James L. Knoll IV, MD

The scientific race to develop a vaccine is in full swing, but when will we begin to develop a more rational, healthy 

response to pandemics? Camus understood that “pestilences” recurred over time, yet always seemed to take us by surprise. In his classic, The Plague (

1947), he writes about a virus that destroys half the population of an ordinary town.

 It is considered one of the greatest novels of the postwar period. Camus lays out our stages of psychological response to a plague, writing: “At the beginning of a pestilence and when it ends, there's always a propensity for rhetoric. In the first case, habits have not yet been lost; in the second, they're returning.” Here, the master of the existential and absurd would have us recognize that inescapable death transforms a habit-constrained life into an exercise in absurdity.

Camus’ Plague may also be viewed as our vulnerability to random extermination by any means. Or as philosopher Alain De Botton

 writes: “Plague or no plague, there is always, as it were, the plague, if what we mean by that is a susceptibility to sudden death, an event that can render our lives instantaneously meaningless.” Camus and similar philosophers believed the Absurd arises out of the conflict between our search for meaning and the apparent random nature and meaninglessness of the universe. What is produced by the conflict will depend on the individual, but may include various forms of denial, dissociation, and sublimation.

And so, it is the Absurd to which we now turn. Indeed, we cannot turn away as we are in the midst of a storm of absurdity. Grocery stores with empty shelves. Hoarding of food and supplies. A 

 Historians of real-life pandemics understand that they unfold as social dramas.

 If this is the case, might this most recent pandemic supply us with some truths about human nature? A relatively clear response pattern has been described by epidemiologists throughout history. The recurring pattern is as follows: 1) deny and ignore, 2) recognize and attempt to explain as the drama unfolds, and 3) the resolution. Epidemiologists are perpetually aghast at our ability to forget this pattern and be caught off guard. Camus understood this conundrum exceptionally well, writing: “So all a man could win in the conflict between plague and life was knowledge and memories.”

Beyond the basic stages of denial, recognition, and recovery, are we able to discern any other psychological themes based on a social and psychological analysis of our behavior? Let us approach this in the manner of a psycho-dynamic anthropologist sent from another planet to observe our species at this moment in time. This investigator would first note our extreme “contamination” fears that go well beyond social distancing, handwashing, and so on.

Our observer would note our curious scramble to obtain and hoard toilet paper. Next, our hoarding of provisions and sudden rush to purchase more weapons would be of interest. The observer could easily discern that the stress humans are currently experiencing has created visible fault lines in our socio-cultural structures. All of these findings would be viewed as our reflexive response to sudden and acute death fears-or what is called “mortality salience” in the terror management literature.

 Our alien observer may well conclude that our species has not yet achieved a rational response to our own mortality-impending or otherwise. Finally, it might be recorded for posterity that humans appear to “forget” the social drama pattern, preferring to bury it back into the unconscious not long after the resolution of a pandemic.

Even a brief review of our past concerning responses to intense reminders of death is both enlightening and disturbing. They include such startling responses as scapegoating, “othering,” and a variety of risky death denying behaviors. Anti-Semitism and blaming of Jewish people were rampant when the Bubonic Plague swept across Europe in the 14th century. The Great Flu Pandemic (1918) is more commonly known as the “Spanish Flu,” despite the fact that the virus did not originate in Spain. Other countries were fearful of reporting their own afflicted status, while Spain transparently reported the problem to the press. It would appear that in the recognition stage of an epidemic, the need to explain is so powerful that if uncertainty remains, identification of a scapegoat becomes the default position. And have we seen such responses recently? Indeed, we have. Early anti-Chinese sentiment spread much more rapidly across the globe than actual virus itself. 

 As the pandemic has progressed over the past few weeks, we have seen all manner of panic-inducing reports in the media.

