Saturday, January 26, 2013

The Bodies Under the Floorboards

The subtitle for this post is: No Crystal Balls Here.

I know ClinkShrink disagrees with me and thinks the NY State gun legislation requiring psychiatrists to report people who, in the judgement of the mental health professional, are likely to be dangerous, is not so bad.  She has pointed out that the information gets reported to another mental health professional employed by the state, and that official makes a decision about moving it to another agency.  Maybe that official will go out and meet all the patients this will include and review their records and examine them.  That would be good.  But I think it will be a lot of individuals -- presumably everyone seen in an ED for a serious suicide attempt, and many people admitted to a psychiatric unit. We'll have to see what that ends up meaning and how that Director of Community Services decides who gets reported on.  I don't think that many outpatient clinicians will be reporting their patients unless they are really, really worried, and reporting someone who tells you that they are stockpiling arms and planning to kill a lot of people, well, that person should get reported.  We really don't think that psychiatrists should keep silent if a very psychotic person is talking about killing the neighbors because they are aliens who have cameras watching him and he knows this because something on his desk was in a different position than where he left it.

Periodically over the years, I've met patients who fit the profile of someone I'd find worrisome.  Male, loner, no social contacts, a little odd, who has expressed some aggressive thoughts.  Decades ago, I remember telling a colleague, "No one will be surprised when they find bodies under his floorboards."  In none of these cases has their been anything to report.  The persons in question have not had histories of violence, they haven't mentioned owning weapons, there is nothing specific other than their inability to relate normally and they have all been actively (and voluntarily) engaged in their  mental health care.  To the best that I can tell, my predictive powers with such individuals has been exactly Zero.  I have never seen an article in the paper that any of them have committed any crimes, that bodies have been dragged up from under their floorboards.  It's a different story if there is a history of violence,  then my predictive power goes up (a little) , and often alcohol and drugs are involved.  And sometimes someone does something that is a complete surprise, that I could not possibly have seen coming.  No guns, one power saw. Ugh.

I don't like guns for anyone.  Perfectly sane people get drunk or angry and if there's a gun there, they may shoot the person who provokes them.  I prefer a good fistfight any day.  Many people start to commit suicide and change their minds.  Many, many people and swallowing pills may let you change your mind, guns generally don't.  And if you read the papers in Baltimore, it's not an unusual event to take out someone else as you go, murder-suicides are not infrequent.  I do realize that criminals have illegal guns that legislation doesn't touch, but I still just don't like guns, even if you're using them to shoot animals for sport.  No stuffed heads hanging over the door in my office.  

I would like the option to report someone I think is dangerous.  I have that option now, I can have them brought to an emergency room for an assessment -- the police will do this for me if I fill out the right form.    In the clinic, we can call hospital security to take someone to the emergency room -- it's not always pretty,  but it doesn't involve the state, at least not a my level.  If the government would like to expand my options by saying I can report someone I believe might be potentially dangerous without being imminently dangerous, that's fine.  There might be times it would be nice to have that option so that if I'm losing sleep over someone where I'm just not sure, it might be a little easier to get them evaluated for hospitalization.  What  I don't want is the government mandating that I am REQUIRED to report someone based on my thoughts of what they might do, because my predictive powers are Zero, and honestly, my thoughts are none of anyone's business.  I'm not sure why the APA and NY Psychiatric Association aren't making more noise about this.  I'm not sure the legislation is awful -- it depends on how it actually plays out -- but I still think it's a slope I don't want to be on.  And regardless of the implications, I worry that people who need help won't get it because of the perception it creates.  We have commenters writing in to say they won't see a psychiatrist because they think they will be reported to a data bank which will prevent them from getting jobs.  Or they're worried their psychiatrist will misinterpret something and report them (--believe me, outpatient psychiatrists are NOT going to be rushing to report their patients and will ask if this is a fantasy or an intention before calling authorities).  Still, regardless of the wording of the legislation, the New York Times has reported that mental health professionals are required to report people who are likely to be dangerous, and even if that doesn't capture the nuances of the NY SAFE Act, that perception is now out there. 

New York mental health professionals: I want to hear from you! 
APA officials : Wake up.

Oh, and while I'm talking about crystal balls, there  great op-ed piece in the NY Times by Elyn Saks.  See Schizophrenic, Not Stupid.  And for the record, I have never told anyone they shouldn't work upon receiving a diagnosis.  Plenty of people pop back from psychotic disorders, and we just don't what someone can achieve until they try.     
Please also see our last post and the comments on The NY SAFE Act, and the articles we wrote on the Clinical Psychiatry News Website.  
Dinah's piece on CPN is also available on Psychology Today without the password.