My phone rang a few weeks ago with an anxious colleague seeking help. It seems he has recently been evaluating someone who lends new meaning to the words "nightmare patient." For shortly after beginning treatment, the patient disclosed that last year he had planned then murdered his roommate. Though questioned by police, he was never charged. Yes, he has killed before—several times in fact—and has never been charged. To make matters even more therapeutically sticky, he committed his last homicide when he was depressed.

Who can blame this poor soul from wetting his pants every time he thinks of patient XYY? He went on to relate that he wanted to find a way to tell the police about this individual, and just wash his hands of him. Wouldn't many have the same reaction to someone so cold and remorseless as the patient he described?

Current medical thinking pans the benefits mental health treatment can offer the scariest of criminals. The recommendation is, essentially, to get the hell away from them, or else become entangled in their web of deceit, manipulation, exploitation, and worse, destruction. What do we then tell the family of XYY's next victim?

Usually, psychiatry encounters sociopaths and psychopaths already behind bars, and the focus is on criminal charges, competency, release, and evaluation for future risk. But what about those as yet untethered to the criminal justice system? Isolated as we would expect a person to be who views human integrity and life as trivial, he drifts from event to event. And a monster on the loose, unincorporated into society, still suffers from the same day to day stresses that in the past he has always solved his way.

Maybe psychopaths don't have major depression. Maybe sexual sadists are really all about control and appetite. Nevertheless, we do understand that suicide and other life altering choices are triggered by stresses, changes, and how people respond to them. For many patients with a history of poor connection to others but otherwise no criminal background, skilled psychotherapists will endorse the benefit of having a healthy ego available to the patient who still exercises decision making before he succumbs to ill-advised impulses. Why not apply the same philosophy to the scary among us?

Many reasons. First of all, no doctor who appreciates the sensitivity of the relationship between doctor and patient wants to end up in the drum next to Jimmy Hoffa because he said something a little too provocative in last Tuesday's session. Occasionally they still talk about the psychiatrist who one day disappeared without a trace from the forensic unit at Bellevue.

Safety and confidentiality are a precarious balance. It's hard not to feel a sense of community responsibility when dealing with a predator who has heretofore escaped justice. But if no actual threat exists, and there is no identifiable victim, then the therapist must swallow that horrified feeling about the patient, or deftly deal with it in his own therapy, or otherwise with a patient who is obviously not known for his mature handling of anyone's feelings.

And then, money. While crime bosses in popular movies can afford to see a therapist even more frequently than Woody Allen, the fringe drifter, erstwhile ex-con, with undeveloped gainful employment skills, simply cannot afford the price tag of the ably qualified psychoanalytic behavioral surgeon.

The result? No doctor except one possessed with anything but passive suicidal ideation will extend a finger to reach that healthy island in the lost province of evil. Are the consequences real? One of our subscribers recently told me of a patient he evaluated, a serial sex murderer denied coverage by his insurance company. Some time later, the therapist learned a body had been discovered in that city of brotherly love, mutilated in a fashion matching the modus operandi of his patient. Could this outcome have been prevented?

Possibly. But a solution requires, first of all, a special collaboration between the Department of Justice and organized mental health. There should be DOJ sponsorship of psychoanalytic institutes specifically earmarked for training experienced and otherwise specially qualified doctors in the treatment of the dangerous personality disordered.

Then, a standard protocol for treating such patients should be adopted. It should mandate that if a therapist learns that a patient has committed a violent crime which he has not yet been convicted of, he can disclose that information to a databank which can be accessed by law enforcement but only if that doctor is later assaulted, kidnapped, or killed. The patient must agree to this as part of a standard treatment contract.

Next, the therapist must be afforded third-party liability immunity, so that if a non-identifiable victim is harmed because treatment did not "work" the relatives cannot turn around and blame the psychiatrist who was willing to try to defuse the time-bomb.

Then, the DOJ should subsidize such psychiatrists with the trappings of security so the doctor can proceed more confidently across the high wire. If we can provide motorcades to emissaries from eighth world countries who view machete slaughter as a form of diplomacy, surely we can subsidize brave professionals we seek to cultivate by the installation of metal detectors, providing secure facilities, and protecting people's families.

Next, we need to subsidize treatment of the most dangerous, or better yet, order insurance companies to do so when eligibility is approved by the Department of Justice. No names need be released. This will encourage doctors to handle these "hot potatoes" out of more than civic-mindedness. This in turn will promote academic interest in the field.

If anyone thinks Megan's Law community notification protects the community, he is oblivious to the freedom we all enjoy to simply get in the car, drive five hundred miles, commit a crime, and drive five hundred miles back. We already know there are beasts in our midst; what we need to do is keep them tame. Until America wakes up to the public safety and long term cost benefits of DOJ-psychiatry collaboration, you analyze...your neighbor.