Saturday, March 02, 2013

My Day With Our State Legislature

It was a long day in Annapolis yesterday.  I was one of an estimated 1,300 people who showed up to give testimony on gun legislation.  For details, see The Baltimore Sun article.

On the public testimony, I was #162  and I went at nearly 9 pm, they were estimating 16 hours of testimony and it didn't start until 4:30 pm. My quick demographic estimates: 99% white, over 90% Male, & over 95% or those who came to testify opposed the governor's bill. The supporters, including busloads of school children, were outside rallying in the morning.

There were 4 hours of expert testimony, then I heard  4 hours of  public testimony with the same handful of messages : civil rights, why I need an assault weapons, statistics on how gun control doesn't decrease violence, I'm gonna move to another state if this passes, you're going to make me a criminal, go after the criminals and the mentally ill,  all of these measure prevent straw purchases but no one is ever prosecuted for straw purchases, this won't fix anything, and my personal favorite: the little girl who testified that if the law passed she'd have to move away from her friends, her school, and going to McDonald's.  Where were the victims of gun violence? Where were the mental health advocates?  They were part of the expert testimony -- I'll talk more about this below--but I was the only one (of those I heard) who was not giving public testimony on the Firearms Act.  I left after I testified, but it went on until early the next day --I've heard 3 AM and 6 AM. 

I got to testify around 9 pm, maybe a little earlier, thanks to our kind psychiatric society lobbyists who signed me up, even though I wasn't the designated speaker for the expert testimony. It fast-forwarded me out of a long line to get into the building and I got me a much better number than I'd have gotten myself, being that I'm not a "morning person."  I was psychologically prepared to stay until 10 or 11, so being heard by 9 was good.  I'd brought a peanut butter and jelly sandwich, a pear, and some carrots.  I resorted to water from a faucet in the rest room, and at one point, I was sitting on the floor of the hearing room with my phone charging while I tweeted, and a kind staffer offered me a chair.  I didn't want a chair, but I did ask if he could get me a cold beer. 

I had prepared three minutes of testimony, but given the numbers, they cut the time to one minute. Everyone ran over, and the Chairman, Delegate Pete Hammen, sometimes let people ramble on, and other times, cut them off.  I thought he was incredibly rude and dismissive to me.  I seem to remember going to meet with him years ago, and that he was dismissive then --not to me specifically but to our psychiatrist group.  Is this my imagination or does he not like psychiatrists?  I think I felt like our readers feel when they talk about being dissed because they are psychiatric patients; I felt dissed because I was a psychiatrist.  I pointed out to him that I was the only person there not testifying on the Firearms Bill, I was talking about HB810 --mandatory reporting of dangerous patients.  He'd been more patient listening to  gun-owner after gun owner make one of the same 4-5 points about why they oppose the legislation.  Me, as the only one giving testimony on a different bill, he cut off repeatedly and was quick to dismiss.  In all fairness, it was nearly 9 pm and everyone was fading, some of the legislators had left, and  I can't imagine what they were like at 3 AM.  I did go over my allotted time and I did give my testimony as a story, not as bullet points, something I knew might be risky. The bill's sponsor had been in and out of the hearing room, but during my testimony, he was gone. 

There was on ob-gyn who testified in favor of the bill --one of only 3 pro-gun control advocates I heard --  and they were much nicer to her.  I guess on the positive side, someone in the room applauded me -- no one else was applauded while I was in the hearing room -- and one of the legislators said, while I was speaking, "That's why we shouldn't pass this."  So I guess it was worthwhile.  No one had any questions for me, but Hammen phrased it as "Any questions? Next." And they were all understandably a bit zoned out by that hour.  One person gave testimony that she'd been mistakenly diagnosed with a mental disorder and could never get a gun because no one would say the doctors at the hospital were wrong, and this was part of the Firearms Act.

By the way, when someone (? I think it wasn't one of the bill's sponsors, but I missed the introduction) described HB810, he described the three Tarasoff options and said this bill would require mental health professionals to tell the police if there was a specific threat against someone else. He proposed it as a tightening of the Tarasoff requirements, while the HB810 actually undermines Tarasoff.   In fact, the bill requires mental health professionals to report to the "Director of Mental Hygiene" : a nonexistent agency.  Perhaps they meant MHA or DHMH.  The Direct of Mental Hygiene then decides whether to tell the State Police for the purpose of preventing gun sales (so reporting to the FBI NICS database, I assume?), who then decides if they should contact the local police. 

