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January 2013 -- Minnesota
DANGEROUS CLIENTS & THE THREAT OF VIOLENCE
Gary R. Schoener*
A Wisconsin Case
In their 4 PM appointment, an experienced psychologist was listening to his client escalate into angrier and angrier talk. He was sounding violent. The man had a history of violence, but had been on medications for years. Once his family took on the duty of monitoring his medication compliance, there had been no more trouble with angry outbursts. But something had changed. The psychologist began thinking about the “duty to warn” standards.
This was a major mistake. The man suddenly arose, taking the psychologist by surprise, and began to strangle him. After a terrible fight, both were knocked out. The psychologist awoke first, called 911, and the police came. Finding that the client was dead, they held the traumatized psychologist at gunpoint and transferred him under guard to a hospital to get care for his 37 stab wounds (from a letter opener which was on the desk). The prosecutor then spent months whether to charge the psychologist with murder.
In the meantime, the psychologist was further traumatized when his life was threatened by the deceased client’s sons who vowed to kill him. Things shifted when the autopsy revealed no trace of medications in the blood stream of the client. Apparently the medication monitoring had either stopped or been ineffective. The psychologist has severe PTSD and is disabled in terms of any work with clients. He moved to another state. His advice is:
Remember that in such a situation knowing the legal standards for
“duty to warn” is far less important than self - protection. You are the
closest potential victim. Worry about yourself – not “third parties.”
Following this advice, let us start with the issue as to your own safety or that of any supervisees. First rule is to not worry about legal standards for third-party warnings or other secondary issues. Focus on your vulnerability and your safety first.
*Gary R. Schoener, M.Eq., Licensed Psychologist (Minn.), Director of Consultation & Training, Walk-In Counseling Center, 2421 Chicago Ave. S., Mpls., MN. 55404 email@example.com This is not meant to be legal or clinical advice for a given situation.
(1) Have a policy in your office about signaling emergencies, and that staff are authorized to call into an office during a session or to interrupt with a knock on the door if they hear anything which is worrisome in terms of safety;
(2) Remember that you can break the client’s angry “set” any number of ways. For example, you can suddenly say something like, “Oh, my goodness, I forgot to tell my receptionist that….” and pick up the phone and call someone.
(3) You can exit the office under a similar pretext or with “I’m terribly sorry, but I have to run to the bathroom …… I’ll be right back ….. please excuse me but nature calls….”
(4) Try to not have potential weapons in sight – scissors, letter openers, etc. should be in drawers;
(5) The best seating arrangement is one where you can go to the door without tripping over the client. It is also good for them to be able to exit easily and neither should be “trapped”
WHEN YOU ARE THE TARGET OF STALKING OR ASSAULT BY A CLIENT
A random sample of university counseling center in the U.S. found that 64% of the staff had experienced harassment from a current or former client. (Romans, Hays & White, 1996). Other studies have found high numbers of professionals who have been threatened or attacked, with physical assaults more likely in hospitals and clinics than in private practices.
A literature review regarding psychiatrists found that more than 1/3 had been assaulted at least once, and that 72 to 96% of psychiatric residents have been verbally threatened while 36 to 56% had experienced physical assaults. (Anonius et. al., 2010).
A study of psychiatric residents received 570 responses – 349 women and 221 men. This group reported 327 face-to-face verbal assaults, 113 incidents of physical assault, 106 harassing phone calls, and three sexual assaults by patients. Respondents were asked if they reported the incident, and 68.1% reported it to the immediate attending physician, 51% to another resident, and/or to other staff at the site (50.7%). (Moran, 2009)
The Canadian Broadcasting Company, in a story on 12 March 2010, reported on a study published in Canadian Family Physician of randomly selected family physicians in Canada. Of the 774 (of 3,802 surveyed) who responded, 98% reported that they had experienced at least one incident of “minor” abuse and 75% reported “major” abuse (sexually harassed or physically threatened). Nearly 40% reported having had at least one incident of “severe” abuse such as a physical attack with injury, sexual assault, or stalking.
In March of 2010 the U.S. Dept. of Justice, Bureau of Justice Statistics, released a Special Report entitled Workplace Violence, 1993 – 2009. It revealed heartening statistics showing that from 2002 to 2009 the rate of nonfatal workplace violence declined by 35%, which followed a 62% decline between 1993 and 2002. Workplace homicides declined by 51% from 1993 to 2009. While bartenders and law enforcement officers top the list, mental health is nearly double the rate for transportation workers (bus, cab drivers). Mental health professionals have a rate of 17 per 1,000, with a rate of 20.5 across all mental health workers. Medical workers, by contrast, are at 6.5 per 1,000, with physicians at 10.1 and nurses at 8.1.
