Defining the competent psychiatrist

What defines a competent psychiatrist?  To staunch critics of the field, perhaps nothing.  Some believe psychiatry has done far more harm than good, or has never helped anyone, rendering moot the question of competency.  What defines a competent buffoon?  A skillful brute?  An adroit half-wit?  Having just finished Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown, 2010), a reader might easily conclude that psychiatric competency is a fool's errand.  From directing dank 19th Century asylums, to psychoanalyzing everyone for nearly anything during much of the 20th Century, to doling out truckloads of questionably effective, often hazardous drugs for the past 35 years, perhaps psychiatry is beyond redemption. Of course, I don't think so.  For one thing, critics often disagree about what is wrong with the field.  For every charge of over-diagnosis and overmedicating, another holds that debilitating disorders are under-recognized and under-treated.  A charge that psychiatry has become too "cookbook" and commodified is answered by the complaint that it is too anecdotal and not sufficiently "evidence-based."  Claims that the field stumbles because it is subtle, complex, and understaffed by well-compensated specialists, are met with counter-claims that checklists in primary care clinics can do most of the heavy lifting at less expense.  Contradictory criticisms offer no evidence that the field is faultless.  But the confusion does suggest that psychiatry's limitations reside at a different level of analysis than that engaged by its critics.

For another thing, the undeniable shortcomings of psychiatry don't make the patients disappear.  Whether the field teems with genius humanitarians or raving witchdoctors, there are still families watching their teenage daughters starving themselves to death; beloved aunts and uncles living unwashed and mumbling to themselves on the street; people ending their lives out of temporary tunnel-vision; tormented souls imprisoned in their homes by irrational fears.  And our society still harbors a nagging ethical sense that a crime is committed only when a person knows what he's doing — and that when he doesn't, he deserves help not punishment.

We can admit that psychiatrists are (at times meddlesome) do-gooders who take on misery and heartache and uncontrolled destructive behavior despite deep controversies over how best to help.  It's the same role filled, in different times and places, by clergy, by family, by shamans, by the village as a whole.  Every society fills it by someone.  This is the modest starting point that bootstraps a meaningful definition of psychiatric competency.

Lists of "core competencies" are issued by the Accreditation Council for Graduate Medical Education (ACGME) for psychiatry residents, and by the American Board of Psychiatry and Neurology (ABPN) for board-certified psychiatrists.  Both organizations categorize psychiatric competency under the six headings established by the ACGME for all medical specialties: Patient Care, Medical Knowledge, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, Professionalism, and Systems Based Practice.  (These categories are also used by the Accreditation Council for Continuing Medical Education [ACCME], so that continuing education required to maintain one's medical license addresses one or more of these competency areas.)  A review of either of these detailed lists reveals two important truths.  First, a committee can make any aspirational standard byzantine and lifeless.  And second, in the eyes of  ACGME and ABPN at least, it's not so easy to be a competent psychiatrist.

However, these official competencies are unlikely to satisfy skeptics, nor do they get to the heart of the matter.  No such list can be exhaustive: the ABPN includes knowledge of transcranial magnetic stimulation, presumably a recent addition, but fails to require knowledge of specific pharmaceuticals.  Focus areas such as addiction, forensic, and geriatric psychiatry are mentioned, but not administrative or community psychiatry.  The linguistic philosopher Ludwig Wittgenstein argues that our inability to precisely define natural categories, even simple nouns like "chair," is a feature of language itself, not of psychiatric competence specifically.  Accordingly, any catalog of psychiatric competencies, whether intended to be comprehensive or a "top ten" list, captures some, but not all, of what constitutes a competent psychiatrist.

