Law Enforcement and Mental Illness: A Sometimes Fatal Encounter

Gary Fields write on the Wall Street Journal's writes in "Live of Mentally Ill, Police Collide" the story of a police officer who shot and killed a mentally ill man who charged at him with a butcher's knife.  The man died, and the police officer, whose brother suffers from bipolar disorder, is haunted.  Fields writes:

Law-enforcement professionals and mental-health advocates believe they are seeing an increase in fatal encounters between police and the mentally ill. They point to a narrowing range of treatment options that has shifted more responsibility for the mentally ill to law officers, jails and prisons. 

"No police officer does well with shooting someone, let alone someone with mental illness," said Michael Biasotti, immediate past president of the New York State Association of Chiefs of Police and a mental-health and law-enforcement policy researcher. "That destroys a bunch of people at once."

Fields writes: 

The Federal Bureau of Investigation keeps track of instances of "justifiable homicide," which it defines as "the killing of a felon by a law-enforcement officer in the line of duty," but it doesn't note which of those involve mental illness. While crime rates nationally have fallen almost every year since the late 1990s, justifiable homicides by police officers have risen, from 297 in 2000 to 410 in 2012.

Hidden within that category is what is known informally as "suicide by cop," when a person intentionally provokes an officer into using lethal force. Chuck Wexler, executive director of the Police Executive Research Forum, in Washington, D.C., which researches law-enforcement issues, said he believes this type of suicide is increasing in frequency. 

Then over on Pete Earley's blog, he has video up of an unarmed mentally ill man who was shot by police.  Unarmed.   Mr. Earley writes:

This shooting terrifies those of us who love someone with a mental illness or have a mental illness. I’ve been asked to help this video go viral so that the public will recognize the need for better police training. Please do your part and send it out.
http://youtu.be/4U1GOTzvBLQ

And over on Clinical Psychiatry News, ClinkShrink is talking about law enforcement from a totally different perspective.  She received a call from a homicide detective who wanted her suggestions for how to interrogate a suspect.  Not quite the job of a forensic psychiatrist, but she talks about the ethical issues in a way that only ClinkShrink can.  See Consultation to Law Enforcement.

The Unwilling Patient: New Yorker Article

In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv

---

Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

Podcast Number 55: What Happens to Shooters with Mental Illnesses?

There has been a lot in the media recently about mental illness and it's relationship to violence.
In this episode we have ClinkShrink walk us through what happens to a mentally ill defendant in a violent crime. First, there is the question of Competence: is the defendant able to meaningfully participate in his/her trial, this is the present mental capacity. If the defendant never becomes competent, he generally remains in a forensic facility indefinitely. At some point (10 years in our state for a capital crime), the law requires a final disposition, and the defendant who is not likely to ever attain competence will be civilly committed and will remain in a forensic facility.

The second question is one of sanity at the time of the crime. ClinkShrink talks about the complexities of insanity evaluations and the rarity of having a Not Criminally Responsible plea. We discuss the idea that incidental mental illness is not enough to be found not guilty by reason of insanity, that the mental illness must have influenced the criminal behavior or obscured the defendant's ability to appreciate the criminality of his behavior. Finally, Clink talks about what happens after an insanity acquittee is released and what type of aftercare planning gets put into place.

The photo is Billy Bob Thornton in Slingblade--he's our example of an insanity acquittee.

Once again, thank you for listening and please do write a review on iTunes.

****************************

This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Yes! I Have Monday OFF!!!!

I got it, again, like clockwork. The joys of city life: yet another jury duty summons.

My number is 897 and that's high, really high, but sometimes on Mondays they call up to 900. The problem with being a shrink is that there's the question of what to do? Pray my number won't get called, or take the day off? In my private practice, I could just give people a heads up that I might need to cancel if I get called, but Monday mornings, I work in a clinic where people are scheduled months in advance, and short notice is a hassle on everyone involved. Family members often take off work to bring in patients, or other agencies send people to appointments with case workers. Last minute doc-outs create problems for everyone.

I used to hate the uncertainty of it all, but I'm trying to grow more flexible as I age, oh so gracefully. I used to call and request a specific day, one that would work better with my schedule, and the courts are happy to oblige this: they'd let me pick any day I want, as long as I agreed to take the number 1. No uncertainty here: I was going to be called.

But how do you give up a number like 897 (and a high likelihood of getting a pass) on an inconvenient day for a number like 1 on another day. Face it, there's never a good day to sit with 900 people in a jury room.

So I gave 6 weeks notice at work and took the day off. And the verdict is in: number 1-650 are to report. I have a day off! See you Monday. Please feel free to write in with suggestions about how I should spend my day.

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.

Neuroscience Funding Gets A Boost

Just a couple weeks ago the Justine and Catherine MacArthur Foundation awarded a $10 million dollar grant to twelve universities to study neuroimaging and the law. The purpose of the grant is to get a better understanding of the relationship between functional neuroimaging studies and forensic issues such as competence to make decisions, criminal responsibiity and disabiity. This grant has the potential to really change the nature of psychiatric expert testimony.

The grant has three components: brain abnormalities, substance abuse and decision-making. There will be some overlap between these areas, but the general idea is to start bridging the gap between what is seen on a functional MRI and the ultimate legal questions of criminal culpability and competence. This can be a life or death question---in Roper v Simmons neuroimaging was used as evidence that juveniles should not be given the death penalty. Hopefully the MacArthur grant will shed some light on whether the degree of brain myelination in juveniles is, in fact, relevant at all to criminal responsibility. Right now the legal opinions based on neuroimaging have tended to leap a bit beyond what science has shown in my opinion.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

Tony Soprano, My Patient, My Prisoner

I've been following the discussion between Roy, Dinah and Anonymous Commenter regarding Dr. Melfi's treatment of Tony Soprano. Yeah, it's just a TV show. No, I'm not obsessed or preoccupied with any of the characters. It's brought up an interesting question and a few ethical issues though. I will apologize in advance if I've misquoted or misattributed any opinions; I'm writing this off the top of my head and I'm not going to claim to be able to remember exactly who said what.

Anyway, Anonymous Commenter wondered why Dr. Melfi was treating Tony Soprano at all given his antisocial involvements and the potential risk he might present to Dr. Melfi's other patients. There was a suggestion that 'evil' could not be cured, and that a certain amount of psychological symptomatology is the natural result of involvement in criminal activity. There was some discussion about whether or not it was fair or appropriate to allow criminals to live with their symptoms, medical or otherwise.

As a forensic and correctional psychiatrist I find it interesting that these questions are being asked.

When people have brain diseases, they deserve treatment. People deserve to be healthy. When I had pneumonia last January I didn't have to give a justification for wanting to be well, and I wouldn't expect that from my offender patients either. The treatment of offenders does get a bit complicated since some of them do present significant safety risks to those around them; some can only be treated in a secure environment. The tricky part, as I believe Dinah or Roy mentioned, is that you don't always know who you have in your office when they first walk in the door. The true level pathology is not always evident until after you've already engaged the person in treatment.

The next question is whether or not 'evil' can be cured. If not, why attempt treatment? As Anonymous Commenter correctly pointed out, 'evil' is a tricky term. It falls outside the realm of medicine and carries quite a boatload of value-laden judgement. There are behaviors that all would agree are so far outside the realm of compassion that most people would consider them evil. On the other hand, one could make the argument that non-violent criminal activity which harms large numbers of people (eg. Enron and the financial devestation of shareholders) is evil.

Regardless, the real question is whether or not psychotherapy can prevent criminal recidivism the answer to that would be no. I blogged about Maryland's experiment with therapeutic prisons a long time ago in Couch Time. The followup from that experience showed that, at best, therapy did not make offenders worse.

