One of the more interesting aspects of our Accessible Psychiatry Project is that as colleagues, we don’t always agree. Sometimes we argue in person; other times by text or email, and other times we argue in more public forums: on our blogs and podcast, where we present viewpoints that are different. At times, we convince each other to see a new point of view, but sometimes we agree to disagree and move on with our work and our friendships. Having said that, please do read Anne Hanson’s post on why you shouldn’t worry about the mandates of the New York SAFE Act on doctor-patient confidentiality, published on this website a few days ago. I’ll move on to tell you why I think you should be concerned, and why I hope the APA will be a vocal objector to the portion of the Act that infringes on confidentiality and suggests that mental health professionals may be able to prevent violence.
Last Tuesday, the New York State Assembly passed the New York SAFE Act which includes a requirement that mental health professionals notify the state about any patient who represents a likely danger. The exact wording of the legislation reads, “Not withstanding any other law to the contrary, when a mental health professional currently providing treatment services to a person determines, in the exercise of reasonable professional judgment, that such person is likely to engage in conduct that would result in serious harm to self or others, he or she shall be required to report, as soon as practicable, to the director of community services, or the director’s designee, who shall report to the division of criminal justice services.”
While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the mandate to report patients to the state quite troubling. Confidentiality requirements extend to very few relationships: physicians, religious leaders, and attorneys, and it the trust in this confidentiality that makes those relationships possible. This law annilates psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into a situation where a violent act has not yet have even occurred -- it mandates government intrusions into our fantasies, and it sets a precedent to end the confidentiality that is necessary to allow for psychiatric treatment.
I’d like to point out a few things.
There are already procedures in place that address treatment of imminently dangerous people. Often, we hospitalize people when the threat is immediate, and our current mental health system has difficulty addressing the needs of those who are “imminently” dangerous, much less those who are dangerous without a given time frame. Notably, this law addresses all patients who convey they are dangerous – either suicidal or homicidal -- to a mental health professional, not just gun owners. The law does not just pertain to the “mentally ill” – whoever that may mean, given that roughly half of all people will experience an episode of mental illness during their lifetime and psychiatric patients don’t neatly divide into “us” and “them” categories. People see therapists and talk about suicide, and even homicide, for reasons that don’t originate in a psychiatric disorder. The hope might be that more funds will be funneled into both the administrative tangle of following up on all those who are identified as dangerous, reclaiming their guns, and overseeing the gun storage methods of their family members and roommates. And then, we’d certainly want increased funding to allow for treatment of those identified as dangerous, but it remains to be seen if such funding will follow these measures, especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.
This legislation was inspired by the tragic Newtown massacre, yet we’ve seen nothing in the media which indicates the shooter would have fallen into a category where he would have brought him to the attention of authorities, even if such laws were in place. We’ve heard he had an autism-spectrum illness, but no reports that he’d been violent or ever told a mental health professional that he was planning a school shooting.
The most concerning issue with such legislation, however, is that it sets in motion a barrier to getting help for those who most need it. Who would willingly seek treatment, tell their clinician their dark thoughts, knowing such thoughts will be reported to an agent of the state, one who then decides (based on what?) whether he or she should be reported to the legal authorities? Certainly no gun owner, and certainly no troubled law enforcement officer. This legislation appears to requires that those who voluntarily seek treatment because they are suicidal must be reported. It’s an interesting quandry since insurers often permit hospital admission only if a patient is imminently dangerous, meaning this could possibly extend to nearly all persons admitted to psychiatric units. Perhaps they just won’t seek help. And for someone who is delusional, this may be one more reason not to trust psychiatrists and not to get treatment. The New York SAFE Act may well have the unintended consequence of increasing suicide rates and violence, and there is no doubt that other states will follow suit with similar legislation if we don’t re-consider the quick response of New York state .
While other laws have over-ridden doctor-patient confidentiality -- for example requirements to report sexually transmitted diseases and abuse of vulnerable populations -- those laws address illnesses and acts that have already happened. These laws require clinicians to report their suspicions and beliefs about a patient’s intentions and it sets the stage to require state-mandated reporting of any number of fantasies told to a therapist. Violent ideas are very common, and mental health professionals are not particularly good at predicting who will act on them. What else might we extend reporting requirements to include? The sexual activities of patients with HIV? The financial behaviors of those running Ponzi schemes?
Is this really what we want? Interestingly, in New York, you can still tell your internist or dermatologist that you’re feeling suicidal, and that doesn’t need to be reported to the state.
Please note this article also appears on the Clinical Psychiatry News website where my colleague, Dr. Anne Hanson, expresses a different viewpoint