See Risdon N. Slate, “ Deinstitutionalization, Criminalization of Mental Illness, and the Principle of Therapeutic Jurisprudence ,” Southern California Interdisciplinary Law Journal 26 (2) (2017): 341–356.
• 23 Mary Kekatos, “ As Gov. Abbott Places Shooting Blame on Mental Health, What Has Texas Done to Address It? ” ABC News, May 27, 2022.
• 24 Jeffrey W. Swanson, Elizabeth E. McGinty, Seena Fazel, and Vickie M. Mays, “ Mental Illness and Reduction of Gun Violence and Suicide: Bringing Epidemiologic Research to Policy ,” Annals of Epidemiology 25 (5) (2015): 366–376.
• 25 Emily P. Terlizzi and Tina Norris, “ Mental Health Treatment among Adults: United States 2020 ,” NCHS Data Brief 419 (Hyattsville, Md: National Center for Health Statistics, 2021).
• 26 District of Columbia v. Heller , 128 S. Ct. 2783, 554 U.S. 570, 171 L. Ed. 2d 637, 2008. The Heller decision doctrine was extended to the states in McDonald v. City of Chicago , 561 U.S. 3025, 130 S. Ct. 3020, 177 L. Ed. 2nd 894, 2010. See also Kim Parker, Juliana Menasce Horowitz, Ruth Igielnik, et al., “ America’s Complex Relationship with Guns: An In-Depth Look at the Attitudes and Experiences of U.S. Adults ,” Pew Research Center, June 22, 2017.
• 27 Gun Control Act of 1968, Pub. L. No. 90-618, 82 Stat. 1213-2, 18 U.S. Code § 922 (g)(4).
• 28 World Population Review, “ Gun Deaths by Country, 2021 ” (accessed September 15, 2021).
• 29 Jeffrey W. Swanson, “ The Color of Risk Protection Orders: Gun Violence, Gun Laws, and Racial Justice ,” Injury Epidemiology 7 (1) (2020): 1–6.
• 30 Centers for Disease Control and Prevention, “ WISQARS : Web-based Injury Statistics Query and Reporting System”; and Jeffrey W. Swanson, Colleen L. Barry, and Marvin S. Swartz, “ Gun Violence Prevention and Mental Health Policy ,” in The Palgrave Handbook of American Mental Health Policy , ed. Howard H. Goldman, Richard G. Frank, and Joseph P. Morrissey (London: Palgrave Macmillan, 2020), 510–542.
• 31 District of Columbia, et al. v. Dick Anthony Heller , 554 U.S. 570, 171 L. Ed. 2d 637, 2008.
• 32 New York State Rifle & Pistol Association, Inc., et al., v. Kevin P. Bruen, in his Official Capacity as Superintendent of New York State Police, et al. , 597 U.S. ___, 213 L. Ed. 2d 387, 2022. See also Ali Rosenblatt, “ Proper Cause for Concern: New York Rifle & Pistol Association v. Bruen ,” Duke Journal of Constitutional Law and Public Policy 17 (1) (2022): 239.
• 33 New York State Rifle & Pistol Association, Inc., et al., Petitioners, v. Kevin P. Bruen, in his Official Capacity as Superintendent of New York State Police, et al .
• 34 Maegan Vazquez, “ Trump Suggests Opening More Mental Institutions to Deal with Mass Shootings ,” CNN , August 15, 2019.
• 35 Jason Noble, “ Mental Health Care, Not Gun Regulation, Is Key to Ending Mass Shootings, Joni Ernst Says ,” Des Moines Register , February 15, 2018.
• 36 Jolie McCullough and Alain Stephens, “ Greg Abbott Invoked Mental Illness after the El Paso Shooting. There’s Been No Indication that Was a Factor ,” The Texas Tribune , August 8, 2019.
• 37 Ann Coulter, “ Guns Don’t Kill People, the Mentally Ill Do ,” January 16, 2013.
• 38 Swanson, Barry, and Swartz, “Gun Violence Prevention and Mental Health Policy.”
• 39 Jeffrey W. Swanson, Nancy A. Sampson, Maria V. Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders: Results from the National Comorbidity Survey Replication ( NCS - R ),” Behavioral Sciences and the Law 33 (2–3) (2015): 199–212,.
• 40 Jaclyn Schildkraut, Rebecca G. Cowan, and Tessa M. Mosher, “ The Parkland Mass Shooting and the Path to Intended Violence: A Case Study of Missed Opportunities and Avenues for Future Prevention ,” Homicide Studies (2022).
• 41 Alan R. Felthous and Jeffrey Swanson, “ Prohibition of Persons with Mental Illness from Gun Ownership under Tyler ,” The Journal of the American Academy of Psychiatry and the Law 45 (4) (2017): 478–484.
• 42 Sheila Dewan, “ What Are the Real Warning Signs of a Mass Shooting? ” The New York Times , August 23, 2022.
• 43 Ibid.; and Swanson, Sampson, Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders.”
• 44 Jeffrey W. Swanson, Richard A. Van Dorn, John Monahan, and Marvin S. Swartz, “ Violence and Leveraged Community Treatment for Persons with Mental Disorder ,” American Journal of Psychiatry 163 (8) (2006): 1404–1411.
• 45 Ginny Brunton, James Thomas, Alison O’Mara-Eves, et al., “ Narratives of Community Engagement: A Systematic Review-Derived Conceptual Framework for Public Health Interventions ,” BMC Public Health 17 (2017): 944.
• 46 Jeffrey W. Swanson, Michael A. Norko, Hsiu-Ju Lin, et al., “ Implementation and Effectiveness of Connecticut’s Risk-Based Gun Removal Law: Does It Prevent Suicides? ” Law and Contemporary Problems 80 (2) (2017): 101–128; Jeffrey W. Swanson, Michele M. Easter, Kelly Alanis-Hirsch, et al., “ Criminal Justice and Suicide Outcomes with Indiana’s Risk-Based Gun Seizure Law, ”  Journal of the American Academy of Psychiatry and Law 47 (2) (2019): 188–197; Jeffrey W. Swanson, “ Understanding the Research on Extreme Risk Protection Orders: Varying Results, Same Message ,” Psychiatric Services 70 (10) (2019): 953–954; and April M. Zeoli, Shannon Frattaroli, Leslie Barnard, et al., “ Extreme Risk Protection Orders in Response to Threats of Multiple Victim/Mass Shooting in Six U.S. States: A Descriptive Study ,” Preventive Medicine 165 (2022): 107304.
• 47 Kerry L. Knox, Steven Pflanz, Gerald W. Talcott, et al., “ The U.S. Air Force Suicide Prevention Program: Implications for Public Health Policy ,” American Journal of Public Health 100 (12) (2010): 2457–2463.
• 48 Bernice A. Pescosolido, Jack K. Martin, J. Scott Long, et al., “ ‘A Disease Like Any Other’? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence, ” American Journal of Psychiatry 167 (11) (2010): 1321e30; and Bernica A. Pescosolido, John Monahan, Bruce G. Link, et al., “ The Public’s View of the Competence, Dangerousness, and Need for Legal Coercion of Persons with Mental Health Problems ,” American Journal of Public Health 89 (9) 1999: 1339–1345.
• 49 Brian Dawson, “ It Was Really a Love Story: How an NRA Ally Became a Gun Control Advocate ,” The New York Times , June 22, 2022.
• 50 Centers for Disease Control and Prevention, “ Fatal Injury Reports 1981–2018: Web-based Injury Statistics Query and Reporting System ( WISQARS ), ” last modified: August 28, 2023.
• 51 Jeffrey W. Swanson “ Preventing Suicide through Better Firearm Safety Policy in the United States ,” Psychiatric Services 72 (2) (2021): 174–179.
• 52 Lay San Too, Matthew J. Spittal, Lyndal Bugeja, et al., “ The Association between Mental Disorders and Suicide: A Systematic Review and Meta-Analysis of Record Linkage Studies ,” Journal of Affective Disorders 259 (2019): 302–313; and Frances L. Lynch, Edward L. Peterson, Christine Y. Lu, et al., “ Substance Use Disorders and Risk of Suicide in a General U.S. Population: A Case Control Study ,” Addiction Science & Clinical Practice 15 (2020): 14.
• 53 Stephanie Brooks Holliday, The Relationship Between Mental Health Care Access and Suicide (Santa Monica, Calif.: RAND Corporation, 2018).
• 54 Khalid Saad Al-Harbi, “ Treatment-Resistant Depression: Therapeutic Trends, Challenges, and Future Directions ,” Patient Preference and Adherence 6 (2012): 369–388.
• 55 Daniel Thomas Chung, Christopher James Ryan, Dusan Hadzi-Pavlovic, et al., “ Suicide Rates after Discharge from Psychiatric Facilities: A Systematic Review and Meta-Analysis ,” JAMA Psychiatry 74 (7) (2017): 694–702.
• 56 Allison E. Bond, Shelby L. Bandel, Taylor R. Rodriguez, et al., “ Mental Health Treatment Seeking and History of Suicidal Thoughts Among Suicide Decedents by Mechanism, 2003–2018 ,” JAMA Network Open 5 (3) (2022): e222101.
• 57 Zhuoyang Li, Andrew Page, Graham Martin, and Richard Taylor, “ Attributable Risk of Psychiatric and Socio-Economic Factors for Suicide from Individual-Level, Population-Based Studies: A Systematic Review ,” Social Science & Medicine 72 (4) (2011): 608–616.
• 58 Jeffrey W. Swanson, Richard J. Bonnie, and Paul S. Appelbaum, “ Getting Serious about Reducing Suicide: More ‘How’ and Less ‘Why,’ ” JAMA 314 (21) (2015): 2229–2230.
• 59 Matthew Miller, Deborah Azrael, and Catherine Barber, “ Suicide Mortality in the United States: The Importance of Attending to Method in Understanding Population-Level Disparities in the Burden of Suicide ,” Annual Review of Public Health 33 (2012): 393–408.
• 60 Paul R. Albert, “ Why Is Depression More Prevalent in Women? ” Journal of Psychiatry and Neuroscience 40 (4) (2015): 219–221.
• 61 Jeffrey W. Swanson, “ Introduction: Violence and Mental Illness ,” Harvard Review of Psychiatry 29 (1) (2021): 1–5.
• 62 Jonathan M. Metzl, Jennifer Piemonte, and Tara McKay, “ Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence ,” Harvard Review of Psychiatry 29 (1) (2021): 81–89. See also Mass Violence in America: Causes, Impacts and Solutions , ed. Joe Parks, Donald Bechtold, Frank Shelp, et al. (Washington, D.C.: National Council for Mental Well-Being, 2019); and Jennifer Skeem and Edward Mulvey, “ What Role Does Serious Mental Illness Play in Mass Shootings, and How Should We Address It? ” Criminology & Public Policy 19 (1) (2020): 85–108.
• 63 Jeffrey W. Swanson, “Mental Disorder, Substance Abuse, and Community Violence: An Epidemiological Approach,” in Violence and Mental Disorder: Developments in Risk Assessment , ed. John Monahan and Henry J. Steadman (Chicago: University of Chicago Press, 1994), 101–136. See also Jeffrey W. Swanson, Charles E. Holzer III , Vijay K. Ganju, et al., “ Violence and Psychiatric Disorder in the Community: Evidence from the Epidemiologic Catchment Area Surveys ,” Hospital and Community Psychiatry 41 (7) (1990): 761–770.
• 64 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition (Washington, D.C.: American Psychiatric Association, 1980).
• 65 Simon Davis, “ Violence by Psychiatric Inpatients: A Review ,” Psychiatric Services 42 (6) (1991): 585–590; and Bronson and Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011–12 .
• 66 Swanson, “Mental Disorder, Substance Abuse, and Community Violence.”
• 67 Eric B. Elbogen and Sally C. Johnson, “ The Intricate Link between Violence and Mental Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions ,” Archives of General Psychiatry 66 (2) (2009): 152–161.
• 68 Jeffrey W. Swanson, Guangyu Tong, Michelle M. Easter, et al., “ Gun Violence among Young Adults with a Juvenile Crime Record in North Carolina: Implications for Firearm Restrictions Based on Age and Risk ,” Preventive Medicine 165 (2022).
• 69 Emily E. McGinty, Shannon Frattaroli, Paul S. Appelbaum, et al., “ Using Research Evidence to Reframe the Policy Debate around Mental Illness and Guns: Process and Recommendations ,” American Journal of Public Health 104 (11) (2014): e22–e26.
• 70 Felthous and Swanson, “Prohibition of Persons with Mental Illness from Gun Ownership under Tyler.”
• 71 Jeffrey W. Swanson, Allison Gilbert Robertson, Linda K. Frisman, et al., “Preventing Gun Violence Involving People with Serious Mental Illness,” in Reducing Gun Violence in America: Informing Policy with Evidence and Analysis , ed. Daniel W. Webster and Jon S. Vernick (Baltimore: Johns Hopkins University Press, 2013), 33–51.
• 72 Swanson, Sampson, Petukhova, et al., “Guns, Impulsive Angry Behavior, and Mental Disorders.”
• 73 Leslie C. Hedman, John Petrila, William H. Fisher, et al., “ State Laws on Emergency Holds for Mental Health Stabilization ,” Psychiatric Services 67 (5) (2016): 529–535; and Paul S. Appelbaum and Jeffrey W. Swanson, “ Law & Psychiatry: Gun Laws and Mental Illness: How Sensible Are the Current Restrictions? ” Psychiatric Services 61 (7) (2010): 652–654.
• 74 Mark Rosenberg, “ Considerations for Developing an Agenda for Gun Violence Prevention Research ,” Annual Review of Public Health 42 (2021): 23–41; and Jeffrey Swanson and John Rozel, “ Doctors and Hospitals Can Help Prevent Gun Deaths. Here’s How ,” American Association of Medical Colleges, March 29, 2023.
• 75 Katherine M. Keyes, Ava Hamilton, Jeffrey Swanson, et al., “ Simulating the Suicide Prevention Effects of Firearms Restrictions Based on Psychiatric Hospitalization and Treatment Records: Social Benefits and Unintended Adverse Consequences ,” American Journal of Public Health 109 ( S 3) (2019): S 236– S 243.
• 76 See Paul Appelbaum, Lanny Berman, Renee Binder, et al., Guns, Public Health, and Mental Illness: An Evidence-Based Approach for State Policy (Washington, D.C.: Educational Fund to Stop Gun Violence, 2013).
• 77 Howard J. Shaffer, Sarah E. Nelson, Debi A. LaPlante, et al., “ The Epidemiology of Psychiatric Disorders among Repeat DUI Offenders Accepting a Treatment-Sentencing Option ,” Journal of Consulting and Clinical Psychology 75 (5) (2007): 795–804.
• 78 Appelbaum, Berman, Binder, et al., Guns, Public Health, and Mental Illness .
• 79 Giffords Law Center to Prevent Gun Violence, “ Extreme Risk Protection Orders ” (accessed September 20, 2023).
• 80 Frederick E. Vars, “Self-Defense against Gun Suicide,” Boston College Law Review 56 (4) (2015): 1465–1499.
• 81 Ian Ayres and Frederick E. Vars, “Libertarian Gun Control,” University of Pennsylvania Law Review 167 (2019): 921–974.
• 82 Jeffrey W. Swanson, Marvin S. Swartz, Susan M. Essock, et al., “ The Social-Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness ,” American Journal of Public Health 92 (9) (2001): 1523–1531.
• 83 Centers for Disease Control and Prevention, “ Prevention Strategies ,” last modified June 8, 2022.
• 84 Garret Hardin, “ The Tragedy of the Commons ,” Science 162 (3859) (1968): 1243–1248.
• 85 Alexandra Spiliakos, “ Tragedy of the Commons: What It Is and 5 Examples ,” Harvard Business School Online’s Business Insights Blog, February 6, 2019.
• 86 Daniel Semenza, “ More Guns, More Death: The Fundamental Fact that Supports a Comprehensive Approach to Reducing Gun Violence in America ,” State University of New York Rockefeller Institute of Government, June 21, 2022.
• 87 Emma E. McGinty, Howard H. Goldman, Bernice A. Pescosolido, and Colleen L. Barry, “ Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services ,” Journal of Health Politics, Policy and Law 43 (2) (2018): 185–228.
• 88 Knox, Pflanz, Talcott, et al., “The U.S. Air Force Suicide Prevention Program.”

• Open access
• Published: 15 July 2016

Taking action on violence through research, policy, and practice

• Ilene Hyman   ORCID: orcid.org/0000-0001-5097-3773 1 ,
• Mandana Vahabi 2 , 3 , 4 , 5 ,
• Annette Bailey 6 , 7 ,
• Sejal Patel 8 , 9 ,
• Sepali Guruge 10 , 11 , 12 , 13 , 14 ,
• Karline Wilson-Mitchell 15 , 16 &
• Josephine Pui-Hing Wong 17 , 18 , 19  

Global Health Research and Policy volume  1 , Article number:  6 ( 2016 ) Cite this article

7915 Accesses

8 Citations

4 Altmetric

Metrics details

Violence is a critical public health problem associated with compromised health and social suffering that are preventable. The Centre for Global Health and Health Equity organized a forum in 2014 to identify: (1) priority issues related to violence affecting different population groups in Canada, and (2) strategies to take action on priority issues to reduce violence-related health inequities in Canada. In this paper, we present findings from the roundtable discussions held at the Forum, offer insights on the socio-political implications of these findings, and provide recommendations for action to reduce violence through research, policy and practice.

Over 60 academic researchers, health and social service agency staff, community advocates and graduate students attended the daylong Forum, which included presentations on structural violence, community violence, gender-based violence, and violence against marginalized groups. Detailed notes taken at the roundtables were analyzed by the first author using a thematic analysis technique.

The thematic analysis identified four thematic areas: 1) structural violence perpetuates interpersonal violence - the historical, social, political and economic marginalization that contributes to personal and community violence. 2) social norms of gender-based violence—the role of dominant social norms in perpetuating the practice of violence, especially towards women, children and older adults; 3) violence prevention and mitigation programs—the need for policy and programming to address violence at the individual/interpersonal, community, and societal levels; and 4) research gaps—the need for comprehensive research evidence made up of systematic reviews, community-based intervention and evaluation of implementation research to identify effective programming to address violence.

Conclusions

The proceedings from the Global Health and Health Equity Forum underscored the importance of recognizing violence as a public health issue that requires immediate and meaningful communal and structural investment to break its historic cycles. Based on our thematic analysis and literature review, four recommendations are offered: (1) Support and adopt policies to prevent or reduce structural violence; (2) Adopt multi-pronged strategies to transform dominant social norms associated with violence; (3) Establish standards and ensure adequate funding for violence prevention programs and services; and (4) Fund higher level ecological research on violence prevention and mitigation.

Violence is a critical public health problem associated with compromised health and social suffering that are preventable. It is also a complex phenomenon that involves a spectrum of behavioral and social interactions that vary across the lifespan and different social, political and economic contexts. The 2014 World Health Organization (WHO) Global Status Report on Violence Prevention indicates that the overall rate for victims of homicide worldwide in 2012 was 6.7 per 100,000 population [ 47 ]. While fatal violence is alarming to society and traumatic to the victims’ families and loved ones, it constitutes a small portion of interpersonal violence. Non-fatal physical, sexual and psychological violence make up the majority of interpersonal violence and these particularly affect children, women and seniors. For instance, an estimated 30 % of adult women worldwide experienced physical and/or sexual violence by an intimate partner (IPV) at some point in their lives [ 46 ], 22.6 % experienced physical abuse, and 36.3 % experienced emotional abuse as a child [ 33 ]. Data also show that 6 % of older adults reported significant abuse in the past month [ 8 ]. Furthermore, incidents of non-fatal violence are often under-reported, thus, actual rates are much higher.

In 2014, only few of the 133 countries surveyed by the WHO implemented prevention programs at a level commensurate with the scale and severity of the problem [ 47 ]. Canada fell short in elder abuse prevention, victim law reforms, and initiatives to promote gender equity [ 47 ]. The WHO [ 47 ] recommended that effective and sustainable global violence prevention efforts must be comprehensive and tackle a wide range of social conditions and structural determinants that fuel violence; that is, economic marginalization, ageism and gender inequality. The WHO’s recommendations imply that the notion of violence must be understood beyond interpersonal violence to make visible the impact of structural violence .

Structural violence, a term first coined by Johan Galtung [ 19 ], is defined as the difference between the potential and actual physical, mental, social and spiritual wellbeing of persons affected. Galtung asserted that interpersonal violence can only be understood in the context of structural violence, which is systemic in nature and often remains invisible. Expanding on Galtung’s work, Paul Farmer [ 17 ] illustrated that inequitable distribution of power and resources across different groups in society produces differential life chances that shape their everyday lived experiences. Wong [ 40 ] considers structural violence as a system of interlocking oppressions manifested in the form of social and economic deprivation, limiting marginalized people’s ability to reach their full physical, emotional, cultural and spiritual potential. She also emphasized that structural violence is an avoidable cause of health disparities that can be addressed through research, policy and practice.

The use of structural violence as an analytical lens to understand health disparities is aligned with evidence generated by research on social determinants of health in a neoliberal advanced capitalist globalized economy (see [ 4 , 10 ]). As in other advanced capitalist countries, the 1970s marked a turning point in Canada from a post-war Keynesian Welfare state that focused on redistributive justice policies, to a free-market neoliberal state that emphasizes competitive individualism and consumption as a source of identity and means for social participation [ 9 ]. It is important to note that neoliberalism did not translate into total withdrawal of the state. Rather, neoliberalism has transformed state intervention from redistributive justice of social welfare for the poor to redistribution of wealth from the ordinary people to the elite; for example, in the form of bailouts or corporate welfare [ 1 ]. In Canada, neoliberal public policies and practices resulted in reduced access to welfare and the social security system. Examples include, welfare-to-work programs that required education and employment participation in order to receive benefits: deregulation of the market, privatization of public services, restructuring of the Unemployment Insurance program to what is now known as Employment Insurance: and the replacement of the Canadian Assistance Plan by the Canada Health and Social Transfer [ 3 ]. To a large extent, neoliberal practice perpetuates structural violence against vulnerable groups. For instance, neoliberal discourse of individual responsibility further marginalizes women who are welfare recipients when they are constructed as the cause of government fiscal deficits [ 6 ], or portrayed in the media and our popular imagination as lazy and undeserving freeloaders. Structural violence embedded in public policy and social institutions is invisible and yet powerful in perpetuating interpersonal violence, which is deemed to be private, random, and individual events. The interlocking cycle of structural and interpersonal violence disempowers individuals and communities, particularly those marginalized at the intersections of gender, race and class [ 5 ], and reinforces health disparities [ 16 , 39 ].

Ryerson University’ Centre for Global Health and Health Equity, in dialogue with external research networks, organized and implemented a forum to explore issues relating to violence. The objectives of the Forum were to identify: (1) priority issues related to violence affecting different population groups in Canada, and (2) strategies to take action on priority issues to reduce violence-related health inequities in Canada. In this paper, we present findings from discussion and dialogue at the Forum, offer insights on the socio-political implications of these findings, and provide recommendations for action to reduce violence through research, policy and practice.

Description of the forum and methods

The Global Health and Equity Forum was held in Toronto, Canada in 2014. Invitations were sent to hospitals, community health centres, non-profit community organizations working with vulnerable groups, universities, and public health units in the Greater Toronto Area. Over 60 researchers, health and social service agency staff, community advocates and graduate students attended the daylong Forum, which included presentations on structural violence, community violence, gender-based violence, and violence against marginalized groups. The presentations were followed by five concurrent roundtable discussions. Participants were invited to join one of five roundtables that interested them: children, youth, women, men and older adults. Each roundtable was attended by 10-12 participants; it was facilitated by a member of Centre for Global Health and Health Equity team and the discussion lasted approximately an hour. Being more participant-driven than researcher-driven, the Roundtable were considered to be an effective strategy for promoting critical dialogues. The composition of each Roundtable is presented in Table  1 .

Roundtable participants were asked to discuss priority issues related to violence based on their current professional experience and observations, and identify strategies for addressing these violence-related priorities and resulting health inequities. A graduate student or member of Centre for Global Health and Health Equity team was assigned to each roundtable as the note-taker to capture the composition of each roundtable group, and notes on the discussion. Notes from the roundtables were circulated to the facilitator of each roundtable for review and to insert additional reflective comments. Upon receiving all the reviewed notes, the first author used thematic analysis as the method to identify and organize findings into relevant themes and categories [ 34 ]. These themes were shared and discussed with the research team members who facilitated the roundtables to reach analytical consensus that inform this paper.

Findings from the forum

Through thematic analysis, we identified four priority areas from the participants’ discussions:

structural violence perpetuates interpersonal violence

social norms of gender-based violence

violence prevention and mitigation programs; and

research gaps.

Structural violence perpetuates interpersonal violence

The notion of structural violence was used by Forum participants to describe the historical, social and economic marginalization that contributes to interpersonal and community violence. Participants in many of the roundtable groups provided examples of factors related to structural violence, including poverty, gender inequity, transphobia, homophobia, racism, and other forms of discrimination and social exclusion. For instance, participants at the Women’s Roundtable identified the association between interpersonal violence and systemic discrimination. They suggested that underlying social inequities in the forms of women’s economic and legal dependency on men, economic and educational exclusion, and neoliberal practice which limits access and opportunities, all contribute indirectly to violence against women. As one participant explained, “People will deny that patriarchal values are still an issue today. We must shed light on the root causes; the sociological values that are embedded into our society and behavior (direct quote captured by note-taker).” Similarly, participants at the Men’s Roundtable highlighted men’s differential access to privilege and power when compared to women and children. However, participants also highlighted that in Canada and other White settler societies, not all men share similar access to privilege and power. Men of marginalized social positions experience structural violence in the form of neocolonialism, racism, homophobia, transphobia, ableism, economic marginalization and other intersecting oppressions that compromise their health and social wellbeing. At the Older Adult’s Roundtable, participants raised concerns about immigration policies, particularly with respect to sponsorship, which combine with racism, classism and ageism, to foster power imbalance and dependency in immigrant families. Participants at the Children and Youth Roundtable recommended that it is important for all people, but especially parents and families, to become aware of the impacts of structural violence on access to safe living environments, education, and aspiration for children and youth.

An overarching theme that emerged across all roundtables was the importance of addressing violence at the level of public policy. Participants identified the need to target policy makers and government leaders to raise awareness of the impact of structural violence in the forms of policies and laws, and to push for commitment of resources to address the structural forms of violence (e.g., poverty, racism, sexism) because education alone is not sufficient to reduce violence-related inequities. Many participants identified the lack of intersectoral approaches (i.e., involving health, employment, social, educational, housing and criminal justice sectors) that require commitment and coordinated efforts across different levels of government and different ministries or departments. For example, effective strategies to reduce youth related violence must include increasing access to inclusive employment and educational opportunities for youth and providing financial and social supports for parents to help reduce the risks that are associated with violence and inequitable outcomes. Participants also suggested that decision-makers and administrators of institutions (e.g., hospitals, police, group homes, and the child welfare system) must examine how structural violence is produced and sustained through their organizational policies and practices that act as barriers to disempower individuals and communities. For example, racial profiling or the discriminatory practice by law enforcement officials to target individuals for suspicion of crime based on the individuals’ racialized background, ethnicity, religion or national origin is found to be common practice in Canada [ 7 , 35 ].

Social norms of gender-based violence

Participants across the different roundtables identified social norms as a powerful force behind interpersonal violence in different populations.

For example, at the Women’s Roundtable, participants noted that in Canada and elsewhere, there exists a culture of gender-based violence manifested in a culture of rape and victim blaming that is very challenging to shift. Women continue to be objectified in the media, which produces and reproduces stereotypes, reinforces power differentials and normalizes violence against women (VAW). As one participant stated, “Women in advertisements become objects. They lose their face and humanism, which is the first step towards making violence more acceptable (direct quote recorded by note-taker).” Women felt that gender-based violence is embedded in Canadian social norms that do not value the equitable participation of women in leadership capacities.

At the Men’s Roundtable, participants identified the need to engage men, especially marginalized men, to (re)define “what it means to be men”. They suggested that gendered norms often condone violence as an expected masculine role expectations and practice, which reinforce self-harm and violence against women and other men (e.g., violence in sports, dating violence, violence against gay men). Men who experience social and economic marginalization are often pushed into street economies that increased their involvement in violence.

Participants at the Youth Roundtable highlighted that children and youth are also expected to fit with gendered norms and role expectation. In addition, they suggested that children and youth often encounter an additional layer of social norms based on age. Forum participants reported, based on their professional experience, that societal norms and adult judgments (e.g., from parents, teachers, and community workers) often produce negative stereotypes about children and youth that are stigmatizing and disempowering; children and youth in marginalized communities bear the brunt of these stereotypes.

Many participants felt that shifting broader social norms and gendered expectations is a necessary prerequisite to the adoption of laws and policies to reduce structural violence and interpersonal violence. For example, social norms for gender-based interactions are taken up by children as they observe adults’ involvement and responses to violence. Furthermore, participants identified the need to deconstruct the neoliberal agenda and practice in which violence is constructed as individual behaviors, and freedom from violence is achieved through individual vigilance and efforts. They emphasized the need to make visible that interpersonal violence is produced through power relations and social structures, and the negative impact of intergenerational violence, as experienced by the Indigenous peoples of Canada and elsewhere. These forms of violence, especially among Indigenous populations, must be addressed through deliberate efforts based on the principles of social justice and equity.

Violence prevention and mitigation programs

Forum participants noted that changing dominant social norms requires strategies of critical dialogue, stakeholder engagement, and political action at multiple levels: (1) at the societal level, there is a need to make visible how neoliberal practice, manifested in current regressive social welfare policies, reinforces structural violence that contributes to social and health inequities, including interpersonal violence; (2) at the community level, there is a need for sector leaders, service providers, activists and community members alike to recognize violence, in its myriad forms, as a priority for health and social wellbeing requiring collective action; and (3) at the individual and interpersonal level, there is a need for critical understanding of the (re)production of dominant social norms and gendered expectations that normalize violence behaviors.

Participants also spoke about the advantage of engaging broader and more diverse stakeholder groups - including the media, faith leaders, health and social service providers, researchers, policy-makers, community members (including older adults, women, men, children and youth), advocates - as agents of change in transforming social norms that perpetuate violence. Although Forum participants recognized that most victims of intimate partner violence are women and most abusers are men, they considered it necessary to engage men in politicized popular education strategies that interrogate the practice of violence against women in the historical, social, economic and political contexts. They also emphasized the importance of promoting critical community dialogue about hegemonic masculinities and the consistent use of gender equity messages by leaders and influential figures.

On a pragmatic note, Forum participants advocated for educational and skills development programs for the primary prevention of interpersonal violence. Examples provided by participants included school-based and community-based educational programming for children and youth that focus on gender relations and gender identities; family dynamics; healthy relationships; anger management, as well as supporting children and youth to develop skills in recognizing problematic behaviors associated with violence and abuse in the home environment, personal relationships, and beyond. Others identified training for health and social service providers as critical to improving consistency and comfort levels in the screening of individuals experiencing abuse and in providing inclusive and culturally safe care.

Participants at the Women’s Roundtable recommended educating young women and men on VAW help address the general belief among younger generation that the issue of VAW has been resolved or is no longer relevant. They also suggested that educational programs do not focus only on VAW. As one participant shared, “You can teach the makeup of a respectful relationship and educate about conflict resolution without even having to mention violence”.

Participants at the Men’s Roundtable recommended strategies and programming designed specifically for boys and men that focus on masculine identities, self-love, and mutually empowering relationships. They suggested the use of cross-sector partnerships that involve leaders and mentors from diverse sectors (e.g., arts, media, sports) to encourage boys and men in expressing their stress and negative emotions through non-threatening or non-harmful outlets such as martial arts and sports. They also emphasized the importance of providing safe gender-specific spaces for boys and men to critically deconstruct masculine expectations such as toughness, stoicism, and emotional disconnectedness as ways to promote their health and social wellbeing. At the same time, some participants identified mandatory community programs for male abusers as an important mitigating strategy to reduce VAW. It is recognized that the evidence to date to support this strategy is inconclusive.

Research gaps on violence

Forum participants identified numerous research gaps related to violence. They felt that there is a need for comprehensive evidence derived from: systematic reviews on violence; community-based research that capture different forms of violence at the grassroots level; community-based interventions that inform violence prevention practice; and evaluation research on multi-sectoral services for individuals experiencing violence. Participants also highlighted the importance of implementation research, which provide evidence-informed strategies for effective program adoption and adaptation to reduce violence.

There was consensus among participants on the need for research that identify and evaluate promising practices in violence prevention and mitigation. Furthermore, participants emphasized the need to translate this research evidence into products that are readily available and accessible to policy-makers and decision-makers in order to inform policy and practice. Some examples of comprehensive implementation evidences include: what works for different age-specific and gender-specific populations in different communities (e.g., neighbourhoods, ethno-specific, socio-economic); and how to create relevant and effective social marketing messages for different populations.

Forum participants recommended the use of community-based and participatory action research to explore the experiences of violence in diverse populations and to capture perspectives of service providers and other community stakeholders. They were also aware of the challenges and barriers in establishing meaningful and sustainable community-research partnerships due to the historical level of community distrust and the potential competing interests among the stakeholder groups, particularly in the current context of neoliberal practice that promotes individualistic competitiveness, and the diminishing resources for non-profit organizations.

The priority issues for Canada raised by the Forum participants were consistent with current global scholarship and practice in violence prevention and mitigation. The recognition of interpersonal violence as a manifestation of structural violence is critical in shifting the focus of blame from marginalized communities that have been further victimized by neoliberal practice holds government and institutions accountable for the inequitable distribution of power and resources that produces and reproduces violence in the first place. This is especially true in Indigenous communities where (neo)colonialism, resulting in imposed loss of land, languages and cultures, and intergenerational trauma, has and continues to pose devastating impact on indigenous people’s individual and collective health and wellbeing, as evidenced in the high rates of poverty, unemployment, substance use, low educational attainment, family violence, disproportionate burden of physical and mental illnesses, and premature deaths (Health [ 2 , 21 , 23 , 26 ]).

The second priority issue identified was consistent with existing evidences that demonstrate the strong association between dominant social norms and violent practices; for example, patriarchy and corporal punishment; gender inequities and normalized VAW; hegemonic masculinities and violence against gay men [ 24 , 31 , 37 ]. There is abundant empirical evidence to illustrate the perpetuating cycle of social norms and violence: values and beliefs that condone violence are shaped and reinforced by patriarchal ideologies; they, in turn, contribute to and perpetuate violent behaviours at the micro- (individual), meso- (community) and macro- (societal) levels and promote a greater tolerance of men’s violent behaviors [ 11 , 28 , 38 ]. Notions of male honor, male dominance, female subordination, female modesty and female chastity are exemplars of how patriarchal beliefs and fundamentalist religious doctrines intersect to perpetuate and sanction VAW [ 14 , 20 , 37 ]. Research evidence also suggests that children who witness violence or are victims of violence are more likely to adopt violent behaviors [ 27 ].

Most of the violence prevention and mitigation strategies identified by Forum participants are consistent with the evidence-based strategies recently endorsed by the WHO (2014) for the violence prevention and response efforts. These include: (1) developing safe, stable and nurturing relationships between children and their parents and caregivers [ 42 ]; (2) developing life skills and relationship skills in children and adolescents; for example, programs designed to help children and adolescents manage anger, resolve conflicts in a non-violent way and develop social problem-solving skills [ 43 ]; and comprehensive intimate partner violence (IPV) prevention interventions to reduce IPV perpetration and victimization among adolescents [ 12 ]; (3) promoting gender equality to prevent and reduce VAW [ 44 ]; (4) changing cultural and social norms that normalize and support violence [ 41 ]; and (5) victim identification, care and support programs [ 45 ].

One unique and important idea about violence prevention and mitigation proposed by the Forum participants was the engagement of intersectoral stakeholders that go beyond the conventional legal, health and social service sectors. Existing literature on intersectoral services for victims of violence tend to report on the effectiveness of the provision of legal, housing, financial and safety advice; and facilitation of access to and the use of community resources such as shelters, emergency housing, and psychological interventions [ 30 ]. Addressing the needs of victims with trauma-focused care, cognitive behavioral therapy or other low-intensity psychological interventions and mental health services can potentially mitigate the serious mental health outcomes of violence [ 15 , 29 ]. However, our Forum participants emphasized the importance of engaging stakeholders and leaders beyond the conventional sectors to include stakeholders and leaders from faith-based, arts, sports and media sectors to transform dominant social norms and support boys and men to engage in positive and healthy outlets of stress and emotions. Their suggestion is critical in that it promotes critical dialogue about violence prevention in the social space of boys’ and men’s everyday life. The involvement of respected community leaders is considered to be very effective in changing social norms [ 13 , 36 ].

Many international bodies, such as the WHO, International Confederation of Midwives, Pan-American Health Organization as well as provincial health agencies in Canada are increasingly looking at the role of healthcare providers in the provision of quality care defined in multidimensional terms such as respect, equity, access, patient centredness and effectivness. Quality also denotes care underpinned by respect for the human rights of women, children and marginalized groups (e.g., right to informed consent, right to refuse treatment, right to equal treatment, right to access healthcare, right to health, right to privacy, right to live) [ 18 , 32 ]. In the context of violence prevention and mitigation, quality care denotes care providers’ competence in screening their clients for actual and potential experience of violence, and provision of care that maximize their clients’ safety and wellbeing and minimize the risk and impact of trauma associated with violence. Quality care also includes contributions to violence prevention through research, advocacy, policy and practice.

Finally, the research gaps identified by the participants are consistent with the current landscape of research on violence, which reflects an imbalance of research that focuses more on violence at the individual and interpersonal level (e.g., personal history of violence, interpersonal violence with peers, intimate partners or family members) and less on violence at the community level, whereby relationships are embedded in social spaces such as schools, workplaces, and neighborhoods, or structural violence at the societal level in the forms of social norms, institutional practices and public polices [ 25 ]. In 1999, the WHO Violence Prevention Alliance adopted an ecological framework developed by Heise [ 22 ] to illustrate how the complex interplay of individual, relationship, social, cultural and environmental factors are associated with intimate partner violence [ 25 ]. Research that promotes a better understanding of how socio-ecological factors interact to perpetuate or reduce violence is a key step to developing effective public health approaches to address violence.

Limitations

While the organizing committee aimed to be inclusive in inviting individuals from diverse sectors, the Forum participants are not representative of all stakeholder groups. For example, there were fewer practitioners from law enforcement, education, and legal services, and fewer community members or public participants. Given the importance of community participation in, and community as the setting for violence prevention, the inclusion of the views of the public would have been informative and important. We relied on taking detailed notes to capture participants’ ideas and perspectives since audio-recording of these dialogues was not feasible in the context of a forum with many concurrent discussion taking place in the same room.

Conclusion and Recommendations

The proceedings from the Global Health and Health Equity Forum underscore the importance of recognizing violence as a public health issue that requires immediate and meaningful communal and structural investment to break its historic cycles. In order to do so, it is important to bring together community members, grassroots organizations, researchers, policy-makers, educators, students and cross-sector stakeholders to advance discussions about effective policy and programming for different forms of violence. Given the nature of structural and interpersonal violence, any significant and lasting change will require intersectoral efforts. This Forum is just one example of the continued efforts needed to solidify violence prevention policies, services, and practices. However, we recognize that effective and sustainable solutions must surpass forums of discussion to actualize policies and regulations that can effectively transform oppressive social structures, address the gaps in violence prevention and mitigation, and reinstate societal responsibility for violence prevention.

Based on our thematic analysis of the information from the forum, the members of the Centre for Global Health and Equity at Ryerson offers the following recommendations:

Support and adopt policies to prevent and reduce structural violence.

Reducing social disparities through social policy reform is essential for both violence prevention and reduction. Social policy reforms must address the root cause of violence, that is, inequitable distribution of power and resources resulting in differential access to social and economic opportunities between the dominant groups and the marginalized groups. While these broad considerations must be central to social policies in general, understanding the specific needs of marginalized groups negatively impacted by racism, sexism, ageism, homophobia, transphobia, poverty and other oppressions is a priority. In recognition of violence as a structural issue, finding solutions requires a political and intersectoral approach (i.e., involving health, employment, social service, educational, housing and criminal justice sectors). For example, strategies to reduce youth related violence should include increasing employment and educational opportunities for youth and providing financial and social supports for parents to help reduce the risks that are associated with violence and inequitable outcomes. Similar actions are needed to inform and ensure that institutions (e.g., hospitals, police, group homes, and the child welfare system) review and revise their organizational policies and procedures to address structural violence that creates barriers to providing inclusive and respectful services to marginalized individuals and communities.

Adopt multi-pronged strategies to change dominant social norms associated with violence.

Since a multiplicity of external and internal pressures function to maintain dominant cultural and social norms, multi-pronged approaches that engage diverse stakeholders to influence community opinions, inform mass media messages and transform public policy or legislation must be used to address violence. Mass media campaigns can be used to convey messages about empowering relationships and social interactions to broad populations via television, radio, the Internet, newspapers, magazines and other social mediums. Legislation is an important strategy in changing cultural perceptions and social norms when violent behaviors are redefined as a criminal offence and the offenders have to face legal consequences. Political will and social accountability are also critical because the presence of legislation without the necessary infrastructure of public education, access to legal services, and person-centred services for victims of violence does not guarantee that the legislation will be carried out effectively.

Establish standards and ensure adequate funding for violence prevention program and services.

Comprehensive research evidence is needed to establish promising practices and reorient services to meet the individual and collective needs of affected groups and communities to reduce violence and its related impact. Community-based services must be strengthened through sustained government funding to promote community empowerment in the continuum of violence prevention and reduction programs. Adequate funding for coordinated and sustainable capacity building programming at the community level is critical to the establishment of effective responses to interpersonal and community violence and to reduce the loss of community capacity to address violence due to resource competition among stakeholder groups.

Fund higher-level ecological research on violence prevention.

The current research agenda, with its focus on violence at the personal or interpersonal level does not provide the necessary knowledge and evidence to inform policy development and change. Adequate resources are needed to support research that investigate the outcomes of upstream policies on violent prevention, the impact of intersectoral interventions to transform dominant social norms, and the effectiveness of population-specific interventions on primary violence prevention.

Aalbers MB. Neoliberalism is dead … long live neoliberalism. Int J Urban Regional Res. 2013;37(3):1083–90. doi: 10.1111/1468-2427.12065 .

Article   Google Scholar  

Adelson N. The embodiment of inequity: Health disparities in Aboriginal Canada. Can J Public Health. 2005;96(Supplement 2):S45–61.

PubMed   Google Scholar  

Bako O. Neoliberalism and its Effect on Women in Poverty. Lyceum. 2011;1(1):32–40.

Google Scholar  

Benatar SR, Gill S, Bakker I. Global health and the global economic crisis. Am J Public Health. 2011;101(4):646–53. doi: 10.2105/AJPH.2009.188458 .

Article   PubMed   PubMed Central   Google Scholar  

Beres MA, Crow B, Gotell L. The perils of institutionalization in neoliberal times: Results of a national survey of Canadian sexual assault and rape crisis centres. Canadian J Sociology. 2009;34(1):135–63.

Breitkreuz R. Engendering Citizenship? A Critical; Feminist Analysis of Canadian Welfare-to-Work Policies and the Employment Experiences of Lone Mothers. J Sociology Social Welfare. 2005;32(2):147–65.

Cole, D. (2015). The Skin I’m In: I’ve been interrogated by police more than 50 times—all because I’m black. Toronto Life, 49 (5). (Online advance version) Retrieved from http://torontolife.com/city/life/skin-im-ive-interrogated-police-50-times-im-black/ .

Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age Ageing. 2008;37(2):151–60.

Article   PubMed   Google Scholar  

Coulter K. Women, poverty policy, and the production of neoliberal politics in Ontario, Canada. J Women Politics Policy. 2009;30(1):23–45. doi: 10.1080/15544770802367788 .

Cushon JA, Muhajarine N, Labonte R. Lived experience of economic and political trends related to globalization. Can J Public Health. 2010;101(1):92.

Davis TL, Liddell DL. Getting inside the house: The effectiveness of rape prevention program for college fraternity men. J College Student Dev. 2002;43:35–50.

De Koker P, Mathews C, Zuch M, Bastien S, Mason-Jones AJ. A systematic review of interventions for preventing adolescent intimate partner violence. J Adolescent Health. 2014;54(1):3–13.

Dobash RE, Dobash RP. Women, violence and social change. London: Routledge; 2003.

Douki S, Nacef F, Belhadj A, Bouasker A, Ghachem R. Violence against women in Arab and Islamic countries. Archives Women Mental Health. 2003;6:165–71.

Article   CAS   Google Scholar  

Elliott DE, Bjelajac P, Fallot RD, Markoff LS, Reed BG. Trauma‐informed or trauma‐denied: principles and implementation of trauma‐informed services for women. J Community Psychol. 2005;33(4):461–77.

Fajnzylber P, Lederman D, Loayza N. “Inequality and violent crime”. J Law Economics. 2002;45(1):1–40.

Farmer P. Pathologies of power: rethinking health and human rights. Am J Public Health. 1999;89(10):1486–96.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Freedman LP, Kruk ME. Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. Lancet. 2014;384(9948):e42–4.

Galtung J. Violence, peace, and peace research. J Peace Res. 1969;6(3):167–91.

Gengler S, Lee JW. Catholic male priests, Protestant female ministers and Protestant male ministers. J Religion Abuse. 2003;3(3):41–52.

Canada H. A statistical profile on the health of First Nations in Canada: Determinants of health, 2006 to 2010. 2014. http://www.hc-sc.gc.ca/fniah-spnia/pubs/aborig-autoch/2010-stats-profil-determinants/index-eng.ph .

Heise LL. Violence against women: an integrated ecological framework. Violence Against Women. 1998;4:262–90.

Article   CAS   PubMed   Google Scholar  

Katz LY, Elias B, O’Neil J, Enns M, Cox BJ, Belik S-L, Sareen J. Aboriginal suicidal behaviour research: From risk factors to culturally-sensitive interventions. J Canadian Academy Child Adolescent Psychiatry. 2006;15(4):159–67. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2277304/?tool=pmcentrez .

Kitzman KM, Gaylord N, Holt A, Kenny E. Child witness to domestic violence: A meta-analytic review. J Consult Clin Psychol. 2003;71:339–52.

Krug EG, et al. World report on violence and health. Geneva: World Health Organization; 2002.

Lavallée LF, Fairney K. In search of identity: Supporting healing and well-being among youth. In: Menzies P, Lavallée LF, editors. Journey to healing: Aboriginal people with addiction and mental health issues. Toronto: CAMH Publications; 2014. p. 117–30.

Markowitz FE. Attitudes and family violence: Linking intergenerational and cultural theories. J Family Violence. 2001;16:205–18.

Murnen SK, Wright C, Kaluzny G. If “boys will be boys” then girls will be victims? A met-analytic review of research that relates masculine ideology of sexual aggression. Sex Roles. 2002;46:359–75.

Poole N. In: Greaves L, editor. Becoming trauma informed. Toronto: Centre for Addiction and Mental Health; 2012.

Ramsay J, Carter Y, Davidson L, Dunne D, Eldridge S, Hegarty K, Rivas C, Taft A, Warburton A, Feder G. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane Database Syst Rev. 2009;3:CD005043.

Salazar LF, Baker CK, Price AW, Carlin K. Moving beyond the individual: Examining the effects of domestic violence policies on social norms. Am J Community Psychol. 2003;32:253–64.

Shamian J. Interprofessional collaboration, the only way to Save Every Woman and Every Child. Lancet. 2014;384(9948):e41–2.

Stoltenborgh M, Bakermans-Kranenburg MJ, van Ijzendoorn MH. The neglect of child neglect: a meta-analytic review of the prevalence of neglect. Soc Psychiatry Psychiatr Epidemiol. 2013;48(3):345–55.

Strauss A, Corbin J. Basic of qualitative research: techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks: Sage Publication; 1998.

Tator C, Henry F. Racial Profiling in Canada: Challenging the Myth of“ a Few Bad Apples”. University of Toronto Press; 2006.

Valente TW, Pumpuang P. Identifying opinion leaders to promote behavior change. Health Educ Behav. 2007;34:881–96.

Vandello JA, Cohen D. Male honor and female fidelity: Implicit cultural scripts that perpetuate domestic violence. J Pers Soc Psychol. 2003;84:997–1010.

Wade J, Brittan-Powell C. Men’s attitudes toward race and gender equity: The importance of masculinity ideology: The importance of masculinity ideology, gender-related traits, and reference group identity dependence. Psychology Men Masculinity. 2001;2(1):42–50.

Wade RH. Is Globalization reducing poverty and inequality?”. World Dev. 2004;32(4):567–89.

Wong JP. Structural Violence & Men’s Health. Presentation to Global Health & Health Equity Forum. Ryerson University: Toronto; 2014.

World Health Organization. Violence prevention: the evidence. Preventing violence through the development of safe, stable and nurturing relationships between children and their parents or caregivers. Geneva: World Health Organization; 2009.

World Health Organization. Violence prevention: the evidence. Preventing violence by developing life skills in children and adolescents. Geneva: World Health Organization; 2009.

World Health Organization. Violence prevention: the evidence. Promoting gender equality to prevent violence against women. Geneva: World Health Organization; 2009.

World Health Organization. Violence prevention: the evidence. Changing social and cultural norms that support violence. Geneva: World Health Organization; 2009.

World Health Organization. Violence prevention: the evidence. Reducing violence through victim identification, care and support programmes. Geneva: World Health Organization; 2009.

World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. In: Department of Reproductive Health and Research, London School of Hygiene and Tropical Medicine, South African Medical Research Council. Geneva: World Health Organization; 2013.

World Health Organization. Global status report on violence prevention. 2014. Retrieved Feb 2015 from: http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/ .

Download references

Acknowledgements

The authors would like to acknowledge the significant contribution of all workshop participants, volunteers and presenters to the Forum.

Funding for the Forum was provided by Ryerson University.

Presentation and roundtable notes can be made available for review.

Authors’ contributions

All authors: Made substantial contributions to conception and design, or acquisition of data, analysis and interpretation of data; Were involved in drafting the manuscript or revising it critically for important intellectual content; Gave final approval of the version to be published. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.

Competing interests

The authors do not have financial and non-financial competing interests to declare.

Declarations

All workshop participants provided consent for the research team to use and publish their ideas and perspectives.

Author information

Authors and affiliations.

Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Ilene Hyman

Daphne Cockwell School of Nursing, Toronto, Canada

Mandana Vahabi

Centre for Global Health and Health Equity, Toronto, Canada

Diverse and At Risk Population, Toronto, Canada

Research Cluster, Ryerson University, Toronto, Canada

Annette Bailey

Centre for Global Health and Health Equity, Ryerson University, Toronto, Canada

Early Childhood Studies, Toronto, Canada

Sejal Patel

Urban Health, Daphne Cockwell School of Nursing, Toronto, Canada

Sepali Guruge

Nursing Centre for Research and Education on Violence Against Women and Children, Ryerson University, Toronto, Canada

College of New Scholars, Artists and Scientists, Royal Society of Canada, Toronto, Canada

Department of Health Sciences, The Open University of Sri Lanka, Toronto, Canada

Midwifery Education Program, Toronto, Canada

Karline Wilson-Mitchell

Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada

Josephine Pui-Hing Wong

Adjunct Professor, Dalla Lana School of Public Health, OHTN-CIHR New Investigator, Toronto, Canada

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Ilene Hyman .

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Hyman, I., Vahabi, M., Bailey, A. et al. Taking action on violence through research, policy, and practice. glob health res policy 1 , 6 (2016). https://doi.org/10.1186/s41256-016-0006-7

Download citation

Received : 19 February 2016

Accepted : 05 July 2016

Published : 15 July 2016

DOI : https://doi.org/10.1186/s41256-016-0006-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Structural violence
• Social policy
• Immigration
• Community services
• Neoliberalism

Global Health Research and Policy

ISSN: 2397-0642

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

Crime and Violence

Neighborhood and Built Environment

About This Literature Summary

This summary of the literature on Crime and Violence as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note, the terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Incarceration literature summary. 

Related Objectives (5)

Here's a snapshot of the objectives related to topics covered in this literature summary. Browse all objectives .

• Reduce the rate of minors and young adults committing violent crimes — AH‑10
• Reduce nonfatal physical assault injuries — IVP‑10
• Reduce firearm-related deaths — IVP‑13
• Reduce adolescent sexual violence by anyone — IVP‑17
• Reduce sexual or physical adolescent dating violence — IVP‑18

Related Evidence-Based Resources (4)

Here's a snapshot of the evidence-based resources related to topics covered in this literature summary. Browse all evidence-based resources .

• Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
• Suicide and Violence Prevention
• Resources for Action for Violence Prevention
• Violence Prevention: School-Based Programs

Literature Summary

Any person can be affected by crime and violence either by experiencing it directly or indirectly, such as witnessing violence or property crimes in their community or hearing about crime and violence from other residents. 1 While crime and violence can affect anyone, certain groups of people are more likely to be exposed. For example, the national homicide rate is consistently higher for Black adolescents and young adults than their White counterparts. 2 Low-income neighborhoods are more likely to be affected by crime and property crime than high-income neighborhoods. 3 Types of violence include, but are not limited to, child abuse and neglect, firearm violence, intimate partner violence, sexual violence, and elder abuse. 4 In addition to the potential for death, disability, and other injuries, people who survive violent crime endure physical pain and suffering and may also experience mental distress and reduced quality of life. 5 , 6 Specific examples of detrimental health effects from exposure to violence and crime include asthma, hypertension, cancer, stroke, and mental disorders. 7  

Individuals can experience different types of violence throughout the lifespan, and the negative health effects of violence can occur at any age. Decades of research has established a connection between adverse childhood experiences (ACEs) such as violence or abuse and lifelong health outcomes, including chronic disease and mental disorders. 8 Children can be exposed to violence such as bullying or cyberbullying, abuse, or witnessing violence in a variety of settings, including at home or school, online, or in their neighborhoods. 9 Children and adolescents exposed to violence are at risk for poor long-term behavioral and mental health outcomes, such as depression, anxiety, and post-traumatic stress disorder, regardless of whether they are victims, direct witnesses, or hear about the crime. 10 , 11 Research has also shown an association between exposure to violence in childhood and an increased likelihood of experiencing intimate partner violence as an adult. 12 , 13  

In adulthood, exposure to violence can also lead to poor health outcomes. For example, women exposed to intimate partner violence have an increased risk of physical health issues such as injuries and mental disorders such as disordered eating, depression, and suicidal ideation. 14 Older adults can also experience violence, including elder abuse or intimate partner violence. 15 Evidence shows that older adults who experience elder abuse are more likely to experience increased stress and depression or develop fear and anxiety than those who do not experience elder abuse. 16

There are serious short- and long-term health effects from exposure to crime and violence in one’s community. For example, one study found an association between gun-related violent crime in a neighborhood and a reduction in park use and park-based physical activity. 17 Higher rates of neighborhood safety fears may lead to poorer self-rated physical and mental health. 18 One study also found that higher rates of neighborhood crime were associated with increased odds for adverse pregnancy outcomes in Chicago. 19 Community gun violence, which generally occurs in public spaces between non-related individuals, is a specific kind of violence that disproportionately affects Black and Hispanic/Latino communities. 20 One study conducted in 4 U.S. cities found that people who were exposed to gun violence fatalities experienced higher levels of depression and suicidal ideation than those who were not exposed. 21

Addressing exposure to crime and violence as a public health issue may help prevent and reduce the harms to individual and community health and well-being. Public health strategies to address crime and violence focus on building resilience and reducing susceptibility, building healthy gender norms, developing healthy relationships, and creating protective environments. 7 The Community Preventive Services Task Force (CPSTF) recommends universal school-based programs that focus on skill-building related to emotional self-awareness and control, social problem-solving, and teamwork to reduce or prevent violent behavior among school-aged children. Besides schools, other places where violence interventions occur are hospitals. Hospital-based violence intervention programs that involve screening and intensive case management have been shown to be successful and cost-effective in reducing violent injury recidivism. 22 , 23 Much of the evidence on strategies to prevent and reduce crime and violence focus on children and adolescents. Additional research and interventions are needed to address crime and violence throughout the entire life course.

Hartinger-Saunders, R. M., Rine, C. M., Nochajski, T., & Wieczorek, W. (2012). Neighborhood crime and perception of safety as predictors of victimization and offending among youth: A call for macro-level prevention and intervention models. Children and Youth Services Review, 34 (9), 1966–1973.

Sheats, K. J., Irving, S. M., Mercy, J. A., Simon, T. R., Crosby, A. E., Ford, D. C., Merrick, M. T., Annor, F. B., & Morgan, R. E. (2018). Violence-related disparities experienced by black youth and young adults: Opportunities for prevention. American Journal of Preventive Medicine, 55 (4), 462–469. doi:  10.1016/j.amepre.2018.05.017

Kang, S. (2016). Inequality and crime revisited: Effects of local inequality and economic segregation on crime. Journal of Population Economics, 29 (2), 593–626. 

Centers for Disease Prevention and Control. (2021, September 28). Violence prevention . https://www.cdc.gov/violenceprevention/

Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. Lancet, 360 (9339), 1083–1088.

McCollister, K. E., French, M. T., & Fang, H. (2010). The cost of crime to society: New crime-specific estimates for policy and program evaluation. Drug and Alcohol Dependence, 108 (1–2), 98–109. doi: 10.1016/j.drugalcdep.2009.12.002

American Public Health Association. (2018, November 3). Violence is a public health issue: Public health is essential to understanding and treating violence in the U.S. https://apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/violence-is-a-public-health-issue

Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A., & Ford, D. C. (2017). Adverse childhood experiences and life opportunities: Shifting the narrative. Children and Youth Services Review, 72 , 141–149.

Moffitt, T. E., & Klaus-Grawe 2012 Think Tank. (2013). Childhood exposure to violence and lifelong health: Clinical intervention science and stress-biology research join forces. Development and Psychopathology, 25 (4 Pt 2):1619–1634. doi:  10.1017/S0954579413000801

Jones-Webb, R., & Wall, M. (2008). Neighborhood racial/ethnic concentration, social disadvantage, and homicide risk: An ecological analysis of 10 U.S. cities. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 85( 5), 662–676. doi:  10.1007/s11524-008-9302-y

Fowler, P. J., Tompsett, C. J., Braciszewski, J. M., Jacques-Tiura, A. J., & Baltes, B. B. (2009). Community violence: A meta-analysis on the effect of exposure and mental health outcomes of children and adolescents. Development and Psychopathology, 21 (1), 227–259. doi:  10.1017/S0954579409000145

Beyer, K., Wallis, A. B., & Hamberger, L. K. (2015). Neighborhood environment and intimate partner violence: A systematic review. Trauma, Violence & Abuse, 16 (1), 16–47. doi:  10.1177/1524838013515758

Raghavan, C., Mennerich, A., Sexton, E., & James, S. E. (2006). Community violence and its direct, indirect, and mediating effects on intimate partner violence. Violence Against Women, 12 (12), 1132–1149. doi:  10.1177/1077801206294115

Stockman, J. K., Hayashi, H., & Campbell, J. C. (2015). Intimate partner violence and its health impact on ethnic minority women. Journal of Women’s Health, 24 (1), 62-79.

Rosen, T., Makaroun, L. K., Conwell, Y., & Betz, M. (2019). Violence In older adults: Scope, impact, challenges, and strategies for prevention. Health Affairs (Project Hope), 38 (10), 1630–1637. doi:  10.1377/hlthaff.2019.00577

Yunus, R. M., Hairi, N. N., & Choo, W. Y. (2019). Consequences of elder abuse and neglect: A systematic review of observational studies. Trauma, Violence & Abuse, 20 (2), 197–213. doi:  10.1177/1524838017692798

Han, B., Cohen, D. A., Derose, K. P., Li, J., & Williamson, S. (2018). Violent crime and park use in low-income urban neighborhoods. American Journal of Preventive Medicine, 54 (3), 352–358. doi:  10.1016/j.amepre.2017.10.025

Meyer, O. L., Castro-Schilo, L., & Aguilar-Gaxiola, S. (2014). Determinants of mental health and self-rated health: A model of socioeconomic status, neighborhood safety, and physical activity. American Journal of Public Health, 104 (9), 1734–1741. doi:  10.2105/AJPH.2014.302003

Mayne, S. L., Pool, L. R., Grobman, W. A., & Kershaw, K. N. (2018). Associations of neighbourhood crime with adverse pregnancy outcomes among women in Chicago: Analysis of electronic health records from 2009 to 2013. Journal of Epidemiology and Community Health, 72 (3), 230–236. doi:  10.1136/jech-2017-209801

Centers for Disease Prevention and Control. (2021, May 4). Firearm violence prevention . https://www.cdc.gov/violenceprevention/firearms/fastfact.html

Smith, M. E., Sharpe, T. L., Richardson, J., Pahwa, R., Smith, D., & DeVylder, J. (2020). The impact of exposure to gun violence fatality on mental health outcomes in four urban U.S. settings. Social Science & Medicine (1982), 246 , 112587. doi:  10.1016/j.socscimed.2019.112587

Juillard, C., Cooperman, L., Allen, I., Pirracchio, R., Henderson, T., Marquez, R., Orellana, J., Texada, M., & Dicker, R. A. (2016). A decade of hospital-based violence intervention: Benefits and shortcomings. Journal of Trauma and Acute Care Surgery, 81 (6), 1156–1161. doi:  10.1097/TA.0000000000001261

Juillard, C., Smith, R., Anaya, N., Garcia, A., Kahn, J. G., & Dicker, R. A. (2015). Saving lives and saving money: Hospital-based violence intervention is cost-effective. Journal of Trauma and Acute Care Surgery, 78 (2), 252–258. doi:  10.1097/TA.0000000000000527

Back to top

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

You will be subject to the destination website's privacy policy when you follow the link.

Impact factor:  1.500

SOUTH AFRICAN MEDICAL ASSOCIATION

Events  |  Careers  | CPD

CURRENT ISSUE

Focus and scope

Editorial team

Submit an article

Receive notifications

• Announcements

ISSUES IN MEDICINE

Violence, violence prevention, and safety: A research agenda for South Africa

Catherine L Ward, Lillian Artz, Julie Berg, Floretta Boonzaier, Sarah Crawford-Browne, Andrew Dawes, Donald Foster, Richard Matzopoulos, Andrew Nicol, Jeremy Seekings, Arjan B (Sebastian) van As, Elrena van der Spuy

Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: ( i ) violence must be understood better to develop effective interventions; and ( ii ) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.

S Afr Med J 2012;102:215-218.

All the authors are associated with the Safety and Violence Initiative at the University of Cape Town, and Catherine Ward, Floretta Boonzaier, Andrew Dawes and Donald Foster also with the Department of Psychology; Lillian Artz with the Gender, Health and Justice Research Unit; Julie Berg and Elrena van der Spuy with the Centre of Criminology; Sarah Crawford-Browne with the Primary Health Care Directorate; Richard Matzopoulos with the School of Public Health and Family Medicine, and the Medical Research Council’s Burden of Diseases Research Unit; Andrew Nicol and Sebastian van As with the Department of Surgery; and Jeremy Seekings with the Centre for Social Science Research.

Corresponding author: C L Ward ([email protected])

Interpersonal violence is the leading cause of injury in South Africa, and the homicide rate is over seven times the global average. 1 Studies have identified risk factors 2 and effective interventions to prevent violence. 4 We suggest a research agenda that can support and extend this work, by attending to South Africa’s unique situation.

The ecological model, a standard in public health and violence prevention (Fig. 1), views individuals as nested within interactive systems. Individual characteristics influence risk and protective factors that may increase or decrease the risk of aggression and exposure to violence. Microsystems are where daily interactions shape their behaviour most closely; exosystems comprise contexts that affect the lives of families, their neighbourhoods, extended family systems, and services; and the macrosystem comprises more distal influences such as government policies, norms and ideologies, and the economy.

Individuals and violence

Individuals are considered from two perspectives: factors that affect ( i ) the likelihood of aggressive behaviour, and ( ii ) the likelihood of victimisation. In relation to the first, Moffitt suggests a typology of offending: life-course-persistent offenders and adolescence-limited offenders. 5 The former start young and continue for life; evidence suggests that neuropsychological deficits (acquired in utero and/or in early childhood) that affect functions such as self-regulation set them on this path, compounded by unsupportive, conflictual parenting. 5 The conduct of adolescence-limited offenders is restricted to that developmental period and declines as they mature into adult roles of work and marriage. 5

South Africa has high proportions of children exposed to risks for neurological damage in early life: the prevalence of fetal alcohol spectrum disorders is the highest in the world; 6 ,7 22.5% of children aged 1 - 9 years were stunted or wasted; 8 and we have high rates of domestic violence and child maltreatment. 9 ,10 These can all alter neurochemistry and result in aggression. 11 , 12 Such children may have learning disabilities 13 that if not identified or adequately addressed may cause them to disconnect from school and increase the possibility of delinquent behaviours. 14 Low-cost screening and cost-effective interventions are urgently needed.

A mechanism for reducing harm to others may be the development of a pro-social orientation termed ‘empathy-based guilt’ associated with harmful transgressions. 15 Children who learn to attend to the harm caused by an action and have a moral rationale for avoiding such harm are likely to internalise orientations to victims that reduce the probability of aggression. We found no studies of South African children’s capacity for empathy, or of factors that influence its development or its role in aggression. Studies to understand and determine suitable interventions to enhance empathy are urgently needed.

Many young South Africans experience complex transitions to employment and the formation of an independent household, and transition to the social status of adulthood may be extended or never completed. 16 The impact of delayed attainment of adulthood on aggression and violent crime, and thereby the larger effect of economic forces (e.g. availability of employment) on individual aggression, should be studied.

Whether violence can be reduced by reducing the vulnerability of potential victims (rather than reducing the aggression of potential perpetrators) should also be explored. Risk for victimisation in South Africa is shaped by context, age and gender: men are more likely to be victims of non-sexual violent crime than women; living in urban environments increases risk; 17 youth are at greater risk than adults; 9 and young black men are at the greatest risk of homicide. 3 Vulnerability is also increased by relative authority or control that the perpetrator has over the victim; low self-esteem or inability to see that victimisation is not warranted; 18 lack of personal support structures; mental illness or mental disability; 18 , 19 learning disabilities; 20 dependence on the perpetrator (material or emotional); exposure to violence as children and violence over a lifetime; 21 , 22 , 23 and substance misuse. 24 How can people with these vulnerabilities be protected and strengthened?

Microsystem contexts

Families in which parents have warm relationships with their children, provide consistent discipline without being harsh, and supervise adequately are less likely to have aggressive children. 25 Where high rates of child maltreatment occur, 10 improving parenting must be a priority. Since only about half of South African children live with both biological parents, and even fewer do so consistently through childhood and adolescence, 26 this must include all caregivers. Research must develop effective, culturally appropriate parenting interventions that are low in cost and easily available to those who most need them. There are some promising interventions from other contexts, but none has been evaluated here, 27 nor have local interventions been evaluated.

Intimate partner violence is prevalent in South Africa. 3 We have insufficient knowledge about how to intervene effectively to reduce domestic violence. Locally and internationally there is no clear evidence that men’s violence has been reduced through participation in programmes for batterers. 28 , 29 There are some promising local alternatives, 30 , 31 but more research in this area is sorely needed.

Schools with clear missions and strong stances against violence have lower rates of bullying. 32 However, many South African schools are in disarray, 33 and over 50% of children report that corporal punishment is used for discipline, despite its being prohibited. 9 This is incongruous with promoting non-violence and pro-social behaviours, and school-based violence prevention programmes and policies must form part of the violence prevention agenda.

Much offending does not occur as a single incident with one offender and one victim; it is much more frequently the case that there is more than one offender (for instance, gang or group violence), or multiple acts of violence by one person, over a period of time, against another person (such as domestic violence or child sexual abuse). However, theories of victimisation and offending frequently fail to consider the cumulative effects of multiple victimisations or chronic offending over a lifetime. 34

Gangs, one form of a violent peer group, are a feature in South African violence. There are many international studies into effective policing and models for detaching young people from gangs, 35 but there is little local research into effective interventions.

Agendas to prevent young people from joining gangs and engaging in delinquency must include pro-social leisure opportunities after school. These can be effective in reducing many risk behaviours, but their mechanisms are little understood and this too needs investigation. 36

Exosystem contexts

Neighbourhood.

Children’s caregivers cannot do parenting in isolation, and their effective parenting is influenced by available social support. For poor parents in particular, this often means support in their neighbourhoods. 37 How neighbourhood quality can be improved to better support parenting and the influence of family and neighbourhood characteristics on the development of antisocial behaviour among South African children is also poorly understood. For instance, how do South African children draw on available support to negotiate safety in unsafe families or neighbourhoods? 38 Understanding these inter-relationships can assist in developing better interventions.

Strong neighbouring relationships may influence rates of crime, e.g. by not tolerating groups of young people ‘hanging out’ on corners. 39 However, how can neighbourhood crime prevention be strengthened without encouraging vigilantism? 40 This must include work on police-community relations, and how these affect crime and violence at the local level. 41 Neighbourhood-level data on violence are key to such research. The South African Police Service must recognise this and make their data available.

Patterns of violence within communities often differ, e.g. within low-income, high-violence neighbourhoods the victims frequently know the perpetrators, 4 2 unlike in affluent communities. What causes this, and what would be effective interventions for different forms of violence? Policing strategies, tailored to meet the challenges of specific communities, must be documented and evaluated. 43

Health services

Those affected by violence are at risk of related psychological and social costs and of secondary victimisation from the criminal justice and health systems and society. 4 4 This may lead to problems such as post-traumatic stress, substance abuse and aggressive responses. The latter make effective services for victims an important part of violence prevention. How can medical and psychological services best be provided? Evidence suggests that recovery from a traumatic experience requires physical or psychological safety. 45 As many South Africans live under continuous threat, it is important to investigate alternative pathways to recovery.

Health services are obvious places to screen for and provide services to reduce aggression, including interventions for substance misuse; promoting maternal health; improving parenting; reducing intimate partner violence; and early detection of child mental health problems associated with aggression. It is critical to investigate whether the state has the capacity to carry out this screening and intervention.

The health system can provide surveillance systems that assess the extent of violence, which are crucial to monitor interventions and to determine their efficacy. The National Injury Mortality Surveillance System (NIMSS) has an important role, 1 but many injuries do not result in death, and until a comprehensive injury surveillance system is established, part of the picture will be missing. Establishing a system that is simple to administer is an important area for research and for implementation.

Under Apartheid, public order policing was associated with use of force. 46 Since the setting up of constitutional democracy the right to participate in public demonstrations has been liberalised, the role of the police circumscribed and the principle of minimum force professed. 47 However, in the context of increased service delivery protests, police action has become less restrained, suggesting the need for vigilance to ensure application of their principles for strengthening rather than diluting the search for peaceful coexistence. 48

Clarification is required regarding the roles of the state (e.g. police) and of non-state entities (e.g. private security companies, street committees) in the governance of violence and crime. The non-state is actively involved in governing crime, sometimes duplicating the state and participating in activities beyond what are expected of the state. 41 , 49 More research must map the range of policing-type functions of non-state entities, and investigate the type of non-state/state collaborations and the effects on (un)safety. Normative questions also arise such as who the state (police) should be in relation to the increasing plurality of policing entities and how to regulate and hold to account new configurations of state/non-state governance while ensuring their effective contribution to decrease crime and unsafety. 52 , 53

Studies have implicated media violence 54 and values of sexism and materialism 55 , 56 portrayed in various media as playing a role in driving violence. Yet their mechanisms are poorly understood, and whether these relationships hold in the high-violence areas of South Africa requires investigation.

Macrosystem contexts

Social norms around violence.

Despite overviews according importance to a ‘culture of violence’, the role of norms has been neglected in violence studies in South Africa. 57 , 58 But there is little empirical basis for these claims, in contrast with the study of violence elsewhere. 4 Cultural and social norms may be divided into two categories: ( i ) violence is deemed legitimate by higher-status individuals (especially men) against lower-status individuals (such as children or women); 10 and ( ii ) the general attitude towards violence in society might consider violence legitimate to resolve disputes or conflicts. Norms may influence violence through shaping the behaviour of possible perpetrators or the behaviour of others present in situations that are conducive to violence, and whose complicity or opposition to the use of violence might serve as fuel or constraint. Investigating norms around violence in South Africa will help in understanding and intervening in relationships between the psychologies of masculinity and femininity, the sociology of opportunity, and the perpetration of violence.

Socio-economic factors

Evidence suggests that violence occurs at higher rates in societies with high levels of economic inequality. 59 Investigation is needed into whether this holds in South Africa, where violence seems to have increased alongside an increase in inequality, high unemployment and income poverty. 60 In high-income countries the relationship between inequality and violence appears to be driven by concerns about status and social exclusion, but there is no strong evidence for this here.

Government policies

There are a number of polices in place in South Africa that are intended to deal directly with violence, e.g. the Children’s Act No. 38 of 2005, the Domestic Violence Act No. 116 of 1998, the Sexual Offences Act No. 32 of 2007, and the Victim Empowerment Policy. The links between government, civil society and community-based organisations must be evaluated. This might encompass economic research investigating the human and financial resources to give effect to them, evaluations of existing programmes (do they reach those in need and provide effective services?), and implementation research on providing potentially large-scale programmes.

Some policies may indirectly affect violence. For instance, government policy is turning towards controlling the availability of alcohol to reduce violence and injuries. Research into understanding the relationship between alcohol and violence, which will drive an appropriate, integrated and comprehensive alcohol policy, is desperately needed. Similarly, careful thought must be given to the control and policing of illegal substances, as the illicit economy is a driver of violence. Evidence suggests that law enforcement interventions to disrupt drug markets are unlikely to reduce drug-related violence and instead result in higher gun violence and higher homicide rates. 61 Another government policy needing ongoing monitoring and evaluation is the Firearms Control Act (No. 60 of 2000). Since its implementation in 2004, firearm-related deaths have decreased, but whether this is clearly linked to the new policy needs further investigation.

This is a complex research agenda, within which are strands that might be considered ‘meta-questions’ that cannot rely solely on health professionals. Health professionals from several specialties all have a role to play in carrying out a comprehensive research agenda for violence prevention in South Africa. But the complex research problems that violence presents demand inter-disciplinary collaboration by the full range of social and human scientists: economists, educationalists, psychologists, sociologists, anthropologists, etc. Only in working together can these problems be sufficiently well understood and effective interventions developed.

Research to understand violence better might take several forms, e.g. understanding ‘norms’ of violence and how they link several drivers of violence, or understanding factors that influence child development for good or for ill. Intervention research may evaluate interventions and assess efficacy and effectiveness; and once effectiveness has been established, understanding how the intervention might be scaled up and retain that effectiveness. Related questions concern effective implementation of programmes in our poorly resourced settings, e.g. nurse home visitation programmes for the first 2 years of life in the USA reduce later youth violence, but rely on trained, expensive nurses. 62 Can such programmes retain their effectiveness if community health workers are employed instead of nurses?

This paper therefore lays out a comprehensive agenda for understanding violence and promoting safety in South Africa. There are many questions about violence that are as yet unanswered, and there are key roles for many different disciplines in answering them.

Author note. This paper grew out of discussions among the authors. C Ward led the discussions and writing of the paper; all others contributed equally, and authorship is given in alphabetical order to reflect the equality of contribution.

Financial support. The University of Cape Town’s Vice-Chancellor’s Strategic Fund.

Conflicts of interest. All authors confirm no potential conflicts of interest.

1. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of injuries in South Africa. Bull World Health Organ 2007;85:695-702. [http://dx.doi.org/10.1590/S0042-96862007000900015]

2. Centre for the Study of Violence and Reconciliation. Tackling Armed Violence: Key Findings and Recommendations of the Study on the Violent Nature of Crime in South Africa. Johannesburg: Centre for the Study of Violence and Reconciliation, 2010.

3. Seedat M, Van Niekerk A, Jewkes R, Suffla S, Ratele K. Violence and injuries in South Africa: prioritising an agenda for prevention. Lancet 2009;374:1011-1022. [http://dx.doi.org/10.1016/S0140-6736(09)60948-X]

4. World Health Organization. Violence Prevention: The Evidence. Geneva: WHO, 2009. http://www.who.int/violence_injury_prevention/violence/4th_milestones_meeting/publications/en/index.html (accessed 7 August 2011).

5. Moffitt TE. Adolescence-limited and life-course persistent antisocial behaviour: A developmental taxonomy. Psychol Rev 1993;100:674-701. [http://dx.doi.org/10.1037/0033-295X.100.4.674]

6. McKinstry J. Using the past to step forward: Fetal alcohol syndrome in the Western Cape province of South Africa. American Journal of Public Health 2005;95:1097-1099. [doi: 10.2105/AJPH.2004.056366]

7. Rosenthal J, Christianson A, Cordero J. Fetal alcohol syndrome prevention in South Africa and other low-resource countries. American Journal of Public Health 2005;95:1099-1101. [http://dx.doi.org/10.2105/AJPH.2004.057372]

8. Hendricks M, Bourne L. An integrated approach to malnutrition in childhood. In: Kibel M, Lake L, Pendlebury P, Smith C, eds. South African Child Gauge 2009/2010. Cape Town: Children’s Institute, University of Cape Town, 2010:46-52.

9. Leoschut L, Burton P, How Rich the Rewards? Results of the 2005 National Youth Victimisation Study. Cape Town: Centre for Justice and Crime Prevention, 2006.

10. Richter L, Dawes A, deKadt J. Early childhood. In: Petersen I, Bhana A, Swartz L, Flisher A, Richter L, eds. Promoting Mental Health in Scarce Resource Contexts: Emerging Evidence and Practice. Cape Town: HSRC Press, 2010:99-123.

11. Liu J, Raine A. The effect of childhood malnutrition on externalising behaviour. Curr Opin Pediatr 2006;18:565-570. [http://dx.doi.org/10.1097/01.mop.0000245360.13949.91]

12. Shonkoff J. Building a new biodevelopmental framework to guide the future of early childhood policy. Child Dev 2010;81:357-367. [http://dx.doi.org/10.1111/j.1467-8624.2009.01399.x]

13. Kavale KA. Learning disability and cultural-economic disadvantage: The case for a relationship. Learning Disability Quarterly 1988;11:195-210.

14. Catalano RF, Hawkins JD. The social development model: A theory of antisocial behavior. In Hawkins JD, ed. Delinquency and Crime: Current Theories. New York, NY: Cambridge University Press, 1996:198-235.

15. Hoffman ML. Empathy and Moral Development: Implications for Caring and Justice. Cambridge: Cambridge University Press, 2000.

16. Seekings J. Entry into the Labour Market. Report for the Centre for Development and Enterprise. Cape Town: Centre for Social Science Research, University of Cape Town, 2011.

17. Williams S, Williams D, Stein D, Seedat S, Jackson P, Moolmal H. Multiple traumatic events and psychological distress: The South African Stress and Health Study. Journal of Traumatic Stress 2007;20(5):845-855. [http://dx.doi.org/10.1002/jts.20252]

18. Miller DT, Porter CA. Self-blame in victims of violence. Journal of Social Issues 1983;39:139-152. [http://dx.doi.org/10.1111/j.1540-4560.1983.tb00145.x]

19. Heidi LS. Interaction between family violence and mental retardation. Mental Retardation 2001;39:461-471. [http://dx.doi.org/10.1352/0047-6765(2001)039<0461:IBFVAM>2.0.CO;2]

20. Hickson IK, Golden H, Chatzistyli A. Profiles of women who have mental retardation with and without a documented history of abuse. American Journal on Mental Retardation 2008;113:133-142. [http://dx.doi.org/10.1352/0895-8017(2008)113[133:POWWHM]2.0.CO;2]

21. Shu-Man P. Prevalence of sexual abuse of people with intellectual disabilities in Taiwan. Intellectual and Developmental Disabilities 2003;45:373-379. [http://dx.doi.org/10.1352/1934-9556(2007)45[373:POSAOP]2.0.CO;2 ]

22. Finkelhor D. Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People. Oxford: Oxford University Press, 2008.

23. Finkelhor D, Ormrod RK, Turner HA, Hamby SL. Measuring poly-victimization using the Juvenile Victimization Questionnaire. Child Abuse & Neglect 2005;29:1297-1312. [http://dx.doi.org/10.1016/j.chiabu.2005.06.005]

24. King G, Flisher AJ, Noubary F, Reece R, Marais A, Lombard C. Substance abuse and behavioral correlates of sexual assault among South African adolescents. Child Abuse & Neglect 2004;28:683-696. [http://dx.doi.org/10.1016/j.chiabu.2003.12.003]

25. Farrington DP, Welsh BC. Saving Children From a Life of Crime: Early Risk Factors and Effective Interventions. Oxford: Oxford University Press, 2007.

26. Rothbaum F, Weisz JR. Parental caregiving and child externalising behaviour in nonclinical samples: A meta-analysis. Psychol Bull 1994;116:55-74. [http://dx.doi.org/10.1037/0033-2909.116.1.55]

27. United Nations Office on Drugs and Crime. Compilation of evidence-based family skills training programmes. Vienna: UNODC, 2009. http://www.unodc.org/unodc/en/prevention/familyskillstraining.html (accessed 18 December 2011).

28. Babcock JC, Green CE, Robie C. Does batterer’s treatment work? A meta-analytic view of domestic violence treatment. Clin Psychol Rev 2004;23:1023-1053. [http://dx.doi.org/10.1016/j.cpr.2002.07.001]

29. Dutton DG, Corvo K. The Duluth model: A data-impervious paradigm and a failed strategy. Aggression and Violent Behavior 2007;12:658-667. [http://dx.doi.org/10.1016/j.avb.2007.03.002]

30. Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006;368:1973-1983. [http://dx.doi.org/10.1016/S0140-6736(06)69744-4]

31. Jewkes R, Nduna M, Levin J, et al. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 2008;337:a506. [http://dx.doi.org:10:1136/bmja.506].

32. Masten AS, Coastworth JD. The development of competence in favorable and unfavorable environments: Lessons from research on successful children. Am Psychol 1998;53:205-220. [http://dx.doi.org/10.1037/0003-066X.53.2.205]

33. Chisholm L. The state of South Africa’s schools. In: Daniel J, Southall R, Lutchman J, eds. State of the Nation: South Africa 2004-2005. Cape Town: HSRC Press, 2004:177-189.

34. Flavin J, Artz L. Understanding women, gender, and crime: Historical and international developments. In: Renzetti C, Miller S, Gover A, eds. Routledge Handbook of Gender and Crime Studies. Oxford: Routledge (in press).

35. Cooper A, Ward CL. Intervening with youth in gangs. In: Ward CL, Van der Merwe A, Dawes A, eds. Youth Violence in South Africa: Sources and Solutions. Cape Town: UCT Press, 2012: 241-274.

36. Durlak JA, Weissberg RP, Pachan M. A meta-analysis of after-school programs that seek to promote personal and social skills in children and adolescents. Am J Community Psychol 2010;45:294-309. [http://dx.doi.org/10.1007/s10464-010-9300-6]

37. Garbarino J, Sherman D. High-risk neighborhoods and high-risk families: the human ecology of child maltreatment. Child Dev 1980;51:188-198.

38. Bray R, Gooskens I, Kahn L, Moses S, Seekings J. Growing Up in the New South Africa: Childhood and Adolescence in Post-Apartheid Cape Town. Cape Town: Human Sciences Research Council, 2010.

39. Sampson RJ, Groves WB. Community structure and crime: testing social disorganization theory. AJS 1989;94:774-802.

40. Seekings J, Jooste, T, Muyeba S, Coqui M, Russell M. The Social Consequences of Establishing Mixed Neighbourhoods. Cape Town: Centre for Social Science Research, University of Cape Town, 2010. http://www.cssr.uct.ac.za/publications/research-report/2010/667 (accessed 18 December 2011).

41. Marks M, Wood J. The South African policing ‘nexus’: Charting the policing landscape in Durban. South African Review of Sociology 2007;38:134-160. [http://dx.doi.org/10.1080/21528586.2007.10419172]

42. Centre for the Study of Violence and Reconciliation. The violent nature of crime in South Africa – a concept paper for the Justice, Crime Prevention and Security Cluster. A report to the Justice, Crime Prevention and Security Cluster of the South African Parliament. Johannesburg: Centre for the Study of Violence and Reconciliation, 2007. http://www.info.gov.za/issues/crime/violent_crime.pdf (accessed 7 March 2011).

43. Dixon B, Rauch J. Sector policing: Origins and prospects. ISS Monograph No. 97. Pretoria: Institute for Security Studies, 2004. http://www.iss.co.za/pubs/Monographs/No97/Contents.html (accessed 18 December 2011).

44. United Nations Office for Drug Control and Crime Prevention. Handbook on Justice for Victims. United Nations Office for Drug Control and Crime Prevention. New York: Centre for International Crime Prevention, 1999.

45. Foa EB, Keane TM, Friedman MJ, Cohen JA, eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press, 2009.

46. Cawthra G. Policing South Africa: The SAP and the Transition from Apartheid. London: Zed Books, 1993.

47. Shearing C, Foster D. Back to the future in South African security: from intentions to effective mechanisms. In: Van der Spuy E, Parmentier S, Dissel A, eds. Restorative Justice: Politics, Policies and Prospects. Cape Town: Juta, 2007.

48. Tait S, Marks M. You strike a gathering, you strike a rock: Current debates in the policing of public order in South Africa. SA Crime Quarterly 2011;38:15-22.

49. Berg J. Seeing like private security: Evolving mentalities of public space protection in South Africa. Criminology and Criminal Justice 2010;10:287-301. [http://dx.doi.org/10.1177/1748895810370315]

50. Minnaar A. Inaugural Lecture: Private-Public Partnerships: Private Security, Crime Prevention and Policing in South Africa. Pretoria: Department of Security Risk Management, School of Criminal Justice, College of Law, University of South Africa, 2004. http://www.unisa.ac.za/contents/docs/inaugural.pdf (accessed 6 March 2012).

51. Schärf W, Nina D, eds. The Other Law: Non-state Ordering in South Africa. Cape Town: Juta, 2001.

52. Shearing C, Marks M. Being a new police in the liquid 21st century. Policing: A Journal of Policy and Practice 2011;5:1-9. [http://dx.doi.org/10.1093/police/par035]

53. Lewis C, Wood J. The governance of policing and security provision. In Fleming J, Wood J, eds. Fighting Crime Together: Challenges of Policing and Security Networks. Sydney: University of New South Wales Press, 2006.

54. Anderson C, Bushman B. Media violence and the American public revisited. Am Psychol 2002;57:448-450. [http://dx.doi.org/10.1037/0003-066X.57.6-7.448]

55. Jiwani Y. Discourses of Denial: Mediations of Race, Gender and Violence. Vancouver: UBC Press, 2006.

56. Hennigan KM, Del Rosario ML, Heath L, Cook TD, Wharton JD, Calder BJ. Impact of the introduction of television on crime in the United States: empirical findings and theoretical implications. Journal of Personality and Social Psychology 1982;42:461-477. [http://dx.doi.org/10.1037/0022-3514.42.3.461]

57. Pelser E. Learning to be lost: Youth crime in South Africa. Discussion paper for the HSRC Youth Policy Initiative, Reserve Bank, Pretoria (13 May 2008). http://www.hsrc.ac.za/Document-2774.phtml (accessed 6 March 2012).

58. Altbeker A. Adding Insult to Injury: How Exclusion and Inequality Drive South Africa’s Problem of Violence. Report #4 of CSVR Study of Violent Crime. Johannesburg: Centre for the Study of Violence and Reconciliation, 2008.

59. Wilkinson R, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin, 2010.

60. Seekings J, Thaler K. Socio-economic Conditions, Young Men and Violence in Cape Town. CSSR Working Paper No. 285. Cape Town: Centre for Social Science Research, University of Cape Town, 2010.

61. Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. International Journal of Drug Policy 2011;22:87-94. [http://dx.doi.org:10.1016/j.drugpo.2011.02.002]

62. Olds DL, Robinson J, O’Brien R, et al. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics 2002;110:486-496. [http://dx.doi.org/10.1542/peds.110.3.486]

Fig. 1. The ecological model.

Article Views

Comments on this article.

Violence as Community Safety Issues and Solutions Essay

Introduction, community safety issues and their solutions, works cited.

The well-being and peaceful state of a society depend on the nature of community safety intervention measures adopted not only by law enforcement agents within that community but also by the society itself. This is because, although law enforcing agents or safety maintaining bodies, for example, fire stations may put in place measures to prevent the occurrence of accidents, health hazards and crimes, the overall role of ensuring such intervention measures succeed depends on society members’ willingness to cooperate with such bodies.

It is important to note that, in any societal setting occurrence of deviant behaviors and accidents is a common phenomenon hence, the need for a society to implement measures necessary to deal with such accidents and deviant behaviors any time they occur. Implementation of such measures is of great significance to a community for it helps to ensure that any act of deviance or accident does not disturb a society’s patterns of living, modes of operation, and peaceful coexistence (National Community Safety Network 1)

Primarily the practice of community safety entails the overall process of preventing, minimizing, or alleviating chances of activities occurring that are likely to jeopardize the peaceful coexistence of a society or threaten peoples’ societal rights. Besides, community safety involves the practice of offering assistance to individuals with specific unsociable behaviors as a mechanism of ensuring they cope with their mental and social conditions.

Depending on the forces behind the occurrence of such activities, such activities can be environmentally, socially, or politically driven hence, the need for cooperation between all individuals in a society. Through co-operation, a society can receive the desired guidance, funding, and help from governmental and non-governmental organizations hence, not only helping itself to combat occurrences of deviant behaviors but also helping the government deal with crime and other societal issues. In it important to note that enforcing community safety measures is a function of not only the local authority, but rather it involves all societal members, who include local authorities, academicians, and any individuals involved actively in combating crime and accidents (National Community Safety Network 1).

For communities to deal properly with any safety threats that surround them, it is of great significance for such communities to firstly identify any safety issues, which are of great risk to its existence. Through early identification of such threats, individuals can be able to formulate not only individual mechanisms of dealing with such threats but also it will give them a chance of collaborating with others and seeking higher-order intervention measures from local authorities. It is important to note that the practice of ensuring society is safe should be a collaborative activity because safety threats are not selective but, rather they affect the entire society in many different ways.

Domestic Violence

One primary community safety issue that affects society is domestic violence. Domestic violence is one of the primary safety issues that are of great concern to many societies. Since time memorial, although societies have come up with measures of dealing with domestic violence, this is one of the most unpunished crimes in societies because most abused individuals do not report their abusers to the authorities.

Globally, more than 40% of women deaths occur annually as a result of domestic violence; a number that increases with an increase in suicide cases associated with domestic violence. The majority of battered individuals suffer silently due to fear of intimidation, a fact that increases most battered individuals’ suffering hence, the suicidal tendencies of most domestic violence victims.

One primary reason why domestic violence is one of the primary threat to society is that, unlike other forms of abuse that cause physical harm, its effects are not only physical, but also they are psychological, emotional, economic, and of great harm to an individual’s sense of being. Perpetrators of domestic violence are many ranging from spouses, both nuclear and extended family members, and in some cases caretakers (Advocates for Human rights 1).

Although in most cases, most individuals associate domestic violence with adults, the practice affects young children very much, them being primary recipients of effects resulting from family breakages and problems. In addition to children, as research studies indicate, animals are not either spared when it comes to domestic violence, as some individuals sometimes vent their anger on animals. Primary causes of this form of violence include marital problems, alcoholism, and drug abuse; practices that pose may other security threats to the peaceful coexistence and integration of a society.

Therefore, because of the aggression associated with the practice, in most cases effects resulting from the abuse are very fatal and devastating hence, making it necessary for a society to have appropriate measures of dealing with the practice. Common effects of domestic violence include increased susceptibility to sexually transmitted infections, chronic pains, psychological trauma, and death, in most untamed cases (Pallito 1-7).

Considering the death of effects resulting from domestic violence, it is of great significance for society to work in close collaboration with local authorities in dealing with domestic violence. It is because, through close collaborations, chances of unreported cases going unpunished are minimal, as a result of individuals ensuring their neighbors have the required protections. It is important to note that, although men are victims of domestic violence, the majority of the sufferers are women and young children; they being the most vulnerable members of society.

Therefore, to deal with the problem adequately, there is a need for the formulation of prevention and early intervention measures necessary for offering the required justice to sufferers of domestic violence. Common strategies of dealing with domestic violence include formulating reporting mechanisms, offering training and education opportunities to the vulnerable members of the society, and offering the necessary support to victims of abuse. In addition to this, there is a need for the government in collaboration with organizations that deal with domestic violence to give employers guidelines necessary to ensure workstations are free from domestic violence and employee intimidation (Suffolk County Council 1).

Child Safety

Child safety is another community safety issue that is of great concern to any societal member. Children are the most vulnerable group to most crime perpetrators because, in most cases, they are easy to convince and lure into traps. In addition to them being easily convincible, with the current technological innovations and because of the availability of computers and internet connections in most homes, most children are victims of internet crimes, for example, bullying and kidnappings.

On the other hand, most school transport services are easily susceptible to gang attacks because of the lack of required security patrol systems in some communities. It is important to note that child safety encompasses all safety measures within and outside the schools and homes because even within school premises, there exist many safety issues that administrations should take note of. For example, in dealing with an emergency, an outbreak of a fire, or a deadly infection, a school must ensure it has in place measures necessary for ensuring it averts risks associated with the spreading of such a calamity (National Association of School Psychologists 1).

In addition to safety in learning institutions, child abuse is another society practice that greatly jeopardizes greatly child safety. As research studies show, more than 56 % of adolescents at one time in their life, they were victims of child abuse. Child abuse takes many forms ranging from simple pain infliction to the worst form of child abuse that involves child labor and sexual abuse in form of prostitution or asking for sexual favors from children. All these forms of abuse cause extreme suffering to children, and in case caretakers fail to recognize such abuses, the likelihoods of most children committing suicide are high because most of them lack mechanisms of coping with the pain (Matthews 1).

Globally, according to the World Health Organisation research studies on child abuse, more than fifty-three child abuse murders occur annually; more than two hundred and eighteen thousand children actively participate in child labor, and more than two hundred and seventy-five million children are victims of domestic violence annually. Appropriate children protection policies should safeguard children’s rights from their homes to school and in all activities children engage themselves in (Usborne 1).

Considering all these threats to child safety, communities have to engage themselves actively in the formulation of policies necessary for ensuring children receive the desired protection from any forces within the society that threatens their security. Right from homes to learning institutions parents, and should collaborate with local council authorities in ensuring their children receive required protection from gang activities or any form of abuse. It is achievable through adopting patrol security measures to safeguard children in their traveling ventures. Within the school’s premises, school administrations should implement measures necessary to ensure all they minimize all threats to children’s security.

Such measures should include the construction of safe buildings, constructing evacuation channels, and health methodologies of preventing the spread of infectious diseases in case they occur. In addition to these measures, it is important for parents in collaboration with school administrations to offer educational training and guidance to children. This is one of the primary mechanisms of ensuring that children are aware of the nature of security threats they are likely to encounter in their daily endeavors hence, minimizing the chances of most of them being victims of gang activities (Matthews 1).

On the other hand, because of the serious nature of child abuse, there is a need for all community members to take a central role in ensuring children receive the required protection. Although individuals report some child abuse cases, most cases of child abuse go unpunished, because some societies lack appropriate reporting mechanism, necessary for ensuring all child law enforcing agents hold all child abusers accountable for their crimes. Therefore, this makes it necessary for a society to have good and secure reporting procedures, crucial in safeguarding all children’s rights (United Nations Children’s Fund 1)

Gang Violence

Another community safety issue that greatly jeopardizes the well being of individuals in society is gang violence. Although the majority of individuals associate gang violence with joblessness adults, in some communities some students may be involved in gang violence, a fact that makes the scenario worse because most students follow mob psychology. Gang violence is one of the worst security threats to a community because, in most cases, most gang activities end with the loss of numerous lives and destruction of property.

It is crucial to note that most gang activities are well organized, and in most cases, criminals will target innocent individuals, for example, mothers and young children. Therefore, considering this, it is of great significance for societal members to work in close collaboration with law enforcement agents; it is the primary mechanism of ensuring the government meets their security needs (Bania 90-92).

Closely related to gang violence is prostitution and drug abuse. These are two other primary threats to a society’s security, because in most cases, as research studies show, there is a close relationship between criminal gangs, prostitution, and substance abuse. Considering the nature of outcomes from gang activities and the impacts of such activities on the societies, firstly, parents should ensure they monitor their children’s activities, for it may provide a mechanism of realizing early gang warning symbols, for instance, tattoos and languages. The monitoring initiative should go beyond the normal family monitoring to monitoring children’s acquaintances, a fact that is only achievable through close collaboration with neighbors (Veale 1).

On the other hand, at the communal level, there is a need for all community members to cooperate amongst themselves through community policing programs in addition to collaborating with law enforcement agents. This is one of the primary mechanisms of discovering the reality behind criminal activity hence, formulating appropriate mechanisms of dealing with such activities. For governments and local authorities to deal with criminal gangs’ activities, there is a need for authorities to formulate criminal activity reporting mechanisms that will ensure reporters and witnesses of criminal activities receive the desired protections. This is one of the primary mechanisms of reducing chances of intimidation from criminal gangs hence, a mechanism of ensuring individuals report all criminal activity (Veale 11

As compared to other community safety issues, fire safety is of great concern because of the destructive nature of fires. Fire hazards range from simple home fires to complex fire scenarios that involve vast tracks of land or property. Hence, considering the destructive nature of fires, there should be many governmental initiatives to sensitize the public on the importance of maintaining a fire-free environment. Such initiatives involve the need for all occupied structures and building to have fire fighting gadgets and evacuating tunnels necessary for fighting fires and avoiding dangers of fire in case they occur.

In addition to fire fighting equipment, there is a need for individuals to ensure their houses have working smoke detectors connected to fire alarms, necessary for providing early warnings of a fire outbreak in case it occurs. It is crucial to note that the availability of fire fighting and prevention equipment is of no use without proper training on how individuals should handle fires. Hence, to ensure every individual, including children, have the required know-how on fire fighting mechanisms, there is a need for all society members in collaboration with local authorities to develop training programs, necessary for ensuring all individuals have the required fire fighting skills (Direct government 1).

To avoid small fires from occurring or spreading as a result of carelessness, there is a need for individuals to learn fire safety rules for all electrical appliances and the necessity of fire retardant cloth ware necessary for avoiding small home fires. Finally, for homes to access the services of firefighters in case the situation goes out of hand, it is necessary for local fire helplines to be functional and to be known to all home occupants (Direct government 1).

In conclusion, regardless of any community safety issue, the overall role of ensuring a community is safe lies in the hand of community members. It is because it is the community members who understand problems that face them; hence, they can easily formulate mechanisms of dealing with such issues, even without the help of local authorities. It is important to note that community issues are inevitable hence, the need for societies in collaboration with local authorities to formulate appropriate methodologies of handling such issues whenever they arise.

Advocates for Human Rights. Effects of domestic violence . Advocates for Human Rights, 1 June. 20006. Web.

Bania, Melanie. Gang violence among youth and young adults: (dis) affiliation and the Potential for prevention. IPC Review, 3 (2009): 89-116.

Direct Government. Fire safety in the home. Direct Government. 2010. Web.

Matthews, John. School safety tips. School Safety Institute. 2009. Web.

National Associations of School Psychologists. Tips for school administrators for Reinforcing school safety. NASP. 2010. Web.

National Community Safety Network. NCSN guide to CDRP/CSP working 2009: An NCSN induction guide for practitioners. NCSN. 2010. Web.

Pallito, Christina. Domestic violence and maternal, infant, and reproductive health: A critical review of the literature. 2010. Web.

Suffolk County Council. Domestic violence. 2010. Web.

United Nations Children’s Fund. Stop violence against children in communities: Safety tips-what you can do. 2007. Web.

Usborne, David. UN report uncovers global child abuse. The Independent . 2006. Web.

• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, February 11). Violence as Community Safety Issues and Solutions. https://ivypanda.com/essays/violence-as-community-safety-issues-and-solutions/

"Violence as Community Safety Issues and Solutions." IvyPanda , 11 Feb. 2024, ivypanda.com/essays/violence-as-community-safety-issues-and-solutions/.

IvyPanda . (2024) 'Violence as Community Safety Issues and Solutions'. 11 February.

IvyPanda . 2024. "Violence as Community Safety Issues and Solutions." February 11, 2024. https://ivypanda.com/essays/violence-as-community-safety-issues-and-solutions/.

1. IvyPanda . "Violence as Community Safety Issues and Solutions." February 11, 2024. https://ivypanda.com/essays/violence-as-community-safety-issues-and-solutions/.

Bibliography

IvyPanda . "Violence as Community Safety Issues and Solutions." February 11, 2024. https://ivypanda.com/essays/violence-as-community-safety-issues-and-solutions/.

• A Gang Culture Among the Latinos
• Girls in Gangs: Reasons that Make Girls Join the Gang
• Gang Involvement of Teenagers
• Racial Inequality and Gangs: Issue Analysis
• Emergence and up rise of street gangs
• Timeline of gangs in America
• Deviance: Social Problems of Youth Gangs
• Gang Violence: Discussing the Problem of Gang Membership
• Public Perception on Gang Activities
• U.S. Prison Gangs: A Threat to Internal Security
• Child Sexual Abuse by Catholic Priests
• Domestic Violence Impact on Child Maltreatment Reporting
• Domestic Violence Management and Budget Cuts
• Violence Against Women and Social Work Services
• Workplace Violence in the Modern United States

Who are your essay writers?

Gombos Zoran

Finished Papers

Some attractive features that you will get with our write essay service

Grab these brilliant features with the best essay writing service of PenMyPaper. With our service, not the quality but the quantity of the draft will be thoroughly under check, and you will be able to get hold of good grades effortlessly. So, hurry up and connect with the essay writer for me now to write.

Check your email for notifications. Once your essay is complete, double-check it to see if it falls under your expectations and if satisfied-release the funds to your writer. Keep in mind that our essay writing service has a free revisions policy.

First, you have to sign up, and then follow a simple 10-minute order process. In case you have any trouble signing up or completing the order, reach out to our 24/7 support team and they will resolve your concerns effectively.

"The impact of cultural..."

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• HHS Author Manuscripts

The Link Between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice

The United States has substantially higher levels of firearm violence than most other developed countries. Firearm violence is a significant and preventable public health crisis. Mental illness is a weak risk factor for violence despite popular misconceptions reflected in the media and policy. That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness. This article summarizes existing evidence about the interplay among mental illness, violence, and firearms, with particular attention paid to the role of active symptoms, addiction, victimization, and psychosocial risk factors. The social and legal context of firearm ownership is discussed as a preface to exploring practical, evidence-driven, and behaviorally informed policy recommendations for mitigating firearm violence risk.

1. INTRODUCTION

The United States is one of only three countries with a Constitutionally protected right to own firearms; of the three, it is the only one with minimal restrictions on that right ( Elkins 2013 ). With over 350 million privately owned firearms ( Ingraham 2015 ), the United States substantially exceeds all other countries in both per capita ownership of guns and absolute number of guns: Approximately 30% of all privately owned firearms in the world are in the hands of US residents ( Small Arms Surv. 2011 ).

The number of lives taken with guns also makes the United States exceptional. The US rate of suicide by firearm is 8 times higher and the rate of homicide by firearm is 25 times higher than the rates in other economically developed countries ( Grinshteyn & Hemenway 2016 ). Although mass shootings capture the news cycle on an all too frequent basis, the quotidian toll of gun-related violent crime, domestic violence (DV), and suicide shatters lives and erodes communities. Mass shootings generally account for 1% or less of all firearm violence, and suicides routinely take twice as many lives as homicides. The public health impact of firearms in the United States is staggering.

Popular media, meanwhile, does little to keep the problem in perspective. The common perceptions driven by news media are that gun violence and mass shootings are increasing and are at historically high levels. Firearm homicide rates have actually decreased despite widespread perceptions to the contrary ( Cohn et al. 2013 ). Estimates of increases in mass shootings, meanwhile, are tenuous at best. Although there has been some suggestion that the absolute number and frequency of these events may have seen a recent uptick ( Blair & Schweit 2014 , Schweit 2016 ), other studies suggest that mass shootings have maintained a relatively steady share of approximately 1% of US violence over the past century ( Duwe 2004 , Stone 2015 ).

A pernicious and false but increasingly common message promoted in the media is that people with mental illness are prone to violence in general and are responsible for mass shootings ( McGinty et al. 2014b , 2016b ). Studies consistently indicate that, even among mass murders and shootings, mental illness is a factor in a minority of these events ( Duwe 2004 , Fox & DeLateur 2014 , Stone 2015 , Taylor 2016 , Vossekuil et al. 2002 ). Nonetheless, the notion that mental illness drives these events is stoked regularly, and the impact of this trend in US media coverage of violence is so significant that it is now seen to be distorting perceptions even outside of the United States ( Jorm & Reavley 2014 ).

The notoriety given to mass shootings and the link made to mental illness have two effects. First, they promote stigma by conflating mental illness and violence—a bias that affects patients, providers, the public, and policy makers ( Clement et al. 2015 , Corrigan et al. 2005 , Price & Khubchandani 2016 ). Second, they distract the public and policy makers from dealing with the issues of violence and mental illness, and gun violence in particular, in an empirically grounded, frank way.

The simplistic model of mental illness driving mass shootings or violent crime leads to a simplistic, politically popular, but ineffectual policy solution: provide more mental health services ( Gold 2013 , Pinals et al. 2015 ). Who could reasonably be against that idea? Policy makers and politicians are attracted to this solution because it helps them avoid more complicated and politically treacherous debates about effective limits on gun ownership, tracking, or registration. Given the overloaded state of current mental health services, mental health professionals are certainly tempted to endorse this solution and to take such funds, even knowing that access to mental health services will have little impact on gun violence, mass shootings, or violence in general. Such Faustian bargains have foreseeable consequences, though, including increased stigma for mentally ill individuals and the diversion of necessary resources from better interventions ( Rozel 2016 ). Policies intending to mitigate gun violence risk by narrowly focusing on the narrow intersection between mental illness and mass shootings will be intrinsically limited in scope and utility and may potentially disrupt effective elements of the mental health system ( Appelbaum 2013 , Metzl & MacLeish 2015 ).

There are additional issues for mental health practitioners beyond the ethics and utility of endorsing funding for mental health services as a solution to gun violence. Firearm access and storage is a bona fide and legitimate focus of clinical concern in a number of cases on many practitioners’ caseloads. The mental health provider’s role in the direct management of firearm access and the overall burden of firearm violence should not be neglected. In addition, innovative policy proposals for regulating access to firearms often imply substantial involvement of mental health professionals in making judgments about the risk of an individual’s access to firearms or of the lifting of a provision prohibiting an individual’s access. As discussions about ways to limit the damage caused by gun violence expand, mental health professionals will likely be called upon more frequently to be part of proposed solutions regarding this issue.

At the outset, it must be recognized that the impact of firearms is highly varied: Injuries due to accidental discharge, suicide, homicide, and mass shootings have different risk factors and will entail different interventions to mitigate risk at individual and population levels. The topics of accidental shootings and suicides, though vitally important from a public health perspective and intriguing from an evidence-based medicine and policy perspective, is left for more in-depth analyses by other authors in other forums. This article addresses the intersection between mental illness and firearm violence and how the nature of that intersection frames clinical and policy interventions to mitigate the damage of gun violence. This review focuses on how scientific information can inform these efforts, but the ethical and legal aspects of working with a legally protected social determinant of a public health issue must also be considered in any policy analysis ( Childress et al. 2002 ).

2. MENTAL ILLNESS, VIOLENCE, AND GUN VIOLENCE

2.1. mental illness and violence.

A useful starting point for examining the relationship between mental illness and violence, particularly gun violence, is to look at this issue from a broad, population-based perspective. Epidemiological studies have shown an association between having a mental illness and being involved in crime or violence ( Elbogen & Johnson 2009 , Stuart 2003 , Tiihonen et al. 1997 , Walsh et al. 2002 ). Although the power of this link is greatly overestimated by the general public ( Pescosolido 2013 ), it has been documented repeatedly that people who report diagnosable levels of psychiatric symptoms also report more involvement in acts of violence toward others than the general population reports. An even stronger association emerges, however, between being a victim of violence and having a mental illness ( Desmarais et al. 2014 , Teplin et al. 2005 ), with individuals with mental illness at least three times more likely to be targets than to be perpetrators of violence ( Choe et al. 2008 ). Several studies have also indicated that, among people with severe psychiatric illness, recent violent victimization is one of the best predictors of imminent violence risk ( Hiday et al. 2001 , Johnson et al. 2016 , ten Have et al. 2014 ).

The most basic lesson of this epidemiological literature is that the overwhelming majority of people with mental illness are not violent and the majority of people who are violent do not have identifiable mental illness ( Choe et al. 2008 ). Because an overwhelming percentage of people with mental illness are not violent, and because the occurrence of serious mental illness is relatively low, it is estimated that only about 4% of criminal violence can reasonably be attributed to mentally ill individuals ( Metzl & MacLeish 2015 , Swanson 1996 ). This means that even if all of the association between mental illness and violence could somehow be eliminated, we would still have to confront 96% of the violence in the United States ( Swanson 2008 , 2015 ).

Studies exploring gun violence by people with mental illness are limited, likely due to the rarity of this type of violence. One study has shown that gun violence by people with severe mental illness occurs in 2% or less of patients in the year after discharge from inpatient settings; rates may be lower among less acute patients ( Steadman et al. 2015 ). Clearly, there is a fairly small nexus at the intersection of people who are mentally ill, armed, and potentially violent. Again, even if all of these individuals could be identified and stopped from engaging in gun violence, the impact on the overall level of gun violence would not be substantial. At a population level, it seems that the designation of being “mentally ill” does little to identify a useful group for targeted violence prevention policy.

From the results of group comparison studies, it is apparent that the estimated relationship between involvement in violence and the presence of a mental illness varies considerably depending on the type of disorder examined and the methodology used. Serious mental illnesses, such as schizophrenia and depression, generally show associations that are several times weaker than those seen in more behaviorally based diagnoses, such as substance abuse or antisocial personality disorders ( Elbogen & Johnson 2009 , Oakley et al. 2009 , Steadman et al. 1998 ). There is some evidence that individuals experiencing first-episode psychosis could be at elevated risk for involvement in violence, with levels of involvement about 3–5 times what might be expected ( Large & Nielssen 2011 , Winsper et al. 2013 ). In addition, meta-analyses show considerable variation among estimates of association related to study design features and evaluation of moderating risk factors ( Fazel et al. 2009 , Fazel & Yu 2009 , Witt et al. 2013 ). Although a majority of studies show an association between serious mental illnesses and subsequent arrests for violence, some field studies using self-report methods ( Lidz et al. 1993 , Monahan et al. 2001 ) show that individuals with serious mental illness alone have no higher likelihood of violence than their neighbors.

2.2. Substance Use and Violence

A number of studies identify substance use and substance use disorders as particularly strong factors increasing the chance that an individual with a mental illness will get involved in violence ( Mulvey et al. 2006 , Swanson et al. 1990 ). The self-report studies cited in the previous section ( Lidz et al. 1993 , Monahan et al. 2001 , Steadman et al. 1998 ) indicate that individuals diagnosed with both a mental illness and a substance use disorder have a higher prevalence of involvement in violence than their neighbors. Other investigations also indicate that increased levels of substance use are associated with increased likelihood of violence in patients in the community ( Skeem et al. 2004 ), and comorbid mental illness is often considered a critical risk factor for violence among people with substance use disorders ( Chen & Wu 2016 ). Illicit substance use is associated with firearm violence in particular, especially when that substance use is also associated with involvement in illegal drug sales ( McGinty et al. 2016a ). Another review has identified a series of intersections between violence risk and alcohol use, including alcohol intoxication as a risk factor for being shot, firearm suicide, and accidental firearm injury ( Branas et al. 2016 ).

2.3. Psychosocial Risk Factors and Violence

The literature on psychosocial risk factors for violence also indicates that certain characteristics of an individual, e.g., age, socioeconomic status, and prior criminal involvement, are much more statistically predictive of involvement in violence than the presence of a mental illness ( Bonta et al. 1998 ). The power of mental illness as a predictor diminishes greatly when these characteristics are taken into account ( Elbogen & Johnson 2009 , Prins et al. 2015 , Skeem et al. 2014 ). This is most likely the case because mental illness and mental deterioration are rarely seen as the major forces behind involvement in violence ( Mulvey et al. 2006 ). Most violent incidents involving individuals with a mental illness involve either a family member or a close acquaintance ( Newhill et al. 1995 , Steadman et al. 1998 ) and are usually embedded in a history of tumultuous encounters. Moreover, examination of crimes involving individuals with mental illness indicate that less than 20% of them are directly preceded by exacerbated symptoms of the illness ( Peterson et al. 2014 ). It is rare that the presence of a mental illness is a dispositive explanation for an act of violence ( Monahan & Steadman 2012 , Skeem et al. 2016 ). Mental illness is one factor in a person’s life that is sometimes relevant to involvement in violence, but it is very rarely the only factor, or even a causal factor.

A particularly salient social and contextual factor to consider for its relation to violence in mentally ill individuals is exposure to and involvement in DV. Assessment and screening for current or prior DV has become a standard of care in most clinical disciplines, and mental health professionals are regularly called on to provide interventions for offenders despite the relatively small impact of most DV interventions ( Babcock et al. 2004 ). An estimated 30% of patients in treatment have been victims of DV, with women with depression or anxiety at the highest risk ( Oram et al. 2013 , Trevillion et al. 2012 ). This issue is clearly within the purview of mental health care and offers an opportunity for the prevention of violence.

It is clear that the social dynamics of DV situations are particularly relevant to assessing and preventing patient violence. Violence involving people with mental illness—both as targets and as perpetrators—is far more likely to involve family members or acquaintances ( Buila & Marley 2001 , Estroff et al. 1998 ). Similarly, 90% of women who are murdered are killed by a person they know, and half of these are victims of a current or former partner or spouse ( Catalano et al. 2009 ). In contrast, a recent meta-analysis places the risk of being killed by a stranger with severe psychotic illness at 1 in 14 million per year ( Nielssen et al. 2011 ).

This review of the literature about the correlates of violence in individuals with mental illness highlights the importance of recognizing the social context surrounding an individual and fluctuations in the state of an individual’s illness. Categorization of individuals by illness appears to introduce a large amount of interindividual heterogeneity on factors relevant to the occurrence of violence, and as a result, the use of psychiatric diagnosis or symptom level alone has very limited utility as a tool for the prediction of violence risk ( Rozel et al. 2017 ). Numerous factors can increase violence risk in people with mental illness, including prior criminal or violent behavior, prior victimization, substance use and intoxication, nonadherence with treatment, and the presence of other psychosocial stressors such as economic distress and housing instability ( Swanson et al. 2014 ).

This reality calls for approaches to identifying individuals at risk in terms of their social context and fluctuations in their life situation and behavior over time ( Mulvey & Lidz 1995 ). Mental illnesses progress, deteriorate, stabilize, or get better with time and circumstance; they are a condition, not an indicator of a person’s unique dangerousness ( Adam 2013 ). Like pulmonary disorders or heart conditions, mental illness must be managed to avoid decompensation and the harm that might occur during those periods of decompensation. Approaches that frame risk as an interaction of both static (or set) aspects of a person (such as history of prior violence or victimization) and dynamic (or shifting over time) factors (such as level of substance use or decreased emotion regulation) align with the greater body of the research on the factors related to violence in individuals with and without mental illness ( Douglas & Skeem 2005 ). This framework can lead to actionable interventions to limit violence risk and address gun violence more effectively. However, any of these approaches would also present new challenges for mental health professionals.

3. THE SOCIAL AND LEGAL CONTEXT OF GUN OWNERSHIP IN THE UNITED STATES

3.1. gun ownership and gun owners.

Any meaningful framing of the problem of gun violence—and any hope of enacting meaningful interventions—must be rooted in an understanding of the social and legal context of gun ownership in the United States. Not examining and appreciating these influences would be a major oversight for those interested in designing interventions to limit the tragedies of gun violence. As demonstrated in many other areas, the gap between efficacy and effectiveness is often determined by the ground truth: where clinical professionals work and their patients live. Clinical and public health interventions to mitigate gun violence are no different: They will only succeed if they accommodate or overcome intrinsic legal or sociocultural barriers. Unfortunately, few topics are currently as politicized and polarizing as the gun control/gun rights debate. The emotional nature of this debate almost inevitably engenders strong and often extreme beliefs in both policy makers and the public, which may not accurately reflect research evidence or the likely effectiveness of particular interventions.

The first clear fact is that gun ownership is common. Although gun ownership by household seems to have declined over the past 30 years, rates remain above 30% ( Morin 2014 , Smith & Son 2015 ), with well over 300 million guns in private hands ( Ingraham 2015 ). Firearms can be easily acquired from licensed gun dealers or through private transfers, the latter often bypassing any opportunity for a background check. Moreover, gun ownership can be concentrated: Half of gun owners have four or more firearms ( Hepburn et al. 2007 ). Ownership rates vary significantly by a number of factors: by demographic characteristics of a locale, by state (from a low of 5.2% in Delaware to 61.7% in Alaska), and by self-identified affiliation with gun culture ( Kalesan et al. 2016 ). Most (60%) of gun owners identify self-defense as a reason for gun ownership, with hunting, sport, and target shooting also commonly endorsed ( Swift 2013 ).

There are also some clear patterns regarding the possible consequences of gun ownership. The number and rates of incidents of gun violence, especially firearm homicides, have been decreasing steadily over the past few decades ( Fowler et al. 2015 , Wintemute 2015 ). When researchers have examined relative accessibility—by, for example, comparing gun-owning household with non-gun-owning households or comparing states with high versus low gun ownership rates—they have found that elevated rates of gun access in households are associated with increased risk of homicide and suicide over time by household and at a population level ( Fowler et al. 2015 ; Kellermann et al. 1992 , 1993 ; Miller et al. 2002 , 2006 ). This is particularly important because access to firearms by DV perpetrators is a critical risk factor in DV-related homicides ( Campbell et al. 2003 ). In addition, a law enforcement officer in a state with a high gun ownership rate is three times as likely to be shot and killed during their work ( Swedler et al. 2015 ).

It should also be noted that high gun ownership rates do not appear to convey any meaningful protection against violent victimization at a population level. The idea that increased firearm ownership leads to decreased crime ( Lott 2010 , Plassmann & Whitley 2003 ) does not appear to hold up to rigorous analysis ( Natl. Res. Counc. 2004 ; Donohue & Ayres 2003 , 2009 ), and international studies instead suggest that handgun ownership is associated with increased risk of violent victimization ( van Kesteren 2014 ). Although the issue remains controversial, the hypothesis can, at best, be described as unconfirmed, and self-defense alone is a weak argument for increased or easy gun access.

3.2. Legal Issues

The second significant point to recognize is that gun ownership is legal; this is unlikely to change in the foreseeable future. The United States is one of three countries to have a Constitutionally protected right to firearms ( Elkins 2013 ). The Second Amendment to the US Constitution, ratified into law in 1791, reads, “A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Although private citizens’ access to weapons has been a point of contention since the earliest participatory governments of Greece and Rome ( Halbrook 2013 ), the debate in the United States has become markedly pitched in the past 25 years. Increased media coverage of shootings; changes in the quantity, variety, and costs of firearms widely available for purchase; changes in the priorities of certain national advocacy groups; and a number of significant court rulings have all contributed to making this a currently volatile topic ( Wilson 2016 ).

One of the central points of contention has been whether the Second Amendment protected the right of individuals to own firearms in general or only in the context of their role in a militia or other state-related function. Removing any doubt on this matter, the US Supreme Court affirmed that the right to bear arms is an individual right not to be unduly limited by federal or state law ( District of Columbia v. Heller 2008 , McDonald v. City of Chicago 2010 ). These rulings are significant because they establish that the right is for the individual (i.e., attachment to a militia is not pertinent) and make clear that the protection expressly extends to firearms well-suited for self-defense—that is, the very revolvers and semiautomatic handguns used in more than 70% of criminal gun homicides ( https://ucr.fbi.gov/crime-in-the-u.s/2014/crime-in-the-u.s.-2014/tables/expanded-homicide-data/expanded_homicide_data_table_8_murder_victims_by_weapon_2010-2014.xls ).

Both Heller and McDonald acknowledge that some limitations on firearm access may be reasonable for persons with clearly identified risks. Specifically, the Court stated that their decision was not meant to eliminate “the longstanding prohibitions on the possession of firearms by … the mentally ill” ( District of Columbia v. Heller 2008 ). The case, however, did not present the necessity for the court to address exactly how these restrictions on the mentally ill would be constructed or the appropriate limits of the restrictions that might be imposed. Current state and federal standards limit access to firearms for people in a number of categories other than the mentally ill, including prior violent felons and people with addiction issues. The standard method for enforcing the restrictions on sales to individuals with mental illness is to have states transmit records of involuntary commitments for potential harm to self or others to a centralized federal data base, the National Instant Criminal Background Check System (NICS). This database must be consulted by federally licensed gun dealers to determine if an individual should be disqualified from purchasing a weapon.

There have been several problems with using this system for limiting purchases by mentally ill individuals. First, of course, is the fact that many purchases do not occur in situations where a background check is required. In most states, private purchases between individuals, transactions at gun shows, or sales of certain types of weapons (e.g., long guns) do not require checks. Second, the enduring wording of the criteria for restricting sale because of mental illness, i.e., the Gun Control Act of 1968’s exclusion of people who have been “adjudicated as a mental defective” [18 USC. § 922(d)(4)], has been quite complex in execution. This phrase has been generally translated as barring the purchase of firearms from a federally or state-licensed dealer by individuals who have been involuntarily committed (either at any point in life or within a stated prior time period). Standards and procedures for involuntary commitment vary considerably from state to state, however, making the standard far from uniform. Third, many states have been very slow to provide data to the registry. Estimates indicate that, before 2007, states had sent only a negligible number of their mental health commitment reports to the federal government ( Liu et al. 2013 ). Reporting is still far from complete ( Swanson et al. 2014 ).

Although broad revocation of the personal right to bear arms could occur either through subsequent court review or by constitutional amendment, neither seems likely or imminent. Continued acceptance of screening for appropriate denials at the point of purchase is the accepted compromise position on this issue. Thus, one may reasonably discard the notion of broad bans on firearms, seizures of existing firearms, or similar interventions as practical measures to reduce gun violence.

Despite the common and nearly clichéd calls for major overhaul of gun laws in the wake of highly publicized tragedies, substantial revisions rarely, if ever, occur. This trend is often the direct result of the fact that most gun laws are state statutes and, as such, affected by political party control of state legislatures. Moreover, many newly enacted gun laws seem to broaden rights rather than restrict them, possibly in reaction to fear of the loss of gun rights ( Luca et al. 2016 ). Highly publicized shootings drive sharp increases in gun sales, as do new gun laws or court rulings, regardless of whether the law or ruling is restrictive or expansive ( Aisch & Keller 2016 ). Given the array of political, social, and legal barriers, it is likely that any call for a broad ban on firearms would have negligible likelihood for success and may, thus, be an unwise application of political capital.

3.3. Gun Culture

Part of the reason that broad statutory changes regarding gun ownership are often met with deep resistance is that they are seen as more than just an attempt to revise a set of regulations; they are often seen as a threat to a way of life or culture. Many individuals who own guns are part of a gun culture that can be difficult for outsiders to understand. Fully grasping or appreciating this aspect of gun ownership may be particularly hard for mental health professionals. No reliable study examining relative ownership rates by profession—i.e., whether psychologists and other mental health professionals own guns at similar rates as the general population—seems to exist. It seems fair to assume, however, that firearm ownership by mental health professionals may be lower than that of the general population, based simply on demographics and related attitudes. This creates a situation that tests mental health professionals’ capacities to integrate respect for these differing cultural beliefs into their practice.

Defining and testing the impact of gun culture on gun ownership and attitudes toward firearm regulation is a difficult task. In general, it seems that there is a sense of identity among firearm owners and enthusiasts that is often anchored in a shared enjoyment of owning and using firearms, often tied to family traditions, personal beliefs, and social relationships. The values of the community of gun enthusiasts have shifted over time, and the current trend appears to be increased identification as a persecuted group ( Somerset 2015 ).

Most relevant to the discussion here, a sizable number of gun owners perceive health and mental health professionals as hostile to their interests, values, and rights ( Wheeler 2015 ). Focused training for these professionals on firearm-related issues has been limited ( Price & Khubchandani 2016 , Traylor et al. 2010 ). The stage is set for professionals to enter discussions about firearms with limited comfort and competence, which seems an invitation for misunderstandings. Cultural blindness on the part of mental health professionals may lead to failures in engaging the patient, understanding their interests, and communicating useful health information to them or their family ( Radant & Johnson 2003 , Shaughnessy et al. 1999 ). Effective work by clinicians with gun owners is increasingly seen as a cross-cultural problem and will require careful integration of both a quantitative understanding of gun violence and a qualitative understanding of the interests of gun owners ( Betz & Wintemute 2015 ).

4. CURRENT POLICY INITIATIVES ADDRESSING GUN VIOLENCE AND MENTAL ILLNESS

4.1. screening firearm purchasers.

Most of the current legal and policy efforts relating to mental illness and firearm violence revolve around limiting access by screening at the time of purchase. As mentioned above, this approach requires background checks on individuals purchasing firearms at a federally registered dealer. If the person has a record of involuntary commitment in the NICS, the seller is required to deny the sale.

Of the more than one million denials of potential purchasers since the inception of the NICS program, mental health issues account for only 1.4% ( Crim. Justice Inf. Serv. Div. 2015 ). Only a small proportion of the people on the NICS have mental health exclusions, and these rarely produce a denial for purchase. The exclusions apply only to people who have been adjudicated incompetent—generally through a judicially ordered involuntary commitment or guardianship— or who have criminal dispositions such as not guilty by reason of insanity. The rate of reporting to NICS and the rate of denial of purchase for this criterion have increased considerably since 2007 ( Swanson 2015 ), but 13 states and territories do not use the federal NICS program at all and another seven only use it for certain types of firearms ( Crim. Justice Inf. Serv. Div. 2015 ). Until the NICS Improvement Amendment Act of 2008, significant operational barriers and conceptual ambiguity remained about what data could and could not be reported to the database because of confidentiality; there remain concerns that past records have not been thoroughly reported ( Liu et al. 2013 ).

In 2014, the federal NICS system provided 3,772,583 background checks, approving 98% of those sales. Of the denials, approximately 3,600 potential purchasers were stopped by NICS from purchasing firearms due to mental health issues; these individuals made up 3.9% of all denials through NICS that year ( Crim. Justice Inf. Serv. Div. 2015 ). Substantially less is known about the disposition of the remainder of the 8,500,000 new firearms manufactured and shipped to US dealers for sale that year ( Bur. Alcohol Tob. Firearms Explos. 2015 ).

Although these screening processes do not appear to have a substantial impact on overall gun violence rates, it appears that they can have an impact on the small sector of gun violence involving people with severe mental illness. A recent study ( Swanson et al. 2016 ) used public records over an 8-year period to examine gun disqualifications and arrests for violent gun crimes as well as firearm suicides for a sample of people receiving publicly funded treatment for severe mental illness. This study found that the implementation of an increased level of NICS reporting of involuntary commitment incidents (in 2007) led to a substantial reduction in the rate of arrest for violent crime for individuals who had, in fact, been involuntarily committed. The level of violent crime in gun-disqualified persons was below that of others with mental illness who were never disqualified. Being denied a gun purchase based on the history of involuntary commitment alone, however, only accounted for 13% of the disqualifications of those who had a prior involuntary commitment and were arrested for a violent crime; 52% of these individuals were disqualified by virtue of a prior criminal record issue. Thus, the narrow criteria of involuntary commitment as an excluding factor affected a relatively small proportion of the patients who went on to engage in significant violence; past history of criminality would have disqualified these individuals ( Swanson et al. 2016 ).

Federal law and most states permit private transfer of firearms between two people, bypassing licensed dealers and background checks. An estimated 40% of firearm transfers occur as private transactions, and an estimated 90% of guns used in crimes came from resold firearms ( Wintemute et al. 2010 ). Private sales at gun shows often take place even when a potential purchaser explicitly indicates that they would not pass a background check. Some states with enhanced regulation of gun show sales limit such transactions ( Wintemute 2013 ).

Some states criminalize the knowing transfer of a firearm to a person who is disqualified from possessing a firearm. Such laws are neither common nor commonly understood, limiting their utility in preventing disqualified people with mental illness from obtaining firearms ( Fowler 2001 ). Prosecution of people who violate such laws also seems to be rare ( Sterzer 2012 ; http://smartgunlaws.org/gun-laws/policy-areas/background-checks/categories-of-prohibited-people/ ).

Private sales and transfers of firearms are easily facilitated through online services. Popular platforms such as Facebook and Instagram have had varying numbers of private sales facilitated through their sites, but recently took steps to limit facilitation of private sales of firearms. Some sites are entirely focused on firearm sales and allow searching based on region, identifying private sales opportunities where background checks are less likely or not legally required ( Daniels 2013 ). Such activities continue despite some limitations instituted by certain sites, and an emerging concern is that these methods of purchase may be serving as a conduit for heavy armament to militias in international conflicts. Private sales of semiautomatic handguns and rifles are routine through some of these websites, with potentially tragic outcomes; it is chilling to think what could happen with transfers of military-grade ordinance ( Chivers 2016 ).

Overall, screening of new purchasers of firearms provides minimal incremental decreases in rates of gun violence by people with severe mental illness and a history of commitment. The coverage of screening practices and their impact are low. Further, such benefits may be comparatively small when one considers the relative ease with which a person can obtain firearms through private sales and Internet-facilitated sales without undergoing a background check.

4.2. Removal After a Prohibiting Event

Several states have statutory provisions that allow for removal of firearms from previously lawful gun owners after a disqualifying event, such as an involuntary hospitalization. Most states obligate a newly prohibited firearm owner to transfer any guns in their possession to a lawful owner within a certain time frame after an event, but there is usually no process to confirm that this transfer has occurred. Only four states—California, Connecticut, Texas, and Indiana— have provisions allowing law enforcement officers to proactively remove firearms at the time of or after a disqualifying event (e.g., an officer who takes a person into custody on an emergency commitment can confiscate firearms at that time) ( http://smartgunlaws.org/gun-laws/policy-areas/background-checks/categories-of-prohibited-people/ ).

Removal of firearms by law enforcement after such disqualifying events is challenging. It is often unclear which agency—if any—would have the authority or responsibility to remove the firearms. There is significant variability in how different jurisdictions enumerate and enforce such laws, and many departments lack clear policies or standards that address this issue ( Int. Assoc. Chiefs Police 2007 ).

Gun violence restraining orders (GVROs) are an alternate pathway to removal established recently in several states. This mechanism creates a specific court order for the removal of firearms from a person who may ( a ) be a prohibited possessor under state or federal standards who has not voluntarily released custody of their firearm or ( b ) have significant risk factors for harming themselves or others with a firearm but not be technically prohibited from having the firearm by other legal standards. Such orders serve as a complementary tool to other prohibitive laws and can be used for people who are identified as posing imminent risk but who do not meet involuntary commitment criteria ( Frattaroli et al. 2015 ). In most instances, one individual seeks an order from a judge for removal of the firearm based on the current state and situation confronting another individual (e.g., heavy drinking with a history of gun-related violence when intoxicated). Additionally, GVROs are not predicated on the presence of a mental illness, which substantially mitigates some of the intrinsic stigma attached to mental illness–specific measures ( Wiehl 2014 ). This innovative strategy for targeted removal requires adequate provisions for weighing the conditions needed to prompt removal and reasonable procedures for reinstating ownership rights ( McGinty et al. 2014a ). There are no current empirical studies on the effectiveness of this strategy.

A variant of screening and gun removal after a precipitating event is found in the New York Secure Ammunition and Firearms Enforcement Act of 2013 (the NY SAFE Act). This act amended the state mental health law, introducing a requirement for mental health professionals to report individuals to a state registry if, in treating that individual, they “conclude, using reasonable professional judgment, that the individual is likely to engage in conduct that would result in serious harm to self or others” [Ment. Health Proced. Act at §9.46(b)]. The report is reviewed by a county official. If approved by the county official, the database for gun permits is then searched to see if that individual has a current permit. If so, the permit is revoked and the gun is seized. The individual is then barred from obtaining a permit until it is reinstated in a revocation hearing.

Systematic research on the effectiveness of the provisions in the NY SAFE Act regarding mental health professionals’ reporting of dangerous individuals has not been conducted. As emphasized above, the likelihood of such provisions having a significant impact on the overall level of gun violence is extremely low. Whether such a statute can have an impact on gun violence or suicide involving individuals with mental illness is the most logical, but methodologically thorny, question that must be addressed. There are also concerns about possible unintended effects, including an undermining of therapeutic relationships, reductions in high-risk individuals seeking treatment, restrictions on clinical discretion in handling potentially violent or suicidal situations, and increased stigma of mentally ill individuals. Sound information about the overall effects of clinical reporting requirements, as exemplified in this law, would be a valuable addition to the current debate on the topic of mental illness and gun violence.

4.3. Prohibitions on Asking About Access to Firearms

Other statutory efforts related to clinical practice and gun violence have been instituted, but primarily with the intent of limiting the intrusion of mental health professionals on this issue rather than encouraging their involvement. The Florida Firearm Owner’s Privacy Act of 2011— colloquially known as the “Docs and Glocks” law—creates disciplinary sanctions for licensed health care professionals who ask about or document ownership of firearms by their patients. Part of the rationale for this law is the suggestion that firearm safety counseling by professionals may increase the risk of people being attacked by limiting an individual’s access to a self-defense weapon ( Paola 2001 ). The notion of widespread use of firearms in self-defense, however, has been widely and repeatedly debunked (e.g., Hemenway & Solnick 2015 ).

The main purported merit of such legislation is that it protects patient privacy around the Constitutionally protected and potentially stigmatized act of owning a firearm. It is unclear, however, why this specific line of inquiry would be prohibited while other inquiries about stigmatized acts, Constitutionally protected or otherwise, are routine. For example, inquiries about sexual orientation, gender identity, and drug and alcohol use are often routinely expected in clinical assessments.

The impact of legal curbs on health professionals asking and counseling about firearm safety remains unclear, but it seems unlikely that this policy will decrease firearm violence and other injuries in people with mental illness. The impact for mental health professionals seems obvious and substantial. Although it should generally be easy to justify such an inquiry, the potential threat of professional sanctions would seem to discourage it, even in the face of clear evidence that asking about guns and discussing safe gun practices can produce a significant reduction in suicides ( Brent et al. 2000 , 2013 ).

5. TOWARD SOUND POLICY

There are many well-considered policy recommendations in the clinical and legal literature about how to address the overlap of mental illness, firearms, and violence. This section examines some of the more common approaches in terms of their likely utility and justifications. There are still a number of unanswered questions to address in this area that could focus the next round of policy suggestions.

5.1. Characteristics of an Optimal Policy

Not all policies are created equal, and relative merit is not always obvious or disconnected from basic values. Although the major aim of public health policies is to reduce disability and illness or to promote positive outcomes within a specific population, these policies are often enacted in a way that curtails the liberties of members of that same population. Policies aimed at preventing gun violence are particularly complicated because they often promote broad public health benefit at the expense of some of the most basic liberties. As such, very specific criteria must be met a priori for a policy in this area to be both ethical and effective ( Childress et al. 2002 ).

