Threats of violence to third parties in group psychotherapy

Steinberg Threats et to al. Parties Third Threats of violence to third parties in group psychotherapy Paul Ian Steinberg, MD, FRCPC Satna Duggal, A.A.R.O.T. John S. Ogrodniczuk, PhD This article considers threats of violence toward third parties during group therapy. An approach to preserve the group work, protect the threatened individuals, maintain the threatening patient’s treatment, and protect the group leader medicolegally is described. Obtaining expert legal advice is very important. Reluctance to seek legal advice and inform third parties needs to be resolved. Knowledge of jurisdictional laws pertaining to disclosure is essential. (Bulletin of the Menninger Clinic, 72[1], 1-18) Since the California Supreme Court’s decisions in the Tarasoff rulings, physicians and psychotherapists are considered to have a duty to warn a potential victim of a potentially dangerous patient. The principles of justice and protection from harm are felt to outweigh the principle of confidentiality in these cases. In the first Tarasoff ruling, the court decided that physicians or psychotherapists with reason to believe that a patient may injure or kill someone must notify the potential victim, his or her relatives or friends, or authorities such as the police. It is left up to the therapist’s or physician’s judgment regarding whom to notify, depending on the circumstances (Tarasoff v Regents of the University of California et al., 1976). The second Tarasoff ruling broadened the physician’s The authors thank Dr. Anthony Joyce for his assistance in the preparation of this article. Dr. Steinberg is Clinical Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada. Mr. Duggal is Team Leader, Day Treatment Program, University of Alberta Hospital, Adjunct Assistant Professor, Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada. Dr. Ogrodniczuk is Assistant Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada. Correspondence may be sent to Dr. Paul Steinberg, Division of Behavioral Science, 420-5950 University Blvd., Vancouver BC, V5Y 2G2, Canada; e-mail: dr.paul. [email protected]. Copyright © 2008 The Menninger Foundation) Vol. 72, No. 1 (Winter 2008) 1 Steinberg et al. and therapist’s mandate from a “duty to warn” to include a “duty to protect” (Weinstock, Leong, & Silva, 2001). Courts have not made a uniform interpretation regarding the “duty to protect”; when a specific identifiable victim seems to be in imminent and potentially serious danger from a threat of an action by a mentally ill patient, the therapist is expected to act (Simon, 2000). Since the Tarasoff rulings, health professionals have been obliged to balance their obligation toward their patients’ rights to confidentiality with the rights of third parties to be informed of threats against them during the conduct of treatment. Knapp and Van de Creek (2000) emphasize the Tarasoff decision as establishing a “duty to protect,” as opposed to merely a “duty to warn.” They refer to Appelbaum’s (1985) three-step procedure regarding responsibilities under Tarasoff. These steps are assessing dangerousness accurately, formulating a treatment plan, and implementing a treatment plan. In assessing dangerousness, one must consider past threats of violence, threats to harm others, accessibility of weapons, relationship with the intended victim, membership in a group that condones violence, and lack of adherence to treatment. We would add to that list a past history of violent behavior. In formulating the treatment plan, one must consider warning the intended victim or others likely to apprise the victim of the danger, notifying the police, or “taking whatever steps are reasonably necessary.” Increasing the frequency of appointments, providing medication for the patient, or referring the patient to a structured program are suggested. It is important to ensure that the treatment plan is implemented. Simon (2001) discusses the duty of mental health clinicians to foresee, forewarn, and protect against clients’ violent behavior. He emphasizes that the risk of harm be serious, imminent, and directed to an identifiable person, adding that the “duty to protect” allows greater treatment latitude than the “duty to warn” alone, emphasizing the need to preserve confidentiality as far as possible. Perhaps issues of dangerousness are more relevant in recent decades because of societal changes. We are not aware of evidence documenting an increase in violence in society. There is even some suggestion of a decrease in crime in some jurisdictions. However, our impression is that it is indisputable that events ranging from 2 Bulletin of the Menninger Clinic Threats to Third Parties the extreme of mass murders to more mundane experiences such as verbal abuse, disrespectful behavior in public, and violent behavior have all increased in frequency in the Western world in the last half century, and that society’s attitude toward the more mundane behaviors listed above has become increasingly tolerant and even blasé. It would not be surprising for behaviors that became more tolerated in society to tend to manifest themselves more freely in a psychotherapy program open to the public. To give a trivial example, it is common for patients to wear baseball caps during therapy sessions, which would have been considered unthinkably disrespectful 50 years ago. Threats in Group Therapy Since the early 1970s, group therapy has become one of the most frequently used forms of nonpharmacological treatment in public mental health settings. The continued growth of group therapy as a major treatment modality constitutes one of the most significant developments in the mental health