Gunman kills 3 including therapist and psychologist

[cara susanna]

I think it's also because it's become trendy to be intellectually lazy and conspicuously virtuous in espousing simple, victimization narratives to explain complex, terrifying truths of existence, e.g., we could all be taken out at any time by a random, violent part of the universe (person or natural disaster) and, if we can find a scapegoat (e.g., lazy/ inept VA therapists) to blame it on, then we avoid both the cognitive work necessary to try to take a fair look at the complexity of the issue while simulaneously avoiding the existential realities implied by such tragedies. There's a surplus of adult developmental disorders and narcissism in the online and veteran populations.

Oh, yeah, for sure. People needing to rationalize tragedy like that is a basic tenant of cognitive processing therapy, and one that I definitely believe.

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[Fan_of_Meehl]

Oh, yeah, for sure. People needing to rationalize tragedy like that is a basic tenant of cognitive processing therapy, and one that I definitely believe.

Great point and probably why folks tend to reflexively look to blame themselves or others for tragedy they witness. I've also (anecdotally) observed that the 'hot' triggers for veteran's (who have PTSD) anger is most typically their detection of the same failings in others (e.g., laziness, ignorance, pride) that they attribute to themselves as having caused the tragedy, and about which they feel tremendous guilt. Prototypical would be the veteran who believes that his own laziness got his men killed in war and finds himself launching into tremendous anger when he apparently detects laziness in others. Maybe we should give some of the dynamic theorists their due

 

[erg923]

Great point and probably why folks tend to reflexively look to blame themselves or others for tragedy they witness. I've also (anecdotally) observed that the 'hot' triggers for veteran's (who have PTSD) anger is most typically their detection of the same failings in others (e.g., laziness, ignorance, pride) that they attribute to themselves as having caused the tragedy, and about which they feel tremendous guilt. Prototypical would be the veteran who believes that his own laziness got his men killed in war and finds himself launching into tremendous anger when he apparently detects laziness in others. Maybe we should give some of the dynamic theorists their due.

I found that some seemed to have a marked sense of external locus of control (and responsibility) regarding their own behavior or reactions.

I think I said in a thread before: When I worked in the VA, more than a handful of times I had veterans ask me what would happen if they just "lost it" on somebody who made them mad, or had a "flashback" and beat someone up killed someone.... or other things to that effect. I matter-of-factly told them that they would go to jail and then rapidly moved on/redirected. But they really seemed to expect a different answer!!! This always floored me.

 

[Therapist4Chnge]

This is the piece that worries me the most right now. Especially if the reports are true - that he was kicked out for threatening one of the women he eventually killed - his actions are confirmation that that decision was the correct one. We should not have to tolerate threats in our treatment settings, and people should not be allowed to bully their way into getting their needs met by threatening providers who set boundaries with them.

The problem with this (from the public perspective) is the expectation that we SHOULD be responsible for fixing these people. It’s an unfair burden driven by their fears, so arguing about it is typically not productive. We aren’t law enforcement, nor should we be...though there is an implied belief that we need to protect the public from “crazy” people....when in reality the vast majority of these attacks are done out of anger and not a loss of sanity. One of the worst things that has happened is the assumption mental health is the cause of the violence.

 

[DynamicDidactic]

The citation I was mentioning earlier
Schizophrenia and Violence: Systematic Review and Meta-Analysis

 

[NeuroLady]

I'm not familiar with all the elements of this case but I'm only an intern and I have seen multiple examples of patients who are not eligible for outpatient treatment due to a threat or a history of aggressive behavior (and for good reason) but are also not eligible for the next higher level of care because there is no imminent threat of harm and no crime to adjudicate. This may be due to limitations in some geographic areas but what are other mental health treatment options? From what little I know about this case, it seems that this guy was seeking help. Was there an alternative available to him? Was he offered those options? I'm not saying that mental illness = violence, but shouldn't we ask the question, "could mental health providers have done more to intervene?" Are our current practices of dealing with threats of violence adequate? If the answer is yes, then who's responsible in cases like this?

 

[erg923]

but shouldn't we ask the question, "could mental health providers have done more to intervene?" Are our current practices of dealing with threats of violence adequate? If the answer is yes, then who's responsible in cases like this?

I think this a dangerous thing to be picking at. We have a due diligence. And so do patients. So far as I can tell, his providers did their due diligence. We are not miracle workers, or sole magical healers. When we start asking what more we could have done, we play into the myth that we alone can fix/cure, that we alone of the one responsible for that, and that we can prevent acts of evil if we just "try harder."

