So this episode went a little off topic, didn't it? Well, I think we should tell the listener that we're from the future, and we already just did the podcast.
Yeah, we were going to talk about forensics in kind of more broad detail, but we pretty much ended up talking about involuntary commitment. Still a pretty good episode, though, I hope.
Yeah, so the intro will make less sense, but I think we kind of got on topics that I thought would be super helpful on their own. So yeah, even though we don't talk about forensics in its entirety, we do, I think, have a productive conversation on involuntary commitment.
All right, let's listen. Good morning, Dr. Malesberg. How are you doing? I'm well. Are you keeping yourself out of trouble? Something like that. Well, not everybody is, especially if you're on the front page of our medicine right now. But, you know, that's related to today's topic, isn't it?
Well, you tell me.
Well, for those who don't know, I think that never made it onto recording. You tell me is something that I've noticed people who are meth intoxicated tend to say to you if you ask them questions. They sort of even assume that you already know because you've been surveilling them. It's a short version of it. Speaking of keeping yourself out of trouble is forensic psychiatry.
No, no, no. It's lessons from forensic psychiatry.
That's right. Lessons from forensic psychiatry. I've been assured by Dr. Malzberg that nobody actually wants to be a forensic psychiatrist and they'll skip the video.
I said if it was forensic psychiatry, I'd go, oh, I'm not doing that specialty, whatever. But this to me, I hope, is Dr. Fu spilling his heart out and giving us the big lessons he's learned. Well, we'll see about that. To me, the deep part of psychiatry, the things that, you know, connecting the legal and the psychiatric and the medical and all that good stuff.
Yeah, yeah. Well, I guess we should briefly go over just literally two sentences. What is forensic psychiatry? There is a lot of variation on what it is. I think a lot of people think it's correctional psychiatry. They think that it means working in a jail setting, basically, or a prison setting. That's not quite true. Forensic psychiatry is when you apply your medical psychiatric expertise to legal questions that overlap with psychiatry in some fashion, also known as answering psychiatric legal questions or addressing those scenarios.
Now, I'm not going to get into the extremely boring whole lecture that I can do on that. Instead, I guess we wanted to talk about what, Dr. Malzberg?
Well, I don't think there's a specific agenda, but just things that you've learned, lessons. Because you mentioned it's the intersection of legal and psychiatry. To me, that's such an enormous area.
Yeah, yeah. I mean, it's pretty broad. I would say that there are some key lessons that I've taken away, personally anyway, that I don't think I would have learned if I wasn't a forensic psychiatrist practicing and if many of my supervisors weren't. Because I see the difference in how people supervise and think about cases, depending on whether or not they're classically forensically trained. Don't get me wrong.
There are a lot of programs out there now. Anyone can say they're a forensic psychiatrist, a psychologist. It just kind of. As you know, quality differs from location to location. But probably the number one thing that I kind of came to realize, and I'm sure many people have realized this without practicing forensics, as long as you work in an involuntary setting at any point in your training or career, is that there are multiple agents of treatment and the agent is not just the patient themselves.
That's an interesting way of framing it. I'm not quite sure what you mean by the agent isn't just the patient.
Let me put it this way. I think if you're used to treating pretty straightforward patients who are patients as clients, people who come in with an idea of what they want and how they want it, then you don't necessarily have an idea of There is a different agent for the treatment than the patient. But then let's think of the person who gets involuntarily admitted to an inpatient hospital and they don't think they have any kind of problem.
They don't think they should be there, yet they're being admitted. Why is that? Well, my answer is that it's because there are multiple agents that drive a treatment. And the agent can be the state for purposes of safety or for the purposes of giving treatment to somebody who lacks insight. The agent can be a parent on behalf of a child, which you see in child psychiatry. The agent of the treatment can be a school.
It can be the nursing home who has referred a difficult resident to the emergency room. There can be multiple agents of treatment, and that agent is not always cleanly the patient.
Before you keep going, can you give me a simple definition of what you even mean by agent?
The person who derives and benefits from or wants the treatment to take place at all.
Mm-hmm.
Yeah, the person with agency, basically. And I don't mean to suggest that the patient in these scenarios has zero agency. What I mean is that there's often split agency or split interest, right?
Yeah, absolutely. Inpatient, I think it's such a shock because you go into medical school thinking like, oh, I'm going to treat these patients and they're going to be so grateful. And then you get thrown into inpatient and you have a caseload of eight people and they all hate you and they don't want to be there. So yeah, this is good stuff.
It's a good trial by fire. It's almost universally unpleasant for most trainees today. But I think it's an important thing to learn. You know, it's not all sunshine and roses. It's a difficult specialty. So why is this important? You need to have clear in your mind who are all the agents of treatment and whether or not they should be agents of the treatment. Because if you don't, The attention field gets split up between the various agents, and that makes it extremely hard to forge a therapeutic alliance with the patient.
In extreme cases, you can't make a therapeutic alliance with the patient hardly at all. You know, again, thinking of the extremely low insight, high dangerousness, involuntarily committed patient. But most cases, if you keep this clear in your mind, I think there's less frustration. Hopefully on both sides, but at least on part of the physician, the clinician, and you can sort things out in your head. You can communicate why you're doing what you're doing.