Psychotherapy does help offenders for other issues, though, in the same way that it helps non-criminals. Prisoners are people who need help adjusting to incarceration, people who have family losses or crises, people who are dealing with serious medical illnesses. Crisis intervention and supportive counselling is invaluable for this. And yes, even Tony Soprano deserves it.

The Call Of The Wild

Oh deer...er, dear. It's been three weeks since my last blog post. I have a good excuse. I was having fun.

Rushing mountain water is very cold. Standing on the top of a mountain as a lightening storm rolls in is rather impressive. I enjoyed watching a hawk in flight and waking up in the middle of the night as some type of wildlife rummaged through the campsite. I even enjoyed the hailstorm, except for maybe the part about wondering whether the tent would be gone when it was all over. I saw loads of deer (including the one that rummaged through the campsite), a bear (it looked at me and was obviously sniffing for beef jerky. Fortunately I wasn't the one carrying it.), lots of cold rushing water and water falls, and even a skunk (see reduced picture).

My favorite find was this very unusual looking mushroom.

It was huge as well as being a bright yellow-orange color. After a bit of Googling I think I've got it identified, but if any of you out there really know mushrooms and can tell me for sure I'd appreciate it. I think it's a jack o'lantern mushroom (omphalotus illudens) which is known to be toxic. Somehow it seemed rather fitting that poisonous plants should be part of a forensic psychiatrist's vacation experience. There were no historical prisons in the mountains, so I had to find something forensically relevant.

Let Me Tell You About My Doctor

Wow, Dinah brought up a great topic. She said: "So how come it's okay for patients to blog about their psychiatrists, without disguise, without permission, without hesitation?"

I just had to address this because this one-sidedness (if that's a word) is something I see in the correctional world. Here's how it happens:

Inmate X gets released and goes to the media. He/she alleges that the correctional facility, as well as correctional physician or nurses, are horrible incompetent sadistic people who provided terrible care. Inmate X is quoted in the newspaper along with detailed allegations of how he/she was mistreated. Because of healthcare privacy laws, the news media cannot be given factual information from the medical record which directly contradicts the inmate's claims. The article states only that 'the facility/administrator declined to provide information about inmate X citing medical confidentiality'. Thus, it appears that someone is covering up something.

Let me be clear that I have never personally been involved in one of these scenarios, but from my professional colleagues I can tell you that it happens. Patients are allowed to reveal their own information, but we cannot do the same without their permission. Over the course of time I've seen some pretty astounding self-revelations: former patients who have gone on TV talk shows to talk about their crimes and subsequent psychiatric care, patients who have had their offenses turned into made-for-TV movies and television episodes, and patients who have written books about their issues. (I made a cameo appearance in one book but was not mistaken for a nun. The author did not seek my permission.) To my knowledge there is no case law to suggest that this behavior constitutes any kind of de facto waiver of confidentiality.

Now we come to the blogosphere. Here, the landscape may be very different. The blogosphere is a public forum of the n^th magnitude. There are numerous cases here in the US in which bloggers, and even their service providers, have been found liable for libel or defamation. I refer you to the Internet Journalist for a very nice little overview of case law surrounding invasion of privacy and defamation on the Internet.

So to get back to Dinah's point, it may really NOT be OK for patients to blog in a negative and undisguised fashion about their mental health providers. The real question is: how do you decide what to do about it? It's a situation similar to the one I discussed in Fully Charged Battery, where I talked about filing criminal charges against patients. If they're still your patient, you will certainly damage what little alliance you may have left by filing a libel suit against them. You could bring it up as a therapeutic issue within session, but then you've created a situation where the patient knows you've read their blog and there are things going on outside the session. Or you could decide that a patient who posts negative information about you is simply someone you don't want to continue treating. Regardless, it's a nasty situation. Patient who blog about their doctors/therapists may do well to consider the same precautions that health care bloggers follow.

