Assessing for firearm ownership

[Iparksiako]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

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[WisNeuro]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

We don't need any sort of evaluation or assessment, to buy firearms, so I don't know how much help people can offer. We can even get a concealed carry permit just sitting through a presentation. In some states you don't even need that.

 

[Fan_of_Meehl]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

Okay...so this highlights a very fundamental issue.

Since single acts of catastrophic violence (murder, mass shootings, etc.) are (thankfully) still extremely rare events, there exists a fundamental statistical barrier of predicting extremely rare events accurately without, basically, predicting routinely 'no' (i.e., that the event will not occur) every single time--otherwise, you're generally going to have TONS of 'false positive' predictions. I mean, if you WANT 9999 false positives to every 'true' positive prediction, then I guess that's fine.

There's also the issue that--as I understand it (it's been poorly articulated/operationalized)--you're basically being asked to predict behavior over an extremely long period of future time (e.g., for the duration of this person's owning of the firearm...possibly the rest of his/her life) vs. making a prediction over a more modest (1 week) time frame. I think this area is a bloody mess, frankly, and the only thing we can really be expected to do is assess imminent risk of violence (such as we already do in the context of determining if someone meets criteria for involuntary hospitalization at a particular point in time due to, for example, specific threats of serious violence, especially against named/specific individuals. The question of, 'Is this person okay to possess/carry a firearm? Are they gonna be the next mass shooter (or will they shoot their spouse) at some point over the next 20 years?' isn't really something that we've mapped out yet as a profession. I think the legislation and public outcry for 'mental health assessment' to predict/prevent these sorts of extremely rare events is way out ahead of any tractable psychological technology to actually do so reliably and validly. We don't have a crystal ball.

 

[Iparksiako]

Even if you detect old or current psychopathology, couldn't that be a false positive?

For instance someone had a depressive episode 3 years ago.

 

[WisNeuro]

Even if you detect old or current psychopathology, couldn't that be a false positive?

For instance someone had a depressive episode 3 years ago.

This would not even come close to triggering an assessment in a red flag law state.

 

[Fan_of_Meehl]

Even if you detect old or current psychopathology, couldn't that be a false positive?

For instance someone had a depressive episode 3 years ago.

And how do you operationalize 'psychopathology?' I mean, the last I read, something on the order of 50% of the population meets criteria at some point for a diagnosable 'mental disorder' according to DSM-5.

Obviously (perhaps), someone with merely a specific phobia of flying shouldn't be denied based on having that disorder.

Equally obviously, someone who is in an active manic phase of bipolar I disorder and who actually believes that he has been told by God to murder all democrats should be denied.

But, between those two extremes, things get tricky.

 

[FrustratedFamDoc]

Off topic, but, any idea how background checks for mental illness before gun ownership would EVER get through without a HIPPA violation, or is this just a political talking point for upcoming re-election campaigns? Like, who the hell do they even query/ask for such records?

 

[WisNeuro]

Off topic, but, any idea how background checks for mental illness before gun ownership would EVER get through without a HIPPA violation, or is this just a political talking point for upcoming re-election campaigns? Like, who the hell do they even query/ask for such records?

We do this in other areas (e.g., FAA evaluations). Granted, those evals are more comprehensive, but this is far from impossible.

 

[michaelrack]

Off topic, but, any idea how background checks for mental illness before gun ownership would EVER get through without a HIPPA violation, or is this just a political talking point for upcoming re-election campaigns? Like, who the hell do they even query/ask for such records?

There are HIPAA exceptions that may apply, or the patient could sign a waiver

 

[wolfvgang22]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

U.S. psychiatrists aren't involved in gun licensing in the U.S. So we in fact may have even less experience in assessing who should have firearms or not. There are no guidelines. There is little research and no training on this topic in the U.S. due ro politics in the U.S. It is a controversial topic even among many U.S. psychiatrists so most answers will be politically motivated and of limited utility. Sorry.

 

[Liquid8]

Working in Australia, reporting on the suitability for a firearms licence is something I’ve had to do on a few rare occasions for similar reasons. Gun ownership in metropolitan areas is also not as common as in the US.

Here, if an applicant is applying for a new or renewing a firearm licence, they are required to declare whether they have been treated for certain medical issues in the past 5 years. These include (but are not limited to) mental health concerns, substance abuse problems and neurological conditions. At that point, the local police will sent out requests for further information if they see fit.

I remember the first one I did was for a patient going through a messy divorce, and as part of that process he had already voluntarily surrendered his licence as part of a frivolous intervention order which the police weren’t going to contest. My patient had been involved in pest control for many years, also had a reference from one of his long term clients and his hunting rifles were with another family member in a locked safe.

Looking over my files, the request was not particularly onerous. They wanted a brief statement addressing the following points:

1) When was the last time you treated the applicant?
2) The patient’s past and present behaviour.
3) The nature of the condition, and its treatment including medications and likely impacts.
4) A clear statement in your opinion as to whether the person is a fit and proper person to be in possession of a firearm licence or whether the patient/client poses a threat to themselves, or the community.