I think things go a little bit more smoothly.
Yeah, I'm really excited because, you know, there were so many times that I actually didn't even know what, you know, in the hospital, like who was I representing? Like the patient was like, you're keeping me hospitalized. And I was a little confused because I didn't care if the person was hospitalized or not. So who was keeping them hospitalized? I know it sounds like an easy question, but it's not.
Yes, it's not an easy question. Exactly. Exactly. And I think, for example, in that situation, it helps to understand that the law is keeping them hospitalized, the law in society. Right. There is just a system of rules that we've vaguely agreed upon as a system to execute for good reasons. And even if you have a complex system for good reasons, bad outcomes are going to happen. Yet you as an individual agent do not have the power ethically or legally to act otherwise.
usually in cases like that. There are good reasons why you can't simply say, hey, you know what? I don't want you here. You don't want to be here. Let's go. Let's just get out of here, right? I mean, frankly, you'll lose your license by the second time you do that or something. So, yeah, keeping that clear and understanding it, I think, helps in dealing with patients. It makes you feel less confused.
And a kind of final point about having separate agents I think is important is that Once you're an outpatient, you have to realize that the patient isn't one agent, that there are separate parts of any one patient with different agencies. You know, there's a part of the patient that wants to get better and change. There's a part of the patient that wants to stay the same. feel safe or at least avoid new and scary things.
And so you have to ally yourself with the part of the patient that does want to change against a part that doesn't. This is an old concept, of course, right? Talking about ego, syntonic, ego dystonic and forging an alliance. But it's true all the same.
Before you go into more of the intra-psychic agency, can you talk a little bit more about the agents at play? Yeah, let's talk about involuntary hospitalization. You mentioned it's the legal system. Can you just kind of expand on that a little bit more?
I don't know if this is going to be all that fruitful. I don't care. OK. In simplest terms, we as a society and I think in any society cannot operate under the will and direction of any one person, even under a dictatorship. Right. Decision making has to play out through a network of rules. That's what is basically meant by the rule of law. And how can those rules be interpreted?
And how can those rules be executed? Through another network of people, each with their own biases and their values and their tendencies. And so we're all trapped under that system. We want to be free sometimes. Sometimes we want to be protected by it. But society can't exist without some set of rules. That's basically what I'm putting forward. And so when you are a doctor operating inside the system, even if it's a system of two people in an office somewhere doing treatment, you are still under the rules and regulations of the society that you live in.
You can't make up your own rules. That would be fundamentally unrealistic and psychotic.
One thing I always struggled with, so what are the rules that psychiatrists are able to impose on their patients in the hospital?
Oh, well, that entirely depends on where you are. So the rules that you follow have to depend on what the rules are and the rules that exist depend on your specific location. In the United States anyway, it's gonna be state to state and there may even be additional regulations on a county level. You're gonna have to go find that out for yourself, but those are the rules that you have to follow.
And I think it's important to remember that in almost every country and probably in most developed countries, Psychiatry is a branch of the executive state. Sorry, it's part of the executive branch of the state. Similarly to prosecutors, police officers, et cetera, in a small way or sometimes in a bigger way, we are part of social control and protection of the people. And we can't escape that. That's just because of our special function in medicine.
One thing, I actually had this conversation recently with my partner, is the rules that we were operating under was danger to self or other. But I never received, and I don't know if this is universal, but I have to imagine that this is true for a lot of people. I received zero education as to what that means. It seems really simple. But then when you're standing there making that assessment, it's such a huge question.
Mm-hmm. I was doing it with no guidance as to what it meant, and it almost felt like it was by design. I'm not saying that there was malevolent forces preventing me from learning these things, but I'm saying that there wasn't a clear-cut instruction as to what that meant and how I was supposed to use it.
Yeah. I mean, I don't know if it's we can say it's by design. There is that concept, right, that the purpose of the system is what it does. I think there's truth to that. I can't speak to every residency out there. I think it's just by necessity, really. To execute a system in an orderly and uniform fashion to the best of our ability, when it's fair and it serves the ends that it's designed to serve, that requires a lot of expertise.
And it requires people who actually care to do that. And if you don't have enough of those people in your system, then your system is going to try to simulate that to the best of its ability and may even devolve into what's effectively a cargo cult. of um operating under such rules right and so you know at a good at the ideal residency and certainly in a residency where most of the faculty are forensically trained uh you know the interns are getting strict education on these legal criteria and the meaning um day one literally day one and um are then coached through that in every legal hearing thereafter you know i testified like almost 10 times before I even graduated as an expert.
So it just depends on the programming and some programs just, they just don't have that human resource of psychiatrists who have a lot of forensic experience.
Yeah. And I definitely was one of them. Can, can you help to explain to me what danger to self and other means?
The funny thing is that it depends. And that's going to be a very frustrating thing when we talk about almost anything in the law, especially forensic psychiatry. It depends. And so how is that terminology even said at all? Well, legislators got together and wrote a den, right? But then whose job is it to determine what that actually meant? It's a judicial branch. So this is a separation of powers issue in the United States.
