August 2nd, 2012

James Holmes’ psychiatrist and the duty to warn

James Holmes’ psychiatrist Dr. Lynne Fenton warned the university’s threat assessment team that he might be dangerous, and, tragically, nothing was done to stop him—at least, nothing effective:

Sources have told KMGH-TV that the threat assessment team never had a formal meeting and never intervened, believing that it had no control over Holmes once he’d left the university…A CU spokeswoman declined comment to KMGH on Fenton or any threat-team team actions, citing a gag order.

Dangerous people often become more dangerous, not less, when they’ve left an institution or job at which they’re having difficulty. But dangerousness can be difficult to evaluate in the absence of very clear signs, and the remedies are not always all that obvious even then.

For example, a mental health professional is required to give what’s called Tarasoff warnings if a person offers threats to a specific individual. That works for stalkers and their ilk, but it’s doubtful that Holmes specified to Fenton who his targets were, since he probably didn’t even know himself. Did he describe his modus operandi in any detail, or did he just mention vague thoughts of violence? Was he specific, or was it just a hunch on Fenton’s part?

Civil commitment is not that easily accomplished these days, although it would probably have been possible in Colorado if Holmes were to have been judged to be dangerous to himself or others.

I can’t even imagine how Dr. Fenton is feeling. One of the heaviest and most difficult responsibilities a psychiatrist has is to predict the violent behavior of patients under his/her care. In the case of Holmes, we don’t know for how long Fenton saw him prior to the murders; it might have been only a very short time. She seems to have properly sounded the alarm. But if and when the ball was dropped and by whom, or whether the threat assessment team’s hands were tied by the law, remains to be seen.

21 Responses to “James Holmes’ psychiatrist and the duty to warn”

  1. Artfldgr Says:

    there is now a holmsian fan club!!!!

    amazing, eh?

  2. Mr. Frank Says:

    We have got to find a way to get a direct route to the FBI gun purchase check list to report persons who receive mental health services and are thought to be mentally ill. We missed on Va Tech, Arizona and Aurora Colorado — all cases where the perpetrator was nuts. The reporter needs immunity from law suits and the person reported should have a route of appeal.

  3. Indigo Red Says:

    Dangerous people often become more dangerous, not less, when they’ve left an institution or job at which they’re having difficulty.

    Conversely, dangerous people can become less dangerous once removed from the stress producing situation and environment. Therein is the rub. Who’s to know which until some action is taken by the stressed individual.

  4. parker Says:

    While I agree that persons legally identified as mentally unstable should be denied access to firearms; I see no way a system could be put in place to accurately and fairly prevent ‘crazy’ people from gaining access to firearms. The solution is to encourage citizens to acquire firearms, become proficient with them, carry them everywhere they go, and laws that allow citizens to carry concealed everywhere except for government buildings. If we want to prohibit guns, the place to prohibit them is in government buildings. Then we make government at all levels responsible (legally) for the safety of citizens.

  5. Artfldgr Says:

    So Mr. Frank…
    let me see if i understand you correctly…

    but first let me put up a few points to make my perhaps misunderstanding you, clearer to see where and why

    Timeline: Mass Killings in the US Since Columbine
    ‘published’ Friday, 20 Jul 2012 07:36 AM
    At least 28 mass killings have now occurred in the United States since two teenagers went on a rampage at Columbine High School in Littleton, Colorado in April of 1999, killing 12 of their fellow students and a teacher.

    That’s about a 13 year period with 2.15 incidents per year… want to make it 5 and make the number higher? If the average number of dead was 10, that.s about 20 people per year… no?

    Seung-Hui Cho is the winner of the worst prize in this period, with 32 people killed and 15 wounded…
    33 if you count him shooting himself.

    In 2010 – the latest year for which detailed statistics are available – there were 12,996 murders in the US. Of those, 8,775 were caused by firearms.

    32 / 8,775 = 0.003646723646… * 100 = 0.36%

    so if 32 people were killed by mass gunman in a year, using the highest mass murder in the examples, it would represent 1/3 of a percent of all killings by guns.

