A packaged warning? Psychiatrist protocol when receiving threats from patients

Written by Loren Grush

About a week before the tragic massacre that occurred at a Colorado movie theater last Friday, James Holmes, the alleged gunman in the shooting, mailed a key piece of evidence to a psychiatrist at the University of Colorado Anschutz.

Inside the package was a chilling surprise – a notebook “full of details about how he was going to kill people,” a law enforcement source told FoxNews.com. Images in the book’s pages included drawings of gun-wielding stick figures as well illustrations of the impending massacre, the source said.

However, the package remained unopened for as long as a week before it was discovered on Monday, taking away the opportunity for a potential warning prior to Friday’s tragic events.

But the question still remains: If the package had been opened, what could the psychiatrist have done?

According to the experts, it depends on a number of factors – including whether Holmes was a patient of the psychiatrist who received the notebook.

“If the person receiving the package was not his doctor, then that person had no obligation than do anything other than immediately call the police,” Dr. Michael First, a professor of clinical psychiatry at Columbia University Medical Center, told Fox News.com. “There’s no doctor-patient confidentiality between them if that’s the case.”

It has not yet been verified if the intended recipient of Holmes’ package had been treating Holmes or if they had even had previous contact with one another. However, Holmes is a recent drop out of the school’s neuroscience department and studying various mental health issues was part of his curriculum.

According to Dr. Keith Ablow, psychiatrist and member of the Fox News Medical A-Team, if a psychiatrist’s patient discusses a plan to do harm to someone during a therapy session, then the medical professional has a legal obligation to take action.

“If they had opened it, any psychiatrist who receives word from a patient that threatens the life of another party – especially if that person is named, but even if they aren’t – is duty bound to report that information to authorities and also to hospitalize that individual against his or her will,” Ablow, told FoxNews.com.

Psychiatrists who knowingly do not notify authorities when receiving this kind of information are subject to civil suits as well as disciplinary action from licensing authorities, Ablow said.

If a person is named in a patient’s threat, psychiatrists are required to go one step further. In a Supreme Court of California case known as the Tarasoff case, a patient had confided with a psychiatrist that he had intentions of killing a girl he had been stalking. While the psychiatrist contacted the police about detaining his patient, he did not notify the woman herself, and she was later stabbed and killed by the patient.

The Tarasoff case ruling set a precedent that mental health professionals would be required to notify people who had been specifically named by their patients as targets for harm.

“If it’s a named victim, that person has to be alerted,” Ablow said. “If James Holmes had said these three people by name are intended, even if [his psychiatrist] did tell police, [they] still have to alert the people named and tell them this person has said he intends to take your life.”

“So the first question: Was this his psychiatrist?” Ablow added. “If it was… if he thought this would constitute a significant threat, he would have been required to put Holmes in a locked psychiatric unit even if it required police intervention.”

However, First noted that it can sometimes be difficult to determine whether or not something a patient says in confidence is a significant danger or if it’s just expressing thoughts that they can’t say to anyone else.

“If a patient has a fantasy, then you want to encourage people to tell you your inner most thoughts,” First said. “It’s important to allow that for the therapeutic relationship to function…. If someone tells you something specific, there’s more than obligation to tell someone. But people say crazy things all the time. There’s a judgment call on the psychiatrist’s part – is this something that should be taken seriously?”

Since details are still coming in about exactly what was in the notebook, First did not say whether or not it justified police notification, noting that if it contained stick figures it may not have been taken seriously. And since it was discovered after the fact, not much could have done in the first place.

Nonetheless, Ablow noted that often times, people reach out in this manner before a crime is committed.

“Most psychiatrically ill people who commit violent acts have tried to tell a mental health professional about their intentions,” Ablow said. “In this way Mr. Holmes is more like other people with violent fantasies than unlike them. Most of these things are telegraphed.”