The Rabbit Hole-Complicated Grief

A movie review written by the author of the recent film “The Rabbit Hole” is presented. The story deals with the responses of two parents to the death of their five year old son. The film shows realistic grieving of each parent. The issue of “complicated grieving” is explained and discussed. It is suggested that this movie should be used as a teaching tool for professional students interested in understanding the grieving process.

One of things that I enjoy doing when I am not writing this blog or doing other professional work, is to watch movies. In fact, my wife and I frequently attend preview screenings and we write brief reviews in our blog named FilmRap.net

Recently we saw a new movie which is going to be released this week in Los Angeles and New York as well as across the country shortly thereafter. Aside from it being an excellent film which will probably get some Academy Award consideration, I believe that it will make an excellent teaching film for mental health professionals who are studying manifestations of grief. I will reproduce our review of it and then add a few additional comments :

The Rabbit Hole – Rating 4/5 stars

David Lindsey–Abaire as screenwriter for this film, based on his own play, really gets into the head and the emotions of two grieving parents 8 months after the death of their five year old son who died running after his beloved dog. We never meet Danny and barely see a picture of him but we come to clearly understand the relentless pain in all it’s forms which his parents Becca (Nicole Kidman) and Howie (Aaron Eckhart) are feeling. Each of them are  grieving in his and her own way which despite sharing this most personal tragedy and a good previous relationship, there seems to be  no room for empathy between them. Becca’s quest to find some way to deal with her deep dark feelings leads her to establish a relationship with Jason (Miles Teller), the 18 year old high school senior who swerved his car, which he confesses to her may have been going a mile or two over the speed limit, which led to the tragedy and  now has created a bond between them. Becca’s somewhat religious mother (Diane Wiest) whose son died at age 31 , eleven years previously, provides a counterpoint from where she is coming. Nicole Kidman who saw the original play and started the ball rolling to make it into a movie chose John Cameron Mitchell to direct it. Mitchell and Lindsey Abaire who were guests at our screening acknowledged that they complemented each other as they explored the fine points of this film. The director, who had only a 4 million dollar budget, shared with us that he let the actors steep  themselves into their emotional  roles which he appeared to nimbly direct as well as spending  a great deal of time in editing the fine points. He gave a touch of humor to   a primarily a dark movie and kept us the audience observing at a slight distance from the unimaginable tragedy. We did not shed a tear for the young boy who we did not meet or really know. As mental health professionals who have worked with many grieving patients, we had the feeling that we were empathizing with people we cared about, as we might with a patient who is   involved in their own dynamics that are unfolding before us at somewhat rapid pace. The fact that the writer, director and the actors really nailed the complicated feelings and interactions without ripping apart the guts of the audience (which they could have easily done) may be judged a shortcoming of the movie by some or the height of sophistication by others.

This movie also merits comparison with four other movies which we have seen in the past year and each of which shows attempts at dealing with grief in a different manner.

A Single Man shows Colin Firth in an Oscar nominated performance as George a college professor whose lover has died in an auto accident and in his grief he is on the verge of suicide when he meets a young student who cares about him. Robin Williams does an excellent job as an unsuccessful writer in World’s Greatest Dad grieving   a teenage son who committed  suicide. The father pretends his late son has written the story of being bullied and the result is a game changer for the community and for the dad which gives some meaning to this tragic loss.  The Lovely Bones deals with the murder of a young teenager (Saoirse Ronan) who had just begun to feel the glimmers of romance which leads the audience to feel her parent’s unresolved grief despite the youngsters ethereal existence. There is a small amount of compensation as the killer is caught through the efforts of the girl’s sister.  The film, which most closely resembles the Rabbit Hole, is The Greatest which brought together a comparable great performance by Pierce Brosman and Susan Sarandon who are the grieving parents of a teenager killed in car accident while he is with his girl friend played by Carey Mulligan. The potential for the parents to live with their grief is the unborn child being carried by the young girl friend whereas  in the film which we reviewed today,   the hope for a better future is only hinted by a subtle but important gesture at it’s conclusion. We thought these two were both excellent films The  Greatest didn’t achieve the critic’s Oscar acclaim and it appears that the Rabbit Hole may get some such bids. However overall, we rated the Rabbit Hole a notch lower. We certainly do believe that  this movie is the finest example and should be used as a teaching tool and stimulus for discussion for those who are studying the grieving process as well as a movie worth seeing for anyone interested in these all too real human emotions

