Tuesday, February 12, 2013

Bang Bang: I'm thinking about Gun Legislation and the Mentally Ill

The figure I've heard is 40.  Forty pieces of new legislation brought before the Maryland General Assembly this year pertaining to firearms.  Some of them specifically address issues of gun ownership and those with mental illness.  Others don't, but simply conflict with one another.  There's a bill that would make it a crime (yes, a crime) to ask someone who purchases ammunition for identification.  Another bill requires that those purchasing ammunition must present identification.  Nothing like having our legislators on the same page.  Please don't quote me on that 40 number, I could be wrong.

Personally, I wouldn't flinch if they repealed the second amendment and did away with guns for everyone.  I've got my curare darts ready to shoot at the bad guys, who needs a gun?  And really, who needs a high velocity assault rifle? People who buy guns may have the best of intentions: shoot Bambi for dinner, protect their families, be ready for that government-overthrowing militia.  No one buys a gun thinking the bad guy will wrestle it from them, they'll shoot themselves while cleaning it, they'll use it when they get into a drunken brawl, their kid will play with it and shoot a friend, their kid will take it to school and shoot someone, they'll fly off the deep end and go postal when their wife has an affair or a boss fires them.  And those mentally ill folks, they aren't "us," the gun owners would never get depressed and kill himself, that stuff happens to "other people," those mentally imbalanced folks who shouldn't own guns.  And of course, the onset of mental illness is predictable, to one can know at the time of purchasing a gun that they or someone in their family won't be affected.  I do hope you'll forgive my sarcasm.

I'm not sure why the Newtown killings spurred this.  Nothing we've heard indicates that these laws would have prevented that (I could be wrong, maybe the shooter was telling a psychiatrist about his plans and the psychiatrist did nothing).  The college student in Colorado had seen a school psychiatrist once (?) and then dropped out.  Do we want every kid who goes to a mental health center to be reported to the FBI?  If you wanted a poster child for gun control and mental illness, then the college student in Arizona who shot the Congresswoman and innocent bystanders may have been the right one-- his behavior was reported to be flagrantly unusual and he was banned from campus.  Perhaps if there were easily accessible databases of people who purchased ammunition, then when these people came to the attention of mental health professionals, they could have run a check to see if they owned guns and were stockpiling ammunition, and maybe that would have spurred preventive action.  But for the most part (and there are exceptions), our spree killers have not been people who would be captured by the current proposals: people who've been hospitalized for more than 30 days, who've informed a mental health professional of plans to kill, people who've been involuntarily hospitalized for being dangerous.  So why now?

Take away everyone's gun, it's okay by me, so why do I feel so strongly that we shouldn't pass laws that use mental health professionals as agents of the state to fill databases?  Because it stigmatizes those with mental illness. Because it may deter people who are dangerous from getting much needed help.  Because we're bad at predicting who is dangerous in the absence of a specific threat.  Because we have measure to deal with specific threats (we can warn the victim, notify the police, hospitalize the patient).  Those requirements don't bother me because they leave me as the agent of the patient -- as far as I'm concerned, it's never in my patient's best interest to do nothing if they tell me they are going to kill someone.  Bad for the victim, and bad for my patient to rot in prison for years.  But mandatory reporting of people I think might be dangerous for the sake of putting them in a database, well, I've told you, I'm not good at guessing. 

 If you wanted to pass a law that says that if a psychiatrist calls the police with concerns that a patient has a gun and might be dangerous and the police are obligated to follow up on this, that would be okay.  As is, we can request involuntary evaluation (we can't demand hospitalization here in Maryland), but sometimes there is little else the police can do.  But mandatory reporting of our suspicions for act that have not occurred?  And even though this year's mandatory reporting law includes an immunity clause, we've seen mandatory reporting laws in other states turn into criminal acts: if you don't report, you can go to jail.  Specifically, there are states where it's a crime for a doctor to not report suspected child abuse. It's a law that get proposed nearly every year in Maryland.

