Therapists and Threats

A dissenting judge said the ruling "will cripple the use and effectiveness of psychiatry." The American Psychiatric Association agrees. Last week it submitted an amicus curiae brief for a rehearing of a case that is alarming psychotherapists across the country. By a 5-to-2 vote, the California Supreme Court recently ruled that doctors or psychotherapists who have reason to believe a patient may harm someone must notify the potential victim, his friends, relatives or the authorities.

The ruling stemmed from a 1969 murder case. While receiving outpatient psychiatric help at a campus hospital, Prosenjit Poddar, then 26 and a student at the University of California at Berkeley, said he intended to kill his former girl friend, Tatiana Tarasoff, 20. On a psychologist's orders, he was briefly detained by campus police, who released him two hours later when he appeared rational. A hospital psychiatric supervisor ordered no further action against him. Two months later, Poddar stabbed Tarasoff to death with a butcher knife.

To Save a Life. The victim's parents sued the university, the psychologist and two hospital psychiatrists for $200,000 for failing to warn them or her about Poddar's threat. Alameda County Superior Court found no grounds for the suit, but the state supreme court's new ruling sends the case back to trial. Substance of that ruling: confidentiality between therapist and patient must yield "when a warning is necessary to prevent a violent attack." Moreover, therapists could be liable to civil damages, unless it can be shown that "sound professional judgment" was used.

Warnings to save a life have long been allowed by accepted medical ethics, but never legally required. "To make a law of this understanding," said Psychiatrist Alfred Freedman, past president of the American Psychiatric Association, "puts psychiatrists in a position where they have to respond even to idle threats."

Many, perhaps most, people who seek psychiatric help have some sort of destructive impulse, and their threats or wishes to see someone dead are routine and generally harmless ways of letting off steam. But many therapists wonder if juries will think so if a patient later really decides to kill someone. "It means," said Psychiatrist Robert L. Marvin of San Francisco, "that a jury can decide by hindsight whether a doctor has used the best professional judgment."

Even more alarming to many professionals is the fear that the ruling will keep violence-prone people away from the therapy they need. "The minute you report them, patients drop out of therapy and become more of a threat to the community," said Dr. Maurice Grossman of Stanford University, an authority on doctor-patient confidentiality. Grossman also worries that a potential victim, warned about a threat, may sometimes assume the right to kill the patient on the grounds that a psychiatrist's warning justifies the action as self-defense.

Lawyers are happier with the ruling than psychiatrists. The president of the Association of Trial Lawyers of America, Robert E. Cartwright, who believes the ruling is defined narrowly enough to be workable, dismissed the argument that patients will drop out of therapy or hide their intentions from therapists. "People in a violent frame of mind," said he, "don't read court decisions."

The state supreme court's ruling came in the wake of another unpleasant surprise for California psychiatrists: a bill passed by the state legislature setting tight restrictions on the use of shock therapy. The new law states that electric shock treatments can be administered only after "all other appropriate modalities have been exhausted," and then only with the approval of a board of three doctors, two of whom must come from outside the institution prescribing the therapy. But on Dec. 30, two days before the law was to go into effect, a superior court judge in San Diego issued a restraining order against enactment of the law on the grounds that it interferes with a patient's right to medical treatment of his choice. It is also, in the eyes of doctors, a dangerous and undesirable precedent, another instance of outside interference with professional treatment of mental patients.

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