"Part of the balance here is that the more requirements you put [in place], where you're required to have the police involved, the more intrusion there is in the relationship between the patient and the caregiver, and there is a lot of concern in the mental health community, if every situation has to be reported, that patients won't seek help," Sharfstein said in a recent interview.

Reporting standards that mental health professionals already follow — and which largely stem from a California Supreme Court ruling in the 1970s case Tarasoff v. Regents of the University Of California — call for them to report threats of violence that are directed toward reasonably identifiable victims, Sharfstein said. In other cases, such as with suicide threats, other methods of treatment and intervention may be preferable to reporting to police, he said.

With those standards already in place, Sharfstein said, Maryland can take the more narrow approach of relying on judges to note violent tendencies at commitment reviews, and avoid overreaching.

"For me, one of the key points is that there are certain clinical situations with mental illness where there is an elevated risk of violence. At the same time, the vast majority of people at risk for mental illness do not pose a risk of violence," he said. "The question is, how do you respond to the challenge of protecting the public without overreacting and damaging care, increasing mental illness and ending up worse off?"

Other mental health professionals in the state, and all across the country, are asking the same questions, according to Appelbaum.

"Currently, a clinician has the discretion to take whatever steps are likely to be effective in preventing the harm from occurring," he said, noting that these can range from moving to hospitalize the person either voluntarily or involuntarily, to starting or changing medication, to seeing the patient more frequently for more intensive therapy, to getting the patient into substance abuse treatments or a day program. "And very few of them require a breach of the confidentiality relationship," he said.

That new regulations requiring reporting will force clinicians to frequently breach that confidentiality is a grave concern, Appelbaum said, because trust is needed to ensure patients open up.

"This is part of what mental health professionals are discussing very actively among themselves," he said. "The very real concern is that if patients know we are compelled to violate their privacy by revealing what they tell us about their impulses to hurt themselves or other people, they are likely to stay away from therapy altogether."

Dr. Patrick Triplett, clinical director of Johns Hopkins Hospital's psychiatry and behavioral sciences department, said he shares those concerns.

"You get into these situations where you're making a clinical judgment, and there are times when that confidentiality can't be absolute, and I think most people understand that," he said. "But there are legitimate concerns. There are things that patients tell us that do need to be kept confidential."

Many clinicians are watching to see whether New York will pass follow-up legislation to resolve some of the concerns raised with the package it already passed, Appelbaum said. They are also watching Maryland, to see whether the task force recommendations end up in legislation.

Across the board, they are uncomfortable with the link between gun violence and mentally ill patients — studies do not show a causal relationship — and are hoping their discretion to treat patients based on their own expertise is not trampled for political expediency, Appelbaum said.

"Lots of people come into a therapist's office and talk about their angry impulses toward other people, or thoughts of hurting themselves," he said. "Very few — very, very few — go on to commit those acts."

krector@baltsun.com

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