How a rabbi's sermon resolved my Tarasoff conflict.

Houses of worship are not places where psychiatrists typically expect to gain insight into forensic issues. But a few years ago, a rabbi’s comments on a familiar passage from Leviticus helped me resolve an intrapsychic conflict that had troubled me for years, ever since I learned about the Tarasoff decisions. When I give first-year residents their introductory lessons on legal issues and psychiatry, “Tarasoff” is a name that, invariably, they have already heard. Most of the residents mistakenly think (along with many of their more senior colleagues in the mental health professions) that Tarasoff stands for a “duty to warn” someone when a patient appears dangerous. As every regular reader of the Journal knows, the Tarasoff decisions arose when the parents of Tatiana Tarasoff, who had been killed in 1968 by fellow student Prosenjit Poddar, sought to sue Poddar’s treating mental health professionals and their employer, the University of California. Before the killing, while Tatiana was visiting Brazil, Poddar had told his psychologist that he was thinking about killing a young woman. The psychologist guessed who the woman was and informed the campus police, who checked on Poddar but did not detain him. Poddar stopped seeing the psychologist, and after Tatiana returned to California, Poddar fatally stabbed her. In its first (1974) decision on this matter, the California Supreme Court ruled that the parents’ cause of action was valid, because the psychologist’s response had been insufficient. The psychologist also should have warned Tatiana about the danger Poddar posed. After the defendants, the American Psychiatric Association, and other professional societies asked for and received a rehearing, the California Supreme Court issued a second ruling that formulated the clinician’s duties even more broadly: “once a therapist does in fact determine, or under applicable professional standards reasonably should have determined, that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger” (Ref. 2, p 439). The volume of commentary on Tarasoff, in both legal publications and those of mental health professionals, has been enormous, and rightly so. California’s Tarasoff case and (as Alan Stone cleverly puts it) its “progeny” in other jurisdictions have profoundly altered the way we mental health professionals think about our responsibilities to our patients and society. The residents I teach readily accept the idea that if a patient poses enough of a danger, the psychiatrist is duty bound to intervene, even if intervening means doing something beyond what is needed to treat the psychiatric problems the patient is experiencing. Immediately after the Tarasoff decisions, what bothered mental health professionals most was the expectation that we should violate therapeutic confidentiality. Commentators, including Alan Stone, objected on practical grounds: Poddar had left treatment after his therapist had called the police, and many other persons might not seek treatment at all without assurance that their most personal thoughts (including some violent thoughts that are merely fantasies) would be kept private. The second Tarasoff decision explicitly acknowledged this problem, recognizing “that the open and confidential character of psychotherapeutic dialogue encourages patients to Dr. Mossman is Professor and Director, Division of Forensic Psychiatry, Wright State University School of Medicine, and Adjunct Professor, University of Dayton School of Law, Dayton, OH. Address correspondence to Douglas Mossman, MD, W.S.U. Department of Psychiatry, East Medical Plaza, First Floor, 627 S. Edwin C. Moses Blvd., Dayton, OH 45408-1461. E-mail: douglas.mossman@ wright.edu