written by: Renee Burns Lonner, MSW and Michele Licht, JD | Reprinted with permission from AAMFT (Family Therapy Magazine, May/June 2018)
It’s not something that most of us would ever imagine having to deal with in our careers — a client makes or poses a threat of violence against you.
Therapists seem to be uniquely challenged in terms of knowing what to do to protect themselves, based on either their nature or education and training, or a combination of both. Therapists sometimes joke that theirs is one of the oddest professions: many spend their entire professional lives sitting in a room with clients listening to the most intimate thoughts and feelings — and pain — and their only curative tool is the spoken word. The therapy office is a most private world, and it must be so for the kind of work that is done there.
Individuals who enter the mental health field tend to be, by definition, other-oriented; people who want to improve the human condition and lessen the suffering of others. They are in the “people business” and people, not things, are their interest and field of study; they are “caretakers” of a particular sort, taking care of the hearts and minds of their clients, helping them to feel heard and understood, some for the first time in their lives.
It should not be a surprise that therapists often do not take good care of their professional selves; they are too busy taking care of the client. Usually, when supervisors tell them to pay attention to their own feelings, it is in the service of the client, or countertransference, feelings that the client often unconsciously provokes in the therapist that are a most useful kind of communication for the therapeutic process. But therapists often deny or minimize feelings of risk to themselves, anxiety or fear. The importance of observing and addressing risk to personal or professional well-being as it develops in the assessment or treatment process, in other words, the ability to identify “red flags” and intervene constructively, will be our main focus here.
In addition to direct risk posed by the client, threats to the therapist may develop from an indirect high-risk situation. The therapist may have met a legal obligation to warn a potential victim (Tarasoff) and inadvertently provoked the client’s anger, or the therapist may be viewed by the client as “taking sides” in a highly contentious divorce or custody matter. In these situations, the therapist may become one of the objects of the client’s anger.
Many therapists who have contacted the authors about a threatening client have observed, and then denied or ignored, weeks or months of warning signs and signals which are, notes Gavin de Becker, pre-incident indictors (1998). It is important to recognize, and, more importantly, pay attention to those signs and become appropriately concerned for one’s safety, a psychological position that is unfamiliar and nearly always uncomfortable for mental health professionals. Therapists need to know when to consult, when to assess and not begin treatment with a client, when to refer and when to terminate. Though we are emphasizing the need for therapists to learn they have a basic right to safety and self-protection, the client’s needs are served here, also — no therapist who is frightened for her or his own safety can provide effective treatment and clients who present such risks usually need to be seen in environments other than a sole practitioner’s private practice office.
Red flags during assessment
There are potentially dozens of red flags that a therapist may observe in the first couple sessions with a client and many resources are devoted to that subject (see Professional Resources section). Most individuals who eventually make or pose a threat have a personality disorder (sociopathic, narcissistic) that renders them devoid of empathy, thus making it easier for them to justify harming another person physically or psychologically. However, having either a personality disorder or many of the traits thereof, in and of itself, does not make someone a risk of violence — for that, one needs to add situational factors having to do with actual loss or narcissistic injury, often combined with the abuse of alcohol or drugs. Being able to observe these red flags at any point in the assessment or treatment phases requires the therapist’s intuition, as well as paying attention to the client’s words (and behavior), and then acting quickly and appropriately to address the risk. Following are statements reflecting incidents related to a client who presented a risk of violence:
- My practice specialty is personality disorders and I take pride in helping a lot of these clients make progress; I guess the fact that she had seen several therapists before me, and did not feel helped by any of them, I took as sort of a professional challenge and I wanted to demonstrate to her that she could get help.
- He pushed the boundaries of the therapeutic relationship from the beginning and did not respond positively when I set limits; however, it never occurred to me that I could or should terminate him for that behavior and I just became increasingly anxious.
- He was extremely depressed and suicidal when I started to see him and I was so concerned that he would kill himself that I entirely missed the violent part of his suicidal thinking. I never thought he could become homicidal until he made the actual threat. Now, I recall that he told me in the first couple sessions that he collected antique guns and had a fascination with them.
- The father in a high-conflict divorce and custody situation admitted that he had struck his child on a couple of occasions, but he said that he did not hit him hard and considered that it was appropriate discipline, and “it worked.” He added that if I told anyone, he would “make sure I was sorry.”
