Shrink Rap News

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Recently, my local newspaper featured a story by Julie Scharper entitled "What I found in the sensory-deprivation chamber" (Baltimore Sun, Jan. 11, 2014) about a new local business known as a flotation spa, a trend currently spreading across the East Coast. For $50 an hour (or $70 for 90 minutes), the customer is escorted to a dark and quiet room, where she floats nude in a body-temperature pool of Epsom salts.

In this environment, the client reportedly enters a "drug-free altered state" intended to soothe aches and tension, as well as ease sleep problems. The author described her experience in the pool, during which she had a vivid daydream of a woman playing a red piano. Soon, a new idea for a children’s book sprang into her mind, and she left the session relaxed and filled with creative energy.

A while ago I reviewed some of the old research about sensory deprivation. Psychologists and psychiatrists began studying this topic following the Korean War, when the Central Intelligence Agency and the Department of Defense wanted to learn more about conditions that would make people more susceptible to brainwashing. They placed people in baths of water while covering their eyes and ears, and encased their limbs in protective coverings to minimize tactile input. The subjects were then interviewed about their experiences and were monitored through EEGs. They reported many disturbances, such as alterations in concentration and attention, illusions, anxiety and panic, and perceptual disturbances inaccurately described as hallucinations.

All of these symptoms resolved spontaneously after the subjects were removed from the deprivation chamber. This amorphous constellation of sensations was later given the label "special housing unit" (SHU) syndrome when it occurred in prisoners held in long-term segregation. One longstanding opponent of long-term segregation, who also frequently appeared as an expert in suits against control unit prisons, referred to sensory deprivation as "toxic" to brain functioning and a cause of stupor and delirium in segregated prisoners.

Critics of this theory, and I count myself among them, point out that current control unit conditions are hardly anything like a sensory deprivation chamber. Although segregation is less noisy and stimulating than a general population tier, it is hardly without distractions. Segregated inmates still have access to mail and recreation if they are not segregated for disciplinary reasons. They have contact with other people, although not always other inmates. Most facilities do regular rounds to check on prisoners in segregated tiers, and confined inmates can still have access to psychiatric services. In contrast to the SHU syndrome proponents, I rarely see psychological deterioration in segregated prisoners. There are even inmates who request segregated confinement specifically because it is less stimulating than general population.

So what makes sensory deprivation "cruel and unusual" to some but a source of energy and relaxation to others?

Expectation counts for a lot. Inmates placed in disciplinary segregation are not happy to be there – they are cut off from visits and ready access to the telephone, as well as certain personal property like a radio or television if they had one. A disciplinary segregation inmate enters the cell with the expectation that the experience will be punishment. In contrast, a flotation spa client is prepared for the experience by being told what positive experiences to expect and that these positive effects will carry over after the spa session ends.

Similarly, when I interview prisoners, I find that the most successful ones are those who are able to shift their own individual mindsets from an expectation of punishment to one of anticipated opportunity. The punishment mindset ("I’m here for no reason, so I’m going to spend my time complaining") is a hefty barrier to rehabilitation. An inmate who is able to accept the reality of his confinement and his responsibility for it ("I put myself here, so I better make my time work for me") will find ways to adapt psychologically, regardless of sentence length.

Reading about flotation spas brought on a weird sense of deja vu for me, but it also was a useful reminder of the effects of expectation and outlook for managing many life experiences.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, my local newspaper featured a story by Julie Scharper entitled "What I found in the sensory-deprivation chamber" (Baltimore Sun, Jan. 11, 2014) about a new local business known as a flotation spa, a trend currently spreading across the East Coast. For $50 an hour (or $70 for 90 minutes), the customer is escorted to a dark and quiet room, where she floats nude in a body-temperature pool of Epsom salts.

In this environment, the client reportedly enters a "drug-free altered state" intended to soothe aches and tension, as well as ease sleep problems. The author described her experience in the pool, during which she had a vivid daydream of a woman playing a red piano. Soon, a new idea for a children’s book sprang into her mind, and she left the session relaxed and filled with creative energy.

A while ago I reviewed some of the old research about sensory deprivation. Psychologists and psychiatrists began studying this topic following the Korean War, when the Central Intelligence Agency and the Department of Defense wanted to learn more about conditions that would make people more susceptible to brainwashing. They placed people in baths of water while covering their eyes and ears, and encased their limbs in protective coverings to minimize tactile input. The subjects were then interviewed about their experiences and were monitored through EEGs. They reported many disturbances, such as alterations in concentration and attention, illusions, anxiety and panic, and perceptual disturbances inaccurately described as hallucinations.