Okay, so I rant at Shrink Rap readers.  Today I also ranted in the Baltimore Sun in the hopes that our legislators might read it and think about the implications of these proposed laws.  Do visit the Sun website and read my article.  You'll note that I titled it "Reporting the Mentally Ill: Will this Really Halt Gun Violence?"  Somehow, the op ed editor was inspired to change the title to one that looks like I'm against any legislation that would keep guns from the mentally ill, and that's not true.  I just don't think the treating clinicians can be agents of both the patient and the state, and I believe that doctor-patient confidentiality is necessary for medical treatment. People may be safer if they're not afraid to get help, and the less barriers the better.

You'll tell me what you think, here, or better yet, on the Baltimore Sun's website where our legislators might see your thoughts.


roblindeman said...

Small quibble, Dinah,

"They" won't repeal the second amendment: YOU do that. Amendments to the constitution must be ratified by the several states.

Another reminder: Rights can't be given to you by the government, they can only be taken away.

I'm begging you and the other respondents to think very very carefully about he implications of your government removing your inalienable rights.

Joel Hassman, MD said...

You are a brave soul Dr Miller. Writing to The Sun, which is a hack Democrat rag, is appreciated for the intent of advocacy. But, wait for it. Your column will either be twisted or just made irrelevant by the majority characterological element that pervades the halls of state and federal governments.

At least we will get rid of O'Malley in two more years, and hopefully his follies as Governor will be plastered onto ads by more seasoned and entrenched candidates for President in 2016. Doesn't it disturb you that Miller and Busch continue to run the legislatures of Maryland like mob enforcers?

The only two things that get rid of incompetent incumbents like these guys are graveyards and prisons. Hmm, see the relationship I am noting said in my blog of late?

It really borders on sociopathy. But, I could be wrong.

Real Doctor said...

" Because we're bad at predicting who is dangerous in the absence of a specific threat. Because we have measure to deal with specific threats (we can warn the victim, notify the police, hospitalize the patient). Those requirements don't bother me because they leave me as the agent of the patient "

Are you kidding me? You are deluded if you think you are acting as somebody's agent when you imprison them in a psychiatric hospital. You are acting as an agent of the state.

It is seriously terrifying to think you have the power to take away people's freedom and you think you are acting as their agent, when you are using legislated power to coerce them. That is the very definition of being an agent of the state.

It's like the TSA claiming they are the traveler's agent when they pat your down.

A psychiatrist, who by definition is someone who has forcibly drugged, labeled and stigmatized, innocent people without proving real brain disease, is a human rights abuser unfit to even comment on issues of Constitutional Law.

Dinah said...

Real Doctor:

We're going to have to just disagree here. In private practice, I don't think I've ever hospitalized anyone against their will. In clinics, I have. There's no way that I can see if that if someone is very psychotic and walking naked down a highway saying they are Jesus, or doing bizarre and dangerous strange things with, or saying they Will kill themselves today, that it is in their best interest interest to allow this to continue. It's never in the best interest of my patient to do absolutely nothing if they inform me that they have a plan to kill 20 small children. Fortunately, it's really rare that such things come up.

Given your feelings about psychiatrists, I suggest you should never go to one.

I don't believe our role should be to populate databases with the names of people who "may" be dangerous. Once it's clear that they are, then they should be banned from owning guns, regardless of whether or not they have a mental illness.

roblindeman said...

Dinah, with respect, you missed Real Doctor's point, and you undermined your own.

When we incarcerate clients, with or without their consent, we are acting as agents of the State, not as the client's agent.

You undermined your own point by admitting that you DO incarcerate people against their will. Everyone agrees that your doing so makes you an agent of the State.

And I would add that claiming to represent a client's best interest constitutes paternalism. When your claim involves removal of a client's Liberty without due process of law, it constitutes paternalism of the ugliest sort.

Sarebear said...
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Anonymous said...

I see a psychiatrist and I don't want my psychiatrist acting as my agent, even in case of emergency. If there were an enforceable psychiatric advance directive (why is there a different one for psych patients, anyway - talk about stigma...) I would sign it today, because I definitely would not want to ever be hospitalized in a psychiatric ward against my will.

