Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Thursday, March 14, 2013
Please take my survey on mandatory reporting of dangerous patients
Oh, you know I love surveys.
The NY Safe Act's requirement that mental health professionals report dangerous patients goes into effect on March 16th. New York has released a video and slideshow for mental health professionals explaining who must report, to whom they must report, and there's a website to enter the information. A Director of Community Services reviews the information and decides if it goes to the FBI's NICS database to prevent such individuals from purchasing guns or to revoke a firearms license if the patient already owns a gun. The Director can also decide to have the patient brought in for emergency evaluation, though presumably the treating clinician might do that if there is an imminent threat. The information is used only for gun permits, and is not accessible for other reasons.
In Maryland, lawmakers are considering a similar measure, currently as House Bill 810, but it may get rolled into the Governor's Firearms Act which has already passed the Senate.
Legislators are aware this may have "a chilling effect" and deter people from getting care. I'm wondering if that's true.
So I'm asking you to take a quick survey for me. Two questions. If you've never felt dangerous, or you've never been in therapy, try to imagine. Obviously, I'm wondering if gun owners would feel differently than those who don't own a gun and who may never wish to own one. Comments are welcome as well. Thank you so much.
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Aha! Unlike what I thought before, if I'm suicidal, I don't just get put on a STATE list in NY, I get my name sent to the FBI! There are a LOT of people who are not gun owners and never want to own a gun who nevertheless, are not criminals and wouldn't want to be in an FBI database. I have only been a gun owner for 12 years, and all the years before when I had no use for a firearm (lived in the city, in safe neighborhoods), I would have objected to being treated as if I am a criminal or incompetent.
I talked this issue over with my psychiatrist, and my psychiatrist does not think the state we live in would do what NY has done and Maryland is proposing, because up until now, this state strongly values the civil rights of mental patients. I don't know if my doc is right or not.
So how does the legislation punish providers for not reporting people?
I took your survey but I don't think the results will be accurate. This doesn't take into account a lot of factors. No, I don't own a gun. Yes, I would (and do) tell my psychiatrist if I felt suicidal. However, that is because I know her and trust her and have discussed this legislation with her and know her response.
Would I seek treatment/disclose suicidality to a new therapist whose policy on reporting suicidal patients to the FBI I did not know? No, I would not.
So while my survey response says one thing (and I imagine many other people's will as well), I actually feel the opposite when it comes to the point you're trying to make.
Dinah, could you reword the question to people who do not own firearms? How can a person who has never been depressed says what he would do or whom he would tell if he were depressed? One can only surmise about something one has never experienced.
I realize this is imprecise and that these vagueries exist, I wanted to keep it simple. Of course you don't know what you'd do if you were depressed (actually, the issue is 'dangerous') but I'm asking for a guess if you've never been before. Some people might think they'd never see a shrink, and then when they feel bad, it's not as unpalatable an idea, guns/danger or not.
Joel: no civil or criminal penalties.
Catlover & LM: outpatient psychiatrists are not going to be rushing to report people and feeling suicidal is not "likely to be dangerous" in the absence of an actual attempt or stated intended threat that the therapist believes is true. Even if your psychiatrist says they won't report or hospitalize, if you stop by their office and say "I just bought some bullets for my gun and I'm going home to load it and kill myself, I just wanted to say goodbye first," then they're probably going to do something. And it's not going to be to fill out an online form to notify a director of community services to decide if the state police should be notified and the NICS database so they can mail you a notice saying your gun permit has been revoked.
I can't think of a worse idea than psychiatrists reporting people to some bureaucrat who then makes a decision about that person and whether or not they should own a firearm. First off, I wonder what they are going to decide? Secondly, it blatantly reduces psychiatrists to agents of the state and suddenly makes the rhetoric of at least one antipsychiatry school of thought - a fact. Where was the state psychiatric association in all of this? There are better ways to deal with this potential problem.
Meh, I'd rather keep my guns and my civil rights and battle out suicidal ideation on my own than be reported to the FBI by an overzealous shrink.
