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Old 08-27-2012, 09:19 PM
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What actually happens when a patient reveals assaultive/homicidal thoughts or intent to a doctor?

I believe that one of the exceptions to the patient/doctor privilege is when a patient expresses interest or intent in harming or killing someone else. The therapist or physician may be allowed to breach confidentiality, or, depending on local law, may be required to report.

I was under the impression that, in most cases in common law countries, bare intent to commit a crime is not a crime unless it reaches the point of an actual attempt (i.e. "crossing the Rubicon"), it becomes a conspiracy, or the crime is completed (e.g. a homicide is fully executed and the victim is DEAD), so it doesn't seem that the very act of revealing an unrealized homicidal or assaultive intent would be grounds to convict the patient of an offense.

What actually happens in these cases? Is expressing homicidal intent to a therapist considered per se cause for involuntary commitment in a mental institution, even if the person is not legally insane to the point where they would be found Not Guilty By Reason Of Insanity if they completed the crime? Does the victim get a nice little letter saying, "Dear Mr. robert_columbia, I am a therapist who is currently treating a John Jones, who lives at 455 Drury Lane, Podunk. In a recent therapy session, he stated, 'I'm gonna get an axe and chop the head off that stupid robert_columbia'. I am notifying you of this pursuant to the Mandated Reporters of Potentially Violent Patients Act of 1989. I am neither required nor permitted to give you any more information on Mr. Jones' condition or current treatment. Sincerely, Harold T. Therapist."

No specific jurisdiction is indicated. This is not a request for professional advice or services. I do not intend to assault or murder any person.
Old 08-27-2012, 10:06 PM
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I heard an interview on NPR a few weeks ago about this. Basically, the therapist said it's up to their discretion. If they believe there in imminent harm to someone, they have an obligation to report it. Otherwise, it's pretty much up to them to determine if it's better to report, or try to talk through the issue.

I can't comment on how accurate that is, of course.

-D/a
Old 08-27-2012, 10:19 PM
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They didn't teach us (nurses, not specifically psych nurses) what to do for homicidal feelings, but for suicidal ones, we're supposed to ask if they have a plan. Most people don't. Then we ask them to make a verbal or written contract promising that they won't kill themselves without calling us first. Most people will. Then it's pretty much up to your professional judgement: do you think they're going to do it? Then you report it to someone higher up, or you try to talk them into self-commitment until they're feeling better, or both. Are you fairly confident they're not going to kill themselves before your next visit? Then you make the contract, probably call them within the next 24 hours to check in on them, and see how it goes. Are you just not sure? Call a supervisor and get someone with more expertise on the case. No matter what happens, you chart the hell out of that visit, to protect yourself and your license if the patient actually does do something. I've had this come up twice in the past year, two different guys. Both are still alive, and actually felt a whole lot of relief just from making that contract with me.

I'll be checking the thread to see what the answer for homicidal urges is, though. I suspect it also depends on whether they have a plan, and how detailed/well thought out/practically possible it is.
Old 08-27-2012, 11:45 PM
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With me, on a visit to an ER for a totally unrelated reason, I told them I had attempted suicide 10 years ago. They asked this and that, and at one point I said about the current trip, "this really is a bummer," and before I knew it, a bored hospital cop was in a chair in front of my bed as I lay bare-assed waiting for blood levels. The then made me change to in-patient clothes.

When the doctor came in she basically said "what the fuck is wrong with them?" and called off the dogs.
Old 08-28-2012, 01:04 AM
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Quote:
Originally Posted by WhyNot View Post
They didn't teach us (nurses, not specifically psych nurses) what to do for homicidal feelings, but for suicidal ones, we're supposed to ask if they have a plan. Most people don't. Then we ask them to make a verbal or written contract promising that they won't kill themselves without calling us first. Most people will. Then it's pretty much up to your professional judgement: do you think they're going to do it?
Note: when you are in the ER, in a lot of pain, and they are asking you about all the medications you take, don't get confused and say Zoloft (an anti-depressant) when you are actually taking Zocor (anti-high cholesterol).

