More and more often, psychiatrists are being held liable for actions taken by patients. Have you ever been forced to warn a third party about a patient's potential action? In other words, is there ever a time when we have a duty to others besides our patients?
During my second year of residency, I treated a 33-year-old African American male with paranoid schizophrenia. He was extremely delusional about his dentist and strongly felt that his dentist made him look weird. He told me that he wanted to kill his dentist, and he refused his medication.
We wrote a letter asking the court to grant permission to keep him in the hospital involuntarily and to start him on forced medication. The court refused our request and sent a police officer to search his apartment. The police discovered a gun in his apartment and removed it. Before discharging him, I called his dentist and told him about the patient's homicidal ideation toward him. The dentist was terrified and quickly took all the appropriate actions to make sure the patient did not gain access to his place of business.
Roselin Arunachalam, M.D.
Foreseeability Is the Key
As a forensic psychiatrist, I haven't been forced to warn others about patients, but when such a problem does arise, the main issue is the foreseeability of the violent act. For instance, if a patient tells me about his desire, to hurt or kill Mr. X--and only Mr. X--for some real or delusional reason and I believe the act may actually happen, I should warn Mr. X so that suitable restraining orders can be placed on the patient and he can be hospitalized. However, if the patient does not harm Mr. X but instead later commits some other unrelated violent act, then that was not a foreseeable event that could have been prevented.
On the other hand, there is a duty to warn if a delusional patient says that he is going to shoot up the police department but instead shoots the urban planner who had an office next to the police department. In that situation, it would be foreseeable for the patient to shoot someone other than his intended target.
Thomas W. Brown, M.D.
Patient Relationship Important
At the institutional setting where I once worked, we had a patient who made a very specific homicidal threat to another doctor. In this situation, we had not only a duty to warn but also a duty to protect the doctor. The police handled the situation as they would with any homicidal threat on another person. We weren't able to follow up with how the situation was resolved, however.
If a patient is clearly agitated, angry, and mentally distressed but doesn't make any specific threats, 1 feel protection may be taken care of adequately without resorting to hospitalization. The issue falls on whether you should institute protection by hospitalizing the person who is having violent feelings toward somebody else or, depending on your clinical assessment of the situation and your relationship with the person, determining that adequate protection is taken care of with medications, settling the person down, and increasing visits.
If you have a good relationship with the person, you can keep him or her engaged and really foster strength and inhibition in that person. Nowadays, however, psychiatrists have so many patients that they no longer have relationships with patients. Instead, they see patients for a medication evaluation once every 3 months, which puts a different level of difficulty on assessing anger. If I don't know the person, I have no way of really engaging him or her and knowing that the relationship will provide the strength necessary to inhibit the patient from taking any harmful action. This is the critical change that has come into practice since the Tarasoff I and II laws came into play
Marilyn Benoit, M.D.