NYAPRS Note: Today’s papers take an analytical view of NY’s new gun control law’s impact on people with mental health needs and the services they may seek. It looks at several concerns about unintended consequences of the law that may deter people from seeking or disclosing fully in a therapeutic relationship.
The Times piece underscores a critical paradox: while it leads off with concluding that mass shooters have to be ‘deeply disturbed,’ a term most will read as having a mental illness, it quotes experts who conclude “most mass murders are done by working-class men who've been jilted, fired, or otherwise humiliated - and who then undergo a crisis of rage and get out one of the 300 million guns in our country...the sort of young, troubled males who...often do not qualify for any diagnosis.”
It concludes with Dr. Paul Appelbaum’s hopeful frame: “Some experts, like Dr. Appelbaum, say the Connecticut school shooting offers the kind of opportunity that only comes once every generation or two: to rethink the entire mental health system. It might include appointing a presidential commission; re-envisioning community mental health care; focusing more on vigilance for problems in young people, and reducing stigma."It seems to me an opportunity to step back and rethink what the entire system should look like," Dr. Appelbaum said.”
Law's Mental-Health Provision Draws Ire
By Tamer El-Ghobashy Wall Street Journal January 16, 2013
A provision in New York state's new gun-control laws that requires mental-health professionals to report potentially dangerous patients is drawing concern from experts who fear it could discourage people from seeking treatment and treads on client confidentiality.
The measure requires physicians, psychologists, nurses or clinical social workers to alert local health officials if a patient "is likely to engage in conduct that would result in serious harm to self or others." After an evaluation, the health officials would pass on the person's information to law-enforcement agencies that would be authorized to seize any firearm owned by the patient.
If a person is found not to own any firearms, the patient would be added to a statewide criminal background check database, marking a significant expansion of who would be made ineligible to legally buy a firearm.
"I understand the intent, but I fear these kinds of practices may well deter people from seeking care or fully disclosing" their condition to psychologists, said Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services.
He said the legislation seems designed to allay public fears of guns in the hands of the mentally ill with little thought given to "the chilling effects" it may have on treatment. Studies have shown that mentally ill people are far more likely to be the victims of violence rather than perpetrators.
The prospect of being put on such a list could be enough to prevent someone from seeking care and creates the impression that "you're turning psychologists into police officers," said Eric Neblung, a psychologist and the president of the New York State Psychological Association.
Patients might worry about being honest: Even the most fantastical violent expressions could be subject to a legal mandate, Dr. Neblung said.
But DJ Jaffe, executive director of Mental Illness Policy Org, an advocacy group, said concerns over the legislation are "hyper-theoretical" and that the greater, and more practical, risk is that very seriously mentally ill people "have a plan to kill people, and it doesn't go reported."
Mr. Jaffe said the legislation should go further by using the names compiled under the law to help those people get "priority treatment."
Mental-health professionals already have an ethical obligation to respond to threats of violence, such as warning potential victims of possible threats. Dr. Neblung said the new law compels caregivers to break confidentiality before clinical remedies are exhausted.
Of particular concern, he said, is that the law could prevent professionals such as police and corrections officers from seeking treatment for fear they could lose their firearms—and their jobs.
Already, officers often pay for treatment with cash rather than going through insurance to avoid anyone knowing about their psychological issues, Dr. Neblung said.
Under the law, therapists and others must use their professional judgment to determine if a patient poses a real threat. A decision to not disclose a patient's violent statements wouldn't lead to punishment if it was made "reasonably and in good faith."
Dr. Neblung said the language is vague and the potential for sanctions must be studied.
-Laura Nahmias contributed to this article.
Warning Signs of Violent Acts Often Unclear
By Benedict Carey And Anemona Hartocollis New York Times January 16, 2013
No one but a deeply disturbed individual marches into an elementary school or a movie theater and guns down random, innocent people.
That hard fact drives the public longing for a mental health system that produces clear warning signals and can somehow stop the violence. And it is now fueling a surge in legislative activity, in Washington and New York.
But these proposed changes and others like them may backfire and only reveal how broken the system is, experts said.
"Anytime you have one of these tragic cases like Newtown, it's going to expose deficiencies in the mental health system, and provide some opportunity for reform," said Richard J. Bonnie, a professor of public policy at the University of Virginia's law school who led a state commission that overhauled policies after the 2007 Virginia Tech shootings that left 33 people dead. "But you have to be very careful not to overreact."