When this request was brought up, I had already seen the patient about 3 or 4 times so was reasonably comfortable commenting on their longitudinal mental state. If it had been on the first appointment, I think I’d have been much more hesitant.

 

[Sushirolls]

Off topic, but, any idea how background checks for mental illness before gun ownership would EVER get through without a HIPPA violation, or is this just a political talking point for upcoming re-election campaigns? Like, who the hell do they even query/ask for such records?

One state I've worked in, only submitted involuntary hospitalizations, to databases. 72 hour holds didn't count and not reported. Only if they truly were court ordered for treatment. The judge would also announce during the hearing that if court deems necessary to be held they would lose their firearm rights.

Often times, you mention this beforehand to some people, and they would say "fine, I'll stay voluntary and hurry up and get me out of here." Court avoided, stabilization typically achieved, and discharged, but with out any records of commitments and firearm loss.

In summary: The court sends the commitment off, so not a HIPPA violation.

 

[Sushirolls]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

Thank heavens I'm in America and firearms are a right.

 

[calvnandhobbs68]

There's also the issue that--as I understand it (it's been poorly articulated/operationalized)--you're basically being asked to predict behavior over an extremely long period of future time (e.g., for the duration of this person's owning of the firearm...possibly the rest of his/her life) vs. making a prediction over a more modest (1 week) time frame. I think this area is a bloody mess, frankly, and the only thing we can really be expected to do is assess imminent risk of violence (such as we already do in the context of determining if someone meets criteria for involuntary hospitalization at a particular point in time due to, for example, specific threats of serious violence, especially against named/specific individuals. The question of, 'Is this person okay to possess/carry a firearm? Are they gonna be the next mass shooter (or will they shoot their spouse) at some point over the next 20 years?' isn't really something that we've mapped out yet as a profession. I think the legislation and public outcry for 'mental health assessment' to predict/prevent these sorts of extremely rare events is way out ahead of any tractable psychological technology to actually do so reliably and validly. We don't have a crystal ball.

So, I agree with you on the very poor positive predictive value of many of these assessments.

However, you have it backwards in terms of ability to predict outcomes. In fact, ability to predict an outcome INCREASES the longer time period you look out because of the increasing prevalence of the event over time. This is very relevant in suicide risk evaluations. So actually, I'm much more comfortable saying someone has a CHRONICALLY elevated risk of suicide compared to the general population statistically due to risk factors because that's what's actually been studied. If you look at outcome assessments for suicide for instance, no studies generally look at risk factors relative to outcome for a time period <6 months and most of them look at years of followup.

We absolutely should NOT assert ourselves as being able in any way, shape or form to predict SHORT TERM risk because, statistically, we are terrible at this. Literally it seems no better than chance, you'd have just as much predictive value flipping a coin and discharging people from the ER. Again, this makes sense because of the relative rarity of these events (suicide, mass murders, etc). Do we still attempt to do this? Yes. Is it primarily a legal CYA thing? Absolutely.

So, it makes much more sense from an actual data standpoint to say "I believe this person is at an elevated long term risk of suicide due to their prior suicide attempt, major depressive disorder diagnosis, lack of social support, ongoing poorly controlled substance use. Because of this, I recommend they engage in long term longitudinal psychotherapy, substance use disorder treatment and psychiatric medication management to attempt to decrease this risk over time."

It also makes more sense to say "I believe this person is an elevated long term risk of homicide/threat to others due to their diagnosis of antisocial personality disorder, history of multiple violent offenses, poor impulse control, substance use, etc" rather than "I think this person is an acute risk of killing someone next week because of X risk factors". There is much more data for the former than the latter.

 

[Fan_of_Meehl]

Of course we predict short-term risk. Routinely. That is the very thing we are doing when someone presents with imminent risk of serious physical harm to self/others in the context of determining whether they need to be involuntarily hospitalized or not.

 

[calvnandhobbs68]

Of course we predict short-term risk. Routinely. That is the very thing we are doing when someone presents with imminent risk of serious physical harm to self/others in the context of determining whether they need to be involuntarily hospitalized or not.

And it's based on literally nothing. So flip a coin. You'll be just as accurate. It's legal handwaving that expects psychiatrists to look into their crystal ball and decide if they think someone is going to kill themselves within the next few days. Let me know what great data you find about short term (ex. 1 week) predictive value of these events. The opinion that "the only thing we can really be expected to do is assess imminent risk of violence"...just isn't supported by actual data.

Did you actually read what I wrote?

 

[PikminOC]

We do this in other areas (e.g., FAA evaluations). Granted, those evals are more comprehensive, but this is far from impossible.

Faa evals are extremely comprehensive

 

[WisNeuro]

Faa evals are extremely comprehensive

Really depends on the context. For a general check prior to getting a license, not so bad. If they are coming in after being reported for substance abuse, or a significant medical condition, now those are comprehensive.

We also probably have a different definition of comprehensive. My evals range from 1.5 hours of testing with some minimal record review, to 6-8 hours of testing with several thousand pages of record review.

 

[Bartelby]

I think those of us based in the U.S. will have little experience. Some people want evaluations to restore firearms rights, but typically that falls into the forensic / expert witness arena.

I would recommend reading the text of any relevant laws in your country and locality. Understanding what question the law is asking of you is a very important starting place.

 

[erg923]

The second amendment of the US Constitution should be repealed.

 

[WisNeuro]

The second amendment of the US Constitution should be repealed.

don't really need to repeal it, the current SCOTUS opened up the doors to eventually just revisit and nullify Heller.

 

[PikminOC]

Really depends on the context. For a general check prior to getting a license, not so bad. If they are coming in after being reported for substance abuse, or a significant medical condition, now those are comprehensive.

We also probably have a different definition of comprehensive. My evals range from 1.5 hours of testing with some minimal record review, to 6-8 hours of testing with several thousand pages of record review.

The neuropsych testing Ive seen for FAA has been the latter. I see psych patients, so they have red flags

 

[WisNeuro]

The neuropsych testing Ive seen for FAA has been the latter. I see psych patients, so they have red flags

If it's 6-8 hours of testing that's a red flag case. There's a shorter battery that can be done if it's a straightforward clearance.

 

[PikminOC]

If it's 6-8 hours of testing that's a red flag case. There's a shorter battery that can be done if it's a straightforward clearance.

I've seen longer clearances than that.

 

[WisNeuro]

I've seen longer clearances than that.

You may have, but it's not required for general clearance.

 

[Stagg737]

I am in Europe, while firearms ownership is not legal, people come and ask license because they either are private security guards, or hunters.

Now, there is no official guide on how to asssess for something like that. For instance some psychiatrists give the license at the first visit, while others ask for a 2-6 month time period.

I guess almost everyone here is American, so you have more experience on that department. How do you approach such an assessment?

Based on the bolded alone, I would not perform these evals. I look at this the same way I look at some letters for emotional support animals (like taking them on planes), if there are no clear guidelines or at the very least some tool that is available as an accepted measure then I'm not going to do this if there could be a risk of a catastrophic outcome.

As said above, the risk may be minimal to us due to the infrequency of such events, especially in some European countries. However, our ability to predict the future, especially the farther out we get, is at best mediocre. While we can discuss the general trends and prognoses of conditions that patients have, we have no ability to predict acute events in their life. That being said, if the event were to occur, it would be catastrophic enough that I wouldn't want my name associated with that case in any way. If we're just there to determine that the patient isn't some psychopath with some violent history, that's fine, but a psychiatrist isn't (usually) needed for that. As discussed in the ESA thread, this just seems like another way to attempt to shift liability to the physician.

 

[PikminOC]

Based on the bolded alone, I would not perform these evals. I look at this the same way I look at some letters for emotional support animals (like taking them on planes), if there are no clear guidelines or at the very least some tool that is available as an accepted measure then I'm not going to do this if there could be a risk of a catastrophic outcome.

As said above, the risk may be minimal to us due to the infrequency of such events, especially in some European countries. However, our ability to predict the future, especially the farther out we get, is at best mediocre. While we can discuss the general trends and prognoses of conditions that patients have, we have no ability to predict acute events in their life. That being said, if the event were to occur, it would be catastrophic enough that I wouldn't want my name associated with that case in any way. If we're just there to determine that the patient isn't some psychopath with some violent history, that's fine, but a psychiatrist isn't (usually) needed for that. As discussed in the ESA thread, this just seems like another way to attempt to shift liability to the physician.

What catastrophe from giving cats to a kid in college?

 

[Stagg737]

What catastrophe from giving cats to a kid in college?

Not catastrophic, but I don't want to be associated if the animal attacks someone. We take on enough liability as it is, I don't want to voluntarily sign up for more when it's unnecessary.

 

[smalltownpsych]

And it's based on literally nothing. So flip a coin. You'll be just as accurate. It's legal handwaving that expects psychiatrists to look into their crystal ball and decide if they think someone is going to kill themselves within the next few days. Let me know what great data you find about short term (ex. 1 week) predictive value of these events. The opinion that "the only thing we can really be expected to do is assess imminent risk of violence"...just isn't supported by actual data.

Did you actually read what I wrote?

Interesting discussion that you are having with fan_of_meehl. I guess one point is that we are often asked to make these kinds of short term predictions. The point you were making was that long term predictions are more accurate. Good point because obviously a doctor can always tell a patient that he is definitely going to die, just not always when.
As far as short term predictors go, I tend to rely on two, intoxication and what the patient tells me. Fortunaltely if they are drunk half the time they will tell you. “send me home so I can kill myself”. “Maybe we can talk about that more in the morning.” If they are in distress and sober, they usually accept hospitalization until they stabilize enough to say the right things to minimize my liability. I also begin administering treatment to mitigate the long range risk.

Back to the original topic of potential gun violence. I wouldn‘t recommend a gun for anyone with a history of violence or suicidality or substance use. I’d write a pet letter any day of the week before saying it’s ok for anyone to have a gun. Do I look that stupid?