(p. 616) Assessing and Responding to Aggressive and Threatening Clients
Dangerous clients pose a special challenge to psychotherapists. If, on the one hand, the therapist underestimates the client’s threats and harm comes to a third party, the therapist may feel that more should have been done to protect the innocent victim, and the victim, or survivors, may initiate a lawsuit. On the other hand, if the therapist incorrectly believes that harm is imminent and acts to warn a potential victim, the client may feel betrayed and the therapeutic relationship may be threatened. Even worse, the client may drop out of therapy and lose faith in therapists, thereby ending any preventive role that therapy may have had in preventing violence.
The American Psychological Association’s (APA) “Ethical Principles of Psychologists and Code of Conduct” (2002) permits psychologists to breach confidentiality if it is necessary to protect the client or others from harm. The option of breaching confidentiality, permitted by the ethics code, may protect the psychologist from charges of ethical violations, but the psychologist must still exercise judgment about when to breach confidentiality or when to engage in other strategies that may reduce the potential for violence.
Decision making with dangerous clients is made more precarious by the increased possibility of legal liability. Prior to the 1976 California Supreme Court decision of Tarasoff v. Regents of the University of California, psychotherapists did not have to contend with legal repercussions surrounding confidentiality in their management of dangerous clients. The Tarasoff ruling, and that of other courts and legislation that followed the lead of Tarasoff, however, has created a “duty to protect” doctrine that psychologists believe applies to them even if their states have not formally endorsed the doctrine through legislation or court decisions (Werth, Welfel, Benjamin, & Sales, 2009). Consequently, psychologists must now consider clinical issues in the context of both ethical and legal constraints. Fortunately, courts recognize that psychotherapists cannot predict dangerousness with complete accuracy. Instead, the courts consider whether the psychologist used acceptable professional judgment in completing an assessment of dangerousness and in developing and implementing the treatment plan (Benjamin, Kent, & Sirikantraporn, 2009; VandeCreek & Knapp, 2000).
One of the difficulties that therapists face, however, when managing dangerous clients is that no standard of care has been established. The recent practice of specifying empirically supported treatments for a variety of mental health conditions has not yet been applied to the diagnosis and treatment of clients who pose a danger to others (p. 617) (VandeCreek & Knapp, 2000). A recent study (Pabian, Welfel, & Beebe, 2007) found that about 75% of psychologists were misinformed about their legal duties with dangerous clients. When faced with dangerous clients, psychologists can consider many options, including hospitalizing the client, strengthening the therapeutic alliance, managing the client’s environment, and breaking confidentiality. Truscott, Evans, and Mansell (1995) presented a model for decision making when working with dangerous clients. Their model is presented here.
The model proposes that clients who pose a threat of violence be thought of as occupying one of four cells in a 2 × 2, Violence Risk × Therapeutic Alliance Strength table. Interventions can be selected to strengthen the alliance and reduce the violence risk. The model is presented in Figure 118.1.
The authors suggest that, whenever possible, psychologists should work to strengthen and maintain the therapeutic alliance because the alliance is the backbone of most interventions. If the alliance is weak, the psychologist has a reduced chance of effectiveness with the client, especially when risk of violence is high. The model suggests that when the alliance is strong, the psychologist can focus on violence management, and if the risk of violence increases, therapy should be intensified and the client’s environment more carefully managed. On the other hand, if the alliance is weak and the risk of violence is high, the psychologist should attempt to strengthen the alliance and/or involve significant others in treatment and consider hospitalization. Breaking confidentiality, then, should occur only in the context of a weak alliance and high violence potential.
To implement this model, or any other decision-making model, when working with potentially dangerous clients, psychologists must make assessments of violence potential. The legal test in predicting violence is one of “reasonable foreseeability.” That is, would other psychologists with a similar client make a similar assessment and draw a similar conclusion? Aspects of client diversity must be included in the calculus. Liability is more likely to be imposed if the psychologist failed to follow appropriate procedures in reaching a decision and in implementing the decision than if an incorrect prediction was made. Thorough records are imperative to document decision making about dangerous clients.
(p. 618) The following variables should be considered when reviewing a client’s potential for violence. Individual characteristics include the following:
• History of violence. This is the single best predictor of violent behavior. The age at which the first offense occurred is also an important variable. Individuals who commit their first violent offense prior to adolescence are more likely to engage in violent behaviors throughout their lifetime.
• Clinical risk factors. A diagnosis of substance abuse or dependence is probably the second most important factor. Persons with mental illness who believe that they are being threatened by others are also more likely to resort to violence.
• Demographic variables. Non-White persons in their late teens and early 20s with low IQ and education are most likely to engage in violent behaviors. Unstable residential and work histories increase the risk. Until recently, men were believed to pose more risks of violence than women, but research now suggests that clinicians, at least those working with more disturbed client populations, should not consider client sex to be a baseline risk factor (Otto, 2000).
Situational characteristics include the following:
• Availability of potential victim(s). Most violent crimes occur between people who know each other.
• Access to weapons. Persons with martial arts training or combat experience, and those who possess great physical strength are capable of inflicting greater harm.
• Stressors. Daily stressors such as relationship and financial problems can reduce a person’s frustration tolerance.
Psychotherapists can assess the quality of their management of dangerous clients by asking the following questions:
1. Am I aware of state and federal laws and agency policies?
2. Have I done a thorough evaluation of the dangerousness of the client and have I updated it recently?
3. When clients have presented a threat of harm, have I modified my treatment plan to address the increased risk, such as by increasing the frequency of sessions, addressing anger in psychotherapy, incorporating other parties into treatment, asking the client to release weapons, and reviewing requirements of relevant duty-to-protect statutes?
4. Have I consulted with a knowledgeable colleague?
5. Have I carefully documented my clinical judgment and treatment and my consultations?
References and Readings
American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073.Find this resource:
Benjamin, G. A. H., Kent, L., & Sirikantraporn, S. (2009). A review of duty-to-protect statutes, cases, and procedures for positive practice. In J. L. Werth, Jr., E. R. Welfel, & G. A. H. Benjamin (Eds.), The duty to protect: Ethical, legal, and professional considerations for mental health professionals (pp. 9–28). Washington, DC: American Psychological Association.Find this resource:
Otto, R. K. (2000). Assessing and managing violence risk in outpatient settings. Journal of Clinical Psychology, 56, 1239–1262.Find this resource:
Pabian, Y. L., Welfel, E. R., & Beebe, R. (2007, August). Psychologists’ knowledge and application of state laws in Tarasoff-type situations. Paper presented at the 115th Annual Convention of the American Psychological Association, San Francisco, CA.Find this resource:
Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P2d 334 (1976).Find this resource:
Truscott, D., Evans, J., & Mansell, S. (1995). Outpatient psychotherapy with dangerous clients: A model for clinical decision making. Professional Psychology: Research and Practice, 26, 484–490.Find this resource:
VandeCreek, L., & Knapp, S. (2000). Risk management and life-threatening patient behavior. Journal of Clinical Psychology, 56, 1335–1351. (p. 619) Find this resource:
Werth, J. L., Jr., Welfel, E. R., Benjamin, G. A. H., & Sales, B. D. (2009). Practice and policy responses to the duty to protect. In J. L. Werth, E. R. Jr., Welfel, & G. A. H. Benjamin (Eds.). The duty to protect: Ethical, legal, and professional considerations for mental health professionals (pp. 249–261). Washington, DC: American Psychological Association.Find this resource: