Aurora shooting suspect's psychiatrist alerted colleagues of threat, but officials never contacted police

http://twitter.com/fossilfuels Funk Daddy

What is up with school administrators/et cetera dealing with issues of public safety within their own bubbles?

Just sayin, if I saw a child being raped in a locker room, i’d call the cops as soon as I could pull my phone out of the caved in face of the assailant.

Palomino

Churches do it. Maybe a statue or two will be torn down in retaliation.
- http://twitter.com/Theranthrope Theranthrope
  
  Perhaps start with the nightmare horse in front of Denver International Airport…
  - http://profiles.google.com/marc.k.mielke Marc Mielke
    
    That’s not a statue. That’s an actual horse of the Apocalypse just waiting for the right time.
Phil Fot

The psychiatrist obligated by law to contact the police if a patient is deemed dangerous to himself or others.

He fucked up by telling the school. He should have been on the phone to the police.

http://twitter.com/rvitelli Romeo Vitelli

Sounds like the SEP syndrome. His dropping out of school made him Someone Else’s Problem.

fuzzyfuzzyfungus

That’s actually what surprises me about this report(if accurate). By leaving the matter in the hands of their internal ”behavioral evaluation and threat assessment” team, the university didn’t succeed in washing their hands of the problem. And, since he was dropping out anyway, there wasn’t even a significant gain to be had by covering for him.

I’m inclined to wonder, given the relative listlessness with which the university didn’t cover its ass, whether danger-to-others reports are sufficiently rare that nobody actually knows what to do with them, or excessively common and treated as almost virtually false alarms…
- bzishi
  
  Dropping out is a red flag. It doesn’t necessarily indicate violence, but it does mean that the mental illness is becoming more severe. Unfortunately, the mental health system in the US is such crap that when a person loses a job or drops out of college that their mental health coverage stops or they are tossed around to different providers and services.
http://noadi.etsy.com/ Sheryl Westleigh

Unless the therapist had reason enough to go through the legal hoops of having him involuntarily committed once he left school he was no longer her patient and legally it was out of her hands. Our mental health system is totally broken and it’s not this doctor’s fault even though she’ll probably carry the guilt anyway for the rest of her life.
- marilove
  
  They couldn’t contact his parents? He had parents. Did they even attempt to do that very minimum? Or reach out to him in ANY WAY? They could have done *something*. They didn’t have to and of course you can’t (generally) force a grown man to get treatment, but they knew something was wrong and dropping out should have been a red flag. They did *nothing* which is awful.
  - http://www.nathanhornby.com/ Nathan Hornby
    
    I don’t think its standard practice for medical professionals to contact your parents with health concerns when you’re a grown man. And for good reason, it’s a very confidential form of treatment.
    
    But if you think he’s a real danger to others then you need to follow through with the correct procedure – but admittedly it’s delicate. Psych’s probably see a lot of unstable people – you can’t call the cops on all of them.
    
    Sounds to me like she did what she needed to do, but it wasn’t followed through. There’s probably only so much you can do off the back of ‘potentially dangerous’. I’m guessing he didn’t discuss anything concrete with her, which I imagine would have led to her informing the police.
    - marilove
      
      Ah, yeah, I didn’t consider that — that’s a good point. That said, there ARE things you can do. And they did nothing. *Nothing*.
    - Phil Fot
      
      In the US, shrinks are obligated to report dangerous patients to the police.
    - http://www.nathanhornby.com/ Nathan Hornby
      
      Dangerous, sure, but ‘potentially dangerous’ ?
    - Phil Fot
      
      @Nathan:disqus ,
      
      Yes, absolutely. Potentially dangerous in the official sense means there’s a strong possibility that the person may hurt himself or others.
  - klobba
    
    He wasn’t a minor, they would not have been allowed to contact his parents. Clearly while they felt there were warning signs, they did not meet whatever threshold they required to have him committed. It really is not as clear cut as people would like. There is only so much you are legally allowed to do, and institutions are cautious of overstepping their bounds because they are way more likely to be sued for huge amounts of money than they are to find a patient on a shooting spree.
    - Phil Fot
      