And again, I'm a little worried that this podcast is getting too off psychiatry if we go down this route. But you seem interested, so we're going to talk about it. I am a fearless leader. So, you know, think of the three branches. The legislature writes the law, the judicial branch interprets it, and the executive branch executes it. You, the psychiatrist, were part of the executive branch. OK, you were arguing on behalf of the executive branch that someone was dangerous.
And how is that actually supposed to be interpreted? It's supposed to be interpreted by the judicial system. So you were probably arguing in front of the judicial officer or in some cases in front of a judge. OK, now, no one is forcing you to be competent and to have read the law and to read the case law and to understand the meaning. No one forces you to do that.
But it's the job of the judiciary to recognize whether the arguments you're putting forward meet the legal criteria. OK, and so if you happen to do so, then you are fine. So that's the bird's eye view of how that's supposed to happen. In terms of what these terms actually mean, I would guess I haven't reviewed all 50 states, but I would guess that most of them are modeled after what happened in California.
You know, California being one of the earliest states to kind of put forward a modern American framework for involuntary commitment. And it's actually, for the most part, plain language. Is this person dangerous to themselves or others? And so it stops being a question of law at that point. Most of the time, what's usually meant by dangerous? Dangerous means, you know, generally speaking, likely to produce some kind of a serious physical harm to themselves or others.
Right. Well, then you might say that raises a lot of questions. Is it in the next minute? Is it in the next hour? Is it in the next year? How serious does that danger have to be? You know, where does that danger have to come from? Well, that's where it gets complicated. But I would say that in most places you need to identify a mental illness. OK, not a personality disorder that is different than the person's normal functioning.
And you need to connect that that mental illness, its symptoms and impairments have somehow resulted in some kind of likelihood that without the commitment, this person would be a danger of some kind physically to themselves or others.
And the obvious question is, what is mental illness? So you mentioned personality disorders aren't mental illness. What is mental illness then?
Good question. So what is considered a mental illness is still, again, set forth in law. OK, that's the weird part. I guess this is the weirdness about forensic psychiatry. We use clinical concepts and we have to apply them to what legislators have put down to the best of our ability. okay traditionally traditionally mental illnesses did not include things like personality disorders because the personality disorders were thought to be fundamental to the person and not independent mental illness per se okay this is not a clinical reality it's a legal reality right you could call the legal fiction even in some places Mental illness under the heading of involuntary psychiatric treatment is different than neurocognitive disorders.
Neurocognitive disorders in some places are monitored, treated and regulated under a separate set of laws for dementias. Right. So then what do you do if somebody has both psychosis and a dementia? Well, that gets complicated, but that's what court is for.
So, yeah, a patient comes in and says, you know, I'm going to kill XYZ and you don't see any underlying mental illness. Make sense of that to me.
How am I supposed to make sense of it? You're asking what I would do?
No, I guess, of course, someone who wants to kill people has a mental illness. That's an obvious sign that they have mental illness.
Is that an obvious sign? I think a lot of people want to kill people and they're not mentally ill.
I'm obviously playing a role here. I need you to play along with me.
I don't know how obvious that is. Some people actually believe that. Plenty of psychiatrists believe that. OK, there is a theory of crime and there's a theory within psychiatry, which is, by the way, the most progressive branch of medicine, you know, based on polls, that all crime is a result of mental illness. OK, so I never really know who I'm talking to and what they believe. And then, of course, there are psychiatrists, physicians who probably go too far the other way.
They think everything is under the agency of the patient and not due to some kind of effect. Right. So it's a problem of language. And I think it's actually more useful to ask two questions rather than trying to get. down into the dirt about what is or is not mental illness, what is or is not personality, and all that stuff. I think you should ask two things.
You should ask, is this a change from the person's baseline? And if so, why? And based on that, is it treatable through psychiatry, the practice of psychiatry as we have it today? And if you ask those questions, you will find that antisocial personality disorder and psychopathy is not treatable and it's not a change from the baseline and is pretty much present up and down to some degree based on circumstances and not some biological issue.
Now, where does substance use come into play here?
Substance use and abuse comes into play because it does alter the functioning of the brain and is transient. Right. And so that is a legitimate use of involuntary commitment. If somebody is violent and dangerous while they're intoxicated and for about maybe, let's say, a week or two after, let's pretend they have a substance induced psychotic disorder. Then that's treatable, right? You monitor, you keep them in a safe location, you give temporary antipsychotics.
And once the derangement of the brain functioning is finished, they're back to baseline. Maybe they still have some antisocial traits or even a full disorder left, but just... You know, there's not much that you can do about that. And it's not the job of psychiatry to take care of that in society, at least our society. And then we just cut them loose at that point. But how do you determine these things?
Well, unfortunately, any good forensic psychiatric determination requires you to be a good psychiatrist. You need experience as a psychiatrist. You need to have actually attempted to evaluate and differentiate all these things in many, many people and seen How successful you've been. You need clinical experience. So, you know, there's no. Algorithmic body of knowledge that can help you do this. It's unfortunately an area just like treatment where you have to get your toes into the mud and wiggle them around, figure out what's going on.
