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.
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