John “Jack” Rozel, MD, MSL, returns to the Psychcast to talk with Lorenzo Norris, MD, about American gun violence and steps clinicians can take to disrupt it.

Dr. Rozel is medical director of the resolve Crisis Network. He also serves as associate professor of psychiatry and adjunct professor of law at the University of Pittsburgh. Dr. Rozel is also past president of the American Association for Emergency Psychiatry. He has no disclosures.

Dr. Norris is associate dean of student affairs and administration at George Washington University, Washington. He has no disclosures.

Take-home points

• Mass violence with guns is occurring with greater frequency and severity in the United States, compared with other countries. Mass shootings have been on the rise. In 2020 there were nearly 200 more mass shootings, compared with 2019.
• The United States has a broad swath of firearm violence: Deaths by suicide account 60% of gun deaths, and the remaining 40% are deaths by homicide. Only 1%-2% of firearm homicides are completed in mass shootings – which are defined as an event in which four or more people are shot in an indiscriminate manner.
• It is also a distinctly American problem that we have so many guns in our country. The United States has more civilian-held firearms (393 million) than the next 39 countries combined. Being an adult in the United States means being 25 times more likely to be the victim of a firearm homicide, compared with adults in any other country.
• Dr. Norris and Dr. Rozel conclude that violence assessments must always cover suicide and homicide risk because they are related types of violence, especially when it comes to guns.

Summary

• Suicide risk is increased by 100-fold when a new gun enters the home, and the risk peaks in the first days to weeks of ownership and then trails off. However, there is a measurable difference in risk of suicide in the 5 years after the purchase. Dr. Rozel emphasizes that it is essential to ask patients about acquisition of new guns, because as circumstances change as with the pandemic, people may feel the need to buy a gun.
• Dr. Rozel presented a model for possibly reducing gun violence:
  • Grievance: All violence starts with feeling like a victim; some people feel aggrieved after a disagreement or even a threat.
  • The Pivot: This is a transition from simply having a grievance to violent ideation and wanting vengeance through violence. Perpetrators of violence shift from fantasy into research about planning and preparing to attack.
  • Preparation: This stage includes acquiring weapons and, in some cases, tactical clothing. It also could include probing into their targets’ vulnerabilities, a “test attack,” and eventually the final attack.
  • Breach: This entails a change in the safety of the potential victim. 
  • Attack: This stage encompasses perpetrating the attack.
• Identifying a person at the grievance stage is the most effective place to intervene and potentially diffuse a violent situation by using motivational interviewing to enhance protective factors. Psychiatry’s greatest strength is meeting the aggressor where they are and hearing out the grievance.

References

Victor D and Taylor DB. A partial list of mass shootings in the United States in 2021. New York Times. 2021 Apr 16.

Kim NY. Gun violence spiked during pandemic, even as the deadliest mass shootings waned. Poynter.org. 2021 Mar 25.

Rozel JS and Mulvey EP. Annu Rev Clin Psychol. 2017 May 8;13:44 5-69.

Metzl JM et al. Har Rev Psychiatry. 2021 Jan-Feb 01;29(1):81-9.

Firearm access is a risk factor for suicide. Harvard School of Public Health.

National Council for Behavioral Health. Mass Violence in America: Causes, impacts, and solutions. 2019 Aug.

Gun Violence Archive

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest.

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