 

[NeuroLady]

I think this a dangerous thing to be picking at. We have a due diligence. And so do patients. So far as I can tell, his providers did their due diligence. We are not miracle workers, or sole magical healers. When we start asking what more we could have done, we play into the myth that we alone can fix/cure, that we alone of the one responsible for that, and that we can prevent acts of evil if we just "try harder."

I think you're right. We can very easily get into the territory of victim blaming and perpetuating the myth that you describe. I don't think that we can point point a singular cause or decision making person but we can [and perhaps should] look at the greater system and ask , "did we do enough" and "can we do more?" The answer may be, "yes we did enough," "no we couldn't have done more," and "we can do everything right and tragedies like this still happen." However, from my newby perspective, there seems to be a hole where services could exist. Would that have prevented this awful event? I don't know. But I would like to hear whether you, and others, also see a gap in services when there is a threat or history of aggressive behavior.

 

[smalltownpsych]

I think you're right. We can very easily get into the territory of victim blaming and perpetuating the myth that you describe. I don't think that we can point point a singular cause or decision making person but we can [and perhaps should] look at the greater system and ask , "did we do enough" and "can we do more?" The answer may be, "yes we did enough," "no we couldn't have done more," and "we can do everything right and tragedies like this still happen." However, from my newby perspective, there seems to be a hole where services could exist. Would that have prevented this awful event? I don't know. But I would like to hear whether you, and others, also see a gap in services when there is a threat or history of aggressive behavior.

Yes. There is a huge gap when it comes to potential aggression. We can't hold someone against their will unless they are communicating an imminent threat and the truly dangerous are not going to tell you. Even when we do hold them, does it really mitigate risk and how long do we hold a non-psychotic potentially aggressive individual? I also don't think it is as much a mental health issue either as opposed to a legal and socio-cultural issue. In fact, part of the problem is when our society and criminal justice system looks at mental health as the solution/scapegoat for violent behavior.

 

[erg923]

I think you're right. We can very easily get into the territory of victim blaming and perpetuating the myth that you describe. I don't think that we can point point a singular cause or decision making person but we can [and perhaps should] look at the greater system and ask , "did we do enough" and "can we do more?" The answer may be, "yes we did enough," "no we couldn't have done more," and "we can do everything right and tragedies like this still happen." However, from my newby perspective, there seems to be a hole where services could exist. Would that have prevented this awful event? I don't know. But I would like to hear whether you, and others, also see a gap in services when there is a threat or history of aggressive behavior.

I want what i want, and if I dont get it, its other people's fault and they must die.

How would you suggest we prevent this?

 

[Fan_of_Meehl]

I'm going to offer the perspective that the same ideology that drives the 'we should/could have done more to prevent this person's final violent actions' is the same ideology that may have led to him being in such a desperate predicament in the first place and the same ideology that promotes maladaptive behavior and thoughts in this population. Whatever else PTSD is (as a psychological construct), it's also a narrative. Increasingly, it's a narrative in the public consciousness that creates what I would consider dysfunctional beliefs (from a CBT perspective) that actually, over the years, invite more tragedy into people's lives. Some of those take the form of...'Because I suffer from PTSD: 1) I'm not responsible for my actions, especially aggressive/hostile actions...because I 'black out' or dissociate or I was 'triggered'; 2) because I have PTSD, I am permanently disabled/useless and can't adopt any responsibility in life (in my family or in society); 3) because I have PTSD, I 'self-medicate' with alcohol/drugs and none of my symptoms are due to self-medication, they're due to 'my PTSD'; 4) my wife left be 'because I have PTSD,' and not because of any behavior I could do anything about (such as excessive drinking, unregulated anger/hostility, never taking responsibility for my thoughts/emotions/actions, etc.). The list is endless. Compassion is a virtue but it is not the ONLY virtue and must be counterbalanced with justice. Any 'virtue,' in excess, becomes a problem.

 

[Fan_of_Meehl]

I'm not familiar with all the elements of this case but I'm only an intern and I have seen multiple examples of patients who are not eligible for outpatient treatment due to a threat or a history of aggressive behavior (and for good reason) but are also not eligible for the next higher level of care because there is no imminent threat of harm and no crime to adjudicate. This may be due to limitations in some geographic areas but what are other mental health treatment options? From what little I know about this case, it seems that this guy was seeking help. Was there an alternative available to him? Was he offered those options? I'm not saying that mental illness = violence, but shouldn't we ask the question, "could mental health providers have done more to intervene?" Are our current practices of dealing with threats of violence adequate? If the answer is yes, then who's responsible in cases like this?

