Podcast #19 is up: Check out Xanax Blues.
Okay, we don't do much in the way of clinical cases here at Shrink Rap, but I've got a borrowed case. Not my patient, this was a "Can I fly this by you?" tale from a colleague.
The patient is a substance abuser with a history of episodic violence, only when intoxicated. The substance abuse continues. The patient is an adult, but his care is paid for by a family member who has been involved. Psychiatric care is divided between a psychotherapist and a psychiatrist who prescribes the medications (split treatment). The patient tells both the psychotherapist and the psychiatrist that he is planning to purchase a gun, for protection. Neither the psychiatrist or the psychotherapist feel that the patient is imminently dangerous, and neither has expressed concern (that I, sitting on the curb, know about) that an actively symptomatic mental illness is the reason for concern. In other words, the patient is not now suicidal, is not purchasing the gun to either kill himself or someone who is the focus of a delusional system. The only danger (aside from the usual dangers) is that the patient is known to have a substance abuse disorder and is known to sometimes become violent with intoxication.
What should the shrink do?
- Cross his fingers and hope for the best?
- Attempt to hospitalize the patient?
- Violate confidentiality and involve family?
- Refuse to treat patient if he buys the gun?
- Refuse to treat patient if he continues to use drugs?
- Buy a gun for his own protection in case patient comes after him?
The actual case had an answer, even before I heard about it (ah, this makes it so easy when someone wants my advice!), I'll post it here after people have had a chance to think about this one.
Okay, so probably Do Nothing comes closest of the choices above: Review with the patient that he has an ongoing substance abuse problem, that under the influence he has a history of becoming compulsive and violent, and he shouldn't get a gun. I believe, but don't know, that this is a college student with no formal legal history and no interest in giving up his substances. Refusing to treat if he doesn't get substance abuse treatment would likely be the end of treatment. Refusing to treat if he buys the gun seems a little weird-- I do have patients with guns. Clink has also pointed out to me that it can be a real issue if such a patient is required to carry a gun for his job-- no gun, no job, no insurance, can't pay shrink. The shrink buying a gun was a joke. Sorry if it wasn't funny.
So the doc who "flew this by me," then told me that the psychotherapist told the family member who pays for treatment and has sometimes been involved. The family member threatened to stop supporting patient if he got a gun, patient reportedly didn't get gun, but got mad at therapist and fired her. My response: "Therapist did you a favor and solved your difficult problem." Was this "legal?" Nope, the therapist violated confidentiality. Can the patient sue-- I suppose so, but for what damages? We'll never know, but if the patient had done something awful with the gun, it would have been very troubling to his treatment team, even if not snitching was the "right" thing to do. I don't know the extent of the past history of violence, and that would have mattered to me. Remember, this question got asked on the heels of the Virginia Tech shootings and I believe we're all still feeling a bit vulnerable.