Saturday, January 26, 2013

The Bodies Under the Floorboards

The subtitle for this post is: No Crystal Balls Here.

I know ClinkShrink disagrees with me and thinks the NY State gun legislation requiring psychiatrists to report people who, in the judgement of the mental health professional, are likely to be dangerous, is not so bad.  She has pointed out that the information gets reported to another mental health professional employed by the state, and that official makes a decision about moving it to another agency.  Maybe that official will go out and meet all the patients this will include and review their records and examine them.  That would be good.  But I think it will be a lot of individuals -- presumably everyone seen in an ED for a serious suicide attempt, and many people admitted to a psychiatric unit. We'll have to see what that ends up meaning and how that Director of Community Services decides who gets reported on.  I don't think that many outpatient clinicians will be reporting their patients unless they are really, really worried, and reporting someone who tells you that they are stockpiling arms and planning to kill a lot of people, well, that person should get reported.  We really don't think that psychiatrists should keep silent if a very psychotic person is talking about killing the neighbors because they are aliens who have cameras watching him and he knows this because something on his desk was in a different position than where he left it.

Periodically over the years, I've met patients who fit the profile of someone I'd find worrisome.  Male, loner, no social contacts, a little odd, who has expressed some aggressive thoughts.  Decades ago, I remember telling a colleague, "No one will be surprised when they find bodies under his floorboards."  In none of these cases has their been anything to report.  The persons in question have not had histories of violence, they haven't mentioned owning weapons, there is nothing specific other than their inability to relate normally and they have all been actively (and voluntarily) engaged in their  mental health care.  To the best that I can tell, my predictive powers with such individuals has been exactly Zero.  I have never seen an article in the paper that any of them have committed any crimes, that bodies have been dragged up from under their floorboards.  It's a different story if there is a history of violence,  then my predictive power goes up (a little) , and often alcohol and drugs are involved.  And sometimes someone does something that is a complete surprise, that I could not possibly have seen coming.  No guns, one power saw. Ugh.

I don't like guns for anyone.  Perfectly sane people get drunk or angry and if there's a gun there, they may shoot the person who provokes them.  I prefer a good fistfight any day.  Many people start to commit suicide and change their minds.  Many, many people and swallowing pills may let you change your mind, guns generally don't.  And if you read the papers in Baltimore, it's not an unusual event to take out someone else as you go, murder-suicides are not infrequent.  I do realize that criminals have illegal guns that legislation doesn't touch, but I still just don't like guns, even if you're using them to shoot animals for sport.  No stuffed heads hanging over the door in my office.  

I would like the option to report someone I think is dangerous.  I have that option now, I can have them brought to an emergency room for an assessment -- the police will do this for me if I fill out the right form.    In the clinic, we can call hospital security to take someone to the emergency room -- it's not always pretty,  but it doesn't involve the state, at least not a my level.  If the government would like to expand my options by saying I can report someone I believe might be potentially dangerous without being imminently dangerous, that's fine.  There might be times it would be nice to have that option so that if I'm losing sleep over someone where I'm just not sure, it might be a little easier to get them evaluated for hospitalization.  What  I don't want is the government mandating that I am REQUIRED to report someone based on my thoughts of what they might do, because my predictive powers are Zero, and honestly, my thoughts are none of anyone's business.  I'm not sure why the APA and NY Psychiatric Association aren't making more noise about this.  I'm not sure the legislation is awful -- it depends on how it actually plays out -- but I still think it's a slope I don't want to be on.  And regardless of the implications, I worry that people who need help won't get it because of the perception it creates.  We have commenters writing in to say they won't see a psychiatrist because they think they will be reported to a data bank which will prevent them from getting jobs.  Or they're worried their psychiatrist will misinterpret something and report them (--believe me, outpatient psychiatrists are NOT going to be rushing to report their patients and will ask if this is a fantasy or an intention before calling authorities).  Still, regardless of the wording of the legislation, the New York Times has reported that mental health professionals are required to report people who are likely to be dangerous, and even if that doesn't capture the nuances of the NY SAFE Act, that perception is now out there. 

