Recently, I had to breach confidentiality and contact the police to report a potentially violent patient.
This is one of the most nerve-wracking decisions I’m faced with as a psychologist. I know when I make that call, I’m increasing, not decreasing, the stress on my patient. I’m damaging, perhaps permanently, my relationship with that person. Privacy is destroyed, and replaced with a police car in front of the house. The most fundamental of civil rights—the freedom to come and go at will—is threatened when I make that call. Things can turn bad very quickly, leading to risk to the patient and the officers who respond (“suicide by cop” is always a possibility—and one that can make PTSD a contagious disease).
It’s never something I do lightly. I agonize over that decision. I look for ways to avoid having to take that action. I seek relief in anything the person might say that could reasonably allow me not to have to take that action. But ultimately, I take my responsibility seriously. In those moments, the risk of harm to my patient and the public overrides any other concerns.
I spent an hour on the phone with my patient, attempting to gain some assurance that he would not follow through with his plan.
I could have chosen to play stupid, to convince myself that his remarks were too vague to interpret as a threat of violence, and that his threat of violence was just a joke, or just a metaphor for his anger, a fantasy rather than a plan—after all, if I called the police every time someone expressed a suicidal or homicidal thought, I’d never get off the phone.
But, I know this man. I know the intensity of his anger, the depth of his hopelessness, the rigidity of his thinking when he's distressed. I could not be certain that a disaster would occur, but the probability of something terrible happening was unacceptably high.
I sought his reassurance that he would not act violently. He could not give it to me. I concluded that I had no choice but to act. I explained this to him.
And so, following through on my ethical responsibility, I phoned the police. I provided as much information as I could about his recent history, and all the evidence I had that suggested to me that there was an imminent risk of violence.
Let’s pause the story for a moment, and consider the Mental Health Act.
The Mental Health Act gives a physician the power to complete a Form 1, which directs the police to take a patient into custody, and deliver that person to a hospital for a psychiatric evaluation, holding the person for up to three days.
The only problem is—I’m not a physician. I am a specialist in mental health; I have far more training in mental health than most physicians; I can diagnose mental disorders; I have extensive training in psychotherapy, and in identifying the risk of suicide and violent acting out.
But in moments like these, my qualifications become irrelevant. Only physicians can sign Form 1; and to do so, they must have seen the patient within the past 7 days.
So phoning this man’s psychiatrist to get the Form 1 signed was not an option—he hadn’t seen the psychiatrist since he had been discharged from the hospital a few weeks earlier.
The police, however, can act without a physician’s authorization. If, in their own opinion, there is evidence that a person may be at risk of harm to themselves or others due to their mental condition, they can apprehend that person so that they can be assessed by a physician, who can sign Form 1.
In practice, this involves the police spending hours in the Emergency Room, watching over a patient until a physician is available. I have no doubt it’s a duty that police officers dread. It’s boring, and it’s a waste of their time. Few people dream of becoming a police officer so they can spend time in ER waiting rooms.
So here we have a conflict: A psychologist, with extensive knowledge of mental health and specific experience with this patient, carefully coming to the conclusion that he poses a risk to himself or others; and a police officer, armed with the knowledge that this man’s psychologist has come to that conclusion—but knowing that the psychologist can’t sign Form 1.
And what happens when the police officer attends the man’s home? He’s calm. He’s rational. He calmly explains that while he couldn’t promise not to be violent, “you can’t predict the future, right?”
That’s a direct quote, one that I heard from the patient during my call, and one that the police officer reported he repeated to her.
And actually, while I can’t precisely predict the future, prediction is exactly what risk assessment is all about: assigning a probability to a given outcome, and taking action to prevent risks that have an unacceptably high probability.
The police officer, no doubt looking (as I was) for a reason not to have to act, decided that there was insufficient evidence to apprehend this man. And the police officer, in defending that decision to me later, agreed with the patient: “You can’t predict the future.”