As implied above, the starting point, although not the end point, for defining the competent psychiatrist is intent.  A psychiatrist aims to relieve suffering in an uncertain human domain.  Brought to bear are skills, knowledge, and personality factors ("professionalism" etc) which bring this goal closer.  These cannot be listed exhaustively: virtually the whole of human knowledge and experience can inform one's understanding of a patient's emotional turmoil.  The best we can say, I believe, is that a competent psychiatrist is curious, has a wide fund of knowledge and life experience, and aims to keep an open mind.  Some of this knowledge certainly should be biomedical.  But knowing about the psychology of aging, common stressors such as job loss and divorce, gender differences, and many other areas are hardly less important. The practitioner's proclivity to observe the human condition both scientifically and humanistically is ultimately a better gauge of competence than whether a specific treatment modality such as TMS has been added to a long list, or whether the practitioner is able to cough up a specific fact.

Given the controversy and uncertainty in the field, another essential of competent practice is humility.  In most cases we don't know the etiology of what we're treating.  Any treatment we offer helps some patients but not others, and nearly always carries risk.  Whitaker makes many good points along these lines.  A competent psychiatrist tempers his or her urge to intervene with the realization that the road to hell is often paved with good intentions.  Psychiatrists virtually always mean well, and (contrary to some critics) help our patients far more often than not.  Nonetheless, a competent psychiatrist is always ready to admit misjudgment or miscalculation.  Self-correction is a feature of competence in psychiatry as well as in many, perhaps all, other domains of human expertise.

For another take on the competent psychiatrist, arriving at a similar endpoint using different reasoning, see this 2011 post by Dr. Raina.

I wrote above that psychiatry's limitations may reside at a different level of analysis than that engaged by its critics.  Psychiatry is a hard job because the brain is the most complex organ, because normality is so hard to define, because human development is a subtle interplay of nature and nurture, and because we don't understand the root causes of many forms of mental distress.  But even if we did know and understand these far better than we do now, the field would still be fraught with controversy and uncertainty.  Our attitudes regarding responsibility, free will, conformity versus deviance, and how we treat each other reflect our politics and deeply held values.  Psychiatry serves as a lightning rod for strong feelings around these matters.  By its very nature, it always will.  Psychiatrists must accept that many will view us skeptically, some with hatred — and others with undeserved adoration — and not let this dissuade us.  A competent psychiatrist hears criticism from individual patients and the public, neither dismissing it unthinkingly, nor allowing it to lead to demoralization and defeat.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.

OpenNotes: Good intentions gone awry

OpenNotes is "a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians."  According to their website, three million patients now have such access, generally online.  Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, Kaiser Permanente Northwest, and several others.  Patients with a premium account in the My HealtheVet program at the VA have access to outpatient primary care and specialty visit notes, discharge summaries, and emergency department visit notes.  The New York Times recently ran a mostly celebratory piece on OpenNotes as applied to mental health visits at BI Deaconess ("What the Therapist Thinks About You"), garnering over 350 public comments.  Significantly, many of these comments expressed annoyance with any mental health professional who cited potential drawbacks — despite the fact that BI Deaconess doctors who actively participate in OpenNotes concede that such openness may be detrimental for those with "psychiatric or behavioral issues" (e.g., see this promotional video, starting at 2:15). The notion of sharing clinical notes with patients enjoys populist appeal.  On a self-report survey with no control or comparison condition, patients reported that OpenNotes helped them remember what was discussed during visits, feel more in control of their care, and improved their medication adherence.  Advocates also say it improves communication with patients and can correct factual errors in the record.  However, the strongest argument seems to be that patients like it.  Defenders repeatedly invoke "transparency," implying that the status quo is intentionally obscure and aims to hide something from patients.  Some of the rhetoric has a defiant, even self-righteous tone: one promotional video (at 3:16) features a patient who pointedly declares that she'll never be refused this access again.  And there's no clear endpoint: about 60% of the patients surveyed in the OpenNotes study believed they should be able to add comments to a doctor's note, and about a third believed they should be able to approve the notes' contents; the overwhelming majority of participating physicians disagreed with the latter.  If OpenNotes is widely accepted, it will be increasingly difficult to draw clear lines regarding the authorship and authority of clinical notes.

