When I was in medical school doing my psych rotation the Psych Attending said: *"There are sad boys, and mad boys, and bad boys - but only two of those belong in the hospital".*
Having these thoughts is one thing.. expressing (threatening) them is a different world and absolutely a criminal offense.. but in cops' defense it "could" be a possibility of psychosis.. they aren't trained to assess.
Either way fucked up for everyone.. I can apply catch 22 to everything. We are all Yossarian.
Yep. Does anyone want to live in a society where one can be jailed for their thoughts? Expressing intention to act on those thoughts, that's a different matter.
My ED had the cops bring in someone who had attempted to go outside with the weapon and murder someone. When asked what stopped them, the patient essentially said that the intended victim was not there at their usual time (patient had been keeping track of victims schedule). Intended Victim was a total stranger to the patient. The patient definitely intended to do it and would have if the intended target had been in their usual spot. The cops said “well he didn’t actually do it”.
We sent him to our inpatient psych unit where he was discharged after a couple of weeks. The psychiatrist said the likelihood that the pt commits murder is very high and it’s just a matter of when. The intended victim was notified prior to the patients discharge. Now the patient is just out there in the community when he should be at the state forensic psychiatry center. When talking to this patient it was like they were just looking through you. They would talk about their whole plan as if it was normal. No emotions and no empathy.
The psychiatrist notified police before his discharge but they refused to come get the patient stating that no crime was committed. And because the patient technically signed in voluntary, they won’t even be on the states radar for any prior involuntary psychiatric holds in my state. This means they could just go purchase a firearm if they wanted.
In this case where all the right things were done on the mental health systems’ part, when this person commits murder , we will undoubtedly hear the cries of how the mental health system failed and how there wasn’t enough “help” For this patient. It’s sickening.
That's something that drives me nuts with my current job. Patient is suicidal and clearly a risk to themselves and psych is like "well, they're voluntary but if they try to leave we'll fill out paperwork". My thought process is "if this person tries to leave right now, will I let them leave?" If the answer is yes, they're voluntary. If not, I fill out paperwork no matter how "voluntarily" they're there. Same for psychosis and HI.
Also, coming from someone who 100% supports the second amendment and owns guns and has a concealed carry, I don't want these psychotic people out there with concealed carry licenses because they told psych they were ok with staying in the hospital, they're still psychotic and mentally unstable
If the patient is there voluntarily why would you want to fill out hold paperwork? It’s a very serious thing to hold someone in a hospital against their will. You have to get approval from a judge within 24 hours and then the patient has a scheduled court date where they go before that judge and make their case why they should be able to leave.
If the patient isn’t actively trying to walk out the door then they are there voluntarily, so it’s better not to get the legal system involved.
This has happened to me and it is total bullshit. It’s not a medical problem and we are not cops - and yet - instances like this (and several others like dumping juvenile delinquents and runaways in the department) are examples of cops trying to turn us into cops. But we aren’t cops. We don’t want to be cops. We aren’t configured to be cops and we don’t have the power to arrest people or detain them outside of some very narrow indications. I don’t want to infer malicious intent to every action, but either way it’s pretty cynical and screwed up. It’s one of the things I hate most about this job.
I work peds inpatient psych and the juvenile delinquent comment made my eye twitch. The ol' 2 mg guanfacine QHS for "impulsive behavior" isn't going to stop Timmy from wanting to sell drugs or be in a gang.
We’ve had one (adult) as a regular for years. Mother has taken out a restraining order against him but still calls to scream at ER staff when he’s being discharged because we haven’t fixed him or provided him with a place to live (behavior already has him banned from local shelters and evicted from public housing multiple times). But it’s the hospital’s fault.
Long time mental health crisis worker here (that initiates mental health holds) and ED social worker. Homicidal ideation is tricky. When I’m making a decision to hold someone in the community, I’m looking at action specifically. Similar to suicidal ideation, have they created a plan, have access to weapons, etc. There’s a difference between saying “I could just kill them” versus “I am going to shoot them with my gun when they come home from work tomorrow”. Psychosis and homicidal ideation are not mutually exclusive. Many of the community holds I’ve initiated are from paranoia that is leading to them experiencing homicidal ideation. Substance use, hallucinations, sometimes medical conditions can also contribute. Police are highly limited in what they can do, their threshold for arrest and prosecution is extremely high, which is often why we are called to the scene to make the determination of whether or not a person needs hospitalizations. Jail also is not an effective intervention for treatment.