An archival study of former hospital inpatients who engage in post-discharge stalking found that the duration was short-term, generally only a few weeks. Such patients were more likely to have a history of fear-inducing or assaultive behavior pre-admission, and were more likely to have personality disorders or a paranoid disorder with erotomanic features. They are more likely male. (Sandberg, McNeil, Binder, 1998) Other research has shown that assaultiveness by certain groups such as schizophrenics is no higher than the general population if you control for alcohol & drug use. Drinkers are far more likely to actually assault.
There are some excellent resources on the internet – Psychologist Ken Pope’s website has a section devoted to this issue – http://kspope.com/stalking.php I would highly recommend Mullen, Pathe, & Purcell (2008) -- Stalkers and Their Victims. Forensic psychiatrist Robert Simon (2011) has done a good summary of this issue entitled “Patient violence against health care professionals (Psychiatric Times, 3 March 2011) which can be found on the internet.
When counseling professionals seek police assistance, 100% report it is helpful. When they talk with colleagues, only 60% do. What do we do wrong when a colleague tells us about stalking or harassment by a client?
A study of the stalking of psychologists by their clients (Gentile et. al., 2002) found that there is no specific profile for those who had been stalked; But, afterwards they did employ more safety measures
For drug abuse evaluation or treatment programs, there is an authorization [section 2.12(c) (5) of the federal rules] to contact a law enforcement agency when a client has committed or threatened a crime on program premises or against program personnel. However, disclosure is limited to: (1) suspect's name & address; (2) last known whereabouts; (3) the fact that he/she is a client of the program. Otherwise, in general, remember these key rules:
(1) Stalking and harassment are generally not confidential -- only how you know the identity of the client & the fact that they are a client are confidential;
(2) Obtain consultation & document it;
(3) Document all incidents in an administrative file – the client file should only contain a note that stalking or harassment have occurred;
(4) Follow directions of law enforcement & other experts;
(5) With consultative help, attempt to get the behavior to stop via:
(a) Direct request by the supervisee;
(b) Administrative demand by supervisor or agency director;
(c) Cease & Desist Letter from an attorney or prosecutor;
(d) Police intervention.
(6) Get help and support – being a victim can have very troubling consequences including PTSD, wanting to leave the field, etc.
DUTIES TO THIRD PARTIES WHO ARE AT RISK OF VIOLENCE
As professionals, as colleagues of other professionals, and as consultants and supervisors we may encounter all sorts of situations in which there is a question of dangerousness of a client towards others. In examining the list below you will note what a wide variety of situations exist in which the dangerousness of the client is an issue:
(1) Ongoing dangerous situations, such as ones involving family violence;
(2) Clients who are antisocial and involved in criminal acts or a violent lifestyle;
(3) Client who talk violently but have no history of violent actions;
(4) Situations in which the client is talking violently and may be going psychotic;
(5) Situations in which the client is talking about engaging in reckless conduct which could endanger others, or where a murder/suicide seems possible;
(6) Situations in which the client is not handling stress well and is in a job, such as that of a police officer, where violence could easily occur;
(7) Situations in which the client threatens to harm a class or group of people (e.g. I'm going to kill rich people in the suburbs…);
(8) Situations in which the client threatens a person who may not exist (e.g. I think my wife is having an affair and if I find out who it is I'll kill him...");
(9) Situations in which the client threatens to harm a specific identifiable person, but that person is present during the meeting and is aware of the threat;
(10) Situations like (9) where the potential victim does not know of the threat.
Other situations, all of which can involve scenarios like the ones above, but where this issue is anger or violence potential aimed at you or your colleagues. For example:
(11) Client is making threats towards a colleague with whom you already have a release to communicate. Where you will not have to breach privacy.
(12) Client is becoming increasingly angry at your or one of your staff and the atmosphere has become violent.
(13) Client is actually threatening you or your family, or during a session has become violent.
RESPONSIBILITIES TO PROTECT PERSONS OTHER THAN YOUR CLIENT
Long before the Tarasoff case it was known that professionals had duties to protect others which supersede their duties of confidentiality owed to their client (e.g. situations involving a accident due to impaired driving, or a direct assault by a person following discharge from a hospital).