    The U.S. Census Bureau announced today that the 2010 Census showed the resident population of the United States on April 1, 2010, was 308,745,538.

    These 32 people represent 0.00000103% percent or so of the population we are taking in to consideration.

    the total number killed by firearms as a percentage is 0.00000284%

    One in four adults—approximately 57.7 million Americans—experience a mental health disorder in a given year. One in 17 lives with a serious mental illness such as schizophrenia, major depression or bipolar disorder1 and about one in 10 children live
    with a serious mental or emotional disorder.

    So technically you want to forbid more than 1/4 of the population from having guns to save 0.00000103% from guns (while not caring if the same nut job uses gas cans. that’s a different column, so that’s someone else’s administration bureaucracy, right?)

    About 2.4 million Americans, or 1.1 percent of the adult population, lives with schizophrenia.

    Bipolar disorder affects 5.7 million American adults, approximately 2.6 percent of the adult population per year

    Major depressive disorder affects 6.7 percent of adults, or about 14.8 million American adults.

    Anxiety disorders, including panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder and phobias, affect about 18.7 percent of adults, an estimated 40 million individuals.

    Fewer than one-third of adults and one-half of children with a diagnosable mental disorder receive mental health services in a given year

    So actually this wouldnt forbid 1/4, but 1/3 of 1/4 who see a doctor, get a diagnosis, and then are subject to reporting… (think reporting might dampen the 1/3 from going to see a doctor so they can avoid the judgment and different treatment? just asking)

    Racial and ethnic minorities are less likely to have access to mental health services and often receive a poorer quality of care

    so the 1/3 will be white crazies, and the others will just not matter… so i guess the dragnet would get Holmes, but not Cho, Hassan, etc.

    Would the ban also include people who go for one off things? you know, like temporary treatments for seeing a doctor during a stressful divorce and child custody case?

    now if so, you may end up achieving the democrats complete gun ban under Obama care depending on mental health services?

    the numbers i gave were for clinical, and ongoing. but there are lots of people who are situational too, and others who in the old days would be called neurotic that use their shrink as some kind of social gig and status icon.

    even more interesting? would this include, say, leftist liberal teachers assessments of kids being good enough as a early preventive intervention? of course the victim, i mean subject has no right to know or appeal the information connected to them… valid or accidental, yes?

    so do i understand you right? based on these real world figures and numbers the solution to save 20 people a year out of 8000 or so from gun death (but not death by other means by the same person), would be to allow the state to get a report if you go seek some form of mental health care and so on?

    Twenty-four percent of state prisoners and 21 percent of local jail prisoners have a recent history of a mental health disorder.

    your point wouldn’t even affect 75% of criminals..
    their sane…

    in fact… notice something else. the sane that do this outnumber the person with a disorder by 3 times.

    so in essence, i believe your solution entails giving up my freedom at the word of another person, who may even be under malpractice suit, and lose a foundational right under the bill of rights, to save 20 people a year from gun death (not other death) and thats it?

  6. Susanamantha Says:

    Another great comment from Artfldgr. Thanks for taking the time to come up with the numbers and explaining it so well.

  7. Artfldgr Says:

    A teenager has been arrested after killing nine people and wounding four others in a knife attack in northeast China, state media reported Thursday.

    The 17-year-old, who was identified only by his surname Li, barged into the home of his girlfriend armed with a knife following an argument and killed two relatives of the girl, the Legal Daily said.

    As he left his girlfriend’s home in Liaoning province’s Xinbin county, he stabbed six more people to death and wounded five, it said.

    One of the injured died Thursday in hospital, the paper said.

  8. Don Carlos Says:

    “One of the heaviest and most difficult responsibilities a psychiatrist has is to predict the violent behavior of patients under his/her care,” says Neo.

    Actually, prediction is not at all the point. Prediction of anything is necessarily followed by a measurable endpoint. If I predict the Dow will be down tomorrow, only tomorrow’s close will speak to the accuracy of my prediction.

