America Is Too Violent: What Can We Do About It?

The United States ranks third in the world for homicides after only Mexico and Russia. Italy, our nearest competitor, has one quarter the homicide rate. Occasionally, dramatic events such as the massacre at Columbine High School in Littleton, Colorado, briefly highlight some aspect of this problem, but the truth is that the U.S. homicide rate has been consistently high over the last 25 years—between 8 and 10 per 100,000 population per year.1 Sixty percent of these deaths involve firearms. During an interview in the wake of the Columbine disaster, a reporter asked me what my first thought was. Unfortunately, my first thought was “How many times does this make?” Gunshot wound has been the leading cause of death among both white and black teenage boys for years. This fact led former surgeon general C. Everett Koop to declare violence a public health emergency in 1992.2 But we are so tolerant of violence in our culture that it takes not 1 or 2, but 6 mass homicides in our schools to get our attention. What is at the root of this propensity for lethal violence? Is violence a symptom? Can we treat it? A number of factors deserve consideration. As with most forms of behavior, there must be some combination of inclination and opportunity. Of these 2, the Calvinist strain in our culture would have us focus on individual inclination. Inclination has contributions from “nature” and “nurture.” Factors related to nurture or environment might include a decrease in adult supervision; the incessant repetition of violence in video games, cartoons, and movies; and a less authoritarian approach to ethical problems. These conditions create more support for and modeling of violent behavior with fewer external constraints. Essentially, we have made things more complicated for children and given them less help. I have been amazed at how dramatically wrong my 6-year-old son's interpretation of a relatively benign movie can be. What he “gets” is not the sweet verbal message delivered quietly at the end, but the repeated visceral message that even the good guys spend most of their time tricking, pushing, hitting, shooting, crashing, burning, and exploding other people. He simply doesn't have the cognitive skills yet to sort it out … even with my help. Nature or endowment contributes to the propensity for violence in a variety of ways also. In one well-designed epidemiologic study, violent acts were reported by 3.7% of respondents.3 The rate of self-reported violent behavior was 2.05% for those with no psychiatric diagnosis and jumped 5-fold for schizophrenia. Substance abuse alone or any 2 psychiatric disorders combined was associated with a 10-fold increase, and adding a substance use disorder to an affective disorder or schizophrenia increased the risk 15-fold. Most of the violent individuals did not have a mental health diagnosis, and most of those with mental illness were not violent. Though most of the mentally ill are not violent, the 20% of respondents with a mental illness or substance use disorder included almost half of the violent individuals in the sample. This has led even strong advocates of the mentally ill to recognize the existence of a violent subgroup of the mentally ill.4 The ways in which mental illnesses contribute to violence differ for each illness. For example, the combination of certain types of delusions or hallucinations and lack of insight is associated with aggressive behavior in schizophrenia.5 Medications clearly reduce these symptoms and associated violent acts. Medication nonadherence, particularly when combined with substance use, again signals higher risk.6 The message here is that one component of violence prevention is the identification and consistent treatment of the conditions that increase risk. I founded the Comprehensive Psychiatric Emergency Program at Bellevue Hospital in Manhattan, and for years an explicit part of my job was to help make New York City safer. As a psychiatrist, I think we should be doing everything we can to diagnose and treat mental illness and thereby reduce the inclination of the mentally ill to behave violently. I think we should have reasonable laws to provide for humane involuntary treatment and adequate resources to treat everyone who needs it. It is important for the primary care provider to screen for symptoms of mental illness, substance use disorder, and violent behavior. Advocacy and collaboration between primary care providers and mental health specialists can then help to ensure appropriate and continuous care for those at risk. But the majority of violence in this country is not a function of treatable mental illness. No matter how well we understand individual inclination to violent behavior, the solutions, both medical and cultural, are a long way off. What about opportunity? Although I have occasionally heard of knife assaults with multiple casualties, I have never heard of a “drive by” stabbing. Guns increase the reach, lethality, and anonymity of violence. You just can't outrun a bullet. While it may be said that “Guns don't kill people; people kill people,” guns make it far easier for people to kill people. So easy, in fact, that a small child can do it by accident. Evidence suggests that gun ownership triples your chances of getting killed in your own home after controlling for other risk factors. I grew up on the Parris Island Marine Corps Recruit Depot in South Carolina. We used the firing range there as Boy Scouts. I learned how to fire a military .45-caliber side arm on the FBI range at Quantico, Virginia, before I could drive. So it's not that I'm allergic to guns. I just want them to be treated like the dangerous product they are. Between 1979 and 1996, unintentional motor vehicle fatalities were reduced 22%, from 53,524 to 41,893. That's 11,631 human beings who didn't die because we made driving safer. During that same time, 30,099 to as many as 39,595 people died each year by firearms.1 Guns, which most people don't really need and don't use much, were killing almost as many people as cars, which most people own and use every day. I suggest that we do for guns what we do for cars—make people take a test, get a license, and buy insurance and require reasonable safety devices. Now I'm going to put my money where my mouth is and go to my son's baseball game. I'm going to remind him that baseball is about skills and camaraderie, not crushing the other team. I'm also going to unobtrusively ask his friend's parents if they have guns and how they store them before his next sleepover.