January 16, 2013

Bad. Very bad.

Today's in-box contained a letter titled "Message to Our Nation’s Health Care Providers" from the US Department of Health and Human Services.

Its release today suggests that it is part of the President's new gun policy proposals.

The letter says, in part,

[T]he Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people.
It goes on to say that

The HIPAA Privacy Rule. . . . allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat.
This is bad.

You can take a look at the letter and see what you think.  When I read it,  I see confusion.

The letter bounces around a lot, telling providers that the HIPAA Privacy Rule doesn't prevent them from betraying their clients' confidentiality, talking about their "professional ethical standards," "the laws applicable to their profession in the states where they practice," and ending with "providers play an important role in protecting the safety of their patients and the broader community."

This letter/policy will have two effects.

1.  Clients will not trust their providers.  A client's relationship with her/his therapist must be based upon trust. 

Some clients or potential clients will have thoughts of suicide, thoughts of murder, thoughts of murder-suicide, or other forbidden thoughts.  It is important that they be able to verbalize these thoughts.  Verbalizing, processing, and understanding these thoughts is important.  Perhaps verbalization would prevent a client from acting on these thoughts.

But if clients with these thoughts value their possession of guns, if they hunt, if they shoot skeet, if they like to shoot targets on a range, if they are survivalists, or if they just don't want to be on a list, they will either stop seeing their counselors, hide their thoughts from their counselors, or refrain from seeking therapy altogether. 

If they do seek therapy and their provider tells the authorities that they are dangerous, how, then, do they continue therapy with that provider?  How, then, do they trust any counselor again?  They are done with therapy.  Maybe forever. 

This is bad.

2.  Providers will be confused.  How do you tell your client or patient that everything s/he says is confidential except suicidal or homicidal thoughts?  Oh, but only if s/he's serious.  What?  What if the entire reason the client is there is because s/he is suicidal?  Or having murderous thoughts?  How does one decide if someone who verbalizes such thoughts is likely to act on them?  Is that even possible?

Ah, but then there is another shooting.  It is revealed that the deceased shooter sought therapy.  The deceased victim's family sues the therapist.  It is a sensational trial.  The therapist's notes are subpoenaed. and they show that the shooter discussed his thoughts about killing another person.  The therapist is ordered to pay damages, and a career is ruined.

After this happens once or twice, providers will learn.  They will understand that they must report anyone who discusses any thoughts of violence or risk their careers and livelihoods.  No more professional discretion, just report it all.

This is bad.

Both of these situations will prevent people who need treatment from seeking it.  These situations will further stigmatize those who seek treatment for a "mental" condition.  They will further shame anyone who has taken psychotropic medications.  They will remove confidentiality from the therapist's toolbox.  And they may not even prevent gun violence at all.

I commend the President and Vice President on assembling a variety of recommendations to end gun violence.  But this letter to providers is a mistake.

I stand by my original proposal1, that people should be added to the no-gun list only if they are admitted to a mental health facility as a danger to self or others.  Any less-strict criteria will only lead to more gun violence, not less. 

And this is bad.


1 Put me on the crazy list, Crazy list part 2


January 09, 2013

Crazy List part 2

An anonymous commenter wrote the following thoughts about a previous post:

I guess I'm wondering if we would have . . . a decrease in those willing to seek treatment for the fear of losing the privlage. I do have a permit to cary a weapon and if I thought I would lose that permit by going to the hospital for help, I'm not so sure that I would go. I have been a hunter since I was 12 and value my permit as much as my drivers licens. I'm wondering how many people would try to push through it instead of getting help if losing there permit was seen as being a punishment for being mentaly ill?
I realized when I wrote the original post that a decrease in seeking treatment could be an unintended outcome, but I decided not to address it.  My thinking was that I can only put so many concepts in a single post before my reader gives up on the post.

But now that this person has asked the question, let's talk about it!

Please note that people who are involuntarily admitted to a mental health facility, because they are a danger to themselves or to others, are already prohibited from possessing, using, manufacturing, controlling, selling or transfering firearms under PA law.  These people would already be labelled as "mental defectives" (!) under federal law, and prohibited from purchasing firearms when a background check is performed.  Thus my proposal would have no effect in this situation.  The change I propose would only affect those who admit themselves voluntarily

That being said, I would like to address two things from the comment.