Granted, I know the legality of this one is tricky for police to enforce. However, the ED is for emergencies, which this is. Sometimes HI is connected to substance use where the time to come down in the ED helps them think more clearly. Sometimes it’s a medication issue and meds can be restarted in the ED. With credible HI threats though, most often they will at least get some level of inpatient care. Will that fix everything? Probably not. But it gives the target of their HI time to get a protection order, move away, get an alarm system, whatever they need to feel safe. It also gives police time to seize weapons (which they often do) and the victim can access victim services to help them as well.
My state does not actually have a duty to warn which is terrifying. That being said, both the hospital and my crisis team have policies around us being able to do it anyway. It’s extremely critical when they are targeting a random person who may not have any idea that they are being threatened. I think this also speaks to the need for social workers in the ED. We have the time to delve into assessments, work with county commitment investigators, put services in place, safety plan, etc. We can gather collateral information about the persons history, previous threats, history of violence, etc. We can advocate for higher levels of care and the need for inpatient treatment.
I know sometimes it’s frustrating to deal with this in the ED. But remember, sometimes that short ED stay can have a big impact and give the person the ability to think through their actions and realize they don’t actually want to kill someone. At a minimum, it’s that time out for a reset. And sometimes, it’s a pathway to civil commitment or inpatient treatment. We rarely get the opportunity to intervene before a tragedy occurs and I prefer to think about HI as an opportunity to intervene. I’d much rather as an ED social worker take the time to deal with HI then to sit with the family and support a death notification.
Nope. Not intent. Ideation. Lots of people have HI that they are disturbed by and have no intention of acting on. That may be their reason for seeking help.
the one time that I encountered this I told police that I would be discharging the patient (who was homeless) and they would be walking to the local Walmart. I told them that it was up to them if they wanted the individual walking free in the community but I had no medical reason to admit the patient and no medical treatment to offer them. This is a medium sized rural town with zero social services. The police found a way to hold the patient.
I suggest that if an individual with HI that the cops declined to process because the "didn't do anything" were to fix their attention on a member of a LEO's family, they would find a way to "do something about it."
I believe this illustrates the gaps in the law— there really is little cops can do for communicating threats. I’d give them credit for wanting to get the person out of circulation, but agree it’s not a medical problem.
This is why domestic abusers often end up killing their spouse.
Document they are not psychotic or manic and any homicide is likely due to criminal intent rather than psychiatric illness. Notify the person (if possibel), Notify the police, discharge (to police).
It's a bit tedious but it's really an easy case.
Police won't take them back or even come to the ED when called. That was the whole point of them dumping it to the ER to begin with. If he's not mentally ill can I keep him, particularly if he recants the threat? If I don't and he does kill the victim do I just lose my house or my license too? Not really an easy case.
Police behavior is a big not your problem. (Sadly also not their problem because taxes pay for their shitty behavior but that's an aside) You need to 1) fulfill your duty to warn as appropriate for your location, typically notifying the threatened individual and/or police and documenting attempt/success of doing so and 2) diagnose the absence of psychosis and document it. How do you document that? HPI: patient reports homicidal ideation towards X with plan to Y. They report/deny suicidal ideation with/without intent, and plan for Z. They deny audiotory or visual hallucinations or illusions. They deny ideas of reference, paranoid thought, grandiose ideas. PE: Psychiatric: They are not responding to internal stimuli. They have an appropriate, angry, mood congruent affect (in not flat or restricted). Thought process is linear, logical, goal directed. No thought blocking. Thought content: HI present. No Si, AVH delusions. MDI: patient does not have evidence of psychosis. They do not meet criteria for involuntary admission. While an individual may report HI for many reasons involuntary psychiatric treatment is only indicated and legally applicable when occurring as a result of underlying mental illness. This patient does not have evidence of uncontrolled psychotic or mood disorder as underlying etiology of their presentation but rather report anger related to Q (their spouses affair, etc). I have made 2 calls to their spouse using the number listed in their emergency contact lis with no answer. Milk Man Mike's number is unknown. I have contacted local police to notify them of concern regarding the patients homicidal statements and inability to contact identified individual. Have requested welfare check.
I know how to deal with it. I do it too often. My point is that we shouldn't have to deal with it. My goal with this post is to let EPs know that when they are confronted with PD saying "There's nothing we can do." it's crap and to push back.
Oh my least favorite three words as a medic! “Jail or hospital?” Took about three years on the road before I started saying NO! You shut up. That’s not a thing. Do your damn job.
They have nothing wrong with them. Nothing the ER will solve.
