Evaluating threats of mass shootings in the psychiatric setting

Abstract

Psychiatrists may encounter patients at risk of perpetrating mass shootings or other mass violence in various settings. Most people who threaten or perpetrate mass violence are not driven by psychiatric symptoms; however, psychiatrists may be called upon to evaluate the role of mental illness plays in the risk or threat, and to treat psychiatric symptoms when present. Regardless of whether psychiatric treatment is likely to reduce symptoms or the potential for violence, the psychiatrist should collaborate closely with law enforcement, potential targets, and other agencies involved to mitigate risk. Such communications are governed by various privacy laws and duties to third parties. Additional measures, like protective orders, may be a means of restricting the subject’s access to firearms.

Keywords:

• Mass shootings
• firearms
• mental illness
• red flag laws
• violence
• forensic psychiatry
• gun violence

Intro, epi and definitions

In the last two decades, mass shootings have become a rare but traumatic part of American life. In 2019, there were 10 heavily publicised public mass shootings (in which three or more people were killed) that took the lives of 73 Americans and injured 112 more (Follman et al., 2020). It is the seemingly random public mass shootings of strangers that are widely reported in the media, despite the fact that they comprise less than 1% of firearm deaths in the United States (Follman et al., 2020; CDC, 2020). Public mass shootings inspire fear because of the perception they could strike anyone in places once considered safe like churches, malls and schools. One-third of Americans reported avoiding certain places because of fear of such incidents (American Psychological Association, 2019).

Mass shootings are the most common form of mass violence in the United States. This is due, at least in part, to the extraordinarily large amount of firearms in civilian hands in the U.S., amounting to approximately 46% of the all civilian-owned firearms in the world. The U.S. has more privately-owned firearms than the next thirty-nine countries combined (Karp, 2018). The abundance of firearms leads to disproportionate burdens of mass shooting casualties as well as smaller scale assaults and homicides, and suicides (Grinshteyn & Hemenway, 2016, 2019; Lankford, 2016). However, many of the considerations for psychiatric evaluation of people suspected of planning to carry out mass shootings apply to mass attacks with other weapons such as knives, explosives or vehicles.

Quantitative reports of mass shootings are inconsistent because researchers and agencies use different data sources and different criteria. Datasets diverge on setting (some exclude incidents occurring in homes; some include only incidents in public places), types of injuries (e.g. firearm injuries vs. injuries incurred in fleeing vs. non-firearm attacks), source (e.g. FBI Crime Reports vs. media reports), and thresholds of the number of people injured or killed to count as a case. Some datasets expressly exclude terrorist acts, but a substantial minority (43%) of these mass violence incidents may have social, political, or ideological motivation, be intended to influence large groups of people, or otherwise qualify as a terrorist act (Hunter et al., 2020). Domestic violence incidents are also frequently excluded from datasets, though there is mounting evidence that intimate partner violence and violent misogyny play a role in many of these incidents (Silva et al., 2021; Zeoli & Paruk, 2020). Because of the variations in definitions and data sources, the datasets never overlap completely and at times can verge on being mutually exclusive (Booty et al., 2019).

These heterogenous datasets make discerning trends amongst mass shooters challenging. However, some common motivations emerge: political or religious ideology, vengeance for longstanding grudges, psychosis (Langman, 2009; Schildkraut et al., 2020). A subset of mass shooters admire prior mass shooters and are seeking similar notoriety for themselves (Langman, 2018; Silva & Greene-Colozzi, 2019). Revenge for a central grievance is often seen as the first step towards engaging in targeted violence (Calhoun & Weston, 2003; Fein & Vossekuil, 1998). While many of these characteristics are identified as commonalities among mass shooters in hindsight, they are common traits among the general population and lack the specificity they would need to be predictive. Additionally, they are not mutually exclusive and often multiple motivations co-exist.

If identifiable, motivations can be useful in identifying an appropriate intervention. An attack planned because of delusional beliefs could benefit from psychiatric treatment; an attack motivated by political extremism may bet better suited for a deradicalization approach. Just as in every aspect of medicine: while broad commonalities may provide useful schema for guiding evaluation and formulation, assessment should be adaptive and treatment planning should be individualised.