Additional  Comments

To experience the death of your young child is one of the most painful, difficult and traumatic events that a human being can go through. Mental health professionals who have studied this event have recognized that the subsequent grieving has certain characteristics that go beyond and are somewhat  different than the usual emotional responses that are seen after the death of a close friend or relative. It has been labeled as  complicated  grief and this term includes other circumstances in addition to the loss of child, such as the death of an adult or child  by murder, suicide, unusual unexpected trauma such as terrorists attacks ie 9/11, etc.  While the loss of a close person is rarely forgotten, there often is a gradual resolution of the intense feelings over the course of a year with amelioration of most of the symptoms such waves of sadness, episodic crying, insomnia, intrusive thoughts, occasional hallucinations, intense anger, etc. Most people who grieve usually do not find it necessary to have counseling or any form of therapy.With complicated grief such feelings rather that resolve often intensify in the months following the loss. There may be evidence of major depression with weight loss, continued insomnia and even suicidal ideation. There can be a resort to heavy drinking or drug use. There can be intense anger, not only at self but at others , often with a demand of some type of restitution or revenge. Relationships are greatly strained and marriages often are not able to withstand this trauma. Psychotherapy is often helpful with or without medication. Sometimes a group process is used which includes other people who have gone through similar losses.   It may be useful for some type of a memorialization process to be developed where the memory of the lost person is perpetuated in some worthy fashion. The above movie certainly did not touch upon most of these issues but it did clearly show the impact on the parents of the traumatic loss of their child. The subsequent behavior and the emotional responses of each of the parents were very real and plausible in view of the loss that they had suffered. As I noted, this film would be an excellent starting off point for professional students to discuss and analyze the grieving responses in this very difficult situation. Obviously the movie gives the viewer a certain cathartic experience and you can also appreciate it as a very good creative artistic accomplishment which may be viewed by many as one of the best films of the year.

First Anniversary of PsychiatryTalk.com

This blog is written to mark the first year of PsychiatryTalk.com being on the Internet. The readership has expanded from 25 hits/week to over 300 hits/day and it is still growing. A followup on the topics of several of the blogs written in the past year was reported.

I started PsychiatryTalk  a little more than one year ago and it has been an interesting experience for me. I have met people from around the world via this blog  and it is very gratifying to see the number of hits on it to continue to grow. Initially, there would be an average of 25 pages /day that were read. Now it is well over 300/day and growing. I originally thought that the blog would generate online discussion.  I was surprised to find that readers are reluctant to put comments on the blog itself, although many people will write to me or people whom I know will speak with me in person about various subjects about which I have written. I still encourage any readers to put comments directly on the blog in the comments section and they will be posted usually within a day or two. It is easier for me to write the blog every other week rather than weekly so I have recently switched to biweekly postings.

I thought that this might be a good time to report some follow-up on various blogs which I have written .

The first blog that I wrote on October 12, 2009 was Review of Fox TV Show Mental. It was a critique of a new television show  which was about a psychiatrist. In my opinion, the program lacked authenticity and missed the opportunity to depict psychiatry and mental illness in a realistic manner.The show was not renewed. There is an excellent program about a psychotherapist on  HBO titled In Treatment which  just began it’s third season. It stars Gabriel Byrne as Dr. Paul Weston who has weekly sessions with patients , including one with his own therapist. This is a scripted show and although the writing is quite good, it is fiction based on a similar Israeli TV show.  I believe that it  would be possible to develop a high quality reality tv show of an actual ongoing therapy which could not only show real therapy sessions but also allow for interesting discussion by experts. There would be some ethical considerations in doing it which but I believe could be overcome and it  could be done in a thoughtful manner.