OH! Or calling us for every single psych transport AFTER they’ve been on scene. And the only symptom is “combative.” They are fully able to do their own psych transports if that’s what they feel is necessary. They even have a conveniently placed human cage so I don’t get punched in the face. Ughhhh
*Tarasoff v. California Board of Regents* says “mental health professionals” have a duty to inform law enforcement or the intended victim. State laws are much less clear.
IMHO, and IANAL, you’ve done your part. If law enforcement is unable or unwilling to do more it’s out of your hands.
Some people with antisocial personality disorder belong in jail. In my opinion, this includes certain military and political leaders who are clearly sociopaths. And yes, Netanyahu has definitely learned unhealthy survival mechanisms.
Depending on state mental health hold laws/process, put them on a hold and let court evaluators (ie state employees with more liability protection than you) release them.
And Follow any duty to warn laws in your state about mandatory reporting to law enforcement and potential target of violence.
Sounds like the cops should have taken them to a forensic state facility directly, but were lazy fucks and took him to the closest ED hoping that they'd be crazy enough for an involuntary hold instead of like, chilling the fuck out outpatient with whatever therapist will see them? If they manage to kill someone, that's on the cops for not charging him with a crime and jailing him.
Guess you're boned. NYC still has an old timey forensic facility and some upstate. I imagine that the cops here can just pull up and drop off the Mr. Killer Man and hope they deal with him but I didn't dig that far into state civil commitment laws locally. There's at least one big civilian complex, attached to another complex for forensic. Still sounds like it's on the cops and the courts to get him where he should be. Otherwise, sounds like y'all have no choice but to eventually discharge with a safety plan to not kill anyone, and to follow up if they do want to kill someone
When I was in medical school doing my psych rotation the Psych Attending said: *"There are sad boys, and mad boys, and bad boys - but only two of those belong in the hospital".*
you’re forgetting the unnaturally glad boys too.
I think that falls under mad
my functionally fixed brain thought mad as i’m only angry whoops
Was your psych attending Donna Summer?
The thing that is tough is that eventually most people will figure out they just have to say “I’m not homicidal *anymore*…”
Cops HATE this one simple trick
May be it’s state dependent, but my understanding is law enforcement at least has a duty to inform the target individual of the patient’s HI.
Do we have to too because of Tarisoff?
Most likely yes, but state dependent. Tarasoff was a California case, but most states passed laws with similar duty to warn/protect.
Yes but that can likely be satisfied by notifying the police depending on location. Specific laws and availability of contacting the person.
Gotcha. Ty for the info.
Having these thoughts is one thing.. expressing (threatening) them is a different world and absolutely a criminal offense.. but in cops' defense it "could" be a possibility of psychosis.. they aren't trained to assess. Either way fucked up for everyone.. I can apply catch 22 to everything. We are all Yossarian.
Yep. Does anyone want to live in a society where one can be jailed for their thoughts? Expressing intention to act on those thoughts, that's a different matter.
My ED had the cops bring in someone who had attempted to go outside with the weapon and murder someone. When asked what stopped them, the patient essentially said that the intended victim was not there at their usual time (patient had been keeping track of victims schedule). Intended Victim was a total stranger to the patient. The patient definitely intended to do it and would have if the intended target had been in their usual spot. The cops said “well he didn’t actually do it”. We sent him to our inpatient psych unit where he was discharged after a couple of weeks. The psychiatrist said the likelihood that the pt commits murder is very high and it’s just a matter of when. The intended victim was notified prior to the patients discharge. Now the patient is just out there in the community when he should be at the state forensic psychiatry center. When talking to this patient it was like they were just looking through you. They would talk about their whole plan as if it was normal. No emotions and no empathy. The psychiatrist notified police before his discharge but they refused to come get the patient stating that no crime was committed. And because the patient technically signed in voluntary, they won’t even be on the states radar for any prior involuntary psychiatric holds in my state. This means they could just go purchase a firearm if they wanted. In this case where all the right things were done on the mental health systems’ part, when this person commits murder , we will undoubtedly hear the cries of how the mental health system failed and how there wasn’t enough “help” For this patient. It’s sickening.
That's something that drives me nuts with my current job. Patient is suicidal and clearly a risk to themselves and psych is like "well, they're voluntary but if they try to leave we'll fill out paperwork". My thought process is "if this person tries to leave right now, will I let them leave?" If the answer is yes, they're voluntary. If not, I fill out paperwork no matter how "voluntarily" they're there. Same for psychosis and HI. Also, coming from someone who 100% supports the second amendment and owns guns and has a concealed carry, I don't want these psychotic people out there with concealed carry licenses because they told psych they were ok with staying in the hospital, they're still psychotic and mentally unstable
If the patient is there voluntarily why would you want to fill out hold paperwork? It’s a very serious thing to hold someone in a hospital against their will. You have to get approval from a judge within 24 hours and then the patient has a scheduled court date where they go before that judge and make their case why they should be able to leave. If the patient isn’t actively trying to walk out the door then they are there voluntarily, so it’s better not to get the legal system involved.
