Kevin Neal's family knew he was mentally ill, but they never thought he would kill five people and attack an elementary school in rural northern California. But Neal committed both those acts on Tuesday, and it has left his family asking some very difficult questions.
"We got, 'I can't take it anymore' a thousand times — like when do you know if it's real?" asked Sheridan Orr, Neal's sister.
Orr said her brother had made such statements for nearly 20 years, and the family came to consider it to be an empty threat. Though they continued to pressure him to receive help for his mental health, he seemed unwilling to pursue treatment.
Experts say it is difficult to know what to do in those situations, but Dr. James Fox, an expert on gun violence and author of "Extreme Killing: Understanding Serial and Mass Murder," said it's dangerous to assume that the mentally ill tend to commit these shootings.
"There's not really a correlation," said Fox, who maintains a database on mass shootings. "We like to think that these people are different from the rest of us. We want a simple explanation and if we just say they're mentally ill, case closed. Because of how fearful dangerous and deadly their actions are, we really want to distance ourselves from it and relegate it to illness."
Despite this, Orr's question is one that is now dogging Washington, as politicians discuss how to resolve a seemingly unending number of mass shootings. And now Republicans have framed the issue as a mental health crisis, rather than a gun control problem.
President Donald Trump pushed that perspective after the shooting in Sutherland Springs, Texas, stating "mental health is your problem here" and calling the shooter "a very deranged individual."
This week Sens. Jon Cornyn, R-Texas, and Chris Murphy, D-Conn., revealed that they are working to pass bipartisan legislation that would improve background-checks for gun sales by incentivizing states to upload and verify the criminal and mental health records to the National Instant Criminal Background Check system.
Fox is skeptical this will bring about any change.
"Most mass murderers don't have criminal records or mental health treatment," said Fox. "The reason we should have [background checks] occurs every day in America. We have an average of 40 shooting homicides a day. That's the reason, not the occasional mass shooting."
Experts say that the public has to be careful with how it thinks about gun violence and mental illness, otherwise it could stigmatize those who suffer from mental health issues.
And considering that suicide by firearm killed 313,641 people between 1999 and 2015, according to the National Center for Injury Prevention, it appears much more likely that the mentally ill will hurt themselves than others.
Dr. Jonathan Metzl, director of the Center for Medicine, Health and Society at Vanderbilt University, said that these mass shootings highlight Americans' desire to reaffirm a stigmatization of the mentally ill as "ticking time bombs" to avoid more difficult conversations about gun violence.
"Mass shootings are horrific and terrifying," he said. "But if we really want to stop gun violence in this country, everyday gun violence is predictable and could be stopped. Ending everyday gun violence would help end mass shootings as well."
According to Everytown for Gun Safety, 34 percent of the mass shootings that occurred between Jan. 2009 and Dec. 2016 were committed by those considered to be "prohibited possessors" — or people who are unable to purchase guns because of their age, criminal conviction(s), history of addiction, a domestic abuse conviction or a person who has been "adjudicated as a mental defective" or been admitted to a mental institution.
According to a 2016 report published by the American Psychiatric Association (APA), just ensuring weapons don't enter the hands of the mentally ill isn't enough to prevent mass shootings from occurring regularly. Instead, the report suggests that public health and education campaigns are needed to teach people how to report concerning behavior to authorities and how to learn coping skills for anger and conflict resolution.
The report also proposes that policies and laws be focused on dangerous behavior that shows risk for committing gun violence, rather than a blanket category for the mentally ill, and recommends that institutions and communities develop threat assessment teams that can evaluate reports of potential danger.
As Fox asserts, the belief that the mentally ill are more likely to take part in a mass shooting appears to be a misleading. There were 198,760 homicides committed by a firearm in the United States between 1999 and 2015, according to the National Center for Health Statistic. Despite the high number, the APA report from 2016 says that fewer than 1 percent of firearm homicides are committed by a person diagnosed with a mental illness.
Metzl has researched the correlation between mental illness and gun violence, and he said that it's a tenuous connection at best.
"There's no mental illness diagnosis that explains causality," Metzl said. "There's no mental illness whose symptoms are shooting anyone else. Most mental illnesses cause people to withdraw from society."