Thursday, May 10, 2007

I Wish I had a Crystal Ball


I wish I could make decisions knowing how things would play out. Don't we all? In my Johnny Get Your Gun Post below, I presented the case of the episodically violent substance abuser who wants to buy a gun and his therapist tells his family, stopping the gun purchase as well as the psychotherapy. In Roy's post on moral and ethical conundrums, he makes us consider the value of one life versus five with a couple of different scenarios. Some of the commenters pointed out things like how we don't know if we sacrifice someone for his organs that the other folks would live, and it got people asking who even deserves an organ.


I love the blog.


So, Roy and others pointed out that it was the wrong thing for the therapist to violate confidentiality and tell the patient's family that he was thinking of buying a gun, given that the patient is an adult, he was purchasing the gun in a sober state, there was no intended victim, it's legal to own guns. It's not okay for a therapist to tell a family member of such things unless there is a clear and identified victim (and then, our Tarasoff-abiding ClinkShrink tells us, in California we should tell the police or the victim, not the patient's family member) or the imminent risk of suicide or homicide. In the short run, I think it's good that the periodically substance abusing episodically violent patient doesn't have a gun. Roy and others have pointed out that the now ex-therapist may have compromised this patient's ability to continue with anyone in a meaningful psychotherapy, that the patient may lie or hide such potentially important issues in the future, that the therapist missed the boat by not exploring exactly why the patient was telling both his psychiatrist and psychotherapist this anyway (Roy, you are sooo good, you can be my shrink anyday). Maybe the psychotherapist was worried about being sued, and that's perhaps sad or bad.


I would contend that for the moment, we just don't know, and it would be so nice if we did. If the mental health professionals all kept quiet, if the patient on his own decided not to buy a gun, or did buy a gun but didn't use it, this would be good (Though perhaps many sleepless Saturday nights for the shrink & therapists for ages to come), and perhaps the patient would have continued on in a healing nurturing wonderful relationship with his treatment team. Not violating confidentiality is the right answer here, now that we know the outcome.


If the patient bought the gun, got drunk, wandered home angry and impulsive, and shot his sister, it would have been the wrong decision. Family member paying for treatment would never understand that the treatment team knew about the gun and chose not to violate confidentiality. They might sue, though perhaps unsuccessfully, and I assure you that regardless of what was "right" the treating professionals would be beside themselves over any bad outcome that resulted in the injury or death of anyone. Even the patient, now sober in his jail cell, might wish that someone had stopped him. And if he killed 32 innocent people in a school, the treatment team would feel really bad, especially given that they'd contemplated other options.


So, the patient didn't buy the gun and fired the therapist. Is this bad/? Roy worries he'll sour on all therapists, that down the line he might not let someone in to prevent an even worse event. If that happens, if he kills someone 5 years down the line and that could have been stopped if he was in therapy but he wasn't because those damn therapists can't be trusted, then violating his confidentiality was the absolute wrong thing to do.


But what if the patient gets drunk on Saturday night and gets into a fight, and then thinks, "Good thing I didn't have that gun." (He won't think this until late Sunday afternoon). Or what if he seeks help from another psychotherapist who he clicks with better than the first and he feels much better, now he's had an opportunity he wouldn't have had if he'd remained in therapy with his first therapist. At this juncture, he remains in treatment with the psychiatrist who prescribes his meds, maybe he'll go into therapy with him, since knows he can be trusted, and maybe that won't be such a bad thing.



What if, what if, what if ?


So I don't know the patient, but I do know the psychotherapist, the one who snitched to the family about the patient's plans to buy the gun. On a sobering note, she had a personal and terribly tragic violent event touch her own life-- one which I imagine precludes sitting by and allowing a substance abuser to buy a gun. It's probably best that they not work together.