Thursday, August 02, 2012

Preventing Violence: Any thoughts?

In the news today, it was noted that the alleged psychiatrist of the alleged Aurora shooter had allegedly been concerned about him enough to report him to the University's "threat assessment team."  He reportedly withdrew from the university before the team could convene.  We don't know any details about what he may have said to the psychiatrist, or what the threshold is for notifying their threat assessment team.  Presumably (and I don't know this for sure, but I'll assume) he would have been hospitalized if there was an imminent risk of danger.

Our laws are pretty clear, and I will only talk about Maryland, because I know nothing about the laws in other states.  If a patient makes a threat to a psychiatrist and there is a specific named victim, the psychiatrist is obligated to do one of three things: warn the victim, tell the police, or hospitalize the patient.  "I'm going to kill my girlfriend" qualifies.  "I feel like hurting people when they're rude to me" does not.  But wait, if a psychiatrist has reason to believe that a patient is at risk of committing an imminent act that endangers himself or others, and the patient has a mental disorder, the psychiatrist may involuntarily certify him to a hospital for psychiatric evaluation and treatment.  In the majority of cases, this occurs in the setting of a suicidal threat or after a suicide attempt.  It's much rarer that we see homicidal people in psychiatric settings, perhaps because depressed people become suicidal and seek care, while homicide more often is the result of anger or other motives (for example, in the course of a robbery) and not related to mental illness.  Mass murders in public settings are extremely rare events -- as opposed to suicide which is a common event, or single murders linked to drugs or alcohol which are also fairly common, at least where we live.  We know very little about what motivates mass murderers, and because they are so rare, they do not represent a single phenomena -- each case may have a very different motive and/or relationship to mental illness.

When something bad happens, and there were warning signs, people say "something should have been done."  If a psychiatrist has been involved, there certainly may be the thought that the psychiatrist should have prevented this.  The shooter involved in the Virginia Tech shooting had been hospitalized, years before the Va Tech incident, but he did not continue in treatment.  In many states, patients whose mental illness leads them to legal difficulties are subject to outpatient commitment.

We don't know what transpired in Aurora, but if a student in Maryland made a vague threat (and vague threats do keep psychiatrists awake at night) and then left the institution, or simply didn't return to treatment, there is little that can be done.  If I'm worried about someone's safety, I like to check in with the family: Are they worried?  Are they aware that the patient owns weapons -- if that's what I've been told.  I like them to at least be aware that I'm concerned, to know how to find me, and to know what to do if there is a emergency.  If there's no family, or if I don't know how to reach them, then this isn't an option.  

Our present laws don't allow us to involuntarily hospitalize people based on vague threats, or shrinky suspicions, and they shouldn't: we don't want to be a society that institutionalizes everyone who seems a little weird or is a loner. ( I don't even think we want a society where everyone has to have their shoes scanned to get on a plane, but nobody asked me. ) We're not terribly good at predicting violence -- people get discharged who then commit violent acts, and people get committed who would not have acted on their violent thoughts.  We're psychiatrists, not fortune tellers.

Are tragic acts of violence a failure of the system, or are they an unpredictable, fact of life where any attempt to prevent such acts would result in an over-correction and too many people would end up having their civil rights violated?    Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment?  Any ideas?
Oh, wait -- before you use this as your gun-control soap box -- the alleged Aurora shooter is not the right poster child, even without guns, his apartment full of explosives could have resulted in a horrible tragedy without guns.  (I'm in favor of tighter gun regulation, and I don't believe it's okay to buy or sell thousands of rounds of ammunition over the internet, but that's a different issue.)

Okay, Clink can tell me why I shouldn't have written this blog post now.   And Roy, for you, I've started balancing my dashes -- I know how difficult it is for you when I don't.  Thanks to Tigermom for the graphic


Jane said...

"Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment? Any ideas?"

It's very sad what happened, and I think any time a mass shooting happens people don't just wonder what role psychiatry could or should have played. What about parents? Siblings? Extended family? Or how about even just a neighbor? How could he have deteriorated this much and no one noticed? Don't know what the answer is to fix that. There were a lot of people who could have stepped in but didn't.

I think people understand that a psychiatrist doesn't see much of a patient. It's a very limited time in the office especially when no psychotherapy is involved.

Anonymous said...

How is it that you can check in with the family if you're concerned about a patient? Wouldn't that violate your confidentiality obligation to the patient?

George Dawson, MD, DFAPA said...

Violence and mass violence can be prevented. I have done it many times myself and any acute care psychiatrist has. It is more than a little ironic that acute care psychiatrists are really never consulted during these incidents because nobody ever cares about prevention. It is much easier to say: "Well these tragedies happen. Let's praise the heroes, mourn the loss of life and move on." That sounds trite because it is and it is all anybody ever says.

A lot more can be done short of an unrealistic repeal of the Second Amendment. That's right guns don't kill people. Access to guns kills people. Colluding with the silence on this issue only assures further mass shootings and violence.

