Part of Minnesota's new PTSD law undermines treatment, experts say

Interest groups banded together this year to promote what state lawmakers touted as ground-breaking legislation aimed at treating public safety workers with post-traumatic stress disorder, which has ravaged police and fire departments.

The law, which went into effect Saturday, requires public safety workers suffering from PTSD — mainly police officers and firefighters — to undergo 24 to 32 weeks of treatment before they can be eligible for state disability pension benefits. The program's price tag: $104 million.

But the law contains a critical flaw, according to PTSD experts and therapists interviewed by the Star Tribune — a flaw that violates the American Psychological Association's ethics and code of conduct, according to the association's Minnesota leaders.

The new law requires mental health providers treating public safety workers to tell their employer — in this case, a government agency — whether the client has recovered sufficiently to return to work after completing treatment.

Most PTSD experts interviewed by the Star Tribune say that if the mental health provider makes that call, it increases the likelihood that the officer or firefighter with PTSD won't be truthful about their psychiatric state, undermining their chances for recovery.

Critics say that the law creates a conflict for the therapist, and that instead a third party should determine whether the client can return to work.

"I think most therapists would consider it to be a problem," said Josef Ruzek, a retired clinical psychologist who was director at the National Center for PTSD, run by the U.S. Department of Veterans Affairs, in Palo Alto, Calif.

"They are trying to form a close working relationship with the client at the same time they are trying to judge the client and make a very important decision about the client's life. In some sense, they are very different roles."

Jeffrey Yarvis, a professor of social work at Tulane University in New Orleans, agrees with Ruzek. Yarvis, a retired colonel, was chief of behavioral health at Walter Reed Army Medical Center in Washington, and has written a book and more than 100 articles on PTSD and evidence-based treatment.

Yarvis said that if the treating therapist is the one determining whether a client is capable of returning to work, it could encourage the client not to be forthcoming with the therapist. The decision on returning to work should be made by a physician or a multi-disciplinary board that can review the client's records in detail, he said.

If someone wants to go on disability and not return to work, they may present themselves a certain way to the therapist, Yarvis said. "That's why the therapist should be independent," he added.

Swamped by PTSD claims

The view of state lawmakers who passed the bill — an opinion shared by many medical experts — is that PTSD is a highly treatable condition, and that mandated therapy could return many public safety workers to departments decimated by PTSD cases.

Legislators expect the funding will ease the strain on the state's public safety pension system, which has been swamped with PTSD claims. The annual cost has risen to about $400 million a year, but officials hope the treatment programs will drop it back to $360 million a year, said Doug Anderson, executive director of the state Public Employees Retirement Association (PERA).

The bill was backed by the Association of Minnesota Counties and the League of Minnesota Cities as well as state organizations representing police chiefs, sheriffs and labor groups.

The league's intergovernmental relations director, Anne Finn, said a therapist raised concerns during the legislative process about the bill's provision requiring therapists to decide whether their clients were fit for duty. But some advocates of the bill were reluctant to alter its language, which had already been substantially revised, Finn said. There was also the question of who would decide on fitness for duty if not the therapist, she said.

So the language containing the requirement went unchanged, the bill passed both houses, and it was signed into law by Gov. Tim Walz.

Now the provision requiring therapists to decide fitness for work is raising eyebrows in the state's therapeutic community. As far back as April, the Minnesota Psychological Association (MPA) opposed the bill because of the provision and submitted a statement critical of the language.

The bill, wrote MPA President Sharon Stein McNamara in a position paper on the legislation, "places unethical burdens on psychologists."

Dennis Hannon, a licensed Golden Valley psychologist and co-chair of the MPA's legislation committee, said in an interview that the provision is at odds with the national organization's ethical principles and code of conduct. The code states that a psychologist "refrains from entering into a multiple relationship if [it] could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness."

Hannon said his group proposed an amendment to the bill that didn't require psychologists to enter into a "dual relationship with an applicant as both a disability evaluator and as a trauma clinician," but no lawmaker introduced the amendment, he said.

Psychologists advocate for their clients, Hannon said, but it's doubtful "we can objectively do that if we have to rule on a disability claim." The law also requires the therapist to conduct a "medical" evaluation, but he said therapists aren't competent to do that.

"We are trained in psychological evaluations," he said.

'An ethical dilemma'

Not everyone agrees. Kelly Harris, a licensed therapist at Warriors Heart, a residential addiction and PTSD treatment center in Bandera, Texas, said she saw no problem with both treating a client and recommending whether a client was fit to return to work. Warriors Heart treats soldiers, law enforcement officers, firefighters, fire dispatchers and first responders.

Clients, Harris said, "trust my expertise. They trust the process. ... Even though [I decide] if they are fit for duty, they have trust in the therapeutic rapport we have built."

Her opinion isn't shared by Beth Jordan, a Maple Grove therapist who estimates she's treated more than 1,000 first responders.

"If you are treating a person, you shouldn't be determining fitness for duty," she said. "If I am doing therapy on a client, that is my client. If I am doing fit-for-duty, the agency is my client."

Margaret Gavian, a Minneapolis psychologist and director of Blue Peak Consulting, treats firefighters and law enforcement officers and consults with agencies statewide on how to deal with mental health issues. Clients, she said, need "a safe and confidential place" to be honest about what's happened to them without worrying about their livelihood.

"Is my job to get that firefighter feeling better and good and treated well, or is my client the department who wants my employee back? That puts the therapist in an ethical dilemma. To keep it clean you want a third party to determine if they will return to work," she said.

Nearly 200 Minneapolis police officers have left the department with PTSD diagnoses since 2019. Steve Wickelgren, a former Minneapolis police officer and a licensed marriage and family therapist, said he has counseled "quite a few" Minneapolis police officers and others who suffer from PTSD. He said he doesn't want to be involved in the decision to return to work.

"We are treating them so that they will feel better," Wickelgren said. "I don't think we should be making the call."

Scott Marks, a Twin Cities police officer who is also a licensed therapist and independent clinical social worker, has a small practice that includes some public safety clients with PTSD. He believes "requiring treatment is a good thing," but not the requirement to have the therapist decide an individual's fitness for duty.

"My goal in treating a client is to treat the injury and to get them to return to normal functioning," Marks said. "If we are also required to be the evaluator, who am I working for?"

Finn, of the League of Minnesota Cities, called the PTSD legislation "a really good bill" that will help public safety workers and provide educational programs about PTSD so department personnel can recognize symptoms early on. Public safety workers will have their wages and benefit costs reimbursed by the state while undergoing treatment.

But she acknowledged that changes in the law may be needed. Issues such as who should decide on fitness for work can be taken up if necessary in future legislative sessions, she said.

"I think we are going to find some things as it rolls out that we will still have to address," Finn said .