Tales from the Couch

Seeing the patient from psychiatry’s perspective

Am I a Double Agent?

The duty to inform

I was treating a patient, John W, who was angry about his work situation. He complained incessantly about his supervisor whom he felt singled him out for unfair criticism. Over the course of months, John’s complaints escalated to the point where he said, “I swear…if there was a chance I’d get away with it, I’d love to get rid of the guy.”

I questioned him about this statement, and while he acknowledged having a fantasy of “shooting” the supervisor (John didn’t own a weapon), he denied any intent to do any harm to his perceived harasser. He insisted his wish to “get rid of the guy” was merely a figure of speech.

I had to make a judgment call about John’s state of mind and his possible intentions.

It’s a well-entrenched principle that when a patient presents an imminent danger to someone, the therapist has a duty to report this threat to the proper authorities. The obligation derives from the famous 1976 Tarasoff ruling in California. Most therapists understand this duty and abide by this common sense decision.

But some states have passed strict gun legislation requiring a therapist to report a patient if it’s likely he or she will cause serious harm to others. Likely is a far weaker criterion than imminent. The term “likely” is equivalent to “probable” which means a 51 percent or greater chance of something happening. “Imminent”, on the other hand, means something is about to happen.

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And, here lies certain danger.

As a psychiatrist, I worry about the real possibility of over-reporting patients who might be considered likely to cause harm. The notion of something being likely requires a judgment about anticipating someone’s future actions.

Dr. Richard Milone, chair of the American Psychiatric Association’s Ethics Committee, recently said, “Your primary job is to be the patient’s doctor. Any time you start being something else to a patient, it’s the start of trouble.” (Psychiatric News, September 20, 2013). In the wake of the Newtown, Connecticut school shootings, Dr. Milone suggested psychiatrists are now being asked to treat their patients and also protect society. Or, as another APA Ethics Committee member said, “Society expects us to be their protectors and to work as double agents.” (Ibid, page 9).

Such legislation rattles the concept of patient confidentiality. Under such laws, can patients truly trust their therapists? Can they really speak their minds without worrying they may cross some subjective line drawn in the therapist’s mind whereby a patient/client is deemed likely to cause harm and be reported? Yes, a severely delusional person, who believes people are conspiring against him and intends to get a rifle, is someone who should be reported. But an angry, disgruntled man like John W is apparently using a figure of speech. Should I report him to the authorities because it could be likely he’ll take action?

Can a trusting, confidential therapeutic alliance between therapist and patient ever develop given the requirement that therapists evaluate, predict, and then report patients’ likely behavior?

During a session, there’s no going “off the record.” Everything in therapy is grist for the mill. And now, everything is subject to being evaluated as presaging likely behavior.

The recent rash of mass shootings and workplace violence are bringing important issues about mental health to the fore. But, in the process of trying to get a better handle on how to prevent such horrors, do we really want to turn our therapists into double agents?

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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