New York mental health professionals: I want to hear from you! 
APA officials : Wake up.

Oh, and while I'm talking about crystal balls, there  great op-ed piece in the NY Times by Elyn Saks.  See Schizophrenic, Not Stupid.  And for the record, I have never told anyone they shouldn't work upon receiving a diagnosis.  Plenty of people pop back from psychotic disorders, and we just don't what someone can achieve until they try.     
Please also see our last post and the comments on The NY SAFE Act, and the articles we wrote on the Clinical Psychiatry News Website.  
Dinah's piece on CPN is also available on Psychology Today without the password.


ClinkShrink said...

Dinah, here's a shock:

I agree with you. I think when this actually plays out most psychiatrists are easily going to be able to tell when someone is just discussing a fantasy versus blowing off steam or reporting a dream versus doing things that causes the psychiatrist to stay up late at night worrying. That's why I prefer the clinician-triggered model.

I think the idea of making the report permissive rather than required is a good one (although required consultation is not a bad idea---I know you do this already when you're concerned about someone even without a law).

The thing that bugs me is knowing that nothing will necessarily happen when a report is made. That's the problem with our state's child abuse statute: we have to report even when we know child protective services will do nothing.

At least it would nice to know that when a Tarasoff warning is made to police, that someone would actually check to see if the patient has a gun permit. Psychiatrists can't do that themselves. My understanding is that now all that happens is they send an officer out to the identified victim's house to give them some information about what to do next (usually domestic violence resource information) but nothing happens with the person who made the threat.

You prefer fistfights? I'll keep that in mind.

So how do you explain all those giraffe heads in your house?

Dinah said...

The giraffes are cute and there are no isolated heads, I checked. All full giraffes.

And no, you don't agree with me, because while I don't believe this will be a big factor for outpatient psychiatrists, I do believe that it will mandate the reporting of:
~Every person who has made a serious suicide attempt, even if they don't own a gun, even if they do agree to get treatment. It may include suicide gestures, but we'll see how that plays out.
~Insurance companies only allow admission for people who are saying they may act on their suicidal by definition, I think this may include every person who goes to a NY ER saying they are suicidal and want to be admitted. And that some won't go knowing that they will be, or might be, reported.
~I think involuntarily committed people are already in some data bank and may find it hard to buy guns, but only in some states. (This is okay with me, since it's the hospital reporting, the patient has already been deemed to be both mentally ill and a danger, and anyone worried about their gun rights can simply sign in voluntarily, go with the program for a few days, and then be released)
~I believe this mandate includes everyone who is EP'd to an ER, even if that person is then released (I'd have to read the law again). Though I imagine the Community Services director will not go on to report to the police anyone who was brought to the ER and then deemed safe enough for release, but who knows. He'd have to review every record to look for past violence, and current issues, and whether the patient was released because they responded to meds in the ER or because they were never sick and dangerous.

So I am predicting that the numbers will stretch beyond what the Director of Community Services can manage as thoughtful consultation and that either nothing will happen or that the system will capture too many people (since I don't like guns, that's not so bad in and of itself), but regardless of how it plays out, the perception it creates is harmful and there is a precedent of telling mental health professionals they must report based on their beliefs. I really value doctor-patient confidentiality and believe it is necessary to allow treatment. This law would not have prevented whgat happened in Newtown and why doesn't the dermatologist need to report? One more push to move mental health care to the primary care doc and not the mental health professional.

We don't have to have fistfights. I'm happy to continue as we do just screaming at each other.

Anonymous said...

As an FYI, here are examples of successful people with schizophrenia who don't take medication:

1. Will Hall, who recently spoke before an APA meeting,

2. Keris Jän Myrick , who is President of the NAMI National Board of Directors,

Don't mean to take away from Ms Saks success story as she deserves alot of credit for what she has achieved. But psychiatry needs to start realizing that not only can people be successful with this diagnosis, they can succeed without medication.


PS - Even if I felt favorable towards psychiatry, I would not seek treatment under the current conditions of scapegoating people with an MI label.

jesse said...