Morbid statistics that rise daily. Breaking news about the latest celebrity to have contracted the virus. One cannot but have sympathy and understanding for the general public who are relentlessly bombarded with confusing, and often divergent, messages. A scientist, who underscores the impact of his op-ed article by noting he is “an MIT-trained physicist and complexity scientist who studies pandemics,” urgently recommends a five-week “national lockdown.”

 Almost simultaneously, a Nobel laureate and Stanford biophysicist, who has analyzed 

 cases worldwide, writes that the data don’t support such a dire scenario, and that “

Without a consistent, calm, level-headed message, how can we expect the public 

to resort to well-worn habits that result from confusion and reminders of death? Certainly, they will-and absurdity will, temporarily, ensue. We will divide and “other” just as surely as viruses will mutate and infect us again in the future. Besides reports of hate crimes against Asians rising, the absurd can be seen in recent generational tensions. Millennials have been 

to the virus as the “#BoomerRemover,” while the older generation responds by shaming the younger for their “#CoronaParty” during spring break.

Virtually every culture engages in rituals to both forestall and ease death anxiety. It was not until the late 80s that researchers began formally studying death anxiety and how it is a “driving force behind the human motives for self-esteem and meaning in life, and thus plays an important role in diverse aspects of human behavior.”

 (TMT), our innate biological instinct for survival, combined with our capacity for self-consciousness, sets the stage for painful awareness of our mortality and its attendant terror.

 TMT research, derived from the Pulitzer Prize winning work of cultural anthropologist Ernest Becker, suggests that increased death terror motivates us towards the familiar (e.g., tradition, in-group worldviews, and cultural orientations.

 TMT research has progressed over the past several decades, finding that “death primes,” or reminders of mortality, are associated with:

• Hardening of traditions and fundamentalist beliefs

• Enhanced efforts to achieve attachment security

• Aggression against others who threaten one’s culture or traditions

Given the continuous media reports of death primes (the pandemic, the precarious nature of our environment, economic and political instability, etc.), one may wonder if the resultant death terror will be more intense than usual.

 Even if this turns out to be accurate, is there any reason for optimism? There is reason to believe so. For example, resilience-a proven strength of humans, is often seen in the midst of crisis and disaster.

What we learn in times of pestilence: that there are more things to admire in men than to despise.

At the heart of every tragedy is the finality of “the end” (e.g., loss) -the ultimate expression of which is death. To reckon with the end and death is to struggle with finding meaning in the face of the absurd. This can be seen in Samuel Beckett’s modernist works dealing with loss, suffering and death.

 Facing the absurd and death terror need not always result in morbid outcomes. TMT research has begun to suggest that resilience, when under the strain of death terror, may lead to positive progress, flexibility and new meanings. Of course, resilience in general is capable of producing personal growth and improved functioning in the face of stress and adversity.

My colleague, Dr Lloyd Sederer, who has led mental health disaster responses in New York, notes that there are always lessons to be learned and optimistic actions we can take.

 In addition to providing calming guidance in the form of organizational mandates and coordinated responses, we can begin with ourselves. In line with TMT research, Dr Sederer suggests turning to our sustaining, meaningful relationships; adequate self-care; exercise and various mindfulness exercises. TMT research from a positive psychology standpoint has found that death anxiety may also result in the following positive opportunities and growth-oriented goals:

• Valuing creativity and creative achievement

• Prioritizing growth-oriented goals and positive standards

Within times of chaos may lie the seeds of opportunity leading to new strategies, novel solutions and expanded meaning. Yet this will depend largely on our ability to sit with uncertainty and avoid the pressure to regress to unhelpful habits. In this way, death fear may serve as a cognitive reorganizer to develop a stronger “existential self-consciousness that sustains a process of self-overcoming.”

 A balance must be achieved, however, between healthy death terror buffers and outright panic driven denial. The influence of death awareness is truly profound, and may generate negative outcomes, as well as impel us along “more positive trajectories and contribute to the good life.”