Let’s pause for a second here to consider: The opinion of a psychologist, with intimate knowledge of this man’s history, and who had just spent an hour assessing the risk of violence, got overridden by the clinical judgment of a police officer. And that police officer clearly missed the point: the Mental Health Act is all about predicting the future—and changing it for the better, by preventing catastrophic outcomes.
Let me be clear: I have nothing but compassion for the difficult position in which we place police officers. They have become our front line mental health workers, a role which they rarely cherish, and which they are forced to fulfill with little or no mental health training.
But the law, as written, allows physicians and police officers to make the decision to apprehend a person at risk of harming themselves or others; the law offers no such power to psychologists.
This story ends well. He did not act out. At least, not this time.
The fact is, if you want to gamble with people’s lives, you can almost always win by betting against the worst outcome. Most people who speak of suicide won’t attempt it; most who attempt it won’t succeed. You can almost always win by betting the person will get through the crisis.
Almost always. But not every time.
So whose judgment should have won that day: Mine, or the police officer’s?
Perhaps she made the right call; perhaps he really had calmed down. After all, there were no headlines the next day about what he had threatened to do. And believe me—there would have been.
And how can I hold the police officer responsible? She spent time with the patient, and did her best to assess someone she’d never met before. The law doesn’t force her to accept my judgment over her own observations. And, no doubt, he said everything she needed to hear to choose not to apprehend him for a psychiatric evaluation.
But as a matter of public safety, it is critical that psychologists should be able to sign Form 1. We have a knowledge of our patients, and of mental health assessment, that allows us to pick up risks that may not be obvious—for example, we know that when veterans and first responders become patients in distress, they know very well what to say to a police officer to convince them everything is fine. They’ve spent their careers hiding their feelings; they can pull that off with no problem. But it can be harder to pull the wool over the eyes of someone who has spent hours with you, listening to you and helping you to get to the root of your issues. I know that a calm demeanour can mean something very different from posing no risk—a calm demeanour can arise from having committed to a course of action that they believe will end their pain.
Sadly, this isn’t the first time I’ve had to make that call—and it’s not the first time that a police officer’s judgment overrode my own, leaving a person in crisis at risk of acting out.
Other psychologists report how their judgment has been overridden by that of physicians, with the same result: A patient whom we know to be at risk of harming themselves or others fails to receive an adequate period of observation and assessment, because the physician declines to sign the Form 1, though the psychologist may have much more intimate knowledge of the patient, and in many cases, much more extensive training in mental health assessment, diagnosis, and treatment.
This isn’t about expanding the market for psychological services—no one is going to choose to see a psychologist so that we can “form” them. This isn’t about increasing our income—we don’t expect to get paid for completing Form 1. After all, we rarely get paid for the time we devote to convincing the police or a Justice of the Peace to apprehend a patient in crisis. If we did get reimbursed for this time, it would be through our existing mechanisms, not through OHIP.
This is something that we will primarily do only for our existing patients, and only when absolutely necessary.
The ability of psychologists to sign Form 1 is, quite simply, a matter of public safety. It’s about letting psychologists use their advanced training and deep knowledge of their patients to protect them, and the public, during times of crisis. It’s about unleashing psychologists to practice to the full extent of their scope of practice, in a way that will enhance the safety of our patients and the public.
--Dr Jonathan Douglas
Ladies and gentlemen, distinguished guests and colleagues:
For those that don’t know me, I’m Dr Jonathan Douglas, the President of the Ontario Psychological Association, and it’s my pleasure to welcome you to our Queens Park Reception. Thank you so much for taking the time out of your busy schedules to join us this evening.
It’s such a thrill to be back at Queens Park for our third consecutive Reception, and our first shared event not only with our friends at CAMH, but with several of the great universities and hospitals that do our training. Each year, this event gets bigger, and each year it feels like we garner more attention. It is such an honour to be back to remind you not only of the great work that psychologists do, but that psychologists are here to help you solve some of the pressing problems that you are faced with.
