In search of Cassandra
San Antonio, Texas, United States
|Cassandra by Evelyn De Morgan, 1898,
depicts Troy burning in the background
as the mythological figure prophesied.
The De Morgan Foundation, Surrey, England.
“Psychiatrists are [not] always wrong with respect to future dangerousness, only most of the time.”
– Barefoot v Estelle, 463 US 880 (1983)
My wife is the smartest person I know, but she is not, to the best of my knowledge, omniscient. This qualification would be unnecessary had she not embarked years ago on a career in medicine, and more specifically, psychiatry.
Nearly every physician is familiar with the plight of attending a social gathering only to be bombarded with impromptu consults. A dermatologist who can get through dinner without someone partially disrobing is no doubt ahead of the game. With psychiatrists there is something else at play, harkening back to medicine’s ancient roots as a quasi-spiritual enterprise. Many people believe that psychiatrists can “read their minds.” This profoundly impacts the way they act in the presence of such awesome powers.
The most common reaction is a mix of discomfort and fascination. Upon learning their conversation partner is a psychiatrist, some people feel judged and make nervous jokes about having their hidden motivations unearthed. Others earnestly expect eureka solutions to their interpersonal problems or heroic mediation of disputes. The unifying thread is a sense that psychiatric training somehow confers an ability to perceive inner thoughts and predict human activity.
There is only one problem with all of this: to the extent I have imbibed wisdom via osmosis, I can attest that this is not what psychiatrists actually do. Clinical psychiatrists apply behavioral (and increasingly neuroscientific) expertise, careful observation, and thorough evaluation to diagnose and treat mental illness. In the forensic context, psychiatric insights inform medicolegal determinations, such as the effect of psychopathology on criminal responsibility or the appropriate compensation for psychosocial impairment. In neither case does the job description include clairvoyance. Even risk-reduction plans intended to mitigate potential violence are tailored to dynamic risk factors, including substance use, interpersonal relationships, and medication adherence. Risk assessments require regular review and modification; they are management tools, not prognostications.1
In some ways, confusion over psychiatry’s role in society is baked into the profession’s history. President Harry Truman’s address to the American Psychiatric Association (APA) in 1948 urged “the pressing need for experts in human engineering.” The President identified sanity as “the greatest prerequisite for peace,” and tasked psychiatrists with leading the way. He doubled down with the establishment of the National Institute of Mental Health (NIMH) the following year, appointing as its first director a charismatic psychoanalyst intent on using the platform to advance social activism. The earliest roots of the NIMH lie not in addressing mental illness, but rather the societal ills thought to breed it.2
Of course much has changed since then, including psychiatry’s emergence as an empirical discipline beginning with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Illness (DSM-III) four decades ago.3 Nowadays the NIMH’s research focus is squarely on neurobiology,4 so much so that it has provoked a backlash of sorts from those urging a middle ground between treating the mind and the brain.5 Yet the notion of psychiatry as social engineering, and the myth of the psychiatrist as seer, stubbornly persist—in some cases spurred on by prominent members of the profession itself.
This is due, at least in part, to a Berkeley graduate student in the late 1960s who fatally stabbed a colleague named Tatiana Tarasoff after she rejected his romantic overtures.6 The victim’s parents sued the university, alleging that the perpetrator divulged his murderous intentions in the course of psychotherapy sessions on campus. The therapist had alerted campus police, but never warned the named target. In a momentous decision, the California Supreme Court famously concluded:
When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger.7
Thus was conferred a judicial imprimatur upon the concept of a therapist’s “duty to warn.” Since then, this Tarasoff doctrine has been enshrined—to various degrees and in various iterations—in state laws, court rulings, professional ethics rules,8 and even medical privacy regulation.9 At the time, however, it was highly controversial, as it contravened the general principle under Anglo-American law that there is no duty to rescue a stranger. In the medical realm, it threatened the corollary assumption that doctors’ liability extends only to their patients.