    Concern about a strong possibility, or perhaps even a not-so-strong possibility is the point. Concern and red flags and prevention and the safety of others should be the shrink’s motivations, not predictive accuracy.

    There is an old truthful saying among ENT surgeons in teaching the neophytes. Begins with a question: in someone with respiratory distress who may come to need a tracheostomy, when should you do the trach? Answer: when it first crosses your mind that a trach may become necessary…ever done a trach on someone in severe resp. distress? It’s damn hard to do, and patients die in the doing.

    Endotracheal intubation has replaced urgent trachs pretty much , but the logic remains 100% valid.

    I add my thanks to Artfldgr. Excellent.

  9. neo-neocon Says:

    Don Carlos: my point about the difficulty of prediction was not meant to be primarily about the decision to report someone to something like the threat assessment team. I was thinking more of the problem of predicting well enough to justify starting a mechanism in play to actually do something about preventing the person from harming self or others by the commitment process, one of the few ways to try to keep the person from acting on the threats (only temporarily, and sometimes for a very short while). Involuntary commitment is a major step, and the health professionals and/or their institution may even be subject to lawsuit if the commitment is deemed unjustified (see also this).

    In the present case, for example, the psychiatrist apparently did judge the patient dangerous and did go through a procedure to tell the authorities. But nothing seems to have been done. Who is liable? What are the rules for this? And if they hesitated, was it because they were afraid of the repercussions if they moved against Holmes in some way and he or his family sued them? Or were they just negligent? That’s the sort of thing I’m wondering about.

  10. Artfldgr Says:

    Too bad he wasnt a Catholic, we could be wondering the same questions as to the sanctity of the confessional vs the privacy of the patient


    on another interesting note..

    Homeless Man Found With Cache of Weapons, Ammo and List of Politicians’ Names…

    If it was common, it wouldn’t be news…
    the less common, the more rare, the more sensational… if these events happened as often as black on black crime we would be inured and normalized to ignore it due to its frequency and the lack of being able to facilitate positive change (not facilitate politicians goals).

  11. Indigo Red Says:

    Or, did Holmes initiate his deadly activity while the appropriate procedures were being implemented? Whether or not people like it, coincidence is real and when it happens sometimes innocent lives are lost.

  12. Don Carlos Says:

    The link you provided indicates the basis for the man’s seven day involuntary commitment was a false death threat allegation by his wife, and a failure to release after the 5 day invol commitment expired. Not an apple to the Holmes apple.

    I have no problem in being sued for malpractice; people screw up, me included, from time to time. I would like the suit allegations grounded in fact, though they often are not, and so become plaintiff & lawyer extortion to settle, and then the defendant must stand his ground, as I have, and I never lost, by virtue of the facts.

    That threat of suit does in no way mitigate failure by a psychiatrist to act. That there exist “threat assessment teams” diffuses responsibility and makes prompt action impossible, as in this case, even though the shrink was reportedly a member of that team(!).

    I say again that CONCERN about possible violence by Holmes and others (e.g. Major Hassan) must pre-empt psychiatric “predictions”. Maybe I’m just engaged in semantics, but words do have meanings.

  13. neo-neocon Says:

    Don Carlos: I think you misunderstand my point. Let me try to make myself more clear.

    If a therapist or a psychiatrist deals with a population of patients in crisis (suicidal, psychotic, etc.), there will be a lot of threats of violence to self or others. Some will be vague, some will be detailed. In-between those two extremes will be a large gray area. And most of these threats will almost certainly not be carried out.

    The therapist cannot involuntarily commit everyone who speaks of violence. Instead, the seriousness of the threat must be evaluated. Involuntary commitment is not an easy process, and one doesn’t want to use it lightly (not just because of a threat of lawsuit, either). I tend to think (just as you do) that a therapist should err on the side of caution, but it is a very difficult decision to make.

    In the Holmes case, the psychiatrist appears to have erred on the side of caution by reporting Holmes to the team, but somewhere the ball was dropped, either by her or by the team, or both. Or maybe the evidence just wasn’t strong enough to justify further action. At this point, we don’t know. Hindsight is 20/20; foresight—and prevention—is far more difficult.