I've had suicidal ideation and my therapist knows about it. She also knows I have "access to lethal means". The most she's ever done about it has been to once mildly suggest that she might feel better if I removed the bullets and put them on the opposite side of the house from the gun. This was during a time I was doing pretty badly. When she later asked me if I'd done what she had suggested and I said no, she asked why not, and I told her it was unnecessary and would have felt silly. She said, "Oh, all right" and that was that.
She's a lovely and brilliant therapist and I've come a long way since working with her. Knowing that she trusts me to take responsibility for my own level of dangerousness means a lot to me. That said, it is something we have discussed extensively. She's made me promise to call her if I'm feeling really bad.
Another therapist I saw before this one told me she wouldn't treat me unless I got the guns out of the house. I never went to see her again. True story.
The other therapist knew her comfort limits and was honest about them. I wouldn't criticize that myself.
I didn't mean it as a criticism, exactly (at least I don't think so), but I also knew my comfort limits and did the honest thing for myself by getting out of there. I felt she was judging me to be more suicidal than I actually was, and I felt uneasy about what measures she might choose to take with me because of that.
I feel lucky to have found my current therapist.
@anonymous above and Clink: here are a few additional thoughts on this. The first therapist, the one Anon did not return to, did not allow enough time with Anon to get comfortable with her ownership of guns, while her current therapist did. It can take some time to learn what is truly important in the care of a patient and setting rules or requirements too early can easily interfere with the development of the necessary judgment and comfort.
So Clink is right that the doctor was not comfortable with her patient's gun ownership, but unfortunately that prevented the best possible treatment. The second, current doctor has developed rapport with her and has developed that judgment, so it is much more likely the guns will never be used for self harm.
There are certainly people who want to always feel in charge of their own fate and gun ownership represents that. Always wanting to have available a way out but hoping, and seeking treatment to ensure it, that it will never prove necessary. So Anon now has an excellent therapist who understands her.
Because guns are such an emotional trigger in our society it is missed that there are many other ways to suicide that also hopefully would never be done, but we would not tell patients we would not treat them if they drove a fast car, moved into a tall building, kept Tylenol in their apartment, owned some rope, go near a bridge...the list is near endless. Guns are easy to use and unfortunately almost foolproof, and so understandably frighten us, but they are not the only way.
Some readers here have said they would not go to a therapist if legislation that requires reporting passes, but that in my opinion is the most unfortunate conclusion. It is the individual therapists who develop the necessary rapport and judgment, as Anon's has, and are therefore much less likely to report anyone. Truly affected will be those patients who are hospitalized or in clinics where it is known to multiple people that the patient is possibly dangerous. There it is certainly more likely that once dangerousness is recorded in a chart the facility will have to report. There will be much less individual judgment. Treatment and psychiatric patients will suffer if this type of legislation passes.
Jesse, the problem with the approach that you're suggesting is that the therapist has then taken on the responsibilty of caring for a patient who has announced at the outset that they will not follow the most obvious treatment recommendation. That's a pretty big red flag. And while there are certainly other ways to kill oneself, we all know that firearms are the leading cause of death. So if you do take the time to get to know the patient and discover they really are seriously determined to die, you end up risking a breach in the relationship anyway by needing to involuntarily separate the patient from the gun. Is that better than not entering into the treatment relationship to begin with? Who knows? That can only be judged in retrospect. Certainly comfort levels vary between therapists, but I imagine a gun-at-home issue will sort that out pretty quickly.
Yes, Clink, it is problemtical, but it is what many therapists I know do. In fact, Anon's current therapist has taken that approach and it is working out. There is a world of difference between recommending, even quite strongly, that a patient should get rid of guns (I have done this many times) and on the other hand refusing to treat the patient unless he does so.
And if the patient says he has, how do you ever know it is true? So yes, I do not want my depressed patients to have guns, but insisting on this as Anon's first therapist did, and refusing to treat the patient if he does not comply (and produced an affidavit that he has done so?) is not the wisest course in my experience.
An experienced therapist uses many factors to judge whether a patient is truly suicidal. He needs to know when to draw a line, but ownership of a gun is only one factor.
Here is one argument FOR insisting a patient get rid of guns and refusing to treat him unless he does: the message is absolute and unambivalent. The patient knows where you stand. However, I think you can do the first part (insisting) without the second part (refusal to treat). The second part can encourage the patient to lie to you, and at the least this could create guilt and interfere with a therapeutic relationship. There may be a point at which the therapist would need to have an ultimatum, but I doubt it would be at the first session.
