Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, March 28, 2013

SAFEty and The Cannibal Cop

For those who didn't follow it, the Cannibal Cop is the case of former NYPD officer Gilberto Valle, convicted on March 12th of conspiring to kidnap, rape, murder, and eat several women, including his wife, as well as illegally accessing a national crime database to research his potential victims.

The thing is, he never actually did the things he was convicted of conspiring to do. He fantasized. He plotted. He even went so far as to show up on the block of a woman he had agreed to kidnap in exchange for $5000. But he never did so. He only conspired to do so.

Am I glad he's behind bars? Yes I am. Do I believe he would have acted out his ghastly fantasies? Yes I do. Am I justified in feeling this way? Not sure.

This case begs the question: How do you differentiate between a fantasy to hurt someone, a wish to do so, the intention to do so, and the acting out of the fantasy?

This is the same question that lies at the heart of NY's SAFE act, which requires that certain mental health professionals, including psychiatrists, "Report to their local director of community services ("DCS") or his/her designees when, in their reasonable professional judgment, one of their patients is 'likely to engage in conduct that would result in serious harm to self or others.'" The information then gets forwarded to the Division of Criminal Justice Services (DCJS), who determine if the patient has a firearms license. If so, it's either suspended or revoked. If not, he gets put on a list so he can't get a firearms license.

There is so much wrong with this act, it's hard to know where to start.

The New York State Psychiatric Association (NYPSA) has taken issue with it because of its language. SAFE claims that the standard to use for determining danger is the same as for deciding whether to hospitalize a patient, or to call the police, or contact a potential victim, as in a Tarasoff situation. But this standard already exists in the law, and we know that if we think a patient is genuinely dangerous, we should do something about it. And that something shouldn't be contacting the local "DCS".

In other words, if the danger is immediate, I shouldn't be worrying about putting the patient on a no-firearms list, I should be hospitalizing him, or calling the police, or the potential victim. And if the danger is not immediate, how am I supposed to know if it's serious and real? It's like that Tom Cruise movie with the "precogs" who predict future crime.

I consider it my job to recognize patterns of thinking and behavior in my patients, and to point these out to them, so they can use that information to their benefit. But that doesn't mean I know what they're going to do down the line. And SAFE is asking me, no requiring me, to point out that information to a government agency, to be used to the patient's detriment.

Sure, there might be some clear cut cases. Shrink Rap mentioned the hypothetical case of a patient who tells her he's hanging around with his Al Qaeda buddies and taking flying lessons (sorry, I couldn't find the exact post). Okay. I can see that. But most of the time it's not gonna be that clear.

And what population are we talking about? Acutely hospitalized psych patients? Prisoners with co-morbid psychiatric diagnoses? Psychopaths? Neurotic outpatients? Dual diagnosis patients? These are very different groups.

I could understand if it were someone else's responsibility to report the patient. Say, the ER, after I've sent the patient there for evaluation, because I think he may hurt himself. Or the inpatient unit if he's admitted. Or the police, if I contact them because I think he's going to hurt someone besides himself. At that point, the immediate danger has been addressed, and then there's time to think about how dangerous this person is likely to be in the long run.

Okay, so let's assume, for the sake of argument, that I know for sure that my patient is going to do something dangerous down the line. And I report him the way I'm supposed to. And he loses his right to bear arms. He still hasn't lost his right to walk into Williams-Sonoma and buy himself a nice, big, sharp Santoku knife. Or to mosey into Costco and buy himself two giant bottles of tylenol.

Why create useless legislation? Oh, yeah, because they're politicians running for office.

Another BIG problem with SAFE is the issue of confidentiality and how it affects trust. Patients sometimes have thoughts about hurting themselves. If you've known your patient for a while, you can usually tell how serious a threat it is. If you don't know the patient, then you really can't tell, and you're now in the position of revealing something significant about her to the government, something that will affect her civil liberties for the rest of her life.

Will someone who needs psychiatric care hesitate to get it because of this possibility? I'm guessing yes. But then, of course, I can't predict the future.