  14. Capn Rusty Says:

    Holmes reputedly wore body armor. We certainly have a right to carry weapons, and some portion of that right is grounded in protecting ourselves from our fellow citizens. But someone wearing body armor defeats our ability to protect ourselves; in effect, takes away our 2nd Amendment right. We could all load up with high-caliber armor-piercing ammo, not unlike the arms race of the Cold War.

    Someone going out the door with a weapon and wearing body armor is expecting to be shot at. Assuming the person is rational, that is a klaxon warning that he intends to do something that will cause the police or armed citizens to be shooting at him.

    Banning the sale of body armor to individuals might be Constitutional. Without the armor, would Holmes have murdered?

  15. Don Carlos Says:

    Involuntary committment is indeed very difficult to achieve, even when the need is clear. That is a partial consequence of the civil-rights-of-the insane movement started by psychiatrists at the dawn of the phenothiazine era.

    It’s analogous to gun control in Chicago, where gun possession permits are impossible to get, yet the black-on-black murder rate by guns is sky-high.

    I would prefer a clear differentiation between “therapists”(MSWs, MS and PhD psychologists) and psychiatrists (MDs), the former having little of substance to do in the realm of acute psychosis.

    Capn Rusty: you are attributing rational thought to Holmes, a clearly irrational person.

  16. Artfldgr Says:

    one cant find a static fix to a transient condition that does not violate the whole of those who dont experience the transient condition.

    that is…

    your not going to find singular solutions to fix a problem that is not uniform, nor even exists without fading.. the crazy with the gun once stopped by his friend, may not ever try again… the person who is labled to potentially exhibit the transient act, may never ever do it.

    and all that presupposes all manner of false answer michief, like spite and race hate, or other reasons to generate conditions int he problem. ..

    this is why, we as a peoples have to learn that you ahve to accept imperfection in an imperfect world.

    noise floor never is zero…

  17. Artfldgr Says:

    Someone going out the door with a weapon and wearing body armor is expecting to be shot at. Assuming the person is rational, that is a klaxon warning that he intends to do something that will cause the police or armed citizens to be shooting at him.

    way too simple…
    not real world at all..

    your premise is false…
    people who train with weapons who intend to wear armor in a bad situation will train wearing the armor… they dont intend to murder people.

    in this case, the facts do not align with your point… your assumption is that he was willing to be shot at…

    and then your forget the costume effect. the idea that you look cooler and are dressed for the job…

    of course. if we really want to analyse it correctly we should analyse it against waht was needed or not, not what was imagined needed.

    a man with a shot gun in his underwear would have done more harm, and not been in any more danger than the man with the body armor, as it was a known gun free zone…

    ie. if he went to a military base with armor on and started shooting, its a fair idea he was going with the idea that he would be shot at

    when you dress up in body armor, and you go to a gun free zone, and you give up with out any fight or tussle as you sit in a parking lot waiting instead of runnng away… your not intending to be shot at. your just putting on your comic book movie costume

    by the way, when an actor gets into body armor,grabs a machine gun, are they intending to be shot at?

    the point is that your logical condition is only logical if you dont try to refute it or point out how it doesnt work

    just as giving away my freedom to the fbi to save 20 people from gun death a year, while leaving themsubjected to a man with a gas can and two cherry bombs… is not workable either.

    with a few parts, he could have made a 10 gallon gas fuel air bomb… for the price he paid for the armor, he could have made lots of them… not to mention that doing so would have made him very hard to find..

    by the way, thats another point..

    when the police show up, does body armor make it easier to focus on who did it, or does wearing kackis a tee shirt, and so on?

    in other words, good thing he was wearing armor, it made it easy to know which clown out of 400 movie goers running in all directions was the clown to shoot at.