To me, the clear answer to the question, "who is responsible in cases like this" is to reject the implied premise (i.e., that 'someone must be responsible or 'to blame' for the incident). Not every tragedy requires a villain.

But I do hear what you're saying about fairly asking the question of 'could we engineer a BETTER system to address those in the middle-ground' and I think it's a fair question to ask.

 

[NeuroLady]

I want what i want, and if I dont get it, its other people's fault and they must die.

How would you suggest we prevent this?

There's no doubt that this is some seriously faulty thinking.

Can we prevent it? I'm doubtful. Can we respond to it differently? Sure. Will it make a difference? Maybe. Are we already doing everything we can? Perhaps. I don't know.

 

[NeuroLady]

To me, the clear answer to the question, "who is responsible in cases like this" is to reject the implied premise (i.e., that 'someone must be responsible or 'to blame' for the incident). Not every tragedy requires a villain.

But I do hear what you're saying about fairly asking the question of 'could we engineer a BETTER system to address those in the middle-ground' and I think it's a fair question to ask.

I suppose my question could be better worded. Not who can we hold accountable, but rather (as you mention), is there a better next step when someone is ineligible to participate in a mental health program due to threats of violence?

 

[Fan_of_Meehl]

There's no doubt that this is some seriously faulty thinking.

Can we prevent it? I'm doubtful. Can we respond to it differently? Sure. Will it make a difference? Maybe. Are we already doing everything we can? Perhaps. I don't know.

I guess we should probably address those questions at the level of *the individual* (patient/therapist/program) and it's hard to say without details at this point. I certainly don't think that there are likely to be any omnibus solutions to the problems of tragedy in mental health. I think we can manage risk, but not eliminate it.

 

[erg923]

There's no doubt that this is some seriously faulty thinking.

Can we prevent it? I'm doubtful. Can we respond to it differently? Sure. Will it make a difference? Maybe. Are we already doing everything we can? Perhaps. I don't know.

Patient seen for eval and LOC triage. Residential PTSD Treatment program offered. Patient admitted. Patient threatening staff, disrupting milieu, uncooperative with treatment. No one should be forced to treat individuals who are threatening them (his veteran status should not come into play here). He was thus administrative discharged from the program. So long as he was offered resources on where he could obtain treatment elsewhere, what are you suggesting? Drive him to a local PP? Do you think the VA should infantalize it's population even more than it already does? Don't you think he has a role to play in being responsible for his treatment? Its not like he was ID or floridly psychotic.

 

[Fan_of_Meehl]

I suppose my question could be better worded. Not who can we hold accountable, but rather (as you mention), is there a better next step when someone is ineligible to participate in a mental health program due to threats of violence?

Only one that leaps to mind is some sort of compelled treatment, which is just as likely to exacerbate as to ameliorate the problem of rage driven by narcissism

 

[NeuroLady]

I'm going to offer the perspective that the same ideology that drives the 'we should/could have done more to prevent this person's final violent actions' is the same ideology that may have led to him being in such a desperate predicament in the first place and the same ideology that promotes maladaptive behavior and thoughts in this population. Whatever else PTSD is (as a psychological construct), it's also a narrative. Increasingly, it's a narrative in the public consciousness that creates what I would consider dysfunctional beliefs (from a CBT perspective) that actually, over the years, invite more tragedy into people's lives. Some of those take the form of...'Because I suffer from PTSD: 1) I'm not responsible for my actions, especially aggressive/hostile actions...because I 'black out' or dissociate or I was 'triggered'; 2) because I have PTSD, I am permanently disabled/useless and can't adopt any responsibility in life (in my family or in society); 3) because I have PTSD, I 'self-medicate' with alcohol/drugs and none of my symptoms are due to self-medication, they're due to 'my PTSD'; 4) my wife left be 'because I have PTSD,' and not because of any behavior I could do anything about (such as excessive drinking, unregulated anger/hostility, never taking responsibility for my thoughts/emotions/actions, etc.). The list is endless. Compassion is a virtue but it is not the ONLY virtue and must be counterbalanced with justice. Any 'virtue,' in excess, becomes a problem.