All of these symptoms resolved spontaneously after the subjects were removed from the deprivation chamber. This amorphous constellation of sensations was later given the label "special housing unit" (SHU) syndrome when it occurred in prisoners held in long-term segregation. One longstanding opponent of long-term segregation, who also frequently appeared as an expert in suits against control unit prisons, referred to sensory deprivation as "toxic" to brain functioning and a cause of stupor and delirium in segregated prisoners.

Critics of this theory, and I count myself among them, point out that current control unit conditions are hardly anything like a sensory deprivation chamber. Although segregation is less noisy and stimulating than a general population tier, it is hardly without distractions. Segregated inmates still have access to mail and recreation if they are not segregated for disciplinary reasons. They have contact with other people, although not always other inmates. Most facilities do regular rounds to check on prisoners in segregated tiers, and confined inmates can still have access to psychiatric services. In contrast to the SHU syndrome proponents, I rarely see psychological deterioration in segregated prisoners. There are even inmates who request segregated confinement specifically because it is less stimulating than general population.

So what makes sensory deprivation "cruel and unusual" to some but a source of energy and relaxation to others?

Expectation counts for a lot. Inmates placed in disciplinary segregation are not happy to be there – they are cut off from visits and ready access to the telephone, as well as certain personal property like a radio or television if they had one. A disciplinary segregation inmate enters the cell with the expectation that the experience will be punishment. In contrast, a flotation spa client is prepared for the experience by being told what positive experiences to expect and that these positive effects will carry over after the spa session ends.

Similarly, when I interview prisoners, I find that the most successful ones are those who are able to shift their own individual mindsets from an expectation of punishment to one of anticipated opportunity. The punishment mindset ("I’m here for no reason, so I’m going to spend my time complaining") is a hefty barrier to rehabilitation. An inmate who is able to accept the reality of his confinement and his responsibility for it ("I put myself here, so I better make my time work for me") will find ways to adapt psychologically, regardless of sentence length.

Reading about flotation spas brought on a weird sense of deja vu for me, but it also was a useful reminder of the effects of expectation and outlook for managing many life experiences.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, my local newspaper featured a story by Julie Scharper entitled "What I found in the sensory-deprivation chamber" (Baltimore Sun, Jan. 11, 2014) about a new local business known as a flotation spa, a trend currently spreading across the East Coast. For $50 an hour (or $70 for 90 minutes), the customer is escorted to a dark and quiet room, where she floats nude in a body-temperature pool of Epsom salts.

In this environment, the client reportedly enters a "drug-free altered state" intended to soothe aches and tension, as well as ease sleep problems. The author described her experience in the pool, during which she had a vivid daydream of a woman playing a red piano. Soon, a new idea for a children’s book sprang into her mind, and she left the session relaxed and filled with creative energy.

A while ago I reviewed some of the old research about sensory deprivation. Psychologists and psychiatrists began studying this topic following the Korean War, when the Central Intelligence Agency and the Department of Defense wanted to learn more about conditions that would make people more susceptible to brainwashing. They placed people in baths of water while covering their eyes and ears, and encased their limbs in protective coverings to minimize tactile input. The subjects were then interviewed about their experiences and were monitored through EEGs. They reported many disturbances, such as alterations in concentration and attention, illusions, anxiety and panic, and perceptual disturbances inaccurately described as hallucinations.

All of these symptoms resolved spontaneously after the subjects were removed from the deprivation chamber. This amorphous constellation of sensations was later given the label "special housing unit" (SHU) syndrome when it occurred in prisoners held in long-term segregation. One longstanding opponent of long-term segregation, who also frequently appeared as an expert in suits against control unit prisons, referred to sensory deprivation as "toxic" to brain functioning and a cause of stupor and delirium in segregated prisoners.

Critics of this theory, and I count myself among them, point out that current control unit conditions are hardly anything like a sensory deprivation chamber. Although segregation is less noisy and stimulating than a general population tier, it is hardly without distractions. Segregated inmates still have access to mail and recreation if they are not segregated for disciplinary reasons. They have contact with other people, although not always other inmates. Most facilities do regular rounds to check on prisoners in segregated tiers, and confined inmates can still have access to psychiatric services. In contrast to the SHU syndrome proponents, I rarely see psychological deterioration in segregated prisoners. There are even inmates who request segregated confinement specifically because it is less stimulating than general population.

So what makes sensory deprivation "cruel and unusual" to some but a source of energy and relaxation to others?