Around 1637, the classical French painter Nicolas Poussin completed a masterpiece titled 

, also referred to as The Arcadian Shepherds. The beautiful painting shows an idyllic pastoral scene in which shepherds are gathered around a tomb. The title can be translated roughly to “Even in Arcadia, there I am,” or “Even in Arcadia, death is there.” Since the time of ancient Greece, Arcadia has been a metaphor for a Utopia, as it was far from the complexities and troubles associated with urban city life. As with all great art, it contains multiple meanings. One message is for us to never forget the fragility and brevity of life. Another message, more subtle but equally important, is that we have a duty to do our best to calm and sublimate our death fears. Recognizing this duty now seems to be an important task-one that we cannot allow ourselves to continue repressing.

Camus would likely have endorsed this approach, as his solution to the Absurd was to fully accept it – while continuing to live on – thereby achieving a transcendent form of freedom and personal meaning. Perhaps we might let this pandemic serve as our creative stimulus to begin to develop and test a set of go-to responses to mitigate panic in the face of a pandemic? We will surely have more opportunities to implement them. This would be a human triumph – to better understand and respond to those in the throes of overwhelming death terror, and develop “robust international responses to affected patients and communities.”

 and adopt a Camus-type philosophy which leads us away from fear and despair, and towards “a softening of the heart, a turning away from judgment and moralizing to joy and gratitude.”

is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of 

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Articles

We often push thoughts of death far out of our awareness, but at the present time they unavoidably re-emerge. Can we learn something helpful from this?

Panic and Pandemics: The Return of the Absurd

Despite advances in addiction research, substance use disorders continue to tighten their grip on society. Forensic psychiatrist and Editor in Chief Emeritus of 

 James L. Knoll IV, MD, weighs in on a case report.

A Rock and A Hard Place, by Eduardo Constantino, MD

Dr Constantino has our gratitude and sincere respect for submitting his case which is both real world and timely. Upon consulting with many respected addiction psychiatrists to formulate my response, all of them added that they were grateful that these difficult issues were being raised for discussion. I must imagine that such cases will be seen with greater frequency, particularly as the specialty of addiction psychiatry advances and substance use disorders tighten their grip on society.

In my view, Dr Constantino’s case is not so much a case about malpractice, but an extremely rich case highlighting the ethical and legal duties of a practicing addiction psychiatrist. There do not appear to be any clear deviations from the standard of care, nor are we made aware of any damages-effectively removing two of the 

that a plaintiff must prove in a malpractice case.

 Nevertheless, the learning value from this case is substantial. Dr Constantino’s “awkward quandary” involved the frustrating dilemma between preserving a patient’s right to confidentiality-and an ethical/clinical duty to act beneficently and preserve life. Yet as with many clinical dilemmas, the resolution often lies along the path of engagement and dialogue with the patient.

All physicians are presumed to have some awareness of confidentiality, given that it is required by professional ethics, hospital policy, and federal and state law. The exceptions to confidentiality are relatively small in number and include: medical emergencies, statutory reporting requirements (suspected child or elder abuse) and an individual state’s legal requirements regarding patients’ credible threats to third parties (Tarasoff statutes). From a legal standpoint, actions for breaching confidentiality may include: breach of contract, breach of statutory duty and professional misconduct. Confidentiality and privacy of psychiatric records is especially important in the field of addiction psychiatry. In fact, this issue is stressed by federal law, which requires that documentation in addiction treatment be held to even higher standards of confidentiality than general psychiatric and medical encounters.

 (AAAP), a “basic principle of confidentiality of personal health information is that, to the greatest extent possible, control of personal medical information should be in the hands of the patient. Nonetheless, when patients receive . . . substance use disorder services, their agreement to begin treatment should include their written consent that certain identifiable health information will be shared with other health professionals.”

A major concern of patients and addiction psychiatrists is that failure to maintain strict confidentiality in the setting of substance use treatment can potentially result in a cascade of highly adverse consequences.