field (Kaplan & Sadock, 1993). It is becoming particularly common for group therapy to be used with more severe patient populations. For example, group therapy has become an integral part of the treatment protocol for patients with schizophrenia (e.g., Granholm et al., 2007). Similarly, in the United Kingdom, group-based partial hospitalization programs are being developed by the Ministry of Health in order to create a network of services for patients with severe personality disorders (Home Office and Department of Health, 2003). Using common search engines relevant to our field, including PsychInfo and Medline, we were unable to find any literature dealing specifically with threats of violence in group psychotherapy, whether to members of the group or to third parties (i.e., individuals outside the group). We are unaware of laws specifically dealing with mental health professionals’ legal responsibilities to third parties following a threat. We understand that the common law is largely based on the Tarasoff decisions and subsequent experience in dealing legally with threats. Vol. 72, No. 1 (Winter 2008) 3 Steinberg et al. Clinical Ramifications of Threats in the Group Group therapists must display strong leadership qualities at times of crisis, including the propagation of a threat against an individual outside the group. The group members need to see that the threat is dealt with effectively to be reassured that no violence will be perpetrated, and that the therapists can contain group members’ aggression safely and nonpunitively. Uttering a threat in group therapy involves a diversion from the structure of treatment, which needs to be dealt with in the group. When the threat is to an individual outside the group, the leaders are required to consider the need to undertake a further diversion from the group structure, which involves informing individuals outside the group about material brought up in the group, which constitutes a breach of confidentiality. Diverting from structure can have serious ramifications in group psychotherapy. Complications, sometimes not easy to identify, may result in a temporary rupture involving significant testing and reenactments. When policy is disrupted or changed, reestablishing stability is important. This can be accomplished if there is a strong alliance between the group leaders (in the case of co-led groups), the leaders and the patients, and the leaders and the group as a whole. Diverting from structure also introduces a risk of ruptures and subsequent impasses developing in the therapeutic alliances. This is complex in a group setting in which various relationships have to be repaired, including between leaders and patients, between the leaders, and the relationships in the group as a whole. Group ruptures have been classified into “withdrawal” and “confrontation” subtypes (Safran & Muran, 2000). Both may occur simultaneously, with some group members withdrawing into a passive, hostile silence, while narcissistic, borderline, and antisocial patients express the group’s hostility and general dissatisfaction. If the antisocial element is relatively strong, more serious ruptures and impasses are more likely to develop. This may result in a collective disturbance (Steinberg et al., 2004) with considerable acting out, pairing, and subgrouping which undermine the treatment. The group is forced to go through a cleansing process before hope and trust can be reestablished and stability restored. Discharges from the group, 4 Bulletin of the Menninger Clinic Threats to Third Parties initiated by patients or the group leaders, are often an unavoidable part of this process. A similar process can be seen when the coleaders of a group are not functioning as an organized and cohesive team. Unidentified or unrepaired ruptures between team leaders can cause serious dysfunction. Although outwardly the coleaders may appear to be functioning competently, there may be critical but stable conflicts that need to be resolved. We have found this situation to be associated with an increase in the risk of threats of violence in our group program (Steinberg & Duggal, 2004). One early sign of leader discontent involves withdrawal from leader discussions, not providing input into decisionmaking, or not fully implementing decisions as planned. Leaders require much resilience and tact to repair this type of rupture and prevent further splits from developing. Case Examples The case examples provided below are derived from psychodynamic psychotherapy groups. The groups are held within the context of the Day Treatment Program (DTP) of the Department of Psychiatry at the University of Alberta Hospital in Edmonton, Canada. This is an 18-week all-day intensive group psychotherapy program based on psychodynamic principles. Most of our patients have severe personality disorders such as borderline personality disorder or narcissistic personality disorder. Many have antisocial traits; at any one time we usually have at least one patient (of about 35) with an antisocial personality disorder. Most of our patients have comorbid Axis I disorders, mood disorders in particular. Patients attend a variety of unstructured and semistructured groups on a daily basis 4½ days each week. Confrontation and interpretation are the chief techniques employed in the groups. Identifying data of these patients have been altered for the sake of anonymity. DTP begins each day with a large group attended by all staff members and patients. This functions as an unstructured psychodynamic psychotherapy group and is essential for the cohesion of DTP participant. At the beginning of this group, administrative issues and medication questions are dealt with. Vol. 72, No. 