Within hours of any mass shooting, high-profile murder, or targeted attack, a familiar speculation about the perpetrator’s mental state begins. Social media erupts with assumptions about psychiatric conditions. Defense attorneys prepare evaluations before anyone has even been assessed. The verdict is in before the facts: This person must be mentally ill.
This reflexive response serves a comforting, but dangerous, purpose. It gives perpetrators a framework for diminished responsibility. It also provides the rest of us with the reassuring fiction that such acts stem from a diagnosable condition rather than from the darker possibilities that exist within ordinary human behavior.
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As someone who performs psychiatric evaluations in forensic and correctional settings, I’ve assessed countless individuals who have committed acts of violence. What I’ve learned aligns with research. Only about 5% of all violent acts are committed by individuals with severe mental illness. In fact, individuals with severe mental illness are more likely to be victims than perpetrators.
Yet our collective response remains unchanged. By rushing to pathologize cruelty, we engage in psychological self-protection. It becomes far easier to sleep at night believing that the capacity for brutality resides in a distinct category of “sick” individuals than acknowledging that danger might live next door or share our bed.
This doesn’t mean mental illness never contributes to violence. In my practice, I’ve seen cases where untreated psychosis or mania were involved in violent behavior. These cases are real and tragic, but they represent the minority. The problem isn’t that mental illness is never relevant. It’s that we assume it always is.
Labeling violence a symptom of mental illness allows us to preserve the illusion that human nature is fundamentally pleasant, if not benign. If violence stems from mental illness, then it’s predictable and treatable. The perpetrator becomes a patient, not a moral agent. We maintain our illusions by medicalizing brutality. But that illusion comes at a cost.
I once evaluated a man who systematically disfigured a woman after she rejected him. He expressed no remorse, no confusion, and no psychiatric symptoms. Instead, he described a disgusting belief system in which women exist to serve men’s needs. When women violated that expectation, he believed they deserved punishment. His logic was heinously sexist but consistent. His values were monstrous.
These are the cases we struggle to face, not because they’re rare, but because they’re chillingly coherent. The most unsettling truth about violence is that it often derives from people whose cognitive functioning is perfectly intact. The reasoning works. It’s the moral code underneath that’s warped.
A person may flawlessly reason from the abhorrent belief that certain groups are subhuman or that humiliation justifies retaliation, or that a righteous cause excuses any means. We’re not always dealing with disordered thought. Sometimes, we’re dealing with deliberate justification.
In high-profile criminal proceedings, mental health evidence often dominates the narrative. The formal insanity defense succeeds in fewer than one percent of cases, but its visibility reinforces a flawed public perception that mental illness is a common driver of violence. It usually isn’t.
More concerning are diminished capacity defenses, which blur the line between explanation and excuse. Defense teams present histories of trauma, substance use, or personality disorders as mitigating factors, but correlation is not causation. Many people experience trauma without harming anyone. Others with relatively stable lives commit acts of extraordinary cruelty.
The limits of medical framing become clear when individuals who make violent threats online are diverted to psychiatric hospitals. But what, exactly, are we treating? I’ve evaluated people who were previously hospitalized after making threats and acquiring weapons. Their planning was detailed. Their reasoning was consistent within their twisted worldview. The brief hospitalization addressed neither their sense of grievance nor their belief that violence was justified. They were released not because they were no longer a danger to society, but because they no longer met legal criteria for mental illness commitment. Later, they ended up in my evaluation room at the jail anyway—after doing exactly what they had planned all along.
Part of the confusion is definitional. Poor mental health, marked by emotional distress, unhealthy coping, or relationship problems, is common. Mental illness refers to specific, diagnosable conditions with established clinical criteria. Conflating these concepts may feel compassionate, but it does neither science nor society any favors.
The rush to pathologize violence also reinforces stigma. It deepens the association between psychiatric illness and dangerousness, making it harder for people to seek care. The irony is sharp. While we wrongly attribute violence to mental illness, we simultaneously create conditions that make treatment harder to access.
I’ve worked with people living with schizophrenia, bipolar disorder, and other severe conditions who would never harm another person. They may hear voices or believe strange things, but they still know right from wrong. They still feel empathy. They struggle with illness, not malice.
Most violence isn’t driven by psychiatric symptoms. It’s driven by entitlement, ideology, revenge, or the pursuit of power. Mass shootings are often methodically planned. The perpetrators understand what they’re doing. They believe they’re justified. They are not confused.
We turn to psychiatric explanations because they feel safer. They let us believe that violence can be identified, treated, and prevented through clinical means, but that belief is false—and dangerous.
Most violence is intentional. Most perpetrators are not mentally ill. They know exactly what they’re doing. These are not symptoms. They are choices.
We need to distinguish between the rare cases where illness plays a direct role and the far more common cases where diagnosis is used to soften accountability. That means confronting the belief systems that justify harm. It means refusing to turn deliberate cruelty into a medical issue. And it means holding people morally responsible for the harm they cause.
The uncomfortable truth is this: Some people do terrible things because they want to. Not because they’re sick. And when we rush to diagnose their actions, we trade justice for complexity and accountability for pathology.