Unfortunately without an advance directive where I could ensure my wishes would be respected in case of an emergency, I am left with being wary about the things I choose to share lest they be misinterpreted. I wish that I could have the same relationship with my psychiatrist that I have with my therapist, who has point blank told me she would never have anything done against my wishes unless I were making a threat against someone else, and since I never have and never would, I have no worries with her. I can be open and honest with her, because there's not that "what if" she has me hauled away thought hanging over my head. I understand that psychiatrists are acting in what they believe is the patient's best interests when they involuntarily hospitalize someone, but having experienced it in the past I can say without question that it was not in my best interests and in fact made things considerably worse. I never saw that psychiatrist again and avoided further care for years afterward. I like my current psychiatrist, but I would be more open with him if I knew that I had the ability to opt out of the things that have been harmful to me, and I don't have that option.

The thing about psychiatric patients is that we are not all the same, and we don't all want the same things done in case of emergency. I respect Sarebear's feelings about what she would want, but what I would want is different. I would not want to be hospitalized involuntarily for psychosis or suicidal ideation.

Blankshot said...

I think it best not to comment about situations once has never been in. If I were the President of the United States, I have no freakin idea what I would do because I am not the prez and never will be and have no clue about circumstances x y and z. Yes, shrinks act as agents of the state. Is this what we want? Is it something we do not want? People are entitled to opinion but to claim that shrinks are not acting on behalf of the state (and often themselves) is absurd. If I happen to benefit or not, no shrink is acting on my behalf. They have been given a mandate, not by me, and that is what they act on. Social control is what our education system is built upon. Did you learn to read and write? Great. Doesn't change that fact. Same for shrinks, be they doctors, psychologists, social workers.Social control. Social workers often recognize this more readily. Generally, they have a better sense of their role as agents of social control. Doesn't make them better or more effective--just more aware. The shrink who lacks awareness--I'd be wary and leery of him or her.

Anonymous said...

Did ya need the bang bang in the title? What for?

Joel Hassman, MD said...

Little tip for those who think us psychiatrists are so evil for involuntarily committing people for inpatient stays for three days, which is what the law allows and maintains: if you as a patient are so inappropriately hospitalized for unfair reasons, you can't get people to mobilize for you and show a legitimate reason to be discharged by 72 hours? If you are not a danger to yourself and others and have sympathetic, supportive, stable people around you as collateral information to show the injustice of the admission, then what is 2-3 days of inpatient care?

Or, let's look at the alternative that most people arguing against inpatient care want to trivialize or hide as consequences for NOT being preemptive as a doc: for not putting a person in a 72 hour assessment situation and instead see it lead to a suicide or homicide or some egregious assault on others in the community at least, oh, who will be blamed, charged, and convicted of those crimes against self and/or the community? Yeah, the psychiatrist.

So, to take a page out of a long ago M*A*S*H episode when Hawkeye had the MPs arrest the Ronald Howard character who was underage so he would not be killed in combat, when Howard rages at Hawkeye and says "I hate you, I will hate you for the rest of my life", Hawkeye's retort is what motivates me to do the best right I can do: "let's hope it is a long and healthy hate."

Better for patients to hate you for doing too much than doing too little. Welcome to why not everyone can be a psychiatrist!

Sarebear said...
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Anonymous said...

Dr. Hassman,

I was discharged after 24 hours, so yes I was able to get out before the 72 hours with family support (it's a long story). On paper, I guess the hospitalization is listed as "voluntary" but I signed consent under verbal threat of force, and signing consent under threat of force is not consent. Anyway, whatever it was it was not the least bit helpful and lead to me avoiding further treatment for years. I understand the intent is well meaning, but that does not mean it's in the patient's best interests.

I like the psychiatrist I have now. He is a little more humble than the other guy, and speaks to me like an adult just as my other physicians do. I walk in an adult woman, and I walk out an adult woman. That's the only kind of psychiatric care I'm interested in.