From The NYTimes: When is a Pain Doctor a Drug Pusher

Oh, no, I did it again, I posted over Roy! I swear, I didn't know. Scroll down for his post.


We like to talk about subjects where the lines get blurry. Who should get care? When is it an illness? Xanax? Seroquel? Which side of the fence and how far over might one lean?

So here's an interesting cover story in the Sunday New York Times Magazine: When is A Pain Doctor A Drug Pusher?

It's the story of a pain doctor who has been sentenced to 30 years in prison for his sloppy and questionable prescribing practices. The article's author, Tina Rosenberg, comes at it with the tone that it's outrageous that he was sent to jail, deemed a criminal, for his lax practice. Bad doctoring, she contends, is cause for civil malpractice litigation, not criminal prosecution. The docs who prescribe in exchange for sex or drugs, they are the criminals. The doctor in the story did none of those things. She makes the point that the standards for prescribing narcotics, especially to a chronic and drug-tolerant population of pain patients (who may be peppered with occasional abusers) are purposely not stated, and leave the doctor open to both scrutiny and criminal charges.

There are red flags that indicate possible abuse or diversion: patients
who drive long distances to see the doctor, or ask for specific drugs by name,
or claim to need more and more of them. But people with real pain also
occasionally do these things. The doctor’s dilemma is how to stop the diverters
without condemning other patients to suffer unnecessarily, since a drug diverter
and a legitimate patient can look very much alike. The dishonest prescriber and
the honest one can also look alike. Society has a parallel dilemma: how to stop
drug-dealing doctors without discouraging real ones and worsening America’s
undertreatment of pain.
* * *
But such guidelines are futile while there is one pain specialist for,
at the very least, every several thousand chronic-pain sufferers nationwide. And
even though pain is an exciting new specialty, doctors are not flocking to it.
The Federation of State Medical Boards calls “fear among physicians that they
will be investigated, or even arrested, for prescribing controlled substances
for pain” one of the two most important barriers to pain treatment, alongside
lack of understanding. Various surveys of physicians have shown that this fear
is widespread. “The bottom line is, doctors say they don’t need this,” said
Heit. “They’re in a health care system that wants them to see a patient every 10
to 15 minutes. They don’t have time to take a complete history about whether the
patient has been addicted. The fear is very real and palpable that if they
prescribe Schedule II opioids they will come under the scrutiny of the D.E.A.,
and they don’t need this aggravation.”

By the time I finished this article, I was glad I'm not a pain doc. I was even more glad I'm not a pain patient.

$#!&*@$ You!

Someone said something rather nice to me the other day. He said, "You don't deserve to be cursed at." I thought that was rather sweet.

I have to say that after a couple decades in the profession I rather took it for granted that getting sworn at occasionally was part of the job. I could be blessed in my morning clinic and cursed in my afternoon clinic and it just goes with the territory. I don't really take it personally and it rather amuses me that people could see me so differently in a single day when I am really the same person all day. (I mean, not having a twin like the psychiatrist in Double Billing. Oh by the way, the next installment of Double Celling is up too.)

I'm not a therapist but I know in therapy the clinician expects that at various times in treatment people may become annoyed or upset or angry for reasons that may or may not be reality-based. Being a good psychiatrist means being able to handle a patient's strong emotions with them while remaining a stable figure in the patient's life. You just can't have thin skin about it.

So anyway, it was interesting hearing this from a non-mental health professional lay person. From the outside it does seem odd. On the inside it's just a way of life.

What I Think About Paris Hilton

I'm really not one for celebrity gossip but this news (and I use the term loosely) item had some good correctional teaching points so I thought I'd address it. Besides, it's just a matter of time before somebody drops a question to My Three Shrinks asking my opinion about Paris Hilton and her jail status.

