Monday, May 07, 2007

Johnny Get Your Gun

Podcast #19 is up: Check out Xanax Blues.

Okay, we don't do much in the way of clinical cases here at Shrink Rap, but I've got a borrowed case. Not my patient, this was a "Can I fly this by you?" tale from a colleague.

With permission:

The patient is a substance abuser with a history of episodic violence, only when intoxicated. The substance abuse continues. The patient is an adult, but his care is paid for by a family member who has been involved. Psychiatric care is divided between a psychotherapist and a psychiatrist who prescribes the medications (split treatment). The patient tells both the psychotherapist and the psychiatrist that he is planning to purchase a gun, for protection. Neither the psychiatrist or the psychotherapist feel that the patient is imminently dangerous, and neither has expressed concern (that I, sitting on the curb, know about) that an actively symptomatic mental illness is the reason for concern. In other words, the patient is not now suicidal, is not purchasing the gun to either kill himself or someone who is the focus of a delusional system. The only danger (aside from the usual dangers) is that the patient is known to have a substance abuse disorder and is known to sometimes become violent with intoxication.

What should the shrink do?

  • Cross his fingers and hope for the best?
  • Attempt to hospitalize the patient?
  • Violate confidentiality and involve family?
  • Refuse to treat patient if he buys the gun?
  • Refuse to treat patient if he continues to use drugs?
  • Buy a gun for his own protection in case patient comes after him?

The actual case had an answer, even before I heard about it (ah, this makes it so easy when someone wants my advice!), I'll post it here after people have had a chance to think about this one.

Okay, so probably Do Nothing comes closest of the choices above: Review with the patient that he has an ongoing substance abuse problem, that under the influence he has a history of becoming compulsive and violent, and he shouldn't get a gun. I believe, but don't know, that this is a college student with no formal legal history and no interest in giving up his substances. Refusing to treat if he doesn't get substance abuse treatment would likely be the end of treatment. Refusing to treat if he buys the gun seems a little weird-- I do have patients with guns. Clink has also pointed out to me that it can be a real issue if such a patient is required to carry a gun for his job-- no gun, no job, no insurance, can't pay shrink. The shrink buying a gun was a joke. Sorry if it wasn't funny.

So the doc who "flew this by me," then told me that the psychotherapist told the family member who pays for treatment and has sometimes been involved. The family member threatened to stop supporting patient if he got a gun, patient reportedly didn't get gun, but got mad at therapist and fired her. My response: "Therapist did you a favor and solved your difficult problem." Was this "legal?" Nope, the therapist violated confidentiality. Can the patient sue-- I suppose so, but for what damages? We'll never know, but if the patient had done something awful with the gun, it would have been very troubling to his treatment team, even if not snitching was the "right" thing to do. I don't know the extent of the past history of violence, and that would have mattered to me. Remember, this question got asked on the heels of the Virginia Tech shootings and I believe we're all still feeling a bit vulnerable.


Anonymous said...

Refuse to treat pt if he continues to use drugs comes the closest to a sane solution. Actually, I would refer the patient out of my practice for substance abuse treatment and get him out of my hair completely. This also has the added bonus of being a responsible turf. He can return to my out-patient office once sobriety has been achieved. What are the chances this will happen? Problem solved.

The other options don’t work for me. Crossing my fingers and hoping for the best is not a strategy, it’s a fantasy. The patient is not suicidal or homicidal so admission is futile. Violating confidentiality and involving family is common sense and tempting, but why risk getting sued if I can avoid it? Refusing to treat the patient if he buys the gun is a he says, she says situation. He could say he didn’t buy the gun, and how would I know he didn’t, or did, for that matter? No, no, no. I’m not a detective and I can’t take the patient’s word for it. Not an option. Buy a gun for my own protection in case the patient comes after me? If the patient is that unpredictable, I need to turf him out of my practice elsewhere. STAT.

Rach said...

I was thinking option C - violate confidentiality and involve family, if only because the family could be imminently in danger, and is the first line contact outside the psychiatric world.

