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Tragedy in Tucson: A national Rorschach test?

January 13, 2011
by H. Steven Moffic, MD
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Martin Luther King Jr. would not have been surprised. So close to the national holiday of his birthday, we have yet another attempt at assassination and mass murder. Maybe he would even recognize some of our current reactions.

From the reactions I’ve heard and read, the tragedy seems to be evoking the sort of various reactions that we obtain from a Rorschach Test. I’ve even heard from a colleague wondering if all the attention on Representative Giffords, compared to the other victims, was because she was “pretty.” Farfetched? An individual’s projection? Perhaps, but note the alleged perpetrator’s preoccupation with her over recent years. In another context, one would begin to wonder about erotomania.
 
Beyond this reaction, there seem to be some common reactions that are especially relevant to behavioral healthcare. Before the focus on this tragedy passes away and the usual goodwill dissipates, let’s review some of these issues:

1. Mental Illness and Violence

Research seems to indicate that the mentally ill are not more violent than the rest of the population, though the risk of violence can be higher for some untreated mental disorders. Moreover, violence is hard to predict in general, though some variables are helpful: prior violence, a target, a plan, and, especially in psychiatry, command auditory hallucinations to hurt someone.

The Tarasoff decision legally requires us to report any patient who seems to be at risk for hurting someone specifically. Of course, the ethical dilemma is that we do so at the risk of losing them as a patient when they find out what we have done, which can be further compounded if law enforcement does nothing about our concern.

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Excellent post.

One minor quibble, Steve - the Tarasoff decision was rendered by the California Supreme Court, and therefore is relevant only to practitioners in California. Many states have written statutes or had court opinions that require some action to protect intended victims, but a plurality do not - legislatures and courts in some states have affirmatively found that mental health providers have NO such duty to a third party, even in the face of an expressed threat. Thus far, nobody has made this into a Federal constitutional issue, so the Supreme Court has not ruled on this matter - as such, States are free to do what they wish in this regard.

It is important that each of us are aware of our own state's law on this topic. for those in Maryland, a brief reminder that we have three choices in the face of a threat toward a specified victim or group of victims:

1. seek civil commitment
2. formulate and document a treatment plan calculated to reduce or elminate the risk (and good documentation would include an explanation of why you think this will reduce the risk) OR
3. notify the relevant law enforcement agency and, if feasible, the victim or victims.

See Maryland Annotated Code, Courts and Judicial Proceedings section 5-609.

Note, please, that we in maryland need do only ONE of these to be in consonance with this law. Even the warning, which is what people mistakenly believe Tarasoff to be about, is mandated to law enforcement, with the victims being secondary.

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H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...