Psychotherapists last year. Now all licensed clinicians in that state must heed credible warnings about a clients threatened violence from the clients immediate family members, as well as threatening statements from clients themselves.

Appellate Court Justice Paul Boland said Los Angeles Superior Court Judge Frances Rothschild adopted too narrow a view of Civil Code Sec. 43.92 in granting Dr. David Goldsteins motion for summary judgment, which dismissed the case against him. The section immunizes therapists from damage claims for harm done by their clients except where the patient has communicated to the pschotherapist a serious threat of physical violence against a reasonably identifiable victim or victims.

Goldsteins client, former Los Angeles Police Department Officer Geno Colello, killed Keith Ewing a day after being released from Northridge Hospital Medical Center. Colello had been depressed about his breakup with his former girlfriend, Diana Williams, and about Williams new relationship with Ewing. Colello told Goldstein about his suicidal thinking, and Colellos father told Goldstein about threats his son had made against Ewing the same evening they were made. Goldstein, an LMFT, arranged for Colello to receive psychiatric care at the Northridge facility, primarily due to the suicidal threats, but did not take steps to ascertain Ewings identity and warn him. The Northridge doctors discharged Colello the next day over Goldsteins objections. After killing Ewing, Colello then committed suicide.

Ewings parents sued both the hospital psychiatrist and Goldstein for negligence, claiming Goldstein should have warned Ewing after he learned from Colellos father that Colello had threatened to harm their son. The trial court had accepted Goldsteins argument that the Sec. 43.92 exception was inapplicable, since the therapist learned of the threats from Colellos father, not from Colello.

The appeals court, however, disagreed with this too narrow reading of the law. Read literally, the justice conceded, section 43.92 would preclude the imposition of liability if information about the patients violent intentions, regardless of the credibility of the information, was received by a therapist from any source other than the patient. The trial court construed the statute in that manner. However, the rule of reason and a review of the circumstances which lead to the enactment of section 43.92 militate strongly against such a restrictive interpretation.

Boland noted that the law was passed in the wake of the California Supreme Courts decisions in Tarasoff v. Regents of University of California (1976) 17 Cal.3d 425 and Hedlund v. Superior Court (1983) 34 Cal.3d 695 in an attempt to limit the potential liability imposed on therapists by those rulings. It attempts to strike a reasonable balance between the patients interest in confidentiality and the need for public protection, he said.

The appellate court held that the expanded rule should state: When the communication of the serious threat of physical violence is received by the therapist from a member of the patients immediate family and is shared for the purpose of facilitating and furthering the patients treatment, the fact that the family member is not technically a ˜patient is not crucial to the statutes purpose. They reasoned, for the sake of public safety, that the Legislature did not intend to shield a therapist from suit in such a situation.

Justice Boland pointed out that the communication of the threats by Colellos father came within the patient-psychotherapist privilege under Evidence Code Sec. 1014, since it was functionally related to the diagnosis and treatment of the patient, but would have been subject to disclosure under Evidence Code Sec. 1024. The Evidence Code privilege provisions and Civil Code Sec. 43.92 should be accorded complimentary interpretations, if at all possible, he explained.

We discern no principled reason why equally important information, in the form of an actual threat that a parent shares with his or her sons therapist about the risk of grave bodily injury the patient poses to another, also should not be considered a ˜patient communication in determining whether the therapists duty to warn is triggered under section 43.92, the justice wrote.

Boland noted further, in light of Tarasoffs requirement that threats be serious, doable, and imminent, that it remained to be determined at trial whether, based on his experience and his past treatment of Colello, Goldstein should have treated the threats as serious. Dr. Goldsteins appeal to the California Supreme Court was denied, making the appellate court decision new law in California. And since California often sets the standard for other states, everyone should be apprised of this new rule of liability.

Legal Implications of the New Rule

So then, California therapists are now liable for failing to make a Tarasoff warning based on a communication from a patients family member. This raises numerous dilemmas that will take time (and likely more court cases) to resolve.

The decision does not relieve clinicians of the legal responsibility to use clinical judgment in assessing the seriousness of a patient threat before issuing a Tarasoff warning"you can still be sued for unwarranted breach of confidentiality if you issue a warning without a clinically reasonable basis. In fact, therapists now have the additional task of determining whether the communication has been made for the purpose of advancing the patients therapy. This puts you in the difficult legal (not to mention clinical) situation of needing to assess the reliability and motivation of a family members communication without violating the patients confidentiality.

_Ewing_ may also lead some therapists into breaches of confidentiality by discussing the patients case with the reporting family member. Many therapists accept communications from third parties, but usually tell these third parties: (1) that they cannot reveal whether they are providing services to the patient, and (2) that their policy is to share such communications with a patient, both to preserve the necessary openness of the therapy relationship and to pursue the safety issues raised by the communication. In some situations this raises problems, of course, such as when the third party is afraid of retaliation. However, it often works smoothly, and when it does, it helps to preserve the viability of therapy while still producing critical information. It also allows the therapist to assess dangerousness by directly querying the patient, which is usually better information than reports from third parties.

Some experts are concerned that the decision will be misused in family, custody and other disputes, the way child abuse reporting has been misused. Yet, other experts view the alarmed responses as exaggerated and believe that the impact of the decision is rather limited. They view the decision as merely implying that therapists cannot ignore third party statements about dangerousness and do not view it as a major change from how therapists have already been practicing. They take the position that, as before, therapists must integrate any statements about dangerousness, regardless of its source, into the clinical-ethical-legal decisionmaking.