Certainly most of us would acknowledge a moral duty to preserve life, and few would argue that the client’s privacy is more important than the life of another person. This might relate to whether the principle of justice (welfare of persons other than your client) is more important than the principle of autonomy (your client's right) in a given situation. However:
(1) Health care professionals cannot reliably predict violence. In fact, the standards for action typically apply when you believe that you have received a serious threat of harm. Typical “duty to warn” statutes do not have standards for assessing risk – just that the professional has come to a conclusion the situation is dangerous.
(2) Secondly, the focus of all the attention is not that one undertakes a professional intervention – it is that one contacts either an intended victim or law enforcement or both – a lay solution. This is not a professional technique or method.
Any examination of a situation in which there is potential for violence may include both the use of professional tools to attempt to help, and also the fact that one may contact the police or a potential victim. Most situations involving potential violence will be dealt with through professional means and tools – not a warning to the police or an intended victim.
The most common complaint or suit involves the individual, or their heirs, who were harmed by the client who was dangerous. On the horizon may be claims by those who are harmed by the client in some sort of a rampage or attack on an institution (e.g. a school). From a purely “risk-management” standpoint, one would err on the side of warning.
However, in the original Tarasoff case, described later, it can be argued that Ms. Tarasoff is dead because the therapist did call the police, driving the eventual assailant out of therapy. So, for the goal of helping the potential assailant, professional interventions may be better. It is possible that your warning could lead to a confrontation in which the angry client is injured or killed.
Breaking confidentiality carries some risks with it and the professional who violates confidentiality (1) without considering less drastic methods, or (2) when the matter is not urgent, risks being sued for any harm caused. The case of psychologist Anthony Stone in DeKalb Co., Georgia, is such an example. In 1999 a police officer won a $ 280,000 judgment after he lost his job as a result of Dr. Stone contacting his employer about his volatility. The treating psychiatrist did not believe it was that urgent and it was noted that Dr. Stone could have first discussed it with the officer and explored clinical options.
CLINICAL ISSUES WITH DANGEROUSNESS
There are factors which have been associated with client dangerousness. A substantial number of instances involving violence have involved teenagers who are excluded and ridiculed or teased by others. Dealing with the abuse of students by other students is an important prevention. It should be noted that while media accounts often focus on this, as they did with the Columbine High School case, this may be not accurate. It was not with Columbine. (Cullen, 2009)
Some who have exploded in violence have given some indication in writings, posting on the internet, etc. If anything we have good reason to “play it safe” and follow-up on such threats and/or statements of despondency. However, murder-suicides, such those at Virginia Tech, Aurora Colorado, and Sandy Hook all involved persons who were troubled but where there is no evidence of any specific warning of the acts they committed.
Although research has focused on static factors (Elbogen et. al., 2005; Harris et. al, 2004) which predict violence, in recent years there has also been an interest in the role of various medications (Swanson et. al., 2004) and treatments in terms of reducing potential for violence. Some of this has focused on the role of drug abuse and medication non-compliance (Swartz et. al., 1998), or even issues with specific subsets of clients such as schizophrenics (Swanson et. al., 2006).
More recently there has been a study of treatment engagement and the client’s perception of treatment effectiveness and the impact on violence in the community (Elbogen et. al., 2006). The degree to which the client believes he/she needs treatment, and is getting it, and the degree of engagement in treatment are all factors which seem to correlate with less violence. .
With the focus on duty to warn and protect, it is easy to forget that our major tools are helping the client and that bringing the police in or breaching privacy has a terrible down-side in that it can undermine the ability to maintain a treatment relationship.
QUESTIONS & APPROACHS TO THIS CHALLENGING PROBLEM.
THE TARASOFF CASE
In the fall of 1967 Prosenjit Poddar came from India to attend the U. of Calif. at Berkeley. The following fall he met and fell in love with Tatiana (aka Tanya) Tarasoff whom he met at folk dancing classes. He asked for a date but she said "no." Her rebuff helped trigger a severe emotional crisis -- he was depressed, weepy, and withdrawn. His friends were concerned
Poddar’s emotional adjustment reportedly improved during the summer of 1969 when Tanya went to Brazil, and friends convinced him to seek counseling. He sought treatment at Cowell Memorial Hospital, an affiliate of the U. of Calif. at Berkeley, and after seeing a psychiatrist for intake began therapy with a psychologist, Dr. Lawrence Moore.
