The deadly shooting at a Nashville school in March epitomized all that is horrific about targeted violence—the unexpected nature of it, the twisted conduct of the attacker, the trauma of the survivors, and the anxiety that oozes into the American limbic system after any such attack.

In its wake, policymakers and media pooh-bahs defaulted to the usual politicized explanations and remedies, hotly arguing over major societal issues such as transgenderism, gun culture, and hate crimes in general. Those crimes are unquestionably on the rise. According to the FBI, in 2020 there were 40 targeted shooting incidents, about a third more than the previous decade’s peak of 31 incidents, in 2009. By 2021, the number had grown again by a third, to 61 active shootings. The year 2021 also set new records both for hate crimes in general and for specifically anti-Semitic incidents. The latter, according to the Anti-Defamation League, increased again by 35 percent in 2022, reaching 3,697 incidents nationwide.

Finding a common root to explain such horrors is incredibly difficult, even more difficult than coming up with useful and effective solutions. But not enough attention is being paid to a distinctly common element in all these cases, and that is mental health. Violent individuals in need of supervision to protect themselves and us from their dangerous impulses are falling through porous gaps in the criminal-justice and mental-health systems. This population has a direct overlap with those committing hate crimes and acts of domestic terrorism. If we look at the hate-crime problem through this lens, it becomes more manageable. There are measured safeguards that we can use to prevent these volatile people from gun ownership, and investments we can make to ensure that first responders are trained to minimize carnage when attacks do occur. These small policy shifts can help us identify and deter potential attackers and can also repair and build general civic trust and the willingness to intervene.

While the vast majority of mentally ill Americans obviously do not commit mass attacks—or any violence at all—a significant proportion of those who do so suffer from severe mental illness. The National Threat Assessment Center’s 2020 report on targeted school violence found that 54 percent of attackers had previously received some type of mental-health treatment. Among this group, 31 percent had received services within their schools, half had received treatment from within their community, and over a quarter had received both.

During 2019’s wave of anti-Semitic hate crimes, about a third of the offenses were reportedly committed by people with psychiatric histories. Similarly, mental illness has been a common factor among suspects arrested in recent high-profile attacks on Asians in New York City, according to the head of New York Police Department’s task force on anti-Asian bias crime. In 2021, NYPD reported that half of those arrested for hate crimes were mentally ill.

The seriously mentally ill also commit the large majority of matricides and patricides. This became anecdotally clear by the examples of Adam Lanza, who murdered his mother directly before attacking Sandy Hook Elementary School in 2012, and by Salvador Ramos, who shot his grandmother in the face before his attack on Robb Elementary School in Uvalde, Texas ,last year.

And this all comes at a time when we have been decreasing our capacity to identify and safeguard this population from hurting others or themselves. This self-inflicted wound has been amplified by the decarceration and criminal-justice reform movements, and exacerbated by a political push to avoid stigmatizing mental illness. Such an approach, while humane on the surface, dangerously downplays the link to violence and makes it harder to insist on rigorous standards for care supervision.

Decarceration advocates point to the tragedy of mentally ill individuals housed in jail facilities rather than hospital settings. About 5 percent of the general adult population has a debilitating psychiatric disorder; among jail and prison inmates, that figure jumps to anywhere between 14 and 26 percent. Currently, 20 percent of New York City’s jail population suffers serious mental illness, which includes schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, and post-traumatic stress disorder.

Concern for public safety lessened after more than 30 years of decreasing crime even as growing sympathy for criminal offenders fueled decarceration efforts. High-profile incidents of police violence, especially George Floyd’s murder in 2020, accelerated the mood, which had already changed the nature of crime and punishment in America. Again in New York, 2021 posted the 15th straight year of decline in state prison population and a 55 percent decrease from its 1999 record high. The population of the city’s main jail facility on Rikers Island also more than halved, from over 22,000 inmates in 1991 down to around 9,500 in 2017—before reform efforts cut that number in half yet again.

Since NYC committed in 2017 to shuttering its Rikers Island facility and replacing it with new facilities holding a combined maximum of 3,300 inmates, the city has increased policies of release rather than detention for criminal offenders in order to pursue that lower population total.

Criminal-justice reform policies have also been making it harder for the system to hold dangerous people. In January 2020, statewide bail reform went into effect. All jail inmates detained pretrial on bail for charges that had newly become bail-ineligible were instantly released. NYC saw an immediate 20 percent increase in index crimes over the following three months (before Covid closures), led by increases in newly bail-ineligible crimes such as auto theft, up 68 percent, and burglary, up 28 percent.

At the same time, another statewide reform exponentially increasing prosecutors’ compliance burden for collecting and sharing evidence forced trial prosecutors to perform triage on their caseloads. Dismissal rates before trial rose in New York City from 44 percent in 2019 to 69 percent in 2021. For misdemeanors, dismissal rates rose from 48 percent to 83 percent of disposed cases.

