All practicing clinicians have occasion to recommend hospitalization to a patient during the initial consultation or treatment. All psychiatrists need to know the legal procedures in their state, as they do vary. For example, in Maryland, a petition for emergency psychiatric evaluation may be initiated by almost any citizen, where there is an imminent danger to self or others. If that petition is executed by a physician or a police officer above a certain rank, it does not have to be reviewed by a judge for probable cause. Such petitions are handled speedily, and the police or sheriff will take the person to the nearest hospital for psychiatric examination.
The consulting or treating doctor, of course, can usually influence the patient, with or without the support of relatives, to go for voluntary hospitalization. Doctors should manage patient crises involving out-of-control aggressive impulses, whether directed to others or self. Various methods of abandoning, or nearly abandoning, such patients should be avoided. These may include prolonged unavailability or apparent indifference to emergency situations. This may, in my opinion, also include putting a recording on one's phone that says, "If you have an emergency, go to the emergency room of the nearest hospital, where someone will help you."
I believe the standard of care requires handling such crises in a professionally competent manner. I discuss what to do in event of emergency with patients I know are prone to decompensation. This would usually involve having them call me or the covering physician. In the event they cannot reach me soon enough, they should go to the emergency room of the hospital where I regularly see patients, and where I know they will get good care and I will be contacted.Tarasoff and the Duty toWarn Third Partides
The Tarasoff case in California created a legal duty for the psychotherapist to take action to warn or protect the known victim or victims of aggression of a patient in treatment (Tarasoff v Regents of University of California, 1976). In its decision, the California Supreme Court said, "The protective privilege ends where the public peril begins."
The holding was unwelcome in the mental health care profession, with many feeling it would unduly compromise confidentiality and interfere with treatment. Appelbaum et al. (1989) wrote, "The ill-defined nature of the duty to protect has led to great confusion about clinicians' obligations."
But more than 25 years later, I believe that, in general, such a chilling effect or detrimental impact upon therapy has not occurred. To alleviate such concerns, a model statute was drawn up by the Council on Psychiatry and Law of the American Psychiatric Association in 1987. This has been quite useful to district branches in guiding post-Tarasoff legislative enactments in the various states. In the early years after Tarasoff, many states either did not adopt the doctrine or their courts enunciated outright hostility to the Tarasoff doctrine: that is, they rejected the idea that the therapist should breach patient confidences in order to warn or protect third parties. In recent years, however, the Tarasoff doctrine has spread rather widely.
While the APA model statute does create a duty to take action, it does so only under the condition that the patient has communicated to the doctor an explicit threat to kill or seriously injure a clearly identified or readily identifiable victim or victims, and "the physician fails to take such reasonable precautions to prevent the threatened harm as would be taken by a reasonably prudent physician under the same circumstances."
Such steps to be taken in Maryland law are: 1) Civil commitment; 2) "Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility the patient will carry out the threat"; or 3) Inform law enforcement and, if feasible, the victim. Immunity from civil liability is given to the physician who adheres to this plan of action.
The law uses the interesting concept of foreseeable. If our patient's risk of killing someone else, or themselves, is foreseeable, a legal duty is created for us to do something to try to prevent loss of life. If homicide or suicide is not foreseeable, we are not legally liable. As Simon (2001) explained, "As a general rule, a psychiatrist who exercises reasonable care in compliance with accepted medical practice will not be held liable for any resulting injury."
On reflection, I believe that what is now required of us is no more than what we should have done anyway in the rare scenario of a patient imparting a specific lethal threat, and that we are now granted legal immunity for doing what we should have done anyway.
We have reviewed the warning signs of actual danger in psychodynamic practice; the method of assessing dangerousness; and the appropriate steps to be taken in managing such risks. The clinician who is armed with such knowledge will practice with increased professional satisfaction and comfort.