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Confidentiality Versus the Duty to Protect

Foreseeable Harm in the Practice of Psychiatry

Edited by James C. Beck, M.D., Ph.D.

  • ISBN 978-0-88048-170-0
  • Item #8170
Winner of the 1992 Manfred S. Guttmacher Award

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Confidentiality has long been a cornerstone of the practice of medicine and psychiatry. In the past 20 years there has been a dramatic increase in the number and type of exceptions to confidentiality. Confidentiality Versus the Duty to Protect: Foreseeable Harm in the Practice of Psychiatry is designed to help psychiatrists and other psychotherapists deal with the problems created by exceptions to confidentiality. The mental health professionals must now have some knowledge of relevant law. Without such knowledge, the clinician carries the double burden of ignorance and anxiety. The wish to lighten that burden is the motive for this book. Written by clinicians, for clinicians, Confidentiality Versus the Duty to Protect: Foreseeable Harm in the Practice of Psychiatry presents a discussion of law as it relates to the clinical issues of confidentiality versus the duty to protect.

This book is divided broadly into two sections. The first section includes a chapter on basic issues, an overview of the law, and chapters on applications of the law in specific clinical settings. This section addresses legal issues surrounding clinical practice in the office, in the emergency room, and in the hospital. In the second section, the chapter authors examine specific clinical situations in which confidentiality and duty to protect issues arise. Chapters focus on issues relating to children and families, sexual misconduct between patients and therapists, HIV-positive patients, patients with a dual diagnosis of mental illness and substance abuse, and two other problematic diagnoses: posttraumatic stress disorder and antisocial personality disorder. The book concludes with the presentation of a clinical case in which the patient poses a threat to the potential victim.


  • The basic issues. Current Status of the duty to protect. The duty to protect in private practice. The duty to protect in emergency psychiatry. The duty to protect in inpatient psychiatry. Managing risk and confidentiality in clinical encounters with children and families. Therapist sexual misconduct and the duty to protect. The HIV antibody-positive patient. Tarasoff and the dual-diagnosis patient. Posttraumatic stress disorder and the duty to protect. The antisocial patient. Driving, mental illness, and the duty to protect. The case of Ms. Troubled.

About the Authors

James C. Beck, M.D., Ph.D., is Associate Professor of Psychiatry at Harvard Medical School, and Director of the Cambridge Court Clinic in Cambridge, Massachusetts.

Tarasoff verdicts have attracted the attention of clinicians about the need to protect patients and members of society from harm. In this superb clinical compendium, a broad definition of dangerousness is adopted. Chapters dealing with potentially dangerous children and families, HIV-positive patients, posttraumatic stress disorder, and therapist-patient misconduct provide a greatly expanded perspective. Although legal obligations are thoroughly discussed, the clinician will find this book especially useful because it addresses good clinical judgment and patient care.—Jon E. Gudeman, M.D., Professor of Psychiatry, Medical College of Wisconsin

Dr. Beck and his colleagues have taken on one of the most ethically challenging issues in psychiatry—confidentially versus the duty to protect—and they have applied it across the spectrum of disorders that challenge us as clinicians and teachers. This will become the standard text in this area for general psychiatrists, forensic psychiatrists, and attorneys. It is scholarly and thorough, and demonstrates a mastery of both clinical and legal contexts. It is also quite readable.—Roger E. Meyer, M.D., Professor and Chairman, Executive Dean, University of Connecticut Health Center, School of Medicine

This volume is an excellent overview of the inherent tension between the issues of confidentiality and the duty to protect or warn. It describes various patient populations, clinical settings, and situations, and offers options to clinicians which are pragmatic, practical, and possible. It is not a cookbook or a Chinese menu offering clear-cut solutions to clinical problems. It is, however, thought provoking and stimulating and shares views and clinical models used by experts who have carefully considered options. It merits careful reading and consideration by contemporary clinicians.—Elissa P. Benedek, M.D., Past President, American Psychiatric Association

This unpretentious book makes no claim to guide doctors through the complexities of philosophical analysis, but restricts itself to an exposition of relevant law, a description of cases, and sound practical advice about balanced approaches to volatile problems.—Criminal Behavior and Mental Health

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