Clinical Implications of the New Rule

Besides incorporating the new rule into their clinical-ethical-legal decisionmaking, California psychotherapists should add to their _Clinical Agreement and Informed Consent_ the following wording (in blue) in the _Confidentiality_ section_:

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, or to others, or is gravely disabled, or when a clients family member(s) communicates that the client has communicated a danger to others.

Dr. Mark Baker, Director of La Vie Center in Pasadena, California advises, We have an ethical and legal professional responsibility to keep our clients from harming others, not just to protect our client and others, because it ends up doing great psychological damage to the client.

Be prepared, thinking through your options and responses in advance.If someone threatens harm to himself or others, assess the eminent danger and know the legal and ethical steps you must take according to your licensing board and state.

Be wise, starting with the first session.Take a thorough history: medical, emotional, early childhood and family. Make sure you have all forms, paperwork (contact names and phone numbers in case of emergency) and releases signed. Also, it is best to explain issues of reporting and times you will need to break confidentiality during the first visit. Make it clear that you have their best interest at heart and you will do all you can to keep him and those around him safe.

When should you be concerned?Dont wait for the crisis moment. Continual assessment is key. At the top of your note-taking page, always write the following words: crisis, legal, ethical. Keep alert to these issues. Listen for words of despair, hopelessness, anger, and revenge, and follow it up with questions regarding a plan and means. Many clients say things like, Why live? or It would just be easier to heal if he was dead! But do these clients have a thought through plan, a way and means of hurting themselves or others?

Listen for cues and clues.Always assess how clients are dealing with their strong feelings: facing them, acting out, or numbness. Are there signs of the abusive cycle? Of male depression? It is often cloaked in anger. Unresolved losses? No social support system? Are they able to put in words their inner rage, sadness and strong emotions? Do they have impulse control? Are they able to step back and review their options before responding?

Document all you do.Write a treatment plan, make careful session notes, and document how you handle situations. It doesnt have to be long and detailed, it just has to show that you know what you are doing and are competent to guide a person along their journey. It will not only help you in case you have to account for your steps, it will also help you find what you are missing and guide you in your treatment.

Referrals are important.Make sure you are not the only support a client has. Referrals are life giving"especially to a medical doctor for ruling out a medical condition, a psychiatrist for medication, and support groups that pertain to your clients struggle: anger management, alcoholism, parenting, caring for the elderly, etc. Research continually shows that we cant, and dont, grow in isolation.

Dont do it alone.Make sure you have good supervision when dealing with difficult clients, not only for wisdom, but also for emotional support for yourself.

FOR THE CLIENT WHO GOES off in your office, your theory will need to be your guide in your treatment plan and intervention. What makes the pain so deep that a client lashes out in hurt and rage in your counseling room?

Attachment theory and Gods principles help me decide what to do in the counseling room. Both agree that we were created for a life of meaning and purpose as we live in close relationship with others. And for as much as we might dislike the imposition of Tarasoff in our clinical work, that rule is rooted in a policy that protects life first and foremost. My theory informs me that when we feel lost, hopeless and when life loses its meaning, or when the bond between two people is disrupted, the pain is deep and the first response to the loss is anger.

John Bowlby, the father of attachment theory, called it the anger of hope. He said that this anger is aimed at protesting the disruption of the bond in hope of restoring the bond. One gets angry in hope that the other will see their hurt and come to their senses and say, What have I done? Im so sorry Ive hurt you; I repent. I will change and come back and love you the way you need to be loved. Gods Word informs me that our anger can be productive and also very damaging. Online therapy can be helpful to get rid of such problems.

Conclusion

Because of the increased liability and the adverse affect of this decision on effective psychotherapy, several organizations sent letters to the California Supreme Court vigorously requesting that they review it. Unfortunately this court decided not to do so. These organizations included the California Psychological Association (the CPA worked with the national legal staff of the APA).

CPA has indicated that possibly the best recourse now is to seek legislation overturning the decision. A bill has now been introduced in the California Assembly that would reverse the Ewing decision by returning the Tarasoff duty to its original contours"triggered only by direct threats from the patient. If you support this effort, please contact Susan Chandler, Ph.D., current CPA Secretary, at schndler@pacbell.net or (415) 551-0061. If you contact her, please tell her whether or not you are a CPA member.

It is mostly rewarding, but sometimes risky, as you attempt to walk alongside your clients in their journey toward healing and wholeness. All behavior in context makes sense. As counselors, we have to understand why it makes sense for our clients to react the way they do, and then guide them toward a more flexible and reflective way of being.

Lets be careful out there.

_Sharon Morris May, Ph.D., is Director of the Marriage, Family and Relationship Institute at La Vie Counseling Center in Pasadena, California. She is in private practice specializing in EFT with couples and conducts couple intensives and EFT training for counselors. Sharons book, Safe Haven Marriage: Building a Marriage You Can Come Home To, outlines attachment and the EFT model for couples. Sharon can be reached at sharon@havenofsafety.com and 626-351-9616, ext. 175._

_George Ohlschlager, J.D., LCSW, is Senior Editor and Writer of Christian Counseling Today and other AACC publications; and is Executive Director of the American Board of Christian Counselors, the AACC-affiliated national counselor credentialing and program accreditation agency. He chairs the AACC Law & Ethics Committee, maintains a nationwide clinical/ethics/forensic consulting and training practice, and teaches in the Liberty University Center for Counseling and Family Studies, and at St. Petersburg Theological Seminary._