Mr. Z, age 38, came to the United States from a predominantly Islamic country to study science and engineering. While in graduate school, he was seen by a primary care physician for complaints of hypersomnia; reduced appetite with an approximate 15-lb weight loss; impaired concentration and memory, which hurt his academic performance; low energy; and occasional thoughts about dying.
Mr. Z’s physical examination and lab results were unremarkable, and he reported no psychiatric history. He was diagnosed with depression and was prescribed sertraline, 50 mg/d, but he refused to take it. He declined referral to a psychiatrist but agreed to weekly psychotherapy with a psychology intern at the student mental health center.
During therapy, Mr. Z said he constantly felt lonely. He feared being ostracized because of his Islamic beliefs and lifestyle, yet reported tremendous guilt over violating Islamic codes forbidding premarital sex. He told his therapist that his longing for a romantic relationship was “contaminating” his soul, and fantasized that death would free him of impure, sexual thoughts.
The severity of Mr. Z’s depression and his preoccupation with death alarmed the therapist. She referred him to a clinic psychiatrist, but Mr. Z refused to see him, saying that his depression was a punishment from God for his sexual sins. He vowed to repent by undergoing psychotherapy.
Continued therapy: A ‘religious awakening’
During the first 4 months of therapy, Mr. Z’s Beck Depression Inventory score fell from 32 to 17, indicating mild depression.
Mr. Z then reported that he experienced a “religious awakening” and began describing his mood and experiences in religious terms. He thanked his therapist for “saving his soul.”
The therapist was stunned by Mr. Z’s sudden transformation in mood and affect. He slept 7 to 8 hours a night, and his academic performance improved dramatically. He exhibited stable (though bright) affect and no thought disorder. His therapist viewed his use of religious terminology, though significant, as a cultural artifact because there were no signs of psychosis. Although no objective signs of mania or hypomania were apparent, the therapist suspected he might have bipolar disorder. She again tried unsuccessfully to refer him to a psychiatrist.
Then came Sept. 11, 2001.
Mr. Z was traumatized by the terrorist attacks on the World Trade Center and the Pentagon. He feared a backlash against Muslims in the United States but showed no signs of paranoia.
A few months later, however, Mr. Z became preoccupied with the attacks and harbored conspiracy theories alleging that the United States government had committed them. His speech was rapid and pressured, and he slept only 2 to 3 hours nightly. We later learned that he had not attended class for months and only sporadically showed up for lab work.
Mr. Z then began to fear he was under surveillance and that his visa would be revoked. His affect became increasingly intense during psychotherapy, and he frequently used religious metaphors and concepts. His therapist realized he was suffering a worsening manic episode, although suicidal or homicidal thoughts were not present.
Down with ‘nonbelievers’
During a subsequent session, Mr. Z reported that he had become engaged to marry a well-known supermodel. He also announced a plan to “rid the world of nonbelievers”—people who were not devout Christians, Jews, or Muslims. His three-stage plan called for:
- gently persuading nonbelievers to change their beliefs and lifestyles
- threatening nonbelievers who did not repent after polite persuasion
- “eliminating all the nonbelievers” who did not respond to intimidation.
Mr. Z viewed his therapist as “commander of the believers” and considered the three-phased plan to be her will. She questioned Mr. Z extensively about how, when, and against whom he intended to carry out this plan. He identified no specific targets, but did say, “I’ll know what do to when the time comes. I am an engineer, and I know a lot about explosives.”
The therapist then recommended an emergency psychiatric evaluation, which Mr. Z declined. She immediately notified the mental health clinic’s attending psychiatrist.
What are the therapist’s options? Can Mr. Z be involuntarily committed based on his threats of violence against “nonbelievers?”
Dr. Kennedy’s and Dr. Klafter’s observations
Two legal principles justify involuntary commitment of a patient who poses a threat to himself or the public:
Police power refers to the government’s role in maintaining public safety. State commitment statutes usually require that a mentally ill person pose a significant and imminent threat to the public. The psychiatrist who files an affidavit alleging danger does not need absolute certainty or perfect information but must act in good faith.1