1 (Winter 2008) 5 Steinberg et al. Patients spend the remainder of the day in smaller groups of 10 to 15 participants with one and sometimes two leaders. These groups may be unstructured therapy groups or may be structured in various ways to invite patients to deal with issues such as separation, loss, developing a sense of agency, self-discipline, and termination. Therapists in DTP are trained on the job. They represent a variety of disciplines, including nursing, social work, occupational therapy, and psychology. The discipline of origin is irrelevant, as the therapists’ formal education did not prepare them for the type of work they do in DTP. On-the-job training, which lasts for the entire duration of therapists’ employment in DTP, consists of meeting with cotherapists after every co-led group, attendance at weekly hour-long staff relations groups (O’Kelly & Azim, 1993), and unscheduled discussions among the therapists, the team leader, and the psychiatrist coordinator as needed. New therapists receive much individual teaching and support from the team leader in the first two years in DTP. An essential component to ongoing staff learning is mutual support and confrontation, which occurs on an ongoing basis, and is given a regular venue in the staff relations group. Prior to admission, a therapist meets with each patient in order to provide an orientation to the program. Included in this orientation are explicit comments regarding the need for confidentiality, i.e., the importance of not disclosing to individuals outside the group anything patients learn in the group pertaining to other members. Patients socialize with each other on breaks and at lunch. However, they are told not to discuss group or DTP issues among themselves outside of groups, and they are not permitted to meet outside of DTP hours, either during or after their attendance at DTP. Patients are not routinely told in their orientation that threats of violence or violence itself are unacceptable in DTP. If the therapists, when meeting with a patient to discuss suitability for DTP, feel that it is necessary to be explicit to the patient regarding the acceptable limits of behavior, this would be done in the orientation. This most likely would occur with a patient who had a history of making threats, violence, or other illegal behavior, or if the therapist who assessed him or her for DTP had reasons for concern based on the patient’s behavior in the assessment interview. 6 Bulletin of the Menninger Clinic Threats to Third Parties In the cases described here, other DTP patients generally did not seem to be personally affected by threats made by their peers toward individuals outside DTP. They generally did not express resentment about the extra time consumed in group or the extra attention given to threatening patients, although at times they expressed exasperation at the lack of cooperation of the latter regarding their repeating threats as opposed to performing psychotherapeutic work. The patients were not tolerant of threats or implied threats made to children, and they confronted the threatening patients strongly about this. Case 1 Fred, a 35-year-old divorced librarian’s assistant with a diagnosis of borderline personality disorder, had a long history of self-mutilating behavior, suicide attempts, and multiple hospitalizations. After completing DTP, he was invited into a weekly psychotherapy follow-up group, which meets for 1½ hours per week. This group is reserved for patients who have demonstrated both a capacity for productive work in psychodynamic group psychotherapy and evidence of being able to benefit from more group therapy. Fred indicated in the follow-up group that he intended to kill his dying father and then himself. Fred’s father had allowed Fred’s uncle (his father’s brother) to sexually abuse him when he was a child. Fred subsequently maintained a distant relationship with his father, in spite of Fred’s wishes for some closeness from him, especially because he had given up hope of a closer relationship with his mother. Fred’s father had been suffering for some years from a neurodegenerative condition, had taken a turn for the worse recently, and was not expected to live more than another few months. Fred indicated that he could not bear to see his father suffering, although there was no indication that he was suffering more than he had been. There was, however, considerable evidence suggesting that Fred was having difficulty containing both his rage at his father and his guilt at wishing over the years that he would die. He had conscious fantasies of murdering him. Fred appeared obdurate in his intent to end his father’s life. The therapists felt that he was less seriously intent on committing suicide at that time. After obtaining advice from legal counsel, the group leaders informed Fred’s mother of what Fred had threatened, because his Vol. 72, No. 1 (Winter 2008) 7 Steinberg et al. father was too ill to come to the phone and was in no position to arrange for protection for himself. Fred’s mother took the news calmly and did not sound surprised. She refused to inform Fred’s father, not wanting to upset him, and feeling that it would be no use anyway. We had asked her to do this on the advice of legal counsel. We also had informed Fred of our intention to call his family. Fred’s mother reassured us that Fred would never be left alone with his father during visits. We informed Fred that he would have to make a choice between maintaining his intent to kill his father or continuing in group psychotherapy, as the two appeared mutually incompatible to us. We told him that he was fully entitled to feel like killing his father, and that his task was to