Annette Hanson, MD

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.