First, the commenter says, "if I thought I would lose that permit by going to the hospital for help, I'm not so sure that I would go."  It's really not likely that you would need admission to a hospital for help with depression.  There are many other treatments for depression besides a hospital stay.  You could get help from a psychologist, psychiatrist, an outpatient program, or even your primary care physician.  You could be treated via talk therapy or medication.  According to WebMD,  over 90% of depression is treated on an out-patient basis.

Second, I'd like to discuss the commenter's assertion that her/his carry permit was just as important as her/his driver's license.  I tried to picture how that would feel:  What if  admitting myself to the hospital for suicidality would result in losing my driver's license? 

Please bear with me now as I try to respond to this honestly.

My gut response was that, of course, I would still admit myself.  After all, if I didn't get into a safe environment, there would be no more driving anyway.  Or sleeping, or eating, or anything.  Because I would end up dead if I didn't get into the hospital.

After some more honest consideration, however, I wondered if I wouldn't try to "push through it instead of getting help," as the commenter suggested.

Because here's the thing.  If I admitted myself to the hospital, I would do so under the assumption that it would stop me from killing myself. And that I would eventually be released.  It would be very important for me to have my driver's license when I left the hospital, especially because I live in a rural area where driving is a necessity. 

So maybe I would not admit myself if I thought I'd be released and then not have my driver's license.

But, dear commenter, I'm afraid I have to reject the idea that guns are as important as drivers' licenses for many Americans, and guns would not be a consideration when seeking voluntary admission to a hospital for suicidality.  Most depressed people would not worry about losing their guns, because they simply don't have any.

I formed this opinion from statistics in the following articles:

There are more women than men in the United States.  Women suffer from depression at roughly twice the rate of men.  So I think it's safe to say that more than two thirds of depressed people in the US are women.

Another study finds that 45% of men own guns, whereas only 10% of women own guns.  So it looks like only a small percentage of depressed people own guns.

And remember that per WebMD, only about 10% of depression cases require hospitalization.

It appears that the loss of firearm privileges would affect only about 2% of depressed people.*  And I would expect that an even smaller percentage would be as passionate as the commenter about potential loss of their Second Amendment rights if they were considering admission to the hospital for suicidality.

So, in answer to the anonymous commenter, I do not think that my proposal to add voluntarily admitted people to the no-gun database would much decrease the likelihood of seeking treatment for depression.


* I tried to come up with a formula to represent what percentage of the population would actually be affected by my proposal, but I'm a word person, not a numbers person.  This is how I did it.  Feel free to correct me!

women - 66% of depression cases  x  10% hospitalization  x  10% own guns
men - 33% of depression cases   x  10% hospitalization   x   45% own guns


for women  -  .66 x  .10  x  .10   =   .0066   = my proposal affects .007 of depressed women or 0.7%
for men  -  .33  x  .10  x  .45  =  .01485   =  my proposal affects .015 of depressed men or 1.5%

add depressed women and men  -  0.7%  +  1.5%   =  2.2%

January 05, 2013

Thinking outside the box of sanity

Yeah, I hate that "outside the box" cliche, too, but it just seemed to fit.

Please consider the following.  I understand that it is probably so far out of the experience of most people as to be offensive.  But hear me out.

Adam Lanza killed 20 children and 7 adults besides himself.  But nobody seems to understand why he chose that elementary school.

What if Lanza thought he was doing the children a very big favor?

Here's the thing.  In my very darkest time, I thought it would be merciful to take another person's life.  I felt a terrible certainty that the person would eventually feel the same anguish I was going through.   So it just made sense (to me) that I should save that person from despair by killing him or her before the torment came.

So if Lanza was depressed enough, as research has shown that 78% of mass shooters have been, he may have gone to the school to save those children from that unspeakable despair. 

Perhaps he was so depressed, so hopeless, in a black pit so deep that he could see no way out ever, that he sought out children to save them from enduring that same despair.  A mercy killing of sorts.

In his mind, maybe the adults he killed were also fortunate, for the same reason.  They just didn't know it.