The law protects mental health personnel whether they do or do not report. It extends the ability of a psychiatrist to take action without fear of reprisal. This is very important.

Dinah said...

Protects them from what? If there's a bad outcome, you can still sue the shrink. They should have reported. The psychiatrist of the Aurora shooter is being sued.

Perhaps the intent isn't bad, but the wording should be different -- it should expand the ability of a psychiatrist to violate confidentiality without imminent danger-- without mandating it. There is nothing here that guarantee anyone will get help or treatment, just that they might go into a databank. Psychiatrists won't be criminally prosecuted (that may well be the next step, some states have criminalized failure to report abuse and they've certainly tried in Maryland), but lawsuits will say "the shrink should have reported this to the state."

I don't think it's about the doctor and the liability, I think it's about the perception it creates that will encourage people not to go to the ER if they are feeling suicidal. And the precedent of annihilating confidentiality on things that have not happened. What next? What else can we say shrinks have to report? Why is this different then a patient with HIV having unprotected sex? Or someone who drinks and drives? Pretty soon, all you can tell your shrink is your happy thoughts.

By the way, I do agree with some of our commenters that psychiatric patients are being scapegoated here. The NRA needs to blame someone. There should be more services, there should be easier access to better care, but I don't think that this piece of the law will result in that. You'll note that I have really limited my opinions to this one sentence, and have not objected to expansion of outpatient commitment laws.

jesse said...

@Dinah: you are right about this. This law protects us only from not reporting as required by that law. What came over me? I actually thought some good was being done.

Anonymous said...

"Protects them from what? If there's a bad outcome, you can still sue the shrink. They should have reported. The psychiatrist of the Aurora shooter is being sued."

Dinah, the psychiatrist did express her concerns about Holmes prior to the shooting,

"The psychiatrist treating James Holmes told a University of Colorado police officer that she was worried about her patient weeks before he allegedly killed 12 people in an Aurora movie theater.

The allegation that Dr. Lynne Fenton warned authorities about Holmes' potential to harm others -- reported by ABC News -- is the second time she told others he was possibly dangerous.

Fenton, a member of the university's threat assessment team, reportedly told other committee members that Holmes, a Ph.D neuroscience student potentially jeopardized campus safety.

Though ABC's anonymous sources said Fenton took her concerns to the university officer "several weeks before" the July 20 rampage that wounded 58 others, it's unknown how the cop handled the tip.

Fenton talked with several members of the Behavioral Evaluation and Threat Assessment team, too, but the full committee never launched an investigation into Holmes because the 24-year-old dropped out of the doctoral program about six weeks before the attack."


Roy said...

The pendulum is gaining momentum.

Ok, so in NY there will be more reporting. I don't know all the details, but I heard it was just mental health professionals. So, people felt to be dangerous don't need to be reported if treated by their PCP, but do if treated by their psychologist?

Here's the thing: this will result in more people being sent to ERs for a psych eval. Flash: most ERs don't have psychiatrists to evaluate these people. Some have clinical social workers. Many evals are completed by the ER doctor. I expect that this will result in more people being hospitalized for a short period of observation before discharging them home. Fear of liability for sending someone home from the ER will contribute to this. ERs are already overwhelmed by overcrowding due to inadequate availability of inpatient psychiatric units, so this will get worse.

And, if the threshold for reporting goes down, so that anyone who has a funny feeling about someone can report them, then when they show up at the ER, what are we supposed to do? We evaluate them, there is no clear evidence of dangerousness, and then they are sent home. We can force them into a hospital based on someone else's Spidey Sense.

I read recently that people with depression can be identified by their Facebook timeline. Perhaps we'll have an army of "social media mental health professionals", scanning for evidence of dangerousness and reporting people for violent flaming behavior.

Let's not let this pendulum swing too far.

Anonymous said...

I predict that this law will be abused. I bet there will be psychiatrists who use this as a threat to get patients to take medication - if you do not take this medication that can give you diabetes, I will have no choice but to report you. If you do not come to your next appointment, I will have no choice but to report you. If you do not sign in to the hospital voluntarily, I will have no choice but to report you....

