Assessing violence risk in Tarasoff situations: A fact-based model of inquiry.
Randy Borum & Marisa Reddy (2001)
Pop-quiz: Your client says “If he does it again, I’ll kill him” … what do you do?
Do you breach confidentiality and report the threat to authorities?
Do you warn the victim?
Do you maintain client rapport and confidentiality and focus on reducing their aggression?
First step is to consider Tarasoff…
What on earth is Tarasoff?
So what, or in fact who, is Tarasoff?
Tatiana Tarasoff was a Brazillian woman who was murdered by fellow university student - Prosenjit Poddar - in California in the 70s. While Ms Tarasoff was in Brazil on holidays, Mr Poddar attended counselling at a University clinic and reported that he wanted to kill Ms Tarasoff. The counsellor was very concerned and reported it to campus police who arrested Mr Poddar and interviewed him. At the time, he seemed rational and promised he did not mean the threat, so he was released. Two months later, Ms Tarasoff returned from Brazil completely unaware of the threats and was murdered by Mr Poddar. Her family sued the counsellor and University for not taking reasonable action to protect Ms Tarasoff.
The case was heard in the Californian Supreme Court on two separate occasions. In the first ruling, the Supreme Court reported that counsellors had a “duty to warn” potential victims, but in the second ruling the Court went further than that and said counsellors had a “duty to protect” potential victims. Acting protectively may include warning the victim, informing authorities, seeking involuntary hospitalisation of your client or other actions that may mitigate the risk to the targeted victim.
While Tarasoff is a US precedent, it is believed that a similar duty would be found in Australia - at least a duty to warn the victim, if not also a duty to protect.
So back to the original question …
What do you do?
Borum and Reddy’s article outlines a recommended framework for responding to a client when they say or do something that raises concerns about the safety of others.
While structured violence risk assessments (like the HCR-20 or SAVRY) may give an indication of someone’s general risk of violence, they are not helpful in determining their risk of undertaking a specific act of violence. While general violence risk uses inductive reasoning to apply group-based norms to individual risk, Borum and Reddy argue that risk of specific violence should be assessed through deductive reasoning with consideration of the facts of the situation. They provided the ACTION framework to guide this deductive reasoning.
When posed with behaviour or comments that indicate there is a risk to others - your decision to breach confidentiality in order to protect potential victims will need to be defensible. The following framework may help guide you to consider when you need to act on your duty to protect (if that duty does in fact exist in Australia - the jury is out on that!)
Attitudes that support or facilitate violence
Making threats is not unusual. You might say “I’ll throttle the next person who asks me that question” but of course when the question is asked, you just grit your teeth and answer. Why don’t you throttle them? Probably because you don’t really believe that violence is the best way to resolve your frustration about intrusive/dumb questions.
Conversely, if you are working with a client who has grown up in a world where violence is used to express anger or solve conflict, then they may be more likely to have attitudes that support the use of violence as a legitimate response to provocation.
Attitudes which may increase the risk of acting on a threat could sound like:
“Some people deserve to get hurt.”
“It’s a kill or be killed world.”
“People will only respect you if they are scared of you.”
If your client has attitudes that support or facilitate the use of violence then they may be more likely to act on threats.
When considering the risk of a threat, you need to consider whether they have the capacity to carry it out. When thinking about their capacity, you should consider things such as:
Their physical and intellectual capacity
Access to weapons or other means required for the threat
Access to the potential victim
The opportunity to commit the act, ie a time and place with minimal risk of interruption or intervention
Another fact to consider is whether your client has already taken some steps towards enacting the threat. For example, they may have made threats about teachers at school and report that they found out where the teacher lives. While knowing where someone lives increases their capacity to carry out the threat (see above), going to the effort of finding out where they live indicates they are moving towards the act.
Where the steps involve breaking rules or laws, this is evening more concerning as it indicates that they are willing to engage in antisocial or illegal behaviour. An example may be where a client does not own a car but often talks about wanting to run down crowds in a vehicle. If this person were to report that they have recently broken into or stolen a car, then this is a clear increase in the risk that they will enact their threats.
We often explore whether clients have a plan for their threats, but it is also important to ask about steps towards this plan.
If a client is discussing thoughts of violence, it is important to explore whether these are thoughts or actual intentions. You can explore the level of intent through consideration of their actions, such as making an effort to increase their capacity for the offence ie purchasing a weapon, or the specificity of their plan. A statement that “I could kill that guy” may indicate less intent than “One day, I will strangle that guy from behind - he will never see it coming.”
You can also explore their consideration of consequences. Clients who say “I would never do that because I would lose everyone I love” may have less intent that clients who believe they have nothing to lose or are suicidal.
Others’ reactions and responses
The reactions of others should be considered from a few perspectives, although access to this information may be filtered through the client.
If other people who know the client well are concerned, or the targeted victim is concerned, then this may indicate a higher risk of the threat being carried out. Often these individuals will have insight into the client’s typical behaviour and propensity for violence. While they may not be able to articulate the exact reasons for their concerns, it is important to listen carefully.
Similarly, if friends and/or family of the client support the anti-social attitudes or condone the use of violence, this may also indicate a higher risk. Statements that indicate victim-blaming or minimise the impact of violence, may indicate implicit support for the client’s plan and increase the risk it will be enacted.
Non-compliant with risk reduction
The final aspect to consider is how willing your client is to engage with strategies to mitigate their risk of violence. Clients may be reporting violent fantasies to request help and be keen to learn strategies to reduce the intensity and frequency of the thoughts, while also taking steps to make sure they don’t act on the thoughts. When considering whether a client can adequately engage in risk reduction strategies you should be mindful of:
Their level of insight, particularly where they may have mental health issues as well.
Your therapeutic rapport and the length of time you have been seeing them.
The client’s belief that the strategies will work.
Their history of compliance with treatment.
And always seek supervision …
While the ACTION framework is designed to be an in-situ assessment during your conversation or session with your client, you should also revisit these aspects regularly to investigate whether there has been a change such as increased intent, capacity, or an emergence of threshold crossing behaviour. If you have a client that you are concerned about, you should also seek supervision. The framework is not summative nor does it provide a ‘risk rating,’ rather it provides a structured way to consider specific threats, but you will still need to use your professional judgement to decide when you may have a duty to protect the potential victim.
So what are your thoughts? Leave us a comment below.