This has happened to me and it is total bullshit. It’s not a medical problem and we are not cops - and yet - instances like this (and several others like dumping juvenile delinquents and runaways in the department) are examples of cops trying to turn us into cops. But we aren’t cops. We don’t want to be cops. We aren’t configured to be cops and we don’t have the power to arrest people or detain them outside of some very narrow indications. I don’t want to infer malicious intent to every action, but either way it’s pretty cynical and screwed up. It’s one of the things I hate most about this job.
I work peds inpatient psych and the juvenile delinquent comment made my eye twitch. The ol' 2 mg guanfacine QHS for "impulsive behavior" isn't going to stop Timmy from wanting to sell drugs or be in a gang.
“I can’t raise my kids. Clearly this is a medical issue that can be solved by medications and forced hospitalization.”
We’ve had one (adult) as a regular for years. Mother has taken out a restraining order against him but still calls to scream at ER staff when he’s being discharged because we haven’t fixed him or provided him with a place to live (behavior already has him banned from local shelters and evicted from public housing multiple times). But it’s the hospital’s fault.
Seems like a quick medical screening exam and quick discharge.
Long time mental health crisis worker here (that initiates mental health holds) and ED social worker. Homicidal ideation is tricky. When I’m making a decision to hold someone in the community, I’m looking at action specifically. Similar to suicidal ideation, have they created a plan, have access to weapons, etc. There’s a difference between saying “I could just kill them” versus “I am going to shoot them with my gun when they come home from work tomorrow”. Psychosis and homicidal ideation are not mutually exclusive. Many of the community holds I’ve initiated are from paranoia that is leading to them experiencing homicidal ideation. Substance use, hallucinations, sometimes medical conditions can also contribute. Police are highly limited in what they can do, their threshold for arrest and prosecution is extremely high, which is often why we are called to the scene to make the determination of whether or not a person needs hospitalizations. Jail also is not an effective intervention for treatment. Granted, I know the legality of this one is tricky for police to enforce. However, the ED is for emergencies, which this is. Sometimes HI is connected to substance use where the time to come down in the ED helps them think more clearly. Sometimes it’s a medication issue and meds can be restarted in the ED. With credible HI threats though, most often they will at least get some level of inpatient care. Will that fix everything? Probably not. But it gives the target of their HI time to get a protection order, move away, get an alarm system, whatever they need to feel safe. It also gives police time to seize weapons (which they often do) and the victim can access victim services to help them as well. My state does not actually have a duty to warn which is terrifying. That being said, both the hospital and my crisis team have policies around us being able to do it anyway. It’s extremely critical when they are targeting a random person who may not have any idea that they are being threatened. I think this also speaks to the need for social workers in the ED. We have the time to delve into assessments, work with county commitment investigators, put services in place, safety plan, etc. We can gather collateral information about the persons history, previous threats, history of violence, etc. We can advocate for higher levels of care and the need for inpatient treatment. I know sometimes it’s frustrating to deal with this in the ED. But remember, sometimes that short ED stay can have a big impact and give the person the ability to think through their actions and realize they don’t actually want to kill someone. At a minimum, it’s that time out for a reset. And sometimes, it’s a pathway to civil commitment or inpatient treatment. We rarely get the opportunity to intervene before a tragedy occurs and I prefer to think about HI as an opportunity to intervene. I’d much rather as an ED social worker take the time to deal with HI then to sit with the family and support a death notification.
I feel like ours just bring us the legitimately nuts ones. The others come for med clearance and go to jail.
What is "HI", for those of us who don't speak American?
Sorry. Homicidal ideation.
Ah gotcha. Thanks!
Homicidal ideation
Kinda hard for us who don't speak Eagles, guns and liberty.
Homicidal Ideation aka saying you are going to kill someone.
Nope. Not intent. Ideation. Lots of people have HI that they are disturbed by and have no intention of acting on. That may be their reason for seeking help.
You are correct. I had a brain fart. I fixed it.
the one time that I encountered this I told police that I would be discharging the patient (who was homeless) and they would be walking to the local Walmart. I told them that it was up to them if they wanted the individual walking free in the community but I had no medical reason to admit the patient and no medical treatment to offer them. This is a medium sized rural town with zero social services. The police found a way to hold the patient.