Let me begin by telling you a little about what a psychologist is. We are both academics, and clinicians, bringing the high quality of our training into our work with our clients.
We are researchers, studying the brain, the mind, and their interaction with society. We are in the schools, identifying students with special needs, and helping them reach their full potential. We are in hospitals and family health teams, providing in-depth assessments and diagnosing psychological disorders and brain injuries. We are in our own clinics, helping the injured recover from automobile or industrial accidents. We provide information to insurers, lawyers, the courts, and programs such as ODSP, helping to ensure just outcomes based on our objective assessments. We help the military members, veterans, and first responders deal with the horrors they face every day. We’re poised to swing into action to serve the Syrian refugees. We do so much great work for the people of Ontario. We are justly proud of our extensive training, our high ethical standards, our commitment to objective assessments, and our ability to diagnose and treat psychological disorders with empirically validated psychological methods.
And yet, there is more that psychology can be doing. We are keenly aware of the two-tiered health care system in Ontario—the one that allows those with mental health issues to see a psychologist right away if they have benefits; the one that puts them on a waiting list if they don’t. The two-tiered health care system allows parents with good jobs to seek psychoeducational assessments of their children, or to go on a waiting list in the school system. There are so many examples like this. And last weekend saw the tragedy in Attawapiskat. The problems there are the most complex imaginable…and yet, they may be the least likely to have access to the expertise of psychologists.
Psychologists have the skills, and the willingness, to help the impoverished. With telehealth, we can extend our reach into the furthest corners of the province. We want to help all the people of Ontario—not just the rich, and not just the urban. The homeless need our services to get off the streets; inmates in jail need our help to stay out of prison. The elderly need our help to live independently, and their families and doctors would like our guidance for such decisions as whether or not they should continue driving. Wherever there is suffering, there should be access to psychologists.
There are so many issues facing this province, and so many of them, at their core, are something that psychologists can help with. And here is the good news, the light at the end of the tunnel: Thanks to people like you, there is increasing access to psychology. We’re seeing positions open in hospitals, in family health teams, in corrections, and in other public facilities. It’s getting easier to see a psychologist.
As we reach out to you, to remind you of who we are, and how we can help, I ask you to reach out to us, the psychologists of Ontario. Look on us a resource. We’re here to help you solve problems for the people of Ontario. And we are so very pleased to know that you’re listening.
--Dr Jonathan Douglas
…and how The System, which wants to save its money, ends up paying more.
When you’re injured in a car accident in Ontario, the insurance provider has the right to request an assessment from a provider they have selected; these are called insurer examinations, and I used to do a lot of them. Typically, I was asked to see people who didn’t seem to be progressing fast enough, two years after the accident. Most had some combination of both physical injuries and psychological issues, including depression, anxiety, trauma, and pain disorders.
In 2008, I had done about 100 of these (almost always of a driver who had been injured--apparently, not a lot of Ontarians carpool), when I began to notice a pattern…something that didn’t quite make sense.
Since most accidents involve two vehicles, if these drivers were randomly distributed, I’d expect there to be roughly a 50/50 split between the at-fault and not-at-fault drivers injured in accidents.
That was NOT what I found. What I saw was that the at-fault driver was assessed 5% of the time. That means that 95% of my sample was the driver who was in the wrong place at the wrong time. NINETY-FIVE PERCENT.
What was going on here? I began to go through the psychological research, but I couldn’t find the right keywords to answer my question…because I didn’t know how to ask it.
It was a year later that I found the paper I was looking for. Its author, Dr Michael Sullivan, had nailed the phrase for me: “Perceived Injustice.” And in his paper, he demonstrated that his simple little 12-item questionnaire on the sense of injustice following a physical injury did a remarkable job of predicting the persistence of post-traumatic symptoms. The more injustice the individual perceived, the more likely their PTSD was to last.