Expectation counts for a lot. Inmates placed in disciplinary segregation are not happy to be there – they are cut off from visits and ready access to the telephone, as well as certain personal property like a radio or television if they had one. A disciplinary segregation inmate enters the cell with the expectation that the experience will be punishment. In contrast, a flotation spa client is prepared for the experience by being told what positive experiences to expect and that these positive effects will carry over after the spa session ends.

Similarly, when I interview prisoners, I find that the most successful ones are those who are able to shift their own individual mindsets from an expectation of punishment to one of anticipated opportunity. The punishment mindset ("I’m here for no reason, so I’m going to spend my time complaining") is a hefty barrier to rehabilitation. An inmate who is able to accept the reality of his confinement and his responsibility for it ("I put myself here, so I better make my time work for me") will find ways to adapt psychologically, regardless of sentence length.

Reading about flotation spas brought on a weird sense of deja vu for me, but it also was a useful reminder of the effects of expectation and outlook for managing many life experiences.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

In a recent blog post, Scott Adams, cartoonist and creator of the popular Dilbert comic strip, talked about his dying father. At the age of 86, his father’s mind was mostly gone and his physical lifespan tenuous. His estate was paying $8,000 a month to provide essentially custodial health care. While the details of his father’s condition were never revealed, Mr. Adams’ grief was undisguised. His anger at his father’s prolonged suffering was raw and unfiltered.

Entitled "I Hope My Father Dies Soon," his blog post excoriated anyone opposed to the idea of physician-assisted suicide:

"If you’re a politician who has ever voted against doctor-assisted suicide, or you would vote against it in the future, I hate your [expletive deleted] guts and I would like you to die a long, horrible death. I would be happy to kill you personally and watch you bleed out. I won’t do that, because I fear the consequences. But I’d enjoy it, because you [expletive deleted] are responsible for torturing my father."

He blamed the government for making his father suffer by taking away the option of physician-assisted suicide.

Hours after the post was published, his father died. Hundreds of readers wrote in to offer condolences and support, and there were more than 5,000 votes on the comments that followed, most in favor of physician-assisted suicide. Many castigated the medical profession and hospitals in general for prolonging suffering at great financial expense, and boiled the issue down to one of mere greed. While I didn’t get through all of the comments, none of comments I read were from people who identified themselves as physicians.

There were a lot of unanswered questions behind this post: Why there was no living will or advance directive, no specifics about who had decision-making authority in the family, and what role (if any) palliative care had in the case or if pain control was an issue. In situations like this, sometimes legal decision-making authority is only part of the picture and end-of-life care gets complicated by family dynamics, financial, or religious concerns.

During the training year, my forensic program addresses state statutes and cases related to advance directives, the right to refuse medical care, and assisted suicide. We talk about the right to privacy and personal autonomy, as well as the potential abuse of assisted suicide. We talk about cases like Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo. We cover the Supreme Court cases that address constitutional issues related to euthanasia, and the legal reasoning behind historical prohibitions against suicide.

Presently only two states, Oregon and Washington, allow physicians to administer lethal medications to patients. Two state appellate courts have found that a law banning discussion of suicide methods was an unconstitutional restriction of free speech. In my state, it is a misdemeanor criminal offense to knowingly provide the means to commit suicide, and as recently as last spring, one local circuit court criminally prosecuted someone for this.

Recently the New England Journal of Medicine sponsored an online opinion survey about the issue. Readers from 74 countries weighed in, and two-thirds were opposed to the practice. Among American states, only 18 voted in favor of permitting it.

Surveys and case law do little to capture how painfully personal end-of-life decisions are. As Mr. Adams’ post illustrates, all of these intellectual discussions feel sterile when confronted with the real, acute misery of a suffering family. The next time this topic comes up in our training year, I’m going to include his post as suggested reading.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In a recent blog post, Scott Adams, cartoonist and creator of the popular Dilbert comic strip, talked about his dying father. At the age of 86, his father’s mind was mostly gone and his physical lifespan tenuous. His estate was paying $8,000 a month to provide essentially custodial health care. While the details of his father’s condition were never revealed, Mr. Adams’ grief was undisguised. His anger at his father’s prolonged suffering was raw and unfiltered.

Entitled "I Hope My Father Dies Soon," his blog post excoriated anyone opposed to the idea of physician-assisted suicide:

"If you’re a politician who has ever voted against doctor-assisted suicide, or you would vote against it in the future, I hate your [expletive deleted] guts and I would like you to die a long, horrible death. I would be happy to kill you personally and watch you bleed out. I won’t do that, because I fear the consequences. But I’d enjoy it, because you [expletive deleted] are responsible for torturing my father."