So here goes:

Looking at this from the Sheriff's viewpoint, I can imagine what was going through his mind. He's got a new inmate who is:

1. a high profile case
2. a previously upstanding citizen
3. crying, distressed and not eating
4. has a known mental disorder (in treatment at arrest)
5. has an active substance abuse problem
6. is in isolation in a single cell
7. is serving a relatively short sentence
8. is within 24 to 48 hours of incarceration

Egad. The next thing this Sheriff is going to imagine is Paris Hilton hanging dead in a jail cell. She has eight separate risk factors for a correctional suicide and it is not good to have a dead celebrity in your facility. Ideally, the proper intervention would be to get her referred for crisis intervention services as quickly as possible. Educate her about what to expect and how the incarceration will run. Get her referred for psychiatric evaluation and pharmacology, if indicated. If all else fails, use suicide observation to preserve safety. I don't know the LA jail or what resources they have; given her relatively short sentence the Sheriff may have felt the more efficient alternative was to release her to home detention.

Home detention is a good tool used to reduce institutional crowding but it is limited to people with relatively short times left on their sentences and to non-violent offenders. Given that she only had less than a month to serve, keeping her in jail was a waste of space. In Charm City she probably would not have been incarcerated for a first probation violation; I think she probably was treated more harshly than the average defendant. Maybe this was because of her celebrity status or maybe she didn't present herself well in court. In our prison system the decision to put someone in home detention is made without judicial input; it's the institution's perogative to assign someone there.

She was being kept in a single cell because of her celebrity status, but she was seen crying and not eating there. Most completed correctional suicides are done by inmates in single cell status. The facility would have had a reasonable concern about maintaining her safety under these circumstances. One option would have been to put her on suicide watch involuntarily, but again this involves a fair amount of embarrassment and discomfort to the person you're doing this to. I understand she is now housed in a special needs unit where she is being monitored, another reasonable alternative. The term "special needs unit" refers to a specific tier or placement within a facility for vulnerable inmates who require therapeutic monitoring. It is not the same as protective custody in that a special needs unit is controlled and regulated by mental health staff. People with chronic serous mental illnesses or developmental disabilities may be housed on a special needs unit. Every facility does not have a special needs unit; they usually just exist in larger (over 500 beds) facilities so your average small local county jail may not have one.

So that's what I think. I'm sure she'd be welcome back at the Charm City zoo or the local television station anytime. As long as she doesn't drink.

Boundaries! Boundaries! Boundaries!

So the psychiatrist is talking to her own psychiatrist and he tells her he saw another psychiatrist in the hallway and this third psychiatrist, in the hallway, gave him a quick review of the literature on psychotherapy of sociopaths, and wouldn't you know it, it seems that psychotherapy validates, rather than cures, sociopaths, and it increases, rather than decreases their criminal recidivism rate. The first psychiatrist, who in this particular setting is the patient, becomes upset. It seems that her own psychiatrist believes that her years of work with a criminal patient have been a waste-- she hasn't helped the patient, rather she's harmed him and also society as a whole by increasing his comfort with his unconscionable violent behavior. And I'm thinking: Well that's not a very therapeutic thing for the psychiatrist to say to his patient!

Soon after, the psychiatrist and her psychiatrist are at a dinner party, with lots of other psychiatrists. What are they doing sitting together at a dinner party? If it's a professional thing, shouldn't they at least sit at separate ends of the long table? Another psychiatrist begins to discuss the negative findings of psychotherapy with criminals, and the first psychiatrist (now a dinner party guest and not a patient in this setting) gets angry with her own psychiatrist-- he set this up, he wants to convince her that she's wrong to continue her work with the sociopathic patient! And then to add to the mayhem, her psychiatrist tells the entire table the identity of his patient's famous criminal patient.

So the poor psychiatrist/patient has transference issues with her own psychiatrist: she wants his approval. Even though after years of sympathetic therapy, he declared himself a HIPAA-violating jerk by telling their colleagues the identity of her nefarious patient.