The majority of public mass shooters do not have a pre-existing psychiatric diagnosis, and amongst those that do, psychosis is an infrequent factor (Silver et al, 2018). Nonetheless, there have been a number of well-publicised mass shootings perpetrated by people with overt psychotic symptoms. The DC Navy Yard shooter had reported that he was being controlled by “extremely low frequency electromagnetic waves” that were coming in through the walls of his hotel room and preventing him from sleeping (Herman and Marimow, 2013). A woman with a diagnosis of schizophrenia and previous hospitalisations opened fire in the lobby of a television station that she believed was broadcasting stories about her sex life (Butterfield, 2000). The man who shot Gabriel Giffords at a campaign event, believed that the US government was faking space flights and printing counterfeit currency (Hudson, 2011).

Regardless of whether mental illness plays a role, psychiatrists faced with such cases have a variety of tools at their disposal to mitigate the risk of public violence, to treat any contributory mental illness, and to minimise personal liability. The approach includes a thorough psychiatric assessment, treatment for any underlying contributing mental illness, close collaboration with law enforcement agencies, communication with potential targets if appropriate (schools or workplaces), and removal of access to firearms.

Psychiatric assessment and treatment

Psychiatrists may encounter patients at risk of perpetrating mass violence in the outpatient, emergency, or inpatient setting. Patients may present because of direct and overt threats or because of subtle but concerning statements. Leakage – a statement or indication of violent intent by the patient to a third party – is common in people who engage in mass violence and often a cause for referral for psychiatric evaluation (Meloy & O’Toole, 2011). The violent intent may be the reason for presentation or simply an issue revealed during an otherwise routine assessment. In crisis or emergency settings, these evaluations may be initiated by law enforcement bringing the patient in on an involuntary hold for dangerousness, at times in the absence of overt psychiatric symptoms or history.

In such cases with both a criminal justice and a mental health component, there may be unrealistic expectations of threat reduction by the different parties. Law enforcement teams may erroneously believe that mental health holds will allow for indefinite detention and loss of access to firearms, or expect that psychiatric treatment will cure the patient of any underlying violent tendencies. Mental health professionals may not be familiar with the level of evidence required to arrest and bring charges in various jurisdictions, and the amount of time needed for a complete investigation. In such cases, it is important to consider the timeframes and potential efficacy of interventions from various agencies working on the case, and keep open lines of communication to ensure public safety.

Understanding the role of psychiatric illness in mass shootings

It should be emphasised that most general violence is not attributable to mental illness or people with mental illness (Swanson, 1996). Amongst people with mental illness, symptoms drive acute risk, not the presence of a diagnosis itself; similarly, current and recent intoxication drive risk in substance users (Mulvey et al., 2006; Skeem et al., 2006).

The view that mental illness is a central risk factor for mass shootings is not substantiated by most available research, and is driven by public misperception and stigma (Metzl et al., 2021; Rozel & Mulvey, 2017; Skeem & Mulvey, 2019). A majority of studies indicate that overt psychiatric illness is present in less than half of mass shooters. In one of the more robust studies from the FBI, only 25% of mass shooters had an identified psychiatric illness and only a quarter of those had evidence of psychosis (Silver, Simons, et al., 2018). More common factors were longstanding grievance, recent loss, and behavioural problems at school or in the workplace (Silver, Simons 2018; National Threat Assessment Centre).

Thus, a person at risk of committing a mass shooting may not present for overt psychiatric symptoms, but instead for acute psychosocial stressors, threats, or indirect statements of intent to kill others – common chief complaints in acute psychiatric settings and risk factors for engaging in violence (Alathari et al., 2019; Silver, Simons, et al., 2018).

It is possible that many mass shooters meet the diagnostic criteria for personality disorders, but there is little recorded diagnostic data to support this. Low rates of diagnosed personality disorders or other psychiatric illness in mass shooters may be due to lack of information about assailants and low rates of access to psychiatric evaluation (Lankford & Cowan, 2020). Given the relatively high baseline rates (55-85% in some studies) (Caspi et al., 2020; Kessler et al., 2005) of psychiatric diagnoses in the United States, the question becomes not whether a potential perpetrator of mass violence has a mental illness, but whether the symptoms of the illness cause the violence, and if there is a potential, plausible way for the mental health system to mitigate said risk of violence.