He blamed the government for making his father suffer by taking away the option of physician-assisted suicide.

Hours after the post was published, his father died. Hundreds of readers wrote in to offer condolences and support, and there were more than 5,000 votes on the comments that followed, most in favor of physician-assisted suicide. Many castigated the medical profession and hospitals in general for prolonging suffering at great financial expense, and boiled the issue down to one of mere greed. While I didn’t get through all of the comments, none of comments I read were from people who identified themselves as physicians.

There were a lot of unanswered questions behind this post: Why there was no living will or advance directive, no specifics about who had decision-making authority in the family, and what role (if any) palliative care had in the case or if pain control was an issue. In situations like this, sometimes legal decision-making authority is only part of the picture and end-of-life care gets complicated by family dynamics, financial, or religious concerns.

During the training year, my forensic program addresses state statutes and cases related to advance directives, the right to refuse medical care, and assisted suicide. We talk about the right to privacy and personal autonomy, as well as the potential abuse of assisted suicide. We talk about cases like Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo. We cover the Supreme Court cases that address constitutional issues related to euthanasia, and the legal reasoning behind historical prohibitions against suicide.

Presently only two states, Oregon and Washington, allow physicians to administer lethal medications to patients. Two state appellate courts have found that a law banning discussion of suicide methods was an unconstitutional restriction of free speech. In my state, it is a misdemeanor criminal offense to knowingly provide the means to commit suicide, and as recently as last spring, one local circuit court criminally prosecuted someone for this.

Recently the New England Journal of Medicine sponsored an online opinion survey about the issue. Readers from 74 countries weighed in, and two-thirds were opposed to the practice. Among American states, only 18 voted in favor of permitting it.

Surveys and case law do little to capture how painfully personal end-of-life decisions are. As Mr. Adams’ post illustrates, all of these intellectual discussions feel sterile when confronted with the real, acute misery of a suffering family. The next time this topic comes up in our training year, I’m going to include his post as suggested reading.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In a recent blog post, Scott Adams, cartoonist and creator of the popular Dilbert comic strip, talked about his dying father. At the age of 86, his father’s mind was mostly gone and his physical lifespan tenuous. His estate was paying $8,000 a month to provide essentially custodial health care. While the details of his father’s condition were never revealed, Mr. Adams’ grief was undisguised. His anger at his father’s prolonged suffering was raw and unfiltered.

Entitled "I Hope My Father Dies Soon," his blog post excoriated anyone opposed to the idea of physician-assisted suicide:

"If you’re a politician who has ever voted against doctor-assisted suicide, or you would vote against it in the future, I hate your [expletive deleted] guts and I would like you to die a long, horrible death. I would be happy to kill you personally and watch you bleed out. I won’t do that, because I fear the consequences. But I’d enjoy it, because you [expletive deleted] are responsible for torturing my father."

He blamed the government for making his father suffer by taking away the option of physician-assisted suicide.

Hours after the post was published, his father died. Hundreds of readers wrote in to offer condolences and support, and there were more than 5,000 votes on the comments that followed, most in favor of physician-assisted suicide. Many castigated the medical profession and hospitals in general for prolonging suffering at great financial expense, and boiled the issue down to one of mere greed. While I didn’t get through all of the comments, none of comments I read were from people who identified themselves as physicians.

There were a lot of unanswered questions behind this post: Why there was no living will or advance directive, no specifics about who had decision-making authority in the family, and what role (if any) palliative care had in the case or if pain control was an issue. In situations like this, sometimes legal decision-making authority is only part of the picture and end-of-life care gets complicated by family dynamics, financial, or religious concerns.

During the training year, my forensic program addresses state statutes and cases related to advance directives, the right to refuse medical care, and assisted suicide. We talk about the right to privacy and personal autonomy, as well as the potential abuse of assisted suicide. We talk about cases like Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo. We cover the Supreme Court cases that address constitutional issues related to euthanasia, and the legal reasoning behind historical prohibitions against suicide.

Presently only two states, Oregon and Washington, allow physicians to administer lethal medications to patients. Two state appellate courts have found that a law banning discussion of suicide methods was an unconstitutional restriction of free speech. In my state, it is a misdemeanor criminal offense to knowingly provide the means to commit suicide, and as recently as last spring, one local circuit court criminally prosecuted someone for this.

