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A version of this piece was originally published in the New York Times Opinion section on February 13, 2019.
The police picked him up from his high school after a terrified student told her principal he had threatened to slit her throat. She showed them his Instagram, where he had posted pictures of the Charleston Church shooter with the word “hero” underneath it, and a picture of their science lab with the caption “Columbine 2.0”. The officers didn’t find any guns or explosives, and couldn’t arrest him for the alleged threats, since the girl was too scared to be interviewed. So they brought him in to the mental health crisis unit for an evaluation.
My job was to see if he needed to be hospitalized and treated for a mental illness. But the first question out of my mouth was a totally unprofessional one.
“Which school?”
As a physician, my loyalty is to my patients: listening to their stories, helping them choose medications, treating them in the least restrictive environment, then getting them back home to their families. In whatever battle it is they are fighting, I’m on their side. But when that patient is a potential school shooter, my loyalties get complicated.
My two teenage daughters go to local public schools. Intruder drills are just another thread woven seamlessly into the fabric of their childhood, a routine whose origins they don’t question. I imagine when they hear the intercom announcement, their primary reaction is glee at getting out of a math quiz or history essay. I picture them huddled under their desks, whispering and laughing with their friends, being shushed by an irritated teacher who is anxious to return to her scheduled classroom activities.
And then sometimes flashes of the real scenario creep in. My daughters at the picnic tables at lunch, their hair shining in the sun, giggling at an image on a friend’s phone, complaining about the cafeteria food. How quickly their heads snap up at the first loud crack, and that frozen second of silence before the realization dawns and the terror sets in. Everyone scattering in chaotic efforts to hide, to escape, to live. My children don’t know how to do this. They have never been taught to survive a massacre. Worse than the noise and the blood must be the realization that the adults can’t help you, that you are on your own now and forever, and that you are never safe.
I can’t wander too far into the paralyzing darkness of this alternate reality; I have things to do. So as soon as those images start to come, I turn my back on them and build a wall in my mind. Each row of bricks rises against the sounds and images spilling out, until the last one is mortared into place. Then I can go on with the questions that are relevant to my assessment.
The young man in front of me answered “no” to almost everything I asked: he hadn’t been in a psychiatric hospital before, he didn’t hear voices, he wasn’t suicidal, he didn’t intend to actually do anything at his school. He seemed unfazed by the implications of his words and his posts, and by the sudden and extensive multi-agency investigation of his entire life. The FBI found a dark web browser he had downloaded onto his computer to buy a gun on the black market. Police discovered his kill list in his locker; his mom was one of the first names.
Like most psychiatrists, I pride myself on my ability to maintain a level of compassionate neutrality with my patients. I don’t get offended when manic old ladies call me vulgar names in front of my medical students. When a patient throws coffee on my shirt because the voices told her to, I just put a sweater over it and increase her medication. My job is to get people better, then get them back home. But with this patient, my instinct was to lock him away indefinitely.
It’s hard to do that through the mental health system. Checks and balances ensure that a patient’s fate doesn’t lie in the hands of a single psychiatrist. Involuntary commitment requires that a judge agree that the person is dangerous because of a mental illness. Even then, the hospitalization is usually limited to a few weeks.
This patient was seen by multiple psychiatrists and psychologists, and there was little agreement on whether he actually had a mental illness. He certainly shared common traits with other mass shooters: anxiety, obsessive-compulsive behaviors, paranoia, narcissism and autism-spectrum traits. But he didn’t quite fit the description of any single diagnosis, nor was there a treatment anyone thought would cure him of his violent fantasies.
As his discharge date crept closer, the treatment team’s best hope was for law enforcement to show up and arrest him. But the detectives had a lot of interviews left to do, and a dark web browser history to sort through, before they could bring charges. They were really counting on further psychiatric treatment to dissipate the threat. But the clock was ticking, and our patient was likely be released home in week or two. Usually, this is the outcome we are all working towards, but in this case, it was a day I was dreading.
The Columbine killers were someone’s kids, too. Dylan Klebold’s mother came to a talk I gave once on the mental health system and mass shootings. Sitting a few rows back in a long skirt and patterned sweater, her grey hair in a bob, she looked like anyone’s mom. I didn’t know who she was, until came up to the panel of speakers afterwards and thanked us politely for our presentation. I had shown a photo of her son striding through the Columbine High School cafeteria in military cargo pants and boots, holding a sawed-off shotgun aloft in his gloved hand. I’m sure that’s not how she remembers him.
I’m hoping this young man’s story has a different ending. With his discharge from the hospital imminent, his attorney, his psychiatrists, and the law enforcement agents investigating his case worked together to create a plan for when he left the hospital. We linked him up with intensive outpatient services so a therapist could go see him every day. He finished his high school diploma online and attends community college, and for the first time, he has friends among his peers. Instead of going to jail temporarily on misdemeanor charges, he checks in weekly with mental health court. His parents aren’t in his life, so the judge is the closest thing he has had to a father figure in a long time. He lives in a group home a few miles from my family.
I send my children to school every day as though nothing will ever happen to them. They whisper and giggle through their intruder drills, blissfully oblivious to the shadow of threat that looms and shifts over their world. I keep my visions of the real thing safely sealed away in my mind, and I go on with my work. My girls come home from school, and I come home from the hospital, and we all sit down to dinner together without so much as a glance at the fear that lurks behind the walls.