Fifty-five percent of eligible primary care doctors declined to participate in the OpenNotes study cited above.  Of those who did participate:

Several doctors struggled with the notion of a one-size-fits-all note, arguing that one document cannot address the needs of billing, other doctors, and patients.  A few changed their own use of the note; for example, eliminating personal reminders about sensitive patient issues, excluding alternate diagnoses to consider for the next visit, restricting note content, or avoiding communication with colleagues through the note.... A substantial minority reported [changing documentation, in particular when addressing potentially sensitive issues], including their reported change in “candor.” For example, some doctors reported using “body mass index” in place of “obesity,” fearing that patients would find the latter pejorative.

§  §  §

"Progress note," not "visit note," is the traditional term for a physician's written entry into a patient's medical record, documenting an outpatient or inpatient encounter.  (OpenNotes advocates may find "progress note" too quaintly optimistic to be publicly acceptable.)  Physicians write other notes for other purposes, including admission notes, procedure notes, transfer notes, discharge notes, and so forth.  Additionally, many notes are written by nurses and a wide variety of other clinical personnel, particularly in inpatient settings.

The traditional format of a progress note documents (1) symptoms and (2) physical examination, including lab test results, obtained by the physician, (3) his or her differential diagnosis, and (4) the next steps, such as further exams, tests, or treatments, that follow therefrom.  Medical students are taught to write SOAP notes as an acronym for these four components.  Such notes assist in performing and archiving medical work, much as a scientist's laboratory notebook records the design, data, and results of experiments.  Progress notes were not designed to be a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts for patients.  Yet these notes now serve many masters, resulting in excessively time-consuming documentation that squeezes out face-time with patients, and is increasingly cumbersome as a clinical tool.   Some of the additional trade-offs in adding yet another stakeholder, the patient reviewer, are cited in the quotation above, and cannot be casually dismissed as balderdash by defenders of OpenNotes.

OpenNotes presumably works best in primary care, and with an electronic medical record that expands abbreviations (and/or provides templates), corrects spelling, and produces legible output that patients can access online.  In contrast, notes with technical jargon by specialists such as ophthalmologists, anesthesiologists, radiation oncologists, and many others would be incomprehensible unless radically altered to be more patient-friendly.  Less "connected" practices would similarly be left out.  But even in the best-case scenario, progress notes are a poor tool for doctor-patient collaboration.  By nature they are shorthand, telegraphing complex medical reasoning in a few words.  Old-fashioned discussion is paradoxically superior for assuring that doctors and patients are "on the same page." Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.

The real thrust of the OpenNotes initiative is less pragmatic.  Many patients want to feel more in control of their care.  In addition, doctors aren't trusted as profoundly as we used to be.  If given the chance, many patients will gladly join the ranks of those who look over our shoulder.  And of course, if the traditional use of progress notes is framed as paternalistic or elitist, reforming these notes into something "democratic" seems like the only sensible thing to do.  The enthusiastic fervor to empower patients in this misdirected way (further) dulls a useful documentation tool which is no more inherently elitist or paternalistic than the work notes of a car mechanic or the recipe notes of a chef.  Everyone feels good about this newfound "transparency."  And that, apparently, is what really counts.

These considerations apply doubly in the case of mental health notes.  My colleague who writes the Psych Practice blog wrote a response to the New York Times piece on sharing therapy notes.  I agree with her completely.  I'd only underscore that psychotherapy based on psychoanalytic and psychodynamic principles depends crucially on gauged disclosure and the timing of verbal interventions.  These treatments anticipate and rely on the reality that the perspectives of therapists and patients inevitably differ, and that this discrepancy is not a simple error or miscommunication, but instead is the engine that drives psychological change.  Arguing for transparency in such treatment is tantamount to wishing that these therapies disappear (some critics will readily acknowledge this).