But accepting weapons in the home would not guarantee honesty either. It seems to me to be an odd thing to be flexible about. If a patient announced ahead of time that he would be late to every appointment, pay each bill 90 days overdue (or not pay at all), I don't think any therapist would accept that. So if payment and financial issues could be a make-or-break condition of therapy, why shouldn't safety?
This is maybe not terribly relevant to the issues under discussion, but I wanted to elaborate a little on my story and also admit I think a gun owning would-be patient may have some responsibility to take for not unduly alarming a therapist they want to work with. I am not sure I managed things well with the first one.
I didn't understand the mental health system at all, that first time around. I was just having all this intrusive, suicidal imagery that was very scary for me. I had read some analytical stuff once upon a time on interpreting dreams, fantasies, and so on, and I thought to myself, "Well, I will try taking all these symbols to a therapist to decipher. Probably there is something behind them I'm not getting at on my own."
It never seriously occurred to me that the guns would be such an issue, since I've always had them and it's sort of part of the culture where I live. I also took it for granted that I wasn't suicidal and that people would believe me when I said I wasn't. But I just went in there and started babbling about my ideations, and then I was alarmed when the therapist began asking about guns and suggesting I wasn't safe to have them, more so when I disagreed and she became quite adamant. Failure to connect, but probably my presentation didn't help. However, her insistence on safety when I didn't think it was in question made me feel she wouldn't be understanding of my real issues (which were causing me significant distress) or be able to help me. I was also scared that if I discussed things with her in more detail she would become alarmed and have me hospitalized. I didn't feel "seen", I suppose you could say.
I was much more careful with my current therapist, and actually did a fair amount of research before going to see her. I didn't even introduce the topic of suicidal ideation until my fourth session, and I phrased things very carefully and began by assuring her I had no intent and no real desire even to die. I said that I felt the ideations were symbolic and I wanted help in understanding them and hopefully making them go away. She believed me, and that was nice. It's been two years now and I'm a much happier and saner person. Still enjoying occasional trips to the shooting range, too. :)
Hope that wasn't too much about me. I'm finding this a very interesting discussion. Obviously I think the legislation in question is a bad idea, but I'm just one data point.
I don't even understand how you get to this topic on a first session. Many patients walk in the door feeling depressed and some have thoughts about suicide, and from there a therapist might explore if there is a plan or intent. So if the patient says "Yes, I'm thinking pretty seriously about killing myself, my plan would be to shoot myself, and I have a loaded gun in the house," then it seems to me the patient needs to be hospitalized, not told to get rid of the gun to continue treatment.
In general (non-forensic) settings, it's not routine to ask about gun ownership, it would only come up if the patient said they were thinking about shooting themselves.
In 20 years, this scenario has never come up, I rarely know if patients are gun owners. Although, plenty of people are late to every session and pay their bills late. I don't know anyone who says "If you don't pay promptly, then I won't see you." I'm not much for keeping track of these things.
Nothing about this legislation requires mental health professionals to ask about gun ownership. The question is one of dangerousness and reporting. If you're dangerous, and you don't own a gun, you still get reported so that you can't buy a gun later. It would capture a lot of people unnecessarily.
I do think a mental health professional's past experience colors these things. I'm sure if I saw someone for a first visit and they went home and shot themselves (and with tens of thousands of gun suicides a year, this is really a distinct possibility), then I might ask people at the first visit about gun ownership and refuse to treat gun owners. Since none of my patients has ever been involved in gun violence, it's just never been on my radar.
Dinah, as usual, you're minimizing the issue and others (patients) experiences. I have never sought out psychiatric help EXCEPT when acutely suicidal. I've never met with a new psychiatrist because I had a bit of maybe depression, maybe a vague suicidal thought or two. My depressions have been acute and severe, and the suicidal ideation and planning accompanyting them equally severe and acute. If I'd owned a gun, I'd be dead a dozen times over. There's no question about it.
