Douglas Mossman, M.D., turns to the philosopher Immanuel Kant for support
in clarifying how therapists should act when patients seem likely to engage in
Mossman spoke at APA's 2008 annual meeting in May after he received the
Manfred S. Guttmacher Award from APA and the American Academy of Psychiatry
and the Law. The award is given for an outstanding contribution to the
Identifying which patients are likely to harm someone fell to therapists
(at least in California) after the famous Tarasoff decision in 1976,
said Mossman, a professor of psychiatry and director of the Division of
Forensic Psychiatry at Wright State University Boonshoft School of Medicine
and administrative director of the Glenn M. Weaver Institute of Law and
Psychiatry at the University of Cincinnati College of
"Sound clinical interventions may be socially useful but they are
secondary to therapy for the patient," said forensic psychiatrist
Douglas Mossman, M.D., speaking of how clinicians should view potentially
dangerous patients 30 years after the landmark Tarasoff
Credit: David Hathcox
The decision did not quite demand prediction, which may be an ambiguous
term, said Mossman. "Tarasoff said that therapists had a duty
to satisfy their profession's standards for determining that a patient poses a
serious risk of danger."
Tatiana Tarasoff was a student at the University of California, Berkeley,
who was murdered in 1969 by a fellow student who had been in treatment for
depression. The student had previously told his therapist that he was thinking
of killing Tarasoff, who had rejected his romantic advances. The therapist
told police, who spoke with the student and warned him to keep away from
Tarasoff. The student ignored the warnings. He was eventually tried,
convicted, released on a technicality, and then he returned home to India,
where he has remained since.
Tarasoff's parents sued the Regents of the University of California, and
ultimately the California Supreme Court ruled that therapists had duties to
determine when their patients were likely to become violent and to protect
those patients' potential victims.
If a patient posed a serious danger, said the court (without specifying the
definition of "seriousness"), then confidentiality was not as
important as protecting the public.
"The court," said Mossman, "acted on two questionable
suppositions: that mentally disordered people were especially violent in some
way and that mental health professionals have some special ability to
intervene and protect others against future violence."
However shaky its scientific basis, the decision left clinicians open to
potential liability if they failed to foresee violent acts by their patients
and warn potential victims.
Risk factors may be quantifiable in populations, but therapists deal with
individuals, said Mossman. Violence by an individual is almost impossible to
predict using measures of probability.
The problem in trying to do so lies in setting a cutoff score that can
separate patients likely to become violent from those without such likelihood.
Set the cutoff too high and nonviolent patients are deprived of their freedom.
Set it too low and the real potential for violence goes undetected, and
someone might get hurt. Studies (including some by Mossman and colleagues)
show little agreement on where the cutoff should fall. Some vary by as much as
five orders of magnitude.
"There is no agreement on what level of risk constitutes a reason for
action," said Mossman. "So Kant would say you can't implement a
'future violence test' from a utilitarian perspective."
Thus the Tarasoff ruling demands abilities well beyond the
professional powers of any therapist and creates impossible expectations,
especially since no court ever said exactly what risk threshold triggers
Recent legislation in Ohio responding to another court case relieved
clinicians there of a duty to predict, but left them with a duty to warn and
protect third parties. Under this legislation, a therapist can be held liable
only if he or she fails to act after an explicit, credible, imminent threat is
made against an identifiable victim by a patient who has the means and intent
to carry out the act.
What, then, can clinicians do?
"We must approach the patient as an end in himself, not just as a
public-safety problem," said Mossman. Clinicians should treat the
patient's psychiatric condition, responding to knowledge gained from the
patient's words and behavior with reasonable, sound precautions. Decisions on
reporting threats should rest not on probability but on the information at
Many elements of good treatment also reduce the risk of violence, he noted.
Accurate assessment and timely intervention are critical. Substance abuse
treatment is an important therapeutic goal in itself but also reduces
antisocial behavior. Improved treatment compliance is associated with less
That doesn't rule out studies of violence prediction, because those studies
can help clinicians make better risk assessments and alert them to factors
that might become the focus of treatment, he said.
"Patients damage themselves when they harm others," said
Mossman. "Sound clinical interventions may be socially useful, but they
are secondary to therapy for the patient. For mental health professionals,
protecting the public should be merely an incidental result of the
autonomy-enhancing effects of good psychiatric care."
Douglas Mossman, M.D., is not only a psychiatrist but also an occasional composer and director of musical performances. At the end of his talk at the APA annual meeting, he shifted to the electric piano to conclude his presentation with a summary of his remarks, sung to the tune of "Danny Boy."
Though many lawyers thought the threat of suing
Would save the world from patients' violent minds,
What all us psychotherapists have been doing
Is finding ways to cover our behinds.
If we were fortunetellers, we'd be better off,
But what the future holds we cannot know.
That's why we long to say, "Good riddance, Tarasoff,"
Though many courts and plaintiffs' lawyers love you so. ▪