President's Column

Since the tragic school shooting in Newtown, Conn., mental health has been part of a nationwide conversation about what to do about gun violence. As the world's largest organization of behavioral health practitioners and scientists, APA has much to contribute to this discussion.

In recognition of APA's expertise, the White House invited Dr. Norman B. Anderson, our chief executive officer, to a Jan. 9 meeting, where he stressed five major points: 1. Improve and expand school violence prevention efforts, including the formation of school threat assessment teams; 2. make communities safer, including instituting a public health campaign to encourage help-seeking for persons in distress; 3. enhance access to mental and behavioral health and substance use services, including making mandatory these services provided by psychologists; 4. increase federal funding for vital service and training programs, including guaranteed funding for the Graduate Psychology Education Program; and 5. enhance the knowledge base for sound public policy on violence prevention, including funding a research agenda.

A week later, as a result of this meeting and others, President Obama presented four steps that he said could be taken immediately: 1. close background check loopholes to keep guns out of dangerous hands; 2. ban military-style assault weapons and high capacity magazines; 3. make schools safer; and 4. increase access to mental health services. As part of the plan to make schools safer, the Obama administration is advocating for $150 million to school districts to hire, among others, school psychologists to help foster safer and more nurturing school climates. As part of its plan to increase access to mental health services, the administration is proposing to fund the training of 5,000 more mental health professionals, including psychologists, by providing stipends and tuition reimbursement. Most relevant to current practitioners, the administration is issuing final regulations governing group health plans requiring that they cover mental health services at parity with physical health plans. The Affordable Care Act already requires all new small group and individual plans to cover 10 essential health benefit categories, including mental health and substance abuse services.

With 30,000 firearm-related homicides and suicides a year, the president called gun violence a public health crisis. But research into gun violence apparently has been barred by Congress as a result of lobbying by the National Rifle Association. The president has disputed that there is any real prohibition and has directed the Centers for Disease Control and Prevention to identify the most pressing research questions and has called on Congress to provide $10 million so that CDC can conduct that research.

APA is already ahead of the game. At Monitor press time, APA's Council of Representatives was considering the creation of a task force to develop a policy on the prediction and prevention of gun violence. In January, the Board of Directors, acting on behalf of the council, allocated almost $35,000 to fund a literature review and working group to evaluate and revise as necessary two APA resolutions on violence in video games and mass media.

There is the danger that tragic events will lead to quick but faulty solutions with unintended consequences. One example is the passage by the New York legislature of its Safe Act. Among other provisions, the act requires mental health professionals to report to the director of community services who shall, in turn, report to the Division of Criminal Justices Services when they determine that a patient is "likely to engage in conduct that would result in serious harm to self or others." This means psychologists in these cases are mandated to breach confidentiality. APA's Code of Ethics requires practitioners to disclose the limits of confidentiality. Knowing that the utterance of violent urges may be disclosed to the state, the patient is likely to avoid discussing these urges. And, if disclosed, the patient may see this as a breach of trust and never return to therapy (just like the patient in Tarasoff v. Board of Regents). That the act holds mental health professionals immune from civil or criminal liability for disclosures reasonably made under the likelihood standard, will only increase the possibility of disclosure. In fact, as I interpret the likelihood standard, it would only require a 50 percent possibility that the patient is dangerous. This in itself will lead to a great many false positives and unwarranted breaches of confidentiality.

Fortunately, APA is more thoughtful than the New York legislature. Its practice and research agenda will, it is hoped, contribute to the national dialogue on gun violence in a responsible and data-oriented way.