Grievances, paranoia, and entitlement

The pathway to targeted violence often begins with a grievance or a grudge: a person perceives they have been wronged and clings to and fixates upon the perceived wrong (Calhoun & Weston, 2003; Corner et al., 2018; Stone, 2015). People with paranoid tendencies, ranging from subsyndromal traits to overt psychotic illness or personality disorder frequently perceive threat or harm from the environment around them. These traits and disorders are frequently seen in people who plan or carry out mass shootings and other types of targeted violence (Knoll & Meloy, 2014; Mullen, 2004). A fixation on the belief that one has been wronged by others and loss of insight may progress at varying rates and may be influenced by peers and social interactions which reinforce such beliefs (Rahman et al., 2020). These features are more common than formal psychotic symptoms or diagnosis, which are present in only a small minority mass shootings and mass murders (Brucato et al., 2021; Silver, Simons, et al., 2018).

Suicide risk

A substantial number of mass shootings end in a suicide, suicide by cop, or attempted suicide (Medical Directors’ Institute, 2019). People who made serious threats of violence towards others are more likely to die of suicide than to complete a homicide (Warren et al., 2008; Warren et al., 2011). Homicides followed by suicides are of significant concern, especially in cases with a nexus with intimate partner violence (Ilic & Frei, 2019; Large et al., 2009; Zeoli, 2018). As such, any evaluation of violence risk should also include a thoughtful evaluation of suicide risk. It has been widely noted that many of the risk factors for imminent violence overlap with those for suicide.

Identification of treatment targets

The priority of psychiatric assessment in clinical settings is to identify treatable psychiatric illnesses, even those which may not appear to directly contribute to violence risk. The alleviation of suffering is a fundamental ethical value of clinical work, and to whatever degree identified psychopathology may contribute to the risk, treatment may help mitigate the risk.

As a secondary goal, identification of other dynamic or modifiable risk factors for violence should be identified and, when possible, interventions offered. These may be psychosocial risk factors (such as homelessness, employment or financial stressors), medical concerns (directly or indirectly contributing to violence risk), or even personality or cognitive issues (such as rigid or inflexible thinking). To be clear, any identified psychiatric illness that is amenable to treatment may and should be a valid target for intervention, but violence is complex, and broad awareness and individualised intervention to address multiple risk factors – psychopathology, environment, sociopolitical issues, and others – is vital (Corner et al., 2018).

The THREATS³ mnemonic incorporates frequent and significant risk factors for mass shootings and other types of mass violence. As a general practice, any person evaluated who has made direct threats or leakage or any person with a history of violence and any of the remaining elements may warrant heightened scrutiny (Table 1).

Table 1. Investigate all THREATS³.

T	Threats, leakage, or other statements of intent to harm made currently or recently
H	History of violence, especially with the identified target or in an escalating pattern
R	Recent stressors (relationships, finances, housing, employment, health, victimization)
E	Ethanol / other drug intoxication, current or frequently present
A	Agitated / annoyed easily (Hostile Attributional Style)
T	Takes no responsibility (External Attributional Style)
S	Suicidality, increasing hopelessness
S	Symptomatic psychiatric illness currently or frequently present
S	Specific target / access / means identified

Table 2. Threat assessment professional organisations.

Association of Threat Assessment Professionals (USA)	https://www.atapworldwide.org
Canadian association of threat assessment professionals	https://catap.ca/
Asia Pacific Association of Threat Assessment Professionals	https://www.apatap.org/
African Association of Threat Assessment Professionals	https://afatap.africa/
Association of European Threat Assessment Professionals	https://www.aetap.eu/

Level of care

In cases in which psychosis or a treatable mental illness is driving the potential for violence but involuntary hospitalisation is unfeasible, court-ordered outpatient treatment, also known as assisted outpatient treatment (AOT), has shown potential to reduce violence. Studies in New York and North Carolina showed that people with serious mental illness who were court-ordered to treatment had reductions in violent acts by around 50% (Phelan 2010; Swanson 2000).

These studies looked at community violence not incidents of mass violence, and the subjects were people with a diagnosed serious mental illness. Thus, the results may not translate well to acts of mass violence in which the person may be more commonly driven by a desire for revenge or a non-delusional ideology of hate. Nonetheless, in some cases, AOT may be a useful tool for psychiatric providers. While it is legally available in nearly all states, the details of the orders and the degree of implementation varies highly between and within states.

When serious threats of violence are encountered in a new patient, or newly revealed in an established patient, acute psychiatric admission may be indicated to support further investigation of the threats or leakage, identification of risk factors amenable to intervention, and clarification of possible targets who may need to be warned. For outpatients, this may be damaging to an established therapeutic alliance. However, with high stakes of public safety, it may be prudent to err on the side of caution and admit for a more detailed evaluation.

