On Oct. 22, 2012, three days before she slaughtered two of the three children she cared for as a nanny, Yoselyn Ortega visited a psychologist, Dr. Thomas A. Caffrey, on New York City’s Upper West Side. He was the kind of guy you’d hope a person on the verge of committing murder would go to see: He had a doctorate in clinical psychology, more than 40 years of clinical experience, and a specialty in forensic psychology—the psychology of criminals. He’d worked for years within the prison system and was a former president of the New York State Psychological Association’s forensic division.
According to the testimony Caffrey gave in the trial that found Ortega guilty of murder just last week, after the perhaps 40-minute session (length remains controversial), he wrote down “Prognosis: good.” (His notes went into evidence.) He did not record having a follow-up appointment, although he says he expected one. He charged her $200 for the visit.
We now know that Ortega’s prognosis was anything but “good.” Eighty hours later, she would fatally stab 6-year-old Lucia Krim and 2-year-old Leo Krim before attempting suicide in the bathroom of the family’s apartment. Hindsight makes perfectly clear that this woman, who reached out for professional help, was descending into a suicidal and homicidal state, probably in need of hospitalization. The jury may have found her legally sane—she likely did not suffer psychosis or dissociation during the crime and was conscious of what she was doing—but her “prognosis” when she left Caffrey’s office could not have been worse.
Just as we would consider someone seeing a pulmonologist, getting an all-clear, and then dying three days later of lung cancer a medical failure, we are obligated to explore how the system failed this patient so that we may prevent identical mistakes. It is even more important to look at how we triage mental health care in this age of monthly mass shootings, particularly when basic treatments may easily change these outcomes. So how was this clinician unable to see how serious Ortega’s case was, and how was he not able to help her in any way that would have prevented the tragedy that was about to occur?
There’s not much point in sandbagging this therapist and painting him as a villain—presumably he wishes he would have conducted the session differently, and surely in the past he has guided clients to wellness. (Caffrey did not want to breach the confidentiality of the client and refrained from commenting for this article.) But it is useful to place this episode in the larger context of the problems with mental health care. Too often we assert that mental health cases are fundamentally more abstract than physical disease—trickier to assess or diagnose, fundamentally outside of the medical framework. But we now know Ortega would be a danger to others and to herself, and as far as symptoms go, that’s standard stuff when it comes to mental health assessment. So what happened, and what can we learn from it?
Ortega was pointed to the psychologist by her health insurance company, possibly via their website. When she called, he said he could not see her because his schedule was full that day, but she repeatedly insisted she needed to see him immediately, so he fit her in at his lunch hour. She arrived well before the appointed time and simply remained outside his office, waiting, with a friend who had accompanied her. He saw her at 12:20 p.m. His next appointment was at 1:30 p.m. He had seven patients scheduled after her.
She complained of a racing heart and anxiety. The therapist noticed her obvious anxiety and observed her speaking fast and having “pressured speech.” He said she “seemed to have the world on her shoulders.” She spoke mostly about her son, who had been separated from her since he was 4, when she sent him to live with a sister in the Dominican Republic, and then reunited with her recently, when he moved back to the United States. He was doing well in school in New York City, but she had to move back into an apartment with her family, and they were now in a crowded situation. She was under extreme financial stress. She felt like she had let her son down, now and for most of his life.
By the end of the session, Caffrey diagnosed her with generalized anxiety disorder, for insurance purposes, and dysthymic disorder, which is a mild but pervasive and chronic depression, in his own records. He recorded her anxieties about money* and her feelings of guilt around not having done as well as she could have for her son.
At trial, defense lawyer Valerie Van Leer-Greenberg* went after the psychologist in typical courtroom-drama fashion, raising her voice with a tone of astonishment during pointed questioning.
“In fact, you never asked Ms. Ortega, ‘Did you ever hear any voices?’ ”
He replied with a simple, “No.”
“Never asked her medical history?”
“Did you ever ask Ms. Ortega how long she’d been feeling sad?”
“Did you ask about her family history?”
“Ask about her sleep?”
“Onset, persistence, duration of symptoms. You never ascertained how long?”
“I didn’t specifically ask about it.”
“You did not ask about her hurting herself?”
“Not that I recall.”
“You never once asked her what she does every day, did you?”
It seems that instead, the psychologist had let Ms. Ortega lead the session with thoughts at the forefront of her mind.
For Caffrey, this seemed by design. As he said on the stand, “I’m not looking for symptoms. I’m looking for understanding.”
And yet, according to the defense team in his notes for the medical insurance company, he did list at least 10 presenting symptoms, a seemingly thorough assessment. He was required to list these symptoms, because the insurance company assumes his job is to assess for them—it’s the most basic requirement of professionals in our health care system.* When staring down the difference between what Caffrey actually did and what he said he did so he could bill for the appointment via medical insurance, we see a conflict that may represent a global problem with our already rickety-as-hell mental health system. It’s still a wild west of rules and protocols, much of it disconnected from the mainstream health care system in which it is embedded. Mental health care is still inchoate in its process, protocol, and triage.