These reforms were supposedly going to help save mentally ill individuals by keeping them out of the city jail system. But while a carceral setting may not be ideal for disturbed individuals, it has historically provided needed supervision for a dangerous subset of people. New research, in fact, shows that incarceration has positive impacts on mentally ill inmates lasting long after release—even improving the mental health of their family members. The new procedures have had significant negative consequences because they remove the leverage that the system once had to get defendants into care. With significantly higher dismissals, defense attorneys can confidently tell clients their cases will likely be thrown out and they should not commit to treatment programs. And since fewer defendants are detained pretrial, they lose a critical period in which to get evaluated, treated, and removed from settings in which they can abuse drugs.

A parallel shift occurred in California in 2014, when Proposition 47 converted many nonviolent property and drug crimes from felonies to misdemeanors. Defendants became much less likely to enroll in drug court programs without the threat of a felony sentence to motivate them. These policy changes have accentuated other gaps in our mental-health system.

Since the deinstitutionalization movement a half-century ago, the country has had a shortage of inpatient hospital beds for those who require long-term supervised care. Data from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) found that, in 2021, hospitals and clinics had only about two-thirds of the inpatient beds needed to accommodate psychiatric patients. This shortfall is worsening, as SAMHSA reported in 2018 that 121 percent of inpatient beds designated for mental-health treatment at psychiatric hospitals were in use; the number was 118 percent at general hospitals; and 115 percent at community mental-health centers.

Looking again at New York City, where there are 45,000 psychiatric hospitalizations annually, Stephen Eide writes that “though there is little indication that the need for inpatient treatment has declined in recent years, the bed supply has. Between 2000 and 2018, NYC lost 459 psychiatric hospital beds.”

The tragically limited bed capacity for the worst cases of mental illness is symptomatic of what might be called the “public health” approach, which invests disproportionately in programs that treat sad or anxious people rather than those that help the most dysfunctional and disturbed.

According to Carolyn Gorman of the Manhattan Institute, this funding strategy for combating mental illness—prioritizing education and prevention over treatment—is not new, but it has been gaining traction since the 1960s. She notes, “This approach is manifest in Mental Health First Aid (MHFA)—an increasingly popular program originally implemented to prevent mental illness-related tragedies, theoretically by teaching everyday citizens ‘how to identify, understand, and respond to signs of mental illnesses and substance abuse disorders.’”

But as Gorman details, there is no evidence of MHFA’s success. After two decades, its broad approach does not produce outcomes such as “fewer crises or tragedies, reduced prevalence or disease burden of mental illness, or greater access to high-quality treatment and services.”

Take as an example ThriveNYC, a program that sought to bolster the mental health of all New Yorkers rather than prioritizing those with severe illness. Under the canopy of investing in mental health, ThriveNYC catered even to those simply experiencing stress due to divorce or money problems. And it funded improving parks, creating public art, raising grades, achieving full employment, ending poverty, and fighting discrimination.

How does this help individuals with severe illnesses such as bipolar disorder or schizophrenia, who are not merely sad, and for whom prevention is not straightforward—and whose effect on social disorder is both palpable and measurable?

Considering how expensive mental-health programs are, spending money inefficiently can mean starving projects that could genuinely make a difference among the most fragile and volatile. ThriveNYC’s budget rose from an initial $200 million in 2017 to nearly $300 million by 2021. That was on top of the roughly $2.5 billion spent annually by the city on mental health.

When it comes to combating extremist violence, a more targeted solution seems an obvious choice, since only a few individuals in the population are violently disturbed enough to pose an actual threat. In almost all cases, their dangerous tendencies become clear to the people around them and to law enforcement, and changes in how we approach these matters could have a preventive effect. But agencies, including the White House’s National Security Council in 2021, have instead adopted generalized policies.

One component of a strategy focused on “education and prevention” is an emphasis on implicit-bias training and similar anti-hate instruction. The federal Domestic Terrorism Prevention Act of 2022, in fact, mandates anti-bias training for all federal employees associated with combating terrorism. Local governments have also been investing in expensive training of this sort. Las Vegas’s Clark County School District signed a contract covering 2022 through 2025 that pays the Anti-Defamation League $75,000 to teach students and staff “to recognize bias and the harm it inflicts on individuals and society; improve intercultural engagement; and combat racism, antisemitism, prejudice, and bigotry.”

But there is no evidence that these types of coaching change anyone’s behavior. And, while learning about the Holocaust may increase inter-group empathy among well-adjusted students, it’s unlikely to affect the attitude of the cohort who would be inclined to hit a Jew over the head with a brick or shoot up a synagogue.

Rather than financing broad public-health approaches, schools and jurisdictions would more successfully prevent hate-inspired violence by making mental-health providers more accountable for the outcomes of specific interactions and patients.