During a therapy session on Aug. 18, 1969 he told Dr. Moore that he intended to kill Tanya when she returned from Brazil. Two days later Dr. Moore consulted with Drs. Gold and Yandell, psychiatrists, and they agreed that Poddar should be involuntarily committed. (This occurred only two months after the passage of the commitment law and both law enforcement and mental health professionals were inexperienced in its use.)
Dr. Moore asked the campus police to pick up Poddar, and followed up with a letter indicating that he was undergoing an acute and severe paranoid schizophrenic reaction and that he was a danger to others. The campus police detained Poddar but did not commit him, judging that he appeared rational and given the fact that he promised to avoid Tanya. The director of the psychiatry department asked the police to return Dr. Moore's letter, ordered that the case notes be destroyed, and ordered that no more attempts be made to commit Poddar.
Tanya returned home, unaware of any potential danger from Poddar. Poddar, meanwhile, had convinced Tanya's brother to share an apartment with him -- only a block from Tanya's residence. On Oct. 17, 1969, Poddar went to her house to speak with her, but she refused. He became insistent and she screamed, at which point he shot her with a pellet gun. She attempted to flee but he caught her and repeatedly stabbed her with a kitchen knife, killing her. He then returned to the house and called the police.
In his trial, Poddar used an insanity defense but was convicted of second degree murder. However, the verdict was reversed on appeal based on an error by the judge in his jury instructions. Poddar was released and returned to India. Forensic psychiatrist Alan Stone (1976) reported that Poddar claimed in a letter to be happily married after his return to India.
The Tarasoff family sued, arguing that the professionals had failed in two duties: (1) duty to commit and (2) duty to warn Tanya. The California Supreme Court issued an opinion in 1974, but reviewed its own decision and issued a second one in 1976 which superseded the first. This is often called Tarasoff II and it is the definitive ruling. The defendants were exonerated on the commitment issue, but found to have failed in a duty to warn her of the danger.
VandeCreek & Knapp (2001) note that such a duty was not new in tort law, citing earlier cases against psychiatric hospitals. A number of these dealt with things such as failing to warn patients being discharged that the medications they were prescribed would not mix well with alcohol. The patient in such cases then went out, drank, and had a car accident. However, Tarasoff extended this duty to outpatient care. Brooks (2005) discusses its application in substance abuse programs where different rules apply due to federal rules & statutes.
Nearly half of the states have enacted statutes which define the responsibilities of professionals for potential dangerous acts by their clients towards third parties. Chapter 380 of Minnesota Statutes went into effect on August 1, 1986. This statute created a duty to warn of or take reasonable precautions to provide protection from violent behavior threatened by a psychotherapy client. The original law covered psychologists, school psychologists, nurses, chemical dependency counselors, and social workers who are licensed or who performed psychotherapy within a program licensed or established in connection with a state statute.
However, although this statute referred to a number of professions, it was actually part of the Psychology licensure law. In 1996, as part of a "housecleaning bill" from the Board of Psychology, a change was made limiting the application of this section to licensed psychologists. This left some ambiguity as to the nature of the duty for other professionals.
In 2001, as a result of an effort by the Minnesota Chapter of NASW, the Minnesota legislature passed and the governor signed a bill into law Minnesota Statutes 2000, Section 148B.281 to include social work licensees and their clients in section 148.975. So, as of 1 August 2001, both social workers and psychologists have the same protection, although other mental health professionals do not.
Psychologists and social workers (as of 2001) are also protected against any cause of action arising out of their good faith efforts to discharge this duty. The law specifically protects them from liability for "disclosing confidences to third parties", and other liabilities such as if your warning an intended victim resulted in that person doing harm to your client. Other counseling professionals would have a good defense in such cases, but not the statutory protection.
So, for psychologists and social workers licensed in Minnesota, or other Minnesota - licensed professionals seeking some guidance, the basics of the current Minnesota Statute are presented in the box below.
The threat must be:
(1) a serious specific threat of harm.
(2) against a specific, clearly identified victim
When in the professional’s opinion both of the above conditions are present,
the duty is to make reasonable efforts to communicate the threat to:
(1) the potential victim, or
(2) if unable to make contact with the potential victim, to the law enforcement agency closest to the potential victim or the threatening client.
OTHER CASE LAW SINCE TARASOFF
Nationally, by the beginning of this millennium the Tarasoff case had been cited in more than 500 published legal cases. Decisions related to the "duty to warn or protect" have ranged widely, with some courts finding such a duty, some extending it beyond Tarasoff, and some not finding it or limiting it to certain circumstances. Courts in Mississippi and Florida have rejected or significantly limited the doctrine. (Hubbard, 2007)
Some limitations have included situations in which only non-specific threats were made, where the intended victim was not specific, where the potential victims could not be foreseen, where the potential victim had pre-existing knowledge of the potential danger, etc. Some decisions have limited those to whom a duty was attributed, holding for example that a school board, teachers, members of a child study team, or parole officers did not have such a duty.