The second blog on October 19th was titled When a Mother Kills Her Children. It was about post partum psychosis with a discussion of the Proposed bill before the US Congress tiltled the Melanie Stokes Mothers Act . I am pleased to say that in March of 2010 it was passed and signed by the President. This  legislation will establish a comprehensive federal commitment to combating postpartum depression through new research, education initiatives and voluntary support service programs.

In December 2009 I first wrote a blog Condolence for Soldier Suicide where I made the case that it was wrong for the President of the United States not to write a letter of condolence to the families of American soldiers who have died by suicide. Another blog was written on this subject in August  2010 titled We Can’t Avoid PTSD and Suicides . While the President has still not changed his policy, the Secretary of the Army has recently written to some of the families and expressed his regret on the death of the soldiers. Perhaps this may be a sign of things to come. I authored an Action Paper with Dr. Roger Peele of Washington D.C. requesting the Assembly of the American Psychiatric Association to ask the President to reconsider his policy on this issue. It was passed by the APA Assembly and also endorsed by the Board of Trustees of the APA . This makes it the policy of our 38,000 psychiatrists organization. In addition Mental Health America and the American Foundation for the  Prevention of Suicide has passed similar resolutions and also are in the process of gathering signature for a petition to  President Obama. I believe we are getting closer to this long over due recognition to the families of these soldiers .

Another important military issue  and human rights issue was discussed in the February 2010 blog titled Abolishing Don’t Ask Don’t Tell (DADT).  Polls have consistently shown a majority of the public supports letting gays serve, and Defense Secretary Robert Gates and top military commanders such as Admiral Mike Mullen have recently endorsed it. In September 56 Democratic senators voted for the defense authorization bill, which included DADT repeal, but the measure failed to achieve the 60 votes needed to overcome a Republican filibuster.  A recent study conducted by the Pentagon concluded that ” …while a repeal of DADT will likely in the short term bring out some limited and isolated disruption to unit cohesion and retention, we do not believe this disruption will be widespread or long-lasting, and can be adequately addressed. The report, based on responses from 115,000 service members and 44,266 spouses, includes interviews with former gay or lesbian service members, some of whom were discharged from the military under the “don’t ask, don’t tell” policy. Of those surveyed, 69 percent said they had served with a gay service member and 92 percent of those respondents said they were able to work together.Fifty to 55 percent of those surveyed said the repeal won’t have any effect, 15 to 20 percent said it would have a positive effect and 30 percent said the effect would be negative.The report went on to say that  “The reality is that there are gay men and lesbians already serving in today’s U.S. military and most service members recognize this,” the report states. “Much of the concern about open service is driven by misperceptions and stereotypes about what it would mean.”I still like the words of Barry Goldwater on this issue who said, ” It is not important if your are straight , just that you can shoot straight.”

When there was a proposal for a 39% hike in healthcare rates purposed in California by private insurance companies, I raised the question in a March 2010 blog titled  Stockholders Must Vote CEO Pay whether  there should be  law where stockholders,not Board of Directors of Compensation Committees, should be required to approve any compensation packages more than 200 times the minimum wage in the US. That controversy seems to have been revived just this past month when compensation at Wall Street firms was reported to be  expected to hit $144 million . A column in the Wall ll Street Journal raised the question I brought up that since the 2008 financial crisis profits remain 20% below the 2006 level while the pay at these firms rose an astonishing 23 % over that time frame,  shouldn’t the owners of these firms be the ones to decide if they want to spend their money raising the compensation of their executives. ?