Payton Gendron, who is charged with killing 10 people at a supermarket in Buffalo, New York, in an anti-black spree in 2022, underwent a mental-health evaluation a year earlier after threatening to carry out a murder-suicide shooting at his high school. He was taken into custody by state police under a New York mental-health law and was evaluated over a day-and-a-half hospital stay. He was released—with no follow-up—after telling officials he was only joking. But in a post on the chat platform Discord, he wrote: “It was not a joke. I wrote that down because that’s what I was planning to do.”

Mental-health evaluators could have committed him involuntarily to an institution as a danger risk, and Gendron would have become ineligible to purchase a gun under federal law. But they were not convinced that he required commitment in that moment. This suggests there should be more kinds of follow-up and supervision—of a sort that would impose accountability on the people who work on such cases. In the criminal-justice system, case histories and outcomes can be traced, and failures to properly identify and contain dangerous people can be attached to individual practitioners. We should demand the same from psychiatric caregivers.

Simon Martial, who pushed Deloitte executive Michelle Go in front of a subway train in Manhattan in what many believed to be a racially motivated attack, reportedly told a psychiatrist at the state-run Manhattan Psychiatric Center five years earlier that he would eventually push someone in front of a train. The lawyer for the 61-year-old schizophrenic estimates Martial has been hospitalized at least 20 times over the years for his psychosis—yet there was no way to determine who should be held accountable for the fact that he was free to attack Michelle Go.

Assisted outpatient treatment, known in New York as Kendra’s Law, has been successful because it does hold systems accountable for providing seriously mentally ill individuals with services. And it zeroes in on the most volatile among us, people who would not voluntarily access treatment the way a lightly depressed person might. Kendra’s Law empowers judges to allow individuals with recurrent homelessness, arrests, and incarcerations to live in the community only by accepting violence-prevention treatment. The NYS Office of Mental Health found that for those whose actions triggered their treatment under Kendra’s Law, subsequent homelessness, psychiatric hospitalization, arrest, and incarceration rates dropped by between 74 percent and 87 percent.

In addition to closing gaps in the mental-health system, there are opportunities around the margins for keeping guns from would-be attackers. Following the Nashville school shooting—in which Audrey Hale used three guns, including the country’s most common rifle, an AR-15—President Joe Biden and others renewed calls for banning assault weapons. But the kind of gun is not the problem; the shooters are. While several school shootings have involved assault weapons, attacking a classroom with another type of gun can create the same carnage. As Robert VerBruggen points out, “most gun murders—and most mass shootings, too—involve normal handguns, not assault weapons, and the actual differences in lethality between an ‘assault weapon’ and other semiautomatic guns are limited.”

Further, from a policy-evaluation perspective, attacks involving assault weapons have occurred in jurisdictions with assault-weapons bans already in place, including Connecticut at the time of the Sandy Hook shooting, and even in the 1999 Columbine horror, which occurred under a federal assault-weapons ban. And some attackers, like Gendron in Buffalo, have bought rifles legitimately and illegally modified them.

This is why a targeted approach to gun control is better than a blanket one and can add accountability. Concerned family members, teachers, and law enforcement in many states can “red flag” individuals of concern, resulting in temporary court orders that preclude them from acquiring or maintaining guns. Had this option been available in Tennessee, perhaps the Nashville shooter’s parents or the doctor who treated her “emotional disorder” would have flagged law enforcement to prevent her from purchasing guns. We should use and monitor red flags more consistently and collect data on their impact. We could also raise the age to 21 for an individual to purchase, for instance, a semiautomatic gun.

Finally, the relatively rapid takedown of the Nashville shooter highlighted the difference that qualified, well-trained police make—especially after the law enforcement missteps and hesitations that prolonged the carnage in Uvalde, Texas. Mass-casualty responses require specialized training—both within agencies and in coordination between them—as well as specialized equipment. But we have reduced funding for law-enforcement agencies over the past decade and a half: Locally and federally, the U.S. spends less than 1 percent of GDP on policing. Relative to our European counterparts, the U.S. underspends on officers and training, especially given our higher crime rates. We need to invest more in order to attract capable recruits, train them for rare but deadly attacks, and ensure communication and coordination between responding agencies.


Targeted violence is terrifying and we can never eradicate it entirely. But rather than recirculating the same overwrought debates demanding assault-weapons bans and decrying the political sources of extreme right-wing and left-wing grievances, we can constructively focus on pragmatic policy fixes.

It’s important to note that reducing criminal disorder, unsupervised mental illness, and adolescent drug abuse all promote the rule of law, the basis for societal trust and stability. And by zeroing in on the few individuals who terrorize the many and by bolstering systems to manage them, all Americans can feel more empowered to intervene when they see a risk.

If increased attacks are a symptom of our fraying social order, making systems accountable will re-ground our civic bonds. And ultimately, that is how we do not let the attackers win.

Photo: AP Photo/Seth Wenig

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