come to terms with those feelings in the group, as opposed to repeatedly stating his intention to act them out. The leaders felt that nothing would be served by certifying Fred and bringing him yet again into hospital, especially because they did not feel that he was actively suicidal, and they believed that adequate arrangements had been made for his father to be protected from him. Fred stubbornly clung to his course of indicating his intention to kill his father and opted to discharge himself from group therapy. One week after Fred discharged himself, he called one of the group leaders, pleading to be readmitted to the group, and promising that he would no longer threaten to harm either himself or anyone else. The leaders agreed to readmit him, which was an exception to usual policy, but one that seemed justified on the basis of Fred’s initiative in calling back and reversing his original destructive plans after thinking them through. We were also influenced by the considerable progress that Fred, who suffered from a very severe personality disorder, had made in DTP, and our feeling that it would be in Fred’s best interest therapeutically to remain in our group. Fred’s course for the months he remained in the group was remarkably stable, given his long history of mood swings, self-mutilations, and suicide threats, gestures, and attempts. The leaders were left with the impression that confronting him with the choice between continuing his therapeutic work in group and embarking on a destructive course that he would be prevented from carrying out was useful in managing Fred. Two years after Fred was discharged from the follow-up group, the authors had 8 Bulletin of the Menninger Clinic Threats to Third Parties a chance encounter with him in the hospital corridor. He was working at a full-time job, was subjectively well, had lost 100 pounds and no longer appeared overweight, and had not resumed his self-mutilating behavior. From his point of view, he was leading a productive, satisfying life. Fred’s return to group was relatively easy to contain and work through in the follow-up group. The duration of treatment in this group varies between 14 and 18 months. The boundaries and structure are the same as in DTP, but patients are expected to function more independently and to be more open to confrontation and to reflecting on themselves. Both therapists were in full agreement with respect to having Fred return to the group. They also had well-established healthy alliances with most group members. To foster Fred’s constructive return to group, strict limits were developed for him to adhere to, and it was made clear to him that his return was conditional. To further involve him within the group and reestablish an element of trust, Fred was also asked to inform the group about what had transpired and to demonstrate a willingness to continue exploring and working through the impending loss of his father. Fred was aware from his previous experience in DTP that he would be confronted by patients, and that some anger might be directed toward him. Therapists were also aware that Fred needed to take the initiative and demonstrate a willingness to work, and that the group members needed support from the therapists to deal with their own mixed feelings regarding Fred’s return. The leaders also monitored the group closely for signs that Fred might be scapegoated. On his return to the group, Fred informed the group members about what had occurred and about his feelings about the therapists’ actions. He felt relieved that his family members were supportive of him, although he was never left alone with his father. The group received this in silence, most members reserving their own thoughts. Only two members responded in supportive terms. It was clear that most members were skeptical of Fred, feeling that he could only reestablish himself in the group by proving himself somehow, which clearly would take time. Eventually, with encouragement, some members expressed frustration toward the therapists, who were viewed as inconsistent parents, favoring Fred. Some expressed relief that the therapists had taken some constructive action. The Vol. 72, No. 1 (Winter 2008) 9 Steinberg et al. real test came when Fred missed a session and returned to announce that his father had died. Because his absence was not addressed, it appeared that the group had not accepted Fred into the group, and there were still unresolved feelings about the decision to readmit Fred. His determination to deal with the loss, without further acting out, probably softened the group members and helped the therapists to assist the group in negotiating the impasse. Case 2 Sylvia was a 50-year-old widow suffering from dysthymic disorder. She was also diagnosed with narcissistic and histrionic personality disorders. Sylvia announced in a group in DTP that she intended to kill herself. She added that she would kill her beloved great-nephew first, not wishing the great-nephew to survive without her in the care of his (according to Sylvia) unloving parents. Sylvia always described her relationship with her great-nephew as very close. She appeared unwilling to consider how much she might envy the great-nephew for having more favorable family circumstances than she herself had enjoyed as a child. Because Sylvia was a patient in DTP, she was able to be monitored closely regarding her suicidal and homicidal intent. As her discharge date approached, Sylvia continued to be unwilling to look at her reasons for wishing to kill herself and her great-nephew, and she expressed with increasing determination her intent to do so. The team followed legal counsel’s advice and sought a court order giving them permission