Therapists Are Not Thought Police

After yet another school shooting, some conservatives  are calling for better mental health care. What they really mean is that mental health providers should be on the lookout for potential shooters & should then intervene to prevent them.

Consider this statement by the Public Defender of Broward County:

Howard Finkelstein, the chief public defender in Broward County, said in an interview that Mr. Cruz’s legal team had not yet decided whether to mount an insanity defense. Prosecutors have not said whether they will seek the death penalty, but Mr. Finkelstein argued that Mr. Cruz should not be a candidate for execution, given his mental health history.

“Every red flag was there and nobody did anything,” Mr. Finkelstein said. “When we let one of our children fall off grid, when they are screaming for help in every way, do we have the right to kill them when we could have stopped it?”

Of course people with mental illness should have access to care! It is a tragedy and a travesty that the criminal justice system should be the gateway to mental health for so many. It’s tragic that Nikolas Cruz should have had the record of problems and troubles he had, but received little or no help. At the same time, however, it is completely unreasonable to expect that mental health providers should be the ones charged with ensuring public safety.

There are a lot of problems with this. The first one is exemplified in the story of a Sacramento area woman who experienced involuntary detention for ten hours even after saying she had no intention to harm herself or anyone else. This was under the existing system in California, which permits certain people in health care and law enforcement to send people to a mental hospital for up to 72 hours against their will (5150). In fact, even when someone isn’t held for three days, the system may take hours to determine that the person doesn’t need to be held.

Patients with psychiatric disabilities took to Cape Town's streets to protest for better health care. Pic by Yazeed Kamaldien

Another problem with this is that, at least in California, mental health professionals are already required to intervene under what is known as  the Tarasoff rule. The Wikipedia article gives the long version, but the short version is that therapists are required to notify authorities if someone makes a credible threat against an identifiable target. But who makes people seek out mental health care?

Well, in California there’s Laura’s Law, which can compel people to engage in mental health treatment, but for someone to qualify a local jurisdiction has to opt in, and then a person needs to have a history of either legal problems or mental health hospitalizations. In the most recent school shooting (and most of the others) the perpetrators would not have qualified.

But it gets worse. In the 2012 Aurora Colorado shooting, the perpetrator was under the care of a psychiatrist prior to the shooting, but apparently neglected to tell the psychiatrist what he was planning. To steal one of Joker’s lines from an old Batman comic, “I may be insane, but I’m not crazy!” People who have mental illnesses are at least as complex and intelligent as people who do not.  They may suffer greatly, but have no urge to do anything violent– to others, or to themselves. We need to remember that gun suicides are almost double gun homicides. So mental health providers are already mandated by law to be on the lookout for violence risks, and to report them.  Patients know that, and can easily choose to not disclose. I personally experienced this when a client who had declined to engage in talk therapy after being referred by his psychiatrist, who was prescribing anti-depressant medication, committed a suicide that was clearly well thought out. It’s not a good feeling for a therapist.

Laws about mental health treatment, who should get it even when they don’t want it, and what mental health providers should report, when, and to whom seem unlikely to have any effect on preventing violence by mentally ill people. Even when someone is getting treatment and on the radar, the ability to predict who really is a risk for violence doesn’t really exist, beyond the obvious fact that people who already have a history of violence are likely to go on being violent.  And then there are those pesky civil rights. You can’t lock people up for Orwellian thoughtcrime. At least not yet.

But wait– it gets worse. Or at least more complicated. I wasn’t able to quickly find a reference, but there was a story about inmates in California prisons who were on suicide watch lying about their suicidality in order to be released from suicide watch– who then killed themselves. This is perhaps different from assessing threats of violence to others, or perhaps not. My experience with mental health clients who were picked up and taken to psychiatric emergency as either a danger to self or danger to others is that when they are picked up by law enforcement, many of them calm down by the time they are transported to the hospital and are not admitted. Others are admitted, perhaps overnight, and then released. The point is, people can be mentally ill, can be very upset, but then can put on a good enough front to “pass” with the people charged with holding them, even if still very ill.

One of the things that makes people more likely to disclose socially unacceptable thoughts, feelings, and impulses to a therapist is the promise of confidentiality.  Chop giant holes in the confidentiality contract between therapist and client and all you do is guarantee the clients won’t disclose such thoughts, feelings, and most important– urges. In fact, one researcher estimates that Duty to Warn laws actually increase homicides. I am not mathematically sophisticated enough to argue with the analysis, but the premise is intuitively acceptable: if a patient is planning something that the therapist would stop, don’t tell the therapist.

 

Tarasoff reporting and other laws already create the obligation for mental health providers to look out for public safety. It would also be great if mental health care really was on a parity with other forms of health care. It would be nice, come to that, if health care of all kinds was more available to more people.  But making therapists into thought police won’t help the school shooting problem.

mental health image from https://yazkam.wordpress.com/2013/07/11/mental-health-patients-protest-for-better-services/

AR-15 image from http://www.thetruthaboutguns.com/2017/02/foghorn/best-3-entry-level-ar-15-rifles/

 

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About jamesmatter

Marriage and Family Therapist (MFT) in private practice in San Francisco. I work with adults, adolescents, and couples, with focus on substance use and abuse and co-occurring disorders (having both a mental illness and an addiction).
This entry was posted in behavioral health, mental health, Violence and tagged , , . Bookmark the permalink.

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