The May 12th 2010  blog titled Autism & FragileX- New Treatment has become the most looked at blog of PsychiatryTalk of the year so far. In it,  two new research projects concerning Autism Spectrum Disorder and Fragile X Syndrome are briefly reviewed. In the first, a random controlled study of children with Autism Spectrum showed that the Early Start Denver Model showed statistically improvement over a control group in regard to intellectual development and adaptive behavior. In the second study, preliminary research showed that a new medication improved behavior associated with Fragile X Syndrome compared to the control group. There is also some belief that such medication would be effective with children with Autism Spectrum.  As a followup I don’t find any announcements of new breakthrough research. However, there is  a $211 million HHS-wide initiative that would invest an additional $1 billion over the next eight years in autism related activities, the NIH budget includes $141 million in FY 2010 for research into the causes of and treatments for autism spectrum disorders (ASD). The funded research will  include identifying biomarkers; improving ASD screening; establishing ASD registries; understanding genetic and environmental risk factors, as well as interactions between the immune and central nervous systems; and enhancing services that can help people with ASD across the lifespan.


Also in May I wrote two blogs addressing financial issues in the  American Psychiatric Association and they were Impact of APA Budget Cuts and  Increase APA Budget $1.5 Miilion. In the the former I discussed the expected impact of the cuts on the APA Assembly and APA Components particularly the Communications Committee and the Disaster Committee. In the second blog I outlined several specific suggestions how I felt that the APA could gain this large increase in it’s budget. Certainly the APA continues as a very vigorous organization representing 38,000 psychiatrist and speaking out on important issues concerning mental health. It is still too early to determine if the cutbacks will seriously hinder it in it’s effectiveness. I understand that some of my suggestions are being considered by some of the leadership but as far as I know no steps have been taken to implement any of them

In a July 14th blog titled I would Like to Thank My Psychiatrist It was stated that Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is was noted to be  example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment. My colleague Bill Arroyo informed me that Artest was mistaken in that his therapist was not a psychiatrist but another mental health professional. While I appreciate the correction, the changing attitudes towards discussing therapy still  holds and is a good trend.

Last month I wrote my first blog on Miners in Chile anticipating any psychological issues that people who have gone through  a traumatic event may experience. As the miners began to emerge from the successful rescue efforts asecond blog was written in conjunction with a blog that I wrote for  CNN.com which I suggest that in this situation I believe that resiliency will be the default and most if not all of these miners will not have any long lasting psychological effects. In fact this brush with death may end up being a positive experience for them . It is obviously too early to tell  but it is very gratifying to see the good feeling around the world for these miners. However, just recently  29 miners  died in an explosion in New Zealand and we are reminded how such tragedies occur all the time and so cause great mental anguish for so many people. In this regard still another report of a recent tragedy caught my eye and that was the traumatic event in Cambodia where more  more than 378 people died and hundreds more were injured in a stampede at the end of the annual Water Festival late Monday in Phnom Penh. So many of these victims  were young people , many in their teens. I hope that there are mental health professionals and others available to help the survivors, families and friends deal with their grief.

Needless to say, I am still enthused about continuing this blog. I do appreciate the growing readership and I would want to encourage each of you to feel free to comment directly on the blog with your own views are particular topics. Whenever I have had occasion to give a talk whether it has been at a national meeting, a Grand Rounds or even a local group, I am always very pleased if there are 25 people in the audience, as it is privilege to share my interest with others. So it becomes a special opportunity to use the Internet to reach much larger numbers throughout the world through this wonderful medium. Thank you all for your continued interest.

First CAPA Graduation Held In China

CAPA stands for Chinese American Psychoanalytic Alliance which is an organization created by Dr. Elise Snyder a New York psychoanalyst. The organization runs a training program where mostly American psychoanalysts teach Chinese psychoanalytic students theory and technique as well as providing individual supervision all via Skype. The first graduation of this two year program was recently held in Beijing China .

Report From Beijing

In the future when Chinese psychoanalysts look back at the beginnings of what may be a vigorous psychoanalytic movement in China, they will remember October 24, 2010 when The Chinese American Psychoanalytic Alliance (CAPA) held the first graduation ceremony of it’s psychoanalytic training program at the Mental Health Institute of Peking University. I had the pleasure and the honor of attending that graduation.