If your'e seeing patients that are acutely suicidal and not asking if they have access to guns, then you are not a smart or competent psychiatrist. And if you're seeing just mildly depressed patients with a bit of perhaps-suicidal ideation, then it's a self selecting population and I don't udnerstand why you're posting this surveys in the first place.
I'm not a smart or competent psychiatrist, apparently. I don't like guns because they allow for quick, impulsive, irreversible decisions. But someone who is driven to complete a suicide can do so through many means, and the suicidal people I have seen have by and large overdosed on pills. Sometimes lots of them. I live in an urban/liberal region of the country, and most people don't own legal guns, so it's not on my radar. I can ask people to get rid of their guns, and they can say "no." I can refuse to treat them if they won't, but so they go to someone else or buy a bottle of tylenol or jump off a bridge. If I call a family member and tell them to get rid of the gun, maybe this will help. Or maybe the patient will not want to return and will feel discouraged that they can't get care on their terms and will stop trying to get care. I don't know the answer here. Since I've never had gun issues, I'm not looking for them.
Why the survey? I'm going to meet with one of the legislators who is sponsoring the mandatory reporting bill and I was hoping to have some data. Unfortunately, there have not been enough responses to make this meaningful. Feel free to send a link to your friends/ to tweet/ whatever. My meeting is Wednesday .
I filled out the survey and also submitted a comment yesterday. My comment still hasn't posted despite many other comments showing up since I submitted mine. Is there a way to know if my answers to the survey were received...maybe you didn't get that either?
Why the survey? I'm going to meet with one of the legislators who is sponsoring the mandatory reporting bill and I was hoping to have some data. Unfortunately, there have not been enough responses to make this meaningful."
If I was going to provide meaningful data, I'd supply them with the statistics that detail the 1000s of homicides each year committed by those not in the mental health system. I'd provide them with the data that show the mass murders used guns owned by others. Data that also shows that those with mental illness are not more likely to commit violent crimes than the non mentally ill.
I voted anyway.
Dinah, ask the legislators to think about what Dr Sharfstein from Sheppard Pratt wrote about today in The Sun, if you are not aware of it:
But, recently knowing of a suicide a patient committed with a shotgun, it doesn't matter how many guns these liberal/Democrat morons think they can take, people will own firearms, and frankly, although I don't own one, I totally understand why there is a sizeable percentage of society who has no trust in the hypocritical, dishonest "leaders" we keep in office.
And now they are removing the Death Penalty from judicial options for terrible crimes of murder without any regard for life.
You know what, I have been saying for months now this adage, "you get the electorate you deserve", which is targeted to politicians. If and when I can leave Maryland, I will. This state is lost, supermajority party rule is example A of corruption gone mad.
And Maryland is headed for populated by a majority of government dependents, illegal residents, and partisan hacks who want a socialist society at least for the state. Just remember this, people with income and options will not tolerate this extremist agenda much longer! Virginia and Pennsylvania are looking more realistic every legislative session since O'Malady stays in office!
So, my point in that above mini rant? Say whatever you want to the "mafioso" bunch in Annapolis, just be prepared to ask again what will happen if providers do not cooperate with reporting. Frankly, it is BS to believe there will be no consequences. Gee, just like the Cell phone ban in vehicles, this year it will become a primary offense. Think they won't alter it once there is an example of providers not genuflecting to the rulers?!
"Would you seek help if you were feeling urges to harm yourself or others?"
Not if my psychiatrist had agreed to be an agent of the Federal Government, and admitting suicidal thoughts meant that I'd be placed on an FBI database for life.
Shades of East Germany ... "Lives of Others". I cannot believe psychiatrists went along with agreeing to do this. With being co-opted as government informers.
As horrible as Bush was, I almost wish he were still the President, because at least citizens were more attuned to the dangers of this sort of thing. If Bush had tried this, in the name of the "war on terror" rather than of the "war on guns", we'd have crowds marching on the capital.
We need to guard our civil liberties no matter who is temporarily in the chair. This is serious stuff.
And no, I've never owned a gun and have no interest or need to do so. But no way do I want to end up on an FBI "crazy guy" list for the rest of my natural life.
Psychiatrists don't support this. Legislators, without our input.
