One week after a 29-year-old psychologist hanged himself from a pipe in his Silver Spring basement, his widow contacted a lawyer.
Two months earlier, her husband had been released from a hospital after another suicide attempt, and his therapist had assured her that the effort was not a serious one. He was "just trying to manipulate" you, the woman quoted the therapist as saying.
The woman sued the therapist for negligence in D.C. Superior Court, and last month he agreed to pay her $75,000 to settle the case.
A decade ago the woman's response to her husband's suicide would have been almost unheard of; mental health professionals rarely were sued, and malpractice insurance was hardly a must. But that is no longer the case, as disgruntled patients, families of suicide victims and strangers who have been attacked by therapy patients are increasingly heading to the courthouse to complain.
One survey shows that the number of suits going to trial against therapists has doubled in the past two years and that judges and juries are making larger awards.
More important, therapists say, concern over liability has grown so great that a number of troubling changes have taken place in the treatment of patients. A number of therapists are recommending longer hospital stays, are refusing to treat violent or suicidal patients, and, in some cases, are ordering medical tests thought to be unnecessary in order to rule out physical problems.
They blame the rising tide of lawsuits on a mistaken belief that self-endangerment or violence against others can be predicted -- and prevented -- with the same degree of scientific accuracy as other medical complaints.
"It's affecting every facet of practice," said Anne Marie O'Keefe, a psychologist and lawyer formerly affiliated with the American Psychological Association. Added Carl Malmquist, a professor of social psychiatry at the University of Minnesota, "Psychiatrists are taking fewer and fewer risks."
Psychotherapists and lawyers say the turning point came in 1974 when the California Supreme Court issued a landmark ruling in the so-called Tarasoff case. Turning aside years of judicial protection, the court found in that case that a psychotherapist had a duty to warn a person in danger from a patient.
In that case, Prosenjit Poddar, a University of California student, told his psychologist that he might hurt or kill a student who had spurned him, Tatiana Tarasoff. The psychologist notified campus police that he thought Poddar was dangerous and should be detained. He did not warn Tarasoff.
Police held Poddar but released him after determining that he was not dangerous. Two months later, after he stabbed Tarasoff to death, her parents sued the psychologist for failing to warn them.
"Not too long afterwards, the case was heard about in other jurisdictions, and that's when we began to hear about other cases coming forward," said Paul Slawson, a professor of psychiatry at the University of California at Los Angeles and chairman of the American Psychiatric Association's risk management committee.
The court modified its ruling two years later to require psychotherapists to "exercise reasonable care to protect the foreseeable victim," but by then, psychotherapists say, the deluge had begun.
Since then, state and federal courts have broadened the potential liability of psychotherapists to victims unknown to the therapist or patient. Juries have returned verdicts against psychotherapists whose patients went on shooting rampages and caused car accidents. In Washington state, a public hospital was held liable when a patient who smoked the hallucinogenic drug PCP five days after being released from the hospital injured a woman in a car accident.
Suits involving suicide account for about a quarter of the complaints now, while those involving violent attacks make up the smallest percentage. Other complaints involve allegations about poor treatment and sexual abuse.
"It's had a fundamental chilling effect," said attorney John Karr, who has represented a number of psychotherapists, including the psychologist in the recent $75,000 settlement.
Attorneys for the plaintiffs in these suits, however, brush aside complaints that the increase in suits may have an adverse effect on therapy. They argue that therapists have been protected for far too long and should be just as accountable for their actions as other medical practitioners.
People who enter therapy "are most often upper-middle-class people who have a strong support structure and family members who care, who have a lot of access to medical care and go out of their way to try to get it," said John E. Turner, lawyer for the family of a 28-year-old woman who placed her head on a Metro track to die four years ago, shortly after being released from a Washington psychiatric ward. The psychiatrist in that case agreed to pay $32,000 to the woman's daughter as part of a court settlement.
"These cases have an immediate appeal to a jury," said psychiatrist Slawson, who blames a significant portion of the litigation on families looking for a scapegoat to explain a particularly embarrassing death.
"You have a patient who dies and a family who says, 'We brought this person to the hospital and to you because we knew he was suicidal, but you let us down. You let him kill himself,' " Slawson said.
In another case recently filed in Superior Court, the family of a successful transportation lawyer argued that his treating psychoanalyst and Sibley Hospital acted negligently when they allowed the man to leave the hospital on an unsupervised pass after he expressed suicidal thoughts. The man went home and asphyxiated himself. He had been seeing his psychoanalyst four times a week for 10 years.
"People look at doctors as those who are skillful and adept and knowledgeable," Turner said, "and when the family members do everything doctors ask them to do and this is nonetheless the outcome, they feel like in this day and age that someone ought to have been able to prevent this person from taking their own life."
There are no exact figures on the number of suits filed nationwide against psychotherapists, but Slawson said his studies of the Los Angeles area show that about one out of every 20 psychiatrists can expect to be sued in a year, compared with about one in 100 in 1970. Although the figure is still lower than the 8 percent frequency rate for the general medical doctor, Slawson said, "it's enough to make you worried."
"Twenty to 30 years ago, a lot of psychiatrists didn't even bother with insurance," Slawson said, noting that on average, cases, including those with large settlements and those with none, cost about $65,000.
Therapists say their biggest concern with these suits is that it is almost impossible to predict with any accuracy when a person is going to commit suicide or hurt someone else, a position vigorously supported by the American Psychiatric Association. Although suicide prevention has received much attention recently, the suicide rate has remained relatively constant for 20 years.
"You can certainly intervene in the short run. But it is fair to say if a patient is truly suicidal and they really want to end their life, there is a great likelihood that they are going to be able to do that," Slawson said.
The therapist who treated the 29-year-old psychologist blamed his client's suicide on a number of aggravating circumstances, including the fact that his wife left him for a day shortly before his suicide. According to his attorney, John Karr, the therapist believed that he had done nothing wrong but settled the suit to avoid the possibility of a large jury verdict.
Many therapists say they are most concerned that the increase in litigation eventually will erase many of the recent advances made in mental health care and could result in patients who need treatment the most getting it the least. Already, they say, some therapists are seeking involuntary commitments for patients in questionable cases and keeping them in institutions longer or refusing to treat patients who suggest suicidal tendencies or dangerous behavior.
Other therapists, said psychologist and lawyer O'Keefe, feel compelled to read patients their "Miranda" rights, a practice that O'Keefe says breaks down the necessary doctor-patient trust and may result in a dangerous patient failing to return for treatment. As a result, some therapists believe the most dangerous patients may not seek help.
"Somebody can make 10 gestures in 10 years and then finally in the 11th year they are successful," said psychiatrist Malmquist. "In the old days, when we committed people for a longer period of time, you might commit the person for 20 years after that first attempt. But we've gotten away from that kind of policy . . . .
"The question now," Malmquist continued, "is whether we assume a higher risk or revert back to institutionalizing more and more patients. I fear that's what's happening. You can't have your cake and eat it too."