Recently the New England Journal of Medicine sponsored an online opinion survey about the issue. Readers from 74 countries weighed in, and two-thirds were opposed to the practice. Among American states, only 18 voted in favor of permitting it.

Surveys and case law do little to capture how painfully personal end-of-life decisions are. As Mr. Adams’ post illustrates, all of these intellectual discussions feel sterile when confronted with the real, acute misery of a suffering family. The next time this topic comes up in our training year, I’m going to include his post as suggested reading.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

cpnews@frontlinemedcom.com

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

cpnews@frontlinemedcom.com

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

cpnews@frontlinemedcom.com

Lately, I’ve been immersing myself in the complex and convoluted world of immigration law. I’ve spoken to law professors and immigration lawyers about this because there were many aspects that didn’t seem to make sense to me, and I figured I just didn’t understand it. After talking with the professionals, I realized I understood it just fine. The laws just didn’t make sense. The adjective that I frequently heard in reference to immigration law was "the Wild West" – an area so new and unsettled that nobody really knew how the process was supposed to work, particularly as applied to mentally ill immigrants facing deportation.

The fun aspect to learning a new area of law is that you get to see fundamental issues challenged and established for the first time, kind of like watching a man land on the moon or the launch of the first space shuttle. The disturbing aspect of it is that real people and real human lives are being disrupted and abused in the process.

Which leads me to the story of José Franco-Gonzales.

José Franco-Gonzales was petitioned for deportation (also known as "removal") after spending a year in the California correctional system. Upon release, he was taken into custody by Immigrations and Customs Enforcement (ICE) and transferred to an immigration detention center, a civil facility housing people facing deportation who haven’t yet had a deportation hearing. (See a video about José here.)

Franco-Gonzales was moderately cognitively impaired and did not have sufficient English skills to defend himself in court. When a psychiatrist opined that he was incompetent to participate in a deportation hearing, the immigration judge administratively closed the case, leaving the man in a legal limbo. He was forgotten – legally and literally – and held in an ICE facility for 4 years, in spite of the fact that he had already served time for his crime and had no new criminal charges pending. Eventually, an American Civil Liberties Union lawyer happened to stumble over his case and filed a habeas corpus petition on his behalf.

He was released in 2010, and his case was combined with others to form a class action suit against the Department of Homeland Security on behalf of all mentally ill, unrepresented detainees in Washington, California, and Oregon. The suit was brought by the ACLU and several other legal advocacy organizations. The suit sought to require qualified legal representation for the incompetent detainees and to allow them to have a bond hearing after 6 months of detention. This past April, the California district court agreed that this was necessary and ordered the government to put these protections in place.

This order hasn’t been challenged or appealed by the government, which is now scrambling to allocate funds and resources to provide low-cost or pro bono counsel and to locate psychiatrists willing to do competency assessments. While this order applies only to the states involved in the case, it is likely that this will soon become the law of the land once other cases are brought elsewhere. In 2011, there were 429,000 immigration detainees in 250 ICE facilities across the country and 15% of them had a mental disability. More than half of those had no legal representation.

I know that few psychiatrists reading this article will have any interest in the law generally or immigration law in particular. I think it is important for psychiatrists to know about this situation, because it’s pretty likely that at any point in time any doctor reading this article could have an undocumented immigrant on his inpatient unit. In that case, an inpatient service could be served with something called an immigration detainer, in other words, a notice from ICE that the patient is being petitioned for removal. The detainer is a request to hold the patient until he or she can be taken into custody by ICE.

Inpatient psychiatrists should be aware that this detainer is not binding. It is a merely an unenforceable request, not a court order, and it doesn’t bar a patient discharge. If the patient is seriously mentally ill, discharging the patient into the custody of ICE could mean that you are sending the patient out of state to an immigration detention center far away from his family, without a lawyer or right to a hearing, indefinitely. You don’t need to care about immigration law to know that would be a bad thing.

If a mentally ill inpatient is taken into custody, the patient’s family can be advised that the Executive Office for Immigration Review maintains a state-by-state list of pro bono legal service providers.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Lately, I’ve been immersing myself in the complex and convoluted world of immigration law. I’ve spoken to law professors and immigration lawyers about this because there were many aspects that didn’t seem to make sense to me, and I figured I just didn’t understand it. After talking with the professionals, I realized I understood it just fine. The laws just didn’t make sense. The adjective that I frequently heard in reference to immigration law was "the Wild West" – an area so new and unsettled that nobody really knew how the process was supposed to work, particularly as applied to mentally ill immigrants facing deportation.