Agree. There's an endless cycle of choosing how we respond. Us. Me. You. This gunman. Our perspective influences our decisions AND we are all responsible for our actions.

 

[Fan_of_Meehl]

Agree. There's an endless cycle of choosing how we respond. Us. Me. You. This gunman. Our perspective influences our decisions AND we are all responsible for our actions.

I think cases like this also strain the medical model/ metaphor of mental illness. The guy's problem may have been more at the existential/spiritual level and this may have prevented his engagement with treatment efforts. I mean, who kills a pregnant woman trying to help them? Someone pretty bitter at existence itself, I'd imagine. No real protocol for that.

 

[NeuroLady]

Patient seen for eval and LOC triage. Residential PTSD Treatment program offered. Patient admitted. Patient threatening staff, disrupting milieu, uncooperative with treatment. No one should be forced to treat individuals who are threatening them (his veteran status should not come into play here). He was thus administrative discharged from the program. So long as he was offered resources on where he could obtain treatment elsewhere, what are you suggesting? Drive him to a local PP? Do you think the VA should infantalize it's population even more than it already does? Don't you think he has a role to play in being responsible for his treatment? Its not like he was ID or floridly psychotic.

I appreciate your point. I agree that we should not be forced to treat individuals who behave like this. I think the reasons why he was discharged from the program make good sense. I support it, I'm not arguing otherwise. I also agree that we have a responsibility to respect and promote the autonomy of our patients and that our patients own a portion of responsibility in their treatment.

This is the point I'm attempting to make. I've seen the circumstance where patients are d/c'd from a psychiatric hospital and no one/ very few will take them because of a history of threats/violence. Shouldn't there be more options for these folks? The one's who want to engage in treatment?

ETA: I suppose I should also ask, do options like I describe already exist and I'm simply ignorant of them?

 

[Fan_of_Meehl]

I appreciate your point. I agree that we should not be forced to treat individuals who behave like this. I think the reasons why he was discharged from the program make good sense. I support it, I'm not arguing otherwise. I also agree that we have a responsibility to respect and promote the autonomy of our patients and that our patients own a portion of responsibility in their treatment.

This is the point I'm attempting to make. I've seen the circumstance where patients are d/c'd from a psychiatric hospital and no one/ very few will take them because of a history of threats/violence. Shouldn't there be more options for these folks? The one's who want to engage in treatment?

Ah...I think I see your point, and would agree. I've seen a definite (case-by-case) aversion to wanting to 'reach out' to patients with a recent history of treatment disengagement or aggressive behavior. Sure. That's a problem. Not sure what the solution is other than protocols/policies mandating the offering of different treatment options and case management followup. And then there's the whole transtheoretical model of behavior change and motivational interviewing stuff. I'm not sure this guy thought that HE actually had a problem or needed to change his approach...just speculating, but that usually underlies his sort of behavior (externalizing blame), which, of course is a poor prognostic indicator for therapy engagement.

 

[PsyDr]

Citation? I’ve seen some stuff linking command hallucinations and extreme persecutory delusions to violence (which, as you said, is limited subset) but not delusional disorder as a whole.

Looked back. I got this from Swanson's research in TCO from 1994-2006 and Beck 2004. I was wrong in some of it, because substance abuse plays a role in delusional violence as well. Swanson's 2000 article is very good.

I suppose my question could be better worded. Not who can we hold accountable, but rather (as you mention), is there a better next step when someone is ineligible to participate in a mental health program due to threats of violence?

Hell yes. I think you are missing that threatening someone with physical violence is called "assault" in legal circles (the physical act is called battery). We report such people to law enforcement, and the trier of fact can figure out how to best modify their behavior.

 

[erg923]

This is the point I'm attempting to make. I've seen the circumstance where patients are d/c'd from a psychiatric hospital and no one/ very few will take them because of a history of threats/violence. Shouldn't there be more options for these folks? The one's who want to engage in treatment?

Well, I know I would not want to treat someone like this. Would you? Maybe others have higher degree of risk tolerance? But I didn't go into forensic/correctional psychology for a reason.

Again, I hope you aren't suggesting creating policy that we mandate providers to take cases that they don't want to because of their assessment or the risk associated with it. Threatening people with serious harm is not some benign act, ya know? It's illegal. At that point, I would prefer the judicial system handle them. I might suspect you have never been seriously threatened by a patient?