 For example, it is not uncommon for disclosure of substance use treatment to result in: loss of employment, loss of child custody, discrimination by insurers and other health care professionals. Of course, the possibilities of arrest and incarceration are ever-present. Unsurprisingly, such concerns may lead individuals in need of treatment to avoid seeking the help they need-often until it is too late. Keeping this in mind, let us turn to Dr Constantino’s first question: “

Even though his probation officer was allowed to speak to any and all medical staff, could we legally call the probation officer against the patient’s specific instructions?”

Based on the case description, the treatment team’s decision to not call the probation officer seems appropriate, as doing otherwise would be a violation of consent and breach of confidentiality. It is recommended that psychiatrists obtain specific signed consents “for release of any personal health information to entities outside of the health-care delivery system, such as . . . judges, prosecutors, police or other legal investigators, or institutional or community corrections officials, even in response to subpoenas, as stipulated in 42 CFR Part 2.”

 Absent patient consent, requests for information from law enforcement or other government agencies seeking information without patient consent should be denied. One exception to this may be a specific court order (per 42 CFR Part 2). However, such court orders are typically reserved for patients who have been involved in serious crimes.

Addiction specialists know that parole and probation officers play a critical role in the lives of their patients. A positive relationship with a parole officer can mean the difference between recidivism-and continued wellness in the community.

 Because of their central role, it is important to have a clear understanding, from the beginning of treatment, about the precise conditions of probation that were ordered by the court. A meeting with the probation officer may be helpful to establish rapport, ground rules, limits of confidentiality and to review any legal documentation from the court. A reliable understanding of the probation officers’ “marching orders” will put the treatment team in a better position to understand any concerns the probation officer may have, as well as what information may be communicated between parties.

Turning to Dr Constantino’s second and third questions regarding notifying the patient’s IOP, and concerns about providing appropriate care-it is noted that the patient refused to give consent to speak to his IOP substance use treatment center. From a clinical standpoint, effective coordination of care is assumed to be in the best interests of the patient. Yet in this case, it can be argued that the same legal restrictions apply to informing the patient’s IOP. This is highly unfortunate, but there appear to be at least two barriers. First, the patient refused to give consent. Second, there is no mention that consent was legally applied by the court to the patient’s original terms of probation, which would allow for communication of health information with the IOP and vice versa.

There are several important points to consider regarding this impasse. The AAAP notes that when patients opt to not allow health information to be shared among other providers, they “should be educated about the implications for the quality of the health care services they may receive, and thus the potential detriments to their own health care outcomes and health status, when they decline to sign the consent.”

 Therefore, an open and serious discussion with the patient regarding the potentially life-threatening consequences of refusing to allow communication between mental health and substance use treatment providers should be undertaken and documented. However, the patient is noted to have poor insight into his dilemma and so we proceed to other options for now, while recognizing that improving insight will remain a continuing goal.

Arguably, the ideal resolution occurs prior to any treatment plan implementation, and involves a clear agreement between patient and treatment team from the outset regarding coordination and communication of care with the IOP. The patient’s signed informed consent for communication with other health care providers is one of the goals of this discussion. Some addiction specialists would advise going no further with a treatment agreement if the patient refuses to allow communication between key health care providers. In contrast, other addiction psychiatrists may view their ethical and clinical duty to the patient as transcending this impasse and would not refuse treatment to a patient who refused to give consent to communicate with other health care providers.

Finally, a third option involves investigating, with legal counsel, the possibility of returning to court to amend the patient’s probation conditions to allow for such communications. This last option would be less preferable, of course, to the patient agreeing with his treatment team to give consent. In other words, a solid and agreed upon plan from outset is superior to one that must confront repeated barriers to coordinated treatment. Nevertheless, there may be no simple or clear-cut answers, as obtaining consent in advance does not preclude a patient from later deciding to rescind consent. What are some possible adverse outcomes if a psychiatrist decides (in good faith) that a duty to the patient necessitates contact with a key health care provider, despite the patient refusing to give consent? A medical malpractice suit brought forth by the patient for breach of confidentiality is one possibility. In such a case, the patient would need to show that the breach of confidentiality directly caused some untoward event (eg, loss of employment, loss of custody, psychological damages.). Another possibility is that an aggrieved patient may lodge a formal complaint with the local medical board, prompting a review and possible sanctions.