      The situation does not need to be one that warrants involuntary commitment. If there exists a serious potential for a dangerous outcome, the practitioner is obligated to contact the authorities.
  - chgoliz
    
    Actually, no, you can’t. HIPAA. The guy was an adult, not a minor. Parents have no right to the medical info on an adult child, unless they are listed in his medical power of attorney and he has been deemed unable to make his own medical decisions.
  - fuzzyfuzzyfungus
    
    Psychiatrists (as mandated reporters of specific things) can breach doctor-patient confidentiality under specific circumstances; but calling Mommy and Daddy on an adult certainly isn’t one of them…
Sparg

Yup. Typical bureaucratic behavior.

http://echofox3.blogspot.com efergus3

Forget about suing the theater – THERE is where the lawsuits should start. THEY knew that he was a possible danger to others.

SomeGuyNamedMark

Hindsight is perfect sight
- http://echofox3.blogspot.com efergus3
  
  Hindsight is always 20/20.
  - retepslluerb
    
    20/20 isn’t actually perfect sight.
    - http://lemoutan.blogspot.com/ Lemoutan
      
      I’d make do if it were for foresight though.
    - klobba
      
      But posters on the internet are always pedantic!
    - retepslluerb
      
      @kloba Yes, but on TV they are lovable! Bazinga!
    - http://www.nathanhornby.com/ Nathan Hornby
      
      I spent so long working with the optician to ensure that I maximised the effectiveness of my glasses that I came out with 20/40 vision.
      
      Although a mild super power, I still consider it one. The ability to see things sharply at twice the distance!
    - awjt
      
      40/20? or 20/10?
CH

I don’t quite understand why the first thought is to sue? Sue because the psychiatrist thought he was a possible danger to others? That doesn’t mean they knew, and the “possible danger to others” doesn’t mean they knew he was going to go on a shooting rampage.
- retepslluerb
  
  It’s the just universe fallacy. If something bad happened to people, they must’ve been either bad (not an option, in this case) or someone must be at fault. (Well, the shooters at fault, but if it turns out that he’s mentally ill, he might not be responsible. Though I understand that this doesn’t necessarily prevent Americans to execute him.)
- http://www.jjsaul.com Jim Saul
  
  I don’t see anyone talking about suing, though that will surely come eventually. I think the issue is clarifying the mechanisms of alert for mental health professionals falling under the “special relationship” rules when they have detailed information about credible and specific threats.
  
  The way I’m reading it, the psychiatrist made the call, but the administrative resistance to intervention smothered any followup.
  - http://echofox3.blogspot.com efergus3
    
    Actually some of the survivors are suing the theater.
- http://www.nathanhornby.com/ Nathan Hornby
  
  From what I understand Americans sue each other for pretty much anything. Apparently wads of cash make everything OK. Because, you know, lives = $$.
http://www.nathanhornby.com/ Nathan Hornby

“possible danger to others”. I’ll just reiterate that for you.

Hindsight is wonderful, but if we locked up every ‘potentially dangerous’ person on the planet there wouldn’t be many people left.

stevelaudig

It is another Paterno moment?

http://mikeoshea.net/ somnambulist

Once he left school there’s no safety net for mental health care. Even with insurance it’s barely covered for the few shrinks that even bother to accept insurance. It’s more then SEP, unless he’s a jabbering lunatic they’re not going to be able to commit him, I’m sure, based on what scant evidence the school psychiatrist had. And if they had committed him? He’d have been placed in a hellhole with the homeless, and likely released even more damaged in a month or two.

It’s easy and cheap as hell to get a gun, but near impossible afforf or receive decent mental health care in this country. But go on, keep finding other things and people to blame.

