In my last column in Winter 2012 Eye, I talked about how important confidentiality is in psychotherapy, and how psychologists are obligated to respect the privacy of their clients. In this column, I want to introduce one major exception to this obligation—when clients present a danger to others. Consider the following case:
A client comes into therapy in an agitated state. A few minutes into the session he talks about how angry he is at his brotherin- law. "I feel like killing him sometimes,” he says. Later in the session, he mentions that he has a gun, and is, in fact, going over to his brother-in-law’s apartment to "take care of business.”
Do you keep the client’s disclosures confidential, or do you take some action to protect the client’s brother-in-law from harm that appears imminent? In fact, this kind of case involves a duty to protect, a principle most notably articulated by the California Supreme Court in the Tarasoff case (Tarasoff, 1976). A description of this case is beyond the scope of this article (see Blum, 1986, and almost any psychology ethics book for more information). Since the court decision in California, many states have written some version of the Tarasoff duty into their laws. For example, the Colorado Revised Statutes, section 13-21-117, states that psychologists need to breach confidentiality when "the patient has communicated to the mental health care provider a serious threat of imminent physical violence against a specific person or persons.”
How do psychologists protect the potential victim of a threat? The first way is by contacting the potential victim—this is called the duty to warn. The second way, in the words of the Colorado law (section 13-21-117), is by "notifying an appropriate law enforcement agency or by taking other appropriate action including, but not limited to, hospitalizing the patient.”
Although not all states have duty to warn or duty to protect provisions, the APA (2002) Ethics Code mentions the duty to protect. Standard 4.05 (Disclosures) states, in part:
(b)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 to …
(3) protect the client/patient, psychologist, or others from harm….”
By the way, clients have a right to know that their confidentiality must be broken if they make such a threat. Thus, the APA Code Standard 4.02 (Discussing the Limits of Confidentality) says:
Psychologists discuss with persons … and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities….
This Standard alludes to the Tarasoff duty but also includes other limits to confidentiality, which we can explore in future columns.
As with many parts of the APA Code (see "The ABCs of the APA Ethics Code”; HERE, this provision seems straightforward enough when you first read it; however, implementing this broad provision includes many judgments. For example, the client’s threat needs to be of physical violence. If our client had threatened to steal all his brother-in-law’s money, the Tarasoff duty would not apply (Think how you would feel knowing that your client will be stealing money but not being able to tell anybody about it).
Three more criteria for breaching confidentiality to protect a victim are stated by Knapp and VandeCreek: "In order for the duty to protect or warn to arise, the victim needs to be identifiable and the threatened harm needs to be substantial and imminent” (2006, p. 132; emphases added). These elements of decision making can involve very difficult judgments. What if, for example, the client had said that he wanted to kill somebody, but did not specify a specific person? Does the therapist need to ask the client who he is threatening? What constitutes substantial harm? What counts as imminent? A gunshot certainly causes harm immediately. But what if a client threatens to infect someone with a sexually transmitted disease? The harm might be substantial, but is it imminent?
I am not going to answer these questions for you; they are too complicated for a short article and involve many gray areas. As I’ve said before, ethics is not a series of specific rules to follow. When somebody definitely threatens to murder an identifiable person immediately, the choice is clear. But students of psychotherapy (and seasoned professionals) need to develop ways to make judgments about the gray area cases. One way to develop these ethical skills regarding confidentiality and moral values is to explore your own experiences with friends, teachers, and other professionals. How do you handle secrets? To what extent do you feel motivated to gossip about friends and enemies? What does it feels like when people do not respect your privacy? Exploring questions about your own background and morality will help you understand and adapt to the ethics of psychology (Anderson & Handelsman, 2010).
Anderson, S. K., & Handelsman, M. M. (2010). Ethics for psychotherapists and counselors: A proactive approach. Malden, MA: Wiley-Blackwell.
American Psychological Association (2002). Ethical principles of psychologists and code of conduct. Washington, DC: Author. Retrieved from Here
Blum, D. (1986). Bad karma: A true story of obsession and murder. New York: Jove Books. Tarasoff v. Regents of the University of California et al., 551 P.2d 334 (Cal. S. Ct. 1976).