The Honorable Joseph R. Pitts: As a forensic psychiatrist and as provider of medical services with more than two decades of experience treating patients, are there situations that you have come across that lead you to believe that the “imminent danger" standard is unworkable and/ or limits access to necessary medical care?
Dr. Michael Welner: It is irretrievably unworkable.
In my professional experience, I have also treated numerous people who have been repeatedly violent. Imagine treating someone who has assaulted (raped, or murdered) before, has no apparent inhibitions to doing so again, and having the burden of considering whether to notify that person’s caregiver or responsible family in case of deterioration.
My professional experience teaches me that to do so would place me at risk. My professional experience also teaches me that to not do so may also place me at risk.
Most important in weighing these competing interests, however, is that when any risk exists, to the patient, unseen others, or to me, the consequences of waiting for me to calibrate “imminent enough” to be allowable by law creates ongoing and unacceptable risk to the community that is unfair and untenable.
Those who think differently do not know what it is like to treat truly scary and unstable people. Nor do they appreciate the despair of the tragedy they could not prevent because the law technically stopped them from preventing a problem that professional’s judgment felt was inevitable.
I have also worked in several different emergency rooms early in my career, supervised others doing so, and I know what it’s like to be on call at all hours and with a full ER.
In some instances, a person comes brought by police with a report of high agitation and nothing more, and the person appears calm when you examine him. You ask all the usual questions. He says he is neither a danger to himself or others, you have some reason to believe that he was drinking and his buzz cleared, or that he does not have a psychotic condition, or his meth is out of his system. You discharge the patient who insists he does not want to come in. He disappears into the void and anything can happen.
In other instances, you may wonder whether he has a psychotic condition. He may smell poorly, and tell you he is homeless. He may tell you he hears voices. You may choose not to believe him, because he may be looking for a place to sleep. You may choose to believe him, but know nothing more about what his voices are telling him because he is vague, as many with schizophrenia are.
Or you may alternatively find him guarded and uncommunicative as a paranoid person, who self-refers about a vague conflict. That’s not enough to tell you what his violence history is, or his plan if he has been violent in the past. What, after all, is “imminent” about something that happened years ago?
Or, like many referrals to emergency rooms, there is absolutely no medical record available.
How then, is one to know that a person is imminently dangerous without having already been violent or suicidal? Yes, one can make an informed decision about “imminent” dangerousness. But the time available for assessment and decision-making, the paucity of valid and reliable data, and the motivation of the examinee to not be committed all conspire to disadvantage the examiner and to conceal imminence that may be just out of view.
The emergency room doctor gets no criminal record or reports of contact with the justice system. Exactly what would tell him that a person is imminently dangerous when the person who is the most detailed historian available knows that he won’t be admitted if he is quiet and professes no wish to harm anyone?
Do you really know a full situation as that examining emergency room attending, even when you contact home and family and they speak to you? What if the family is not very verbal or animated and cannot capture the intensity of what you do not see? Even if your gut tells you as a physician that something is wrong, unless you feel something is imminently dangerous, you cannot admit.
Even if you play your gut but cannot substantiate it, the patient will convince another doctor to sign him out so that a person who has already been seriously injuring others and who waits in the emergency room for a bed to open up can then be admitted to a restricted census of spots for hospital treatment.
At the opposite end of the assessment spectrum is the person brought in by family. That person reflects a calm demeanor and refutes the notion that she is even ill. The family you meet with, however, has a very different account. They speak of how confused she has been and that she has refused care. They don’t know, however, of any indication of her illness.
Indeed the “imminently dangerous” standard is unworkable.
Risk assessment has been well-refined in recent years. The latter point is significant. For as much as we have learned in psychiatry about predicting risk to one’s self or to others, risk assessment continues to be an exercise of low vs. lower probabilities. Violence among the mentally ill is low. Some how does one know whether it is imminent? Especially when the evaluation of seriously mentally ill person is informed by the very examinee who does not want to be committed, knows the standard as well as the examining doctor, knows what to say in order not to be deemed dangerous, knows to go to a hospital where there are no medical records, knows not to give telephone numbers of people who know him, because they will be called by the ER physician.
However the ability to predict dangerous is informed, and however more specific the data must be to appraise “imminent,” these obstacles in the face of public safety render “imminently dangerous” an unworkable term for responsible public safety.
From a patient welfare standpoint, it is likewise unworkable. The patient who is descending into crisis or into more acute phases of a serious mental illness may have the one professional encounter with an examiner on a given day. There may be obvious deterioration and uncertainty as to where this is leading. Included in that uncertainty is the inability to realistically contract with a very sick person to return to the emergency room should his condition “worsen.” How, really, would a person that impaired know the difference between “really sick” and “really really sick?” That voices aren’t just angry, they’re really angry?
These reference points quite obviously do not embed in the experience of what is happening in the mind of the acutely ill person presenting for the emergency room.
What of the seriously mentally ill person who is acutely ill but not suicidal or homicidal? The discharge decision may be obvious. So, too, is the downward trajectory. It may not be imminent. Does he return to the trauma ER only because he was attacked and knifed because he became agitated with the wrong person? Or does someone else end up in the morgue because I never knew he was a sex offender, with a predatory history, and he presented only as “stressed and unable to sleep?” The people we discharge may not keep in touch, or become so ill that they no longer mobilize to seek help. When they are lost, or others lost because of them, that is likewise evidence of how the “imminent danger” standard fails those who should be routed into help but never are until the unthinkable had happened.
Washington Navy Yard shooter Aaron Alexis, for example, was examined in three different emergency rooms over the course of six weeks before undertaking a mass shooting. He might not have been imminently dangerous on any of those visits. When Alexis decided to be dangerous, asking a psychiatrist what he thought was no longer an option. That is representative of the problem we are facing today, even under the circumstances of the most competent assessments.
Of all of the reforms contemplated to make a difference in crisis mental health, reforms to 1) thresholds for involuntary commitment that account for the degree and pace of deterioration (as is done in HR 3717) and 2) refinement of HIPAA to enable a lifeline to families supporting those in crisis, are the two specific changes that directly impact public safety. Crisis mental health reform is not real without them. Both remedies require no costs or additional programs; only the willingness to engage denial and to be decisive as good physicians must be, and to respect the responsibility that families take for crisis intervention.