Bear in mind: The concept of “perceived injustice” is NOT about malingering or delusion. While perception can be inaccurate, that’s not automatically being implied here; all experience is perceived. It might just as easily be called “experienced injustice.” When a person feels that they have been treated unjustly, that’s what sets the wheels of this vicious cycle in place, regardless of whether they’re right or wrong.
There are two themes in Sullivan’s questionnaire: “Blame” (someone did this to me; I’m suffering, and it wasn’t even my fault) and “Severity” (no one gets how bad this is; I might never get better).
It’s a great start, and it’s been extended with some interesting work. But, with all due respect to Dr Sullivan and those who are exploring this idea further, there is so, so much more to this groundbreaking concept.
Some features of the event, I’ve found, enhance the perception of injustice: Being injured as a victim of a crime; betrayal of trust, as when a doctor abuses a patient; the mere presence of a child, even if the child wasn’t injured.
But one of the biggest ones has been written about under its own label: Sanctuary Trauma. That’s what happens when those who were supposed to support you following your injury failed to be there for you. The boss that dismissed your concerns; the failure of workplace insurance, long-term disability, or Veteran’s Affairs to accept the claim; the campus police who refused to take your sexual assault seriously; the service that tossed you aside like a broken toy…
In some cases, the failure of The System is worse than the injury caused by the original accident or crime. When the people who are supposed to help you turn you away, doubt your story, or drop the ball, the result can be devastating.
This is a concept that goes so much further than injuries in motor vehicle or industrial accidents. It speaks to a fundamental truth of human psychology: We get better when we feel heard and supported; if we feel invalidated and rejected, our bitterness, and the need to constantly prove that we’ve been injured, can cause us to double down on our symptoms. And that’s not just consciously inflating symptoms…it’s an unconscious process that can actually make the injury and impairment worse, like a placebo effect in reverse.
And this isn't just about the psychological injury. Perceived Injustice causes physical injuries to take longer to heal, and it's associated with longer periods of disability from employment. Perceived Injustice carries a huge cost, economically and in quality of life.
I’ve developed this theory of how Perceived Injustice seems to work.
Think of someone running a stop sign by mistake…a stupid thing that, admit it, we’ve pretty much all done.
There’s a variety of outcomes to this. Usually, there’s nothing at all; you look around, hope no one saw you, and drive away. There’s getting a ticket. There’s a close call, and subsequent embarrassment. There’s a minor accident; an accident causing injury; and worst of all, an accident causing death.
Clearly, it’s much worse to run a stop sign and kill someone than to run a stop sign and hit nothing, right? Bigger injury=bigger injustice.
Except, of course, that the error is the same in all those outcomes. The outcome is determined by physics, timing, and probability. Running a stop sign is a bad thing to do because it increases the probability of a bad outcome; but the driving error is the same whether that outcome is neutral or severe.
But that’s not what we feel! We feel that the greater the injury, the greater the injustice that’s been perpetrated. My life is ruined, and all that other guy got was a frickin’ ticket for running a stop sign!!
The greater the injury, the greater the injustice. And here we have the seeds of an unconscious, but potentially devastating conflict: If I were uninjured, there’d be no injustice. My injury is the proof of the injustice I’ve endured. I need to prove my injury in court, to the insurer, to VA, to worker’s comp. They keep screwing me over. But my injury is proof of the injustice I’ve endured. My suffering and impairment shows them how wrong they are.
And even if there’s no legal battle, there’s a psychological battle. The anger and bitterness towards that other driver, perhaps, or towards the insurer who refuses to pay. My injury proves that what you did was horribly wrong. If I get better, it’s like I’m letting you off the hook!
So…how can I get better, when my injury is the proof of what’s been done to me, and my injury is proof that my anger and bitterness is justified?