The case which established privilege in federal courts, Jaffee v. Redmond (116 S. Ct. 1923 1996) has a footnote allowing for an exception to privilege if a serious threat of harm to the patient or to others can be averted only by means of a disclosure by the therapist. At least one legal scholar predicted that the application of Tarasoff will likely expand to cases where the third party is a pedophile with the potential to commit a sexual offense (Perlin, 1999).
At present, the issue as to whether a particular professional has a duty to warn or protect a third party from harm by a client, and whether this duty overrides confidentiality, is quite unsettled nationally. As an illustration, two cases are worthy of note. In Thapar v. Zezulka (994 S.W. 2nd 635 -- Texas Sup. Ct. 1999) the Texas Supreme Court declined to impose a duty on mental health professionals to warn third parties of threats of violence because it would conflict with therapist-patient privilege. The court allowed for therapists to use their discretion to breach the privilege if circumstances warrant. [The case involved a psychiatrist who had allegedly failed to warn a man's stepfather that during a psychiatric hospitalization the man had made a threat to kill him -- a threat carried out a month later.] So, a psychotherapist in Texas can breach confidentiality to warn, but does NOT have a common law duty to do so.
However, the Delaware Supreme Court in Bright v. Delaware, Del. Sup. Ct., (1999WL 403607, June 15, 1999) ruled that in Delaware there WAS a common law duty of a mental health care provider to persons other than the patient involving a duty to warn potential victims when they know their client is a danger to others. [The case involved the appeal of a conviction for attempted murder and terroristic threats where the defense had argued that the trial court had erred in admitting the psychiatrist's testimony in violation of the psychotherapist-patient privilege. The psychiatrist had notified the man's wife and the police after he cancelled an appointment and told her that he was going to carry out his plans to murder his former wife.]
A stir was created by a decision by the California Court of Appeals in Ewing v. Goldstein (2004), Cal.App.4th [No. B 163112.Second Dist., Div. Eight, Jul. 16, 2004]. This decision reversed a lower court’s rejection of a claim based on a marriage and family therapist having received a communication from the patient’s father – not the patient – that indicated that he might pose a danger to his former girlfriend’s new boyfriend. The therapist, Dr. Goldstein, had helped get the client hospitalized due to suicide threat, and then based on input from the father tried to dissuade a psychiatrist from discharging him from the hospital.
The murder occurred the day after the discharge. Dr. Goldstein had not known the surname of the victim, and the client had not directly revealed the threat to him, but it was argued that he should have contacted the police. Note that the issue was that the trial court was deemed to have too narrowly defined “communication from a patient” and that the appellate court believed that this might include the information from the father. Thus there is a “triable issue” and the case was sent back for trial. This does not mean that a court will actually find liability.
It should be noted that the Minnesota Statute, which is discussed in a previous section, is clear that the communication can be from the client or someone like a family member, so such a dispute should not arise in a Minnesota case. This is also a reminder that legal responses to what a therapist does will vary state to state based on differences in case law and statutes.
DANGEROUSNESS AND CIVIL COMMITMENT
The issue of dangerousness can be examined from the perspective of civil commitment standards. One option for addressing dangerousness is civil commitment. In fact, the Tarasoff case, as noted earlier, grew out of a failure to properly execute an emergency civil commitment. The original suit filed by the Tarasoff family alleged a failure to commit, but the court ruled that there was no such course of action. Although it is not required, civil commitment is a commonly used tool when a client is deemed to be dangerous and have a likelihood of violence. “Danger to self or others” is the universal requirement for an involuntary detention or commitment.
In Schuster v. Altenberg, the Wisconsin Supreme Court allowed for the possibility that a therapist could be held accountable in a professional negligence action if it could be established that the client was a “proper subject for involuntary commitment under the statutory standards…” The issue is not some “duty” to seek commitment, but that this is recognized tool that might be useful in a given situation. It would appear that actions of any professional will be judged based on a weighing of the alternatives.
PROFESSIONAL ETHICS CODES
Some professional codes of ethics have sections which pertain to the duty to warn or protect. The American Bar Association, at its 2001 Convention, voted that this duty can trump lawyer-client privilege. Many codes refer vaguely to complying with the law or legal mandates. It is unclear whether this is intended to refer to case law as well as statutes.