So the sociopath comes for his regular psychotherapy session. Life has been hard: his son has been psychiatrically hospitalized after a serious suicide attempt and the Lexapro just isn't working for the kid, and come to think of it, only weeks ago his favorite nephew died after he killed him.

The sociopath is warm and gentle with his psychiatrist today, commenting on how meaningful her work is because she spends her days helping people the way she's helped him. The psychiatrist, now a complete transference-to-her-own-shrink/countertransference-to-her-gangster-patient mess, is visibly angry and fires the sociopathic patient after 7 years of psychotherapy. The angry sociopath leaves declaring the psychiatrist to be immoral, and I believe he's right.

I've watched this therapy evolve, and yes, it started with ducks. The series started when mob boss Tony Soprano presented to Dr. Melfi in the throes of panic attacks. Something to do with migrating ducks in his pool. Really. They've been through a lot together-- he's stolen her car to have it repaired, offered to off her rapist, driven her to drink, declared his love and survived the rejection. One more episode, and this is how they end?

ClinkShrink asked that I tell you that she wasn't any of the three psychiatrists mentioned above. And the weird thing is that I never knew Clink was in The Sopranos.

The Boston Globe had a nice write up about Tony's prospects for redemption that appeared before this episode aired: Tony Is A Monster

Tarasoff Overview & Inservice

Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.

First some background:

In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.

Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.

This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.

Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?

If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.

Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:

§ 5-609. Mental health care providers or administrators.

(a) Definitions.-

(1) In this section the following words have the meanings indicated.

(2) "Mental health care provider" means:

(i) A mental health care provider licensed under the Health Occupations Article; and

(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.

(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.

(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.

(c) Duties.-

(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.

(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:

(i) Seek civil commitment of the patient;

(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or

(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:

1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.

(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.

[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]

The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.

Unspeakable

The Shrink Rappers have been quiet for a few days. It's hard to know what to say. I've called Clink, told her she has to post, I'm sure she'll have some thoughts soon. My oldest is thinking about colleges, here stands a reminder that safety, both ours and our children's, is a just an illusion. For everyone, my heart wraps around the unthinkable grief and sadness-- mostly it's too painful to even watch for more than a few minutes.

The New York Times ran a piece today about mass murders and mental illness, it didn't say much of substance. Cho was angry, maybe he had a personality disorder-- they speculate on which one, avoidant, paranoid, perhaps he was depressed or psychotic. Certainly, he was angry, and the article starts by saying he had a hole in his soul. I don't know what that means, but it sounds like as good a way to explain the inexplicable as any.

Sometimes, people tell us things about their mental life that suggests a diagnosis, at least an explanation. The depressed person who commits suicide out of guilt, pain, and hopelessness. The person who kills someone because voices tell them the victim is going to kill them, as distorted as it is, we get that in this person's mind, it is self-defense.

I watched a few minutes of the video. Cho Seung-Hui was filled with rage, he felt victimized, in the little I've seen, he didn't say why. Somehow, he believed his actions made him a martyr and he deemed this an act done for his children (---?). Somehow, in his mind, it made sense. He'd been hospitalized once briefly a few years ago, perhaps he had a diagnosis, as somehow we'd all like something-- an explanation, someway of grabbing on to this and believing we might catch and prevent acts that linger between severe untreated mental illness and pure evil.

Whatever it means, Cho Seung-Hui most certainly had a hole in his soul.

My Three Shrinks Podcast 16: Encyclopedia of the Weird

[15] . . . [16] . . . [17] . . . [All]

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ClinkShrink here. I volunteered to help Roy by editing one of our podcasts--heaven help me, I did the best I could. Be patient, I'm using Windows. This is podcast number 16 which was actually podcast number 14 taped about a month ago and taken out of order for no particular reason.