Concrete action can be taken right now and it starts with the recognition that homicidal thinking - especially in certain contexts is abnormal and should be immediately assessed. Why don't we ever see a public service announcement like that?

Sarebear said...

My psychologist, on two occasions, felt a duty to warn, to breach confidentiality. He was going to tell my husband to keep all my medications in a place only he knew, and he'd dole em out week by week.

He asked me if I'd tell my husband instead, since it would be better coming from me, instead of from him; he talked me into doing that, since I knew my husband would learn I'd been hoarding medications for the purpose of using them, or saving them for use in an inevitable future mood downswing.

Some might say, if you weren't actively suicidal, what was there to justify breaking confidentiality; well, how "actively" I was suicidal kept swinging so frequently and severely all over the place, that not taking this step of making sure my husband knew to restrict access to medications would have been irresponsible, and quite likely unsafe. That, I think, was enough for him to breach. At the time(s) I was pissed, but I get it now. These incidents were several years apart, and the second time, he kept them restricted for over a year. The therapist had said until he indicated it was safe, which he never did, but it got kind of old, without further instruction from my psychologist.

Oh, also, he had said to not leave me alone for long stretches of time; THAT one interfered with life quite often, but he had legitimate reason(s) to be quite concerned.

I believe there are sometimes concerns that are severe enough to warrant talking to family members (with only the info absolutely necessary, no more), without necessarily being severe enough for hospitalization.

Anonymous said...

Thank you for your take on this issue. I feel it is important to show how common murder is in our country for drug related issues and yet our media went non-stop with this story for days.

The "over"coverage of this horrible event certainly fueled more gun sales which doesn't really move us forward.

There should be a way to "profile" certain behavior for the safety of others.

For example; if a hunter buys ammo and weapons every year, that wouldn't trigger any further worry.

But if a newbie suddenly buys 6 guns and 1000's of rounds of ammo,and gas masks,and throat protectors, there should be some suspicion raised.

We have checks and balances for other things. For example,if a doctor starts billing Medicare for 60 patient encounters a day, you know an audit is looming!
(One would hope anyway).

The pattern or sudden change of behavior may be the red flag.

This will not work 100% of the time, but what safety net do we have now?


rob lindeman said...

I'll amend Dr. Dawson's comment. Violence cannot always be prevented. It is hubris to suggest otherwise.

Agree with Dinah that we should not prophylactically lock up weirdos. Free societies don't do that.

Andreas said...

I chuckled a bit at Dr Dawson's claim. I am glad Rob picked it up. He cannot possibly know whether or how many times he has prevented violence or mass violence. If a patient threatens and gets locked up, I suppose that might count, but the patient cannot be locked up indefinitely based on a threat and anyone truly intent on violence or mass violence (how many wounded or dead people qualify the act as mass?) will end up doing it by convincing the docs and cops that they are not a threat, just as many suicidal people are discharged as no longer having suicidal thoughts or impulses and then go off themselves.
I have heard kids say that if they fail an exam they will kill themselves. Some do, most just say it and go on with life. That would be the outcome whether or not every kid who said it was or was not locked up. The expression of violent wishes and access to weapons does not mean that a threat is real and will be acted upon. There are enough people with violent wishes who never speak about them and who just go do it.
Yet, if the alleged shrink was that worried, it seems a bit of pass the buck to refer to an assent team and then not do anything further when the student withdrew. On the other hand, I do not think that doctors or anyone else can predict with much accuracy who will or will not end up going on a killing spree.

rob lindeman said...

Thanks, Andreas,

To continue, one cannot measure violence prevented, except in fiction (Minority Report)

Dinah said...

These issues are rare in outpatient practice. They are common in the ER, but I haven't worked in an ER in ages.

My belief is that if I'm awake at night worrying about a patient, the patient belongs in the hospital. I never involuntarily hospitalized anyone from my private practice, a handful of times in clinics, but not in recent years. I'm not a big fan of hospitals.

I can check in with the family because the patients consent to this. In an ER with someone who is acutely ill, there may be distrust, but in an ongoing relationship, people often bring their family members to meet me-- usually their idea. My "new patient information sheet" says that confidentiality may be breached if I have worries about danger, and people give an emergency contact. I also tells people they are welcome to bring family members with them to the evaluation if they'd like. I sometimes even get boyfriends/girlfriends, neighbors, children, or the whole gang. I leave them in the waiting room until the end.

No one has ever told me they are about to go out and kill people.

It is never in a patient's best interest to kill anyone. (except in self defense at the moment, but that's not a psychiatric issue, and it's also never happened in my practice).

Suicide is really the bigger issue, and I have had family members hold medications and asked them to watch people who have not wanted to be hospitalized.

Psychiatrists certainly can't prevent all violence. Maybe no one can if someone is motivated enough. It's all sad.

I am still not a robot, I don't think.

Andreas said...

I'm not a robot: I do think. It sounds much better.

