By Lynda McCullough

Psychiatrists walk a tightrope when a patient vocalizes thoughts or fantasies that might be interpreted as indicating a risk of harm to an outside party. The so-called "duty to warn" concept, while varying from state to state, may impose an obligation on the therapist, in some instances, to alert third parties to the risk of a patient's potential for aggressive acts. But what happens when the patient is a psychiatric resident in training analysis?

Eleven years ago, one psychiatrist seeing a potential sex offender found himself faced with having to make a decision about his duty to warn potential victims as well as his patient's residency program. Douglas Ingram, M.D., a clinical professor of psychiatry at New York Medical College and training supervisor at the Psychoanalytic Institute of the department of psychiatry and behavioral sciences at New York Medical College, was faced with this dilemma when an analysand told Ingram he had pedophilic fantasies. The analysand, Joseph DeMasi, M.D., was a resident in the child psychiatry program at the college. He also was studying psychoanalysis and was therefore required to undergo psychoanalysis. According to Ingram's deposition, DeMasi did not specifically describe any incidents or intents of acting on his pedophilia in the analysis.

Ingram, after consulting with other psychiatrists and some lawyers, discontinued the psychoanalysis, but continued to see DeMasi for psychotherapy. He did not reveal DeMasi's pedophilia to anyone.

In late September 1986 DeMasi was investigated for accusations of child molestation. He pleaded guilty to reduced charges stemming from molestation of a 10-year-old boy during a four-month rotation at Danbury Hospital in Connecticut and two boys unrelated to Danbury hospital. At that time DeMasi was stripped of his medical license and sentenced to five years in prison. The child and his parents, subsequently filed a suit against Ingram and New York Medical College, which is scheduled to come to trial in U.S. District Court in Bridgeport, Conn., in September. The lawsuit claims that Ingram and the college should have done more to prevent the abuse.

DeMasi began seeing Ingram in fall 1985 because DeMasi was required to undergo analysis to meet the requirements in the New York Medical College's division of psychoanalytic training. According to his deposition, Ingram terminated the analysis with DeMasi after the resident revealed his pedophilic thoughts in May 1986. Ingram said in his deposition that he discontinued the analysis because pedophilia that is not seen by the patient as a condition to be treated and psychoanalysis are incompatible. By mutual agreement, their psychotherapy sessions continued, and Ingram said in the deposition that his goal was to challenge DeMasi's thinking, manage his stress, and try to make sure he did not act on his desires.

Because of legal constraints, Ingram and the New York College of Medicine were not available for comment on the course of events and decisions made , but Ingram said in his deposition, "This was not something that could be reconciled and resolved in any easy way."

Psychiatrists struggling to protect both confidentiality of patients and the safety of potential victims know how difficult it can be to weigh the evidence and make a choice about which takes precedence at a given time.

Peter Gruenberg, past chair of APA's Ethics Committee, said of Ingram's case, "There is no clear ethical issue here-it's a muddy field. APA's code says to keep confidences unless you're obliged not to, and it says to protect society. These goals are in conflict."

The principle cited in California Supreme Court's Tarasoff decision may not apply to this case because DeMasi didn't inform Ingram of any specific intent or particular victims, said Gruenberg. If he had named potential victims, Ingram might have been legally bound to warn them. Paul Appelbaum, M.D., a member of APA's Commission on Judicial Action, noted that barring any naming of victims by patients, it is very difficult to evaluate another psychiatrist's decision.

"What we as a profession are interested in is, Did the psychiatrist go through an adequate evaluation process? How careful an evaluation did he do of the propensity to act? Maybe he found something that led him to believe these fantasies wouldn't be acted on," he said. Psychiatrists, Appelbaum continued, "have to gather information about patient impulses, past actions, and their likelihood of acting on these impulses in the future. Their predictions may be right or wrong."

If psychiatrists decide to breach confidentiality, he observed, they run the risk of aborting treatment, and the patient may be even more likely to hurt others.

Confidentiality and Training

The fact that DeMasi was in analysis with Ingram and a resident at the medical college where Ingram taught further complicates the question about the duty to warn versus the duty to protect confidentiality. According to Robert Pyles, M.D., president of the American Psychoanalytic Association, the association has an elaborate organizational structure in place to help people deal with these kinds of clinical problems. Training analysts (who analyze students), he said, first go through a careful selection process. Psychoanalytic candidates, who are also carefully screened, have several supervisors who oversee their work and analysis cases weekly. A progressions committee reviews candidates' academic work. Analysis of people in training is not ordinarily reviewed because of confidentiality issues, said Pyles, but a training analyst with concerns about an analysis can consult with a colleague or a committee set up for that purpose. The committee discusses options for action.

The American Psychoanalytic Association has an extensive code of ethics designed to govern the behavior of analysts and training analysts. "We are conscious of our responsibility to protect the public," said Pyles. "These situations are so difficult. The treater gets caught between wanting to help the patient overcome the problem and the option to end treatment. It's a tough call. The result may not be good, but there is a difference between a bad result and a bad decision. Sometimes there are no winners."

