Thursday, 17 February 2011

When a client confesses to murder

Dr. Jennifer Melfi: What line of work are you in?
Tony Soprano: Waste management consultant.
Client confidentiality in psychotherapy only goes so far. If a client threatens the therapist, another person, or themselves, and the threat is perceived as serious, then most jurisdictions (including the BPS ethics code) recognise this as a valid reason to breach the client's privacy and go to the authorities. But what about the situation in which the client confesses to a past violent act for which they were never prosecuted? What if they tell their therapist that they've previously murdered someone?

Steven Walfish and his colleagues have investigated this issue in a survey of 162 US psychological psychotherapists recruited randomly via the National Register of Health Service Providers. Astoundingly, 21 of the psychologists said that on at least one occasion they'd had a client disclose in therapy that they'd murdered someone, but never been found out (one unlucky psychologist said they'd encountered this scenario six times!).

One hundred and three of the psychologists said they'd had a client disclose having committed an act of previously unreported sexual assault, and 111 of them had had a client disclose a previously unreported act of physical assault. The majority of psychologists said disclosure of past physical assault had happened on three or more occasions; one of them said it had happened more than 200 times!

From an ethical point of view these disclosures of past violent acts are trickier to resolve than threats of future violence, especially if there's no other reason to believe that the client remains a threat. Among the psychologists surveyed in the current research, the majority (63.2 per cent) said such disclosures had had a neutral effect on therapy, 18.8 percent said it was harmful to therapy and a similar proportion (17.9 per cent) viewed it as beneficial.

From a therapeutic perspective, the researchers pointed out that those therapists who viewed the disclosure negatively were at obvious risk of 'negative counter-transference'. This is a fancy way of saying that the disclosure could negatively affect the way the therapist relates to their client, especially if the therapist has themselves previously been a victim of violence. Psychotherapists could be trained to guard against this, but Walfish and his colleagues point out that it's not unusual for therapists to be attacked or threatened by clients and so: 'fears of potential client violence may not always represent an unresolved conflict on the part of the therapist. The psychotherapist knowing this piece of clinical information [the disclosure about past violence], and knowing that the best predictor of future behaviour is past behaviour, may be concerned that they themselves may become a victim of violence.'

Somewhat worryingly, nearly one fifth of the current sample did not feel fully informed about what to do when a client makes a disclosure about past acts of violence, and nearly two thirds felt inadequately prepared for the situation by their graduate training.

Walfish and his colleagues concluded that therapists need to be prepared to hear any material in their consulting rooms, 'regardless of how unusual or unpleasant.' They also need to be aware of their own emotional reactions to disclosures of past violence, how to maintain their own safety, as well as their legal and ethical obligations. 'Graduate training programmes, internship and postdoctoral training settings, and continuing education courses should be encouraged to explore this often difficult topic area in greater depth,' the researchers said.
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ResearchBlogging.orgWalfish, S., Barnett, J., Marlyere, K., and Zielke, R. (2010). “Doc, There's Something I Have To Tell You”: Patient Disclosure to Their Psychotherapist of Unprosecuted Murder and Other Violence. Ethics and Behavior, 20 (5), 311-323 DOI: 10.1080/10508422.2010.491743 [ht: Ian Leslie]

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

A further note on the BPS Ethics Code: The code emphasises the importance of peer support and supervision. If you are a psychologist and unsure how to proceed following a client disclosure, you should seek guidance from your peers and supervisor, fully evaluate the situation, consider alternative courses of action and fully document the process of decision making [thanks to Dr Lisa Morrison Coulthard for this advice]

19 comments:

  1. Call me silly, but I'd think it's obvious that therapists should report such cases to the police.

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  2. Mr. Meadon:

