The duty to warn/protect: issues in clinical practice

The duty of therapists to warn or protect third parties when a patient expresses a threat was established by the court in the Tarasoff decision. Confidentiality, disclosure, and prediction of violence are clinical, ethical, and legal issues that the therapist must address in the context of a therapeutic relationship. Clinical case material from the literature, as well as cases from the authors' experiences, indicate that when confidentiality is breached and a potential victim is warned, the therapeutic results may be positive, especially if the patient participated in the process. Other methods of protection, such as commitment, use of medications, police involvement, and confiscation of a weapon, may be necessary. Each case deserves individual consideration as to what appropriate and necessary steps should be taken. Through careful assessment of a patient's threats, concern for the patient and victim, adherence to ethical standards of care, and knowledge of the law, one can often protect a victim as well as engage the patient in an ongoing therapeutic relationship.