What did James Holmes' psychiatrist know -- and when?

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James Holmes, the Colorado student accused of killing 12 people and wounding dozens more, was reportedly under the care of Dr. Lynne Fenton, a psychiatrist who serves as the University of Colorado mental health services director.

Dr. Fenton is also the person to whom James Holmes reportedly mailed a notebook detailing his plans to attack others.

If both reports are true, it would be very unlikely that Holmes’ notebook was the first time he communicated his violent fantasies to Fenton. Having worked with thousands of mentally ill patients — some of whom have had very violent intentions and shared them with me (often resulting in my hospitalizing them, against their will) — I have never known a single one who contains all thoughts of violence while in treatment, but catalogs them in writing, then sends the written documentation through the mail.

It would be such a rare and shocking event that a psychiatric journal would be more than happy to publish the clinical account.

It is much more likely that Holmes alluded to his thoughts of harming others during one or more sessions with his psychiatrist, in one or more emails to his psychiatrist or during phone conversations with his psychiatrist.

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Therefore, the Holmes case has the potential to become not only one of the most tragic criminal cases in America, but one of the most tragic cases of malpractice — ever.

No one can know at this moment what Fenton knew and when she knew it, but that investigation is, no doubt, now under way. It will, at some point, include a review of Fenton’s progress notes and other elements of Holmes’ medical chart, a review of Fenton’s and Holmes’ email accounts, a review of any data retrievable from Fenton’s and Holmes’ text messages and a deposition of Fenton in which she is questioned directly about any violent thoughts, whether delusional or not, Holmes may have shared with her.

The reason one can have no confidence that a story like the Colorado shooting will turn out to have no “fingerprints” from psychiatry on it is that psychiatry as a profession remains far too timid about hospitalizing the violent mentally ill against their will. Certainly, no one would suggest that anyone err on the side of caution, rather than the side of civil rights (not me, certainly), but I have found it very frustrating to battle again and again with colleagues when I urge them to hospitalize — or keep hospitalized more than a day or two — patients who present a clear risk to themselves or others.

Occasionally, in fact, people will confess extremely concerning thoughts in my office, some of them even in response to hallucinations, then be released from the emergency rooms where I have them taken (sometimes by police) because they “contract for safety” (meaning, faced with being placed on a locked psychiatric unit they — not surprisingly — promise not to hurt anyone).

Medical insurance companies are accomplices in this incredibly dangerous game. They often refuse to pay for inpatient hospitalization for any individual who is willing to retract a violent threat once in the emergency room, despite the fact that it was made with grave seriousness in a doctor’s office or to a family member.

Again, as I have said before, the tragedy in Colorado will turn out to have nothing whatsoever to do with gun laws and everything to do with our broken mental health care system. Just watch.