    I am not calling you silly, but if clients knew that they were going to be turned in, wouldn't that lead them to not discuss the problem with the therapist? After all, I would guess that the majority of people who need to discuss the murder to alleviate themselves of the guilt are going to the therapist for that reason. Take away the trust factor and you have murderers, child molesters and rapists out on the street speaking to no one but their next victim. Now, put those same people "on the couch" discussing their crimes and they may receive the help that they need. In addition to this, what about the "crimes of passion"? A great number of murderers simply do it in a moment in a rage and then have to live with that crime for the rest of their lives, but more than likely they are not a danger to themselves or anyone else. Should the opportunity to discuss this with a trusted therapist be taken away, then what? Possibly they will become a danger to themselves via suicide or some other self destructive behaviors. I am not condoning what these people have done, but they are still people with real problems that need to be discussed in a PRIVATE therapeutic session in which they as clients can openly discuss their past without fear of being exposed before they can be directed to turn themselves into the proper authorities. Or have the psychological/psychiatric fields now become law enforcement?

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  3. Bobby,
    I agree with you. Those in the profession of practicing psychological therapy are not law enforcement. I think that the key question here is: Is this person a danger to themselves/others? Once that has been evaluated, the therapist should proceed with very careful planning and peer support.

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  4. John Gibson1:32 pm

    When a client confesses to a murder... if we set aside the impact of the disclosure on the therapeutic relationship, ethically speaking, what *is* the psychologists' obligation? (Assuming no immediate threat of future violence that has been detected). Or is there one?

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  5. Anonymous10:23 pm

    So when they come back and confess, "opps I did it again", then what?

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  6. Cokehead11:22 pm

    Obviously, the client would be a danger to themselves and others. The law allows for the client to be reported to the police.

    But if it was a murder they were willing to discuss, clearly they're ready to be over it - and likely no longer a danger to anyone.

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  7. Anonymous3:10 pm

    If they're ready to be 'over it' then there's probably deeper issues there. How can someone just get over the fact they've killed someone?
    Bobby, I understand your point that if they don't get help due to a lack of trust then who can they turn to, but ultimately they've broken the law and so it needs to be reported, no matter what the motive was or how long ago it was. Psycholists are not law enforcers, but by that very statement nor can they decide if someone should be allowed to walk free of a crime they've commited just because they think they won't do it again. The issue isn't whether they'll murder again for me, it's the fact they've already done it. They need psychological help, but that help should be provided for them in prison.

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  8. Anonymous3:13 pm

    *psychologists

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  9. Anonymous1:40 am

    "but by that very statement nor can they decide if someone should be allowed to walk free of a crime they've commited just because they think they won't do it again."

    "They need psychological help, but that help should be provided for them in prison."

    I'm lingering on these point - I think I agree. I personally could not work with someone who had committed murder outside of a prison system where I could be confident that protections were in place for my safety (and the safety of the population). There are psychologists within these systems who can teach their clients to be less 'passionate' if that was the cause of their offense.

    I'm not surprised so few people felt prepared for such a situation after graduate training. I'm currently undergoing post-graduate training and I still feel like it is an uncomfortable grey area. Ethical issues were covered in 2-3 classes in undergrad - hardly enough time to dedicate to such an important subject.

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  10. Anonymous12:28 pm

    Surely this is a straightforward dilemma - that is - there is no right or wrong answer but a process to go through, such as:
    risk assessment
    psychological assessment
    competence to practice
    the legal implications for the work
    psychologist's support
    job description and purpose of the work
    employment/agency/institution contract and procedures
    client contract

    and that these are all discussed with a supervisor with whom you meet every month.
    Surely it is not about training therapists to deal with each and every specific instance of all ethical dilemmas but the generalised processes which could apply to all ethical issues. These frameworks could then allow therapists to work through the 'shock' of the extreme and think clearly about how to proceed.

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  11. Anonymous9:03 pm

    You guys such babies! Seriously you guys have a very elementary view on what it is being human Go read the book When Good People Do Bad Things... Do murders, rapist etc have the right to disclose their wrongdoing to a Physciatrist....ABSOULUTELY! They have a guilty conscience for what they did.They have a right as a human being to help get over their guilt...THATS RIGHT I SAID IT...They have a right to be helped to be get over their guilt.