Elyn Saks wrote an interesting book about involuntary treatment, and she makes a pretty compelling argument against forcibly treating patients who did not find it helpful in the past. What is the rationale for forcing treatment on a patient who at a point when they were legally competent to make decisions said they would not want forced treatment in an emergency? I think she said it was about 50-50 who felt forced treatment was helpful vs harmful. So for those like myself who found it harmful, shouldn't they be able to get treatment without that being a worry? Why not make it where those who found forced treatment helpful able to continue on down that road, and those who didn't find it helpful able to receive treatment without that being a worry? Of course some would argue that there's the risk that a psychiatric patient who is anti-force would end up dying if her wishes were respected. That's true, it is a risk and it's a risk in any are of medicine. But, respecting decisions made by people who are legally competent to make them is the right thing to do.

Does anyone know why there is a different advance directive for psych patients? Why not treat all legally competent patients the same way and let them make decisions about their future that will be respected?

Anonymous said...

Just a brief response to what I find to be a disturbing array of comments.
Obviously, the public is quite upset already with the role that psychiatrists represent within the health system and social system. I would add that our own "house" is in extraordinary disarray--there is no professional solidarity amongst psychiatrists, there is virtually no research or genuine examination of our treatment modalities and, in particular, our, use of medications which may well not be terribly safe or effective. Patients are less and less able to afford adequate psychiatric treatment because we have not had the will to fight discriminatory payments for psychiatric care by "managed care organizations," psychiatric hospitals have become charades of care.
Don't we have enough to do without taking on another coercive role.
The point I believe I tried to make before I will make again: when we (as psychiatrists) have less and less real power, we will become more and more coercive in the use of the little power that we have. I think that is in part the reason for the negativity of the responses that are being expressed in this blog.
I understand it sounds absurd to think that psychiatrists can actually say "no" to participating in legislation like the proposals in New York and elsewhere; it also has seemed ridiculous to expect psychiatry to say no to being chronically discriminated against by insurance companies to the point that most people who need mental health insurance do not have any;, or no to pharmaceutical companies that will not allow us to examine the real data on psychotropic medications; or to say "no", we will not be forced into using more and more psychotropic medications that are untested in children on children because that is all we are being paid to do.
At a certain point, and in my judgment that time is now, we are going to have to say "no", and start determining what we do and who we are as professionals, even if it is uncomfortable. For me, as a psychiatrist, I am already uncomfortable enough to recognize that we are over the cliff of ethical and responsible practice if we continue to accept the pressures on us by the government and corporate interests to be what they want us to be.

HarrietMD said...

The above comment should have listed my name.

Alison Cummins said...

HarrietMD, you say:
"Obviously, the public is quite upset already with the role that psychiatrists represent within the health system and social system."

Could you please be specific about what upsets me so much? Since you've chosen to speak for me in a forum where I am able to speak for myself, you must beleve that you know what I think better than I do myself and that you can express my concerns better than I can. So I'm curious.

Dinah said...

Enough. My op ed piece in the Sun was simply to say that our legislators should not pass legislation that mandates psychiatrists report patients based on their 'beliefs' about dangerousness or that psychiatrists be the gatekeepers on who is safe with a gun, and I don't believe these measures will prevent gun violence. I pointed out that these measures are 'doing something' at the expense of stigmatizing people. Read the op piece if you haven't. It was meant for our legislators, and I didn't think it was terribly controversial.

It wasn't about involuntary hospitalization or any other role of psychiatrists, and people are getting rude here. It's time to stop. We're all on the same side here, unless you think psychiatrists should be required to report their patients to the FBI based on their 'beliefs' about who might be dangerous.

HarrietMD said...

To Alice,
Having essentially made the observation that people are very angry with psychiatrists, and that there is real justification for much of it, and then for you to respond with the hostility that you did unfortunately proves my point.

I was trying to urge psychiatrists to address legitimate and widespread concerns that are evident, including on this blog, about psychiatric practice. I obviously do not mean to speak for any individual except to make my own observations.