The Ethical Principles of Psychologists and Code of Conduct of the American Psychological Assn. (2002 Revision, effective June 1, 2003) indicates in section 4.05 Disclosures that:
4.05(a) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose, such as... (3) to protect the client/patient, psychologist, or others from harm...
This wording has shifted from the 1992 code to specifically list the psychologist’s protection, even though in the previous code the psychologist could be assumed to be one of the “others.” The word “or” which used to stand between “permitted by law” and “a valid purpose” is dropped. The new language appears to focus more attention on whether it is required or permitted by law, although still asks that the psychologist consider this a “valid purpose.”
Licensure Boards in Iowa, North Dakota, and South Dakota use the American Counseling Association (ACA) Code of Ethics, but Illinois, Minnesota, and Wisconsin do not. However, such a code would be used as a point of reference in any state. The 2005 Revision of the ACA Code of Ethics and Standards of Practice indicates in section B.2. Exceptions, that:
B.2.a. Danger & Legal Requirements. The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception.
The previous ACA code utilized the terms “clear and imminent danger” and the revision committee believed that the new language broadened this slightly (David Kaplan. The end of ‘clear and imminent danger’ Counseling Today, January 2006, v. 38, p. 10). The 2005 revision also has a new section proposed which is of relevance here:
B.2.b. Contagious, Life-threatening Diseases. When clients disclose that they have a disease commonly known to be both communicable and life-threatening, counselors may be justified in disclosing information to identifiable third parties, if they are known to be at demonstrable and high risk of contracting the disease. Prior to making a disclosure, counselors confirm that there is such a diagnosis and assess the intent of clients to inform the third party about their disease or to engage in any behaviors that may be harmful to an identifiable third party.
The NASW Code of Ethics of the National Association for Social Work, in section 1.07 Privacy and Confidentiality, states:
1.07(c) Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person...
The Code of Ethics of the Clinical Social Work Federation, in section III. Confidentiality, states:
III.(b) Clinical social workers know and observe both legal and professional standards for maintaining the privacy of records, and mandatory reporting obligations. Mandatory reporting obligations may include, but are not limited to.....the duty to take steps to protect or warn a third party who may be endangered by the client(s).....
The situation in marriage and family therapy is very unclear. The AAMFT Code of Ethics, effective July 1, 2001, does not refer to a duty to warn or protect in any fashion I can discern. It does reference making disclosures "mandated or permitted by law" but there appears to be no mention of protecting third parties from harm. Research “duty to warn” on the website www.aamft.org, “Family therapist’s decision-making processes in two duty-to-warn situations” (E. Burkemper (2002) discusses reporting of child abuse and HIV infection.
PROFESSIONAL LICENSURE STANDARDS
Any professional can be disciplined by practicing unethically or below the standards in his/her field. Specifically in psychology, social work, marriage & family therapy, and professional counseling, the licensed professional can be disciplined for “Gross negligence” which means performing services which do not comply with an accepted standard of practice.
In Minnesota licensure laws for psychologists, social workers, and substance abuse counselors have specific standards on duties with regard to threats of violence.
SUBSTANCE ABUSE EVALUATION & TREATMENT PROGRAMS
Although the focus of attention has been on social workers, psychologists, and psychiatrists, alcoholism and substance abuse counselors are often in a position to learn of potential violence. Should they receive a threat of violence that they believe to be credible, they are thought by many to have the same duty as psychotherapists who work with mental health clients. Twenty three percent of reported Tarasoff cases, examined in one study, involved clients with a history of alcohol or drug abuse (Egley & Ben-Ari, 1993).
The substance abuse counselor is generally working for a program which comes under the requirements of 42 Code of Federal Regulations (CFR) based on the Drug Abuse Prevention, Treatment and Rehabilitation Act (42 U.S.C. 290). While limited to "federally assisted" drug abuse treatment programs, it includes any program which receives any funds from a unit of government (local, state, federal), through direct funding or payments from Medicaid, Medicare, Social Security, or state treatment funds. This also includes any non-profit which is tax exempt (the feds argue this is "assistance"). This law and rules do not authorize breaking confidentiality based on a state law or professional mandate to warn of intended violence. Thus far only one ruling has addressed this potential conflict between state law and federal law (Hasenie v. United States, 541 F. Supp. 999, D.Md.1982) and that concluded that the federal rules take precedence.
