Shoot to Kill: The Enduring Anger of the Mass Shooter

If you’re anything like me, you’ve been inundated recently with stories of mass shootings. On April 19, for instance, a Louisiana man entered a house in the middle of the night and shot and killed eight children execution-style. On April 25, an armed man charged a security checkpoint at the White House Correspondents’ dinner: he was quickly subdued, but not before a Secret Service officer was shot in the chest. And just this week, five individuals (including the two teenage perpetrators) died during a mass shooting in San Diego’s largest mosque.

As the former director of disaster preparedness for a large health system in Northern California, the possibility of a mass shooting in one of our facilities used to keep me up at night. When it comes to mass shootings, hospitals are classic “soft targets”: they’re emotionally charged environments, open 24/7, and filled with people, including many mobility-challenged patients. And the incidence of hospital-based shootings is only increasing.

Amidst a complex and often contentious debate about gun violence, it can be easy for healthcare workers to feel helpless in the face of this vulnerability. There is, however, a powerful tool all healthcare workers can start using to improve their ability to protect staff, patients, and visitors: threat assessment.

Threat assessment is predicated on the idea that many mass shooters share a collection of fairly predictable behavior patterns before their assault. By learning to recognize these warning signs and encouraging the reporting of concerning behavior, it’s sometimes possible to identify would-be assailants while there is still time to intervene. Threat assessment is far from perfect, of course, but it’s a shift from more traditional reactive strategies to upstream prevention. And it restores some much-needed agency to healthcare workers.

Stereotype Versus Reality

So, what should healthcare workers be looking out for? The stereotype, of course, is a young white man with a history of severe mental illness who suddenly snaps. (A quick word about definitions: a “mass shooting” is sometimes defined as an event in which four or more individuals are shot. An “active shooter event” is federally defined as an individual actively engaged in killing or attempting to kill people in a confined and populated area. This lack of standardized definitions makes mass shooting data murky. But no matter how you slice the mass shooter pie, it’s still a big pie: mass shootings are more common in the U.S. than in any other country.)

But as it turns out, the stereotype isn’t particularly accurate. Mass and active shooters are overwhelmingly male, but they don’t otherwise conform to a tidy profile. In one study, they ranged in age from 12 to 88 years, spanned all races (although the majority were white), were just slightly more likely to be employed than unemployed, and were closely divided between high school, college, and graduate levels of education. A quarter had a history of mental illness, but few had been diagnosed with a psychotic disorder.

What these men do have in common is that they are almost always in crisis in the days and weeks prior to the shooting. It might be financial strain, a relationship rejection, marital problems, a change in job status, physical health concerns, the death of a loved one, or a combination of multiple such stressors. Whatever the cause, the shooter is left with a grievance and a grossly distorted sense of injustice. In other words, the defining trait of mass shooters is that they are angry. Aggrieved. Offended. Rejected. Pissed.

And they often show it. In the months leading up to a shooting, 93% of all mass shooters exhibit warning signs, such as agitation, social isolation, or abusive behavior. According to an FBI report, other concerning behaviors leading up to an attack may include recklessness, impulsivity, physical aggression, violent media usage, and changes in hygiene and weight.

Not Random. Not Senseless Either.

Furthermore, mass shooters don’t usually “just snap.” They often meticulously plan their assault. Among active shooters, 77% spent at least a week planning, and almost half (46%) spent at least a week actively preparing by procuring a firearm, ammunition, special clothing, or body armor. Nor is their choice of victims random: about 70% of mass shooters and two thirds of active shooters knew at least some of their victims.

This preparatory phase represents a window of opportunity because, rather astonishingly, shooters commonly leak their plans: nearly half signal their intentions via conversations, social media, or writings. Why would a man proactively reveal his intentions? Leakage is sometimes thought to be a cry for help, especially among the substantial portion of shooters who are suicidal. At other times, it may be multi-factorial and related to factors such as attention-seeking, a desire to intimidate, and excitement.

A Social Contagion

The final quality common to many shooters is that they are impressionable. Anywhere from a fifth to a quarter of shooters study prior events, searching for a script to follow or embellish. We know this because many shooters admit to it. The 2007 Virginia Tech shooter left a manifesto citing the Columbine shooters. The 2022 Buffalo shooter carved the names of his favorite mass shooters into his semi-automatic. The 2024 Apalachee School shooter adapted the Sandy Hook School shooter’s name as his social media username. And the Sandy Hook shooter admired the 2011 Norwegian mass shooter.

The higher the body count, the more infamy a shooter earns, and the more likely that event is to inspire other would-be assailants. This “copycat” behavior means that shootings often occur in clusters. The impressionable nature of would-be shooters is so well-documented that multiple organizations have called for news media to stop disseminating assailants’ names and photos.

Reason for Hope

The good news is that the emerging field of threat assessment shows promise. Historically, mass shooting research focused on completed events, but more recently, a small body of evidence has examined averted shootings. The initial findings are tantalizing — they suggest that proactive intervention on the part of friends, family, colleagues, students, and teachers can thwart some shootings. Among 194 averted public shootings, nearly half were averted when the would-be assailant told another person about their plan, and that person reported it.

Where does all this leave us? I would argue it’s time to discard old stereotypes and familiarize ourselves with the basics of threat management. This could be life-saving both in healthcare facilities and more broadly. By no means do I wish to oversimplify the complex dynamics of mass shootings, which include debates about gun regulation, background checks, and red flag laws. But it just may be that threat assessment opens a window into an opportunity to mitigate these incidents, while simultaneously empowering healthcare workers. We should take advantage of that window.

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