Alison Cummins said...

HarrietMD - That would be a "No."

Fine said...


I have a dream and it seems that you have a similar dream. I dream that a day will come when people do not ( or only extremely rarely) have tio be forced into hospital and psychiatrists do not have to resort to force to get people the help they need. I accept the fancy term for denying that I might need any help but imagine if the help looked completely different. Imagine a safe place to go when you feel yourself unravelling but can still keep it together. A place to get help that is not demeaning or intrusive or violent or humiliating. A place to get help to stabilize and that place is somewhere you would not fear going to because it would look so different from what we have now. And if things are too bad for too long and you are beyond taking yourself to such a place, imagine someone taking you who is calm and not in cop clothes and imagine finding a place you might be relieved to land as opposed to a frightening and cold and isolating experience. If the system were totally different, psychiatrists would be seen as allies, not enemies. I do not mean to suggest we create resort hotels for rest cures for the wealthy. I mean we treat people like people and meet them on the highest not the lowest level. I have seen it written on this blog that forced hospitalization is no worse than being forced to spend time in a medical ward. Well patients on medical wards can check out against doctors orders and they can seek second opinions and they can refuse treatment. And it would be great to see quality of all medical care improved in terms of how it feels to be a patient. I am lucky to have a doctor who, knowing the trauma of past hospitalizations, works very hard with me to keep me out of hospital and agrees it is an awful choice. We spend so much money on treatments that don't really work, drugs that don't really work and some of that money could be redirected.

roblindeman said...

"[O]ur legislators should not pass legislation that mandates psychiatrists..."

Dinah, I acknowledge that your op-ed was not about involuntary incarceration, but it WAS about being an agent of the State. You made your point quite forcefully that psychiatrists should not be mandated to act based on their own subjective states (i.e., "So-and-so owns a gun, and I believe so-and-so will commit an illegal act") I could not agree more with you.

You cannot have it both ways. If you allow the State to give you your marching offers, and you're in for a penny, you're in for a pound. As long as I'm torturing metaphors, it's too late to lock the barn door now that the cow is gone:

Psychiatrists (and Pediatricians, by the way) are agents of the State. Now to quote Sean Connery in Brian DePalma's epic "The Untouchables"

"You see what I'm saying is, what are you prepared to do?"

Nathan said...

I appreciate Dinah's reiteration. I know I have complained about lack of public response by psychiatrists against new proposed post-tragedy mandates on mental health professionals. While I'd like more organized responses by leading organizations and a push back against the whole enterprise of psychiatrists being co-opted by state power, she did put herself out there to stand against the expansion of that power. While not systemically different, better psychiatrists have the power to involuntary commit than have the power to involuntary commit and mandate to report on any notion of dangerousness to authorities. Don't really believe I'm saying that, but at this point (tired of it all), I'll take what I can get.

Joel Hassman, MD said...

Respectfully, I interpret the pending legislation in this state to do exactly what the thread has diverged to, that being patients with SI or HI and have access to firearms will be made to be involuntarily hospitalized if not completely agreeable to hand over said firearms once a doctor identifies the alleged risk. I have worked at a state hospital as a Locums for about a year on and off in 3 month blocks that ended about 2 years ago, and there are more people in these facilities for forensic matters than there are for primary psychiatric ones. And it is disrupting the primary psychiatry needs of these facilities.

Face it folks, the State will turn what amount to primary legal matters into psychiatric ones simply for the sake of grabbing guns if someone is deemed "a risk" to the public. It is how politicians and bureaucracy think, black and white, right or wrong, to thus create an alleged quick fix for public approval.

And as someone who is working for a community mental health clinic, I am disturbed by the growing amount of Axis 2 antisocial disorders masquerading as alleged Axis 1 issues, with more legal matters forcing the care interventions. Oh, and do you think these patients come in gravitating to therapy treatment needs first? Yeah, right!