---

April 17, 2007
Topics include:

• First up are the Top 25 Crimes of the Century, a topic that could only be mine. It's a Time article that lists some of the most infamous or unusual crimes, but I have a couple bones to pick about their choices. Roy and Dinah just think I'm weird for even knowing this stuff. [Listen in to find out Clink's favorite crime. -Roy]
• Next we answer a question from Driving Miss Molly regarding how much and what kind of preparations psychiatrists do before their patients' appointments.
• Finally we do the Shrink Rap blog rollcall, where Shiny Happy Person deals with medical training in the UK and under the NHS, Roy flirts with the Girl with the Blue Steth, and Intueri talks about bipolar disorder in kids.

Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Ladies' Night Out

Or why I don't do custody cases anymore

A friend of mine desparately needed a night out on the town recently so last night we did it, a group of us each in our own various stages of life. I heard about past marriages (or more than one) current boyfriends, behaviors that make up the "why" in the Y chromosome, children, teenagers, laundry and discipline (or lack of it). By the end of the evening I came home feeling somewhat guilty that my life was so peaceful and relieved that I just didn't have to deal with any of that.

It brought back memories of doing court-ordered child custody evaluations. Keep in mind that over the years I've interviewed and worked with psychotic killers, rapists, drug kingpins, death row inmates, mafia figures and various other low-level criminal types.

I'll take them any day over a disgruntled non-custodial parent. Now, most divorces don't end up in court-ordered custody evaluations. The majority of people with kids split up, talk (or shout) amongst themselves and generally figure out what they need to do and when to do it without any court involvement other than a rubber stamp. Those weren't the cases I got. By definition, by the time a case came to me the couple had already been through one hearing, or three, as well as emergency motions for visitation and/or custody, domestic violence petitions, protective orders, social services investigations and/or criminal charges. These were not easy cases.

Over time I learned that all the allegations back and forth could generally be boiled down to four or five categories: allegations of abuse or neglect (physical or sexual), drug use, domestic violence, mental illness or something I call generic "lifestye differences". Non-custodial Mother alleges that Father dresses Daughter in age-inappropriate clothing so she looks like a "biker-chick" while Custodial Father complains that Mother wants Daughter in black patent leather shoes with white anklets. Or Mother alleges that Father is a lying psychopath with sexual interests in their teenage babysitter. Or Father really has been convicted of multiple felonies and the interview alone is enough to get you thinking about the distance between yourself and the nearest security alarm.

In memory of Kurt Vonnegut: So it goes. One must fight the temptation to toss the child to the nearest passing stranger.

The fathers I interview assume that because I'm a woman I will naturally side with the mother. The mothers assume that because I'm a woman I will naturally agree with their childrearing tactics and the fact that all men are rats. And they all want to know whether or not I have kids. (I don't.) Being childless is an advantage in these situations. I am not saddled with my own personal shtick of past marriages (or three), domestic violence and childrearing issues. And if being a biological parent had anything to do with good parenting skills we wouldn't need these evaluations to begin with.

The children are the most honest ones of everybody involved in the litigation. My ears would always perk up at any sentence out of their mouths that began "My mother wanted me to tell you..." They were honest even about their coaching. I was also surprised by some of the things the parents admitted: quizzing a child in detail about the other parents' sex life, plans to take the child and run, attempts to undermine the child's medical or mental health care. Sometimes the main goal of the evaluation was just to make sure the child didn't disappear or die in the process of growing up.

The fact of the matter is that there is no litmus test for being a good parent. In spite of the thousands of dollars being paid (to private forensic evaluators, not the court-employed folks) for interviews and psychological testing, no psychological test can tell you which parent is best for which kid. And the answer may be different for each individual child even when the same parents are involved. A child who is unpredicatable, emotionally labile and impulsive may do best with the parent who is patient, stable and consistent while the shy, slow-to-warm-up child needs an extroverted parent. Regardless, most kids are pretty resilient and they grow up to be normal responsible folks in spite of the craziness between their parents. I just hope they manage their own custody issues as well when they're adults.