    this is why mob hits, which have a lot more risk of the opponents shooting back, dont happen with body armor…

    body armor is not as much of a plus as you think it is… at least not the way most wear it. cops get benefit because most criminals dont go to a gun range and practice with their illegal unlicense weapon. so at 8 feet, they cant hit the whole body, let alone the head.

    i guess the point i keep trying to make is that your fellow men (and sometimes women) are a lot more clever at finding the idea you miss or knowing sometig you dont than you.

    the more you know the more you know that these ideas wont work at all..

    its just one level up from “lets remove all guns”

    a man with a car driving through a country fair can do more than a man with a gun that has to accurately find limited zones that harm.

    just pick any big street march or parade and zoom without stopping… how far can you go?

    personally, i would rather have them spend months buying crap they dont need and potentially someone noticing, than they be smart enough to just go to a gas station, get a can, tape, and a bit of elbow grease and make a vastly more powerful indiscriminate weapon.

    in a way, we are also missing the point that easy tends to attract more than hard

    and to such minds, body armor, a cape, a rousing letter, and bright noisy flashing weapons is it..

    but to a real murderer who isnt nuts? you start a cult, and get everyone to show up and drink cool aid.

    jim jones was able to get 909 people to kill themselves with coolaid… 200 children.. and a few guns got the US government official trying to escape…

    you see… no matter what you try to fix in this area, your going to leave an infinite bunch of alternatives, many of them worse and not used only because if you have a simple answer, why work harder to the other answer. but in the absence of that, you have no choice and so removal of the easy moves them to the worse and worse things

    and ALL of these solutions are ignoring that the problem was caused by the priuor cultural social engineere progressive changes that destroyed family, moved owmen into labor causing children to be under educated in life becasue most of their real educastion in family was taken away.

    it has nothing to do with ease of weapon availability… want to kill the person in the room? you have a gun if you bouyght and prepared it. but you can easily just pick up a chair and beat them over the head with it. no chair? kick them to death

    we will only be safe from each other if we are made into quadriplegics and are arranged beyond spitting distance…

    then, completely isolated and incapable of movement… we will still hurt each other saying bad things to each other…

  18. Richard Aubrey Says:

    Appears the guy wasn’t wearing body armor. However, the effort and planning in accumulating the guns, the ammo, in rigging the apartment to explode, costuming himself either because he’s weird or because it was camo and would give him an advantage, and the access [reports are he left by an emergency exit, blocked it, and returned the same way], all point to rational forethought.

    He really wanted to do this. For some reason.
    Problem with stopping somebody before he goes off like this is the same thing as an armed citizen stopping a mass shooting. If it’s stopped, it doesn’t happen and you can’t prove it would have, especially in the case of the armed citizen because the perp may be dead.

  19. jim murray Says:

    why did holmes leave the theater alive?

  20. leigh Says:

    Long-time lurker here.

    I believe Holmes left the theatre alive because his mission was accomplished. He sat by his car, waited for police and surrended peacefully.

    Now, what his mission may have been is anyone’s guess until we either hear from the psychiatrists at trial or there is a leak of some sort.

    I also believe he is suffering from schizophrenia, but that he may be malingering in jail.

    We’ll have to wait to see.

  21. jasper Says:

    Curious thought: What are the odds that someone in the theatre was carrying a concealed weapon and failed to use it? I’m not sure that I would have been so heroic, but I would hope that I would have shared with media why I did not use it.

    Too many people with their minds already made up and don’t want to be confused by the facts….this happens too often and this situation is a lightening rod for this kind of thinking.

    Our culture is a violent one. Best to let us have our guns but we will have to live with some restrictions. At the very least, we need to be prepared to keep our eyes open for others that pose a risk and to take action. If we choose to not go to the authorities we need to confront the individual asap.

    The black panther party armed themselves with assault rifles and they carried them, openly. Ronald Reagan spoke vehemently against this practice and used the weight of the law against it. Go check out those facts. He selectively violated gun rights of our citizens and he was right to do this.

    The biggest risk to our country is financial and I have contempt for both parties that avoid the problem. There is a point out there that will be the critical mass for violence that we have never seen in our life times.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.


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