The relationship between doctors and patients should always be collaborative, but it is never equal.  One party is ill and needs help, the other offers expertise and resources the other doesn't have.  "Giving everyone a say" sounds democratic, but medicine isn't practiced democratically.  Try asking a car mechanic or a chef at a fine restaurant (or your child's schoolteacher, or an architect, or a police officer...) if you can share in their work-flow and decision making.  Most will initially appreciate your interest and offer you an overview.  A kind one may let you look under the hood.  However, very soon you will be told that you are in the way — that you can watch intently or enjoy a good result, but not both.  There is nothing paternalistic about this, it's how skilled workers do their jobs.  When reminded that this applies to physicians as well, and once the thrill of the "forbidden" behind-the-scenes look wanes, we will see that the remaining advantages of OpenNotes are better served by other means.

Military brain-chips to cure psychiatric disorders?

Sounding like something straight out of science fiction, DARPA recently announced grants to fund research and development of implantable brain-stimulation chips aimed to relieve, or even cure, mental disorders.  The Defense Advanced Research Projects Agency thinks big, and it has the money, i.e., our tax dollars, to back it up.  Decades ago, DARPA brought us the internet.  In comparison, revolutionizing psychiatry ought to be a walk in the park — right? Find a need and fill it: "Current approaches — surgery, medications, and psychotherapy — can often help to alleviate the worst effects of illnesses such as major depression and post-traumatic stress, but they are imprecise and not universally effective."  You can say that again.  So DARPA created a program called SUBNETS (Systems-Based Neurotechnology for Emerging Therapies) "to generate the knowledge and technology required to deliver relief to patients with otherwise intractable neuropsychological illness."   SUBNETS aims to create an "implanted, closed-loop diagnostic and therapeutic system for treating, and possibly even curing, neuropsychological illness."  In other words, computer chips in the brain.

SUBNETS will pursue the capability to record and model how these systems function in both normal and abnormal conditions, among volunteers seeking treatment for unrelated neurologic disorders and impaired clinical research participants. SUBNETS will then use these models to determine safe and effective therapeutic stimulation methodologies. These models will be adapted onto next-generation, closed-loop neural stimulators that exceed currently developed capacities for simultaneous stimulation and recording, with the goal of providing investigators and clinicians an unprecedented ability to record, analyze, and stimulate multiple brain regions for therapeutic purposes.

SUBNETS is hedging its bets.  With an overall budget of $70 million, it is funding both a diagnosis-based arm, in the manner of the DSM5 of the American Psychiatric Association (APA), as well as a “trans-diagnostic” approach, in the manner of the Research Domain Criteria (RDoC) of the National Institute for Mental Health (NIMH).   The ideological rift between the APA and NIMH last year was awkward and impolitic; fortunately,  SUBNETS has the resources to avoid choosing sides.  A research team at the University of California San Francisco (UCSF) will receive up to $26 million to study diagnostic groups, specifically post-traumatic stress, major depression, borderline personality, general anxiety, traumatic brain injury, substance abuse and addiction, and fibromyalgia/chronic pain.  Another team at Massachusetts General Hospital (MGH) will receive up to $30 million to tackle trans-diagnostic traits, such as increased anxiety, impaired recall, or inappropriate reactions to stimuli.  Both groups will include public and private partnerships, including with device manufacturers Medtronic, Draper Laboratory, and the start-up Cortera Neurotechnologies.

What to make of this?  Well, it's certainly ambitious.  As I read it, the effort relies on several unproven premises.  First, that psychiatric diagnoses, as currently construed, can be differentiated by monitoring activity in specific brain pathways.  This has been tried before without success, and it isn't clear that sensor technology was the reason.  An alternative model would suggest that mental states are an emergent property of widely integrated brain states.  If so, chips implanted in specific areas could no more capture this complexity than carefully listening to the trombone section could capture a symphony.