It has been suggested by some that the federal rules might be circumvented to some degree if the counselor does not reveal that the person is a client of a drug abuse treatment or assessment program. I do not see how this is lawful. As a practical matter there are a few other options:
(1) If the client is a minor who is applying for admission to the program, and you ask them for a release to share the information with their parent or guardian, if you do not believe that he/she is using good judgment in denying permission, you can contact the parents with your concerns about the violence potential.
(2) If the client commits a violent act on premises or threatens to do so to staff of the program, it is permissible to contact law enforcement under the existing rules. (Note that this does NOT permit contact with the potential victim -- only law enforcement.)
(3) If the client is in a criminal-justice connected program with a standing release to talk to a probation officer or some other correctional official, one can talk to the authorized parties.
(4) If the program has a statement in their consent form that such a duty exists so that clients are, in theory at least, consenting to this. The substance abuse counselor licensing law requires that counselors do this, although it remains to be seen if this is “informed consent” since the client does not know they are giving away a privacy right.
WHAT ABOUT CLIENTS WHO ARE MINORS?
The issue of clients who are minors is different from the typical case which is discussed as a “duty to warn” situation. First the privacy rights of minors are less than those of adults, so that the professional is obligated to release information to the parent or guardian. Even in a state like Minnesota where a minor who has special rights due to having born a child, been married, or who is living away from home and managing their own finances, there is a presumed authorization to contact parents or guardian if the failure to do so might harm the child.
This does not mean that there are not important issues to examine in such cases. The treatment contract with a minor – especially with an adolescent – needs to be considered in terms of not only any promises of privacy but the nature of the relationship. As with the Tarasoff case, undermining the treatment relationship can bring about harm in the long run because it removes the professional’s best tools and the ability to help.
As regards terroristic threats, such as blowing up a school or killing students and teachers, contacting the parents may be of value and importance, but this does not guarantee safety and so the police, school, or other organization may need to be contacted. The duty to warn or protect assumes that there is a threat against a specific person and does not apply, but one needs to undertake an efforts at protection nonetheless.
VIOLENCE IN THE SCHOOLS
From the Columbine High School and Virginia Tech killings to the Feb. 2012 shooting in a school in Ohio, there has been a growing concern about violence in both high schools and colleges. Although statistically, violent crime in the age groups involved has actually declined in the USA substantially in the last ten years, the high visibility of such killings has led to a great deal of debate and also research.
More recently the Aurora Colorado movie massacre on July 20, 2012, involved a young man who was having serious emotional difficulties and being treated while a graduate school student. The shooting incident occurred when he was no longer a student.
Studies by the US Secret Service, the FBI, and the US Department of Education have advised schools to develop threat assessment teams to respond to apparent threats of violence by students. A useful link to many resources can be found at the website for the Virginia Youth Violence Project at http://youthviolecne.edschool.virginia.edu
It is important to note that we still lack good tools for predicting violence. As an aftermath of an incident of school violence it is common to have extra scrutiny and focus of student writings in class, postings on the internet, etc. But at present we are not able to reliably distinguish students who are heading towards violence and those who are not.
THE CURRENT SITUATION
There are a number of articles and other resources which provide advice or guidance for clinicians with the hope of helping prevent violent situations. These are focused on practical guidance rather than simple recitation of Tarasoff-related standards. Many such articles can be found on the internet
Psychiatric violence risk assessment, which often examines the issue of risk of assault by patients in a hospital unit and has looked at assessment tools (e.g. the HCR-20-C) and training to improve the ability to predict violence (Teo et. al, 2012). The Group on Violence Risk Assessment of the APA Council on Psychiatry and Law has produced a useful Resource Document on this issue (Buchanan et. al., 2012).
Fishkind’s (2002) “Calming agitation with words, not drugs: 10 commandments for safety. These “commandments” are: I. You shall respect personal space; II. You shall not be provocative; III. You shall establish verbal contact; IV. You shall be concise and repeat yourself; V. You shall identify wants and feelings; VI. You shall listen; VII. You shall agree or agree to disagree; VIII. You shall lay down the law; IX. You shall offer choices; X. You shall debrief the patient and staff.