 

[psychRA]

I'm not familiar with all the elements of this case but I'm only an intern and I have seen multiple examples of patients who are not eligible for outpatient treatment due to a threat or a history of aggressive behavior (and for good reason) but are also not eligible for the next higher level of care because there is no imminent threat of harm and no crime to adjudicate. This may be due to limitations in some geographic areas but what are other mental health treatment options? From what little I know about this case, it seems that this guy was seeking help. Was there an alternative available to him? Was he offered those options? I'm not saying that mental illness = violence, but shouldn't we ask the question, "could mental health providers have done more to intervene?" Are our current practices of dealing with threats of violence adequate? If the answer is yes, then who's responsible in cases like this?

I am not directly familiar with this case, but it's been reported that this particular patient was asked to leave the program after TWO YEARS of treatment because he had knives in his belongings (in violation of the rules) and he made threats against one of the women he killed. I am indirectly familiar with this program and the staff involved, and I can assure you that patients are offered numerous options and resources upon discharge.

I don't know what you think could have been done differently, but I'd love to hear your suggestions.

Violence is not a symptom of PTSD. The person responsible in this case is the person who pulled the trigger.

 

[WisNeuro]

Yeah, in the VA system, it's usually like a "10 strikes and you're out!" policy. In no other system do I see patients given the same leeway following threatening actions/behavioral issues.

 

[Fan_of_Meehl]

Yeah, in the VA system, it's usually like a "10 strikes and you're out!" policy. In no other system do I see patients given the same leeway following threatening actions/behavioral issues.

And I do believe that the extreme leniency and excuse-generation that the VA offers in the spirit of 'helping' these folks may actually backfire and harm them in the long run. Sometimes the kindest thing you can do to a person is tell them the truth or, at least, not tell them something that you KNOW to be untrue, in the spirit of being 'helpful.'

 

[cara susanna]

I'm going to offer the perspective that the same ideology that drives the 'we should/could have done more to prevent this person's final violent actions' is the same ideology that may have led to him being in such a desperate predicament in the first place and the same ideology that promotes maladaptive behavior and thoughts in this population. Whatever else PTSD is (as a psychological construct), it's also a narrative. Increasingly, it's a narrative in the public consciousness that creates what I would consider dysfunctional beliefs (from a CBT perspective) that actually, over the years, invite more tragedy into people's lives. Some of those take the form of...'Because I suffer from PTSD: 1) I'm not responsible for my actions, especially aggressive/hostile actions...because I 'black out' or dissociate or I was 'triggered'; 2) because I have PTSD, I am permanently disabled/useless and can't adopt any responsibility in life (in my family or in society); 3) because I have PTSD, I 'self-medicate' with alcohol/drugs and none of my symptoms are due to self-medication, they're due to 'my PTSD'; 4) my wife left be 'because I have PTSD,' and not because of any behavior I could do anything about (such as excessive drinking, unregulated anger/hostility, never taking responsibility for my thoughts/emotions/actions, etc.). The list is endless. Compassion is a virtue but it is not the ONLY virtue and must be counterbalanced with justice. Any 'virtue,' in excess, becomes a problem.

I think that this is one reason I'm concerned about how PTSD is increasingly portrayed/treated by the public. It's basically that the public, and not the person, is responsible for managiing the person with PTSD's emotions and that no one should have to experience any emotional distress unless it is chosen. This seems to come up a lot in comments on articles about trigger warnings or service/emotional support animals.

I think another concern I have is that the VA's focus on suicide prevention is mandating us to make some choices during treatment that, IMO, are not always therapeutically indicated.

 

[Fan_of_Meehl]

I think that this is one reason I'm concerned about how PTSD is increasingly portrayed/treated by the public. It's basically that the public, and not the person, is responsible for managiing the person with PTSD's emotions and that no one should have to experience any emotional distress unless it is chosen. This seems to come up a lot in comments on articles about trigger warnings or service/emotional support animals.

I think another concern I have is that the VA's focus on suicide prevention is mandating us to make some choices during treatment that, IMO, are not always therapeutically indicated.

Absolutely. One example is the mandatory detailed interviewing (and Suicide Behavior Report in CPRS) around non-suicidal self-injury. Textbooks will tell you not to freak out or over-respond, or reinforce (with attention) things like cutting (especially if you are very familiar with the person's history and have performed a thorough functional assessment of the behavior and have determined it is a means of getting social attention). However, when I raised this in an administrative setting, I was told to go ahead and do all the detailed interviewing (you know, because my clinical judgment could be suspect) and then let the 'suicide prevention coordinator' (LCSW) review my work to see if I'd made the right call.