I do not want to see a psychiatrist or therapist who can turn me in based on their political beliefs, or a hunch, or because they are angry, or because of what they think. It needs to be about what the person has done not about what the person could do.

Patients need to think very carefully if they want to put themselves in the position to give up their rights. I'm not going to continue seeing a psychiatrist if anything remotely similar to the law in NY is passed in my state. It's too risky.

Anonymous said...

Smart patients will quit seeing shrinks if all it takes to have police take them to hospital for assessment is the shrink's trouble falling asleep. For anyone planning to continue seeing a shrink, don't tell them how you feel because lots of shrinks have trouble sleeping and that could land you in an ED

Anonymous said...

Some of these posts assume that psychiatrists have evil and controlling intentions. If you have a shrink with evil and controlling intentions, you should find another psychiatrist.

If you aren't telling your doctor about plans to kill people, even with the new legislation in New York, then there is nothing to worry about.

If you are thinking about killing people or yourself because of a psychiatric disorder, then it would be better to be helped then to be dead or to have killed someone else. Even if it means you won't be able to purchase a gun.

Anonymous said...

To the last anon,

It's not about whether I think they are evil or not. I'm sure it's all done with the best of intentions. But, if I were suicidal (and I'm not) I would not tell a psychiatrist anything if a law like that existed in my state because I don't need to be in any fbi database. I have not committed any crimes. And, I bet there will be many patients who feel the same way as I do. It's not about buying a gun. It's about treating people who sought help as less deserving of basic human rights to privacy and respect. NY is punishing people with mental illness because of what Adam Lanza did, and that's disgusting. Why not punish people based on sex? Or race? Why are we fair game? Because people would considerate it discrimination to punish an entire group of people for the actions of one, ok with mental illness though.

There may be enough patients in New York willing to tolerate a law like this. But, I predict it won't fly in my state.

Anonymous said...

Yes, there is a need to scapegoat something. Why is it that we are unable to have a dialogue about NOT scape-goating anything? Evil exists. All the laws in the world will not control it.

Newtown was evil. Good guns exist. Good psychiatric patients exist (a little simplistic, but just run with the thought). Evil won in Newtown. Period.

I live in a part of the country (rural) where guns are a needed part of life. Do bad things happen with these firearms? Yes, but far more constructive things happen (killing feral hogs, rabid skunks and the like).

I have a history of major depression. I have worked with two psychiatrists that were not comfortable with the depths of my depression. One hospitalized me (btw, that didn't help me, just made living more difficult for the next 2 years with comments like "I don't know how people like you think...."). The second fired me (for refusing to consider ECT). Despite THEIR inadequacies, I have continued on becoming a successful professional. I anticipate had psychiatrist #1 chosen to report me to some non-specific state database, my life would not have been able to continue on this course. The stigma of mental illness is bad enough without creating some potentially unyielding database.

You know, we go through contortions for HIPPA and then we say we are going to report the thoughts of a psychiatrist to.....whom? Who will be able to see the database of people with possible bad intent? Are these thoughts of psychiatrists going to be given the same protection as the medical record? Yes? Then what good does this database do (since it would require patients to sign a release accept in emergencies (tic))? No HIPPA protection to the patient for the random thoughts of a psychiatrist or therapist? Then what happened to privacy....oh, yeah....the thoughts of a psychiatrist/therapist can abolish that.

Newtown was horrible and tragic. Until thoughts and intentions can be predicted with a modicum of accuracy, we must accept living will always be imperfect. There will always be a way that evil finds to be destructive. It's the nature of this world.

Anonymous said...


They have to blame mental illness. To blame men would be discriminatory. To blame race would be discriminatory. To blame parenting would be unfair. To blame the person who did it, certainly not! It's pc to discriminate against people with mental illness. Apparently, we don't deserve the same rights as other patients who have committed no crimes, but don't worry it's all being done in our best interests.

Nathan said...

