Risk Management Considerations When Treating Violent Patients

Kristen Lambert
Psychiatric News
Originally posted September 4, 2018

Here is an excerpt:

When a patient has a history of expressing homicidal ideation or has been violent previously, you should document, in every subsequent session, whether the patient admits or denies homicidal ideation. When the patient expresses homicidal ideation, document what he/she expressed and the steps you did or did not take in response and why. Should an incident occur, your documentation will play an important role in defending your actions.

Despite taking precautions, your patient may still commit a violent act. The following are some strategies that may minimize your risk.

• Conduct complete timely/thorough risk assessments.

• Document, including the reasons for taking and not taking certain actions.

• Understand your state’s law on duty to warn. Be aware of the language in the law on whether you have a mandatory, permissive, or no duty to warn/protect.

• Understand your state’s laws regarding civil commitment.

• Understand your state’s laws regarding disclosure of confidential information and when you can do so.

• Understand your state’s laws regarding discussing firearms ownership and/or possession with patients.

• If you have questions, consult an attorney or risk management professional.

The info is here.

How Should Physicians Make Decisions about Mandatory Reporting When a Patient Might Become Violent?

Amy Barnhorst, Garen Wintemute, and Marian Betz
AMA Journal of Ethics. January 2018, Volume 20, Number 1: 29-35.

Abstract

Mandatory reporting of persons believed to be at imminent risk for committing violence or attempting suicide can pose an ethical dilemma for physicians, who might find themselves struggling to balance various conflicting interests. Legal statutes dictate general scenarios that require mandatory reporting to supersede confidentiality requirements, but physicians must use clinical judgment to determine whether and when a particular case meets the requirement. In situations in which it is not clear whether reporting is legally required, the situation should be analyzed for its benefit to the patient and to public safety. Access to firearms can complicate these situations, as firearms are a well-established risk factor for violence and suicide yet also a sensitive topic about which physicians and patients might have strong personal beliefs.

The commentary is here.

Does Volk v. DeMeerleer Conflict with the AMA Code of Medical Ethics?

Jennifer L. Piel and Rejoice Opara
AMA Journal of Ethics. January 2018, Volume 20, Number 1: 10-18.

Abstract

A recent Washington State case revisits the obligation of mental health clinicians to protect third parties from the violent acts of their patients. Although the case of Volk v DeMeerleer raises multiple legal, ethical, and policy issues, this article will focus on a potential ethical conflict between the case law and professional guidelines, namely the American Medical Association’s Code of Medical Ethics.

Here is a portion of the conclusion:

The Volk case established legal precedent for outpatient mental health clinicians in Washington State. Future cases against clinicians for their patients’ harm to third parties (e.g., medical negligence, wrongful death) will be tried under the Volk standard. It will be up to the trier of fact to determine whether the victims of a patient’s violence were foreseeable and, if so, whether the clinician acted reasonably to protect them.

Without changes to this law, there is increased likelihood that future clinicians and employers in similar situations, fearful of being in Dr. Ashby’s position, will more willingly (and likely unhelpfully) breach patient confidentiality. This creates a dilemma for clinicians in Washington State, who could find themselves caught between trying to meet the requirements of the legal case and also adhering to their professional ethical guidelines.

The article is here.

APA Signs Onto Amicus Brief Supporting Confidentiality

Aaron Levin
Psychiatric News
Originally published August 11, 2016

APA has signed on to an amicus curiae brief with the California Psychiatric Association and the California Association of Marriage and Family Therapists in a case before the California Supreme Court with important implications for patient confidentiality and clinicians’ liability.

APA is concerned that a ruling in favor of the plaintiff would change the existing California standard (the so-called Tarasoff rule) requiring action when “a patient has communicated to the psychotherapist a serious threat of physical violence against a reasonably identifiable victim or victims.”

The case, Rosen v. Regents of the UCLA, arose when Damon Thompson, a student treated by UCLA’s counseling service, attacked and stabbed a fellow student, Katherine Rosen.

Under California law, a therapist has a “duty to protect” a potential victim if the patient makes a reasonably identifiable threat to harm a specific person.

The entire article is here.

Tarasoff's catch-22.

By Stephen R. Huey
The American Psychologist
2015 Apr;70(3):284-5. doi: 10.1037/a0039064

Abstract

Comments on the article by D. N. Bersoff (see record 2014-28692-002). Bersoff poses a much-needed challenge to the rationale of laws based on Tarasoff v. Regents of the University of California (1976), which exist in most states and require therapists to warn the intended victim, police, and/or others when a patient voices serious threats of violence. If Tarasoff-related laws were ever to be modified, research support would be required. To begin with, what is the experience of other countries that happen to address this issue differently and of the seven states that, according to Bersoff, have not adopted Tarasoff-related requirements? Another question is whether patients who are unwilling to invite the consequences of therapist disclosure ever reveal reportable intentions to their therapists anyway-say, by mistake or impulse-thus making current law marginally useful? Rules that undercut sacrosanct confidentiality create a catch-22 in which the indisputable ethical necessity of informed consent has an unintended consequence- namely, therapy is preceded by informed consent but precluded by it.

The entire article is here.

The Tarasoff Rule: The Implications of Interstate Variation and Gaps in Professional Training

By Rebecca Johnson, Govind Persad, and Dominic Sisti
J Am Acad Psychiatry Law 42:4:469-477 (December 2014)

Abstract

Recent events have revived questions about the circumstances that ought to trigger therapists' duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic across time. In this article, we review the implications of this variability and dynamism, focusing on three sets of questions: first, what legal and ethics-related challenges do therapists in each of the three broad categories of states (states that mandate therapists to warn or protect, states that permit therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.

The entire article can be found here.