Aren't you allowed to violate confidentiality if there is concern that the patient's (or someone else's) life or limb is endangered?

ClinkShrink said...

Where's the trick here?

I'll let readers run with this for a while before I post my own thoughts.

You brought up a topic I was thinking about blogging about.

Midwife with a Knife said...

In obstetrics, when patients are doing things that are potentially harmful for themselves and their baby, we counsel them. Something like, "If you don't take your insulin, either you or your baby could easily die."

I think that shrinks probably take this approach with people who want to do things that are maybe harmful. Something like, "You have a history of violence, you're at risk for performing a violent act that could either kill someone or yourself or ... blah blah blah, and I really think that it would be better if you tried to avoid buying the gun."

Midwife with a Knife said...

Oh, sorry, I picked an answer not on the list. I'm not very good at coloring inside the lines.

Gerbil said...

I don't think there's a perfect solution, but the best one to me seems to be crossing his fingers and hoping for the best.

Hospitalization is inappropriate because there is no immediate risk to anyone.

Violating confidentiality and involving the family member is inappropriate for exactly the same reason.

Refusing to treat the patient because he's purchased a gun is inappropriate because it's way out of proportion to the situation.

Refusing to treat the patient if he continues to use drugs is inappropriate because he's presumably in treatment for substance abuse. (Hm, sounds like a podcast topic that I might have submitted...)

Buying a gun to protect himself from the patient is inappropriate because, um, it just is.

The overarching issue here seems to be whether past behavior is an absolute predictor of future behavior, or merely a risk for future behavior. The patient's history of episodic doesn't mean he will be violent in the future, just that he might be. Plus, he only becomes violent while intoxicated some of the time.

So: keep the patient in therapy, talk about why the patient thinks he needs a gun, and document the heck out of the situation.

ClinkShrink said...

Tricky situation. Here are my thoughts before I run off to sleep:

It's easy because he can't buy a gun.

Not legally, not in Maryland.

Maryland gun laws forbid ownership of weapons to substance abusers and "habitual drunkards" (actual statutory language) as well as anyone of "unsound mind" regardless of dangerousness. If anyone has a psychiatric history they're required to get a physician's certificate that they're safe to own a weapon.

The penalty for filing a false gun application is $3000 and up to five years of incarceration. It would also put him at risk of a perjury charge (since the application is filed under oath) or a handgun possession charge if he's a convicted felon. These cases are definitely enforced in Maryland.

So...a frank discussion about gun laws and penalties for breaking them. Then tell him that you won't sign the certificate he needs to purchase the weapon.

Of course he could decide to get the weapon illegally. In that case you won't have to refuse to treat him because eventually he'll become my patient.

Dinah said...

I think maybe the plan was to order it off the internet.

If he was going to lie to get it, then he only becomes YOUR patient if he gets caught and convicted (and I believe this can take a while). Are you proposing the psychiatrist report his illegal gun purchase to the police? I've yet to have any patient change their behavior simply because I've pointed out that it was illegal.

For the sake of argument, and since I really don't know all the details: Let's say the patient is procuring this gun legally, that past episodes of violence did not result in convictions. I have no details.

Sarebear said...

He/She could always go into a less strict state to get it, too.

Cross Fingers. It seems to me in this situation it's the only thing the professional is allowed to do, that's on that list.

ClinkShrink said...

Based on your hypothetical he can't procure a gun legally in Maryland. Even Internet gun shops have to disburse the weapon through a registered local dealer, and the dealer has the responsibility of doing the background check, etc and getting the gun application which is why it costs more to order through the Internet.

Yes, I agree that talking to people about their illegal activity usually isn't enough to prevent it which is why I rarely ever recommended therapy as an alternative to incarceration when I was doing presentence evaluations.

So the question is really how to you manage someone who announces their intention to do something illegal?

