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After 10 people at a Colorado supermarket were gunned down this week, a question familiar in America's cycle of bloodshed began to echo: Does mental illness drive mass shootings?
The 21-year-old suspect arrested in the rampage, the second in a week, was almost immediately described by family members as paranoid and antisocial. And on Thursday, his defense attorney asked for a mental health assessment "to address his mental illness."
But researchers and advocates say the rush to cast blame on a mental illness is misplaced.
"There's no psychotic illness whose symptom is shooting other people," said Dr. Jonathan Metzl, director of the Center for Medicine, Health and Society at Vanderbilt University.
"People are searching for explanations for behavior they don't understand. It's easy to put a label like mental illness on behavior that frankly seems just beyond the pale," said Angela Kimball, national director for advocacy and public policy at the National Alliance on Mental Illness.
"We didn’t know what was going on in his head," Ali Aliwi Alissa, the suspect’s 34-year-old brother, told The Daily Beast. He also told the outlet his brother was paranoid and would say people were after him when he was a high school student.
"(It was) not at all a political statement; it’s mental illness," he said.
Police have not yet said what the gunman's motive was, but Metzl said immediate blame on mental illness does not tell the full story of what causes a mass shooting.
"There's nothing sane about killing strangers, but I think the problem is it turns out to be a kind of deceptive narrative" to blame mental illness, Metzl said.
Why mental illness is immediately thought to be the cause
Many often jump to cast mental illness as the cause of a mass shooter's action because people want a quick answer, Metzl said.
"Mass shootings are so traumatizing, and part of why they're traumatizing is they rupture in a terrorizing way the safety of daily life. And we want there to be a coherent answer.
We want it to be one thing very often. It's human nature," Metzl said.
Mass shootings and mental illness': Experts say the link is vastly overstated
But the true causes are more complicated and not fully understood, if ever, until long after the shooting fades from news coverage, Metzl said.
Paul Gionfriddo, president and CEO of Mental Health America, said the narrative around mental illness causing mass shootings has gotten worse over time and has prevented a more meaningful discussion, especially among policymakers, about how to address the actual causes.
Almost immediately after a shooter's mental health is questioned, gun control is the next topic, Gionfriddo said. And that's "not necessarily the answer" either.
"For people to use those weapons in that way, something else has to happen," he said. "Plenty of people are walking around with serious mental illness never having had a single violent thought."
'Intermeshing' factors linked to mass shootings
In June 2018, the FBI released a report studying active shootings from 2000 and 2013 and their perpetrators' behaviors before the attacks. The report found that in only a quarter of the cases could the agency verify that an active shooter had been diagnosed with a mental illness. Only three had been diagnosed with a psychotic disorder, the report said.
The FBI report also identified multiple common stressors, or forces that put pressure on a person and may have caused distress, experienced by shooters. Though mental health was the most common stressor shared among shooters, multiple stressors are usually at play, the FBI report said.
"Mental illness alone is not a predictor of violence," Kimball said. "If mental illness were a cause, we would be seeing proportionally so many more mass shootings."
Metzl pointed to an "intermeshing" of factors, rather than one simple cause.
Things such as access to guns, family dynamics, past behavior, racism and misogyny are much more likely to be determinants of who commits a mass shooting, Metzl said. According to the FBI report, active shooters on average displayed four to five concerning behaviors that others observed before the shooting. Among them are threats or confrontation, anger or physical aggression.
In many cases, shooters are young and male. "We don't look to why that is or how that's come about," Gionfriddo said. "We don't seem to want to ask those questions and how our policies decisions in this country may have moved us in a direction that has allowed things like that to continue or to fester."
People don't just 'have a bad day'
According to the FBI report, the vast majority of active shootings can be tied to a motive, too, whether it's some action taken against the gunman in their personal life or at work or whether it's driven by hate or an extremist ideology.
In only 21% of cases studied in the FBI report, the primary grievance that led the shooter to committing the act was never determined.
More on mass shootings and mental health: What if motives behind mass shootings never emerge?
The FBI report also found that in 77% of cases, the attack was planned for at least a week, casting further doubt on the theory that shooters simply "snap."
Earlier this month, when a gunman opened fire at three Atlanta-area spas and killed eight people, most of them women of Asian descent, a sheriff's office spokesperson described the suspect as having "a bad day." The comment drew widespread condemnation.
Gionfriddo said that comment and others like it not only minimize the "bad days" victims' families will have for the rest of their lives and absolve policymakers and public officials of responsibility, but they also prevent meaningful discussions around the societal conditions that cause shootings.
"Usually there is tension and pressure that is built up over days, months, years and then something happens," Gionfriddo said. "If people understand that, then it makes it possible to go upstream and say, 'This is something we can prevent.'"
Suspected Boulder gunman displayed other risk factors
In family interviews with news outlets and court documents, other factors in the suspect's life that more closely align with what experts say are risk factors for identifying mass shooters have emerged.
Ali Aliwi Alissa told CNN his brother was bullied heavily in high school, that students made fun of his name and him being Muslim.
More on suspect in Colorado shooting: Gunman asked for his mother after killings; bought gun 6 days before rampage
The suspected gunman has also faced charges stemming from a fight with a classmate after he said he was bullied over his background.
When he was a high school senior in 2018, he was found guilty of assaulting a fellow student in class after knocking him to the floor, then climbing on top of him and punching him in the head several times, according to a police affidavit. Alissa complained that the student had made fun of him and called him “racial names” weeks earlier, according to the affidavit.
According to Kimball, a history of violence and abuse is associated with suspects in mass shootings.
Gionfriddo said other risk factors should never be seen as excuses, but it does begin to explain where accountability can begin and who should intervene sooner.
While a variety of complex factors can contribute to a gunman's behavior, the solutions can be simple and involve one intervention in someone's life, he said.
"Figure out the one thing that was the predictor of this episode," Gionfriddo said. "You don't have to rebuild the whole American society to address why 20-something-year-old men end up committing mass shootings."
Mental illness narrative stigmatizes people experiencing mental illness
When people unfairly connect mass shooters with mental illness, it stigmatizes the millions of people living with mental health struggles who are not violent, Kimball said.
"When they hear people falsely associate mental illness with a mass shooting, people tend to feel a kind of dread of this being associated with a condition that they may be living with every day of their lives," she said.
In the United States, mass shootings account for a small percentage of gun violence deaths. But suicides account for about 60% of gun violence deaths, according to the Centers for Disease Control and Prevention.
Gionfriddo said blaming mass shootings on people with mental illnesses may then make it harder for someone to seek help for a mental health condition or discuss suicidal thoughts because of the stigma.
"To see (mental illness) being equated with monstrous act does an immense disservice to people who then become afraid to talk about self-harm," Gionfriddo said.
"We need those people to be able to talk openly and without fear and without stigma."
Contributing: Christal Hayes and Jorge L. Ortiz
Follow USA TODAY's Ryan Miller on Twitter @RyanW_Miller
This article originally appeared on USA TODAY: Boulder shooting: Mental illness likely not only cause in Colorado