The fun aspect to learning a new area of law is that you get to see fundamental issues challenged and established for the first time, kind of like watching a man land on the moon or the launch of the first space shuttle. The disturbing aspect of it is that real people and real human lives are being disrupted and abused in the process.

Which leads me to the story of José Franco-Gonzales.

José Franco-Gonzales was petitioned for deportation (also known as "removal") after spending a year in the California correctional system. Upon release, he was taken into custody by Immigrations and Customs Enforcement (ICE) and transferred to an immigration detention center, a civil facility housing people facing deportation who haven’t yet had a deportation hearing. (See a video about José here.)

Franco-Gonzales was moderately cognitively impaired and did not have sufficient English skills to defend himself in court. When a psychiatrist opined that he was incompetent to participate in a deportation hearing, the immigration judge administratively closed the case, leaving the man in a legal limbo. He was forgotten – legally and literally – and held in an ICE facility for 4 years, in spite of the fact that he had already served time for his crime and had no new criminal charges pending. Eventually, an American Civil Liberties Union lawyer happened to stumble over his case and filed a habeas corpus petition on his behalf.

He was released in 2010, and his case was combined with others to form a class action suit against the Department of Homeland Security on behalf of all mentally ill, unrepresented detainees in Washington, California, and Oregon. The suit was brought by the ACLU and several other legal advocacy organizations. The suit sought to require qualified legal representation for the incompetent detainees and to allow them to have a bond hearing after 6 months of detention. This past April, the California district court agreed that this was necessary and ordered the government to put these protections in place.

This order hasn’t been challenged or appealed by the government, which is now scrambling to allocate funds and resources to provide low-cost or pro bono counsel and to locate psychiatrists willing to do competency assessments. While this order applies only to the states involved in the case, it is likely that this will soon become the law of the land once other cases are brought elsewhere. In 2011, there were 429,000 immigration detainees in 250 ICE facilities across the country and 15% of them had a mental disability. More than half of those had no legal representation.

I know that few psychiatrists reading this article will have any interest in the law generally or immigration law in particular. I think it is important for psychiatrists to know about this situation, because it’s pretty likely that at any point in time any doctor reading this article could have an undocumented immigrant on his inpatient unit. In that case, an inpatient service could be served with something called an immigration detainer, in other words, a notice from ICE that the patient is being petitioned for removal. The detainer is a request to hold the patient until he or she can be taken into custody by ICE.

Inpatient psychiatrists should be aware that this detainer is not binding. It is a merely an unenforceable request, not a court order, and it doesn’t bar a patient discharge. If the patient is seriously mentally ill, discharging the patient into the custody of ICE could mean that you are sending the patient out of state to an immigration detention center far away from his family, without a lawyer or right to a hearing, indefinitely. You don’t need to care about immigration law to know that would be a bad thing.

If a mentally ill inpatient is taken into custody, the patient’s family can be advised that the Executive Office for Immigration Review maintains a state-by-state list of pro bono legal service providers.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Lately, I’ve been immersing myself in the complex and convoluted world of immigration law. I’ve spoken to law professors and immigration lawyers about this because there were many aspects that didn’t seem to make sense to me, and I figured I just didn’t understand it. After talking with the professionals, I realized I understood it just fine. The laws just didn’t make sense. The adjective that I frequently heard in reference to immigration law was "the Wild West" – an area so new and unsettled that nobody really knew how the process was supposed to work, particularly as applied to mentally ill immigrants facing deportation.

The fun aspect to learning a new area of law is that you get to see fundamental issues challenged and established for the first time, kind of like watching a man land on the moon or the launch of the first space shuttle. The disturbing aspect of it is that real people and real human lives are being disrupted and abused in the process.

Which leads me to the story of José Franco-Gonzales.

José Franco-Gonzales was petitioned for deportation (also known as "removal") after spending a year in the California correctional system. Upon release, he was taken into custody by Immigrations and Customs Enforcement (ICE) and transferred to an immigration detention center, a civil facility housing people facing deportation who haven’t yet had a deportation hearing. (See a video about José here.)

Franco-Gonzales was moderately cognitively impaired and did not have sufficient English skills to defend himself in court. When a psychiatrist opined that he was incompetent to participate in a deportation hearing, the immigration judge administratively closed the case, leaving the man in a legal limbo. He was forgotten – legally and literally – and held in an ICE facility for 4 years, in spite of the fact that he had already served time for his crime and had no new criminal charges pending. Eventually, an American Civil Liberties Union lawyer happened to stumble over his case and filed a habeas corpus petition on his behalf.