This case highlights the growing importance of addiction psychiatry, as well as appropriate legal arrangements 

 of treatment to ensure proper coordination of care. Addiction psychiatrists know well that substance use and criminal recidivism are irrevocably linked,

 and that relapse prevention is necessary to prevent a return to jail or prison.

 For justice-involved individuals with substance use disorders, continued illicit drug use likely inhibits the ability to “mature out” of a criminal lifestyle in young adults.

 The stakes are extremely high for this population of patients. Release from prison is associated with significant mortality rates and a leading cause is drug overdose.

 The first two weeks after release appears to be a particularly vulnerable time of high risk for opioid overdose.

Dr Constantino is appropriately concerned about the challenge involved when a prolonged period without opioid use can simultaneously be a sign of recovery, as well as a risk factor for fatal overdose.

 I would add that the patient’s focus on getting through his “five months” of probation and refusal of long acting naltrexone would reasonably make a treatment provider nervous. There is now some data supporting extended-release naltrexone being associated with a decreased risk of overdose. Thus, naltrexone is currently an option for patients who decline or are unable to obtain opioid agonist treatment.

 This can become critical in that opioid use disorder treatment remains quite limited in US correctional facilities.

 Looking towards the future, it is hoped that concerted efforts are made to implement programs across the criminal justice continuum to address this deadly public health issue.

Dr Constantino and his team seek consultation from their risk management department-always a sound decision that follows the dictum of the great Tom Gutheil, MD: “Never worry alone.” Finally, I would add that Dr Constantino’s team appeared to exert due diligence with “repeated” follow up calls and a letter. This is particularly important in that proper termination with patients involves such efforts, along with documentation they occurred and that some other potential providers in the community were offered to the patient. In this case, a follow-up communication letter letting the patient know you are willing to arrange communication of important health care information with his new provider would be ideal.

I conclude again with a thanks to Dr Constantino, as well as a supportive proclamation that competent and evidence-based substance use disorder treatment “is a more appropriate intervention than incarceration for non-violent drug offenders,” and “non-violent drug offenders should be diverted to treatment programs while being monitored through intensive probation drug courts, or other means, instead of expensive and less effective incarceration.”

 Further, treatment and monitoring following incarceration should be available, and likely court mandated, for those on probation to prevent relapse, deadly overdose and recidivism.

Dr Knoll would like to thank Professor Andrew J. Saxon, MD, Director, Center of Excellence in Substance Abuse Treatment and Education, University of Washington School of Medicine, for his helpful review and comments.

Dr Knoll is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of

This article was originally published on July 1, 2019, and has since been updated. The print version of this article is titled 

2. Chapter 42 of the Code of Federal Regulations, Part 2, (42 CFR Part 2)

3. Confidentiality of Patient Records and Protections Against Discrimination: A Joint Statement by American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Osteopathic Academy of Addiction Medicine and the Association for Medical Education and Research in Substance Abuse https://www.aaap.org/wp-content/uploads/2018/07/confidentiality-2018-final.pdf. Accessed June 28, 2019.

4. Dept. of Health and Human Services. Confidentiality of Substance Use Disorder Patient Records. 42 CFR Part 2; 2017: 82(11). 

https://www.govinfo.gov/content/pkg/FR-2017-01-18/pdf/2017-00719.pdf

5. Chamberlain A, et al.: Parolee-Parole Officer Rapport: Does It Impact Recidivism? 

6. Fearn NE, Vaughn MG, Nelson EJ, et al. Trends and correlates of substance use disorders among probationers and parolees in the United States 2002–2014. 