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    1. Anonymous5:21 pm

      the point of therapy is not to extinguish appropriate reaction (guilt) for murder. It is to help/encourage the client to be treated for sociopathic, antisocial, PTSD from abuse or whatever they are suffering from that manifested itself as violence. It is a sign that something is wrong if they have intentionally murdered, and that person deserves help to either reduce their sociopathic/antisocial violent behavior or support to overcome their PTSD or whatever abuse they have in a way that does not risk others or themselves (by prison or worse mental states from committing murder)

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  12. Anonymous5:32 pm

    The legal precedent of the Tarasoff case in the U.S. gives mental health professionals a duty to warn when clients pose a realistic danger to others. Just because someone committed murder in the past does not make them a danger to others at present. Further evaluation is needed to determine present risk factors. If, as a mental health professional, you are unable to work with certain clients due to personal beliefs or values, then it is up to you to acknowledge those issues. You must refer if you are unable to objective due to your own values. Often sex offenses are one of these issues for therapists. Some can work with sex offenders objectively. Others cannot. Same goes for perpetrators of violent crimes. Just because you feel that this should be reported does not save you from legal recourse.

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  13. Anonymous6:27 am

    So if I had committed a murder lets say 7 years ago when I was a Heroin/Meth addict. I was remorseful for what I did, so much so that I gave up all drug use and drinking and have not touched it since. I even went to college and got a degree to help others who suffer from addiction.
    If I decide that it is time to talk about it The Therapist I see should have to report me. I don't pose a threat to anyone anymore; in fact I have helped many people change their lives for the better.
    Would you really rather seek punishment of one person that has changed; or let that one person continue to help others from making the same mistake?
    Just saying!

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    1. Anonymous5:51 am

      Yes, good on ya, in this example you took a life and whose to say you won't again, but what makes you think helping many people for the better makes up for a life lost? Lost life will be forever lost to the dead and those who loved, cared, were acquainted with, and the murder may have denied the dead to have his/her own children, so a ultimately future generations will not know what it is to have life either. Anyway, it goes against the 4th Step to not deal with it.

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  14. Anonymous10:02 am

    The importance of remorse and taking responsibility as part of people moving on in a healthy way seems to be lost here. If someone was genuinely sorry for committing a murder they would want to at the very least see the murder resolved so everyone else can move on. Psychologists shouldn't be offering absolution to those who have intentionally hurt other, they should be supporting them to take responsibility for their actions. That said, there may sometimes be homicides that are defensible (women defending their children or trapped abuse victims acting out) and many years past where therapist should hold off reporting in the usual way. In more recent case of this nature therapists should help clients connect with advocacy and legal rep and to self report.

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  15. Anonymous6:27 pm

    What about In group therapy? We signed a paper saying whatever is said in the room of group therapy stays there but I heard someone admit to murder because a crack addict broke into his house and he shot him but he disposed of the body himself because he was a drug dealer..and now I have the burden of this in my head. According to the therapist running this group we aren't suppose to tell anyone but im having a hard time with this.

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  16. Anonymous8:29 pm

    wow i think it is hilarious that the forum stopped right there...
    why get a seperate individual therapy? so that you could discuss it there. I'm one of those people who love to find the loophole in everything

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  17. The issue with historic disclosure, well any disclosure but in particular historic, you have nothing to go on. They may be lying to test a reaction or sharing a fantasy as a reality. Therapists are not mind readers and cannot tell the motive for the disclosure or whether they are going to do again. Without that declaration of intent, a breach in confidentiality is not possible.

    Such is the same if a client discusses suicide but is not explicit in intent. There are stages of this from ideation to intent to commit. Past attempts do not mean thoughts of suicide would lead to an attempt.

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