I am not excusing his murderous behavior, just trying to get a handle on what he may (or may not) have been thinking.

I had an appointment with my psychologist the week after the shooting. 

I asked her the question, "What if Adam Lanza thought he was helping those children?"

She said, "You're the second person who has asked me that this week."  So I'm not the only person who thought of this. 

Does this explain his targeting of young children?  We'll probably never know.

But thanks for reflecting on this with me.

January 03, 2013

Put me on the crazy list.

First and foremost, let me state that mentally ill people are far more likely to be the victims than the perpetrators of violent crime. And that it's not clear that the Newtown shooter was being treated for any mental illness. And that I don't speak for anyone but myself. Other people will have other, perhaps conflicting, ideas; I welcome your ideas in the comments section below.


I have been seriously suicidal multiple times. I have been hospitalized because of this, also multiple times. If you read my previous post, you can see that I was definitely a danger to myself. And sometimes I was a danger to others.

I have been healthy for a decade at a time and then gotten depressed and suicidal again. So, regardless of how happy and healthy I appear to be, there is a chance that things will change and I will become suicidal again.

I should never be able to purchase a gun.*

Since the Sandy Hook shootings, I have been drowning in research. Here is some of what I found:

A Harvard School of Public Health study that analyzed data on three groups of adolescents found that "[t]hose who died by suicide were twice as likely to have a gun at home than either of the other two groups." They agree with my previous post that firearms are a more lethal means of suicide because there is no changing your mind once the trigger is pulled. Take a look at their chart showing the fatality rate for different methods of suicide.

Also consider that for individuals who kill their children and commit suicide (filicide-suicide), "The large majority (73%) of parents killed their children by shooting." A 1993 study concluded that there was a correlation between defensive gun ownership and suicide, but not beween sporting gun ownership and suicide. There is also a multitude of research on mass shootings, if you want to check it out.

It has also been shown that severe mental illness is a common feature of filicide-suicide.

So firearms are the most lethal means of suicide and the most prevalent method of filicide-suicide. And many people who commit filicide-suicide have a serious mental illness. To me, this suggests that we must stop seriously mentally ill people like me from having guns.

I understand that changes to background checks wouldn't have made a difference in the Newtown shootings, because the shooter used weapons that his mother purchased legally. So should background checks include searches for those who live with the potential buyer? I have had to list people who lived with me for an employment background check. If it's okay to review this for employment, why not include this search in firearms background checks?

Currently, one of the reasons you can be denied the purchase of a gun is if you have "been adjudicated as a mental defective or ha[ve] been committed to any mental institution" (page 9). The NRA's Wayne LaPierre thinks we should go even further and have "an active national database of the mentally ill." In fact, 38 states already have such databases. The problem is that it's a patchwork project, and each state has different criteria.

Some firearm owners are afraid that such a database is a slippery slope. Other people reject the idea of a database listing those with "a history of mental illness." So do I; that terminology is much too broad.

There is also a concern about labelling and stigma. Some people object to being labelled as "mentally ill" at all, let alone being on a federal list. Being on such a list could cause more shame for those who already feel stigmatized. But the rules already state that the person performing a background check will not see "any of the underlying information in the records checked by the system" (p. 113).

My friend Neil is afraid that the method of getting on such a list would be hinky, and that the list could be used for other purposes, up to and including denying employment. This is another slippery slope, where initial intent could be corrupted by a panicky public.  And I share that concern.  But if this is a piece of the puzzle that will help stop mass shootings, I am willing to take that chance.

Clearly, the language for this must be precise. Stop referring to people as "mental defectives" and don't target people with "a history of mental illness." Here are my suggestions:
  • Change the language to say that you cannot buy a gun if you have been admitted to a hospital because you were a "danger to yourself or others," whether you were adjudicated or you admitted yourself.
  • Only designated employees of hospitals should be able to add to the list.
  • The list should only be available to firearms dealers and the Bureau of Alcohol, Tobacco, and Firearms.
  • It must be a federal database, with uniform, specific criteria regarding who should be added to the database.
And put me in that database right now.


* It makes me very sad to say this, because, having gotten used to the idea of killing myself, the thought of suicide is like an old friend, and I would really like to have a gun to keep that old friend company.