Other clinical considerations: consultation and documentation

A brief evaluation in a PES or a new referral to an outpatient clinic may not afford the time or resources for fully evaluating, formulating, and mitigating violence risk. Fatigue and time pressure can impair the emergency psychiatrist’s ability to provide a thorough and thoughtful evaluation and to identify the flexible and compassionate interventions that may be needed (Scarry, 2011).

The mantra of “never worry alone” is ubiquitous in forensic and emergency psychiatry. At a minimum, this may consist of formal or informal consultation with a seasoned colleague and coordination with others involved in the care of the patient. When possible, a formal second opinion may be prudent, or in the outpatient setting, a referral made to a PES for further evaluation.

The medical record should convey the content of an evaluation, the formulation of the patient, and the judgement and decision-making process of the clinician. Careful documentation may also serve to mitigate liability in as much as reflect the appropriate judgement of the clinician (Rozel & Zacharia, 2021). Elements to consider in documentation (beyond traditional elements of a psychiatric evaluation) include detailed information about putative targets, access to firearms and other weapons, experience or history with weapons, and a detailed discussion of the identification and mitigation of risk factors and the reinforcement of protective factors. Documenting consultation may be helpful but caution should be taken when documenting consultation with the hospital’s or physician’s legal advisor, as it may contain privileged information.

Reducing access to firearms

Firearm prohibitions

While the motives for mass violence may be difficult to ameliorate (or even identify), restricting access to firearms is a crucial component of risk reduction in cases where mass shootings are threatened. In the United States, many firearm restrictions are aimed at people with mental health histories, while others target those who have made specific threats. However, mental-health based prohibitions appear to lack the sensitivity and specificity to be effective mechanisms of violence prevention (Swanson et al., 2016). Research indicates that the likelihood of a mass shooter having a psychiatric illness severe enough to disqualify them from firearm access was less than 5% (Silver, Fisher, et al., 2018).

The Gun Control Act of 1968 prohibits anyone “committed to a mental institution” from owning or purchasing a firearm. However, this prohibition does not apply to people on emergency psychiatric holds; it is activated only at the time of a hearing before a judge or hearing officer who certifies their civil commitment in a court of law. Thus an emergency psychiatric hold or admission to a psychiatric facility will not necessarily result in a firearms prohibition. Additionally, while a certified commitment may make any firearms the person already owns now illegal, most states besides California lack comprehensive registries of owners, and few have protocols to remove illegally owned guns from a person’s possession (Wintemute et al. 2017).

Other prohibitory criteria include mental health conservatorships, findings of incompetency to stand trial, pleas of not guilty by reason of insanity, convictions on felony charges, and court-ordered outpatient treatment. Patients who have experienced one of these disqualifying events will, in theory, have their names uploaded to the federal NICS database. Then, at the time they attempt purchase from a federally licenced dealer, their background check would show they were prohibited and the sale would be denied. However, millions of names of prohibited persons are missing from the federal database. Additionally, in twenty-eight states (Giffords), background check are not required on private sales, so this system of preventing access to firearms is imperfect.

Protective orders

Depending on the target of the threat and the jurisdiction, various protective orders may be available to restrict contact with the threatened parties, prohibit firearm possession, or both.

Many mass shooting incidents are at least in part incidents of domestic or intimate partner violence, and a domestic violence protective order (DVPO) is a potential mechanism of both protection and firearm prohibition. Federal law prohibits respondents to an active DVPO from owning or purchasing a firearm. Some states require an order in full effect (not an ex-parte or emergency order) before firearm prohibitions are enacted, though some allow for firearm removal and prohibition with an order before hearing (Zeoli and Paruk, 2020).

Clinicians are generally not able to petition for DVPOs on behalf of their patients, but in cases where there is concern for overlapping domestic and mass violence, they can provide resources and assistance to patients who wish to file a DVPO.

Many states also have workplace or school protective orders to address threats of violence that are not directed at an intimate or domestic partner. These are applicable in cases in which there has been violence or a credible threat of violence directed at an employer or co-worker, or in the workplace. In most states, the employer can petition on behalf of an at-risk employee. These orders prohibit contact between the parties, and in some states can prohibit the respondent from owning or purchasing a firearm. As with DVPOs, clinicians cannot petition for a workplace protective order on behalf of the threatened party (unless they were the employer whose work place was at risk), but may be able to advise affected parties of the option.

Extreme Risk Protection Orders (ERPOs), also known as “red flag laws”, are available in nineteen states and the District of Columbia (Campbell, et al. 2018). They provide a way to remove any firearms and ammunition currently in the possession of the subject, and prohibit them from purchasing more for a time period in the future (usually six months to a year). ERPOs generally do not require any mental health history nor any criminal activity, only an imminent risk of harm to self or others.

In most states, family members and law enforcement can petition for these orders, though in Maryland, Washington DC, and Hawaii, certain healthcare providers can also petition. In California, teachers and employers can petition. ERPOs are focussed on removing access to firearms and do not include the stay away or no-contact orders that may be part of other protective orders. They are focussed on violence risk, not mental health history, and do not include a provision for mandatory psychiatric treatment. However, one study in Connecticut found that they did serve as a bridge to mental health services for about 15% of respondents. This study also identified a substantial reduction in suicide risk based on the use of ERPOs, again highlighting the intersection between violence risk and suicide risk (Swanson et al., 2017).

In situations in which a patient owns or has intent to purchase a firearm, the evaluating psychiatrist may wish to consider discussing such an order with the involved law enforcement agency or concerned family member.

One case series of California’s ERPO looked at 21 orders filed out of concern for mass shootings, in which 52 firearms were removed. Though it’s unknown what would have happened without the orders, there were no acts of firearm violence or suicide perpetrated by any of the respondents in the subsequent year (Wintemute et al., 2019), indicating it may be an effective intervention in cases of mass shooting threats. While many states passed ERPO laws in direct response to mass shootings, the majority of these orders have actually been used in cases where there was concern for suicide (Swanson et al., 2017). However, given the number of public mass shooting perpetrators who ultimately take their own lives, there may be overlap between risks.

Collaboration with law enforcement

Many of these cases will have both a legal and a mental health component, thus it is important to consider both aspects of intervention, and keep open lines of communication between agencies working on the case.

Developing formal threat management teams can be a critical step and can be done following established best practices for communities and medical centres. (Behavioral Analysis Unit, 2016; Medical Directors’ Institute, 2019). Working across silos is an essential element of effective threat management and building a network of colleagues involved in threat work can be critical to successfully and safely resolving cases, expanding resources, and supporting training.

Cross jurisdictional challenges

In the United States, threat cases often cross state lines and thus may exceed the resources or authority of local law enforcement to investigate or intervene. This is especially true for threats made on social media and cyberstalking. The Tips Line of the Federal Bureau of Investigation may often be the best resource in such cases that transcend local law enforcement jurisdictions (http://www.fbi.gov/tips or 1-800-225-5324 [800-CALLFBI]). Internationally, resources will vary substantially based upon nation and region. It is critical to identify a point of contact who has a leadership or investigatory role with whom to establish ongoing communication.

Duties to third parties

Privacy concerns

Within the United States, communication with law enforcement to prevent violence is a permitted disclosure under the Health Insurance Portability and Accountability Act (HIPAA) (Rodriguez, 2013). HIPAA explicitly allows for disclosure if a patient makes a “serious and imminent threat” of violence and such a disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others” and “is to a person(s) reasonably able to prevent or lessen the threat.” The US Department of Health and Human Services states, “HIPAA expressly defers to the professional judgment of health professionals in making determinations about the nature and severity of the threat to health or safety posed by a patient.” Extensive guidance is available on appropriate information sharing and building collaborative relationships within the framework of HIPAA (Petrila & Fader-Towe, 2010).

Thus, in the case of a patient who poses a risk for public violence, it is appropriate and allowable to communicate with law enforcement about clinical progress, court hearings and discharge plans. Releasing a patient under investigation without alerting the investigating or legal authorities could result in a bad outcome that could have been mitigated by sharing the information about their release. Ongoing communication may also allow law enforcement time to gather evidence for an arrest, file an ERPO petition and remove firearms, or plan for further surveillance or outreach.