Another assumption is that carefully focused electrical stimulation can treat a variety of mental disorders.  The efficacy of transcranial magnetic stimulation (TMS) to treat depression provides some support for this idea.  In contrast, typical comparisons to deep brain stimulation to treat seizures and severe obsessive-compulsive symptoms only go so far.  Analogous stimulators may quell a panic state or chronic pain.  It is less clear how complex interpersonal patterns, such as those seen in borderline personality or substance abuse, could respond to this type of intervention.  Of course, we shall see.

A central tenet of SUBNETS is that implanted technology can promote healthy (or curative) neural plasticity.  Plasticity is a popular concept at the moment, highlighting the fact that brain wiring is not static, as was previously assumed.  "Neurons that fire together wire together" — that is, synaptic connections change dynamically in response to input, i.e., life experience.  This property underlies the hope that implanted stimulators may change the activity of neural pathways in a permanent way, "firing" the pathway together to make it "wire" together, and allowing the device eventually to be removed.  Again, we shall see.

Of course, there are many stumbling blocks ahead.  Implanting brain chips is no small matter, and this approach is unlikely to be used in the foreseeable future for anything short of the most severe, treatment-resistant disorders.  Initial public commentary immediately honed in on the "military mind control" aspect of the project, with visions of soldier drones being controlled on the battlefield via implanted chips.  The potential abuse of such technology is manifest and terrifying, and careful controls and standards are needed to assure freedom, not to mention safety.

At the most mundane level, the technology will only work if the science behind it is sound, and that remains to be seen.  Nonetheless, if even a portion of the SUBNETS agenda comes to pass, it would represent a monumental leap for psychiatric treatment.

Psychiatric uncertainty and the neurobiological buzzword

A few years ago I wrote that uncertainty is inevitable in psychiatry.  We literally don't know the pathogenesis of any psychiatric disorder.  Historically, when the etiology of abnormal behavior became known, the disease was no longer considered psychiatric.  Thus, neurosyphilis and myxedema went to internal medicine; seizures, multiple sclerosis, Parkinson's, and many other formerly psychiatric conditions went to neurology; brain tumors and hemorrhages went to neurosurgery; and so forth.  This leaves psychiatry with the remainder: all the behavioral conditions of unknown etiology.  Looking to the future, my fervent hope that researchers will soon discover causes and definitive cures for schizophrenia, bipolar disorder, and other psychiatric disorders comes with the expectation that these conditions will then leave psychiatry for other specialties.  We will always deal with what is left.  At minimum we psychiatrists should accept this reality about our chosen field.  After all, there appears to be no alternative.  Some of us go beyond this to embrace uncertainty as intellectually attractive.  We like that the field is unsettled, in flux, alive. Yet many of us clutch at illusory certainty.  Decades ago, psychoanalysis purportedly held the keys to unlock the mysteries of the mind.  It later lost favor when many conditions, particularly the most severe, were unaffected by this lengthy, expensive treatment.  Now the buzzword is that psychiatric disorders are "neurobiological."  This is said in a tone that implies we know more than we do, that we understand psychiatric etiology.  It's a bluff.

Patients are told they suffer a "chemical imbalance" in the brain, when none has ever been shown.  Rapid advances in brain imaging and genetics have yielded an avalanche of findings that may well bring us closer to understanding the causes of mental disorders.  But they haven't done so yet — a sad fact obscured by popular and professional rhetoric.  In particular, functional brain imaging (e.g., fMRI) fascinates brain scientists and the public alike.  We can now see, in dramatic three-dimensional colorful computer graphics, how different regions of the living brain "light up," that is, vary in metabolic activity.  Population studies reveal systematic differences in patients with specific psychiatric disorders as compared to normals.  Don't such images prove that psychiatric disorders are neurobiological brain diseases?