Elise Snyder, M.D. Driving Force Behind CAPA

Elise Snyder, M.D.

The creative and driving force behind CAPA is a New York psychoanalyst by the name Elise Snyder. It all began several years ago when she was visiting China with her husband Michael Holquist who is Professor Emeritus of Comparative Literature at Yale University and was attending a conference there. Dr. Snyder met several Chinese mental health professionals who were very interested in learning more about psychoanalytic theory and practice. This led to a series of visits to China by Dr. Snyder where she gave lectures, held various meetings and did some consultations. She returned several times and also became very involved during a subsequent major earthquake where she was helpful in advising about mental health services.

Dr. Snyder was encouraged to set up a training program for Chinese therapists and students interested in learning about psychoanalysis and psychodynamic psychotherapy. She began to involve American colleagues and utilized Skype an Internet Video Conferencing tool. This evolved into a program which was training Chinese psychiatrists and other mental health professionals in 4 different cities. There would be 4 hours of classes per week via SKYPE. Each class would be an hour taught by an expert mostly in the United States, although psychoanalysts in Canada, Australia and France also were recruited as teachers. In addition the students were required to have one hour per week of a supervisory session for their own clinical work also done by Skype with CAPA instructors. Many students chose to have their own psychoanalysis or psychoanalytic therapy mostly via Skype.

CAPA is Non Profit but Students Pay a Fee

CAPA is a nonprofit organization. The students do pay a tuition, the equivalent of about $1500 /year, which goes towards administrative expenses. The teachers donate their time for teaching classes and supervising students. Those students, who are being treated, pay very modest fees in the range of $5-25/session, which means that most of the therapists are essentially donating their time. The students themselves are usually employed as mental health professionals. Some are psychiatric residents working in a hospital or if graduated may be working in mental health clinics or a few may be in private practice. There are even medical school faculty members in China who have chosen to get the credential as a CAPA graduate. Others are psychologists, counselors or other mental health professionals who may be working in clinics, hospitals or other settings.

I was asked to participate in in the CAPA teaching program about one year ago. I subsequently have taught classes in Wuhan and Shanghai, both via Skype. I am now supervising a young psychiatrist who is in Qingdao, Shandong Province, an eastern coastal city of China. There is a 16 hour difference between China and Los Angeles where I am located. So for example, on Tuesday evening at 11pm I sit in my office and fire up my computer and will be viewing my supervisee and chatting with him for his supervisory session on Wednesday at 3 pm in China. While I was in China  with the recent CAPA tour I  meet with him in person.

CAPA has caught on in China and in the United States. There are over 200 faculty members who donate their time to the training of psychoanalytic theory and therapy in China. Approximately 30 students were graduated in Beijing in October. There were also informal graduation ceremonies for another 20 students in Shanghai and Wuhan. This means that  this nascent organization of Chinese and American professionals has close to 350 members and counting. In Beijing and in other cities where I traveled as part of the three week CAPA tour, I met Chinese professionals and professional students who were eager to learn about CAPA. Many were preparing themselves for a career in the mental health professions and were anxious to get training through CAPA.

The Historic First CAPA Graduation

Prior to the historic graduation and the handing out of diplomas, there was an academic program for the CAPA students, the faculty and for other guests from the Mental Health Institute at Peking University. The moderate size auditorium was quite filled. First, there was a case conference, which was led off by Dr. Ba Tong, one of the graduates who presented a clinical case in which she demonstrated her knowledge of transference and countertransference. Dr. Cecile Bassen, a psychoanalyst form Seattle, sensitively discussed the case. We later met Dr. Ba Tong who came across as a very capable young woman who showed us pictures of her new private office, which she will be sharing with a colleague as they start their private practice in Beijing. The second part of the academic program was a presentation by Dr. Shari Thurer from Boston who gave a lecture on Sexuality and Gender identity in which she reviewed homosexuality, transgender sexuality and transsexuality. There was a very interested response from the students in the audience some of whom told of their clinical experience with patients.