New York State legislators on Tuesday passed a gun bill that would require therapists to report to the authorities any client thought to be "likely to engage in" violent behavior; under the law, the police would confiscate any weapons the person had.
And in Washington, lawmakers said that President Obama was considering a range of actions as part of a plan to reduce gun violence, including more sharing of records between mental health and law enforcement agencies.
The White House plan to make use of mental health data was still taking shape late Tuesday. But several ideas being discussed - including the reporting provision in the New York gun law - are deeply contentious and transcend political differences.
Some advocates favored the reporting provision as having the potential to prevent a massacre. Among them was D. J. Jaffe, founder of the Mental Illness Policy Org., which pushes for more aggressive treatment policies. Some mass killers "were seen by mental health professionals who did not have to report their illness or that they were becoming dangerous and they went on to kill," he said.
Yet many patient advocates and therapists strongly disagreed, saying it would intrude into the doctor-patient relationship in a way that could dissuade troubled people from speaking their minds, and complicate the many judgment calls therapists already have to make.
The New York statute requires doctors and other mental health professionals to report any person who "is likely to engage in conduct that would result in serious harm to self or others."
Under current ethical guidelines, only involuntary hospitalizations (and direct threats made by patients) are reported to the authorities. These reports then appear on a federal background-check database. The new laws would go further.
"The way I read the new law, it means I have to report voluntary as well as involuntary hospitalizations, as well as many people being treated for suicidal thinking, for instance, as outpatients," said Dr. Paul S. Appelbaum, director of the Division of Law, Ethics, and Psychiatry at Columbia University's medical school. "That is a much larger group of people than before, and most of whom will never be a serious threat to anyone."
One fundamental problem with looking for "warning signs" is that it is more art than science. People with serious mental disorders, while more likely to commit aggressive acts than the average person, account for only about 4 percent of violent crimes over all.
The rate is higher when it comes to rampage or serial killings, closer to 20 percent, according to Dr. Michael Stone, a New York forensic psychiatrist who has a database of about 200 mass and serial killers. He has concluded from the records that about 40 were likely to have had paranoid schizophrenia or severe depression or were psychopathic, meaning they were impulsive and remorseless.
"But most mass murders are done by working-class men who've been jilted, fired, or otherwise humiliated - and who then undergo a crisis of rage and get out one of the 300 million guns in our country and do their thing," Dr. Stone said.
The sort of young, troubled males who seem to psychiatrists most likely to commit school shootings - identified because they have made credible threats - often do not qualify for any diagnosis, experts said. They might have elements of paranoia, of deep resentment, or of narcissism, a grandiose self-regard, that are noticeable but do not add up to any specific "disorder" according to strict criteria.
"The really scary ones, you have a gut feeling right away when you talk to them," said Dr. Deborah Weisbrot, director of the outpatient clinic of child and adolescent psychiatry at Stony Brook University, who has interviewed about 200 young people, mostly teenage boys, who have made threats. "What they have in common is a kind of magical thinking, odd beliefs like they can read other people's minds, or see the future, or that things happening in their dreams come true."
Even if such instincts could be relied on, the mental health system is so fragmented in the country that it is hard to know whether the information would get to the right person in time. According to Dr. Bonnie, the Virginia law professor, the Virginia Tech gunman was ordered to outpatient treatment by a judge more than a year before his rampage but was never hospitalized, which would have shown up on a background check.
The state database now includes such cases, after the reforms. "But we're a state that has a centralized database like that; in many states there's no one place to get it all; it's all kept locally, community by community," Dr. Bonnie said.
The federal background check database, which is supposed to have updated information from states, has only a patchwork, because of the wide variety of state laws on reporting, experts said. Even if it were entirely up to date, it would not catch the many millions who never see a mental health professional despite deep distress.
Some experts, like Dr. Appelbaum, say the Connecticut school shooting offers the kind of opportunity that only comes once every generation or two: to rethink the entire mental health system. It might include appointing a presidential commission; re-envisioning community mental health care; focusing more on vigilance for problems in young people, and reducing stigma.
"It seems to me an opportunity to step back and rethink what the entire system should look like," Dr. Appelbaum said.
New Gun Law Offers Reply to Mass Killings
State Becomes the First in the Nation to Act After Horror of Newtown, Conn.
By Casey Seiler Albany Times Union January 16, 2013
ALBANY - "We are fighting back," Gov. Andrew Cuomo said before signing a sweeping gun control bill at the Capitol just an hour after the Secure Ammunition and Firearms Enforcement Act was approved by the state Assembly.