Not quite.  Readers of these exciting reports often overlook two crucial facts.  First, these metabolic differences only appear in group studies and cannot be used to diagnose individual patients.  As of this writing there is no lab test or brain scan to diagnose any psychiatric disorder.  Attempting to do so would be like diagnosing malnutrition based on height.  While malnourished people are shorter than the well-nourished on average, there is wide overlap and height is not diagnostic.  Second, etiology — the cause of these differences in brain function — remains unknown.  Differences in brain function (and structure) are not necessarily inborn.  Brain anatomy can change as a result of life experience, and metabolic activity (function) from experimental manipulation of cognitive effort, induced mood, guided imagery, etc.  Just as multiple factors affect a subject's height, multiple biological and psychological factors affect brain findings as well.  Thus, learning that patients with borderline personality show decreased metabolism in the frontal lobes (hypofrontality) is neither surprising nor indicative of a neurobiological etiology.  We already know the frontal lobes inhibit impulsive activity, and we already know borderline personality is characterized by impulsivity.  What else would we expect?

Genetic studies consistently show both heritable and environmental factors at play in psychiatric disorders.  Since the 1960s, psychiatry has called this combination the diathesis-stress model: an inborn predisposition meets an environmental stress, leading to an overt disorder.  The model helped shift the field from "nature versus nurture" to "nature and nurture" — and no research discovery or neurobiological rhetoric so far has shifted it back.  Patients and their doctors still contend with diathesis and stress: recreational drug use tips one patient into psychosis, sudden abandonment tips another into borderline rage.  Indeed, clinicians remain much more able to influence stress than diathesis.  A dispassionate assessment of what we currently know should lead to humble agnosticism about psychiatric etiology.  Genetics, biology, and environment all play a role, but beyond that there isn't much we can say.  This is why all current psychiatric medications treat symptoms and are not curative.

In this light, the popularity and zeal of neurobiological language is startling.   The American Psychiatric Association (APA) subtly changed the wording in its new Diagnostic and Statistical Manual, DSM-5, to imply that all psychiatric conditions are biological in nature.  The National Institute of Mental Health (NIMH) assumes that "Mental disorders are biological disorders...."  The National Alliance on Mental Illness (NAMI) says, "A mental illness is a medical condition...."

A more ground-level version is expressed by editor-in-chief Henry A. Nasrallah, MD in the latest edition of Current Psychiatry.  In an editorial not-so-subtly titled, "Borderline personality disorder is a heritable brain disease," Dr. Nasrallah proclaims BPD a "neurobiological illness" and "a serious, disabling brain disorder, not simply an aberration of personality" — as though these were distinct alternatives rather than two terms for the same thing.  After citing a number of biological findings which fail to prove etiology (e.g., the hypofrontality mentioned above) and which show partial heritability, Dr. Nasrallah concludes that "the neuropsychiatric basis of BPD must guide treatment."

Of course, it already does.  We already treat borderline personality disorder the best we know how, with psychotherapy (shown by functional imaging to modify brain metabolism, by the way) and often with adjunctive medication to treat symptoms.  What more do breathless declarations of brain disease buy us, other than reduced credibility?  It's not as though any of us currently withhold neurobiological treatment as a result of outmoded ideology.  On the contrary, the moment the FDA approves a cure for borderline personality disorder based on an established neurobiological etiology, I will gladly refer my patients to the neurologist, virologist, or genetic counselor who would thereafter treat such patients.

Do patients avoid psychiatrists for fear of legal holds?

Over on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I've written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco's transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably "bus-like," and that there is a legitimate role for higher-cost "taxi-like" services for those willing and able to pay for them. It's important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even "bus-like" mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise "come to some agreement" with cash-strapped patients in ways taxi drivers don't.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy "shallow at best."

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the "5150" here in California), is uncommon in office psychiatry, and in any case didn't bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who "truly need psychiatric intervention ... from even attempting to access 'help'."

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it's a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I'm sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I've reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there's much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its "probable" likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won't fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist's power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don't make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients' fears of subjectivity and loose criteria are partly based in reality.  A casual "better safe than sorry" attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a "frame issue" as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn't play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn't truly interested in overcoming suicidal feelings, and I wouldn't engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a "death by cop" scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one's just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.