Maybe you can help me with maybe a specific case. Not a specific case. I'm thinking of a case that maybe will help see how you think through it. Maybe help define who the agents are and how you think through it. So let's say I have a case of a patient who comes in on meth use. They come in acutely psychotic. They're threatening. They're going to kill everyone in XYZ building.
They sleep overnight. They wake up and they go, oh, I was on meth. Please let me get out. You call collateral. And the parents say, for the past two months, he's been using drugs. He's not normally like this. He's a sweetheart. It's just when he starts using meth, he becomes violent. Walk me through this. And so then you go speak to him and he goes, yeah, my parents always say that, you know, I don't have interest in rehab right now.
I don't have interest in getting connected to care. Can you walk me through who the agents are there and how to think about what to do?
Okay. I would say one, the primary agent right now is the state and society, right? This is someone that was involuntarily committed for danger to others. Is that correct? Did I hear that correctly?
Overnight in the emergency room.
Yeah. Yeah. But that's the main reason why he's in the hospital at all. Right. Correct. Something made someone worried enough that they thought this guy is dangerous and needs to be committed at least for a bit. Right. And then we also have the agent of the patient. There's always the agent of the patient. OK. To some extent, maybe there is the agent of the parents. It just depends on how much they are active in the patient's life.
Those are the main agents, at least for this case. So since the presenting problem is dangerousness and it's danger to others, then you need to think about what are my physicianly duties at this stage? And again, with the caveat that everything depends on your jurisdiction, I'm just going to speak from my knowledge and experience. OK, you're a physician. So your job is to make a differential diagnosis to explain why did he do what he did?
OK, obviously methamphetamine is at the top of the differential, but the practice of medicine is not one where we find the most likely one and we stop. Right. We don't just go like, well, it seems to be that and I feel like it is. And so I'm going to stop thinking now. Right. Don't get me wrong. Plenty of people do do that out there, but that's not how you're supposed to practice medicine.
So the second thing to consider would be some kind of mood and psychotic disorder that is either brought on by methamphetamine or worsened by it. Right. That's number two. Number three is probably personality problems that are interacting with the drug use in order to produce the overall output. Okay. Number four would probably be all of these things happening at the same time. Number five would be other conditions of the brain or the mind that could produce that output.
And so just because everyone has told you that it's meth, the patient has told you, you have told yourself that it's meth, and the parents have told you that it's meth, doesn't mean that you should automatically assume that's that. So then you ask yourself, given that we have all these possibilities weighted, what is the most prudent course of action? What would a reasonable doctor do in this situation?
Well, some people like to be a little bit more risk friendly, right? Some doctors would say, I've seen this a million times and the likelihood that this guy is going to go out and do something dangerous again is slim to none. So I'm going to cut them loose, right? And a lot of people do that. The probably more balanced approach would be to say, so far, this case seems to be acute meth intoxication and have a lot of data to support that.
However, I've never seen this guy before. The only person I'm relying on is his parents and himself, and they may be interested parties. OK, these may be people who want this guy out and they're leaving out information that would prevent him from getting out quickly. OK. Moreover, if I discharge him right now because he says so and his parents say so, his dangerousness has not been mitigated.
Right. What makes people dangerous from a mental health standpoint? The number one thing is drug use. And I don't care if he's not interested in rehab. Do I really know that he's had enough time sober to actually reflect on what has happened to him and what the appropriate treatment is? There's an argument there to keep him longer. I'm not saying he has to go to an inpatient hospital, but maybe he needs more time with observation and counseling.
So it could be then that you're going to continue to observe to make sure that he remains stable, that he can exist in the milieu, that you can interact with people appropriately, that his thinking is pretty much about as good as it's going to be. And then you make your recommendations and your warnings. You warn him. And you warn the parents, you say, listen, he was in a state that was quite dangerous before.
People who use drugs with and without mental illnesses, especially when they get in that state, they can be dangerous. They can hurt or kill other people or themselves. My strong recommendation to you and your family is that you get together and you get into a rehab. OK, it's going to damage his brain. It's going to mess up his life. You know, even if he knows that intellectually, I don't know if he's feeling that emotionally.
So that's my recommendation. I can only keep you so long. And then after that, I can only recommend you to stay voluntarily. But if you refuse, I can't do anything about it. So there is a difference between acting in a standard of care and within the confines of what's possible for you and simply acquiescing. And when you do that and how is a matter of risk tolerance and your appraisal of the situation.
Now, one thing that's confused me a little bit is, let's say someone does meth. Has a long history of using meth and wanting to kill people. And they come to your hospital, and this is actually, I don't do this. This is honestly just something I've thought about. They come to the hospital, they say they're going to kill people, and then they get discharged immediately. And they go and do a violent crime.
What would be the responsibility of the physician there?
Responsibility of the physician? As in, what's the liability? Liability. Okay. I mean, here's the thing. Broadly speaking, a rule is only as powerful as its outcome. OK, this is true when you try to set rules and regulations for yourself. This is true when you try to set them up or have your patients set them up in a psychotherapy. And this is true in society. And it's chance.