He was released in 2010, and his case was combined with others to form a class action suit against the Department of Homeland Security on behalf of all mentally ill, unrepresented detainees in Washington, California, and Oregon. The suit was brought by the ACLU and several other legal advocacy organizations. The suit sought to require qualified legal representation for the incompetent detainees and to allow them to have a bond hearing after 6 months of detention. This past April, the California district court agreed that this was necessary and ordered the government to put these protections in place.

This order hasn’t been challenged or appealed by the government, which is now scrambling to allocate funds and resources to provide low-cost or pro bono counsel and to locate psychiatrists willing to do competency assessments. While this order applies only to the states involved in the case, it is likely that this will soon become the law of the land once other cases are brought elsewhere. In 2011, there were 429,000 immigration detainees in 250 ICE facilities across the country and 15% of them had a mental disability. More than half of those had no legal representation.

I know that few psychiatrists reading this article will have any interest in the law generally or immigration law in particular. I think it is important for psychiatrists to know about this situation, because it’s pretty likely that at any point in time any doctor reading this article could have an undocumented immigrant on his inpatient unit. In that case, an inpatient service could be served with something called an immigration detainer, in other words, a notice from ICE that the patient is being petitioned for removal. The detainer is a request to hold the patient until he or she can be taken into custody by ICE.

Inpatient psychiatrists should be aware that this detainer is not binding. It is a merely an unenforceable request, not a court order, and it doesn’t bar a patient discharge. If the patient is seriously mentally ill, discharging the patient into the custody of ICE could mean that you are sending the patient out of state to an immigration detention center far away from his family, without a lawyer or right to a hearing, indefinitely. You don’t need to care about immigration law to know that would be a bad thing.

If a mentally ill inpatient is taken into custody, the patient’s family can be advised that the Executive Office for Immigration Review maintains a state-by-state list of pro bono legal service providers.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Recently, I received a phone call from a local homicide detective. He was investigating the death of a child, and the suspect in the case was a 19-year-old woman who was also a caretaker. She had a history of psychiatric problems, and family members implicated her in the death of another child. The detective expressed concern about a potential future risk to other children in the home, and he wanted help with his investigation.

While speaking to a detective can be a routine part of forensic work, this is usually done in the context of a larger pretrial evaluation after someone is charged with a crime. Psychiatry residents looking for a career in forensic psychiatry, as well as some members of the general public, sometimes think of forensic work as being a CSI-type investigator who helps the police catch the "bad guy." In fact, consultation to law enforcement is a tricky business fraught with ethical implications.

Let’s consider what this detective wanted. The first issue he wanted help with involved the design of interrogation questions. He wanted to know what he should ask this young woman to trigger a "tell," or in other words, a reaction indicative of guilt. His second question was to ask for help eliciting information that could be grounds for an involuntary psychiatric admission – an opportunity for "further study" or information-gathering, potentially for incriminating purposes.

There are several ethical imperatives for both general and forensic psychiatrists that apply to this situation. Honesty, nonmalfeasance, and respect for persons would always require a psychiatrist to disclose the purpose and limits of questioning, and to refrain from aiding or participating in deceptive practices. Deception is a standard practice in an interrogation and is legally allowed for police investigators. Identifying points of psychological weakness to elicit a confession, true or otherwise, would violate the principle of nonmalfeasance. The forensic psychiatrist’s duty to strive for objectivity would be violated by accepting the investigator’s implication of guilt. Finally, general medical ethics dictates that a physician should practice competently within the limits of one’s training and experience. Neither general nor forensic training prepares a practitioner to be a qualified lie detector.

Once the investigator failed to get the response he had hoped for to either question, he fell back to the last resort of a risk to public safety. "Think of the children," he told me, thus giving me a firsthand taste of another interrogation tactic – an emotional appeal for empathy and justice. This guy was good.

Psychiatry as a profession bears a duty to exercise police powers in order to protect public safety under certain well-circumscribed conditions. Professionals who consult with law enforcement take the position that this duty must supersede the imperatives I’ve just outlined. My personal view is that this line of justification has been extended far enough; psychiatry is now at risk of being coopted and corrupted in the name of safety and national security. A psychiatrist’s skills should not be usurped and turned against those they were designed to protect and treat.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, I received a phone call from a local homicide detective. He was investigating the death of a child, and the suspect in the case was a 19-year-old woman who was also a caretaker. She had a history of psychiatric problems, and family members implicated her in the death of another child. The detective expressed concern about a potential future risk to other children in the home, and he wanted help with his investigation.