And the deeper that sense of injustice, the more persistent the physical and
psychological injuries will be, the greater the anger and bitterness…and the more ridiculous words like “acceptance” and “forgiveness” will sound. “Letting go” won’t seem like much of an option.
When the anger and bitterness of Perceived Injustice are added to the mix, the injury, whether it’s physical or psychological, is going to be a hell of a lot less likely to heal.
Psychologists can help people find their way out of Perceived Injustice, by helping them learn that "acceptance," "forgiveness" and "letting go" aren't something you do for the perpetrator or The System; they're something you do for yourself.
But it would be an awful lot easier to achieve that if more people experienced more compassion when they seek the help they need.
The great irony is, The System usually treats people badly in an effort to save money. In reality, The System may be costing itself millions, by creating the conditions in which people are least likely to heal.
If only The System knew…Compassionate care saves money.
We get better when we feel heard and supported.
--Dr Jonathan Douglas
There’s a dark side to increasing awareness of suicide among first responders.
In the past, there was silence. Police services would quietly cover up the suicides of one of their own, in an effort to sidestep the shame and stigma that they assumed would go with such a thing…thereby contributing to that stigma, by making suicide something that couldn’t be discussed.
Today, we do the opposite. A suicide by a first responder is now announced in the media within hours; the annual counter goes up by one as we track the suicide statistics; Twitter and Facebook light up, as we respond with heartfelt dismay to yet another tragedy. Light is being shone in the places where there was once only darkness. The shame of suicide is reduced; it’s no longer viewed as a dishonourable act, but instead, for what it is: The final, fatal symptom of an insidious, festering wound.
This increased awareness, we sincerely hope, will save lives. It will encourage those in pain to seek help. It will force the authorities to provide the desperately needed services.
Unfortunately, the reporting of first responder suicides can also have a downside: It can create the impression that suicide is the inevitable, “natural” result of PTSD.
When “PTSD” and “suicide” become linked in the mind, the diagnosis can become a self-fulfilling prophesy. And that’s the last thing we want to happen, when the whole point of raising awareness is to save lives.
In fact, PTSD does carry a serious risk of suicide. But, it’s very far from inevitable. Many people will struggle with their traumatic memories for the rest of their natural lives; many will benefit significantly from treatment; some will find their own ways to heal. Only a few will attempt suicide; fewer still will die.
But those are the stories that grab our attention. The stories of recovery and hope are out there…but they’re buried in the back of the paper. Stories of recovery don’t go viral within minutes of being posted; stories of recovery don’t get added to an annual counter.
We must remember: The lives lost to suicide are getting the attention in the media now. Not all who are exposed to trauma will get PTSD; not all with PTSD will try to end their lives. Most live; many get better.
So that’s the first part of my advice to those who are triggered by media stories of suicide. Remember this: My story doesn’t have to end like that. I can get a lot better from here. Feeling like this means I need to get help. And help is out there.
And here’s a great way to make sure your story isn’t added to the count someday.
You need a buddy.
First Responders and Veterans know you don’t go into a dangerous situation without letting someone know where you are.
When the black dog is stalking you, you’re in a dangerous situation. You need to tell someone where you are.
Right this moment, think of who you will tell if you’re in that dark place. If you find yourself thinking about suicide…if you’re looking for the means, weighing the options, or loading the weapon…make yourself this promise, right now: I’m going to tell someone. And right now, you need to choose who that person will be: Your best friend, your spouse, your family doctor, your psychologist…. Who will you call? Who will your buddy be?
You’ve got someone who will be there for you, someone you can trust, someone you know will move heaven and earth to help. That’s the person you’re going to decide, right now, before you need it, that you will tell.
Make yourself that promise. And make that promise to the person that will be there for you, because, guaranteed, they want to help.
--Dr Jonathan Douglas
With thanks and profound appreciation to Dr Dee Rajska for the concept of the Buddy System as a way to get through the darkest times, and to Badge of Life Canada for suggesting the post.