Technically speaking, if you don't perform the standard of care and warn appropriately for a dangerous patient and you release them and they commit something that harms someone, you are liable. You're professionally liable. Most of the time, it's very rare that that can rise up to criminal liability. I can't imagine a scenario where that would happen personally. But yeah, you're going to be liable. And yes, I have consulted on cases where people have been sued for that.
And you can look in the case law. There are people... doctors who have been found liable simply for not warning family about the dangerousness of a patient when it was pretty much obvious to anyone who wasn't a psychiatrist. But unfortunately, or fortunately, society raises us up as... psychiatry doctors to a level that I don't think we should be at. They think we're these magic men, magic men and women who can predict the future and have special insights into people and all of that and that we can protect people, we can save them from suicide, we can keep them from harming others.
It's not true. We simply have a very special medical expertise in an area, but unfortunately, the responsibility and power has been foisted upon us, and we have to deal with it through things like warnings. You probably heard about Tarasoft, for example, and our standard of care treatments.
Yeah, and I don't want to go too far in what I'm about to speak about because I want to stay on what we're talking about. But having trained in New York City, one thing that's really frustrating is the system is not good in that... It's not good anywhere. You're making decisions based off of bed limit. Like there's no beds available ever. So you have a patient where you're running out of time to make the decision and your options are not...
are completely limited by what's available. So it's like there's no bed availability. There's no EOB. And you've run out of what legally, the amount of time that you can hold the patient. So there's no option. And you'd think that that would be a very rare case. I would say that's the standard case is that there's almost no beds available and you have four patients who need a decision made.
Mm-hmm. Sometimes you have one bed available and you have four patients that a decision need to be made. And that means that you have no option but for three of them to likely be discharged. What advice do you have for residents who find themselves in those situations?
Well, I'm going to be pretty cynical here. You can go about that in a number of different ways, but ultimately you need to triage, right? That's part of medicine. We have limited resources and we have to spend them wisely. So you have to triage and you can triage based on medical need. And if medical need is completely equal in your assessment, then it's not unreasonable to also consider your liability.
OK, I hate to say consider your liability. Another way of putting that might be to say consider the dangerousness of the actual patient. Right. What's the danger? The danger can be to others. The danger can be to self. The danger can simply be to the trajectory of their health. right, in the long run and the short run. So the patient who owns guns and has threatened people with them over the patient who simply is quietly psychotic on the street, there is one that you can argue that is higher acuity.
Even if their clinical state in front of you is similar, their history and their situation outside of the hospital can inform you differently. And are you documenting this thought process? Well, it depends. Is it important? Now, here's another thing about documentation, by the way, and you can contact Dr. Malzberg if you are a clinician having a lot of problems of documentation and you want some paid advice, I'm happy to help.
You can document very badly or very well, and that doesn't necessarily... No, I'm saying either way. You can document either way. And that doesn't rely on the length of your note. OK, a lot of people kind of feel like if I document more, it's a better note. That's not true. You know, documentation has a purpose and you don't document every single thing that goes through your brain.
When you've interacted with a patient in the course of your practice of medicine, right, you document just the facts and enough to show your medical decision making. So whether or not you document something that you think there just kind of depends on what the purposes are and what the situation is. I can't give anything more specific, unfortunately.
No, that was definitely very helpful. Now, you have a lot of stuff. I think people are going to really enjoy this conversation because I know this stuff.
I feel like we really got derailed. I can admit we had like a whole plan. I think we're going to have to save that for another episode. Can we call this one forensic derailment?
Yeah, absolutely. I think that the difficulties with involuntary stuff was stuff I struggled with so much in training. So I apologize for keeping us here, but I do think people are going to appreciate it.
Yeah, I think it'll be a good change of pace. I feel like our conversation is mostly outpatient stuff. But yeah, I mean, it feels bad to involuntarily treat people, right? It feels bad. It's difficult. I don't like it. That's why I don't do it anymore. But it's necessary. It is a part of life. It's a part of what agreements we've made as a society. It does protect people in some cases, and it does help people get the treatment in other cases.
I'm not going to say it's every case. But I think that if you're a clinician that's working in an involuntary unit or setting, you've got to understand those things. And I think you should be both harder and easier on yourself. I think you should be easier on yourself in the sense that you are not there to please the person in front of you necessarily. You are an agent of either society or the state, however you want to put it.
And you're serving different ends than simply giving the patient what they want. At the same time, You also have an awesome responsibility and you should be hard on yourself in the sense that you should be familiar with the laws in their whole and the practice of involuntary commitment. And you shouldn't violate either treatment practices or the law knowingly or unknowingly without good cause.
So, Dr. Fu, you know, we're talking in terms of assessing, let's kind of go back to the danger to self or others. How is that assessment made if a patient isn't, you know, when a patient's being held involuntarily, they're usually not the friendliest and easygoing and most forthcoming and transparent. So how do you even go about making an assessment for a patient who's not really cooperating?
