Healthcare Training Institute - Quality Education since 1979
Psychologist, Social Worker, Counselor, & MFT!!

Section 1
Track #1 - Therapist-Client Confidentiality & the Risk of Violence

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Welcome to the Home Study Course sponsored by the Healthcare Training Institute, homestudycredit.com.  This course is entitled, School Shootings: Ethical & Confidentiality Boundary Issues.

Our primary intent for this home study course is to provide quality education to foster your professional growth.  The Institute has provided quality education since 1979.
 
We appreciate that you have chosen us as a vehicle for you to earn your Continuing Education Credit.

The purpose of the course is to assist you in increasing your knowledge regarding how to treat patients, clients, etc.  As each case study is given, if the concepts seem to be applicable to your situation, I encourage you to turn your CD player off and make a few notes regarding the application of the principle to your setting.  However, these notes are for your purposes only and are not to be sent to the Institute.  Also each track is very content dense.  So feel free to replay the track to review the content either for your own purposes, or if you feel appropriate play the track in an individual or group session for client education.  Also permission is granted to reproduce this CD.  We encourage you to duplicate and give copies of this CD to colleagues, clients, etc. as you deem appropriate. We feel the information on our CD's is valuable.  Thus, we have an interest in distributing CD's in as many ways as possible, to benefit the greatest number of people, who have a need and are receptive to this practical information.

The questions in your Test are sequential and deal with the section of content that preceded it.  For this reason, to facilitate the answering of each question, you might read the question from the Test prior to listening to that CD track.  By knowing what the question is ahead of time, you will then know the content to listen for that contains the answer.  So just a hint, after you write down the answer to a question in your Test, read on to the next question in order to give you a "heads up" to listen for the content that contains the answer to the next question.

Merely write the correct letter on the corresponding blank line in your Test. Each answer is only used once. Keep in mind there is nothing tricky or hard about these questions.  They are merely intended to verify the playing of this CD.

For the purpose of brevity, most generally, I will use the term "therapists" or "mental health professional."  However, don’t let these terms deter you from applying the concepts to your situations.  When you hear the word "therapists," if your job title is social worker, psychologist, marriage and family therapist, mental health counselor, professional counselor, resident director, program assistant, etc. merely substitute the appropriate term that is the most meaningful to you. In short, don’t let my use of the term "therapists" cognitively set you off track from hearing the content because your job title is school counselor, for example.  I will also use the term "client" for the purposes of brevity.  However, if you deal with patients, residents, students, consumers, etc., transpose "client" for the term that is the most meaningful to you in your work setting. 

On this CD set we will discuss such topics as: therapist-client confidentiality and the risk of violence, popular explanations for rampage shootings, structural secrecy, weak or mixed signals, cultural scripts, what keeps children from reporting threats, early community recovery, conflicts in community recovery, the 5 Factor Model, preventing shootings, encouraging students to come forward, and understanding hostage situations.

So  let’s get started

On this track, we will discuss concerns regarding the therapist-client confidentiality boundary in regards to the risk of a school shooting incident.  We will also discuss the six step Action technique for fact based risk inquiry regarding confidentiality ethics.  These six steps are attitudes that support or facilitate violence, capacity, thresholds crossed, intent, other’s reactions, and non-compliance with risk reduction interventions.

In Michigan in 2000, six-year-old Kayla Rolland and a little boy who was her classmate had an argument.  The next day, the little boy, also six, brought a 32 caliber semiautomatic to school.  Bringing the gun out of his bag, the little boy told Kayla, "I don’t like you" and shot her in the chest.  The bullet pierced Kayla’s heart.  The little boy who shot Kayla later reported that he had not meant to kill Kayla, merely to scare her.  He did not seem to display any comprehension that pulling the trigger of a gun kills, nor did he show any remorse.

School shootings seem to have become a nationwide crisis.  Incidents have occurred in almost every part of the United States, and in almost every age group, from Kayla’s death in early elementary school, to the Columbine shootings in high school, to the shooting perpetrated by a college student at Virginia Tech.  As you know, much attention among education and mental health professionals has focused on what can be done to identify the perpetrators of these shootings before violence occurs.  In my experience, one of the most crucial issues discussed has concerned issues of confidentiality in counseling students at risk.

Before we begin our discussion of issues specific to confidentiality in regards to school shootings, I will briefly review the Tarasoff case and its implications for therapists.  As you know, the Tarasoff (Ter-AS-off) case concerned a young man named Prosenjit (pro-ZEN-yet) Poddar (po-DAR), who indicated in a session with a university counselor that he wished to harm a woman.  Even though Poddar did not mention her by name in the session, the woman was identifiable by information given to the counselor.  Her name was Tatiana (Tah-TEE-ahn-na) Tarasoff.  Although the counseling center informed police, Poddar was released after questioning, and not considered a significant risk.  When Tarasoff returned from a stay abroad two months later, Poddar killed Tarasoff.  Clearly the counselor knew there was a risk and took steps, but the legal question that remained was whether these steps had been sufficient.

