Thursday, January 17, 2013

Psychiatrist, not Psychic

The horror just keeps growing.

Some of my friends think I'm paranoid because the new gun law scares me.

Yes there are gun issues, gun rights, second amendment, self protection and other issues.

This is about my role as a psychiatrist.  This is about the state and federal government asking me to be a psychic.

The newly passed New York gun law states:

"Section 9.46 of the Mental Hygiene Law will require mental health professionals, in the exercise of reasonable professional judgment, to report if an individual they are treating is likely to engage in conduct that will cause serious harm to him- or herself or others."


Why?  We already have a requirement to report anyone who is am imminent danger to themselves or others.  It's called a 72 hour legal hold.  If someone is an immediate threat to themselves I can call security or the police and have that person held against their will for up to 72 hours.

There is also the Tarasoff Law which requires me to warn a potential victim.  If a patient of mine makes a threat against a specific person - I have duty to warn that person or get the police to protect them or something to better ensure their safety.

This new law is different.  It doesn't ask a psychiatrist to look at an immediate threat (which is all we can do).  This asks us to predict if a patient is "likely" to be violent.

Do you have any idea how horrific psychiatrists are at predicting suicide or violent acts?

In the very short term - we're pretty good.  When psychiatrists were asked to predict which patients would be violent WHILE INSIDE the psych hospital - they were right 82% of the time.

Predicting OUTPATIENT violence in the next 3 days we get it right about 65% of the time.

After 1 week our predictions are no better than a flip of the coin in fact we're worse.  Psychiatrists trying to predict violent behavior more than a month out were wrong more than 50% of the time.

SO - how liable are we as psychiatrists for our patients behavior?  How long are we liable?  Does this new gun law change that?

Suing of a psychiatrist for failure to intervene has already happened.  The Aurora Theater shooting in July 2012 has led one victim's spouse to sue the shooter's Psychiatrist.

The shooter was making violent threats in June

OVER 30 DAYS LATER he shot those people in the theater.  The wife of one of the victims state's that the psychiatrist should have put him on a 72 hour legal hold when he made violent threats to her in June.

I wasn't there, I don't know what happened.   I know I have patients threaten me all the time because they don't get the treatment they had expected. I rarely put patients on a legal hold because unless I believe they are an immediate danger to themselves or others, I'm not going to revoke their civil liberties.

I doubt the case will be decided against the doctor - but that's because it's in Colorado.  What if this case were brought forth in New York?

Can we sue the shooter's mom?  After all - she likely knows him much better than the psychiatrist.  What about school teachers, friends, counselors, etc? 

What else am I supposed to be able to predict?  Robbery, Suicide, Infidelity, going AWOL???

This is a scary slippery slope.  I understand the need for mental health treatment, and for reducing gun violence - but calling a medical doctor a mind reader is, well, insane.


Sage said...

Yeah. I wish we had a redo on all these laws. Scrap everything since the constitution and go back to judeo-christian values. Or better yet, bring on the millenium!

Dinah said...

Oh, it could be worse. In France a psychiatrist was convicted of murder when her patient killed someone weeks after she saw him.

Anonymous said...


I thought Holmes psychiatrist did express concerns but was blown off. Sorry, I don't have a link.

Anyway, all these laws are going to keep people away from treatment who need it. You think anyone is going to seek help if they think something they say might be misconstrued as as threat and lead them to being involuntarily committed?

And the folks who do have bad feelings certainly aren't going to share them.

I mean, providers like yourself are understandably going to CYA to avoid getting sued and when it doubt, will report a patient.

Way to go politicians for stigmatizing a group of people like the Muslims were after 9-11. And it is a true bipartisan effort.


ClinkShrink said...

Auughhhh....I just wrote a post-length comment here and Blogger ate it. Stupid blogger. It was brilliant too, ya know, like the fish that got away...

In a nutshell:

We can't plead out of the SAFE act reporting requirement by claiming incompetence to predict dangerousness. It's not totally true (no we're not 100% but we're not as horrible as all that in the short term. We're actually quite good at predicting safety) and we do it all the time. Inpatient docs predict dangerousness (or safety) when they make a decision to discharge someone. ER docs predict risk when they decide to admit or discharge someone.

Even people with no clinical training whatsover predict risk when a commissioner sets bail or a parole board cuts loose a felon or a judge decides to give someone probation rather than incarceration.

If non-clinicians routinely assess risk, then psychiatrists really can't plead incompetence.

The other trick with NY (and I don't practice there, so correct me if I'm wrong) is that their Tarasoff duty isn't really a duty---warnings are permitted by not required. The statute explicitly states there is no obligation for a clinician to breach confidentiality to carry out a warning. So I think in a way the SAFE act seemed to be a way to rehabilitate a lax Tarasoff requirement. That's just my take on it, I could be wrong.

So the concern about a capricious risk assessment by a nervous CYA-oriented therapist is also addressed in the act, by the fact that the law mandates that the clinician first report (ie consult) with another clinician. If and only if the second clinician agrees does the patient gets put on the 'do not buy a gun' list. No clinical information is turned over, and after five years it gets destroyed. And the patient can petition to have it removed.

In other words, I don't think it's as horrible as it could have been and there's a chance it may actually do some good. I'm sure we're going to see worse.

Simple Citizen said...

ClinkShrink - Not only are you intelligent but also quite humorous.

Well said. I know we make judgment calls all the time. We have to. Everyone does.

(I guess that maybe the underlying issue is how often psychiatry is mocked or shunned as a lower level of medicine - until someone with mental illness makes national news for some tragedy. Then we become these all knowing sages who could prevent all violence and should be obligated to do so by law.)

FYI - Blogger seems to eat a lot of comments. Any idea how to fix that?