OK, this is one of the core lessons from forensic psychiatry, I think, that you learn from its practice that is applicable across all of psychiatry. And it's how do you assess a patient who is uncooperative? That's tricky, right? I think that especially since TSM3, the impression has been given to the field at large that what an assessment is, is what a patient tells you. It's the output statements of the patient or what you can literally see in front of you only.
And that's not true. An assessment is just based on all the medical data that you can gather for that case. OK. And so when a patient is not cooperative, then your hands are tied. You can't. simply make no decision. You can try and wait and reassess at a later time. That's also possible. But you just have to go off the information that you have available. And so it's really more about the story.
What has happened to this patient before? What happened to this patient that brought them in? And why, based on that, could they be behaving the way they are? So you can pay attention to what the patient is doing when you are not talking to them, when they are in the milieu, or when you are talking to them, what they're behaving and doing rather than saying. And then, unfortunately, you're just going to have to go off of collateral.
And collateral contacts are one way of doing things. A powerful way of doing things that is underrated is a review of records. Please, please review the records of all of your patients, including your outpatients. Request the records from other hospitalizations and treatments and outpatient clinicians. You've got to review the records. It's not complete to rely on what someone tells you because there is always some degree of editing, conscious or unconscious.
And all that failing, if all that fails and you can't get any extra information, then you're just going to have to continue to observe. and that's what you have to go off of it's it's i think to a degree getting comfortable with the fact that often in those settings we have to operate on limited information and just do the best we can interesting so you're saying a lot
of um you know the the patient being there and what they're doing there is a big part of the story and is a ton of information in regards to how they're going to act on the outside
Yes, it tells you about what's going on. You know, the output behaviors and statements of anybody are being generated by some kind of internal process. And so what you're trying to do is that you're forming hypotheses and testing ideas about that internal process itself. Why does this person do what they do? What happened to them? What's the lead up? What's the best explanation for why they're here today is what you're doing.
And, you know, there's a kind of I think this has become a little bit of a meme or a little bit of just kind of general wisdom. You know, the joke, your response to the test is part of the test. Well, that's absolutely true in psychiatry. You know, the way someone responds is almost as important, if not more important sometimes than what they're actually responding with. You know, going back to what I referenced.
There was that Reddit post on, I think, our medicine about the guy who was involved with the impaired physicians program. And he mentioned that during a official during an official forensic assessment to determine basically his level of addiction. That's a short version from what I read in the post. Someone asked him if he ever craved. Drinking, I think. And I'm going off memory here. I think his response was like, sure, I crave a drink after I have a nice steak.
OK, that's not a wise response to be giving in a forensic assessment. OK, as this was a physician, as a physician, you know, when they say craving, they are using a word that means something specific to the context of addiction. OK, and so if you have the level of self-awareness and ability to self-censure enough to think of that and to prevent yourself from responding kind of flippantly to it, that's also implication about your general level of functioning.
OK, and if your general level of functioning is impaired enough that you can't track that meta issue and stop yourself appropriately, that says something about your general mental state. And I don't know if that's clear, but then that's the same way that you can sort of assess people who are in the emergency room in the inpatient with you. Ask yourself if a completely theoretically mentally healthy person presented in this situation, how would they be acting right now?
OK, and then how is this patient acting? Is there a significant divergence? If so, what are the medical explanations for that? Let's do a differential diagnosis of it. That's what I'm basically referring to.
One thing is I'm listening to this with an ear of not a psychiatric provider. And what that part of me is hearing is that you're saying that a person should know to lie in these answers. Yeah. And, you know, what about the patient who's there and gives the answers authentically and then gets inpatient hospitalized and then they say, but I was just trying to tell the truth.
Like, I guess, you know, with the example of you saying the craving question for a non-medical provider wouldn't know to think of that as,
you know,
maybe there's answering authentically. Are you saying that a person should be lying in these scenarios? Like, what about the patient who's just telling the truth?
This isn't about should or shouldn't. I'm talking about comparing it to some model of what is quote unquote normal. There is no normal. OK, but normal is a norm. It's something that's a general population. So whether or not someone would be expected to lie or massage the truth depends on the reason why they're there. Right. So. You know, are you there on your own accord? If you're there on your own accord and you're trying to get help, then it makes more sense to be completely forthright.
If you're there under duress, then it makes more sense to massage the truth or even outright lie. I'm not giving prescriptions here. I'm just stating what I see to be facts about how most people would behave in certain situations. And if you're so there's such a thing as pathological lying, I think there's such a thing as well as pathological truth telling in some situations. And you have to question what the motivation for that might be.
Yeah, and I guess I'm imagining, you know, let's say someone from anti-psychiatry clipping this and saying, you know, a psychiatrist says on evaluations it's stupid to tell the truth. How would you respond?
Well, I mean, that's the danger of any media today, right? Any little snippet can be taken out of context and misinterpreted. And I suppose that actually connects to what I'm saying, especially when a patient is new to you or especially when a patient you suspect is uncooperative or hiding parts of the truth. You cannot take their statements out of context. You have to try your best to gather data about the whole context of the patient, their life course, what brought them to you and where they're going.
If you look at things out of context, you're always going to be looking at a lie. OK, it's not like we ever reach the truth, but we can get more truthful closer to the truth based on effort and investigation.