"Dangerous" does not mean suicidal 'thoughts' to a psychiatrist. We hear about suicidal thoughts all day, it's not news. "Dangerous" means having an attempt bad enough to land you in the hospital, or sounding so serious about an imminent plan with intent that a psychiatrist feels you need to be hospitalized to be kept safe. Many people have thoughts, often chronically, it's the ones who act on them who will be considered dangerous. Yes, there will be shades of grey: "I'm thinking about hurting myself and I can't promise I won't do it tonight, and I might." That will be a tough line, unless of course the patient says this every week and the therapist has been hearing it for 20 years and there has never been an incident.
Psychiatrists hate reporting patients unless they are really afraid something bad might happen.
@Skeptic, as Dinah said, we psychiatrists are not behind this. But what does the legislation exactly stipulate? How is "dangerousness" determined? In all my years of practice I have never hospitalized a patient because I had determined that he was "dangerous," and very rarely because of suicidality.
Quite obviously, if you go to a psychiatrist and convincingly let him know that you are taking flying lessons with your Saudi friends and plan to hijack an airplane, do not be surprised if he takes action. But he has to believe you are not simply fantasizing and spinning a story.
We hear patients talk about suicidal thoughts very frequently, and we try to separate "thoughts and fantasies" from imminent danger. Is that not what anyone would want a good psychiatrist to do?
" "Dangerous" means having an attempt bad enough to land you in the hospital, or sounding so serious about an imminent plan with intent that a psychiatrist feels you need to be hospitalized to be kept safe."
That STILL doesn't mean that such a patient belongs on a government list as if they are a criminal (not saying you're advocating that). Mouthing off about harming others and never doing anything about it also isn't a crime, although scary and distasteful. What, throw due process out the window altogether because someone MIGHT do something? This is an issue for the courts. And frankly, the whole thing is the same as the PreCrime Division in the movie Minority Report, only a lot less accurate.
Unrelatedly - Dinah, are you having reports of new code 90791/2 being denied due to preauthorization reasons? Also, would you bill 90792 for a short (20 min) intial consultation - is there a length of time necessary?
I sympathize with the person who said his/her therapist would discontinue treatment of him if he didn't get all of the guns out of the house. It's always frustrating for me to pay to see a therapist and then I suddenly find out that the person doesn't feel comfortable treating someone with my disorder. I can remember finding out one therapist I saw only had experience treating children with my condition. Another one told me he didn't feel comfortable treating me. Personally, if a therapist doesn't feel comfortable treating really depressed people who own guns, then I think they should screen for that beforehand rather than have the patient pay for a visit that won't pan out.
I remember a Kevin MD article about a doctor who was teaching a medical student who wanted to be a family doctor. The student did not believe in birth control and would not counsel patients on it's use. The only form of birth control she was tell people about was the one where ladies track their cycles. Her teacher tried to get her kicked out of medical school. She asked the student how she would ever screen her patients. Would she leave a message on her voice message? "This is doctor so and so's office. I am in family practice, but if you want any help with birth control then I do not feel comfortable seein you." In the end, the medical student didn't have to participate in educating anyone on birth control because the medical school decided that she has freedom of religion and her religion dictates no birth control. Still...her teacher made a good point. If a doctor feels uncomfortable treatign certain patients (one's who own guns, use birth control,
homosexual, whatever) then I think they should screen for that beforehand.
Found the article. This would make for the most ANNOYING family doctor. I can just imagine a future psychiatrist saying, I'm sorry but I don't believe in guns.
I won't participate in evaluating patients who are having suicidal thoughts and yet still insist on keeping guns in the home. I'll make sure I let my secretary tell everyone I don't treat gun owners when I go into private practice.
catlover: “Mouthing off about harming others and never doing anything about it also isn't a crime, although scary and distasteful.”
Actually it is. Death threats, harassment, stalking — all crimes. Uttering death threats is usually considered to be quite a biggie.
I see a psychiatrist to make things better not to add more stress to my life. The bottom line is I don't want to have to worry about everything that comes out of my mouth. I have enough to deal with. I don't think mine would be one who would overreact, but I also don't want to have to wonder what if he does. So, I am watching the legislation closely in my state.