The measure expands the definition of banned assault weapons, creates a state database for pistol permits, reduces the maximum number of rounds in a magazine and requires background checks on all gun sales, including those between individuals.
"You can overpower the extremists with intelligence and with reason and with common sense," Cuomo said Tuesday afternoon in the Red Room, which was filled with reporters as well as law enforcement officials, including Albany County Sheriff Craig Apple and city of Albany Police Chief Steven Krokoff.
The governor expressed regret that it "required tragedies and loss of life to actually spur the political process to action," a reference to the Dec. 14 school shootings in Newtown, Conn., and the killings of two firefighters in the Rochester suburb of Webster 10 days later.
After passing the state Senate 43-18 late Monday night, the bill cleared the Democrat-dominated Assembly 104-43 at the end of an almost-five-hour debate Tuesday.
"Let us be perfectly clear: This bill is about protecting people - protecting our children, protecting our families, protecting first responders, police officers and firefighters," Assembly Speaker Sheldon Silver said at the signing ceremony, which was also attended by two of the state Senate's three conference leaders: Jeff Klein of the five-member Independent Democratic Conference and Andrea Stewart-Cousins of the main Democratic body.
Senate Republican Leader Dean Skelos, who controls the chamber jointly with Klein, did not attend. A dozen members of the GOP conference voted in favor of the measure.
Also not celebrating was the National Rifle Association, which released a statement saying it was "outraged at the draconian gun control bill that was rushed through the process late Monday evening." The powerful gun lobbying organization called it "a secretive end run around the legislative and democratic process... with no committee hearings and no public input."
While the Senate moved directly to the roll call of votes on the measure, Tuesday's Assembly debate saw Republicans peppering Democrats for details of the bill's provisions.
Assemblyman Jim Tedisco, R-Schenectady, held up a copy of the U.S. Constitution that the lawmaker said he never leaves home without. "Amendment Two - you're going to turn that into Amendment 1.5 today," Tedisco said of what he described as the diminishment of gun rights.
Others called out Cuomo for what they accused was an overweening desire to pass the nation's first legislative response to the recent spate of shootings. Assemblyman Steve Katz, R-Westchester County, knocked what he called Cuomo's "misguided, egotistical" attempt to boost his presidential prospects in 2016.
Others expressed concern over the bill's expansion of mental health providers' ability to commit those found to be a danger to the public under what's known as Kendra's Law. The SAFE Act also requires mental health professionals to report to local officials if they think a patient could prove to be a danger to himself or the general public, and empowers local law enforcement to collect the patient's guns and suspend firearms permits.
"I think many of us object to the connection between violence and mental illness ... that seems to inform these new policies," said Harvey Rosenthal, executive director of the state Association of Psychiatric Rehabilitation Services, which represents mental health care consumers and providers. "... You get this kind of round-'em-up mentality that I think will only deter care."
Newtown shooter Adam Lanza, Rosenthal pointed out, was apparently never diagnosed with the sort of mental illness that would have triggered the provisions of the new law.
"Whether it's Adam Lanza or any number of people who are at risk, I think the system in New York for too long has been unresponsive," said Rosenthal, who served as a member of Cuomo's Medicaid Redesign Team. " ... I don't think Kendra's Law, which depends on cops and courts, does that."
Glenmont's Michael Carey, whose 13-year-old autistic son Jonathan died in 2007 at the hands of a health care worker who was trying to restrain him, said he was less bothered by the chance the bill would stigmatize the mentally ill than with what he described as the state's inadequate resources to serve them.
"If there are families in trouble but no crisis care to take them to, what do you do?" said Carey, a vocal critic of Cuomo's mental hygiene reforms.
In another sign of guns' diminished status in state government, New York Comptroller Tom DiNapoli on Tuesday announced that the state's vast Common Retirement Fund will freeze its investments in publicly traded commercial firearm manufacturers.
The freeze affects the pension fund's holdings in an index fund of 45,325 shares of Sturm, Ruger and Company valued at approximately $2.2 million - pin money compared with the fund's full value of $153 billion.
The pension fund's holdings in Smith and Wesson Holding Corporation were sold in December, just four days after the shootings in Connecticut.
In a statement, DiNapoli - like Cuomo a Democrat - insisted that the decision was not political, but strictly business.
"After the terrible events in Newtown," he said, "it is clear that the national movement toward greater regulation of firearms manufacturers will impose significant reputational, regulatory and statutory hurdles that may affect shareholder value."