Dr. Kennedy’s and Dr. Klafter’s observations
The formation of a professional relationship establishes a duty of care and requires the clinician to provide reasonable notice of termination and alternative sources of care. Although 30 days’ notice is generally appropriate, several factors may dictate the need for more or less notice (Box 2).
In Mr. Z’s case, we view the psychologist’s behavior as appropriate because:
- Without psychotropics, Mr. Z’s psychosis would likely persist. To continue treating him with psychotherapy alone would fall below the standard of care.
- By threatening to terminate psychotherapy, the therapist tried to use the patient’s transference and desire to maintain the therapeutic relationship as an incentive to accept medication.
Continued observation: A clue from the past
Mr. Z’s brother, who was contacted by the treatment team, reported that the patient had never been violent. He did note, however, that as an adolescent Mr. Z talked about joining a terrorist organization, though he had never followed through. The brother tried to persuade Mr. Z to leave school and live with him on the West Coast, but he instead chose to continue his studies.
Mr. Z’s hospital treatment team realized that his continued work in engineering—where he had access to explosive materials—posed a significant risk given his impaired judgment. Acting on a forensic expert’s advice, the team warned university officials about Mr. Z’s mental state and preoccupation with violence. The FBI was also contacted.
Was the treatment team justified in reporting Mr. Z’s behavior to authorities, even though he never identified any potential victims?
Dr. Kennedy’s and Dr. Klafter’s observations
Various legislative and judicial remedies—some more restrictive than others—address the psychiatrist’s duty to third parties:3
- Some states require psychiatrists to notify or protect third parties when any danger is foreseeable, regardless of threat or victim.
- Other states require specific threats but charge the psychiatrist with foreseeing all potential victims regardless of whether they were named.
- Still other states limit protection to identifiable victims, even if no threat is issued.
- In some states the psychiatrist is responsible only if the patient makes specific threats to identifiable victims.
Again, psychiatrists need to make their best professional judgments in good faith about risk of violence. Hospitalizing a threatening patient provides the most protection to third parties, but this option is intrusive, coercive, and is not always appropriate or feasible. If the threat is directed toward the public rather than specific individuals or groups, law enforcement agencies can reduce the risk somewhat through monitoring and surveillance.
Although it is a judgment call, clinicians should notify:
- all persons or organizations against whom a patient might commit violence
- and those who might be targeted as instruments for violence towards others, such as family members who have guns the patient could obtain.
A terrorist would not likely seek psychiatric help relative to his goals of terrorism because such behavior is not rooted in major mental illness. However, the heightened sense of paranoia and anxiety created by events involving terrorism, religious animosity, and hatred provide patients who struggle with psychosis an outlet for their paranoia. As such, we should take a patient’s terroristic threats seriously.
Conclusion: Going home
The university granted Mr. Z medical leave and placed him on academic probation for 2 months, during which he returned to his native country to stay with his parents.
The faculty later dismissed Mr. Z from the program, citing poor academic and laboratory performance. His visa expired, with renewal contingent upon enrollment in a full-time academic program.
Related resources
- American Academy of Psychiatry and the Law. www.aapl.org.
Drug brand names
- Sertraline • Zoloft
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.