As far as the expert testimony went -- the first 4 hours of the proceedings --Dr. Brian Zimnitsky from the Maryland Psychiatric Society did a great job, and an internist testified who also did a wonderful job-- he described that 1/4 of his patients have psychiatric issues and how hard it is to get people in to see psychiatrists, how many don't take insurance and how clinics aren't open late for people who work, and the long waits.  And he was very articulate about how the process to get your gun back doesn't/won't work because psychiatrists  won't certify people to use guns, either because they are liberal urbanites against gun ownership, or because they won't accept the liability.  Dr. Zimnitsky did a good job of re-iterating that with a little more detail about what it is we can do.  It was very confusing because the Firearms Act was the focus of attention, yet there were other mental health issues which got no space for discussion.  And most of the testimony was about the details of guns and assault rifles and statistics about how gun control effects morbidity and mortality.

Overall, Dr. Zimnitsky was the only psychiatrist, and there were 2 psychologists and 1 lawyer from the Maryland Disability Law Center -- in 4 hours of expert testimony, and the 4+ hours I watched of public testimony.  Is there anyway to get a stronger psychiatrist presence at the table?  These lawmakers clearly don't understand the issues, and I think it's hard because they seem to have their minds made up about psychiatric patients and either they are not open to learning, or we're not doing a good enough job explaining.  Even with the Emergency Petition issue that came up, it sounded like EP's happen when a doctor files one, and there was no mention of the fact that a family member or neighbor can easily obtain one, and then if the professional in the ER doesn't have enough information, they may want to hold a patient for a day or two to observe and clarify whether they are safe. In this case, a person will be deprived of a civil right without any due process. This was an 11th hour amendment that was brought into the Firearms Act on the night it passed the state senate.

There was nothing mentioned about doctor-patient confidentiality and how this is necessary for psychiatric treatment to ensue.  The point was made they times that using a 30 day cutoff for reporting would affect eating disorder patients who aren't dangerous, but I think the point should be that reporting voluntary patients forces physicians to violate the doctor-patient confidentiality that is necessary for psychiatric treatment it and  deprives people with mental illness of a civil right and that this singles out psychiatric patients as the only group of people who can be deprived of civil rights without any legal due process.  It's all terribly stigmatizing and may well serve the opposite of the intended effect: to leave people fearful of psychiatrists and less willing to get help.  And it's striking that HB810 only applies to mental health professionals and no other health care provider is being asked to report dangerousness.  I wasn't really sure by then end of all of it if the 30 day voluntary inpatient reporting was still part of the bill passed by the senate; it was twice mentioned that this had been removed.  We need to move the terminology from "the mentally ill" to "those who are dangerous" for any reason.

It's amazing that there is nothing about substance abuse, that you can go for eight rehabs, and still have your arsenal. 

In terms of actual safety issues, I think it might be helpful, though I imagine it's too late, to have a  process by which all physicians are "allowed" (as opposed to required) to violate confidentiality and the police are "required" to investigate and confiscate weapons then have a quick legal process that would ensue to return such weapons if they were confiscated in error.  This could be used for psychiatric patients, substance abusers, or simply angry, mean people who are making threats or behaving erratically.  And because it wouldn't be about just reporting to a database, it might serve as a mechanism to get guns out of the hands of those who have them illegally, something none of this legislation addresses.

If you read through all this, thank you.  Eleven hours yesterday and I needed to vent.  It was really fascinating and I'm so glad I went.


Joel Hassman, MD said...

The paragraph above about Chairman Hammen interested me the most. I think his attitude does reflect our alleged representatives in Maryland.

Otherwise, why write a bill and not be getting the the input of the very people it affects the most first?

The arrogance of the Democrat supermajority clearly shows why people need to stop having an alliance to a party and resume the responsible alliance to, the public.

Oh, and sorry to say, I found your choice of picture to highlight this post to be just painful to have to see. O'Malley is such a fraud.

Just for the record, have no interest in Republican representation either, they not only ignore the mental health population, I really think they would abandon them by cutting mental health care out of the budget completely if able.

Have to credit you for sticking around to over 9PM. Starting the hearings at 4:30, what a passive aggressive way of dismissing the public!!!

Joel Hassman, MD said...

Read the Baltimore Sun now on the net or tomorrow in print, I think you will find the article about Spring Grove and the disturbing incidents of assaults on staff reflect at least how the courts view the value of mental health care. And doesn't our legislature just echo court opinion?

As I said earlier here, Perkins now has satellite units in Sykesville, Catonsville, and even over on the eastern shore in Cambridge.

And soon to house more criminals simply because people who use guns are just crazy.

jesse said...

Thank you, Dinah. Well done! Very well done indeed.

Dinah said...