I have my opinion, one from 20 years of experience working in community mental health in several counties here and two other states, and private practice docs commenting here are basically immune from this matter of dealing with antisocial issues becoming psychiatric management alone, if not correctional interventions put into place sooner.

I'll finish my commenting at this thread by simply asking this of colleagues: do you really think we can make a difference in a positive manner treating antisocial people in psychiatric settings? Do you want state and private inpatient facilities to become the primary site of interventions for primary characterological problems with criminal charges prompting the request for care? In simple terms, do you want inpatient care to become defacto Perkins' extensions?

Show me I am off base, what will reasonable and fair political interventions request of psychiatry? I truly want to hear thoughtful and realistic alternatives.

Anonymous said...

Dr. Hassman,

Regarding what is 2-3 days of inpatient psych care? I have never been hospitalized fortunately when I was taking psych meds but judging from the experiences of people who have been, in one word, it is a 4 letter word beginning with H.

To be honest, I found that statement quite cavalier even though I am sure that wasn't your intention. But if it was as benign as you think, that let me ask you why someone I ran across a few years ago refused to tell her therapist she as suffering daily suicidal ideation out of fear of being committed. You all don't seem to understand that people are terrified of going to psych hospitals and for good reason.

You also seem to think that Democrats are to blame for all this evil legislation when this seems to be a bi-partisan affair at least regarding commitment issues in various states.

Dinah, thank you for doing what you did. I seriously doubt anything will come of it as politicians let their need for a quick fix solution to look good override any common sense.


Joel Hassman, MD said...

Per AA's above reply to me:

1. Inpatient stays are never fun or uneventful, nor should they be because being hospitalized is a more invasive matter than outpatient treatment, and that is the point, that outpatient care will not maximize safety nor provide intensive interventions seen as needed. My point in my earlier comment about people getting out within 72 hours I hope is fairly clear, if it was a misunderstanding or effort to use inpatient care as a punishment by outside sources, then that should be exposed within 72 hours.
2. Politicians by in large are to blame for the consequences of disrupting health care ongoing, but the Democrats have played the larger role with PPACA. And, in my state at least, Democrats are a supermajority party rule, and that is the operative word in this state, RULE. So, you focus on who are the poster children of outrageous and compromising behaviors, and for me, it is primarily Democrats. I am an independent, vote third party 90% plus in elections, and will never vote for an incumbent who serves more that 10 years in one office, never for that person again once serving 18 years total.

But, thank you for your reply.

Anonymous said...

It's sad that legislation like this is even being considered. It pretty much tells me what the public and our legislators think of people diagnosed with mental illness.

As a psychiatric patient myself I think the discussion of involuntary treatment is very relevant because the fear of it already keeps patients from returning for further care, and causes some patients like myself to be guarded about the things they share with their psychiatrist. The move toward making it even easier to commit someone or take away more of our rights will ensure that many patients like myself drop out of treatment altogether, and others will never walk through the door to begin with. I would drop out if legislation like this passes in my state. I am not interested in turning my civil liberties over to my psychiatrist, even if he seems like a nice guy.

I think HarrietMD is correct and there is not solidarity among psychiatrists, but I'm glad that they do not all support the same things. I would not see a psychiatrist if they all behaved like some I have read about. I do not want a psychiatrist like the ones who have had patients such as Elizabeth Ellis and Ray Sandford dragged from their homes for forced ECT, against the patients' wishes and even against the wishes of family members who know and love them, and who continue to do it until they are outed in the press. I read about psychiatrists who disregard patients and family wishes like this and it turns my stomach. So, it's a good thing there is not solidarity among psychiatrists because if they all did stuff like this I would not see one.

If psychiatry moves toward more force, threats, and coercion they will lose a lot of patients, and the anti-psychiatry crowd will gain more members. This will not help patients.

Anonymous said...

None of you has mentioned that genocidal tyranny has been a genuine threat in recent history, and that all the other risks the writer mentions pale in comparison. Guns might be the only thing standing between the present U.S. government and one that is a copy from the early Soviet Union or Nazi Germany. Not so much paranoia as understanding history.