It is not clear if threats made by a patient to attack third parties, when made within the context of mental health treatment, can be used for criminal prosecution. The matter of whether therapist-patient privilege includes threatening communications, and the specific question of whether those communications are admissible in criminal court, has been considered in a number of Federal Circuit Courts with varied outcomes (Hills 2017). Note that the purpose of warning under the Tarasoff doctrine is generally interpreted to support the overarching goal of protection, not prosecution. Further, some laws on threatening communications require that they be heard by the putative target or that they be made in non-privileged contexts (e.g. on social media) to be criminal. That said, in some cases criminal justice referral may be appropriate or necessary; proactive consultation with legal counsel is advised.

In addition to communications with law enforcement, potential targets should be notified if possible. Such a communication would be to “a person(s) reasonably able to prevent or lessen the threat”, and therefore an allowable disclosure under HIPAA.

Whereas HIPAA permits such a disclosure, in most of the United States, there is a duty to warn or protect a potential victim under specific circumstances: if a patient communicates to a psychotherapist a threat of serious harm to an identifiable victim. Based on a famous lawsuit in California, Tarasoff v. Regents of the University of California, these laws are often collectively referred to as the Tarasoff Duty. Such rules may protect the therapist from civil liability for negligence if the therapist makes reasonable efforts to protect or warn the potential victim in such a case.

Duties to third parties vary substantially across jurisdictions and professions with each state approaching the issue in its own distinct way (Johnson et al., 2019; NCSL, 2018). Whether the duty is to warn or protect (or both) depends on the jurisdiction. Interpreting and applying these rules across state lines may be especially complex given the interstate variations which may be a particular challenge for professionals who work across state lines via telehealth or who work near a state border. Law enforcement are frequently involved in either case. This duty is regardless of any psychiatric contribution to the potential for violence (NCSL 2010; Soulier 2010).

Legal and ethical standards for duties to potential victims vary substantially across nations (Leach, 2009). Most European and economically developed countries appear to have some sort of duty to warn – with the possible exception of Austria which has statutes which protect therapeutic communications absolutely (Gavaghan, 2007; Gutiérrez-Lobos et al., 2000; Mulheron, 2010). Japan has no statute creating such a duty and appears not to have court rulings establishing such a duty (Kadooka et al., 2016).

When possible, psychiatrists can consult with available legal advisers who have the expertise in complex duty to third party cases. Depending upon the clinical context, risk management consultants or even malpractice insurance providers – which may be the only readily available expert for consultation for private practice professionals – may also be useful resources. Such consultation can provide aid in deciding between the alternatives of facing litigation for breach of confidentiality versus failure to warn of threats with potential for serious harm.

While legal duties to third parties, if any, are often limited to warning or protecting a target, in some situations it may be reasonable to explore helping the target if possible. Being a target of a threat is not just about physical security; it is also a stressful, frightening, and isolating experience. Linking targets to social services, victim advocacy, local law enforcement who may be able to assist with charges or restraining orders, counselling, and other resources may be beneficial. This may be an unrealistic undertaking, however, and can foster novel conflicts of interest for patient care.

Conclusion

Most people who threaten or perpetrate mass violence are not driven by psychiatric symptoms. Nonetheless, psychiatrists are commonly involved when people make overt threats to harm others or whose actions raise such concerns. Decisions about emergency holds or involuntary admissions should be made conservatively when there is a risk of danger to third parties. Though rare, delusions or other psychotic symptoms may drive violence potential; in others, symptoms like depression or anxiety may be related to the problem, though not causal. In either case, standard psychiatric treatment should be provided when indicated.

In cases of mass shooting threats not likely to respond to psychiatric treatment, protective orders may be a mechanism of both reducing the risk to the victim. In some jurisdictions, such orders may also be a way to remove the patient’s access to firearms. Protective orders, civil commitment standards and firearm prohibitions will vary by country and jurisdiction.

Even more so than in other cases, communication with collaborating agencies is of paramount importance when public violence is threatened. In the emergency and inpatient setting, law enforcement may be the party initiating the psychiatric evaluation. However, in the outpatient setting, the provider may have to involve them when allowable by privacy policy. Generally, disclosures of PHI to law enforcement or a potential target are permitted to lessen a threat, and there may be instances where disclosures to third parties are mandated. Threat assessment teams are a multi-disciplinary approach that help coordinate psychiatric and legal efforts.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Amy Barnhorst, MD, is funded by the State of California through the UC Firearm Violence Research Centre. John S. Rozel, MD, MSL, is partially funded through the Department of Homeland Security Office of Targeted Violence and Terrorism Prevention.