Thanks Joel and Jesse for you comments,

I've been told that Pete Hammen is well-versed in mental health issues. One reason that I may have been quickly dismissed is that he may know that there is no steam to pass such an obviously flawed bill. In New York, the mandatory reporting was incorporated in there SAFE Act. Here, a mental health task force (16 people including 1 psychiatrist who worked for the state and likely opposed it) recommended mandatory reporting and the Governor chose not to incorporate this into the bill. Sharfstein has been on the radio talking about how it's important to not do things that would deter people from getting health. I asked our lobbyists if it might pass, and she said, "I don't know" so I decided to invest a day (plus lots of writing and my article in the Sun) in fighting this. Seeing what Texas does makes me feel like you can never be too sure of anything when it comes to legislators, but Hammen may know that this is a dead issue and wanted to move on. The shocking part (which addresses my unpredictability issue) is that Sandy Rosenberg --often lauded for being very pro-mental health issues --is a CO-SPONSOR of this insanity.
My testimony will be my CPN piece for this week.

I sent ClinkShrink a link to the article on Spring Grove. Ugh.

ClinkShrink said...

I read the article. The trick is that some staff, if they don't like the patient or get assaulted, may be tempted to be dismissive and say, "Oh, they're just criminals," even when there is something more serious going on. This is not to say that hospitals don't get malingerers, but generally defendants don't get admitted unless they are assessed as incompetent to stand trial. Occasionally, particularly from Baltimore City judges, you will get an order to do an inpatient evaluation and that is the issue we need to tackle. An admission should be based on clinical need, not merely a judicial desire to get someone out of jail.

The bigger challenge is sometimes getting the defendant/patient transferred back to jail when they no longer need to be in the hospital. If it takes three months to get a competency hearing you really can't tie up a bed for that long after they've been restored to competence. And in regional facilities the courts require a community treatment plan prior to discharge, even when it's unlikely that the defendant-patient will be returning to the community.

It's a complicated issue. My blog post about this is in draft form, to come later.

Joel Hassman, MD said...

I disagree with ClinkShrink (surprise), that is the rhetoric that just continues this problem.

It is rationalizing, deflecting, and minimizing to me. I don't read any outrage or concern in the comment. When an article of this magnitude is printed, in this case the front page top right column lead story in the Sunday paper, it should be a serious matter to us as colleagues!!

I worked at a state inpatient site for about a year, it was getting more forensic referrals as the year progressed, it was EASY almost always in a short period of time to identify who was genuinely mentally ill and who was malingering, or who was openly voicing success at avoiding correctional confinement.

No, the problem was, and still is apparently, either the forensic services for the state are overwhelmed,(which I know they are, but, and this will not be received well by some readers) or, bureaucracy does not give a rat's behind about the mental health element to judicial processes, and by the way the judges were reported in replying to Applebaum's report, I rest my case!

As long as there are apologists, defenders, and just silent naysayers who will not speak up, well, hope you as a citizen with genuine mental illness do not get committed to a state mental health hospital for awhile.

Unless you are allowed to bring in your sneakers and can sleep with one eye open.

Yeah, this comment was harsh, and so are the conditions in our state hospitals. Oh, and when I spoke out while working where I was, you think I was heard, much less respected? Readers know that answer!!!

if interested, you can read my last 2 posts about this issue at my site, which doesn't seem to be linked with my name of late:

Thanks for letting me comment here.

Joel Hassman, MD said...

Apologies about saying not being linked, I see I am now. thanks.

Dinah said...


ClinkShrink is from Minnesota. They don't do "outrage" there. It's the Midwest, everyone is nice. They smile a lot and they never raise their voices or throw things.

It's infuriating. I call her when I'm outraged, looking for someone to share my distress with, and she is always so calm and "eh...." It's like we have an entire part of our nation that is the exact opposite of Italian. And no one does anything about this!!!!! The real question is why I keep calling, looking for empathy and validation, when I'm going to get a calm, soothing, anti-problem. At the most, there is an emphatic "Exactly!" And if things are really bad, she may utter "uffda."

Don't take it personally, but you might want to move to Brooklyn. Steer clear of Milwaukee.

Joel Hassman, MD said...

Thank you for noting your colleague's background. I think a little outrage, when it involves the management of care dictated by judges and politicians, seems appropriate, at least once in a while. (Sorry, but after reading what I wrote further, a rant, but I still forward it as hopefully worth the explanation):

Let's be honest, our profession does not advocate for itself very well these past, what, 15 or more years? We've let managed care basically castrate us, then let other professions affiliated with mental health erroneously claim peer equivalent rights and abilities and then perform them less than adequately too often, then the pharmaceutical industry basically made us "performers with a pad"(as the "w" word has gotten me in trouble previously), and more recently have let our own professional leadership redefine our billing abilities and will also redefine psychiatric illness come May.

