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