to inform Sylvia’s nephew of the threat to his son. In Canada and the United States, three criteria are generally necessary for a health professional to be permitted to inform a third party of danger to him or her based on the threat of a psychiatric patient. The first is that an identifiable person needs to be at risk. The second is that the risk needs to be imminent, a qualification that may be interpreted in various ways. The third is that the physician or therapist needs to have learned of this risk in the context of a professional relationship with the patient. Permission is sought from court if it is felt that the risk is not so immediate that delaying disclosure of the risk might endanger the life or health of the individual at risk. If the risk is felt to be more immediate, the individual at risk and the police may be informed without a court 10 Bulletin of the Menninger Clinic Threats to Third Parties order. At a court hearing attended by the psychiatrist involved, his legal counsel, Sylvia, and her legal counsel, permission was granted to inform Sylvia’s nephew of the risk to the great-nephew. The nephew indicated that he would not permit Sylvia to see his son alone. Sylvia continued in treatment and at no time following the court appearance appeared to be at serious risk of suicide. Yet her involvement in psychotherapeutic work appeared to be quite limited. The group leaders were left with the impression that Sylvia may have felt that she could utter threats with impunity as a method of dealing with uncomfortable affects, and that taking a legal course of action culminating in a court order was a useful method of confronting her with the limits of her freedom of speech. It is impossible to know whether Sylvia would have carried out her threat to kill her great-nephew. We decided in Sylvia’s case that her threats could not be ignored, either from the point of view of her great-nephew’s safety, her treatment, or the potential for medicolegal complications. The DTP staff felt that it was feasible to maintain Sylvia in treatment while indicating that her threats were unacceptable. It was felt that she derived some benefit from the combination of ongoing confrontation regarding her destructive behavior and support in functioning in a more constructive manner. For Sylvia to be contained within the treatment environment, it was important to consider the impact of the legal action upon group members. Any mention of “legal action” generates considerable anxiety because most of our patients not only come from abusive and neglectful backgrounds, but also have been abusive or neglectful to others. Patients are encouraged to talk about destructive aspects of themselves. Most are unable to differentiate between dealing with violent impulses in a constructively therapeutic fashion and planning to act on them. This leaves them in a position in which they feel easily threatened. It was imperative that the group members be made aware of the seriousness of Sylvia’s threat. Patients were encouraged to help her work through this. Considerable patient and staff energy was invested in helping Sylvia to deal constructively with her envy. Patients appeared aware of her resistance to doing therapeutic work, and they did not overreact when Sylvia informed them about having to go to court with the psychiatrist. Most patients appeared Vol. 72, No. 1 (Winter 2008) 11 Steinberg et al. supportive of the psychiatrist’s decision. Sylvia presented herself in a manner that appeared manipulative, designed to generate an envious reaction from the group. She presented herself as unique and requiring some special attention. This was unsuccessful; the group shifted from a state of trepidation and anxiety to one of anger at Sylvia. Perhaps it was less damaging to Sylvia to have made this attempt to attract attention, rather than treating the legal intervention as a narcissistic injury. She completed the 18- week treatment. Generally, patients were relatively supportive and had an opportunity to deal with the envy and destructive wishes that Sylvia’s behavior had evoked. Three years after discharge, Sylvia spontaneously called the psychiatrist just to let him know that she had figured out on her own the motivation for some difficulties she was having in her relationship with her nephew, which was an issue that had come up during treatment. She appeared clearly to have maintained a positive attachment to the treatment staff, in spite of the legal involvement. Case 3 Henry, a 26-year-old accountant and married father of two with a diagnosis of narcissistic personality disorder with antisocial traits, was making little progress in treatment. He remained unengaged with most of the patients and all of the therapists, sitting quietly through the groups, doing little therapeutic work. Henry had revealed to the group that he and his wife had secured a contract to consult at a school regarding the school’s accounting procedures. He indicated in a self-satisfied manner that only his wife was formally acknowledged to be involved in their business. Because they would be working in a school, they were obliged to undergo a check of police records. Henry had a criminal record for having sexually abused a child in the past, and he did not believe he would be allowed to enter a school on a regular basis to work. The leaders of the group were anxious about the possibility of Henry abusing the children to which he would have access, although when confronted, he stated outright that he would not do this. He added that he would not be “actively involved.” The leaders were concerned about Henry’s deception in the securing of the position. After seek- 12 Bulletin of the Menninger Clinic