Ah, doesn't that chain of events outrage a person like you who seems to care and be invested as an advocate? Yes, you went to the hearings the other day, which was more than admirable, but, you gotta get in peoples' faces sometimes, because being nice doesn't have much clout with politicians and judges, although the latter must involve much diplomacy. Thus, I don't deal with the legal side anymore. Diplomacy I leave to you folks. Good luck with it.

Some movie lines just resonate so well, and you know what made the movie "Network" so famous. And I think some patients do appreciate us as advocates making some loud noise in moments like now where O'Malley et al are just looking for quick fixes, and O'Malley specifically has one eye on the Exit door before he even finishes 2 more years for the position he campaigned to do.

Personally, if he did a Sarah Palin move and left early, I would thank him for thinking of the public. For once.

(to reflect my displeasure with judges, I once wrote a letter to the judge who ruled continuing a conditional release on a terminally medically ill patient, after I testified in court on the patient's behalf, because the state's psychiatrist had a personal issue with the patient. How was I received with a honest and fair letter? I was served with a contempt of court charge that the SAME judge was going to hear and rule on the charge, which was and still is against MD law for the circumstances, and thank god I had a good lawyer to get the matter served right. Oh, and the judge who did this? Got arrested for a DUI in Ocean City about 4 years later and tried to threaten the police officers to get out of it.
Really reinforces your trust and admiration for the bench! So, yes, I do not challenge the legal system anymore.)(And, how ironic the state psychiatrist in that case was the same one who gave that first forensic lecture in my residency I spoke of previously with CS.)

Have a good week, good luck with further efforts to fight this crap!

Dinah said...

Dear Joel,

I don't think you need to spending too much time worrying that I'm not in anyone's face.

As my children once agreed, "If Mom has a feeling, they know it in China."

moviedoc said...

"We need to move the terminology from "the mentally ill" to "those who are dangerous" for any reason."

That, and acknowledge that we have no good way to determine which people "are dangerous" or for how long.

Thanks for the effort Dinah.

Anonymous said...

Hi Joel -
I spent 6 years as an underage ward of the state, committed to a state psych hospital, from '72-78. Pure hell - patient deaths due to abuse/negligence, 24 hour full strait jackets and seclusion in a filthy room, mostly without MD's orders and maybe once a shift visual checks. The floors were bathrooms. Elderly patients wore donated rags or went halfnaked mostly.Shoes were rare.Many of us slept near radiators on the floor of the day rooms and curled around latrines. Anyway, I lived thru that to become a mother, nurse aide, and college graduate. I have watched, disparagingly, as psychiatrists have been demoted to scriptwriters and backseat commentators for the mentally ill. As a writer who chronicles extensively on the 'ins and outs'of living w/ MI, I could write voluminously on how one relationship with one forensic psychiatrist who being so talented at his art, that he alone became the sole instrument of my eventual healing. Besides twice weekly therapy sessions, beginning when I was a newly diagnosed teen, he involved himself in my care long after we both had moved on,(professionally of course) becoming an advocate and friend until his passing a few years ago. He saved my life. When you have a serious mental illness, and your prognosis is iffy, at best, and drugs like lithium are not in use yet, and your family is set to find you a farm, doctors such as this one - save lives. No social
worker,or half trained aide can do that. This man used all of his skill and training, the heart and soul that made him go into medicine, to help me. I am deeply saddened at what I observe in the mental health clinics, and psych hospitals of today. Maybe I was spoiled by old-fashioned psychiatrist's care at its best. But it works, saves lives, and nothing in my opinion can replace the usefulness of a patient to doctor relationship. The public may be scared of mentally ill people, but a psychiatrist who knows the illness can allay the patient's own fears, and help steer them toward hope and recovery, and answer questions that no other MH worker can. Why, after years of medical school, internships, and more school, must today's psychiatrists be made to bow to the ridulousness of capitalistic legalities? I think there may be others, like me, who miss the engaging, caring psychiatrists, that would talk w/ us for hours, and get to know us- and always left discussion on medications to the last few minutes of the session. We know you all still exist; we are sad that you're not being allowed to do your job as you'd like.
Please be encouraged, at the end of the day, everyone with serious or debilitating mental illness looks to you, the only professionals who have taken the time and care to learn about our illnesses, the same that we cannot understand without you.
I am sorry that your profession is suffering under heartless bureocrats.