One requirement of an ethical public health policy is broad impact. Funding interventions that only address the needs of a small segment of the population are an expensive and inefficient use of cognitive, political, and financial resources and should be avoided. One could reasonably suggest that an intervention that only targets firearm violence risk by people with severe mental illness but ignores or has no impact on the other health needs of people with mental illness or does not mitigate other types of violence would be narrowly targeted. That is not to say that such a narrow target is unreasonable, but limited resources may be better spent on interventions that would have broader impact. Ideally, policies directed at the intersection of mental illness and gun violence should have significant benefits along the fuller spectrum of needs of people with mental illness or reduce a broader swath of potential violence.

Interventions should ideally be evidence based or at least reflect the best understanding of existing evidence. When there are rapidly emerging threats to public health, there may be a clear and pressing need to provide interventions that are untested (e.g., in the response to rapidly emerging infectious diseases such as Zika). Firearm violence, however, is not a novel or rapidly emerging threat and would not seem to qualify for this exemption from the need to be grounded in—or at the very least not expressly contrary to—known empirical evidence.

Interventions should also recognize that implementation of some interventions proceed quite differently in the real world than in a lab. Interventions targeting mental health, firearms, and violence need to take into account the heterogeneity of violence, the importance of non-mental-health risk factors for violence in people with mental illness, and the political and practical challenges of any intervention attempting to shift the ownership or use of the 300 million privately owned firearms in the United States. The real-world constraints in fashioning effective policy on firearm violence and individuals with mental illness cannot be downplayed.

Finally, any intervention needs to be assessed in terms of the balance of potential clinical benefit against the abrogation of rights. Whether by utilitarian or deontological standards, a public policy to mitigate violence risk must have an acceptable cost in terms of the civil rights of individuals. The test is not whether the policy or intervention is cost free in terms of rights but, instead, how expensive and expansive it is in the limitations it might create.

5.2. Ineffective Approaches

Many commonly proposed interventions for firearm violence fail to meet the above criteria for sound policy investments. Some interventions have a focus that is too narrow. Bans on assault weapons and large-capacity magazines would have a small, though delayed, impact on some mass shootings but only a negligible impact on most firearm violence. Achieving these meager benefits would require significant political and fiscal outlay to enact legislation and craft restrictions that could not be easily bypassed by manufacturers.

Some proposed policies are largely shaped by stigma or inflame stigma to such a degree that the ethical costs would outweigh any nominal benefit. Proposals for blanket bans of access to firearms for people with mental illness or extended hospitalization fail to pass the aforementioned criteria at multiple levels. The interventions are overly broad given the rarity of violence by people with mental illness; the net effect would be broad denial of rights to most people with mental illness who are not dangerous while leaving most firearm violence unaddressed. Such policy proposals scapegoat people with mental illness and have the potential to expand rather than correct stigma and bias ( Corrigan et al. 2005 ).

Similarly, calls to broadly ban or abolish firearms are also grossly impractical for the United States. Although state-sponsored gun buyback programs have been successful in Australia ( Chapman et al. 2016 ), they seem unlikely to be even remotely successful in the United States. In addition to the constitutional protection of ownership and high numbers of firearms in civilian hands, which create practical obstacles, a buyback program would also be unlikely to have a substantial impact on violent crime. While studies are challenging to conduct, most firearms intercepted in criminal investigation appear to have been illegally acquired ( Fabio et al. 2016 ) and, thus, seem unlikely to be easily surrendered.

Some interventions, though, may be more promising. There are several policy changes that could affect the level of firearm violence by people with mental illness and have a potentially positive impact on other types of violence and other risks such as suicide.

5.3. Potentially Effective Interventions

Several interventions would appear to meet Childress et al.’s (2002) criteria for effectiveness and proportional impact. Outlined in the following sections are potential public policy initiatives based in evidence and specifically intended to target the intersection of mental illness, firearms, and violence.

5.3.1. Expanded funding streams for well-designed objective research on firearm violence and violence prevention

It is difficult to take informed action when there is so little information about gun violence in general and gun violence in individuals with mental illness in particular. The ban on federally funded research on firearm violence in the United States has left many critical questions unanswered. Careful evaluation of comparative efficacy of firearm legislation in different jurisdictions is promising ( Rostron 2016 , Swanson et al. 2016 ) but often underfunded. Prospective studies to evaluate violence and suicide risk factors among firearm owners could help clarify the processes of gun ownership and use and identify potential high-risk groups. Improved legal and funding structures to promote and simplify retrospective evaluation of how people engage in violence, looking for differences relating to mental illness and other factors, could provide guidance for more refined clinical practice.

5.3.2. Promotion of safer storage as a standard goal

Much as reproductive health education professionals have moved from the overly reassuring notion of safe sex in favor of that of safer sex, professionals should shift from the idea of safe storage and removal to that of safer storage. These discussions have already occurred regarding ways to reduce suicide risk ( Mann & Michel 2016 , Stanley et al. 2016 ), with many clinicians—and, for that matter, firearm owners, policy makers, and other stakeholders—presenting gun access in stark and realistic terms. Guns, if present in the home, are dangerous; absence of guns in the home is not dangerous. The reality is that, in a nation with 300 million firearms, guns are easily accessed through dealers, private sales, or sharing among friends. The absence of a gun in a patient’s home should provide little assurance that the patient would have any difficulty accessing firearms elsewhere. Improving tools and practices for safer storage (e.g., locks, safes, or even use of smart gun technology) may limit impulsive acts of aggression or suicide, but can still be breached by a determined actor.

The resistance to these initiatives is strong. Most firearm owners identify personal or family safety as a factor in gun ownership ( Swift 2013 ), and even a simple lock or safe can impede access to a firearm in an emergency. This resistance, however, does not make the discussion of such issues futile. Open and frank discussion of relative risks and benefits may be useful in clinical settings, introducing the issue of safe storage as a reasonable compromise to competing needs. This is the basic building block of a series of reasonable changes in clinical care that could promote reductions in firearm violence in individuals with mental illness.

5.3.3. Assessment of firearm access and effective counseling about risk as a standard of care

It has become increasingly accepted that firearm access, as an element of general health and mental health assessment, is an ethically and clinically appropriate domain of interest for health care professionals ( Betz & Wintemute 2015 , Butkus et al. 2014 , Laine et al. 2013 , Wintemute et al. 2016 ). Formal enumeration and acceptance of this principle in the form of practice guidelines from major mental, public, and physical health institutions would certainly promote this reform in practice.

5.3.4. Development and distribution of evidence-based education on effective firearm safety counseling practices for clinicians

Establishment of gun safety counseling as part of core or continuing educational requirements for licensed practitioners could promote such efforts. For example, requirements to have a minimal level of education time spent on firearm safety or violence management or minimum standards for new trainees relating to firearm safety and violence management would promote the acceptance of firearm safety counseling being a standard of care.

One of the common critiques of counseling on firearm safety by health professionals is that high-quality training on such activities is difficult to find ( Price et al. 2015 ), even though appropriate and effective educational strategies and resources have been developed ( Brown & Goldman 1998 , McGee et al. 2003 , Rozel et al. 2015 , Slovak & Brewer 2010 ). Getting these methods into the hands of clinicians and endorsing their use is an essential step toward reducing firearm violence in cases appearing in the mental health system.

5.3.5. Evidence-based education on effective firearm safety practices for gun owners and family members of persons with mental illness

Although the effectiveness of widely available firearm safety training for youth is questionable ( Gatheridge et al. 2004 , Himle et al. 2004 , Jackman et al. 2001 ), this does not eliminate the necessity to develop more sound approaches for enlisting and educating those closest to individuals at risk. All of these efforts would benefit from explicit statutory protection for health professionals’ freedom of speech when they communicate evidence-based information and their interpretation thereof to patients.

5.3.6. Development of evidence-based education on effective firearm safety practices and on recognizing mental illness and acute mental health emergencies for firearm dealers

We have limited systematic data on the link between recent firearm purchase and suicide risk ( Wintemute et al. 1999 ); we have even less on the link between recent firearm purchase and violence toward others. It is possible, however, that interventions aimed at processes other than just screening at the point of purchase might reduce dangerous sales. For example, the expansion of mental health training for firearm dealers—programs such as those implemented by the New Hampshire Firearms Safety Coalition ( Vriniotis et al. 2015 ) or Mental Health First Aid training— could promote screening and intervention by licensed dealers in situations where a sale might be related to a mental health crisis.

5.3.7. Establishment of gun safety counseling as part of core or continuing educational requirements for licensed practitioners

States have an array of continuing education requirements for licensed health professionals; common required topics may include child abuse, safety and quality, pain management, or other topics often stipulated by state legislatures. Enacting requirements to spend a minimal level of education time on firearm safety or violence management may be beneficial. Additionally, agencies responsible for the national accreditation of training programs might consider developing minimum standards for new trainees relating to firearm safety and violence management.

5.3.8. Establishment of national best practices guidelines on evaluation for expungement

Many states provide a legal pathway for a person prohibited from owning or acquiring a firearm to have those rights restored. Not all of these states, however, require any type of mental health evaluation as part of that process. Clarifying and routinizing these procedures can provide safeguards for appropriate gun access, promotion of safe storage, and conditions for continued ownership related to clinical concerns.

It may seem counterintuitive to think that promoting restoration of firearm rights to people previously excluded from firearm ownership for mental illness reasons could be seen as a prevention initiative. However, given the earlier observation that individuals with mental illness go through periods when risk of violence may be reduced or elevated, it is reasonable to see the restoration process as an opportunity to promote safe practices and monitoring for such periods. In addition, reasonable restoration procedures might enhance reporting. Clinicians—as well as law enforcement officers, hospital administrators, and judges—may be reticent to involuntarily hospitalize a person out of a concern that such a commitment may infringe on that individual’s right to firearms. Although this may be a concern about Second Amendment rights in the abstract, it may also be a more specific concern about the negative effect that a commitment might have on a gun enthusiast or a person who has or aspires to a career in law enforcement or the military. Such reticence may ensure that an untreated or undertreated person with mental illness still has largely unfettered access to firearms, an obviously counterproductive outcome. A consensus-based standard for restoration of rights to gun ownership, if reasonable and practical, could better protect the rights of people with mental illness and potentially decrease the stigma attached to involuntary hospitalization.

5.3.9. Improved legal tools for temporary removal and safe storage of firearms during periods of crisis

Clarifications in the procedures for reinstating rights to own a firearm would be most effective if they operated in conjunction with a clear set of rules about the removal and safe storage of firearms for individuals in times of emotional or psychiatric crisis. As mentioned above, some individuals in acute mental health crisis should not have access to firearms, and some individuals with a history of violence and repeated criminal acts should also be limited in their access ( McGinty et al. 2014a ). Prior violence in general, intimate partner violence in particular, and recurring substance use stand out as highly sensitive risk factors for people both with and without mental illness. Stricter processes to prohibit firearm access or trigger heightened review of potential mental illness in people with these risk factors may help curb access to firearms and mitigate future harm. For example, a misdemeanor domestic violence charge in a person with known substance use or mental illness issues may be considered adequate for prohibiting— temporarily or permanently—that person from owning firearms even if the individual risk factors would not reach the threshold for firearm prohibition on their own.

The current, broad-brush approach of limiting gun sales to individuals with a history of commitment, however, does little to accommodate either the definition of people likely to use firearms violently or the reality of the fluctuating risk states of people who might do so. Legislation that allows for the removal of firearms during times of crisis in validated high-risk groups should produce a more targeted and effective use of the state’s power. In addition, although individuals who have firearms removed can improvise arrangements with friends or family or place them in storage, they may still be relatively accessible, or the individual may not have such resources. Permitting law enforcement agencies or licensed gun dealers to temporarily store and secure firearms for such persons, in conjunction with well-delineated processes allowing input from mental health professionals on removal and return, could be significantly beneficial.

More focused efforts such as these would also require improved legal tools and incentives for active or confirmed removal of firearms after disqualifying events. Few law enforcement agencies are permitted or willing to enter a person’s home to search for or remove firearms after a disqualifying event, such as a domestic violence arrest or terroristic threat. Legal requirements and adequate resources for law enforcement to actively remove firearms in such situations need to be in place to allow for targeted removal of firearms. If a person does not voluntarily give up possession of firearms within a reasonable time after a disqualifying event, application of civil forfeiture principles to confiscated firearms may provide added incentive to encourage active law enforcement intervention.

5.3.10. Exclusion of firearms from bars and other areas where alcohol or substance use is common or expected

Numerous studies, presented above, have identified strong links among substance use, particularly alcohol use ( Mulvey et al. 2006 ), violence, and firearm violence. Oddly, some states have taken steps to expressly permit or encourage concealed or open carry of firearms in bars. The promotion of laws and policies with the exact opposite intent would seem to make sense in light of the weight of available evidence. Potentially, such efforts could take advantage of the integration of firearm and alcohol regulation through offices such as the Bureau of Alcohol, Tobacco, Firearms and Explosives.

5.3.11. Clear media reporting guidelines for major violent events

Although they were a long time in coming, ( Hunt 1845 , Sonneck et al. 1994 , Bohanna & Wang 2012 ), there are currently guidelines on reporting about suicides that minimize the risk of copycat suicides and contagion. Similar guidelines could be developed and adopted by major media outlets for ethical reporting of mass shootings and similar events. Links between sensational reporting of mass shootings and copycat events are becoming better established ( Cantor et al. 1999 , Towers et al. 2015 ), and early proposals for media guidelines are already being developed ( Perrin 2016 ).

General considerations might include avoiding glamorization of assailants or speculation about motivations or the role of mental illness, as well as avoiding detailed descriptions of injuries or tactical methods that may provide practical guidance to potential copycats. Journalists may, instead, wish to consider emphasizing coverage about the victims and the impact of their loss; the acts of victims, bystanders, and law enforcement officers who intervened; or law enforcement investigation and prosecution of offenders. Task forces integrating media, mental health, violence, and health and media ethics experts would be useful in developing such formal guidelines.

6. CONCLUSION

Guns are ubiquitous, easy to access, and intrinsically linked to both US culture and the risk of suicide, violence, and injury. However, they are not, by and large, a mental health problem. Any intervention focusing on the link between mental illness and violence will have limited impact on overall gun violence. The amount of violence in general, and gun violence in particular, involving mentally ill individuals is so small that focusing on this aspect of the problem is largely a distraction. It can even be argued that interventions for narrow problems like the link between mental illness and gun violence are so ethically and logistically unwieldy that they inevitably spawn inefficient and ineffective approaches to an important public policy and public health issue. It is likely that interventions targeting mental illness and firearm access could have substantial impact on suicide risk, and that benefit should not be minimized or discarded lightly. The focus on violence to others, however, seems misguided if the idea is to fashion broad policy reforms.

This does not mean that mental health professionals can simply ignore firearm policies. Mental health professionals are called upon to help in efforts to reduce the harms associated with firearms. As responsible professionals, we can introduce empirically sound evidence and evidence-based approaches as considerations in the ongoing and often heated dialogue on these issues. We can provide perspective on clinical issues, respond firmly to policies driven by stigma, and promote reasoned and reasonable statutes grounded in our understanding of mental illness and the limitations and potentials of mental health services.

This review makes it clear that this role is likely to expand. Existing and proposed approaches to gun policy call for more refined determinations of the eligibility to access and retain firearms, and many of these determinations will involve mental health professionals. It is becoming increasingly clear that blanket provisions based on factors such as having a prior involuntary commitment are both expensive and ineffective. There are other risk factors that are far more predictive of future violence. Moreover, an examination of current research makes it clear that the link between mental illness and violence resides in fluctuating patterns of risk, not in static categorizations such as diagnosis. This implies that judgments about the current status of individuals will become more relevant to determinations about the ability to buy or retain possession of a firearm. Mental health professionals cannot evade their evolving role in assisting in the determination of useful risk factors and methods for making reasoned judgments about gun ownership.

Mental health professionals will also in all likelihood be called upon to help fashion more useful regulations regarding the provision of clinical care related to gun access and use. Health care professionals will likely be pushed to adopt standards of care related to screening for gun access and counseling about gun safety. Evidence-driven clinical interventions for assessing risk related to firearm access and counseling patients and families will need to be prioritized and disseminated. Evidence-based clinical practices will have to be mirrored and supported by evidence-based public policy. Neither can exist without adequately funded and carefully directed research to strengthen that evidence base.

The current research seems to indicate that mental health professionals must become more actively involved in the formulation of policies and changes in practice that recognize the realities and risk of gun ownership and access. Failure to do so will leave a looming vacuum, which will be readily filled by ill-informed and politically inspired policy makers, leaving our patients and communities vulnerable to ongoing violence.

SUMMARY POINTS

• Firearms and firearm violence are ubiquitous in the United States.
• The intersection of mental illness and firearm violence is limited, but public health opportunities relating to this intersection should not be ignored.
• Media reporting on violence and mental illness drives stigma and misdirected policy efforts.
• Mental illness alone is a weak predictor of violence and firearm violence risk.
• Violence risk in mental illness is driven by active symptom states, comorbid addiction, prior victimization, and other psychosocial risk factors.
• An expanded evidence base is needed to drive improved clinical interventions and health policy recommendations.
• Mental health professionals need to take an assertive role in helping to shape public policy relating to violence, firearms, and mental illness.

FUTURE ISSUES

• Improved research is needed on the pathways from firearm purchase to adverse outcomes such as violence.
• The outcomes of varying firearm policies, as applied across different states and jurisdictions, need to be studied and disseminated.
• Assessing access to firearms and effectively counseling patients and families on firearm safety is a public health imperative and will need to be protected from political incursion.
• Improved health education research on effective strategies for educating clinicians, patients and families, and firearm dealers on safer storage and injury prevention needs to be developed.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.