Threats to Third Parties ing legal advice, they discussed their concerns with the city social services department. Henry’s treatment in DTP concluded shortly thereafter. He expressed little regarding his feelings about the staff’s legal involvement in his planned work. He subsequently visited the office of his attending psychiatrist and made vague threats of physical violence toward both that psychiatrist and the psychiatrist of DTP. Legal counsel was again consulted and application to court was made for a restraining order, such that Henry not be permitted to approach within 500 feet of either of the psychiatrists’ houses, should he be aware of their locations. He was also prohibited from returning for assessment or treatment at the Department of Psychiatry in which DTP is located. The social services department was left to investigate and deal with the question of the appropriateness of his involvement with the school. Several attempts were made to engage Henry to get a clearer sense of how he intended to help his wife without being actively involved. He remained uncooperative. Frequently, group pressure can be utilized to break down resistance to doing therapeutic work. However, group members remained passive when invited to confront or encourage Henry. Either Henry’s lack of participation and ongoing resistance had frustrated group members such that they had given up on him, or they were fearful of confronting him. This was difficult to determine because Henry completed treatment before any further action was taken. Discussion Physicians and therapists who are confronted with threats to third parties by their patients need to choose from a number of options that will adequately protect the threatened individual, provide legal protection to the physician or therapist, and, when feasible, enable the treatment of the threatening patient to continue. These options include, but are not limited to, warning the threatened third party and/or his or her relatives, friends, and the police; applying to the courts for permission to inform these individuals; contacting social service agencies for advice when unidentified children may be at risk; and discharging the threatening patient from the group. If the threat is felt to be associated with acute psychiatric disturbance in the patient, consideration should be given to having the patient cerVol. 72, No. 1 (Winter 2008) 13 Steinberg et al. tified for psychiatric assessment. Expert legal advice provides objective guidelines regarding defensible and appropriate approaches to dealing with threats. It also provides support to physicians and therapists, which in turn enables them to deal with their feelings about the threat and potentially to continue their treatment relationship with the threatening patient. Fear and anger are understandable and probably almost universal reactions among physicians and therapists to threats (Steinberg & Duggal, 2004). This appears to pertain whether the threat is directed toward a physician or therapist, a group member, or an individual outside of a group. It is plausible that when the threat is directed toward a third party, the anger and especially the fear elicited in physician, therapist, or group members may not be as intense as when the threat is directed toward the physician or therapist or group member. However, in groups like ours, in which many of the members have experienced abuse, violence, and threats of violence, threats of violence uttered can elicit extremely strong emotional reactions from other group members. This, of course, may occur in physicians and therapists as well as in patients. Situations in which the threat is directed toward a member of the group, however uncomfortable they may become, inherently may have some practical and psychotherapeutic advantages compared to situations in which threats are directed toward third parties. In the former case, there is no need to consider whether or how to inform the object of the threat; presuming that she is in attendance, she is aware of the threat as soon as it is made. She can also expect the emotional support of the group members, and both the psychotherapeutic support of being helped by the therapists in dealing with her feelings about the threat as well as the practical support of receiving reassurance that (and observing how) the threat will be dealt with in a manner so to protect her and the psychotherapeutic process of the group. As anxiety provoking as threatening situations may be, in cases when a threat is made to a group member, therapists generally do not have to be involved in extra-group interactions, apart from the possibility of having a threatening patient certified for psychiatric assessment or admission to a psychiatric facility. With threats to third parties, physicians and therapists must consider involving 14 Bulletin of the Menninger Clinic Threats to Third Parties individuals outside the treatment relationship. It also becomes prudent to seek legal advice, which may make some physicians anxious, and also may incur significant financial expense. We hasten to add that the anxiety, financial cost, and potential guilt and grief involved in not appropriately seeking legal advice when a threat is followed by a physical attack or even murder exceed out of all proportion whatever discomfort and cost may be incurred by seeking legal advice and appropriately informing third parties. A very important part of the process is to seek advice from a lawyer who is experienced in this field. In Canada, physicians are fortunate in having a national organization that provides both malpractice insurance and legal consultation for a very reasonable annual fee. We have concluded from our experience