Imagine if Ortega had, instead of going to a psychotherapist, gone to any medical doctor for any reason at all: achy feet, skin rash, pounding heart. As soon as she would have walked in, she would have been handed a clipboard and asked to fill out an intake form. Before setting foot in the office, she would have been required to describe her current symptoms (as she saw them), her medical history, her current medications, and perhaps much more: recreational alcohol and drug use, occupation, and a request to tick off boxes next to a long list of symptoms and ailments.
While psychiatric symptoms can be especially difficult for the typical patient to discern, a psychiatric intake form, with its questions designed for mental health issues, would have forced her to consider objectively her sleep issues, appetite issues, level of sadness and anxiety, delusions and hallucinations, and feelings of self-harm. Some intake forms have a suicide-assessment checklist and even ask about access to guns. There had been a suicide in her family, and this would be an important indication of the possibility of suicidal depression. Her intake form would have then provided a guide for the appointment.
And the point of the intake form and initial consultation would be, as in any medical profession, deducing symptoms. What are they, how severe are they, what may be causing them, and is there anything we can do relieve them, both immediately and in the long term? But the field of mental health is still not wholly placed within the field of medicine, and that means patients are not treated as systematically as is required in medical practice.
“The idea that this therapist didn’t look for symptoms means, ‘OK, I’m not in the mental illness business, I’m in the dealing-with-people’s-personalities-and-relationships business,’ ” says Jeffrey Lieberman, chairman of psychiatry at Columbia University.
This is not to say that the psychologists who are interested in dealing with people’s personalities and relationships are not doing valid work, just that patients who are seeking treatment for mental health issues deserve to be assessed in a standardized manner that helps them access the right level of care for the problems they are facing before they begin treatment. Currently, people are expected to make the right choice of what kind of mental health care professional they need when they first make contact with the system. It’s a Chinese menu of treatment options even when we are at our most clear-headed, never mind when we are in urgent need of help. And mental health care is almost entirely made up of varieties of “psychotherapists,” which could refer to anything from a barely trained New Age spiritualist who sets up practice in her living room to a person with the many degrees and decades of experience as Dr. Caffrey. What they both have in common is that there is no real health protocol in their duties, as there is in the field of medicine.
It is a grave mistake to think of mental health care issues or, better put, psychiatric issues as outside of the field of medicine. Mental health issues often stem from environmental stress, but they manifest as very real physiological conditions, including imbalances of nervous-system chemicals and missed neurological connections that result in feelings of extreme and uncontrollable depression, or manifestations of nervous-system overload, like panic attacks.
The panoply of nonmedical psychotherapists are essential to mental health care. Indeed, the good ones, who follow evidence-based treatment protocols, are the heart and soul of the profession. Most psychotherapists are caregivers with the best of intentions, and for most people, upon consultation and with regular visits, symptoms are relieved and the client is set on a path for a more fulfilling life. But these psychotherapists should not be tasked with catching patients like Ortega who could be a harm to themselves or others. The point is that, for anything beyond routine life stressors, an initial mental health evaluation should be medical, performed by a psychiatric specialist.
“A psychiatrist is trained more extensively, has a broader scope of knowledge with which to define potential diagnoses, and can deliver treatment more expeditiously,” says Lieberman. “They can then refer them to psychotherapy, group or family therapy, or anyone else. There’s no question the place to start is with a psychiatrist, however, the practice pattern is not in place.”
Not only is the pattern not in place, there are, in fact, enormous hurdles between the average person and a visit to a psychiatrist’s office. They are the highest proportion of medical care practitioners who do not accept insurance, and they often charge hundreds for a single appointment. There is also a shortage of psychiatrists in practice. Although there are estimates that 1 in 5 people have a mental health condition, a 2017 study found that not a single psychiatrist could be found in 60 percent of U.S. counties.
This is all to say that transforming the mental health care system to center around psychiatrist-conducted intakes is by no means a simple fix. It would take an extraordinary overhaul, and in the United States, these problems are part of the larger frustrations of our entire health care system—it still costs too much, resources are still short in supply, and service to low-income communities remains uneven.
But as we continue to discuss how failure to access proper mental health care may have contributed to mass public violence, we must also consider how those who do make contact with the system can be failed by it, and we must examine those failures to improve the system. If mental health care were better understood by the public, and if access to psychiatrists as first point of contact were a standard, the most serious cases would have a much better chance of ending in treatment, not tragedy.
If Yoselyn Ortega had been handed a simple intake form and asked the right questions by a doctor looking for common, clear-cut symptoms, such as suicidal ideation, she may have been hospitalized on the spot. If she was less than forthcoming about her suicidal (much less homicidal) feelings, she may have at least been given medication for her debilitating anxiety, medicines that could have diffused the fury building in her mind. It’s impossible to say how that would have changed what ended up happening, but it is essential that we reconsider how the system worked, and how it didn’t work. It’s the best chance we have of improving it for the next patient who ends up searching through an insurance company’s protracted list of mental health professionals, in need of psychiatric help.
*Correction, April 24, 2018: This post originally misspelled Valerie Van Leer-Greenberg’s first name.
*Correction, April 27, 2018: This piece originally misstated that Caffrey referred to Ortega’s financial anxieties as “money phobia.” He says he did not use that phrase. Kruglinska also misstated that Caffrey listed 10 presenting symptoms in a report to the insurance company. He listed those symptoms, according to the defense team, in his notes.