The first version of the Tarasoff decision, made in 1974, identified the responsibility of therapists as the "duty to warn,"  or inform third parties of a risk posed by a client.  However, as you know, the decision was extended in 1976, to establish that therapists have a "duty to protect"  third parties from dangers posed by a client.  Possible actions that may discharge this duty to protect, in connection to duties imposed by state regulations, include warning the potential victim that he or she may be in danger, notifying law enforcement, or taking other steps that may be appropriate considering the particulars of the situation, such as pursuing hospitalization.

One proposed technique for managing Tarasoff situations in regard to school shootings is a six step fact based risk inquiry.  This technique is called the "ACTION" technique.  "Action" can be used as a simple mnemonic to easily recall these factors.

The first step in the Action technique concerns attitudes that support or facilitate violence.  Clearly, if an inappropriate communication or behavior from a client has raised concern about whether a client may intend violence toward a particular third party, it is helpful to know about the nature and strength of the client’s attitude towards that behavior.  Specifically, in the first step the therapist assesses whether the client believes the use of violence is justified under the client’s perception of the circumstances.  The greater the perceived justification, the greater the likelihood of action.  In addition, it is useful to assess the client’s appraisals of provocation or intentionality from others (a hostile attribution bias), violent fantasies, self-statements, expectations about the success of violence, and whether the client believes that violence will accomplish or further his or her goal.

The second step in the Action technique concerns capacity.  This includes assessing the client’s intellectual and physical capabilities, access to means such as weapons, access to the target, and opportunity to commit the act.  I also find it important to consider how well the client knows his or her target’s routines, security systems at the school, and the protection available to the target.  Additionally, I consider the target’s degree of sophistication about the need for self-protective measures.

In addition to attitudes and capacity, the third step in the Action technique is thresholds crossed.  In this step the therapist considers whether the client has already engaged in behaviors in furtherance of a plan for the attack, particularly those behaviors that involve breaking laws or rules.  As you know, acts committed in violation of the law are particularly important, because they indicate the client has a willingness and ability to engage in antisocial behavior to accomplish his or her objective.  In summary, it is helpful in considering potential Tarasoff applicability not only to ask about the existence of a plan, but what steps the client has taken to further that plan.

The fourth step in the Action technique is intent.  Clearly, a client who makes a threatening statement may or may not have any intent to carry out an attack; having an idea of harming a third party is not dispositive of intended action.  I feel that level of intent can be inferred from the following:  specificity of the plan, access to means, or behaviors that indicate a commitment to action.  These behaviors that indicate a commitment to action include consideration of potential consequences, consideration and rejection of alternate solutions, and an attitude of having ‘nothing to lose’.

The fifth step in the Action technique is other’s reactions and responses.  Obviously it is not always possible to review external records or obtain collateral information, but such information can be potentially helpful in appraising risk.  The theory of planned behavior posits that a key factor in determining a person’s attitude towards a behavior is the reactions he or she anticipates from others.  For example, a client who reports that when he angrily told his best friend he was going to kill a teacher perceived as antagonistic, his friend responded with, "well someone ought to" might perceive the justification for his violent act as stronger.  The client’s perceived barriers or discouragements to the act might also be fewer.

In addition to attitudes, capacity, thresholds crossed, and other’s reactions, the sixth step in the action technique for fact based risk inquiry is noncompliance with risk reduction.  Clearly, if a client appreciates that he or she may be at risk for harming a third party, then his or her movement on the pathway towards violence has a greater likelihood of being slowed or redirected.  A client beliefs about the efficacy of the treatment, his or her alliance with the therapist, and history of adherence to treatment regimens may be good indicators of his or her risk to others.

On this track, we have discussed concerns regarding the therapist-client confidentiality boundary in regards to the risk of a school shooting incident.  We also discussed the six step Action technique for fact based risk inquiry regarding confidentiality ethics.  These six steps are attitudes that support or facilitate violence, capacity, thresholds crossed, intent, other’s reactions, and non-compliance with risk reduction interventions.

On the next track, we will discuss the first five of nine explanations of school shootings, and how these theories hold up under professional scrutiny.  These first five popular explanations of school shootings are, mental illness, ‘he just snapped’, family problems, bullying, and peer support.

QUESTION 1
What are the six steps in the Action technique regarding fact based risk inquiry under the Tarasoff decision? To select and enter your answer go to Test.