Duty to Warn: The Tarasoff Rule

I had a patient one time--an active duty soldier--who, during my initial assessment with him, looked me square in the eye and said, "My buddies brought me in here because I'm going to kill our First Sergeant." His words were dramatic, but there wasn't a lot of emotion there. He was intense--very intense--but not in a rage or floridly psychotic. He was simply stating his intentions. He later told me that he "needed" to kill his 1SGT because his 1SGT was "dangerously incompetent," and that killing this guy would save the lives of some of his team. He truly saw this as the only viable solution to what he considered to be an otherwise inevitable tragedy (friends dying because of the inexperience/ ineptitude of this 1SGT.)

This could have been seen as a "simple" matter of criminal intent, prompting us to call in the police to deal with him. But during that initial conversation with him, I noticed several things. First, he talked of his 1SGT without blinking. At all. He appeared to be in a kind of fugue state where he had lost the ability for rational thought or problem solving regarding this one subject. Second, his buddies reported that this preoccupation with wanting to hurt or kill someone was quite uncharacteristic of him. And third, he had done three tours in Iraq and, by all accounts, had a pretty significant case of PTSD. Three tours in a war zone like Iraq would often cause Complex PTSD (cPTSD), with layers of trauma stacked on top of each other. Almost more a brain injury than a transient psychological condition.

In this case, I recommended to the ER team that we 1) immediately put the patient on a psychiatric hold, then 2) initiate Duty to Warn through the military hospital system, and finally, 3) offer him an antipsychotic to, as I phrased it to him, "help you feel more comfortable." He readily accepted the offer of medication (because he was indeed immensely uncomfortable in all kinds of ways). We notified the chain of command that was appropriate to the situation so that the 1SGT was protected. And finally, with the encouragement and support of his closest active duty buddies, he accepted hospitalization for treatment of his cPTSD.

This is the only time in my career where we had to invoke the Tarasoff Rule, allowing us to breach HIPAA in order to save someone being specifically targeted by someone psychologically unsound who has the intent of doing that person serious harm. And it all worked because his buddies took his intentions seriously and brought him in for psychiatric care. Without his being brought in, it is very likely that one soldier would be in a grave and another would be in a prison.

The exam may refer to this by either of it's names, so I wanted to make sure you were familiar with both.