The program concluded with a few words from Dr. Snyder who is now seeing her “baby” coming to fruition. She seemed quite proud, as she should be as she called the graduates to the podium. There were also many beaming faculty in the audience. Dr. Snyder announced that there would soon be an advanced additional two year segment available in the CAPA training program, making a total of 4 years of training being provided by CAPA. I later asked Dr. Snyder what she was thinking as she saw the graduates come up to the podium to shake her hand and receive their certificate.  She said, “I felt overwhelmingly moved. I felt happy. I started to cry and couldn’t believe it was happening.” She want on to explain how proud she was of the students and the faculty. She viewed  this event as an historical moment . She ended by saying “This is really the  beginning of an interest in psychoanalytic therapy (in China) that arises from the bottom rather than from the top down.”

Resiliency Expected From Rescued Miners

A piece the author wrote for cnn.com upon the release of the 33 trapped miners in Chile is presented. The author anticipates rather than psychological problems such as post traumatic stress, most if not all of the rescued miners will show resiliency.

The following is based on a  piece I wrote for the Opinion Page of CNN.com upon the release of the 33 trapped miners in Chile (Photos from Chile government)

It is only human nature to be concerned about the psychological welfare of the 33 miners who are emerging from their prolonged stay trapped underground. Those of us who work in the specialty of mental health especially as it applies to disasters and posttraumatic stress have pondered the differential list of possibilities that we know can happen to survivors of individual and mass traumatic events.

Possible Psychological Problems

The range of psychological sequelae includes symptoms of posttraumatic stress such as nightmares and flashbacks of being trapped in small tight living quarters with the possibility that they would never get back. There could be reoccurrences of the memories, thoughts and feelings which they had at the moment that the mine collapsed when they realized that they could be facing immediate death. The miners may find that despite their freedom, after being rescued, that they have become claustrophobic and fear and avoid any type of closed spaces. Their nervous systems may be reset in a manner, which makes them high strung and easily aroused. A sudden noise may cause them to be very jumpy.

The newly rescued miners may have significant problems in sleeping as their biological clock may be quite altered. It is possible that the  radical changes in nutrition and the diminished hydration which they have experienced  has effected their medical health which could further impact on their mental health. It is been suggested that they could be candidates for kidney disease which could lead to them being sluggish in their ability to concentrate as well as the other serious effects of such a medical condition.

There may have been some interpersonal conflicts which festered with the close proximity and could preoccupy the miners even after they are rescued. Then there is the issue of reestablishing relationships with family, friends and workers, which were abruptly suspended since the accident. There may be expectations that will not be met by spouses, lovers, children and others. Similarly those awaiting the rescue on the outside, may be disappointed if the miners do not respond as they anticipated. The pressures and overall experience with the media may be overwhelming for some of the men. Those miners who may have had a problem or a tendency to use alcohol and drugs may turn to these substances to try to relieve anxiety and other feeling which they have in the aftermath of being rescued. This could easily spiral out of control leading to serious problems.

Resiliency Expected to be The Default

Having said all this, I believe that the majority, if not all of the rescued miners will psychologically do very well. I base this view on the fact that although we know there are many post traumatic problems that people do have who have suffered individual and mass trauma, most people show resiliency and get through these events without long lasting psychological damage.  In addition the factors, which appear to contribute to enduring psychological issues either were, not present or seemed to have a short lived effect.

