Dr. Blumenfield review a case that a resident presented to a psychotherapy supervisor a few years ago.
The following was originally posted to PsychiatryTalk.
A few years ago I heard about a resident who presented the following case to his psychotherapy supervisor. (I have changed some details for confidentiality):
The patient is a 22-year-old woman who is working as a nanny for a prominent celebrity. She entered twice-per-week psychotherapy two months previously because of difficulty in relationships with men. She has just started to talk about how she was physically abused by her alcoholic stepmother as a child. During a recent session, she appeared to be distracted and wasn’t her usual organized self. Near the end of the session, she blurted out that she became very angry with the 18-month-old child that she cares for and slapped the child. She was scared she might have hurt the child, but he seemed to be OK. The therapist was stunned, and for the first time, was at a loss for words. The patient changed the subject and spoke about another subject, and then the time was up. Her parting words were that she was really glad that the therapist didn’t condemn her. She knew that she did the wrong thing with the child and would try not to do it again. She added that if the therapist had reprimanded her, she never would come back again. She feels she can trust the therapist and is now very hopeful about getting help in therapy.
What would You Do?
Before you read further, I would like to suggest that you jot down on a piece of paper if there is anything that you think that the therapist should do. Then let us see if the discussion below changes or supports your approach.
Mandatory Reporting of Child Abuse
It is well known that there is a bond of confidentiality between a patient and a physician that is recognized by the law. This also extends to other licensed therapists, clergy, and attorneys. Recognized confidentiality is the keystone of our ability to do psychotherapy. Patients understand that they can trust us with their deepest secrets.
In fact, our patient was initially concerned about talking about her stepmother because she has a 17-year-old sister at home, and she didn’t want any repercussions to occur to her stepmother, who she feels has been good to her despite the episodes of abuse when she was younger. Most people have awareness that a special court order by a judge is required for a doctor to turn over medical records without permission of the patient. There are situations in which doctors have even refused to do so even after such a court order and have faced the consequences. In this particular case, there is obviously no court order. However, there are some other reasons that the psychiatrist might feel compelled to break his patient’s confidence.
In some states, including New York where this patient was being treated, there is a law that mandates physicians to report any known or suspected cases of child abuse. When such reports are filed, there would be a case file opened, and an investigation is supposed to be immediately conducted. In such a case, the parents who are obviously responsible for the child would be questioned to determine if they have put the child in any jeopardy. It would seem that in such a case the parents would be informed that a physician has reported suspected abuse and would obviously act accordingly.
On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff. Both had been students at the University of California at Berkeley. They had met a year earlier, and Poddar became convinced that they had a serious relationship. Tarasoff told him she was involved with other men and not interested. Poddar became depressed. He talked to a friend and was eventually convinced to go to student health. He started therapy with a psychologist on staff. During his ninth session, Poddar confided to his therapist that he was going to kill Tarasoff when she returned from summer break. The therapist subsequently informed the campus police that he felt Poddar was dangerous and that he should be hospitalized involuntarily. The police picked up Poddar, but after questioning, felt he had “changed his attitude” and released him after he promised to stay away from Tarasoff. Poddar stopped therapy and later went to Tarasoff’s house and stabbed her to death with a kitchen knife. He then called the police and asked to be handcuffed. Her parents then sued the psychotherapist for failing to warn them or their daughter about the danger. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty to the woman because she was not his patient, holding that if a therapist determines or reasonably should have determined “that a patient poses a serious danger of violence to others, he bears a duty to exercise reasonable care to protect the foreseeable victim of that danger.” Many states, including New York, followed California’s lead and now have expectations of a “duty to warn” potential victims. Under the Tarasoff Rule, a therapist, therefore, does not incur any liability for breaking confidentiality to warn a victim who is in danger and is expected to do so.
If the patient were to have a serious mental illness, such as severe depression with suicidal ideation or psychosis with command hallucinations, the psychiatrist could fairly easily arrange an involuntary hospitalization for further evaluation and treatment. This apparently is not the situation in this case.
What could Happen?
If the therapist attempted to do a Tarasoff warning, let us consider how this would work. First of all, she would have to know how to reach the parents of the child to warn them. She wouldn’t necessarily have that information. In this case, since the parent was a celebrity, she might have some clues, but such attempted warning would no doubt involve some intermediary parties prior to speaking directly with the parents. This might involve publicizing the concern and the abuse, which might even end up in the media. This could embarrass the parents, although one would think they would want to know. However, if the actual danger were exaggerated, then this could be creating bigger problems.
If the therapist were to submit a report of suspected abuse as mentioned, this would trigger an investigation, which would involve the parents. In the same way, if the therapist had called the police and reported a potentially dangerous situation, the police would track down the nanny who could be caring for the child. They would have to take the child into protective custody until they located the parents (who sometimes are out of town). Then they would turn the situation over to an agency that would investigate potential abuse.
As all the above were considered, the therapist also had to consider the strong possibility that any of the above actions would most probably lead to the termination of therapy. In addition, the patient who had resisted entering into psychotherapy in the past would be further alienated from seeking help. She would most probably obtain employment as a nanny in the future, even if she didn’t have a letter of recommendation from her current employer. She interviews very well and actually had a letter of recommendation from a previous employer that would only show a two-month gap. She would then be in the same situation to potentially harm children with no one who would know about it. It is unlikely that there was sufficient evidence to support any charges being brought against the nanny that would lead to her being put in jail or hospitalized with a mental disorder.
On the other hand, the nanny could have seriously injured the child, and there is an obligation to that child and any future children under her care.
What did Happen?
The therapist ultimately decided, with the assistance of the supervisor, that she would not take immediate action that would lead to the patient leaving therapy and thus lose any chance of preventing this young women from abusing children in the future. During the next session two days later, she brought up the subject of her hitting the child. The patient said that she hadn’t done that again. The therapist said that she was pleased about that but she shared the dilemma that she would be obligated to warn the parents if she believed the child was in danger, as well as have to report abuse. She suggested that the nanny take a leave of absence for a few weeks from her work, which was easy to do since there were other nannies who also cared for this child. She was able to take on work that she had done before, assisting elderly people where the patient had no inclinations for abuse. They agreed they would work on this problem and in the future they could decide when she was ready to return working with children. The patient was receptive to this idea and appreciated the concern of the therapist in wanting to help her and yet not get her into trouble, as well as understanding of the legal and ethical obligations of the therapist.
Do You Have Any Comments on this Case
Your comments on this case are especially welcome since there is no easy answer here.