- I was uncomfortable with the way he looked at me during the initial session and he asked a couple of very personal questions. I felt shaky by the end of the hour, but I’m an intern and I didn’t think my supervisor would react well to my not wanting to see him.
These situations developed over time into cases of stalking and homicidal threats, and consultation involved very sensitive and strategic interventions aimed at reducing the threat and protecting the therapist. De Becker (1998) makes the point in The Gift of Fear, while referring to workplace situations, the range of interventions narrows and the risk increases if the threat is allowed to develop and increase over time. Though not involving the context of the usual “workplace,” the authors see this phenomenon regularly in consultations. Many therapists who seek consultation after weeks or months, or in rare cases, even years, of a client’s presenting a risk of harm learn that their options are far fewer than they would have been with early intervention. This phenomenon is created, on a most basic level, because the person who is making or posing the threat has become more and more empowered by the absence of consequences. The relatively simple setting of a limit or boundary usually does not work at advanced stages of risk. That timeline is the dynamic at play in some consultation cases where the situation is so dangerous that it is advisable to terminate the client by phone or in writing, but in no circumstances in the office, in person.
At a most basic level, the therapist’s concern about risk in general (therapist or other-directed) should be activated by clients who assume no responsibility for their behavior, have a level of anger or rage that is excessive for almost any situation, have a history of violence and/or make threatening statements (even if they are implied, conditional or indirect) and have substance abuse issues. Often in such situations, the therapist’s anxiety takes over and he or she seeks the client’s assurance or a verbal contract regarding safety. By expanding the conversation briefly at this point, the therapist can be in a position to take appropriate action, if that is indicated; such action might be to not see the client and refer him or her to a clinic or specialized practice setting. Such questions might be:
“You mentioned that you ‘got even’ on social media with your last girlfriend for breaking up with you — what did you post, how often and how do you know her response?”
“You said that you saw your last therapist for several years, but it turned out she was not helpful and you think she was not ethical on some occasions — would you be willing to sign a release so that I could speak with her?”
Generally, the authors only hear from therapists whose case situations have become very difficult, and those are the examples provided here. With that caveat, we have observed that some therapists seem averse either to not accept a client who arouses concerns during the assessment phase, or to terminate clients who are not following the key elements of the treatment plan. Often during these consultations, the view expressed by the authors that “responsibility is a two-way street” comes as a surprise to the consulting therapist, and he or she responds with 1) Isn’t that abandonment? 2) I have no colleagues to whom I can refer this client, or 3) I don’t want to reject him and repeat his early history with his parents.
Informed consent. Younggren, Fisher, Foote, and Hjelt (2011) make the basic point of mutual responsibility in “A Legal and Ethical Review of Patient Responsibilities and Psychotherapist Duties”; however, this almost common-sense, legally and ethically sound position seems to be rarely communicated in education and training. Also, not emphasized before licensure is the potential depth and breadth of the informed consent process. Here, the therapist has the opportunity to discuss, among other things, the protection and limits of confidentiality, details of the treatment plan, the client’s responsibilities to cooperate and participate in order for effective treatment to be provided, and the conditions under which termination (and not always a mutually-desired termination) may be necessary.
Some therapists are uncomfortable with this process, rush through it and see it as simply the need to obtain a signature — not as a discussion of the content and an opportunity to determine if roadblocks to effective treatment posed by the client may be foreseen. An open discussion at the point of assessment may not only prevent serious issues from developing later in treatment, such a discussion also opens the door to these issues before a crisis arises. It communicates to the client that the therapist is in control of the treatment process; that is, the therapist sets and maintains the framework and boundaries for therapy. That responsibility includes ensuring that the treatment setting, for example, outpatient therapy on a regular basis, provides the correct level of care. If at any point in the treatment process outpatient treatment is not enough to ensure that treatment goals can be met, the therapist needs to initiate a discussion with the client and recommend the correct level of care. The patient’s willingness, or not, to move to that level of care should not control the therapist’s next move; that move may need to be an appropriate termination and referral.
Authorization for disclosure of confidential information
The “release of information” form is another opportunity for the therapist to communicate boundaries and scope of the therapeutic relationship. In some cases, the client requests the therapist communicate with another healthcare professional or family member; in other situations, the therapist believes it is in the client’s best interests to communicate with another person in the client’s life and the client may or may not wish such communication to occur. Alternatively, the client may not object in concept to the sharing of information with a third party, but may prohibit the therapist from discussing certain issues or facts relative to his or her situation. The therapist must assess whether any limits imposed by the client could potentially cause the client harm or interfere with the treatment process, and if so, communicate that information to the client. If the client continues to refuse (for example, that the therapist discuss current drug or alcohol use with the psychiatrist prescribing medication), the therapist needs to determine if safe and effective treatment under those circumstances can be provided. Of course, these situations can become contentious and may be viewed by the client as a “power struggle” rather than the therapist acting in the client’s best interests. The therapist should explain the reason the communication with another professional or other third party is important for the treatment process; ultimately, the therapist must be the one to make the decision as to whether treatment can move forward under those circumstances.
When the threat to others turns toward the therapist
In the execution of legal or ethical duties, therapists may become an additional, or even the main, focus of anger for the client. Some of these case situations become quite complicated, from a risk management point of view. For example, when a client makes a credible threat of violence toward a third party and the therapist warns and takes action intended to protect the intended victim (such as calling the police), the client may become infuriated with the therapist. In such cases, the client may deny intent or means, even though he or she may have communicated this clearly to the therapist in a session, and claim that the therapist misunderstood “expression of feelings.” The client may feel that the action by the police, for instance, caused embarrassment in the community or, if the threat was communicated to an employer, threatened employment standing. Clients with these feelings may threaten legal action (such as filing a complaint against the therapist) and/or harm to the therapist. Particularly risky are domestic violence situations and therapists are well advised to protect themselves with early consultation in these cases. A private practice office can be a difficult setting in which to treat either the perpetrator or the victim in a domestic violence situation; in many of these cases, a clinic setting in which there are other professionals present is a safer environment.
Also, child abuse situations may present risk if the parent client is also the suspected perpetrator of the abuse. In most of these situations, it is not appropriate for the therapist to continue to provide treatment (there are exceptions), and referrals are in order. There are similarities here to “duty to warn” situations in terms of the client’s feeling humiliated and embarrassed, as well as not in control, and the therapist may become a target of the ensuing anger or rage. In short, anytime the therapist moves to protect a third party (a child, spouse/partner, supervisor, or teacher) and gets “in between” the threatening client and third party, there may be risk in terms of physical or psychological violence. Therefore, almost at the same time as taking action to protect others, the therapist needs to assess the risk to self, and take appropriate security precautions. Consultation at this point can be very useful and can help the therapist feel, and actually be, more in control of a volatile situation.
The role of consultation
Connected with therapists’ commonly positive and expansive view of what kinds of issues may be dealt with in therapy and their occasional minimizing of their sound clinical intuition on the front-end, is their reluctance to obtain appropriate legal or clinical consultation early in the treatment process. For the reasons previously mentioned, consultation is most effective when it is obtained early in the assessment or treatment process. Therapists should not hesitate to contact an attorney who specializes in mental health law if they believe that their treatment, referral or termination of a client may raise legal concerns. The fact that the therapist may feel as if he or she has already made an “error” with the client, or records are not pristine, should not deter one from seeking a legal consult — in fact, it should hasten one. Alternatively, when seeking a clinical consult, the therapist should seek a peer consultant (expert) who has extensive experience in assessing risk and the potential for violence. A qualified consultant should be able to quickly assess the situation and make clear recommendations to protect therapist safety, as well as assisting the therapist in identifying appropriate treatment resources for the client.
Therapists are encouraged to identify red flags in the assessment and treatment process and take the initiative to gather more information to assess the level of risk and make an informed decision as to the wisdom of accepting a client into practice and/or terminating the client. Clinical and/or legal consultation is encouraged in any case situation involving risk of violence and therapists are reminded that, in these cases, they need to pay attention to their basic need for safety, at the same time they are addressing the client’s treatment needs.
Renee Bums Lonner, MSW, LCSW, maintains a private practice in Sherman Oaks, California, providing individual, marital and family psychotherapy with children, adolescents and adults. She is a consultant for mental health clinicians and organizations in general practice areas, as well as the specific area of risk assessment. She is an AAMFT Clinical Fellow.
Michele Licht, JD, is an attorney specializing in the representation of mental health practitioners on a wide range of issues. Over the past 35 years, she has represented over 2,500 psychotherapists in legal and ethical consultations, before licensing boards, in disputes regarding hospital and medical staff privileges, and general practice issues. She represented psychology before the California Supreme Court in CAPP v Rank, setting a precedent for psychologists’ scope of practice in hospital settings.
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