For example there was not death or any serious injury to the miners. While there may have been initial moments where the miners feared for their lives, this appeared to have been mitigated once they found the safe area in the mine.  They also understood that a rescue effort was being undertaken and was expected to be successful. Just as important, they had communication (which included video and audio) with their families so their isolation was far from complete. In fact, they knew that their entire country and people around the world were following their ordeal and were rooting for them. While such enormous expectations can sometimes create pressure on a person, in this case there were no actions, which they had to perform but rather they could just appreciate the  support that they had from other people

While I do not know the details, it has been reported that while they were trapped they also had access to mental health counselors via their communication channel and could also be given tranquilizers or other psychotropic medication if needed along with any other medical supplies. They were given miniaturized video players as well as games to divert and exercise their minds during their confinement. I also assume that in the aftermath, when they are out of the mine, they and their families will have some meeting with sensitive and knowledgeable counselors who will address any symptoms which they may have. These professionals will be alert for potential substance abuse problems, as well.

This Will Change Their Lives Forever

In the end this experience will change their lives forever. People who have had a brush with death often are able to reevaluate their life trajectory and make positive decisions for themselves that they might not otherwise have done.

While the miners were trapped below the ground a Uruguayan rugby player who survived more than two months of isolation in the Andes with 15 others after a 1971-plane crash brought a message of hope for them. This survivor,

Jose Luis Incicarte
Jose Luis Inciarte said, “They are in the process of discovering the joy of being alive and the will to survive.”   I hope that this message and the good wishes for the miners from  people around the world will allow them to triumph over this traumatic experience.

When A Nanny Slaps a Child

A nanny tells her psychiatrist that she has slapped the 18 month old child under her care. A course of action for the therapist could include filing a report of child abuse, a Tarasoff warning to the family and an involuntary hospitalization of the patient if indicated. The possibilities of what could happen if the therapist did the above or some other action were discussed.

(Due to technical difficulties this blog was offline the previous week so therefore it will be run for an additional week)

A few years ago I heard about a resident who presented the following case to his psychotherapy supervisor. (I have changed some details for confidentiality):

Case History

The patient is a  22 year woman who is working as a nanny for a  prominent celebrity. She entered twice per week psychotherapy two months previously because of difficulty in relationships with men. She has just started to talk about how she was physically abused by her alcoholic stepmother as a child. During a recent session she appeared to be distracted and wasn’t her usual organized self. Near the end of the session she blurted out that she became very angry with the 18-month-old child that she cares for and slapped the child . She was scared she might have hurt the child but he seemed to be OK. The therapist was stunned and for the first time was at a loss for words. The patient changed the subject and spoke about another subject and then the time was up. Her parting words were that she was really glad that the therapist didn’t condemn her. She knew that she did the wrong thing with the child and will try not to do it again. She added that if the therapist had reprimanded her, she never would come back again. She feels she can trust the therapist and is now very hopeful about getting help in therapy.

What Would You Do?

Before you read further, I would like to suggest that you jot down on a piece of paper if there is anything that you think that the therapist should do. Then let us see if the discussion below changes or supports your approach.

Mandatory Reporting of Child Abuse

It is well known that the there is a bond of confidentiality between a patient and a physician which is recognized by the law. This also extends to other licensed therapists, clergy, and attorneys. Recognized confidentiality is the keystone of our ability to do psychotherapy. Patients understand that they can trust us with their deepest secrets.

In fact our patient was initially concerned about talking about her stepmother because she has a 17-year-old sister at home and she didn’t want any repercussions to occur to her stepmother who she feels has been good to her  despite the  episodes of abuse when she was younger.  Most people have awareness that a special court order by a judge is required for a doctor to turn over medical records without permission of the patient. There are situations where doctors have even refused to do so even after such a court order and have faced the consequences. In this particular case there is obviously no court order. However there are some other reasons that the psychiatrist might feel compelled to break his patient’s confidence.

In some states including New York where this patient was being treated, there is a law, which mandates physicians to report any known or suspected cases of child abuse. When such reports are filed, there would be a case file opened and an investigation is supposed to be immediately conducted. In such a case the parents who are obviously responsible for the child would be questioned to determine if they have put the child in any jeopardy. It would seem that in such a case the parents would be informed that a physician has reported suspected abuse and would obviously act accordingly.

