Should shrinks probe the violent fantasies of patients?
They often don't. And that failure can be tragic.

Editor's note: This is the second of two parts. Read Part 1.

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By Dawn MacKeen

May 26, 2000 | "There are people out there who are going to kill you and your family." Like a song played over and over, this warning looped in David's head for three days straight. Wherever he went, it followed. Each night, his mother and girlfriend begged the doctors at the local hospital to admit him. Each night, they were turned down. About 12 hours after the last attempt, his mother lay dead on her living room floor, a gunshot to her chest. His stepfather was wounded. David, at 28, was led away by police, to the same chorus of voices.

"I think if I would have gotten some type of help, I think my mom would have been alive today," says David, who asked that his real name not be used. "Even though I was insane, I knew to get help."

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Over a cup of coffee on a recent morning at a Starbucks in a San Francisco suburb, David tells me the details of a story that is tragic at almost every turn. The mental health system failed him. His mother, always his greatest ally, became his greatest victim. Only after she was buried, and only after he went to jail, did her son finally receive the help she had desperately tried to get him.

In the final days of her life, while David was swinging through the hospital's revolving door, psychiatrists asked him many things: about his feelings, his hallucinations, his drug problems. They asked whether he was thinking of hurting himself. But no one asked the now-obvious question: "Do you have violent intentions toward others?"

It's impossible to know whether one question could change the outcome of any case. But many mental health professionals believe that at least some violent fantasies can be defused by simply asking patients about them. A new study found, however, that psychiatrists rarely explore this line of questioning.

The researchers studied 114 patients in a psychiatric ward in Britain. While almost all the patients said they'd been asked if they felt suicidal, only 13 percent said they'd been asked if they had violent thoughts. The study was published April 22 in the British Medical Journal. An accompanying editorial said the failure to ask about violence endangers lives.

"If you are not asking, you are not doing your job, you are not saving lives, you are a hack," says Dr. Carl Bell, CEO of the Chicago Community Mental Health Council and a professor of psychiatry and public health at the University of Illinois at Chicago.

Although the American Psychiatric Association says asking about violent thoughts is "standard practice" in this country, interviews with psychiatrists and stories like David's suggest otherwise.

Why would therapists ask patients if they are thinking about firing a bullet into their own head, but not someone else's? In part, it's because suicide prevention has been a cornerstone of the mental health field; discussions about violence have not. But many admit it's more than that. Therapists are trained to deal with suicidal people, not potential killers.

"Their comfort level is a lot higher with suicide. If the patient says this and this, they know what to do. But they have to clarify what to do in a parallel situation that involves violence toward others," says Dr. Drew Ross, a forensic psychiatrist and author of "Looking Into the Eyes of a Killer." "For a lot of psychologists and therapists, intervention is very different than what they were trained to do and why they went into this field."

High-profile crimes committed by kids who have been under psychiatric care have increased pressures on therapists to focus on the possibility of violence. But psychiatrists largely resist the idea that they can, or should, play a significant role in crime prevention. They are neither "lie detectors" nor "crystal balls," as one psychiatrist put it. Their offices should be havens for the distressed and emotionally vulnerable, not police department outposts.

"We have a lot of horrible things happen like at Columbine and at the National Zoo, and the idea that psychiatry should do something is perfectly understandable, but that idea that it can do something is a matter of science," says Dr. Alan Stone, a professor of psychiatry at Harvard. "In my opinion, psychiatrists have no reliable and valid way of predicting future violence. They do just a little better than flipping coins."

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