A past president of the American Psychoanalytic Society, Joseph Weisberg, M.D., said that he believes Ingram handled the situation well. "The candidate had a condition not treatable by psychoanalysis," he said. "The psychiatrist discontinued analysis and succeeded in advising him to withdraw from the psychoanalytic institute."

Thomas Gutheil, M.D., a professor of psychiatry at Harvard Medical School and codirector of the program in Psychiatry and the Law at Massachusetts Mental Health Center and Harvard Medical School, noted that there are large numbers of people in analysis who through describing dreams and fantasies share material they have no intention of acting on.

"In analysis, all perversities may be revealed," he said, "pedophilias, fantasies of all kinds. How are you supposed to decide whether it is likely that someone will act out fantasy material? If patients thought that analysts would see these as indication of behavior, no one would be in analysis. Analysts have to separate the wheat of action from the chaff of fantasy."

Faculty Influence

While the confidentiality issues raised for Ingram as an analyst raise one set of questions, those raised in the context of his role as faculty member in DeMasi's medical college constitute another. A resident in psychoanalysis is different from an ordinary patient, said Appelbaum. When an analyst is a faculty member of a medical school, the analyst's position then carries a responsibility to make some kind of decision about whether a resident is the kind of person to be practicing medicine, he said.

The issue raised, said Richard Ciccone, M.D., chair of APA's Commission on Judicial Action, is what is the obligation of the psychiatrist to the training program when treating a resident of that program? "The treating faculty member may well have to tell the program something. That information is essential to the well-being of the resident and to patients seen in the program. All of that would be made clearer if there was an understood policy for faculty member treaters."

Faculty members and resident patients need to be aware of the conflicting roles of faculty member and analyst, he said.

According to Gutheil, though, informing the medical school about an analysand/resident's pedophilic fantasies may not be an easy thing to do for many reasons.

"Great attention may be paid to due-process safeguards" at universities, he said. "Fundamental fairness demands that faculty members not abuse their power." Therefore, if Ingram were to raise concerns about DeMasi with the resident training director at the New York Medical College, DeMasi could have said, "You have no right to cast a blight on my career-those were only fantasies," said Gutheil. DeMasi could have sued Ingram for breach of confidentiality. It also would have been difficult to instigate probation without naming the reason, he added.

Like the American Psychoanalytic Association, a residency training program has a system for dealing with behavioral and ethics problems. The Psychiatry Residency Review Committee of the Accreditation Council of Graduate Medical Education requires that a residency program have a written set of due-process procedures. Faculty or residents bring such problems to the attention of the training director who will investigate by speaking with those involved in the situation. If necessary, disciplinary action up to and including dismissal is possible.

"If I found out that a resident was potentially dangerous to patients or the public, that person would be in trouble," said John Herman, M.D., director of the residency training program at McLean Hospital in Belmont, Mass. "Our mission is to produce well-trained and safe physicians. The foundation of medicine is to do no harm."

But, said Herman, there is a clear distinction between the training director talking to a faculty member and soliciting information from a resident's therapist. Echoing Gutheil's opinion, he noted that an analyst "can't do anything if the patient is not talking about actions but just about feelings."

The Law and Confidentiality

The lawsuit against Ingram, if it goes to trial, will take place in Connecticut, a state that has no specific Tarasoff statute. According to Howard Zonana, M.D., chair of APA's Task Force on Sexually Dangerous Offenders, the Connecticut Supreme Court has looked at whether psychiatrists have the duty to warn and determined that they did not when there was not an identifiable or readily identifiable class of victims. Connecticut law reads that "communications or records may be disclosed when the psychiatrist determines that there is substantial risk of imminent physical injury by the patient to himself or others."

It is important to remember, said Weisberg, that events with DeMasi occurred 12 years ago and that the "climate"-the laws, policies, and perspectives on confidentiality-has changed a great deal since that time. "Ten years ago there was not the awareness and concern about sexual assault and post-traumatic stress disorder stemming from it that there is now," he said. "Confidentiality was more highly valued then. It's not fair to judge his actions then based on the climate now. Ingram might behave differently now given the change in climate."

There are three layers involved in a case like this one that psychiatrists have to be aware of, said Gutheil. They must work on documentation and seek consultation, walk the balance between giving students a second chance and considering their future roles as practitioners, and work on coming to grips with the limits of control over patients' behavior.

"I recommend active consultation in situations where the risks are ambiguous and the limitations of confidentiality are unclear," he said.

APA could look at the issue of therapy in training when that therapy is strongly recommended or required by the training program to develop some model guidelines for obligations and responsibilities of the faculty member treaters, suggested Ciccone. But, as any psychiatrist knows, balancing the duty to warn with protecting confidentiality remains a complex issue with no easy answers. Determinations have to be made on a case-by-case basis.