ldquo;I'm going to kill that b-----!" I'd heard my client vent his anger and frustration about his wife before, but this time it was different. There was a cold, steely seriousness about it that penetrated my soul and made me imagine him doing it. Plus, she had separated from him a week earlier—which had really rattled and angered him—and she had put out a restraining order due to a second domestic violence incident against her. I decided to call my expert friend across country and consult about whether or not to report this to his wife and the police. Nothing strikes fear into the heart of a therapist faster than hearing a client threaten to harm herself or someone else, or even worse, disclose that they have already have.
How do we respond? What should we do? Or not do? Not only are there clinical issues, it is critical that we are familiar with the ethical and legal dilemmas involved in such cases. Briefly, I'd like to review four areas we must be vigilant in so we will handle these difficult situations in a clinically and ethically responsible manner. CompetenceRecently I was asked by a pastor to counsel a man in his church whose grandson had disclosed had sexually abused him. This potential client posed a danger to other children. Was I trained to assess this risk? Did I have the clinical skills to work with this person? Being a Christian or obtaining a degree or a license to practice doesn't guarantee that someone has the level of training or expertise necessary to counsel certain individuals with particular problems. The apostle Paul tells us that "love does no harm to its neighbor" (Romans 13:10). When we agree to work with people who have difficulties beyond our level of training, we risk hurting them and possibly others that they interact with.
The boundary between competence, consultation, and referral here is crucial for all counselors to know well. If you have some competence and take on a case slightly beyond your skill level, make sure you are consulting frequently with an expert therapist who can help you bring your skills up to par as you work through the case. If the case is clearly beyond your level of competence, make sure you have a good network of competent counselors to whom you can refer the needy person. Working incompetently with a dangerous client increases the danger to all involved exponentially. Know your limits and respect them! Limits of ConfidentialityMost clients assume that everything they tell us is completely confidential.
That is not true. Counselors must provide new clients with information in writing regarding the counseling process and the limits of confidentiality so that they are informed, prior to disclosure, of the consequences of certain kinds of revelations. A while back, even after reading the confidentiality guidelines ahead of time, a client asked me if everything he told me was confidential. I told him most of what he told me would be held in the strictest confidence, but if he told me he was going to hurt himself or hurt someone else or had abused a child, then I would break confidentiality as required by law. He then disclosed that he molested a child. I was thankful that he was fully aware of the limits of confidentiality before he confessed to me.
As a counselor, you must make yourself aware of the laws in your state regulating your professional responsibilities and what you must report. Every state, for example, has mandated reporting laws regarding the disclosure of child abuse, but the criteria of what constitutes reportable abuse might vary from state to state. In addition to things we must report like suspected child abuse, or dependent elder abuse, there are things we may report, thereby breaking confidentiality.
For example, if a client threatens to harm herself and other interventions like a suicide contract, increased monitoring or extra sessions haven't helped to mitigate her suicidal intent, we may have to inform her family, or when necessary call the police to initiate an involuntary hospital commitment to prevent her from harming herself. When a client threatens to harm an identified person, and in our clinical judgment, that threat is credible, notifying the proper authorities may not be sufficient. The Tarasoff rule (which is not the law in every state—know your state's rule here!) holds a counselor liable for not warning the intended victim and law enforcement. Subsequent cases have also suggested that we have a duty to warn not only the victim, but also family members and others who may be in close proximity to the intended victim (such as a child or roommate). George Ohlschlager has long advocated that all Christian counselors adopt the _Tarasoff_ rule because of its inherent life ethic—an ethical policy that errs on the side of life when life values clash with privacy values. He sums up the rule as stating essentially a two-part clinical assessment process that could trigger a duty to warn others: •
The counselor has conducted a thorough and competent assessment of the risk of client violence that considers _current risk, past behavior, family history of violence, drug use/ abuse, psychological/personality disorders, and relevant demographic and situational factors_; and • that assessment has yielded reasonable and verifiable evidence of • a communicated threat of violence or intent to harm • that is serious, doable, and imminent • against an identified or reasonably identifiable victim(s). More on Assessment of DangerSince it is impossible to predict with 100% accuracy dangerousness ahead of time, violation of a client's confidentiality must be undertaken with great care and in consultation with others. The art of counseling involves learning to discern what a client is really saying. When someone says, "I wish I (or someone else) was dead" are they talking suicide or homicide or just expressing frustration with their current stress levels or relationship difficulties? How do we distinguish between the client who vents in scary ways and those who may carry out their threatening words? Assessing seriousness and imminence of danger is fraught with trouble.
The best predictor of future violence is a history or pattern of past violence. Make sure you take a careful history of previous threats and violent behavior and whether there is a family history of these behaviors. In addition to good history taking, talk with family members (when permission is given) about their perspective and whether the client has threatened them or acted out in violent ways. This is especially important when working with domestic violence as perpetrators typically minimize their behaviors. Don't forget to contact previous therapists the client may have seen or obtain records from prior hospitalizations. These records give you a more informed clinical picture and enhance your treatment planning. Consult with other professionals such as a psychiatrist, medical doctor, an attorney, or a person who specializes in ethical dilemmas if you're unsure whether to report, who to inform or how to proceed with treatment.
Keep Good RecordsGood documentation is essential in every case, but with dangerous and threatening clients, it's critical. Make sure you have a treatment plan and you update and date it regularly. In your case notes record specifically what a client said, your assessment of the threat, what you did, and why you decided to do it. In addition, make sure you document and date who else you informed, what phone calls you made, who you consulted and the results of these contacts. Make sure your records include a signed consent for treatment and the limits of confidentiality. Unfortunately, if someone later challenges your care or treatment, it is his or her word against your records. If it's not down on paper, it's as if you didn't do it. Working with threatening and dangerous clients presents many difficult clinical, legal and ethical dilemmas.
It is crucial that we understand and act in a responsible way as we weigh the risks involved to our clients if we break confidentiality with the danger to potential victims and to ourselves. Seek Divine WisdomDangerous clients will challenge your best clinical knowledge, fray your nerves and interrupt your sleep. They will also drive you to your knees and make you fervently seek after divine wisdom that sometimes is the only true guide out of the near-impossible dilemmas that dangerous threats create. Asking God to directly and supernaturally intervene to stop imminent violence unlocks powers of prevention that nothing on this Earth can match. And nothing demands infusing our own clinical expertise with God's miraculous wisdom like threats of violence and acts of danger by clients who have gone out-ofcontrol. Leslie Vernick MSW, LCSW is a popular speaker for women's conferences, couple's retreats and professional workshops. She is the Director of Christ-Centered Counseling in Pennsylvania. She is the author of Getting Over the Blues: Find a therapist for immediate help.
A Woman's Guide to Fighting Depression (Harvest House, 2005) and How to Act Right When Your Spouse Acts Wrong (WaterBrook, 2001). She may be reached at , D.E., & Martin, D. (1993). The danger-to-self-or-others exception to confidentiality. Alexandria, VA: American Counseling Association. American Association for Marriage and Family Therapy. (2001). Bennett, B.E., Bryant, B.K., VanderBos, G.R., & Greenwood, A. (1990). Professional liability and risk management. Washington, D.C.: American Psychological Association. Herlihy, B., & Corey, G. (1996b). Confidentiality. In B. Herlihy & G. Corey. (Eds), ACA ethical standards casebook (5th ed.) (pp.205-209). Alexandria, VA: American Counseling Association. Ohlschlager, G., & Mosgofian, P. (1992). Law for the Christian counselor:
