Yash Joshi, MD, PhD

 

The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th¹ U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.² In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”³

This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.⁴ The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.

This expansion of reporting requirements led to approximately 75,000 people being placed in the database, and New York Gov. Andrew Cuomo recently declared that this measure “kept guns out of the hands of dangerously mentally ill people.”⁵ On the face of it, this appears to be an extension of Tarasoff laws in many states, where providers’ duty to maintain confidentiality to patients is superseded by a duty to protect the targets of violence. We empathize with the motivations underlying these new laws: They would reasonably allow for easier identification of violent individuals.

However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves⁶; 41% of depressed mothers have experienced thoughts of harming their children⁷; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed⁹ gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.¹⁰

 

Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, we can imagine a prohibitive additional hesitation if patients worry that their rights and liberties may be taken away if they said “the wrong thing.” Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.¹² Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.

As shootings continue to occur, we will continue to see proposals of reporting laws such as NY SAFE. It is our opinion that mental health providers should support and participate in attempts at recognizing and treating dangerousness. However, we must acknowledge that in an effort to stop future atrocities, we may inadvertently identify and label people who will never commit acts of violence, and, in the process, disenfranchise some patients who could benefit from treatment. In anticipation of this possibility, we need to expand the discourse beyond merely agreeing that we should increase surveillance on troubled individuals. The question should not only be whom should we be on the lookout for, but also how do we ensure that mental health providers are more accessible to patients who might benefit from treatment?

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.

References

1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting

2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018

3. https://twitter.com/realDonaldTrump/status/964110212885106689

4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73

5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104

6. MMWR 2004;53(2):1-96

7. J Affect Disord. 1999 Jul;54(1-2):21-8

8. Ethol Sociobiol. 1993;14(4):231-48

9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf

10. Ann Rev Clin Psychol. 2017 May 8;13:445-69

11. Psychotherapy Theory Res Prac. 2001;38(4):357-61

12. J Affect Disord. 2006 Jun;92(2-3):287-90

 

The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th¹ U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.² In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”³

This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.⁴ The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.

This expansion of reporting requirements led to approximately 75,000 people being placed in the database, and New York Gov. Andrew Cuomo recently declared that this measure “kept guns out of the hands of dangerously mentally ill people.”⁵ On the face of it, this appears to be an extension of Tarasoff laws in many states, where providers’ duty to maintain confidentiality to patients is superseded by a duty to protect the targets of violence. We empathize with the motivations underlying these new laws: They would reasonably allow for easier identification of violent individuals.

However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves⁶; 41% of depressed mothers have experienced thoughts of harming their children⁷; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed⁹ gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.¹⁰

 

Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, we can imagine a prohibitive additional hesitation if patients worry that their rights and liberties may be taken away if they said “the wrong thing.” Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.¹² Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.

As shootings continue to occur, we will continue to see proposals of reporting laws such as NY SAFE. It is our opinion that mental health providers should support and participate in attempts at recognizing and treating dangerousness. However, we must acknowledge that in an effort to stop future atrocities, we may inadvertently identify and label people who will never commit acts of violence, and, in the process, disenfranchise some patients who could benefit from treatment. In anticipation of this possibility, we need to expand the discourse beyond merely agreeing that we should increase surveillance on troubled individuals. The question should not only be whom should we be on the lookout for, but also how do we ensure that mental health providers are more accessible to patients who might benefit from treatment?

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.

References

1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting

2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018

3. https://twitter.com/realDonaldTrump/status/964110212885106689

4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73

5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104

6. MMWR 2004;53(2):1-96

7. J Affect Disord. 1999 Jul;54(1-2):21-8

8. Ethol Sociobiol. 1993;14(4):231-48

9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf

10. Ann Rev Clin Psychol. 2017 May 8;13:445-69

11. Psychotherapy Theory Res Prac. 2001;38(4):357-61

12. J Affect Disord. 2006 Jun;92(2-3):287-90

 

The tragic Feb. 14 massacre at Marjory Stoneman Douglas High School in Parkland, Fla., which left 17 people dead and 15 hospitalized, was the 34th¹ U.S. mass shooting of 2018. Last year was a record year, with 346 mass shootings.² In response to these tragedies, mental health providers are being looked at to help solve the problem. In fact, the day after the Florida shooting, President Trump tweeted: “So many signs that the Florida shooter was mentally disturbed ... Must always report such instances to authorities, again and again!”³

This response is reminiscent of how the state of New York reacted to the 2012 Sandy Hook massacre in Newtown, Conn. One month after the shooting, the NY SAFE (New York Secure Ammunition and Firearms Enforcement) Act was passed, which, among its measures, requires mental health providers to report individuals “likely” to engage in harm.⁴ The act represented an attempt to empower mental health providers to report high-risk, potentially violent individuals to the appropriate authorities.