Sagodjur

The individual in these types of scenarios is always the one who bears the full blame for their actions. However, society as a whole can do more to mitigate and attempt to deter and prevent such scenarios by reducing the costs of mental health coverage.

It’s not the same dire issue, but it’s similar to the fact that our society doesn’t want to make sure their neighbors have more than living wages or good, affordable educations, despite the benefits that these things bring to preventing unwanted pregnancies, improving fiscal responsibility, and generally improving the quality of life for everyone.

http://mychemicaljourney.blogspot.com The Chemist

What this should become: A moment where we start to talk about mental health and the social infrastructure of this country.

What this will become: A moment where we pass long term legislation that will fuck over people with mental illnesses.

Stonewalker

To expand on yours, should be like this: Mandated reporting police about this stuff, which gives them some room to start an investigation.

What it will become: People with conditions a, b, c, d, e…. cannot do 1, 2, 3, 4….

Edit: Even mandated reporting might be too much… I don’t know. I do know that if people think their psychiatrist is going to go to the police, then people aren’t going to be talking to their psychiatrists.
- http://profiles.google.com/marc.k.mielke Marc Mielke
  
  The first thing every one of the mental health personnel I’ve talked to say is that everything is confidential EXCEPT for a short list of things I pretty much agree should be reported, namely threats of violence to one’s self, other people, and specifically the therapist zirself.

Brian McCabe

Without a specific threat, neither the therapist nor the school could do anything about it under federal law. Having a general sense that he could potentially do something is NOT enough to conclude culpability.

bzishi

Yes, exactly. Breaking confidentiality is a big deal in the mental health profession. For a psychiatrist to break confidentiality a person would have to make a threat to harm someone else or threaten to kill themselves. In those cases, that person would be committed to a psychiatric hospital.

I know there is a kneejerk response to say that the mental health system should inform police anytime someone could in any way potentially harm someone else. Unfortunately, there are a lot of people like that. If mental health services handed over the cases of everyone who could potentially harm someone else to police, there would be too many cases for the police to do anything about it. Alcoholism, anger management issues, drug abuse, psychosis, etc., make it possible for a person to potentially go and kill people (with alcoholism and drug abuse being the most dangerous attributes). There are thousands of people like this in EVERY community.

What I fear is that this is going to be used to lower the confidentiality requirements. The result will be that people who might have received treatment don’t because they are afraid of their private information being turned over to the police.

What is confusing in this case is why the psychiatrist broke confidentiality to report to the threat board, but didn’t try to commit him. Perhaps there is a part of the treatment contract that allows this. I don’t know, but it is strange.
- Palomino
  
  Then what’s her “job”? Why even do what she does? Not every psych visit is a “crisis”, most visits are “preventative”. What she didn’t do was trust her own observations. I know she’s going to live with that for the rest of her life. Maybe she’s the one on the couch now.
  
  CORRECTION: Meant to be a response to Brian McCabe.
  - bzishi
    
    Preventative? What are you talking about? How often have you gone to a psychiatrist and paid $250 – $500/hr just to verify your mental health is okay?
    
    Psychiatrists treat people who have a mental illness. That is her job. If a person threatens to hurt others then she is required to take action and commit that person to a psychiatric hospital. If a person has issues with anger, drug abuse, etc., then she uses her judgement. In some cases commitment may be needed, and in others treatment can continue in an outpatient clinic.
    - http://noadi.etsy.com/ Sheryl Westleigh
      
      I think what Palamino means by “preventive” is that it prevents a mental health issue from progressing to a crisis by treating it before the patient is a threat to themselves or others. To use an analogy: Diabetes can lead to serious complications that can kill the patient but treatment with insulin and dietary changes help prevent that from happening.
    - Palomino
      
      Not all people who visit a psychiatrist have a mental illness.
      
      A visit to a psychiatrist is usually a med visit, usually a referral from a psychologist.
      
