Gun Violence & Mental Health in Maryland

by Michael Reeder on February 3, 2013

There are several scary laws being considered or implemented around the country regarding the rights of the mentally ill.  This is true even in Maryland.

This is one of those issues I frankly think I should not post on if I was merely blogging for marketing purposes.  Well — nope — I’m sometimes going to go scary places.  A combination of public service and getting on my soap box if you like.

I hesitate to even use the term “mentally ill” here because it makes clients seem like a permanent class of the downtrodden.  When such is true (like people on long-term disability for serious mental illness) I support their rights.  But “mentally ill” in the context of this conversation also refers to people who are temporarily depressed for 3 months or so and see a therapist.  In other words — you, I, and every other person on earth will get a bit of “mental illness” now and then (depression is like the common cold of mental health).

Various laws and proposals around the country seek to mandate that therapists report dangerous persons to the police so that their access to guns can be taken away.  Other laws and proposals seek to make it easier to involuntarily commit persons who may be or become dangerous.  Still other laws seek to mandate through the courts who must take psychiatric medication.  These laws are popping up all over the United States in state capitals everywhere in response to recent high profile shootings.

It’s hard to oppose several of these laws that, on the face of it, seem good ideas.  Especially with piles of dead children in the news.  Who wants to let children be hurt?

In Maryland the Baltimore Sun had a January 28th article concerning a meeting mental health professionals had with the state mental hygiene administration and police officials to urge them NOT to adopt recent official task force recommendations that all mental health providers be required to report all suicide threats to the police.

**Again — Mandate to report all suicide threats to the police.**

The police might then take their guns and do who knows what else with that data.  What depressed person in their right (or wrong) mind would ever, ever risk seeing a therapist?  Down at the bottom of the article is some verbiage that one of the governor’s advisers did not agree with that mandate and also that not all task force members were in agreement with each other. Good. Does that mean we don’t have to worry?

One of my colleagues informs me that New Jersey is considering a law in which judges can mandate that outpatient clients take their psychiatric medications or else be committed.  (Gov. Christie commits to ‘fully implementing’ mental health treatment law)

The recently enacted New York law is the one that has gotten the most press.  It mandates mental health professionals to report potentially violent clients to be added to a database for gun restrictions.

See:

http://www.theithacajournal.com/article/20130116/NEWS10/301160086/NY-gun-law-s-mental-health-provisions-draw-concerns?nclick_check=1

http://www.npr.org/blogs/health/2013/01/17/169529792/mental-health-gun-laws-unlikely-to-reduce-shootings

In all of these scenarios I can see instances where common sense and my own civic obligation would leave me wanting to report extreme cases.  A client reporting command hallucinations to kill someone.  Perhaps the heart-breaking cases where the client is not quite dangerous enough to self or others to be involuntarily committed or ordered onto medication under today’s laws — but is slowly wasting away, wandering the streets, and we all know they are going to get hurt or killed in a few months to a few years.  I don’t begrudge reporting the truly and clearly homicidal — this just needs careful and narrow implementation.  In fact, when someone is clearly a danger to self or others there are already reporting laws in place to handle these things!

As usual, the devil is in the details.  Or perhaps lack thereof.  Most news reports (and some of the laws) totally lack specifics on what these terms mean.  What does “potentially violent” in New York mean?  Does that mean someone expressing homicidal intent, or does that cover just about any anger management client who walks in the door?  In Maryland, just how “suicidal” would a client need to be?  I can tell you that nearly every average depressed client on the planet has had some passing thoughts of suicide.  In New Jersey, who gets ordered onto involuntary psych meds?

The further rights of clients and therapists need to be addressed in these laws.  How does a client get out of a database once they are feeling better?  How do they fight an incorrect report by a mistaken mental health professional?  What else besides denial of gun access could that database be used for — job background checks, loan applications?  Therapists too need some protections.  Can the therapist be sued for making a good faith report?  If a routine (not especially dangerous seeming) anger management client shoots his wife five years later, does the former therapist automatically get named in a lawsuit for not reporting him?

I hope there are some sensible brackets around how such laws are interpreted and implemented.  I hope we don’t have to wait for years of court cases to work out the details of vague laws.

There are some potentially HUGE problems with the impact of such laws:

1. They can increase stigma and encourage people to NOT to seek help.

2. Mental health professionals don’t have an exact way of really figuring out who will be violent.  These laws set up an expectation that therapists should be able to stop such events.

3. They turn mental health professionals into distrusted narcs. Similarly, they change the expectation of mental health professionals from helpers to guardians.

4. How broadly are we talking? If I see, say, an anger management client, at what point am I supposed to report from an abundance of caution?

5. What is the lawsuit potential? I think this problem has not been discussed in the media yet, in part, because no one wants to sound petty with the lives of children supposedly at stake.  I can easily envision situations in which therapists get sued for both reporting and not reporting.  This matters — to clients — because it effects your outcomes and therapeutic relationships.  If the main lawsuit danger to clinics is in NOT reporting, then there becomes an incentive to report at the drop of a hat.  When clinics become distrusted by clients for this, yet another healing avenue is cut off and the pharmaceutical industry gains yet another advantage in medicating problems instead of solving them.

6. The potential to further divide our mental health system into two tiers for the rich and the poor.

Number 6 above needs some explaining.   IMHO public mental health clinics are the clinics most likely to reflexively report to police as a CYA if not reporting carries high potential penalties. They are filled with newbie therapists (whose judgement is carefully controlled), they get some of the sickest clients, and their payment depends upon sufficiently severe medical diagnoses (unlike cash out-of-pocket therapists).  Their low-income, frequently more ill, clients will be in far less of a position to fight any injustices.  If the clients are on disability, they may need to keep attending their clinics to keep their disability.  So imagine a low-income, poorly-educated client — who needs to attend therapy for both mental health and keeping state benefits — trying to get a second opinion, refuse court-ordered medications, or fight his/her way out of a database of potentially violent/suicidal/whatever persons?  Lots of luck.  Throw in liberal use of court-ordered medications and a whole new forced medication market is born.

Meanwhile the rich and the smart will pay out-of-pocket for therapy without clearly reported medical diagnoses, just get medications without therapy (to avoid saying anything damaging), or find a creative alternative treatment modality not covered by mandated reporting.

It is critically important that we stay on top of the laws currently being proposed in Maryland and around the country.  They run the risks of driving people from the very therapeutic help they need,  creating an underclass of people in police databases who may or may not be able to clear their names, and/or creating an underclass of people stuck in legally-mandated treatment that may not be best for them.  We need to be very, very careful in the implementation of any new laws as we seek the worthy goals of fewer shootings and better mental health response to those in crisis.

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