Psychiatrist Duties: Tarasoff

Psychiatrist Duties: Tarasoff

John M. Greene, M.D.

Adjunct Clinical Faculty

Stanford University Department of Psychiatry

August 3, 2006

 

OVERVIEW:

 

There are many requirements, or duties, that the psychiatrist has toward his patients, defined by local, state and federal law. The duties of the psychiatrist include:

 

Duty to Protect (Based on the Tarasoff decisions)

Duty to Inform (Informed Consent)

Duty to Report (Child/Elder Abuse, Domestic Violence)

Duty to Prescribe (Specific requirements prior to dispensing medication)

Charting (Specific requirements about how to document notes in the patient’s chart)

 

All of these duties are extensively covered by the website created and updated by Dr. Dondershine. This lecture focuses on the Tarasoff decisions.

 

SUMMARY OF TARASOFF LECTURE:

 

A. Tarasoff:

 

Facts, Issues, Holding, Reasoning of Tarasoff I and II

 

B. Relevance of Tarasoff Decisions:

 

            Cases relevant to the California Supreme Court Decision regarding Tarasoff

 

C. Meaning of Tarasoff Decisions to Mental Health Professionals:

 

            Duty to Protect, Not Duty to Warn

 

            Problems Arising in Treatment of the Duty

 

            Landmark Cases dealing with the Tarasoff Decision

 

D. Steps for the Psychiatrist to take for Tarasoff:

 

            Assessment

 

“Discharge the Duty”

 

            Avoid Liability

 

A. TARASOFF:

 

Facts of Case:

 

1974: Prosinjit Podder, an Indian Graduate student, studying at Berkeley, begins to date Tatiana Tarasoff. They kiss. He feels that she is his intended.

 

He gets upset when she expresses interest in other men. He goes to counseling at the University Health Service.

 

He tells the psychologist, Dr. Moore, that he wants to get a gun and shoot Tarasoff.

 

Dr. Moore sends letter to campus police, they investigate Podder, they think he is not a danger, tell him to avoid Tatiana.

 

When Tatiana returns from Brazil at the end of summer, Podder stalks, stabs her to death.

 

Legal Action:

 

Parents of Tatiana sue campus police, UC Regents, Health Service, for failure to warn Tatiana about Podder’s desire to kill her.

 

At trial court, case is dismissed (not heard), judge rules that there is no cause of action, because of confidentiality between doctor and patient (Dr. Moore and Podder): Doctor has a duty only to patient, not to third parties.

 

Tarasoff appeals, California appeals court supports the decision of trial court. Appeal taken to California Supreme Court.

 

Tarasoff I:

 

California Supreme Court reverses the trial court’s decision, stating that the trial court must hear the case. Reasoning: “therapist bears a duty to use reasonable care to give threatened persons warnings as are essential to avert foreseeable danger.”

 

This causes uproar in community of MDs and policemen, causing the Cal Supreme Court to rehear the case again, in 1976

 

Tarasoff II:

 

California Supreme Court: “When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger.”

 

B. MEANING OF TARASOFF DECISIONS TO MENTAL HEALTH PROFESSIONALS:

 

Duty to Protect, Not Duty to Warn

 

How is a psychiatrist supposed to protect a victim, rather than just warning a victim?

California Supreme Court: “The discharge of this duty may require the therapist to take one or more of various steps. This, it may call for him to warn the intended victim, to notify the police, or to take whatever steps are reasonably necessary under the circumstances.”

 

Problems that arise With a Duty to Protect:

 

Disruption of therapeutic alliance

 

Possible precipitation of violence (by victim, or by patient if he subsequently does not seek treatment)

 

Stigmatization of the patient

 

Fear of Liability by the Psychiatrist, resulting in change of practice

 

Subsequent Cases related to Tarasoff (Landmark Cases):

 

Lipari v. Sears, Roebuck and Company, US District Court, Nebraska, 1980:

 

            Mr. Cribbs, history of involuntary treatment at VA, buys gun at Sears. one month

later, he leaves outpatient VA program AMA. Thirty days later, he fires shotgun in Omaha club, kills Mr. Lipari, wounds Mrs. Lipari. Lipari sues Sears, Sears sues VA, Mrs. Lipari sues VA. District Court rules that the therapist has a duty to detain dangerous people if they are a threat to the public (based on Tarasoff).

 

Jablonski by Pahls v. United States, United States Court of Appeals, Ninth Circuit, 1983:

 

            Ms. Kimball and Mr. Jablonski are dating. She loves him, but is afraid of his past threats, attempts to kill her mother (Ms. Pahls), and her. She takes him to the Loma Linda VA when he has threatened her mother, on 7/10/78. Doctor says that she should leave him, but feels that he is not dangerous, as Mr. Jablonski has not threatened her currently. He’s released, then he kills Ms. Kimball 7/16/78. Kimball’s daughter (with help of Kimball’s mother Ms. Pahls) sues VA, alleges that there was a duty of the psychiatrist to protect Ms. Kimball. Court rules that Ms. Kimball was a foreseeable victim of Jablonski’s violence, and necessary steps were not taken in protecting her.

 

Naidu v. Laird, Supreme Court of Delaware, 1988:

 

            Mr. Putney is released from the Delaware State Hospital, after being treated for the seventh admission, for paranoid psychosis symptoms. Leaves voluntary admission March 1977. Five months later, he drives over Mr. Laird, while in a psychotic state, and kills him. Ms. Laird sues, Supreme Court of Delaware holds that Mr. Laird was a foreseeable victim to Mr. Putney’s dangerousness, and did not discharge duty to warn properly.

 

How Courts Have Recently Interpreted Tarasoff:

 

A duty is present by the therapist to take some action to prevent foreseeable harm to a third party injured by the client.

 

Most states that have dealt with a Tarasoff interpretation now require the third party be defined as an “identifiable victim,” before the therapist can be said to have a duty to this victim. This is commonly now defined as a person the client has actually defined as a potential victim, and therefore the therapist has a knowledge of this specific need to protect.

 

Because of this new definition, the above Landmark Cases would not result in the same court decision today, because this definition now exists in Nebraska, Federal Court, and Delaware (as well as California).

 

This is not the case in all states; some states continue to hold that foreseeable harm to any third party creates a duty for the therapist.

 

STEPS FOR THE PSYCHIATRIST TO TAKE FOR TARASOFF ASSESSMENT:

 

Assessment of Violence:

 

Investigation of any threat of violence by the patient:

 

Establish the four important parameters: type of harm, seriousness of harm, imminence of harm, likelihood of harm.

 

Determine which threats are likely to be real, based on details about the threat: past history of violence (the most important risk factor for future violence), impulsiveness, ability to resist violent impulses, reaction to violence, motivation to maintain self-control, use of alcohol and drugs (another major risk factor of violence). Try to obtain data from other family members about history.

 

Discharge the Duty:

 

“The discharge of this duty may require the therapist to take one or more of various steps. This, it may call for him to warn the intended victim, to notify the police, or to take whatever steps are reasonably necessary under the circumstances.”

 

Changing the treatment program for the patient.

 

Requesting the patient be voluntarily committed.

 

Civil commitment (California: 5150).

 

Warning the potential victim.

 

Warning others who would be likely to notify the victim.

 

Contacting the police in the area of the victim or the patient.

 

Minimize Liability:

 

Follow the above steps.

 

Consult with colleagues.

 

Document all steps taken, document details about how violence was assessed, conclusion of determination of violence based on the assessment.