I Am My Brothers' Keeper

On October 14, 2015 Caroline Ekong, M.D., a respected Delaware psychiatrist, was brutally murdered by a former patient. Dr. Ekong had no idea she was being targeted. The young man who killed her seems to have done so out of rage at Dr. Ekong for placing him on a temporary commitment in a psychiatric facility in 2012.

On October 1, 2015, a shooter killed nine and injured nine others at Umpqua Community College in Oregon. Although we don’t know much about the shooter’s mental health, his behavior was rageful and he did commit suicide. These are just two recent examples of violence against others in our country.

Mental illness is a treatable illness. It can affect one’s mood (e.g., depression, anxiety), one’s thought processes (e.g., schizophrenia) or both mood and thoughts (e.g., bipolar disorder with psychotic features, schizoaffective disorder).

Mental illness is treatable with medication, psychotherapy and the support of family and friends. With treatment, many people can live a full life. Like any medical illness, mental illness can be mild, moderate or severe. People with a severe form of a mental illness may need societal supports, such as housing, help getting to doctors’ appointments, help buying food and clothing. Mental illness can be debilitating in its severe form. It’s easy to misunderstand because you can’t see it with your eyes.

There is evidence that mental illness can be genetic which is helpful in early detection, psycho-education and diagnosis. We have also known for a long time that initial episodes of psychotic thinking occur between the ages of 18 and 22, which could further aid us in diagnosis and treatment of some severe mental illness.

In the past few years, we have seen increased violence due to mental illness. These deaths have been initiated by individuals between the ages of 18 and 22. In at least one incidence, college counselors were unable to communicate their concerns to the parents due to confidentiality. With the passing of the Health Information Portability and Accountability Act (HIPAA), professionals were stopped from communicating with others unless a patient signed a release authorizing an outreach to family.

Before HIPAA, we could easily engage one's family and friends in treatment to help our patients understand that they have a treatable illness—there’s hope, in other words. The capability to communicate easily and quickly with significant people is crucial to helping patients with psychosis. Why? People who exhibit psychotic thinking typically believe that their thoughts are true and “normal”. In other words, if a person thinks you’re trying to poison him/her, the person really believes that. Strangers (like mental health professionals who are evaluating someone for treatment) are often seen as threatening because they are asking questions that may threaten the existence of the delusional thought.

To be more specific, an evaluator may ask, “have you heard any voices when no one else is in the room with you?” The patient may think, “this person thinks I’m crazy and they’re going to try to put me away against my will.” Exploring possible psychotic thinking is more complicated than this example and can take some time to investigate. Even an evaluator who is adept at building trust can be suspect to someone suffering from delusional thinking. The presence and support of family and/or friends can help the evaluation. These key people provide information needed to evaluate and diagnose. Family members and/or friends can facilitate safety for their loved one.

With HIPAA, our hands are tied. We must have a release of information signed by the patient before we can reach out to others. If someone doesn’t want others to know that they are having problems or if the patient thinks the MH professional is trying to harm them—or any other reason—the patient may not authorize an outreach.

Even though we may need the support of family and friends in order to help a severely ill person, we might not be able to do so. We can’t help people fully when we can’t explain our diagnosis, treatment and prognosis to the very people who could help their family member or friend.

Family and friends can help their loved one understand and trust that the MH professionals want to help the loved one regain their ability to love, connect, learn, grow and lead the best life possible.

Each of us can help our family members, our friends, our neighbors. “I Am My Brothers’ Keeper” means we are a community, a society of people who care about each other enough to get involved and help. As a society, we need to get away from the idea that “this is none of my business”. We need to stop being frightened by mental illness. Again, mental illness is treatable.

Specifically, we want the portion of HIPAA that affects medical and mental health professionals’ ability to reach out to others needs to be changed. If a physician, psychologist, clinical social worker or mental health counselor makes a clinical decision that their patient is at risk for harming self or others, this professional needs to have the ability to reach out to family and/or friends to join the discussion of diagnosis, treatment planning, prognosis, and treatment compliance—without risk of being sued and losing one’s license to practice due to breach of confidentiality.