This expansion of reporting requirements led to approximately 75,000 people being placed in the database, and New York Gov. Andrew Cuomo recently declared that this measure “kept guns out of the hands of dangerously mentally ill people.”⁵ On the face of it, this appears to be an extension of Tarasoff laws in many states, where providers’ duty to maintain confidentiality to patients is superseded by a duty to protect the targets of violence. We empathize with the motivations underlying these new laws: They would reasonably allow for easier identification of violent individuals.

However, we must acknowledge that some practical difficulties arise with such mandates. First is the reality that the overwhelming majority of patients in therapy who endorse violent impulses do not go on to commit harm toward themselves or others, nor do they break the law. Up to 25% of teenagers have thoughts of killing themselves⁶; 41% of depressed mothers have experienced thoughts of harming their children⁷; and up to 68% of individuals have homicidal fantasies.8 It would be difficult to argue that we would be doing our due diligence in reporting all patients who share such thoughts. Even if we agree that we ought to report only those who are at high risk for potential future violence, few guidelines are useful in stratifying risk for future violence outside of forensic settings. Prognostication is particularly difficult in cases where there is no history of previous criminal activity, as was the case with the confessed⁹ gunman in the Florida case. We also must acknowledge that evidence is scant suggesting that mental health treatment as a whole can reduce the incidence of mass murders. Evidence does suggest, however, that patients with serious mental illness are not involved in a majority of cases.¹⁰

 

Second, these types of mandates can perpetuate stigma in mental health, both potentially driving away patients who could benefit from therapy, and straining the relationships between patient and provider for those in treatment. Given the high degree of effort it takes for some populations to engage in mental health services, we can imagine a prohibitive additional hesitation if patients worry that their rights and liberties may be taken away if they said “the wrong thing.” Indeed, it has been demonstrated many times that nothing matters more to the outcome of mental health treatment than the relationship between the providers and their patients,11 an effect that is true even for medication management.¹² Being more wary of one’s treating provider may, therefore, limit the effect of treatment from the patient’s perspective. In the same vein, some therapists may rightly pause to consider whether they should be more vigilant and dutifully extract statements confirming a nonviolent mindset at every meeting, much in the way we perform suicide risk assessment to assess safety. Or, therapists could hesitate to probe for violent themes out of an underlying wish to avoid discovering something that they would have to report. Such tensions created within the therapist also may lend to suboptimal treatment.

As shootings continue to occur, we will continue to see proposals of reporting laws such as NY SAFE. It is our opinion that mental health providers should support and participate in attempts at recognizing and treating dangerousness. However, we must acknowledge that in an effort to stop future atrocities, we may inadvertently identify and label people who will never commit acts of violence, and, in the process, disenfranchise some patients who could benefit from treatment. In anticipation of this possibility, we need to expand the discourse beyond merely agreeing that we should increase surveillance on troubled individuals. The question should not only be whom should we be on the lookout for, but also how do we ensure that mental health providers are more accessible to patients who might benefit from treatment?

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Joshi is a research track psychiatry resident at the University of California, San Diego. His current research focuses on developing novel therapeutic strategies to target cognitive impairment in schizophrenia. His interests include graduate medical education and applied bioethics.

References

1. Gun Violence Archive http://www.gunviolencearchive.org/reports/mass-shooting

2. https://www.abc15.com/news/data/mass-shootings-in-the-us-when-where-they-have-occurred-in-2018

3. https://twitter.com/realDonaldTrump/status/964110212885106689

4. http://www.nyspsych.org/index.php?option=com_content&view=article&id=73

5. https://www.politico.com/states/new-york/albany/story/2018/02/15/after-florida-school-shooting-cuomo-again-touts-safe-act-256104

6. MMWR 2004;53(2):1-96

7. J Affect Disord. 1999 Jul;54(1-2):21-8

8. Ethol Sociobiol. 1993;14(4):231-48

9. http://www.dcf.state.fl.us/newsroom/publicdocuments/Headquarters/Records20180219/Petition%20to%20Publically%20Release%20DCF%20Records.pdf

10. Ann Rev Clin Psychol. 2017 May 8;13:445-69

11. Psychotherapy Theory Res Prac. 2001;38(4):357-61

12. J Affect Disord. 2006 Jun;92(2-3):287-90