Okay. Now, you mentioned in terms of like how you think through a case and come up with a differential and the possibility. So why don't I present a case and you kind of just out loud think through it? Sure. Let's say a case of a girl is, a 30-year-old female is brought to the emergency room by her boyfriend, reports that she texted him she was going to kill herself.
She's sitting there denying everything. She's saying, you're not allowed to talk to my family. You're not allowed to talk to my boyfriend. I just want to get out of here. I'm not suicidal. This is her first presentation. Tell me how you would think about it and how you would proceed.
Well... You know, we're going to, I think, abbreviate things for the purposes of the podcast. But then there are two major possibilities that you're going to think about there. Right. Number one, she's telling the truth. Number two, she's lying. OK, so if she's telling the truth, she sent the text in a provocative fashion to try to get something out of the boyfriend and not because she actually wanted to hurt or kill herself.
Right. The scenario, most likely, if she's lying, is that she did or does actually have suicidal intent planning and that she's now lying about that in order to get released so that she can immediately hurt or kill herself. This does happen. Right. And so how can you figure out which one is more likely? Right.
Well, and then a part that I wanted to be added for you to talk about, I think you'll naturally get there, is she said the text never happened. And you have the boyfriend's number, but she says you can't call it.
Yeah. Yeah. So you can leverage motivation to gather more information, right? It is objectively true that you will probably have to keep this patient longer under observation, if not hospitalization, if you can't gather more information. Because let's basically pretend that based on your full assessment, the truth versus lie does not really differentiate, right? If that's true and she refuses for you to call collateral, then it is in fact true that you will probably have to, that you should professionally, clinically continue observation, right?
And she wants to leave the hospital, it sounds like. So you might say to this patient, listen, I don't want to keep anyone here that doesn't need to be here. And that's usually true for most doctors, okay? Despite what anti-psychiatry might think. I'm not going to be able to make a reasonable determination about whether or not you can leave the hospital unless I can talk to some people about why you got here.
So you do have the right to prevent me from talking to them. But... You know, I can't move forward without it. And that can motivate some people. OK. Another thing is this. And again, consult with your local risk management and your local laws. But in many areas, it is not. You're allowed to gather information, but you can't disclose. If it's known, if it's known from the facts of the case, let's say the boyfriend is the one that dropped her off to the hospital, okay, you can't disclose information about her or her care to the boyfriend.
But there is, in many places, no law that forbids you from simply calling the boyfriend and saying, hi, I'm Dr. Malzberg. I can neither confirm nor deny any information about a specific patient. But has anything happened recently that you'd like to tell me about? You can get information. You can't disclose it.
Yeah, I was curious if you're going to bring up emergency exemptions with regards to collateral collecting.
I'm not going to bring that up because that's so murky that it's going to depend on your local law.
Okay.
Okay. Yeah, that's too specific. I can't give advice on that. There may or may not be emergency exemptions to gather information, okay? But that's going to depend on your local law, and you're going to have to look that up.
Yeah, but I just wanted to, yeah, I expected you to say that.
In some states,
there is an exemption for imminent harm to be able to call collateral and disclose protected health information. But again, it's very state-to-state dependent, so...
Also, we're not saying that would be imminent harm, you know, a text.
Oh, and I'm not saying it is. I just wanted to bring up.
Oh, sure.
That it exists.
But I mean, more importantly, I think that a lot of people kind of stop short once a patient has said something. But I don't think that you should be afraid. In fact, as a clinician, you should be comfortable, familiar with being the whiny five-year-old who won't stop asking why. Don't take it for granted already. Once she says, oh, I never sent it and I don't want you to talk to the boyfriend.
Ask why. Well, why is that? Why not? What do you think is going to happen? What's going to happen? OK, let's pretend you sent the text. Why do you think you would have sent it? What have you been doing recently? Just get into the details. Get into the details. Don't take someone's word for it only. Continue to investigate. Dig deeper. You can get a lot more information that way.
Sometimes it doesn't go anywhere. Sometimes a patient is going to just clam up. OK, but then even then you can sit there silently with the patient and simply watch them. OK, some people will begin to talk. Some people will you'll be able to, through the mental status exam, start to observe certain signs that may be indicative of certain conditions. So don't take just one word for it.
Get a lot of words out of your patients.
Yeah, and talking about the therapeutic frame, you know, you can divulge what your thought process is as to why you want the information. You know, it's not just that I want the information or else you're in big trouble. You know, you can be, you know, thoughtfully transparent as to why you want that information that information. And right now with the information provided, you don't really know the story.
And until you have a better ground for the story, you really can't make your prediction for her risk and if there's an imminent risk. And this information isn't... If the boyfriend talks to you, it doesn't mean that whatever he says is 100% going to... I'm able to make an assessment and gauge how imminent I think it is based off what he says. It's not... Yeah, I'm trying to say that being transparent as to how you're thinking about the case can help the patient understand why you want the information.
Not just that if he says you sent the text, then you're going to be locked away forever.
