TARASOFF? DO NOT ENGAGE

Human services workers report mounting levels of anger and hostility in this country. The causes—psychological, economic, social and spiritual—are debated widely, but the rising tides of rage and incipient violence are not.

Editorial, Journal Gazette (Fort Wayne), April 29, 1997

What training would a reasonable clinician need in order to face their most dangerous work hazards?

The Tarasoff law was written in 1969 for good reason; if a client states a plan to harm someone, common sense dictates the mental health worker intervenes appropriately to interrupt that plan where possible within the limitations ofthe role.

But we can’t help anyone if we are dead.

Informed consent exceptions to confidentiality expanded after the tragic foreseeable murder of Tanya Tarasoff, such that now every counselor is charged with the duty to warn if a client states a plan to harm an identifiable victim. But there seems to be a common expectation among practitioners and educators that counselors engage with such clients to determine if a client’s threat is “viable”, or “credible”, or even try to de-escalate and treat such a client even though their education has not afforded them any training to do so.

How does that unfold if our client happens to be concealing a weapon in that moment, and perceives us as now being in their way? How does that unfold if our client has been using substances recently, and has reduced impulse control? How does that unfold if our client is actually socipathic, and we are just now realizing that? How does that unfold if our client is having an acute psychotic break, and we had just barely begun to assess some prodromal symptoms?  How does that unfold if we are suffering from the delusion that our basic talk interventions, our graduate degree or license, somehow endows us with ninja skills to disarm an angry and violent client? Did the SWAT team offer something to your counselor education program that we are missing in ours?

If the SWAT team, or Navy SEALs, or CIA, or FBI came to your counselor education program to give you intervention tactics on disarming an angry and violent client, could you give me the number of someone over there to teach our students thosehigh-level skills before Practicum?

If we have performed informed consent according to ethical mandates, then we have tested for comprehension regarding every salient point of said contract, including the exceptions to confidentiality, in every client prior to beginning treatment.This means that we have been very explicit with our clients regarding physical safety of themselves and others, including clarifying that, “If you are going to kill yourself or anyone else, I have to get help for that. What questions do you have about that?”.

Any client who has an actual conversation about this duty to warn has been duly informed that they better not be sharing murder plans with their counselor, or the counselor will be calling the police. Our due diligence to our client regarding this particular expression of anger has thus been performed within the first twenty minutes of meeting them, and we owe them no more engagement around it. Any client who makes an offhand remark about “killing my _______”, and then doesn’t reel it back with an embarrassed flush and a quick “Just kidding! I don’t mean that! I’m just so angry and I don’t know how to cope! Don’t call the cops! I would never do that!” is probably beyond our scope. Technically, it’s insurance fraud to be working with someone outside of scope, in addition to being a bad idea for everyone involved.

There are mounting cases of mental health and social service practitioners at every level, both in private practice, and community mental health, being attacked or killed by clients (see reference list). Are we to believe this is inevitable, or that a fair amount of this is to be expected?  What can we do a scounselor educators to adequately prepare our students for the work hazards they face? What would a reasonable clinician do if a client states an intention to kill someone, or is manifesting behavior that would lead a reasonable clinician to suspect they are planning to do so?

I assert thatrisk assessment of danger-to-other should not be done in the field (whether private practice or community mental health); clinicians with advanced training and supported by sufficient infrastructure, such as while the client is handcuffed to the gurney in the ER or in a prison interrogation room, may reasonably manage the risk of such an engagement. Some clinicians that work on the other side of a metal detector would have been exposed to less risk in thepast, but with the advent of ghost guns and 3-D printers, this is no longer the case.

I assert thatif a client who has been provided true informed consent is stating an intention to kill an identifiable victim, a reasonable clinician would have good reason to assume that client is currently armed and dangerous, or would be able to kill with their bare hands. It is possible that the physical capacity of the clinician may override the client in some situations, but this would not reliably hold true if the client is armed.

I assert that are asonable clinician who has gone through standard education to address mental health conditions within their scope has zero training to disarm any client,and must act for their own safety in order to be able to complete their duty towarn. “What is lacking is a formalized approach from training programs. Several authors have called for increased training in risk reduction and workplace violence yet few training programs across mental health disciplines provide this service” (Saturno, n.d.).

The counselor education community must have an ongoing dialogue to expand upon this beginning list of steps to take in session should a counselor be informed by aclient of intention to harm, or be exhibiting signs of escalating agitationconsistent with risk to other, including the clinician:

1) As smoothly as possible, gently acknowledge the client’s had a stressful time recently, and express your empathy for their struggle in one brief statement such as, “It’s been such a tough time lately”’; draw out the exhale to a 6-count rhythm to slow down the body’s natural reaction to life-threatening panic.

2) As smoothly as possible, shift away from the mental set igniting the anger, and aim to peacefully distract your client towards a safer topic, to regulate them;“Thank you for showing up again today, I know life is busy”.

3) As smoothly as possible, either let the clock run down on the session while allowing your client to think they are going to see you next week, or,

4) As smoothly as possible, gently apologize for having to go to the bathroom, leave the room, and call the police (skip steps 5-6), stay hidden in a locked room until the arrest is made.

5) Gently escort your client out of the office without the slightest indication anything is wrong, or different.

6) As soon as possible, quietly lock the door, drop to your knees under the desk (if possible), and call the police, your supervisor, the intended victim (if possible).

7) Move up your appointment with your Compassion Fatigue Specialist therapist to tomorrow, have your practitioner run all five validated measures from that training for the next two months to keep a close eye on your recovery while addressing the effects of the overwhelm on your system.

8) Request an unmarked car provide protection for the clinician by the local police.

The counselor education community also must develop national standards for self-defense training, risk assessment and intervention. There should be no confusion among managers, supervisors, or line staff regarding the level of risk being asked ofa ny practitioner in varying circumstances, their right to life, and the lack of protection they are afforded to manage high-risk situations without the benefit of commensurate protection.

Karen Roller, PhD, MFT, FAAETS, DNCCM, CT, CFT, CSCR, worked in field-based settings for 20years. Upon retiring from public mental health and moving back on the grid, aformer client with psychotic process found her new address two hours away and showed up at her house; this puts the author in the group of practitioners who tend to adopt a more proactive stance towards clinician safety. She teaches at Palo Alto University.

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