We often hear about the “Tarasoff warning” and the “duty to protect,” but what do these mean, and who was Tarasoff? In today’s episode, we’ll break down the Tarasoff rulings and how you can navigate the legal ambiguities surrounding our duty to protect.
Published On: 04/14/2022
Duration: 10 minutes, 47 seconds
Related Articles: “Tarasoff: Making Sense of the Duty to Warn or Protect,” The Carlat Hospital Psychiatry Report, January/February/March 2022
Each State’s Laws Related to Tarasoff
Victoria Hendrick, MD, and Zachary Davis, BS, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Dr. Hendrick: We often hear about the “Tarasoff warning” and the “duty to protect,” but what do these mean, and who was Tarasoff? In today’s episode, we’ll break down the Tarasoff rulings and how you can navigate the legal ambiguities surrounding our duty to protect.
Welcome to The Carlat Psychiatry Podcast.
This episode is brought to you by the Carlat Hospital Psychiatry team.
I’m Dr. Victoria Hendrick, the Editor-in-Chief of The Carlat Hospital Psychiatry Report, and a clinical professor at the David Geffen School of Medicine at UCLA. I’m also the director of inpatient psychiatry at Olive View -- UCLA Medical Center.
Zachary Davis: And I’m Zachary Davis. I’m a content-coordinator at The Carlat Report. And I’m also a pre-med student who’ll be applying to medical school this year.
Before we dive into this episode, we have some news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.
Dr. Hendrick: And here’s a sneak peak of a CME question for this episode:
In a recent 12-month study, what percentage of explicit and clear violent threats resulted in violent actions by the threatening party?
Zachary Davis: Tatiana Tarasoff was a student at Merritt College in Oakland. In 1968, when she was 18, she met 22-year-old Prosenjit Poddar, a graduate student at UC Berkeley. They dated, but Tarasoff told Poddar that she was seeing other men, and he was crushed, becoming increasingly depressed. He eventually began therapy with Lawrence Moore, a psychologist at the student health service. Poddar told Moore that he intended to kill Tarasoff by stabbing her. In response, Moore informed campus police and recommended that Poddar be civilly committed for treatment of paranoid schizophrenia. Police detained Poddar but released him because he appeared rational. Neither Tarasoff nor her parents received any warning directly. A few months later, Poddar stabbed and killed Tarasoff, carrying out the plan he had confided to his therapist.
Dr. Hendrick: The family sued the university, leading eventually to two important California Supreme Court decisions, referred to as Tarasoff I and Tarasoff II. In Tarasoff I, the court ruled that doctors and psychotherapists have a legal obligation to warn a patient’s intended victim if that person is in foreseeable danger from the patient. Warning the police or other authorities is not good enough. This is a concept known as the “duty to warn.”
Zachary Davis: In Tarasoff II, a rehearing of the case, the court added the concept of “duty to protect.” This duty requires providers to take whatever steps are necessary to protect the intended victim. You can warn them, but you can also protect the intended victim by, for example, placing the patient on an involuntary psychiatric hold. This option has the advantage of not breaching patient confidentiality.
Dr. Hendrick: Still, many clinicians continue to warn intended victims in addition to placing patients on involuntary psychiatric holds, from a belief that the Tarasoff ruling requires this warning—but in 2013, California courts clarified that the current duty is solely to protect and disregarded the previous duty to warn.
Zachary Davis: Do you have a duty to warn anyone if a patient makes nonspecific threats to the general public?
Dr. Hendrick: Most state legislatures have adopted “Tarasoff-limiting statutes” that provide specific criteria for Tarasoff warnings, including the requirement that the threat be made against an identifiable intended victim. Of course, in those situations, if you believe the threat to be associated with a mental illness, you would place the patient on an involuntary hold on the grounds of danger to others, thereby keeping the public safe.
Zachary Davis:Does Tarasoff apply to clinicians who practice outside of California?
Dr. Hendrick: Most states have adopted similar or modified versions of Tarasoff. In 26 states and Puerto Rico, Tarasoff applies much the same way as it does in California in that the duty is mandatory—ie, you may face civil liability, fines, or other penalties if you fail to warn/protect a potential victim. You can find each state’s laws by clicking the link in the episode description.
Zachary Davis: Even if you live in a state with a clear-cut Tarasoff ruling, you will still face legal ambiguity: How do you decide whether a patient’s threats are serious enough to warrant action?
Dr. Hendrick: Yeah, this can be tough, considering that your patient might express violent fantasies but have no intention of following through with them. In a 12-month study of patients who made explicit and clear violent threats, 23% of the threats resulted in a violent act by the threatening party.
Zachary Davis: Here are some ways you can hone your risk appraisals:
Dr. Hendrick: 1. Look for red flags that increase the likelihood of a threat leading to actual violence: prior violence, substance use, and untreated mental illness
Zachary Davis: 2. Ask yourself these questions: Is the threat clear and imminent? Is the patient able to carry out the threat? Has the patient engaged in preparatory actions, such as buying a weapon or rehearsing a planned attack? Is the intended victim identifiable?
Dr. Hendrick: And, 3. Consider the difference between a patient with dementia who threatens to “hurt people who want to hurt me” versus a patient with psychosis who informs you that they plan to stab a specific family member later that day as they exit their home because they believe that family member is trying to poison them. The second patient presents a far more urgent scenario, warranting immediate action to warn/protect.
Zachary Davis: So, Dr. Hendrick, what should clinicians do when they believe that a third party is in danger?
Dr. Hendrick: When you have a compelling reason to believe that a third party is in danger, you must take steps to protect that person. If you’re unable to place the patient on an involuntary psychiatric hold, you’ll need to warn the intended victim and notify the police.
Zachary Davis: If you don’t have any contact information for the intended victim, you can try to reach out to the patient’s family members who might have the intended victim’s contact information, or you can conduct an online search.
Dr. Hendrick: You are going to want to warn the police too. In the case that you are unable to reach the intended victim, make sure to tell law enforcement that you’re having trouble with warning the intended victim. And it’s important that you document all of these efforts in an accurate and timely manner, and be clear as to your reasoning and actions. Describe the threat using verbatim quotes. If you contact the police, take down the name and badge number of the officer you speak with.
Zachary Davis: Ultimately, clinical judgment and good faith efforts to protect potential victims are the most important tools in preventing harm to a third party. Most states have adopted statutes concerning a duty to warn or protect, like California’s Tarasoff rule.
Dr. Hendrick: While we risk breaching confidentiality, our overriding principle is to make good faith efforts to protect intended victims. By involuntarily hospitalizing and treating a patient so they no longer pose an imminent threat, we can fulfill our obligation to protect third parties without needing to contact the intended victim and thereby breach confidentiality. But check your state’s laws, and keep in mind that the most prudent course of action is to protect and warn.
Dr. Hendrick: The newsletter clinical update is available for subscribers to read in The Carlat Hospital Report. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
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As always, thanks for listening and have a great day!