Yeah, you know, and that goes back to what we mentioned about multiple agents, right? As you're interacting with this hypothetical patient, if you remember that you are also acting as an agent for the systemic rules of society, you can communicate, right? You can say, look, you know, in a perfect world, I can just believe you. You're going to go on your way. You're going to be safe.
But the reality is that if I don't do my due diligence under the general rules and how people do this job, I could lose my license and you could be in a lot of dangers and I don't know what's going to happen. You know, I'm not perfect. So help me out here. You want to get out of here? Let's get some more information. You can ally yourself with what the patient wants.
And in a way, obviously, that does correspond to what you really clinically think could be happening.
Okay. So now let's go to the next step with this patient. First, they say, I'm not giving you the boyfriend's number. You kind of do some of the things that you mentioned. They give you the boyfriend's number. You call up the boyfriend. The boyfriend says she's been making these vague threats about wanting to hurt herself for the past month. This time she said, you know, I'm going to go to a bridge if you, you know, I'm going to go to a bridge and I'm going to jump.
Walk me through then how you continue to think about these things.
Well, now you've confirmed, at least to some reasonable degree, that there has been suicidal ideation, intent planning, and threatening. And now we get a little bit more medical. We now need to gather information from the patient and from observing the patient about what is producing that. So top of the differential usually is substances, personality, and mood disorders. OK, so now you're going to assess for those and you're going to you can't just assess responsibly when there is high dangerousness based on the output statements and behaviors on one look of a patient.
You're probably going to want to observe them across a couple of days at least. Right. Depending on what you find. And so you need to interview the patient. You need to observe their interactions with you and with other clinicians and other patients and see what's going on. Are they totally euthymic, calm, no anxiety, no dysphoria, talking in clear sentences, putting their thoughts together correctly, maybe even being provocative sometimes or, you know, interpersonally fractious with other patients or members of staff?
Well, we're gathering some information there. that may indicate that there could be personality components. Are they despondent, sad, crying, having panic attacks, anxious, repeatedly asking questions, ruminating, stuck in bed, not coming out of bed in order to go to the milieu? This is stuff that may indicate the presence of mood disorder, right? And similarly, on the other direction, if she's agitated, not sleeping, not sleeping even after getting a PRN for sleep, that sort of thing.
And then In the absence of those two, identifiable personality and identifiable axis one condition, then what remains is volitional behavior, right? Was this volitional behavior in order to garner some kind of a response or to discharge stress or emotions in the context of a relationship? Well, you know, that's a little bit more of a diagnosis of exclusion when someone has presented with something so serious. But you, again, get that through observation and interview.
Ask her, so what are things been like in your relationship? Why did you do those things? I know you're saying you're not doing it, but he's saying it did. Can you explain how it got to this point? How did you get here? Can she provide a rational explanation for how things got here that seems to be free of evidence for axis one or personality stuff? You got to go find out.
And then finally, when it comes to discharge time, your job is not to predict the future. Your job is to do your job, which is to be practicing within the standard of care. And so you just have to do a risk assessment, right? You got to do a risk assessment for the factors that are of elevated risk for short-term dangerousness and long-term dangerousness. And then based on that, you're going to recommend certain treatments and you're going to treat to the extent that the law allows you.
So those are all the things that you should be doing with that patient across the time period that you have.
That's great. And I, you know, one little thing I wanted to point out in terms of things I saw a lot in my training was, you know, someone comes, does assessment, they come back and go, oh, they're, it's just narcissism or, oh, it's just borderline discharge them. Which we have to remember that those are populations at a higher risk of completed suicide. So those, I think it's fairly common.
I'm sure you've seen that in terms of like, some people think once they get a whiff of personality, a whiff of borderline personality disorder, or a whiff of narcissism, then all the other stuff is explained away and the person can be discharged, which is... ridiculous. And we have to remember that these are serious risk factors for completion of suicide, as well as, you know, suicide attempts. And I think what we're trying to say is the full story is much more important than heuristics, like if they're borderline, then they're not going to kill themselves.
Yeah. And, you know, let's dig in a little bit, even if it's personality. The questions I had then have for that clinician is, did you follow the standard of care in making that diagnosis? And did you follow the standard of care and ruling out the competing diagnoses in your differential? And then. If that was the correct diagnosis, then what's the treatment recommendations that you're leaving the patient with and how are you mitigating the risk long term?
What are you suggesting? Are you telling them what to do with your family? Are you telling them where to follow up? That's really more important than being right, that you followed the correct process. You're not expected to be right. It's not possible to be right all the time. This is an imperfect practice. Humans are imperfect, but you need to follow the standard of assessment and treatment planning.
Yeah, this is great. I think this conversation is going to be helpful for a lot of new trainees. Anything else you want to finish up with before we wrap things up on this topic?
No, I just think it is a little bit of a neglected area. You know, it's funny. Anytime you label something as different, like forensic psychiatry, as different than psychiatry, I think people can often tune out and not learn the things that they should learn because they feel like, well, some other expert is supposed to take care of that. But so much of forensic psychiatry is just general psychiatry.
And you are doing yourself a disservice as a clinician if you don't kind of read up, train up, and ask questions about it. I think it's very important here. Spectacular.
Thank you.