I'd also like to reiterate what Dinah said about her utter lack of ability to predict accurately predict dangerousness of her clients. As she said, it is ZERO. I've heard this said by a lot of mental health professionals, and I trust them on this. This is an area where I don't know why policymakers don't trust them too.

If you can't predict whether people are dangerous or not (or even have diagnostic and treatment data to make good predictions about treatment outcomes), what is the point of reporting people? If people engaged in the mental health system or no more likely to be dangerous, why do their names go on a list? This is discriminatory policy, leads to tremendous false positive reporting that can really damage lives, and doesn't make anyone safer or healthier.

Mental health professionals! Do some psychoeducation to policymakers about your own anosognosia in regards to your lack of ability beyond anyone else in predicting dangerous behavior, and that you do not want to be used a state agents who abuse the trust patients put in you to pacify a misinformed and scared public. I repeat, you are not skilled in predicting violence (nor have any data to suggest that folks who experience mental health issues are any more violent than anyone else). It only erodes your ability to be helpful and trusted to be used in such a way by state power.

Dinah said...

Mental health professionals do not want that require them to report anything to the government. I believe it's 1) pressure to "Do Something" on the legislators, and 2) the NRA's need to deflect attention from gun control on to "those people."

Government reporting aside, my point was that my ability to predict based on a hunch is Zero, however, if someone states that they are considering or intending to commit a violent act, my predictive value goes up quite a bit. And if someone has previously been violent, my ability to predict actually gets quite good.

Given that substance abuse is really much more associated with violence, why are legislators bothering AA/NA and all substance abuse facilities to report? Shouldn't a DUI or a possession charge be absolute no-go for getting a gun?

And mental health professionals are meeting with policy makers for education. NY passed their law before anyone even knew to blink.

Nathan said...


Seems like we agree on a lot.

I know mental health professionals don't want to have to report. I think there needs to be a greater concerted effort by leaders of mental health professional organizations with policymakers, as they are the only folks with enough clout to maybe get across to them (they will not listen to people with mental health issues due to their belief in anosognosia of people with mental health issues professional organizations had previously convinced them of, and this belies opportunity for people who have actually engaged with mental health systems to be taken seriously).

Isn't "doing something" simply out of political pressure bad policy making?

In terms of predictive power, I agree with you that your chances of predicting violence increases when someone states intention of violence, but so is everyone else's. There is nothing in your training that makes your predictions better, and I would bet that we all tend to overpredict violence in people who report intention of violence of have past histories of violence, even if we can predict their violence more often. (It may just be because they are more likely to be violent, our positive prediction of violence is more likely to be right and not false and we pay attention to that over the times we are incorrect, not that we are necessarily better at predicting.)

I agree with you in rhetoric in regards to AA/NA and substantively in regards to folks with DUIs. People with DUI's have a shown history of doing something incredibly dangerous (just as dangerous as a gun in terms of potential/actual lethality). I don't think people should have professional licences (to practice law, medicine, or whatever) and maybe even be able to have custody of their children or adopt within a substantial period of time of having a DUI conviction. However, people with DUIs have much greater rights and freedoms than folks who go to mental health professionals seeking help and receive particular stigmatizing diagnoses, regardless of their intent for violence or history of it, to whom such rights and freedoms are routinely stripped.

I believe it is the great stigma against people who seek help with mental health issues, stigma that these policies and the meetings you mentioned in the more recent post perpetuate. Furthermore, cars, guns, drugs, and booze all have really great lobbies that advocate for the people who use them, their safety, and their normalcy with policymakers. These lobbies are far better than the ones people with mental health issues have, which are really just drug company lobbies by different names. Mental health professionals would be great advocates, but I do not see public discourse anywhere where mental health professionals take a stand against such profiling and infringement. Not only does such policy harm people with mental health issues, it damages mental health professionals' abilities to be helpful and trusted. All I see are expert mental health professionals brought in to make a case for such increase discrimination and infringement, and then cash checks from from companies that profit increased forced monitoring and treatment of people who were only interested in asking for support.