I do think some mental health professionals will overreact. Some already are overreacting. We have only have to turn on the t.v. when a person commits a high profile crime to be reminded of the mental health professionals who overreact. THey're frothing at the mouth before they even have any data other than the guy is weird, before they are hammering away at taking away more of our rights. They don't even have to examine the perpetrators, they are that good! It doesn't help that it is these folks who the government turns to for their expert opinions.
It seems that those who will be reported to the government have everything to do with the mental health professional and less to do with the patient.
Choose your mental health professionals wisely.
I would,because her response came from fear and fear/other emotional reactions are what is causing alot of the probs in the world.Patients will fear seeking treatment because they will fear being profiled as a potential future killer by the FBI,Psychs fear consequences if they don't report.All this fearbased solutions lead to a dissolving of trust and to greater stigma towards mental health patients.Anyone with a history of violence doesn't need to have weapons,but it should be done in a way that isn't stigmatising but selfsacrifing.At the same Psychiatrists & society need to do a lot more for people like Adam Lanza & I believe people should look after each other and befriend these kids/people who are different as their actions are prob often based on a sense of ostratization,hatred,suspicion,anger etc.How many parties etc have these kids been invited to?Why didn't society care enough about them to try to make them feel included?Also psychs need to get greater insight into the brain areas involved in people who become pathologically violent etc- isn't the same as "normal" psychosis & antidopaminergics like risperidone often don't help them.Doctors/nurses need to find new ways to deal with their emotions including fear & people need to have more social contact with people with mental illnesses-and yes-that means Psychiatrists too.
PCH thank you for the link to the KevinMD article, very thought provoking, about the medical student who plans to be a primary care doctor but refuses to write for oral contraception for anyone of any religion because of her own religious beliefs. I gotta wonder how that ends up going down.
The idea of fair warning is interesting. I think I agree with you if it's a common issue. So if a shrink is uncomfortable treating anyone who owns a gun and asks about this then tells people they must get rid of their guns at the first visit, and it's a region of the country where a fair percentage of people own guns and this is a common occurrence that people pay for an evaluation and then have to go else where, it should be screened for in advance. If, however, guns aren't part of the initial screening or the therapist doesn't routinely ask people to get rid of guns, but something one particular patient said that made the therapist uncomfortable (for example, I plan to leave here and shoot myself, or even that the patient has had multiple past suicide attempts, even if by other less lethal means), then no up-front warning is required.
More commonly, we see this problem when a patient comes with expectations for a specific medication -- often an addictive one, and the shrink is uncomfortable with that.
Leann -- I do a 120-140 minute evaluation. No insurance company reimburses for this service. I've been billing it as 99215.
I'm not sure about the definition of "dangerousness". The objection the NY State Psychiatric Association is making to SAFE is that it does NOT require that the threat be imminent, in addition to serious.
Furthermore, according to the NYSPA, the online form that psychiatrists are required to fill out for SAFE includes the reminder: "In the event of imminent risk of harm to self or others, call 911."
So SAFE is asking that psychiatrists figure out whether a patient is going to be dangerous, not immediately, but sometime in the general future. I'm certainly not capable of making that judgement call.
I've never owned a gun, I never intend to, and I don't like even the idea of guns, but I also don't believe that ownership of firearms inherently makes someone a danger to self or others.
So am I supposed to put someone on a list simply because she owns a gun? Or a knife? Or rides the subway?
I'm a psychiatrist myself (not in NY) and own a legal gun, a pistol locked up at home. I've never been suicidal or homicidal in my life. I was in psychoanalysis with an experienced senior psychiatrist a few years ago and divulged my gun ownership, not in any threatening or scary way. My, this was disturbing news to her. My poor analyst seemed completely unfamiliar with the idea of private gun ownership, or why anyone sane might have one.
I think this largely boils down to a political divide, where pro-gun-control and pro-2nd-Amendment zealots mutually consider each other nuts. I'm in neither group, and recognize why some choose to own guns responsibly, while others see no need, or even feel moved to oppose their risks. My analyst's alarm revealed more about her than about me or any risk my pistol represented. Until we can talk in calm tones about the risks, benefits, and meaning of gun ownership, I'll be glad my state does not follow NY's lead.
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