7. Kopak A, Haugh S, Hoffman N. The entanglement between relapse and posttreatment criminal justice involvement. 

8. Walters G. Does Drug Use Inhibit Crime Deceleration or Does Crime Inhibit Drug Use Deceleration? A Test of the Reciprocal Risk Postulate of the Worst of Both Worlds Hypothesis. 

9. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison--a high risk of death for former inmates. 

10. Babu K, Brent J, Juurlink D. Prevention of Opioid Overdose. 

11. Friedmann PD, Wilson D, Hoskinson R Jr, et al. Initiation of extended release naltrexone (XR-NTX) for opioid use disorder prior to release from prison. 

12. Csete J. Criminal Justice Barriers to Treatment of Opioid Use Disorders in the United States: The Need for Public Health Advocacy. 

13. Brinkley-Rubinstein L, Zaller N, Martino S, et al.: 

Criminal justice continuum for opioid users at risk of overdose

14. Criminal Justice System and Substance Use Disorder Treatment Policy. 

https://www.aaap.org/wp-content/uploads/2018/07/AAAP-FINAL-Criminal-Justice-System-and-SUD-Treatment-Policy-HC_rr.pdf

James L. Knoll IV, MD, analyzes the ethical and legal duties of psychiatrists treating substance use disorders.

Psychiatric Malpractice Grand Rounds: Addiction Psychiatry 

In the wake of the horrific mass public shootings in El Paso and Dayton, the public dialogue has turned to focus more squarely on mental illness. Many are unable to fathom how a human being could commit such acts without being under the influence of some powerful “alien” force.

An example of a recent question posed to us by the media was: 

“Psychiatrists say that violence and mass killing are not closely linked to mental illness. But can we agree that shooting 20 strangers more or less at random is not normal, rational behavior? So, if it's not ‘mental illness,’ what is it?” 

Although we typically do not entertain media queries in the wake of these tragedies, this particular question suggested to us an opportunity to begin a more reasonable and open public dialogue about:

• What psychiatrists consider a mental disorder-and what they do not

• How people with and without a mental disorder may be capable of cruel, violent behavior

• The strengths and limitations of psychiatry in terms of preventing mass violence

We understand why questions about mental illness often arise in the wake of these horrific acts of targeted violence. When a violent, sadistic, or bizarre act is carried out, there is a certain comfort obtained by distancing ourselves from the perpetrator. The perpetrator may be easily dismissed as “deranged” or “out of his mind.” Some may employ labels that seem psychiatrically official, such as “delusional,” or “psychotic” to give emphasis to the appearance of certainty. In this way, we protect ourselves from the disturbing notion that, given different circumstances, the horrific act might have been carried out by one of our own children, friends, or neighbors. We understand all of this, and with empathy. But the time for seeking the comfort of an intellectual short cut is long past.

We accept the criticism leveled at psychiatry that we have not done enough to clarify the boundaries of “mental illness.” In our defense, it is a Promethean task of unimaginable complexity. Even our US Supreme Court has acknowledged this in a case dealing with the insanity defense. The Court warned about the potential of mental-disease evidence to “suggest that a defendant suffering from a recognized mental disease lacks cognitive, moral, volitional, or other capacity, when that may not be a sound conclusion at all.”

 Where boundaries are uncertain, it is important to minimize misunderstanding and be aware of limitations. The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations.

 Keep in mind that even pathologists may disagree, for example, on whether a tissue sample represents true malignancy, or merely “atypical” cells.

 immediately confronts us with a problem of definitions. We do not know the meaning or denotation being employed by the media or public when using the term “mental illness,” and thus we begin speaking past or around each other. Do they mean a formally recognized mental disorder specified in DSM-5? Or are they simply referring to a shocking act of cruel violence? If it is being used to mean the latter, or refers to socially deviant behavior (eg, violent revenge, sexual assault, ideologically driven hate) and/or conflicts that are primarily between the individual and society-this would 

 be considered a “mental disorder” by formal psychiatric standards.

