The psychiatrist will get you if you don't watch out

The current dialogue over gun control and public safety in the wake of Sandy Hook reveals what society expects of its mental health resources.

A double mission. The primary mission is to help people make progress in their lives. The second mission is to support public safety.

In other words, the second mission of mental health is to collaborate in the exercise of state legal power. Think of the range of areas where mental health and related disciplines affect a person's legal life.

-- Criminal law: Insanity, diminished capacity
-- Family law: Custody determinations
-- Probate law: Capacity to make a will
-- Civil law: Damages related to pain, suffering, trauma
-- Administrative law: Disability determinations, payee decisions
-- School law:  Special education placement and programming

The above list is limited in one key way: These are all situations where mental health experts ADVISE a court or administrative agency about what the government should require or decide about a person. An expert might testify, but the judge or jury decides if the defendant is Not Guilty By Reason Of Insanity, according to legal standards made up by judges, legislators and other non-medical folks. The legal standards don't align with any version of the DSM. In Texas, for example, you can be executed unless you are as impaired as Lenny, the fictional character from John Steinbeck's book Of Mice and Men.

There's another list, situations where the state simply DELEGATES power to mental health professionals. The prime example is the 72-hour hold. Depending on which state you live in, a psychiatrist can write an order, have you arrested and brought to a hospital against your will for one to three days. Once you're in the hospital, you are expected to submit to the relevant protocols. (Forced medication or ECT requires a court order. That puts the mental health worker back in an advisory role. Outside the US,  you may never get a medication or hospitalization hearing before a non-medical person.)

This delegation of power to mental health professionals is one reason people fear the mentalhealth system. Your psychiatrist is your gateway to the locked ward and the surly white-suited attendant. If you think that your therapist is judging you, you're right. Are you safe enough to go back home? Are you likely to attack someone? And, at least in New York, are you safe enough to own a gun?

Power like that scares people. Patients want a kindly sort of mental health, all support, no orders, no crappy meds, no threats, an easy journey back to health, maybe a spa day, or a pill to get you going on the trip back to work. A little something to take the edge off the mood or the encounter with the boss.

But we know we can't have that. We are realists. We know state power is inherently coercive. And as kind and positive and recovery-focused as we try to make it, mental health does have that double mission.

Why not embrace it? No one wants psychiatry to be like military recruiters who talk about paying for a kid's education, but neglect to mention the war.

Psychiatry delivers value when it offers access to safety. People show up at the clinic when they are scared of their own thoughts and feelings. Why not an alliance around safety, around risk?  Around a plan to secure your weapons when you're hurting?

And in the community, in our homes and schools and churches, why not focus on support?

After all, social support is the only truly non-coercive mental health option. Delivered by amateurs. You know, those people you love, your friends, your neighbors, the folks at church. It's the low-stakes way to start that chat about how what you feel relates to your safety.