Okay, I have an issue with: "My belief is that if I'm awake at night worrying about a patient, the patient belongs in the hospital."

I suppose that you do not stay up worrying about your patients too much since you rarely hospitalize them on an involuntary basis. I don't know how other shrinks might apply your standard. Some people worry more than others. I can imagine two docs looking at the same patient,one deciding to hospitalize and the other not. I have seen it happen. In fact, an outpatient psychiatrist has patient sent to hospital, only to have patient not be admitted by ER psychiatrist. Patient is in the same condition as when originally shipped off the hospital: suicidal, obviously unwell. Hospitals take a look at the fact that there are no beds, the halls are crowded with stretchers, staffing levels are inadequate to provide care. Patient gets walking papers. Some have walked off the earth. So does the outpatient shrink feels better, knowing they sent the patient to hospital? Case can't come back to haunt them in court? When you do lie awake, are you more worried about the patient or about a lawsuit? Either and both are legit.

Anonymous said...

Psychiatrists are in a real bind here: they are obligated to report if XYZ and obligated NOT to say bubkus otherwise. That's not going to catch that unusual paranoid-type-planning-something-big. Everyday people, family members, etc don't have those restrictions, right? They can voice suspicions about people to the police. My town has PERT, the psychiatric emergency response team. But would Holmes' withdrawn behavior been enough to trigger a visit? It goes against the NAMI line, but it might be that "showing signs of schizophrenia" should warrant a police check-in.

Curious that the campus threat assessment team was willing to drop investigating as soon as Holmes was no longer on campus...

Question: if a patient is hospitalized involuntarily as a "threat to others," do the police automatically get involved? No one searched my house when I was suicidal; the hospital even gave me back the rope I came in with!

George Dawson, MD, DFAPA said...

I continue to be amazed at how easily people can dismiss the experience of somebody who actually deals with extreme aggression. Whether or not anyone prevents aggression is always a probability statement because there is no ethical experiment that would allow definitive proof. The fact that no human subjects committee would allow such an experiment says something. The lack of definitive proof does not mean that it does not happen. That is kind of like that guy in your freshman philosophy course who takes the position that nothing has meaning.

It turns out the best predictions of violence occur on inpatient units where the staff may be engaged in preventing severe injury and homicide to both themselves and other patients on the unit. In that case the result is readily observable but it is protected information that cannot be openly discussed. Additional information comes from people who actually come back and express their gratitude that they were prevented from killing one or more people. In the case of a psychotic heavily armed person with homicidal intent there is a very high probability that aggression is prevented by treating the psychosis and in some cases the associated substance abuse disorder. Sure – you can always explain that away and it is certainly popular to do that, but it ignores the probabilities.

I think the reluctance to engage on this issue has nothing to do with whether or not psychiatrists can prevent all homicide or some homicide. I think that it comes from the stigmatization of aggressive psychiatric patients. They really have few advocates and not many people interested in treating them. Everybody knows that if there is a bad outcome, their mental illness will usually not be a defense. We are destined to ongoing incidents unless somebody gets serious about the problem. Saying that nothing can be done is not a serious approach but it is apparently the currently politically correct one.

rob lindeman said...

"Saying that nothing can be done is not a serious approach but it is apparently the currently politically correct one."

Would that this were true. To the contrary, political correctness fairly demands that we keep binoculars trained on our neighbors' windows! The classic, politically-incorrect approach is to refrain from depriving your neighbor of liberty.

Anonymous said...

Inpatient, I can see being able to claim violence prevention. Patient is already in hospital, docs can drug them into passivity. That does not apply to the world outside the hospital or when we are talking about people who may be acting "off" but have no hx of violence. That is much harder to predict and almost impossible to address if the person has not drawn attention to themselves.
It does not have very much to do with stigma. All people with mental illness are stigmatized even though it is now politically correct to feature movie stars and their mentally ill relatives in magazines and talk shows. I do not think that we have a greater stigma against mentally ill people who are aggressive or violent. The public is frightened of the mentally ill as it is, often for no reason. I cannot think of anyone who is not frightened when approached on the street by an aggressive or violent individual who may be mentally ill, may not be.We are programmed to respond to danger. When I have been inpatient, I did not fear my roomies. I was frightened of the big dude who threatened everyone and threw a television. Because we were all "mentally ill", not much was done to protect us. He was not restrained. We had to sit next to him at meals. The staff were nicely locked behind their glass cages. Our cell phones were confiscated. The staff had phones and pagers. Yes, we had several people who were restrained. These were the folks who committed sins such as being rude to staff by questioning authority or who said they were going to "escape".
So don't be so quick to pat your own back when you are dealing with a captive audience. I don't believe that anyone, shrink, doc of any kind, school counselor, parent, neighbor, would fail to act to prevent a violent attack if it were possible. No one wants to feel responsible for that. That is evidence enough to me that it is far more difficult to monitor and stop than you present.I do recognize that my evidence is not evidence; neither is yours.