 Forensic psychiatrists and others who study criminal behavior quickly learn in their training that it is a mistake to assume a particular crime flowed from a mental illness, simply because it was horrific, deviant or bizarre. In other words, the heinous nature of a crime does not necessarily entail mental illness-but the “pull” to assume so is often very strong.

It may be more comforting to believe that some “disease of the mind” took over and caused someone to commit an unspeakable act than to recognize that “sane” persons are quite capable of violent and sadistic behavior. Sadly, the ancient problem of 

 choosing to act in a supremely selfish and violent manner has always been with us. Do we advance our understanding by labeling such behavior “mental illness,” and calling for greater scrutiny of “mentally troubled” individuals? As psychiatrists, we think not, even as we acknowledge the problem of untreated psychiatric illness.

Another way of posing the question is to ask-

Does immoral, callous, cruel, and supremely selfish behavior constitute a mental illness?

 These socially deviant traits appear in those with and without mental illness, and are widespread in the general population. Are there some perpetrators suffering from a genuine psychotic disorder who remain mentally organized enough to carry out these attacks? Of course, but they are a minority. To further complicate matters, psychotic individuals can also commit violent acts that were motivated by base emotions (resentment, selfishness, etc.), while their psychotic symptoms may be peripheral or merely coincidental.

It bears repeating that reliable, clinically-based data or complete psychological autopsies on perpetrators of mass public shootings are very difficult to obtain. That said, some of the best available research on mass public shooters indicates that they often display “rigidness, hostility, or extreme self-centeredness.”

 found that only 25% of mass shooters had ever had a mental illness diagnosis, and only 3 of these individuals had a diagnosis of a psychotic disorder. The FBI’s cautionary statement in this report is incisive: “. . . formally diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence…. declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”

Psychiatric and mental health treatment has its limits, and is not traditionally designed to detect and uncover budding violent extremists. It is designed to work together with individuals who are invested in their own mental health and seek to increase their own degrees of freedom in life in a pro-social manner. This is why calls for more mental health laws or alterations in civil commitment laws are likely to be low-yield at best, with respect to preventing mass killing-and stagnating to mental health progress at worst.

Even if psychiatrists were to create a dubious diagnosis called “Mass Shooting Disorder,” it would be utterly useless. The diagnostic criteria for “MSD” would be so broad and nonspecific that “diagnosing” would be meaningless. Similarly, this is why “profiling” does not work for this population. The profiles are too non-specific and lead to so many false positives that it is a pointless endeavor. As chair of a School Safety Task Force’s Threat Assessment Committee, one of us (JLK) can 

 the fact that thousands of young people each day “fit the profile.”

 Further, there are no diagnostic criteria that would allow one to reliably “flag” an individual. Factors such as poor stress tolerance, impulse control problems, substance abuse, hopelessness, desperation, and social isolation also occur in those 

It is highly unsatisfying to entertain the notion that severe selfishness, resentment and desire for infamy are simply a part of the broad range of human nature. But such traits have been with us since the dawn of our species. This type of psychological turmoil might possibly be helped by mental health professionals, but only with engagement and dedication on the part of a “patient.” Coerced, threatened or unengaged individuals tend to make very poor patients.

To be clear: we do not wish to deny what our colleague, Dr E. Fuller Torrey

, that “. . . without treatment, some seriously mentally ill people are at greater risk for violent behavior than the general population.” (Dr Torrey has argued that, “For those who are seriously mentally ill but who, because of their brain disease, are unaware of their illness and refuse treatment, it is sometimes necessary to require them to accept treatment as a condition for living in the community.”

Nor are we claiming that psychosis and serious mental illness play no role at all in mass shootings. If we had access to adequate, pre-shooting, clinical and forensic data, we might find that some individuals who go on to become mass shooters do indeed suffer from SMI, or experience psychotic symptoms-though, importantly, this would 

, rather than from the usual motives such as resentment, vengeance and a desire for infamy.