While speaking to a detective can be a routine part of forensic work, this is usually done in the context of a larger pretrial evaluation after someone is charged with a crime. Psychiatry residents looking for a career in forensic psychiatry, as well as some members of the general public, sometimes think of forensic work as being a CSI-type investigator who helps the police catch the "bad guy." In fact, consultation to law enforcement is a tricky business fraught with ethical implications.

Let’s consider what this detective wanted. The first issue he wanted help with involved the design of interrogation questions. He wanted to know what he should ask this young woman to trigger a "tell," or in other words, a reaction indicative of guilt. His second question was to ask for help eliciting information that could be grounds for an involuntary psychiatric admission – an opportunity for "further study" or information-gathering, potentially for incriminating purposes.

There are several ethical imperatives for both general and forensic psychiatrists that apply to this situation. Honesty, nonmalfeasance, and respect for persons would always require a psychiatrist to disclose the purpose and limits of questioning, and to refrain from aiding or participating in deceptive practices. Deception is a standard practice in an interrogation and is legally allowed for police investigators. Identifying points of psychological weakness to elicit a confession, true or otherwise, would violate the principle of nonmalfeasance. The forensic psychiatrist’s duty to strive for objectivity would be violated by accepting the investigator’s implication of guilt. Finally, general medical ethics dictates that a physician should practice competently within the limits of one’s training and experience. Neither general nor forensic training prepares a practitioner to be a qualified lie detector.

Once the investigator failed to get the response he had hoped for to either question, he fell back to the last resort of a risk to public safety. "Think of the children," he told me, thus giving me a firsthand taste of another interrogation tactic – an emotional appeal for empathy and justice. This guy was good.

Psychiatry as a profession bears a duty to exercise police powers in order to protect public safety under certain well-circumscribed conditions. Professionals who consult with law enforcement take the position that this duty must supersede the imperatives I’ve just outlined. My personal view is that this line of justification has been extended far enough; psychiatry is now at risk of being coopted and corrupted in the name of safety and national security. A psychiatrist’s skills should not be usurped and turned against those they were designed to protect and treat.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, I received a phone call from a local homicide detective. He was investigating the death of a child, and the suspect in the case was a 19-year-old woman who was also a caretaker. She had a history of psychiatric problems, and family members implicated her in the death of another child. The detective expressed concern about a potential future risk to other children in the home, and he wanted help with his investigation.

While speaking to a detective can be a routine part of forensic work, this is usually done in the context of a larger pretrial evaluation after someone is charged with a crime. Psychiatry residents looking for a career in forensic psychiatry, as well as some members of the general public, sometimes think of forensic work as being a CSI-type investigator who helps the police catch the "bad guy." In fact, consultation to law enforcement is a tricky business fraught with ethical implications.

Let’s consider what this detective wanted. The first issue he wanted help with involved the design of interrogation questions. He wanted to know what he should ask this young woman to trigger a "tell," or in other words, a reaction indicative of guilt. His second question was to ask for help eliciting information that could be grounds for an involuntary psychiatric admission – an opportunity for "further study" or information-gathering, potentially for incriminating purposes.

There are several ethical imperatives for both general and forensic psychiatrists that apply to this situation. Honesty, nonmalfeasance, and respect for persons would always require a psychiatrist to disclose the purpose and limits of questioning, and to refrain from aiding or participating in deceptive practices. Deception is a standard practice in an interrogation and is legally allowed for police investigators. Identifying points of psychological weakness to elicit a confession, true or otherwise, would violate the principle of nonmalfeasance. The forensic psychiatrist’s duty to strive for objectivity would be violated by accepting the investigator’s implication of guilt. Finally, general medical ethics dictates that a physician should practice competently within the limits of one’s training and experience. Neither general nor forensic training prepares a practitioner to be a qualified lie detector.

Once the investigator failed to get the response he had hoped for to either question, he fell back to the last resort of a risk to public safety. "Think of the children," he told me, thus giving me a firsthand taste of another interrogation tactic – an emotional appeal for empathy and justice. This guy was good.

Psychiatry as a profession bears a duty to exercise police powers in order to protect public safety under certain well-circumscribed conditions. Professionals who consult with law enforcement take the position that this duty must supersede the imperatives I’ve just outlined. My personal view is that this line of justification has been extended far enough; psychiatry is now at risk of being coopted and corrupted in the name of safety and national security. A psychiatrist’s skills should not be usurped and turned against those they were designed to protect and treat.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.