It depends upon your jurisdiction and the intended activity. Non-violent activity (embezzlement) may trigger an obligation to report if your treatment is being paid for by a third party (eg an employer). Usually in those cases there is a contract that spells out the information sharing agreement between the provider and the payer, and this is clarified in advance with the patient.

For violent illegal activity everybody knows about Tarasoff duties. However, in Maryland the Tarasoff law is written specifically to relieve the clinician from protecting the unforeseeable general public. (Eg. how do you know who to protect or warn---a bank? A school? A shopping mall? A post office? McDonald's?). Here we owe a duty only to an intended, foreseeable victim.

Your hypothetical doesn't suggest that the patient has any specific intended victim, nor is there any suggestion that he is presently dangerous.

Your alternatives are limited to a strong discussion about the criminality & consequences of illegal gun purchases.

Feisty5150 said...

Physicians have a "Duty To Warn". Someone needs to send them Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976).

Anonymous said...

I have to agree with Daniela, at least a little. The difference being that I already have a gun for protection, not only from my patients, but from whomever.

Anonymous said...

I have to agree with daniela: the only difference being that I already own a gun (of course legally); not only for protection from a patient, but from whomever.

Anonymous said...


Anonymous said...

Physicians have a "Duty To Warn". Someone needs to send them Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976).

in this case, warn whom?

NeoNurseChic said...

Dinah, OT but the other day you asked for an update on what happened with the boy. Today I got a bit of a surprise over it all - and I blogged about it.

And tomorrow I'm taking a mental health day.

Whatever it was that I did in a past life to deserve all this, I'm sorry! *sigh*

Take care,

ClinkShrink said...

Feisty, the Tarasoff cases aren't the law in Maryland. I just posted an overview here for those who are interested.

Ladyk73 said...

What would I do?

I think it would be foolish to minimize the risk of harm to others simply by the basis that he cannot "purchase" a gun. Guns are sometimes easier to get than illicit drugs.

I am upset that a therapist would consider terminating treatment. However, I admit that it was my first choice. I can imagine that being effective for some personality disorder clients (I did say SOME), however, terminating therapy may lead to destabilization, and increase the risk to the public.

My comment to Daniela, is that I have heard 60% (finding a source will disrupt my chain of thought) of substance abusers have co-occurring axis I disorders , and the rest....with there axis II issues..... I just feel that those with substance disorders and mental illness should be treated co-currently.

But...back to the question:
What would I do?

I would increase the frequency of sessions.

Anonymous said...

I think that most times we all cross our fingers and hope things work out. Otherwise, who would see all these patient's? Our laws have painted the corner and we are all standing in it.
He is not going to buy a gun. Not only can he not buy a gun, he doesn't plan to. This is where the true fantasy comes into play. Maybe cross fingers and toes.

Roy said...

Posted after Dinah's red notes

The problem with the final outcome is that the pt feels betrayed by therapist, vowing to never be honest to a therapist about this topic again... maybe even planting a seed of resentment and need for revenge which gets played out 5 years from now after a different therapist performs a more benign, maybe even unintentional, betrayal.

...24 spoiler coming...

It's like the train track, but you don't know where the diverted track goes or how many people are at the other end. In the TV series, 24, President Logan permits his wife to get killed in order to save 200,000 citizens from getting gassed. Fortunately, Jack Bauer refused to accept the idea of forced, fixed choices and found a way to prevent both. Ethical dilemmas are sometimes resolved by reframing, or by cheating. (James T. Kirk resolved some impossible Star Fleet exercise in one of the first Star Trek movies by cheating on the exam.)

I think that in Dinah's original example, it is possible to threaten to (and carry out, if necessary) terminate with the patient if he buys the gun, if it is expressed in a way that communicates genuine concern for the patient's safety and well-being ("because I care about you, I refuse to stand idly by and watch you arm yourself with a potential time-bomb").

Isn't that why he told you about the gun in the first place? To get you to talk him out of it? What's the patient's motivation in telling you this in the first place? THAT should be the therapeutic discussion, not the gun so much.