Apr 28, 2021
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.
Norris is associate dean of student affairs and administration
at George Washington University, Washington. He has no
- 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
- 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.
- 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
- Breach: This entails a change in the safety of the potential
- 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.
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;13:445-69.
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
Gun Violence Archive
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
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