Psych · Forensic psychiatry — duty to warn and third-party risk
Duty to warn and third-party risk
Also known as Tarasoff duty · Duty to protect · Duty to warn · Third-party violence risk disclosure · Confidentiality exceptions psychiatry · Protective disclosure · Tarasoff warning · Identifiable victim threat
Exam-exhaustive fellowship reference on Tarasoff principles, duty to warn versus duty to protect, limits of confidentiality when third parties are at serious risk, Appelbaum assessment-action-implementation model, protective options including treatment and containment, minimum necessary disclosure, documentation, alliance repair, and jurisdiction variation without inventing statutes. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Named, readily identifiable third party with plan, means, and access — treat as high-acuity protective emergency until safety secured
- Weapons available and recent rehearsal or stalking of the target — escalate containment and multi-agency notification under local lawful pathways
- Command hallucinations or delusional jealousy targeting a specific person — do not rely on reassurance alone; reassess capacity for control and implement protect steps
- Imminent attack language during the session (leaving to harm now) — stop routine interview mode; secure environment and emergency services as indicated
- Victim access on leave or after discharge with unresolved threat — cancel or restructure leave; document protective plan before step-down
- Threat retracted after clinician raises disclosure — reassess credibility and dynamic risk; do not treat retraction as automatic clearance
Meet the patient
A 31-year-old man in weekly outpatient therapy tells you he has been driving past his former partner's house at night. He names her, describes what he intends to do, and mentions the rifle at his brother's farm. He then says: "You can't tell anyone. That's the deal."[1][6]
He has never been violent. He is not psychotic. He is not intoxicated. He has an appointment next Tuesday.[16][17]
The examiner is not asking whether you would break confidentiality. They are asking whether you can structure the next hour: assess the danger, choose a protective course from more than one option, and record why you chose it.[1][2]
References22ShowHide
- [1]Appelbaum PS Tarasoff and the clinician: problems in fulfilling the duty to protect Am J Psychiatry, 1985.PMID 3976915
- [2]Anfang SA, Appelbaum PS Twenty years after Tarasoff: reviewing the duty to protect Harv Rev Psychiatry, 1996.PMID 9384976
- [3]Roth LH, Meisel A Dangerousness, confidentiality, and the duty to warn Am J Psychiatry, 1977.PMID 848576
- [4]Binder RL, McNiel DE Application of the Tarasoff ruling and its effect on the victim and the therapeutic relationship Psychiatr Serv, 1996.PMID 8916238
- [5]Weinstock R, Vari G, Leong GB, et al. Back to the past in California: a temporary retreat to a Tarasoff duty to warn J Am Acad Psychiatry Law, 2006.PMID 17185483
- [6]Knoll JL The psychiatrist's duty to protect CNS Spectr, 2015.PMID 25712614
- [7]Soulier MF, Maislen A, Beck JC Status of the psychiatric duty to protect, circa 2006 J Am Acad Psychiatry Law, 2010.PMID 21156904
- [8]Johnson R, Persad G, Sisti D The Tarasoff rule: the implications of interstate variation and gaps in professional training J Am Acad Psychiatry Law, 2014.PMID 25492073
- [9]Johnson R, Persad G, Sisti D The Tarasoff Rule: The Implications of Interstate Variation and Gaps in Professional Training Focus (Am Psychiatr Publ), 2019.PMID 32015727
- [10]Guina J, Dornfeld B, Pinals DA A 20-year follow-up survey of police officers' experience with Tarasoff warnings: How law enforcement reacts to clinicians' duty to protect Behav Sci Law, 2022.PMID 35195297
- [11]Scarano VR, Baily CM, Banfield JR The Texas Supreme Court speaks: mental health professionals have no duty to warn or protect third parties Tex Med, 2002.PMID 12448958
- [12]Boulos N, Mallela D, Felthous A Tarasoff in Missouri: The jurisprudence of a mental health provider's duty to warn and protect non-patients of potential risks from patients J Forensic Sci, 2023.PMID 37282852
- [13]Appel JM Trends in Confidentiality and Disclosure Focus (Am Psychiatr Publ), 2019.PMID 32047382
- [14]Bersoff DN Protecting victims of violent patients while protecting confidentiality Am Psychol, 2014.PMID 25046702
- [15]Felthous AR The clinician's duty to protect third parties Psychiatr Clin North Am, 1999.PMID 10083944
- [16]Buchanan A Risk of violence by psychiatric patients: beyond the "actuarial versus clinical" assessment debate Psychiatr Serv, 2008.PMID 18245161
- [17]Large MM, Ryan CJ, Nielssen OB Helpful and unhelpful risk assessment practices Psychiatr Serv, 2010.PMID 20439381
- [18]Fazel S, Singh JP, Doll H, et al. Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis BMJ, 2012.PMID 22833604
- [19]Fazel S, Gulati G, Linsell L, et al. Schizophrenia and violence: systematic review and meta-analysis PLoS Med, 2009.PMID 19668362
- [20]Simpson AI, Allnutt S, Chaplow D Inquiries into homicides and serious violence perpetrated by psychiatric patients in New Zealand: need for consistency of method and result analysis Aust N Z J Psychiatry, 2001.PMID 11437811
- [21]Witt K, van Dorn R, Fazel S Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies PLoS One, 2013.PMID 23418482
- [22]Storey JE, Watt KA, Hart SD An examination of violence risk communication in practice using a structured professional judgment framework Behav Sci Law, 2015.PMID 25615811