 

[cara susanna]

On a similar note, does anyone familiar with this program know to what extent it enforced VA rules and policies? For instance, does this program have the same disruptive behavior reporting system? AFAIK, it's affiliated with the VA, but not itself VA, right?

 

[psychRA]

AFAIK, it's affiliated with the VA, but not itself VA, right?

It is (or was...operations are suspended indefinitely) a nonprofit organization and not affiliated with the VA. Certainly lots of patients were referred there through VA services and many staff members were former VA employees and/or trainees. Not governed by VA policies and not linked into CPRS or a DBRC.

 

[temppsych123]

I often try to imagine, in cases like this, how people would react if we had the same expectations of other professionals as are implicitly (or explicitly) put onto psychologists and other mental health care providers.

Imagine a person is financially struggling, at risk of being homeless, out of work, and in need of a loan. They go to a bank, fill out the paperwork, and the loan officer decides that they aren't eligible for the loan (maybe they don't have good credit, or whatever). The person pleads with the loan officer, explaining how much they need the money and how bad it will be if they don't get it. Loan officer says no. The person threatens the loan officer - give me the money or I'll come back here and kick your ass! Loan officer gets security to escort the person out of the building. The person comes back a day or two later and, lo and behold, they beat up the loan officer, who ends up in the hospital. Would the average person think, "Well, why didn't the loan officer just give him the loan? That's what the loan officer's job is, to give people loans, right? This whole problem could have been avoided! He really needed the money! Loans are meant to help people when they are struggling." Seems like there would be a very different set of expectations and reactions.

 

[smalltownpsych]

Absolutely. One example is the mandatory detailed interviewing (and Suicide Behavior Report in CPRS) around non-suicidal self-injury. Textbooks will tell you not to freak out or over-respond, or reinforce (with attention) things like cutting (especially if you are very familiar with the person's history and have performed a thorough functional assessment of the behavior and have determined it is a means of getting social attention). However, when I raised this in an administrative setting, I was told to go ahead and do all the detailed interviewing (you know, because my clinical judgment could be suspect) and then let the 'suicide prevention coordinator' (LCSW) review my work to see if I'd made the right call.

Makes me real happy I don't work in a VA. What the heck is detailed interviewing anyway? I was trained in DBT where you do a chain analysis of what caused the behavior and also I would do a risk assessment to determine risk of suicide and appropriate safety plan/intervention. Then to cap it off by having my documentation reviewed by someone else who wasn't there and never met the patient to make sure I documented right?

 

[erg923]

Makes me real happy I don't work in a VA. What the heck is detailed interviewing anyway? I was trained in DBT where you do a chain analysis of what caused the behavior and also I would do a risk assessment to determine risk of suicide and appropriate safety plan/intervention. Then to cap it off by having my documentation reviewed by someone else who wasn't there and never met the patient to make sure I documented right?

I used to work at a VA, and I actually don't know either. I was somewhat protected from this stuff, as worked in primary care and was not under the Mental Health Service Line formally. I rarely did the SBRs, even when, perhaps, I was "suppose to. I did do them on on a handful of new patients where it was serious attempt, and no other documentation of it existed in CPRS. They could be helpful, but usually were not.

 

[msgeorgeeliot]

Well, I know I would not want to treat someone like this. Would you? Maybe others have higher degree of risk tolerance? But I didn't go into forensic/correctional psychology for a reason.

Again, I hope you aren't suggesting creating policy that we mandate providers to take cases that they don't want to because of their assessment or the risk associated with it. Threatening people with serious harm is not some benign act, ya know? It's illegal. At that point, I would prefer the judicial system handle them. I might suspect you have never been seriously threatened by a patient?

In terms of providers having the right to refuse to take potentially violent patients — I can’t help but think of my training, where I had almost zero choice on this matter during my time at several VAs and other (non-forensic) settings. I do believe that everyone deserves help, but real talk here: clinical ish runs downhill to junior providers who lack autonomy/choice.

Eg, When I was in training, I had a new patient who suddenly jumped at me and tried to scratch my face. (Luckily I escaped due to my cat-like reflexes.) Subsequently, I told my training director that I couldn’t treat this person anymore. And...I was urged to reconsider, “for the sake of the patient to learn and grow from this experience.” Another eg, when I was in training, I was assigned a new patient who was clearly sociopathic, actively suicidal, and extremely violent by history. I asked the non-clinical person who blithely put him on my schedule about why he had stopped seeing his psychologist in the community several weeks prior. Response: “oh, because she refuses to see him anymore.”

To be clear, I don’t think trainees should refuse patients who are somehow novel or challenging (that’s what training is for). But I have seen so many examples of trainees feeling afraid to see certain patients, but more afraid of speaking up to their supervisors about their concerns.

I did speak up to my superiors in both instances, saying something to the effect of, “I appreciate that this clinic would like me to treat this patient, and that this patient might benefit from working with me, but I am not comfortable being this patient’s therapist.” In both cases, I was given the very clear message that I was “causing problems,” and that this might affect my letters of recommendation.

Based on my lived experience (re: a prior thread), I decided that I valued my safety and integrity more than a letter. I know I’m not alone in this experience from conversations I’ve had, though I don’t know how universal the phenomenon is. (Anecdote does not equal data, etc)

 

[erg923]

Eg, When I was in training, I had a new patient who suddenly jumped at me and tried to scratch my face. (Luckily I escaped due to my cat-like reflexes.)

 

[psychRA]

In terms of providers having the right to refuse to take potentially violent patients — I can’t help but think of my training, where I had almost zero choice on this matter during my time at several VAs and other (non-forensic) settings. I do believe that everyone deserves help, but real talk here: clinical ish runs downhill to junior providers who lack autonomy/choice.

That's disappointing. Aside from forensic settings, I think that all clinicians should have the right to set boundaries around violent or threatening patients, and trainees should be given even more leeway.

I don't recall very many situations coming up regarding potentially violent patients when I was a VA trainee (internship and postdoc, different sites) but those sites were very training-oriented and supportive of trainees. Now that I'm staff, I feel like one of my responsibilities is to shield our trainees from taking on clinical experiences that they're not yet prepared to handle.

I chose this position and this setting and I knew what I was getting myself into, but trainees have less experience and a lot less autonomy over where they're placed. When we go over expectations at the beginning of supervision, I'm very clear with my trainees that they have the right to end any clinical interaction that feels threatening or unsafe. I also add that if another other staff member implies anything to the contrary, the trainee should direct that staff member to me so that I can set them straight. It hasn't happened yet, but I would absolutely take on any staff member who tries to tell me that trainees aren't allowed to set boundaries around safety.

 

[msgeorgeeliot]

Erg, I am only liking this *ironically*

 

[msgeorgeeliot]

That's disappointing. Aside from forensic settings, I think that all clinicians should have the right to set boundaries around violent or threatening patients, and trainees should be given even more leeway.

I don't recall very many situations coming up regarding potentially violent patients when I was a VA trainee (internship and postdoc, different sites) but those sites were very training-oriented and supportive of trainees. Now that I'm staff, I feel like one of my responsibilities is to shield our trainees from taking on clinical experiences that they're not yet prepared to handle.

I chose this position and this setting and I knew what I was getting myself into, but trainees have less experience and a lot less autonomy over where they're placed. When we go over expectations at the beginning of supervision, I'm very clear with my trainees that they have the right to end any clinical interaction that feels threatening or unsafe. I also add that if another other staff member implies anything to the contrary, the trainee should direct that staff member to me so that I can set them straight. It hasn't happened yet, but I would absolutely take on any staff member who tries to tell me that trainees aren't allowed to set boundaries around safety.

Thanks for modeling a great supervision practice. I trained at excellent APA-accredited settings but was never given this message, which would have been awesome.

 

[cara susanna]

Makes me real happy I don't work in a VA. What the heck is detailed interviewing anyway? I was trained in DBT where you do a chain analysis of what caused the behavior and also I would do a risk assessment to determine risk of suicide and appropriate safety plan/intervention. Then to cap it off by having my documentation reviewed by someone else who wasn't there and never met the patient to make sure I documented right?

I've actually never had to file a suicidal behavior report for NSSI (or, as the VA calls it, self-directed violence without suicidal intent). Generally, I've been told it's only if the behavior actually was done with suicidal intent. You can do all of the above that you mentioned in the VA, but the safety plan follows a specific format. And you definitely can't implement the same behavioral contingencies surrounding suicidal behavior that you would in traditional DBT.

And I'm so sorry to hear that, msgeorgeliot. Even in settings in which I felt very micromanaged, threatening behavior was taken very seriously and we were allowed to refer those patients outside for care. I had a patient engage in a harassing and inappropriate behavior towards me. Not only were swift actions taken, but the administration kept checking in with me to see how I was doing.