LITERATURE CITED

• Adam D. On the spectrum. Nature. 2013; 496 :416–18. [ PubMed ] [ Google Scholar ]
• Aisch G, Keller J. What happens after calls for new gun restrictions? Sales go up. New York Times. 2016 Jun 13; http://www.nytimes.com/interactive/2015/12/10/us/gun-sales-terrorism-obama-restrictions.html .
• Appelbaum PS. Public safety, mental disorders, and guns. JAMA Psychiatry. 2013; 70 (6):565–66. [ PubMed ] [ Google Scholar ]
• Babcock JC, Green CE, Robie C. Does batterers’ treatment work? A meta-analytic review of domestic violence treatment. Clin Psychol Rev. 2004; 23 (8):1023–53. [ PubMed ] [ Google Scholar ]
• Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA. 2015; 314 (5):449–50. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Blair JP, Schweit KW. A study of active shooter incidents in the United States between 2000 and 2013. Texas State Univ./Fed. Bur. Investig. Rep.; San Marcos, TX/Washington, DC: 2014. [ Google Scholar ]
• Bohanna I, Wang X. Media guidelines for the responsible reporting of suicide: a review of effectiveness. Crisis J Crisis Interv Suicide Prev. 2012; 33 (4):190–98. [ PubMed ] [ Google Scholar ]
• Bonta J, Law M, Hanson K. The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychol Bull. 1998; 123 (2):123–42. [ PubMed ] [ Google Scholar ]
• Branas CC, Han S, Wiebe DJ. Alcohol use and firearm violence. Epidemiol Rev. 2016; 38 (1):32–45. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Brent DA, Baugher M, Birmaher B, Kolko DJ, Bridge J. Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression. J Am Acad Child Adolesc Psychiatry. 2000; 39 (10):1220–26. [ PubMed ] [ Google Scholar ]
• Brent DA, Miller MJ, Loeber R, Mulvey EP, Birmaher B. Ending the silence on gun violence. J Am Acad Child Adolesc Psychiatry. 2013; 52 (4):333–38. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Brown RL, Goldman LS. Physician Firearm Safety Guide. Chicago: Am. Med. Assoc.; 1998. [ Google Scholar ]
• Buila S, Marley JA. Crimes against people with mental illness: types, perpetrators, and influencing factors. Soc Work. 2001; 46 (2):115–24. [ PubMed ] [ Google Scholar ]
• Bur. Alcohol Tob. Firearms Explos. Annual firearms manufacturing and export report 2014. Dep. Justice Rep., Bur. Alcohol Tob. Firearms Explos.; Martinsburg, WV: 2015. [ Google Scholar ]
• Butkus R, Doherty R, Daniel H. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160 (12):858–60. [ PubMed ] [ Google Scholar ]
• Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003; 93 (7):1089–97. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Cantor CH, Sheehan P, Alpers P, Mullen P. Media and mass homicides. Arch Suicide Res. 1999; 5 (4):283–90. [ Google Scholar ]
• Catalano S, Smith E, Snyder H, Rand M. Bureau of Justice Statistics: Selected Findings. US Dep. Justice Rep. NCJ228356, Off. Justice Progr.; Washington, DC: 2009. Female victims of violence. https://www.bjs.gov/content/pub/pdf/fvv.pdf . [ Google Scholar ]
• Chapman S, Alpers P, Jones M. Association between gun law reforms and intentional firearm deaths in Australia, 1979–2013. JAMA. 2016; 316 :291–99. [ PubMed ] [ Google Scholar ]
• Chen D, Wu L-T. Association between substance use and gun-related behaviors. Epidemiol Rev. 2016; 38 (1):46–61. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002; 30 (2):170–78. [ PubMed ] [ Google Scholar ]
• Chivers CJ. New York Times. 2016. Apr 7, Facebook groups act as weapons bazaars for militias; p. 1. [ Google Scholar ]
• Choe JY, Teplin LA, Abram KM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv. 2008; 59 (2):153–64. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015; 45 (1):11–27. [ PubMed ] [ Google Scholar ]
• Cohn D, Taylor P, Lopez MH, Gallagher CA, Parker K, Maass KT. Gun homicide rate down 49% since 1993 peak; public unaware: pace of decline slows in past decade. Pew Research Center Social and Demographic Trends. 2013 May 7; http://www.pewsocialtrends.org/2013/05/07/gun-homicide-ratedown-49-since-1993-peak-public-unaware/
• Corrigan PW, Watson AC, Heyrman ML, Warpinski A, Gracia G, et al. Structural stigma in state legislation. Psychiatr Serv. 2005; 56 :557–63. [ PubMed ] [ Google Scholar ]
• Crim. Justice Inf. Serv. Div. National Instant Criminal Background Check System (NICS) operations 2014. US Dep. Justice Rep., Fed. Bur. Investig.; Washington, DC: 2015. [ Google Scholar ]
• Daniels A. The online gun marketplace and the dangerous loophole in the National Instant Background Check System. John Marshall J Inf Tech Priv Law. 2013; 30 :757. [ Google Scholar ]
• Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS, Swartz MS. Community violence perpetration and victimization among adults with mental illnesses. Am J Public Health. 2014; 104 (12):2342–49. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• District of Columbia v. Heller , 554 U.S. 570 (2008)
• Donohue J, Ayres I. More guns, less crime fails again: the latest evidence from 1977–2006. Econ J Watch. 2009; 6 (2):218–38. [ Google Scholar ]
• Donohue JJ, Ayres I. Shooting down the “more guns, less crime” hypothesis. Stanf Law Rev. 2003; 55 :1193–312. [ Google Scholar ]
• Douglas KS, Skeem JL. Violence risk assessment: getting specific about being dynamic. Psychol Public Policy Law. 2005; 11 (3):347–83. [ Google Scholar ]
• Duwe G. The patterns and prevalence of mass murder in twentieth-century America. Justice Q. 2004; 21 (4):729–61. [ Google Scholar ]
• Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009; 66 (2):152–61. [ PubMed ] [ Google Scholar ]
• Elkins Z. Rewrite the Second Amendment. New York Times. 2013 Apr 4; http://www.nytimes.com/2013/04/05/opinion/rewrite-the-second-amendment.html .
• Estroff SE, Swanson JW, Lachicotte WS, Swartz M, Bolduc M. Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders. Soc Psychiatry Psychiatr Epidemiol. 1998; 33 (1):S95–101. [ PubMed ] [ Google Scholar ]
• Fabio A, Duell J, Creppage K, O’Donnell K, Laporte R. Gaps continue in firearm surveillance: evidence from a large U.S. city Bureau of Police. Soc Med. 2016; 10 (1):13–21. [ Google Scholar ]
• Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLOS Med. 2009; 6 (8):e1000120. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Fazel S, Yu R. Psychotic disorders and repeat offending: systematic review and meta-analysis. Schizophr Bull. 2009; 37 :800–10. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015; 79 :5–14. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Fowler TL. Ignorance of the law: Should it excuse violations of certain federal restrictions on the possession of firearms? Campbell Law Rev. 2001; 23 (2):283–304. [ Google Scholar ]
• Fox JA, DeLateur MJ. Mass shootings in America: moving beyond Newtown. Homicide Stud. 2014; 18 (1):125–45. [ Google Scholar ]
• Frattaroli S, McGinty EE, Barnhorst A, Greenberg S. Gun violence restraining orders: alternative or adjunct to mental health-based restrictions on firearms? Behav Sci Law. 2015; 33 (2–3):290–307. [ PubMed ] [ Google Scholar ]
• Gatheridge BJ, Miltenberger RG, Huneke DF, Satterlund MJ, Mattern AR, et al. Comparison of two programs to teach firearm injury prevention skills to 6- and 7-year-old children. Pediatrics. 2004; 114 (3):e294–99. [ PubMed ] [ Google Scholar ]
• Gold LH. Gun violence: psychiatry, risk assessment, and social policy. J Am Acad Psychiatry Law Online. 2013; 41 (3):337–43. [ PubMed ] [ Google Scholar ]
• Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med. 2016; 129 (3):266–73. [ PubMed ] [ Google Scholar ]
• Halbrook SP. That Every Man Be Armed: The Evolution of a Constitutional Right. 2nd Albuquerque, NM: Univ. New Mexico Press; 2013. [ Google Scholar ]
• Hemenway D, Solnick SJ. The epidemiology of self-defense gun use: evidence from the National Crime Victimization Surveys 2007–2011. Prev Med. 2015; 79 :22–27. [ PubMed ] [ Google Scholar ]
• Hepburn L, Miller M, Azrael D, Hemenway D. The US gun stock: results from the 2004 National Firearms Survey. Inj Prev. 2007; 13 (1):15–19. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hiday VA, Swanson JW, Swartz MS, Borum R, Wagner HR. Victimization: a link between mental illness and violence? Int J Law Psychiatry. 2001; 24 (6):559–72. [ PubMed ] [ Google Scholar ]
• Himle MB, Miltenberger RG, Gatheridge BJ, Flessner CA. An evaluation of two procedures for training skills to prevent gun play in children. Pediatrics. 2004; 113 (1):70–77. [ PubMed ] [ Google Scholar ]
• Hunt EK. Statistics of suicides in the United States. Am J Insanity. 1845; 1 (3):225–34. [ Google Scholar ]
• Ingraham C. There are now more guns than people in the United States. Washington Post. 2015 Oct 5; https://www.washingtonpost.com/news/wonk/wp/2015/10/05/guns-in-the-united-states-one-for-every-man-woman-and-child-and-then-some/?utm_term=.5117859b189f .
• Int. Assoc. Chiefs Police. Taking a stand: reducing gun violence in our communities. Int. Assoc. Chiefs Police Rep.; Washington, DC: 2007. [ Google Scholar ]
• Jackman GA, Farah MM, Kellermann AL, Simon HK. Seeing is believing: What do boys do when they find a real gun? Pediatrics. 2001; 107 (6):1247–50. [ PubMed ] [ Google Scholar ]
• Johnson KL, Desmarais SL, Grimm KJ, Tueller SJ, Swartz MS, Van Dorn RA. Proximal risk factors for short-term community violence among adults with mental illnesses. Psychiatr Serv. 2016; 67 (7):771–78. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Jorm AF, Reavley NJ. Public belief that mentally ill people are violent: Is the USA exporting stigma to the rest of the world? Aust N Z J Psychiatry. 2014; 48 (3):213–15. [ PubMed ] [ Google Scholar ]
• Kalesan B, Villarreal MD, Keyes KM, Galea S. Gun ownership and social gun culture. Inj Prev. 2016; 22 (3):216–20. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Kellermann AL, Rivara FP, Rushforth NB, Banton JG, Reay DT, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med. 1993; 329 (15):1084–91. [ PubMed ] [ Google Scholar ]
• Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992; 327 (7):467–72. [ PubMed ] [ Google Scholar ]
• Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence. Ann Intern Med. 2013; 158 (6):493–94. [ PubMed ] [ Google Scholar ]
• Large MM, Nielssen O. Violence in first-episode psychosis: a systematic review and meta-analysis. Schizophr Res. 2011; 125 (2–3):209–20. [ PubMed ] [ Google Scholar ]
• Lidz CW, Mulvey EP, Gardner W. The accuracy of predictions of violence to others. JAMA. 1993; 269 (8):1007–11. [ PubMed ] [ Google Scholar ]
• Liu EC, Bagalman E, Chu VS, Redhead CS. Congr Res Serv Rep. Washington, DC: 2013. Submission of mental health records to NICS and the HIPAA privacy rule. 7-5700/R43040. [ Google Scholar ]
• Lott JR. More Guns, Less Crime: Understanding Crime and Gun-Control Laws. 3rd Chicago: Univ. Chicago Press; 2010. [ Google Scholar ]
• Luca M, Malhotra DK, Poliquin C. The impact of mass shootings on gun policy. Negot. Organ. Mark. Unit, Harv. Bus. Sch.; Cambridge, MA: 2016. (Work. Pap. 16-126). [ Google Scholar ]
• Mann JJ, Michel CA. Prevention of firearm suicide in the United States: what works and what is possible. Am J Psychiatry. 2016; 173 :969–79. [ PubMed ] [ Google Scholar ]
• McDonald v. City of Chicago , 651 U.S. 742 (2010)
• McGee KS, Coyne-Beasley T, Johnson RM. Review of evaluations of educational approaches to promote safe storage of firearms. Inj Prev. 2003; 9 (2):108–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• McGinty EE, Choksy S, Wintemute GJ. The relationship between controlled substances and violence. Epidemiol Rev. 2016a; 38 (1):5–31. [ PubMed ] [ Google Scholar ]
• McGinty EE, Frattaroli S, Appelbaum PS, Bonnie RJ, Grilley A, et al. Using research evidence to reframe the policy debate around mental illness and guns: process and recommendations. Am J Public Health. 2014a; 104 (11):e22–26. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• McGinty EE, Kennedy-Hendricks A, Choksy S, Barry CL. Trends in news media coverage of mental illness in the United States: 1995–2014. Health Aff Millwood. 2016b; 35 (6):1121–29. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• McGinty EE, Webster DW, Jarlenski M, Barry CL. News media framing of serious mental illness and gun violence in the United States, 1997–2012. Am J Public Health. 2014b; 104 (3):406–13. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Metzl JM, MacLeish KT. Mental illness, mass shootings, and the politics of American firearms. Am J Public Health. 2015; 105 (2):240–49. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Miller M, Azrael D, Hemenway D. Rates of household firearm ownership and homicide across US regions and states, 1988–1997. Am J Public Health. 2002; 92 (12):1988–93. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Miller M, Azrael D, Hepburn L, Hemenway D, Lippmann SJ. The association between changes in household firearm ownership and rates of suicide in the United States, 1981–2002. Inj Prev. 2006; 12 (3):178–82. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Monahan J, Steadman HJ. Extending violence reduction principles to justice-involved persons with mental illness. In: Dvoskin JA, Skeem JL, Novaco RW, Douglas KS, editors. Using Social Science to Reduce Violent Offending. New York: Oxford Univ. Press; 2012. pp. 245–64. [ Google Scholar ]
• Monahan J, Steadman HJ, Silver E, Appelbaum PS, Robbins PC, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford Univ. Press; 2001. [ Google Scholar ]
• Morin R. The demographics and politics of gun-owning households. Fact Tank. 2014 Jul 15; http://www.pewresearch.org/fact-tank/2014/07/15/the-demographics-and-politics-of-gun-owning-households/
• Mulvey EP, Lidz CW. Conditional prediction: a model for research on dangerousness to others in a new era. Int J Law Psychiatry. 1995; 18 (2):129–43. [ PubMed ] [ Google Scholar ]
• Mulvey EP, Odgers C, Skeem J, Gardner W, Schubert C, Lidz C. Substance use and community violence: a test of the relation at the daily level. J Consult Clin Psychol. 2006; 74 (4):743–54. [ PubMed ] [ Google Scholar ]
• Natl. Res. Counc. Firearms and Violence: A Critical Review. Washington, DC: Natl. Acad. Press; 2004. [ Google Scholar ]
• Newhill CE, Mulvey EP, Lidz CW. Characteristics of violence in the community by female patients seen in a psychiatric emergency service. Psychiatr Serv. 1995; 46 (8):785–89. [ PubMed ] [ Google Scholar ]
• Nielssen O, Bourget D, Laajasalo T, Liem M, Labelle A, et al. Homicide of strangers by people with a psychotic illness. Schizophr Bull. 2011; 37 (3):572–79. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Oakley C, Hynes F, Clark T. Mood disorders and violence: a new focus. Adv Psychiatr Treat. 2009; 15 (4):263–70. [ Google Scholar ]
• Oram S, Trevillion K, Feder G, Howard LM. Prevalence of experiences of domestic violence among psychiatric patients: systematic review. Br J Psychiatry. 2013; 202 (2):94–99. [ PubMed ] [ Google Scholar ]
• Paola FA. Physicians, firearm counseling, and legal liability. South Med J. 2001; 94 (1):88–92. [ PubMed ] [ Google Scholar ]
• Perrin PB. Translating psychological science: highlighting the media’s contribution to contagion in mass shootings: comment on Kaslow 2015. Am Psychol. 2016; 71 (1):71–72. [ PubMed ] [ Google Scholar ]
• Pescosolido BA. The public stigma of mental illness: What do we think; what do we know; what can we prove? J Health Soc Behav. 2013; 54 (1):1–21. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Peterson JK, Skeem J, Kennealy P, Bray B, Zvonkovic A. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? Law Hum Behav. 2014; 38 (5):439–49. [ PubMed ] [ Google Scholar ]
• Pinals DA, Appelbaum PS, Bonnie R, Fisher CE, Gold LH, Lee L-W. American Psychiatric Association: position statement on firearm access, acts of violence and the relationship to mental illness and mental health services. Behav Sci Law. 2015; 33 (2–3):195–98. [ PubMed ] [ Google Scholar ]
• Plassmann F, Whitley J. Confirming “more guns, less crime” Stanf Law Rev. 2003; 55 :1313–69. [ Google Scholar ]
• Price JH, Khubchandani J. Firearm violence by the mentally ill: mental health professionals’ perceptions and practices. Violence Gend. 2016; 3 (2):92–99. [ Google Scholar ]
• Price JH, Khubchandani J, Payton E. Vision impaired or professionally blind health education research and firearm violence. Health Promot Pract. 2015; 16 (3):316–19. [ PubMed ] [ Google Scholar ]
• Prins SJ, Skeem JL, Mauro C, Link BG. Criminogenic factors, psychotic symptoms, and incident arrests among people with serious mental illnesses under intensive outpatient treatment. Law Hum Behav. 2015; 39 (2):177–88. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Radant LJ, Johnson TM. The Wisconsin Research Network Firearm Safety Survey. WMJ Off Publ State Med Soc Wis. 2003; 102 (4):46–50. [ PubMed ] [ Google Scholar ]
• Rostron A. A new state ice age for gun policy. Harv Law Policy Rev. 2016; 10 (2):327–59. [ Google Scholar ]
• Rozel JS. Rhetoric, reactivity, and evidence-based policy in the wake of shootings. Psychiatry Advisor. 2016 Jan 19; http://www.psychiatryadvisor.com/anxiety/rhetoric-reactivity-and-evidence-based-policy-in-the-wake-of-shootings/article/466055/
• Rozel JS, Jain A, Mulvey EP, Roth LH. Psychiatric assessment of violence. In: Sturmey P, editor. The Wiley Handbook of Violence and Aggression. Vol. 2. Hoboken, NJ: John Wiley & Sons.; 2017. In press. [ Google Scholar ]
• Rozel J, Soliman L, Jain A. The gun talk: how to talk to patients and families about guns and gun safety. Presented at Am. Psychiatr. Inst. Psychiatr. Serv.; Oct. 10; New York. 2015. [ Google Scholar ]
• Schweit KW. Active Shooter Incidents in the United States in 2014 and 2015. US Dep. Justice Rep., Fed. Bur. Investig.; Washington, DC: 2016. [ Google Scholar ]
• Shaughnessy AF, Cincotta JA, Adelman A. Family practice patients’ attitudes toward firearm safety as a preventive medicine issue: a HARNET study. Harrisburg Area Research Network. J Am Board Fam Pract Am Board Fam Pract. 1999; 12 (5):354–59. [ PubMed ] [ Google Scholar ]
• Skeem J, Kennealy P, Monahan J, Peterson J, Appelbaum P. Psychosis uncommonly and inconsistently precedes violence among high-risk individuals. Clin Psychol Sci. 2016; 4 (1):40–49. [ Google Scholar ]
• Skeem JL, Mulvey EP, Appelbaum P, Banks S, Grisso T, et al. Identifying subtypes of civil psychiatric patients at high risk for violence. Crim Justice Behav. 2004; 31 (4):392–437. [ Google Scholar ]
• Skeem JL, Winter E, Kennealy PJ, Louden JE, Tatar JR. Offenders with mental illness have criminogenic needs, too: toward recidivism reduction. Law Hum Behav. 2014; 38 (3):212–24. [ PubMed ] [ Google Scholar ]
• Slovak K, Brewer TW. Suicide and firearm means restriction: Can training make a difference? Suicide Life Threat Behav. 2010; 40 (1):63–73. [ PubMed ] [ Google Scholar ]
• Small Arms Survey. Estimating civilian owned firearms. Small Arms Survey Res. Note 9; Geneva: 2011. [ Google Scholar ]
• Smith TW, Son J. General Social Survey final report: trends in gun ownership in the United States, 1972–2014. NORC Rep., Univ. Chicago; Chicago: 2015. [ Google Scholar ]
• Somerset AJ. Arms: The Culture and Credo of the Gun. Windsor, Ont.: Biblioasis; 2015. [ Google Scholar ]
• Sonneck G, Etzersdorfer E, Nagel-Kuess S. Imitative suicide on the Viennese subway. Soc Sci Med. 1994; 38 (3):453–57. [ PubMed ] [ Google Scholar ]
• Stanley IH, Hom MA, Rogers ML, Anestis MD, Joiner TE. Discussing firearm ownership and access as part of suicide risk assessment and prevention: “means safety” versus “means restriction” Arch Suicide Res. 2016 https://doi.org/10.1080/13811118.2016.1175395 . [ PubMed ]
• Steadman HJ, Monahan J, Pinals DA, Vesselinov R, Robbins PC. Gun violence and victimization of strangers by persons with a mental illness: data from the MacArthur Violence Risk Assessment Study. Psychiatr Serv. 2015; 66 (11):1238–41. [ PubMed ] [ Google Scholar ]
• Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry. 1998; 55 (5):393–401. [ PubMed ] [ Google Scholar ]
• Sterzer J. The good, the bad and the ugly: a 50-state survey exploring federal and state firearm regulations related to mental health. J Leg Med. 2012; 33 (1):171–99. [ PubMed ] [ Google Scholar ]
• Stone MH. Mass murder, mental illness, and men. Violence Gend. 2015; 2 (1):51–86. [ Google Scholar ]
• Stuart H. Violence and mental illness: an overview. World Psychiatry. 2003; 2 (2):121–24. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In: Monahan J, Steadman HJ, editors. Violence and Mental Disorder: Developments in Risk Assessment. Chicago: Univ. Chicago Press; 1996. pp. 101–36. [ Google Scholar ]
• Swanson JW. Preventing the unpredicted: managing violence risk in mental health care. Psychiatr Serv. 2008; 59 (2):191–93. [ PubMed ] [ Google Scholar ]
• Swanson JW. Explaining rare acts of violence: the limits of evidence from population research. Psychiatr Serv. 2015; 62 :1369–71. [ PubMed ] [ Google Scholar ]
• Swanson JW, Easter MM, Robertson AG, Swartz MS, Alanis-Hirsch K, et al. Gun violence, mental illness, and laws that prohibit gun possession: evidence from two Florida counties. Health Aff Millwood. 2016; 35 (6):1067–75. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Swanson JW, Holzer CE, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry. 1990; 41 (7):761–70. [ PubMed ] [ Google Scholar ]
• Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Ann Epidemiol. 2014; 25 :366–76. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Swedler DI, Simmons MM, Dominici F, Hemenway D. Firearm prevalence and homicides of law enforcement officers in the United States. Am J Public Health. 2015; 105 (10):2042–48. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Swift A. Personal safety top reason Americans own guns today. Gallup. 2013 Oct 28; http://www.gallup.com/poll/165605/personal-safety-top-reason-americans-own-guns-today.aspx .
• Taylor MA. A comprehensive study of mass murder precipitants and motivations of offenders. Int J Offender Ther Comp Criminol. 2016 https://doi.org/10.1177/0306624X16646805 . [ PubMed ]
• ten Have M, de Graaf R, van Weeghel J, van Dorsselaer S. The association between common mental disorders and violence: To what extent is it influenced by prior victimization, negative life events and low levels of social support? Psychol Med. 2014; 44 (7):1485–98. [ PubMed ] [ Google Scholar ]
• Teplin LA, McClelland GM, Abram KM, Weiner DA. Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey. Arch Gen Psychiatry. 2005; 62 (8):911–921. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Tiihonen J, Isohanni M, Rasanen P, Koiranen M, Moring J. Specific major mental disorders and criminality: a 26-year prospective study of the 1966 northern Finland birth cohort. Am J Psychiatry. 1997; 154 (6):840–45. [ PubMed ] [ Google Scholar ]
• Towers S, Gomez-Lievano A, Khan M, Mubayi A, Castillo-Chavez C. Contagion in mass killings and school shootings. PLOS ONE. 2015; 10 (7):e0117259. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Traylor A, Price JH, Telljohann SK, King K, Thompson A. Clinical psychologists’ firearm risk management perceptions and practices. J Community Health. 2010; 35 (1):60–67. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Trevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLOS ONE. 2012; 7 (12):e51740. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• van Kesteren JN. Revisiting the gun ownership and violence link: a multilevel analysis of Victimization Survey data. Br J Criminol. 2014; 54 (1):53–72. [ Google Scholar ]
• Vossekuil B, Fein RA, Reddy M, Borum R, Modzeleski W. The final report and findings of the Safe School Initiative: implications for the prevention of school attacks in the United States. US Dep. Educ./US Secret Serv. Rep., Off. Elem. Second. Educ., Safe Drug-Free Sch. Progr./Natl. Threat Assess. Cent.; Washington, DC: 2002. [ Google Scholar ]
• Vriniotis M, Barber C, Frank E, Demicco R, N.H. Firearm Saf Coalit A suicide prevention campaign for firearm dealers in New Hampshire. Suicide Life Threat Behav. 2015; 45 (2):157–63. [ PubMed ] [ Google Scholar ]
• Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. Br J Psychiatry J Ment Sci. 2002; 180 :490–95. [ PubMed ] [ Google Scholar ]
• Wheeler TW. What to do when your doctor asks about guns. Doctors for Responsible Gun Ownership Blog. 2015 Jun 27; https://drgo.us/?p=1621 .
• Wiehl T. The presumption of dangerousness: how New York’s SAFE Act reflects our irrational fear of mental illness. Seton Hall Legis J. 2014; 38 (1):37–69. [ Google Scholar ]
• Wilson HL. Gun Politics in America: Historical and Modern Documents in Context. Santa Barbara, CA: ABC-CLIO; 2016. [ Google Scholar ]
• Winsper C, Singh SP, Marwaha S, Amos T, Lester H, et al. Pathways to violent behavior during first-episode psychosis: a report from the UK national EDEN study. JAMA Psychiatry. 2013; 70 (12):1287–93. [ PubMed ] [ Google Scholar ]
• Wintemute GJ. Comprehensive background checks for firearm sales: evidence from gun shows. In: Webster DS, Vernick JS, editors. Reducing Gun Violence in America: Informing Policy with Evidence and Analysis. Baltimore, MD: Johns Hopkins Univ. Press; 2013. pp. 95–107. [ Google Scholar ]
• Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Annu Rev Public Health. 2015; 36 (1):5–19. [ PubMed ] [ Google Scholar ]
• Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016; 165 :205–13. [ PubMed ] [ Google Scholar ]
• Wintemute GJ, Braga AA, Kennedy DM. Private-party gun sales, regulation, and public safety. N Engl J Med. 2010; 363 (6):508–11. [ PubMed ] [ Google Scholar ]
• Wintemute GJ, Parham CA, Beaumont JJ, Wright M, Drake C. Mortality among recent purchasers of handguns. N Engl J Med. 1999; 341 (21):1583–89. [ PubMed ] [ Google Scholar ]
• Witt K, van Dorn R, Fazel S. Correction: risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies. PLOS ONE. 2013; 8 (9) https://doi.org/10.1371/annotation/f4abfc20-5a38-4dec-aa46-7d28018bbe38 . [ PMC free article ] [ PubMed ] [ Google Scholar ]