From Warnings to Predictions
Through the years, the Tarasoff doctrine has been consistently misinterpreted to somehow imply that mental health professionals possess inherent insight into what human beings are going to do, and when. Yet the interesting thing about the original court decision is what it actually says. The judges did not presume that the killer’s therapist divined his plans based on prognostic expertise; in fact, they assumed largely the opposite. The court specifically acknowledged therapists’ “professional inaccuracy in predicting violence” and “the uncertain character of therapeutic prediction.”7
Rather, the majority’s ruling was grounded in the intimacy of the “special relationship” between psychotherapists and their patients. The trust and confidentiality inherent in that therapeutic alliance vest mental health clinicians with “concealed knowledge” that others may never discover. In extreme circumstances, therapists may need to break the very secrecy that underpins this bond in order to avert serious and imminent threats to clearly identifiable targets. Whatever the merits of the Tarasoff decision as a medicolegal construct, the fact remains that the killer’s psychologist in that tragic case did not deduce the danger through clinical perspicacity. He knew Tatiana Tarasoff was in peril because his patient explicitly told him.7
This distinction has not prevented the duty to warn from being cited in a variety of inapposite circumstances. During the first Gulf War, Dr. Jerrold Post—a pioneer in the field of psychiatric profiling of foreign leaders on behalf of the U.S. government—provided public Senate testimony on Iraqi dictator Saddam Hussein’s “malignant narcissism.”10 When faced with criticism that he had violated the psychiatric profession’s proscription against diagnosing an individual without conducting an examination,11 Post responded with a Tarasoff-like rationale that his warnings about the Iraqi ruler’s mentality could save countless lives.12 Of course, Post may have had many legitimate and compelling reasons for sharing his opinions with Congress and the public, but a duty to warn was not one of them.13 Having never met Saddam, let alone treated or examined him, there was no “special relationship” endowing Post with “concealed knowledge” of the leader’s lethality.
More recently in our politically polarized times, a small but vocal group of mental health experts has cited a duty to warn to justify their public pronouncements that President Donald Trump’s mental state is dangerous.14-18 This approach dubiously presumes that dangerousness can be established through media reports and warnings disseminated via op-eds.19 An urgent political plea couched in the language of psychiatry does not make it a Tarasoff alarm.
Nor, unfortunately, can psychiatry offer a panacea for intractable social problems that bedevil policymakers. Framing endemic gun violence as a mental health issue, for example, conveniently overlooks voluminous evidence that the connection between shootings and mental illness is small.20-23 More to the point, psychiatric diagnosis is not a proxy for dangerousness writ large.24 To quote the prominent psychiatric researcher Dr. Jonathan Metzl, “Psychiatric diagnosis is itself not a predictive science.”25 Diagnosis is not destiny, and predisposition is not predestination. Outside narrow time windows of heightened risk, there are few if any diagnostic tools to forecast which patients may engage in harmful conduct. Psychiatrists assuming the mantle of expertise in violence prediction may bring additional authority and accolades to the profession, at least in the short run. Yet if they prove only marginally better than laypeople in prophetic accuracy, the consequences for both mental health clinicians and patients may be calamitous indeed.
A Reverse Cassandra?
As illustrated by President Truman’s call to arms to the APA seventy years ago, psychiatry is deeply attractive as a political tool because it offers a bevy of labels to explain behavior that we do not understand. If someone commits a heinous crime, it is oddly comforting to attribute their actions to mental illness. Psychopathology is amenable to interventions that sociopathy is not. The next step is to infer that what can be treated can be predicted. Who better to do so than those trained and charged with healing our emotional afflictions?
Except that psychiatrists are not oracles. They are people with a medical degree who have completed a residency. Their purview—and a noble one at that—is to attend to the well-being of those suffering from mental illness. Foretelling the future and saving the world sadly remain above their pay grade, or at least outside their competencies.
In Greek mythology, Cassandra is cursed by the god Apollo to utter prophecies but never be believed. She devolves into madness as her visions, including the fall of Troy, are ignored yet invariably come true. There is, however, an equally tragic predicament to seeing the future to no avail: namely, to be viewed as a prophet without possessing the attendant clairvoyance. For the good of their patients and their profession, psychiatrists must avoid this fate at all costs.