that it is prudent to err on the side of conservatism and safety, and we tend to seek legal advice whenever it occurs to us as a serious consideration. We have been gratified by how seriously our legal consultants take our concerns, how helpful their advice is from a practical point of view, and how often threatening patients can be contained and their treatment continued with an approach that combines informing third parties and confronting the patients’ threatening behavior in a therapeutic manner. Physicians and therapists may hesitate to seek legal advice or to inform third parties for a number of reasons. As threats hopefully are not a common feature in any one physician’s or therapist’s experience, one may be reluctant to tread upon the unfamiliar ground of medicolegal considerations. One may be (misguidedly) concerned about the ramifications of breaching one’s patient’s confidentiality, if one is not well informed about the limits of therapist-client or physician-patient confidentiality. One may rigidly and mistakenly place a higher priority on one’s patient’s right to confidentiality than on a third party’s need for protection. One may feel, utilizing what might be called a manic defense (Racker, 1968), that one can manage the threatening patient on one’s own, without external help or advice. Physicians who are aware of the laws in their jurisdiction pertaining to third party disclosure and who are prepared to seek advice in areas (such as the law) that are outside their area of expertise are in a much better position to fulfill their professional Vol. 72, No. 1 (Winter 2008) 15 Steinberg et al. obligations. These include offering competent psychotherapy, including treatment to the threatening patient when it is possible to maintain the treatment relationship, and (in a group context) helping the group to deal with the threat; ascertaining when it is appropriate to notify individuals and/or agencies outside the group, and doing so; and protecting oneself from a medicolegal point of view. Knowing about the appropriate options for dealing with a threat provides support to physicians and therapists in a manner similar to how competence in other areas of their work provides a realistic sense of self-confidence. Managing threats against third parties in a day treatment program appears to be easier than doing so in most other groups. We have the advantage of being able to assess our patients’ potential for violent behavior in an ongoing manner, for 4½ days every week. This offers a much greater opportunity for observation, both with respect to time and to number of observers, than, for example, an outpatient psychotherapy group that meets for an hour and a half once a week. Group therapists under the latter circumstances might be obliged to act more quickly upon the utterance of a threat to a third party if they did not expect to see the threatening individual for another week. One concern involves the risk of becoming so preoccupied by the threatening patient’s behavior (that is, his or her threat) that the treatment of the patient suffers. A physician’s or therapist’s preoccupation with the danger his or her patient may represent to a third party may result in a tendency to deny the danger and not continue a needed ongoing assessment assiduously enough. Conversely, one may deal with one’s anxiety by assessing the patient in a frequent but ineffective manner, possibly becoming oblivious to other psychiatric concerns that need to be addressed. Obtaining an elective, urgent, or emergency second psychiatric opinion must always be considered. Treatment can take on an unduly behavioral coloring if leaders and patients are preoccupied with the extent of a group member’s dangerousness. The threatening behavior must be dealt with appropriately to vitiate the threat. The danger is that, especially if the physician is not satisfied that necessary practical steps have been taken to deal with the threat, s/he may remain preoccupied 16 Bulletin of the Menninger Clinic Threats to Third Parties with the danger which the threatening patient presents. This also depends on to what extent the physician’s countertransference fear and anger have been consciously experienced and adequately contained (Steinberg & Duggal, 2004). If the physician or therapist remains preoccupied with the threat, he or she may try to deal with the threat in a concrete practical manner in order to reassure himself or herself that the danger is under control; that is, in a defensive manner, designed to ward off his or her own fear. Alternatively, the physician or therapist may act out his or her anger in an unproductive way, assuming a censorious attitude toward the threatening patient, whether the patient is present or not. Clearly, both practical and countertransference ramifications of the threat need to be dealt with adequately if the patient and physician are to continue in a treatment relationship. It is impossible for physicians and therapists to find a place to engage in our clinical work when we do not feel safe. Conclusions Threats of violence toward third parties are inevitable in psychiatric practice. Physicians and therapists need to be prepared to deal with these threats, from both a clinical and a legal point of view. It is important to deal with the issue of concerns about threats in order to be able to continue devoting attention to one’s therapeutic work. The threatening behavior must be dealt with (and, in group settings, be seen to be dealt with) effectively. Practical and countertransference aspects of threats need to be resolved if patient and therapist are to continue in a treatment relationship. 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