They write that all in your record, and for the rest of your time in the hospital, all the doctors & nurses will be constantly be asking you if you are feeling depressed. And it will probably take a couple of days before you figure out why they are all asking this. And another day or more before you can get that corrected in your patient record! (But it is kinda nice that 'everyone here is so concerned that I'm not feeling down'.)

Last edited by [email protected]; 08-28-2012 at 01:04 AM.
Old 08-28-2012, 07:15 AM
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Originally Posted by [email protected] View Post
Note: when you are in the ER, in a lot of pain, and they are asking you about all the medications you take, don't get confused and say Zoloft (an anti-depressant) when you are actually taking Zocor (anti-high cholesterol).
Ha! Yeah...written medication lists are good. In your wallet, so you don't have to remember specifically to bring them with you.

(I had a patient scare the crap out of me a couple of weeks ago. She's had a lot of health problems and is pretty fragile, and she'd been having trouble moving her bowels. I came back from a two week vacation, and she told me by phone that she'd been in the hospital and "they wanted to do a colostomy, but I told them no. Three times they tried and I told them no, no, I can't do it, send me home!" So here I am, freaking out that my very ill patient had refused a major surgical procedure that was her only hope and signed out Against Medical Advice and would now die on my watch...turned out they were trying to do a colonoscopy and couldn't get her all the way cleaned out, so they discharged her to home and rescheduled the colonoscopy as an outpatient procedure. This is why nurses keep asking you questions they've already asked you. Some patients are just terrible reporters!)

I did think of one particular subset of homicidal thoughts which I do know what to do for: if they're directed towards a child or an elderly person, and I believe they're genuine urges (not, "I'm gonna kill that kid if he doesn't start doing his homework!") and the person has access to the person they wish to harm...then I am a mandated reporter for those two groups. I call my supervisor and, theoretically, then I've done my bit. In reality, after the whole Penn State debacle, I'd also call law enforcement and family services myself, to protect myself.
Old 08-28-2012, 08:45 AM
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Originally Posted by WhyNot View Post
...I did think of one particular subset of homicidal thoughts which I do know what to do for: if they're directed towards a child or an elderly person, and I believe they're genuine urges (not, "I'm gonna kill that kid if he doesn't start doing his homework!") and the person has access to the person they wish to harm...then I am a mandated reporter for those two groups. I call my supervisor and, theoretically, then I've done my bit. In reality, after the whole Penn State debacle,...
Yeah, but what happens next after the report has been made? Does the person making the threat automatically get committed to a mental instutition or jail? Does the person threatened get a police escort in the community or a permit to carry a firearm? Is the threatened victim asked if they want a restraining order? Do they just file the report at city hall and then twiddle their thumbs?
Old 08-29-2012, 12:31 AM
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A situation like this came up when I was working for a psychiatrist some years past -- a specific threat of harm to the patient's child. The doctor filled out a 'pink slip' and police officers picked up the patient at his house and escorted him to a locked facility for a couple days of mandatory observation.
Old 08-29-2012, 05:15 AM
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Quote:
Originally Posted by robert_columbia View Post

What actually happens in these cases? Is expressing homicidal intent to a therapist considered per se cause for involuntary commitment in a mental institution, even if the person is not legally insane to the point where they would be found Not Guilty By Reason Of Insanity if they completed the crime?
Unless you are such a bleeding heart that you think all crime is a mental condition, what happens in practice is that a clinician attempts to separate an expressed intent to commit harm into one of two broad categories: mental illness or criminal intent.

If the cause is deemed to be mental illness, then an attempt is made to get the individual (forcibly, if necessary, by calling for a police escort) to the local evaluation facility (typically, the Emergency Department). There a formal assessment is made and the individual is forcibly incarcerated if circumstances warrant, with a further formal psychiatric evaluation (typically within a day or two).

On the other hand, if the clinician thinks there's just ordinary homicidal intent, and it's legit, it's reported to the Police. They then have to make an evaluation of how to proceed. But of course, in a "therapist" situation that you describe this would be less common, since the person is chatting up the therapist in the first place because they have some sort of psychiatric issue.

No competent therapist would simply ignore specific homicidal intent and try to just counsel the patient out of it, although there is room for a judgment call between "I'm gonna kill my sister" and "I'm gonna kill my sister," even if the words are identical.
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