While no profession has been shown to be able to predict violence with any degree of certainty, somewhat similar to predicting suicide, one should be mindful of the fact that some factors would tend to indicate seriousness:
(1) A detailed plan of violent action which the client reveals to you;
(2) Having the means to do it as threatened (e.g. gun, car, etc.);
(3) A specific threat which seems convincing to you;
(4) A history of past violent behavior, or past careless behavior such as reckless drunken driving which appeared suicidal or homicidal
(5) A "close call" for such behavior in the past
(6) Anything which would indicate desperation or that the client doesn't care about living, or about consequences, anymore
One should disclose as little confidential information as possible to provide for the warning and for protection. Details of therapy or diagnosis would not seem relevant. However, the client's articulated plan of action, current location, place of residence, or even their current appearance may all be relevant.
In the case of a minor, it is important to warn both the parents/guardian, and whoever might be in charge of security at the site where the violent acts are supposed to occur, such as a school. Bear in mind that with substance abuse counseling clients, there is less protection if you report.
THREATS MADE WHEN THE INTENDED VICTIM IS PRESENT
Unfortunately, the codes of ethics and available law do not specify that the threat needs to be latent -- that is, not known to the intended victim. So, if the threat occurs during a session when the intended victim is present, I would recommend the following:
(1) Draw the intended victim's attention to the threat in case they missed it.
(2) Indicate that you hear it as a serious threat and hope that the intended victim takes it seriously, and takes whatever precautions seem in order.
(3) Document clearly in your notes that you carried on this discussion.
The duty when the threat is not latent is unclear, but in circumstances when the intended victim does not seem to be taking it seriously, one can easily argue that there is a duty to try to impress upon them the risk that you perceive. Then one can engage in the discussion of “safety plans.”
WHAT HAPPENS NEXT? THE AFTERMATH OF THE WARNING
The NASW Code of Ethics which went into effect at the beginning of 1997, when referring to duty to warn and protect type situations, states in part: 1.07(c)...In all instances social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.
This sounds reasonable and would be consistent with codes of ethics for other professions. In practice it is far more difficult to judge what information is "directly relevant." Unforeseen in ethics codes and statutes is the terrorizing effect that such a warning may have on the person being warned. Receiving such a warning may have some very negative side-effects. The story below is true with a few details changed for disguise:
Mr. Smith picked up the phone. A man claiming to be a therapist, whose name he didn't recognize, was on the phone. The man indicating that he was calling because of some sort of ethical (or was it legal?) duty to warn him of a serious threat. He said that a woman named Joan Dawes said she was going to shoot him and his family.
Mr. Smith was bewildered and frightened, and to make matters worse, didn't know who Joan Dawes was.
He tried to get more information but the "therapist" appeared reluctant to say much else. Finally he got him to reveal that "Joan Dawes" was his estranged stepdaughter who had apparently changed her name. He had no idea that she was back in town....and immediately wondered where she lived and worked. He asked about precautions, the seriousness of the threat, why the therapist had not had Joan committed on a 72 hr. hold, etc. but the therapist would say no more.
A week has gone by and Mr. Smith and his family are living in terror. They have barely slept. Calling the police did not help much. What little the police were able to get out of the therapist didn't provide grounds to take any action. In fact, even if they were to have a "talk" with Joan Dawes they indicated that this might only serve to make her angrier at them, at Mr. Smith, and at the therapist.
The literature does not discuss what should be communicated and what the outcome of doing this might be. So, put yourself in the position of the person receiving the call and think about what information might help them deal with what they are about to be told.
THREATS AGAINST THE PRESIDENT
A plot against federal officials can be reported to the local police, but can also be reported to the FBI or Secret Service. The Secret Service has argued that since a verbal threat against the President, Vice President, or members of their immediate families is a felony, professionals should report such threats and to not do so might be construed as misprision of a felony. (I have not heard of any case where this actually occurred and a professional was charged.) While some highly regarded professionals such as Dr. Walter Menninger have written and spoken favorably about their experiences in making reports to the Secret Service, it is hard to believe that a verbal threat, as opposed to a plan or plot (which would be more of a "duty to warn or protect") would be sufficient grounds to violate confidentiality.
A FINAL WARNING
There is a tendency for professionals to focus on legal standards for taking action. However, standards set out in case law, statute, and codes of ethics rarely address the complex situations we find ourselves in from time to time. First and foremost is to consider what might be the best clinical response to the situation.
Situations of "creeping dangerousness" are more common than true "duty to warn" situations in which a failure to act quickly could have fatal results. Most of the time we need to be focused on what is occurring and how we intend to intervene clinically. Obtaining consultation and identifying and considering options are usually the best route for the appropriate handling of a volatile situation. The central task in such situations is to prevent or diffuse harm while not losing the working relationship with the client (Knapp & VandeCreek, 2003)
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