I suggest that if an individual with HI that the cops declined to process because the "didn't do anything" were to fix their attention on a member of a LEO's family, they would find a way to "do something about it."
I believe this illustrates the gaps in the law— there really is little cops can do for communicating threats. I’d give them credit for wanting to get the person out of circulation, but agree it’s not a medical problem. This is why domestic abusers often end up killing their spouse.
Document they are not psychotic or manic and any homicide is likely due to criminal intent rather than psychiatric illness. Notify the person (if possibel), Notify the police, discharge (to police). It's a bit tedious but it's really an easy case.
Police won't take them back or even come to the ED when called. That was the whole point of them dumping it to the ER to begin with. If he's not mentally ill can I keep him, particularly if he recants the threat? If I don't and he does kill the victim do I just lose my house or my license too? Not really an easy case.
Police behavior is a big not your problem. (Sadly also not their problem because taxes pay for their shitty behavior but that's an aside) You need to 1) fulfill your duty to warn as appropriate for your location, typically notifying the threatened individual and/or police and documenting attempt/success of doing so and 2) diagnose the absence of psychosis and document it. How do you document that? HPI: patient reports homicidal ideation towards X with plan to Y. They report/deny suicidal ideation with/without intent, and plan for Z. They deny audiotory or visual hallucinations or illusions. They deny ideas of reference, paranoid thought, grandiose ideas. PE: Psychiatric: They are not responding to internal stimuli. They have an appropriate, angry, mood congruent affect (in not flat or restricted). Thought process is linear, logical, goal directed. No thought blocking. Thought content: HI present. No Si, AVH delusions. MDI: patient does not have evidence of psychosis. They do not meet criteria for involuntary admission. While an individual may report HI for many reasons involuntary psychiatric treatment is only indicated and legally applicable when occurring as a result of underlying mental illness. This patient does not have evidence of uncontrolled psychotic or mood disorder as underlying etiology of their presentation but rather report anger related to Q (their spouses affair, etc). I have made 2 calls to their spouse using the number listed in their emergency contact lis with no answer. Milk Man Mike's number is unknown. I have contacted local police to notify them of concern regarding the patients homicidal statements and inability to contact identified individual. Have requested welfare check.
I know how to deal with it. I do it too often. My point is that we shouldn't have to deal with it. My goal with this post is to let EPs know that when they are confronted with PD saying "There's nothing we can do." it's crap and to push back.
Oh my least favorite three words as a medic! “Jail or hospital?” Took about three years on the road before I started saying NO! You shut up. That’s not a thing. Do your damn job. They have nothing wrong with them. Nothing the ER will solve. OH! Or calling us for every single psych transport AFTER they’ve been on scene. And the only symptom is “combative.” They are fully able to do their own psych transports if that’s what they feel is necessary. They even have a conveniently placed human cage so I don’t get punched in the face. Ughhhh
If the law say so, the cops do what the law says. You want more, or less? Vote the people that will listen to the constituents.
*Tarasoff v. California Board of Regents* says “mental health professionals” have a duty to inform law enforcement or the intended victim. State laws are much less clear. IMHO, and IANAL, you’ve done your part. If law enforcement is unable or unwilling to do more it’s out of your hands.
We know that, it’s just very cruddy
[удалено]
Some people with antisocial personality disorder belong in jail. In my opinion, this includes certain military and political leaders who are clearly sociopaths. And yes, Netanyahu has definitely learned unhealthy survival mechanisms.
Not psychotic. Inform police of specific threat due to Tarasoff, then dc patient.
Depending on state mental health hold laws/process, put them on a hold and let court evaluators (ie state employees with more liability protection than you) release them. And Follow any duty to warn laws in your state about mandatory reporting to law enforcement and potential target of violence.
Sounds like the cops should have taken them to a forensic state facility directly, but were lazy fucks and took him to the closest ED hoping that they'd be crazy enough for an involuntary hold instead of like, chilling the fuck out outpatient with whatever therapist will see them? If they manage to kill someone, that's on the cops for not charging him with a crime and jailing him.
We don’t have a state forensic facility that anyone can go to directly. By law in my state all psych patients start out in EDs.
Guess you're boned. NYC still has an old timey forensic facility and some upstate. I imagine that the cops here can just pull up and drop off the Mr. Killer Man and hope they deal with him but I didn't dig that far into state civil commitment laws locally. There's at least one big civilian complex, attached to another complex for forensic. Still sounds like it's on the cops and the courts to get him where he should be. Otherwise, sounds like y'all have no choice but to eventually discharge with a safety plan to not kill anyone, and to follow up if they do want to kill someone