But some psychiatrists say it's irresponsible to take a "don't ask, don't tell" approach to the question of violence. "In most cases, there are no discernible signs unless a patient volunteers the information," says Dr. Paul Appelbaum, vice president of the American Psychiatric Association. That's why it's critical to ask. "The responses are sometimes surprising. Patients who you wouldn't expect to have violent impulses often talk about it directly. Many patients are waiting to be asked. They are reluctant to volunteer information about violence they may have committed or violent thoughts that they may be having because they are embarrassed about it."

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David sincerely believes that had he been asked, he would have told someone more about his mental state. Then, he believes, he would have been committed -- and he would not have killed his mother. But it's easy to see why a psychiatrist wouldn't peg David as potentially violent. He had no history of mental illness. His only brush with the law was for drunken driving. He is short, with a mustache and light brown hair. He seems insecure, not aggressive.

"I never in my worst dreams thought that I would be capable of doing something like this, and then you wake up and you're in the mental health system," he says.

The judge called his case "tragic."

Under a 1976 California Supreme Court ruling known as the Tarasoff decision, a therapist who knows that a patient intends to hurt someone must take action. The therapist may commit the patient, warn the possible victim or call the police. But this "duty to warn," as it is known in mental health circles, does not translate into a duty to ask. Therapists are under no mandate to bring up violence if the patient doesn't, although at some facilities, such as Chicago's Community Mental Health Council, questions about violence are part of the psychiatrist's checklist.

Of course, there's a large difference between thinking about harming someone and doing it. It would be absurd for psychiatrists to report, or commit, every person who angrily utters that he wants to kill someone. But a forthcoming study of hospitalized psychiatric patients found that telling a clinician about violent thoughts was significantly related to carrying them out within 20 weeks of discharge. One-third of the 1,136 patients studied reported having violent thoughts, double the percentage in the general population.

"It is certainly not the case that most people with thoughts of harming another go the next step and actually harm, but violent fantasies do seem to be a risk factor for violence and any useful risk factor could be used to prevent violence," says John Monahan, a professor of psychology and legal medicine at the University of Virginia School of Law and a co-author of the study, to be published in July in the Journal of Consulting and Clinical Psychology.

It's been 11 years since David killed his mother. Ultimately, psychiatrists called it a "psychotic break," and he was found not guilty by reason of insanity. He spent five years locked up, in jail and a mental facility. Antipsychotic drugs silenced the voices.

He is in a program for violent offenders, living not far from where the tragedy happened. Sometimes, he runs into old friends from high school, who have no idea what happened. He wonders what to tell them.

"I wish that I could say that I think all the time that it's OK to carry on with my life," he says. "It's not easy to deal with; it's something I'll carry with me forever. But I know in my heart that I'm not that type of person."

He says his mother was one of the only people who believed in him when he was addicted to heroin. He wishes she could see him now, clean and sober. He says his brother once told him that she would be proud. "I don't know if he was just trying to be nice," David says, "but it's what gets me through each day."

David then whispers that he really loved his mom, as hard as that seems to comprehend.
salon.com | May 26, 2000

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