In the wake of yet another mass shooting, some Texas politicians have called for increased mental health services to help prevent the next tragedy.
But experts working in the field warn that there is no fully effective solution to stop these shootings before they happen, with some saying that blaming mental health is a deflection from the fact that gun control is a necessary part of prevention.
"We can do all the things we can to help students, but at the end of the day, if a student has the notion to go shoot up a school and has access to the weapons to do that, I'm not sure any measures that may or may not have taken place would necessarily prevent it," said Jill Cook, the executive director of the American School Counselor Association.
"If somebody comes to a door with a semiautomatic weapon," Cook said, "that's it then."
On Tuesday, 19 children and two teachers were shot and killed at Robb Elementary School in Uvalde, Texas, by an 18-year-old gunman. State authorities have said that within days of his 18th birthday earlier this month, the shooter had purchased two semiautomatic rifles at a local gun store. He also purchased 375 rounds of ammunition.
Although Texas Gov. Greg Abbott said Wednesday that a "mental health challenge" had played a role in the massacre, the gunman had no known criminal history or mental health issues.
And Abbott wasn't alone in pointing to mental health. In the days after the shooting, Uvalde Mayor Don McLaughlin told News 4 San Antonio that the tragedy may have been prevented if more mental health resources were dedicated to his region.
"Maybe we could have caught it," he said. "Maybe if we had the counselors, maybe if we had the mental health people, we could do it."
Hurdles to accurately predicting violence and ensuring treatment
Dr. Ziv Cohen, a forensic and clinical psychiatrist based in New York City, said boosting mental health services in communities and making them more affordable could help reduce gun deaths, particularly suicides, but there is no fully effective mental health solution to stop mass shootings.
That is largely because they can be hard to predict. Mass shooters rarely show obvious signs of severe mental illness, such as having hallucinations or being completely out of touch with reality, Cohen said. Instead, of those who do exhibit signs of mental illness, the vast majority share commonalities with many people who do not go on to become shooters.
Those characteristics include depression, isolation from family and classmates, narcissism, paranoia and suspicion, Cohen said. Many may feel easily threatened or insulted by others or feel they are on a mission to prove a point.
"If you're looking at a group of people with those mental health issues, it's almost impossible to pick out the one that's actually going to commit a mass shooting," Cohen said. "This is why we haven't really found a solution."
A 2015 article in the American Journal of Public Health notes that "psychiatric diagnosis is largely an observational tool."
"Largely for this reason, research dating back to the 1970s suggests that psychiatrists using clinical judgment are not much better than laypersons at predicting which individual patients will commit violent crimes and which will not," the authors wrote.
Cook said no single test, assessment or metric could identify a mass shooter early enough to seek mental health treatment.
She said schools should ensure that every adult in the system — teachers, bus drivers, coaches, janitors and cafeteria workers — understands warning signs of someone at risk of harming themselves or others and have systems in place to report potential threats.
But even then, she said, there are hurdles. Mental health providers are limited when a person suspected of being at risk rejects help or lies through a mental health evaluation.
Earlier this month, authorities said a white teenager in upstate New York underwent a mental health evaluation after a teacher reported a chilling comment he made in class about a murder-suicide. But he was cleared and eventually gunned down 10 Black people in a racist rampage at a supermarket in Buffalo, officials said.
And last year, prior to a shooting at Oxford High School in Michigan that left four dead, a teacher alerted school officials to drawings found on the 15-year-old suspect's desk depicting scenes of violence. A counselor showed the drawing to the suspect's parents, who were told they needed to get their son into counseling within 48 hours.
The parents, who purchased the gun used in the shooting and have since been charged with manslaughter, declined to take their son home and he was returned to the classroom. The teenager allegedly carried out the massacre later that same day. His parents have pleaded not guilty to the charges.
"At the end of the day, if somebody has access to a mechanism that might give them the capacity to do this, I don't know the answer," Cook said.
And the notion that mental health counselors can identify threats and prevent mass shootings isn't clearly backed by research.
In an article published last year in the Harvard Review of Psychiatry, the authors argue that defining a role for mental health providers in preventing massacres is "inherently difficult."
"The assumption that mass shootings are driven solely or even primarily by diagnosable psychopathology stretches the limits of mental health expertise," the article stated. "It also sets up a false expectation that advancing neuroscience and better therapies to manage psychiatric symptoms will provide 'the answer' to solving gun violence."
It continues: "There is no existing or forthcoming unified theory of impaired brain functioning or of cognitive, mood, or behavioral dysregulation that could adequately explain mass shootings or multiple-victim gun homicides."
The topic is complicated, yet the public discourse around it "tends to be very simplified," said Peter Langman, a psychologist who has studied mass shooters and is the author of "Warning Signs: Identifying School Shooters Before They Strike."
"We have to be careful not to stigmatize mental health issues and associate them with mass violence because that is a mistake," he said. "On the other hand, happy, well-adjusted people don't commit mass murder."
But behavioral health treatment has not been a one-size-fits-all solution in preventing massacres, he added. Langman said it requires a multi-pronged approach, including putting more threat assessment teams in schools and restricting access to firearms, particularly in homes with minors.
"There have been school shooters who were in mental health treatment who still carried out attacks because they wanted to, and they didn't disclose what was going on in their minds to the mental health professionals," Langman said.
Cook said millions of people in the U.S. have mental health issues, but the percentage of those who carry out mass murders is minuscule.
"To equate this solely to mental health is a misstep and a deflection," she said.
Less than 10 percent of shootings nationwide involve a suspect who has a mental illness, according to the National Alliance on Mental Illness.
Experts said mental health providers can only do so much, as gun violence and firearm purchases surge nationwide.
"Mental health is not going to take us all the way there," Cohen said. "The mental health community cannot solve the problem of gun violence in America."