      I would excuse these decisions to treat or not to treat, seek advice from peers, if they were made by a psychologist, not a psychiatrist.
- Antinous / Moderator
  
  For a psychiatrist to break confidentiality a person would have to make a threat to harm someone else or threaten to kill themselves. In those cases, that person would be committed to a psychiatric hospital.
  
  Which appears to be the case here since the psychiatrist did break patient confidentiality, just not to anyone who would use the information.
  - bzishi
    
    Which appears to be the case here since the psychiatrist did break patient confidentiality, just not to anyone who would use the information
    
    This is the part that doesn’t make sense. If a person makes a threat against themselves or others, an involuntary commitment is usually ordered. Basically, it is considered a medical emergency, which is why extraordinary powers are used.
    
    A threat board appears to be something unique to colleges and universities. From their webpage:
    
    The Behavioral Assessment and Threat Assessment Team (BETA) is a new resource at the University of Colorado Denver that can provide resources and information to faculty, staff or student community members who are confronted with individuals who may be threatening, disruptive, or otherwise problematic. The Team provides guidance and consultation and may make referrals to appropriate campus or community resources. BETA is one component of the newly formed University Emergency Management Operations Group (EMOG).
    
    They also have a note on the webpage:
    
    If you feel that there is an immediate threat to health and/or safety please contact Campus Police or 911.
    
    From this, the only conclusion that I can draw is that the psychiatrist didn’t think the shooter was an immediate threat and that the policies of BETA would be enough to assist in treatment.
    
    Of course, as I posted above, dropping out should be a red flag for this group as well as any other mental health organization.
    - Antinous / Moderator
      
      In a world….where armies and prisons are outsourced to private corporations, it may seem perfectly reasonable to report an emergency to your boss instead of calling 911. Not good, but in keeping with current trends.
  - jim weed
    
    in university counseling centers, counselors regularly consult with each other about their clients. this is not considered a breach of confidentiality–in fact, to NOT consult about cases is considered unethical.
    
    we don’t know what holmes actually said to his psychiatrist but it was likely something that was ambiguous enough to raise concern but not specific enough to be actionable.
    
    also, psychologists/psychiatrists are not fortune tellers and it is unfair to treat them as such.
  - Manny
    
    He could have signed a form that allowed her to share the information with other people in the university’s health care system, but not with anyone else. That’s what I’ve signed at clinics and hospitals. Even at my regular doctor’s group practice.
    - chgoliz
      
      Good point. Students’ rights are often abridged in this area.
  - Palomino
    
    Strange how I can’t stop comparing these statements with a church confessional.

teapot

Jesus fucking christ.

http://twitter.com/Theranthrope Theranthrope

“Christ, what an asshole.” Is acceptable too.

atimoshenko

It’s easy to be indignant about this is hindsight, but it makes for a very difficult balance to strike before the outcomes are known. If police/family/everyone else were to be alerted immediately at first indications of threat, the system would be flooded, lots of innocent lives ruined (people would shun all individuals thus reported), and many would no longer be trusting enough to seek psychiatric help. I doubt that this was an instance in which Holmes clearly and convincingly indicated that he was about to go on a mass murder spree.

The problem, therefore, is not with reporting people who one has begun to fear might become somewhat violent. The problem is with access to tools that make it easy for people who want to inflict significant damage to be actually able to do so. The only action which would have had any reasonable chance of succeeding in this situation (initiating a process to verify and then continue to track gun purchase history) is something that cannot be done. The only price at which we, as a society, can purchase unfettered gun access is that of periodic mass shootings.

Manny

I’m a mandatory reporter in my state, so I’ve looked into this. Here, the law is about an IMMEDIATE threat to himself or others, which means now or in the next day or so. If I believe this is the case, I file a petition for emergency evaluation with the court. Presuming a magistrate is persuaded by my description (and I’ve been told that since I’m not a psychiatrist or psychologist, the magistrate would expect corroborating witnesses) and signs off on the petition, the person is taken to the hospital for an evaluation by a psychiatrist there within 6 hours. If the person is still raving and threatening then, the psychiatrist can send the person to a mental hospital for observation for 36 hours. If the person stops raving by then, or hasn’t asked for voluntary commitment, they send him home, probably in even worse shape and now alienated from the person who was trying to help.

awjt

Exactly. Nice summary. People keep looking for a single shortfall to point at, and then to pin it on one person: the psych doc, the school admins, the police… when what we have in pretty much every state is a general system failure with flaws all over the place. It’s not a donut and this guy slipped through the donut hole. It’s swiss cheese: multiple simultaneous points of failure.

