Over the past few days new details have emerged about James Holmes, the suspected shooter in the Aurora movie theatre massacre. Included is the fact that Holmes was seeing a psychiatrist named Dr. Lynne Fenton prior to the shooting, and that Holmes sent a package to her that his defense team wants handed over.
But should Dr. Fenton, or any psychiatrist for that matter, be required to disclose private information about a patient? And, had she known in advance that Holmes struggled with violent thoughts and delusions, should she have alerted police?
Art Caplan heads the division of medical ethics at the NYU Langone Medical Center. He explores the fine line between confidentiality and safety in therapist sessions.
"It's a tough, tough problem because the first requirement is certainty, that you really believe that harm to someone is imminent, that it's going to happen soon," Caplan says. "Not some vague threat, not some abstract expression of violence, but an imminent threat. You're also supposed to know against whom or at least where [the violence will occur]." Psychiatrists have to maintain a level of trust with their patients, and reporting everything that their patients say would cause them to lose trust.
Dr. Paul Appelbaum is a practicing psychiatrist and professor of psychiatry, medicine and law at Columbia University. During his career, he has notified people who have been threatened by his patients, albeit rarely. "I think we're all extremely vigilant [about] inquiring about aggressive histories or thoughts of harming others as part of a routine mental status evaluation," Appelbaum says, and depending on the responses that we get, we will follow up to a greater or a lesser extent in order to determine just how firm and [carefully planned] and likely to be acted on those ideas are."
Caplan cites the 1976 case Tarasoff vs. Regents of the University of California, which arose out of a murder at U.C. Berkley. Prosinjit Podder, an Indian graduate student, became enamored with a woman named Tatiana Tarasoff. She rejected his advances, and Podder fell into depression. In counseling sessions, he expressed his intent to do harm to Tarasoff, and the therapist notified the campus police, but not Tarasoff. Podder then killed Tarasoff, and her family sued the school.
"The California court said that ultimately, you have to protect patients, you have to protect people who are innocent victims, so if you believe that there really is an imminent threat, you've got to tell not only the authorities, but also the intended victim," Caplan says. The 'Tarasoff standard,' as Caplan calls it, is a landmark case for therapist-patient confidentiality.
With regards to the case of Dr. Fenton and her patient, Appelbaum believes that the public holds therapists to unrealistic expectations.
"It is extremely difficult to know when, of the many people who come into our offices, many of whom are angry, many of whom are threatening, that one needle in the haystack patient who will act on those impulses. That's a very, very difficult distinction to make," he says.