The Tarasoff Rule

On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Both had been students at the University of California at Berkeley. They had met a year earlier and  Poddar became convinced they had a serious relationship. Tarasoff told him she was involved with other men and not interested. Poddar became depressed.He talked to a friend and was eventually convinced to go to student health. He started therapy with a psychologist on staff. During his his ninth session, Poddar confided to his therapist  that he was going to kill Tarasoff when she returned from summer break. The therapist subsequently informed the campus police that he felt Poddar was dangerous and that he should be hospitalized involuntarily. The police picked up Poddar, but after questioning felt he had “changed his attitude” and released him after he promised to stay away from Tarasoff. Poddar stopped thaerapy and later went to Tarasoff’s house and stabbed her to death with a kitchen knife. He then called the police and asked to be handcuffed. Her parents then sued the psychotherapist for failing to warn them or their daughter about the danger. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty to the woman because she was not his patient, holding that if a therapist determines or reasonably should have determined “that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger.” Many states including New York  followed California’s lead and now have expectations of a “duty to warn” potential victims. Under the Tarasoff Rule a therapist, therefore, does not incur any liability for breaking confidentiality to warn a victim who is in danger and is expected to do so.

Involuntary Hospitalization

If the patient were to have a serious mental illness such as severe depression with suicidal ideation or psychosis with command hallucinations, the psychiatrist could fairly  easily arrange an involuntary hospitalization for further evaluation and treatment. This apparently is not the situation in this case.

What Could Happen?

If the therapist attempted to do a Tarasoff warning, let us consider how this would work. First of call she would have to know how to reach the parent of the child to warn them. She wouldn’t necessarily have that information. In this case since the parent was a celebrity she might have some clues, but such attempted warning would no doubt involve some intermediary parties prior to speaking directly with the parents. This might involve publicizing the concern and the abuse, which might even end up in the media. This could embarrass the parents although one would think they would want to know. However, if the actual danger were exaggerated, then this could be creating bigger problems.

If the therapist were to submit a report of suspected abuse as mentioned, this would trigger an investigation, which would involve the parents. In the same way if the therapist had called the police and reported a potentially dangerous situation, the police would track down the nanny who could be caring for the child. They would have to take the child into protective custody until they located the parents  (who sometimes are out of town). Then they would turn the situation over to an agency which would investigate potential abuse.

As all the above were considered, the therapist also had to consider the strong possibility that any of above actions would most probably lead to the termination of therapy. In addition the patient who had resisted entering into psychotherapy in the past, would be further alienated from seeking help.  She would most probably obtain employment as a nanny in the future even if she didn’t have a letter of recommendation from her current employer. She interviews very well and actually had a letter of recommendation from a previous employers that would only show a two-month gap. She would then be in the same situation to potentially harm children with no one who would know about it. It is unlikely that there was sufficient evidence to support any charges being brought against the nanny that would lead to her being put in jail or hospitalized with a mental disorder.

On the other hand, the nanny could have seriously injured the child and there is an obligation to that child and any future children under her care.

What Did Happen?

The therapist ultimately decided with the assistance of the supervisor that she would not take immediate action which would lead to the patient leaving therapy and thus lose any chance of preventing this young women from abusing children in the future. During the next session two days later, she brought up the subject of her hitting the child. The patient said that she hadn’t done that again. The therapist said that she  was pleased about that but she shared the dilemma that that she would be obligated to warn the parents if she believed the child was in danger, as well as have to report abuse. She suggested that the nanny take a leave of absence for few weeks from her work which was easy to do since there were other nannies who also cared for this child . She was able to take on work which she had done before assisting elderly people where the patient had no inclinations for abuse. They agreed they would work on this problem and in the future they could decide when she was ready to return working with children. The patient was receptive to this idea and appreciated the concern of the therapist in wanting to help her and yet not get her into trouble, as well as understanding the legal and ethical obligations of the therapist.

Do You Have Any Comments On This Case

Your comments on this case are especially welcome since there is no easy answer here.