Unlevel Playing Field

From the New York Times this week:

“Police departments around the US are turning to crisis intervention training in response to high-profile shootings of people with mental illnesses. Twenty-five percent or more of people fatally shot by the police have had a mental disorder.”

We all learned about power differentials at a very young age. At first it was our parents who made the rules, told us what to do and when to do it, and inflicted punishments on us if we did not learn and obey. 

Next it was teachers, or Scout masters or football coaches or a myriad of other people, usually adults, who were in authority and could therefore hold sway in most any situation. 

We learned that there was a hierarchy,  and that we had a definite place in it. As we got older, wiser, and more skilled, we took our places higher up the ladder of responsibility and power. Hopefully, we learned to use our places and our skills wisely, compassionately and fairly. 

Now, that being said and that general background being clear, in medical school and residency training, spanning eight years of my life, I learned that this went even further than I was originally taught. 

Once you have MD after your name, you are (and should definitely be, in my personal opinion) held to a higher standard. You are privy to information, secrets, confidences that run the gamut, and it is your sworn duty to honor those confidences and do your best to make your patient whole again. You know a lot of things about medicine and the healing arts, yes, but you are also expected to work in tandem with, and in collaboration with, your patients to search for and find the best treatment that will lead to the best outcome. This has never been more important than today. 

Another thing we were taught, that was drilled into us in many ways, was that we were NEVER to abuse this relationship, this partnership, this collaboration. Now, some of you will balk at this next point, but it’s true nonetheless. Physicians were taught, and should still be taught, that there is a definite power and influence differential in the therapeutic relationship and the consulting room. Advocates, especially in mental health, may talk about being on equal footing with physicians and being partners in their treatment and the like. I’m not saying that this is wrong. What I AM pointing out to you is that the physician has a power over his patient, given to him by centuries of history and practice and backed by law to a large degree, that can never be equaled on the other side of the stethoscope. 

Any time I can sign a piece of paper that takes away your right to walk out of a hospital emergency room of your own accord, there is a power differential. 

Any time I can, with proper consultation from other licensed physicians, decide to give you a powerful medication for your obvious psychosis, even against your will, there is a power differential. 

When I have the obligation to break confidentiality and report certain actions that you have taken to the police, the department of social services, or other agencies, even though you beg me not to, there is a power differential. 

A well trained physician will always be very aware of this and use this power and influence wisely, for the good of his patient. 

A poorly trained one, an impaired one, or a physician with another goal other than his patient’s well being, will not.

In mental health, infractions might be as simple as saying negative things to a vulnerable patient, as bad as giving potentially lethal amounts of medication to a patient that has a known risk for suicide, or as terrible as coercing a patient to have a sexual relationship with the doctor. 

You see, when our patients are ill, they may be moody, depressed, manic, or indifferent. They might actually be psychotic, or suicidal, or homicidal. They are sometimes impulsive. They make bad decisions and their judgment may be impaired. They might be very angry at us, or even afraid of us. They might run from us, literally run out of the office or the ER. 

Might this happen, has this happened when a mentally ill person is confronted by a uniformed police officer, much as it might happen when confronted by a white coat wearing doctor?

Of course! 

A well trained police officer, much like the doctor, would much more easily recognize the limitations in judgment, the poor decision making, the rage or the fear, or the potential for harm to self or others in a distraught, agitated patient. He or she might be aware that allowing the person to have more space, talking them down, using de-escalation techniques, calling for backup, utilizing family members, or using other techniques might prevent escalation and the potential for harm to suspect or officer. 

The high profile cases alluded to, alas, usually show us by shaky cell phone video how someone with  a gun, and an obvious power differential, might be prompted too quickly to resort to deadly force short of trying other methods to get the situation under control. 

Crisis intervention training would be a wonderful way to begin to teach police officers, EMS workers, and other first responders to adequately assess a situation that might involve a person with mental illness. I have no doubt that lives would be saved. 

Any of us who have this power differential with those we serve should remind ourselves of these simple principles:

1) WE are responsible for the actions we take in a crisis or urgent situation involving a person with mental illness. 

2) WE are responsible for adequately assessing the situation and the state of mind of the person we are dealing with, to the best of our ability in any given situation. 

3) WE are responsible for using our very best judgment, falling back on rigorous training that was done looking to this very day. 

4) WE are responsible for continued training and self assessment so that we can accomplish the above.

5) WE are responsible for always acting in the best interest of the person we are trying to serve, even if that service involves involuntary commitment, detention, medication, or incarceration. 
Having a license to practice medicine, or carry a gun, or make arrests does not give any of us the right to abuse our power, and believe me, it is real and actionable power. 

On the contrary, it creates an obligation and a sacred trust that demands our very best in the very worst and challenging of times. 

Be safe out there, friends. 

2 thoughts on “Unlevel Playing Field

  1. Good post, Greg. Power differential is not taught or emphasized enough, other than learning how to take charge of a situation in terms of projecting a kind of strong command presence.

    Do you have any ideas on how to to teach police, for example, how to make the kinds of quick evaluations that will help them to differentiate between suicidal, homicidal or simply confused behavior, for example? Particularly, how to look at their own very natural fear in such a situation and “take their own pulse” before taking deadly measures that may be terribly wrong?


  2. Yes, we already have some modules and live training that teaches clinicians and officers about physical aggression, changes in verbal interactions, deescalation techniques, and containment. Sounds like this is being done on a wider scale now, and that’s a good thing.


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