- Knoll JL, Pies RW. Psychiatry, “dangerousness,” and the president. Psychiatr Times. February 2018;35(2):C1-2.
- Lieberman JA. Shrinks: The Untold Story of Psychiatry. New York: Little, Brown and Co.; 2015.
- Decker HS. The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. New York: Oxford University Press; 2013.
- Insel TR. Transforming diagnosis. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml. Published April 29, 2013. Accessed April 11, 2019.
- Kendler KS. The structure of psychiatric science. Am J Psychiatry. 2014;171(9):931-938.
- People v Poddar, 518 P2d 342 (Cal 1974).
- Tarasoff v Regents of University of California, 551 P2d 334 (Cal 1976).
- American Medical Association. Code of medical ethics opinion 3.2.1(e): confidentiality. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-3.pdf. Accessed April 12, 2019.
- 45 CFR 164.512(j)
- Goleman D. Experts differ on dissecting leaders’ psyches from afar. New York Times. January 29, 1991:C1,9.
- American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. 2013 ed. [Section 7.3] https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Ethics/principles-medical-ethics.pdf. Accessed April 12, 2019.
- Post JM. Ethical considerations in psychiatric profiling of public figures. Psychiatr Clin North Am. 2002;25(3):635-646.
- Friedman RA. Role of physicians and mental health professionals in discussions of public figures. JAMA. 2018;300(11):1348-1350.
- Voelker R. Finding a better way to assess presidential fitness. JAMA. 2017;318(23):2285-2286.
- Lee BX, Glass LL, Fisher EB. The ethics of warning the public about a dangerous president. Boston Globe. January 2, 2018. https://www.bostonglobe.com/opinion/2018/01/02/the-ethics-warning-public-about-dangerous-president/PimY2PNNKnOd1QG0lbc17N/story.html. Accessed April 13, 2019.
- Dodes LL, Schachter J, et al. A mental health warning on Trump. New York Times. February 14, 2017:A26.
- Lee BX, ed. The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a president. New York: St. Martin’s Press, 2017.
- Lee BX. Psychiatrists warn about Trump’s mental state. New York Times. December 1, 2017:A26.
- Stone A. The psychiatrist’s Goldwater Rule in the Trump Era. Lawfare. April 19, 2018. https://lawfareblog.com/psychiatrists-goldwater-rule-trump-era. Accessed April 13, 2019.
- Swanson JW, McGinty EE, Fazel S, Mays VM. Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Ann Epidemiol. 2015;25(5):366-376.
- Hirschtritt ME, Binder RL. A reassessment of blaming mass shootings on mental illness. JAMA Psychiatry. 2018;75(4):311-312.
- Qiu L, Bank J. With gun violence and mental illness, truth isn’t simple. New York Times. February 16, 2018:A15.
- Konnikova M. Is there a link between mental health and gun violence? New Yorker. November 19, 2014. https://www.newyorker.com/science/maria-konnikova/almost-link-mental-health-gun-violence. Accessed April 13, 2019.
- Rubin R. Mental health reform will not reduce US gun violence, experts say. JAMA. 2016;315(2):119-121.
- Chang A. A look at the narrow point of intersection between mental health and gun violence. All Things Considered. February 28, 2012. https://www.npr.org/2018/02/28/589600339/a-look-at-the-narrow-point-of-intersection-between-mental-health-and-gun-violence. Accessed April 13, 2019.
CHARLES G. KELS, Lieutenant Colonel, JD, is a judge advocate (JAG) in the U.S. Air Force. He practices health and disability law and researches in the areas of medical privacy, informed consent, and professional ethics. The views expressed are those of the author alone and do not reflect those of the Air Force or Department of Defense.
Highlighted in Frontispiece Volume 11, Issue 3 – Summer 2019
Spring 2019 | Sections | Psychiatry & Psychology