Manny

I would like to point out that there is no global “in the United States”. Each state has its own laws, rules, and procedures. They may be similar, but they are not identical. It makes a difference where you go off the rails.

My state, for example, has a “guilty but crazy” verdict, but no “crazy, so not guilty” acquittal. In some states, the penitent solely “holds the privilege” of confidential religious counseling and decides whether or not the clergyperson may testify. In others (California, e.g.), the clergyperson also holds the privilege and can decide for himself not to testify, no matter what the penitent says.

http://germanwotd.com Amelia_G

Maybe U.S. higher ed institutions will take this tragedy as a reason to review their procedures for schizophrenic students. They’re on the front line for this disease, since adolescence and college ages are when most people become schizophrenic. That’s when my kindergarten friend manifested the disease.

Palomino

Could it be that the main issue is the definition of “threat”? What may be a threat to some, may not be to others, this argument works well in defense of a police shooting, re “the officer perceived a reasonable threat”.

Manny

I think that “threat” in this kind of situation usually means imminent and concrete. “I’m afraid I’m going to kill someone!” in the doctor’s office is alarming. “I am going to kill the bitch now!” while waving a gun is a threat. (Disclaimer: IANAL)

Professor59

Clearly the proper course of action is for the NCAA to remove 10 scholarships a year from the football program as punishment.

fiatrn

In Colorado, you generally have the person brought to an ER. This most often happens through contacting the police bc you are concerned. The police contact the person and bring them into the ER to be evaluated.

If the person does not want to be seen, the appropriate person must fill out a “72 hour hold” called and M1.

You can see the M1 at this website. Click on the top most form to see a pdf.

http://www.colorado.gov/cs/Satellite/CDHS-BehavioralHealth/CBON/1251581850603

This basically states that, within their rights (the M2 form, second one down), the ER must evaluate the patient and place them or release them within 72 hours. In order to be placed on an M1 the patient must be an Imminent Danger to themselves or to others, or be Gravely Disabled. These are all legal terms with specific definitions.

In the ER, a physician reviews the M1 hold, and evaluates the patient. In most (probably ALL, but I can not promise) CO ERs, the patient is then seen by some type of mental health worker (there are various specialties that evaluate people, but they are often referred to as Psychiatric Triage Specialists, and they go through a great deal of training. In conjunction with the MD, they help decide on dispositions for these folks – home, family, admission somewhere, etc. These triage folk are working under/with a psychiatrist. If the patient is in the ER long enough, the psychiatrist will be personally part of their care. The hold can be dropped and the patient sent home – perhaps their threats are deemed calls for attention and not serious, perhaps they have sobered up, or taken medications: there are many reasons. You document those reasons on form M3.1

In many cases, people are brought in on holds for their behavior or statements, and later released. Not all holds result in the full 72 hours (most do not) and not all holds result in admission (most do not). There are very limited numbers psychiatric care facilities for patients that do need admission, and criteria can be strict. Payment often becomes an issiue with placement, as some places require patients to be able to pay, an ability many mentally ill people do not have. You can’t easily force people into care they do not want: the system is actually fairly filled with oversight, including presenting evidence to judges for things like involuntary medications.

That’s the tip of the system that the psychiatrist in this situation was dealing with. It isn’t nearly as clear cut as we would all believe – that you talk with someone at their office visit and think they are dangerous and they simply get locked away until they are safe.

Jonathan
The Fiat RN
denver, CO