 

[Fan_of_Meehl]

I've actually never had to file a suicidal behavior report for NSSI (or, as the VA calls it, self-directed violence without suicidal intent). Generally, I've been told it's only if the behavior actually was done with suicidal intent. You can do all of the above that you mentioned in the VA, but the safety plan follows a specific format. And you definitely can't implement the same behavioral contingencies surrounding suicidal behavior that you would in traditional DBT.

And I'm so sorry to hear that, msgeorgeliot. Even in settings in which I felt very micromanaged, threatening behavior was taken very seriously and we were allowed to refer those patients outside for care. I had a patient engage in a harassing and inappropriate behavior towards me. Not only were swift actions taken, but the administration kept checking in with me to see how I was doing.

I'm glad to hear that the folks in charge at your VA appreciate the distinction between NSSI and behavioral acts committed with the intent to die as a result. They probably even appreciate a distinction between topography vs.function of behavior. Gives me hope

 

[smalltownpsych]

That's disappointing. Aside from forensic settings, I think that all clinicians should have the right to set boundaries around violent or threatening patients, and trainees should be given even more leeway.

I don't recall very many situations coming up regarding potentially violent patients when I was a VA trainee (internship and postdoc, different sites) but those sites were very training-oriented and supportive of trainees. Now that I'm staff, I feel like one of my responsibilities is to shield our trainees from taking on clinical experiences that they're not yet prepared to handle.

I chose this position and this setting and I knew what I was getting myself into, but trainees have less experience and a lot less autonomy over where they're placed. When we go over expectations at the beginning of supervision, I'm very clear with my trainees that they have the right to end any clinical interaction that feels threatening or unsafe. I also add that if another other staff member implies anything to the contrary, the trainee should direct that staff member to me so that I can set them straight. It hasn't happened yet, but I would absolutely take on any staff member who tries to tell me that trainees aren't allowed to set boundaries around safety.

Agree with this 100% and have always communicated something along those lines to my supervisees. Talking about ensuring safety and setting appropriate boundaries is to me the first part of training. Should come right before suicide risk assessment.

In terms of providers having the right to refuse to take potentially violent patients — I can’t help but think of my training, where I had almost zero choice on this matter during my time at several VAs and other (non-forensic) settings. I do believe that everyone deserves help, but real talk here: clinical ish runs downhill to junior providers who lack autonomy/choice.

Eg, When I was in training, I had a new patient who suddenly jumped at me and tried to scratch my face. (Luckily I escaped due to my cat-like reflexes.) Subsequently, I told my training director that I couldn’t treat this person anymore. And...I was urged to reconsider, “for the sake of the patient to learn and grow from this experience.” Another eg, when I was in training, I was assigned a new patient who was clearly sociopathic, actively suicidal, and extremely violent by history. I asked the non-clinical person who blithely put him on my schedule about why he had stopped seeing his psychologist in the community several weeks prior. Response: “oh, because she refuses to see him anymore.”

To be clear, I don’t think trainees should refuse patients who are somehow novel or challenging (that’s what training is for). But I have seen so many examples of trainees feeling afraid to see certain patients, but more afraid of speaking up to their supervisors about their concerns.

I did speak up to my superiors in both instances, saying something to the effect of, “I appreciate that this clinic would like me to treat this patient, and that this patient might benefit from working with me, but I am not comfortable being this patient’s therapist.” In both cases, I was given the very clear message that I was “causing problems,” and that this might affect my letters of recommendation.

Based on my lived experience (re: a prior thread), I decided that I valued my safety and integrity more than a letter. I know I’m not alone in this experience from conversations I’ve had, though I don’t know how universal the phenomenon is. (Anecdote does not equal data, etc)

No one should ever be pressured to work with someone who has attacked them. It is my understanding that the duty to care is terminated at the moment that the patient is threatening to harm you both from a legal standpoint and an ethical standpoint. Actual aggression is not something to be “worked through”. That is more psychobabble bs that goes along with the belief that aggression is something to be therapized as opposed to managed with boundaries and consequences. Number one consequence being if you are not able to act appropriately, then you don’t get to talk to me. This belief that we just need to understand or talk through bad behavior is really harmful when it comes to kids too and I see that one every day. “No, little Johnny just needs to stop getting any type of positive reward for acting like a jerk. In other words, he can go to his room and come out when he is able to behave.” It isn’t that complicated.