Dr Knoll is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of 

 (2010 to 2014). Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston. He is Editor in Chief Emeritus of 

Editor's note: This article was originally posted on August 19, 2019, and has since been updated.

The authors report no conflicts of interest concerning the subject matter of this article

2. Stein DJ, Phillips KA, Bolton D, et al. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. 

Diagnostic and Statistical Manual of Mental Disorders.

 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

4. Dietz,PE. Mentally disordered offenders: Patterns in the relationship between mental disorder and crime. 

5. Mullen PE. The autogenic (selfâgenerated) massacre. 

6. Silver J, Simons A, Craun S. A study of the pre-attack behaviors of active shooters in the United States between 2000 and 2013. US Department of Justice: Federal Bureau of Investigation. June 2018. 

https://www.fbi.gov/file-repository/pre-attack-behaviors-of-active-shooters-in-us-2000-2013.pdf/view

7. Report of the Onondaga County School Safety Task Force: A Joint Initiative Between the Offices of the Onondaga County District Attorney Onondaga County Executive City of Syracuse Mayor Onondaga County Sheriff. August 13, 2018. 

http://www.ocmboces.org/tfiles/folder3365/Onondaga%20County%20School%20Safety%20Task%20Force%20-%20Report%20-%202018.pdf

8. Torrey EF. Mental Illness and Mass Murder. 

https://www.wsj.com/articles/mental-illness-and-mass-murder-11564955203

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In the spirit of honoring and guiding trainees, the authors provide advice to today’s psychiatric residents-the psychiatric leaders of tomorrow.

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 James L. Knoll IV, MD, weighs in on a duel case report: 

To Invoke or Not to Invoke: Tarasoff Is the Question

Thou shalt not stand idly by the blood of thy neighbor. 

Psychiatrist Elliott Martin, MD, graciously provides us with two rich clinical scenarios and notes the understandable confusion, anxiety, and ethical conundrum that may arise when the Tarasoff conflict is “invoked.” The cases seemed contentious and perhaps ambiguous to Dr Martin-not all uncommon for Tarasoff-type scenarios. In his case examples, Dr Martin refers to the Tarasoff duty as a duty to warn, and so let us take a moment to clarify this often misunderstood concept.

It has been my experience that confusion persists regarding the meaning and use of the terms duty to warn and duty to protect. This may be partly due to the fact that there were two Tarasoff decisions. The first Tarasoff decision in 1974 created a 

 in California and was based on the special relationship between therapist and patient.

 This first decision was unprecedented, and quite upsetting, to therapists due to its legal compromise of patient confidentiality. An oft quoted line from this first Tarasoff decision made it clear that the Court was concerned with social policy: “The protective privilege ends where the public peril begins.”

In “Tarasoff II,” the California Supreme Court reheard the case, noting plaintiffs’ argument that therapists failed to exercise reasonable care to 

 Although the police were warned, no other steps were taken such as detaining Poddar or warning Tatiana of the danger. In its 1976 ruling, the Court replaced duty to warn with a 

 The famous quote from Tarasoff II, which was adapted by many states across the country, made the change clear: “When a therapist determines, or should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim from danger.”

Initially, there was concern that this exception to confidentiality would have a disastrous effect on psychiatric practice, despite the fact that most therapists had embraced such a duty before the Tarasoff ruling.

 Over time, it became clear that the concerns about the potential loss of confidentiality did not have an adverse impact on psychiatric practice.

 In 2013, after decades of misunderstanding, California passed legislation which unambiguously established a sole duty to protect.

 The California statute removed all references to duty to warn, and provides a “definitive clarification.”

The persisting confusion among clinical psychiatrists about the duty to protect is understandable given that: 1) there are no widely accepted clinical guidelines to follow; 2) the duty varies by state; and 3) individual states’ duties have changed over time according to case law and/or state statute.

An expert provides sage advice to avoid a malpractice lawsuit, even in the face of potentially tragic outcomes.

Author | James L. Knoll IV, MD

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